Attributes of Pediatric Music Therapists: A Qualitative Analysis of Parent Descriptions

Abstract

Therapist attributes are known to contribute to positive therapeutic outcomes and are important to effective training and clinical practice. Although well researched in psychology and play therapy, few studies have directly explored music therapist attributes. To explore and understand these descriptions, we conducted a secondary analysis of parent interview data from a multisite trial investigating a music therapist-delivered intervention for young children with cancer and their parents. We used qualitative descriptive analysis to identify music therapists’ attributes as described by parents who participated in the intervention. Our inductive analysis of 28 interviews revealed 135 descriptors of music therapists. We discovered that these descriptions grouped naturally using essential therapist attributes of supportive, attuned, and nonjudgemental, as identified in the extant literature. This analysis highlights music therapists’ attributes perceived as central to their work with parents and young children in cancer settings.

Introduction

Music therapy is an established health profession that uses music within the context of a therapeutic relationship to meet the needs of individuals across the lifespan (Bradt et al., 2021). The practice of music therapy with children is common, including in pediatric hospital settings (Knott et al., 2020). In professional circles, music therapists discuss being described by their clients, families, and/or colleagues as “fun” or “playful” and make comments like “here comes the party” or “you have the fun job.” While not ill-intentioned, these comments can feel incongruent with the intentional, creative, emotionally taxing, and human work of pediatric music therapists.

This feeling of incongruence may be related to an absence of published research exploring how pediatric music therapists build therapeutic relationships with young children and their parents. Several studies have looked at related topics such as markers of interplay between the music therapist and hospitalized infants (Shoemark & Grocke, 2010), affective attunement using improvisation (Trondalen & Skårderud, 2007), music therapist attributes in clinical training (Nemeth, 2014), and therapeutic presence in music therapy education (Eggerding, 2023). However, we were unable to identify any other studies that directly explored music therapist attributes. In the absence of music therapy-specific research, findings from related disciplines like psychology and play therapy can be used to inform initial studies that seek to identify attributes of music therapists working in pediatric medical settings.

In psychology and play therapy, a significant body of research has examined the effect of the therapeutic relationship on client outcomes (Ryan et al., 2023). In particular, findings have established that the strength of this relationship is not only theoretically important but also predictive of positive outcomes (Crenshaw & Kenney-Noziska, 2014; Jayne, 2013; Jayne & Ray, 2015; Lambert & Barley, 2002; Orlinsky, Ronnestad & Willutzki, 2003; Schottelkorb et al., 2014; Shirk et al., 2011). Personal attributes of the therapist are central to understanding how strong therapeutic relationships are established.

Therapist attributes can be characterized as nonmodifiable or modifiable. Nonmodifiable attributes are those that cannot be changed, such as age or race. Modifiable attributes are those that can be developed through education and training, such as empathy, awareness, and interpersonal abilities (Delgadillo et al., 2020). Variations in modifiable attributes can explain clinically and statistically significant differences in treatment outcomes for patients, even when using a manualized intervention (Delgadillo et al., 2020; Nalavany et al., 2005). They are primarily derived from the seminal work of Carl Rogers, identifying important “relational conditions” of the therapist including unconditional positive regard, empathy, and congruence or genuineness (Rogers, 1957). After nearly 70 years, these attributes remain relevant, though their definitions have been expanded and refined based on studies across different contexts, therapists, and modalities, including work with children (Eggerding, 2023; Heinonen & Nissen-Lie, 2020; Jayne, 2013; Jayne & Ray, 2015; Lambert & Barley, 2002; Nemeth, 2014; Nunez et al., 2021; Ryan et al., 2023; Schottelkorb et al., 2014; Shirk et al., 2011; Velasquez & Montiel, 2018).

Building therapeutic relationships with children, especially young children, is different than for adults (Crenshaw & Kenney-Noziska, 2014; Jayne & Ray, 2015; Nalavany, 2005; Ryan et al., 2023; Shirk et al., 2011). Illustrating this point, Shirk et al. (2011) state

“Children’s positive feelings for the therapist may be connected to features not typically regarded as therapeutic, for example, how fun, stimulating, or rewarding the therapist might be. In such cases, it is unclear if the ‘bond’ reflects an experience of the therapist as an ‘ally,’ or as a valued playmate” (p. 18).

