THE LOVE THAT DARE NOT SING ITS NAME: AN EXPLORATIVE INVESTIGATION INTO THE STATUS OF LESBIAN, GAY

AND BISEXUAL ISSUES IN MUSIC THERAPY TRAINING AND EDUCATION

TRABAJO DE INVESTIGACIN MASTER UNIVERSITARIO DE MUSICOTERAPIA

Autor: Bill Thomas Ahessy Fecha 28 Septiembre 2007 Facultad de Ciencias de la Educacin Puerto Real, Cdiz - Espaa

Abstract
This thesis investigates the status of lesbian, gay and bisexual (LGB) issues and perspectives in the field of music therapy. It is divided into three parts. First, a comprehensive review of lesbian, gay and bisexual issues in the music therapy literature and the related disciplines of psychology and psychotherapy; second, a global survey of music therapy programs which assesses the provision of lesbian, gay and bisexual issues in music therapy education; and finally, a global survey of music therapy associations which assesses guidelines and opportunities for continuing professional education regarding LGB issues. The provision of LGB issues for both music therapy programs and associations is examined using quantitative and qualitative perspectives. Although the data from both surveys indicate that the music therapy community considers LGB issues important they are largely overlooked in case reports, journal articles and the music therapy literature. LGB issues are relatively neglected in music therapy curricula, education and professional development. An analysis of the data supplied by the surveyed music therapy programs indicates that these issues are receiving more attention now than they were in former years in music therapy programs. Nevertheless, LGB issues are under addressed, in comparison with other multicultural topics. Although many respondents thought LGB issues an important component of music therapy education, less than half specifically addressed LGB issues in their training programs. The majority of music therapy directors agreed that university music therapy programs were the place to best address LGB issues, and there was support to address these issues in continuing professional education too, with a majority of the respondents indicating that guidelines or further training opportunities in LGB issues from the music therapy associations would be professionally beneficial for music therapists. Analysis of the data supplied by the surveyed music therapy associations, reveal that only 1 association out of those surveyed provided guidelines and further training opportunities for its member music therapists. A majority of the respondents also thought that training in LGB issues at university level would professionally benefit practicing music therapists. Many of the music therapy associations were also aware of members working with LGB clients or in LGB clinical settings. This paper is an exploration of this relatively untapped area of music therapy. A comprehensive literature review together with descriptive research by questionnaire-based survey was used to achieve the aims of developing and broadening our understanding of the status of LGB issues and perspectives in music therapy. The implications of these findings from the literature review and the surveyed education programs and professional associations for music therapy training practice and future research are discussed. Key Words: Music therapy training and education, LGB issues, music therapy curriculum,

II

Dedication

This thesis is dedicated to my grandfather Sean Kennedy and my grandmother Angela McKeogh

III

Acknowledgements
Firstly I would like to thank my Professor, Patricia Sabbatella for inviting me to Spain to do this Masters by research in Music Therapy. Patricia encouraged and supported me studying in a new language and guided me in all aspects of this work. I would like to thank my parents, Shay and June Ahessy and my brother Mark for their encouragement. I would not have been able to undertake this project without them and I am truly grateful. Much gratitude to Professor Tom Hayden for his help with project design and revisions. He was a constant support to me and his input was greatly valued throughout the year. I would like to especially thank Maria Rey Piulestan for her patience and work on the translation of the questionnaires. I would also like to thank Mr. Alan Frisby, who was involved in reviewing the questionnaires and his knowledge of statistics and survey research was of great help. I wish to acknowledge Professor Celia Kitzinger (University of York) for advice and guidance on LGB topics and terminology, and Dr. Gregory Herek (University of California at Davis) for his advice on terminology. I would also like to thank Dr. Joanne Harrison (University of South Australia) for sending articles and resources on LGB ageing issues. Sincerest thanks to Carla Bongiorno for the editing and proof reading of the thesis and Anya Gardiner for her online support and advice throughout the research. Finally, I wish to express my sincere gratitude to all the music therapy programs and associations, without whose participation, this study would not have been possible

IV

Table of Contents
Title page........ Abstract... Dedication... Acknowledgements.. Table of contents. List of tables & figures Authors note.... Prologue........... I II III IV VI X XI XII 1 5 6 9 10 11 13 14 18 19 19 21 23 23 24 24 28 31 33 33 34 35 36 38 39

Introduction....... Chapter I Theoretical Foundations .

1.1: Music therapy practice and research 1.2: Emerging issues in music therapy and music therapy training.... 1.2.1: 1.2.2. 1.2.3. 1.2.4. Multicultural music therapy. LGB issues in music therapy Multicultural issues in music therapy training.. LGB issues in music therapy and psychotherapy training...

Chapter II Literature review.

2.1: LGB sexualities and therapy. 2.1.1: Historical perspectives.... 2.1.2: Homophobia and heterosexism.. 2.1.3: Societal and institutionalised forms. 2.1.3.1: Education. 2.1.3.2: Media.. 2.1.3.3: Health care.. 2.1.4: Internalised homophobia 2.1.5: Mental health among LGB individuals 2.2: LGB lifespan issues 2.2.1: Youth and adolescence. 2.2.1.1: 2.2.1.2: 2.2.1.3: 2.2.1.4: 2.2.1.5: The coming out process Models of coming out Disclosure to parents... Adopting a LGB identity.. Conversion/reparative therapy. V

2.2.2: LGB midlife. 2.2.2.1: Prejudice against LGB families.... 2.2.2.2: Affirming LGB families 2.2.3: LGB ageing 2.2.3.1: Aged care settings and fears.. 2.2.2.2: Affirming ageing LGB individuals... 2.2.2.3: Ageing successfully...... 2.3: Gay affirmative therapy.... 2.3.1: Critique. 2.4: Summary

40 40 41 42 43 44 45 46 52 53 55 56 57 59 60 60 62 63 64 65 68 70 71 71 73 73 73 74 75 76 76 77 78 78

Chapter III Methodology..

3.1: 3.2: 3.3: 3.4: Justification for the Investigation.... Investigative method.. Participants Survey A

3.4.1: Participants in Survey A 3.4.2: Structure of Questionnaire A 3.4.2.1: 3.4.2.2: 3.4.2.3: 3.4.2.4: 3.4.2.5: Introduction to Survey A... Professional and program contexts (questions 1-5) Provision of LGB issues (questions 6-13). LGB issues in music therapy (questions 14-17)..... Final section (questions 19-21).....

3.5: Survey B... 3.5.1: Participants in Survey B.. 3.5.2: Structure of Questionnaire B... 3.5.2.1: 3.5.2.2: 3.5.2.3: 3.5.2.4: Introduction to Survey B Association information (question 1) Provision of LGB issues (questions 2-4) LGB issues in music therapy (questions 5-7).

3.6: Ethical Implications. 3.7: Method of Distribution... 3.8: Procedure................ 3.9: Data Collection.. 3.10: Data Analysis.

VI

Chapter IV Results..
4.1: Results of survey A Music Therapy University programs.. 4.1.1: Professional and program contexts.. 4.1.1.1: 4.1.1.2: 4.1.1.3: 4.1.1.4: Characteristics of the respondents... Theoretical orientations of the respondents music therapy training Academic levels and duration of the music therapy programs... Theoretical orientations of the music therapy programs..

79 80 80 80 83 85 86 87 87 88 89 91 92 93 94 96 97

4.1.2: Provision of LGB issues in music therapy programs 4.1.2.1: 4.1.2.2: 4.1.2.3: 4.1.2.4: 4.1.2.5: 4.1.2.6: 4.1.2.7: 4.1.2.8: Multicultural topics addressed in music therapy training. LGB topics in the music therapy programs... Reasons for not addressing LGB issues Manner in which LGB issues are addressed. LGB topics in music therapy curriculum The Importance of LGB issues in the music therapy programs. Preparation for working with LGB clients Clinical practicum with LGB clients...

4.1.3: LGB issues in music therapy education 4.1.3.1: 4.1.3.2: 4.1.3.3: 4.1.3.4: 4.1.3.5:

Importance of LGB issues in music therapy education.. 97 Academic level for the provision of LGB issues... 98 Most important LGB topics for music therapy curriculum. 99 Guidelines and training opportunities for working with LGB clients 102 Provision of LGB issues in the respondents own music therapy training... 103 104 104 106

4.2: Results of survey B Music therapy Associations... 4.2.1: Association information... 4.2.2: Provision of LGB Issues...

4.2.2.1: Provision of guidelines for working with LGB clients.... 106 4.2.2.2: Training opportunities in LGB issues. 106 4.2.2.3: Music therapists working with LGB clients 107 4.2.3: LGB issues in music therapy 107

4.2.3.1: Training in LGB issues at university level.. 107 4.2.3.2: Importance of LGB issues for practicing music therapists. 107 4.3: Comparative results... 108

4.3.1: Guidelines and training opportunities in LGB issues.... 108 4.3.2: LGB issues in music therapy education 108 4.4: Main findings. 109

VII

Chapter V Discussion & Conclusion...................................................................................

5.1: Discussion of results - Survey A..

111 112

5.1.1: Professional & program context. 112 5.1.2: Provision of LGB issues... 114 5.1.3: LGB issues in music therapy 124 5.2: Discussion of results - Survey B... 128 5.2.1: Association information... 5.2.2: Provision of LGB issues... 5.2.3: LGB issues in music therapy 5.3: 5.4: 5.5: 5.6: Limitations.. Recommendations and implications for music therapy... Directions for future research Conclusion.. 128 129 130 131 131 134 135

References .. 137 Appendices. 153

Appendix 1 Music Therapy associations codes of ethics 154 Appendix 2 Appendix 3 Appendix 4 . Appendix 5 Appendix 6 Appendix 7 Appendix 8 Appendix 9 Survey A Introductory letter and debrief page... 155

Survey A Questionnaire 156 Survey B Introductory letter and debrief page 160 Survey B Questionnaire Survey A Introductory letter (Spanish version).. Survey A Questionnaire (Spanish version) 161 162 163

Survey B Introductory letter (Spanish version)... 168 Survey B Questionnaire (Spanish version). 169 170 172

Appendix 10 Survey A Further comments... Appendix 11 Survey B Further comments...

VIII

List of Tables
Chapter I Theoretical foundations
Table 1.1: The range of music therapy settings and clients Table 1.2: Professional Research Topics. Table 1.3: Implicit and active gay affirmative therapy. 6 8 17

Chapter II Literature review

Table 2.1: Essential qualities of therapist working with LGB clients 51

Chapter III Methodology

Table 3.1: Survey research dealing with training and education in music therapy. Table 3.2: Music Therapy websites consulted. Table 3.3: Number of eligible participants for Survey A (by country)... Table 3.4: Eligible music therapy programs who received the survey Table 3.5: Questionnaire A Dimensions... Table 3.6: Number of eligible participants for Survey B (by country) Table 3.7: Eligible music therapy associations who received the survey. Table 3.8: Dimensions of questionnaire B... 58 59 60 61 63 71 72 73

Chapter IV Results
Table 4.1: Music Therapy Programs that responded Table 4.2: Responses continent by continent. Table 4.3: Respondents years of clinical experience Table 4.4: Association between experience and provision of LGB issues. Table 4.5: Theoretical Orientations of the respondents own music therapy training Table 4.6: Academic levels of music therapy programs... Table 4.7: Duration of music therapy programs... Table 4.8: Theoretical orientations of the music therapy programs.. Table 4.9: Multicultural topics addressed by the programs.. Table 4.10: Programs that specifically address LGB issues Table 4.11: Reasons for not addressing LGB issues in music therapy programs. Table 4.12: Where LGB issues were addressed in the programs... Table 4.13: LGB topics addressed.. Table 4.14: Importance of LGB issues as a component of the music therapy program Table 4.15: Clinical practicum with LGB clients... Table 4.16: Importance of LGB issues as a component of music therapy... Table 4.17: The importance of LGB issues as a component of music therapy education Table 4.18: Academic level for the provision of LGB issues... Table 4.19: Important LGB topics for music therapy education.. Table 4.20: Guidelines and training opportunities in LGB issues Table 4.21: Provision of LGB issues when the respondents trained as music therapists... Table 4.22: Respondents who received training in LGB issues in their own training... IX 81 81 82 83 84 85 85 86 87 89 89 91 92 93 96 97 97 99 100 103 103 103

Table 4.23: Respondents by continent Table 4.24: Music therapy associations that responded to the survey... Table 4.25: Establishment of associations.. Table 4.26: Provision of guidelines on LGB issues... Table 4.27: Further training opportunities in LGB issues. Table 4.28: Members working in LGB area... Table 4.29: Would training in LGB issues professionally benefit music therapists.. Table 4.30: Importance of LGB issues for music therapists in your country. Table 4.31: Guidelines and training opportunities in LGB issues Table 4.32: Provision of guidelines and training opportunities in LGB issues.. Table 4.33: Would training in LGB issues professionally benefit music therapists.. Table 4.34: Programs that specifically address LGB issues

104 105 105 106 106 107 107 108 108 108 109 109

Chapter V Discussion & Conclusion

Table 5.1: Important topics for working with LGB clients 126

List of Figures
Chapter III Methodology
Box 3.1: Introductory letter. Box 3.2: Debrief page... 63 70

Chapter IV Results

Figure 4.1: Continental response: Survey A 80 Figure 4.2: Duration of experience of directors of music therapy programs.. 82 Figure 4.3: Duration of experience in relation to provision of LGB issues... 83 Figure 4.4: Theoretical orientations of the programs respondents attended/direct... 84 Figure 4.5: Duration of programs... 86 Figure 4.6: Multicultural topics addressed by the music therapy programs 88 Figure 4.7: Reasons why LGB topics were not addressed... 90 Figure 4.8: The manner in which LGB issues are addressed 92 Figure 4.9: The importance of LGB issues in the programs. 94 Figure 4.10: The importance of LGB issues (LGB+/LGB-)... 98 Figure 4.11: LGB topics which respondents addressed and rated important. 101 Figure 4.12: Correlation between important LGB topics between LGB+ and LGB . 102 Figure 4.13: Continental response: Survey B... 104

Authors Note
Throughout the course of this thesis the acronym LGB is used rather than the term homosexual or homosexuals, to refer to lesbian, gay and/or bisexual persons/individuals.
The word homosexual has several problems of designation. First, it may perpetrate negative stereotypes because of its historical associations with pathology and criminal behaviour; second, it is ambiguous in reference because it is often assumed to refer exclusively to men and thus renders lesbians invisible. Third, it is often unclear (American Psychological Association, 1991).

The researcher contacted two leading professors in the field of LGB psychologies to ensure the wording for this thesis is politically correct and up to date. 1
Both professors approved that the title for this thesis and reported that usage of the term LGB was in line with what is in common use in both scholarly and activist context.

The term heterosexual will be used in the course of this thesis as an adjective for those who do not engage in sexual relations with people of the same gender. The American Psychological Association (1991) suggests that heterosexual as an adjective is acceptable for people who have male-female affectional/sexual relationships. The term sexual orientation is used rather than sexual preference inline with the guidelines of the American Psychological Association, due to the word preference suggesting an element of voluntary choice that is not necessarily reported by lesbians and gay men, and that has not been demonstrated in psychological research (American Psychological Association, 1991). The American Psychological Association defines sexual orientation as an enduring emotional, romantic sexual or affectionate attraction to individuals of a certain gender (Fordham, 1998:14). Although transgender and intersex issues are not addressed in this thesis, they are mentioned by other authors.

Glossary
LGB lesbian, gay and/or bisexual LGBT lesbian, gay, bisexual and/or transgendered LGBTI lesbian, gay, bisexual, transgendered and/or intersex

Prof. Celia Kitzinger Department of Sociology, University of York... She is author of the book Social Construction of Lesbianism (1987) and co-author of the books Heterosexuality: a Feminism & Psychology Reader (1993), Changing Our Minds (1993), Feminism & Discourse: Psychological Perspectives 1996), and Lesbian & Gay Psychology: New perspectives (2002) as well as many scholarly articles. Dr. Gregory M. Herek Professor of Psychology at the University of California at Davis, editor of the Journal of Sex Research, the Journal of Homosexuality and Applied Social Psychology. His edited and co-edited books include Hate Crimes: Confronting violence against lesbians & gay men (1992), AIDS Identity & Community: HIV & Lesbians & Gay Men (1995), Out in Force: Sexual Orientation & the Military (1996), and Stigma & Sexual Orientation (1998).

XI

Prologue
Two Loves
I dreamed I stood upon a little hill, And at my feet there lay a ground, that seemed Like a waste garden, flowering at its will With buds and blossoms. There were pools that dreamed Black and unruffled; there were white lilies A few, and crocuses, and violets Purple or pale, snake-like fritillaries Scarce seen for the rank grass, and through green nets Blue eyes of shy peryenche winked in the sun. And there were curious flowers, before unknown, Flowers that were stained with moonlight, or with shades Of Nature's willful moods; and here a one That had drunk in the transitory tone Of one brief moment in a sunset; blades Of grass that in an hundred springs had been Slowly but exquisitely nurtured by the stars, And watered with the scented dew long cupped In lilies, that for rays of sun had seen Only God's glory, for never a sunrise mars The luminous air of Heaven. Beyond, abrupt, A grey stone wall. o'ergrown with velvet moss Uprose; and gazing I stood long, all mazed To see a place so strange, so sweet, so fair. And as I stood and marvelled, lo! across The garden came a youth; one hand he raised To shield him from the sun, his wind-tossed hair Was twined with flowers, and in his hand he bore A purple bunch of bursting grapes, his eyes Were clear as crystal, naked all was he, White as the snow on pathless mountains frore, Red were his lips as red wine-spilith that dyes A marble floor, his brow chalcedony. And he came near me, with his lips uncurled And kind, and caught my hand and kissed my mouth, And gave me grapes to eat, and said, 'Sweet friend, Come I will show thee shadows of the world And images of life. See from the South Comes the pale pageant that hath never an end.' And lo! within the garden of my dream I saw two walking on a shining plain Of golden light. The one did joyous seem And fair and blooming, and a sweet refrain Came from his lips; he sang of pretty maids And joyous love of comely girl and boy, His eyes were bright, and 'mid the dancing blades Of golden grass his feet did trip for joy; And in his hand he held an ivory lute With strings of gold that were as maidens' hair, And sang with voice as tuneful as a flute, XII

And round his neck three chains of roses were. But he that was his comrade walked aside; He was full sad and sweet, and his large eyes Were strange with wondrous brightness, staring wide With gazing; and he sighed with many sighs That moved me, and his cheeks were wan and white Like pallid lilies, and his lips were red Like poppies, and his hands he clenched tight, And yet again unclenched, and his head Was wreathed with moon-flowers pale as lips of death. A purple robe he wore, o'erwrought in gold With the device of a great snake, whose breath Was fiery flame: which when I did behold I fell a-weeping, and I cried, 'Sweet youth, Tell me why, sad and sighing, thou dost rove These pleasant realms? I pray thee speak me sooth What is thy name?' He said, 'My name is Love.' Then straight the first did turn himself to me And cried, 'He lieth, for his name is Shame, But I am Love, and I was wont to be Alone in this fair garden, till he came Unasked by night; I am true Love, I fill The hearts of boy and girl with mutual flame.' Then sighing, said the other, 'Have thy will, I am the love that dare not speak its name.' (Douglas, A. 1896)

XIII

Introduction

1.1. Introduction
Lord Alfred Douglass prose was used by the prosecution in the famous trial of Oscar Wilde, the Irish playwright, novelist and poet in 1895 that lead to him being imprisoned and sentenced to two years hard labour for his sexual orientation. The trial resulted in public attitudes towards same-sex sexualities becoming increasingly harsher and less tolerant. Over one hundred years later, sexual minority rights have improved greatly in many countries around the world and there are many anti-discrimination laws are in place to ensure equality for sexual minorities and to enforce the protection of LGB individuals. Unfortunately widespread prejudice and intolerance exists in many countries and in others, blatant oppression and sanctioned discrimination of sexual minorities.
Despite the improvements in societal acceptance of LGB individuals, we LGB individuals are one of the only minority groups that are met with continued legalised discrimination (Safren, 2005: 29).

in recent years the President of the United States attempted to make a constitutional amendment to ban same-sex marriage; the Prime Minister of Australia initiated an adoption bill prohibiting same-sex couples from adopting babies from outside the Australian jurisdiction; participants in the LGB pride parade in Warsaw this year were repeatedly attacked during their improvised march after the Mayor of the city refused the participants a permit to hold the parade; and then issued a permit for a normality parade, which in reality was preaching hate and intolerance against sexual minorities; and currently around 85 member states of the United Nations consider LGB sexual relations to be a criminal act and some of these countries impose the death penalty (Flamer-Caldera & Kahramanoglu, 2007; Joint United Nations Program, 2007). Since the late 1800s activists have long taken up the cause for LGB rights. However it has only been since the late 1960s, after the Stonewall riots, and the beginning of the gay liberation movement in the 1970s, that activists came to prominence in their fight for equal rights, benefits and protections for the LGB community. A momentous occasion for the LGB community was the declassification of homosexuality as pathology, and its removal from the list of mental illnesses in the American Psychiatric Associations (APA) Diagnostic Statistical Manual (DSM) III (Davies & Neal, 1996). Although music has been used therapeutically in many cultures for centuries, the specific discipline of music therapy is a middle-to-late twentieth century development (Bunt, 1997: 249). The first training courses were initiated after the Second World War, but as with LGB activism it was only from the beginning of

Introduction the 1970s that the profession became established internationally. During this decade music therapy associations in Australia, Canada, Norway and the United States were established and more music therapy programs were initiated in the Australia, Denmark, the United Kingdom and other countries (Bunt, 1997:249). By this decade the music therapy community and had two peer-reviewed journals in the United States and Canada and pioneers such as Juliet Alvin, Mary Priestley, Helen Bonny, Rolando Benenzon, Serafina Poch Blasco, and Clive and Carol Robbins were paving the way forward and solidifying the growing profession. The World Congress of Music Therapy was also initiated in this decade and the seeds for the development of a World Federation of Music Therapy were sown (World Federation of Music Therapy, 2007). It can be seen from this brief summary that the 1970s was a decade in which both the music therapy profession and the gay liberation movement were both gaining strength, maturing and making themselves heard in the world. Since music therapy as a profession was just establishing itself at this time, it is perhaps understandable that LGB issues and gay affirmative approaches were not incorporated into the field to the extent they were in the longer established disciplines of psychology and psychotherapy. Over thirty years later, LGB issues and perspectives have still not been sufficiently explored or addressed in music therapy. There was a development of multicultural music therapy literature in the 1990s (Moreno, 1988 1989 1995; Toppozada, 1995; Sloss, 1996; Brandt, 1997; Darrow and Molloy 1998; Ruud, 1998; Estrella, 2001; Brown, 2002; Stige, 2002; Chase, 2003), resulting in more attention being given to this area in music therapy in regard to education, training and supervision. Nevertheless LGB issues were not specifically addressed in this domain and as consequence they have been largely neglected by all but by a few authors. Chase (2004) reviewed LGB psychotherapy literature on working with LGB clients and provided implications for music therapists. Lee (1996) and Bruscia (1998b) published case studies on gay men living with HIV/AIDS, and Hedigan (2005) presented a paper on working with a chemically dependent gay male. There have been no music therapy case studies, which focus on LGB lifespan issues, nor research on the provision of LGB issues in training programs or professional development. This is the reason that this researcher wanted to explore LGB issues and perspectives in music therapy and to evaluate developments in the literature, and music therapy education and professional development.

Introduction Questions that were of interest to the researcher included: where and how have LGB issues been addressed in the music therapy literature? what are the central topics regarding therapy with LGB clients? And LGB individuals topics the lifespan? are LGB topics being addressed in music therapy training programs? which LGB topics do the music therapy programs address? And what format does the provision of LGB issues take? do music therapy associations provide any guidelines or opportunities for continuing professional education regarding LGB issues? are music therapists working with LGB clients? and how important do music therapy programs and associations view LGB issues as a component of music therapy education and the field at large? This project aimed to answer these questions and explore LGB issues in music therapy by a. a comprehensive review of LGB issues in the music therapy literature and related disciplines of psychology and psychotherapy, to identify the central LGB topics across the lifespan; b. a global survey of music therapy programs investigating the provision of LGB issues in music therapy education; and c. a global survey of music therapy associations investigating the provision of guidelines or training opportunities in LGB issues. Chapter 1 sets out the theoretical orientations of the project. It examines music therapy practice and research; multicultural issues and LGB issues in music therapy. It also explores, multicultural training in music therapy, as well as LGB issues in music therapy training and psychology and psychotherapy training. Chapter 2 sets out a review of the LGB psychology and psychotherapy literature, with the aim of identifying central LGB topics relevant for music therapists and music therapy educators. The literature that has formed the subject of this review has been divided into 3 main sections for the purpose of this discussion (1) an inquiry into LGB issues that have direct impacts on healthcare and therapy, (2) an exploration of LGB issues over the lifespan, and (3) an exploration of gay affirmative therapy. Chapter 3 contains a detailed explanation of the methodology used in the execution of the surveys. After a justification for the study, both questionnaires for the survey of music therapy programs and the music therapy associations are presented. There 3

Introduction is an explanation of the method of distribution, the procedure and ethical implications of the surveys, as well as a discussion of the data collection process, data analysis. Chapter 4 sets out the results for each question in the surveys. There is a final section, in which comparative results between the two surveys are presented, finishing with a summary of the main findings. Chapter 5 is a discussion of the survey results, presented by theme. The limitations of the study are discussed, as well as applications and implications for music therapy. Finally recommendations and possibilities for future research are discussed. Because there is more visibility and acceptance of LGB individuals than ever before, it is urgent that music therapists explore and become familiar with LGB issues and perspectives. Music therapists will encounter more opportunities to work with LGB clients and families and therapists need to be certain that they possess the knowledge, skills, and sensitivity to provide competent care to this population (Eubanks-Carter et al. 2005, p. 1). Many LGB individuals will present for therapy at some point in their lives, perhaps more so than the general population. So it is imperative that music therapists have been exposed to, and addressed LGB issues in their music therapy training, and have opportunities for continuing professional development regarding working with LGB clients (Bradford et al. 1994; Jones & Gabriel, 1999. In. Safren, 2005). This thesis deals only with LGB issues. It does not include transgender or intersex issues. The researcher felt that although sharing some common issues with LGB individuals, transgendered and intersex individuals have very specific issues related to their gender identity and for that reason they have not been included in this work. Although bisexual individuals have distinctive issues too, they also share many issues with gay men and lesbian women, and so perhaps it is easier to speak about LGB issues than LGBTI2 issues. If there were no discrimination and sexual orientation was as insignificant as the colour of a persons eyes or hair, then there would be no need to focus on and highlight on LGB issues; however sexual minorities are stigmatised and still very much discriminated against. Discrimination on the basis of sexual orientation can in turn lead to important LGB issues being hidden, by LGB individuals, health-care workers and larger communities. As the literature reveals, attention to and discourse on LGB issues in music therapy is long overdue. This thesis is the first study in the field of music therapy to assess the provision of LGB issues in music therapy training programs and the provision of guidelines and opportunities for continuing professional education in LGB related matters.

LGBTI Lesbian, Gay, Bisexual, Transgendered, Inter-sex

Theoretical Orientations

Chapter I Theoretical Orientations

Theoretical Orientations

1.1. Music therapy practice and research

Music was perhaps the first art form to be employed therapeutically. There is evidence of this in Egyptian medical papyri, biblical passages, Greek medical practice, as well as creation stories, magic and mythology and tribal medicine (Bunt, 1997). Ruud (1998, p. 53) defines music therapy as
The use of music and/or its elements (sound, rhythm, melody, and harmony) by a music therapist, and client or group, in a process designed to facilitate and promote communication, relationship, learning, mobilization, expression and organization (physical, emotional, mental, social and cognitive) in order to develop potentials and develop or restore functions of the individual so that he or she can achieve better intraand interpersonal integration and, consequently a better quality of life.

Music therapy its application is varied and holistic. Educational, recreational, rehabilitative, preventive, or psychotherapeutic goals can be addressed and physical, psychological, emotional, intellectual, social and spiritual needs can be met (Bruscia, 1998a, p. 11). Music therapy is thus a unique fusion between science and art, and can work effectively as a treatment intervention with clients in medical, psychoanalytical, behavioural and humanistic domains. Music therapy today is employed in many settings and for the benefit of a great variety of clients, as illustrated in table 1.1 below.
Employment of Music Therapy Range of clients Range of settings Autistic children and adults Schools Emotionally disturbed children and adults Clinics Adults with psychiatric disorders Hospitals Cognitively disabled children and adults Residential centres Individuals with visual, hearing, speech and Group homes motor impairment Nursing homes Learning disabled children and adults Day-care centres Abused children, and abuse survivors Hospices Sex offenders Prisons Individuals with behavioural, language and Community centres communication disorders Institutes Prisoners Private practices Substance abusers Medical patients Ageing individuals, Terminally ill children and adults Adopted children Families Refugees and asylum seekers Bereaved individuals Neonates

Table 1.1: The range of music therapy settings and clients (Bruscia, 1998a, p. 11). The range of clients with whom music therapists work with is constantly growing, and therapists can now be found working with communities as well as individuals for life enhancement, stress management, personal growth, spiritual development and a range of other problems (Bruscia, 1998a, p. 11). 6

Theoretical Orientations Bruscia (1987) has identified two types of music therapy; music in therapy and music as therapy. Music in therapy: Music as a form of relaxation to support verbally-based psychotherapy or in dentistry and surgery (Bunt, 1997, p. 251). Music as therapy: Music is the central ingredient, changes in the music often being mirrored in changes within the client-therapist relationship (Bunt, 1997, p. 251).
The clinical practice of music therapy straddles many disciplines. Every music therapist brings to the profession a unique blend of musical and personal skills and experiences, applied practically in the service of children and adults with wide-ranging physical and mental health care needs. Effective clinical practice also requires awareness of the relevant psychological and therapeutic processes and knowledge of the appropriate medical background (Bunt, 1997, p. 249).

Research is a vital aspect of the discipline and profession of music therapy. Research, theory and practice depend on each other, likened to a tripod by Gaston (1968) each necessary in order for the other to stand (Wheeler, 2005a: 5). Wheeler (2005) differentiates between basic research and applied research as follows 1) Basic research is conducted with the aim of increasing knowledge. The application of research findings is not the central aim, but rather knowledge for its own sake which may ultimately lead to changes in practice. 2) Applied research on the other hand is conducted with the aim of solving a practical problem, to test a hypothesis or model in a real situation of interest or to expand our understanding of an actual situation. The author notes how basic research can become applied research once the results are applied to real problems Wheeler (2005a, p. 11) Bruscia (1998a) divides music therapy research topics into two distinct categories; topics on the discipline and topics on the profession. In research topics on the discipline of music therapy, he observes three broad topical areas: assessment, treatment and evaluation. Research of the profession of music therapy is any systematic, self monitored inquiry which leads to a discovery regarding music therapists, professional standards, education and training, employment, history, and public relations and conditions affecting the discipline of music therapy (Bruscia, 1998a, p. 253). For research to be discipline orientated the topic must include four elements: the client, the therapist, the musical experience and the therapeutic process (Bruscia, 1998a, p. 253). Research on the profession of music therapy covers a broad scope of interrelated topics (Table 1.2: Bruscia, 1998a, p. 251).

Theoretical Orientations

Professional Research Topics Employment practices Music therapists Professional education and training Professional standards Legislation and public relations History and culture

Themes Work settings, job titles, salaries, job duties, music therapys place in health care settings and institutions, music therapy policies and procedures and accountability Demographics, profession related stress and burn-out, personality profiles, levels of education, attitudes and opinions regarding clinical work, and employment Teaching and supervision methods, student experiences and personality profiles, curricula, and academic requirements Ethics in music therapy clinical work, competency standards and registration procedures and issues, academic and clinical training program standards Effects of laws and regulation on music therapy, licensing issues, relationships between music therapy and other disciplines, political and cultural factors in the advancement of music therapy Historical narratives of the discipline and profession of music therapy and music therapy associations and organisations, biographies, metaanalysis and descriptions of research literature

Table 1.2 Professional Research Topics (Bruscia, 1998a, p. 251)

Research in music therapy has been growing steadily over the past four decades and Edwards (2005) observes that for the last 10 years there have been music therapy journals produced in English in six countries compared with 1 journal in the 1970s and two in the 1980s. Six categories of research in music therapy were identified in a survey of nine journals: quantitative, qualitative, clinical reports, philosophical and theoretical research, historical research and professional articles, (Brooks, 2003). Quantitative articles and clinical reports were found to be the most common, making up two thirds of the articles analysed, Qualitative, philosophical/theoretical and professional research were equally represented, while historical research received the lowest attention (Edwards, 2005). More recently, there has been an increase in qualitative designs in music therapy such as; hermeneutic, phenomenological and naturalistic inquiry, art-based research, participatory action-research, first-person research and ethnographically informed research inquiry as well as mixed designs. After a relatively brief history of research when compared with other disciplines, music therapy has an effectual, developed and comprehensive body of research with a variety of designs and we are poised in this new century to use this body of knowledge to consolidate, refine and further develop our approaches to research (Edwards, 2005, p. 20).

Theoretical Orientations

1.2. Emerging Issues in music therapy and music therapy training

Music therapy is an ever-evolving and expanding discipline both in clinical practice and research. Although music therapists still work in the traditional clinical areas, the 2005 World Music Therapy Conference in Brisbane, Australia presented some more recent and emerging client groups with whom music therapists work, such as: women survivors of violence, adopted children; mother and infant asylum seekers, indigenous families; sexually abused children; children from war-torn countries; and offenders from ethnic minorities. More recent and emerging themes in music therapy theory, practice and research were also highlighted, such as: music therapy and spirituality, cultural competency in music therapy; community music therapy; and multicultural music therapy. Music therapists have always worked in communities to some extent. In recent years there has been more of a focus on community based music therapy and systems theory. From this perspective ill-health is seen within a totality as a part of social systems and embedded in material processes (Ruud, 2004, p. 11). Music therapy in some of these contexts has become more socio-political, dealing with whole communities, focusing on systemic interventions, network building, and providing symbolic means for underprivileged individuals or being used to empower subordinate groups (Ruud, 2004, p. 13).

Today, music therapy is used alongside other therapies in many conflict zones and deprived areas. There have been music therapists working with Tsunami victims in Thailand and music therapy projects in other disaster areas (Fachner, 2007). At the Brisbane World Conference in 2007 the World Federation of Music Therapy initiated a new commission called Global 9

Theoretical Orientations Crisis Intervention. Its purpose is to compile information about music therapy work that is being done internationally to help the victims of natural disasters, The aim of the commission is to create a central pool of information for those in need, and to refer music therapists where they are needed (Magill, 2007).
Music therapists have humanitarian skills that that may play key roles in helping to attend to the multi-faceted needs of child and adult survivors, who may be experiencing traumas of illness, impoverishment, residential displacement and personal hardship.

(Magill, 2007, p. 84).

The Middle East is also a new and developing area for music therapy, in which groups like Music in Me are working to promote the profession. Music in Me is a non-governmental organization initiated in the Netherlands in 2003 and active in a growing number of countries. It supports the musical needs of individuals or groups in the Middle East to whom music would otherwise be denied due to war, poverty and limited access to music education (Music in Me, 2007). The organisation is focusing on 23 projects in Egypt, Iraq, Israel, Jordan, Lebanon, Palestine and Syria. Many of these are music therapy projects. Pilot projects are planned in three refugee camps in Bethlehem, under which professional music therapists from the Department of Music Therapy of the Saxion Conservatory (the Netherlands) will train a team of Palestinian social workers and teachers as music therapy assistants, who can support traumatized children until fully qualified Palestinian music therapists become available. The organisation also strongly supports the establishment of music therapy programs in the Middle East (Music in Me, 2007).

