Music Therapists’ Understanding of Trauma and Trauma-Informed Care: A Survey of Board-Certified Music Therapists Open Access

Abstract

Trauma-informed care is a treatment framework that addresses the pervasiveness of trauma and minimizes harm in therapy spaces and sessions. While many music therapists aspire to utilize this framework in their practice, most seem to conflate the trauma-informed framework with trauma-focused techniques. In this survey study, music therapists were asked about their experiences in learning about trauma or the trauma-informed care framework, how they viewed or valued the framework, and how relevant they felt it was to their clinical practice. Survey results showed that while respondents felt that the trauma-informed care framework was valuable and relevant to their music therapy clinical work, they also expressed doubt about their understanding of the framework and their ability to incorporate the framework into their clinical practice. Participant comments were analyzed using an inductive content analysis; results showed respondents had questions and concerns about how the framework fits into the bachelors-level music therapy curriculum and might be adapted and implemented into a variety of treatment settings. Suggestions for meaningfully incorporating trauma-informed care frameworks into the bachelor-level music therapy curriculum and ideas for future research are also discussed.

Introduction

Trauma can be defined as exposure to a physically, emotionally, or life-threateningly harmful event or circumstance (Substance Abuse and Mental Health Services Administration [SAMHSA], 2024) and may include complex and intergenerational trauma (Dass-Brailsford, 2007; Herman, 1992). Exposure to trauma can lead to a diagnosis of post-traumatic stress disorder (PTSD), characterized by various hypervigilant and/or dissociative behaviors (American Psychiatric Association [APA], 2022). When left untreated, exposure to traumatic events has lasting physiological and psychological effects on children and adults (Felitti et al., 1998; Perry et al., 1995).

As researchers and clinicians learned more about trauma, they began to develop frameworks to support their clients in addressing its harmful effects. The trauma-informed care framework includes principles of physical and emotional safety, collaboration between therapist and client, transparency around policies and procedures, interventions focused on peer support and empowerment, and increased therapist cultural humility (Butler et al., 2011; Centers for Disease Control and Prevention [CDC], 2020). However, many healthcare professionals do not feel they have the necessary competence in trauma-informed care, despite valuing it highly and demonstrating adequate knowledge of its characteristics and principles (Bruce et al., 2018; Padden, 2021). There is little research related to how music therapists are trained in trauma and trauma-informed care practices, if at all, and how they understand and see the relevance of these principles. Therefore, the purpose of this study is to explore how music therapists have received training and education in trauma and trauma-informed care and how they understand its relevance to their clinical practice.

Evolution of Understanding of Trauma

Prior to the 1990s, there was limited research on trauma and its effects on the human mind and body, mostly focusing on the psychological effects of war (van der Kolk et al., 1994). Herman (1992) helped introduce the concept of complex trauma and complex post-traumatic stress disorder (C-PTSD), its impact on the health and well-being of those who have experienced it, and a treatment framework to support clients as they work through their symptoms and traumatic experiences.

Felitti et al. (1998) discovered that exposure to four or more adverse childhood experiences—including but not limited to domestic violence, drug or alcohol abuse in the home, and parents divorcing or being sent to prison—led to a significant increase in physical and emotional health risks. Left untreated, exposure to trauma in childhood is associated with a myriad of negative physical, psychological, and behavioral effects (Perry et al., 1995), which may lead to issues with working memory and self-regulation due to changes in brain chemistry and physiology (Bremner, 2006; Sherin & Nemeroff, 2011).

Beyond individual exposure to traumatic experiences, trauma also includes systemic racism in health care. In the United States, the COVID-19 pandemic disproportionately infected and killed Black, Latine,¹ and people of other marginalized identities in relation to their representation in the general U.S. population (Tirupathi et al., 2020), a possible indication of the systemic inequities of the U.S. healthcare system (Hooper et al., 2020). Increased understanding of intergenerational trauma, where unresolved emotional and psychological wounding is passed down through multiple generations and results in emotionally and physically harmful behaviors (Dass-Brailsford, 2007), further discussions about cultural humility in therapy (Denby, 2011; Goodman, 2014).

Most trauma treatment typically follows the stages outlined by Herman (1992): (1) establishing a safe environment and therapeutic relationship, including awareness of physical and emotional safety and outside factors that might affect this; (2) reconstructing the full story of the traumatic experience as a way to mourn the various losses experienced because of it; and (3) reconnecting with the self and society to gain a renewed sense of hope. In describing the second stage, Herman writes that the reconstruction of the traumatic event must include a “full and vivid description of the traumatic imagery” (p. 177), and may include a variety of creative expression techniques, like artistic imaging, with the goal of eventually putting the experiences into words.

