Clinical Training in Music Therapy

Objective: This paper examines the experiences of music therapy students throughout their clinical training. Three surveys inquired about: 1) the perception from both interns and supervisors as to interns’ needs, 2) interns’ preparedness, their skills, their priorities when choosing an internship, and whether their expectations for training were met (with comparisons between American and International respondents), and 3) satisfaction with clinical training. Method: Three separate surveys were distributed. The first survey’s respondents included pre-interns ( n = 19) and internship supervisors (n = 14) who had completed their training in the Great Lakes Region of the United States. The second survey’s respondents included American interns (n = 50), American professionals (n = 353), International interns (n = 12), and International professionals (n = 50). Respondents for the third survey included professional music therapists who completed their curriculum in the United States and held the MT-BC professional credential (N = 777). Results: Some differences between interns’ and supervisors’ perceptions of the interns’ needs were found in Survey 1; significant differences were found between the preparedness and strengths/weaknesses between groups in Survey 2; and Survey 3 found general satisfaction with training with some areas respondents felt needed improvement. Conclusions: While there is overall satisfaction with training for music therapists, there are inconsistencies in students’ experiences in, and perceptions of, their training.

Lit Liter eratur ature R e Re eview view

Music Therapy Curriculum
Beginning in 1919, music therapy training in the United States was offered informally by pioneers such as Margaret Anderton, Isa Maude Ilsen, Harriet Seymour, Eva Vescelius, (Davis & Gfeller, 2008) and Wilhelmina Harbert (Davis et al., 2018). Each had their own curriculum, philosophy for conducting music therapy, and indications of what instruments and/or types of music were most or least appropriate (de l'Etoile, 2000). Students were trained to work in hospitals and schools to address physical and mental needs of those with whom they worked (Davis et al., 2018). The first structured music therapy course was taught by Anderton and later by Ilsen at Columbia University starting in 1919 (de l'Etoile, 2000). The first recognized undergraduate and graduate university training programs were established at Michigan State University in 1944 and the University of Kansas in 1946, respectively (de l'Etoile, 2000. Due to the variety of training occurring across the country, the need arose to establish education standards to further the recognition of the profession. With assistance from Music Teachers National Association, the National Association for Music Therapy (NAMT) was established in 1950 with the purpose to progress music therapy education and training, and determine standards for music therapy practice (Davis et al., 2018). This effort culminated in the undergraduate curriculum being formalized in 1952formalized in (de l'Etoile, 2000, based on specific required music therapy courses and nationally rostered internships occurring outside the university setting (de l'Etoile, 2000). NAMT credentialed music therapists from their programs as Registered Music Therapists (RMT), with NAMT maintaining a roster of credentialed professionals within the association. Over time, philosophical differences regarding education and training arose within the music therapy community, which led to a split in the profession and the formation of the Urban Federation for Music Therapists (later renamed the American Association of Music Therapy [AAMT]) in 1971 (Davis et al., 2018). AAMT addressed education and training more flexibly through the use of professional competencies instead of required courses, and university-affiliated internships that were more closely related to the university (Davis et al., 2018). Music therapists who studied at AAMT programs were credentialed as Certified Music Therapists (CMT) or Advanced Certified Music Therapists (ACMT), with AAMT maintaining a roster of credentialed professionals for that association. In order to have one set of standards for credentialing music therapists, the Certification Board for Music Therapists (CBMT) was established in 1983 to serve as the single credentialing agency for the profession (CBMT, n.d.), consolidating credentials issued by NAMT and AAMT (AMTA, 2011). CBMT administered the first board-certification exam in 1985, which granted candidates the credential of board-certified music therapist (MT-BC). The MT-BC credential verifies that candidates meet the required knowledge to practice music therapy, and requires the professional to engage in 100 hours of continuing education over five years to maintain MT-BC status.

