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Author(s): Tuomi, Kirsi; Thompson, Grace; Gottfried, Tali; Ala-Ruona, Esa

Title: Theoretical Perspectives and Therapeutic Approaches in Music Therapy with Families

Year: 2021

Version: Published version

Copyright: © 2021 The Author(s)

Rights: CC BY 4.0

Rights url: https://creativecommons.org/licenses/by/4.0/

Please cite the original version:

Tuomi, K., Thompson, G., Gottfried, T., & Ala-Ruona, E. (2021). Theoretical Perspectives and
Therapeutic Approaches in Music Therapy with Families. Voices, 21(2).
https://doi.org/10.15845/voices.v21i2.2952
RESEARCH | PEER REVIEWED

Theoretical Perspectives and Therapeutic

Approaches in Music Therapy with Families:
An International Survey Study
uomi *, Gr
1 2 3 4
Kir
Kirsi
si TTuomi Grac
acee Thompson , Tali Gottfried , Esa Al
Alaa-Ruona
1 Department of Music, Art and Culture Studies, University of Jyväskylä, Finland
2 Faculty of Fine Arts and Music, University of Melbourne, Australia
3 Graduate Program for Special Education, Herzog Academic College, Israel
4 Department of Music, Art and Culture Studies, University of Jyväskylä, Finland
*[email protected]

Received: 16 January 2020 Accepted: 26 May 2021 Published: 1 July 2021

Editor: Marisol Norris Reviewers: Jasmine Edwards, Scott Horowitz

Abstr
Abstract
act
Music therapists have described the importance of working collaboratively with fam-
ily members in various populations throughout the history of the profession. Despite
the growing amount of literature, not enough is known regarding the scope of the-
oretical perspectives and therapeutic approaches that guide family centered music
therapy. The aim of this international survey study was to better understand the pro-
fessional perspectives and approaches of music therapists who work with families
around the world. This article presents the results of the survey where a total of 125
responses were analysed. Participants’ responses indicated that music therapy with
families is well established as an important field of practice that includes a large
range of populations across the life span. Music therapists working with families em-
phasise that the work is holistic and flexible, both in terms of the theoretical ap-
proaches that inform their work and the methods/techniques that are included in
sessions. The participants in this study advocated for more continuing professional
development opportunities to further deepen and develop their practice. In addition,
the survey data offers priorities and recommendations for future research.

Keywords: music therapy, family work, families, survey

ywords:

Back
Backgr
ground
ound
Music therapists have acknowledged the importance of working with the whole family
throughout the history of the profession. Pioneers such as Juliette Alvin (1978), who
1
worked with children with disabilities and autism, described the value of guiding par-
ents to use music therapy strategies in the home and community. Since then, music
therapy practitioners and researchers have continued to document and describe their
work with families. The 1990s were a time where seminal research that included fam-

VOICES: A WORLD FORUM FOR MUSIC THERAPY | VOL 21 | NO 2 | 2021

Publisher
ublisher:: GAMUT - Grieg Academy Music Therapy Research Centre (NORCE & University of Bergen)
Cop
opyright
yright:: 2021 The Author(s). This is an open-access article distributed under the terms of the
http://creativecommons.org/licenses/by/4.0/, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
DOI: https://doi.org/10.15845/voices.v21i2.2952
VOICES: A WORLD FORUM FOR MUSIC THERAPY RESEARCH

ily perspectives, including case studies and theoretical frameworks, were published
around the world (Hibben, 1992; Muller & Warwick, 1993; Oldfield, 1993; Shoemark,
1996; Trondalen, 1997). The growing amount of literature published over the past
10 years (Tuomi et al., 2017) indicates that ‘music therapy with families’ may now
be considered a field of its own, influenced by ecological understanding (Williams et
al., 2014), and the shifting descriptions of theoretical influences (Lindahl-Jacobsen &
Thompson, 2017b). In light of this tendency, the Music Therapy with Families Network
was founded at the 2011 Nordic Music Therapy Conference in Jyväskylä, where the
first family centered symposium was presented (Thompson, 2017). Since then, the Net-
work has continued to grow, and to date has attracted over 400 international members
who are part of a professional social media group. The Network members collaborate
regularly to present at international music therapy conferences.
Music therapy is, broadly speaking, a relational and contextual practice (Helle-Valle
et al., 2017; Rolvsjord & Stige, 2015). Family centered practice in music therapy has
been described as an ecological approach where the primary focus is on promoting
health within and between family members (Bruscia, 1998). An ecological systems ap-
proach is a developmental viewpoint where the environmental conditions necessary
for the development of human beings are considered and emphasised (Brofenbrenner,
1979, 1981; Crooke, 2015). From this viewpoint, the notion of “client” includes the
whole family—the therapist may work to facilitate changes in one family member
which will ultimately lead to changes in the whole family system and vice versa (Brus-
cia, 1998).
The first three authors have been working together in the Music Therapy with Fam-
ilies Network since 2011. They each have extensive clinical experience working with
families in music therapy, have all conducted research in the field, and also have teach-
ing and training experience. The fourth author has extensive experience in clinical
work, consultation, training and research within various fields of music therapy. The
authors come from Scandinavian, Middle Eastern and Australasian countries, which
brought together a diverse range of perspectives to the research.

Lit
Liter
eratur
ature
eRRe
eview
Many music therapists describe the importance of working collaboratively with family
members in various populations, demonstrating the vast breadth of work that can be
considered part of this field. Populations where there have been several publications
include: neonates (i.e., Gooding & Trainor, 2018; Ettenberger et al., 2017; Haslbeck,
2012; Haslbeck et al., 2018; Loewy, 2015; Shoemark et al., 2015; Teckenberg-Jansson
et al., 2011) autistic children (i.e., Blauth, 2016; Gottfried, 2016; Gottfried et al., 2018;
Thompson, 2012; Thompson et al., 2014; Walworth, 2012), disabled children (i.e.,
Loth, 2008; Oldfield, 2008; Williams et al., 2012), hospitalized children and adults
(i.e., Ayson, 2008; Baron, 2017; O’Callaghan & Jordan, 2011; Shoemark, 2004; Shoe-
mark & Dearn, 2008), survivors of trauma (i.e., Colegrove et al., 2018; Drake, 2011;
Hasler, 2008; Salkeld, 2008; Stuart, 2018; Tuomi, 2017), survivors of child abuse (i.e.,
Jacobsen & McKinney, 2015; Oldfield, 2017), people with life limiting conditions (i.e.,
Aasgaard, 2001; Lindenfelser et al., 2008; Lindenfelser et al., 2012; Savage & Taylor
Johnston, 2013), refugees (i.e., Edwards et al., 2007; Oscarsson, 2017), and people
with dementia (i.e., Beer, 2017; Raglio et al., 2016; Ridder, 2017).
While the number of publications focused on music therapy with families has stead-
ly increased (Tuomi et al., 2017), little is known about the professional practice of
qualified music therapists. Various workforce surveys have been conducted around the
world that provide some insight into the professional profile of therapists working with
families. For example, a national survey study in the United States of America (n =
328) documented the ways music therapists work with people on the autism spectrum
(Kern et al., 2013). In Finland, approaches to early childhood music therapy was doc-
umented (n = 25; Tuomi & Ala-Ruona, 2011, 2013) and parent-infant music therapy
was surveyed in the Netherlands (n = 106, from which 25 people identified as working