The child’s perception of their therapist as an ally or playmate has implications for effective outcomes, especially for young children who communicate and process life experiences best through play. Play therapy is a form of psychotherapy specifically developed for children. Play therapy research has identified and described attributes of therapists who work with children including being genuine, accepting, open, present, supportive, attuned, and nonjudgmental (Jayne & Ray, 2015; Nalavany et al., 2005; Nunez et al., 2021; Ryan et al., 2023; Shirk et al., 2011).

To better understand the attributes of pediatric music therapists, we conducted a secondary analysis of interviews with parents who had participated in a dyadic music-based play intervention designed for young children with cancer (aged 3–8 years) and their parents. The purpose of this analysis was to explore how parents describe their experience working with the music therapist, including how the therapist worked with their child.

Methods

Design

To ensure clarity about the origin of the data used for this secondary analysis, we will first describe relevant background information and methods used in the primary study. Qualitative and quantitative methods are described in detail in the primary papers (Robb et al., 2023; Stegenga et al., 2024).

The data used for this study were parent interviews collected during a randomized controlled trial of a music-based intervention (R01NR1578, Robb, PI; Robb et al., 2023). The intervention, active music engagement (AME) is a theoretically grounded intervention that uses interactive music play to counteract stressful qualities of the cancer treatment environment and reduce the interrelated distress experienced by young children and parents during cancer treatment. Active music engagement is a dyadic intervention that involves both the parent and child, with sessions delivered by a board-certified music therapist who tailors music experiences that encourage active engagement in and independent use of music play to manage distress (Robb et al., 2008, 2017, 2023; Stegenga et al., 2024). In the primary trial, 30-minute sessions were delivered daily over a 3-day course of chemotherapy (Robb et al., 2023).

Participants

Pediatric patients (aged 3–8 years) receiving chemotherapy for acute lymphoblastic leukemia, and their primary parent or caregiver were recruited from four Children’s Oncology Group pediatric hospitals across the United States from September 2016 through April 2020. Parents and children were recruited as dyads. Dyads were eligible if (1) the child was between the ages of 3 and 8 years of age at the time of enrollment; (2) had an expected course of at least three consecutive days of moderate to high-intensity chemotherapy (inpatient or outpatient); and (3) one parent (≥18 years of age or older) who could be present for all sessions. Dyads were excluded if the parent was unable to read and speak English (Robb et al., 2023). Of the 166 eligible parent/child dyads, 136 enrolled and completed baseline measures. Sixty-nine dyads were randomized to the intervention group, 63 completed all measures, and 43 completed the post-intervention qualitative interview (Robb et al., 2023). Parents were included in the qualitative interviews if the dyad was randomized to the study’s intervention arm and consented to the optional interview at the end of study activities. Purposive sampling for inclusion into the qualitative data set was based on child age, parent role (father/mother/grandparent), and parent/child race and ethnicity to provide a maximally varied sample (Stegenga et al., 2024).

Procedure and Data Collection

Methods for interviewer training, participant sampling, interview guide, and data collection were established for the primary study and are available in the primary paper (see Stegenga et al., 2024). All interviews were conducted within 21 days of the last AME session. A team member trained in qualitative methods completed interviews with parents in person or by phone based on parents’ preferences. Interviews lasted an average of 13 minutes. Parents answered a series of semi-structured questions about their experience in the trial, which included the question, “What was your experience working with the music therapist?.” However, since parents referenced therapists in other parts of the interview, full interviews were analyzed for therapist-related content.

Data Analysis

For this study, we reanalyzed parent interviews using a qualitative descriptive approach focused on the parent’s experience and description of their experience working with their music therapist. Our qualitative descriptive approach included the following steps: (1) open coding to identify salient units of meaning or codes; (2) categorization of conceptually similar codes together; (3) further category definition and refinement; and (4) re-analysis to ensure final category fit (Colorafi & Evans, 2016).

