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International Journal of Qualitative Studies on Health and Well-being logoLink to International Journal of Qualitative Studies on Health and Well-being
. 2023 Apr 4;18(1):2197750. doi: 10.1080/17482631.2023.2197750

Polyphonic perspectives: a focus group study of interprofessional staff’s perceptions of music therapy at an inpatient unit for children in mental health care

Guro Parr Klyve a,✉, Randi Rolvsjord, Irene Bircow Elgen b,c
PMCID: PMC10075520  PMID: 37014967

ABSTRACT

Purpose

In an inpatient unit for children in mental health care, a variety of services are provided through interprofessional collaborations. Music therapy is a relatively recent proposition in this context, but there is increasing acceptance for music therapy as a therapeutic method. However, there is limited knowledge about music therapy in this field, and this study aims to address this research gap.

Method

Through focus group interviews with staff at an inpatient unit in mental health care for children, this article explores interprofessional perspectives of music therapy. A thematic analysis with an inductive approach informed by constructivist grounded theory was used in the analysis of the interviews.

Findings

Several dimensions were involved in the findings, concerning the children and the interprofessional collaboration. The two main categories that emerged were: “What music therapy offers the children” and “What music therapy contributes to the interprofessional understanding of the children”.

Conclusion

The interprofessional perspectives of music therapy revealed potentials for emotion regulation, and experience of identity and freedom for the children. As part of the integrated services, music therapy provided a new perspective of the child and enhanced relationship between the child and the health services.

KEYWORDS: Music Therapy, Children, Mental health care, Interprofessional perspectives, Focus group interviews

Introduction

Loud drum beats and guitar strumming can be heard through a door at an inpatient unit for children in mental health care. Behind the door, a child and a music therapist play and sing together. Why are they playing music here? Does this musical interaction have any significance in such a context?

The mental health of children worldwide has recently become a field of special concern due to the COVID-19 pandemic (United Nations Children’s Fund, 2021). In Norway, this has led to a strengthening of the services in mental health for children and youth and a focus area for the Norwegian Government (Government.no, 2021). However, it is a field which needs further strengthening and focus in the time to come.

The health care services in Norway comprise both primary health care and specialist health care services. The primary health service cares for children struggling with mental challenges. When children show symptoms of more serious mental illness, they are referred to the specialist health service, where the out-patient clinics have primary responsibility for further mental health care. If the children’s needs require even closer follow-up, they are referred to an inpatient unit in the specialist health service (Norwegian Directorate of Health, 2018). At an inpatient unit, a variety of services are provided through interprofessional collaborations, including, at some hospitals, music therapy. However, the inclusion of music therapy as a service in the various hospital units appears to be random. This may be because music therapy is a relatively recent proposition compared to others,1 and the knowledge and research base for music therapy in this context is sparse. There is however a larger evidence base for the positive effects of music therapy on adults in mental health care, and music therapy is thus recommended in national treatment guidelines for psychosis (Norwegian Directorate of Health, 2013).

Previous research in the field of music therapy for children in mental health care does identify it as an effective intervention for some (Geipel et al., 2018; Gitman, 2010; Gold et al., 2004, 2007; Porter et al., 2017), but it also indicates a need for further study. Linked to this current study, Klyve and Rolvsjord (2022) explored children’s experiences of music therapy in an inpatient unit for children in mental health care. In this study, the word fun became a prominent theme in the children’s expressions of their experiences of music therapy, used in different ways with various dimensions. In this, the word fun should not be understood as an experience of music therapy as being mere “entertainment”, but rather as something existential for the child with therapeutic and developmental potentials. There has been a large amount of research on music therapy for children with autism spectrum disorder, as the recently published Cochrane review shows (Geretsegger et al., 2022). Other topics of research in this field are music therapy for children with anxiety (Goldbeck & Ellerkamp, 2012), for children and youth with social challenges (Gooding, 2010), for children in relation to ADHD and restlessness (Helle-Valle et al., 2015, 2017; Jackson, 2003), music therapy as part of the assessment process (Jacobsen, 2012; Layman et al., 2002; Loewy, 2000), self-esteem and music therapy (Kirkerud, 2016), music therapy and traumatic loss (Hakomäki, 2012), active versus passive music therapy (Montello & Coons, 1998), as well as emotional regulation and interactions in music (Johns, 2018; Sannes, 2012; Uhlig et al., 2016).

In research focusing on adolescents and mental health, some of the topics considered to be particularly relevant to this study are the unintentional and intentional use of music (McFerran & Saarikallio, 2013; McFerran et al., 2018), musical identity and recovery (Hense & McFerran, 2017; Hense et al., 2014; Hense, 2015, 2019), music therapy and ADHD (McFerran, 2009; Rickson & Watkins, 2003; Rickson, 2006), young people with anorexia (Trondalen, 2004) and music therapy assessment (Aitchison & McFerran, 2022a, 2022b; Hense et al., 2018; Wells, 1988).

This article explores interprofessional perspectives of music therapy in mental health care for children. Research on interprofessional perspectives of music therapy in mental health care in general has yielded some knowledge (Bibb et al., 2018; Choi, 1997; Rolvsjord, 2018; Silverman, 2018), but it is limited as concerns children and youth in particular (Hense, 2018; Thorgersen, 2015). To address this research gap, it is important to gain an understanding of staff’s perceptions of music therapy in mental health care for children.

This study forms part of the first author’s PhD project, and the research question for this study was: What are interprofessional staff’s perceptions of music therapy at an inpatient unit for children in mental health care? The main aim of the study was to explore these perspectives in order to better understand the possible significances and potentials of music therapy in this context. Several dimensions were involved, focused on both the children and the interprofessional collaboration.