Trauma-Informed Care

While there is no universally accepted definition, trauma-informed care has four primary principles: (1) an environment that consistently promotes physical and emotional safety, (2) transparency in decision-making and policy creation to promote trust between clients and caregivers, (3) empowering clients to make their own treatment decisions in collaboration with caregivers, and (4) recognizing and addressing personal and systemic biases (Butler et al., 2011; CDC, 2020). Because of the importance of the physical and emotional safety of clients and caregivers, clinicians have an ethical responsibility to consider how personal and systemic biases affect interpretations of and approaches to safety, including the therapist’s own understanding of the concepts of “health,” “wellness,” and “safety” (Scrine & Koike, 2022).

The lack of a universally accepted definition may affect how clinicians understand and apply these concepts in treatment. Recent research indicates a variety of clinicians express feeling discouraged by the lack of adequate training in trauma-informed care, which leads to a perceived lack of understanding and competence in these approaches, despite expressing high value and demonstrating sufficient knowledge of key concepts (Bruce et al., 2018; Padden, 2021). This may be because the topic of trauma is often not introduced until the master’s level (Vasquez & Boel-Studt, 2017), and even then, it is rarely included in curricula for counselors (Chatters & Liu, 2020).

Music Therapy, Trauma, and Trauma-Informed Care

There is a strong potential for music therapy to be an effective treatment modality for trauma recovery and management of PTSD symptoms (Sutton, 2002). However, the literature on music therapy and trauma recovery is inconclusive; a meta-analysis by McFerran et al. (2020) found that there was little to no integrity in the studies analyzed, with inconsistencies in theoretical rationales and music-based approaches, no use of control groups, and little to no justification for the specific interventions being studied. In addition, while the trauma literature emphasizes a difference between trauma-informed care and trauma-focused techniques, which directly address the traumatic symptoms and experiences of clients (Leenarts et al., 2013), much of the available music therapy literature seems to focus on resolving symptoms of trauma, often with individual clients, rather than demonstrating a trauma-informed care framework (for example, Amir, 2004).

Research Questions

This study explored music therapists’ understanding and incorporation of trauma-informed care in their clinical practice in continuation of previous research done in this area (Bruce et al., 2018; Padden, 2021). Specifically, this study focused on the following research questions:

• 1) How have music therapists in the United States learned about trauma and trauma-informed care in their clinical training and education, and did they find this training satisfactory?

• 2) What value do music therapists in the United States see in trauma-informed care as a clinical framework?

• 3) What are music therapists’ in the United States understanding of the relevance of trauma-informed frameworks in their clinical practice? In music therapy training and education overall?

Methods

Survey

A 33-question survey was created in Qualtrics, drawing on questions asked in similar surveys that were administered on this topic (Bruce et al., 2018; Padden, 2021). The study was approved by the Institutional Review Board (approval number 2023-18-02), and the survey was sent to 9,535 board-certified music therapists through a mailing list purchased from the Certification Board for Music Therapists (CBMT).

The survey had four sections. First, participants were asked about their level of education and current clinical experience. The second section asked about their educational experiences with trauma and trauma-informed care. Section three asked participants to rate their level of agreement with different aspects of trauma-informed care, including an operant definition created for this study. Finally, participants rated their own understanding of and ability to practice within a trauma-informed framework. Respondents had opportunities to leave comments and reflections on the questions. The full survey is available online in the Supplementary Materials.

Analysis

Items from the Likert scales were assigned numerical values and means and standard deviations were calculated. With the help of two student research assistants from a small liberal arts college in the Midwest United States, we performed an inductive content analysis of comments left by survey respondents, which involved several rounds of close reading to identify common themes and ideas expressed by survey respondents (Vears & Gillam, 2022). Each round of analysis involved individual identification and coding of themes, which were then brought to the whole group to ensure validity and consistency.

