Music therapy: Building Bridges Between a Participatory Approach and Trauma-informed Care in a Child Welfare Setting
Abstract
Despite a growing interest in music therapy within child welfare practice, music therapy practices within these contexts are still under-researched in Norway. The present study takes a collaborative community music therapy practice as its point of departure. We interviewed nine social workers aged 30–55 from four different child welfare institutions about their ideas on the advantages and disadvantages of music therapy as an approach to promote mental health and development. Informants’ ideas about the benefits of music therapy circled around four main themes: a) safety and well-being, b) relationships and mastery, c) dealing with complex emotions, and d) continuity and stability, across situations. Findings show that the social workers’ reflections around music therapy correspond with child welfare issues such as trauma-informed care and participation.
Introduction
Many children and young people in the custody of child welfare services are struggling with mental health challenges. Kayed and colleagues (2015) found that 70 percent of adolescents in child welfare institutions met the criteria for a mental disorder, while Lehmann and colleagues (2013) found that the same was true for over 50 percent of foster children aged 0-12 years. For many of these, their problems are related to a trauma history. About 70 percent of children and young people in institutions had experienced traumatic incidents in their upbringing, and the same was true for over 50 percent of foster children (Kayed et al., 2015; Lehmann et al., 2013).
Norwegian child welfare systems need practices that can improve the quality of participation in child welfare work (Christiansen et al., 2015). Some scholars have demonstrated that the system is not sufficiently designed to facilitate dialogue and communication amongst young people and their supporting adults (Kayed et al. 2015). Others have even implied that the rules, procedures, and programmes provided by the child welfare system may actually hinder participation processes (Tjelflaat & Ulset, 2007).
Previously, the first and third author of this article have conducted research on how music therapy can function as an approach to create well-being and emotional connectivity, structures for learning and participation, the experience of belonging in a community, and the ability to speak and be heard as a group (Krüger, 2012; Krüger & Stige, 2014; Krüger et al., 2014). In Norway, music therapy has been used in the context of child welfare institutions and in foster care services in some municipalities of the country (Krüger & Stige, 2015). Music therapy has been facilitated based on the acknowledgment that children and young people in custody of child welfare services have rights stated in the United Nation’s Convention on the Rights of the Child (UNCRC) – it may support these children’s given rights of protection, to be seen, and to be heard and understood in questions about leisure time, school, and decision making. UNCRC rights are embedded in Norwegian legislation, and in the Norwegian Child Welfare Act, we find the right to participate exemplified in Chapter 2 § 3. Children should be given the chance to express their meanings and preferences through both verbal and non-verbal communication (Norwegian Child Welfare Act, 2018).
Music therapy has a long tradition of implementing practices that facilitate both verbal and non-verbal communication. In the context of Norwegian music therapy, a resource and community-oriented tradition is strong, with a clear sense of the importance of user-involvement (Rolvsjord, 2010; Ruud, 1998; Stige & Aarø, 2012). In recent national guidelines for the treatment of psychosis and substance use problems, music therapy is recommended (Directorate of Health, 2013,, 2016). The evidence basis for music therapy as treatment for psychosis is strong, not the least in terms of effects on motivation, emotional awareness, and social interaction (Geretsegger et al., 2017). The aforementioned guidelines clarify that treatment must be given by a therapist with approved music therapy education, which in Norwegian context implies a 5-year university degree (master’s level).
A review of music therapy applied in work with adolescents (Gold et al., 2012) showed that music therapy could promote motivation, develop social relationships, and understanding of their own emotional lives. Music therapy can provide an alternative to traditional counselling therapy, especially because it works when the need is to establish contact with children and adolescents (Austin, 2010; Bolger, 2013; Gold et al., 2004; Hussey et al., 2007). Because many young people are occupied with music in general, music therapy can help promote an environment that creates well-being and happiness (Jonsdottir, 2008; Williams, 2014), for example in school or institutional contexts (Rickson & McFerran, 2014; Sullivan, 2003).
Research literature shows that music therapy can provide special opportunities in relationships with children and young people (Jacobsen & Killén, 2015). A safe relationship with the music therapist can help children and young people develop self-esteem in the face of other children and adults, for example, following a music therapy course (Kim, 2015; Pasiali, 2013; Trondalen, 2016; Zanders, 2015). The Norwegian psychologist and music therapist, Unni Johns (2017), has studied the relationship between music therapy and experiences of childhood trauma. She emphasized music’s potential to help children get in contact with their own feelings.