Background on AMTA Professional Competencies
The presence of two professional associations (NAMT and AAMT) resulted in confusion for the public and the profession, and limited the growth of the profession (Davis et al., 2018). Members from both associations voted to unify as one association in 1996, with ratification occurring in 1998, which formed the American Music Therapy Association (AMTA). AMTA established the Commission on Education and Training to study and design education and training standards for the new association. The use of AAMT's competency-based education was adopted (AMTA Professional Competencies, Adopted 1999, Revised 2013, with both nationally rostered and university-affiliated internships being offered (AMTA, 2011). The credentialed registries from both NAMT and AAMT were maintained through 2020 for the RMT, ACMT, and CMT credentials; while the MT-BC became established as the sole credential for the profession (AMTA, 2011). The approved AMTA competency-based curriculum was designed to impart entry-level competencies in music foundations (45%), clinical foundations (15%), music therapy foundations and principles (15%), general education (20-25%), and other electives (5%) (AMTA Standards for Education and Clinical Training, Adopted 2000, Revised 2017), while allowing each college/university program diversity in determining how to address competencies.
A bachelor's degree in music therapy addresses three main areas: 1) music foundations, 2) clinical foundations, and 3) music therapy foundations and principles. Each main category is comprised of several subcategories to be addressed through coursework, pre-internship clinical hours, and internship (AMTA Professional Competencies, Adopted 1999, Revised 2013. Since academic programs across the country vary in training styles, course requirements, and pre-internship clinical experiences, students may enter internship with different skill sets than peers from other institutions.

Internship
In addition to coursework, music therapy students are required to complete a minimum of 1,200 hours of clinical training through fieldwork and an internship. This involves music therapy students completing 180 hours in pre-internship experiences (practicum assignments from academic programs) and at least 900 hours of internship experience (AMTA Standards for Education and Clinical Training, Adopted 2000, Revised 2017). All AMTA-approved colleges and universities follow the above standard; however, depending on their philosophical orientation, coursework requirements for students may vary between institutions. The AMTA Professional Competencies are addressed through both academic courses and in the development of a training plan and written internship agreement. The academic training program periodically assesses students' progress through coursework and clinical training, and collaborates with the internship site to determine when a student has met all of the competencies to graduate (AMTA, Standards for Education and Clinical Training, Adopted 2000, Revised 2017). Upon completion of AMTA-approved academic training and internship, students are eligible to sit for the board certification exam administered by CBMT.

Differences Between American & International Students
AMTA has a total of 88 accredited educational programs, which provides many opportunities for international students to study music therapy in the United States (AM-TA Organization Directory Search, 2019). For international students, internship can be a difficult part of their academic experience. International students have additional challenges when studying outside of their home country due to unfamiliar learning contexts, differing learning styles, language barriers, and cultural differences, among other issues (Ruhanen et al., 2013). These differences can produce acculturative stress in international students not experienced by Americans, which can potentially have a negative impact on clients if such stress affects the well-being of interns during their internship experiences (Kim, 2011). The present research further explores these differences between American and international students.

Internship Director Perceptions of Incoming Interns on AMTA Professional Competencies
At the start of the internship, the supervisor may notice some significant deficiencies in the intern's ability to perform their job. If a pre-intern shows signs of severe professional competency problems prior to the start of the internship, the individual can be identified by academic faculty. However, sometimes these students move on to internships, nonetheless. In a survey of 32 academic program directors and 77 internship directors, "inadequate music skill development" was rated by both groups as the top indicator of students with severe professional competency problems. The same survey identified additional deficiencies that included poor musical skills, ethical violations, poor boundaries, and social inappropriateness (Hsiao, 2014). In a survey of 96 internship directors, respondents rated the majority of their interns as below average competency level for guitar, keyboard, percussion, and improvisational skills at the start of their internship (Jenkins, 2013). In another survey, 94 internship directors were asked to identify the most difficult aspects of supervision; "making sure competencies were met" was rated as one of the two top-ranked responses (Tanguay, 2008). The present research explores the different perceptions of internship directors and incoming interns on AMTA Professional Competencies.

Professional Preparedness
Since the music therapy curriculum was revised by NAMT in 1996, there have been few studies focused on educational satisfaction related to music therapy. One study in occupational therapy surveyed current students and graduates about professional education and preparedness (Hodgetts et al., 2007). The study indicated that students and recent graduates from occupational therapy felt that they lacked technical and intervention skills, yet both students and graduates were satisfied with their education.