1.2.1. Multicultural issues in music therapy

A major emerging issue in music therapy has been multicultural or culturally-sensitive music therapy. Multiculturalism has been established much longer in the disciplines of counselling and psychotherapy than it has in music therapy and has been referred to as the fourth force in psychology. Although there has been sparse attention to multicultural music therapy when compared with other disciplines (10 peer-reviewed articles between 1974 and 1994 (Darrow and Molloy, 1998), the area begun to receive more attention from the mid 1990s (Moreno, 1988 1989 1995; Toppozada, 1995; Sloss, 1996; Brandt, 1997; Darrow and Molloy 1998; Ruud, 1998; Estrella, 2001; Brown, 2002; Stige, 2002; Chase, 2003). Multicultural topics that have been addressed include: the use of multicultural music in therapy, ethical considerations, clinical practice with multicultural clients, multicultural training 10

Theoretical Orientations in music therapy programs and multicultural approaches in music therapy supervision. The practice of culturally-sensitive music therapy is intertwined with personal awareness and requires a music therapist to take another step towards this awareness. It calls for examination and sensitivity to ones own worldview and a willingness to be open to others, recognising that both differences and similarities exist (Brown, 2002: 85). Sue (1996) highlights the fact that the Eurocentric or Euro-American view has been the standard to judge normality, abnormality and characteristics of good counseling within the psychotherapeutic tradition (Estrella, 2001, p. 44). The multicultural music therapy literature has emphasised the need for music therapists to examine their own worldviews, while becoming more familiar with cultural differences (Chase, 2003). Familiarity with world musics and the role they play within cultures is also seen as a therapeutic asset for music therapists (Moreno, 1995). Therapists need to be aware of differences in attitudes and value-systems of their culturally diverse clients. Lack of attention to these cultural differences may lead to misdiagnosis and hinder effective therapeutic results (Brandt, 1997).

1.2.2. LGB Issues in music therapy

In music therapy LGB issues are not covered sufficiently in any of the discourse on multicultural issues, and nor are they addressed in other contexts including: music therapy case studies, clinical reports and research. There have been some case studies of music therapy with gay men, but only in relation to having HIV/AIDS or substance addiction. Bruscia (1998b) has two guided imagery through music (GIM) case studies with two gay men suffering from AIDS and Colin Lees (1996) Music at the Edge: The Music Therapy Experiences of a Musician with AIDS describes the journey of a gay man who eventually dies from the disease. More recently at the 10th World Music Therapy Congress (2005) in Brisbane, Australia, music therapist John Hedigan presented his work on Using music therapy to explore sexual orientation with a heroin- dependent male. They are all extremely valuable case studies, but none of them examine the complex spectrum of issues specific to LGB clients presenting for therapy. The case studies are mainly in relation to HIV/AIDS, and do not sufficiently explore the multitude of LGB specific lifespan and societal issues. Furthermore the focus of such case studies has been on gay males, excluding lesbian and bisexual experiences. The only exception is an article, which focuses more directly on lesbian and gay issues in therapy with implications for music therapists by Kristin Chase (2004). Chase reviewing the literature on therapy with gay and lesbian clients identified four areas relevant to music 11

Theoretical Orientations therapists. These were (i) general issues and approaches, (ii) attitudes towards therapists, (iii) choice of therapist, and (iv) heterosexual therapists working with gay lesbian and gay clients. She highlights some key issues for music therapy music therapists must feel confident to refer a client if they are not comfortable or experienced in this area, rather than risking culturally incompetent care; music therapists may not work directly with lesbian and gay clients, but may encounter lesbian and gay parents, family members across many settings and be aware of the effects of negative attitudes in these circumstances and their effects on therapeutic outcomes. Music therapists may also take on the role of a family advocate to their lesbian or gay client; and It is important to have an understanding of transference and counter-transference, as well as issues such as: the effects of oppression and heterosexism and loss and mourning of the heterosexual self, or of family and friends. Chase (2004) also recommends that music therapists engage in rigorous self reflection by means of a complete cultural self-assessment or reflective journal writing, and that we become familiar with lesbian and gay culture through literature, films and LGB networks finally. She also recommends that therapists adapt the clinical practice of music therapy to be more inclusive by using inclusive terminology, a wider variety of music and adopting a cultural assessment tool as part of clinical assessment. This author also reviews how lesbian and gay clients bring a diversity of typical and atypical issues to therapy and that music therapy is a valuable treatment modality for these clients music therapy has been effective with grieving persons, hospitalised patients, persons with psychiatric illness, adolescents with emotional issues and well adults seeking therapy (Austin, 1996; Bednarz & Nickkel, 1992; Frish, 1990; Heaney, 1992; OCallaghan, 1997; O Callaghan & Cosgrove 1998 in Chase, 2004, p. 37). Chase does not consider bisexual individuals in this article. Music therapy in its integration of multiculturalism traditionally looked to the disciplines of psychology and psychotherapy, with their larger bodies of research to inform and familiarise itself with multiculturalism, thus evolving the field and encouraging multicultural music therapy literature and research to grow. LGB issues have not sufficiently been dealt with in the music therapy literature so it seems appropriate to look to the psychology and psychotherapeutic literature to investigate LGB issues and perspectives further in Chapter 2.

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Theoretical Orientations

1.2.3. Multicultural issues in music therapy training

In Toppozadas (1995) study of music therapists attitudes toward multicultural issues, she found that although the issue was perceived to be important for music therapy, training in this area was taking place in professional contexts, rather than in training programs and there was a need for music therapy students to do more coursework in the areas of multicultural psychotherapy and ethical issues. It has been emphasised that multicultural issues need to find their foundation in music therapy training courses (Brandt, 1997) and that training courses need to prepare students for working with diverse populations
How can music therapists be aware of possible ethical issues when working with culturally different clients? if they were never taught so during the training programs (Brandt, 1997, p. 140).

In a survey of music therapists, Darrow and Molloy (1998, p. 30), found that while music therapy programs in the United States were incorporating multicultural issues into their curricula and viewed them important, often there is was little attention given to these issues in course work or central modules in comparison with music education programs. They also found that the majority of music therapists felt their training programs did not adequately prepare them to work in multicultural settings. Brown (2002) argues that training in multicultural issues should work on Iveys (1997) first and second order skills. These are: 1) The therapists ability to communicate culturally, effectively and sensitively within the therapeutic relationship 2) The therapists ability to appropriately apply therapeutic interventions within in the cultural context (Brown, 2002: 88). Furthermore, the skills needed to practice within culturally-centred music therapy will be learned through training, but also with time and experience. Practicing within a culturecentred framework is to be seen as an ongoing and incremental process (Brown, 2002). Stone (1997) defines two approaches in multiculturalism: 1) Inclusive: A broad and international definition of cultural groups; race, ethnicity, nationality, social class, religion, gender, sexual orientation, age, disability 2) Exclusive: Visible ethnic and racial groups; Native Americans, Australian aboriginal peoples, Hispanic (Estrella, 2001, p. 47).

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Theoretical Orientations Culture is a complex concept, and an individual may belong to one or multiple cultures simultaneously, especially if culture is defined inclusive terms. In the majority of the music therapy, psychology and psychotherapy literature on multicultural therapy, the definition of culture has been somewhere in between inclusive and exclusive, however there has been primarily a focus on nationality, ethnicity, race and religion in relation to culture, exclusive to sexual orientation.

1.2.4. LGB issues in music therapy and psychotherapy training

There have been no specific studies in music therapy regarding LGB issues in music therapy training, curricula and continuing professional education. This study being the first in the field to assess this area, the researcher reviewed the psychotherapy and psychology literature, to assess the current situation regarding training in LGB issues and highlight key points in relation to LGB issues in curricula and education. Educational institutions can be vehicles for communicating heterosexual bias, and this bias has often served as an integral part of the underpinnings of theoretical and research paradigms (Greene, 1994, p. 17). This may explain the dearth of LGB content in psychology and psychotherapy literature and training courses (Rodolfa & Davis, 2003). Milton, Coyle and Legg (2002) interviewed 14 gay affirmative therapists and found that many of these stated that there was limited coverage of LGB issues in training courses and as a result there was difficulty discussing these issues openly. Participants emphasised the limited coverage of LGB issues in their own training and also how the provision of these issues were presented in a highly medicalised context, as opposed to a sociological context and as a result there was difficulty discussing these issues openly. They were also of the opinion that the professional literature holds either absent or limited and stagnant views of therapy with LGB individuals and LGB issues in general (Milton, Coyle & Legg, 2002, p. 16). This was highlighted by Rodolfa & Davis (2003), who surveyed eight major psychology journals published during the 1990s and found there were only 2.11% of articles in these publications addressing LGB issues a haunting and abysmal number and a challenge for psychology (Rodolfa & Davis, 2003, p. 70). The Guidelines by the American Psychological Association for working with LGB clients state that even though there has been an addition of diversity training in graduate education, students often report a lack of education and training in LGB issues and that graduate students and novice therapists feel unprepared to work effectively with LGB clients (Garnets & Kimmel, 2003, p. 773). This means that the lacunae of LGB issues in graduate training and the psychological literature will mean that most therapists will lack valuable tools for working with LGB clients, including knowledge 14

Theoretical Orientations about LGB experiences over the lifespan. This knowledge could naturally enhance therapeutic skills and provide a more effective service to clients (Eubanks-Carter, 2005). The promotion of LGB affirmative practice relies heavily on the provision of LGB issues in therapeutic training courses. Adequate space needs to be created within the curriculum to address LGB issues and educators need to promote competence in LGB affirmative practice among trainees. This will entail staff developing and refining their own competence in this domain and becoming skilled in disseminating it to trainees (Milton & Coyle, 1999, p. 56). The American Psychological Association encourages faculty members and supervisors to integrate LGB issues throughout training for professional practice. This could be achieved by providing guest lecturers who have expertise in LGB issues or by faculty members seeking out continuing education in LGB matters (American Psychological Association, 1998). This is important for music therapy educators to consider. In A Delphi study (Godfrey et al. 2006) examining essential components in curricula for preparing therapists for work with LGB clients, panellists reached consensus on five important in classroom learning experiences for students , which might prove useful for music therapy educators: listening to an LGB panel and guest speakers, including LGB people of colour; providing therapy to LGB clients with supervision; doing role plays of coming out scenarios with unaccepting parents, at work, with friends; observing therapy with LGB clients; and writing papers on students own journeys around sexual orientation and goals for development in reducing heterosexism in their own lives/families/work settings/schools (Godfrey et al. 2006, p. 498). It is important that up-to-date information and current research is used in the provision of LGB topics at all levels in professional development, undergraduate, post-graduate, continuing education and in-service training (Garnets et al. 1991). Which LGB topics should be included in program curricula? There may obviously be core topics, which deserve more attention, and others, which could be followed up through private guided reading. Rodolfa & Davis (2003) list some core topics that should be minimally known by psychology trainees if they are to be adequately prepared to work with LGB clients. These include: sexual minority development, oppression and discrimination, coming out & identity development, HIV/AIDS, bisexuality, assessment of sexual orientation and sexual identity, dual-minority 15

Theoretical Orientations status, and LGB parenting. Homophobia, including its internalised and institutionalised forms, was the topic picked by respondents as the most important LGB topic to address in another study on components of curricula (Godfrey el al. 2006). In the treatment of LGB issues, there could be a specific module or part thereof so designated to address these issues in isolation. However, it has been found that addressing diversity issues across the curriculum has lead to higher student satisfaction and understanding as opposed to isolated seminars or classes (Rodolfa & Davies, 2003). It has also been suggested that role play and reviewing case material for insensitive approaches may help students to develop a more thorough understanding of LGB issues (Greene, 1994, p. 20). Godfrey et al (2006) highlight three areas for adequate training in LGB issues: 1) opportunities for students to acknowledge and discuss any homophobic or heterosexist biases they might have; 2) opportunities for students to become familiar with the strengths and specific challenges faced by LGB individuals and their families; and 3) exploration of the similarities and differences between LGB culture and the dominant culture. Engaging in self-evaluation should also be an important aspect of any training in LGB issues. Failure to do this may result in an LGB client receiving ineffective or potentially harmful therapy (Davies, 1996). Reflecting on ones own feelings about construction of sexual identity and gender as well as examining internal homophobia, heterocentrism and heterosexism3 is perhaps one of the most important tasks trainees and therapists can undertake. It may often involve clarifying, evaluating and potentially changingbiases, prejudices and values (Godfrey et al. 2006, p. 500). Creating space within training programs should allow students to undergo this process (Milton & Coyle, 1999). In Bersteins (2000) Cultural Literacy Model it is suggested that heterosexual therapists should employ an attitude inventory in order to access their conscious and subconscious anti-gay prejudice and one of the three steps in Purnell and Paulankas (1998) Cultural Competence Model is engaging in rigorous self-reflection (Chase, 2004, p. 37). Chase has also developed a
3

Homophobia has usually referred to describe individual bias towards heterosexuals and anti-gay attitudes or behaviours whereas heterosexism has been employed to describe cultural bias towards heterosexuals and refer to societal level ideologies and patterns of institutionalised oppression of non heterosexual people (Herek, 1999, p. 2). Heterocentrism is also the assumption that everyone is heterosexual and the attitudes that derive therefrom. Heterocentrism is often subconscious and shows up in less intentional ways (Bowers et al. 2006).

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Theoretical Orientations cultural self-assessment model for music therapists, which may be useful for personal evaluation. In university psychology courses in the United Kingdom LGB issues if mentioned at all are often only addressed by LGB educators and these issues are said to be barely covered in important areas such as social, developmental and health psychology. And although people may ascribe to broadly pro gay principles LGB concerns are often ignored, excluded and marginalised (Clarke & Peel, 2006, p. 2). There is a need for inclusive curricula, teaching materials and practices and for the hidden curriculum of heteronegativism to be updated since is a vital and necessary component of the discipline rather than at best marginal, speciality concernsa mere add on (Clarke & Peel, 2006, p. 2). Training programs need to address LGB issues, ensuring that their trainees possess empathy, open-mindedness and ability and willingness to reflect on ones strengths and weaknesses as well as the essential qualities for therapists working with LGB clients (Table 1.3.), such as:

Comfort with LGB individuals; Awareness of ones own comfort level, values, biases and prejudices about sex, gender, and sexual orientation and how these can affect interactions with clients; Interest in the life of the client and willingness to educate ones self about issues and social conditions for LGB individuals; Willing to hold ones self accountable for values, biases and prejudices; Awareness of ones own construction of gender and sexual identity, and the origins of related beliefs (e.g., family, peer norms, religion); Understanding that sexual orientation is about affection attachments; LGB affirmative (acceptance and non judgemental attitudes are not sufficient); and Ability to nurture queerness versus manage or cope with it Godfrey et al. 2006, p. 498 Table 1.3: Essential qualities of therapist working with LGB clients The literature on LGB issues in psychotherapy and psychology training suggests that LGB issues in these training environments are often severely neglected. It remains to be seen whether the same occurs in music therapy training programs and continuing professional education. Chapter two of this thesis will fulfil the second aim of this study and identify the central LGB topics and lifespan issues, which are central to providing effective therapy with LGB clients, relevant for music therapists, and should be included in the provision of LGB issues in music therapy educational settings.

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Literature Review

Chapter II Literature Review

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Literature Review

2.1. LGB Sexualities and Therapy 2.1.1. Historical Perspectives

The history of the psychological treatment of LGB individuals by the mental health experts is marked by a repeated pattern of good intentions and negative consequences, and is often linked to the Freudian psychoanalytic tradition (Eubanks-Carter et al. 2005,p. 3). It is said that Freud had a complex view of homosexuality. On one hand he described homosexuality as an arrest in psychosocial development and on the other observing that same sex attraction is found in people whose efficiency is unimpaired and who are indeed distinguished by especially high intellectual development and ethical culture (EubanksCarter et al. 2005, p. 4). Freud also believed that people were born with both heterosexual and same-sex feelings. Nevertheless later psychoanalysts did not follow Freuds view that people were born with psychological bisexuality, and proposed that LGB individuals could be converted through long-term psychoanalysis. It has been observed that post-Freudian American psychoanalysts in the 1940s and 1950s such as Bieber, Bergler and Socarides mobilised an almost McCarthyite zeal in labelling homosexuals as sick, inadequate personalities and grievance collectors (Milton, Coyle & Legg, 2005, p. 182). LGB individuals up to the mid 1990s were also barred from training as psychoanalysts in the United States and Britain due to their unresolved and unanalysable neuroses and the fact that they were seen as too political and therefore inappropriate for training. (Neal & Davies 1996, p. 22) Psychology and more specifically psychoanalytical theory have often contributed towards the turbulent relationship between mental health and LGB sexualities (Neal & Davies, 1996, p. 22). Psychoanalytical theories on LGB sexualities have been criticised for not being empirically tested on the grounds that the personal beliefs and attitudes of the analyst biased observations and furthermore subjects who were already in psychiatric care were used (Herek, 2007). Although there is still much discussion of LGB sexualities in psychoanalysis and many issues are unresolved, psychoanalysis has at least engaged with its ambivalence towards same-sex sexualities (Milton, Coyle & Legg, 2005, p. 184). Behavioural therapists throughout the twentieth century also tried to cure same-sex desire, developing a range of techniques to convert LGB from sexual activity with the opposite sex. These included: the use covert conditioning, where clients were asked to imagine same sex activities, while being exposed to anxiety-inducing images, chemical aversion therapy and electroshock treatments (Eubanks-Carter et al. 2005). The idea of cure and treatment throughout much of the twentieth century was derived from quasi-medical models, which 19

Literature Review seemed more appealing than the models of good and evil which, they largely replaced and measures such as: neurosurgery, hormone injections, heterosexual assertiveness training, religious exorcism and prayer were sometimes used in an attempt to cure homosexuality even into the 1970s and 1980s (Neal & Davies, 1996, p. 17). From the 1950s some researchers endeavoured to not only show that LGB sexuality was a degree on the sexual orientation continuum, but also that there was no difference in psychological functioning between LGB persons and heterosexuals. Kinsey, Pomeroy & Martins landmark study (1948) posited a sexual orientation continuum, revealing that many more American adults than previously thought had engaged in same sex behaviour or experienced homoerotic fantasies (Herek, 2007). Evelyn Hooker was one of the most influential researchers of homosexuality of the twentieth century and her 1957 study was ground breaking in several ways. Hooker recruited a group of gay men who were not under psychiatric care and used a control group of heterosexual men who were matched for IQ and education. Hooker in her famous case-controlled study known as the fairy project found no difference in adjustment or psychopathology between gay men who were not under psychiatric care and heterosexual men (Kimmel & Garnets, 2003). Hookers studies were replicated later with lesbian and heterosexual women and had a direct hand in the de-classification of homosexuality as pathology. This directly affected psychological practice, paving the way for new affirmative models in psychotherapy (Rothblum, 2003). Psychologists and psychiatrists could not ignore the weight of empirical data with which they were being confronted as more and more studies were undertaken over the next two decades confirming that homosexuality was not pathology and LGB individuals had similar mental health to heterosexuals (Neal & Davies, 1996). Furthermore the growth in humanistic models of therapy fostered a shift in ways of thinking about human sexuality (Mair, 2003). As a result in 1973 homosexuality was removed from the list of mental illnesses in the American Psychiatric Associations (APA) Diagnostic Statistical Manual (DSM) III.4 Nevertheless in a survey conducted of 2500 psychologists soon after declassification it was evidenced that a majority still though homosexual to be pathological and also perceived

Although homosexuality was declassified a new classification was introduced in 1980 called ego-dystonic homosexuality where a person has failed to accept their homosexuality and consequently experiences persistent distress and wishes to be heterosexual (Milton, Coyle & Legg, 2005: 183). This has been seen as a loophole for conversion therapies, which continued to cause oppression on LGB individuals and it was removed entirely in 1987 (Davies & Neal, 1996).

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Literature Review homosexuals to be less happy and less capable of mature, loving relationships than heterosexuals (Rothblum, 2003: 675). Old habits die hard! In an attempt to influence this majority The American Psychological Association in 1975 adopted a resolution, Homosexuality per se implies no impairment in judgement, stability, reliability, or general social or vocational capabilities (Garnets et al. 1991, p. 964). This resolution not only supported the removal of homosexuality as pathology, but also advocated equal civil and legal rights for all LGB persons, urging psychologists to remove the stigma that had become linked to LGB sexualities and to foster affirmative approaches with LGB clients (Eubanks-Carter et al. 2005). The shift in thinking about homosexuality moved at a more rapid pace in the United States than elsewhere, perhaps due to the founding of the Journal of Homosexuality in 1974 and other journals that followed, and the establishment of such organisations as The Society for the Psychological Study of Lesbian, Gay & Bisexual Issues, who promoted of LGB affirmative research & practice (Kilgore et al. 2005). In Europe and in other parts of the World, the shift in thinking was much slower. Homosexuality was still classified as a pathology by the World Health Organisation until 1992 (Neal & Davies, 1996) and was only decriminalised in Ireland, a member of the European Union in 1993. During the last two and a half decades there has been a significant growth in gay affirmative therapy and LGB psychology as well as changing attitudes in relation to LGB individuals and their health care needs. Nevertheless, recent theorists such as Limentani (1994), Rayer (1986), Socarides (1978) and others still view homosexuality from a pathological perspective (Milton & Coyle, 1999). Socarides is quoted to have said as recently as 1997 that Homosexuality is a psychological and psychiatric disorder, there is no question about itIt is a purple menace that is threatening the proper design of gender distinction in society (Tozer & McClanahan, 1999, p. 725).

2.1.2. Homophobia & Heterosexism

Homophobia and Heterosexism are central issues for LGB individuals, which can not only greatly affect their daily lives, but can have immense impacts on the level of treatment and care they receive in the healthcare domain. Homophobia as a term was coined by clinical psychologist Weinburg in 1972 to describe the phenomenon in heterosexuals of the dread of being in close quarters to gay persons. Its equivalent in gay persons manifesting as self-loathing (Shidlo 1994, p. 177). This was later expanded by Hudson and Ricketts (1980) to include feelings of anxiety, disgust, aversion, anger, discomfort and fear, which heterosexuals may feel in the presence of gay people (Davies, 1996, p. 41). The term 21

Literature Review homophobia has not been widely accepted in the literature, as it is not considered to be a phobia in the classic sense. It is also seen to reflect a prejudice reinforced by society as opposed to an individual phobia (Herek, 1990). Unlike a clinical phobia, homophobia often includes hatred and anger, it is sometimes judged to be understandable or justifiable, it often manifests as aggression or hostility, it can be politically based and is not seen as a disability with a motivation to change (Bowers et al. 2006, p. 31). Other suggestions for the term have been homoerotophobia, homosexism, homonegativism, and anti-gay prejudice to name a few (Davies, 1996). Davies (1996) points out that it has been demonstrated that some individuals may have a fear response to homosexuality and says that for this reason the use of the term homophobia seems reasonable. On the other hand Herek (1999, p. 1) proposes the term sexual prejudice linking it with the research tradition on prejudice in social psychology. It may be a more suitable because it conveys no assumptions about the motivations underlying the negative attitudes and avoids value judgements about such attitudes. Heterosexism has been used over the last two decades sometimes interchangeably with homophobia and was chosen for its parallel structure to racism and sexism. Heterosexism or heterosexist bias was defined by Morin (1977) as the belief system that values heterosexuality as superior to and/or more natural or normal than gay and lesbian orientations (Greene, 1994, p. 8). Homophobia has usually referred to describe individual bias towards heterosexuals and anti-gay attitudes or behaviours whereas heterosexism has been employed to describe cultural bias towards heterosexuals and refer to societal level ideologies and patterns of institutionalised oppression of non heterosexual people (Herek, 1999, p. 2). Heterocentrism or heteronormativity should not be confused with heterosexism and are terms used to express the perceived reinforcement of beliefs whether by social institutions or policies, which assert that heterosexuality is the only normal or natural orientation, against which other sexualities are to be judged. Heterocentrism is also the assumption that everyone is heterosexual and the attitudes that derive therefrom. Heterocentrism is often subconscious and shows up in less intentional ways (Bowers et al. 2006).

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Literature Review

2.1.3. Societal & Institutionalised Homophobia/ Heterosexism

Bowers et al. (2006) highlight that for LGBT5 people, the impact of discrimination on cultural, institutional, inter-personal and internalised levels leads to a reporting invisibility in relation to harassment, a poorer general health status, diminished utilisation of health care facilities and a decreased quality of health services (p. 12). Societal homophobia and heterosexism can be influenced by and reflected back by the media, and have an effect on LGB individuals in many areas of their daily lives. In educational, employment and health care sectors, institutionalised homophobia and heterosexism may have negative impacts resulting in direct mental health problems for LGB individuals. Rather than being inherent in humans, homophobia is considered to be a cultural phenomenon, something thatis a learnt behaviour. If homophobia is indeed cultural and it a learnt belief, it is widespread. Eightyfive member states of the United Nations consider LGB sexuality a criminal offence, and this type of state sponsored homophobiapromotes a culture of hatred reinforcing sexual prejudice and continuing the cycle of oppression and discrimination of sexual minorities (Ohosson, 2007, p 4). 2.1.3.1. Education In education sectors there has often been a fear of discussing, or portraying positive images of, LGB sexualities. In the United Kingdom for many years the promotion of LGB sexualities was forbidden under Section 28 of the Local Government Act 1990 and as a result many schools omitted discussion of LGB identities, increasing the conspiracy of silence (Tinney, 1983, in Davies 1996, p. 45). Davies (1996) highlights that the omission of representations of positive LGB lives in school curricula further stigmatised and devalued the sexualities of those students who might be LGB and denied them opportunities to learn about themselves. Davies (1996) also observes how history has been edited to exclude positive references to homosexuality and the contributions made by LGB people in many disciplines (p. 45). The situation today has not improved and one recent study revealed that 70% of secondary pupils have never been taught about LGB people or seen LGB issues addressed in class (Hunt & Jensen, 2007). Homophobic language is commonplace and current comments like thats so gay (meaning bad) and general verbal abuse is often overlooked. Homophobic

LGBT lesbian, gay, bisexual, transgendered. Transgender is an umbrella term used to describe people whose gender identity (sense of themselves as male or female) or gender expression differs from that usually associated with their birth sex. Many transgender people live part-time or full-time as members of the other gender. Broadly speaking, anyone whose identity, appearance, or behaviour falls outside of conventional gender norms can be described as transgender. However, not everyone whose appearance or behaviour is gender-atypical will identify as a transgender person (American Psychological Association, 2007a).

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Literature Review bullying is also said to have reached endemic levels in British schools with two-thirds (156,000) of LGB pupils experiencing being victimised. From this group 92% had experienced verbal homophobic bullying, 58% had been ignored or isolated, 41% had been physically bullied and 17% had received death threats. It was also revealed that teachers often turn a blind eye to homophobic language and bullying (Hunt & Jensen, 2007). It is paramount that students are educated about LGB issues and this kind of bullying is not tolerated. Many of these students will be tomorrows health care workers. 2.1.3.2. Media LGB individuals are not often portrayed in the media, and when they are they are often stereotyped or negatively portrayed as mal-adjusted or dangerous. Hollywood is noted for its homophobia, the absence of positive portrayals of LGB people and resorting to LGB stereotypes, unlike the fringe cinema and stage where diverse sexualities have been celebrated (Davies, 1996). Television can be a powerful influence in challenging prejudice, but also in perpetrating it. In over 168 hours of broadcasting by the BBC in 2006, portrayal of lesbians and gay men occupied a mere 6 minutes. Furthermore, 80% of LGB references were negative, 72% of references were in the entertainment sector relied on clichd stereotypes while half of all gay references were for comic effect (Cowan, K. & Valentine, G, 2006). There were no scenes of homophobia being challenged and in 30 instances gay male sexuality was used as an insult in 22 programs. There were also no references to LGB individuals with disabilities or from ethnic backgrounds, and no references to bisexuality (Cowan & Valentine, 2006). These negative or stereotypical portrayals of LGB identities oppress sexual minorities and further add to the collective homonegativism which exists in the dominant culture, providing intolerant heterosexuals with limited information of LGB lives that may well sustain or solidify their negative attitudes (Greene, 1994). 2.1.3.3. Health Care In health care professions there has been and still exists institutionalised homophobia and heterocentrism. Bowers et al. (2006, p. 17) argue that despite being charged with a fundamental caring role and being a safe-haven for those in need, the health care system has been repeatedly documented in various studies to have endemic levels of discrimination and disadvantage against LGBT peoples health care. Although the relationship between LGB sexualities and the mental healthcare systems has greatly improved, there still exists widespread homophobia and heterosexism within these 24

Literature Review systems (Davies, 1996, McFarlane, 1998). LGB individuals are more likely to use mental health services than their heterosexual counterparts, with problems often stemming from negative reactions to their sexuality and discrimination. Nevertheless research has suggested that such service users are likely to encounter the same homophobia in the mental health services as they do in wider society (National Disability Association, 2005). LGB individuals may face many barriers in accessing services or in the process of coming out6 to health professionals. They often have fears of availing of services, especially those who were treated for homosexuality in the past. Fears may include Safety concerns Being judged negatively, stigmatised or pathologised Confidentiality concerns Invisibility or lack of acknowledgement of diversity Multi-oppression7 (McFarlane, 1998: 43). The decision to disclose ones sexual orientation to mental health workers may still result in negative outcomes for the LGB individual according to recent studies in Europe, Australia and the US (Golding, 1997, McFarlane, 1998; King & McKeown, 2003). In one study 73% of LGB service users in mainstream health services had experienced some form of prejudice or discrimination in relation to their sexual orientation (Golding, 1997). Furthermore, in the cases of 51% of participants, their psychological distress had been inappropriately affiliated with their sexual orientation by mental health professionals. This was supported by the fact that for LGB service users negative experiences were found to be more common than positive ones. These included: physical abuse, verbal abuse and ridicule, ignorance, lack of awareness, stereotyping, voyeurism, inappropriate questioning, lack of privacy, being silenced and having relationships trivialised (McFarlane, 1998: 57). There has been a reluctance noted among some LGB individuals to contact mainstream health services, due to the perceived prejudices and discrimination. For some individuals this may leave them in precarious circumstances. In one Irish study, gay and lesbian help line providers expressed much concern for a certain proportion of callers in acute crisis situations who did not feel
6

Coming out involves a complex process of intra- and interpersonal transformations, often beginning in adolescence and extending well into adulthood which lead to, accompany and follow the events associated with acknowledgement of ones sexual orientation (Hanley-Hackenbruck, 1989 in Davies, 1996: 67). 7 Multi-oppression refers to the oppression suffered by belonging to more that one minority group. LGB individuals who also belong to other stigmatised groups may face multiple-oppression. Other groups may include racial or ethnic, people living with disability, people living with HIV/AIDS or religious groups.

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Literature Review able to discuss their sexuality with mental health professionals (Dillon & Collins, 2004). Mental health workers just like anyone else, are influenced by the culture around them and may have been received little or no training in LGB-specific issues. This can directly impact on the LGB service users wellbeing. LGB service users have reported receiving very little support from staff. It was also experienced by some LGB users in the McFarlane (1998) study that homophobia or homophobic behaviour by other service users was condoned or ignored by staff. Non-intervention in such circumstances is unthinkable and such actions or collusion by staff undoubtedly compounds feelings of fear, isolation and of being unsupported (King & McKeown, 2003, p. 101). Diagnosis, treatment and care of LGB individuals seem to be subject to variation and rely on the individual ignorance, prejudice or education and training of healthcare workers. Some workers still pathologise, ignore, or deny non heterosexual orientation and such perspectives affect the overall care of LGB individuals (McFarlane, 1998, p. 54). Even if professionals do not hold homophobic attitudes, heterosexist attitudes lead to ignorance and lack of awareness, which can affect the support and level of treatment an LGB service user receives. Many mental-health workers have received no training in challenging anti-gay attitudes and respecting the differences and unique challenges that LGB individuals may face. There are also staff working in mental health services that were trained in an era when homosexuality was viewed as pathology (McFarlane, 1998). Recent studies have highlighted the levels of homophobia and heterosexism in the healthcare sector, and the need for training in this area (Golding, 1997; McFarlane, 1998; King & McKeown, 2003). These findings really illuminate the need for an assessment of the provision of LGB issues in music therapy education There are many issues which need to be addressed in the training and retraining of mentalhealth workers such as, the coming out process, LGB lifestyles, community and affirming approaches and education on homophobia, heterosexism that challenges the ongoing prejudice and discrimination that prevail. Davies, (1996) emphasises the importance of exploring and evaluating ones attitudes on both personal and professional levels. Therapists must be aware of the specific needs of LGB clients, the unique challenges they face, and the issues they may bring into the therapeutic setting. Chase (2004) also emphasises this point, urging music therapists to take attitude inventories and make time for self reflection to work through any homophobic or heterosexist attitudes they may hold.

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Literature Review Davies (1996) observes three areas, which can be affected by homophobia and heterosexism: training courses, supervision, and clinical practice: 1. In training courses it has been noted that staff often fail to recognise the political nature of homophobia and heterosexism and that there has been a lack of attention given to LGB lifespan issues in psychology and psychotherapy programs (Davies, 1996, p. 51). Course syllabi and assignments may also contain heterosexual bias or a hidden heterosexist agenda. Therefore music therapy program directors and developers need to be vigilant to ensure that the curriculum used in music therapy training is LGB inclusive and unbiased. 2. In supervision heterosexual supervisors can impose their own frame on LGB clients or students and non-affirming environments may lead to self censoring by clients and trainee therapists (Davies, 1996, p. 53). As clinical practicum is such a huge component of music therapy training, it is imperative that these issues be examined in this area and that supervisors have some training in LGB issues. 3. In clinical practice homophobia and heterosexism can sabotage therapeutic endeavours, affect diagnosis and treatment, and result in ineffective or even damaging care of LGB clients. All practicing music therapists need to ensure that their services are supporting of and affirming of LGB sexualities and that LGB clients feel safe and comfortable to come out or talk about their sexuality openly with a therapist, with the confidence that the therapist will have experience and at least knowledge of LGB issues. LGB sexualities and issues are often overlooked in relation to people with disabilities. LGB persons with learning disabilities often do not receive the same support as their heterosexual counterparts in developing relationships. For example in one study only a small proportion of staff across twenty learning disability services recognised the need to affirm and support LGB people with learning disabilities, and staff attitudes towards LGB sexualities acted as a barrier to working on this (Abbott & Howarth, 2004). Many LGB individuals with disabilities lack access to LGB services and often felt they could not discuss their sexuality with health care providers or carers for fear of discrimination and negative outcomes (Brothers, 2003). Coping with dual minority status can greatly affect the mental well-being of LGB individuals, and they often face prejudice not only from the community of people with disabilities, but also from within the LGB community. A disabled persons 27

Literature Review sexuality is often ignored and (s)he is often viewed as asexual and may not be encouraged to discuss sexual feelings or sexual identity, leading to isolation, which can be intensified by levels of access to LGB venues. These and other practical, social and attitudinal barriers faced by lesbian, gay or bisexual individuals with disabilities have a very real impact (National Disability Association, 2005). For the field of music therapy these are very relevant issues that need considering, as many music therapists work in disability settings. Heterosexual bias in language used in publications in psychology research is something that organisations such as the American Psychological Association have been trying to reduce by publishing guidelines (Herek et al. 1991). For example heterosocial competence is a term still used in clinical psychology and behaviour research, especially in relation to adolescence, which has offensive connotations for LGB individuals and promulgates the view that heterosocial behaviour is the only kind of competent social behaviour (Safren, 2005, p. 30). The American Psychological Association (1991) published guidelines on reducing heterosexist bias in language, both of which may be a useful starting point for music therapists and other health professionals. It is important that all therapists use inclusive terminology in assessment forms, documentation and research and do not ignore LGB experiences. Homophobia and heterosexism exist at all levels of society, in our expectations and our subconscious thoughts. This is the phenomenon of nonconscious ideologies (Bem & Bem, 1973). This describes those mindsets and beliefs so deeply ingrained that we are not even aware of holding them. They often are likened to the fish that does not recognise the water in which it exists. The water is so completely a part of its experience, that it is not seen, not known as a separate part of the creatures world (Tozer & McClanahan, 1999, p. 734). Another form of homophobia that has been cited as a central theme when working with LGB clients, but is also a very contentious topic in the literature is personal or internalised homophobia (Shildo, 1994; Davies, 1996).