The data presented in this article were collected in continuation of Norwegian studies of young people's own experiences with a participation-oriented music therapy in the setting of a child welfare institution (Krüger, 2012; Krüger & Stige, 2014; Krüger et al., 2014). The aim of the present article is to supplement the young person’s own narratives by exploring professionals' experiences with music therapeutic practice. We have chosen to focus on the experiences of social workers, as they represent practice-based "field-oriented" knowledge and are important partners for the music therapist in the community-oriented practice we have chosen to study (see description of practice below). Accordingly, our main research question is: How do social workers describe their experiences with music therapy practices in child welfare setting?
Method
Research Approach
The study is based on qualitative research methodology. Data were collected through individual face-to-face, semi-structured interviews (Kvale, 1996) and by the use of a hermeneutical research (Alvesson & Sköldberg, 2009). The interviews followed a “funnelling approach” (Guba & Lincoln, 1981), which, in short, describes as a process where the interviewer first asks general questions, before proceeding to structuring and more focused formulations. We developed an interview guide which focused on the social workers' experiences of music therapy as an approach for working with children and young people at child welfare institutions, based on topics such as music therapy, leisure, mental health, popular culture, participation, school, institutional aspects, and relationships with peers and adults. The Interview Guide was prepared based on the UN's 2009 Guidelines for the Alternative Care of Children. The study was approved by Norwegian Centre for Research Data (NSD). All informants were informed of the purpose of the study, the duration of the interview, and of various ethical aspects such as anonymity and the possibility to withdraw from the research project. All participants signed an informed consent form. All individuals who were asked to join gave an affirmative answer.
Informants
We interviewed nine social workers between the ages of 30 and 55, who were selected following a strategic approach (Kvale, 1996). We chose participants with experiences and roles we assumed would enable them to illustrate the relevance of music therapy, as seen from a social worker perspective. Informants were in the roles of department leaders or foster care parents, and all had contact with children and adolescents who had participated in music therapy. They had experienced the effects of music therapy in different ways, either from participating in audiences at events organized by music therapists, or from talking with children and adolescents between or relatives who had received music therapy. The group they drew their experiences from were between 12 and 18 years old and had attended music therapy for a period of more than three months. Informants came from four different child welfare institutions, both in the public and private services.
Procedure for the interviews
The first author conducted the interviews at the workplaces of the selected informants. Most interviews lasted about 45 minutes. The conversation followed the themes from the interview guide, but the interviewees were allowed to speak fairly freely around them. The interviewer made it clear to the informants what topics it was particularly interesting to talk about, such as the impact of music therapy on participation, aftercare, and health. It was also made clear that the informants could illustrate their answers with examples from practice. All participants were interviewed once.
Data Analysis
The interview data were transcribed from an MP3 player to a Word file. Three hundred fourteen pages were transcribed with the help of master students in music therapy. Data were then analysed, emphasizing a hermeneutical approach and an abductive analysis strategy in which the designed subjects were sought in the light of current theory (Alvesson & Sköldberg, 2009). The analytic process can be divided into four phases: 1) organizing and coding the data, 2) finding corresponding patterns in the data material, 3) linking themes to theory, and 4) assessing implications for practice and research. The first and third authors were responsible for the first two steps of the analysis process, while all three authors have collaborated on the last two steps of the analysis process. In the first two stages of the analysis process, the first and third authors discussed which codes to use and follow. Codes were identified by searching corresponding patterns in the data material that created relationships in different ways. Corresponding patterns gradually evolved into themes presented in the findings section, for example, music therapy provides the opportunity to process complex emotions. Themes were then linked to theory and assessed in relation to implications for practice and research. In the process of analysing the data, it became apparent for the authors that it could be relevant to illuminate findings in relation to perspectives from trauma-informed care (Bath, 2015). The second author was then invited into the analysis and writing process. In the analysis process, the authors repeatedly returned to the original data material in order to look for complementary data.
Transferability and credibility
Participants are not representative of a larger population. We therefore cannot argue that our findings are generalizable in an empirical sense. When we discuss the empirical evidence in relation to theory, this can still be regarded as an "analytical" or theoretical generalization (Andersen, 2013).