Methodology

Study context

The location of the study was the inpatient unit for children at the Department of Child and Adolescent Psychiatry, Division of Mental Health, at Haukeland University Hospital in Bergen, Norway. The staff teams comprise a variety of professions, including two psychologists, two psychiatrists, 18 social workers with different relevant professional backgrounds, and one music therapist. The hospital school with one-to-one teaching is closely connected to the unit, and the teachers are also part of the interprofessional teams at the unit.

There are various reasons for referrals to the unit, but they are usually due to challenging and complex conditions. Children from birth to 12 years old are admitted to the unit together with one of their parents, and they usually stay there between four and eight weeks. The unit accommodates six children with parents at a time, and each interprofessional team is linked to one child whom they provide care for. The work of the teams is mainly based on a relational therapy approach and emotion regulation (Campos et al., 2004; Nordanger & Braarud, 2017; Nyklíček et al., 2011), and a common language among the staff at the unit is based on the Circle of Security (COS) therapeutic model (Coyne et al., 2019). This is a model founded in attachment psychology, focusing on relational abilities and guidance for the parents.

Music therapy

Music therapy is an integrated part of the various therapeutic services at the unit, and can be defined as “an effort to increase people’s possibilities for action” (Ruud, 1990, 1998, p. 3). The music therapist at the unit has a resource-oriented approach (2010and is especially influenced by relational perspectives (Johns, 2018; Trondalen, 2016). A resource-oriented perspective in music therapy was originally developed as a perspective to work with adults in mental health (Rolvsjord, 2010), and aligns with recovery perspectives (McCaffrey et al., 2018). It implies a focus on the children’s strengths, awareness of the potentials to use music as a resource, and encourage equal relating. In a relational approach to music therapy, therapeutic involvement involves intersubjective sharing that is adjusted to the children’s needs and signals (Johns, 2018). In this, communicative musicality (Trevarthen & Malloch, 2000), in combination with an affective communication, is central (Trondalen, 2016). The referrals to music therapy are made by the psychiatrist/psychologist, often following consultations with the music therapist.

The music therapy sessions take place in the music room at the hospital school. In this room, the children have access to a varied selection of musical instruments, such as piano, keyboard, drums, guitars, bass, djembes, xylophones, rhythm instruments, ukuleles and digital music programmes on a computer.

The sessions that formed part of the study were offered twice a week and usually lasted one hour. They were mostly individual, except in cases where parents were included in one or two sessions due to specific relational challenges. The children often brought songs with them to music therapy, and the sessions consisted of playing songs together, learning instruments, improvising together, making songs on the computer as well as singing and dancing. All the sessions were held as usual, but some extra attention was given to the music therapy service by the interprofessional staff due to the study. The music therapists in the study were the music therapist at the unit, Anita Barsnes, and the first author.2

When a child at the unit is referred to music therapy, the music therapist becomes a part of the interprofessional team linked to that particular child. The team meetings are held regularly once a week, and address the various observations through the week, possible therapeutic changes for the child and further therapeutic focuses in each case.

Study design

Project

This study is one part of a multi-part qualitative study, exploring music therapy in a children’s mental health care unit from various perspectives. Informed by feminist perspectives, the researchers have been aware of the importance of accessing multiple voices (Munday, 2014; Rolvsjord & Hadley, 2016). This article presents a substudy exploring the staff’s perspectives. Another substudy focusing on children’s voices is already published (Klyve & Rolvsjord, 2022).

Participants

The participants in this study were staff in interprofessional teams at the inpatient unit. The inclusion criteria were to be a member of an interprofessional team that was linked to a child who participated in music therapy and was part of this study. Each interprofessional team would normally consist of a child psychiatrist/psychologist, a teacher, a social worker, and the music therapist. In total, there were 16 team members between 25 and 65 years old that participated in the interviews, slightly more women than men. The multicultural representation among the staff was scarce, and both this and the imbalance of gender reflected the realities of the staff at the unit. This representation of gender and multicultural identities differed from the normal population of families at the unit, who were half boys and half girls and of somewhat different cultural backgrounds. The staff’s different professions and thus their potential various observations and perceptions of music therapy were important for the exploration of music therapy in an interprofessional collaboration at the unit. The staff’s engagement with and knowledge of music therapy varied. As the music therapist was normally a member of the teams, the other staff had secondary knowledge from the sharing and discussions in the team meetings held regularly each week focusing on the child’s process. Some of the participants would have observed the child before and after the music therapy sessions, and/or talked with the child about music therapy. Only occasionally the team members would observe music therapy sessions. The staff were part of eight different interprofessional teams linked to eight different children aged eight to 12 years old who participated in the study. The eight children were four girls and four boys. Six of the children had various neurobiological behavioural disorders and two of them were diagnosed with attachment disorders. All of the children had challenges in social interaction, attachment and verbalizations of thoughts and feelings. They were all admitted for a four-week period in the hospital for assessment and to commence a treatment plan.

Data collection

The research question was explored through eight focus group interviews (Malterud, 2012; Wilkinson, 2008). Focus groups allow for the multiplicity of perspectives and integration of differing voices (Wilkinson, 2008). This method for data collection is perceived as “naturalistic” (Munday, 2014, p. 239) and the researchers considered that this choice of method resembled the usual situation in the interprofessional team. The focus group design allowed for natural conversations among the staff and provided space to each of the voices in the group.