Research Questions
An understanding of all of these factors -interns' preparedness, their skill in relation to the AMTA Professional Competencies, their satisfaction with their training, and the perception of both the intern and the supervisor as to the intern's needs -is necessary to give a full picture of the system used to train music therapists in the United States. In addition, understanding a student's growth from internship into the professional world for both American and International interns can help to improve the quality of training and provide support where needed. The questions below served as the primary research questions across the surveys administered: Survey 1: • What are the similarities and differences in how pre-interns and internship supervisors perceive areas of need within the AMTA Professional Competencies in terms of a) music foundations and b) clinical foundations?
Survey 2: • What are the differences between American and International interns and professionals in clinical training in terms of a) AMTA Professional Competencies, b) general strengths and weaknesses, c) choosing an internship, and d) strengths and weaknesses of their internship?
Survey 3: • How satisfied are music therapists with their undergraduate or equivalency curriculum as preparation for professional practice?

Survey 1
The purpose of this survey was to investigate the differences in how pre-interns and internship supervisors perceive areas of need within the AMTA Professional Competencies. The study was approved by an institutional review board i . The pre-interns were required to have completed at least two semesters of music therapy practicum courses to participate, while internship supervisors were required to be board-certified music therapists who had supervised at least one intern in the past two years. A list of internship supervisors was compiled using the AMTA National Roster website. Using purposive sampling, pre-interns were contacted through the Great Lakes Region (GLR) Music Therapy Association, GLR Student Association, and university faculty. The survey was made available in September 2016 for a duration of a month. The survey was a closed-form questionnaire developed by Knight (2008) with 36 Likert-scale rating (5-level) questions. The participants rated their need for assistance from "Little or no need for assistance" [1] to "Very high need for assistance in this area" [5]. Questions included inquiries about clinical foundations, music therapy, and music foundations competencies. In order to clarify the language for the participants, the phrase "concern for assistance" was changed to "need for assistance," "diagnosing client needs" was changed to "assessing client needs," and "closing a knowledge gap between academic program and internship" was added to the end of the first section of the questionnaire. The survey asked pre-intern respondents to rate their perceived need for assistance and asked internship supervisors to rate their own perception of the needs of their typical intern to meet the AMTA Professional Competencies. Between-group responses were compared using t-tests and Mann-Whitney tests.

Survey 2
The purpose of this study was to investigate internship preparedness and the differences between International and American music therapy interns and professionals. The study was approved by an institutional review board. The inclusion criteria required interns to have completed the first half of their internship and professionals to have earned their MT-BC credential within the previous five years (no earlier than March 2012). The investigators requested email addresses from the Certification Board for Music Therapists for professional music therapists and accessed the approved internship sites list posted on the AMTA website to obtain contact information for clinical training directors. The survey was open for one month. Participants who completed the survey were entered into a drawing for $10 Amazon gift cards.
The survey instrument was created for this study by the investigators. It contained 13 questions, formatted as yes or no, multiple-choice, Likert-scale rating (4-level), and short answer. Five of these questions were modified from surveys used in earlier studies (Knight, 2008;Madsen & Kaiser, 1999;Young, 2009). The survey included questions on demographics, how respondents decided where to complete their internship, perceived strengths and weaknesses in accordance with the AMTA Professional Competencies, and how those competencies were met during their internship. Response items were based on the major categories of the AMTA Professional Competencies and were used by permission from the Western Michigan University (WMU) music therapy pre-internship self-evaluation. Chi-square analyses were used to compare the four different groups with different sample sizes.

Survey 3
The purpose of this study was to examine the satisfaction level of undergraduate and equivalency students who have completed their degree program, with respect to their professional education and preparedness for practice in the United States. The study was approved by an institutional review board. The inclusion criteria for participants in this study required that participants be professional music therapists who completed their undergraduate degree or an equivalency curriculum in the United States and held the professional credential of MT-BC at the time of data collection. Participant emails were obtained from the CBMT email list for music therapists who held an MT-BC credential, and the survey was open from October 16th, 2017 -November 16th, 2017. The survey contained one main research question with 20 sub-survey questions. Questions were modified from Hodgetts et al. (2007)

Survey 1
Approximately 70 individuals were contacted for this study and 33 self-selected to enroll, including pre-interns (n = 19) and internship supervisors (n = 14) in the Great Lakes Region (GLR) of AMTA. Pre-interns had an age range of 18-25 with two males (10.53%), 16 females (84.21%), and one who identified with the "other" category (5.26%). Internship supervisors in this study had an age range of 25-55 with one male (7.14%) and 13 females (92.86%). Determining the varying levels of perceived need required to meet the AMTA Professional Competencies by both students and internship supervisors is an important step to improving the quality of internship training. In this survey, the means of the music therapy pre-interns and internship supervisors were compared across 36 questions regarding clinical foundations and music foundations using a t-test and Mann-Whitney test (Field, 2013) utilizing the program SPSS.

