What is music therapy? A survey study of public awareness and perceptions of the profession

Authors: Sarah Morgan, MA [email protected]

Dr Jane Humphreys, MA, MSc, PhD [email protected]

Dr Catherine Warner, MA, PhD [email protected]

The authors declare no conflicts of interest with respect to the authorship and/or publication of this article.

The authors received no funding for this research.

1 Abstract

Since emerging in the 1940s, the music therapy profession has grown to an estimated 15,000 qualified music therapists practising in 55 countries across a diverse range of contexts (e.g. Tsiris, 2015; WFMT, 2020). Yet music therapists feel the public have a poor understanding of the profession (e.g. Kern and Tague, 2017; Pearson, 2018); to date, however, there is no empirical evidence to support such claims. The current study sought to address this gap in the literature by conducting an online survey to explore public awareness and perceptions of music therapy. Quantitative and qualitative methods were used to analyse data from 359 non-music therapists aged 18 or over, of whom 46% were from the UK, 18% from the US, and the rest from 37 other countries. Results revealed that participants appreciated the therapeutic value of music but lacked awareness and understanding of professional music therapy services—this paper argues that such poor understanding is likely to reduce people’s prospects of seeking the service. Therefore, governing bodies of the profession should focus their attention on improving public awareness of fundamental aspects of music therapy, and helping the public distinguish between the profession of music therapy and a therapeutic use of music.

Key words: music therapy, public awareness, public perception, uptake, survey

2 Introduction

In March 2018 Kalee Oravec posted a blog titled “To the Music Therapist Who Saved My Life” (Oravec, 2018). The blog was written while Kalee was struggling with an eating disorder, and she describes feeling empty, and wanting to die from malnutrition. She writes about meeting a music therapist who helped her make positive changes to her psychological and physical health. The music therapist used song lyrics to inspire Kalee to engage with supressed emotions and used music as both a distraction from emotional pain and as a motivation to challenge Kalee’s thinking and behaviour. In her blog this young anorexic woman thanks the music therapist for making her laugh, distracting her from thoughts of calories and suicide, and helping her to “finally feel something after feeling numb for so long”. Kalee claims that without the care and compassion of the music therapist she would not be alive today.

Other accounts of self-proclaimed life-changing music therapy experiences have been shared online, each testament to powerful services provided by music therapists (e.g. Cumming, 2018; Kaplan, 2013; NAMI, 2018). The music therapy profession indeed exists to help people who are living with trauma, disability, or physical or mental illness through supporting their psychological, emotional, physical, cognitive, communicative and social needs (BAMT, 2020). As such, music therapy could be helpful to the 1.1 billion people across the world suffering from mental health or substance use disorders, or the 1 billion people that experience a form of disability (Ritchie and Roser, 2018; World Bank, 2018), as well as people affected by issues such as bereavement or life- threatening illness. The point to note here is that it is therefore remarkable— concerning, even—that music therapists feel the public have little awareness or understanding of what the music therapy profession actually is (Astom, 2016; Kern and Tague, 2017; Pearson, 2018).

It is possible that members of the public who have never used therapy services have limited awareness of therapies in general—perhaps drawing knowledge only from dubious mainstream media portrayals of Freudian-type couch therapy or unethical practice (Robison, 2013). And music therapy, being comparatively young and less

3 established as a profession, receives considerably less mainstream publicity than traditional talking therapies. Furthermore, the music therapy profession contends with thousands of years of mankind viewing music as a ‘healer’ (Horden, 2017; Levitin, 2006). While this appreciation of music as medicine is not undesirable, it does suggest people might have little consideration that the music therapy profession offers anything more specialised than their own personal use of music for enjoyment and emotional stimulation. Yet to date no research has asked the general public what they understand about music therapy: the current study therefore provides the first investigation into public awareness and perceptions of the profession and, in doing so, it sheds light onto barriers to uptake of the service.

The growth of music therapy The discipline of music therapy has grown from an experimental use of music with American and British hospital patients in the 1940s to an evidence-based practise used internationally across a vast range of settings with diverse populations. The United States was the first country to offer an academic degree in music therapy when Michigan State University launched its curriculum in 1944, and the United Kingdom followed in 1968 when the Guildhall School of Music and Drama opened a full-time post-graduate music therapy course (AMTA, 2020; Trepper et al., 2013). Training programmes have since been introduced in countries across the world. By 2020 there were nearly 250 institutions believed to be offering music therapy training programmes across 44 countries and more than 15,000 music therapists practising across 55 countries (CBMT, 2020; EMTC, 2020; Schmied, 2014; Tsiris, 2015; WFMT, 2020).

