Music Therapy in a Parent-Child Reunification Program : Benefits and Challenges of Implementation

Families separated due to abuse and neglect may experience compounded stress, and neglect in childhood may have negative effects on children’s resilience and development (Jacobsen, 2017; Pasiali, 2012). Music therapy can address the needs of these families seeking reunification, however the process for implementing treatment requires the collaboration of social service agencies, funders, and service providers. This article describes two different implementations of a music therapy group within a reunification program, the clinical and contextual challenges to implementation, and the benefits to the families.


Intr Introduction oduction
Children who experience parental neglect might not have received love or other positive, nurturing experiences from their parents (Jacobsen, 2017), and these children may have difficulty in coping and relating to others (Zanders, 2013).In New Jersey, United States, 6,874 children lived apart from their families in out-of-home care in 2015, an increase of over 450 children from 2011.As of 2014, there were 3,507 children aged five or younger in out-of-home care (U.S.Department of Health, 2015a).Of the 4,742 children exiting out-of-home care in 2014 in New Jersey, 56% were reunited with their parents or primary caretakers (U.S.Department of Health, 2015b).Some of these families participated in the Reunity House program.The Reunity House's annual goal is for 87% of the families served to remain reunified.This goal was exceeded each year: between 95% and 100% of the families remaining reunified.
The Reunity House program incorporated group music therapy for families seeking reunification who were legally separated due to concerns of abuse or neglect.Music therapy addressed the families' needs through intensive parental modeling, education, and providing the families an opportunity to practice skills related to emotion-supportive and parent-child relating, through the shared experiences of music (Jacobsen, 2017).The music therapy program implemented at Reunity House afforded parents the opportunity to practice these skills with their children within a supportive environment.

Reunity House
In New Jersey, Reunity House offers families who desire to be reunified with their children the opportunity to work toward that goal.The process of reunification is monitored by the court, and families in this program progress through various stages of reunification.Children are removed from their homes by the New Jersey Department of Children and Families only if they cannot safely remain at home (New Jersey Department of Children and Families, 2014).A case plan is developed to identify necessary changes to the family situation, necessary support services, court-mandated expectations, and a reasonable timeline for completion.Families who live within Reunity House's catchment area who have been referred by Child Protection and Permanency agency can be enrolled.Reunification and the ability to attend all programming is required (Family Connection, n.d.).
Reunity House, a program offered by Family Connections, is a "model of therapeutic supervised visitation to safely reunite families separated due to abuse or neglect.The program teaches personal responsibility and parenting skills in a respectful, nurturing, home-like environment to reduce child abuse and neglect, decrease the time children spend in foster care, and strengthen families throughout our communities" (Family Connections, 2017).When the goal is to reunify families, rather than terminate parental rights, Reunity House clinicians observe how parents communicate and interact with their children during court mandated visits to make recommendations to the court.They also support the families by increasing parenting skills through the implementation of an evidence-based parenting curriculum.Parenting skills are implemented, assessed, and shaped through weekly family visitation nights with the parents and children together in a central location.Parents are also provided with job-training and other supports for finding gainful employment.
Interest in the inclusion of music therapy in the Reunity House program began after a music therapy presentation by Tempo!Music Therapy Services (TMTS) for another program at the same agency.The Reunity House program in this location was just starting and after attending the presentation, the clinical director of Reunity House expressed interest in including music therapy in the program.After several meetings, the following components were agreed to: the number of weeks for the program period (10 weeks), the material support for parents and staff (songbooks, CD, and instruments for families and the Reunity House staff), the budget, and the maximum number of families served.After a period of discussion regarding the goals of the population and intervention options, a proposal was accepted, and funding was secured.
An important aspect at the outset of this collaboration was learning how the Reunity House staff, the program coordinator, and the clinicians were situated within the larger social service organization.The Reunity House staff understood the needs of the clientele, and the relevant timing concerns with respect to funding cycles and program flow in light of the implementation of the evidence-based parenting curriculum.Staff who implemented the program components, supervised the families, and prepared court reports also participated in the music therapy groups.
TMTS is a for-profit, owner/clinician music therapy private practice with experience working within the social service structure.Prior contracts with other local social service agencies and other programs within the same parent agency placed TMTS in a positive position for consideration.The owner/clinician provided the service, secured the materials, and provided feedback to the staff that allowed them to understand the relevant signs of growth in the children's music development and parent skills.Commitment to offer the program required a collaboration from a variety of stakeholders.Even when commitment was assured, the program's implementation could be delayed due to unknown factors.The social service agency, the staff, and administration were all in agreement that music therapy would be offered to their clients, but a variety of factors such as scheduling, space, family readiness, staff availability, transportation, and funding impacted the program's start dates.Even though the buy-in from all the stakeholders remained high, the music therapy program did not run regularly due to any one of the aforenamed factors.This is not a reflection of the need for music therapy service.Rather it is a sign of the ebb and flow of working within a complex social system.

