Rap in Music Therapy with Appalachian Youth with Adverse Childhood Experiences: Struggle, Reflection, and Self-Work as a Music Therapist

[1] Central Ohio Music Therapy


Children and adolescents in Appalachia are often exposed to Adverse Childhood Experiences and may have higher levels of depression, anxiety, and aggression than youth in other areas of the United States. The unique challenges of working with youth in Appalachia and the unexpected prevalence of rap as a preferred genre are summarized in this article. Rap is a frequently requested genre with youth in Appalachian Ohio and the youth in the area frequently identify with common themes in rap such as social criticism, social empowerment, humanistic values, and negative behavior criticism. Despite success with these methods within music therapy sessions, this Caucasian music therapist has experienced internal conflict due to the potential for cultural appropriation by using rap music in music therapy with clients who are not indigenous to Hip Hop Kulture. Discussion of the implications of therapeutic application, this therapist’s self-reflections and supervision process, potential for appropriation, and personal outcomes are included.

Keywords: music therapy, rap, Hip Hop, supervision, cultural appropriation, Appalachia, Adverse Childhood Experiences


Imagine curvy roads, flowing through beautiful rural landscapes and small townships that are full of friendly people who may have lived in Appalachia all of their lives. Given the scenery, one might assume that the only music present in the region is country and bluegrass, expecting to hear the echoes of banjos and mandolins through the abundant rolling hills. However, the music heard through of the headphones of some of the adolescents walking these picturesque roads through the abandoned mining towns is often rap music. Many of the adolescents growing up in Appalachia experience extreme poverty, lack of access to healthcare, and exposure to drug addiction (Earley, Asti, & Chisolm, 2015; Prest, 2013) and find themselves drawn to the narratives found in rap music. Rap music may be the expressive medium they need to help form a unique identity within Appalachia and to cope with the inherent struggles in the region that they face every day. In this article, I will discuss how I implement rap music within music therapy practice in Appalachia as well as dealing with my own bias, fears, and concerns about appropriating Hip Hop culture.

Encompassing Appalachia

Figure 1.

Map of the Appalachian Region. Adapted from “The Appalachian Region”. 2008. Appalachian Regional Commision. Retrieved August 31, 2018, from https://www.arc.gov/appalachian_region/MapofAppalachia.asp. Copyright 2008 by Appalachian Regional Commission


My home in Southeastern Ohio, where I both live and work is located within Appalachia. This is a unique area of the United States of America that spans rural regions in 13 states from as far north as parts of New York and Pennsylvania to as far south as parts of several southern states including Georgia, Alabama, and Mississippi (Pollard, 2003). Appalachia is a distinct cultural area that faces historical poverty, geographic isolation, and lack of access to healthcare services (Earley, Asti, & Chisolm, 2015; Prest, 2013). Families in this area often find it challenging to break out of the cycle of poverty, to provide opportunities for new generations, and to trust healthcare providers enough to get the services they need (Hartman, Stotts, Ottley, & Miller, 2017). Children in Appalachian Ohio are more likely to be white, insured by Medicaid, and meet the definition of children with special healthcare needs than those residing in Ohio’s urban areas (Early, Asti, & Chisolm, 2015). Children living in rural areas, such as Appalachia, are more likely to experience certain kinds of adversity than those living in urban areas (Lukens, 2017). In fact, many children in Southeastern Ohio face traumatic stressors most likely because of the lack of resources in the area, prevalence of poverty, and the rural nature of the area (Shamblin, Graham, & Bianco 2016).

Adverse childhood experiences, or ACEs, are defined as traumatic or stressful events that occur in childhood. These experiences may include physical/sexual/emotional abuse, emotional or physical neglect, intimate partner violence, witnessing substance abuse, mental illness in the household, family separation or divorce, or an incarcerated household member (“Adverse Childhood Experiences,” 2017; Hartman, Stotts, Ottley, & Miller, 2017). These experiences can impact social, emotional, and cognitive development for the child as well as increase the potential for adopting risky health behaviors. ACEs can also increase the risk for drug/alcohol use, suicide attempts, depressive episodes, sleep disturbances, and high-risk sexual behaviors (“Adverse Childhood Experiences,” 2017).