Interview data were received by the first author after professional transcription and deidentification. MAXQDA software was used for data management (MAXQDA 2022, 2021). Initial coding focused on the parent’s perceptions of the music therapist. These initial codes were checked with the other authors for agreement. Any discrepancies were discussed by the authors until a consensus was reached. As codes were being formulated into categories, we noticed that therapist attributes as identified by Shirk et al. (2011) encompassed the groupings of our codes. This led to our decision to re-code the data using the three primary attributes identified by Shirk et al. (2011) (i.e., supportive, attuned, and nonjudgmental). While our data appeared to fit well with these attributes, the terms were not well defined. To ensure that our categorization was indeed a good fit and to add clarity to our analysis, we synthesized descriptions from the extant literature to develop clear definitions for each term (see Table 1).

Table 1.

Therapist Attributes: Defining Behaviors and Characteristics

Definitions of key terms
Attribute	Definition	Behaviors and characteristics
Supportive	A supportive therapist is warm, sensitive, and consistent while providing structure that ensures predictability, and physical/emotional safety while encouraging autonomy.	Directing or guiding the child to promote physical and emotional safety (Shoemark & Grocke, 2010). Providing supportive structure and predictability in times of uncertainty (Nunez et al., 2021). As the child gains confidence and comfort, guiding gives way to encouraging autonomy (Crenshaw & Kenney-Noziska, 2014; Shoemark & Grocke, 2010). Consistent, warm, and genuine (Nunez et al., 2021).
Attuned	An attuned therapist matches affect and energy, connecting with the child through responsive, playful interactions and conveying that their verbal and nonverbal communications are understood and accepted.	Attending and attuning to the child and their internal world, to both their verbal and nonverbal communication (Crenshaw & Kenney-Noziska, 2014). A “playful stance” that allowed the therapist to connect with their child clients in a developmentally relatable way, through play (Nunez et al., 2021). The therapist that is fully engaged in play with the child, matching their behaviors and style of play, appearing child-like and fun (Crenshaw & Kenney-Noziska, 2014; Nalavany et al., 2005). The therapist is responsive to the child’s verbal and nonverbal communication (Shoemark & Grocke, 2010). Attentive (Nunez et al., 2021)
Nonjudgmental	A nonjudgmental therapist accepts and values the child as they are, accepting their play and behavior as communication without labeling as “bad.”	Accepting and offering “unconditional positive regard” (Jayne, 2013). “valuing all aspects of the child’s play and self-expression” and trusting and accepting the child (Jayne & Ray, 2015, p. 128).

Results

The sample included 28 parents (or caregivers) of children with cancer. The mean age of parents was 38.3 years old (range 27–65 years). Sixty-one percent of the children were aged 3–5 years, with the remaining 39% ranging from 6 to 8 years of age (see Table 2 for demographics). Our analysis revealed 135 statements that were categorized into three attribute categories. Each of the three attribute categories includes descriptors with exemplar statements. Statements are attributed using the following labeling convention: relationship to child (mother [M], father [F], or grandmother [GM]) with designated participant number; followed by the child’s age and relationship to caregiver (son [S] or daughter [D]). For example, mother (participant number 4) of a 5-year-old daughter is labeled as M4-5D. Supporting data including categories, descriptors, and illustrative quotes are reported in Table 3.

Table 2.

Demographics

(N = 28)	N (%)
Site
1	11(39%)
2	3 (11%)
3	8 (29%)
4	6 (21%)
Parent/caregiver age
Mean	38.3 years
Range	27.0–65.0
Caregiver role
Father	6 (21%)
Mother/Grandmother	22 (79%)
Parent/caregiver race
Black	4 (14%)
White	17 (61%)
Asian	3 (11%)
Other	1 (3%)
More than one race	2 (7%)
Did not answer	1 (3%)
Parent/caregiver ethnicity
Hispanic or Latinx	3 (11%)
Non-Hispanic or Latinx	25 (89%)
Child age
3–5 years	17 (61%)
6–8 years	11 (39%)
Child gender
Female	13 (46%)
Male	15 (54%)
Child race
Black	4 (14%)
White	15 (54%)
Asian	2 (7%)
Other	2 (7%)
More than one race	4 (14%)
Did not answer	1 (3%)
Child ethnicity
Hispanic or Latinx	4 (14%)
Non-Hispanic or Latinx	24 (86%)

(Stegenga et al., 2024).