Level of Need for Assistance in Clinical Foundations
The clinical foundations portion of the AMTA Professional Competencies covers skills used to facilitate a therapeutic session and knowledge required to be a successful clinician. Identifying the level of need for incoming interns in this area is a valuable tool for the internship supervisors to use when designing their internship program. The mean scores of pre-interns and internship supervisors were calculated on each item to find areas requiring the highest level of need. The surveyed pre-interns were moderately to highly concerned about "finding out what is expected of me as an intern" (M = 3.526), "closing the knowledge gap between academic program and internship" (M = 3.368), "understanding the facility's intern evaluation process" (M = 3.526), and "obtaining instructional resources and materials" (M = 3.053). In contrast, the internship supervisors were moderately to highly concerned about "facilitating group discussions" (M = 3.714), "assisting students in assessing client needs" (M = 3.571), "dealing with stress" (M = 3.5), and "closing the knowledge gap between academic program and internship" (M = 3.357). "Closing the knowledge gap between academic program and internship" was the only commonality between the pre-interns and the internship supervisors. The mean scores of the internship supervisors were compared against the mean scores of the pre-interns using the independent t-test. The independent t-test was used to compare the mean scores due to the assumed normality of data distribution, independence and homogeneity. One area was found to be statistically significant: "understanding the facility's intern evaluation process," t(31) = 4.217, p = .001 with an effect size of 1.514. See Table 1 for remaining statements.

Level of Need for Assistance in Music Foundations
The music foundations section of the AMTA Professional Competencies covers musical skills needed to be a successful clinician and sets music therapy apart from other expressive arts therapies. The surveyed pre-interns identified the following areas as requiring the highest levels of assistance: "knowledge of multicultural music" (M = 3.421), "selecting standard works for your client's needs" (M = 2.737), and "improvising vocally" (M = 2.52). The internship supervisors rated their highest levels of concern regarding "improvising vocally" (M = 3.00), "demonstrating basic piano skills" (M = 2.786), and "leading and accompanying on guitar and piano" (M = 2.714).
Only two responses differed significantly between pre-interns and supervisors within the music foundations section: "demonstrating basic piano skills" t(31) = -2.929, p = .006 with an effect size of 1.049 and "leading and accompanying on guitar and piano" U(N pre-interns = 19, N supervisors = 14,) = 140.5, z = 2.063, p = .046. These strong effect sizes show that pre-interns perceive they need much less assistance to meet the competencies compared to internship supervisors' perceptions. See Table 2 for remaining statements.

Summary
Pre-interns reported a higher need for assistance in the area of "understanding the facility's intern evaluation process" compared to internship supervisors. Pre-interns reported lower need for assistance in "demonstrating basic piano skills" and "leading and accompanying on guitar and piano" than was reported by internship supervisors.

Survey 2
The purpose of Survey 2 was to investigate internship preparedness and the differences between International and American music therapy interns and professionals. The survey was sent to a total of 2,673 individuals. A total of 465 individuals self-selected to complete the survey. Chi-square tests were used to compare the frequencies of International Interns (II), American Interns (AI), International Professionals (IP), and American Professionals (AP) as they reported the AMTA Professional Competencies they felt most and least competent in, as well as their perceived strengths and concerns when entering their internship. Two respondents did not meet the eligibility requirements, so their data were excluded from analyses. Of the respondents, participants were orga- ), two participants identified as "other" (0.43%), and two individuals did not respond to this question. Two hundred and thirty-seven of the respondents had earned or were pursuing a bachelor's degree (51.18%), 219 had earned or were pursuing a master's degree (47.3%), and seven had earned or were pursuing a doctoral degree (1.51%). A total of 416 respondents reported their first language was English (90.24%) with Chinese being the second highest reported (5.86%). Four hundred and thirty-nine of the participants were between the ages of 20-40 (94.38%), while 26 were over the age of 40 (5.62%).
Chi-square analyses indicated there were no significant associations across categorical groups in the top three strengths when entering internships: "general aptitude"  Results for this question were calculated from 452 total participants. Frequency counts determined the primary concerns in relation to internship preparedness included "physical environment concerns (money, moving, etc.)" (42.5%, n = 192) and "specific preparation/lack of specific content knowledge" (34.5%, n = 156), followed by "expectations (not meeting)" (27.4%, n = 124). See Table 6 for remaining statements. Chi-square analyses indicated there was a significant association across categorical groups in the top three areas of concerns/worries of "physical environment concern," X 2 (3) = 14.838, p < .005, "clients not responding," X 2 (3) = 9.348, p < .05, and "not being professional," X 2 (3) = 18.259, p < .001.

