A Sequential Mixed-Methods Study of Pre-Professionals’ Understanding of the Undergraduate Music Therapy Internship

Abstract

Despite the importance of the clinical music therapy internship, little research has been conducted to understand the perspectives, perceived musical, clinical, and personal skills, concerns, challenges, and anxieties of pre-professionals prior to and upon completion of the internship. This sequential mixed-methods study aimed to assess the perspectives and experiences of undergraduate students in the United States at two stages in the internship in music therapy practice. In total, 177 pre-professionals from the United States participated in this two-part study: (1) an online survey and (2) individual interviews with 25% (n = 44) of the participants. Survey results indicate statistically significant increases in clinical, musical, and personal skill development from pre- to post-internship. Six broad categories emerged from the interviews: confidence, anxiety, role clarity, professional suitability, loneliness, and boundaries/ethics. The results are encouraging, showing that the internship is a valued clinical experience that fosters improvement in the clinical, musical, and personal skills needed to work as a music therapist. This paper concludes with recommendations and suggestions for educators and supervisors on preparing and supporting pre-professionals in their skill development prior to and during internship.

The music therapy clinical internship is the final step in the completion of an undergraduate degree program in music therapy. Under the supervision of a credentialed music therapist, the music therapy internship provides pre-professionals with the opportunity to connect their education and theoretical understanding in a working environment. Internship duration is based on the student’s past clinical training background and typically ranges from 900 to 1,200 hours (Rushing & Capilouto, 2016). By the end of the internship, pre-professionals must demonstrate entry-level competencies evaluated by the internship director and/or their academic institution.

Twenty professional competencies have been formalized by the American Music Therapy Association (AMTA) across three domains, which include music therapy as well as clinical and music foundations (American Music Therapy Association, 2013). Post internship, pre-professionals are eligible to sit for the Music Therapy Board Certification Examination and begin working. However, it is important to consider that pre-professional music therapists have expressed feeling unprepared for their internship and have anxiety and fear, even after studying for several years before this final step (Baker & Krout 2011; Barry & O’Callaghan, 2008; Clements-Cortés, 2015; Grant, 1990; Knight, 2008; Watson, 2005; Wheeler, 2002). The application of textbook theories and classroom learning in clinical practice is a foremost concern for music therapy students (Baker, 2007, 2011; Barry, 2008; Madsen, 1999), given that each client has unique needs requiring different care strategies. The internship experience is also feared by pre-professionals due to the expectation to demonstrate clinical care reflecting their comprehension of multiple theories and execution of music skills (Baker, 2007; Baker & Krout, 2011; Barry & O’Callaghan, 2008).

It is important for music therapy educators, internship supervisors, and pre-professionals to become aware of the research surrounding the issues pre-professionals may experience in order to continue to advance education and training in the discipline. By anticipating skill development progress, and concerns which pre-professionals may face, faculty and internship supervisors will be better equipped to support students and undeveloped skill areas.

In this study, data were collected and analyzed to assess undergraduate students’ (in the United States) perceived skills and primary issues pre- and post-internship. In 2015, the researcher completed a similar study on the internship in music therapy experiences of undergraduate students in Canada (Clements-Cortes, 2015).

Literature Review

A small pool of research has investigated the personal and situational factors that influence the perceived success of pre-professional music therapy internships (Brown & Alley, 1983; Cassidy, 1990; Legette, 1997; Madsen & Kaiser, 1999; Madsen, Standley, Byo, & Cassidy, 1992; Standley & Madsen, 1991). Appraising the current literature, four broad themes have been emphasized based on the perceptions of the internship that pre-professionals experience: academic preparation; lack of confidence; pre-professional-–supervisor relationship; as well as personal and financial concerns.

Academic Preparation

Undergraduate education serves as the foundation for pre-professional music therapists’ clinical training (Lloyd, Richardson, Boyle, & Jackson, 2017). Madson and Kaiser indicated that the foremost fear that music therapy interns had was “general preparation/being prepared” (1999, p. 17). Pre-professional music therapists have recently drawn attention to the somewhat limited practical applicability of the general education and core music requirements in the music therapy curricula (Lloyd et al., 2017). The need for additional courses in secondary instruments, music therapy, fieldwork, recreational music, and clinical populations have been cited; concurrent with a reduction in coursework pertaining to music theory, music history, and applied lessons (Braswell, Maranto, & Decuir, 1979; Madsen, 1965; Petrie, 1989). Contrastingly, Jenkins (2013) found that overall pre-professionals’ musical skills were underdeveloped, and suggested that teaching functional music skills, in addition to developing standardized proficiency examinations, be given priority amongst music therapy academic directors. In my recent study on Canadian pre-professionals, music therapy students overall felt that entering internship they had a solid music therapy knowledge base, clinical documentation skills, and musical skills (Clements-Cortes, 2015).