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VOICES: A WORLD FORUM FOR MUSIC THERAPY RESEARCH

with families; Krantz, 2014). In the United Kingdom, a survey explored music therapy
practice in children’s hospices and attitudes towards the service (n = 22; Hodkinson
et al., 2014). Most recently, music therapists working in neonatal intensive care unit
in the USA participated a survey exploring the focus and approach of clinical work, as
well as training factors (n = 54; Gooding & Trainor, 2018).
Looking across the results from these different studies indicated that collaboration
in various forms was an important aspect of music therapy practice with families. For
example, in the study from the USA, 78% of music therapists working with autistic
people collaborated with family members or other caregivers (Kern et al., 2013). In
the Netherlands, the most common practice was to include parents directly within the
sessions (Krantz, 2014), and this tendency was also reported from children’s hospice
settings in the UK (Hodkinson et al., 2014).
Other common approaches to music therapy practice with families include consul-
tation with family members and professionals or separate conselling sessions for dif-
ferent family members. In Finland, counselling sessions for parents are reported to be
the most common way of approaching family centered practice (Tuomi & Ala-Ruona,
2013). In USA, 79.3% of music therapists working with people with autism spectrum
include consultative services to families or other professionals (Kern et al., 2013). In
addition, informal support for parents is provided by music therapists before and after
sessions in children’s hospice settings (Hodkinson et al., 2014).
In previous surveys of paediatric settings, music therapists indicated that they ad-
dress the needs of parents in the NICU environment (Gooding & Trainor, 2018) and
children’s hospice environment (Hodkinson et al., 2014). However, only the first men-
tioned survey documented the music therapy methods and techniques most commonly
used in music therapy, such as infant-directed singing, parent counseling, psychoed-
ucation, music-assisted relaxation, musical recordings and information about how to
use music at home (Gooding & Trainor, 2018).
More recently, a large survey study collected descriptive data about practice status,
clinical trends and training needs of 2,495 music therapists from around the world
(Kern & Tague 2017). Although this study did not include direct information concern-
ing family centered practice per se, it is the only international study of this magni-
tude from the field of music therapy. The study findings revealed that communication,
emotional support, and social skills were the predominant aims of music therapy ses-
sions. Singing/vocalization, instrument play, and musical improvisation were the most
frequently used music therapy techniques. Music therapists most commonly reported
working with people with conditions such as autism (44.2%), developmental disabili-
ties (32.4%) and depression (31%).
These surveys offer some insight into the working practices of qualified music ther-
apists. However, in relation to working with families, the data is fragmented, local and
in many cases concentrated on a specific client population. Additional information is
therefore needed to better represent the breadth of theoretical perspectives and ther-
apeutic approaches that guide music therapists who work with families around the
world. Furthermore, not enough is known about the music therapy methods used in
collaborative relationships with the family members during the sessions.

Aim of the Study

The aim of the study was to better understand the professional perspectives and ap-
proaches of music therapists who work with families around the world. In particular,
the survey questions aim to map the main theoretical perspectives, therapeutic ap-
proaches, and practical considerations of this professional community. Not only will
this information potentially help to plan future professional education/training and su-
pervision, it will also provide a snapshot of the profession in order to track changes in
the relevance of different therapeutic frameworks utilized by music therapists working
with families.

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VOICES: A WORLD FORUM FOR MUSIC THERAPY RESEARCH

Method
Design
The survey method was selected to hopefully capture a comprehensive international
view of the professional perspectives and approaches of music therapists working with
families. The survey questions were developed by the authors through a series of steps
with the intention that responses could be completed anonymously by participants via
an online platform. The first step involved a series of research meetings. The authors
identified key issues (Smith et al., 2016) and discussed differences in terminology ac-
cording to their own international perspectives and cultural contexts. Through these
discussions, diverse definitions and experiences of educational and theoretical frame-
works, clinical populations, and music therapy methods were explored. The multiple-
choice questions were designed to be easy and quick to answer. Since there was no
budget for translation to multiple lanugages, the questions needed to be clear and con-
crete, and written in accessible English language expression for a professional and mul-
ti-lingual audience who are experienced with accessing literature, training seminars
and conference presentations in English (Smith et al., 2016).
The second step involved a pilot of the questions. Since the survey was targeted to
professional music therapists who define themselves as working in a family-centered
way, the authors approached several colleagues from an online support group Music
Therapy with Families Network and asked them to complete the questions and provide
feedback. The group consists of professional music therapists working with families,
many of whom are also experienced researchers in the field, and whose first language
is not necessarily English. Altogether, nine evaluations of the pilot questions were re-
ceived between March and April 2018. The authors then worked to refine the questions
into their final format taking into account the feedback provided. The final version of
the survey consisted of 22 questions (see Table 1).
The third and final step involved the roll-out of the online survey via Webropol. The
survey was open from 13.9.2018 until 7.1.2019. An invitation to participate in the sur-
2
vey was published in several closed Facebook groups including the Music Therapy with
Families Network (275 members), Music Therapy in Child Welfare (128 memembers),
Music Therapists Unite! (5901 members), School Based Music Therapists (335 members),
Music Therapists Working in Mental Health (953 members), and Music Therapy and Hos-
pice & Palliative Care (1112 members). In addition, national Facebook pages for profes-
sional music therapy associations were invited to post an invitation, including China,
India, Latin America, Spain, Australia, Israel and Finland. E-mail invitations to par-
ticipate were circulated to members by the World Federation for Music Therapy, Eu-
ropean Music Therapy Confederation, and British Association for Music Therapy. All
announcements and invitations were posted up to three times. Individuals were also
encouraged to forward the invitation to other colleagues. Despite the high numbers
of people in each professional group, it is likely that the same people were members
of multiple networks/groups. Therefore, it is not possible to estimate the final invited
sample size.
At the beginning of the survey, the respondents were asked to authorize that their
data can be used by the research team for the purposes of the study. The study follows
the ethical codes of the University of Jyväskylä, Finland. While the online platform did
not collect names and contact information, any survey responses in the open comments
were checked and deidentified prior to analysis. The survey questions are provided in
Table 1.