Expectations Met in Internship
To compare the differences between subgroups regarding if expectations were met in their internship, a nonparametric test was completed using the Kruskal-Wallis test. A total of eight areas were significantly different between subgroups. Statements included: "major performance medium" (H(3) = 8.16, p = .043), "keyboard skills" (H(3) =   Table 7 lists all statements.

Summary
In relation to the top five AMTA Professional Competencies respondents felt most and least confident in, there were no significant differences across the four groups. There were also no significant differences in respondents' top three perceived strengths when entering internship. There were, however, differences in respondents' top three concerns when entering internship in terms of preparedness relating to "physical environment concern," "clients not responding," and "not being professional." There were also significant differences across groups outside of the top five responses. A Kruskal-Wallis test was used to compare which expectations were met in internship between groups. Items that significantly differed across groups included "major performance medium," "keyboard skills," "voice skills," "therapeutic applications," "therapy implementation," "therapy evaluation," "professional role/ethics," and "interdisciplinary collaboration."

Survey 3
While Surveys 1 and 2 examined specific elements of clinical training, Survey 3 sought to understand participants' overall satisfaction with their academic curriculum and internship. The survey was sent to a total of 7,183 MT-BC's and 777 participants self-selected to complete a survey that explored the satisfaction of music therapy professionals with music therapy courses and programs. The respondents included 210 from the Great Lakes Region (27.03%), 183 from the Mid-Atlantic Region (23.55%), 125 from the Southeastern Region (16.09%), 95 from the Midwest Region (12.23%), 64 from the Western Region (8.24%), 58 from the Southwestern Region (7.46%), and 42 from the New England Region (5.41%) of AMTA. Respondents reported graduation years ranging from 1971-2017. A total of 50.84% of the respondents graduated between 2011-2017 (n = 395).

Satisfaction with Training
Overall, 92.72% (n = 688) of respondents were satisfied with their courses, 92.73% (n = 689) were satisfied with the quality of teaching in their program, and 88.46% (n = 664) were satisfied with their clinical practicum coursework. However, 11.54% (n = 84) of respondents reported their clinical practicum coursework was not sufficient. In terms of practicum experience, 90.01% (n = 658) were satisfied with the range of practicum experiences offered.
Individuals were largely satisfied with their overall preparation for professional practice with 92.88% (n = 587) feeling satisfied with their undergraduate training. A chi-square test was used to analyze the relationship of responses regarding the overall satisfaction level with the undergraduate or equivalency curriculum and the satisfaction level related to the relevancy of the courses. Results indicated that a relationship existed between the satisfaction levels of overall curriculum and relevance of the courses, X 2 (25, N = 587) = 823.583, p < .001. In addition, a chi-square test indicated that a relationship existed between satisfaction level with curriculum and the quality of teaching, X 2 (25, N = 587) = 672.611, p < .001. A Spearman correlation test was used for three analyses: 1) graduation year and the satisfaction level of the relevance of courses; 2) graduation year and the satisfaction level of the quality of teaching; and 3) graduation year and the overall satisfaction level of undergraduate or equivalency curriculum. There was no significant relationship between graduation year and the satisfaction level of the relevance of courses (r s = -.041, p < .135). Also, there was no significant relationship between graduation year and the satisfaction level of the quality of teaching (r s = .038, p < .151). However, there was a significant relationship between graduation years and the overall satisfaction level of the undergraduate/graduate equivalency curriculum (r s = .070, p < .040). The music therapists who graduated more recently had a higher satisfaction level, though it is important to mention the effect size is small.