Groene and Pembrook (2000) argued that in order to address music therapy graduates with underdeveloped skills, the internship could be completed at a master’s level. Although this longstanding idea is highly controversial, job-related outcomes such as higher salaries, job satisfaction, and work opportunities amongst music therapists attaining advanced degrees have been cited (Clements-Cortes, 2006; Groene & Pembrook, 2000; Oppenheim, 1987; Vega, 2010). In July 2018, the AMTA Board of Directors, in consideration of the Masters Level Entry Subcommittee (MLE) recommendation to move to the minimum training of music therapists to the master’s level, forwarded an alternate interim action, creating the Education and Clinical Training Commission of 21st century of music therapists, in order to assess this issue further.

Lack of Confidence

A lack of confidence may impede a pre-professional’s ability to learn and perform during their internship. Nix (2015) assessed the ways in which music therapy students increased their confidence over the internship, noting that respondents experienced an increase in confidence largely from lab-based assignments. Coinciding with Gooding and Standley’s (2010) finding that music therapy students with less clinical work experience reported lower levels of self-confidence, students gained a higher sense of confidence by having their knowledge and skills affirmed through direct patient/group interactions (Nix, 2015).

In Madsen and Kaiser’s (1999) study comparing music therapy and music education students entering internship, they found music therapy students had more concerns surrounding the working environment, expressed considerable concern about their supervising therapist, and whether clients were responding to treatment. Similarly, at the beginning of the internship, Wheeler (2002) not only found that students felt challenged by the new experience, but were also concerned about meeting the clients’ needs. Exploring the emotional climate of pre-professionals over a 6-month internship, Grant (1990) found significant personal and professional gains, including feelings of insecurity and confidence in the fifth and sixth months.

Results from a study of music therapy students who were offered Bonny Method of Guided Imagery and Music (Bonny Method) as a form of personal therapy (Fox & McKinney, 2015) suggested that the Bonny method was helpful for developing strategies for personal reflection (e.g., journaling and meditation) and self-care as outlined by the AMTA (American Music Therapy Association, 2009). Furthermore, participants indicated the greatest personal growth happened in their sense of confidence as well as several other positive self-nurturing areas such as awareness of personal issues, motivation, stress reduction, and feelings of independence. From a multicultural perspective, Zhang, Shi, and Hsu (2016) concluded that amongst international music therapy interns, acculturation and adapting to a new lifestyle were the main cause of the lack of confidence and low self-esteem.

Pre-Professional–Supervisor Relationship

The dyadic intern–supervisor relationship can profoundly impact the intern’s sense of self-worth and clinical practice, as the supervisor can provide opportunity for professional growth (Salmon, 2013). When receiving positive and negative feedback, interns tend to focus on the negative (Clements-Cortés, 2009). Supervisors can help foster pre-professionals’ self-worth by providing examples to improve clinical sessions, scaffolding opportunities, and framing these as chances to grow, and to help diminish feelings of anxiety and insecurity. Brown (1997) described that music therapy students may experience negative emotions such as anxiety, insecurity, resentment, and even anger, possibly aggravated by the intern’s response to their supervisor’s perception and assessment of their clinical performance. Often a relationship between the pre-professional and the supervisor can serve to mediate the intern’s perceived experience of the music therapy internship; however, this can lead to a somewhat low frequency of boundary issues (Lasco, 2013). An online survey investigating the frequency of boundary issues occurring within the supervisory relationship found that social media connections and meetings outside the clinical settings were the root of most boundary-crossing issues (Lasco, 2013).

Itzhaky and Ribner (1998) discussed how an intern’s feelings of tension can manifest without feedback provided on behalf of the supervisor. Interns at times can feel overwhelmed and experience uncertainty as a result of the supervisor not acknowledging the intern’s provision of quality care and music therapy skills (Itzhaky & Ribner, 1998). On the basis of a study of the differences in perception of professional competency, Knight (2008) suggested that music therapy educators address training expectations between students and supervisors prior to starting the internship, to facilitate a comprehensive work-dynamic. Finally, Salmon (2013) examined in-depth the complexity of the supervisor and intern affiliation, noting how parallel process, style of supervision, transference, and countertransference affect the supervisory relationship.