Participants and Data

A total of 134 people responded to the survey. Of these, nine people indicated that
they were not trained music therapists, and were therefore removed from the analysis.
The final number of complete responses was 125.

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Tabl
ablee1
Survey questions

Question
Question
Number

1 I confirm that I am a qualified music therapist.

2 I am willing to participate in this international survey of music therapy with families, and un-
derstand the purpose of the survey is for research.

3 I authorize the team of the researchers (xxxxxxxxxxxx) to use the survey data for the research
purposes according to the etchical guidelines of the University of Jyväskylä, Finland, which in-
cludes preserving the anonymity of the participants and secure storage of data.

4 What is your gender?

5 What is your age?

6 What is your highest level of education in music therapy?

7 In which country did you complete your first qualification in music therapy?

8 In what year did you start working as a music therapist?

9 In which country are you currently practicing music therapy?

10 In what year did you start working with family members in your music therapy practice?

11 With which clinical population do you work with families in music therapy? *

12 When working with families in music therapy, where do sessions take place? *

13 Please describe your theoretical framework when working with families *

14 What music therapy methods do you use when working with families in music therapy ses-
sions? *

15 What non-music based therapy techniques do you use when working with families in music
therapy sessions? *

16 There are various models for working with families in music therapy. Which of the following
models best describe your work? *

17 If the family members are present in music therapy sessions, who typically attends with the
child/adult client?

18 If family members participate in separate / additional counselling sessions, how frequently

do these sessions occur? *

19 If family members participate in counceling sessions, which techniques / methods do you

use with them? *

20 In general, how would you describe your role as a music therapist working with families?

21 To your knowledge, do any specialist music therapy training courses in working with families
exist in your country?

22 What would you like to see included in music therapy training programs and updating educa-
tion to help students and music therapy clinicians develop their skills in working with fami-
lies? Please describe.
*Note: These questions included “other” as part of the multiple choice answers, and respondents could provide more in-
formation as free text.

Of the 22 questions, 19 were multiple choice and three allowed a free open-text
answer. The respondents were asked to answer every question, with several multiple
choice questions including an “other” option that also allowed for further explanation
via an open-text field (see Table 1). The complete survey is provided in Appendix 1.

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Tabl
ablee2
Age of respondents

Ag
Agee n Per
erccent

20-29 21 16.80 %

30-39 43 24.40 %

40-49 27 21.60 %

50-59 20 16 %

60-69 14 11.20 %

over 70 0 0%

Analysis
The first step when analysing the data was to examine the “other – please describe”
free-text answers to the multiple-choice questions. The first author read through the
free text and determined if the answer could be incorporated into the existing cate-
gories. If it could not, a new category was proposed and discussed by all authors. In
this case also those entries mentioned only once were categorised as their own, aiming
to present the picture of the data as authentic as possible. The meaning of some an-
swers were unclear, provided feedback on the survey question, or more conversational
in nature and were excluded.
Next, the three open-ended questions which invited a free-text response underwent
a qualitative content analysis (QCA). Using the guiding question “What is intended to
be said?” (Bengtson, 2016; Bruscia, 2016), the first author worked to systematically
analyse and classify the text into an organised and concise summary of key categories
(Bruscia, 2016; Erlingsson & Brysiewicz, 2017). The systematic coding was carried out
in an inductive way in order to identify meaningful themes that addressed the research
questions (Bengtsson, 2016). The first round of coding was broad and aimed to stay
faithful to the original text and expressions of the participant. Next, the codes were
categorized by grouping related codes together, and discussed amongst all authors. Fi-
nally, the frequency of comments related to each category was descriptively analysed.

Results
Demographic Data
The respondents were mostly female (90%) and aged between 30-39-years-old. There
were no participants over 70 years of age (Table 2).
Most respondents stated their highest qualification in music therapy to be Masters
(44%), followed by Bachelors (21%) and Doctoral (18%). Only 2% of respondents indi-
cated that they had a pre-Bachelor (sometimes called ‘clinical training’) qualification.
Further, 19 respondents had aquired additional music therapy training, including GIM
(Guided Imagery and Music Bonny Method; n = 4), NICU (Neonatal Intensive Care
Unit music therapy; n = 3), NMT (Neurologic Music Therapy; n = 3) and APCI (As-
sessment of Parent-Child Interaction; n = 1).
Geographically, most respondents reported that their first qualification was under-
taken in Europe (n = 54) and North America (n = 43), followed by Oceania (n = 16),
Asia (n = 9) and Latin America (n = 3). There were no respondents from Africa. In re-
sponse to the question “In which country are you currently practicing music therapy?”
there was no significant difference compared to the respondents’ country of qualifica-
tion (Figure 1).
The highest number of respondents reported to have begun working as a music ther-
apist within last 7 years (44%, n = 55), while 28% of the participants had been work-
ing for over 18 years (n = 49). Further, 72% (n = 91) of the respondents reported
that they began working with families within 2006–2018. However, according to this

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VOICES: A WORLD FORUM FOR MUSIC THERAPY RESEARCH

Fig
igur
ure
e1
Geographical diversity of respondents’ country of qualification and current country practicing music ther-
apy

Fig
igur
ure
e2
Compairing the years between starting to work as music therapist and starting to work with families in
music therapy

sample, the more experienced music therapists reported working with families as early
as the 1980s (Figure 2).