The first writer is involved in the practice of music therapy and child welfare that the social workers talk about. The double role as a participant and researcher provides opportunities but also represents some challenges. The advantage is that the interviewer is close to the field in question, and also to the people interviewed. The role as an “insider” provides some kind of “hands on” integrity that might enrich the data (Hammersley & Atkinson, 2007). Challenges are partly due to the fact that proximity to the field can also decrease the quality of the interview, for example, because the informants may hold back scepticism to music therapy or avoid reporting negative experiences. Proximity can also influence reflexivity in the analysis work. To compensate for such pitfalls, a reflexive dialogue with informants and between co-authors was emphasised. The informants were given the opportunity to read through and comment on the full answers, a process that could help ensure credibility (Seale, 1999). Despite the fact that the informants were given the opportunity to read through and comment on the answers, few of them chose to do this.
The music activities
The social workers discussed the various music activities that children and adolescents had participated in. The following case example may give valuable a background for the reading of the article. The case example is taken from the setting of a music workshop where children and adolescents can receive instruction on instruments, write songs, play together in rock bands, or perform in concerts. Music therapy activities are offered on an individual and a collective basis. Often individual music activities are offered as a preparation for participation in a group. It is also possible to invite family members, social workers, or teachers from school as participants or as audiences. Activities consist of many different tasks, with possibilities for the development of many associate social roles and social identities. It is possible to take different positions and roles in a range from being a more active to being a more passive participant. The passive participant might have a prominent role, such as the audience, sound technician, or stage worker. The active participant can get into the role as an actor, guitarist, singer, or rapper.
The example (see excerpt below) presented below is written by an adolescent boy called Ali. Ali 18 years old and has a multicultural background. He has lived in Norway for about three years, most of the time in various institutions. As a 15-year-old boy, he fled to Norway from his home country as a refugee. He travelled alone and during his journey he experienced many dangerous and unpleasant situations. During the working phase of music therapy, Ali brought lyrics to the session. Through a collaborative process of trying and failing, Ali discovered a way he could sing the lyrics. First, he sang in his mother tongue, and later in Norwegian. Based on the collaborative process, recordings were made, and performances held. Ali used his songwriting to express his feelings and thoughts. He wrote at home and brought lyrics to the music sessions. We used our time to look at grammar and fix language errors. He worked with lyrics lasted for months before Ali was satisfied. He used songwriting as a form of a diary account, but he also had ambitions of being a songwriter and performer. Both of the goals were taken into consideration. Ali told the music therapist that it was easier for him to express himself through a song than through a conversation. Writing songs helped him to articulate thoughts that otherwise would be difficult to communicate directly through conversation. The following song was written in music therapy.
Translated to English:
Traveling alone, many bad days
My mind keeps wandering, my head keeps spinning
Traveling alone, many bad days
My mind keeps wandering, my head keeps spinning
I travel many miles through foreign countries
I can’t stand still, I am split in two
My head explodes, and my thoughts are torn
Everything is going bad, now I have to pass
Left my mum and dad, and every friend that I had
I miss them like hell, can I please come back?
Not so lucky in life, can I choose again?
Traveling alone, many bad days
My mind keeps wandering, my head keeps spinning
After highlighting examples from practice, we now return to a presentation of the interviews with the social workers.
Central themes in the interviews
The overall finding was that the social workers experienced music therapy as an important and useful therapy for young people in child welfare institutions. This was emphasised by all informants. Several also had experience that not all of the adolescents could or would make use of the approach. Some of the informants reported that some of the adolescents did not like to be part of activities organized by adults. Other reported that conflicts in the institutions made it difficult to facilitate participation.
Through the analytical steps mentioned above, we found that the informants' views on the usefulness of music therapy mainly focused on the following four themes. These themes were clear in the empirical material, and we highlighted them here due to their relevance for UNCRC issues such as the rights to participation and protection (United Nations, 2009).
