The Clinical and Theoretical Trends of Music Therapists: The Israeli Case

Participants

One hundred and seven (107) MTs that live and work in Israel participated in the study, all of whom were trained as MTs in Israel. There were 85 women and 22 men and a balanced distribution of training programs from which they graduated: 41 graduated from the Levinsky program, 23 graduated from the David Yellin program, 35 graduated from the Bar-Ilan program (including the Haredi College), and 8 graduated from the newly established Haifa University program. The age distribution was as follows: 8 MTs were between 25 and 30; 32 between 31 and 35; 16 between 36 and 40; 15 between 41 and 45; 12 between 46 and 50; 24 aged 51 and older. The median age was 38. Experience wise, participants were distributed as follows: 24 MTs had 1 to 3 years of experience; 34 had 4 to 8 years of experience; 23 had 9 to 15 years of experience; 13 had 16 to 20 years of experience; 13 had 21 years of experience and more. The median of this variable was 8 years of experience.

Tools

An online survey was devised for the purpose of this study. Items in the survey included demographic questions (e.g., age, gender, seniority, training program, etc.); questions regarding the instruments and techniques MTs used and felt most proficient with (e.g., "What do you consider your primary instrument? What is your secondary instrument?", "What techniques do you feel most comfortable with?"); questions regarding preferred populations (e.g., "What population group do you feel most comfortable working with?"; “What age group do you feel most comfortable working with?" ³ ); and questions regarding the theoretical orientation of the MTs (e.g., "How do you define your treatment approach: music in therapy, music as therapy?", To what extent are your treatments verbal? Musical?"; "Do you work according to a pre-defined psychological approach? If so, what is it?"). A pilot study with a draft version of the survey was conducted. Twenty MTs answered the survey and questions were subsequently revised and edited. A final version with 31 questions was used.

Procedure

The survey, a Google Doc, was sent electronically to 396 MTs whom we found a way to contact ⁴ . To facilitate this, a link to the survey was sent to all Music Therapy Program Heads in Israel, to be disseminated to their alumni lists. In addition, the link to the survey was sent to numerous MTs that supervise and train music therapy students in various work places. The questionnaires were also sent to various mailing lists containing MTs. Once a week, a reminder was sent to the mailing lists. After 2 months, the survey ended and 107 MTs replied (response rate of 27%). Data were organized in an SPSS data file and then analyzed by a proficient statistician.

Main Musical Instruments and Music Therapy Techniques

Participants were asked to indicate the two instruments (primary and secondary) that they felt most proficient with. Results are presented in Table 1, separately for MEMTs and LEMTs. For the MEMTs, the piano was highly dominant (65.3% of the MEMTs reported it as their primary instrument), and the other instruments were more marginal. For the LEMTs, in contrast, both the piano and the guitar were reported as their primary instrument (75.8% of the LEMTs reported one or the other as their primary instrument), and other instruments were marginal. Regarding the secondary instrument, the MEMTs and LEMTs had different profiles here, as well. While 56.3% of the MEMTs reported the guitar as their secondary instrument, LEMTs reported both guitar and piano as their secondary instrument (67.2%). MEMTs and LEMTs were similar, however, in that the piano and the guitar, taken together, were the most dominant instruments.

Independent t-test revealed no significant differences between LEMTs and MEMTs regarding their confidence playing their primary instrument (M = 4.1, SD = 0.86 vs. M = 3.9, SD = 0.95, respectively). However, differences were found regarding confidence playing the secondary instrument: LEMTs felt more confident in comparison to the MEMTs (M = 3.3, SD = 1.09, vs. M = 2.7, SD = 1.04, respectively; t(105) = 2.63, p < 0.01). In addition, LEMTs were more confident using their voice in comparison to MEMTs (M = 4.04. SD = 0.97, vs. M = 3.43, SD = 1.1, respectively; t(105) = 3.02, p < 0.001).

Participants were asked what techniques they used and to what extent. Figure 1 shows this information, comparing MEMTs and LEMTs.

Figure 1

Music therapy techniques used by MEMTs and LEMTs

A two-way repeated measure analysis of variance with musical technique as a within subject factor, and seniority as a between subject factor showed that there was a significant difference between the extent to which different techniques were used (F (4,101) = 93.8, p < 0.001]. Improvisation (M = 5.0) and existing songs (M = 4.9) were the most highly rated, songwriting (M = 3.5) and vocal improvisation (M = 3.6) were intermediate, and Guided Imagery in Music (GIM) was used the least (M = 2.4). Generally, there were no significant differences between MEMTs and LEMTs except for a higher use of vocal improvisation among the LEMTs (M = 4.1) compared to the MEMTs (M = 3.6, t (104) = 2.0, p < 0.05).