Given all the complexities of their experiences, children of Appalachia present with unique needs as music therapy clientele. While many adolescents and children are intuitively drawn to music, it has been my experience that music therapy might be an unfamiliar treatment modality and might be seen as strange, ridiculous, or superfluous by individuals residing in Appalachia. Between the rolling hills, small, tight knit communities have formed, and clients may be (for good reason) distrusting of new people, healthcare or helping professions, and new therapies (Hartman, Stotts, Ottley, & Miller, 2017). In order to best connect with children and adolescents who have experienced ACEs, I find it incredibly important to practice from a humanistic and person-centered approach. I constantly strive to meet clients where they are and allow them to ease into new therapeutic ideas within music therapy treatment as feels comfortable for them (Prest, 2013). I also consider client agency and practice unconditional positive regard and empathy for the client. This means incorporating client interests and their preferred music into the therapy setting are my priorities and help lead to progress in treatment. For instance, I recently asked a teenage client about his fondness for rap music as he began to rapidly succeed in his treatment. He continually expressed that music was his main coping skill, but sometimes struggled to express how he was feeling, the reasons behind his emotions, or why he liked certain songs. However, when ask about why rap was so important to him, he paused before simply stating, “Because it’s true.”

Rap and Southeastern Ohio

When I returned to work in the Southeastern Ohio region where I grew up, I was surprised to find the children and adolescents I work with often request rap as their preferred genre. However, upon further reflection and experience with these clients, the reasons why they are so drawn to and passionate about rap music became apparent. In the United States, the origins of Hip Hop began in the late 1970s to early 1980s, when racism and economic strife plagued The Bronx (Hara, 2012; Viega, 2017). The genre of music spread quickly throughout the five boroughs of New York City as an innovative and creative means to express the poverty, racism, and injustices that were occurring there. Access to the lower cost equipment (drum machines, mixers, keyboards, turntables, etc.) needed to create Hip Hop played a role in the quick spread of the genre. Suddenly, music with incredible depth, complexity, and truth was able to be created, on a reasonable budget, by the public. The residents of The Bronx created a new voice despite their marginalization through the passion and flexibility of rap (Hara, 2012; Viega, 2017). Adolescents in Appalachia struggling with familial drug abuse, poverty, or abuse may relate to the rap lyrics voicing feelings of marginalization.

The music behind the lyrics can also be physiologically regulating, due to the heavy rhythms included in most rap music (Hara, 2012). Repetitive and grounding rhythms within rap, can create a comfortable, predictable, and relaxing environment. However, the layering of the rhythmic, melodic, lyric, and harmonic elements within rap can play against expectations to make a certain lyric or meaning stand out to the listener. Within these layers, syncopation or dissonant harmonies might be used purposefully to create a sense of discomfort, anger, anxiety, fear, or even calm (Hara, 2012).

The clients that I work with often identify with the themes of drug abuse, depression, poverty, disempowerment, and even hopelessness found within the rap narrative. A study by Tyson, Detchkov, Eastwood, Carver, and Sehr (2012) found that rap songs primarily fit four main themes: social criticism, social empowerment, humanistic values, and negative behavior criticism. The above themes fit well into typical goals for children and adolescents who have experienced ACES (which include improving emotional expression, improving coping skills, improving empowerment, etc.) and the themes they bring up when discussing their preferred rap music or writing their own music.

The individuals I work with are much more open to trusting and expressing themselves to the therapist when discussing their preferred rap music. When I bring a client-chosen rap song to the session (often one that has been rejected before outside of therapy due to prejudice of content), there is a genuine eagerness and passion (as an expert of their own music) to explain why this song or artist is so meaningful to them. For instance, a client who had been having trouble opening up to her therapist repeatedly mentioned wanting to talk about the song “Tunnel Vision” by Kodak Black, which had not been allowed in other areas of the facility due to lyric content. When I brought the song to the session, she used it to open up about how the lyrics inspire her to keep focused on her goals and not to backslide, that she needed to keep trying and not let the consequences of her past actions get her down.