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Can help establish the sense of safety and well-being
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Provides the opportunity to establish relationships and experience of mastery
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Provides the ability to process complex emotions
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Can contribute to continuity and stability over time and across situations
Safety and well-being
All informants were concerned with how music therapy in different ways offers the young people a safe environment for contact with peers and adults, and a way to participate in positive activities. Some emphasized that music therapy creates a framework for adult contact through relations experienced as stable and predictable, for example, by organizing music therapy on a weekly basis, in the form of exercises in music workshops, music cafes, rehearsals, or studio recording.
D4: Thus, in relation to my own experiences, it is first and foremost that they (the adolescents) have a place to go to where they meet adults who take care of them - who see them. In a vulnerable start-up phase, it may be particularly important to maintain sense of continuity.
Young people who have trouble regulating their own feelings are vulnerable if appointments are violated or not maintained.
D5: He could be furious if music therapy was postponed or moved, and not all the messages he received came through. If we had to say to him one Wednesday that today you're not going to [the name of music therapist], then he could go completely in black.
Music therapy is developed through phases where contact establishment and safety-creating activities are more prominent in the beginning of a music therapy course than later, as this quote shows:
D4: In a start-up phase, they need clear boundaries in relation to now we are going to do that and so. Eventually they get warmer in the sweater and safer in the setting. To achieve this we must have a dialogue with them.
Several informants emphasized that the safety that is established through music therapy can provide grounds for young people to trespass their boundaries.
D2: When we talk about conflicts that we may have had in school or at home - when we are very negative in the daily routines, we may have received a feedback that is a bit surprising, that it actually works better with the adolescents than we thought in the first place. They may have worked well with others in such settings [music therapeutic settings].
Some of the informants told us that the safety and well-being established by participating in music groups with peers, for example through participation in a band setting, can lead the adolescents to acquire new friend relations in a safe environment that is harmless to them.
D5: It does not help that they have social skills inside the house and in the institution. They must go out and spend time with other young people and adults. Everybody knows that it's hard to get new friends, and at least when you're 15-16. Getting into a (music) group can be more harmless to them.
One informant was concerned that the establishment of sense of safety through music therapy often starts with one-to-one time may work as a preparation for participation in group session. In one-to-one session, the adolescents can acquire skills they can use later when they meet others. Experiencing mastery in a safe environment, such as participation in one-to-one hours, can be a basis for well-being, for example, an interaction group with other young people.
D3: If he is to succeed in music, I think at least he must start with one-hour, not with others. He needs to get some kind of experience of mastery before he dares to take the step further. You cannot put him into a group of six beginners on the guitar.
One informant mentioned that music therapy facilitated the establishment of a safe arena where the young people can be themselves.
Relationship and coping
All informants addressed how participation in music therapy activities was suitable for establishing relationships, both with adults and with peers. According to informants, relationships in music therapy were established by the young ones able to unfold in the music and thus show new sides of themselves. They also got valuable feedback on their own way of being, both from peers and adults. The information we got from these differs from the information obtained by participants of music therapy (Krüger et al. 2014). The latter said it was inspiring to participate in something new and exciting and that music therapy give them challenges for them to work with something they can master. In various ways, music therapy was described as establishing arenas where the young people showed courage in the community and where the individual can perform aspects of themselves that are not just perfect. The music therapy arenas developed as a gradual approach, from looking at others who dare, to eventually trying themselves, like this informant expressed it.
D6: The girl has grown a lot to get involved with the music. She has had a steep learning curve in relation to learning to play instruments and being able to participate in interaction with other youngsters.
Several of the informants emphasized that music therapy was suitable for creating arenas where adults get perspective on youth resources.
D4: In music therapy, they can exercise in relation to social skills, and they can recognize themselves in the stories of others. They learn from others who are in the same situation living in a foster home. Their own problems become something recognizable for others. Most people have little faith in themselves. They need to build faith in what they can do, believe in themselves and that they can master something in line with others.
Through music therapy, the adolescents can help each other and create belonging to a community of peers. Maintaining relationships with peers and adults becomes part of the relationship creation and mastering experience. This is important, as many have experienced severe losses in their childhoods.
D5: So, [music therapy] can at least be part of this mastery bit, as we have talked about. Some of them will experience loss as they interrupt school, lose friends or lose contact with close family.
Some of the informants said that music therapy may enhance participation in activities that are beneficial to them.