Personal and Financial Concerns

Lloyd et al. (2017) described how some American music therapy students experience frustration prior to their internship in terms of the State Authorization Reciprocity Agreement (SARA) limiting their internship placement options despite completing the required prerequisites. Nearly two decades earlier, Madsen and Kaiser (1999) noted that pre-professionals expressed concerns about finding suitable living accommodation, and having the funds to support themselves during the internship. Furthermore, Grant (1990) acknowledged that many pre-professional music therapy students could not manage holding a part-time job during their internship which could potentially alleviate some financial strain/worry associated with higher education pursuits. Other fears related to intern’s personal wellbeing included the stress of being far from home (Grant, 1990), as well as not being able to deal with the death and dying of clients (Baker & Krout, 2011; Grant, 1990; Wheeler, 2002).

Nix (2015) revealed how pre-professionals may feel that part of their job is taking the initiative to advocate for the widespread need for music therapists, as patients/healthcare workers may not be familiar with music therapy and the potential health benefits. Pre-professional music therapists have also spoken about how allotting adequate amounts of time towards course work, while also trying to engage in job opportunities through networking within their professional field, can be difficult (Nix, 2015). Contrarily, Ferrer (2017) pointed out that music therapy job opportunities are increasing so rapidly that the demand for these types of music professionals often exceeds the number of applicants.

From the review of literature, it was clear to the researcher that there were still a number of areas where more information and research would assist educators and supervisors in (1) preparing students for internship and (2) providing clinical music therapy internship experiences; and subsequently, this study was undertaken. Specifically, the researcher wanted to learn from pre-professionals what skills they felt they needed to develop, their experiences with supervisors, personal and financial issues, feelings about working as an intern, as well as their overall perspectives and experiences in their final stage of training. The purpose of the study was to assess and compare the perceived clinical, musical, and personal skills, concerns, challenges, anxieties, perspectives, and experiences of undergraduate students in the United States at two stages in the internship in music therapy process. The research questions included:

1. How do undergraduate students in the United States at two stages of the internship in music therapy process perceive their clinical, musical, and personal skills?

2. What are the issues, concerns, challenges, anxieties, and experiences of undergraduate students in the United States at two stages of the internship in music therapy process?

3. What suggestions can be proposed to music therapy educators and clinical internship supervisors to further support students in their clinical, musical, and personal skill development; as well as help alleviate some of the internship concerns, challenges, and anxieties?

Method

Study Design

An explanatory sequential design was chosen for this study where the Primary Investigator (PI) completed the research in two stages (Creswell & Plano Clark, 2011). First, survey results were gathered and analyzed. Next interview questions were created based on the quantitative results, in order for a more focused and in-depth understanding of the pre-professionals’ experiences. This design was purposefully selected in order to encourage participants to further elaborate on their survey rankings and comments; and from the researchers’ past internship study (Clements-Cortes, 2015) where there was no further elaboration of the survey rankings in the interviews, as the interview questions were designed in advance of the survey analysis.

Participants

Participants included 177 undergraduate music therapy students, who completed their internships required for the fulfilment of their undergraduate degrees and eligibility to sit for the Music Therapy Board Certification Examination. Participants were required to be fluent in English, and were asked to identify their age, gender, and the location (city and state) of their internship. A total of 208 participants signed consent forms and agreed to the study protocol. Nine of those persons did not complete the pre-internship survey, and 10 did not complete the post-internship survey, regardless of e-mail reminders to do so. Six participants were excluded, as they had not completed their internship when the PI was completing and closing the study, and six dropped out of their internships.

According to the American Music Therapy Association (AMTA), there are 174 active national roster internship programs (NRIP) and as of May 11, 2018, 73 NRIP directors submitted annual reports noting that 142 students completed their internship at an NRIP program in 2016 (Personal communication Jane Creagan, May 11, 2018). Based on that information (as updated information was not available), it was estimated that the potential pool of applicants for this study was approximately 320–350 students. The response rate of the completed surveys was approximately 51–55%. Informed consent was obtained via email, fax, or hard copy sent in the mail.