Researcher Lenses and Biases

To practice cultural humility on the nuanced topic of trauma, it is important to be clear about biases and lenses that we, as researchers and assistants, hold on this topic. Collectively, we identify as white, middle-class individuals who received our undergraduate music therapy degrees from a private liberal arts institution in the Midwest United States. We are drawn to the topic of trauma and trauma-informed care for various reasons. The research assistants, graduating seniors who completed roughly 300 practicum hours in settings that included eldercare facilities, adolescent mental health, and elementary special education at the time of data analysis, were drawn to the study because they hoped to supplement their education about trauma-informed care practices as they prepared for their clinical internships. As a primary researcher with nearly a decade of clinical experience in child and adolescent mental health in residential treatment settings, I saw the clinical value of trauma-informed care early in my career and have incorporated a trauma-informed lens in my treatment and educational philosophies. We recognize that music therapists at large have different experiences and understandings of this topic. We attempted to set aside our biases to approach this topic with curiosity so we could understand the limitations of music therapists’ understanding of trauma and trauma-informed care and to find the best way, if at all, to incorporate this topic into clinical education and training.

Results

A total of 547 respondents completed the survey, resulting in a response rate of 5.7%; of the total responses received, approximately 9.5% (n = 52) did not fully complete the survey. I opted to include data collected from the incomplete surveys to ensure as complete a picture as possible when exploring how trauma-informed care is taught within and outside of the classroom.

Level of Education and Clinical Experience

Tables 1 and 2 provide a breakdown of respondents’ self-reported education level and clinical experience. A total of 45.6% of respondents (n = 238) reported having a bachelor’s degree, compared to 54.4% (n = 284) who reported a master’s or doctorate in fields such as music therapy, education, social work, and music degrees outside of music therapy. Most respondents (24.6%, n = 138) received clinical training in the Mid-Atlantic Region of AMTA, the Great Lakes Region (21.2%, n = 119), and the Southeastern Region (17.1%, n = 96). A total of 35.8% of respondents (n = 187) reported having five or fewer years of clinical experience, followed by 32.6% (n = 171) with between 5 and 15 years in practice and 10.7% (n = 56) with over 30 years of experience. Caseload demographics were primarily in four age groups: elementary-aged children (53%, n = 275), teens (55.3%, n = 287), young adults (58.4%, n = 303), and adults (57.6%, n = 299). Clinical settings varied, with the top three settings being hospitals (28.9%, n = 150), private practice (29%, n = 151), and residential care settings (24.3%, n = 126).

Education and Training in Trauma-Informed Care

Table 3 provides a breakdown of music therapists’ self-reported experiences with trauma education and levels of satisfaction with those experiences. Most respondents (70.4%, n = 364) reported little to no training in trauma or trauma-informed care in their music therapy coursework, and those that had were “somewhat satisfied” (42.4%, n = 164) or “somewhat dissatisfied” (36.2%, n = 140) with their educational experiences. Many respondents (84.9%, n = 439) reported receiving training through self-study options and felt “extremely satisfied” (46.7%, n = 221) or “somewhat satisfied” (48.6%, n = 230) with their experience.

Importance of Trauma-Informed Care in Clinical Contexts

Table 4 provides a breakdown of responses about the relevance of trauma-informed care in clinical practice. Respondents were given an operant definition of “trauma-informed care” that attempted to combine the four principles of trauma-informed care into one inclusive statement (see the full survey for the complete definition) and asked how relevant this framework was to their clinical practice. Respondents then read concepts related to the principles of trauma-informed care and rated how relevant these concepts were to their clinical practice on a six-point Likert scale anchored from 1 (“Not at all relevant”) to 6 (“Completely relevant”). Though some of these concepts reflect the American Music Therapy Association Professional Competencies (AMTA, 2013) and CBMT Board Certification Domains (CBMT, 2020), not all aspects of the trauma-informed framework are present in these documents.

Perceived Value of the Trauma-Informed Care Model

Table 5 details a breakdown of responses regarding self-reported confidence to practice within and the value of the trauma-informed care model. The first three statements of this section asked respondents to rate their confidence in their understanding of trauma-informed care, their ability to practice within a trauma-informed care framework, and their ability to respond to clients experiencing traumatic stress. While respondents reported strong beliefs in the value of trauma-informed care frameworks and their importance to bachelor’s level music therapy education, with scores averaging slightly below the “Strongly Agree” threshold, they were less confident in their understanding of and ability to practice within those frameworks.

Content Analysis of Respondents’ Comments

After an inductive content analysis of participant comments (Vears & Gillam, 2022), themes that emerged included differing perspectives about trauma education in the music therapy curriculum, concerns about implementing trauma-informed care frameworks in clinical practice, and a desire for more education and training in trauma and trauma-informed care.