Eight focus group interviews were conducted with the interprofessional teams set up for each child. One interview was conducted per team, and each lasted for approximately 45 minutes, a duration defined by the staff’s busy workdays. The second author was the moderator of the interviews, while the first author participated as facilitator and secretary. In half of the cases, the first author had been the music therapist. There were four to five participants in each focus group, as well as the moderator and secretary. In some of the interviews, both the two social workers involved in the case participated, and some of the participants were included in two or three focus groups because of their role in the different interprofessional teams in the specific cases. The two music therapists participated in four interviews each. In each focus group interview, the interprofessional team was asked to reflect on questions specifically about the individual child to whom the team was linked. There was a shared interview guide for all the eight focus groups, and semi-structured interviews were conducted (Kvale & Brinkmann, 2015).

Ethical considerations

The PhD study of which this study is a part was approved by REK—Regional Committees for Medical and Health Research, 29.03.2017, 2017/52/REK vest. The first author was, as previously mentioned, one of the two music therapists in the study responsible for the music therapy with the children. The multiple roles as therapist, researcher, facilitator and secretary required a critical awareness in the interview setting, as well as self-reflexiveness in the music therapy sessions (Finlay, 2002). There was a risk that these multiple roles could contribute to biased questions or answers. However, our consideration was that, in combination with thorough reflection along the way, these multiple roles contributed a unique perspective on the music therapy, the children and the context, and thus strengthened the study in several ways. The first author’s previous experience in this context contributed to a rare access to this particular unit, in terms of both being allowed to carry out the study and access to the participants.

Informed consent was collected through signatures from all participants on information sheets provided to them prior to the interview. The names of the children given in this article have been changed to protect their identities.

Data analysis

The interviews were analysed through a thematic analysis (Kvale & Brinkmann, 2015), with an inductive approach informed by constructivist grounded theory (Charmaz, 2014; Charmaz & Belgrave, 2012; Thornberg & Charmaz, 2014). This approach allowed for an exploration of the various voices in the interviews, which is essential when analysing focus groups, and it facilitated the researchers to recognize and be aware of the unique dynamics, as for instance between the various professional groups, in the interviews (Charmaz & Belgrave, 2012). Constructivist grounded theory has previously been used in the analysis of focus groups, both as a basis for an inductive approach with a thematic analysis (Galle et al., 2020; Garrido et al., 2021) and as the main approach (Davidson et al., 2022; Johansen et al., 2011; Nygaard et al., 2020; Warran et al., 2019).

The codes and categories emerged from the raw data, generated in the thorough process of coding at different levels of the analysis. The data went through the process of line-by-line, open coding, where discrete parts of the transcribed text were assigned different codes. After this, focused coding followed, deciding which of the codes made the most analytic sense, highlighting what was found important in the emerging analysis. These focused codes identified eight different dimensions from which, in the final step, the two main categories emerged. The dimensions and the categories were thoroughly discussed by the interprofessional research team consisting of the three authors. The transcribed raw data were organized and analysed in the NVivo computer software for qualitative data analysis during the analysis process.

Analysis of focus group interviews involve certain concerns and challenges, with a complexity of participants’ voices across each interview, as well as between groups (Barbour, 2014). In the data, there was a great variety of content in the different focus groups, but at the same time clear recognizable elements between the groups. In the analysis process, a balancing of the disparities and similarities between the focus groups was key. Furthermore, the dialogues in the focus groups entailed two different levels, that is, the perceptions related to the specific child, as well as more general perceptions and thoughts about music therapy at the unit. In the analysis, we carefully considered the balance of various voices.

After the analyses, the quotes were translated from Norwegian into English. It is in the nature of translation that certain nuances of the original utterances may be lost, and to minimize this, among other things, key concepts were discussed thoroughly with native English speakers.

Findings

Through the data analysis, eight dimensions of the perceptions of music therapy emerged through the multiple perspectives in the different focus groups. The dimensions are representative for all the eight focus groups, although some were more prominent in certain groups than in others, and two main categories emerged: “What music therapy offers the children” and “What music therapy contributes to the interprofessional understanding of the children”. The categories and dimensions are not presented in any quantitative order in this section, but with the aim of providing the best possible understanding of the findings. The presented quotes have been slightly edited for clarity when transcribing from speech to text. This included, for example, removing “erm” for hesitancies, replacing them with “ … ”. “Mmm” on the other hand is retained, meaning agreement/confirmation, and these are included in the extracts to display the multiple voices and the interaction between these. The various perspectives from the social workers (SW), the psychologists/psychiatrists (P), the teachers (T) and the music therapists (MT) in the framework of the questions from the moderator (M) are linked to the different focus groups of each of the different children (FG “name”). Although the dimensions are divided into two separate categories, they are closely connected. The staff’s perceptions of how music therapy is experienced by the children, named “Kristin”, “Kato”, “Kristian”, “Tone”, “Fredrik”, “Chris”, “Ellen” and “Dina”, affects how music therapy contributes to the interprofessional collaboration, and vice versa.

Category: What music therapy offers the children

The focus group interviews with the staff revealed a variety of perceptions of what music therapy offered the children during their stay at the unit. These findings were described in different ways and constituted the dimensions of this category as presented below.

Music therapy as a place to be free

The staff’s perceptions of music therapy were of a place where the children had the opportunity to have different expectations of themselves. Music therapy was perceived as a place where the children could relax and feel freer, and described as an arena for playing music without a focus on performance.