Clinical Population
Music therapy practice is often highly varied, and this trend was reflected in the data.
Many of the respondents reported that they work with several clinical populations.
Therefore, there was a total of 381 selected answers to question 11. When “other” re-
sponses were added retrospectively to the initial options, there 415 populations select-
ed by 124 participants (Figure 3).
According to these results, disability was the largest clinical population in which
music therapists work with families. Of these, 16.9% (n = 70) of the respondents work
with preschool aged children with disabilities and 13.7% (n = 57) with school aged
children with disabilities. Mental health was the next most common population for

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Fig
igur
ure
e3
Clinical population

music therapists working with families, with 9.4% (n = 39) working with children,
7.5% (n = 31) working with adolescents, and 2.7% (n = 11) working with adults.
Families at risk/child protection were also highly represented, with 8.7% (n = 36) of
music therapists working with this population.
From the “other – please describe” comments, three new categories were construct-
ed, including 4.3% (n = 18) of respondents who indicated that they worked with fami-
lies in hospice or palliative care settings. However, other responses were more difficult
to categorise where they did not refer to a specific clinical population, such as “special
needs,” “public school” or “mainstream children’s center and school.” The authors con-
sidered that these answers could be referring to children with behavioural problems,
ADHD or learning disabilities or children with no specific diagnosis. Therefore, a “Chil-
dren – general” category was established. In a similar way, “Older adults – general”
was added as a category even though this was represented by only 0.2% of the respon-
dents. Additionally, respondents indicated that they work with populations including
emergency settings post-disaster and conflict, military families as well as asylum-seek-
ing families.
While there is great variety, when clustering the results into broader categories, the
dominance of certain populations became more apparent. According to these results,
35% of music therapists working with families work in the field of disability, and 20%
in mental health (Figure 4). If the categories of families at risk/child protection and so-
cial care settings were combined, 12% of the respondents could be classified as work-
ing in this area. Similarly, 13% of participants work in medical settings with clients
of all ages. Dementia care/seniors and hospice/palliative care may not be easily com-
bined, since end-of-life care involves clients of multiple age groups.
Taking this broader view one step further, an approximate analysis of the age dis-
tribution could also be made. Based on the population descriptions, it seems that 79%
of the respondents work with children and adolescents, while 21% of music therapists
surveyed work with adults (Figure 5). To avoid ambiguity, the categories of hospice/
palliative care, community based preventative programs, and social care settings were
left out from this age analysis because the exact age was able to be determined.

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Fig
igur
ure
e4
Clinical population clustered

Fig
igur
ure
e5
Working with children/adults

Clinical Setting
The survey findings revealed that music therapy with families commonly takes place in
community settings (n = 54; Figure 6). This category included i.e., music centres, mu-
sic schools, community centres, and libraries. Hospital/medical settings, including hos-
pice units (n = 53) and music therapy taking place at the client’s home (n = 50) were
also common. Specialist multidiciplinary services clinics (n = 24) included i.e., fami-
ly rehabilitation centres and centres specialized in pregnancy, birth and early parent-
ing. From the “other – please describe” comments, one new category was constructed:
“Residential care facility for older adults.” This category includes rest homes, nursing
homes, assisted living communities and seniors home.

Theoretical Framework
Respondents indicated there was a large variety of theoretical frameworks applied to
working with families (Figure 7). The responses indicate that each music therapist on
average has three theoretical influences in their work. The humanistic framework was

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Fig
igur
ure
e6
Where do sessions take place

the most salient with 72% (n = 90) of people indicating they align with this theory,
including more specific approaches such as wellness based theories, validation thera-
py, and existential and phenomenological viewpoints. Developmental frameworks (n
= 55) included play-based interventions and Floortime. Psychodynamic (n = 48) and
resource oriented (n = 41) approaches were both well represented. Integrative (n =
39) and systems/ecological oriented (n = 34) were nearly equally often mentioned as
well as neurological (n = 19) and behavioral (n = 19) approaches.
From the “other – please describe” comments, five new categories were constructed.
Three respondents described their approach as based on attachment theory. The au-
thors debated whether this approach could be considered part of psychodynamic the-
ory, but ultimately could not be sure given that the participants had included this
answer within the “other” response. The “narrative” framework (n = 3) was also in-
cluded as a new category. Only one respondent described “mentalization,” and simi-
larly the authors debated whether this approach could be considered as belonging to
the psychodynamic framework. However, it seemed important to emphasize this ap-
proach, especially when working with families, and therefore it remained as a separate
category. “Music-centered” (n = 1) and “interactive” (n = 1) approaches were includ-
ed as their own categories as well since both seemed to accent particular features of
their framework.

Clinical Methods and Techniques

For question 14, “What music therapy methods do you use when working with families
in music therapy sessions,” multiple answers were possible resulting in 634 choices
from the 125 participants. This equates to an average of 5 methods per person, sug-
gesting that a large variety of music therapy methods are relevant to working with
families. The most commonly reported methods were improvisation with instruments
(n = 115), singing pre-composed songs (n = 101) and structured activities with mu-
sical instruments (n = 91). Also, improvisation with voice (n = 85), music listening
(n = 79), music and movement (n = 78) and song writing (n = 63) were commonly
reported.

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Fig
igur
ure
e7
Theoretical frameworks

From the “other – please describe” comments, two new categories were constructed.
The first was integrative methods and integrating musical activities, where different
methods were used in a holistic and dynamic way depending on the needs of the fam-
ily. The second was including other non-musial methods in music therapy sessions,
such as the use of pictures, play, meditation, story telling, and Eye Movement Desensi-
tization and Reprocessing (EMDR).
These results could also be clustered into broader categories as follows: 1) singing,
including pre-composed songs and improvisation with voice; 2) playing instruments,
including structured activities with musical instruments and improvising with instru-
ments; 3) music listening, including Guided Imagery and Music (GIM); 4) music and
movement; 5) song writing; and 6) other. When responses were analysed from this
broader viewpoint, singing (29%) and playing instruments (33%) together accounted
for 62% of the data (Figure 9).
According to this survey, “consultation and discussion” was the most popular non-
music-based technique, with 82.2% (n = 104) of respondents stating they use this ap-
proach with families in music therapy sessions (Figure 10). This approach included
several ways of working, including therapeutic discussion, verbal processing, reminisc-
ing and life review. Imaginative play with toys (n = 53), art-based methods (n = 48),
and playing games with rules (n = 41) were also used frequently.
“Techniques from other therapeutic approaches” was a new category developed dur-
ing the analysis of the free-text responses. This category (n = 9) included approaches
such as Theraplay®, narrative exposure therapy, Adaptive Mentalization-Based In-
tegrative Treatment (AMBIT) and Mentalization Based Treatment (MBT), trauma-in-
formed care approaches, and cognitive therapy. The integrative methods category was
also retrospectively added to acknowledge the flexible, shifting and dynamic way of
working described by one respondent. In addition, two other categories were added
based on the free-text responses, including: multisensory activities (n = 1), meaning
multisensory actions (lifting, waving); and interactive play (n = 1) including the use
of early childhood play/games between the child and the carer.