Recruitment

Participants were invited to participate in the interview and surveys via an e-mail invitation. The e-mail addresses of 1,100 were obtained from the AMTA. The PI and Research Assistant (RA) did not know these persons. The invitation was a general e-mail sent to all undergraduate students enrolled in music therapy programs, not only interns or those in their last year of study. Music therapy educators and supervisors were also made aware of this study via an e-mail sent out through the AMTA list of contacts. Music therapy educators and supervisors were not required to encourage students to participate. The e-mail sent to them was simply to inform them of the study.

Materials/Data Sources

Survey

Each participant was asked to complete a survey pre- and post-internship. Surveys were sent to participants by the RA and/or PI via e-mail. The pre- and post- surveys were compared to determine any perceived changes in clinical, musical, and personal skills as well as to identify issues, challenges, anxieties, and concerns of students.

Interview

Twenty-five percent of participants (n = 44) were intentionally invited to take part in an interview via Adobe Connect or telephone, by way of maximum variation sampling (Creswell & Poth, 2017). The PI-identified participants, and invited interviews based on age, gender, geographical location, and clinical population/workplace setting to ensure a sample where participants would be influenced by different factors (Creswell & Poth, 2017). In total, 56 participants were invited to be interviewed; however, six declined and the remaining six found it too challenging to find a mutually agreed upon date and time for the interview. In conclusion, 44 interviews were audio recorded for transcription and followed an interview guide approach (Patton, 1980). Both survey and interview questions were designed based on the work of Clements-Cortés (2015), McClain (2001) and Wheeler (2002).

Data Analysis

Quantitative Analysis

Descriptive and inferential statistical tests were used to compare the self-assessment scales of pre-professionals in four domains (clinical skills, music skills, personal skills, and issues/concerns). These tests were administered before and after the participant’s internship. The response set for each question was a 5-point Likert scale. Proportions of each of the values in the response set were calculated for each question pre- and post-internship. For each question, an average of the 1 to 5 numerical response rating was calculated pre- and post-internship. Paired t-tests were used to find any significant differences between pre- and post-internship ratings in the various domains.

Qualitative Analysis

The PI and two credentialed music therapists who did not assist in recruitment or data collection analyzed the interview transcripts to enable objective data analysis through inter-coder reliability (Cho, 2008). As described by Braun and Clarke (2006), thematic analysis was conducted by the three persons individually to determine the principal codes and themes (Joffe & Yardley, 2004). The PI selected the Braun and Clarke (2006) guidelines for thematic analysis which unfolds in six phases, alongside incorporating Joffe and Yardley’s (2004) coding guidelines. Final coding decisions were made by the PI in instances when there were discrepancies and the results are presented below in broad themes.

Ethical Considerations

Research Ethics Board approval was obtained from the University of Toronto. Participants were assigned a participant number to ensure confidentiality. The letter of information and consent form indicated the right for participants to withdraw from the study at any point. The list of participants’ names, audio recordings and transcriptions, as well as survey results were discarded after participant verification. All electronic files were kept on the PI’s password-protected laptop.

Results

Quantitative Results of the Pre- and Post-Internship Survey

Figure 1 indicates the proportion of responses to the categories of the Likert scale concerning participant’s clinical skills. The figure shows that the highest proportions of feelings were both satisfactory and good (38%) in pre-internship and good (52%) post-internship. Figure 2 indicates the proportion of responses to the categories of the Likert scales concerning the participant’s musical skills. In pre-internship, the highest proportion of feelings were satisfactory (46%) and post-internship were good (52%). Figure 3 indicates the proportion of responses to the categories of the Likert scales that describes the participant’s personal skills. The highest proportion of feelings in pre-internship was satisfactory (44%), and post-internship was good (58%), displaying a similar pattern as participants’ musical skills. Figure 4 indicates the proportion of the categories of the Likert scales for participants’ issues and concerns. The figure shows that the highest proportion was moderate (41%) in pre-internship and was good (48%) post-internship.

Paired t-tests were used to examine the differences on the self-assessment scales from pre- to post-internship. Table 1 shows the number of group, mean, standard deviation, p values, and significance of all questions. For the paired t-tests, all the questions demonstrated significant differences on the self-assessment scales from pre- to post-internship (p < .05) except for question 23a (p = .05) and 31a (p = .96). The following are the 10 largest significant differences as recorded in Table 1:

1. Level of comfort and implementation of clinical improvisation on piano (question 1a).

2. Current vocal skills when singing in a music therapy session (question 12a).

3. Guitar skills when using guitar in a music therapy session (question 1b).

4. Level of writing music therapy treatment summaries/case studies (question 5f).

5. Participants’ verbal communication skills (question 15).

6. Current level of insight into their own strengths and needs, and how they affect their clinical work (question 18).

7. Level of completing music therapy treatment plans (question 5a).

8. Ability to manage a heavy work load (question 16).

9. Level of current piano skills when using piano in music therapy sessions (question 10a).

10. Current level of comfort and use of verbal dialogue in music therapy sessions (question 4a).

The adjustments that are made to correct for multiple comparisons assume that there is a level of significance alpha such that a p-value below alpha results in a rejection. Using the standard Bonferroni correction and alpha = .05 then for the largest subgroup of questions (Clinical Skills n = 25) a p-value would have to be less than .05/25 = .002 to be declared significant, and this is the case for all of these questions as all the p-values are less than .001. The Holm–Bonferroni method will give the same result in this case. The same reasoning applies to the other groups of questions as well with two exceptions, namely for the Issues/Concerns group the differences for question 23a and 31a are not considered to be statistically significant as both p-values are greater than .05/13 = .004.

Qualitative Results Arising from the Interviews and Survey Follow-Up

Interviews were conducted to ask pre-professionals post-internship about their internship experiences and to gain further information on the data collected on the surveys. Participants chosen for interviews worked with the following clinical populations: abused/sexual assault (n = 4); developmental disabilities (n = 4); substance abuse (n = 3); multiple disabilities (n = 4); stroke (n = 3); Alzheimer’s and dementia (n = 8); hospice/palliative care (n = 6); cancer care (n = 5); autism spectrum disorder (n = 3), eating disorders (n = 2); and post-traumatic stress disorder (n = 2). The interview questions (see  Appendix) were not exclusive to the clinical populations, but asked about participants’ overall experiences; musical, personal, and clinical skill development; as well as specifically about clinical improvisation, clinical writing, anxiety, verbal communication skills, and techniques in sessions. Similar issues and topics surfaced irrespective of the clinical population. From the analysis of the 44 interview transcriptions, results have been placed into six broad topics: confidence, anxiety, role clarity, professional suitability, loneliness, and boundaries/ethics.

Confidence

Participants discussed feeling unprepared and doubting their musicianship, specifically with respect to improvising on guitar (n = 25), piano (n = 19) and percussion (n = 14) and singing in sessions (n = 21). However, participants (n = 35) felt their musicianship and musical skills had improved post-internship and they indicated confidence in improvising: in a variety of styles (n = 21), on various instruments (n = 22) and including their voices in sessions (n = 30). Also surfacing was increased skill development and confidence in writing progress notes (n = 33), and planning sessions for clients (n = 21). While participants (n = 33) noted they felt much more confident about their verbal skills in sessions, they desired continued learning and skill development in this area. Managing a large caseload was also mentioned by participants (n = 17) as something they were proud to have accomplished at internship completion.

Anxiety

For question 31a, there were no statistically significant scores on the paired t-tests with respect to the amount of anxiety a pre-professional felt towards beginning or ending their internships. Therefore, the PI specifically inquired about anxiety in the interviews, finding that pre-internship anxiety surrounded: providing music therapy to clients (n = 30), finances (n = 25), not “measuring up” to past interns (n = 23), not knowing what to say to clients in challenging situations (n = 22), managing a large caseload (n = 19), making a good impression on the clinical supervisor (n = 18), and leaving supportive friends (n = 10). Post-internship anxiety was stemming from worry about: finding employment or having to create a job (n = 40), not having anywhere to go to each day (work or school) (n = 30), not feeling they had the verbal dialogue and/or counselling skills to effectively help some clients (n = 26), concerns over whether to apply to graduate programs or begin working (n = 25), and paying off student debts (n = 20).

Role Clarity

Participants (n = 37) spoke at length about the frustration with having to explain what music therapy is to members of the healthcare team, caregivers, and clients. This lack of awareness of music therapy seemed to stem from misconceptions about music therapy, and calling all music experiences music therapy. While participants were discouraged that they had to explain music therapy, their real concern was that the lack of awareness of music therapy was so widespread in the United States. Furthermore, participants (n = 22) were upset that healthcare workers would interrupt their sessions or make comments such as “Isn’t it nice that you are singing for ‘Mary’”, which participants said demonstrated the lack of understanding of the benefits of music therapy, and the recognition that music therapy is a healthcare discipline. Additionally, participants (n = 12) felt that they were asked to do things that were not music therapy (generally those working in long-term care and hospice settings). Some participants said that they did provide music for sing-alongs or religious services to be team players, and others stated that they chose not to provide non music therapy interventions. Some participants (n = 15) also shared concerns about knowing what they could do to help a client who might need assistance standing or transferring, and indicated a lack of confidence in understanding their scope of practice when it came to these types of issues.