Bachelor’s Level Versus Master’s Level Trauma-Informed Care Training

Comments related to where and how to incorporate trauma and trauma-informed care into clinical training fell into two categories: the importance of trauma-informed care education at the bachelor’s level and the desire for this training to be reserved for master’s level education. Supporters of including trauma-informed care in the bachelor’s level music therapy curriculum described the approach as foundational to the profession and relevant across client demographics and settings, whereas opponents noted that this type of training should be reserved for master’s level education, or, at the very least, continuing education offerings.

Implementing Trauma-Informed Approaches in Clinical Work

Many respondents noted that while a trauma-informed framework is important in their clinical practice overall, factors that limited or prevented robust implementation in their clinical work included a lack of institutional support, incongruence with overall treatment philosophy, and limitations in treatment structures.

Clarifying and Expanding Our Understanding of Trauma

Finally, while some respondents took issue with the phrase “assuming all clients have been exposed to a trauma,” others noted that, because of their clinical populations, the likelihood that their clients have experienced some form of trauma is almost inevitable. A few respondents advocated for a more expansive and inclusive definition of trauma that included generational and systemic traumas.

Discussion

The purpose of this survey study was to explore music therapists’ experiences and perspectives in learning about trauma and trauma-informed care, how music therapists view trauma and value trauma-informed care, and how, if at all, they implement the trauma-informed framework in their clinical practice. Results show that while music therapists consider trauma-informed care to be foundational to clinical practice, there is a lack of consensus regarding what a trauma-informed care framework looks like, how it should be implemented, and the education music therapists should have regarding this framework.

Music Therapists’ Understanding of Trauma and Trauma-Informed Care

Respondents were not always clear about what trauma-informed care means, often conflating it with trauma-focused techniques, which require advanced training. Some respondents called knowledge of trauma “foundational” to music therapy education, with one respondent noting that “music therapists should have at least a basic understanding of how trauma affects the body and behaviors in order to best serve our clients.” Respondents who stated that training in trauma and trauma-informed care should be reserved for advanced degrees and/or continuing education seemed most likely to conflate trauma-informed care with trauma-focused techniques. One respondent noted, “I believe the young clinicians at the Bachelor’s Level of training are not prepared or mature enough to adequately manage clinical work with Traumas.”

Roughly 43% of music therapists in the United States are practicing with a bachelor’s level education (AMTA, 2021), and while, anecdotally, there is a desire in the music therapy field to embrace trauma-informed approaches and trauma-focused techniques, the CBMT (2021) explicitly states that a music therapist shall “only [provide] services within the scope of practice that reflects his/her level of competence.” Music therapists who attempt to address trauma without adequate training may risk causing psychological or physical harm to their clients (Murakami, 2021).

Improving Music Therapists’ Understanding of Trauma-Informed Care

Improving music therapists’ understanding of the trauma-informed care framework may help reduce this confusion. Respondents noted, given the ever-increasing knowledge of what trauma is and how it affects our clients, trauma-informed frameworks should be included in bachelor’s level education; as one respondent noted, “If we can practice at the bachelor’s level, we should be trauma-informed at the bachelor’s level.” One-way educators and approved trainers can do this is to focus more specifically on the characteristics of the trauma-informed framework. Many aspects of trauma-informed care, like developing culturally responsive musical experiences and being aware of one’s personal and unconscious biases, are already present in the AMTA Professional Competencies (AMTA, 2013) and CBMT Certification Domains (CBMT, 2020), which are required for bachelor’s level education and practice.

Trauma-Informed Care Continuing Education

It is also worth exploring the role continuing education plays in the education of trauma-informed frameworks. Some respondents noted the difficulty of incorporating yet another competency into an already overcrowded bachelor’s level education and proposed requiring trauma-informed care training as part of the continuing education requirements. Wilson (2020) found that, after a 3-hr continuing education course on trauma and trauma-informed care, participants reported significant improvement in their understanding of the effects of trauma on development and how to incorporate trauma-informed practices into their clinical work. However, the sample size was small and there was no follow-up to understand how the participants implemented this approach into their clinical practice.