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Fig
igur
ure
e8
Music therapy methods used with families

Fig
igur
ure
e9
Music therapy methods clustered

Clinical Models
The most selected answer to question 16 “Which of the following models best describe
your work”, was “family members are active participants in music therapy sessions
with the child/adult client” (93.6%, n = 117). Forty of the respondents (32%) reported
that family members were present but not active in music therapy sessions. Taking

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Fig
igur
ure
e 10
Non-music based therapy techniques used with families

these two categories together, it is therefore much more common for family members
to be present in the music therapy session with the child/adult client than not. Even so,
33 participants (4.8%) reported that they conducted “separate/additional counselling
sessions” for family members.
Analysis of the free-text responses highlighted that people also use a combination
of models. Therefore, a new category of "integrative methods" was created to reflect
this approach. Further, in the free-text response, one person described a model where
family members participated in separate music therapy sessions provided by another
music therapist. A new category was created to capture this reponse.
When these results were clustered into broader categories, results showed that
77.0% (n = 157) of respondents stated that family members pariticipate in music ther-
apy sessions, either actively or more passively. Counselling sessions provided by the
same music therapists in individual or group meetings appeared in 19.1% (n = 39)
of the answers. Family members observing the session from outside the therapy room,
along with family members’who received separate music therapy sessions, were clus-
tered into the “Other” category and covered 3.9% (n = 8).
With the earlier clustered data from question 11 indicating that 79% of respondents
work with children or adolescents, it is perhaps not surpising to see that 86.4% partici-
pants indicated that the parent(s) (n = 108) were most often present in music therapy
sessions, followed by sibling(s) (43.2%, n = 54). For those music therapists working
with adult clients, the data also shows that the partner/spose is included 32.8% of the
time (n = 41). There may also be other extended family members (n = 34) and grand-
parent(s) (n = 30) included in music therapy sessions.

Counselling Sessions
The question concerning counselling aimed to map how frequently separate coun-
selling sessions with family members occur. However, it should be noted that 54.4% (n
= 68) of respondents stated that the question was not relevant to their work. There-
fore, the actual analysis included only 59 answers (Figure 14). According to this data,
separate sessions for family members typically take place less frequently than sessions

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Fig
igur
ure
e 11
Models best describing work with families

Fig
igur
ure
e 12
Music therapy models clustered

with the client (n = 39). Only one respondent (n = 1) mentioned that the counselling
sessions take place more frequently than sessions with the child/adult client. One new
category was constructed based on the free-text analysis: The frequency varies depend-
ing on the client’s needs (n = 6). Again, in this question music therapists seemed to
advocate for flexibility in their practice and explained that the frequency depends on
the demands, goals, context and needs of different cases.

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Fig
igur
ure
e 13
Who attends music therapy sessions with child/adult client?

Fig
igur
ure
e 14
Frequency of counselling sessions (n = 59)

When asked about the most common techniques used in these separate counselling
sessions, discussion and consultation was highly reported (n = 68; Figure 11). Music
therapy methods were also used widely within counselling sessions. Improvisation
with instruments (n = 38), music listening (n = 28), song writing (n = 24) and im-
provisation with voice (n = 22) were all mentioned. From the non-music-based tech-
niques, the use of video feedback (n = 19) was most common. However, similar to

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Fig
igur
ure
e 15
Techniques used in counselling sessions

the question above, 40% (n = 50) of respondents chose the option “not relevant to my
work.”
While analysing the free-text response, four new categories were constructed: tech-
niques from other therapeutic approaches (n = 3) which included Mentalization Based
Treatment (MBT) for families, breathing activities, and mindfulness. Modelling was
formed as a category of its own (n = 1), including modelling Applied Behavior Analy-
sis (ABA) techniques. The use of a self-report assessment form, Spence Children’s Anx-
iety Scale (SCAS) for parents was placed in an idependent category of self-report
assessment forms (n = 1). Using movement to music was categorized in the integrat-
ing musical experiences with other methods category (n = 1).

Role of the Music Therapist

Question 20 provided opportunity for a free-text response: "How would you describe
your role as a music therapist working with families?" There were 105 responses to
this question, which underwent a qualitative content analysis. The analysis generated
159 codes which were then further grouped into 12 categories. Table 3 shows the fi-
nal categories along with the numbers of individual codes within each category and a
summary description incorporating exemplars of the words used by the respondents.
A descriptive quantitative analysis revealed that the first category “To share their
expertise: as a counsellor, teacher or guide” included 45.7% of the responses. The role
of the music therapist was described as “to support” in 35.2% of answers, whereas the
role “to provide, create, and offer” followed with 25.7% of responses.
Similar to responses to previous questions, some respondents described that their
role varied depending on the context, clients and their needs (n = 7). A small number
of respondents emphasised that their role is to be a therapist for the parents (n = 3)
or both to the child and the parent (n = 1).
Overall, these 12 categories describing how music therapists view their role in work-
ing families could be further distilled in order to highlight the main features. The sur-

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Tabl
ablee3
The role of the music therapist when working with families (n = number of codes)

Cat
ateg
egory
ory Description of ccat
ateg
egory
ory

To share The stance of the therapist is more on the expert level. The therapist knows something
their exper- which they want to share with the family. It might be providing direct advice, modelling,
tise: as a techniques, or knowledge of i.e., disablity or trauma.
counsellor,
teacher or
guide (n =
48)

To support Therapist is a supporter concerning development, interaction and relationship. They give
(n = 37) support on an emotional level as well, i.e., in grief and in the form of debriefing.

To provide, The role of the therapist is to provide a supportive and safe place and space. The therapist
create and is a provider of music, contact and interaction, as well as new experiences. Therapist may
offer (n = also be a provider of memories and a bridge through loss. The therapist creates space and
27) atmosphere in addition to contact and interaction with meaningful, shared experiences.
The therapist offers room and space where music can be used as a bridge or to make
memories.