The excerpt below concerns music therapy with Dina. Dina showed great motivation and joy in learning and playing the guitar, and the interprofessional team’s perception of what these sessions offered Dina was a place where she could feel liberated from the challenging situation of her everyday life:

SW: I think it [music therapy] has had a positive meaning. She experienced being capable.

P: Mmm.

T: Mmm.

MT: Mmm.

SW: … something she likes … a place to be free …

T: Yes.

P: Mmm.

SW: … not having to deal with … all the things that are out there which are…

P: Which are quite serious.

SW: … quite serious …[P and SW talk simultaneously.]

SW: … and which are burdensome and … affect her everyday life all the time.

P: Mmm.

SW: Just being oneself and flowing with what is happening.

P: Mmm.T: Mmm.

(FG “Dina”)

Music therapy as motivation and opportunity for music

The staff emphasized that the children usually showed up for music therapy, even in cases where this was expected to be challenging. On a general level, the teams had the impression that the children were interested in music and motivated to learn instruments. For some of the children, music therapy was their first real encounter with music, and the staff highlighted that they would possibly not have encountered music in any other way.

Kristian’s interprofessional team reflected on how music therapy contributed to motivation in other arenas. The teacher described how it was a break from schoolwork and a motivation for Kristian both before and after the music therapy session.

T: So… I think, if you had not had that [music therapy] … then you probably would not be able to get through the other things as well.

(FG “Kristian”)

Another teacher, in Fredrik’s interprofessional team, described how music therapy became an opportunity for Fredrik to encounter music in a way which he probably would not have done in his everyday home life:

T: I think it [music therapy] was probably very valuable, because … it’s quite exclusive to have such an encounter with music, then to … be creative with music. And he had probably not met it in any other way … it’s not an option to enrol him in a marching band and not in a … barely in a choir. Yes, maybe he can participate, but… we sing at school and he is not the one who sings that much. So, he is not participating in the world of music, so that is… must represent a new area.

(FG “Fredrik”)

Music therapy as an arena for identity

There was a clear perception among the staff that music therapy was an arena where the children could feel capable in music. They pointed to music therapy as a space for development, as a place that brings out resources, as something the children experienced as important and as something that had an impact on how they viewed themselves.

Kristin was a girl who showed great enthusiasm in the music therapy sessions, and the interprofessional team emphasized the opportunities for her to view herself a bit differently through the musical interactions:

T: I think it has an impact on how she looks at herself. Yes. I think it has … an effect, that it has an impact on how she looks at herself …

SW: Yes.

T: Right? And … especially when she comes out and is proud and can tell me what you have been doing … and then, like [laughs a little]. Yes. Right? So, it … gives her a kind of identity and, says something more about who she can be.

(FG “Kristin”)

However, the teams discussed how a four-week period appeared to be too short a process for some of the children. For others, it seemed to be a familiar, somewhat easy-going arena where they felt safe after a few sessions.

Music therapy as an arena for feelings and expressions

In general, the staff perceived that music therapy facilitated the children’s opportunities for expressing who they are and for showing other sides of themselves. The staff pointed at the children’s expressions of joy and anger, and the possibility for emotion regulation through music.

In one of the cases, the interprofessional team discussed how Fredrik expressed his feelings through the music, despite the fact that he was not good at putting feelings into words:

M: You said that it was quite special that, in the first session, he commented that … something about that the music was sad, or something like that?

MT: What we … me and him made, and then he said … “that sounded sad”. And I can’t remember anyone else say something like that … at least not … in the first session …

T: But I think he has broad challenges with expressing … to put emotions into words. He has broad … challenges with having … a language of his own emotions there and then.

But he can talk about emotions … … in … a theoretical … like, but emotions there and then he isn’t … I don’t think he is very good at … communicating.

MT: And that … the last two sessions we have tried to … I have asked him if he maybe wants to … like playing how he is feeling today, then he has laid down on the piano.

P: Yes, that’s also an emotion …

MT: Yes.

[Everyone laughs].

T: But it … I can understand that …

SW: Yes, because he is tired …

T: … or I think that’s him. It is … “POFF” [T makes the sound and illustrates the boy with body language. T laughs a bit. T and SW talk at the same time].

MT: Yes.

SW: He is tired, he uses energy … on normal activity.

(FG “Fredrik”)

The team’s perception of Fredrik’s expression of tiredness through the music is that it is a genuine expression of how he is feeling. The team talked about how the unit had responded to this feeling with understanding, and that it is good that he has been able to convey these feelings in music therapy as well.

In another case, however, the child had a complex emotional reaction in the music therapy session, and the team experienced this as a useful observation of how the child reacted to the focus on emotions in the session, and how this became too challenging for this particular child. Ahead of this particular music therapy session with Kato, the team discussed the opportunity to focus specifically on emotions in music therapy since Kato had difficulties in expressing his emotions verbally. The team wanted to see if Kato could more easily express emotions through music, and the music therapist brought this into the session. Kato often faced challenges with avoidance, and after this session he did not return to music therapy until the last session. According to the social worker, Kato put into words some of the things he found difficult:

SW: Yes… the boy actually has an interest in music, or … he likes and thrives on music … but he said, that if one mixes music and emotions, and especially with people that one is not yet confident and familiar with, then it can become difficult. He said that it was difficult in one of the sessions you had not so long ago.

MT: Yes.

SW: He confirms this very clearly. He doesn’t say these exact words that I use, he uses much shorter and simpler words, but that it is … that it is difficult for him, he describes quite clearly.