Professional Suitability

A number of participants (n = 27) shared that at some point or at several points in the internship they questioned whether music therapy was the right career for them. Some of the reasons given surrounded early clinical sessions that were not ideal, taking feedback from their supervisors personally, worrying about finding a job and making a living, and feeling this was a profession they could stay in for their full career without burning out. It is also surfaced that the majority of the participants (n = 39) felt they had chosen the right career and were happy to be entering the profession.

Loneliness

Loneliness was something that participants (n = 24) stated that they experienced more so in the first 3 months of their internship, but also at times when a client died, or was discharged from music therapy, and around holidays such as Thanksgiving. Loneliness also stemmed from participants stating they did not have anyone to talk to that could understand what their job was like, and the stressors that came along with it. Other participants (n = 13) said they felt lonely as they were used to seeing their peer music therapy friends and they missed that interaction.

Boundaries/Ethics

Participants spoke about the challenge of knowing what personal information to share with clients (n = 18), wanting to do more for clients and thinking about them after leaving the workplace (n = 21), feeling hopeless and sad about client prognosis (n = 15), understanding the need to seek support with client populations they do not feel ready to work with (n = 13), challenging ethical scenarios (n = 12), and stating they feel they may have crossed boundaries (n=7).

Discussion

Pre-professionals on average assessed their skills to be ‘satisfactory’ pre-internship. Overall, it appears from the results that the internship is an experience where pre-professionals can build upon and strengthen their clinical, musical, and personal skills, preparing them to enter the workforce and begin their careers. This assessment is supported by the pattern (shape of graph) of the Likert scales, which was similar for these three domains where the highest portion were ‘satisfactory’ for pre-internship scores and ‘good’ for post-internship scores. This shift indicates a positive increasing trend for clinical, musical, and personal skills development. Furthermore, the interview data also revealed that participants expressed feeling a successful change in their skillset, most prominently in the musical skill development area. Jenkins (2013) noted that functioning music skills were underdeveloped in interns, and the findings of this study resonate with this study, as participants ranked their skills on using and improvising on guitar and piano, as well as singing in sessions low pre-internship. It is encouraging to see the strong increase in participants’ perception towards musical competencies, and their increased confidence, which other researchers have found (Grant, 1990; Nix, 2015). Specifically, interview participants (n = 31) stated that they felt more confident and prepared to begin working in the field post-internship. They indicated that their musicianship has increased, making them more confident, and that simply being immersed in clinical work fostered their skills and contributed to reduced anxiety about clinical work and increased confidence. It is also possible that, due to lower confidence pre-internship, participants ranked themselves poorer than a supervisor would in these domains, underestimating their skills. There is conceivable support for this consideration in other findings of this study, which established that some participants had anxiety over measuring up to other interns the supervisor had in the past; which could also suggest that pre-professionals are not confident in their skills, or that they are worrying that others have more developed skillsets.

A similar pattern surfaced on the Likert scales for the issues/concerns domain, which indicated a negative trend as there was an increase from pre- to post-internship. In alignment with earlier findings some pre-internship anxieties stemmed from not measuring up to other interns and having to explain music therapy and the role of a music therapist (Clements-Cortés, 2015); worrying about meeting client needs (Wheeler, 2002); as well as experiencing feelings of loneliness earlier in the internship (Clements-Cortés, 2015); Grant, 1990). During the interview process, when asked about the increase in issues/concerns as found in the survey, participants noted that post-internship they were stressed about finding work, role clarity, verbal dialogue skills, debt and questioning if they should go to graduate school or begin work. These concerns are similar to the findings of Grant (1990) who noted financial concerns, as well as Clements-Cortés (2015), who found participants expressed a lack of skills in counseling and verbal interaction as well as worrying about finding work post internship. To the researcher, these anxieties appeared natural ones to emerge for a variety of students entering careers in various fields. Upon graduating, many students have loans to pay back, and it is a time of transition from being a student to being a young professional, which may be stressful. Furthermore, graduates may lack the same tight circles of school peers and friends. Participants in this study noted that while they kept in contact with their school peers, they were not as close or not able to be in touch with them as much as when they were in school together. Verbal skills increased from pre- to post-internship on the surveys, which again seems logical given the augmented opportunity for participants to work with a larger case load than in practicum placements. In the interviews, participants agreed their verbal skills did improve from pre- to post-internship but still felt that they required additional work and skill in this area, suggesting that they may seek out additional courses to further their education. This was another finding that was not surprising to the researcher, given that verbal skills develop over time with more clinical experience. It is promising that participant rankings for documentation skills also showed a large increase in comfort, which again similar to the improvement in verbal skills is likely due to the increased opportunities to write them.