Clinical Populations

MTs were asked to indicate which clinical population they preferred to work with. Table 2 shows the results, comparing MEMTs and LEMTs.

Overall, the population the participants most preferred to work with were clients with emotional disabilities (38.5%), and the least preferred clients were those with physical disabilities (3.8%), youth at risk (5.8%), and older adults (5.8%). A breakdown into MEMTs and LEMTs shows, however, different fields of preference. While the MEMTs indicated clients with emotional disabilities as their foremost preferred population (50.0%), and clients with physical disabilities (2.2%), clients with intellectual disability (2.2%), and youth at risk (2.2%) as their least preferred population, LEMTs indicated both clients with emotional disabilities (29.3%) and clients with autism (29.3%) as their preferred populations, and older adults (3.4%) and clients with physical (5.2%) and learning (5.2%) disabilities as their least preferred populations. A chi-square analysis showed that the differences between the preferences of MEMTs and LEMTs were significant (x ² (7) = 19.34, p < 0.01).

MTs were asked to indicate which age group they prefer to work with. Table 3 shows the results, comparing MEMTs and LEMTs.

Overall, the MTs preferred to work with children (38.1%) and they least preferred to work with older adults (5.7%). When referring separately to MEMTs and LEMTs, significant differences were found. While MEMTs preferred working with children (52.1%) and adults (20.8%), LEMTs preferred to work with toddlers (33.3%), children (26.3%), and adolescents (22.8%). A chi-square analysis showed that the differences between the preferences of MEMTs and LEMTs were significant (x ² (4) = 17.1, p < 0.01).

Theoretical Orientation

MTs were asked to what extent they define their theoretical orientation as "music as therapy", and to what extent they define it as "music in therapy" on 1 (not at all) to 6 (extremely so) scales ⁵ . That is, participants were not limited to choose one or the other, but rather had the freedom to define any combination of the two. A two-way repeated measures analysis was conducted where theoretical orientation (music as therapy vs. music in therapy) was a within subject factor and seniority (MEMTs vs. LEMTs) was a between subjects factor. As can be seen in Figure 2, overall, MTs defined themselves in terms of "music in therapy" (M = 4.5, SD = 1.2) and less as "music as therapy" (M = 3.8, SD = 1.6; F(1,104) = 12.6, p < 0.01). This difference, however, was much more pronounced among the MEMTs than among the LEMTs. With MEMTs, the music as therapy approach was significantly lower than the music in therapy approach (M = 3.6, SD = 1.5 vs. M = 4.7, SD = 1.08, respectively, t(48) = 3.82, p < 0.001) while with the LEMTs, the approaches were more evenly distributed (M = 3.9, SD = 1.6 vs. M = 4.4, SD = 1.28, respectively, t(56) = 1.28, p > 0.05).

Figure 2

Music therapy approach (music as therapy vs. music in therapy), comparing MEMTs and LEMTs

MTs were asked to refer to the verbal vs. musical orientation of their work, that is, to what extent their work is musically oriented, and to what extent they were verbally oriented. To examine their responses, a repeated measures analysis of variance was conducted with verbal vs. musical orientation in treatment as a within subject factor and with seniority (MEMT vs. LEMT) as a between subject factor. Results (see Figure 3) show that in general, MTs report a more musical (M = 4.6, SD = 0.96) orientation than a verbal one (M = 3.8, SD = 1.21; F(1,104) = 21.1, p < 0.001). The difference, however, was much more pronounced for the LEMTs (4.7 musical vs. 3.7) than for the MEMTs (4.4 musical vs. 4.0 verbal). That is, less experienced MTs defined their work as more musically oriented and less verbally oriented than the more experienced MTs as is indicated in the significant interaction between the factors (F(1,104) = 4.1, p < 0.05).

Figure 3

Music therapy orientation (musical vs. verbal), comparing MEMTs and LEMTs

MTs were asked to indicate what their general theoretical framework was. They could indicate any one of the theoretical frameworks that appear in Table 4 or any combination of the frameworks.

Note. Percentages add up to more than 100% in each group because participants were free to choose one or more theoretical frameworks.

Overall, MEMTs and LEMTs were quite similar in defining their theoretical framework with humanistic, psychodynamic, and intersubjective frameworks being most frequently mentioned.