To support this growing number of music therapists and training programmes, associations have been created to advocate for the use and development of the music therapy profession. The first such formal organisation was the National Association for Music Therapy (NAMT), founded in 1950 in the United States. NAMT‘s objectives included advancing research, distributing information, and developing education and training standards for those studying nationally to work in the profession (Michel, 2000). The remit of current music therapy associations is largely similar although, with several countries having now established national standards for training and regulations for practise, there is an emphasis placed on publicising music therapy (Moore, 2015;

4 Register, 2013). By 2020 approximately 115 music therapy associations were in operation (Tsiris, 2015; WFMT, 2020).

In addition to associations operating nationally, there are organisations working to grow awareness of the profession across larger regions, specifically: the European Music Therapy Confederation (EMTC) and the World Federation of Music Therapy (WFMT), established in 1989 and 1985, respectively. In 2014 EMTC initiated an annual European Music Therapy Day which directly targets increasing public awareness by encouraging music therapists across Europe to hold workshops and open house events to promote their profession (EMTC, 2020).

Public perceptions of therapies Despite this increasing number of music therapy associations working diligently to promote the discipline, the general public appear confused about what the term “music therapy” actually means (Holmes, 2012; Pearson, 2018). And worryingly, research indicates that even some professionals working alongside music therapists do not accurately understand music therapy or the role of the music therapist (Astom, 2016; Daykin et al., 2007; Ferrer, 2017). One domain in which this confusion seems particularly prevalent is the medical profession, with notable accounts of nurses administering recorded music as part of their care and referring to this use as music therapy (Pearson, 2018). As yet no research has sought to specifically investigate the general public’s misconceptions of music therapy. One reason for this neglect could be the young age of the profession; researchers likely find it more pertinent to first understand the experience and effects of music therapy before widening their research to consider the impressions of those outside of the discipline. And, of course, articles evidencing beneficial outcomes of music therapy are important for boosting the relevance and credibility of the profession. It is vital, however, to note that the core reason for striving to raise the profile of music therapy should not be to increase professional status but rather to allow people that could benefit from music therapy to become aware of a valid therapeutic option with unique characteristics (Barrington, 2008; Procter, 2002).

5 The lack of research into public views on music therapy does not equate to a lack of interest in public perceptions of therapies generally; to the contrary there are a number of studies which investigate public perspective. For example, a review and meta-analysis of 162 population surveys published between 2000 and 2015 showed that global attitudes towards seeking psychiatric help for schizophrenia and depression improved over a 25-year period (Angermeyer et al., 2017). Other studies have explored public perceptions of therapies with regard to the impact of stigma on seeking treatment for mental health issues (e.g. Clement et al., 2015; Corrigan, 2004; Vogel et al., 2007). No studies, however, have investigated public perceptions of music therapy.

Applications of music therapy Today music therapy serves a diverse range of clients in a wide spectrum of settings, including mental health centres, schools, dementia and stroke clinics, hospitals, prisons, addiction rehabilitation clinics, and care homes. Moreover, a growing body of evidence supports music therapy’s effectiveness in numerous domains, for example: Standley’s (2012) meta-analysis of research regarding music therapy in neonatal intensive care units found that the intervention is highly beneficial for premature babies in promoting both stress reduction and effective sucking for feeding. Music therapy has also been shown to stimulate social, emotional and motivational development in children with autism (Kim et al., 2009), while a meta-analysis of randomised controlled trials evaluating music therapy for terminally ill patients found that the intervention can reduce pain, anxiety and depression, and improve quality of life (Gao et al., 2018). An analysis of literature published between 2006 and 2016 concluded that music therapy has the potential to reduce cognitive decline, improve neuropsychiatric symptoms, and enhance quality of life for people living with dementia (Fang et al., 2017). And furthermore, the neurologic branch of music therapy (NMT) is used to help facilitate cognitive, sensorimotor and speech and language rehabilitation for people affected by brain injury, stroke, or neurodegenerative disorders such as Parkinson’s disease (e.g. Thaut, 2013; Thaut et al., 2015).

The array of literature evidencing music therapy’s use across such a variety of domains suggests that this creative therapy might be applicable in more settings than traditional talking therapies. For instance, the ability of music to have emotional impact

6 and to act as a safe vessel for that which is difficult to verbalise makes music therapy a powerful option for people dealing with psychological trauma, or for people needing an alternative method to talking to process difficult emotions (e.g. Heath and Lings, 2012). Music also activates multiple areas of the brain making it a useful tool for neurologically- based therapy (e.g. Thaut, 2013), meaning music therapy can help people who physically can’t talk, through the use of the aforementioned NMT methods. And furthermore, music can be used by a trained professional to engage people who are non- or pre- verbal—people for whom talking therapies would be inappropriate—in expressive and healthy interaction.