2.1.4. Internalised Homophobia

Shidlos (1994, p. 178) defines internalized homophobia as A set of negative attitudes and affects toward homosexuality in other persons and toward homosexual features in oneself. These feelings can significantly hinder self-acceptance and make the coming out process more difficult for LGB individuals. Most gay people grow up experiencing negative messages about their sexuality. These messages are not just transmitted from society in general, but also from family members, friends, educators and the media. It is naive to

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Literature Review assume that LGB individuals do not take on or internalise some of these messages, on conscious and subconscious levels. Meyer (2003), states that LGB people begin to internalise societal anti-homosexual attitudes long before they are aware of their own sexuality. These attitudes are directed from society towards the self, once one acknowledges ones own sexuality. This may occur long before one discloses their sexual orientation publicly. Thoits (1985) describes the process, role taking, similarly found in psychiatric patients, which enables the individual to view themselves from the imagined perspective of others (Meyer, 2003, p. 703). One could imagine this kind of negative thinking on conscious and subconscious levels would be very detrimental to the self-worth and mental well-being of an LGB individual over a long period of time. Psychology researchers Fassinger & Miller (1996) suggest that gay men and lesbians develop an individual sexual identity that includes acceptance of the LGB orientation, followed by a group membership identity, involving the acceptance of membership in an oppressed group, and initiating relationships within that group (Mayfield, 2001). In this way LGB individuals might be accepting of their own sexual identity, but not accepting of the gay community in general. Internalised homophobia is likely to be more severe during adolescence and the coming-out process. This does not mean that once a person accepts their sexuality their internalised homophobia will completely fade. It is thought that internalised homophobia remains a salient factor in LGB peoples psychological adjustment and health throughout their lives due to the strength of early experiences and the continual exposure of anti-homosexual attitudes (Meyer 2003, p. 703). Internalised homophobia can be an ongoing hurdle for some LGB individuals and has been proposed a fundamental clinical theme when working with LGB clients in therapy (Davies, 1996). Shidlo (1994: 177) states four reasons why the construct of internalised homophobia is a central organising concept in LGB affirmative psychology (1) it is a developmental event experienced by varying degrees by the majority of LGB individuals raised in a heterosexist society; (2) it is often a catalyst or stressor of psychological distress for LGB individuals; (3) reducing internalised homophobia can be an important measure of the outcomes of therapy; and (4) it can be a heuristic construt, which can organise elements specific to LGB people in areas such as development, psychopathology, psychotherapy and prevention.

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Literature Review There has been much criticism in the literature of the term internalised homophobia because of the opinion that it is not a phobia in the classic sense (Shildo, 1994; Davies, 1996; Friedman & Downey, 1999; Russell & Bohan, 2006). It has the ability to pathologise the individual, and is more than likely a natural reaction to living with a stigmatised identity in a heterosexist society. In this case homophobia is the problem as opposed to internalised homophobia. The assumption that it comes from within the individual has also been criticised in that it depoliticises lesbian and gay oppression (Kitzinger, 1987, p. 188). Russell & Bohan (2006) propose a model, which allows people address their own part in homonegativity without a burden of guilt. They assert that internalised homophobia is not an internal quality, but rather an expression of the collective experience. It results from interactions between LGB people and their society. They argue we are all embedded in pervasive, socially and linguistically constructed homophobia: we are all its enactors and recipients. (Russell & Bohan, 2006, p. 350). They use the term ventriloquation to describe this process whereby we all non-intentionally absorb stereotypes and prejudices throughout our lives and ventriloquate the assumptions we have absorbed through our actions and language, thus conveying, reproducing and strengthening them in our collective knowledge, the attitudinal fog in which we are immersed (Russell & Bohan, 2006, p. 350). It follows that the homophobic discourse will be experienced by people differently as a result of geographic location, family and social contexts, religious beliefs, race, ethnicity and economic status and of course sexual orientation. The impact of homophobic discourse obviously has a much more powerful and personal effect on LGB individuals, whereas heterosexuals may experience it as impersonal or sometimes even affirming (Russell & Bohan, 2006). In the past internalised homophobia was viewed as something intrinsic to the individual, a shame or hatred of their sexual orientation; however it now clear that internalised homophobia and societal stigmatisation of homosexuality are intertwined. Internalised homophobia is a direct result of societal oppression. Even though the majority of LGB individuals are perhaps happy with their sexual orientation, internalised homophobia may surface in relation to other issues the client may bring up in therapy. It may exist at some unconscious level and the therapists role is to uncover these self-oppressive beliefs and behaviours, and by making them conscious, assist the client to see the material as a result of societal pathologising of their natural and healthy sexuality (Davies, 1996, p. 55).

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Literature Review

2.1.5. Mental health among LGB individuals

Stigmatisation of homosexuality along with victimisation and discrimination may have a direct result in the health and psychological well-being of LGB individuals, (Cochran & Mays, 2000; Meyer, 2003; Cochran, Sullivan & Mays, 2003; Warner et al. 2004; Ferguson et al. 2005; & Pitt el al. 2006). It has been said that positive mental health is the cornerstone of overall well-being, and homophobia and heterosexism on societal and institutional levels, can have profound impacts on the mental health, thus well-being of LGB individuals (National Disability Association, 2005). These stressors can result in illnesses including depression, substance addiction, anxiety disorders, deliberate self harm or even suicide. Mental illness prevalence is often higher in LGB individuals when contrasted with their heterosexual counterparts (Cochran, Sullivan & Mays 2003), and gay men often present with higher levels of mental health disorders than lesbians (Ferguson et al. 2005; Pitt et al. 2006). There have been numerous recent studies examining levels of mental illness in LGB populations and how they differ to heterosexual population rates of mental disorders in the United States, Europe, Australia and New Zealand. LGB individuals have been found to have higher rates of mental health morbidity, co-morbidity and the use of mental health services than heterosexuals (Cochran, Sullivan and Mays, 2003). There is also significantly higher prevalence of depression, panic attacks and psychological distress among LGB individuals when compared with their heterosexual counterparts (Ferguson et al. 2005; Warner et al. 2004; Pitt et al. 2006). Results from within the LGB population are somewhat variable. For example lesbian and bisexual women revealed higher levels generalised anxiety disorder in the Cochran, Sullivan and Mays (2003) study, but in a birth cohort study from New Zealand gay males showed much higher rates of a range of mental health problems than lesbians. These included: major depression, anxiety, suicide ideation and suicide attempts (Ferguson et al. 2005, p. 979). The authors theorised that there is a greater stigmatisation of male homosexuality; and this may make gay males more susceptible to mental health problems. This theory concurred with Herek (2002) who also perceived that there is a greater stigmatisation of male homosexuality. Epidemiological type studies using population-based surveys conducted since 2000 in Europe and the United States have also revealed increased lifetime risks of major depression (Cochran & Mays, 2000) and greater risk for some affective, anxiety and substance use disorders for LGB individuals (Cochran & Mays 2001, Gilman et al. 2001,

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Literature Review Sandfort 2001). Suicide ideation is another factor that had high prevalence in LGB individuals in certain studies and higher rates compared to previous community-based studies (Warner et al. 2004; Ferguson et al. 2005). Although young LGB people may generally be more open about their sexuality in current times, this has not resulted in better outcomes for them, and LGB youth are still very much vulnerable to both discrimination and mental health problems (Warner et al. 2004; Ferguson et al. 2005). Higher levels of alcohol and substance abuse disorders have been detected among the LGB community and the overrepresentation of LGB individuals with alcohol and drug problems in the general population has been observed. In some studies, LGB individuals were found to be more than twice as likely to have or have had alcohol or drug dependencies as their heterosexual counterparts. They engaged in heavy drinking for much longer and notably diverged from the general population in associated factors such as age and gender (Kowszun & Malley, 1996, Hillier, 2004). There are a number of difficulties with epidemiological studies in this area. LGB populations unlike ethnic and racial populations are hidden and as a result most of the research in this area has had to over rely on convenience-based or snowball sampling. Individuals accessible to researchers are those openly involved in the LGB community, networks and events. This method of sampling has been seen as problematic because there are no equivalent heterosexual groups to act as controls (Cochran, 2001). People who are willing to engage in detailed health surveys and disclose their sexuality and sexual history may be more likely to disclose information on psychiatric illness (Cochran, 2001). On the contrary it has also been argued that there may be an overrepresentation of healthier members of the minority group due to selection bias on the basis that self acceptance is associated with better psychological wellbeing. Therefore individual who are not out to themselves or in denial may be less likely to take part in a survey (Meyer, 2003, p. 701). Both of these points bare true when sampling is convenience-based, however, more recent epidemiological and birth cohort studies may give less biased results. Higher rates of mental health problems in LGB individuals may result from the stigmatisation of LGB sexualities (Cochran et al. 2003, Ferguson el al. 2005). Cochran (2001) highlights that the early exposure to negative experiences emanating from this stigmatisation, may encompass; rejection from family, harassment, threat of, or actual violence. A multitude of issues that can arise out of the totality of the minority persons experience in the dominant society (Meyer, 2003, p. 700). In a recent survey with a sample of over 40,000 LGB adults 32

Literature Review enacted stigma (criminal, victimisation, harassment, and discrimination based on sexual orientation), and felt stigma (perceptions that sexual minorities are disliked and devalued by society) were assessed revealing that 55% of respondents manifested some degree of felt stigma, which tended to be higher among respondents who had experienced enactments of stigma (Herek, 2007, p. 8). The study also revealed that approximately 20% of the sexual minority population in the United States had experienced a crime against their person or property since age 18 (Herek, 2007, p. 7). Verbal harassment was much more widespread and was encountered by the more than half of the sample. Enacted stigma, may well increase felt stigma, however the two combined will surely affect the mental well-being of LGB individuals. Adjusting to a LGB identity in the presence of social stigma involves a considerable investment of emotional energy and...a considerable psychic toll (Warren, 1980 in Meyer, 2006, p. 704). The sometimes lack of typical life events such as marriage or childbirth, and in some cases the presence of atypical life events such as loss of custody of a non biological child, or being disowned by ones family may cause extreme stress on the individual resulting in negative psychological effects (Cochran, 2001, p. 937). Higher levels of alcohol and substance abuse among LGB individuals have been linked to the centrality of nightlife in the gay scene, minority stress and adherence to sexrole stereotypes and age related social changes (Kowszun & Malley, 1996). Adjusting to ones sexual identity in the presence of societal stigma and discrimination, experiencing early negative events or later atypical life events as a result of stigmatisation may act as stressors and influence the mental health of members of a sexual minority. However it is most likely that these factors act in combination and must be examined contextually, although there is very little empirical evidence or research being done to prove this (Cochran, 2001).

2.2. LGB Life Span Issues

2.2.1. LGB Youth & Adolescence
Adolescence is an exciting, but sometimes confusing and difficult time for most people, a time characterised by experimentation, exploration and risk taking (Ryan, 2003, p. 138). For LGB adolescents there are added developmental tasks and issues, which make it even more challenging. First sexual experiences and relationships may occur for some, but these experiences can become more complicated for LGB youth who often negotiate them without guidance or help from adults who routinely provide support for children and adolescents (Ryan, 2003, p. 138). Many heterosexual adolescents experiment sexually with members of the same sex, without adopting a LGB identity and similarly many LGB 33

Literature Review adolescents may have experiences with members of the opposite sex, but eventually acknowledge their same-sex orientation. Of those who acknowledge or act on their samesex attractions, they may or may not come out, disclose their sexuality to their parents or adopt a LGB identity. This can be influenced by many factors. 2.2.1.1. The Coming out process Coming out is defined as the developmental process through which gay people recognise their sexual preferences and choose to integrate this knowledge into their personal and social lives (Monteflores & Schultz, 1978 in Zera, 1992, p. 850). Even though society is more aware and open about sexuality than before, the coming out process is still difficult, challenging and complicated for LGB youths (Mair, 2003). Once an individual self-identifies as being LGB, the need to disclose this aspect of their identity to their family and friends can become stronger, particularly if the individual begins to feel that they are deceiving those around them. They may need to present the whole picture, with a desire for authenticity growing. Prior to coming out some LGB youth may use certain coping strategies to deal with unhappiness related to their sexual orientation. Herek & Martin (1987) outline three coping strategies 1) learning to hide. This may involve monitoring or modifying ones behaviour in situations where it is dangerous or disadvantageous for ones sexual orientation to be known. 2) denial of membership. This involves: rationalisation or denial of homosexuality/bisexuality and efforts to identity as heterosexual. 3) gender deviance. This involves displaying exaggerated of stereotypical homosexual attributes (in Zera, 1992, p. 850). Other strategies used may include repair, in which the LGB youth may attempt to change their same-sex feelings with professional help, or redefinition which involves regulating same-sex behaviour or feelings with certain circumstances or people, or by adopting a bisexual identity (Zera, 1992, p. 850). If the LGB individual decides not to come out, continuing to pass as a heterosexual is the other alternative. The term pass refers to an individual concealing (being closeted), denying ones sexual orientation, or not challenging an assumption that they are heterosexual (Greene, 1994). Greene (1994) emphasises that passing can be an adaptive coping strategy and can be an adaptive survival tool, but when used on a long term basis it deprives its user of the spontaneity required for

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Literature Review authenticity in interpersonal relationships (p. 4). As a result, the individual may be constantly on guard, protecting their secret, and may feel they are deceiving those they love and those around them. Both passing and coming out are challenging for the individual. Both passing and being out are accompanied by varying types and degrees of psychological demands and the stress that is a result of those demands (Greene, 1994, p. 4). Although both passing and being out may both cause psychological stress on the individual, being out is seen as a much is a much healthier stress and is linked to higher self esteem (Savin-Williams, 1995; Anhalt & Morris, 2003). 2.2.1.2. Models of coming out There have been many coming out models developed which try to explain the stages of the coming out process (Davies, 1996). They are often linear-type models, which in the person is presumed to pass sequentially through the various stages of the coming out process, arriving at the last stage, where all aspects of the identity are integrated and synthesised. These models may be helpful to therapists working with LGB clients, to assist them to recognise stage-connected issues that their clients may be facing. At this time there is no direction for use of these models in a therapeutic context (Rust, 2003). The most famous model, to which others are compared, is the Cass model (1984) in which the individual is supposed to navigate through six stages of identity awareness: feeling different from others; comparison: considering the possibility of being LGB; tolerance: acknowledging same-sex attractions; acceptance: coming out, exploring the LGB community pride: feeling proud of the self and ones involvement in the LGB community, possible discrimination against heterosexuals; and synthesis: integrating sexual identity into the whole personality, accepting of self and others This model is concerned with harmony between three factors: the self, behaviour and the outside world. The individual may move through all six stages or stop at any stage. Disharmony between these factors causes the individual to move forward in the process. Developmental tasks are to be completed before moving on to the next stage (Davies, 1996). Cass did not suggest age ranges for the model and so it could be applied at any stage of the lifespan. The various models of coming out have been criticised for being too

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Literature Review rigid, and that individuals may work on more than one developmental task simultaneously. Davies, (1996) does not see the coming out process as a linear and sequential process, which the individual completes. He argues that coming out is a complex developmental process of intra-psychic and interpersonal transformations extending well into adulthood, with a range of different outcomes, not a once-and-for-all event (Davies, 1996, p. 84). It has also been argued these models often take a black and white polarised view of sexual orientation, which can lead to bisexual orientation being seen as a refusal to adopt one or other sexual orientation, or that it is pathologised by suggesting immaturity or psychological disharmony (Rust, 2003). Models can also become prescriptive if used to try and predict or facilitate processes an individual may be experiencing (Rust, 2003). Coming out is a contextual process and so will naturally not be experienced in the same way by everybody. Gender, age, locale, religious beliefs, political beliefs, ethnicity, race and other factors will affect the process (Greene, 1994). After the individual has come out to themselves, they may later disclose their sexual orientation to some trusted friends, or perhaps a sibling. Coming out to parents is one of the most difficult developmental tasks that many LGB young people will face and sometimes one of the most difficult aspects of their childs development for parents to accept. 2.2.1.3. Disclosure to Parents Therapists, counsellors, and educators have observed that LGB youth and their parents face unique developmental issues not encountered by families in which all immediate members are heterosexual (Savin-Williams, 2003: 297). Disclosure for some may occur in their early or late teens and for others during young adulthood or later. Parents can often be the last to know, and the hardest to tell. From narratives, most youth perceive that the response will not be one of support or affirmation and LGB youth fear being disowned, rejected, thrown out of the home or emotionally or physically harassed. Nevertheless disappointing or hurting parents is often cited as their greatest fear (Savin-Williams, 2003, p. 299). When parents are aware of their childs sexual orientation, they often display a range of emotions including anger, self- blame, and shock. Parents might feel anger, blame themselves or grieve and mourn the loss of their heterosexual child and all of the expectations associated with a heterosexual identity. Based on the models of grief and loss, to which this phenomenon has been compared, parents may move through several stages before accepting their childs sexual orientation. The initial disclosure may be followed by shock, denial, anger and guilt finally leading to acceptance. For some this might be a short process, for others a lengthier one. Some parents may experience several stages

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Literature Review simultaneously, and some might never work thorough all the stages reaching acceptance (Savin-Williams, 2003). LGB youth are faced with a dilemma. On one hand, they may want to disclose, to abate feelings of isolation, deception or burden. On the other hand, they may not want to disclose for fear of disappointing their parents, causing hurt or placing their parents in an awkward position with relatives or neighbours (Savin-Williams, 2003, p. 304). Disclosing to parents has been related to better self-esteem, better psychological functioning and feeling protected and supported when outcomes are positive. When the outcomes are negative disclosure to parents has been linked with poorer psychological functioning, attempted suicide, substance abuse, homelessness and low self esteem (Savin-Williams 2003). Obviously the outcome depends on the reaction of the parental and family unit, however if the family are supportive of their LGB teenager, they can act as a buffer to victimisation that the LGB youth may encounter in the community. One study found of LGB youth teenagers found that 80% had experienced verbal abuse, 44% were threatened with violence, 33% had objects thrown at them, 31% had been chased or followed, and 17% had been psychically assaulted as a result of their sexual orientation (Pilkington & DAugelli, 1995). Disclosure of LGB sexual orientation for young persons within ethnic minorities can pose more complex problems for LGB youth. These often involve the risk losing their extended families (homosexuality may bring shame upon the family) and experience prejudice from the dominant society and from their own ethnic/racial group (Garnets & Kimmel, 2003). Having dual or triple minority status can mean suffering multiple oppression, related to living in three often competing and sometimes mutually exclusive communities, for example: gay, ethnic, and white (Savin-William, 2003, p. 317). For the individual with multiple identities such as, a woman who is Asian American, lesbian, and disabled the oppressions are many as are the cumulative negative effects (Schreier, Davis, and Rodolfa, 2005). Conflicts of ethnic and sexual identity have resulted in relatively lower levels of disclosure among ethnic groups in the United States and high levels of rejection and harassment from families (Savin-Williams, 2003, Garnets & Kimmel, 2003). Presently LGB youth are recognising, acknowledging, and publicly proclaiming their same-sex attractions at increasingly younger ages (Savin-Williams, 2003, p. 306). This may be a result of increased visibility of LGB individuals in the media, and a more open-minded society. Nevertheless, LGB youth are still faced with difficulties and challenges of being part of a sexual minority, in largely heterosexist and homophobic societies. LGB youth may receive eventual affirmation and support from their families nowadays, but it remains an issue that

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Literature Review gay people may be in fact the only minoritywhose families consistently reject them (Savin-Williams, 2003, p. 300). 2.2.1.4. Adopting a LGB Identity Perhaps for this reason many LGB youth choose not to adopt a gay identity in addition to such perceived negative consequences LGB youth may feel alienated or disgusted by their sexual orientation or the idea of living a gay life. Savin-Williams (2005) states the new generation of LGB youth also reject gay identity for other reasons: fluidity: feeling constricted by sexual labels, same-sex attractions and encounters are viewed as discreet and imply nothing permanent and the gender of a love interest is not considered to be of central importance; philosophy: LGB labels are viewed as reductionist, and there is opposition to sexuality being boxed in and compartmentalised and sexual desire being politicised; fit: feeling alienated from the portrayal of gay culture and community in the media, because of over commercialisation and the proliferation of gay stereotypes. This isnt me! politics: opposing political implications associated with being LGB, or feeling that they are not political enough to take on a LGB identity. (Savin-Williams, 2005, p. 18).
New gay teenagers revel neither in the singularity nor the banality of same-sex attractions. Their desire is to witness the elimination of sexuality per se as the defining characteristic of the person. If achieved, gay identification would be relegated to an archaic memory, its social construct forgotten except as a historic footnote (Savin-Williams, 2005, p. 19)

This may be the case for some LGB teens, but many still value the support of the LGB community when they come out, and sometimes when their biological family reject them, being part of the LGB community can be a affirming and validating experience. They may adopt a LGB identity proudly in defiance to bullying or victimisation they may have experienced. Media representation of gay culture and community can have a huge influence on young LGB youth and their perceptions of what it means to be gay or bisexual. LGB youth often lack LGB role models and instead are bombarded with stereotypical gay characters. LGB adolescents need positive, visible role models, which they do not get from mainstream culture or media. They also need the opportunities - taken for granted by most heterosexuals to socialise with their homosexual peers (Zera, 1992, p. 851). This can be difficult because most activities in the wider gay culture tend to be adult orientated. This is 38

Literature Review changing with the emergence of more LGB youth groups, which tend to be concentrated in the urban areas. LGB youth especially those in more isolated areas lack opportunities to explore their identity without placing themselves at risk for victimisation (DAugelli, 1995, in Ryan, 2003, p. 145). Music therapy could be a very effective vehicle for LGB youths to express and explore their sexual identities and deal with rejection and discrimination in a safe and contained environment through group music-making or song writing. Music therapy could also encourage socialisation with other LGB youths, improve interpersonal relationships, confidence and promote group pride through improvisation. This kind of music therapy may be a lifeline to isolated LGB youths. Music therapy might also prove a unique and effective modality for working with families, who have difficulty accepting their LGB child. Bright (2006) emphasises, that music therapy offers support for clients and families as they deal with difficult life changes, whatever their root. Music therapy can facilitate both the painful and emotional aspects of change, and the adaptation to new circumstancesclients and families are thus better able to cope with the present, and then move into the future with greater confidence (Bright, 2006). 2.2.1.5. Conversion/reparative therapy Although the majority of LGB will not undergo or even consider conversion/reparative therapy, these therapies are by no means a thing of the past, and continue to exist in abundance, especially in the United States. The Intersection of psychology, gay rights, religion and public policy has formed a crucible, in which conversion therapy sits at an often stormy centre (Haldeman, 2002, p. 264). Conversion therapy programs are very frequently religious based and view homosexuality as a choice and as changeable. There are two camps for conversion therapies in the United States. There is the ex-gay movement, with groups such as Exodus International which are religious based, and there are also the secular reparative therapists coming from a more scientific perspective involved in such organisations as the National Association for Research and Therapy of Homosexuality (NARTH), which helps clients bring their desires and behaviours into harmony with their values (NARTH, 2007). If our values framework is derived from the world around us it is possible that social attitude and pressure coerce people into these therapies (Haldeman, 2002, p. 262). Research on conversion therapies have been heavily critiqued for sampling flaws and methodologies, (Tozer & McClanahan, 1999). Conversion therapies are seen a breech of the ethical principal of competence, integrity and a disrespect for peoples rights 39

Literature Review and dignity (Tozer & McClanahan, 1999). Conversion therapy constitutes a cure for a condition that has been judged not to be an illness and second, that it reinforces a prejudicial and unjustified devaluation of homophobia. (Haldeman, 2003, p. 691). Considering the societal homonegativism that exists and its influence on individuals seeking these treatments, Haldeman (2003, p. 264) states the most important work off all is not what changes sexual orientation, but what changes society, so that we may all live and work together, while respecting each others differences. Music therapy has been used effectively in work with adolescents (Tervo, 2001; De Backer, 1993; Nirensztein, 2002; Fruchard & Lecourt, 2002) and could be successfully applied to working with LGB youth in group or individual work. Music can also provide adolescents with opportunities to experience closeness and isolation and to explore their sexual fantasies and feelings (Tervo, 2001, p. 79). Through music-making LGB youth could explore their sexual identities and issues in relation to coming out or isolation. Music therapy in group work with LGB youth could provide a safe and affirming environment, where LGB youth could bond, support each other and feel validated and accepted.

2.2.2. LGB Midlife

LGB individuals are sons, daughters, sisters, brothers, aunts, uncles, grandparents and grandchildren and have always been a component of family life (Lassiter et al. 2006, p. 245). Where previously LGB individuals may have fulfilled the role of parent through heterosexual relationships nowadays more LGB individuals are becoming parents outside of traditional heterosexual contexts too (Lassiter et al. 2006, p. 245). The issues for LGB individuals considering becoming parents or not will be significantly different from those raised in a heterosexual context (Hargaden & Llewellin, 1996, p. 117). 2.2.2.1. Prejudices against LGB families There are many prejudicial attitudes regarding LGB individuals and children, and in some European Union countries LGB sexuality and paedophilia are routinely intertwined (Taylor, 2006, Attitude). It is broadly supposed that the western heterosexual nuclear family is the perfect model for raising children. However, this model is not the reality for many children, is no longer sufficient for many heterosexuals and is not the only structure in which they [children] flourish (Hargaden & Llewellin, 1996, p. 120). Furthermore, it may be unfair on the children argument used against gay marriage was also once an used against mixed race marriages and the argument that children will be embarrassed or confused usually

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Literature Review come from people who are experiencing those feelings themselves (Hargaden & Llewellin, 1996, p. 122). Again, based on the heterosexual nuclear family model prejudicial arguments imply that children need a role model of both sexes, when in many single-parent heterosexual families they only have one gender as a role-model. In any case role-models are often available outside the family. The focus should be on the quality of the role-model and not the gender. Children in LGB families follow expected patterns of gender identity, development of social relationships and gender role behaviour falls within the typical limits of conventional sex roles (American Psychological Association, 2005). Assessment of aspects of personal development such as psychiatric and behavioural problems, personality, selfconcept, moral judgement and intelligence also reveal no differences to children in heterosexual families (Patterson, 2003). Despite this clear evidence to the contrary it is often argued that children in LGB families will turn out mal-adjusted. It is also argued that these children will turn out gay, even though the probability of this is the same as any heterosexual family. Even if this were not so, the affirmative response would be so what! (Hargaden & Llewellin, 1996, p. 121). Despite the fact that no study has found children of LGB parents to be disadvantaged in any significant respect relative to children of heterosexual parents, LGB families constantly experience discrimination and face difficult challenges (The American Psychological Association, 2005). This can be more intense for gay men with children for whom legal issues can be more difficult. This may be based on the commonly held beliefs, none of which have any basis in research, that men are not as nurturing as women or that gay men are more involved in promiscuous sex or are more likely to sexually abuse their children (Ariel & McPherson, 2000, p. 422). 2.2.2.2. Affirming LGB Families LGB families can have a different composition than the nuclear western heterosexual family and these families have sometimes been referred to as families of choice (Ariel & McPherson, 2000). Clients may have a functional family that may include biological family members, friends and past lovers (gay or straight). These families of choice function just like an extended biological family, nurturing, supporting and providing a broader sense of community that can combat feelings of alienation and experiences of discrimination (Ariel & McPherson, 2000, p. 424). Therapists should therefore value and validate the unique constellations that can make up LGB families and not superimpose maps of heterosexual dyads on LGB couples or families, recognising the differences as well as similarities between heterosexual and LGB families (Bernstein, 2000, p. 451).

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Literature Review LGB families may seek therapy for guidance, support and validation, which they might not receive in the broader social arena (Ariel & McPherson, 2000, p. 431). Appropriate training and education is necessary to understand the lived experiences of lesbian and gay parents, their children, their extended families and their families of choice (Ariel & McPherson, 2000, p. 431). Professionals are also encouraged to be aware of and challenge their own conscious and unconscious prejudices against LGB parents raising children (Lassiter et al. 2006). Music therapists may work with LGB clients and or LGB family members and need to be aware of their own attitudes towards LGB families, and have an understanding of the unique challenges these families may face. In family work with LGB clients, music therapy could act as a supportive buffer against discrimination, and foster affirmation and validation. Bright (2006) says that music therapy establishes a milieu in which our clients and their significant others are empowered to confront difficulties and move into the future.

2.2.3. LGB Ageing

When we think of old age we do not think of sexuality, and we certainly do not think of LGB sexualities. The construct of old age from the dominant heterosexual culture regards ageing people not only as heterosexual, but as asexual heterosexual beings (Philip & Marks, 2006, p. 71). Images of lesbians are not even included in stereotypes of ageing women earth mother, available divorcee, merry widow, mother-in-law, granny, matriarch or old game bird but rather in caring or asexual roles such as unmarried daughter or maiden aunt (Young, 1996, p. 153). Ageism coupled with heterosexism, can pathologise and conceal LGB identities leading to invisibility. As a result the LGB individuals human need for emotional and affectionate love in their autumn years is often overlooked. There are many life changes and transitions for LGB ageing individuals. These are the same for all ageing individuals and include changes in or deterioration of health, adjustment to retirement, financial issues, death of friends/family and spiritual issues. Nevertheless, transitions in later life for LGB individuals can be more complex and develop into crises due to psychosocial stressors and heterosexism (Adelman, 1990; Berger & Kelly, 1996; American Psychological Association, 2003). Ageing LGB individuals have experienced many changes in societal attitudes towards LGB sexualities, having lived through eras when LGB sexualities were pathologised, and criminalised, with heterosexism and homophobia rife and unchallenged. Stigmatisation from 42

Literature Review the dominant culture was also commonplace, rendering individuals isolated and marginalised (Grossman, DAugelli & O Connell, 2003). Certain LGB individuals may have spent their entire lives passing for heterosexuals because of oppression and may have even married and had children (Harrison, 2002). Many ageing LGB individuals may never have come out publicly, do not regard themselves in terms of a contemporary LGB identity, nor have been involved in LGB communities. Their experiences may have influenced them to adopt different coping strategies for living in a homophobic society and possibly to regret the increased visibility, politicisation and overtness of contemporary gay cultures (Ratigan, 1996). On the other hand, some older LGB individuals will have been publicly out or involved in activism, and experienced milestones and momentous events such as the declassification of homosexuality as a mental illness, the gay liberation movement, and the AIDS epidemic. Many older lesbians may have been involved in the feminist movement and many gay men may have lived in mental and physical male ghettos in the larger cities (Ratigan, 1996, p. 168). 2.2.3.1. Aged Care Settings & Fears Whether ageing LGB individuals are out or not, they have experienced more stigma and oppression from society than their younger LGB counterparts regarding their sexual orientation. The option to disclose their sexual orientation in later life is a personal choice. It is however important that therapists and service providers provide a non-discriminatory and affirming environment where this choice can be made with confidence and without fear of negative consequences and service providers have a responsibility to keep open the option of coming out, without threatening, enhancing fears, or making incorrect assumptions about older LGBTI8 individuals (Harrison, 2002, p. 2). LGB individuals sexual identities may be ignored or frowned upon in an aged care setting particularly if issues in relation to sexuality are seen as a private matter or inappropriate for public discussion or disclosure. Hughes (2006, p. 58) emphasises the importance of being aware that certain identities and sexualities remain disparaged, private and invisible. It also important to consider the continual affects of stigma on these identities and sexualities. Fears of prejudice and homophobia are a reality for many ageing LGB individuals. In the United States and Canada over 50% of ageing LGB individuals were concerned about negative experiences caused by professional attitudes towards homosexuality and over 50% never disclose their
8

LGBTI lesbian, gay, bisexual, transgendered, intersex Intersex A variety of conditions that lead to atypical development of physical sex characteristics, are collectively referred to as intersex conditions. These conditions can involve abnormalities of the external genitals, internal reproductive organs, sex chromosomes, or sex-related hormones (American Psychological Association , 2007b).

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Literature Review sexual preference to health care providers (Philip & Marks, 2006). In a meta-study on ageing LGBTI individuals, the most prevalent concerns were disclosure of sexual identity resulting in physical or emotional abuse; prejudiced attitudes from carers resulting in lower standards of care; hiding sexual orientation because of the perceived threat of homophobia; taboos surrounding displays of same-sex affection resulting in lack of physical intimacy with partners; and homophobic attitudes of religious aged care service providers. (McNair & Harrison, 2000 in Philips & Marks, 2006) Ageing LGB individuals may fear suffering discrimination not just from service providers and carers, but also from heterosexual residents in the facility. Older people may become silent about their sexual and gender identity by going back to the closet (Pitts et al. 2006). This silencing could be an affect of ageism and the general assumptions of asexuality in relation to older people, but it is more likely to be related to homophobia, stigmatisation and accommodation needs. If accommodation becomes an issue for older LGB individuals needing to live with family, children or in residential care, they may be literally forced back into the closet (Harrison, 2002, p. 3). Although in some countries attention has been given to LGB ageing in the gerontology research, in others it has been severely neglected (Harrison, 2006). The issue of privacy can have a silencing effect on ageing LGB individuals. If therapists and trainees hold the view that sexuality and sexual orientation is a private issue this can lead to invisibility and discourages public discussion regarding this topic (Harrison, 2001, p. 143). It can also lead to peoples needs being unmet and a dont ask, dont tell, dont know approach to homosexuality (Philips & Marks, 2006, p. 67). If heterosexual sexual orientation is not private, then LGB sexual orientation should not need to be private. 2.2.3.2. Affirming LGB Sexualities in Aged Care Valuing and affirming a clients sexual orientation, especially in aged care setting is of paramount importance. This idea of privacy or silence around a clients sexual orientation could have direct impacts on a clients self esteem and general wellbeing. The privacy of residents is extremely important, but completely ignoring issues associated with sexuality and intimacy can lead to clients needs not being met. A client wishing to have some time alone with their same-sex partner may be unable to approach staff about this, and staff

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Literature Review may not acknowledge this need, or even the relationship itself, considering it to be a private matter. Respect for privacy is not the same as ignoring peoples needs (Philips & Marks, 2006, p. 68). The privacy argument can affect our work with clients, becoming a hindrance to their own personal growth. Harrison (2001) If we see ourselves as practitioners in any sphere as enabling the doing being and becoming of human beings (Wilcock, 1999) surely we will recognise the privacy argument, as a potentially dangerous cop out and a serious obstacle to people realising their human potential with their sexual identities as integral (Harrison, 2001, p. 145). Recognising the sexual and intimacy needs of LGB ageing individuals may seem like a subtle change; however it is a step towards challenging institutional homophobia and heterosexism. The American Psychological Associations (2003) guideline 12 for working with LBG clients encourages psychologists to consider generational differences within LGB populations and the particular challenges that lesbian, gay and bisexual older adults may experience. This guideline stresses that attention needs to be given to the significantly different developmental experiences LGB individuals may have had and that special consideration needs to be given to same-sex older couples that do not have the same protection or legal rights as their heterosexual counterparts (Garnets & Kimmel, 2003, p. 770). One of the most subtle changes that can encourage and promote openness about sexuality in aged care-settings is the reduction of heterosexist bias in assessment forms. The use of significant other/ partner in place of husband or wife is far less assuming and from anecdotal evidence such subtle signals encouraged older gay clients to discuss issues and concerns that may otherwise have remained unaddressed (Philips & Marks, 2006, p. 71). 2.2.3.3. Ageing Successfully Kimmel (1978) and Friend (1980) both assert that LGB individuals may be able to age with more success, having resolved major life crises, such as coming out and adopting less rigid gender roles (Hughes, 2006, p. 55). They may be better equipped to adjust to transitions in old age having developed a certain level of crisis competence (Hughes, 2006, p. 55) and having addressed issues associated with being part of a stigmatised minority (The American Psychological Association, Garnets & Kimmel, 2003, p. 770). Nevertheless, there are those who spend much of their lives concealing their identities, and either living a lie or in denial. Perhaps, only in their later years, after the death of a spouse or a same-sex lover from their youth, may they begin to acknowledge their same-sex attraction. The decision to disclose or not in this situation may be a huge psychological stress on the individual. As with

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Literature Review LGB youth, older LGB individuals will have to balance the desire to be honest and authentic against the perceived disappointment or hurt this revelation may cause to family or friends. Having unresolved major life issues, a life spent in hiding or denial and fear of discovery would then certainly hinder LGB ageing individuals of ageing successfully. Access to life stories and oral histories, as well as opportunities for inter-generational exchange of narratives, are severely restricted by lack of attention to LGB ageing experiences (Harrison, 2002). Narratives can be vital for asserting LGB identity and particularly for institutionalised older people asserting their identity they can be experienced as empowering and challenging the identities that might be imposed on them by aged care workers (Hughes, 2006, p. 57). Music therapy then may prove a very effective modality for asserting identity for LGB ageing individuals who share narratives through song and music making. For over 40 years music as a therapeutic tool has been used effectively with aged care clients, especially those suffering with dementia and Alzheimer disease (Bright, 2006; Clair, 1996), however music can be a vehicle for authenticity in later years and through music, ageing LGB individuals can come to know and reflect upon heir own personhood (Hays & Minichiello, 2005, p. 440). Music may help to fight isolation and invisibility, if ageing LGB clients can express their emotions freely and create a sense of meaning through music. Music-making can foster self-acceptance and validation and provide LGB individuals with legitimate ways of expressing and feeling emotions that culturally were not always accepted by society (Hays & Minichiello, 2005, p. 445).