Table 3.

Categories, Descriptors, and Illustrative Quotes

Categories  Descriptors	Illustrative quotes
Supportive
Nice/Friendly	“She was super-friendly, super-involved and positive, so yeah, she was good.” Mother of a 6-year-old son (mother 1 of a 6-year-old son; M1-6S).
Consistent	“… having the therapist come to the room, and having it be the same person, because so often you see different people every day, and so having it be the same person who came by was really great.” Mother of a 3-year-old daughter (mother 2 of a 3-year-old daughter; M2-3D).
Helpful	“[she] was good, very helpful, very caring and helped guide him through the process” (M3-4S).
Encouraging	“I like that she was very encouraging too, if that doesn’t work, you can also try this…” (M4-4D).
Likable	“My baby, she liked her” (M5-6D).
Attuned
Energetic	“She was helpful for the play. She was real energetic” (M6-7S).
Fun	“She’s really fun” (M7-8D).
Child-like/playful	“Her and [Child] just making up silliness” (Grandmother of an 8-year-old daughter; GM1-8D)
Intuitive/Observant	“[She] didn’t push, and sometimes you worry, this individual is gonna push a little bit more. I only want to do so much singing, but it wasn’t like that. It was more of a try it, if you like it, great, if not, we won’t do it again.” (Father of an 8-year-old son; F1-8S).
Responsive	“she’s very interactive and engaging” (M1-6S). “it allows the therapist to respond to and go based off what she is doing, sort of validating what she is doing, so if she’s playing to a particular beat, the therapist can play along to that beat. It’s nice to have that response” (M2-3D).
Good with kids	“she did really good with [Child], because sometimes people don’t, I mean obviously she works with kids I guess. Sometimes people aren’t that great, but she did really good” (M9-3S). “She was awesome. She was really awesome. She just, you can tell, with me working in education, you can tell when certain people are good at what they do, and she’s good at what she does” (F1-8S).
Nonjudgemental
Patient	“There was never any time where I saw her get exasperated agitated or nothing” (F2-4D).
Understanding	“She was real easy to work with and understanding” (M10-6S).
Flexible	“Sometimes [Child] would stray off of what we were doing, and she was really good about just going along with whatever he was doing, and that worked out really great. I was like that makes sense, just go with it, instead of saying no, that’s not what you’re supposed to do, just go with whatever he’s doing, and it worked out really well” (M9-3S).
Comfortable	“I felt so comfortable with her like I’ve known her for a long, long, time” (M8-8D).

Supportive

The supportive attribute included five descriptors offered by parents. These descriptors included: nice/friendly, consistent, helpful, encouraging, and likable. One parent described their therapist saying, “She really like influenced him to get in and actually play” (M12-8S). Some statements also described the parents perceiving the music therapist as supportive to them as the parent. One grandmother stated, “She’s [the music therapist] really, really great. She encourages you, even if you change the words [of the song], it was ok because sometimes I would forget... but she said it was ok … she was wonderful” (GM2-3D).

Attuned

Attuned was the most frequently described attribute in parent interviews and offered six descriptors: energetic, fun, child-like/playful, intuitive/observant, responsive, and good with kids. One parent said of her child’s music therapist, “I thought it was really cool; like [she] put the toy on his head or something, she would sing a song about that, or he would put the toy on his foot, she would make a silly song about it” (M11-4S). Another parent described how her child’s therapist was “so great with [child’s name]. The way she [the music therapist] interacted with her, and it was like sometimes you’ll pull back and you’ll feel a little embarrassed with other people around you about how you play or whatever. … She [the music therapist] didn’t care” (GM1-8D).