Given the evidence supporting music therapy as an effective intervention, it is discouraging that music therapists feel the public have poor understanding of this profession (Pearson, 2018). Public perceptions of any therapy are integral for uptake (Angermeyer et al., 2017; Clement et al., 2015; Silverman, 2013), and as such it is important and timely to examine what impression music therapy is making upon people outside of the discipline. The current study is designed to capture an initial snapshot of public awareness and perceptions of music therapy, and explores the following research questions: How aware are the public of music therapy? What are public perceptions of music therapy? And what are possible barriers to uptake of music therapy?

Method Participants The sample size was set at 385 participants (using Cumming’s Exploratory Software for Confidence Intervals [2017] and specifying a 5% margin of error at a 95% confidence level). In total, 359 non-music therapists completed the survey. A further 27 participants were excluded from the dataset as they claimed to have experience working or training in music therapy: as such their data would not aid the research aims to better understand the general public’s awareness and perceptions of music therapy. Females represented 72.7% of the sample, while the majority of participants (40.4%) were aged 18-25, and nearly half (46.0%) resided in the UK. See Table 1 for participant demographics.

7 All participants were over 18 and there were no geographical restrictions to taking part in the study; participants did not receive payment.

Table 1 Participant demographics % Count

Gender Female 72.7 261 Male 25.9 93 Other 1.4 5 Age-group 18-25 40.4 145 26-35 25.9 93 36-45 10.6 38 46-55 13.6 49 56-65 7.2 26 66+ 2.3 7 Prefer not to say 0.3 1 Work status Employed 44.0 158 Unemployed 7.5 27 Student 42.6 153 Retired 3.9 14 Prefer not to say 1.9 7 Employees’ sector of work (n = 158) Education 16.5 26 Healthcare, allied health professions 12.7 20 Academic and research 7.6 12 Other 63.3 100 Students’ area of study (n = 153) Psychology 32.7 50 Business management & economics 32.7 50 Other 34.6 53 Highest level of completed education None completed 3.1 11 GCSE 4.5 16 Vocational training 3.3 12 A-Level/AS-Level 9.5 34 Undergraduate degree 40.4 145 Master's degree 24.8 89

8 Doctoral degree 3.1 11 Prefer not to say 1.9 7 Other 9.5 34 Country of residence UK 46.0 165 USA 18.1 65 Netherlands 11.1 40 Rest of world 24.8 89

Study design and instrument The study used a non-experimental, exploratory online survey design. In the absence of an existing instrument for measuring public perceptions of music therapy, the survey was created specifically for this piece of research. Question development was influenced by the researcher’s prior experiences of conversations with people not involved in music therapy, most of whom had demonstrated a limited and confused understanding—or a complete lack of awareness—of the profession. Indeed, such limitations in public knowledge of music therapy are noted in some of the profession’s literature (e.g. Kern and Tague, 2017; Ferrer, 2017; Pearson, 2018). For the current survey study, the researcher created questions to address three main areas of interest: public awareness; public perceptions; and (barriers to) uptake of music therapy. These areas form the basis of the study’s three research questions. To provide objective validation, the draft survey questions were emailed to two non-participating, qualified music therapists who gave suggestions for modifications, based on their expert knowledge of the profession. Changes were subsequently made: one question was omitted as it had no function in answering the research questions, and some ambiguous terminology was clarified. The survey was programmed using Qualtrics® software and a pilot version was trialled via Reddit’s survey distribution platform, SampleSize (https://www.reddit.com/r/SampleSize/). A total of 38 people participated in the pilot. Some question response options were subsequently rephrased due to participants

9 noting confusion over the wording, and minor refinements were made such as formatting font. None of the pilot responses were included in the final data. The final survey (available as supplementary material) consisted of two sections: the first was designed to collect participants’ demographic data and the second section sought information about music therapy. Ethical approval to conduct this research was obtained from the Low Risk Board of the University [removed for anonymous review].

Procedure The survey link was distributed on the following online platforms: Survey Circle (https://www.surveycircle.com/en/), Survey Tandem (https://www.surveytandem.com/ #/), Reddit https://www.reddit.com/r/SampleSize/), Call for Participants (https://www.callforparticipants.com/), Facebook (https://www.facebook.com/), and Instagram (https://www.instagram.com/). As such, participants were recruited through opportunity sampling, based on whether or not they saw the survey online and chose to complete it. Due to the routing programmed within the survey, participants saw either five or six of the demographic questions and between eighteen and twenty of the music therapy questions. Randomisation was assigned to the response options of nine questions to reduce potential response bias. Finally, participants were debriefed on the aims of the study. Data collection occurred over ten weeks at which point the survey was closed.