2.3. Gay Affirmative Therapy

An affirmative approach to working with LGB clients was developed in the 1970s and 1980s after a long history in the psychotherapeutic tradition of an approach that pathologised LGB sexualities. This was the first therapeutic movement that acknowledged the harm done to LGB individuals through heterosexist socialization and institutional homophobia (GLBTQ, Inc, 2005). The gay affirmative model served to counter the negative socio-cultural and familial environments in which LGB individuals may live, to improve the negative impact of growing up in an oppressive society and to facilitate clients in the coming out process and the embracing of a positive LGB identity. Since then the gay affirmative approach has been cultivated and adapted by many therapists. It has developed more as an approach or a therapeutic stance rather than a theoretical model of psychotherapy that is supported by theories of development, health and illness (Milton et 46

Literature Review al. 2002, p. 25) and there have been many problems in defining gay affirmative perspectives and praxis. Maylon (1982) states that the paramount objective of gay affirmative therapy is to aid the client in creating a sense of meaning and purpose in a heterosexist society (Lebolt, 1999, p. 366). Harrison (2000) in his critical analysis of gay affirmative therapy literature presents us with 5 dimensions of the gay affirmative model, working from within the core to the periphery of the model: 1) at the heart of the model is adopting a non pathological view of LGB sexualities, and viewing them as equally healthy, natural, normal and as fulfilling as heterosexuality. It has also been seen as important to have a contextual focus with clients and to avoid thinking in terms of self contained individuals (Strawbridge 1996 in Milton, Coyle & Legg 2005, p. 186); 2) drawing on this non-pathological view, the therapist tackles heterosexism, homophobia and internalised homophobia in self and others; 3) this dimension highlights those who can adopt the model; therapists, clients, friends and family of clients, professional organisations and associations, a culture, a sector of society or society as a whole. Work can be done on micro and macro levels. (Coyle, 1995); 4) the fourth dimension elucidates issues presented by LGB clients (effects of oppression, coming out difficulties, interpersonal and relationship difficulties, mental health concerns such as addictive disorders, isolation, anxiety, depression and low self-esteem; 5) the fifth dimension is concerned with the range of therapeutic interventions which can address both the issues in dimension four and ethical codes for practice. These may include assertiveness training, therapist self-disclosure, bibliotherapy and role modelling (Harrison, 2000). The periphery of the model is an amalgamation of all the dimensions and is concerned with other methods for use within the model, such as; self reflection/awareness, familiarity with LGB lifestyles, resources and networks and being aware of ones own limitations and areas for future development (Harrison, 2000, p. 45). The model is integrative with connections between all dimensions, but only therapists can provide gay affirmative therapy while other people or organisations may provide a gay affirmative approach (Harrison, 2000). Gay affirmative approaches from organisations and associations are

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Literature Review imperative as is work at macro levels because the target of change is not the individual but rather the culture (Tozer & McClanahan, 1999, p. 739). The therapists stance towards LGB sexual orientation or what Milton, Coyle & Legg (2005, p. 187) refer to as countertransferrential response has been considered to be a fundamental factor in determining whether a therapist can work with LGB individuals in a affirming way. Countertransferance can be viewed as blind spots or any aspects arising out of the therapists own life experiences or perspectives which may potentially limit their therapeutic endeavours with LGB clients (Milton, Coyle & Legg, 2005, p. 183). Countertransference can be positive or negativeconscious, preconscious, or unconscious (Hadley, 2002, p. 14). The therapists awareness of countertransference will determine if reactions will hinder or better therapeutic results. For this reason the therapists awareness of their stance towards LGB sexualities is of utmost importance and this stance should be examined in two domains. 1) interpersonally 2) in relation to LGB sexualities in general (Milton, Coyle & Legg, 2005) Tozer & McClanahan (1999) emphasise the importance of the therapist moving beyond the neutral environment. Awareness of the differences between non-homophobic and affirmative therapy is vital. In affirmative therapy, the therapist must be willing to acknowledge the destructive role of heterosexism, both internal and societal, and how this may affect LGB individuals. Neutrality on the therapists part can be problematic because gay men and lesbians are frequently the objects of intense disapproval, a client may misunderstand the therapists neutrality as disapproval (Greene, 1994, p. 11). There have been noticeable gender differences in the provision of affirmative approaches in psychotherapy. In a study of psychologists attitudes to approaches with LGB clients, it was evidenced that female therapists were more likely than their male counterparts to provide an affirming approach (Kilgore et al. 2005). This correlates with Hereks (2002) study of gender differences towards lesbian and gay men which showed that heterosexual men hold significantly stronger negative opinions and stereotypes of LGB individuals than heterosexual women. The importance of understanding the unique challenges that LGB individuals face has been well documented in the literature (Milton & Coyle, 1999; Greene, 1994; Eubanks-Carter, 2005; Garnets & Kimmel, 2005). Mohr (2000) argues that some therapists democratic 48

Literature Review working model of heterosexuality can lead them to ignore these unique challenges by assuming that there are no differences between a heterosexual and homosexual life experience (Eubanks-Carter et al. 2005, p. 6). The idea that therapists can apply certain skills to all clients ignoring definitive differences denies the distinct experience of the other (Milton & Coyle, 1999, p. 44). Becoming familiar with LGB culture and society has also been emphasised in providing more competent therapy for LGB clients. In addition the personal experience of having LGB friends or relatives may be a key factor of successfully working with LGB clients (Milton & Coyle, 1999). Eubanks-Carter et al. (2005) propose two possible reasons for therapists providing ineffective treatment to LGB clients 1) a lack of information about LGB specific issues and experience 2) the influences of homonegativism9 Personal experiences with LGB individuals could counter these factors in two ways. If the therapist has LGB friends or colleagues they could become familiar with LGB lifestyles and become more knowledgeable about issues specific to LGB individuals. The lowest levels of homonegativism are manifested in heterosexuals with LGB friends or family members to whom they are close to and with whom they have discussed issues relating to sexual orientation (Herek, 2000). . There are two distinct perspectives which are both intended to update existing therapeutic models, the first, having the intention of raising experience of oppression to consciousness and undoing conditioning associated with negative stereotypes of lesbian and gay men and the second having a non-discriminatory contextually aware attitude when working with LGB clients that can be incorporated into mainstream psychotherapeutic theories and practice (Milton et al. 2002, p. 1). Incorporating the latter stance into existing models of therapeutic theory may be resisted depending on the core theories of that model and the degree to which the model must change to integrate this stance (Milton et al. 2002, p. 26). Many theories on human development and identity have overlooked the LGB experience and Patterson (2003, p. 500) comments that when considering the research on LGB families there are theoretical concerns at hand, in that theories of psychological development have traditionally emphasised distinctive contributions of both mothers and fathers to the healthy personal and social development of their children. Therefore predictions based on

Homonegativism another term offered for homophobia by Hudson & Ricketts, 1980 (Davies, 1996, p. 41).

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Literature Review psychoanalytic theory or social learning theory could result in negative outcomes related to personal and social development for the children of LGB parents (Patterson, 2003). To practice affirmatively with LGB clients the therapist must have an understanding and knowledge of LGB sexuality and culture and the issues that confront sexual minorities. Psychological distress, however may not be caused by a persons sexuality, but may be a natural reaction to societal prejudice and oppression. The ability to distinguish this is critical for all aspects of the therapeutic process. The therapist needs to be open and at ease with their own sexual identity to avoid their own issues regarding sexuality becoming involved. (Milton, Coyle & Legg, 2002, p. 3). Everyone has a complex sexual identity whatever their sexual orientation, and understanding this will change how we approach LGB issues specifically and multicultural issues more generally (Bieschke, 2002, p. 579). The therapist must be able to reflect on their on their own attitudes and biases and challenge their own prejudices about LGB individuals. It is also important that heterosexual therapists examine their own privilege as heterosexual, and member of the dominant societal group. The ultimate goal is that the therapist can stand outside the dominant culture far enough to gain insight into what is heteronormative, what is heterosexist and what is homophobic (Bernstein, 2000, p. 445). Therapists are also encouraged to become familiar with the models of sexual identity development. Central to Daviess (1996) proposed model of gay affirmative therapy is the idea of respect. respect for the clients sexuality the therapist must review any dual views of sexuality, and in place understand the continuum of human sexuality, while regarding all sexualities as equal and valid forms of expression; respect for personal integrity the therapist must respect the clients autonomy and resources, and aim to create a team relationship working together; respect for lifestyle and culture the therapist must value and respects LGB lifestyles in all their diversity and becomes familiar with the LGB cultures that make up the LGB community; and respect for attitudes and beliefs the therapist must self reflect on their own values and prejudices and belief systems, and be aware that there are many different lifestyles within the LGB community, which should be equally valued, even if they are unfamiliar tithe therapist. Therapists should feel confident in referring a client to another therapist if they feel their own values and prejudices will conflict with the clients best interests (Davies, 1996).

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Literature Review In the role an educator, the therapist can serve to validate the clients experience and feelings as natural, while delineating some of the developmental tasks necessary for a healthy integration of sexual identity into the wider personality structure (Davies, 1996, p. 35). Mair and Izzard (2001) define two styles of gay affirmative therapy; implicit and active. Both styles have similar objectives, but differ in paradigm. The two approaches view homophobia as the pathology. However, the active gay affirmative model seeks to replace and de-programme negative, internalised views of homosexuality, which have been internalised in the process of growing up in a homophobic society. The implicit gay affirmationoffersby way of contrast, a space in which to work through the implications of these internalised views in a less systematic, more exploratory way (Mair & Izzard, 2001, p. 488). Both styles are presented in Table 2.1.
Implicit LGB Affirmation A gay affirmative stance, but not necessarily leading to the use of gay affirmative interventions. Not to initiate the subject of sexuality but to articulate the silence around it in relation to living in a homophobic world. Client experiences a mini-version of the outside world in therapy Interventions focused on intra-psychic or object relations in the inner world Homophobia is the crux of the LGB peoples difficulties in the world Knowledge that of societal homophobia though selfreflexion, literature and involvement in gay culture, friendships. Sensitivity rather than collusion or refuting transferences Implicit & Active Gay Affirmation Model an open & positive approach to LGB sexualities Avoid adopting a gay affirmative approach as a panacea for all problems arising for LGB clients To work with clients so that they may become more authentic, whatever that means for them When a client his/her sexual orientation, there must be an engagement with this. (Mair & Izzard, 2001, p. 485) Active LGB Affirmation Safety of the therapist/client relationship is actively established to provide containment and confidence in the therapist and the therapeutic space for exploration. Initiate the subject about sexuality, and communicate that it is safe to talk about any issues related to sexuality or homophobia. Client experiences something other than a miniversion of the outside world Interventions focused on communicating acceptance, building self esteem. Openness and willingness to explore what being LGB means for the client and the difficulties that may entail in as open a way as possible May involve revealing ones one sexual orientation, and exploring how this may impact the therapeutic relationship.

Table 2.1 Implicit and active gay affirmative therapy

51

Literature Review Mair (2001) encourages a more active approach, where there is affirmation and engagement with issues surrounding sexuality from the therapist to encourage the client to recognise internalised homophobia, which might otherwise may stay remain buried and blocked within the client.

2.3.1: Critique
In the US affirmative therapy has been criticised as having retreated into an intellectual ghetto as a result of becoming too involved in identity politics (Milton, Coyle & Legg, 2002, p. 28). Affirmative therapy has also been criticised for becoming prescriptive. When affirming something we make it solid, and we make it real, its consequence is to benchmark, set a standard, or create the illusion of certainty. Therapeutic affirmation should be at the level of possibility if we are not to risk prescription and ultimately disfranchising those we seek to assist (Cross, 2005, p. 342). There has also been criticism of the idea of affirming LGB sexual identity, which infers that sexual identity is static or fixed Simon & Whitfield (1995) regard a persons identity as fluid and continually being co-constructed in different contexts and propose that a co-constructive relationship tackles the power imbalance of the therapist having the authority to empower and affirm the clients experience and ask whether it is always better to be affirmative of a persons self description. Other academics have criticised gay affirmative therapy on the ground that it needs to do more than just accept. Cross (2001) argues that to be generative, gay affirmative therapy must be prepared to be critical and facilitative of the process of unique meaning-making (Cross, 2001, p. 339). There has been a growing divide between the North American and British attitudes to psychotherapy with LGB clients. Although both are concerned with the well-being and health of LGB clients, there is a perceptible divide in the dominant theoretical perspectives in both countries. The liberal humanistic models of LGB identity formation adopted by psychologists in the United States have been replaced by social constructionist10 approaches in the United Kingdom. Social constuctionism is now seen as a defining feature of lesbian and gay
10 Building on developments in systemic therapy, social constructionist therapy does not work with the notion of pathology in an individual or social system (for example, a 'dysfunctional family' or a 'disturbed individual') but rather with how the description of the problem arises and how it may be a problem in itself. More attention is paid to the language we use and to the consequences of ideas we construct with each other. Social constructionism is concerned with meaning-making between people and the contexts in which the meaning arises which might influence the accounts we develop to describe our circumstances. A key hypothesis proposes that people are recruited into particular stories by more dominant discourses at the expense of other descriptions that might be differently useful (Simon & Whitfield, 2000).

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Literature Review psychology which separates it from the United States (Clarke & Peel, 2007). Debate between the essentialist, positivist, empiricist, quantitative and liberal camp and the constructionist, discursive, qualitative, and critical camp is a definitive feature of LGB psychologies in the United Kingdom (Clarke & Peel, 2007). LGB psychology in the United Kingdom is said to resemble social psychology both in epistemology and methodology and is closely affiliated with qualitative research methods (Clarke & Peel, 2007). Finally, Simon & Whitfield (1995), view gay affirmative therapy as an indication of a discourse in transition and encourage looking at gay affirmative therapy from a critical therapy perspective in which there is a constantly evolving relationship between theory and practicewhich recognises the influences of our thinking of different contexts such as race, culture, class gender and sexuality. Today gay affirmative therapy may appear to be an historic concept that is no longer necessary to counterbalance the homophobia of the therapeutic systems. Perhaps, a more contemporary LGB affirmative therapy needs to develop a wider understanding of sexuality and the development of gender identity, and more focus on systemic and critical theories. Meanwhile there are still LGB clients and service users being disempowered and disenfranchised in psychotherapy and in mental health systems, and gay affirmative therapy can be an effective tool to combat this. It has been emphasised that much development is needed in the areas of literature, training and education, personal development and clinical practice if an authentic affirmative therapy for LGB individuals is to exist (Milton & Coyle, 1999). However, changes are occurring within the literature of psychoanalytical, psychodynamic, humanistic, with cognitive-behavioural, evidence of a systemic rethinking and of existential-phenomenological approaches

psychotherapeutic theory in relation to LGB sexualities (Milton, Coyle & Legg, 2005). There has also been a growth in affirmative literature and professional guidelines for working with LGB clients. These factors have a knock on effect and as a result many psychologists are eager to attend to issues of sexualitymore directly and creatively than before (Milton, Coyle & Legg, 2005, p. 193)

2.4. Summary
Because of the dearth of music therapy case reports, journal articles and discourse on LGB issues, the literature from the related disciplines of psychology and psychotherapy was reviewed to identify central LGB lifespan issues and LGB issues and perspectives in relation

53

Literature Review to therapy and health services. After examining the turbulent relationship between therapeutic disciplines and LGB sexualities, LGB sexualities are today still a hidden minority who experience discrimination and prejudice from health services. The existence of homophobia and heterosexism in heath care settings was examined and it has been seen how these matters can have a direct impact on diagnoses, treatment and therapeutic outcomes. These forces can affect the lives of LGB individuals in a multitude of ways, and discrimination and stigmatisation of LGB sexualities can result in internalised homophobia, poorer mental well-being and more chronic forms of mental illness among the LGB community. Key LGB life span issues have also been identified and examined from adolescence to old age. LGB clients can bring many specific problems related to their sexuality to therapy. LGB youth and adolescence face significantly different developmental tasks from their heterosexual counterparts, such as recognition of LGB feelings, isolation, disclosure to parents, and constructing a healthy LGB identity. In midlife LGB individuals may encounter problems in relation to marriage and parenthood, and LGB families face specific challenges and may have to negotiate many issues without support from the wider community. In relation to ageing LGB individuals, issues like invisibility and isolation are commonplace, and sometimes as accommodation or health needs become a dilemma, many LGB elders fear disclosing their sexuality for fear of discrimination and negative outcomes. Once LGB individuals come out, they will have to negotiate heterosexism, homophobia and stigmatisation from the dominant culture throughout their lives. These mental health stressors as well as stigmatisation and victimisation may lead to poorer mental health conditions. The gay affirmative approach has also been examined, and how it can provide a framework to help LGB clients with the coming out process and other lifespan issues, counter oppression from the dominant culture, and facilitate the development of a healthy LGB identity. At the core of the model is a non-pathological view towards LGB sexualities and the understanding that psychological distress may not be caused by a persons sexuality, but may be a natural reaction to societal prejudice and oppression, and distinguishing this is critical for all aspects of the therapeutic process. The importance of understanding the unique lifespan challenges that LGB individuals face is central to the approach, and in affirmative therapy the therapist must be willing to acknowledge the destructive role of heterosexism, both internal and societal, and how this may affect LGB individuals. The gay affirmative approach can easily be adapted and integrated into many theoretical frameworks and would meld well with many music therapy models. 54

Methodology

Chapter III Methodology

55

Methodology

3.1. Justification for the Investigation

Australia 2004 From a personal perspective, this researcher first came across a music therapy article focusing on therapy with gay and lesbian clients in the first year of his Post Graduate Diploma in Music Therapy at the University of Technology (Sydney, Australia) in 2004.11 At that time this was one of the few pieces of literature focusing on gay and lesbian clients in therapy with implications for music therapists. In the course of his studies, this researcher noticed how there was very little or no attention given to lesbian, gay or bisexual clients in music therapy case studies, clinical reports and narratives across all clinical settings. Being an openly gay male in his music therapy training and clinical practicum, the researcher felt that LGB sexualities, perspectives and issues were unrepresented in the music therapy. However, with practicum hours to complete and much coursework to do in completion of the Post Graduate Diploma, the ideas were put on the back burner with an interest in returning to the topic at a later stage. Spain 2007 Two and a half years later in a new country, undertaking a Masters by research in Music Therapy, this researcher returned to the topic, to see if there were any new developments in the field. It was observed that there had been very little growth or attention to the topic in music therapy literature, research and discourse since 2004. As a result this researcher felt it was apt time to highlight LGB issues in the field of music therapy, and to encourage some discourse on the topic. A comprehensive review of the music therapy literature was planned, followed by a review of the psychology and psychotherapy literature on LGB issues. The review of the relevant music therapy literature revealed a substantial lacuna regarding music therapy with LGB clients, in clinical reports, case studies and research. Unlike multicultural music therapy, there have also been no studies reported in the music therapy literature that investigates the provision of LGB issues in music therapy education and continuing professional development. Although it can be said there is also a paucity of LGB topics in the psychology and psychotherapy literature, over the last two decades there has been a growing interest in gay affirmative therapy, a marked increase in articles focusing on LGB issues, and a growing body of both quantitative and qualitative research (Rodalfa
11

Chase, K. M. (2004). Therapy with gay and lesbian clients: Implications for music therapists. Music Therapy Perspectives; 22: 34-38

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Methodology & Davis, 2003). A central theme in this growing body of literature and research is the lack of attention to LGB issues in psychology, psychotherapy and counselling training programs, curricula and education, (Greene, 1994; Davies, 1996; Milton & Coyle, 1999 Milton, Coyle & Legg, 2002; Rodolfa & Davis, 2003; Clarke & Peel, 2006; Godfrey et al. 2006). These developments focused the present research and the provision of LGB issues in music therapy training programs and continuing education became the focus for the investigation. It was of interest to know if music therapy educators were addressing LGB issues in the training of music therapists and in music therapy program curricula, and if so, what form the treatment of these issues took, and what topics were being addressed. Also of interest was whether music therapy associations provide any guidelines or opportunities for continual education in LGB issues for music therapists. LGB issues in music therapy seem to have been overlooked in the literature and research, and there has been little or no discourse in relation to LGB issues in therapy or in music therapy training, curricula and continuing education. (This, along with a personal wish for the unique perspectives and issues of people belonging to sexual minorities to be represented in music therapy, provided the researcher with his rationale for investigating this topic). The objectives of the surveys included: to discover are LGB topics being addressed in music therapy programs; to identify which LGB topics are music therapy programs addressing, and the format the provision of these topics take; to discover if music therapy associations provide any guidelines or opportunities for continuing professional education regarding LGB issues; to discover if music therapists are working with LGB clients; and to assess whether music therapy program directors and associations view LGB issues as an important component of music therapy education and the field at large.

3.2. Investigative method

This investigation falls in the category of applied research, with the aim being to develop and broaden our understanding of the status of LGB issues in music therapy. It is also research on the profession of music therapy focusing on professional education and training, including curricular content in music therapy programs and potential opportunities for continuing education. The investigative method chosen to investigate the provision of LGB issues in music therapy training and continuing education was descriptive research by questionnaire-based survey. Questionnaire-based surveys have been frequently used in the 57

Methodology music therapy literature to evaluate music therapy training courses, curriculum and effectiveness, as well as students experiences of clinical practicum. Surveys have also been used to investigate multicultural training for music therapists and competency requirements for practice (Wigram, 2005, p. 272). Survey research is crucial to the field of music therapy in that it fulfils an important role in presenting demographics and other information that informs the profession as a whole and provides supportive evidence to underpin the current and future development of music therapy services (Wigram, 2005, p. 272). There is a dearth of survey research in music therapy when compared with other types of research; however survey research has been used to explore important areas in the field. Surveys in music therapy often focus on reviewing published literature to see what is being published, reviewing published literature in specific clinical areas, training of music therapy students and exploring professional attitudes (Wigram, 2005, p. 273). The surveys conducted on training in music therapy have focused upon many topics such as curricula in music therapy programs, the personal backgrounds of music therapy students, the experiences of music therapy students during training and clinical practicum, and the evaluation of training programs as shown in table 3.1.
Authors Groene & Pembrook (2000) Wyatt & Furioso (2000) Wheeler (2000) Darrow & Molloy (1998) Clark & Kranz (1996) Toppozada (1995) Petrie (1993) McClain (1993) Maranto Dileo & Bruscia (1989) Taylor (1987) Braswell, Maranto & DeCuir (1980) Gault (1978) Focus Curricular issues in music therapy Music Therapists evaluation of their undergraduate or equivalency education Survey of music therapy program directors regarding aspects of their music therapy pratica Examination of the provision of multicultural issues in music therapy educational curricula Exploration of backgrounds, attitudes and experiences of music therapy students Exploration of multicultural training for qualified music therapists Evaluation of undergraduate academic curricula The content, structure and supervision of clinical training Status of music therapy education and training Competency requirements for music therapy practice Assessment of the effectiveness of clinical training for music therapy students

Table 3.1: Survey research dealing with training and education in music therapy Since research by questionnaire-based surveys has been used to explore training in music therapy, and aspects of curricula including the impact of multicultural issues in music therapy 58

Methodology education, training and practice it was considered apt to use this method to explore the provision of LGB issues in music therapy training programs and continuing education. A questionnaire is a useful method to get an overview of the status of LGB issues in music therapy in that it is inexpensive, has the capacity to include all potential participants regardless of their geographic location, is easy to implement, does not necessarily require complicated data analysis, and can provide supportive evidence in relation to the topic being researched. Another advantage of using questionnaire-based surveys over other methods of data collection is that all potential participants may receive it simultaneously, thus, the potential influence of events outside or related to the study that might influence a potential respondents experiences, opinions or attitudes are reduced and can be assumed to be equal for all recipients of the questionnaire (Bourque & Fielder, 1995, p. 12).

3.3. Participants
There were two groups targeted in this study: 1) the directors or coordinators of music therapy, university programs (Survey A); and 2) the music therapy associations (Survey B). The music therapy program directors were selected to elicit information on the provision of LGB topics in music therapy training courses. The music therapy associations were selected to elicit information regarding guidelines or continuing education opportunities for music therapists in LGB issues. The objective with the two surveys was to explore the status of LGB in music therapy from both the educational and the professional perspective. A provisional list of participants in each group was drawn up following an internet search. A list of the music therapy courses and associations was compiled, continent-by-continent, with the aid of various websites and databases as well as general search engines. The websites consulted are given in Table 3.3.
Voices Music Therapy World The Nordic Journal of Music Therapy The American Association of Music Therapy The Australian Music Therapy Association ADIMU www.voices.no/ www.musictherapyworld.de/ www.njmt.no/ www.musictherapy.org www.amta.org www.geocities.com

Table 3.2: Music Therapy websites consulted A special effort was made to invite participation from as many countries as possible in both surveys. This was necessary to obtain a global perspective on the status of LGB issues in music therapy education and practice. When the list of universities with music therapy 59

Methodology programs and music therapy associations was compiled, the contact details for each program director and association contact were obtained from each university website via the music therapy web page or association web page. Certain websites provided databases of music therapy programs and associations containing contact details and email addresses and these were all checked against each individual university and association website to ensure that they were up to date. The questionnaires for both surveys will be presented in the next section, Questionnaire A (music therapy programs), and questionnaire B (music therapy associations). Both questionnaires have been fragmented in the text to include an explanation and context for each question.

3.4. Survey A
3.4.1: Participants in Survey A
Because of the nature of the survey, the potential participants were course directors or coordinators of active university music therapy programs in 29 countries across five continents (Table 3.3). Undergraduate, post-graduate and masters programs were included, as were the doctoral programs directed by some of the universities. Only publicly funded universities were invited to participate.
Country Europe Austria Belgium Denmark Finland France Germany Hungary Ireland Israel Italy Latvia Netherlands Norway Poland Portugal Serbia United Kingdom Universities 1 1 1 2 3 9 1 1 1 1 1 3 2 1 1 1 7 Country Spain Sweden Switzerland Africa South Africa Australasia Australia New Zealand North America Canada United States Asia Korea South America Argentina Brazil Chile Total 29 Universities 5 2 3 1 4 1 5 64 2 3 6 1 Total 134

Table 3.3: Number of eligible participants for Survey A (by country)

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Methodology The names of the eligible universities can be seen in table 3.4.
Country Argentina Australia Austria Belgium Brazil Canada Chile Denmark Finland France Germany No. 3 4 1 1 6 5 1 1 2 3 9 University Universidad del Salvador - Universidad de Buenos Aires - Universidad abierta Interamericana University of Melbourne - University of Technology, Sydney - University of Western Sydney - University of Queensland University of Music and Performing Arts Vienna College for science and Art, campus Lemmensinstituut Conservatrio Brasileiro de Msica (CBM) - Faculdade de Artes do Paran Universidade de Ribeiro Preto (UNAERP) - Instituto Superior de Msica de S. Leopoldo - Universidade Federal dePiau - Universidade Federal do Esprito Santo Capilano College, N. Vancouver, British Columbia - Universit du Qubec Montral, Qubec - Wilfrid Laurier University, Windsor, Ontario - University of Windsor, Windsor, Ontario - Canadian Mennonite University, Winnipeg University of Chile Aalborg Universitet, Institut for Musik og Musikterapi Eino Roiha Institute - Eino Roiha sti (Foundation) - Eino Roiha Institute - Department of Music, University of Jyvaskyla LA Forge Formation metz - University of Nantes - Universit Ren Descarte, Paris V Hochschule fr Musik Nrnberg-Augsburg, Abt. Augsburg Masterstudiengang Musiktherapie Frankfurt - Hochschule fr Musik und Theater Hamburg - Fachbereich Musiktherapie an der University of Applied Sciences Heidelberg - Hochschule Magdeburg-Stendal - Berufsbegleitende Weiterbildung Musiktherapie BWM am Freien - Institute for Music Therapy/ Medical Faculty of the University Witten/Herdecke Universitat Koln - Universitat Muenster ELTE University; Training Faculty for Teachers of the Handicapped The Irish World Music Centre), University of Limerick Bar Ilan University Cesfor Centro Studi e Formazione - MusicSpace Italy / University of Bristol (UK) EWHA Womans University - Sookmyung Womens University Liepajas Pedagogical Academy University of Nijmegen en Arnhem - Zuyd University Sittard Hogeschool Ultrecht Wellington Conservatorium of Music, Massey University Norwegian Academy of Music - Sogn og Fjordane University College UMCS (Maria Curie-Sklodowska University) Universidade Lusada de Lisboa (Lusada University of Lisbon) Institute of Psychiatry Clinical Center of Serbia University of Pretoria Universitat Ramon Llull Universidad de Barcelona - Universidad Nacional De Educacion a Distancia(UNED) - Universidad Pontificia de Salamanca Universidad Autonoma de Madrid Musikhgskolan Ingesund, Arvika - Musikterapiinstitutet Uppsala Berufsbegleitendes Aufbaustudium Musiktherapie bam an der Hochschule Musik und Theater HMT Zrich - Ecole Romande de Musicothrapie - Ausbildung Musiktherapie mit Instrumentenbau Forum Musiktherapeutischer Weiterbildung Schweiz University of Bristol - Anglia Polytechnic University, Cambridge Queen Margaret University College, Edinburgh - Guildhall School of Music and Drama London - NordoffRobbins UK, London - Roehampton University London - Royal Welsh College of Music and Drama

Hungary Ireland Israel Italy Korea Latvia Netherlands N Zealand Norway Poland Portugal Serbia South Africa Spain Sweden Switzerland United Kingdom

1 1 1 1 2 1 3 1 2 1 1 1 1 5 2 3 7

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Methodology
United States 64 University of Alabama - Arizona State University - California State University Northridge - Chapman University, California - University of the Pacific, California Colorado State University - Florida State University - University of Miami, Florida Georgia College and & State University University of Georgia - Illinois State University - Western Illinois University - Indiana Purdue University, Indianapolis - Indiana Purdue University, Fort Wayne - St. Mary of the Woods College, Indiana - University of Evansville, Indiana, University of Iowa University of Kansas - University of Louisville, Kentucky - Loyola University, Louisiana Anna Maria College, Massachusetts - Berklee College of Music, Massachusetts - Lesley University, Massachusetts - Eastern Michigan University - Michigan State University Augsburg University, Minnesota - Minnesota State University - Mississippi University for Women - William Carey University, Mississippi - Drury University, Missouri - Maryville University, Missouri - University of Missouri KC - Mont Clair State University, New Jersey - Nazareth College, New York - New York University - SUNY Fredonia, New York SUNY New Paltz, New York - Appalachian State University, North Carolina - Queens University of Charlotte, North Carolina - University of North Dakota, North Dakota Baldwin Wallace University, Ohio - Ohio University, Ohio - University of Dayton, Ohio S W Oklahoma State University - Marylhurst university, Oregon - Drexel University, Pennsylvania - Duquesne University, Pennsylvania - Elizabethtown College, Pennsylvania - Immaculata University, Pennsylvania - Mansfield University, Pennsylvania - Marywood University, Pennsylvania - Seton Hill University, Pennsylvania - Slippery Rock University, Pennsylvania - Temple University, Pennsylvania - Charleston Southern University, South Carolina - Converse College, South Carolina - Sam Houston State University, Texas Southern Methodist University, Texas - Texas Womens University - University of the Incarnate World, Texas - West Texas A&M University - Utah State University - Alverno College, Wisconsin - University of WI Eau Clair, Wisconsin

Total

134

Table 3.4: Eligible music therapy programs who received the survey

3.4.2. Structure of Questionnaire A

The questionnaire was designed after reviewing the literature on LGB psychology and psychotherapy and a draft was submitted to three people for critique.12 The questionnaire was then revised to take into account a number of recommendations and submitted for final approval. The questionnaire consisted of 17 closed questions including 5-point Likert scales and multiple-choice questions, and two open-ended questions. A final section containing questions 18, 19 and 20 addressed matters of confidentiality, method of receipt of the results of the survey, and an open text box for any further comments respectively. In Questionnaire A, items were organised into three main sections (Table 3.5)

12

Dr. Patricia Sabbatella Ricardi - Professor of Music Therapy Professor & Director of the Masters Program in Music Therapy, University of Cadiz Prof Tom Hayden - Professor of Mammal Biology and Director of the Degree Programme in Zoology and of the MSc Programme in World Heritage Management, University College Dublin, School of Biology and Environmental Science Mr. Alan Frisby Market Research Consultant (member of the Market Research Society (MRC)

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Methodology

Section I II

Theme Professional & Program contexts Provision of LGB Issues

Questions 1-5 6 13

LGB Issues in Music Therapy III 14 17

Information solicited Professional status, Length of professional career, Participants training, Program information. Curricular treatment of issues, topics addressed in treatment and evaluation of issues in relation to program. LGB issues in relation to the field of music therapy and continual education

Table 3.5: Questionnaire A Dimensions 3.4.2.1. Introduction to Survey A An electronic introductory letter provided participants with the educational background of the researcher, a brief explanation of the topic and an outline of the purpose of the survey. It invited interested participants to click on the link provided which would take them directly to the questionnaire (Box 3.1)

Dear Music Therapists, My name is Bill Ahessy I received my BMus at University College Cork in Ireland. Following that I received my Graduate Diploma in Music Therapy and clinical training at the University of Technology in Sydney, Australia. Last year I moved to Spain to undertake a Masters by Research in Music Therapy at the University of Cadiz under the supervision of Prof. Patricia L Sabbatella. This questionnaire is a part of my Masters Thesis. After reviewing much of the lesbian, gay and bisexual (LGB) psychology and psychotherapy literature, It appears that there is a serious lack in the provision of LGB issues in psychology and psychotherapy training courses. Even though there have been numerous developments in LGB psychologies over the last two decades and a significant growth in gay affirmative approaches, there seems to be a huge gap between theory, training and practice. I am sending this survey to music therapy courses worldwide to assess the provision of LGB issues in music therapy education. (I am also be sending a survey to music therapy associations to assess LGB issues in continuing education). Results of the survey will be of course be available to participating Universities. All the participating institutions will be acknowledged, but no individual contribution will be traceable to the source, unless specific permission is explicitly given. Please click on the link below to fill out this brief survey. http://FreeOnlineSurveys.com/rendersurvey.asp?sid=morpgsp6chzlliu290990 Thank you for your time, Bill Ahessy billahessy@gmail.com c/ Libertad 9 - 3A Cadiz 11005, Espaa Mobile: +34664518612 Home: +34856170764l

Box 3.1: Introductory Letter

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Methodology 3.4.2.2. Professional and program contexts (questions 1 5) The objective of the first section of the questionnaire was to acquire the professional history of participants, the duration and type of music therapy program they offered, the duration of program practicum/clinical placement, the theoretical orientation of the program and the theoretical orientation they were exposed to in their own training. Question 1
Question type Descriptive (5), Numerical (1) 1) Details University/Institution name Your name Position Year you graduated as an MT University you graduated from Theoretical orientation of that program Explanation and motive Respondents were asked for general and professional information. These included the year they graduated as a music therapist, which university they graduated from, and the perceived theoretical orientation of that program. These three questions were linked to question 18 (Were LGB issues addressed when you trained as a music therapist?). It was necessary to identify if music therapy courses were addressing LGB issues when the respondents were trained as music therapists. It was also of interest to identify which countries first addressed LGB issues in music therapy training or indeed which universities within those countries.