To facilitate The role of the therapist is to facilitate i.e., engagement, interaction and communication,
(n = 22) development, attachment and bonding. In addition, they may facilitate normalization,
space, understanding, solutions, and emotions.

To care and The therapist takes care and helps with emotions, answers to the needs of the family. Also
help (n = 21) the therapist may help to build new understandment and knowledge.

To empow- The therapist’s role may be to empower the family and give new positive viewpoints of the
er, encour- child. The therapist can help the family to find and be aware of their strengths and re-
age and sources and reinforce the identity of the clients. The role of the therapist is to encourage
give posi- and challenge the family.
tive in-
sights (n =
18)

To enable Therapist enables connection, interaction and communication. In addition, the therapist
(n = 15) can enable peer support, new ways of seeing the child, performace for parents and memo-
ry making.

To promote The role of the therapist is to promote integration from therapy to everyday life. The ther-
(n = 11) apist promotes wellbeing, relationships and communication.

To be a The therapist is a companion, co-worker, collaborator and contributor with the family. The
companion therapist may see their role to be part of the group.
(n = 6)

To collabo- The therapist may be seen as a collaborator by liasing with other professionals, and han-
rate with dling referrals. They may be a mediator for the client’s wishes or providing material for
networks (n fund-raising.
= 5)

To collect The therapist may have a role to explore or identify issues conserning development or
information emotions. Also, the therapist can be a receiver of information.
(n = 4)

To regulate The therapist’s role may be seen as a regulator of emotions. The therapist helps the family
(n = 4) to cope with difficult emotions and may serve as a container.

vey results showed that the role of the music therapist was most often related to: 1)
Supporting family members to interact and communicate; 2) containing, regulating
and holding emotions; 3) promoting family relationships by fostering attachment and
bonding; 4) facilitating accessible music experiences; 5) empowering and supporting
parent; and 6) fostering and supporting development.

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Fig
igur
ure
e 16
Role of music therapist when working with families (n = 105)

Existing Training Courses in Working with Families

In response to question 21, respondents identified that there are some specialist train-
ing courses in working with families in different countries. The free-text responses in-
cluded the following training courses: assesment of parent-child interaction (APCI) by
Lindahl-Jacobsen (i.e., Jacobsen et al., 2014) originally developed in Denmark; a short
course in family centered music therapy and dialogic parent counselling by Tuomi and
Jordan-Kilkki from Finland (Jordan-Kilkki & Tuomi, 2016); specialist courses focused
on music therapy in hospice settings (no trainers or names were provided); a short
course in music therapy and families from Spain; neonatal intensive care unit (NICU)
music therapy training (www.nicumusictherapy.com); and the “Sprouting Melodies”
training model available in the USA (www.sproutingmelodies.com). In addition, re-
spondents broadly described workshops, visiting lecturers and short courses taking
place in various locations around the world for music therapists working with families.

Perspectives on Future Content for Training in Music Therapy with

Families
In response to question 22, there were 92 participants who provided their perspective,
insights and ideas. The high level of engagement in this question perhaps indicates
the passion these respondents have for promoting further skills and training in music
therapy with families. From these 92 responses, 120 codes were identified through a
Qualitative Content Analysis, and from these codes 11 categories were formed. Some
respondents indicated that short courses (n = 5) and advanced training seminars (n =
5) for qualified music therapists are needed; however, others indicated that training
should also take place within clinical placements (n = 4) and as part of initial music
therapy qualification courses (n = 3).
The categories describing the focus of future training courses in music therapy
with families could be clustered into three main themes: Theory, Practice and Context
(Table 4).

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Tabl
ablee4
What should be included in music therapy training programs and continuing education (n = 92)

Main themes

Theory (n = 85) Practic

acticee (n = 774)
4) Cont
onteext (n = 12)

Theoretical knowledge (n = Techniques and methods (n = 40) Contextual features (n = 8)

47)

Family work (n = 31) Verbal facilitation (n = 23) Working collaboratively (n =

4)

Parental support (n = 7) Music methods (n = 7) Relevant supervision (n = 3)

Working in the home & community (n =

4)

Theory
Overall, theoretical knowledge (n = 47) was emphasised as an important part of train-
ing and continuing education. Respondents specifically mentioned the need to include
theoretical perspectives around cultural issues (n = 2), child developmental (n = 2),
philosophy (n = 2), attachment issues (n = 1) and community-oriented work (n = 1).
Family centered theory (n = 31) was a prominent category that suggests respon-
dents consider that music therapists need to be better informed about working within
these principles. This category includes the specific examples of family dynamics (n =
7), the role of family members and the therapist (n = 5), and the value of family inclu-
sion (n = 4). Family therapy approaches more specifically were mentioned by three
respondents.
Similarly, parental support was described specifically by seven participants. The re-
pondents expressed the need to have more specific information about how to work
with parents (n = 2), understand parental stress (n = 1), promote parental respon-
siveness (n = 1) and support parental relationship in musical communication (n = 1).

Practice
The respondents expressed a need for more training in specific techniques and methods
relevant to working with families (n = 31). Further, they saw value in receiving de-
tailed practical guidance, excercises, activities and interventions (n = 8), while tech-
niques and strategies (n = 6), assessment tools (n = 4), and video assisted work (n
= 4) were also described. In the more specific answers, some respondents expressed a
desire to develop specific techniques and skills such as drama and role play (n = 3),
documentation skills (n = 1), and self-care (n = 1).
Another important practice skill identified by participants related to the need to de-
velop their verbal facilitation skills (n = 23). More specifically, respondents identified
the need for training in conversational techniques, such as consultation and coun-
selling skills (n = 15), feedback techniques (n = 2), reflective and reflexive practices
(n = 2) and interviewing skills (n = 1).
Seven respondents specifically mentioned the need for more training in music skills.
Of these, music improvisation (n = 2), supporting interactive music interventions be-
tween family members (n = 2) and information about typical musical development (n
= 1) were described.
Four respondents stated that training should also include information about how
to best work outside of more traditional clinical spaces, such as in the home or other
community settings (n = 4).

Context
The theme “contextual features” (n = 8) captured responses where the participants
highlighted the need to better understand ethics in special educational (n = 2), ther-

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apeutic relationships with disabled people (n = 2), coping with needs of family mem-
bers (n = 1) and the policies and procedures of child protection systems (n = 1).
Further, respondents also saw a need to better understand how to work collaboratively
with other professionals and networks involved with the family (n = 4). Lastly, re-
spondents expressed the need for more opportunities for supervision of family-based
clinical work in future training and education (n = 3).