Nonjudgemental

The attribute of nonjudgement included four descriptors: patient, understanding, flexible, and comfortable. Parents described the therapists’ nonjudgemental approach both for their child and for themselves. One parent noted when talking about how she observed the music therapist’s approach to working with her son, “he was really silly during a lot of them [the music sessions], and like changing the words [to the songs] and just getting really creative…and she was like ‘okay’…she did really well with letting him lead” (M13-6S). Regarding her own experience, another parent commented, “I felt so comfortable with her [the music therapist] like I’ve known her for a long, long time” (GM1-8D).

Discussion

This paper explores attributes of music therapists as described by parents who participated in a manualized music therapy intervention with their child during pediatric cancer treatment. Understanding how parents perceived and described their music therapist offered an opportunity to identify important therapist attributes and how they relate to those described in the psychology and play therapy literature. Music therapists were often described as “fun,” “sweet,” or “entertaining.” While these descriptors might seem superficial, inconsequential, or incongruent, they are the external manifestation of attributes known to foster an effective therapeutic alliance between therapist, child, and family members (Heinonen & Nissen-Lie, 2020; Jayne, 2013; Nalavany et al., 2005; Nunez et al., 2021; Shirk et al., 2011). Here, we contextualize findings for each attribute within the extant literature and discuss relevance to clinical practice.

Supportive

Descriptors of support centered across three areas and included music therapists’ expressions of warmth and sensitivity, consistency, and encouragement, along with providing structure to support child success. Together, these qualities help the therapist create a physically- and emotionally-safe environment that encourages independence and autonomy. These supportive attributes are particularly important in pediatric cancer settings where parents and children experience high and sustained levels of uncertainty and stress (Kazak et al., 2005; Koumarianou et al., 2021; Perez et al., 2018). This is consistent with play and music therapy literature, where in addition to warmth, sensitivity, and playfulness, therapist support includes providing direction, guidance, and structure that helps bring predictability into unpredictable or chaotic environments (Crenshaw & Kenney-Noziska, 2014; Nunez et al., 2021; Shoemark & Grocke, 2010).

Parents also described how the therapist supported them in their role as parents. The encouragement, warmth, and structure from the music therapist established trust, helping the parent to let down their guard and playfully connect with their child. Engaging a young child in sustained play, particularly the type of responsive play that is essential to support child coping, requires physical and emotional energy (Gunnar et al., 2015; Komanchuk et al., 2023). This level of energy can be difficult for parents to access during times of high stress, such as hospitalization (Klassen et al., 2007, 2008). As such, the music therapists’ ability to establish this trust helps parents feel supported to more fully engage in play with their child.

Attuned

Descriptions of attunement included music therapists’ ability to take a child-like stance that was playful and matched the mood, energy, and interests of the child. Parents noticed that the therapist joined the child in their play and paid careful attention to the child’s responses. They also noted how the therapist would weave the child’s responses and interests into the music play, allowing the child to lead and contribute to the play experience. These therapist behaviors are consistent with the concept of attunement, which is central to creating a meaningful connection between a therapist and child (Jayne, 2013; Nalavany et al., 2005).

Attuning to a child serves as the point or place of connection between the child and therapist, where the therapist joins the child in their world of play, not requiring the child to conform to the therapist’s space (Crenshaw & Kenney-Noziska, 2014; Jayne & Ray, 2015). As the therapist attunes to the child, they match or mirror the child’s energy and affect, becoming playful and child-like, open to and accepting of the child’s actions (Jayne, 2013). In practice, attunement looks like simple play, making it easy to overlook or underestimate its therapeutic value. It is through attunement that the therapist meets the child in their world and establishes a safe and familiar space for therapeutic work to take place.