(FG “Kato”)

Music therapy as an opportunity for relationship

It was emphasized by the various interprofessional teams that music therapy facilitated being present in the moment together. In some cases, it was relevant to include parents in the music therapy, based on current challenges and referral to the unit. In all the cases where this was relevant, it was the mother who was included in music therapy. The staff stated that this had been a useful arena of observation, in which the child-mother challenges and resources were made evident, and that it was usually a positive experience for them to be together in music therapy, but also sometimes challenging. In one of the cases, the interprofessional team discussed how music therapy seemed to be a place that both Kristian and his mother enjoyed. However, they emphasized that it was important in this case to focus on the experience of being in something here-and-now and not on musical performance. The first author followed up asking whether the team had the impression that music therapy could be a good arena for interaction between children and parents:

P: Oh, yes, definitely. Very! But, there must … there must be a … like for these parents, a clear clarification of expectations in advance.

(FG “Kristian”)

Practising interaction and being present in the moment together in music also applied when the parents were not included, and only the child and the music therapist were present:

T: He needs a lot of practice in interaction … and I think that this is a way to play at interaction.

MT:Mmm.

P: Yes.

T: Like, if he had … if you had done this a lot, then he had practised listening, conforming, taking the lead a lot, right?

MT: Mmm.

T: And then … that is his weak … that is his big challenge in the interaction with peers … and rigid adults … [laughs a bit]

MT: Mmm.

T: But, right, he is … he needs a lot of training in that.

(FG “Fredrik”)

Category: What music therapy contributes to the interprofessional understanding of the children

The staff described music therapy as a contribution to the understanding of the children through observations in music therapy, through being a complementary service, through collaboration in the team and through visions of music therapy as part of continued treatment for the children. Music therapy was understood as an integrated aspect of the services at the unit. The staff also highlighted the positive aspects of how this study led to a prioritization of music therapy and reflections on the different meanings of this service.

Music therapy as part of the assessment process

The staff stated that they often experienced observations from music therapy as useful in the assessment process, offering different perspectives and as a contribution to a better understanding of the child. Hence, the observations from music therapy strengthened the assessments, and they were often described in the child’s medical record. In some particular cases, the team expressed uncertainty about the choice to include music therapy due to the turbulent circumstances of the case, while in most other cases the staff emphasized the importance of having observed the children in a different context and that music therapy was something that complemented the whole.

One example is where the team experienced a more playful aspect of the child:

P: Yes, it is important to see that side of her too, or to see that she has that side …

SW: Yes.

MT: Mmm.

P: … where she can relax and maybe be a bit more playful and …

SW: Yes.

MT: Mmm.

(FG “Tone”)

In another case, a better concentrated side:

P: More specifically, this is a girl that … in relation to diagnosis, then … it has always been a topic about ADHD and concentration difficulties, right?

MT: Mmm.

P: … and here we see a … yes, another side of her, then, or she has some resources there. And especially in this context …

(FG “Dina”)

Music therapy as an integrated part of the treatment context

Music therapy was generally understood by the staff as a “harmless approach” (P, FG “Tone”) and as a complementary service which certainly had a place at the unit. The staff’s perception of music therapy was that it could contribute to creating a better relationship between the child and the health professionals, and that it was important to have it located in the hospital due to the possibility of “optimal adaptation” (P, FG “Kristin”) in this context and “fast transfer of information” (P, FG “Kristin”). It was also stated that the health service at the unit had improved due to the inclusion of music therapy. It was a common view among the staff that music therapy contributed to the teams’ understanding of the child, and also that the music therapist was a natural part of the interprofessional team. The staff observed that it could be especially difficult for the children at the unit to participate in conversations, and that by doing something fun together, such as playing music, while talking together, could make this a little easier. The staff discussed how this, in addition to facilitating experiences of capability, contributed to creating a better relationship between the children and the health services.

P: As a service on this unit, I think it is very good, and … as we talked about previously, positive experiences of being capable for these children we have here, which often don`t experience … helps to create a better relationship with the health services, I think …

(FG “Dina”)

In one case, the team reflected on how the health services would have been poorer without music therapy:

P: If I think about how it would … how would the stay at the hospital have been without music therapy? It’s maybe easier to think like that. It would have been a poorer service, I think. And a … it contributes to a more holistic and … varied service … in a way, yes. An extended frame. Which has been very positive for this girl, I think.

(FG “Ellen”)

However, the staff pointed to several logistical challenges in the communication within the team, one of which was the timing of the team meetings. It was specified that it was important and useful for the process for the music therapist to participate in the team meetings so that the communication went both ways, and not just through the digital health records. It was emphasized that better communication would lead to better collaboration.

P: It is important that we continue to work with integrating music therapy in the more holistic treatment of the child at the unit.

Everyone: Mmm.

P: That it doesn’t become a satellite.

(FG “Ellen”)

P: I think that music therapy shows what it’s good for when we can work with it as a topic in an interprofessional discussion.

(FG “Kristin”)

MT: Because it often helps, the more one understands about the child, the better it gets.

SW: I think we owe it to the children to do that.