Question 2
Question type Descriptive 2) What type of music therapy program do you direct? Undergraduate Post-graduate/Masters Doctoral Other (please specify) Explanation and motive This question was a closed question to identify the type of program provided (undergraduate, postgraduate/masters, doctoral or other), to see if LGB issues in music therapy were addressed more in undergraduate or post-graduate level programs. It was set in a multiple-choice format, as it was likely that some universities provided both undergraduate and post-graduate programs.

Questions 3
Question type Numerical 3) What is the duration of your music therapy program? 1 year 1.5 years 2 years 2.5 years 3 years 4 years 5 years (2 semesters) (3 semesters) (4 semesters) (5 semesters) (6 semesters) (8 semesters) (10 semesters) Explanation and motive This was a closed multiple-choice question to identify the duration of the music therapy program. This information was required to examine for a correlation between the lengths of music therapy programs and the provision of LGB issues.

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Methodology Question 4
Question type Numerical 4) What is the duration of your practicum/clinical placement for students? 3 months 6 months 1 year 1.5 years 2 years 3 years (1/2 semester) (1 semester) (2 semesters) (3 semesters) (4 semesters) (5 semesters) Explanation and motive Question 4 asked respondents, in multiple-choice format to provide the duration of practicum/clinical placement for students in their music therapy program. This question was linked to question 13 (Can you provide practicum/clinical placement for students who wish to work with LGB clients?). This was required to reveal whether the duration of practicum/clinical placement in programs was a factor in the provision of LGB practicum/clinical placement opportunities.

Question 5
Question type Descriptive 5) What is the predominant or central theoretical orientation of your program? The aim of this question was to define the theoretical orientation of the program directed by the respondent. This researcher wanted to reveal if there was any relationship between the theoretical orientations of programs which addressed LGB issues and those that did not. This was an opened-ended question allowing respondents more freedom to describe the central philosophy or philosophies of their program

3.4.2.3. Provision of LGB issues (Questions 6 13) The objective of the second section of the questionnaire was to assess the provision of LGB issues within the music therapy programs. This was to reveal, the treatment of LGB issues in relation to multicultural issues; if LGB issues were not addressed to explore the reasons why; and if LGB issues were addressed, to identity how this was done within the programs. It also identified topics addressed in the treatment of LGB issues. Question 6
Question type Descriptive 6) In the provision of multicultural/culturally sensitive issues in your music therapy program, which of the following topics are addressed? (Please tick the relevant boxes) Ethnicity Race Gender Lesbian, gay & bisexual Religious Immigration Other (please specify) Explanation and motive This question asked the respondent to select, from the 6 topics offered, those which they addressed in the treatment of multicultural issues in their music therapy course. The purpose of this was to identify the provision of LGB issues in relation to other multicultural issues such as Ethnicity, Race, Gender and Immigration. Respondents were invited to use the Other option for different topics, which may not have been included.

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Methodology Question 7
Question type Categorical 7) Do you address issues specific to lesbian, gay & bisexual clients in your music therapy program? Yes No If Yes, please skip the next question (Q.8) And continue with the survey. If No, please answer the next question (Q.8) and then move to question 13 Explanation and motive This question was a closed question in a yes/no format to identify respondents who specifically addressed LGB issues in their music therapy program, and to direct respondents to the relevant parts of the remainder of the survey. Questions with skip patterns can confuse participants in surveys, with this in mind; the skip pattern was clearly marked out with use of bold (Fink, 1995).

Question 8
Question type Descriptive 8) Issues specific to lesbian, gay & bisexual clients are not specifically addressed due to (please tick one or more) Time constraints Curricular pressure Lack of appropriate staff Perceived low priority Insufficient clinical need No student demand No professional demand Other (please specify) Explanation and motive This aim of this question was to determine why issues specific to LGB clients were not addressed in the program and respondents were given a multiple-choice of seven items. Respondents were allowed pick more than one answer to elicit more detailed information. An Other box was provided for alternative responses.

Question 9
Question type Descriptive 9) Treatment of issues specific to lesbian, gay & bisexual clients are addressed in (please tick one or more) A core module Part of a core module An optional module Part of an optional module Integrated in all modules across the curriculum Workshops, role-play Presentations by guest lecturers/speakers Guided private reading/study Practicum/clinical placement Contact with LGB organisations Other (please specify) Explanation and motive This question aimed to identify where the treatment of LGB issues was addressed in the curriculum of the music therapy programs. Respondents were given ten options in multiple-choice format, and an Other box was provided with space for alternative responses. Respondents were able to choose more than one item to elicit a more details.

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Methodology Question 10
Question type Descriptive 10) Which of the following topics do you address in the provision of LGB issues in your music therapy program? Gender Development The coming out process Internalised homophobia Discrimination/ant-gay violence LGB adolescence Relationships LGB ageing Children of LGB individuals Transgender/inter-sex issues Ethnic minority status & sexuality Conflicts of religious & sexual identities Suicide, substance Abuse Sexual identity development Homophobia (societal, institutional) Heterosexism Minority stress & mental health LGB midlife Parenthood Families of LGB individuals Bisexuality HIV/AIDS Disability & sexual orientation Conversion/reparative therapies Affirmative approaches Other (please specify) Explanation and motive This question in multiple-choice format presented the respondents with 24 LGB topics and asked them to choose 10 that should be addressed in music therapy education. These topics offered were selected, after a comprehensive review of the literature on LGB psychology and psychotherapy. Topics were selected to represent issues for LGB individuals across the lifespan. It was of interest to see which topics the respondents felt were important and relevant for music therapy students. There was an Other option included for alternative topics, which the respondents felt were important, but not included in the survey.

Question 11
Question type Descriptive 11) How important would you rate LGB issues as a component of your music therapy program? Very important Important Moderately important Of little importance Unimportant Explanation and motive This question was to determine the level of importance assigned to LGB issues as a component of the respondents music therapy program. A 5-point Likert-type scale13 was used in this question to assess the attitude of the respondent.

Question 12
Question type Descriptive 12) How do you prepare students for work with lesbian, gay & bisexual clients? Explanation and motive This was an open-ended question to inquire how the music therapy programs prepared their students to work with LGB clients. This was intended to retrieve any information that was not answered in the previous closed questions on the provision of LGB topics and to gather quotable material.

13

A Likert type question is a closed-ended question that allows respondents to indicate how closely their feelings match the question or statement on a rating scale. Such questions are used for measuring the degree of respondents' feelings or attitudes about something.

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Methodology Question 13
Question type Categorical 13) Can you facilitate students who wish to do practicum/clinical placement with LGB clients? Yes No Explanation and motive This was a closed question asking whether the respondents could facilitate students who wished to do practicum/clinical placement with LGB clients. Respondents who did not address issues specific to LGB clients (question 8) rejoined and continued with the questionnaire at this point. This is because even though LGB issues may not explicitly addressed in the curriculum, respondents may still be able to facilitate students who wish to work with LGB clients in supervised practicum/clinical placement.

3.4.2.4. LGB issues in music therapy (Questions 14 17) The objective of the last section of the questionnaire was to assess the participants general opinions of LGB issues in relation to music therapy education, continuing professional education and the field as a whole. From a historical point of view, it also aimed to identify whether LGB issues were addressed in music therapy education in former years. Question 14
Question type Descriptive 14) How important would you rate LGB issues as a component of music therapy education? Very important Important Moderately important Of little importance Unimportant Explanation and motive This question aimed to identify where the respondents felt LGB issues should be addressed. It was another 5-point Likert-type question asking respondents to rate how important were LGB issues in music therapy education in general ranging from unimportant to very important. It was essential to know the feelings and attitudes of respondents on the importance of LGB issues for music therapists irrespective of whether these issues were addressed or not in their programs.

Question 15
Question type Descriptive 15) Where do you think in music therapy education LGB issues would be best addressed? Undergraduate Post-graduate/Masters Continuing education Other (please specify) Explanation and motive This question asked respondents to indicate at what academic level they thought LGB issues should be addressed. It was important to determine if there was coherence in attitude to the appropriate timing of education in LGB issues. Information was sought on whether these issues should be dealt with before music therapists are practicing professionally and at what academic level, or if these issues would be more suitably addressed in continuing professional education after qualifying. This was a multiple-choice question with three options and an Other option with space for alternative suggestions.

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Methodology Question 16
Question type Descriptive 16) Which do you think are the most important topics that should be addressed in music therapy education? Please tick 10 of the following topics Gender Development The coming out process Internalised homophobia Discrimination/ant-gay violence LGB adolescence Relationships LGB ageing Children of LGB individuals Transgender/inter-sex issues Ethnic minority status & sexuality Conflicts of religious & sexual identities Suicide, substance Abuse Sexual identity development Homophobia (societal, institutional) Heterosexism Minority stress & mental health LGB midlife Parenthood Families of LGB individuals Bisexuality HIV/AIDS Disability & sexual orientation Conversion/reparative therapies Affirmative approaches Other (please specify) Explanation and motive This question in multiple-choice format presented the respondents with 24 LGB topics and asked them to choose 10 that should be addressed in music therapy education. These topics offered were selected, after a comprehensive review of the literature on LGB psychology and psychotherapy. Topics were selected to represent issues for LGB individuals across the lifespan. It was of interest to see which topics the respondents felt were important and relevant for music therapy students. There was an Other option included for alternative topics, which the respondents felt were important, but not included in the survey.

Question 17
Question type Categorical 17) Do you think it would be beneficial for music therapists if music therapy associations provided guidelines or training in issues related to LGB clients? Yes No Explanation and motive This was a closed (yes/no) question to determine whether the participants considered that guidelines/ training opportunities, provided by music therapy associations, would be beneficial to practicing music therapists. This question was related to Questionnaire B for the music therapy associations and their provision of guidelines and training opportunities. A comparison of the attitudes of providers and practitioners might prove illuminating.

Question 18
Question type Categorical 18) Were LGB issues addressed when you trained to become a music therapist? Yes No Explanation and motive This question was for historical interest to see if LGB issues were addressed in former years in the music therapy curriculum. Section one would have revealed the year of graduation of respondents, the university they graduated from and the programs theoretical orientation, answers to this question would identify which countries and, universities were earliest in addressing LGB issues in music therapy and perhaps how theoretical orientation might influence this.

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Methodology 3.4.2.5. Final section (Questions 19 21) The last section included a question on confidentiality, an inquiry as to whether respondents would like to receive the survey results, and an opportunity to make any additional comments in relation to the survey. Questions 19, 20 & 21
Question type Categorical (19 & 20) 19) All participating universities will be acknowledged, but no individual contribution will be traceable to the source unless permission is explicitly given. Would you like to give permission? Yes No 20) Would you like to receive the results of this survey? Yes No 21) Any further comments Finally there was an open text-box for respondents to make any further contributions or comments. This provided respondents the opportunity to comment on the topic itself, the content of the questionnaire, or add omissions. This removed any constraints imposed by the more structured questions. This type of question has been referred to as a ventilation question (Bourque & Fielder, 1995, p. 104) This enquired if the respondents would like to receive the results of the survey, to ensure that only respondents in the results would receive a copy. Explanation and motive Here respondents were assured of complete confidentiality to make participants feel comfortable about responding and confident to give honest answers.

Debrief page
A debrief page was designed, thanking the respondents for their contribution and time, also providing the contact details of the researcher for any outstanding issues their might have as is shown in box 3.2.

I would like to thank you for taking the time to fill out the survey. The results will be available later in the summer and can be sent to interested universities. For any further comments or questions please feel free to contact me by email. Bill Ahessy Grad Dip MT, BMus Universidad de Cdiz Facultad de Ciencias de la Educacin, Campus Universitario de Puerto Real, 11519 - Puerto Real - Cdiz Espaa, Tel: 0034 664 518 612 billahessy@gmail.com - musictherapyresearch@gmail.com

Box 3.2: Debrief Page 70

Methodology

3.5. Survey B
3.5.1. Participants in Survey B
The invited participants for the second survey consisted of national associations for music therapy in 29 countries across four continents. The numbers of eligible participants from each country are shown in Table 3.6.
Country Europe Austria Belgium Bosnia Herzegovina Croatia Denmark Finland France Germany Iceland Hungary Ireland Israel Italy Netherlands Norway Poland No of Associations 1 1 1 1 2 1 1 3 1 1 1 1 1 2 1 1 Country Portugal Spain Sweden Switzerland United Kingdom Australasia Australia New Zealand North America Canada United States Asia Korea South America Argentina Brazil Chile Total 29 countries No of Associations 1 6 1 1 2 1 1 2 1 1 2 9 1 49 Associations

Table 3.6: Number of eligible participants for Survey B (by country) In some countries a national association did not exist or else multiple organisations coexisted, and smaller regional associations were included in those cases. Table 3.7 sets out all eligible music therapy associations who were sent the survey.

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Methodology
Country Argentina Australia Austria Belgium Bosnia - Herz Brazil N 2 1 1 1 1 9 Music Therapy Association Argentine Association for Music Therapy Ambito de Asistencia, Docencia e Investigacin en Musicoterapia Australian Music Therapy Association Austria Osterreichischer Berufsverband der Musiktherapeutlnnen Professional Music Therapy Association of Belgium The Pavarotti Music Centre, MUSERS Associao Baiana de Musicoterapia Associao de Musicoterapia do Estado do Rio de Janeiro Associao de Musicoterapia do Estado de Rio Grande do Norte (AMTERN) Associao de Musicoterapia de Minas Gerais (AMT-MG) Associao Gacha de Musicoterapia (AGAMUSI) Associao de Musicoterapia do Rio Grande do Sul Associao de Musicoterapia do Paran (AMT-PR) Associao de Profissionais e Estudantes de Musicoterapia do Estado de So Paulo Paulista (APEMESP) Comit Latino-Americano de Musicoterapia Canadian Music Therapy Association Music Therapy Association of British Columbia The Chilean Institute for Music Therapy (ICHMU) Croatia Association of Music Therapy Dansk Forbund for Musikterapi (DFMT) Musikterapeuternes Landsklub (MTL) Finnish Society for Music Therapy Association Francaise de Musicotherapie Berufsverband der Musiktherapeutinnen und Musiktherapeuten in Deutschland (BVM) Deutsche Gesellschaft fr Musiktherapie (DGMT) Berufsverband fr. Kunst-, Musik- und Tanztherapie (BKMT) Magyar Zeneterpis Egyeslet Felag Islenska Musikterapista Irish Association of Creative Arts Therapists The Israeli Association of Creative & Expressive Therapies Federazione Italiana Di Musicoterapia Korean Association for Music Therapy Dutch Association for Creative Therapy (Vaktherapie) Stichting Muziektherapie The New Zealand Society for Music Therapy Norsk Forening for Musikkterapi Polish Association of Arts Therapists (KAJROS) Portuguese Music Therapy Association Asociacion Espanola de Musicoterapia Asociacion de Profesionales de Musicoterapia Asociacion Catalana de Musicoterapia Asociacion Castellano de Musicoterapia Asociacion Msica Arte y Proceso Asociacion Valenciana de Musicoterapia Association for Music Therapy in Sweden Schweizerichen Fachwerband fur Musiktherapie Association for Professional Music Therapists British society for Music Therapy American Association for Music Therapy

Canada Chile Croatia Denmark Finland France Germany Hungary Iceland Ireland Israel Italy Korea The Netherlands New Zealand Norway Poland Portugal Spain

2 1 1 2 1 1 3 1 1 1 1 1 1 2 1 1 1 1 6

Sweden Switzerland United Kingdom United States Total

1 1 2 1 49

Table 3.7: Eligible music therapy associations who received the survey

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Methodology

3.5.2. Structure of Questionnaire B

The questionnaire was designed after reviewing the literature on LGB psychology and psychotherapy and a draft was submitted to three people for critique.14 The questionnaire was then revised to incorporate recommendations and submitted for final approval. The questionnaire consisted of five closed-ended questions including 4 (yes/no) type questions and one Likert- type question. There was also an open text box for any further comments. The three sections of the questionnaire can be seen in table 3.8.
Section I II III Theme Association information Provision of LGB Issues LGB Issues in Music Therapy Questions 1 24 56 Information solicited Name of association, Country, Year of establishment, Professional role, Provision of guidelines, further training opportunities, members working in the area LGB issues in relation to practicing music therapists, LGB issues in music therapy training

Table 3.8: Dimensions of questionnaire B 3.5.2.1. Introduction to Survey B An introductory letter provided participants with the educational background of the investigator, a brief introduction to the topic and an outline of the purpose of the survey. It invited interested participants to click on the link provided which would take them directly to the questionnaire. This letter was in essentially the same format as the introductory letter to Survey A at Box 3.1. 3.5.2.2. Association information (Question 1) The objective of the first section of the questionnaire was to identity general information about the association and the participant.

14

Dr. Patricia Sabbatella Ricardi - Professor of Music Therapy Professor & Director of the Masters Program in Music Therapy, University of Cadiz Prof Tom Hayden - Professor of Mammal Biology and Director of the Degree Programme in Zoology and of the MSc Programme in World Heritage Management, University College Dublin, School of Biology and Environmental Science Mr. Alan Frisby - Market Research Consultant (member of the Market Research Society (MRC)

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Methodology Question 1
Question type Descriptive (3) Numerical (1) 1) Details Name of association, Country Year of establishment Your name Professional role Explanation & motive General information about the respondents and when the association was established. One aim of the opening question was to identify if there might be a correlation between the length of time an association had been established and attention to LGB issues.

3.5.2.3. Provision of LGB issues (Questions 2 4) This objective of this section was to discover if the music therapy associations provided any guidelines or continuing educational opportunities for their members on LGB issues in music therapy or working with LGB clients. Music therapy associations often provide day and weekend courses as well as presentations on a variety of issues in music therapy. It was also directed towards whether the music therapy associations to their knowledge had any members working with LGB clients or in LGB specific settings.

Question 2
Question type - Categorical 2) Do you provide guidelines for music therapists addressing, working with LGB clients? Yes No Explanation and Motive This was a close-ended question to identify if associations provided any guidelines for their members regarding working with LGB clients

Question 3
Question type Categorical 3) Do you provide opportunities for music therapists to receive further training/continuing education in issues specific to LGB clients? Yes No Explanation and motive This close-ended question aimed to identify if music therapists could avail of any continuing education or courses in LGB specific issues organised or supported by the music therapy associations

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Methodology Question 4
Question type Descriptive 4) Do you have to your knowledge any members working with LGB clients or in LGB specific settings? Yes No Explanation and motive This was to determine if any associations to their knowledge had members who worked specifically with LGB clients or in LGB specific settings,

3.5.2.4. LGB issues in music therapy (Questions 5 7) The objective of section 3 was to assess the attitudes of music therapy associations towards LGB issues and how important they considered LGB issues to be for practicing music therapists in their countries. It also asked if the respondents thought that training at undergraduate and postgraduate level in LGB issues would be professionally beneficial for music therapists. Question 5
Question type Descriptive 5) Do you think it would professionally benefit music therapists to receive some training in issues specific to LGB clients at undergraduate or post-graduate level? Yes No Explanation and motive This close-ended question was to determine if the associations thought undergraduate and postgraduate training in LGB- specific issues would be beneficial to music therapists. This question was related to Questionnaire A sent to the music therapy university programs in order to compare the responses from the music therapy associations and the university programs.

Question 6
Question type Descriptive 6) How important do you perceive LGB issues for practicing music therapists in your country? Very important Important Moderately important Of little importance Unimportant Explanation and motive This close-ended question used a Likert-type 5-point scale with the intention of investigating the respondents attitudes towards the importance of LGB issues in their country and its importance for practicing music therapists.

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Methodology Question 7
Question type Open text box 7) Any further comments Explanation and Motive This was an open text box for the respondents to make any further comments or ventilate their feelings (Bourque & Fielder, 1995: 104) because all of the previous 6 questions were close ended. For this reason it was stated that if respondents had any comments or outstanding issues in relation to specific questions, they should place the question number in front of their comment.

A debrief page was designed, thanking the respondents for their contribution and time, also providing the contact details of the researcher for any outstanding issues their might have. The debrief page for this questionnaire was identical to that of Questionnaire A, and can be seen in Box 3.2. (p. 70)

3.6. Ethical Implications

All participants for both surveys were involved willingly and voluntarily. The introductory letters provided participants with the objectives of the surveys prior to the provided link for the questionnaires and before they submitted their response. Participants were assured of confidentiality in both the introductory letter and at the beginning of both surveys. The survey assured participants that except for being acknowledged for their participation in the survey, no participating institution would be traceable to the source unless specific permission was given to the researcher. Participants responses were only available to the researcher and the researchers supervisor, which were stored in the survey account online and in the designated email inbox created for the duration of the investigation. Both accounts had passwords only known to the researcher and his supervisor. Questionnaires were critiqued and reviewed for content, and the questionnaire items were critiqued for relevance and appropriateness by three people15 and submitted to the researchers supervisor for final approval before final copies were made.

15

Dr. Patricia Sabbatella Ricardi - Professor of Music Therapy Professor & Director of the Masters Program in Music Therapy, University of Cadiz Prof Tom Hayden - Professor of Mammal Biology and Director of the Degree Programme in Zoology and of the MSc Programme in World Heritage Management, University College Dublin, School of Biology and Environmental Science Mr. Alan Frisby - Market Research Consultant (member of the Market Research Society (MRC)

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Methodology

3.7. Method of Distribution

Both surveys were distributed by email. Email-based surveys are becoming increasingly popular in many types of research. Until recently, most surveys were conducted by postal mail; however Silverman & Hairston (2005) conducted an email survey to investigate music therapists with private practices in the United States. This suggested that music therapy researchers too are utilising the internet more as a means of communication and for Internet Mediated Research (IMR). The internet has revolutionised communication, business and the distribution of information and now the internet is being used as a rich medium for research purposes in many fields in both qualitative and quantitative designs (Kraut et al. 2003). Hewson (2003) notes the growing popularity of IMR from the increase in published articles, which utilise this method of investigation. The internet provides many opportunities and scope for researchers. The majority of studies use questionnaire or experimental designs, interviews, observational research, online focus groups, and analysis of linguistic archives are all feasible (Hewson, 2003, p. 290). IMR is thought to be advantageous for researchers with time constraints and limited funding, both of which were relevant to this study. Considering the geographical locations of the participants a postal survey would have been considerably more expensive. Costs such as reproducing materials, running participants and data input can all be vastly reducedautomation of these aspects can also have a knock-on affect greatly reducing the timescale of a piece of research (Hewson, 2003, p. 290). Internet based questionnaires are also advantageous because they are available 24 hrs a day for respondents to complete and submit, and the time constraints of post office opening hours are eliminated. The researcher also received email notification for any new responses. Another advantage of creating an electronic questionnaire with an online survey company is the added features in questionnaire design such as, the required answer feature. This prevents participants submitting the questionnaire until all required questions are answered; and this control is not possible in a postal survey. There is also the asset of online customer support for any technical problems that may arise (Wright, 2005). An electronic questionnaire seemed more user-friendly than a protected word document, which respondents would have to save and then resend after completing it. It was more likely to deliver explicit and unambiguous data because it was more secure and clearer than embedding the questionnaire in the body of an email, which would allow respondents less flexibility.

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Methodology

3.8. Procedure
When the questionnaires were approved and electronic versions were produced using an online survey company www.freeonlinesurvey.com. Two links were created for the questionnaires and they were pasted into two emails to be sent to the respondents. Spanish-language versions of the questionnaires were sent to the universities and associations in Spain and Spanish-speaking countries in South America. All other countries received them in English. The introductory letters and the links for the questionnaires were placed in the same email to avoid filling up respondents inboxes and also to cut down on environmental waste.

3.9. Data Collection

The data from the respondents were received in two ways. Aggregated summary statistics were provided automatically to the project account at www.freeonlinesurvey.com. In addition, each response was transmitted individually to a dedicated email account set up for the duration of the survey at musictherapyresearch@gmail.com. Respondents were allowed four weeks to complete the questionnaire and return it. A polite follow up was sent by email after the end of the first week, the second week and the third week to those who had not returned the survey. At the end of the fourth week access to the questionnaire was closed. An advantage of using an online survey company for data collection is that data can be collected while the researcher works on other tasks and preliminary analysis can be done while waiting for more responses.

3.10. Data Analysis

One the advantages of using the online survey account was that it presented the data in aggregate results, but also provided them in spreadsheets. The account also allowed the researcher to place multiple filters to be applied to the aggregate results for cross-analysis and to view the data in new ways. Percentages and totals were provided by the online account and were checked manually by the researcher to ensure that they were correct. The next chapter provides the results to both surveys in the same sequential order as the questionnaires have been presented above.

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Results

Chapter IV Results

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Results

4.1. Results of Survey A

4.1.1. Professional and program contexts
4.1.1.1. Characteristics of the respondents Forty-one directors of music therapy programs responded and returned the survey within the four weeks that the survey was active online. This was a response rate of 30.37%. The responses were from programs in four of the six global regions considered here, and all respondents were representative of the target sample. The majority of the responding music therapy program directors were from North America (25) followed by Europe (5), with equal amounts from South America (4) and Australasia (4). Three of the respondents remained anonymous. Continental response for survey A can be seen in Figure 4.1

Continental Response: Survey A

Europe 13% Australasia 11% South America 11%

North America 65%

Figure 4.1: Continental response: Survey A

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Results The 38 known participating music therapy programs can be seen in Table 4.1
Country Australia Brazil Canada Chile Germany Israel New Zealand Serbia Spain Utd Kingdom United States No. 3 3 3 1 1 1 1 1 1 1 22 University University of Melbourne - University of Technology, Sydney University of Queensland Universidade de Ribeiro Preto (UNAERP) - Instituto Superior de Msica de S. Leopoldo Universidade Federal do Esprito Santo Capilano College, N. Vancouver, British Columbia - Universit du Qubec Montral, Qubec - Wilfrid Laurier University, Windsor, University of Chile Berufsbegleitende Weiterbildung Musiktherapie BWM am Freien Bar Ilan University Wellington Conservatorium of Music, Massey University Institute of Psychiatry Clinical Centre of Serbia Universidad Nacional De Educacion a Distancia (UNED) Anglia Ruskin University, Cambridge Chapman University, California - University of Georgia - Indiana Purdue University, Fort Wayne - Illinois State University - University of Evansville, Indiana - University of Louisville, Kentucky - Loyola University, Louisiana - Berklee College of Music, Massachusetts - Lesley University, Massachusetts - Eastern Michigan University - Augsburg University, Minnesota Mississippi University for Women - SUNY Fredonia, New York - Appalachian State University, North Carolina - University of North Dakota - Baldwin Wallace University, Ohio - S W Oklahoma State University - Drexel University, Pennsylvania - Temple University, Pennsylvania - Converse College, South Carolina - Southern Methodist University, Texas University of the Incarnate World, Texas + 3 anonymous responses = 41/135 = 30.37% response rate

Total

38

Table 4.1: Music Therapy Programs that responded

There was a marked disparity in the response rates when viewed continent by continent. Australasia had the highest response rate, followed by South America and North America. Europe had a low response rate and there was no response from the two programs in Asia and the only program in South Africa (Table 4.2).
Continent Australasia South America North America Europe Asia Africa Total Number of recipients 5 10 69 47 2 1 135 Number of respondents 4 4 25 5 0 0 34+ 3 anonymous Response rate 80% 40% 36.2% 10.6% 0% 0% 30.37%

Table 4.2: Responses continent by continent

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Results The respondents were music therapy program coordinators or directors. There were 31 female respondents (81.5%), 7 male respondents (18.5%) and 3 anonymous respondents. The respondents had many years of clinical experience since they trained as music therapists. The range of experience among respondents was from 9 to 39 years with a mean of 24.2 years, indicating an experienced and mature group of music therapists (Table 4.3).
Years of clinical experience 1 9 years 10 19 years 20 29 years 30 39 years Respondents (N=39) 1 12 14 12 % 2.56% 30.76% 35.89% 30.76%

Table 4.3: Program directors years of clinical experience

Distribution of the duration of experience was bi-modal and there were two local maxima, 11- 15 years and 26- 30 years experience (Figure 4.2).

Figure 4.2: Duration of experience of directors of music therapy programs. The distribution of programs that address LGB issues (LGB+) and those that do not (LGB-) in relation to the experience of the program director is shown in figure 4.3.

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Figure 4.3: Duration of experience in relation to provision of LGB issues

To examine if there was a relationship between the provision of LGB issues and the experience of the directors, the directors were divided into two groups, based on the modal values observed these were, those with 15 or fewer years of experience or 21 years or more of experience. There was a significant association between the duration for which the director was qualified and if LGB issues were addressed. For example in the more experienced group (21yrs +), 14 of the 28 directors addressed LGB issues, where as in the less experienced group (0 15 yrs) only 2 out of 11 did so. See table 4.4 below
Qualified in years 0 15 21 40 Total LGB + 2 14 16 LGB 9 14 23 Total 11 28 39

Table 4.4: Association between experience and provision of LGB issues

4.1.1.2. Theoretical orientations of the respondents music therapy training The 41 respondents indicated the theoretical orientation of the music therapy program, when they trained as music therapists. The most common orientation indicated by the respondents was eclectic, with 12 respondents (29.26%) who had received this type of training. The next most common theoretical orientation was behavioural (8 respondents 19.51%). Six of the respondents (14.63%) indicated they were trained under a humanistic orientation and 5 (12.19%) indicated a psychodynamic orientation. Three respondents

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Results (7.31%) received a psychoanalytical oriented training. Only one respondent (2.43%) indicated a cognitive, phenomenological and a morphological training. The various theoretical orientations can be seen in table 4.5.
Theoretical Orientation Eclectic Behavioural Humanistic Psychodynamic Psychodynamic/integrative Psychoanalytical Behavioural/humanistic Psychodynamic/humanistic Cognitive Phenomenological Morphological Respondents (n=41) 12 8 6 5 2 3 1 1 1 1 1 % 29.26 19.51 14.63 12.19 4.87 7.31 2.43 2.43 2.43 2.43 2.43

Table 4.5: Theoretical Orientations of the respondents own music therapy training.

To examine if there had been a change in emphasis within music therapy, the frequency of the types of courses taken by directors when they were students was compared to the types of courses now offered by those directors. There was a strong correlation between the proportion of courses of varied emphasis studied and offered by directors (r = 0.83; Figure 4.4). Eclectic course represent the major type studied and offered. There were two marked outliers. There were relatively more courses with a behavioural or psychodynamic emphasis among those studied by directors than among those, which they now direct.

Figure 4.4: Theoretical orientations of the programs respondents attended and now direct

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Results 4.1.1.3. Academic levels and duration of the music therapy programs Thirty-one of the music therapy programs were offered at undergraduate level. Nineteen offered study at post graduate level, and 8 programs at doctoral level. The majority of the programs only offered one level of study; however others offered two and some three levels from undergraduate to doctoral level (Table 4.6).

Academic Level Undergraduate Post-graduate Undergraduate & post-graduate Undergraduate, post-graduate & doctoral Post-graduate & doctoral

Programs (n=41) 20 8 5 6 2

% 48.78 19.51 12.19 14.63 4.87

Table 4.6: Academic levels of music therapy programs The music therapy programs in the survey lasted from 1.5 to 5 years (Table 4.7, Figure 4.5). Eighteen of the programs (45%) lasted 4 years, and 14 lasted 2 years (32.5%). Five of the programs (12.5%) lasted for 3 years and 2 programs lasted for 5 years. There was also a program of 2.5 and 1.5 years duration. Program lengths vary depending on academic levels. Many of the undergraduate programs in the United States were 4 years, although others were between 2 and 3 years. Some of the programs that offered undergraduate and postgraduate programs were also 4 years. Two programs that offered doctoral level study were 5 years.

Duration of program 1.5 years 2 years 2.5 years 3 years 4 years 5 years

Programs (N=40) 1 13 1 5 18 2

% 2.50 32.50 2.50 12.50 45.00 5.00

Table 4.7: Duration of music therapy programs

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Results

Figure 4.5: Duration of programs Duration of clinical practicum varied greatly among the programs too. The majority of clinical practica were between 6 months and 2 years. Many of the American university programs had 6 months internships after their 4-year undergraduate program, which are more intensive than a clinical practicum over the course of an entire program. Many music therapy programs, especially at post-graduate level, include, a clinical practicum, which is spread out over the entire course, thus resulting in up to 2 years duration of clinical training. 4.1.1.4. Theoretical orientations of the music therapy programs Seventeen of the 41 (41.46%) of the music therapy programs had an eclectic theoretical orientation, focusing on several theoretical orientations. Two of these indicated an eclectic orientation with a focus on humanism, and 1 indicated an eclectic orientation with a focus on behaviourism. Ten programs (24.39%) cited a dual theoretical orientation with two main theoretical stances, while 14 (34.14%) were centred on one theoretical framework. The theoretical orientations of the participating music therapy programs can be seen below in table 4.8.
Theoretical Orientation Eclectic Humanistic Psychodynamic/humanistic Cognitive/behavioural Behavioural/eclectic Eclectic/humanistic Behavioural/humanistic Psychodynamic Psychodynamic/integrative Psychoanalytical Phenomenological Programs (n=41) 14 7 6 4 2 1 2 2 1 1 1 % 34.16 17.07 14.63 9.75 4.87 2.43 4.87 4.87 2.43 2.43 2.43

Table 4.8: Theoretical orientations of the music therapy programs 86

Results There were far fewer behavioural programs offered by participating universities, than the individual participants had been exposed to when they trained as music therapists. From 8 of the behavioural programs, in which the respondents trained, (7 solely behavioural programs and 1 behavioural/humanistic) now in the programs the respondents now directed there were no programs with solely a behavioural orientation. There were 5 programs with dual orientations (2 cognitive/behavioural programs, 1 behavioural/eclectic program and 2 behavioural/humanistic programs). There was also a reduction in the amount of psychodynamic-only programs, and an increase in psychodynamic/humanistic orientated programs. In the respondents own music therapy training there were 5 psychodynamic courses and 2 psychodynamic/humanistic programs, however in the current programs there was only 1 psychodynamic program and 6 psychodynamic/humanistic programs.

4.1.2. Provision of LGB issues in music therapy programs

4.1.2.1. Multicultural topics addressed in music therapy training Question 6 aimed to examine the provision of LGB issues in relation to other multicultural issues in the music therapy programs (Table 4.9, Figure 4.6). Twenty-six out of the 41 programs (63.41%) addressed LGB issues in some form, but not specifically. Ethnicity (35/41: 85.36%) and gender (34/41: 82.92%) were the topics selected by most respondents Race and religious issues were addressed by 30 programs (73.17%) and the least-selected topic was immigration (24/41: 58.53%).
Multicultural topics Ethnicity Gender Race Religion LGB Immigration Respondents (n=41) 35 34 30 30 26 24 % 85.36 82.92 73.17 73.17 63.41 58.53

Table 4.9: Multicultural topics addressed by the programs

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Figure 4.6: Multicultural topics addressed by the music therapy programs. Respondents gave some extra comments in relation to the way multicultural issues are addressed in their music therapy programs. One respondent said that LGB issues and other multicultural issues are addressed with the aid by Dileos Ethical Thinking text16. In one program these issues are addressed in developmental psychology and another program addresses LGB issues in topics such as community music therapy and critical music therapy. One program encourages students to undertake special-interest topics, which could include multicultural issues. Another program indicated how awareness of multicultural issues is important when addressing clinical issues.
Clinical issues are addressed as cross cultural with the intention of meeting a client where a client is at, regardless of cultural characteristics, and thus with the intent of understanding the person in light of their own cultural system.