Appr Appro oach ach
There are few clinical writings pertaining to music therapy approaches when working with children in foster care (Zanders 2012(Zanders ,, 2015) ) and little on the role of music therapy in the reunification process.The literature in family music therapy for children who have experienced trauma focuses on the importance of rhythm to co-regulate and connect parent and child (Hasler, 2017).Rhythm requires repetition which serves the dual function of establishing new neural pathways and regulating the player's energy level.
Intentional music making offers parents and children the opportunity to play together, create new memories, and increase opportunities for attachment.Music therapy interventions focused on promoting emotional and musical synchronicity can repair irregular patterns of parent-child relating (Hasler, 2017;Pasiali, 2017).Experiences of music making that encouraged co-creation of rhythms or melodies increase each individual's tolerance for individuation while promoting the experience of togetherness and become another pathway to communication (Pasiali, 2017).Developmentally appropriate early childhood instruments which easily produced sound such as rainsticks or egg shakers, and instruments which provided structure such as rhythm sticks, were specifically chosen for this group.The instruments were incorporated into sessions intentionally based upon the co-regulation of the children and parents (Tuomi, 2016).The focus was not on the musical product, rather the interaction between the parents and their children in music therapy sessions.

Role of Music Therapy in Reunification Process
The clinical application of Music Together (called Music Together Within Therapy) was the music therapy component of treatment.Other clinical components implemented by the social service agency included psychoeducational parenting skills groups, infant massage, play therapy, and yoga.
Families participating in the music therapy groups had children 6 years of age and under and were in different phases of reunification, however reunification was the goal for all families in the Reunity House program.Some families were recently separated, some were already in the foster care system, and others were reunified during the course of the 10-week music therapy group.These reunified families continued to attend the full course of the therapy.The music therapy group was implemented once per week and was followed by parenting classes taught by the social service agency clinicians.
These music therapy groups afforded parents the opportunity to bond with their children during the parental visits through a family participation model, parent education, and developmentally appropriate approaches to music making.The music therapist led the group through developmentally appropriate family music therapy interventions: singing, rhythm play, small and large guided and creative movement, and instrument exploration.The Reunity House clinicians modeled skills when appropriate and observed the parents demonstrating parenting skills.

Description of Music Therapy Interventions
The intervention choice was the clinical application of Music Together's approach to family music making.In addition to the family music-making session design, the clinical decision to use the Music Together program considered the quality of materials (CD and songbook) which could be used by anyone, parents and clinicians alike.The accessibility of materials was important and supported all participants' ability to make music -those who were already comfortable music-makers and those who were less comfortable making music with their child.Music Together 1 is an international program that promotes family music-making worldwide.Families across the world use the same song collections during the same semesters.Parents are guided to become observers and active participants in their child's music development through an intentional practice of education, modeling, and support facilitated by the Music Together provider.This model of family music-making and parent education is innate to the Music Together program.In the Reunity House program, parent education and modeling focused on the therapeutic structure to create a safe space for family music making.
The format of Music Together's lesson plan became the basis for the music therapy group session plan.Clinicians offering Music Together Within Therapy are free to design the session plan as necessary to meet their clients' assessed needs.A conscious decision was made in the program's implementation design to give the materials (songbook, CD, and instruments) to the staff and the families in the reunification process and not the foster families.Parents were encouraged by the staff to make music with their children outside of music therapy in supervised visits and at home when reunified, to encourage family bonding in the reunification process.Music Together's approach to family music making includes experiences of rhythm, singing, rhythm and tonal pattern recognition and repetition, instrument play, chants, and movement to music.Children attend with their parent or caregiver in a mixed age format appropriate for children birth through early elementary.The mixed age format was a critical component of the work at Reunity House; many families had several children spanning a number of years.The repertoire includes a variety to tonalites, meters, genres, instruments, languages, and voices

Benefits and Out Benefits and Outc comes omes
The most important area of focus for the parents through this intervention was parenting skills.At the outset, Reunity House implemented the Nurturing Parenting Program (Bavolek, 2007), which is a psychoeducational model of building skills in parents.The five core values of the Nurturing Parenting Program are positive self-worth; empathy empowerment and strong will; structure and discipline; laughter, humor, and play.The parenting curriculum used in subsequent years was the Strengthening Families Program.The five core factors emphasized through the Strengthening Families Program 5 were: parental resilience, social connections, concrete support in times of need, knowledge of parenting and child development, and social and emotional competence of children (Music Together LLC, 2012).