Implementing Trauma-Informed Care Framework into Clinical Practice

An incomplete understanding of trauma-informed care also affects how music therapists view their ability to implement this framework into clinical practice. One primary factor noted was the lack of support from coworkers, supervisors, and overall agency culture. As one respondent wrote: “It is very challenging to engage in trauma-informed care while working within a behavioral framework, and often [it] leads to conflict and tension between the care workers and me as a therapist.” This is not to say that music therapists do not believe in the importance of trauma-informed care in these various settings; rather, it may be difficult to conceptualize what implementation looks like across clinical settings. Future training opportunities in trauma and trauma-informed care should include clear explanations and advocacy ideas for trauma-informed practices across settings.

Music Therapists and Self-Care

Finally, it is worth acknowledging that respondents identified struggles with practicing self-care. “With our profession’s increasing demands, I believe many music therapists do not have time for self-care while maintaining a full-time work schedule,” wrote one respondent. There is a growing body of music therapy research attempting to understand and mitigate the effects of burnout in clinicians (Clements-Cortes, 2013), and it may be beneficial to explore music therapists’ understanding and implementation of self-care practices, especially when considering the effects of vicarious or secondary trauma, as an inability to be fully present in sessions may be a source of harm in clinical practice (Murakami, 2021).

Limitations

There are several limitations present in this study that are important to acknowledge. The first is the low sample size of respondents; of 9,535 board-certified music therapists (as identified by CBMT) who were contacted to complete the survey, only 547 MT-BCs, or roughly 6%, responded. I received many automatic email replies that stated the email address on file with CBMT no longer existed, which was likely the greatest contributing factor.

Another limitation may be the insufficient breakdown of education opportunities. This survey broadly focused on trauma and trauma-informed education in music therapy coursework, non-music therapy coursework, and continuing education and self-study opportunities, and did not take into consideration when music therapists received that education. Almost 11% of respondents reported having over 30 years of clinical experience, and knowledge of trauma and how to effectively address it has grown exponentially in that time. It may also be beneficial to explore how other aspects of music therapists’ identity and training affect their views of trauma and trauma-informed care, including theoretical orientations or training in advanced music therapy approaches (e.g., Neurological Music Therapy).

One final limitation of this study may be the U.S.-centric focus of the study and cultural positionality of the researcher and research assistants, who all received their undergraduate education from the same liberal arts institution in the Midwest. It may be interesting to look at music therapy training and education across the globe to explore how trauma and trauma-informed care practices are taught, as the cultural differences in music therapy training internationally may influence how this training is completed in the United States.

Conclusion

Trauma-informed care is a treatment framework that is increasingly relevant in medical and mental health care and includes structural and procedural considerations to help patients feel more in control of their care (Butler et al., 2011; CDC, 2020). Though the framework overall is straightforward, previous research shows that healthcare providers highly value the framework and are knowledgeable about the specific characteristics of it but are unsure about how to implement it into their clinical practice (Bruce et al., 2018; Padden, 2021).

This study sought to explore how music therapists in the United States understand and implement the trauma-informed care framework into their clinical practice. Results showed that while music therapists tend to value the trauma-informed care framework and feel it is foundational to clinical practice, there seems to be a conflation between trauma-informed care and trauma-focused techniques that affects their confidence in their ability to practice within the trauma-informed framework. When presented with the individual characteristics of the trauma-informed care framework, music therapists identified that they were highly relevant to their own clinical practice.

Future research should focus on both clinical training in university settings and continuing education opportunities. A deeper exploration of music therapy coursework is needed to determine if and where trauma-informed principles can be integrated into the overall curriculum. As music therapy in the United States is currently a bachelor-level-entry field, research on music therapy curricula should primarily focus on baccalaureate degrees. It is also important to explore how trauma-informed care is addressed in the interdisciplinary aspects of music therapy coursework. Additionally, an examination of continuing education on trauma-informed care should explore the content that is covered during these trainings, how approved trainers talk about integrating trauma-informed care frameworks in clinical practice, and a longitudinal look at how effectively the attendees were able to implement and advocate a trauma-informed framework in their clinical spaces and agencies.

Funding: There was no funding received for this research.

Conflicts of interest: None declared.

Acknowledgments: I wish to thank my thesis committee at Augsburg University—Annie Heiderscheit, Kathy Murphy, and Kristin Stewart—for their help and guidance during the thesis process. I also wish to thank Tessa Burger, MT-BC, and Josie Hemeseth, MT-BC, for their help with data analysis.

References

Kyle Fleming, MMT, MT-BC, is an Assistant Professor of Music Therapy at Wartburg College in Waverly, Iowa.

Footnotes