Data analysis

Quantitative data were exported from Qualtrics® into an Excel file then copied into the Statistical Package for the Social Sciences (SPSS, Version 24). Data were analysed using descriptive and inferential statistics. Qualitative data from the three open-ended questions were exported from Qualtrics® and organised into a separate Excel file. Data were analysed using thematic analysis (Braun & Clarke, 2006).

10 Results

The anonymised quantitative and qualitative data from this study are available to view on the Open Science Framework at: https://osf.io/g3xsb/

Quantitative results Research question 1: How aware are the public of music therapy? To determine public awareness of different types of therapy, we examined participants’ responses to the question “Have you heard of the following therapies?” As shown in Figure 1, 84.4% of participants said they had heard of music therapy, though over two-thirds (66.9%) said they did not know much about it. Counselling received the highest overall awareness (95.0%), and significantly more participants claimed to know a lot about counselling than a lot about music therapy (difference = 45.1%, 95% CI [39.2%, 51.0%], t = 15.09, df = 358, p < .001).1

Figure 1

1 CIs provide an estimate of the size of the effect—in 95% of cases the mean difference will fall within this range of values (Cumming et al., 2012).

11 100 Yes, I know a lot about this therapy 90 Yes, but I don't know much about it

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To determine whether any individual factors (gender, age, highest level of education, studying psychology) influence awareness of music therapy, an exploratory binary logistic regression analysis was performed, with awareness classified as “yes” or “no”. As Table 2 shows, only one variable reliably predicted awareness of music therapy —being a student studying psychology. Although it is beyond the scope of the current study to determine why, it is possible that the content in psychology courses raises awareness of therapies.

Table 2

12 Results of the binary logistic regression to determine variables that predict awareness of music therapy. Predictor B OR [95% CI] P Gender = Female 0.53 1.69 [0.68, 4.25] 0.26 Age = 18-35 1.48 4.40 [0.53, 36.25] 0.17 Educational attainment = 0.31 1.37 [0.46, 4.09] 0.58 University degree Student studying 1.57 4.83 [1.33, 17.53] 0.02 psychology = Yes Note. CI = confidence interval. OR = odds ratio (the exponentiation of the B coefficient). An OR of 1 indicates no effect of the predictor variable on the dependent variable (awareness of music therapy); values of 1.5, 2.5, and 4.0 are generally considered to reflect small, medium, and large effect sizes, respectively (Rosenthal, 1996). A total of 143 cases were analysed. The category order for factors was set to descending to make the reference level 0. The reference groups are: Gender = Male, Age = 36+, Educational attainment = Not holding a university degree, Student studying psychology = Student studying another subject.

Research question 2: What are public perceptions of music therapy? To examine public opinions of music therapy, participants answered a series of questions regarding their perceptions and understanding of music therapy. First, we looked at participants’ views regarding who music therapy is for. Results revealed that the majority of participants (85.8%) said music therapy can be for groups as well as individuals, and just slightly fewer (81.3%) believed music therapy can be used with all age-groups.

Next, we examined participants’ beliefs about whether music therapy impacts upon various human functions, as shown in Figure 2. Most participants thought cognitive (e.g., attention span, concentration, memory), social (e.g., listening, turn- taking, use of body language), behavioural (e.g., following instructions, not acting on impulse), and physical (e.g., fine and gross motor skills, heartrate, breathing) functions could be impacted by music therapy. Importantly, nearly all participants (94.4%) said music therapy can affect emotion (e.g., emotional expression, management and

13 processing of emotions). Participants were less sure whether music therapy can affect language and speech (e.g., vocalisations, pronunciation, expressing and understanding language) or musical (e.g., ability to play an instrument, performance skills) functions. While these results suggest a relatively good appreciation of the basic impact of music therapy, it should be noted that participants were forced to select from limited response options (“Yes”, “No”, or “Don’t know”), thus it is beyond the scope of this question to infer how far participants’ understanding goes.

Figure 2 100 90 No Yes Don't know 80 70 60 50 s

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In terms of participants’ knowledge of the qualification needed in order to become a music therapist, the majority of participants (86.6%) recognised that “Completion of a formal music therapy training course” is required; these participants were subsequently asked to specify the level of formal training, to which most selected “Undergraduate degree” (45.7%) and “Master’s degree” (32.8%). (It is useful to point out here that the qualifications required to become a licensed music therapist vary across countries—for a discussion of training programme models, see Bonde and Wigram, [2002].)