Music Therapy Group Goals
The overall goal of this program is to reunify families.To that end, the specific music therapy group goals included: a) increased parent-child bonding; b) parental awareness of children's musical developmental milestones; c) increased parent comfort with and competence in using music as a parenting tool.The Music Together session structure served as a framework for addressing these goals.The session plan arch provided an artistic flow and energetic direction that enabled parents and children to experience a variety of states of arousal (i.e.ritualized greeting, focused attention, choreographed and free small and large movement, guided and free instrument play, lullaby, and ritualized closing).Through deliberate paring approaches to songs to address the three music therapy goals (increased parent-child bonding, parental awareness of children's musical developmental milestones, and increased parent comfort and competence in using music as a parenting tool), the therapist provided multiple opportunities to implement the knowledge and practice skills the parents were learning in the parenting class.Social workers attended and participated in the music therapy groups to support parents.Active participation by all adults in the room was key to program's success.
Parents were further supported through the provision of materials for at home use: CD, family songbook, instruments, and movement scarves.During supervised visits with their children, the parents were encouraged to sing and play musically with their child using the songs they were now familiar with from the music therapy group.Social workers facilitating the visits also were familiar with the songs, providing an additional support, modeling, and encouragement for the parent.

Music Therapy Group Structure
Family music making in a group setting appeared to be unfamiliar to the families enrolled in music therapy.Yoga mats were used early in the program to define the physical space.This helped to guide parents and children to sit in a circle on the floor (chairs were available for those unable to sit on the floor).In subsequent semesters and in different locations, furniture and carpeting was arranged to create a structured area for the group.
The predictable structure of the music therapy group afforded parents the opportunity to become comfortable making music with their children.Positive signs of increased parent-child bonding included parents sitting comfortably with their children and other families in the circle, and increased use of instruments and movement props.

Improve Parental Awareness of Child's Music Development
Parent education moments addressed the goal of improving parental awareness of children's musical developmental milestones.These parent education moments consisted of a few sentences on a particular topic (e.g.ways parents can support children's music development) embedded within the music therapy session.They included a rationale for why the music therapy experience is important and how parents can replicate or approximate this experience with their child outside of music therapy.The music therapist also explained the importance of observation: parents realized that they could learn about their children by observing them interacting with the instruments or taking notice of the quality of their vocalizations.Parents were also provided additional information in informal ways through interactions with the music therapist and social workers on the ways they can use music outside of the music therapy session.For example, parents were provided mentoring on how to use lullabies to calm their child.

Increase Comfort and Competence with Music
The music therapist observed signs of increased parent comfort with and competence in using music as a parenting tool during the session when parents sang more freely and allowed their children to interact with others and with the instruments without interfering.Parents also showed increased comfort with singing when they engaged in more complicated song forms such as remaining on an ostinato while the therapist and children sang the melody of the song.Parents were also encouraged to bring in favorite songs to use for the play-along (exploration of instruments in the presence of recorded music) or free movement portions of the music therapy session.The music therapist provided guidance regarding developmentally appropriate considerations for making choices of music suitable for young children (i.e.appropriate language).In this way, families were supported in the creation of their own "repertoire" of songs.

Parent Report Post Intervention
At the start and conclusion of each music therapy program (or 10-week semester), parents completed a survey adapted from a Music Together Parent Satisfaction survey, and some parents participated in interviews at the conclusion of the program.Parents reported in interviews that they rediscovered their own musicality and felt more comfortable making music with their children.Parents also described increased understanding of their child's music development and the use of music as a parenting strategy.One mother reported that singing her daughter's favorite songs from music therapy group shortened the duration and intensity of her young child's tantrum.The mother was amazed at how many songs her child (aged 4 years) learned.She noted that her daughter often learned the songs more quickly than she learned them.
C Cha hall lleng enges t es to P o Pr rogr ogram Impl am Implement ementation ation