Overall Satisfaction
The responses showed that 78.58% (n = 491) of professionals would choose the same university/college music therapy program again. However, 20.42% (n = 126) indicated they would choose a different music therapy program. The results also showed that 76.26% (n = 453) would choose music therapy again, or, if possible, they would double major with another discipline during their undergraduate training or earn a higher degree in another discipline. However, 23.74% (n = 141) of respondents specified they would choose another profession. Responses included: occupational therapy (n = 28); psychology (n = 25); social work (n = 20); and speech language pathology (n = 16). According to the responses, the most common reasons respondents indicated a desire to choose another profession were related to low income (n = 24), limited job availability (n = 24), burn out (n = 4), and constant advocacy efforts (n = 3).

Summary
Broadly, respondents were satisfied with their clinical training and preparation for professional practice. However, there were still some who reported that their training was insufficient or that they would choose a different academic program or a different field entirely.

Survey 1
This study examined differences in perception between pre-interns and internship supervisors in regard to clinical and music foundations according to the AMTA Professional Competencies. This study replicated questions from the Knight (2008) study with some additional questions regarding music foundations. Areas of difference between the two studies are explained below.
In other studies that surveyed students' pre-internship concerns, results showed that the top concerns of most students were musical skills (Wheeler, 2002), general preparation for an internship or not having knowledge (Madsen & Kaiser, 1999), and knowing what is expected of them as an intern (Knight, 2008). The musical skills concern is mirrored in the internship supervisors (Jenkins, 2013) with the addition of other concerns for their interns. Internship supervisors and directors identified "making sure competencies were met" as the most difficult aspect of supervision (Tanguay, 2008). The results of this study fall in line with the results of previous studies and reinforce some areas of concern that can be addressed in academic programs.
The pre-interns reported a higher need for "understanding the facility's intern evaluation process" compared to the internship supervisors. This area cannot truly be addressed in the academic program due to each facility having a different evaluation process. The responsibility of addressing this concern for assistance lies solely with the internship supervisor and can only be addressed once the internship has begun.
Pre-interns reported a lower concern for "demonstrating basic piano skills" compared to internship supervisors. Additionally, there has been a reduction in the perceived importance of piano skills in music therapy internship supervisors in the last 25 years (Jenkins, 2013). A survey of 92 internship directors showed that piano skills are now ranked third behind vocal skills and guitar skills (Jenkins, 2013), whereas a similar study by Brookins (1984) ranked piano skills as the most essential (Jenkins, 2013;Brookins, 1984). The reduction of importance in piano could be tied to the portability of the guitar and the ease in which a session can be led from a guitar rather than be-hind a piano. More experienced internship supervisors may place a higher importance on piano skills and individual clinical preferences may sway the outcome of internship supervisors.

Limitations
A limitation of this study is that this survey only targeted the Great Lakes Region and was not available nationally.

Survey 2
This survey examined differences in perceptions of clinical preparedness in relation to the AMTA Professional Competencies, personal strengths and concerns prior to internship, factors in choosing an internship as well as satisfaction with clinical training, and whether there were differences based on cultural demographics. Some significant differences were found in the responses between American and International respondents.

Perceived Preparation Related to AMTA Professional Competencies
International participants reported "documentation" as one of their top five skills that they wanted to improve during their internships while American participants chose it as an area in which they felt competent. Since documentation is typically in English, American participants may be comfortable completing paperwork in their first language whereas the language barrier makes paperwork more difficult for International participants.
A higher percentage of American participants chose "voice skills," while a higher percentage of International participants chose "piano skills" as competencies they felt confident in prior to internship.
Two points of particular interest to academic programs and internship sites: 1) "Termination/discharge planning" was least selected for all groups as a competency in which they felt confident, 2) "Guitar skills" was selected by American participants as a competency they felt most confident about, but it was also a competency they most wanted to improve during internship. This could indicate that there is a wide range of needs concerning students' training on guitar.

Perceived Top Three Strengths and Concerns Entering Internship (Not Related to AMTA Professional Competencies)
"Physical environment (money, moving, etc.)" was in the top three choices for all groups. Internships are often unpaid and require students to move to unfamiliar places. Participants who chose "other" mentioned concerns about financial instability, their inability to work full-time during internship, and working in a new city. International interns also chose "embarrassing (saying something inappropriate)" as a concern. For Asian students especially, their cultures are very different in terms of communication, social practice, and belief systems. Therefore, International interns may have more worries about communicating something inappropriate.