Disc
Discus
ussion
sion
The 125 music therapists who participated in this survey indicated that working with
families is a substantial part of their practice. While it was difficult to estimate the ex-
pected sample size, the demographic characteristics of the participants reflect those of
other music therapy surveys. For example, female participants represented 90% of the
respondents, which is similar to the demographics of a large international workforce
survey of music therapists (81.6% female; Kern & Tague, 2017). The age distribution
in this survey showed that 24.4% of respondents were between 30–39-years-old, which
was similarly aligned with the demographics reported by Kern and Tague (2017) of
29.4% of respondents within the same age group.
The majority of respondents began working with families between 2006-2018,
which may indicate that this is a developing field in music therapy practice. The grow-
ing body of music therapy literature and research suggests there is an increasing em-
phasis on family centred and relation-oriented approaches (i.e., Edwards, 2011; Kern
& Humpal, 2012; Lindahl-Jacobsen & Thompson, 2017a; Tomlinson et al., 2012; Tron-
dalen, 2016; Tuomi et al., 2017). With 18 different clinical populations described by
participants, the results indicate that working with families is a practice approach that
is becoming more relevant across the life span. While music therapy practice in neona-
tal care has had a long standing focus on working with families (i.e., Gooding & Train-
or, 2018; Haslbeck, 2012; Haslbeck et al., 2018; Ettenberger et al., 2017; Loewy, 2015;
Shoemark et al., 2015; Teckenberg-Jansson et al., 2011), music therapy with older
adults (i.e., Beer, 2017; Raglio et al., 2016; Ridder, 2017) and within end of life care al-
so has an increasing emphasis on working with the whole family (i.e., Aasgaard, 2001;
Lindenfelser et al., 2008; Lindenfelser et al., 2012; Savage & Taylor Johnston, 2013).
However, the results from this survey suggest that music therapy with families is still
dominated by work with children and their parents, with 79% of respondents describ-
ing their work with children and adolescents.
Respondents reported that they draw upon a variety of theoretical frameworks,
methods, techniques and models in their music therapy practice, and they incorporate
these influences in a flexible and holistic way. These findings were similar to earlier
surveys which found that humanism is the most commontly reported framework in the
NICU (Gooding & Trainor, 2018). While previous literature and research in music ther-
apy with families has not emphasised psychodynamic theory within practice (Tuomi et
al., 2017), 40% of respondents selected this option. These findings are similar to the re-
sults from a broader international survey (Kern & Tague, 2017) where 33.6% of partic-
ipants reported drawing upon this theory. Similarly, common music therapy methods
such as improvisation were highly reported in work with families (31.6%) reflecting
the broader music therapy literature which highlights improvisation as being key to
supporting, enhancing or promoting interpersonal interaction (i.e., Haire & McDonald,
2019; Jacobsen & McKinney, 2015; James et al., 2015; McFerran & Wigram, 2002;
Ridder & Gummesen, 2015). The improvisation literature also highlights the way this
method can heighten emotional and relational qualities between players, which is per-
haps reflected in the way these respondents described their role as being to promote
relationships and contain emotions.
Some of the literature in this field describes how verbal interactions and support
to parents and other family members often take place in short, informal encounters
before, during and/or after the music therapy sessions rather than in separate indi-
vidual or group meetings (Blauth, 2016; Gooding & Trainor, 2018; Hodkinson et al.,

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2014; Oldfield, 2011; Loth, 2008). The current study supports the literature, with only
18.1% of respondents indicating that they offer separate counselling sessions for family
members. While some recent studies report benefits to parents who received separate
conselleing sessions (Blauth, 2016; Gottfried 2016; Tuomi, 2017), only one respondent
reported providing separate counselling sessions to family members more frequent-
ly than sessions with the child/adult client. The opportunities for different models of
work are likely to be highly contextual, since the results from the survey of NICU mu-
sic therapists in the USA found that 35.85% of respondents worked exclusively with
parents (Gooding & Trainor, 2018). There may also be differences in how respondents
understood who the “client” is when working with families. For example, an ecolog-
ical framework typically assumes the family is the client (Bruscia, 1998, p. 299) and
therefore the therapist may take a broader environmental and contextual perspective
(Brofenbrenner, 1979,, 1981; Crooke, 2015; Helle-Valle et al., 2017; Rolvsjord & Stige,
2015). In this survey, 27.2% of respondents reported being influenced by systemic and
ecological orientations to practice, which was lower than expected. This result may
indicate that respondents more commonly focus on the individual child/adult client
rather than the family as a whole.

The Role of the Music Therapist When Working with Families

The results identify that the role of music therapists working with families is broad and
versatile. Lindahl-Jacobsen & Thompson (2017b) mapped out a model for the thera-
pist’s role (also described as their “stance” or “position”), to encourage music thera-
pists to consciously consider their approach when working with families. Their model
proposed that there are three continua interacting together that the therapist might re-
flexively consider, including: 1) the way the therapist guides and challenges the family,
ranging from a more expert position through to an equal partner; 2) the way the ther-
apist shares knowledge and assists the family, ranging from a more directive approach
through to more supportive problem solving; and 3) the degree to which the thera-
pist engages with the family, ranging from a more distant outsider to a close insider.
Rather than a protocol for how to work with families, Lindahl-Jacobsen and Thompson
(2017b) stress that there is no “best” stance but merely a “best fit” for each family and
context.
In reflecting on the analysis of the free-text responses to question 20, the 12 cate-
gories could be mapped within the first two dimensions of Lindahl-Jacobsen & Thomp-
son’s (2017b) model when they are presented as four quadrants. When considering the
results through the lens of this model, music therapists adopting a more supportive–ex-
pert role are in the majority (n = 95), followed by the directive-expert role (n = 57).
However, the work cannot be interpreted in a binary way as any model might imply.
The respondents in this study frequently highlighted how their approach is more likely
to be dynamic and responsive to the context.