Clinical Challenges
One of the challenges to program implementation was navigating the varying levels of comfort with personal music-making among each of the adults, both parents and clinicians.Children participated in activities when their loving adult exhibited comfort and delight in the activity, therefore it was crucial to structure the experiences of music such that each adult could find their way into the experience comfortably, authentically, without anxiety or loss of emotional expression.Each staff member and family came to music-making with a different degree of comfort.For some, family music-making was a novel experience, fraught with some anxiety or discomfort.For others, simply being in the presence of other parents and staff was uncomfortable.Parents knew that this was one of the few times they would see their children that week and felt pressure to make it "perfect."Despite, or perhaps because of this pressure, family compliance was a concern.Parents were required to check in a day in advance of the program each week to confirm that they would be in attendance to prevent children being brought to the center only to find their parent was absent.Despite this requirement, there were instances of children showing up when their parents did not.Similar studies involving other early childhood family music making experiences indicated that a minimum therapeutic dose of six sessions was necessary (Nicholson, Berthelsen, Abad, Williams, & Bradley, 2008); the remaining four sessions provide opportunity for mastery and deepening sense of community.
It was necessary to provide ongoing coaching to the parents regarding the quality and consistency of their participation in music therapy in light of their awareness of the need for ongoing evaluation.Social workers were present at every session and were integral to the facilitation of the ongoing reunification process.Reports generated by the social workers were reviewed by the court.While the music therapist was not directly responsible for writing reports that the judge would see, the participants did not know this.This posed difficulty with accurate data collection (paper survey at the beginning and end of the 10 week series); parents may have felt the need to over-report their level of comfort and competence in an effort to appear ready to have their parental rights reinstated.
Issues of capacity and family readiness for participation in music therapy were addressed as lessons learned from the first program implementation.While the contract stated the number of families, it was clear that the families were large, leading to group sizes that were less than ideal.Subsequent implementations of the program limited the number of children (without splitting families) in order to provide a more appropriate treatment model.The first implementation of the program happened shortly after Reunity House opened and included families who were all at a high level of crisis and need.Subsequent implementations of music therapy were scheduled to include families who had experienced a longer time in the program and were farther along in the reunification process.

Context Challenges: Maintaining the Program
Keeping the program going depends on a variety factors, including, in this case a) funding, b) the requirements of the parenting program for a variety of activities (rotation of services), and c) availability of appropriate referrals.Funding is always a problem -this program was funded through a larger grant awarded by the state.The parenting program calls for a rotation of services including play therapy and yoga to broaden and enrich families' positive experiences.Program implementation at Reunity House is designed to be responsive to the needs of the clientele.When the level of acuity of parents enrolled in Reunity House varies, and if there are insufficient numbers of families who are in an appropriate stage of the program, music therapy services may be delayed.
While clinical interventions were of utmost importance, working in this setting also involved networking, explaining the music therapist's scope of practice, understanding the existing system, understanding the program's goals, and learning about the evidence-based parenting curriculum utilized throughout the program.The mechanism for Reunity House's overall program evaluation was dictated by agencies and grantors.The parents participating in the music therapy group completed a survey tool adapted from a Music Together Parent Satisfaction survey implemented in other projects.Additionally, interviews with parents (and selected children), and staff allowed for further nuanced development of the program for future implementation.
Through observation and interviews with the clinicians, it was determined that supporting the clinicians to become comfortable music makers was crucial since their level of comfort impacted their participation in the music therapy group and ability to support families, decide on the level of intervention required, and make robust observations of the families' progress.Parents enrolled in music therapy tended to be less comfortable music makers and have less understanding of their child's developmental needs in all domains.Peer support for the music therapist implementing the program was an essential component in the development of approaches to music making that were comfortable for the adults as well as engaging for the children, given the level of need exhibited by the parents enrolled in the music therapy group.This allowed the clinician to structure experiences of family-based music-making that increased the parents' disposition to make music with their children as a pleasurable activity outside of music therapy.

C Conclusion onclusion
Music therapy was an important component of the reunification process for families who had been legally separated due to abuse or neglect.While program implementation was not without challenges, the benefit to the families in terms of increased positive parent-child relationships, positive parenting practices, and supporting children's development after a traumatic period in their lives was recognized.
Clinicians should not be discouraged if a program does not run continuously.Social service programs are designed to be flexibly implemented and responsive to the needs of their community.Maintaining contact with the stakeholders and decision-makers may lead to additional work in the future (i.e.renewal of contract) or an introduction to another program in need of music therapy services.

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Music Together providers serve families across the world, including vulnerable populations 3 Rather than provide a formally manualized approach to clinical work, Music Together Within Therapy providers work within their scope of practice to craft interventions that address the assessed needs of their clients 4 .