(FG “Kristian”)

Music therapy as potential for continued treatment

In several of the different cases, there was an experience among the staff that it was worth continuing with music therapy for the children after discharge from the hospital. In this ensuing process, they envisioned various potentials in music therapy, such as using music to remember, as interaction with others, as a way to calm down, as well as emotion regulation in general, and to work with specific challenges through music. The staff observed that, for some of the children, four weeks was too short a time, and that a follow-up process for them could have revealed the potentials in music therapy to an even greater degree. In one of the cases, music therapy was recommended as the primary treatment for the child in the further process back home. In another case, the boy Chris stopped coming to music therapy after some sessions, and he chose not to participate in the interview in his last session. The staff discussed whether a longer music therapy process could have made any difference for him and what potentials this could have contributed to Chris’ experience of music therapy:

P: I think that, in relation to his emotions, I think that’s his major challenge. That he has a lot of strong emotions and he doesn’t know what he … how he should handle them, he becomes overwhelmed and he needs a lot of help from his parents, his teachers, from those around him to help him with these emotions. And I think that music therapy could have been such a space where he could … explore a bit, challenge himself in small doses—both in relation to taking space, making sound … and giving up control eventually … yes. So, I … think it could have been a good … yes, a good form of therapy for him. In any event, he has not responded well to talking in therapy.

(FG “Chris”)

One of the teachers saw potentials in music therapy in relation to memory and suggested that this could have been a specific focus in music therapy with Ellen in a possible follow-up process:

T: I see potential in what you’re talking about, but also a bit concerning the concentration part, about the working memory, about … Yes, in such things I think that music has a lot of potential, at least when working with it for a while.

(FG “Ellen”)

Discussion

The aim of this study was to explore interprofessional staff’s perception of music therapy at an inpatient unit for children in mental health care. The staff’s perceptions of music therapy convey a broad picture of what music therapy may offer the children as well as what it contributes to the interprofessional understanding of the children.

The findings corresponded to some extent with previous research in this field, both regarding the staff’s perceptions of the usefulness of music therapy for the children as well as music therapy’s contribution to the interprofessional understanding of the children (Hense, 2018; Thorgersen, 2015). But the findings also pointed towards new perspectives and contributions which are not much elucidated in previous research on interprofessional teams in mental health care for children, such as music therapy as a place in which to be free.

In the discussion, we will initially examine two therapeutic potentials that we found both interrelating and possibly contradictory across both of the main categories: the perceptions of music therapy as a “space of freedom” and the potentials for emotion regulation in music therapy. We experience a certain tension between these aspects that might be linked to the various opinions and levels of analysis that emerged from the staff group interviews. Finally, we discuss the role of the music therapist in the treatment team.

Freedom to regulate emotions?

The staff highlighted how mental health issues for children can involve complex family situations and challenging everyday lives, and that a place such as music therapy to be oneself, feel capable and express oneself through music could be very important for the children. It may have been experienced as a place to be free from both the hospital and the world outside, “not having to deal with … all the things that are out there” (SW, FG “Dina”). The context of the music therapy—the assessment and treatment processes at the hospital—is important for the understanding of this experience of music therapy. The staff’s emphasis of music therapy as a place to feel free for the children correspond to previous research on music therapy in hospital context (Aasgaard, 2002), in mental health care with children (Kirkerud, 2016), and in adult mental health (Solli & Rolvsjord, 2015), accentuating the importance of music therapy as it may facilitate a break from the usual hospital context. The children’s possibility to express themselves non-verbally, within their unfamiliar situation, was perceived by the staff as an important dimension that could provide an experience of freedom in the music therapy process. In Fredrik’s case, the team discussed how Fredrik had challenges in verbalizing emotions, and that he had used music and bodily expressions to express himself in music therapy. Also, the opportunity to use music as a way to regulate emotions was one of the reasons why the staff described music therapy as a place in which the children could feel free.

However, there is herein, as previously mentioned, a possible contradiction, whereby music therapy is perceived, on the one hand, as a place in which the children can feel free and, on the other, as a place to achieve treatment goals with certain expectations which may be experienced by the children restricting this freedom. An important aspect for further discussion is that the possible contradiction between music therapy as emotion regulation and music therapy as a place to be free may be linked to a perception that the former is therapeutic, while the latter is not. However, this freedom in music therapy might resemble the children’s natural way of being in play (Bratton et al., 2005; Johns & Svendsen, 2016), and through play, as well as through music, children have the opportunity to non-verbally express inner feelings and vitality on their own terms (Johns & Svendsen, 2016; Johns, 2021). Could this indicate that the “space of freedom” in music therapy in itself can offer optimal emotion regulation for the children in this context?

The ability to regulate emotions and communicate in general is understood as an intrinsic musicality, “an aspect of motivation and emotion that has power to communicate” (Trevarthen & Malloch, 2000, p. 4). This communicative musicality is an innate ability, a “psychobiological capacity that supports infants’ immediate needs for human companionship” (Ansdell, 2014, p. 146). Three parameters define this capacity: pulse, quality and narrative, and these lay the foundation for our common musicality (Malloch, 1999; Trevarthen & Malloch, 2000). It is this common musicality “that makes it possible for us to share time meaningfully together” (Malloch & Trevarthen, 2009, p. 5), and an experience of such an intimate relationship is critical for the development of the infant’s sense of being part of a community and of themselves as a social being (Pavlicevic, 1997). An important notion in respect of communicative musicality is the distinction between this non-verbal communication—also referred to as protomusicality—and music as culturally informed, “in and as a specific situation […] enacted and experienced as musicking, that is, as the performed establishment of relationships” (Stige, 2012, p. 174). Emotion regulation is thus a natural part of the interaction and happens continuously in a musical companionship, “intersubjectivity seems itself to be a ‘musical’ phenomenon” (Ansdell, 2014). Hence, emotion regulation in itself as a treatment goal is not something that leads to a restriction of freedom per se, but an experience of the restriction might arise when there is a perception that the music is not enough, that the emotions must also be put into words and “translated” from their musical expression. This also touches upon an important discussion about what music is and can be.