Another respondent said that even though attention had been given to cultural sensitivity, in practice LGB issues in music therapy have been largely neglected.
I think we are beginning to consider cultural competency more explicitly now, but gender and lesbian/gay/bi-sexual issues have not been seriously addressed by programmes I have been involved in, up till now. Although many gay people have trained, and in mental health, students have encountered issues specific to gay clients

4.1.2.2. LGB topics in the music therapy programs Question 7 identified the respondents who specifically address LGB issues in their music therapy programs and those that did not. Table 4.10 shows that 58.54% of the respondents (24/41) did not specifically address this topic in their curriculum, while 41.46% (17/41) did.
16

Dileo, C. (2002). Ethical Thinking in Music Therapy. Cherry Hill, NJ: Jeffrey Books

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Address LGB topics Yes No

Programs (n=41) 17 24

% 41.46 58.54

Table 4.10: Programs that specifically address LGB issues From a geographical point of view 15 of the 17 programs that specifically addressed LGB issues were from North America. The other two were from Europe. There was a mixture of theoretical orientations from programs that addressed LGB issues, although it was predominantly humanistic, eclectic and psychodynamic followed by behavioural blends and then one analytically informed program.

4.1.2.3. Reasons why LGB topics were not addressed Question 8 targeted those 24 programs that did not specifically address LGB issues and sought to understand why this was so. Table 4.11 and Figure 4.7 show that 45.83% of the programs (11/24) perceived that LGB issues were low priority; while 37.5% (9/24) of the programs indicated that time constraints were an issue for them. One third (8/24: 33.33%) of the programs did not address LGB topics because of curricular pressure and because there was no student demand for this topic. While 29.16% (7/24) perceived there is an insufficient clinical need. Low professional demand and lack of appropriate staff were the reasons given by 16.66% (4/24).
Reasons Perceived low priority Time constraints Curricular pressure No student demand Other Insufficient clinical need Lack of appropriate staff No professional demand Programs (n=24) 11 9 8 8 8 7 4 4 % 45.83 37.50 33.33 33.33 33.33 29.16 16.66 16.66

Table 4.11: Reasons for not addressing LGB issues in music therapy programs

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Reasons why LGB issues were not addressed

12 10 8 6 4 2 0 1 Reasons
Time constraints Curricular pressure Lack of appropriate staff Perceived low priority Insufficient clinical need No student demand No professional demand Other

Figure 4.7: Reasons why LGB topics were not addressed

Eight respondents expanded on their answers using the other option. Although perceived most respondents chose low priority as to why they did not address LGB specific issues in their programs, time constraints and curricular pressure were a factor for many programs.
no opportunity There are so many sub populations with specific issues that if we tried to cover each one separately it would double the length of the course.

Another respondent indicated LGB issues may be addressed in supervision, but not in the program unless a student expresses a desire to cover the topic The issue may be addressed in supervision, but not in the program we discuss and read articles related to the subject only if it comes up in the students experience. LGB issues were not addressed in another program due to LGB issues not fitting in to the structure of the curriculum, focused on clinical populations.
Curriculum is clinical population specific, and being lesbian, gay or bisexual doesnt fit into this structure. The curriculum does however, discuss issues surrounding AIDS/HIV.

One respondent indicated that LGB topics could be selected in optional modules, that LGB issues were not a popular topic for students special interest areas, and that appropriate practicum sites were difficult to find
So far in 9 years of teaching on the course, I cant remember one student, who brought this up as a special interest topic in the subject I teach, or found a suitable practicum site with LGB clients, however these options are available for anyone who wants to pursue this line of work.

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Results Although some program directors felt there were more dominant issues to address, the view was also expressed that this was not a reason not to cover LGB topics.
I think bi-cultural issues predominate here, but that is not necessarily a reason!

Finally one program director felt personally unprepared to address LGB issues in their program, citing:
Lack of personal knowledge.

4.1.2.4. Manner of addressing LGB issues There are a variety of manners in which LGB issues are addressed (Table 4.12, Figure 4.8).
Manner of addressing LGB issues Part of a core module Integrated into all modules across the curriculum Workshops, role-play A clinical placement Presentations/guest speakers Contact with LGB organisations Guided private reading and study Other An optional module Part of an optional module Programs (n=17) 8 6 4 4 3 2 1 1 0 0

%
47.05 35.29 23.52 23.52 11.76 17.64 5.88 5.88 0.00 0.00

Table 4.12: Manner in which LGB issues are addressed in the programs From the 17 programs that did address issues specific to LGB clients, 8 (47.05%) addressed these issues in part of a core module. In six of the programs (35.29%), LGB issues were integrated across the curriculum. Workshops or role-plays were used by 4 of the programs (23.52%) in the provision of LGB issues, and these issues were also addressed in a clinical placement by 4 of the programs (23.52%). However for 3 of these programs the clinical practicum was also supported by lectures. Only 1 program addressed these issues solely in clinical practicum without addressing them in the classroom. Presentations or guest lecturers/speakers were features of 3 of programs (17.64%) and 2 programs (11.76%) had contact with LGB organisations. Only 1 program (5.88%) addressed these issues through guided private reading and study. Only 1 program (5.88%) addressed LGB issues in a core module, which was a required graduate multicultural course. There were a variety of modes in which LGB issues were addressed in the programs; however 35% of the programs integrated these topics across the curriculum rather than addressing them in an isolated unit or subject. One respondent commented how they address LGB issues in an introductory music therapy class.

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Results
Thankfully, in the US, the Code of Ethics at least lists "sexual orientation" as a protected category along with race, ethnicity, etc. It is the Code which is a point of entry into the topic for my students, and I address it in the Introduction to MT class.

Figure 4.8: The manner in which LGB issues are addressed 4.1.2.5. LGB topics in music therapy curriculum There was a range of LGB topics addressed in the music therapy programs (Table 4.13).
LGB topics addressed HIV/AIDS Homophobia Relationships Ethnic minority status & sexual orientation Conflict of religious & sexual identities Minority stress & mental health Gender development Discrimination/Anti-gay violence Sexual identity development LGB adolescence Suicide/substance abuse Transgendered/intersex issues The coming out process Internalised homophobia Families of LGB individuals Children of LGB individuals Disability & sexual orientation Bisexual issues Parenthood Gay affirmative approaches Heterosexism LGB midlife LGB ageing Conversion/reparative therapies Other Programs (n=17) 15 12 11 11 11 10 9 9 9 8 8 8 8 7 7 6 6 5 5 4 4 2 1 0 2 % 88.23 70.58 64.70 64.70 64.70 58.82 52.94 52.94 52.94 47.05 47.05 47.05 47.05 41.17 41.17 35.29 35.29 29.41 29.41 23.52 23.52 11.76 5.88 0.00 11.76

Table 4.13: LGB topics addressed 92

Results The topic most addressed by the music therapy programs was HIV/AIDS (12/17 programs: 88.23%) Homophobia was the next most selected item (12/17 programs: 70.58%). Eleven programs (64.70%) addressed LGB relationships, ethnic minority status and sexual orientation, and conflicts of religious and sexual orientations. Minority stress and mental health were addressed by 10 programs (58.82%) and 9 programs (52.94%) addressed gender development, discrimination/anti-gay violence and sexual identity development. Less than half of the programs (47.05%) addressed LGB adolescence, suicide and substance abuse, internalised homophobia, the coming out process and transgendered and intersex issues. Gay affirmative approaches were only addressed by four programs (23.52%), and the least addressed topic was LGB ageing (only 1/17: 5.88%). No program in the survey addressed issues related to conversion/reparative therapies. There were also some additional comments made by respondents in relation to the topics, including topics that the respondents felt were important. One respondent felt that attitude awareness was important, and another commented how these topics may be addressed in relation to critical music therapy and in clinical studies.
My approach to addressing these issues would be to provide a framework of critical music therapy in which assumptions of the prevailing majority are subject to scrutiny and critique. Our music therapy training in no way attempts to be psychotherapy training, and the difference between music therapy and music psychotherapy is emphasized. Some of the above issues may be specifically addressed in the clinical studies subjects.

4.1.2.6. The Importance of LGB issues in the music therapy programs Question 11 was designed to assess the importance ascribed to LGB issues by directors of the 17 programs that already address issues specific to LGB clients. Nevertheless all respondents (n=41) answered the question whether or not they addressed issues specific to LGB clients (Table 4.14).
Importance of LGB issues Very important Important Moderately important Of little importance Unimportant Respondents (n=41) 5 10 15 9 2 % 12.19 24.39 36.58 21.95 04.87

Table 4.14: Importance of LGB issues as a component of the music therapy program. Overall 30 respondents out of 41 (73.17%) felt that LGB issues were moderately important/ very important as a component of their program, while 11 (24.40%) felt that these issues were of little importance or unimportant (Figure 4.9).

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Figure 4.9: The importance of LGB issues in the programs From the programs that already address issues specific to LGB clients (n=17), 15 programs (88.23%) considered these issues to be moderately important to very important as a component of their program, while only 2 (11.77%) considered them of little importance. In addition, most of the directors of the programs that did not specifically address LGB issues also considered them important. For example of 24 such programs 15 (62.5%) felt that LGB issues were a moderately important to very important component of their program, while 9 (37.5%) indicated that LGB issues would be of little or no importance. Respondents from two programs who did not specifically address LGB issues nevertheless felt that this was an important area that needed more attention in music therapy education and training:
Currently we dont explicitly (address LGB issues), but I think we probably should. We have not given sufficient attention to these client groups.

4.1.2.7: Preparation for working with LGB clients Question 12 was an opened-ended question as to how the music therapy programs prepared their students for work with LGB clients. The responses showed that there is a variety of ways in which LGB issues are addressed. Some programs addressed LGB issues in structured classes, while others addressed them in less structured classes with a focus on personal work. Other programs dealt with LGB issues in a more general manner and these issues were addressed from a client centred, humanistic approach. For the programs that had formalised structured classes and discussions on LGB issues in music therapy guided readings, self and group reflection, and role play were some of the methods used to

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Results address these LGB issues, and in one program LGB issues were addressed as part of a compulsory graduate multicultural course:
Throughout several readings and class discussions (approx 1 hr/week over 3-4 weeks), we review theories and apply them to case studies/life experiences and situations. Personal analysis individually and in group, theoretical lectures and practical work under supervision. Literatures were assigned for reading and class discussion and projects are facilitated. Readings, class discussions on readings, supervision of clinical placement, course on Power, Privilege and Oppression, lecture presentations, films etc.

For the programs that dealt with LGB Issues in a less structured manner. Students can elect special interest topics on LGB issues or other areas, but there was not any other formalised attention to the topics otherwise.
We stress multiculturalism and diversity understanding cultures other than our own. Students have the opportunity to discuss how they may feel working with people of different cultures and lifestyles. Students often have sub-populations which they desire to specialise in working with when they graduate, and there is lots of room within the course structure for students to focus their studies (both practical and theoretical).

Programs addressed LGB issues in a variety of areas in music therapy training. Some programs addressed LGB issues in a single module or course and others incorporated LGB issues across the curriculum. Some programs addressed these issues in classes on ethical standards by reviewing the code of ethics:
The main preparation has to do with examining ones own belief systems and values and understanding how to practice ethically when faced with ANY cultural group who might be at odds with ones own value system. By reading the Ethical Thinking textbook and holding seminar discussions about the textbook readings.

Another program introduced LGB relationship issues into family therapy class with role play, and another addressed these issues from a counselling therapy perspective. Many courses said they addressed LGB issues in the same manner as they would any other client issues, through a client-centred or person-centred approach, valuing the uniqueness of the individual:
Non judgemental attitude, through assessment, meet client at his/her level, move towards greater health. By focusing on the uniqueness of each individual person and that individuals needs and cultural orientation. No different than with any other people by being open to all situations, gender, illness etc.

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Students are strongly encouraged to treat all clients with the same positive regard, regardless of personal differences. Sensitivity to needs, issues and client-centred therapy for self development.

Other courses were more directive in challenging attitudes and biases.

Addressing prejudice, attitudes, countering ignorance. By addressing: 1) those areas of bias, countertransference and lack of information within our heterosexual students; 2) possible over-identification in LGB students.

Other programs had an openly LGB program directors or faculty, who highlighted LGB issues from a personal perspective and their own experiences:
At the training program at undergraduate level, the bachelor's degree students are exposed to LGB through instructor's personal stories, some in clinical work and in classroom - I don't think there is an emphasis on it, but it does come into play at some extent. Gay faculty address the issue personally, and in most cases a gay student self-identifies resulting in peer-education. As a openly gay professor I feel it is crucial that I model not only my own identity for students but guide them in issues specific to gay people that may be their clients.

4.1.2.8. Clinical practicum with LGB clients Although programs may not address issues specific to LGB clients, they may be able to facilitate students who wish to work with LGB clients in their clinical placements. Question 13 asked respondents if they could facilitate students with clinical practicum/placement with LGB clients. Twenty-three out of 41 programs (56.09%) could facilitate students who wished to do clinical placement with LGB clients, while 18 (43.91%) could not. The provision of clinical practica by programs in relation to addressing LGB issues in shown in Table 4.15. From the programs that did specifically address LGB issues (LGB +), 11/17 (64.7%) could facilitate a clinical practicum with LGB clients, while 6 (35.3%) could not. From the music therapy programs who did not specifically address LGB issues (LGB -), 11/24 (45.83%) could still facilitate students who wished to work with LGB clients.
Clinical Practicum with LGB clients Can facilitate students Can not facilitate students Total LGB + 11 6 17 LGB 11 13 24 Total 22 19 41

Table 4.15: Clinical practicum with LGB clients

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4.1.3. LGB issues in music therapy education

4.1.3.1. Importance of LGB issues in music therapy education In answer to question 14 respondents indicated how important they viewed LGB issues as a component of music therapy education in general. Four fifths of the respondents (33/41: 80.49%) considered LGB issues to be moderately important to very important in music therapy education, while 19.51% (8/41) indicated that LGB issues were of little importance (Table 4.16).
LGB issues in music therapy education Very important Important Moderately important Of little importance Unimportant Respondents (n=41) 5 14 14 8 0 % 12.19 34.14 34.14 19.51 00.00

Table 4.16: Importance of LGB issues as a component of music therapy Almost all (16/17: 94.22%) of the programs that did address LGB issues indicated that LGB issues were moderately important to very important in the field of music therapy, and only 1 respondent considered them of little importance. Similarly of the programs that did not address LGB issues, a majority of 70.32% (17/24) also thought that these issues were moderately to very important, while 29.68% (7/24) indicated LGB issues were of little importance. Therefore almost three quarters of program directors who did not specifically address LGB issues still considered them moderately important to very important component of music therapy education (Table 4.17, Figure 4.10).
LGB issues in music therapy education Moderately important, important, very Important Of Little Importance , unimportant Total LGB + 16 1 17 LGB 17 7 24 Total 33 8 41

Table 4.17: The importance of LGB issues as a component of music therapy education

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Figure 4.10: The importance of LGB issues (LGB +/LGB-) A comparison of responses to question 11 and question 15 reveals how respondents perceived LGB issues were as a component of the music therapy program they directed against how important they perceive the issues as a component of music therapy education in general. Although 73.17% of respondents perceived LGB issues as a moderately to very important component of the program they directed, 80.49% indicated these issues were a moderately to very important part of music therapy education in general. One respondent commented that they considered LGB issues to be important, but not more so or less so than other issues in music therapy.
There are many potential populations with whom music therapists work. I think LGB issues are as important as other lifestyle issues, not more important or moderately important, but equally important.

4.1.3.2. Academic level for the provision of LGB issues Question 15 asked respondents where they thought LGB issues would be best addressed in music therapy education. Two respondents one of which did and one who did not address LGB issues in their program did not answer this question. A majority of 87.18% of respondents (36/39) felt that LGB issues should be addressed at university level (Table 3.18). Almost two thirds (25/39: 64.10%) of the respondents indicated that the issues would be best addressed at least at one level of university study and continuing professional education, while 41.02% (16/39) of the respondents thought that LGB issues should be addressed at all academic levels: undergraduate, post-graduate and continuing professional education (Table 4.18).

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Academic level All three levels (UG, PG and CPE) Post graduate & continuing professional education Undergraduate Continuing professional education Undergraduate & continuing professional education Postgraduate Undergraduate & post graduate Respondents (n=39) 16 6 6 5 3 2 1 % 41.02 15.38 15.38 12.82 07.69 05.12 02.56

Table 4.18: Academic level for the provision of LGB issues Comparing the two groups, those who addressed LGB issues and those that did not; 62.5% (10/16) who addressed LGB issues and 26.08% (6/23) of the respondents who did not specifically address LGB issues chose all three levels as appropriate. From the 23 responding programs who did not address LGB issues specifically, 52.17% (12/23) of the directors indicated that these issues would be well addressed at undergraduate level, and 60.86 % (14/23) indicated they would be well addressed at post-graduate level. Continuing professional development was a favoured option by many. For example 76.92% of the respondents (30/39) indicated that LGB issues would well-addressed in continuing education, however about one-eight (5/39: 12.82%) preferred that treatment of these issue be confined to continuing professional education, without any previous exposure. In an open-ended comment one respondent explained why LGB issues would be better dealt with in continuing professional education:
I am not sure how it should be given priority, as there is always too much to do in 2 year masters programmes. It may be good to start with continuing professional development so that the mature professionals lead the way with thinking about the issues.

Another respondent agreed that LGB issues would be better addressed in continuing professional education
LGBT 17 issues shouldn't be heavily addressed in undergraduate training because that makes it seems as though it is a disability or disorder, like the other populations groups that are studied at this level. I see this as an advanced practice topic for people who are specifically interested in working with individuals who have issues related to their gender and sexual identities.

Countering this, another respondent argued that issues of diversity need to be addressed at undergraduate level
I strongly believe that undergraduate students need to understand issues of diversity and their feelings and issues surrounding all different lifestyles and cultures.

4.1.3.3. Most important LGB topics for music therapy curriculum

17

LGBT Lesbian, Gay, Bisexual and Transgender

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Results Question 16 sought to identify which LGB topics respondents felt were most important and should be addressed in music therapy education (Table 4.19). The LGB topic seen as most important was HIV/AIDS (28/41: 68.29%). Suicide/substance abuse was the next most important (27/41: 65.85%) followed by sexual identity development (25/41: 60.97%). Homophobia and relationships were chosen by 24 respondents (58.35%). Minority stress and mental health was perceived as equally important as conflicts of religious and sexual identities and chosen by 23/41 respondents (56.09%). The topic viewed as least important was conversion/reparative therapies and only chosen by 1 respondent (2.43%). LGB midlife was also perceived as not important with only (3/41: 7.31%). LGB ageing and heterosexism were also not seen as very important for music therapy education with only 5 respondents (12.09%) closing these topics. Gay affirmative approaches were only chosen by 7 of the sample (17.07%), indicating that this topic is not viewed as important for music therapy education. The topics are ranked as chosen by respondents in order of importance (Table 4.19)
LGB topics HIV/AIDS Suicide Sexual identity development Homophobia Relationships Conflict of religious & sexual identities Minority stress & mental health Gender development Discrimination/Anti-gay violence The coming out process Internalised homophobia LGB adolescence Ethnic minority status & sexual orientation Disability & sexual orientation Children of LGB individuals Transgendered/intersex issues Families of LGB individuals Bisexual issues Parenthood Gay affirmative approaches Heterosexism LGB ageing LGB midlife Conversion/reparative therapies Other Respondents s (n=41) 28 27 25 24 24 23 23 22 21 20 17 16 16 15 13 11 10 9 8 7 5 5 3 1 5 % 68.29 65.85 60.97 58.35 58.35 56.09 56.09 53.65 51.21 48.78 34.14 39.02 39.02 36.58 31.70 26.82 24.39 21.95 19.51 17.07 12.19 12.19 07.31 02.43 12.19

Table 4.19: Important LGB topics for music therapy education The correlation between LGB topics addressed (question 10) and the importance ascribed to them by the directors of the 17 courses that addressed LGB issues is shown in Figure 4.11. In total 25 topics were referred to. Importance was assessed as the number of course directors who included that topic in a list of the ten most important elements that should be 100

Results included in a program. Similarly the number of courses that included a topic in its program was taken as a crude measure of the strength of emphasis placed upon it. There was a strong correlation between the number of courses that addressed a topic and the number of directors that selected it as important (r = 0.81). In general the probability of a topic appearing in a course was as predicted from the frequency with which it was stated to be significant. There were two outliers. These were Suicide and Parenthood. Both of these topics were less frequently addressed in courses that the importance ascribed to them. Suicide was only the 10th most addressed topic by 47.05% of the respondents (LGB+), but was then ranked as the second most important topic to address in relation to LGB issues.

Figure 4.11: LGB topics which respondents addressed and rated important There was a general agreement between directors of programs as to which were the important LGB issues. There was a strong correlation between the relative importance ascribed to various LGB issues by directors of programs that included consideration of LGB topics and by those who directed programs that did not (r = 0.70; Figure 4.12). In general directors of courses that did not address LGB issues agreed, with directors of courses that did so, on which topics were more important. HIV/AIDS and suicide were identified as the most important issues. There were two obvious outliers. Relationships and Adolescence were ascribed far more importance by directors of programs that addressed LGB issues, than did their counterparts. In the former group they were ranked third and ninth respectively, while in the latter group they were ranked, 25th and 14th. 101

Results

Figure 4.12: Correlation between important LGB topics between LGB+ and LGB 4.1.3.4. Guidelines and training opportunities for working with LGB clients In answer to question 17, a majority of 75.60% of program directors (31/41) indicated that guidelines or training opportunities for working with LGB clients from music therapy associations would be beneficial for music therapists (Table 4.20). Nine of the 10 programs, who thought guidelines on working with LGB clients would not benefit music therapists, did not address issues specific to LGB clients in their programs, nor could they facilitate students who wished to do clinical placement with LGB clients. Most (60%) of these programs felt that LGB issues in music therapy were moderately important to very important, while 40% felt these issues were of little importance.

Guidelines/training from music therapy associations Would be beneficial for music therapists Would not be beneficial for music therapists

Respondents (n=41) 31 10

% 75.60 24.40

Table 4.20: Guidelines and training opportunities in LGB issues

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4.1.3.5. Provision of LGB issues in the respondents own music therapy training In answer to question 18, 90% of respondents (37/41) had not received any training in relation to LGB issues in their own music therapy training. This data can be seen below in table 4.21.
LGB issues in music therapy programs Were addressed Were not addressed Respondents (n=41) 4 37 % 09.75 90.25

Table 4.21: Provision of LGB issues when the respondents trained as music therapists The remaining 4 respondents had studied LGB issues, which were addressed in their training as music therapists, and 3 out of the 4 of them now address these issues in the music therapy program they direct. All four of these respondents felt that guidelines for working with LGB clients would benefit music therapists. Two of these respondents indicated that their own training in music therapy was psychodynamic, 1 indicated a psychoanalytic training and the fourth received a humanistic/client-centred training. Three of the 4 respondents who received training in LGB issues completed their training more recently in 1995, 1996 and 1998. One of the respondents completed their training in 1987. One respondent commented that it might be that LGB issues were not addressed in their own music therapy training, due to the era in which they trained.
I think the reason this wasn't addressed when I was a student was that in was in the eighties and it just wasn't discussed as openly as it is now.

Details of the four respondents who received training in LGB issues in their own music therapy training are presented in Table 4.22. Two of the programs respondents graduated from were from the US and two of the programs were from Europe.
Sex M F F F Year of graduation as a music therapist 1987 1995 1996 1998 Theoretical orientation of that program Psychodynamic Humanistic PsychodynamicIntegrative Psychoanalytic Address LGB issues in program now Yes Yes Yes No Theoretical orientation of the program Humanistic Humanistic Psychodynamic Integrative Psychoanalytic

Table 4.22: Respondents who received training in LGB issues in their own training

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Respondents made some further comments in relation to the survey or the theme of LGB issues in music therapy and are shown in Appendix 10.

4.2 Results of Survey B Music Therapy Associations

4.2.1. Association information
Participants responded on behalf of music therapy associations from four of the five continents in the survey (Table 4.23).
Continent Europe North America South America Australasia Asia Associations (n=11) 5 2 3 1 0

Table 4.23: Respondents by continent The majority of the respondents were from Europe (45.45%) followed by South America (27.27%), North America (18.18%) and Australasia (9.09%). Continental responses are shown in Figure 4.13.

Continental Response Survey B

North America 18% South America 27% Australasia 9% Figure 4.13: Continental response: Survey B Europe 46%

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Results The response for the music therapy associations was 22.44%. Nine out of the 29 countries included in the survey giving a country-based response rate of 31.03% (Table 4.24).
Country Argentina Australia BosniaHerzegovina Brazil Canada Croatia Germany The Netherlands Sweden Total N 2 1 1 1 2 1 1 1 1 11 Music Therapy Association Argentine Association for Music Therapy Ambito de Asistencia, Docencia e Investigacin en Musicoterapia Australian Music Therapy Association The Pavarotti Music Centre, MUSERS Associao Gacha de Musicoterapia (AGAMUSI) Canadian Music Therapy Association Music Therapy Association of British Columbia Croatia Association of Music Therapy Berufsverband der Musiktherapeutinnen und Musiktherapeuten in Deutschland (BVM) Dutch Association for Creative Therapy (Vaktherapie) Association for Music Therapy in Sweden 11/49 = 22.44% response rate

Table 4.24: Music therapy associations that responded to the survey The responding associations were established in different decades (Table 4.25). One respondent did not indicate the year the association was established. The mean time since foundation was 15.3 years with a range from 1 year to 47 years. One was established in the 1960s, two in the 1970s, 1 in the 1980s, 3 in the 1990s and 3 since the year 2000. Two of the associations established since the year 2000 had formerly been music therapy associations but had joined other bodies to create national associations.

Establishment of Association 1960s 1970s 1980s 1990s 2000 -

Associations (n=10) 1 2 1 3 3

% 10.00 20.00 10.00 30.00 30.00

Table 4.25: Establishment of associations

4.2.2. Provision of LGB Issues

4.2.2.1. Provision of guidelines for working with LGB clients Question 2 inquired whether the associations provided guidelines for working with LGB clients in music therapy (Table 4.26).
Provide guidelines on LGB issues Yes No Associations (n=11) 1 10 % 09.09 90.91

Table 4.26: Provision of guidelines on LGB issues

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Results Only 1 music therapy association provides guidelines on LGB issues for music therapists (9.09%). another respondent commented that the code of ethics gives general guidelines for all clients, but does not specifically address LGB issues.
Code of Ethics provides general guidelines regarding ethical treatment of clients regardless of background, but not specific reference to LGB clients.

4.2.2.2. Training opportunities in LGB issues Question 3 identified associations that provided further training opportunities in LGB issues in music therapy. Again only 1 association out of the 11 (9.09%) provided opportunities for further training or continuing education in LGB issues for music therapists (Table 4.27).
Provide training opportunities in LGB issues Yes No Associations (n=11) 1 10 % 09.09 90.91

Table 4.27: Further training opportunities in LGB issues One respondent commented that continuing professional development requirements were new in their country and addressing LGB issues would be considered part of addressing music therapy competencies.
Continuing Professional Development requirements are fairly new in this country, so specific provision of courses by the association is limited and not prescriptive. Continuing education about LGB issues would be considered as addressing music therapy competencies, however, and would be counted toward CPD requirements.

4.2.2.3. Music therapists working with LGB clients Question 4 asked respondents if to their knowledge they had members working with LGB clients. On behalf of the 11 associations, 4 respondents (36.36%) had to their knowledge members working with LGB clients or in LGB specific settings.
Knowledge of members working in LGB areas Yes No Associations (n=11) 4 7 % 36.36 63.64

Table 4.28: Members working in LGB area

4.2.3. LGB issues in music therapy

4.2.3.1. Training in LGB issues at university level Question 5 asked respondents to indicate if they thought training in LGB issues at university level would be beneficial for music therapists. Table 4.29 shows that 63.64% (7/11) of the

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Results respondents on behalf of the associations considered that training in LGB issues at undergraduate or post graduate level would professionally benefit music therapists in their clinical work. About one third (36.36%: 4/11) see no such benefit in such training.
Training in LGB issues in music therapy programs Would professionally benefit music therapists Would not professionally benefit music therapists Associations (n=11) 7 4 % 63.64 36.36

Table 4.29: Would training in LGB issues professionally benefit music therapists? 4.2.3.2. Importance of LGB issues for practicing music therapists In answer to question 6, seven of the 11 respondents (63.64%) felt that LGB issues were moderately important or important for practising music therapists in their country, while 4 (36.36%) felt thee issues were of little importance or unimportant. The latter 4 respondents had also indicated in the previous question that training in these issues would not be of benefit to music therapists (Table 4.30).
Importance of LGB issues for music therapists in your country Very important Important Moderately important Of little importance Unimportant Associations (n=11) 0 2 5 2 2 % 00.00 18.18 45.46 18.18 18.18

Table 4.30: Importance of LGB issues for music therapists in your country

4.3. Comparative results

4.3.1. Guidelines and training opportunities in LGB issues
Examination of responses to question 17 (Survey A) and questions 2 and 3 (survey B) compared program directors and respondents from music therapy associations views on whether guidelines and training opportunities on LGB issues would professionally benefit music therapists. Most of the program directors (31/41: 75.60%) felt that guidelines or opportunities would benefit music therapists professionally. But, although 75.60% of the music therapy program directors thought guidelines and opportunities for training in LGB issues would professionally benefit music therapists, only 1 association (9.09%) provided guidelines on LGB issues for its members and provided opportunities for training in LGB issues (Tables 4.31 and 4.32).

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Results

Guidelines/training from music therapy associations Would be beneficial for music therapists Would not be beneficial for music therapists

Respondents (n=41) 31 10

% 75.60 24.40

Table 4.31: Guidelines and training opportunities in LGB issues

Guidelines and training opportunities Guidelines for working with LGB clients Yes No Training opportunities in LGB issues Yes No

Respondents (n=41) 1 10 1 10

% 9.09 90.01 9.09 90.01

Table 4.32: Provision of guidelines and training opportunities in LGB issues

4.3.2. LGB issues in music therapy education

In response to question 5 in Survey B, seven of the 11 responding music therapy associations (63.64%) felt that training in LGB issues at university level would beneficial for music therapists (Table 4.33).
Training in LGB issues in music therapy programs Would professionally benefit music therapists Would not professionally benefit music therapists Associations (n=11) 7 4 % 63.64 36.36

Table 4.33: Would training in LGB issues professionally benefit music therapists? From the participating music therapy programs 17 (41.46%) did specifically address LGB issues.
Address LGB issues Yes No Programs (n=41) 17 24 % 41.46 58.54

Table 4.34: Programs that specifically address LGB issues Some participants made further comments in relation to the survey, and the theme of LGB issues in music therapy and are shown in Appendix 11.

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Results

4. 4. Main findings
Although LGB issues may be underemphasised in music therapy education and continuing professional development, more programs are now addressing LGB issues than in former years. Many program directors felt LGB issues were important, however less than half specifically addressed LGB issues in their training programs and only one program addressed LGB issues as part of a required graduate multicultural course. Nevertheless, many programs that did not specifically address LGB issues could still facilitate students who which to work in clinical placements with LGB clients. Although a majority of the programs did not address LGB issues, paradoxically they still indicated that they should be a moderately to very important component of music therapy education. The low priority accorded to LGB issues was mainly due to time constraints and curricular pressure. Presumably LGB issues are currently at a competitive disadvantage in the struggle for curricular time. Nevertheless, a majority (85%) of program directors whether they themselves addressed LGB issues or not indicated that university level was the appropriate time to best address these issues. They further stated and that guidelines and further training opportunities from music therapy associations would be beneficial to music therapists (75%). Many respondents have the view that LGB individuals represent a clinical population, rather than seeing LGB issues as relevant to all populations. HIV/AIDS is the topic viewed by music therapists as most relevant to the LGB population, and other important LGB topics are being overlooked. There is a serious lack of awareness about ageing issues for LGB clients in terms of both attention to, and value placed on the topic. There is also very little attention given to gay affirmative practice and approaches, which could greatly benefit music therapists. Responding music therapy program directors indicated that LGB issues in music therapy education are under-addressed. Among multicultural issues, it ranked lower than ethnicity, race, gender and religion. Almost two thirds of the (63%) music therapy associations had members who worked with LGB clients, and thought that LGB issues were moderately to very important for practicing music therapists in their country, although only one association provided guidelines and further training opportunities in LGB issues. Nevertheless most associations indicated that training in LGB issues at university level would be beneficial for music therapists. In conclusion, this study has clearly shown that although the music therapy community considers LGB issues important they are relatively underdeveloped and overlooked.

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Discussion

Chapter IV Discussion

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Discussion

5.1. Discussion of results - Survey A

5.1.1. Professional & program contexts
It is important to consider the extent to which the survey is representative of the educational and training phase of the music therapy profession. The respondents represent an experienced group, with 66% indicating between 20 and 39 years of clinical experience, 30% indicating 10 to 19 years, and 1 program director indicating 9 years of experience since graduating from a music therapy training program. Female programme directors outnumbered males by four to one in the respondents who supplied the information (there were 3 anonymous respondents). The gender imbalance is not surprising, as music therapy as a profession generally attracts more women than men. The percentage of male participants was higher than in other surveys of music therapists. In Wyatt & Furiosos (2000) survey of Masters level music therapists in the U.S, 13% of the respondents were male. However the sex ratio in this survey is in line with music therapy as a profession, which is made up of over 80% of women (Hadley & Edwards, 2004). The response rate of 29.71% although disappointing fell close to the expected return rates of electronic surveys. Using Electronic surveys as a data collection tool has increased greatly in the last decade; however it has been observed that response rates have been decreasing. Sheehan (2001) observed that response rates diminished from 41% in the 1990s to 24% at the year 2000, with a mean response rate of 36% over the period. Truell (2003) also observes how electronic surveys get mixed results, averaging at around 35%. Electronic surveys in music therapy have performed similarly, and in Silverman & Hairstons (2005) descriptive study on private practice in music therapy a response rate of 33.4% was achieved. This was a global survey; however there was a marked disparity in response rate between continents. Only 5 of the 51 European programs responded to the survey, where as in North American 25 out of the 69 programs responded, and in Australasia 4 out of the 5 programs did so. Although the United States and Canada together have over 69 programs, there is one official music therapy association in both countries, which is responsible for professional registration; the same system exists for Australia and New Zealand. This perhaps leads to more tightly knit community of music therapists and closer connection between music therapy programs. Europe on the other hand is a much more diverse and divided continent, and in this survey 51 programs were included across 19 countries. The

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Discussion music therapy communities within European countries are perhaps more fragmented with some countries having up to 7 associations, which most likely result in less solidarity between music therapy programs. This survey of music therapy program provides a relatively good guide to attitudes towards LGB issues in music therapy in North America and Australasia, but further work needs to be done to gage the situation in Europe. There was a wide variety of theoretical orientations in the respondents own music therapy training, with eclectic programs being the most popular, where students are exposed to several theoretical models. This was followed by behavioural programs, humanistic programs and psychodynamic programs. In the programs that the respondents now directed, eclectic orientations were again the most common, followed by humanistic, and then by psychodynamic. Many of the programs nowadays offer a dual or eclectic theoretical orientation to their students, whereas in previous years a single theoretical orientation was more common. There was a reduction in the amount of psychodynamic-only programs from 5 to 2 and an increase in psychodynamic/humanistic orientated programs from 1 to 6; mixed behavioural programs also increased from 1 to 5. The results clearly document the shift in emphasis within music therapy programs over the last 3 to four decades. There were far fewer behavioural programs in the current programs that respondents directed, than in the period during which they themselves trained. From 8 behavioural programs when respondents own training, there were now 5 behaviourally based programs. However of those 8 programs, 7 were solely behavioural in emphasis, while none of current programs are purely behavioural, although 5 have a behavioural element to their approach. All of the former 8 behavioural programs from which respondents had graduated were based in the U.S, where there was an increase in behavioural approaches from the mid 1960s through to the 1980s. Literature reviews from the Journal of Music Therapy from this period indicate the use of behavioural approaches and the application of behavioural research techniques (Standley et al. 2004). The fact that 2 of the respondents trained in behavioural programs in the early 90s, and that the 5 behaviourally-based programs, which the respondents currently direct are from the U.S, further emphasises the link between behavioural theoretical orientation and music therapy training in the United. Humanistic approaches such as client-centred and gestalt therapies, systemic therapy and eclecticism have all been considered approaches that can meld well with gay affirmative approaches. Considering that eclectic and humanistic were the most common theoretical orientations indicated by respondents who address LGB issues in their programs, perhaps 113

Discussion indicates that these theories are more open to diversity and LGB issues. However, it is really down to the individual educator to choose to include and address LGB topics, and these theories do not stand-alone unaffected. Milton & Coyle (1999, p. 54) argue, this does not mean that clients are guaranteed a lesbian and gay affirmative experience from any specific approach. The values and prejudices of individual practitioners and of the social and historical contexts in which they are embedded affect all therapies. It is important that when addressing LGB issues, programs strike a healthy balance between LGB affirmative topics and coursework and evidence-based practice and treatments. Anhalt et al. (2003) asserts that It is a possibility that LGB clients will not receive the best possible care for their problems, compared with heterosexual clients because training programs that tend to focus on LGB affirmative psychotherapy largely do not have adequate coursework in empirical informed treatments. Conversely, training programs that do focus on empirically informed treatments do not have adequate coursework in LGB issues (In. Safren 2005, p. 31). It is therefore encouraging to note that many programs in the survey highlighted their commitment to evidence-based practice.