While I will expand upon this later in the article, rap music and Hip Hop are not the same, as rap is something that is “done” while Hip Hop is something that is “lived” (KRS-One, 2009). Hip Hop is defined as the name of the artistic elements of Hip Hop Kulture, which include DJ’ing, MC’ing, graffiti, and breakdancing (or b’boying and b’girling) (KRS-One, 2009; Viega, 2017). So while one may enjoy listen to and identify with the experiences in Rap, they may not necessarily identify with Hip Hop Kulture. When it is a preferred client genre, using rap or rap writing in music therapy sessions is a way to break down barriers with clients and quickly engage them in therapy since it is a medium they request and enjoy (Schlabach, 2015). It has been my experience that the clients tend to identify and relate to the adverse experiences found within rap.

I often first ask clients “what is important to you about this song?” when discussing their favorite music. When asking this question in relation to rap music, I often get the response, “’Cause that’s my life” or “[the artist] understand how it feels.” Clients will point to references of ACEs in the lyrics and say, “It’s nice to know someone else has experienced this” or “I like knowing that I’m not alone and that they got through it.” Furthermore, clients refer to the structure and form of rap as a “way to say all you need to say in a [concise] way” or “sometimes [rap] says what you need to say when you can’t find the words.” Recently I had a client ask to write a song about what it’s like to have depression and specifically asked for this to be a rap song. He had in mind what he wanted the beat to sound like and through GarageBand, he chose loops that sounded and represented what depression sounds and feels like to him. When I asked why it was so important for this to be a rap song, he responded “because it’s my favorite.” In further sessions, he stated that “it’s really important [for the music] to sound good and to really make the meaning of my lyrics [about depression and coping] to stand out.”

My Journey Using Rap in Music Therapy:

My journey with using rap in music therapy began in my final practicum in my undergraduate training. In this practicum, I worked with female incarcerated adolescents in Cleveland, Ohio. This practicum marked the first time (to my knowledge and memory) that I was in a room where I was in the minority in skin color. I was initially very apprehensive to use the requested rap music, because I was afraid of the violence, explicit language, and sexual themes expressed within the music. I worried about using it within music therapy sessions because I felt it was “inappropriate”. In fact, I hesitated to use the requested rap music within treatment because I worried the violence and explicit language might be contraindicated or even increase these behaviors in the clients. However, after reflective consideration and seeking out supervision, I realized that this preferred music was so meaningful to them that it was a way to connect with the clients and their culture. I was surprised to find that there was incredible value to this music and often a passionate cry for understanding within the message. I realized that it was really my bias, fear, and unfamiliarity with the music that was stopping me from initially including the music in treatment, not the actual content of the music. Once I started to let go of my preconceived notions, and frankly my prejudice against rap music, sessions became much more fluid and clients were much more open to working with me. Since then, I have worked on and off with rap in music therapy as clients continue to connect with the music and request it often.

However, my apprehension arose again when I began working in Southeastern Ohio with adolescents who are primarily white and may not be indigenous to Hip Hop culture, who requested rap music in their sessions. The Cambridge Dictionary defines cultural appropriation as, “the act of taking or using things from a that is not your own, without showing that you understand or respect this culture” (Cultural Appropriation, n.d.). I worried about appropriating the Hip Hop culture by using rap music in sessions, despite it being a preferred genre, in a setting where both the therapist and client do not necessarily come from Hip Hop culture. While rap continues to be very effective within sessions in Southeastern Ohio, I find it difficult at times to balance using their music to gain insight and provide truly therapeutic experiences and keeping in mind that we are not indigenous to Hip Hop culture.

The Potential for Appropriation

Using rap in music therapy has been a successful intervention time and time again with youth who have experienced ACEs, yet I still continue to struggle with the ethics and potential cultural appropriation of using rap in music therapy. I am an advocate for focusing sessions on the preferred music of the clients, but I remain constantly aware of the potential for appropriation when using rap in music therapy. Rap in the United States has African American origins and describes experiences unique to African American lives, but my work in Appalachia is with primarily white clientele who are not indigenous to Hip Hop culture. Over the years, I have sought out supervision from other music therapy professionals who use rap and Hip Hop in their practice, Hip Hop scholars outside of music therapy, etc., to work through these feelings and provide best practice to my clients.