Factors in Choosing an Internship
"Client population" was a top choice for all four groups. "Location" was the second highest factor for American interns, American professionals, and International professionals. Additional comments were similar to those in the Top Three Concerns question, citing mainly concerns about the ability to work part-time while in internship to combat financial instability. Another top factor in choosing an internship was "opportunities to work with other disciplines/professions." This may be notable for internship sites as it indicates that students have a strong interest in interprofessional collaboration.
It was surprising that "start date" was not chosen as a top factor for International participants. International students in music therapy typically hold F1 visas, which require that the student be enrolled in a certain number of credits. This means that they need to be enrolled in other courses during their internship, making the start and end dates of their internship very important.

Expectations Met in Internships
Over 91% of participants indicated their expectations were mostly or completely met during their internship in the following AMTA Competencies: "therapeutic relationship," "professional role/ethics," "therapy implementation," "documentation," and "voice skills." This supports findings from the Clements-Cortes (2019) mixed-methods study on the importance of a clinical internship in providing valued experience and supporting improvement in clinical, musical, and personal skills. In the Clements-Cortes study, the significant areas needing improvement from pre-to post-internship that align with the present study include "current vocal skills when singing in a music therapy session," "level of writing music therapy treatment summaries/case studies," and "level of completing music therapy treatment plans" (Clements-Cortes, 2019). This study expanded on this information by comparing the weighted scores of expectation evaluations of the AMTA Competencies between American groups and International groups, finding that weighted scores were higher in the American groups. This may indicate that American interns' expectations were met to a higher degree than those of International interns due to higher demands placed on International interns as they encounter more obstacles in learning and clinical training.

Limitations
There are several limitations for Survey 2: 1) differing group sizes affected betweengroup comparisons, 2) respondents could have misunderstood some questions due to lack of details/specificity (i.e., more than 10 respondents skipped rating the category "exceptionality," possibly because of confusion as to what the term was referring to, and 3) individuals within the International groups still have diverse experiences related to their cultural backgrounds that could have caused heterogeneity within the group.

Survey 3
This portion of the present study looked at professional music therapists' satisfaction with their undergraduate experience. Based on the survey results, most professional music therapists were satisfied with their undergraduate or equivalency curriculum training in regard to the quality of teaching, course relevance, pre-internship clinical practicum settings, and overall training experience.
Most respondents were satisfied with their pre-internship clinical training. However, when compared to a similar study by Hodgetts et al. (2007) in the field of occupational therapy, the percentage of music therapy students satisfied with the teaching quality was lower (92.73%, n = 689) than occupational therapy (98.77%, n = 241). The percentage of respondents satisfied with their training (92.88%, n = 587) was also lower than occupational therapy (97.95%, n = 239). This could be due to a smaller sample size as well as a smaller range of graduation years in the Hodgetts et al. (2007) study. A larger range of graduation years allows for more variation in the quality of curriculum and ability to remember undergraduate training. Additionally, the survey by Hodgetts et al. (2007) was limited to a single university.
Many factors may contribute to the number of respondents who reported they would choose a different profession instead of music therapy (23.74%, n = 141). Approximately the same number of respondents indicated they would not choose the same university/college's music therapy program (20.42%, n = 126). Among other things, this could be attributed to the fact that academic programs have different the-oretical orientations, and a student may find they have a different preference in their professional life. Dissatisfaction may have less to do with the music therapy program itself and more to do with the university as a whole. Additionally, if some students are underprepared when they enter the field, they may find their work more difficult and less enjoyable and rewarding. Another reason as to why individuals may want to choose another profession could be the average salary related to years in the profession (AMTA Member Survey and Workforce Analysis, 2018).

Limitations
Since the extant literature on music therapy curriculum research is limited and outdated, current parallels could only be drawn between other professions. However, this is limited by the difference in content. Thus, deep comparisons between early studies, current studies, and other professions are limited.