Limitations
With music therapists belonging to numerous professional groups and no single inter-
national registry for qualified music therapists available, it was difficult to estimate the
expected sample size. The lack of statistical data for the profession may contribute to
challenges with validity and have implications for study replication. While a variety
of countries are represented in the sample, the fact that the survey was only avail-
able in English may have been a barrier to participation. Future studies should include
funding to enable translation of surveys to several international lanuauges to promote
participation. In addition, funding would have enabled access to resources to support
recruitment and advertising which may have increased accessibility and the number of
responses.
Formulating multiple choice questions for an international audience is also chal-
lenging. Despite careful consultation in the pilot stage, different traditions, termi-
nology and cultural considerations might not have been adequately included. This

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Fig
igur
ure
e 17
Mapping the role of the therapist

challenge may be reflected in the need to add new categories during the analysis of the
free-text answers to the multiple choice questions.

Future Guidelines
While surveys are useful in collecting a breadth of persectives, depth is limited. For
example, the results do not explain when, how and why (or why not) particular music
therapy methods are used with families or how they are put into action. A follow up
interview study could further explore these deeper questions.
Within the data, there are valuable suggestions for future training and education of
music therapists who wish to work with families. For example, within the non-music-
based methods, verbal facilitation skills are commonly used, yet respondents see this
area of practice as needing further training. These results are echoed in previous re-
search from NICU settings (Gooding & Trainor, 2018). While there is some music ther-
apy literature exploring the use of verbal facilitation skills (i.e., Amir, 1999; Gooding,
2017; Lindblad, 2016; Nolan, 2005) more research is needed.
Beyond the profession of music therapy, the importance of therapists adopting men-
talization approaches to increase the family’s capacity for reflective functioning is
highlighted in the broader research into family work across clinical populations (i.e.,
Dimitrova et al., 2016; Fonagy, 2012; Fossati & Somma, 2018; Kalland et al., 2016; Pa-
julo et al., 2012; Philipp, 2012; Solbakken et al., 2011). The ability to mentalize is seen
as a crucial part of parenting and is especially important when there are challenges
in the child's development. In this survey, only one respondent mentioned including
mentalization theory as part of their approach. Within the music therapy literature,
mentalization is more commonly described in work with adults with mental health is-
sues (Hannibal, 2014; Hannibal & Schwantes, 2017; Strehlow, 2016). In the field of
music therapy with families, there have only been preliminary discussions about incor-
porating mentalization theory as part of recent conference presentations (Lindahl-Ja-
cobsen et al, 2018; Tuomi, 2018, 2019). It is important to acknowledge that working

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in this way requires advanced training and/or counsultation with other professionals
from this field, such as family therapists. In addition, given that the broader field of
family therapy includes mentalization as a key theoretical framework, there is scope
for further research in this area in music therapy.
In terms of the role of the therapist in working with families, this survey only pro-
vides the therapists’ perspective. Studies exploring the outcomes of family-centred ses-
sions have demonstrated that parents and family members often gain knowledge and
skills from participating in the sessions (Thompson, 2018; Schwartzberg & Silverman,
2017; Warren & Nugent, 2010), or from receiving parallel counselling sessions (Blauth,
2017; Gottfried, 2016). In either approach, the music therapist’s facilitation style was
important to the perceived success of the sessions (Edwards, 2014; Nicholson et al.,
2008; Thompson, 2018). Future studies should consider researching the role of the the
therapist from the family’s perspective.
In addition, the survey results cannot provide a deeper insight into who is consid-
ered the “client” in family-centered music therapy sessions. In other words, is the focus
on the child/adult client, on the parent/carer or on the whole family? When reflect-
ing on the analysis to the open-text questions, it seems that the participants conceptu-
alised their work with families as involving a child/adult client who are accompanied
by others who share the session with them. This topic needs further research to better
understand practice, since there are flow on ethical implications for determining the
goals/focus of therapy, and for raising awareness about the potential benefits of music
therapy with families. Further, more research exploring how music therapists interact
with family members who are not present within the client’s session, and who are not
receiving parallel services, is needed.

Conclusion
Music therapy with families is well established as an important field of practice that in-
cludes a large range of populations across the life span. Music therapists working with
families emphasise that the work is holistic and flexible, both in terms of the theoret-
ical approaches that inform their work and the methods/techinques that are included
in sessions. In order to ensure that this field continues to deepen and develop, music
therapy training courses may need to reflect more family-centred and relational-orien-
tated frameworks. In addition, participants in this study strongly advocated for more
continuing professional development opportunities to continue to deepen their prac-
tice.

About the Author

Authorss
Kirsi Tuomi, MM, is a music-, Theraplay- and Attachment focused family therapist and
certified supervisor. She has worked as a clinician over 20 years focusing on attach-
ment issues mainly with foster and adoptive families. She regularily teaches music
therapy students and has given numerous national and international presentations and
workshops. Currently she is finishing her PhD studies at the University of Jyväskylä.
Grace Thompson is Head of Music Therapy at the University of Melbourne. Her
research focuses on music therapy with disabled and autistic children, and delivered
within ecologically oriented strategies. She is the co-editor of "Music Therapy with
Families: Therapeutic Approaches and Theoretical Perspectives."
Tali Gottfried, PhD, is a licensed music therapist, certified supervisor, lecturer and
researcher. Her main clinical and research areas are families of children with devel-
opmental challenges. Tali works within a parallel clinical model, where music takes
a central role in the therapeutic process of both the children and their parents, MEL
Assessment co-developer.
Esa Ala-Ruona, PhD, is a music therapist and psychotherapist (advanced level)
working as a senior researcher at the Music Therapy Clinic for Research and Training,
at University of Jyväskylä. His research interests are in music therapy assessment and
evaluation, and in studying musical interaction, meaning making and clinical process-

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VOICES: A WORLD FORUM FOR MUSIC THERAPY RESEARCH

es in multimodal music therapy. He has an extensive experience in clinical music ther-

apy in various of fields of health care and rehabilitation. His special expertise lies on
creating clinical models, as well as clinical practice of integrative music psychothera-
py, and vibroacoustic therapy.

Acknowl
Acknowledg
edgements
ements
We want to express our warm gratitude to our colleagues who provided their expertise
when formulating the survey questions on the piloting stage of the research.

Appendix 1
The questionnaire is available from the following link: https://voices.no/index.php/
voices/article/view/2952/3218

Not
Notes
es
1. We have chosen to use “identity first” language in this article our of respect for disability
advocacy groups who express a preference for this terminology.
2. All member numbers are from the time the survey was distributed.

Ref
efer
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