One of the ways I initially attempted to deal with the potential appropriation of Hip Hop culture is being mindful of the terms I used and how I defined this work in music therapy. Hip Hop is the culture, including all of the artistic elements of Hip Hop, and rap music is a form of expression from that culture (KRS-One-2009; Lightstone, 2012; Viega, 2017). Most of the youth I work with only identify with rap music and not other forms of artistry within Hip Hop (e.g., DJ’ing, MC’ing, graffiti, and breakdancing), so I feel it is most appropriate to refer to the genre as rap when working with them and describing their therapeutic processes. This is why I chose to use the word Hip Hop when writing and discussing the overall usage of the genres (especially in reference to research), but used rap when discussing the music therapy work with the youth in Southeastern Ohio (KRS-One, 2009; Schlabach 2015).

As a continuation of my journey navigating the potential for appropriation of Hip Hop culture, I sought out the advice of Hip Hop scholar, Dr. Lavar Pope, to discuss the use of rap in music therapy. Dr. Pope is published discussing rap music as a form of political communication after the Civil Rights Movement and developed this focus and specialization through practice as a professional DJ (Pope, n.d.). I raised my concerns about the potential of appropriation when using the medium of rap with white clients. He expressed that discussions of race in Hop Hop “can get weird, but it is not the end of the world,” focusing mainly on the issue of the N-word and addressing this directly if clients are writing this into their own compositions (L. Pope, personal communication, March, 12, 2018).

So far, my clients have not attempted to use the N-word in their compositions and refrain from using it when rapping along with their preferred song in my practice thus far. I have honestly tried to avoid even considering the possibility of a client attempting to use this word in an original composition in my own head out of fear of misstep, but having this discussion with Dr. Pope has helped me consider how to react in an appropriate, respectful, and therapeutic manner if this situation were to arise. Despite this portion of the conversation with Dr. Pope being a little uncomfortable (most likely due to my own whiteness and privilege), I better understand where I may need to implement a therapeutic conversation regarding the N-Word within the context of the music and draw a clear line with clients if they try to use the N-word when handling rap. I recognize that it is harder for us (the white music therapist and the white client) to understand the implications, impact, and meaning of the N-word because of our whiteness and navigating this within the context of Hip Hop can be difficult. While I will continue to consider how to manage these tough and uncomfortable discussions, I feel discussing the issue and bringing it out in the open with Dr. Pope was incredibly beneficial.

However, Dr. Pope was very moved with the idea using rap as a therapeutic medium for any youth attempting to find their own identities. From what he heard me describing in my work with Appalachian youth who experienced ACEs, he felt the purpose of using rap in music therapy was truly for expression, which harkens back to the origins of Hip Hop as a means to express struggle, identity formation, and create a space for marginalized voices to be heard (L. Pope, personal communication, March, 12, 2018).

Importance of Reflection and Self-Work:

While I have continually sought out supervision and advice from experts/those native to Hip Hop culture, the majority of my process has been reflective and introspective in order to really evaluate my thoughts, feelings, and intentions with using rap in music therapy and the implications of doing so in Appalachian culture. To assist in this process, I underwent a reflexive process outlined by Hadley and Norris (2016). They stated, “It is our contention that musical cultural competence can be achieved only once music therapists begin the process of transformational learning needed for more authentic self-awareness” (p 129).

Music therapists often have Western based backgrounds and music training which often leads them to be ethnocentric musically. Some genres of music, such as rap, are often not included in music therapy university programs because the instructors are unsure of or afraid of how to use the music or might even see rap as inappropriate/contraindicated for music therapy (Hadley & Norris, 2016). Therefore, it is up to the individual music therapist, for the time being, to find ways to incorporate rap music in sessions, when requested or indicated by the client, without colonizing or Westernizing the genre. Our intersectional identities, which includes anything from race, gender, sexual orientation, religion, ability, socioeconomic status, education, age, ethnicity, etc., affect how we experience life and how we carry ourselves in the world. While this is not something that is necessarily enjoyable to face or work through, most music therapists should take time to consider their own cultural identities, potential bias, and how this influences their thoughts, feelings, and attitudes within the music therapy clinical setting (Hadley & Norris, 2016).