C Conclusions onclusions
This study provides information on the experiences of music therapy students before, during, and after the completion of their AMTA internships. It highlights how intern supervisors perceive the preparedness and development of their interns based on the AMTA Professional Competencies. A unique aspect of this research is comparisons across American and International interns and professionals, shedding light on how International interns and professionals may have different experiences within the process of completing or supervising music therapy internships in America. Overall, those surveyed were satisfied with their training and coursework. Future research might follow up with students and supervisors after internship experiences have been completed to determine what areas they improved in and how prepared interns truly are to enter the professional world. The internship is a crucial experience for the developing music therapist, as experiences from practicum and knowledge taken from coursework are applied in increased depth in a new setting and under new supervision. The level of preparedness for this experience, combined with supervision that helps interns to develop in areas of need, sets the foundation for effective clinical work in this rapidly developing field.
About the Author About the Authors s Edward Roth: Edward Roth, PhD, MT-BC currently serves as Professor and Director of Music Therapy and Director Brain Research and Interdisciplinary Neurosciences (BRAIN) laboratory, both at Western Michigan University. His research has addressed the nexus of music and neuroscience by studying the neurobiology and clinical application of music improvisation and how improvisation creates experiences of flow, creative self-expression, and social bonding for people with issues related to mental health.
He has worked with clients diagnosed with various neurological, physical, and mental health disorders. He completed his clinical internship training in adult and adolescent psychiatry at the University of Michigan Medical Center (Ann Arbor, MI) and while a graduate student at Colorado State University, he co-facilitated music therapy and counseling groups for adolescents diagnosed with post-traumatic stress and acute anxiety from Columbine High School (Littleton, CO). His clinical work focused on children and teenagers with neurologic disorders, particularly traumatic brain injuries. Contact: edward.roth@wmich.edu Xueyan Hua: Xueyan is from China and has lived in the US since 2010. She completed her bachelor's degree and master's degree in music therapy at Western Michigan University. Xueyan published a case study for the book "Music Therapy for Multisensory and Body Awareness in Children and Adult with Severe to Profound Multiple Disabilities" by Roberta S. Adler and Olga V. Samsonova-Jellison. Currently, she is working on her MBA degree at Western Michigan University, at the same time she is mainly taking care her little baby and doing some clinical practices. Contact: xueyan.hua@wmich.edu Wang Lu: Wang Lu is a music therapist and the founder of music therapy and recreation programs at Beijing Taikang Yanyuan Rehab Hospital in China. Wang loves popularizing knowledge of music therapy. Since 2016, she runs a music therapy official account through WeChat with her schoolmates for professionals and others who are interested in music therapy field in China. After graduating from Western Michigan University, she worked with some Chinese pioneer music therapists, and published Music Therapy-Melody for Wellness by People's Medical Publishing House, which is the top medical press in China. Contact: 253048715@qq.com Jordan Blitz Novak: Jordan Blitz Novak, MM, MT-BC is the founder and owner of The Great Lakes Music Company, a community-centered music therapy private practice in Northwest Indiana that serves over 200 individuals. She completed her undergraduate degree in music therapy in 2011 from Illinois State University and completed her master's in music therapy from Western Michigan University in 2016. Jordan has been a practicing music therapist since 2012, specializing in autism spectrum disorder and intellectual disabilities. She presented at the GLR regional conference in 2018 on music therapy and ABA collaboration. Jordan plans to continue her efforts in advancing music therapy education and training by supporting students, interns, and professionals to have meaningful and long careers. Contact: jnovak@theglmc.com Fei Wang: Fei Wang graduated from Western Michigan University with a master's degree in Music Therapy. Fei Wang is a teacher who works at Wuhan Conservatory of Music teaching music therapy courses, works as a psychological consultant, and supervises students' clinical practicum. Fei Wang has 7 years of clinical experience, she worked at the hospital, nursing home, and special education school with different kinds of clients. Contact: feiwang900706@126.com Taylorlyn N. Mehnert: Taylorlyn (she/her) completed her bachelor's degree and her master's degree in music therapy at Western Michigan University (WMU). She completed her internship in San Diego at MusicWorx Inc following her undergraduate degree. Taylorlyn worked as a research assistant in the Brain Research and Interdisciplinary Neurosciences (BRAIN) Lab affiliated with WMU under the direction of Alycia Sterenberg Mahon and Edward Roth. Contact: taylorlyn.n.mehnert@wmich.edu Michigan University. She completed her undergraduate work at Wartburg College in music therapy and psychology. Following her internship, she received a master's in music therapy at Western Michigan University. Currently, Alycia is pursuing a doctoral degree in Evaluation, Measurement, and Research at Western Michigan University in which she has completed courses in qualitative, quantitative, and mixed methods; evaluation; and measurement. Alycia has 14 peer-reviewed presentations at regional, national, and international conferences. Alycia's interests include pursuing continued knowledge of research methodologies and advancing the field of music therapy through research. Contact: a.j.sterenbergmahon@gmail.com

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