14 Next, exploring participants’ understanding of what types of events they would expect to observe in a music therapy session, “Listening to pre-recorded music” received the highest number of “Yes” responses (82.7%), as shown in Figure 3. Nearly three- quarters of participants (73.0%) said they would expect to observe “Musical instruments being played by non-musicians”, and a little over half of participants (56.5%) said they would expect to observe “Disorganised musical sounds”. The least expected event was “Lyrical analysis” (38.2%). It is possible to observe any of the events displayed in Figure 3 in music therapy sessions, as techniques and interventions are applied depending on the needs of the client and the aims of the work (e.g., Bunt and Stige, 2014; Odell-Miller, 2016).

Figure 3 100 90 82.7 78.8 80 73.3 73 70 61.3 60 56.5 56.3 50 44.3 40 38.2 30 s I C 20 % 5

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Event expect to observe in music therapy session

15 As shown in Figure 4, the majority of participants understood that the following factors are not pre-requisites to participating in music therapy: “Being a skilled musician” (83.8%); “Being able to write songs” (81.9%); “Having previous experience of playing music” (80.8%); and “Being willing to perform music to an audience” (66.0%). These results indicate a general appreciation that music therapy does not require prior music playing experience.

Figure 4

90 80 70 60 50 40 30 20 10 0 Disagree s c e Not sure an g si c ci n u n si o ie Agree u s m d te g u m i in a d r y n le w la a il o p o k t f t s le o a b e rm e a c o B e en rf B ri e e p xp to e g s n u lli io i v w re e p B e av H

Research question 3: What are the barriers to uptake of music therapy? To explore uptake of therapy, participants were asked: “Have you ever had, or considered having, music therapy?” and “Have you ever had, or considered having, other therapies?” Significantly fewer participants said they had had or considered music therapy (8.3%) than other therapies (63.8%) (difference = 57.6%, 95% CI [52.0%, 63.2%], t = 20.341, df = 341, p < .001). Participants that said “No” they had not accessed or considered either music or other therapy services were directed to respective questions asking them to rank-order reasons (in descending order, primary reason first) for why not. During analysis we

16 considered the number of times each reason was placed in top position, and converted these numbers to percentages (see Figure 5). “I don’t have issues that require [music] therapy” received the most top-place rankings as a deterrent to both music therapy (39.6%) and other therapies (66.1%). Interestingly, “I don’t understand what [music] therapy is or how it helps” received the second most top-place rankings (17.6%) for music therapy, compared with the fifth most top-place rankings (3.4%) for other therapies (difference = 14.2%, 95% CI [5.6%, 21.1%], t = 3.43, df = 111, p = .001).

Figure 5

Music therapy Other therapies

66.1% I don't have issues that require [music] therapy 39.6%

3.4% I don’t understand what [music] therapy is 17.6%

16.1% I have my own methods of self-therapy 14.6%

Other therapies are better 12.1%

2.5% I don't have access to [music] therapy 9.6%

8.5% [Music] therapy is too expensive 4.6%

3.4% People would judge me for seeking help 1.9%

Only 13.6% of participants said they knew of somebody (excluding themselves) who had engaged in music therapy. In terms of accessing music therapy, most participants (79.9%) said they did not know of services in their local area. Considering how they might find out about music therapy, the majority of participants (73.5%) said

17 they would use the internet to search for a service, highlighting the importance of providing useful and accurate information about the music profession online.

Qualitative results Qualitative data were analysed using Braun and Clarke’s (2006) six-phase process of thematic analysis (reading the data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; reporting the findings). Following initial coding the first author separated data into 11 meaning units. These units were reviewed, consolidated further into 9 units, then collated into three themes using a constant comparison method throughout (Glaser and Strauss, 2009). A second author on the paper reviewed the thematic analysis, raising some alternative interpretations of the data, after which a small number of changes were made to coding and themes. This thematic analysis resulted in the generation of the three themes discussed below and displayed in Table 3, with quotation examples.