With respect to professional suitability and loneliness, Rykov (2001) noted that music therapists may feel misunderstood and are often isolated by being the only music therapist in a workplace. While the majority of pre-professionals in this study had onsite music therapy supervisors, participants noted they did not have persons to speak to who might understand their stressors other than a supervisor. Participants shared that they talked with friends and family about some of their feelings, but that they did not always feel understood even to empathetic listeners. Others have found that working environments where medical professionals do not understand the outcomes of music therapy can lead to burnout and stress (Clements-Cortés, 2006; Hills, Norman & Forster, 2000), and similarly participants in this study were frustrated with the lack of understanding by members of the healthcare team. Similar to questioning if one is suitable for a profession and career longevity which were concerns participants raised in this study, primary reasons why music therapists leave the profession include poor salaries and no administrative support (Vega, 2007).

On average, participants seemed to expand their insights with respect to boundaries and ethical concerns. They appreciated the need for taking breaks and setting clearer boundaries, perhaps pointing to an increasing awareness of the importance of self-care in this profession. Participants also stated that their strengths and needs are dynamic, such that they will change over time as music therapists. Acknowledging goal-setting and more attention to underdeveloped skills were primary to the participants and these qualities indicated pre-professionals demonstrated reflective skills and a desire to stay current and continually improve.

Recommendations for Educators and Supervisors

To answer research question 3, a list of suggestions to help further support students in their clinical, musical, and personal skill development; as well as help alleviate some of the internship concerns, challenges, and anxieties follows.

1. Functional music and clinical improvisation skills. While it was encouraging to see the strong increase in pre-professionals’ comfort including the guitar, piano, percussion, and voice in sessions by post-internship, it may be helpful for educators to include more opportunities for developing functional music skill, as well as improvisation skills in a variety of styles. These opportunities might be built into existing classes or even practicum experiences. It is quite likely the students underestimate their skills, especially if they have lower confidence, therefore another strategy is to engage students in their learning by asking them to share in functional music and improvisation courses the skills they are desiring to strengthen. As internship supervisors, acknowledging improvements in these skills throughout the internship and even providing some guidance in supervision sessions may help bolster pre-professional comfort and confidence as well as skill development.

2. Verbal dialogue and counselling skills. Participants desired more verbal dialogue skills. This is challenging to address, as comfort in incorporating verbal dialogue and counselling skills likely improves with more direct client contact, thus leaving pre-professionals feeling unprepared pre-internship. Suggestions for educators and supervisors (who may already be including these) include: role playing with practice scenarios, having open discussions with pre-professionals on what to say in practice or case examples, having students observe other therapists as they are able, and teaching more verbal and counselling skills as the curriculum has room for inclusion.

3. Professional and career issues. If educators and supervisors are not having discussions about career and future, it is recommended to include these discussions in the upper years of study and throughout the internship. Discussing and engaging students in dialogue about finding work, advocacy for the profession starting a private practice, and writing proposals to establish music therapy in a new facility will perhaps help pre-professionals feel less alone with their worries when they may experience some of these issues or feel discouraged. These discussions may also provide them with useful skills they desire. Furthermore, educators and supervisors should encourage students to think about their next steps for the future and their careers. For example, Do they anticipate returning to school to do an advanced degree? And if so, in what field? It also seems important to have the conversation with students about career suitability, doubt, and burnout at various points in the music therapy education, both pre-internship and during internship, to once again acknowledge that these are real issues of which others have struggled.