Preferred Musical Instruments

The piano was, by far, the most prevalent instrument among music therapists in this study. Although the guitar was also dominant, especially among the LEMTs, the piano still seems to be the most frequently used musical instrument by MTs in Israel. Other instruments, such as drums and voice, were reported to be used to much lesser extents. Studies conducted in North America have shown a more heterogeneous scene. Goodman (2011), for instance, reported that voice, piano, and guitar are the most common instruments used in music therapy in the United States (and see Cohen, Hadsell & Williams, 1997 for similar findings). Voyajolu (2009), who surveyed 250 therapists regarding the instruments used most often during music therapy, found that voice (27.6%) and piano (26.4%) were the most important instruments while the guitar was ranked lower (7.2%).

The reason why the piano is so dominant amongst Israeli music therapists could be explained by the focus that it has been given throughout the years (since the early 1980s) in the Israeli music therapy training programs. First of all, according to the entrance requirements stated in guidelines for registering students ⁶ , most programs required high-level piano skills as an admission criterion, which naturally excluded potential music therapists who had no piano skills but were proficient in other instruments. Secondly, for many years, and in several of the MT programs, improvisation and songwriting courses were encouraged primarily using the piano and only later using other instruments. This might have been the influence of earlier training in the world based on Creative Music Therapy in which the piano was central, although no Creative Music Therapy program exists in Israel. What we see in the programs we head and in other programs is that in the past decade or so, the use of a wider range of instruments has been encouraged. Although this piano-oriented trend is passing, as it is in other places in the world (Jenkins, 2013), we suggest that the MEMTs who completed their training more than 8 years ago are still under its influence. This explains why LEMTs were indeed less piano-oriented, more open to other instruments, and more competent with their voices. It seems though, that more should be done to encourage competence with other basic instruments as voice, drums, and guitar, to achieve figures similar to those mentioned in the American surveys. We believe that the more different instruments are included in the music therapists' toolkit, the more inclusive the practice is. It enables candidates with different musical backgrounds to enter the training programs and it eventually enables more potential clients to connect to music and to music-making in the room.

Music Therapy Techniques

The results showed that Israeli music therapists use a variety of music therapy techniques, the leading ones being instrumental improvisation, work with existing songs, vocal improvisation, and songwriting. This is not a surprise because these techniques are the four most basic "tools" of many music therapists. GIM, in contrast to the others, was rarely used among the respondents in this study. This is probably connected to the fact that no music therapy program in Israel provides GIM training. In this respect it is significant that more than a third of the respondents that expressed a need to develop professionally, mentioned their need for GIM training. If policy makers in Israeli music therapy are to consider this clinical expertise as important for potential music therapy clients, there should be a systematic implementation of GIM training in at least one of the training programs or perhaps as a post-masters diploma or continuing professional development for graduates seeking this path of clinical development. We believe that enabling more paths for music therapists will eventually make music therapy available to more potential clients.

Clinical Populations

Regarding the clinical populations that were most preferred by the respondents, there was a significant difference between the LEMTs and the MEMTs. While the MEMTs mostly preferred the age group of children and people emotional disabilities as their preferred clientele, the LEMTs were more flexible as to their preferred age groups (toddlers, children, and adolescents) and regarding their preferred clientele groups (emotional disabilities and autism). Respondents, both MEMTs and LEMTs, were less enthusiastic about working with older adults or clientele with intellectual disability, learning disabilities, mental disabilities, physical disabilities, or , youth at risk.

Studies have shown that there are several factors influencing which clientele MTs prefer. Blachman (2012), who interviewed Israeli MTs, found that the choice of population often serves the music therapists in that it enables them to express elements of their personality and that the encounter with the chosen population facilitates coping with personal issues which, in turn, contributes to their growth. Based on a survey in the US, Marrison (in Blachman, 2012), found that the therapist’s choice of population stems from the feeling of hope and success and what drives them is the challenge and interest and not necessarily the remuneration. Other studies (Pervin, 1968; Stewart, 2000) found that the work environment (e.g., good communication with colleagues) is a key factor in choosing one clientele or another. It is also important to mention "reality constraints" that have an effect on MTs choice of population. In Israel, for instance, the ministry of education is much more advanced and supportive of music therapists compared to the ministry of health, and therefore, offers more jobs and better conditions. This definitely has an effect on MTs' choices.

It is unclear which of these factors influence MEMTs to prefer a specific and narrow clientele, or what affects LEMTs to have broader preferences. Has something in the perspective of music therapists changed so that they feel it is possible to work in a wider variety of working environments? Or has something changed in the field so that new client possibilities such as kindergartens and high-schools opened their gates to MTs? The answers to these questions are still unclear and further research is required to understand the inter-relationships between the field, the MTs, and how the MTs perceive the field in regard to their personal and professional developmental aspirations.