Dealing with complex emotions
In various ways, all the informants discussed how the therapeutic music activities helped the young people to express and process complex and difficult emotions. They were concerned about how activities like improvisation and song writing could help the young people express what is difficult to say, to express it elsewhere than in foster homes or institutions, and for people other than environmental therapists or foster parents. Informants’ experiences were that expressing emotions becomes easier in music therapy, where they are given an arena where storytelling is part of the community's activities. Several of the informants thought that the youth living at the institution needed an extra valve to express difficult emotions.
D7: Music take away the therapeutic aspect of it, I think. [The music therapist] gets into the private and personal arena, without being a psychologist.
Some informants say that in music therapy, the adolescents can tell about what has happened to them and gain recognition for their own link to the community.
D2: The [youngsters] are seen and heard, and they have the opportunity to put words on parts of what they are going through.
Another informant told us that music therapy helped the adolescents express sadness, whether it concerns sadness of lack of contact, or loss of contact with their own parents. The music therapy provided tools to deal with grief.
D8: The music therapy had an impact on her situation. It was very important that the foster father was playing the drums. She was told that she probably will never move back to her mother and father. She was very sad. And, as a result, she walked up to the computer and started writing a song lyric. I think that with the music therapy, she got a tool she can use to "deal" with her sorrow.
One informant was concerned with how music therapy may function as a channel where emotions can be let out.
D7: I think that music therapy is a complementary expression in terms of language and conversation. Yes, a channel where you can get out of things, express feelings, or get in touch with things that you cannot get in touch with if you talked about it.
The music therapist also helped the adolescents understand their own feelings, such as rage.
D6: They (the adolescents) discover bands like "Green Day" or (the genre) "Death Metal". Learning to like such bands help them deal with rage or anger. But they are still alone with the feelings in a way. When the music therapist is with them, they get help to understand their experiences in a community.
Continuity and stability, across situations
All the informants talked about how music therapy work over time. They shared various arguments for this viewpoint. One argument was that music is an important part of the adolescent’s everyday lives. Because of the availability music provides, it is already available as a resource in an effort to create relationships and create positive environments for upbringing. Another argument was that music therapy is an accumulative process, where the individual first learns to master individual skills, such as playing guitar or singing, and then gradually participates in more complex collaborative processes where other participants are involved. The informants further stated that the music therapy processes created ripple effects that had implications beyond the single-action measure. As such, music therapy may potentially mobilize resources across a wide span of different situations and contexts. Experiencing continuity and stability in a music therapy setting, may help the adolescent master a school setting or a job-like situation.
D8: It's amazing that they get in contact with such an arena. They get a lot of issues with them that can be transferred later in life into other arenas, such as school, workplace and in the various local community settings.
Some of the informants described that the music therapist could be a significant support person in transitions between locations, for example in context of an aftercare situation.
D4: As I see it, music therapy should be a part of the aftercare when music has been important at the institution.
Several informants described situations where music therapy had been integrated as part of meetings, such as group meetings or treatment meetings. In various ways, such situations affect the possibility for stability and continuity. Because the music therapist met the adolescents in situations characterized as well-being activities, the young person may be able to convey resource-oriented aspects by themselves and to demonstrate new skills. This is particularly important when important decisions are to be taken.
D4: Tomorrow we will have a staff meeting for all employees at [name of institution] where she [the music therapist] and [name of adolescent] will attend. She [the adolescent] is going to sing and she will show a music video (made in music therapy). I think that experiences in music therapy may have transfer value to other people who have been in similar situations.
One of the informants said that music therapy provides opportunities for the young people to act something different from potentially stigmatizing roles. Creating variation in role patterns can contribute to the experience of continuity and stability when the adolescents are to act across different situations.
Discussion
Our findings correspond to a large degree with findings from previous qualitative studies on young peoples’ own experience of music therapy in the setting of Norwegian child welfare. As mentioned in the introduction, several studies show that participation in music therapy can create a sense of well-being and emotional connectivity, structures for learning and participation, the experience of belonging in a community, and the ability to express oneself and to be heard as a group (Krüger, 2012; Krüger & Stige, 2014; Krüger et al., 2014). The social workers in our study pointed to similar aspects, but they emphasized to a greater extent dimensions such as music therapy’s potential to create a sense of safety, to make it easier to deal with complex emotions, and to establish continuity and stability across situations.