4. Staying connected. If educators are able, it might be helpful for students to be offered a free platform (paid by University or freely available) where they can engage in peer interaction with their classmates during their internships. A peer-to-peer network may be challenging to establish, as interns will be spread throughout various geographical locations and working with numerous populations. However, it may be beneficial to have peer dyads that are required to meet virtually or in person one time per month to check in with each other and engage in peer supervision. Either modality could perhaps help students to feel connected and reduce feelings of loneliness or isolation. Supervisors who are in workplaces where there are more than one intern can also encourage peer supervision, or perhaps help to set up peer supervision in a nearby facility with another supervisor and pre-professional. If possible it might also be helpful for pre-professionals to meet virtually for a class one time per month. This is already happening at a number of institutions and this researcher recognizes this may not be possible as it has implications on faculty time and resources. Pre-professionals may also be encouraged by both educators and supervisors to get involved in local music therapy associations, and maintain their connection to the AMTA by going to conferences as finances enable them, and even submitting to present their work at these types of events.

Limitations

The results reflect the internship experiences of undergraduate students in the United States, and may not be generalized to internship experiences in other countries. While the study did include a sample representation of the population studied, it is possible those who accepted the invitation to complete the study are more motivated and positive about their internship experiences. As the PI had no funding to carry out this research, the number of persons invited to be interviewed while representative was fairly small.

Conclusion

The music therapy internship remains the final step between classroom learning and entering the profession post-examination completion. While this is a critical stage, there is not a weighty body of research in this area and continued research is recommended to understand how pre-professionals can best be supported. The results of this study which assessed pre-professionals prior to and post internship shows support for this experience in helping to augment clinical, musical, and personal skills needed to work as a music therapist. The results also point to a number of issues and concerns such as finances, role clarity, loneliness, improvisation, and verbal dialogue skills which have been a consistent concern in other past research in internship experiences. A list of recommendations for supervisors and educators on how to continue to support pre-professionals has been included.

Conflict of interest

None declared.

Acknowledgements

Thank you to Dr. Michal Evans and Ms. Kyurim Kang for assistance in completing the quantitative statistical analysis.

Appendix: Interview Questions

1. Please describe your overall experience of the Internship.

2. Do you think that your University education in music therapy helped prepare you?

3. If so in what ways?

   • (a) Clinically?

   • (c) Personally?

   • (d) Professionally?

4. What if anything would have been beneficial during your education and training to help prepare you better?

5. Can you talk about your comfort and experience with clinical improvisation on piano, voice, guitar and percussion instruments?

6. Do you think that clinical opportunities earlier on during your undergraduate degree would have been beneficial in preparing you for the Internship (i.e., mandatory observation sessions in 1st and 2nd year, earlier practicum training in 1st and 2nd year, etc.)?

7. What type of orientation or education sessions were provided by your internship supervisor or facility at the beginning of your Internship?

8. Can you tell me about your comfort level with clinical writing and if it has changed from internship onset?

9. Can you tell me about your verbal communication skills and if you have or had any concerns during internship?

10. Can you tell me about anxiety you experience if any prior to, during and post-internship?

11. Did you work with populations you had experience with or new populations? Describe

12. When did you start leading sessions independently? How did your schedule unfold? (i.e., Did you begin all individuals and groups simultaneously?)

13. Did you feel prepared when beginning to lead independently?

14. Was there enough time given to observe other therapists before you began leading sessions independently? Please describe.

15. Do you feel that the level of difficulty associated with client needs/goals was appropriate for the beginning of your Internship? Near the end?

16. Can you share with me some techniques and/or music therapy approaches that you implemented in your internship?

17. Please describe any issues that you had during your Internship?

18. If applicable were these issues still present and or unresolved or requiring further action when completing your Internship? Please describe

19. What strategies did you use to address any issues that you experienced in your Internship?

20. How did your supervisor help in addressing issues?

21. Did any issues arise with your supervisor or with the supervisory process?

22. How were those issues addressed (if any)?

23. Do you feel that the amount of supervision that you received is adequate for the music therapy Internship?

24. Did you experience any anxieties during your Internship?

25. What strategies did you use to address any anxieties that you experienced in your Internship?

26. Did you ask others for assistance in working through any issues? That is, faculty advisor, peers, other professionals

27. Did any ethical dilemmas or situations arise that you needed to address?

28. Did you engage in any research opportunities or professional development opportunities during your Internship? If so what were they?

29. Do you feel prepared to enter the world of music therapy as a professional music therapist?

30. What are some of your concerns on starting your career?

31. Were you satisfied with the overall supervision experience?

32. Was there anything that you were not expecting that occurred during your Internship?

33. Is there anything that you want to elaborate on from the rankings and responses to the survey questions?

34. What advice would you give to a student who is just about to enter an Internship?

35. Do you have any other comments or concerns that we have not addressed?

References