Nonjudgemental

Parents described their therapists as patient, understanding, flexible, comfortable, and accepting; with qualities of nonjudgement. Parents observed the therapist accept and value them and their child, providing a foundation for emotional safety and trust. In the play therapy literature, nonjudgement is described as the therapist trusting and accepting the child, joining the child in their play, even if that play is “inappropriate” by adult standards (Jayne, 2013). Examples include silliness, potty humor, and repetitive play, all behaviors that are developmentally appropriate but often discouraged by parents or other adults. During cancer treatment when a child’s typical play is negatively impacted, silliness and potty humor can be an indicator that the child is feeling better, becoming less withdrawn, and acting more like themselves (Nijhof et al., 2018). Parents noted that the music therapist was patient, flexible, and never irritated by their child’s behavior; rather, they remained accepting and understanding.

Parents perceived that the music therapist was nonjudgmental towards them as well. Parents described a “flexibility” and “understanding,” perceiving the therapist’s acceptance of the child while not judging the parent’s ability to make them “comply” or “conform.” This allowed parents to become less guarded, more playful, and follow the music therapist’s lead in engaging with their child. This can be especially challenging in medical environments where privacy is limited and parents can become self-conscious about their own parenting (Bakula et al., 2020; Feudtner et al., 2015). The nonjudgmental therapist supports the parent in their overwhelmed state and gently guides them into a playful space with their child.

Implications

These results have implications for music therapist training and the development of manualized interventions. Our data offer greater understanding about the attributes of pediatric music therapists that parents notice and view as important. Parent descriptions and identified attributes are consistent with those from the psychology and play therapy literature, offering additional evidence to support their importance. The identified attributes are modifiable and represent teachable skills that can be developed through clinical training and education, especially for those who plan to work in pediatric hospital settings. Further investigation and elaboration of all three attributes are needed, especially how they manifest musically and contribute to or explain differential outcomes from music therapy interventions.

Limitations

The limitations of this study are threefold. First, as a secondary analysis of available data, this study has limited generalizability to other therapeutic contexts and client groups. While there may be similarities in practices, this study did not consider music therapists working in any other context. Second, the interview questions were not designed to directly explore the attributes of the music therapist. Although information about the music therapist was solicited as part of the interview, more direct questions about the therapists’ work, their use of music, and what made them effective would support a more comprehensive examination. In particular, the nature of the data set limited our ability to explore the therapists’ use of music in establishing a therapeutic relationship. This is a critical limitation given that music plays a unique and central role in the practice of music therapy (Edwards, 2016).

Third, this study is limited by the homogeneity of the intervening music therapists in terms of race, ethnicity, and gender identity. All 13 music therapists who participated in the primary trial were white females. It is well documented that nonmodifiable therapist factors like race and ethnicity can affect the therapeutic experience for patients and family members. For example, a recent systematic review reported that for some groups of children and adolescents, racial and ethnic matching between the therapist and client can significantly improve therapeutic outcomes, though matching on the basis of gender appeared to have mixed results (Ryan et al., 2023). Further research is needed to explore how race, ethnicity, and culture affect the experiences of families, and how we can create culturally relevant and sensitive interventions.

Conclusion

This study represents an initial step toward identifying and defining attributes of pediatric music therapists. This analysis highlights essential but previously unspecified attributes that parents identify in pediatric music therapists: supportive, attuned, and nonjudgemental. Connecting parents’ descriptions of their child’s music therapists with extant literature from fields of psychology and play therapy adds important context to these common descriptions. This information provides a strong foundation for further research, intentional clinical practice, and focused training for music therapists working in pediatric hospital settings.

Author contributions

Elizabeth Harman (Conceptualization [Lead], Formal analysis [Lead], Methodology [Lead], Writing—original draft [Lead]), Kristin Stegenga (Conceptualization [Equal], Methodology [Equal], Validation [Equal], Writing—review & editing [Equal]), and Sheri Robb (Conceptualization [Equal], Funding acquisition [Equal], Validation [Equal], Writing—review & editing [Equal])

Funding

This study was supported by National Institute of Nursing Research of the National Institutes of Health (NINR) R01NR1578 (Robb, PI) and The National Cancern Institute of the National Institutes of Health T32CA117865 (Champion and Mosher, MPI).

Conflicts of interest

The authors have no conflicts of interest to report.