“The concept of music” is not “a static or fixed term in music therapy” (Trondalen, 2016, p. 80), but varies according to the music therapist’s previous experiences, theoretical approaches and individual musical traditions. Communicative activity through music and its effects plays a part in what conceptual content we put into music, “it is the practice that decides the content of the concept of music” (Ruud, 1990, p. 220, our translation). The music does not produce specific emotions or reactions, “the music offers a variety of emotions and interpretations” (Trondalen, 2016, p. 78) and it is how one appropriates what the music affords that makes the “effect” (DeNora, 2000). In this, the individual is always a part of their culture and context and this is an important aspect of the music in music therapy (Ruud, 1990, 1998; Stige, 2002, 2012). Along with the communicative and interactive functions of music and their potentials, it is also important to keep in mind the music’s inherent value, “as a direct lived experience” (Trondalen, 2016, p. 81). The music therapist’s awareness of each individual’s communication capacity and possible needs in the various specific situations is thus crucial in order to retain the opportunity for the children to experience feeling free in music therapy. Also, in the context of the hospital, which is not the children’s usual context, it is important to not exclude the context outside, but to show interest in the children’s use of music in their everyday lives and provide opportunities to transfer their experiences of music therapy into their lives back home, as emphasized in resource-oriented perspectives (Rolvsjord, 2010).

As previously mentioned, emotion regulation is a central aspect of the treatment processes in general at the unit (Campos et al., 2004; Nordanger & Braarud, 2017; Nyklíček et al., 2011). Hence, the perception that music therapy potentially facilitates emotion regulation is an important observation given that this is also an approach fundamental to the unit in general. Achieving one’s own therapy goals through music therapy is emphasized by other professions as eye-opening to new treatment possibilities (Ledger et al., 2013). Previous research with children in mental health care shows that non-verbal musical dynamics and musical interaction can facilitate emotion regulation (Johns, 2018; Sannes, 2012). Dealing with complex emotions through music has also been highlighted by staff in child welfare as an advantage of music therapy in relation to children’s mental health (Krüger et al., 2018). Emotion regulation is also relevant in music therapy with children with trauma, helping facilitate new possibilities for action (Johns, 2017). Children are naturally in motion, and possibilities for action and development are inextricably linked (Johns, 2017).

The influence of communicative musicality supports intersubjective contact throughout life, and a particular strength of music therapy is how the therapist “mobilize[s] and support[s] communicative musicality” (Ansdell, 2014, p. 147). Several of the children that are referred to mental health care experience a lot of stress which they need help to regulate. In music therapy, “mutually synchronized and attuned musical expressions” (Trondalen, 2016, p. 52) are used to modulate the children’s level of stress. Emotion regulation through music is a non-verbal way of regulating where the children interact through music together with the music therapist. In a relational perspective on music therapy, it is the quality of the communication that matters, where sharing of inner feeling states is enabled through affect attunement (Johns, 2018; Stern, 1985; Trondalen, 2016). By returning to communicative musicality, the children can get the sense that they can “be contacted, known and understood ‘from the inside’” (Ansdell, 2014, p. 154). Experiencing the ability to share inner feelings through affect attunement contributes to a development of emotion regulation (Johns & Svendsen, 2016).

Emotion regulation in music therapy was a recurring theme raised by all focus groups. Obviously, this aspect linked closely to the main agenda and theoretical underpinnings of the therapeutic stance taken at the unit. Thus, this was also a theme of particular interest to the staff. In Kato’s case above, however, it turned out that it was too difficult for him to handle emotions in the music therapy session. The interprofessional team discussed how emotional dysregulation was one of his main challenges in general and that his way of dealing with this was often avoidance. This also appeared to be a challenge in music therapy, and he stopped attending music therapy. The team’s perception of the observations in music therapy was that they were useful as a means to better understand Kato, as well as an acknowledgement of some children’s need for more time and a better rapport with the music therapist before specifically focusing on emotions. Turning back to our dilemma, the episode with Kato might also reflect a possible contradiction between the staff’s understanding of music therapy as a place to achieve treatment goals with specific directions, and their understanding of music therapy as a place where the children can feel free. Aiming to reduce this possible contradiction, it is important to be aware of the children’s need to feel “safe” in order to feel free. The children may experience avoidance, a barrier where new situations such as music therapy are avoided, and they may thus need a certain amount of security in order to feel safe. An awareness of the importance of the music therapist’s attunement to each child, that takes into account the children’s identities, needs, initiatives and communication on their own terms, seem to be crucial in order to achieve a freedom to regulate emotions in music therapy. Finally, we want to emphasize that the musical interaction and the joint attentiveness to the music is at the core of fostering a space of freedom and emotion regulation.

The music therapist in the interprofessional team

The music therapist, as a part of the interprofessional team, is the bridge between the children in music therapy and the interprofessional team. One might claim that the music therapist operates as a translator in this context, conveying experiences from music therapy and complementing the pre-existing models in the team (Pavlicevic, 1997). Playing music in music therapy, however, might be a way for the children to express feelings which are too difficult, or maybe impossible, to express through words. Verbal communication in music therapy can potentially “increase the meaning of the musical experience” (Trondalen, 2016, p. 15), but it cannot replace the non-verbal meaning within the intersubjective musical relationship. Thus, a translation of the musical expressions might be contradictory and maybe impossible to do (Rolvsjord, 2002), and this might have been the issue of the complex experience in Kato’s case. But conveying the children’s interactions and their way of being in the music is a possible and useful way to build the bridge between the music therapy and the interprofessional team. In this, it is important that the music therapist also translates music-therapy-specific terms into a language that is easily understood by the other disciplines (Twyford, 2008). However, it is a complex process to represent non-verbal processes verbally to the interprofessional team, and the many implications of this have been highlighted and thoroughly discussed by Ansdell (1999).