5.1.2. Provision of LGB issues

There is a paucity of literature on LGB issues in music therapy, and minimal emphasis of these issues in music therapy programs. LGB issues were the least addressed topic by programs along with immigration; and it could be argued that until LGB topics achieve a higher profile, based on clinical findings in the literature, it will be difficult to increase emphasis in educational programs. LGB topics can be considered part of multicultural music therapy if the definition of multiculturalism is inclusive. If the definition is exclusive then the emphasis is more likely to be on ethnicity and race (Estrella, 2001, p. 47). Perhaps LGB topics sit better outside of the multicultural domain. An inclusive definition of culture to the researcher seems problematic when speaking about LGB issues. In general, people may share more commonalities with people from their own country, ethnic group or race, whether LGB or not than, individuals from other countries, ethnic group or race. Ethnicity, which was a major preoccupation, has been addressed in multicultural music therapy for many years; (Moreno, 1988; Brandt, 1997; Estrella, 2001; Stige, 2002; Stige & Kenny, 2002; Chase, 2003). Gender, which was the second most emphasised topic, has also received increased attention in the field of music therapy. Music therapy from feminist perspectives and gender issues have been growing in the field in relation to theory, ethics, practice and supervision following the work of Baines (1992), Curtis (1996) and Susan Hadleys (2006) book Feminist Perspectives in Music Therapy (Hadley & Edwards, 2004). This indicates that

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Discussion programs are open to including minority issues and perspectives into training programs, which in turn indicates that LGB issues could be incorporated as well. It has previously been reported from a survey of multicultural curriculum that many programs address multicultural issues in secondary courses. It was observed that more coursework was needed in the area of LGB issues, in which music therapists felt their training had been inadequate (Darrow & Molloy, 1998, p. 30). Although in the study reported here a high percentage of programs addressed multicultural issues, it is not known if these issues are addressed in primary or in secondary courses and if sufficient coursework is given. Only one program in this survey had a compulsory graduate course in multicultural music therapy. It would figure that if LGB issues were the least selected topic, then they will be likely to be dealt with in secondary or optional courses, and students will be more likely to feel inadequately prepared to work with LGB clients. Overall the music therapy program directors thought LGB issues to be an important part of their programs, with 30 out of the 41 respondents indicating LGB issues were a moderately important to very important component of their program. This question was aimed at those who specifically addressed issues specific to LGB clients in the curriculum, however all respondents answered this question. LGB issues were of course considered an important part of the music therapy programs by those who specifically addressed them, with almost 90% (15/17) of those programs considering these issues moderately important to very important. It was unexpected to find that over almost two-thirds (15/24) of those who did not address LGB issues specifically nevertheless considered them a moderately important to very important component of their program. Although many of the programs did not address LGB issues specifically, they could provide clinical placement with LGB clients, while others offered students special interest topics in which elected areas of music therapy could be explored, and so perhaps it was these components they saw as important in their programs. Some directors who do not specifically address LGB issues emphasised that these issues have not been given enough attention in music therapy education.
Currently we dont explicitly (address LGB issues), but I think we probably should. We have not given sufficient attention to these client groups.

Although most programs thought LGB issues to be moderately to very important less than half of the surveyed programs specifically addressed LGB issues. This means that half of all music therapists are entering the profession knowledgeable about working with LGB clients and half are not. Therefore LGB clients will have a fifty-fifty chance of seeing a music 115

Discussion therapist who is informed on LGB issues and is adequately prepared to work affirmatively and effectively with them. The survey results show that 15 out of the 17 programs, that addressed issues specific to LGB clients, were from North America. This could be explained by the longer history of LGB issues and perspectives in North American psychology and psychotherapy literature and discourse, the establishment of gay affirmative approaches, and the development of LGB theoretical perspectives and research. In the United Kingdom for example, the Lesbian and Gay Psychology Section of the British Psychological Society was only established in 1998, after almost a decade of campaigning (Clarke & Peel, 1997). Since then LGB issues in psychology from British perspectives have increased dramatically with many scholars coming from social constructionist paradigms. This may mean that programs in other parts of the world will start to address LGB issues, when these issues gain more prominence in other health-care fields and the broader community. However, if one is to presume there are as many LGB individuals in one country as there are in the next, it is of concern that almost 90% of the music therapy programs who address issues specific to LGB clients are in one continent. There were many reasons why respondents did not specifically address LGB issues: perceived low priority, time constraints, and curricular pressure being the most selected reasons. Time constraints and curricular pressure are of course issues in every program, but vital LGB topics could be integrated into many parts of a program. One of the respondents commented that there is not enough time to cover all of the sub-clinical populations in music therapy programs, and that if they did; it would double the length of the course. The opinion that LGB individuals are a sub-population was expressed by many program directors. LGB individuals are not a sub-population, and as music therapists we will work with LGB people across all clinical populations. Awareness of LGB issues is invaluable in all clinical settings in music therapy and perhaps these issues can be addressed when studying the various clinical populations, highlighting the specific LGB issues relevant for that age group or population. Another program indicated that the structure of the curriculum was population-specific, and LGB issues did not fit into the structure. However, because LGB issue are applicable to all clinical populations it would seem that rather than excluding LGB issues, they should for this very reason be included in, and integrated across the music therapy curriculum.

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Discussion There were various methods of addressing LGB issues in the 17 music therapy programs and many of these programs addressed these issues in more than one way. Only one program addressed LGB issues as part of a required graduate multicultural course in the music therapy program, and although another 16 programs addressed LGB issues, the level of attention to these issues varied greatly. The survey revealed that almost half (8/17) of the programs addressed LGB issues as part of a core module, while about one-third (6/17) of the programs integrated LGB topics throughout the curriculum. It has been shown that integrating LGB issues across the curriculum results in a clearer understanding of these issues (Lee et al. 1999). Infusion of diversity issues into all training experiences rather than an isolated training seminar or course increases intern satisfaction and understanding of the issues discussed (Rodolfa & Davis, 2003, p. 81). Some programs used a combination of methods to address the issues such as: workshops/role-plays, presentations/guest speakers and contact with LGB organisations within or outside the university. Listening to LGB panel speakers and role-play have both been identified as essential components in curricula for preparing therapists for work with LGB clients (Godfrey et al. 2006). Only 3 music therapy programs used guest speakers or lecturers in their provision of LGB issues, and this type of learning experience may be more interactive and beneficial for music therapy students. LGB guest speakers and personal exploration through self-reflection and writing are seen as critical and favoured over more removed methods of study, such as watching videos or reading materials (Godfrey et al. 2006, p. 500). Indeed these interactive learning experiences would encourage students to challenge their own heterosexist and homophobic biases and prejudices. Four programs address LGB issues in clinical practicum. Three out the four programs who addressed the issues in clinical practicum also addressed them as part of a core module or supported the clinical work with role-play or presentations. Only 1 program addressed LGB issues in clinical practicum with no other learning or support. Supporting on site learning experiences with classroom learning experiences is imperative for working with LGB clients. LGB specific practicum sites may be difficult to provide unless there is a gay mens specific AIDS ward in a local hospital or an LGB special needs or youth group, however, knowledge of LGB issues will enhance music therapists practice at any clinical site and ensure effective and professional care with any LGB clients they encounter. An understanding of LGB issues will also enhance our dealings with LGB family members, carers or staff that are outside of the client-therapist relationship. Observing and providing therapy to LGB clients with supervision has also been highlighted as an essential learning experience for working with LGB clients (Godfrey et al. 2006). 117

Discussion The music therapy programs surveyed that addressed LGB issues, covered a wide range of topics. The topic most addressed by the music therapy programs in relation to LGB issues was HIV/AIDS, which was addressed by over 85% of the programs. This indicates that HIV/AIDS is not only viewed as primarily an LGB issue, but that it is viewed as one of the only issues that could be relevant to the LGB population for music therapists. This is of concern given the broad range of LGB issues that will be overlooked if this view persists among music therapy educators. HIV/AIDS is not exclusive to the LGB population and should rather be approached from a medical perspective or in relation to palliative care and end of life topics. The reason HIV/AIDS was not discussed in this thesis is because the author did not want to routinely associate it with LGB issues. HIV/AIDS is a non-prejudiced, impartial disease, and to so routinely associate it with LGB issues seems in itself homophobic. The second most addressed topic was homophobia (societal/institutional). Homophobia is a very important topic when addressing LGB issues. It permeates our health systems, directly affects client services and can act as a major stressor in LGB individuals lives. Other popular LGB topics included: LGB relationships, Ethnic minority status and sexual orientation, conflicts of religious and sexual orientations and sexual minority stress The importance of understanding minority stress and stigmatisation has been well documented in the literature (Cochran & Mays, 2000; Meyer 2003; Cochran, Sullivan & Mays, 2003; Warner et al. 2004; Ferguson et al. 2005; Pitt el al. 2006). Conflicts of Religious and sexual orientations have also been well documented in the literature with emphasis on exploration of religious and sexual identities, and supporting the integration of these aspects of the self (Haldeman, 2007; Eubanks-Carter et al. 2005; Lynch, 1996). Ethnic minority status & sexual orientation and disability & sexual orientation are both dualminority topics, which are important for music therapists, as many work with heterosexual and LGB clients of different ethnic backgrounds and/or disabilities. It was disappointing that less than half of the programs addressed LGB issues from the perspectives of adolescence, internalised homophobia and the coming out process. The coming out process and internalised homophobia are key aspects of therapy with LGB individuals and can be issues relevant throughout the lifespan. The coming out process in particular is an important experience exclusive for LGB individuals and every persons coming out process is unique. Eubanks-Carter et al. (2005) highlight that therapists can become sensitive to the type of issues LGB individuals face by becoming familiar with the proposed models and stages of coming out (p. 9). Music therapists could examine some of the coming out models to better understand this experience. One of the least addressed topics was LGB ageing. This is arguably a key area for music therapy training because many music therapists work in aged care settings and many music therapy students have 118

Discussion clinical placements with this population. As discussed there are many issues specific to LGB ageing, invisibility and isolation being central (Wilton, 2000; Harrison, 2001; Garnets & Kimmel, 2003). It was disappointing that this topic was so under-addressed, but as Harrison (2006) highlights, LGB issues in gerontology research and literature have been neglected in many countries. Gay affirmative approaches were only addressed by 4 programs, and perhaps this is one of the most important topics for clinical work with LGB clients; the approach serving as a guide to enhance therapy with LGB clients. A gay affirmative approach can be introduced to most theoretical frameworks and become part of the music therapists working theoretical model. Heterosexism another important topic was underaddressed. Heterosexism is a key issue when talking about healthcare experiences of LGB individuals and a topic that goes hand in hand with homophobia. It is relevant for all populations, clinical settings and is an issue relevant across the LGB lifespan. The topic viewed as least important was conversion/reparative therapies. Although this may not be a central issue for music therapists, it is important to know the ethical implications of conversion therapy and how to react if a client ever expressed a wish to under go such therapy. From the literature it would seem this is more of a contemporary issue in the United States, although many teenagers are sent to therapy with the hope of changing their sexual orientation (Clarke & Peel, 2007). A concern expressed by one respondent was that there would not be enough time to cover all of the LGB topics mentioned in the survey, and of course this is a reasonable concern. Not all of these topics could realistically be covered in depth, however the central and most important topics could be addressed in class time, and other topics could be integrated across the curriculum where applicable. Case studies with LGB individuals in music therapy would be useful to examine LGB issues and improve students critical thinking; and it is possible to include LGB examples in the ongoing pedagogical discourse in many areas (American Psychological Association, 1998). There was a variety of ways in which the programs prepared their students for working with LGB clients. Some of the programs with more structured learning experiences commented how class discussions and group and personal analysis were a part of their strategy for addressing LGB issues. The latter is extremely important, and personal analysis and self reflection is cited in the literature as being one of the most important preparations a therapist can do to work more effectively with LGB clients (Davies, 1996; Garnets et al. 2003). It is imperative for trainees to explore their own sexuality and be comfortable and open about it to avoid personal issues related to sexual identity becoming entangled with 119

Discussion their clients issues (Milton, Coyle & Legg, 2002, p. 3). Trainees also need to address both conscious and subconscious heterosexist bias and homophobia, irrelevant of their own sexual orientation, to ensure that they do not affect therapeutic endeavours (Greene, 1994; Davies, 1996). One program was quite directive in this by challenging prejudices, attitudes and countering ignorance. An attitude inventory such as Bersteins (2000) Cultural Literacy Model or a more specific LGB attitude inventory may help to access students conscious and subconscious anti-gay prejudice (Chase, 2004, p. 37). In turn this may involve clarifying, evaluating and potentially changingbiases, prejudices and values (Godfrey et al. 2006, p. 500). Music therapists must challenge their assumptions and beliefs about sexuality if they are to provide ethical effective therapy for LGB clients. A commitment to this dictates that therapists be ardent and determine what work they need to do be it personal, informational, or a combination of the two to offset these assumptions and beliefs (Tozer & McClanahan, 1999, p. 736). Countertransference was also addressed by one program, and this is a salient feature of work with LGB clients, which needs to be explored by heterosexual and LGB students alike; both interpersonally and in relation to LGB sexualities in general (Milton, Coyle & Legg, 2005). Another respondent felt it was important to strike a balance between attending to the lack of information within their heterosexual students, while also being aware of possible over-identification in their LGB students. It is important for all students whether heterosexual or LGB to understand LGB issues in therapeutic contexts. It is likely that LGB students will have had personal experience of some LGB issues, and their narratives can enhance class discussions. However, It is possible that they may over- identify with certain issues, and therefore, a guide with a more objective view is necessary. One program addressed LGB issues through several readings and class discussions approx 1 hr/week over 3-4 weeks, and although it maybe necessary to create such space to address LGB specific issues in the curriculum, as discussed earlier there is support in the literature for the integration of rather than isolation of LGB topics (Clarke & Peel, 2007). In some programs LGB Issues were dealt with but in a less structured manner. Students may elect special interest topics on LGB issues or other areas of interest, but otherwise there may not be formalised attention to the topics. Some students may wish to specialise in LGB issues or carry out LGB specific research during their training; however, these essential topics and their inclusion should not be dependent on students personal interests. The survey results indicate that many students may be exposed to LGB issues only if they bring them up in class. This may result in students missing out on valuable clinical knowledge, which could enhance their work with clients. Students who later work with LGB clients may 120

Discussion feel inadequately prepared and have to learn on the job. Students may not demand coursework or exposure to LGB issues in music therapy, but that does not mean that they are not important for trainee therapists. To rely mainly on student demand presupposes a substantial clinical knowledge that is unreasonable. It has been noted in psychology education that often it is only LGB students who bring up these topics for attention and discussion and that often the responsibility is on their shoulders (Clarke & Peel, 2006). LGB students should feel represented and included in the curriculum and not feel if they do not raise LGB issues no one else will. In this context a huge risk seems that trainees might be inadequately prepared to work with LGB clients if there were no LGB students in the class. One respondent commented that in nine years of teaching they could not remember one student bringing up LGB issues as a special interest topic, nor find a suitable clinical practicum with LGB clients. The sole responsibility to raise LGB issues should not be on the students shoulders, because if so, these issues may never be addressed. Although it is often the situation that LGB students take responsibility to raise LGB issues in the classroom, this can be problematic although it can be empowering for students to be informally teaching in their areas of interest, identity or expertise, it can also become a burden if these students are the only ones taking responsibility for this workIn addition their efforts would typically not be as effective as discussions or assignments initiated by professors (Godfrey, et al. 2006, p. 493). A more structured treatment of these issues would be invaluable to all trainee therapists. Trainee and practicing music therapists may feel they see very few LGB clients in their clinical areas; be those areas in aged care, or child and family settings; nevertheless it is certain that all therapists will work with an LGB client at some stage, given that an estimated 7% of adults in mental health services are LGB, and that LGB individuals utilise therapy at a higher rate than their heterosexual counterparts (Cochran et al. 2003; Cochran, Sullivan & Mays, 2003). Reviewing theories and applying them to case studies and real life experiences is another manner of addressing LGB issues (chosen by one respondent). As discussed, models need to regularly updated, and models that address diversity in all its forms must be developed (Milton & Coyle, 1999). Other programs used multi-faceted approaches in the provision of LGB issues, such as specific readings; followed by discussions, lecture presentations, films and projects. Class discussions are an interactive way of learning about LGB issues, however the literature emphasises the importance of using current and up-to-date research and findings on LGB issues (Greene, 1994). Film may be an effective way of familiarising students with LGB history, culture and community with time for discussion afterwards. One program addressed LGB issues in a taught course entitled Power, privilege and 121

Discussion oppression. The dominant discourse is often under the assumption that heterosexuality is the norm and those others sexualities only deviate from this. Privilege is a concept, which is mentioned in the literature in relation to heterosexuality. Bieschke (2002, p. 575) notes, participants in the dominant discourse often do not even think of their heterosexuality as a social identity and thus remain unaware of the privileges (i.e. unearned assets) and status associated with that identity. Having LGB faculty members is obviously a bonus if implementing or addressing LGB issues, and one openly gay respondent modelled his own identity for students, and guided them in LGB specific issues. Another respondent said that gay faculty addressed the issues personally and often LGB students self-identified and educated peers. Having LGB faculty members is obviously an asset to a program when addressing LGB issues; however they must be knowledgeable on LGB issues in therapeutic contexts. LGB faculty and students can share their own narratives with students, which could give their classmates a clearer view of LGB perspectives, but the responsibility should not be on LGB students to educate their classmates on important issues and a more structured treatment of LGB issues is imperative. This should be facilitated by a staff member who has explored and is knowledgeable about LGB specific issues, whether they themselves are heterosexual or LGB. Heterosexual educators can address LGB issues as confidently and as successfully as LGB educators. In the same way, heterosexual therapists can work with LGB clients as effectively as LGB therapists, as long as they are knowledgeable about LGB perspectives and issues and have some experience or training in the area. Being LGB does not automatically equip a therapist with the necessary knowledge to competently treat all LGB clients (EubanksCarter et al. 2005, p. 3). As we have discussed being a member of a sexual minority in our society is a distinctly different experience from being heterosexual. It is however, an experience often overlooked and many respondents in this vein said they addressed LGB issues in the same manner as they would any other client issues, though a client-centred or person-centred approach. Many scholars are of the opinion that the generalist training model is not adequate to prepare therapists to work effectively with LGB clients, in fact the inherent heterosexist biases of this model, may result in harm to LGB clients (Philip & Fisher 1998. in Godfrey et al. 2006, p. 91). Some respondents commented that their students learn to approach all clients, with the same positive regard, and that LGB clients are treated no different to any other people, however client-centred methods and non-judgemental attitudes are not sufficient, without a comprehensive knowledge of LGB issues across the life 122

Discussion span. Davies (1996, p. 25) asserts it is not enough to offer Rogers (1951) core conditions. Therapists should learn the particular strengths and unique challenges of LGB persons and their families, as well as the ways in which LGB culture is both similar and different from the dominant culture (Godfrey et al. 2006, p. 491). It should also be stressed that it would be beneficial for therapists to be aware of the differences and diversity within the LGB community too. Over half of the 41 programs in the survey could provide a clinical practicum with LGB clients. However just 6 out of the 17 programs that addressed LGB issues specifically could provide a clinical practicum with LGB clients. Twenty-two programs in total could provide a clinical practicum, but half of these did not address issues specific to LGB clients in their program. It may be the case that some programs who do address LGB issues can not facilitate students who wish to work with LGB clients, due to lack of appropriate clinical sites. On the other hand, some programs may not address LGB issues specifically in the curriculum, but a clinical site working with LGB clients may be available for students who wish to pursue it. The results then would indicate that some students learn about LGB issues only if they request to work specifically in a setting with LGB clients and the university can facilitate it. They then may examine issues specific to LGB clients with a supervisor on the clinical practicum, rather than during their class time. Attention to issues concerning different clinical populations is an important component of music therapy education. Students learn about the needs and issues facing many clinical populations in class. It is perhaps impossible to address every single population and sub-population in class, and often students learn a great deal through their clinical practicum. Students may have a particular clinical interest and pursue a practicum in this area, whether or not they have studied this population in class. In some programs, where students have practicum for the entire duration of the program, students may begin a practicum with a client population, which they have not yet covered in class. The student would then learn about that population, under supervision on practicum. Then when the population is later being studied in class, they would have the practical knowledge and experience to support the theory. However, the fact that students may work with LGB clients in any clinical population from adolescence to older adults, makes it vital that they have been exposed to LGB issues in the classroom environment, whether or not a practicum site is available specifically with LGB clients. It is unlikely that students will work in a LGB specific clinical placement unless working at a gay mens health project, a LGB specific ward or a LGB youth centre. Geographic location, city or town size, class size, rotation of practicum sites and popularity of certain practicum sites will of course come into play and affect the availability of an LGB specific site. It is nevertheless certain 123

Discussion that LGB clients will be scattered among all clinical populations where students train and therefore, they must be adequately prepared to work effectively with LGB clients, having addressed LGB issues as part of the program.

5.1.3. LGB issues in music therapy

In a similar vein, to the importance of LGB as component of the respondents programs, here over 80% indicated these were moderately important to very important issues for music therapy education in general. Of particular interest again was that more than two-thirds (70.3%) of the programs that did not address LGB issues, still thought that these issues were moderately to very important as a component of music therapy education in general. These results are reminiscent of Toppozadas (1995) study of music therapists attitudes toward multicultural issues, where she found that although the issue of multiculturalism was perceived important for music therapy, training is this area was taking place on the job, rather than in training programs. Program content is generally tailored to meet professional requirements, therefore although some programs may consider LGB issues an important part of music therapy education, perhaps there is no encouragement from associations or professional bodies to address these issues. There was a general consensus on the academic level at which LGB issues would be best addressed with a majority of 87.2% of respondents indicating that university music therapy programs would be most suitable. Considering that only 41% of the programs addressed issues specific to LGB clients, this suggests that although, many respondents do not specifically address LGB issues, they feel that music therapy programs are the place to best address them. Over 76% of the respondents felt that LGB issues would be suitably addressed in continuing professional education, however only 5 of those respondents indicated that LGB issues would be best addressed here in isolation, without previous exposure to LGB topics at university. Although one respondent said that due to curricular pressure it might be good to start to address LGB issues in Continuing Professional Development, so that mature professionals lead the way with thinking about the issues, the majority felt that university level programs were the place to best address the issues. The literature emphasises that LGB issues should be discussed and addressed at undergraduate level, graduate programs, continuing education and in-service training (Garnets et al. 1991; Greene, 1994; Eubanks-Carter et al. 2005). In this survey a total of 41% of the respondents indicated that these issues would be best addressed at all three levels of education from undergraduate through to continual

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Discussion professional development. There was a marked disparity between those who addressed LGB issues and those that did not, with 62% of respondents who addressed LGB issues and only 26% of the respondents who did not specifically address LGB issues choosing all three levels. Perhaps, the disparity is due to the fact that the music therapy programs, that address LGB issues, see them as valuable and practical for therapists at all levels, while those that do not indicated perceived low priority was the biggest reason for not addressing LGB issues in their programs. Interestingly, from the programs who did not address LGB issues specifically, 52% of the directors indicated that these issues would be best addressed at undergraduate level, and 60% indicated they would be well addressed at post-graduate level, highlighting the fact that many of the programs who dont address LGB topics, still consider university, the time to address them. Overall, a majority of over 70% of the programs that did not address LGB issues indicated that these issues would be better addressed in continuing professional education, perhaps indicating that although many feel LGB topics should be dealt with at university level, these issues are more suitable after qualifying, or for those who wish to specialise in this area. One program expressed concern that if LGBT are addressed at undergraduate level, students may view LGBT sexualities as a disability or a disorder like the other clinical populations they study. It can be supposed that LGBT sexualities might be associated with clinical disorders only if they are portrayed in that way. If these issues are approached in structured manner and are integrated throughout the curriculum from ethical studies to developmental psychology; students would then understand that these are relevant and important issues for working with all clinical populations. One program commented that LGB issues could be an advanced practice topic for people who are interested in working with individuals who have issues related to their gender and sexual identities. However, these issues are relevant to all therapists whether or not they are specifically working with LGB clients or want to specialise in that area. Perhaps LGB issues would be more suitably addressed at post-graduate and masters level, when students have a little more maturity and are addressing other issues in relation to ethics, but it seems that these issues should not be isolated in one part of the curriculum. If undergraduates are studying developmental psychology or another subject, where LGB topics are relevant then they should be included. It is important that music therapy students are familiar with LGB issues and issues of diversity at undergraduate level; it also might be an opportune time for student to reflect on their own sexualities, and values, and beliefs in relation to LGB sexualities. As one respondent said I strongly believe that undergraduate students need to understand issues of diversity and their feelings and issues surrounding all different lifestyles and cultures. The majority of the music therapy directors in this survey feel LGB issues would be best addressed in music therapy programs, and many 125

Discussion also would encourage further attention to be given to these issues in continuing professional education. There was a high correlation between the LGB topics that program directors addressed and those they thought important for music therapy education, with HIV/AIDS, sexual identity development homophobia and ethnic and religious orientations all ranked at the top; however the suicide and substance abuse topic was different. This topic was ranked in 11th place by respondents in the LGB topics they addressed in the various programs, but it was ranked 1st place in the topics they thought were important for music therapy education and this is quite significant. Suicide and substance abuse can be a serious risk for LGB individuals, but especially LGB youth, however it was placed quite highly on the list of important topics, perhaps ahead of more important and central issues such as the coming out process, which can be a mental health stressor for many LGB youth causing substance abuse, para-suicide and suicide (Cochran, 2001; Ferguson et al. 2005). There are many LGB topics, which can be covered in the provision of LGB issues, but program space and time constraints, obviously have an impact on the attention given to these topics. Certain topics would seem to cover all populations and age groups such as homophobia, heterosexism, discrimination and gay affirmative approaches, while others may be more age-specific such as sexual identity development, the coming out process, and families of LGB individuals being important topics for dealing with LGB adolescents. However, many of these topics can be relevant at later stages in the lifespan too. Rodalfa & Davis (2003) identified central issues that LGB clients are likely to bring to therapy and Godfrey et al. (2006) indicate topics which that should be minimally known by trainee therapists for working effectively with LGB clients. The topics are presented in Table 5.1 and compared with the topics chosen by the respondents of this survey (Ahessy, 2007).
Essential topics music therapists
Ahessy, 2007 HIV/AIDS Suicide/substance abuse Sexual Identity & Gender Development Homophobia Relationships Conflicts of religious & sexual orientations Minority stress & mental health Discrimination/ Anti-gay violence The Coming out process

Issues relevant in therapy

Rodalfa & Davis, 2003 Sexual minority development Oppression and discrimination Coming out & identity development LGB parenting Bisexuality Assessment of sexual orientation and identity Dual minority status, religious, ethnic.

Essential topics- trainee therapists

Godfrey et al. 2006 Homophobia internalised, institutional Heterosexism Impact of family of origin dynamics Effects of Stigma on LGB clients Coming out issues Long-term relationship skills Societal impact on LGB development

Table 5.1: Topics for training in LGB issues

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Discussion Topics such as homophobia, sexual identity development, relationships and dual minority status were similar to topics selected in table 4.1, however the respondents of this survey placed HIV/AIDS and suicide/substance abuse at the top of their list, which also included gender development. These topics were not included in the other lists; however neither was LGB ageing issues, which highlights the neglected emphasis on LGB ageing issues in psychology and psychotherapy too. Other content areas observed that are essential to effective LGB training include: 1) the increasing fluidity in how LGB individuals self-define; 2) the increased conceptualization and acknowledgment of multiple identities in LGB individuals; 3) alternative clinical services for these changing populations; 4) the importance of community connections and support as a vital factor in clinical services and 5) the ever increasing presence of transgendered individuals. (Schreier, Davis and Rodolfa, 2005) Over three quarters of the program directors thought that that guidelines or training opportunities on working with LGB clients from the music therapy associations would professionally benefit music therapists. This indicates that program directors themselves feel that this is a neglected area in music therapy. Because there is such a scarcity of literature or research on LGB issues in music therapy, there are very few ways in which therapists can become familiar with the needs and issues of LGB clients. Continuing professional education would be one way of developing knowledge in this area and music therapy associations could provide guidelines or resource lists for music therapists, who were not given any training in LGB issues, and feel inadequately prepared to work with LGB clients. Only 4 of the respondents received training in LGB issues when they trained as music therapists. Against this background it is encouraging that 17 programs are now addressing LGB issues, and the area is receiving more attention. One of the latter four respondents graduated in 1987, and the other three between 1995 and 1998. Two of these respondents trained in psycho-dynamically-orientated programs and one trained in a psychoanalytically orientated program. This was surprising considering that psychodynamic and psychoanalytical training programs have not always adequately or positively addressed LGB issues; however the situation has improved in recent years and two of these 127

Discussion respondents trained in the mid-to- late 90s (Milton, Coyle & Legg, 2005). Three of the respondents who were trained in LGB issues now addressed those issues in the training programs they directed, suggesting that perhaps LGB issues are more likely to be addressed if the program director has had some exposure to LGB issues and training in the area. This makes sense and strengthens the relationship between training in, and exposure to LGB issues resulting in the provision of these issues. The fact that three of the respondents who covered LGB issues in their own training, graduated from North American universities, is more than likely linked to the fact that declassification of homosexuality and gay affirmative approaches started much earlier in the North America, than in other parts of the world (Clarke & Peel, 2007).

5.2. Discussion of results - Survey B

5.2.1. Association Information
The response rate from survey B was 22.4%, but viewed by country a response rate of 31% is achieved, and 9 out of the 29 countries included in the survey responded. Many of the countries included in the survey had one national association for music therapy, and others had two organisations, however, Spain had 7 associations and Brazil had 9. There was one response from Brazil and one from Spain, and these two countries accounted for 16 out of the 49 (32%) associations in the survey. The responses from both countries were disappointing considering that they both had considerably more associations than other countries. It has been observed that the reason some countries have multiple associations is due to differences in the professionals disciplines that were developing the profession, such as the psychotherapeutically oriented clinical professions of psychology and psychiatry and the educationally oriented disciplines of special educators and music teachers (Bonde, Pederson & Wigram 2002, p. 294). The philosophical differences between the early pioneers who were promoting the profession of music therapy, could also have affected the number of associations established in some countries this resulted in a cohesive and integrated approach to the development of music therapy, in others competitive elements crept in, and resulted in the flourishing of increasing numbers of associations (Bonde, Pederson & Wigram, 2002, p. 294). There was no response from the American Association of Music Therapy, which was disappointing considering that a large number of American music therapy programs responded to Survey A, and that this association represents such a large number of music therapists.

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Discussion

5.2.2. Provision of LGB issues

Only one association provided guidelines for working with LGB clients, and could offer training opportunities on LGB issues or working with LGB clients. It was disappointing to learn that some of the larger more established associations did not provide guidelines or further training opportunities related to LGB issues. Music therapy associations are not always responsible for training opportunities and continuing professional development, but most have members who work with an array of clients, who follow a code of ethics. Providing guidelines for working with LGB clients would be a simple start in providing resources for music therapists working with LGB clients. Many of the associations make reference to sexual minorities in their codes of ethics, but only in general guidelines in relation to equality or discrimination (Appendix 9). There was a marked disparity between what music therapy program directors and associations thought about LGB guidelines and opportunities for further training in LGB issues. Just over 75% of the music therapy programs in Survey A thought that guidelines in LGB issues and further training opportunities would be professionally beneficial for music therapists, yet only one association provided these. This raised a broader issue as to whether music therapy programs and music therapy associations communicate with each other. The results would suggest that there may be little cross-talk between music therapy programs and associations in many countries. Since many music therapists graduated without exposure or training in LGB issues, retraining in LGB issues would surely be beneficial to practicing therapists, enhancing their clinical work. Davies (1996, p. 30) emphasises the purpose of retraining is twofold: 1) to explore ones own attitudes to homosexuality, from a personal and professional perspective 2) to gain sufficient information regarding LGB lifestyles and a sound understanding of homophobia and heterosexism. A recent survey of therapists reported that 42% of participants had commonly dealt with LGB issues in therapy (Ford & Hendrick, 2003. In Eubanks-Carter, 2005). The results from Survey B indicate that over 35% of the respondents to their knowledge indicated they had members working with LGB clients. This figure is probably an under-estimate. It may mean that 35% of the associations have members working specifically with LGB clients, but any practicing music therapist will be likely to work with LGB clients at some point irrelevant of

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Discussion the population with which they predominantly work with. Due to more public awareness and acceptance of LGB individuals, therapists are likely to encounter more and more openly LGB clients than ever before. With LGB individuals openly acknowledging their sexual orientation and with many LGB couples raising families, therapists can expect to see more and more LGB clients as well as LGB members of clients families (Johnson & OConnor, 2002. in Eubanks-Carter et al. 2005).

5.2.3. LGB issues in music therapy

A majority of over 60% of the respondents thought that training in LGB issues at university level would professionally benefit music therapists and those same respondents thought that LGB issues were moderately important to important for practicing music therapists in their country. They supported undergraduate and post-graduate training in LGB issues, so that music therapists would qualify with some expertise in the area. Survey A indicates that only 40% of the music therapy programs specifically address LGB issues, which means that many trainee music therapists may not be exposed to these important issues. The four respondents who indicated that these issues were of little or no importance, also indicated that the inclusion of LGB issues in the music therapy training curriculum would not be beneficial for music therapists. This divide created two groups in the survey of associations; one group, who did not consider LGB issues important for music therapists, or consider training in LGB issues worthwhile, and another group with a contrary view. The results indicate that both music therapy programs and associations feel that addressing LGB issues would benefit music therapy students and music therapists, but that neither group is adequately addressing these issues.

5.3. Limitations
Although the response rate for the music therapy programs in Survey A was close to expected response rates from electronic questionnaires, it was disappointingly low. The majority of respondents who answered the questionnaire did so in the first week, and directly after the second reminder was sent out. Nowadays people receive personal, business, and commercial emails on a daily basis, and often emails are ignored. It is also difficult to know if email addresses are working correctly, as sometimes they do not get resent if they are not functioning. An introductory letter may have been a good strategy to ask respondents if they would like to receive the survey or not, at least that way you could

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Discussion be sure that the respondents received the email, before sending the survey, followed by reminder emails. The low response from the European university programs was another limitation. If it had been higher it would have given the survey a more of a balanced geographical return. As it stands the survey response from the universities is mainly from a North American, and Australasian perspective. The only countries that responded from Europe were: Spain, United Kingdom, Germany, Serbia and Israel. It was a pity not to have had a response from more of the central European and Scandinavian programs. This would have given the survey more weight, and made it more relevant for Europe.