As previously mentioned, I initially was very uncomfortable with using rap in music therapy sessions as I saw it to be inappropriate or contraindicated due to the themes of violence, misogyny, drug use, and vulgar language. However, upon further introspective reflection I realized that it was my own bias that was keeping me from using rap within sessions. This bias grew out of my privilege growing up as a white woman in the middle class, which afforded me an education rooted strongly in Western music traditions. My privileged upbringing and fear/unfamiliarity with the genre was really stopping me from using rap in my music therapy sessions. When I realized that it was my issue, I decided to listen to the client rap requests and really delve into the atmosphere, meaning, and message of the music.

Music therapists must strive to focus inward and really reflect and consider why they may be rejecting or avoiding a certain type of music, culture, or interventions within their clinical practice. This can be a challenging, painful, and awkward process, but it often reveals how the therapist’s own culture and identity is impacting the therapeutic process and their music choices within sessions (Hadley & Norris, 2016). I encourage music therapists to evaluate and push themselves to undergo this process even if they do not work with individuals who are that different than their culture of origin. If you become aware of your own values and influential perceptions, then it is easier to realize how one’s communication, actions, and words may perpetuate stereotypes, microaggressions, and bias.

Hadley and Norris (2016) stated, “The culturally sensitive therapist actively seeks opportunities where further personal discernment may be gained. It is for these reasons that we desperately need to seek and foster cross-cultural interactions in our day-to-day lives” (p. 136). It is even more important to attempt reflection and undergo unlearning practices if you are a music therapist who lives or works in an area, especially a rural one, where there might not be the opportunities for daily cross-cultural interactions. Undergoing these practices will help the music therapist to identify is there are any harmful or appropriative music practices within their clinical practice that they might not otherwise realize due to working in an area lacking diversity.

From my own experience, I feel that it is important for music therapists to undergo their own reflexive processes to identify potential bias and ethnocentric music behaviors within their own clinical practices. Because most of my clients, and most of the population in Southeastern, Ohio and I are white (United States Census Bureau, 2017) it could be very easy to skip or ignore the process of self-reflection when using rap in music therapy. However, because of my brief experiences working with individuals indigenous to Hip Hop culture, I chose to undergo these necessary reflexive processes and am committed to not getting stuck in sameness.

The Journey Continues

From my own personal work with the genre, if possible, I make sure to use the original recording of the rap artists when engaging in music discussion, as it is difficult for me to recreate all the intricacies of the tracks on my own, live. Using the recording is one way I try to reduce the possibility for appropriation or improper usage of the genre or culture. Plus, this is a great way to discuss all the aspects of rap including the lyrics, placement of the lyrics, instrumentation, layering, the beats, etc. When engaging clients in rap writing, I consider myself to be in the producer role, primarily defaulting to the client as the expert of their preferred genre and how they would like the music rapped and what kind of instrumentation/mood they would like underneath their words, unless they request help, support, or assistance. I also take the time to be familiar with requested songs and artists requested by clients. When therapeutically indicated, I discuss the history of Hip Hop with the clients in order to inform their rap writing or music discussions.

Viega (2016) discussed his own journey with using Hip Hop in music therapy and discussed three challenges that I feel mirror some of my own conflict with Hip Hop in a therapeutic setting.

  1. Recognizing and Acknowledging—I continue to be mindful of my intersectional identify and aware of my privilege as a Caucasian female from a middle-class background. This affects my relationship with rap music, how I present it, and how it may be received. I also try to be open to acknowledging and discussing how this may affect clients and have sought out supervision and advice from those indigenous to Hip Hop culture.