One of our main concerns in this survey is that older adults were not a popular choice among the respondents, despite the growing numbers and needs of potential clients in this age group and the growing developments in the field of gerontology in Israel (Glicksman & Litwin, 2011). Indeed, research conducted in other countries indicates a similar trend. In Spain there is a growing demand for music therapists in the fields of geriatric music therapy, neurological rehabilitation, psychiatric and medical music therapy (Sabbatella, 2004). In Taiwan, music therapy services for the older adults and individuals dealing with end-of-life issues are increasingly in demand (Lee, 2003). In Norway this field has expanded in recent years (Trondalen, Rolvsjord, & Stige, 2010). Although more focus is placed on this field in some of the music therapy training programs in Israel (e.g., a course about music and older adults), and in placement in retirement homes, there is definitely a lot more that needs to be done (Dassa, 2012). Other professions such as social work, nursing, and medicine, which have already made such changes, can provide valuable ideas and insight. Gorelik, Damron-Rodriguez, Funderburk, and Solomon (2000) and Robert and Mosher-Ashley (2000), for instance, found that previous acquaintance with older adults promotes motivation to work with this population and that positive field-experience during training is important and reinforces positive feelings and willingness to work in this field.

Theoretical Orientation

Measuring the theoretical orientation of MTs is quite difficult and it was therefore approached in several different ways in our survey. One way was to see how music and words were intertwined in music therapy. In general, the respondents of this survey combined music and words, music in therapy, and music as therapy. Interestingly, however, the MEMTs did this in different proportions than the LEMTs. While the MEMTs combined more evenly the verbal and the musical in their sessions, the LEMTs gave more emphasis to the musical. While the MEMTs gave more weight to music in therapy, the LEMTs gave equal weight to music in therapy and music as therapy. Assuming that music as therapy applies more music making than music in therapy, it seems that the younger generation of music therapists is drifting towards making more music in sessions and talking about it to a lesser extent. On the other hand, it could be that the more experience MTs feel more accomplished using both words and music while the less experienced MTs did not gain enough experience using words in therapy. Yet other possibilities to understand the difference between MEMTs and LEMTs is that MEMTs are less comfortable using music or that different client groups require different emphases altogether. Further research might show which of these possibilities is more probable.

A second way to evaluate theoretical orientation is to ask what framework MTs rely on in their work. Here we found that Israeli MTs, both more and less experienced ones, rely on psychodynamic, humanistic, and intersubjective approaches and less on educational, developmental, and cognitive approaches. It seems that the respondents in this survey were geared to psychotherapeutic work, despite the fact that most of the music therapists in the country work with children in schools. It could be argued that developmental, educational, and cognitive approaches would be more suitable for them. This incongruence between what MTs bring to work (i.e., music psychotherapy – perhaps because this is what they were trained to do) and what they ought to be doing (music therapy in educational settings) was brought up in two separate masters theses that examined music therapy in education (Neuman, 2010) and in special education (Amitay, 2011) settings. These two studies found that there is not sufficient preparation of MTs to work within educational environments and that this results in severe communication problems with the educational system. Another possibility is that many music therapists in these places are provided with the supervision of psychotherapists, not music therapists, thus not attending the uniqueness of the music therapy setting. Here, too, the conclusions bounce back to the policy makers in the field of music therapy training as to what the emphases should be in the training program and whether these are biased towards one type of music therapy (i.e., psychotherapeutic) at the expense of another (i.e., educational). This point was brought up in both Amitay's (2011) and Neuman's (2010) studies.

It is interesting to contrast the orientation of MTs in Israel to clinical orientations reported in other countries. Undoubtedly, the theoretical orientation of MTs stems from the framework of the training programs and contexts in which practitioners work in that country. It is expected, therefore, that in Denmark where the Aalborg University program is dominant, MTs will abide to the tradition and the concepts of humanism as well as psychodynamic ideas of this school (Bonde, 2007). In Spain we might expect a variety of theoretical orientations reflecting the variety of music therapy training courses in the country. Sabbatella (2004) referred to this and mentioned that in Spain, many music therapy courses are taught by foreign professors who bring different approaches. The theoretical orientation of some music therapy programs is eclectic while others are based on the principles of Benenzon's music therapy that is influential in this country. In Japan, to give one last example, the orientation is said to be either "clinical" or "bio-musical", as a reflection of the two music therapy associations that exist in the country. Okazaki-Sakaue (2003) claimed that the members of the former tend to use psychotherapeutic and humanistic approaches in practice, while the latter focus more on the medical/biological and behavioral aspects and that very few clinicians focus on psychodynamic or music-centered approaches since there is no established training in the country in this field. Apparently, a nation-wide survey such as the one conducted in the present study, could enable more accurate information regarding the approaches adopted by MT in each of these countries.