5.4. Recommendations and implications for music therapy

In the survey conducted regarding LGB issues in music therapy programs, 75% of program directors indicated that they thought that guidelines from the music therapy associations on working with LGB clients and LGB specific issues would be beneficial for music therapists, and this would seem be an indication for practicing music therapists to begin demanding such resources. Associations could look at existing guidelines like those provided by the American Psychological Association and modify them for music therapists. Courses on LGB issues could be initiated with help of LGB groups and counsellors to provide practicing music therapists with opportunities for continuing professional development in this area. This is especially vital for those therapists, who were not exposed to LGB issues in their music therapy training, and feel inadequately prepared to work with clients who are LGB. Because there is a dearth of literature on LGB issues in music therapy, music therapists need resources to increase their knowledge of LGB issues. Music therapists could consult LGB specific journals such as The Journal of Homosexuality and The Gay & Lesbian Issues & Psychological Review, as well as assessing LGB internet sites to become more familiar with the LGB community and LGB issues. One such site is the American Psychological Association (www.apa.org), which provides guidelines to improve understanding, knowledge and recognition LGB issues in four areas (1) attitudes toward LGB people and sexual orientation issues, (2) relationships and family concerns, (3) the complex diversity within the LGB community, and (4) the training and education of current and future members of the profession. The University of California (Davis) has another comprehensive counselling and psychological website (www.caps.ucdavis.edu), which has a wealth of information and articles on LGB issues, as well as a list of potentially useful publications and resources. Music therapists should be aware of local LGB organisations and groups, which can be 131

Discussion recommended to clients who may feel isolated. Music therapists could also acquire a contact such as an LGB counsellor or psychologist, with expertise in the area for consultation, who could assist them in any difficulties that might arise while working with LGB clients in therapy. Clearly there is a need for research in relation to LGB issues and perspectives in music therapy Music therapists working with LGB clients on LGB specific issues could publish case studies and clinical reports to increase the literature on these themes, which in turn would provide texts to study in music therapy programs. Music therapists working with LGB clients could also present their experiences and findings at conferences and educate colleagues in the area. LGB guest lecturers could be provided who have expertise in LGB issues to work along side educators or faculty to increase their understanding on LGB issues and how to address them. Music therapists should strive to be LGB affirming, and assessment forms and other documentation could be revised for heterosexist-biased language. Music therapists should also recognize how their attitudes and knowledge about lesbian, gay, and bisexual issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals where necessary. In the survey of music therapy directors 75% of respondents also indicated that training opportunities in LGB issues would be beneficial for practicing music therapists. Music therapy educators could seek out continuing professional education in LGB issues, in order to then address these issues confidently in their programs and adaptations could be made to existing curricula to incorporate LGB issues. It is imperative that music therapy educators examine topics throughout music therapy training from many perspectives including LGB perspectives. Music therapy programs need to strive to be LGB inclusive in their provision of lifespan issues, something that many psychotherapy programs have neglected to do Since education is a socialisation process that imparts the values of the dominant culture, the majority of therapy training programs through both course work and practice, continue to explore individual development, sex, gender, coupling, family and relationship issues solely within a heterosexual context (Davies, 1996, p. 29). Music therapists need to consider diversity and generational differences within LGB populations, and the particular challenges that may be experienced LGB older adults. This was an area completely under-addressed in the music therapy programs that addressed LGB issues, and as discussed, is a key area for music therapy students in aged care practica. 132

Discussion Music therapy educators could reassess the curriculum, in order to integrate these topics where necessary, and provide student with opportunities for self-reflection, attitude inventories as well as LGB bibliographic resources. Music therapy students could also be encouraged to pursue LGB research in music therapy at masters and doctoral level, in order to increase our literature base in the area. We need to be reviewing and updating our theoretical models, and developing models that address diversity and are LGB inclusive. Davies (1996, p. 25) explains how the existing theoretical schools can be incorporated, augmenting them where necessary with gay affirmative concepts and current thinking on human sexuality and that LGB affirmative guidelines should take priority and that when there is conflict between an existing therapeutic model and the gay affirmative guideline when working with LGB clients, the gay affirmative guideline should take precedence. Music therapy departments could form alliances with the university LGB organisations, invite guest lecturers to present different topics for the students, so students hear first hand the experiences of LGB individuals. Faculties could also strive to be gay affirmative and ensure that all students know that diversity is celebrated, and encourage LGB students to share their experiences with classmates. Supervisors could be more aware of LGB issues and prepare students on clinical practicum for working with LGB clients.
Well-meaning practitioners with good intentions may, for example, believe their

acceptance of lesbian, gay, and bisexual people is enough to provide effective psychological services to members of this population, however, music therapists need to be aware of the homonegativism that to a degree all people carry. Therefore, it is paramount that music therapists explore and challenge any assumptions and beliefs they have towards LGB individuals and strive to value and affirm LGB life experiences (Schreier, Davis and Rodolfa, 2005). Schreier, Davis and Rodolfa (2005) give three practical actions therapists can take in relation to improving practice with LGB clients, which are equally important for the music therapy community: 1) therapists need to support the provision of professional education and training on LGB issues; 2) therapists need to increase their knowledge and understanding of homosexuality and bisexuality through continuing education, training, supervision, and consultation; and 3) therapists need to make reasonable efforts to familiarize themselves with relevant mental health, educational, and community resources for LGB individuals.

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Discussion Coming out can be a life long process for LGB clients and educating ones self about the ever-changing LGB world should be a lifelong process for therapists (Schreier, Davis and Rodolfa, 2005).

5.5. Directions for future research

Clearly there is a need for research in relation to LGB issues and perspectives in music therapy. Clinical reports and case studies by music therapists working with LGB clients would be beneficial to the field, providing literature that could be studied when examining LGB issues in music therapy programs. Music therapists working with LGB clients could also present at conferences and educate colleagues in the area. One program director felt the researcher could have asked other questions in relation to the topic: I think that several important questions you did not ask: how many LGB students have you had in your program throughout the years? Were they open about it? Did the group accept them? Did they have difficulties in their internship sites? Although not addressed in this thesis, these are important questions, which could be answered by future research. The experiences of LGB students in music therapy training programs is a separate issues and rather than incorporating it into the present study, this researcher thought it would be more appropriate to treat this topic in isolation in the future. Another topic for future research, which might be illuminating, is the experiences of music therapists who are LGB. Are they open about their sexualities in their work? Have they experienced discrimination from service providers, in their work environments, or from professional bodies? Is there a need to conceal their sexual identities in certain circumstances? How do they deal with homophobic clients? How do they deal with homophobic or heterosexist colleagues? Research could be conducted on music therapists who specifically work with LGB clients to investigate if they use any specific methods and techniques when dealing with certain LGB related problems. Further research on LGB content in music therapy curriculum could also be conducted, and the survey used in this study could be replicated at a later stage to evaluate developments in the provision of LGB issues in music therapy programs. Future research might also evaluate the provision of LGB issues in training programs from trainees perspectives. An investigation of music therapy students views on LGB coverage within training programs and if students feel adequately prepared for working with LGB clients would be valuable.

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5.6. Conclusion
The literature review in this thesis has identified important issues that affect healthcare, diagnoses, treatment and therapeutic endeavours with LGB clients. It has examined central LGB lifespan issues, as well as affirmative approaches and observed much neglect in LGB issues in the training of therapists in related disciplines. The two surveys have revealed that a large proportion of music therapy training programs do not specifically address LGB issues, however, reasons such as time constraints and already overloaded curricula make addressing these issues difficult. Those that do address LGB issues do so in a variety of manners, but there is support to integrate these issues across the curriculum, rather than addressing LGB issues in isolation. The majority of the program directors considered LGB issues to be an important part of music therapy education, and indicated that these issues should be addressed in music therapy training programs. Some program directors indicated that this is a much neglected area and an area that needs attention. They also expressed a need for associations to provide guidelines on working with LGB clients and opportunities for further training in LGB issues. Music therapy associations are not providing any guidelines or further training opportunities for working with LGB clients, however many are aware of member music therapists working specifically with LGB clients. The respondents from the associations also support the provision of LGB issues in training programs and the majority thought that addressing these issues at university level would professionally benefit music therapists. LGB issues require urgent attention in the field of music therapy from an ethical point of view to ensure that we foster competent care for LGB individuals. Because the research highlights that LGB individuals experience considerable stress and hostility in society, and legal systems limit the human rights of LGB individuals on the basis of their sexuality, there is an urgent need for LGB affirmative approaches in music therapy praxis, in which LGB identities are valued, supported and affirmed. It is very likely that the practice of gay affirmative music therapy shares many similarities to the practice of culturally sensitive music therapy in that it is an incremental processnot something that is achieved immediately a journey of discovery (Brown, 2002, p. 92). Music therapists need to explore LGB issues and develop skills in this area. The only way we can foster gay affirmative music therapy is through education, both at undergraduate and post graduate levels, through continuing professional education and with an increase in LGB resources for music therapists, as well as an increase in published LGB related music therapy literature. It is high time for these issues to be addressed in music therapy, and high time that the love that dared not speak its name, sings its name loud and clear and is heard by the field.

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References

References
Abbott, D. & Howarth, J. (2004). Secret Loves, Hidden Lives: what do learning disability staff think about same sex relationships for people with learning difficulties? Norah Fry Research Centre, University of Bristol. American Psychological Association. (2007a). Answers to your questions about transgender individuals and gender identity. Retrieved 23 May, 2007 from
http://www.apa.org/topics/transgender.html

American Psychological Association. (2007b). Answers to your questions about individuals with intersex conditions. Retrieved 23 May, 2007 from
http://www.apa.org/topics/intersx.html

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Appendices

Appendices
Appendix 1 Appendix 2 Appendix 3 Appendix 4 . Appendix 5 Appendix 6 Appendix 7 Appendix 8 Appendix 9 Music Therapy associations codes of ethics.................................... Survey A Introductory letter and debrief page Survey A Questionnaire... Survey B Introductory letter and debrief page... Survey B Questionnaire... Survey A Introductory letter (Spanish version) Survey A Questionnaire (Spanish version)... Survey B Introductory letter (Spanish version).. Survey B Questionnaire (Spanish version) 153 154 155 159 160 161 162 167 168 169 172

Appendix 10 Survey A Further comments.. Appendix 11 Survey B Further comments..

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Appendix 1: Music Therapy associations codes of ethics

In the European Music Therapy Confederations code of ethics there is a mention of sexual minorities, but only in relation to equality of opportunity. Insofar as it lies within the music therapists discretion, patients/clients shall have equal rights of access to assessment and treatment regardless of their race, religion, ethnicity, gender, sexual orientation or any form of disability not relevant to the advisability or otherwise of treatment. Insofar as it lies within the music therapists discretion, candidates for training, prospective supervisees, applicants for professional recognition or research funding shall not be discriminated against on grounds of race, religion, ethnicity, gender, sexual orientation or any form of disability which does not affect competence. (European Music Therapy Confederation, 2000) The American Music Therapy Association makes reference to sexual orientation in the general standards section and section on relationship with clients/students/research subjects. The music therapy refuses to participate in activities that are illegal or inhumane, that violate the civil rights of others, or that discriminate against individuals based upon race, ethnicity, language, religion, marital status, gender, sexual orientation, age, ability, socioeconomic status, or political affiliation. In addition, the music therapist works to eliminate the effect on his or her work of biases based upon these factors. The MT will not discriminate in relationships with clients/students/research subjects because of race, ethnicity, language, religion, marital status, gender, sexual orientation, age, ability, socioeconomic status or political affiliation. (American Music Therapy Association, 2006).

The Australian Music Therapy Association makes a reference to sexual preference rather than sexual orientation in its section on general principles. Members have respect for all people without discrimination on the basis of colour, culture, nationality, gender, sexual preference, religion, politics or social status,. Members will have inclusive respect for the cultural and societal norms of all people. (Australian Music Therapy Association Inc, 2001).

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Appendix 2: Survey A l Introductory letter and debrief page

The Provision of Lesbian, Gay & Bisexual Issues in Music Therapy Education
Dear Music Therapists, My name is Bill Ahessy I received my BMus at University College Cork in Ireland. Following that I received my Graduate Diploma in Music Therapy and clinical training at the University of Technology in Sydney, Australia. Last year I moved to Spain to undertake a Masters by Research in Music Therapy at the University of Cadiz under the supervision of Prof. Patricia L Sabbatella. This questionnaire is a part of my Masters Thesis. After reviewing much of the lesbian, gay and bisexual (LGB) psychology and psychotherapy literature, It appears that there is a serious lack in the provision of LGB issues in psychology and psychotherapy training courses. Even though there has been numerous developments in LGB psychologies over the last two decades and a significant growth in gay affirmative approaches, there seems to be a huge gap between theory, training and practice. I am sending this survey to music therapy courses worldwide to assess the provision of LGB issues in music therapy education. (I am also be sending a survey to music therapy associations to assess LGB issues in continuing education). Results of the survey will be of course be available to participating Universities. All the participating institutions will be acknowledged, but no individual contribution will be traceable to the source, unless specific permission is explicitly given. Please click on the link below to fill out this brief survey. http://FreeOnlineSurveys.com/rendersurvey.asp?sid=morpgsp6chzlliu290990 Thank you for your time, Bill Ahessy billahessy@gmail.com c/ Libertad 9 - 3A Cadiz 11005, Espaa Mobile: +34664518612 Home: +34856170764l Debrief page for the music therapy programs I would like to thank you for taking the time to fill out the survey, it is much appreciated. The results will be available later in the summer and can be sent to interested universities. For any further comments or questions please feel free to contact me by email. Bill Ahessy Grad Dip MT, BMus Universidad de Cdiz Facultad de Ciencias de la Educacin Campus Universitario de Puerto Real 11519 - Puerto Real - Cdiz - Espaa Tel: 0034 664 518 612 billahessy@gmail.com musictherapyresearch@gmail.com

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Appendix 3: Survey A Questionnaire

1) Details University/Institution name Your name Position Year you graduated as an MT University you graduated from Theoretical orientation of that program

2) What type of music therapy program do you direct? Undergraduate Post-graduate/Masters Doctoral Other (please specify)

3) What is the duration of your music therapy program? 1 year 1.5 years 2 years 2.5 years 3 years 4 years 5 years (2 semesters) (3 semesters) (4 semesters) (5 semesters) (6 semesters) (8 semesters) (10 semesters)

4) What is the duration of your practicum/clinical placement for students? 3 months 6 months 1 year 1.5 years 2 years 3 years (1/2 semester) (1 semester) (2 semesters) (3 semesters) (4 semesters) (5 semesters)

5) What is the predominant or central theoretical orientation of your program? 6) In the provision of multicultural/culturally sensitive issues in your music therapy program, which of the following topics are addressed? (please tick the relevant boxes) Ethnicity Race Gender Lesbian, gay & bisexual Religious Immigration Other (please specify)

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7) Do you address issues specific to lesbian, gay & bisexual clients in your music therapy program? If Yes, please skip the next question (Q.8) and continue with the survey. If No, please answer the next question (Q.8) and then move to question 13 Yes No 8) Issues specific to lesbian, gay & bisexual clients are not specifically addressed due to (please tick one or more) Time constraints Curricular pressure Lack of appropriate staff Perceived low priority Insufficient clinical need No student demand No professional demand Other (please specify) 9) Treatment of issues specific to lesbian, gay & bisexual clients are addressed in (please tick one or more) A core module Part of a core module An optional module Part of an optional module Integrated in all modules across the curriculum Workshops, role-play Presentations by guest lecturers/speakers Guided private reading/study Practicum/clinical placement Contact with LGB organisations Other (please specify)

10) The following topics are addressed in the treatment of LGB issues in our program (please tick all that apply) Gender Development The coming out process Internalised homophobia Discrimination/Ant-gay violence LGB adolescence Relationships LGB ageing Children of LGB individuals Transgender/inter-sex issues Ethnic minority status & sexuality Conflicts of religious & sexual identities Suicide, substance abuse Sexual identity development Homophobia (societal, institutional) Heterosexism Minority stress & mental health LGB midlife Parenthood Families of LGB individuals Bisexuality HIV/AIDS Disability & sexual orientation Conversion/reparative therapies Affirmative approaches Other (please specify)

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11) How important would you rate LGB issues as a component of your music therapy program? Very important Important Moderately important Of little importance Unimportant

12) How do you prepare students for work with lesbian, gay & bisexual clients?

13) Can you facilitate students who wish to do practicum/clinical placement with LGB clients? Yes No 14) How important would you rate LGB issues as a component of music therapy education? Very important Important Moderately important Of little importance Unimportant

15) Where do you think in music therapy education LGB issues would be best addressed? Undergraduate] Post-graduate/Masters Continuing education Other (please specify)

16) Which do you think are the most important topics that should be addressed in music therapy education? Please tick 10 of the following topics Gender Development The coming out process Internalised homophobia Discrimination/Ant-gay violence LGB adolescence Relationships LGB ageing Children of LGB individuals Transgender/inter-sex issues Ethnic minority status & sexuality Conflicts of religious & sexual identities Suicide, substance abuse Sexual identity development Homophobia (societal, institutional) Heterosexism Minority stress & mental health LGB midlife Parenthood Families of LGB individuals Bisexuality HIV/AIDS Disability & sexual orientation Conversion/reparative therapies Affirmative approaches Other (please specify)

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17) Do you think it would be beneficial for music therapists if music therapy associations provided guidelines or training in issues related to LGB clients? Yes No 18) Were LGB issues addressed when you trained to become a music therapist? Yes No 19) All participating universities will be acknowledged, but no individual contribution will be traceable to the source unless permission is explicitly given. Would you like to give permission? Yes No 20) Would you like to receive the results of this survey? Yes No 21) Any further comments

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Appendix 4: Survey A Introductory setter and debrief page

Lesbian, Gay & Bisexual Issues in Music Therapy: Continuing Education & Associations
Dear Music Therapy Associations, My name is Bill Ahessy. I received my BMus at University College Cork in Ireland. Following that I received my Graduate Diploma in Music Therapy and clinical training at the University of Technology in Sydney, Australia. Last year I moved to Spain to undertake a Masters by research in Music Therapy at the University of Cadiz under the supervision of Prof. Patricia L Sabbatella. This questionnaire is a part of my Masters Thesis. After reviewing much of the lesbian, gay and bisexual (LGB) psychology literature, It appears that there is a serious lack in the provision of LGB issues in psychology and psychotherapy training courses. Even though there has been numerous developments in LGB psychologies over the last two decades and a significant growth in gay affirmative approaches, there seems to be a huge gap between theory, training and practice. I have sent a survey to university music therapy programs to assess the provision of LGB issues in music therapy education. The purpose of this survey is to assess the provision of LGB issues in continuing education or guidelines from the music therapy associations across the globe. Results of the survey will of course be available to participating associations. Although all participating associations will be acknowledged, no individual response will be traceable to the source unless specific permission is given. Please click on the link below to fill out this brief survey. http://FreeOnlineSurveys.com/rendersurvey.asp?sid=ulb281bffqi21qg294873 Thank you for your time, Bill Ahessy billahessy@gmail.com c/ Libertad 9 - 3A Cadiz 11005 Espaa Mobile: +34664518612 Home: +34856170764 Debrief page I would like to thank you for taking the time to fill out the survey. The results will be available later in the summer and can be sent to interested universities. For any further comments or questions please feel free to contact me by email. Bill Ahessy Grad Dip MT, BMus Universidad de Cdiz Facultad de Ciencias de la Educacin Campus Universitario de Puerto Real 11519 - Puerto Real - Cdiz - Espaa Tel: 0034 664 518 612 billahessy@gmail.com musictherapyresearch@gmail.com

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Appendix 5: Survey B Questionnaire

1) Details
Name of association Country Year of establishment Your name Position/role held

2) Do you provide guidelines for music therapists addressing, working with LGB clients? Yes No 3) Do you provide opportunities for music therapists to receive further training/continuing education
in issues specific to LGB clients?

Yes No 4) Do you have to your knowledge any members working with LGB clients or in LGB specific settings? Yes No 5) Do you think it would professionally benefit music therapists to receive some training in issues
specific to LGB clients at undergraduate or post-graduate level?

Yes No
6) How important do you perceive LGB issues for practicing music therapists in your country? Very important Important Moderately important Of little importance Unimportant

7) Any further comments

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Appendix 6: Survey A Introductory letter (Spanish)

Temas relacionados con Lesbianas, Gays y Bisexuales en la Formacin de Musicoterapeutas
Hola, mi nombre es Bill Ahessy. Soy licenciado en Musica por la University College Cork, Irlanda, y especialice en Musicoterapia en la University of Technology de Sydney, Australia. Actualmente estoy cursando estudios de Master en Musicoterapia en la Universidad de Cadiz, Espaa bajo la supervisin de la profesora Patricia L Sabatella. El cuestionario que se presenta a continuacin forma parte de mi trabajo de investigacin de tesis de master. El tema de mi tesis se centra en el enfoque se brinda al tema de la poblacin homosexual en los cursos universitarios de formacin de musicoterapeutas, siendo su objetivo el conocer el estado de la cuestin sobre este tema.

Muchas gracias por responder a este cuestionario.

Bill Ahessy Grad Dip MT, BMus Universidad de Cdiz Facultad de Ciencias de la Educacin Campus Universitario de Puerto Real 11519 - Puerto Real - Cdiz - Espaa Tel: 0034 664 518 612 billahessy@gmail.com musictherapyresearch@gmail.com

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Appendix 7: Survey A Questionnaire (Spanish)

1) Detalles Universidad/Institucion Nombre Cargo Ao de graduacin como musicoterapeuta Universidad Orientacin terica de la formacin que recibi como musicoterapeuta

2) Nivel acadmico del programa de formacin en musicoterapia Licenciatura Experto/Master PHD Other (please specify)

3) Duracin del programa formacin en musicoterapia ofertado 1 ao (2 semstres) 1 ao y medio (3 semestres) 2 aos (4 semestres) 2 aos y medio (5 semstres) 3 aos (6 semestres) 4 aos (8 semestres) 5 aos (10 semestres) Other (please specify)

4) Duracin del periodo de prcticas de musicoterapia que contempla el programa de formacin 3 meses 6 meses 1 ao (2 semestres) 1 ao y medio (3 semestres) 2 aos (4 semestres) 2 aos y medio (5 semestres) 3 aos (6 semestres) Other (please specify) 5) Cul es el modelo terico central o predominante en la programa que imparte? 6) Del siguiente listado Indique los temas que son abordados en el programa de formacin que ustedes imparten (marca una o mas opciones) Minorias Etnicas Temas relativos al Racismo Cuestiones de Genero Temas relativos a la poblacin Lesbiana/Gay/Bisexual Temas relativos a la religin Temas relativos a inmigracion Other (please specify)

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7) Se tratan en la formacin cuestiones especficas relativas a las poblaciones gays, lesbianas y homosexuales? Si la repuesta es No, continue en la pregunta 8 y salta a pregunta 13 y contiue con el cuestionario Si la repuesta es Si, salta pregunta 8 y continue con el cuestionario Si No 8) Esto es debido a (marca una o mas opciones) Restricciones de tiempo Organizacin curricular Falta de personal adecuado Es una prioridad secundaria dentro de la filosofia de la formacin Infraestructura clnica insuficiente Falta de demanda estudiantil Other (please specify) 9) En caso de ofertar este tipo de formacin, de qu forma se organiza? (marca una o mas opciones) Un modulo obligatorio Parte de un modulo obligatorio Un modulo optativo Parte de un modulo optativo Integrado en los diferentes mdulos del currculum En forma de taller o clases prcticas Conferencias y charlas de invitados Estudios y lecturas individuales y guiadas Prcticas clnicas Contacto con organizaciones de gays, lesbianas y bisexuales Other (please specify)

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10) Indique cules de los siguientes temas se abordan en la formacin ofertada sobre las cuestiones de gays, lsbianas o bisexuales? Cuestiones de gnero El proceso de "Salir del Armario" Homofobia individual Discriminacin/Violencia antigay La adolescencia gay, lesbiana o bisexual Las relaciones de gay,lesbiana o bisexual La tercera edad gay, lesbiana o bisexual Los hijos de los gays, lesbianas o bisexuales VIH/SIDA Discapacidad y orientacin sexual Enfoques Terapeuticos en gays, lesbianas y bisexuales Enfoques "gay afirmativo" Desarrollo de la identidad sexual Homofobia (social e institucional) Heterosexualidad Estrs y salud mental de minoras El adulto gay,lesbiana o bisexual La paternidad de gay,lesbiana o bisexual Las familias de gays, lesbianas o bisexuales La bisexualidad Estatus en la minora tnica y orientacin sexual Conflicto de identidades religiosas y sexuales Suicidio / abuso de sustancias Transexuales Other (please specify)

11) Cmo calificara usted las cuestiones de gays, lesbianas y bisexuales como componentes de su programa de msico-terapia? Muy importante Bastante importante Importante De poco importancia No muy importante

12) Cmo preparan a los estudiantes que van a trabajar con clientes gays, lesbianas o bisexuales 13) Facilitan a los estudiantes prcticas clnicas de musicoterapia con clientes gays, lesbianas o bisexuales? Si No 14) Cmo calificara usted las cuestiones de gays, lesbianas y bisexuales como componentes de la formacin en msico-terapia? Muy importante Bastante importante Importante De poco importancia No muy importante

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15) Considera que es mas adecuado abordar las cuestiones de gays, lesbianas y bisexuales en el nivel universitario, en la formacin profesional continua, o en ambos? (marca una o mas opciones) Licenciatura Experto/Master Formacin profesional continua Other (please specify)

16) Cules cree usted que son los 10 asuntos esenciales a tratar en la formacion de musicoterapia?

Cuestiones de gnero El proceso de "Salir del Armario" Homofobia individual Discriminacin/Violencia antigay La adolescencia gay, lesbiana o bisexual Las relaciones de gay,lesbiana o bisexual La tercera edad gay, lesbiana o bisexual Los hijos de los gays, lesbianas o bisexuales VIH/SIDA Discapacidad y orientacin sexual Enfoques Terapeuticos en gays, lesbianas y bisexuales Enfoques "gay afirmativo" Desarrollo de la identidad sexual

Homofobia (social e institucional) Heterosexualidad Estrs y salud mental de minoras El adulto gay,lesbiana o bisexual La paternidad de gay,lesbiana o bisexual Las familias de gays, lesbianas o bisexuales La bisexualidad Estatus en la minora tnica y orientacin sexual Conflicto de identidades religiosas y sexuales Suicidio / abuso de sustancias Transexuales Other (please specify)

17) Considera que puede ser beneficioso para los musicoterapeutas que las asociaciones de msicoterapia brinden directrices para el trabajo con clientes gays, lesbianas o bisexuales? Si No 18) En su propia formacin como terapeuta musical Se trataron las cuestiones de gays, lesbianas y bisexuales? Si No

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19) Todas las instituciones participantes sern mencionadas en los resultados de esta investigacin, pero no se expondr ninguna contribucin individual a menos que explcitamente la institucin est de acuerdo y lo permita. Esta usted de acuerdo y permite que se difundan los datos de su institucin en los resultados de esta investigacin? Si No 20) Le gustaria a recibir los resultados de esta investigacion? Si No 21) Comentarios: Si desea indicar algo ms, por favor hagalo en este apartado

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Appendix 8: Survey B Introductory letter (Spanish)

Temas relacionados con Lesbianas, Gays y Bisexuales en la Formacin Continua de Musicoterapeutas
Hola, mi nombre es Bill Ahessy. Soy licenciado en Musica por la University College Cork, Irlanda, y especialice en Musicoterapia en la University of Technology de Sydney, Australia. Actualmente estoy cursando estudios de Master en Musicoterapia en la Universidad de Cadiz, Espaa bajo la supervisin de la profesora Patricia L Sabatella. El cuestionario que se presenta a continuacin forma parte de mi trabajo de investigacin de tesis de master. El tema de mi tesis se centra en el enfoque se brinda al tema de la poblacin homosexual en los cursos universitarios de formacin de musicoterapeutas, siendo su objetivo el conocer el estado de la cuestin sobre este tema. Muchas gracias por responder a este cuestionario.

Bill Ahessy Grad Dip MT, BMus Universidad de Cdiz Facultad de Ciencias de la Educacin Campus Universitario de Puerto Real 11519 - Puerto Real - Cdiz - Espaa Tel: 0034 664 518 612 billahessy@gmail.com musictherapyresearch@gmail.com

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Appendix 9: Survey B Questionnaire (Spanish)

1) Detalles Associacion Pais Ao del establecimiento Tu Nombre Cargo

2) Proporcionan ustedes a los msico-terapeutas directrices para el trabajo con gays, lesbianas y bisexuales? Si No 3) Facilitan ustedes a los msci-terapeutas formacin especfica en temas relacionados con los gays, las lesbianas, y los bisexuales? Si No 4) Tienen ustedes conocimiento de que algunos de sus miembros trabajen con gays, lesbianas o bisexuales o en entornos de gays, lesbianas y bisexuales? Si No 5) Piensa usted que la formacin universitaria en temas relacionados con gays, lesbianas y bisexuales beneficiara a los msico-terapeutas? Si No 6) Cmo calificara usted las cuestiones de gays, lesbianas y bisexuales para musicoterapistas trabajando en su pais? Muy importante Bastante importante Importante De poco importancia No muy importante

7) Si tienes comentarios acerca de las preguntas encima, por favor escribe el numero de la pregunta (P. ?) antes de tus comentarios.

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Appendix 10: Survey A Further comments

- I think it is useful that this issue is raised in your research. It is something that the programmes I have been involved in teaching/managing have only considered inexplicitly (i.e. as part of group dynamics, and currently as part of tolerance and understanding of 'the other', and awareness of discrimination in a 'World Music and Music Therapy' Paper. However in music therapy, I think we are beginning to consider cultural competency more explicitly now, but gender and lesbian/gay/bi-sexual issues have not been seriously addressed by programmes I have been involved in, up till now, although many gay people have trained, and in mental health, students have encountered issues specific to gay clients. I am not sure how it should be given priority, as there is always too much to do in 2 year masters programmes. it may be good to start with CPD so that the mature professionals lead the way with thinking about the issues. - Muy interesante la encuesta. Por parte de la formacin de Postitulo en CHile, la primera prioridad tiene ensear la musicoterapia, sus metodologas, sus escuelas, tcnicas musicales, indicacin, abarcando contenidos ms bien generales; preparar los campos de trabajo de prctica, que son psiquiatria adulta y ed. diferencial principalmente, algunas temticas mdicas, rehabilitacin neurolgica entre otras, y no incluye el tema de la homosexualidad. Tenemos aun muy pocos musicoterapeutas; confo en que el da maana con ms variedad de personas e inquietudes, el tema de la homosexualidad ser un tema a tratar y ser incluido en las prcticas. En general, es un tema poco tratado. - My gay friends have educated me to believe that they are not a 'special' category just because of who they choose to sleep with. I guess I have taken this attitude into my training of students, and frankly I stick by it. However, if an individual student was grappling with their sexuality, perhaps it would be helpful for them, but I see it as encompassed by the Humanist approach of positive regard when it comes to clients. - This is an important topic for continuing exchange among educators. - I work to help my students have an inclusive attitude and recognize stereotypes and prejudices - thus I think that some of these issues are addressed, although not directly. - When I graduated in '80 with my MMT, AIDS/HIV was not a know disease. The reason that these issues are not more fully addressed in the curriculum is because the majority of MTs don't work with lesbian, gay, or bisexual clients. The courses at Loyola are based on the AMTA Sourcebook and change according to where the majority of MTs are working in the US. Maybe AMTA should have a more specific clinical area on their survey to reflect the number of MTs working with these clients. - Congratulations!!! -O assunto demais importante e espero ter contribuido com sua pesquisa. - Your survey is too specific. In Brazil, the seven existing undergraduate MT programs are not designed to address issues in the way you ask. We strongly address MT to everybody, with no exceptions related do gender, sexual orientation and all the other issues you enlisted above. Thank you and good luck. - It is a complicated issue. I think that several important questions you did not ask: how many LGB students have you had in your program throughout the years? Were they open about it? Did the group accept them? Did they have difficulties in their internship sites? etc. Thanks

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Appendices for doing this research. I think it is important. - Interesting survey, simply wondering where the researcher is coming from and what life/clinical experience informed him/her to carry out such survey - A comprehensive understanding of humankind, in all of its diversity, is an essential for the education of all students, not only music therapists. - I strongly believe that undergraduate students need to understand issues of diversity and their feelings and issues surrounding all different lifestyles and cultures. - Good work. An important topic that is not being given enough attention. - Good luck! - There are many potential populations with whom music therapists work. I think GLB issues are as important as other lifestyle issues, not more important or moderately important, but equally important. - To some extent these competencies are integrated into multicultural competencies which have been addressed in the literature. I do think that further discussion and articulation is really important and our university is really committed to this. -I think the reason this wasn't addressed when I was a student was that in was in the 80s and it just wasn't discussed as openly as it is now. -Best of luck with this important topic - I'm very glad you're doing this survey. I think it is an extremely important issue that doesn't receive enough attention in the profession of music therapy. - LGBT issues shouldn't be heavily addressed in undergraduate training because that makes it seems as though it is a disability or disorder, like the other populations groups that are studied at this level. I see this as an advanced practice topic for people who are specifically interested in working with individuals who have issues related to their gender and sexual identities. For the rest, the emphasis should be on developing enough selfawareness about one's own beliefs and feelings about this topic to make ethical decisions about working with clients who have LGBT identities. Additionally, as a faculty member, I have participated in training to prepare me to effectively address needs and concerns of LGBT students and colleagues at our university. -we deal with these issues whenever they arise -As an openly gay professor I feel it is crucial that I model not only my own identity for students but guide them in issues specific to gay people that may be their clients. -I am very pleased this is being done and will look forward to the outcomes -Thank you for doing this. Good luck in your research -Good luck with the research. It is certainly a needed topic in the music therapy curriculum -Thank you for addressing this important topic. I feel that LGBT issues are not dealt with openly in our field, and that many educators are hesitant to integrate LGBT content into their coursework. Thankfully, in the US, the Code of Ethics at least lists "sexual orientation" as a protected category along with race, ethnicity, etc. It is the Code which is a point of entry into the topic for my students, and I address it in the Introduction to MT 170 class.

Appendices

openly in our field, and that many educators are hesitant to integrate LGBT content into their coursework. Thankfully, in the US, the Code of Ethics at least lists "sexual orientation" as a protected category along with race, ethnicity, etc. It is the Code which is a point of entry into the topic for my students, and I address it in the Introduction to MT class.

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Appendix 11: Survey B Further comments

-I wish you good luck with your Master's thesis! -Our association organizes music therapists. It doesn't provide courses. The answers are my personal comments and do not engage any other member of the organisation. -Our work is with children who have been traumatized by armed conflict. Most are prepuberty and the issues are related to either being traumatized by war or by secondary trauma in the immediate environment. LGB issues are not relevent to our clinic. -My personal opinion is that any patient can be gay, lesbian or bisexual but so are may people and if it is part op the problems we work on in therapy than we deal with that also. I did not consult the members of our association. With kindly regards -Q 2 Code of Ethics provides general guidelines regarding ethical treatment of clients regardless of background, but not specific reference to LGB clients. Q 3 Continuing Professional Development requirements are fairly new in this country, so specific provision of courses by the association is limited and not prescriptive. Continuing education about LGB issues would be considered as addressing music therapy competencies, however, and would be counted toward CPD requirements.

-I do not see that people who have one or the other sexual orientation belong to a certain client group, and should be called LGB clients?? Maybe it is more accepted in our country that people have different ways of living with their sexuality.

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