There is an increasing awareness of the importance of collaborative work within interprofessional teams working with children in general (Twyford, 2008). Although the importance of music therapy and communication was highlighted in the various teams, the staff also pointed to a need for a better cooperation to integrate the music therapy more closely into the service, preventing it from becoming “a satellite” (P, FG “Ellen”). An awareness of this, and reasons why this was sometimes difficult to implement, such as various logistical challenges, was discussed by the staff in many of the focus groups. An openness within the teams provides a greater understanding of each profession involved and “contributes to a holistic view of the child” (Twyford, 2008, p. 34). This perspective was also highlighted by the staff when they pointed to how the service would have been poorer without music therapy, and that it contributed to a more holistic and varied service (FG “Ellen”). The staff perceived that the music therapist’s participation in the team meetings contributed to a better understanding of the children. At the same time, the music therapists pointed out that they also gained a better understanding of the children through the interprofessional collaboration, which in turn led to better music therapy. Also, the perception of music therapy as a service that helped to “create a better relationship to the health services” (P, FG “Dina”) points to an important aspect of music therapy in this context and illuminates its potential significance.

Implications for interprofessional teamwork

Considering the staff’s perceptions of useful cooperation, a specific focus on inclusive interprofessional teamwork will be important in the further development of music therapy with children in mental health care. There are several measures that would be useful to implement music therapy, including involving the music therapist early in the case or ahead of hospital admission, as well as education about music therapy and observation by the staff of music therapy sessions. Observation and education are highlighted in previous research on interprofessional teamwork in music therapy, both in mental health care and in general, as positive and useful approaches to a better understanding of music therapy, and hence nurturing better teamwork (Choi, 1997; Hense, 2018; Ledger et al., 2013; O’kelly & Koffman, 2007; Thorgersen, 2015). Also, the staff’s emphasis on how music therapy shows its benefits when it is an interprofessional topic (P, FG “Kristin”) reveals that it is important to prioritize meeting points between the music therapist and the other staff in the interprofessional team, facilitating good collaboration through good communication.

Strengths and limitations

Inviting the staff in the interprofessional teams into the music therapy sessions could have provided important understanding of music therapy (Choi, 1997; Hense, 2018; Ledger et al., 2013; O’kelly & Koffman, 2007; Thorgersen, 2015; Twyford, 2008), but this was considered to be both disturbing and non-beneficial for the children participating in the study and not crucial for the team members’ understanding of music therapy. But the staff may have perceived music therapy differently if they had attended, for example, a single music therapy session with each child. It is also possible that they would have used music therapy differently, perhaps more purposefully, if they had had better understanding of its potentials. One option to strengthen the analysis could have been to distribute the analysed data to the participants in the focus group interviews, but, because this was real-world research, several of the participants were no longer at the unit at the time of the analysis. We do not consider that this would have been essential for understanding the study’s findings.

In conclusion

This study explored the interprofessional staff’s perceptions of music therapy at an inpatient unit for children in mental health care. The findings agreed to some extent with previous research in this field, regarding the usefulness of music therapy for the children as well as the music therapy’s contribution to the interprofessional understanding of the children (Hense, 2018; Thorgersen, 2015). But the study also explored how music therapy was a place to be free in such a context, a perspective that has not been much elucidated in previous research with interprofessional teams in mental health care for children. Through an exploration of the prominent topics that emerged from the findings, and possible contradictions between them, the individual’s culture and context seem to be crucial, as well as the music therapist’s awareness of the children’s communication capacity and possible needs. A further discussion of what is considered therapeutic is needed, and we pose the question of whether the “space of freedom” in music therapy in itself can allow optimal emotion regulation for children in mental health care? The findings also highlighted how music therapy contributed to a more holistic view of the child, a potential better relationship between the health services and the child, as well as how better interprofessional collaboration in this context could provide better service to the children.

Acknowledgments

We would like to express our gratitude to the staff at the children’s unit at Haukeland university hospital for your valuable contributions and participation. A special thanks to Anita Barsnes for your contribution to the music therapy processes.

We would also like to thank all the children for your participation in the music therapy.

Biographies

Guro Parr Klyve is a PhD candidate at The Grieg Academy – Department of Music at the University of Bergen, Norway, affiliated with GAMUT – The Grieg Academy Music Therapy Research Centre. She is a music therapist and has had her clinical practice at the Department of Child and Adolescent Psychiatry, Division of Mental Health at Haukeland University Hospital in Bergen for several years.

Randi Rolvsjord is a professor in music therapy and head of department at the Grieg Academy – Department of music, University of Bergen. She holds a PhD from Aalborg University. Her research and publications include resource-oriented perspectives on music therapy in mental health, user- involvement and feminist perspectives.

Irene Elgen is a professor in child and adolescent psychiatry at the University of Bergen. She is a senior doctor at the Department of Child and Adolescent Psychiatry, Division of Mental Health at Haukeland University Hospital in Bergen for several years. Her research and publications include risk factors for mental health challenges, aspects of mental health services.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Notes

1.

In Norway, music therapy is provided by music therapists with a master’s degree.

2.

The first author was a music therapist at this particular unit for several years. In this study, both Anita Barsnes and the first author had the role as music therapists at the unit.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

There is a risk that the data set may violate protection of the participants’ confidentiality.

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