Table 3 Themes from qualitative data Theme Sub themes Example quote Theme 1: Music Music makes  “Music can make feel itself is innately people feel good everyone better.” therapeutic  “Music heals the broken and Music promotes soothes the soul” positive change in  “Music does a lot for people, non-musical areas it can help with concentration, relaxing, Music connects sleeping, feeling happy, people coordination etc etc.”  “Music helps people to relax, so it can be used to heal certain diseases”  “Music is the universal

18 language. It breaks down language barriers and is accessible to all, regardless of age, ability and understanding.”  “The power of music as the universal language has massive benefits on a person's holistic development and recovery.” Theme 2: Music Music is personal  “Music has always been my as personal vs. therapy own personal therapy and no professional matter what can lift my therapy Music therapy is a spirits, touch my soul and profession in and of make me feel alive and happy, itself music is food for the soul.”  “Although I have not formally Music therapy used music therapy I use supplements other music as therapy most days of therapies my life. It is like healthy food that sustains and calms and embraces us.”  “[Music therapy is the] use of music to support and restore people's mental, physical, emotional wellbeing through a trained and accredited music therapist.”  “[Music therapy is] using music to help with relaxation techniques so that talking therapy may be delivered.”

19  “[Music therapy] involves musical activities as part of a course of therapy, in conjunction with whatever treatments are traditionally applied.” Theme 3: “I Self-admitted lack  “I've heard of [music therapy], don’t really of music therapy but know nothing about it understand awareness. and hence really have no what music opinion. Probably needs therapy is” Confusion about better publicity.” the profession.  “I don't know anything about music therapy, so I don't A need to raise "think" anything about it. I awareness of music simply don't know dammit.” therapy.  “I find listening to music helpful generally but don't know enough about what music therapy is.”  “I have a friend who is a music therapist but am not really sure what she does. I think she plays guitar and sings with children. She might have them use instruments or make music as a way to manage anxiety.”  “I think there is a need to raise awareness of music therapy as an option for helping people.”  “I wish the uses of music

20 therapy had been made clear to us in elementary school to know what it is, what it does, and when it is appropriate to seek it.”

Theme 1: Music itself is innately therapeutic Within their responses to the open-ended questions many participants claimed that music has an innate therapeutic value. It was noted that music can “soothe a person in ways nothing else can” (P69), “heal emotional wounds” (P341) and create “a feel good factor for all” (P92). Moreover, some participants alluded to the positive change that music can promote in non-musical areas, such as to “help with memory” (P269) or to “help regulate physiological responses” (P21), “for instance one [type of music] for sleeping which will calm your nerves, one for sports which will make you energetic” (P115). Other participants viewed music as a universal language, claiming it “crosses languages and cultures” (P277) and can provide “social connectedness” (P385).

Theme 2: Music as personal vs. professional therapy Many participants commented on their own personal uses of music to feel better and improve mood. Music was acclaimed by one participant as “the best therapy you can do yourself” (P100), with another stating: “I know music I listen to affects my own thoughts and emotions deeply and I depend on it to lift my spirits when I need to” (P278).

A few participants demonstrated awareness that music therapy is a profession in and of itself, one that “uses musical activities to help clients” (P385), and requires a “trained and accredited therapist” (P13). Alternatively, some participants believed that music was used only as an aid to other therapies, something to be administered “in conjunction with whatever treatments are traditionally offered” (P258) or “to help with relaxation techniques so that talking therapy may be delivered” (P233).

Theme 3: “I don’t really understand what music therapy is”

21 When responding to the open-ended questions, some participants admitted they “don’t know anything about music therapy” (P198), or said they “don’t really understand what music therapy is” (P318). Other participants acknowledged poor awareness of the profession, saying they had “heard of it, but know nothing about it” (P237) or were “aware of it but couldn’t in all honesty say who it’s useful for or what it entails” (P173). Some participants explicitly specified a need for better publicity for the profession, saying “there is a need to raise awareness of music therapy as an option for helping people” (P2), there should be “more effort in informing the public” (P122), and “music therapy should be a much bigger field, more people should know, and use it” (P82).

Discussion

The current study is the first to examine public awareness and perceptions of music therapy. Although previous research indicates music therapists think their profession is poorly understood by the public (e.g. Ferrer, 2017; Kern and Tague, 2017; Pearson, 2018), there are no published data to support this belief—thus, this study was designed to investigate this gap in the literature. The findings evidence a lack of public awareness and understanding of the music therapy profession and, furthermore, suggest that these are key factors in limiting uptake of the service.

Public awareness of music therapy The majority of participants in the study claimed to have heard of music therapy, though a closer look at the qualitative data implied some misinterpretations of the term. Specifically, participants’ descriptions of music therapy could be separated into two broad categories: one describing music therapy as a profession, with participants recognising the involvement of a therapist and clinical goals, and the other describing music therapy as a personal and non-professional use of music to affect an individual’s emotional or mental state. Therefore, although the vast majority of participants claimed to be aware of music therapy, when given the opportunity to elaborate on their understanding it became clear that many were demonstrating an awareness of music’s therapeutic value, rather than the actual music therapy profession.