As addressed in the introduction, many young people in child welfare institutions have lived in potentially traumatising caring environments. Based on their experiences, informants in our study believed that music therapy may be particularly fruitful for adolescents with such a history. As such, music therapy is highly consistent with what recent developmental trauma perspective emphasise (Nordanger & Braarud, 2017). Derived from a developmental trauma perspective, Howard Bath (2015) suggested that our efforts to facilitate these children’s and adolescent’s development must rest on “Three pillars of trauma-informed care,” which are safety, relationship, and sense of mastery. As evident from above, this corresponds well with our informants' ideas of how music therapy works through its potential to promote safety, good relational experiences, and coping skills. Also, in accordance with Bath's model, they see these three dimensions as mutually dependent, but with safety as the foundation and necessity for the other two. Music therapy offers contact with safe adults and the opportunity to establish relationships with peers, which in turn allows them to unfold and use their creativity.
Several of the informants emphasized how music therapy in this way may provide a basis for learning. Trauma research shows that children exposed to continuous threats in their environment often live in a state of constant alertness and are oriented towards guarding themselves (Nordanger & Braarud, 2017). Being in such a state supresses the ability to learn –in neurobiological terms the “survival brain” supresses the "learning brain" (Ford, 2009). Nordanger and Braarud (2017) explained the same by saying that these children typically develop at a narrow "tolerance window" for affect; they are easily triggered into a state of alarm, where they are overwhelmed by negative emotions. In this perspective, the informants’ impression of how safety provided through music therapy could serve as a springboard to challenge one’s own borders and explore new personal sides, makes sense. The informants explained how music therapy could help expand the young people’s window of tolerance, which is a goal for any trauma therapy as well.
The way the informants reflected on music therapy’s potential to promote continuity and stability makes sense in a developmental trauma perspective as well. In this perspective, children and adolescents need an "overdose" of good relational experiences for a long time to compensate for what they have lost in earlier stages of childhood (Nordanger & Braarud, 2017). Unfortunately, many of them have experienced the opposite. Due to their threat orientation and emotional reactivity, these young people easily provoke and push others away so that their experiences of rejection are repeated. If music therapy can provide a tool that makes it easier for them to establish stable relationships and open up new social arenas where more such relationships can be established, it could imply substantial health gains. Young people’s possibilities for participation in local and broader communities could be strengthened.
Research and practice taken from music therapy discourses makes sense in a developmental perspective. Many scholars believe that interventions for children and adolescents should seek to recreate as much as possible of the stimulations and relational experiences that promote development early in life, also in neurobiological terms (Nordanger & Braarud, 2017).
In practice, this means recreating patterns of good rhythmic and somatosensory interaction experiences (Ogden, Minton, & Pain, 2006; Perry & Dobson, 2009), which is precisely what music therapy offers. Informants' stories are thus compatible with recent trauma theory: safe children can unfold and participate in activities in new contexts.
In the implementation and evaluation of approaches bridging trauma-informed care and participation, it is important that there is continuity in the activities. We suggest that an integrative perspective can be developed from an ecological model, in which the transactional interaction between the person's participation, the development of the organism, and the potential of the environment are considered (Cicchetti & Lynch, 1993).
The informants' experiences, of how music therapy makes sense on the basis of recent trauma theory, is interesting but remains to be tested empirically. A limitation of the study may be that it is likely that several of the informants are familiar with trauma-informed theory, so that the statements not only illustrate the relevance of music therapy as trauma treatment but also reflect the theoretical discourses that inform the informants’ thinking more generally.
Conclusion
The informants' experiences indicate that music therapy can be an important contribution to child welfare work in the bridging of trauma-informed care and participatory practices. However, not all children and young people benefit from music therapy, and there may be situations where other approaches should be chosen. We therefore hope that music therapy will be explored further as a relevant treatment for mental disorders and social challenges in children and adolescents who have many traumatic stresses in their upbringing.
There is need for more studies of user experiences, studies on the effects of music therapy on trauma-related problems, studies of how music therapy can be adapted to different contexts and group needs, and there is need for theoretical studies that can integrate our understanding of the development of the organism, the environment, and the person's participation in music therapy.
Editorial Note
This article is a rewritten and edited version of an article originally published in the Norwegian journal Tidsskrift for Norsk psykologforening (Krüger, et al. 2017).
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