  2. Appropriation and Gain—I constantly reevaluate and am mindful of why I am using rap in sessions with clients and am careful not to use or appropriate Hip Hop for my own gain as a clinician. I do not push rap music on clients who may not have a favorite type of music yet or have a different favorite type of music. Even while writing this article, I continually reflected upon why I was writing and is this taking advantage of Hip Hop culture for professional gain. Or am I truly seeking to spread awareness and educate about the therapeutic uses of Hip Hop and the struggles of implementing it in music therapy?

  3. Appreciation and Difference—I am open and willing to reflect upon and discuss the difficulties that arise from listening to and implementing rap music within clinical practice. I may be moved, motivated, and filled with emotion by Chance the Rapper or Kendrick Lamar’s music, but must be aware of the differences between our experiences and how this affects my listening to their music. I can be appreciative of the aesthetic, the complexities of the music, and might even relate to some of the emotions expressed within the music. However, I am constantly aware that this is not my story and very different than my experiences.

Continuing the Discussion

I truly believe in the healing and transformative power of Hip Hop because of its history, complex musicality, lyric potential, and therapeutic success when it is a preferred genre with clients. The nature of Hip Hop to provide a voice to the voiceless and the open, yet complex, emotional nature of the music behind the expressive lyrics connects with clients who may feel marginalized by the struggles they face by living in Appalachia. In writing this article, I have continued serious reflection on this issue of appropriation. Maybe it is most important that these clients living in Appalachia are finding a voice in rap and are perhaps using the music as it is truly intended. In the 2018 Netflix documentary “Rapture,” rapper Logic, who is half African American, described why he was driven to create rap music and why he feels empowered to share his past experiences with his family abusing drugs or how he has been hurt so honestly. He said, “because that’s my way to vent. That’s my way to also let other people know that I’ve been there, that I understand, and I know what it’s like” (Dekajlo, 2018).

Music therapists should not reject, be tentative, or be afraid of using rap in their sessions when clinically indicated. I hope the takeaway of this article is that music therapists are less afraid, less discriminatory, and more open to using rap in their sessions. That there is an understanding that music therapists who are not native to Hip Hop culture, should undergo self-reflections, supervision, and read relevant literature in order to prepare to use the genre thoughtfully when rap is clinically necessary in their sessions. If you are going to use rap in your sessions, you should take the time to prepare and actively listen to the requested rap songs in order to better understand the genre and messages the artist is trying to convey. Because it is part of a larger, marginalized culture, the preparation and time needs to be put in to sitting with, appreciating, and immersing oneself in the music in order to be familiar enough to bring it into sessions. The consideration and reflection of the therapeutic purpose of rap in music therapy, as well as other genres or culture that the therapist may not be indigenous to, should continue to be examined and discussed as the field develops.

I recently used the prejudices many people have against rap music as an intervention with a client. She deeply loves rap music but sometimes struggles with anger and how to describe her feelings or advocate for her own needs. We discussed how many people think I should not use rap in music therapy and she rolled her eyes and said, “That’s stupid.” I encouraged her to tell me what she would say to anyone who automatically assumed rap music was “inappropriate” or “bad.” She began to get frustrated, and I encouraged her to use her passion to advocate for why rap music is so important to her. After much encouragement, she stated, “It helps to calm me down and lets me know I can get through the bad stuff. That I’m not in it alone.”

To close, I want to leave you with lyrics from local Hip Hop artists The DysFunktional Family that feel Hip Hop is the best medium to express the struggles of growing up in Southeastern, Ohio:

Conundrums and quagmires, Inspired, it’s rapid fire

Probably be working for steel if all the mills didn’t expire,

Probably be worth it to steal if the stores didn’t close,

probably be serving’ em steel if that was the life I chose […]

I was born in the same state that I was raised,

but don’t say to my face that I wasted my days

cause man I traveled the world and know that I love that

but every time I left home, I wanted to come back

And every time I come back, I wanna just get high

It’s easier to find weed than trying to get by in my town,

Yeah you get how it feels, to see half of your friends all get addicted to pills

so I write for them, spit on the mic for them.

(Schwartzhoff, Hackworth, & Jones 2010)




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