22 To better understand participants’ confusion about the term music therapy, it is helpful to consider that music has been used as medicine throughout antiquity (e.g. Horden, 2017). By way of illustration, some two-and-a-half thousand years ago Greek scientist Pythagoras proposed that harmonic sounds are medicine for the soul, and philosopher Plato celebrated the healing effects of rhythm and melody (Pratt and Jones, 1987); it is probable, however, that recognition of music’s medicinal value dates back even further than this, to ancient Egypt and even, perhaps, to the very dawn of humanity (Levitin, 2006; Zanders, 2018). Comparatively, the discipline of music therapy remains in its infancy, having emerged only in the 1940s (e.g. Bunt and Stige, 2014). Taking these timeframes into consideration, it is possible that modern society carries an ingrained awareness of music’s healing power, while the relatively new profession of music therapy is yet to reach mainstream consciousness.

In addition, it seems likely that people experience the powerful effects of music in everyday life and that this might add to their confusion surrounding what the music therapy profession is. Indeed, research evidences the ability of music to induce emotional reactions and engage brain systems such as reward, arousal and motivation (e.g. Chanda and Levitin, 2013; Swaminathan and Schellenberg, 2015), and people frequently listen to music to regulate their emotions (Ferwerda et al. 2015; Lonsdale and North, 2011; Ter Bogt et al., 2017). As such it is likely people can intuitively appreciate that music itself can be therapeutic.

When considering that music has qualities enabling it to be considered a therapy in and of itself, it is important to draw upon Bruscia’s exploration of the difference between music as therapy and music in therapy (Bruscia, 1989). Bruscia writes that to use music as therapy is to utilise music as the primary agent of therapeutic change—the music itself directly influences the listener. Contrastingly, music in therapy encompasses not only the use of music but also the client-therapist relationship—and here it is that relationship and the therapist’s expert facilitation of meaningful musical experiences that are primary agents of change. It is perhaps this very distinction that Bruscia discussed thirty years ago that participants in the current study evidenced confusion of —some participants understood music itself to be a therapeutic agent while others

23 understood that therapeutic change is aided by the qualified professional who facilitates a client’s interactions with music in a therapeutic way.

In summary, the findings in the current study suggest that people readily appreciate the therapeutic value of music and are familiar with using music to improve their mood, however most are yet to recognise how the discipline of music therapy differentiates from using music therapeutically—this differentiation is a key point for communication in order to set professional music therapy services apart from the non- professional therapeutic use of music.

Public perceptions of music therapy The current study also begins to uncover where specifically confusion about the music therapy profession lies. When given a choice, most participants were accurate in their responses regarding certain fundamental aspects of music therapy—for example, that completion of formal academic training is required in order to become a music therapist—but conveyed confusion about more detailed features—such as the particular level of academic training required. It is perhaps unsurprising that there is some confusion in this area because music therapy training models do vary, no doubt partly due to the vast scope of music therapy (Bonde and Wigram, 2002; Ferrer, 2017).

Given that many participants specifically commented on using music to elicit emotional responses it is unsurprising that nearly all participants said music therapy can impact upon emotional function. In addition, the majority recognised that music therapy can affect cognitive, social, behavioural and physical functions—here, however, it might have been helpful that tangible examples of what these areas cover were given within the question, such as “Cognitive (e.g. attention span, concentration, memory)”. Indeed, the qualitative data revealed only vague references to such areas of function, for example: [music therapy helps] “a range of cognitive and physical issues” or “various kinds of development”. This implies participants might have only a surface-level understanding that music therapy can benefit such areas.

Fewer participants were sure of music therapy’s impact upon speech and language. This is despite the growing field of neurologic music therapy (NMT) where techniques such as melodic intonation therapy, musical speech stimulation, and

24 rhythmic speech cueing are used to help people affected by issues such as stroke or brain injury retrain to use language and speech (Altenmüller and Schlaug, 2015; Mainka and Mallien, 2014; Thaut, 2013). This lack of awareness that music therapy can help speech and language development is indicative of a need for increased promotion of the profession—even in spite of the rare stint of mainstream publicity that music therapy received in 2011 when brain-damaged congresswoman Gabrielle Giffords relearned to talk during music therapy sessions (e.g. Moisse et al., 2011).

Participants showed most confusion when asked what they might expect to observe in a music therapy session. For example, little more than half of participants said they might expect to hear “Disorganised musical sounds”. Yet the aim of musical improvisation or re-creation in music therapy is typically to facilitate expression, growth, and change in the client, rather than to teach them technical musical skills (e.g., Zanders, 2018). Hence it is probable that both the musically-trained music therapist and a non-musically-trained client will engage in making disorganised sounds. One feasible explanation for this finding is that some participants based their responses on the premise of music therapy being the personal use of music to affect mood. People’s personal use of music typically does not include making or hearing disorganised sounds, rather it involves listening to organised music for reasons such as mood enhancement, social connection or emotional regulation (e.g. Lonsdale and North, 2011; Papinczak et al., 2015; Tarr et al., 2014). This explanation would also support the fact most participants said they would expect to observe “Listening to pre-recorded music” in a music therapy session but less than half said that “Recording music” or “Lyrical analysis” would take place.

Seeking a music therapy service Given the lack of awareness and inaccurate understanding of the music therapy profession evidenced in this study, it is unsurprising that participants revealed such low uptake or consideration of music therapy services. If people feel that music therapy is “Listening to music to make yourself feel better” or “Listening to positive, upbeat music to improve mood”, then it is very plausible they would not consider paying to see a music therapist. The crucial point here is: not only is there a need to improve public understanding of the profession but also—firstly—public awareness. As such, figure 6

25 visualises a theoretical model for the steps that need to occur in order for a person to consider seeking a music therapy service. The model conveys that music therapists and those working in music therapy associations should utilise various promotional tools to raise public awareness and improve public understanding of the profession, in order for music therapy to reach the consciouness of those members of the public who might benefit from the service.

Figure 6

Practical implications

26 The findings in this study might not be surprising to professional music therapy bodies. This research does, however, provide the first data evidencing limitations to public knowledge of music therapy and also offers some practical guidance for advocacy. In terms of awareness, our findings show that the public need informing that music therapy is a profession that exists to improve or maintain health or development and is facilitated by a trained music therapist. As such, advocacy efforts should target clarifying the distinction between music therapy the profession and music as a therapeutic source of enjoyment or catharsis. In terms of perceptions, this study has revealed specific areas of public confusion (such as the use of music therapy to develop speech and language skills, and the use of techniques such as lyrical analysis), which directs music therapy advocates to some specific aspects of music therapy which require clarification.

Of course, in line with improving public understanding, it is vital to continue evidencing the benefits of music therapy. Undertaking more large-scale research—such as collecting regional, national, and international quantitative data on outcomes for music therapy clients, and undertaking systematic reviews and meta-analyses of existing research—will support important qualitative case studies and in turn complement efforts to promote the efficacy of music therapy.

Limitations and future research As this research was the first to explore public perceptions of music therapy, there was no existing study to use a guide. Thus the survey questions were developed largely using the researcher’s own experiences of discussing music therapy with family, friends and acquaintances, and subsequently basing questions upon areas of misconception that became apparent from such conversations. It is inevitable that other music therapists would be influenced by their own experiences and would create different questions and response options. Moving forward it would be useful to collaborate with other music therapists or music therapy organisations, combining a variety of professional experiences and expertise, to develop survey questions which would provide further insight into public perceptions.

27 This study seeks to better understand awareness and perceptions of the general public but it must be noted that the sampling method was restrictive. The online survey excluded responses from those without access to the internet as well as likely deterred those who feel less “tech-savvy”. Participant demographics show the sample is weighted to a younger, student population which suggest our findings might not be representative of the general public. Future research in this area of public perceptions of music therapy should target a more representative sample of the public by offering multiple survey distribution methods, including paper, face-to-face, and over the phone, in addition to online.

Future research could also focus on gaining a wider international public response to better understand similarities and differences in music therapy awareness across the globe. One method to aid this could be to communicate the intent of the study to music therapy practitioners around the world, thus encouraging wider promotion and dissemination of future related surveys.

The current study gathers data to obtain a snapshot of current public awareness of music therapy, aiming to initiate a conversation on the topic. Future research should explore PR methods from within, and outside of, the music therapy profession to better understand how experts disseminate information to the public, and to measure which methods are effective and how they can be utilised to increase understanding of music therapy.

Conclusion Music therapy advocates work hard to promote the profession. It is, however, generally accepted amongst music therapists that the public currently lack a clear and accurate appreciation of what music therapy is (e.g. Ferrer, 2017; Pearson, 2018). This study is the first to provide data to evidence such a belief. The diverse scope of music therapy and the growing body of research supporting its benefits imply the importance of raising awareness and understanding of this multi-faceted profession. It is hoped that this research will confirm to music therapists and music therapy associations that public awareness and perceptions of the profession are indeed poor, while also clarifying some aspects of music therapy that are most misunderstood. Moreover, it is hoped that this

28 initial investigation will inspire further, deeper, research into public understanding of the profession. Once people are equipped with knowledge, those who could benefit from music therapy are better positioned to consider seeking the service.

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