Contemporary cultures of service delivery to families: implications for music therapy.

Williams, Kate E. ; Teggelove, Kate ; Day, Toni 等

Government policy on early years intervention and prevention programs, and family support programs, has direct and important implications for the work of allied health professionals. Such policies are fundamental to society as a whole because the years from birth to age five constitute a critical period of development within the human lifespan (Shonkoff & Phillips, 2000). Developmental research and early intervention and prevention efforts are essentially geared towards identifying and addressing risk and protective factors for families during these early child-rearing years in order to best support optimal development for all children. Programs are funded through relevant policy mechanisms on the basis of economic evidence that investment in the early years pays exponential dividends long term in relation to the productivity and wellbeing of a society (Heckman, 2011).

Over the last decade, such policies and support program funding agreements have increasingly reflected ecological understandings (Bronfenbrenner & Morris, 2006). This reflects an effort to shift the culture of service delivery away from one characterised by individual service silos towards a more integrated and seamless service experiences for families (Moore, 2009). There is also increasing concern over the extent to which early interventions are effective in reaching those families most in need of support and highly isolated families, reflected in funding and policy mandates that refer to hard-to-reach families (Cortis, Katz, & Petulancy, 2009). Within this developing policy environment, each intervention service must find a way to negotiate these cultural shifts while maintaining integrity and fidelity of the core intervention.

This paper has three aims: to provide an overview of the defining features of the contemporary culture of family service delivery in Australia; to advance an argument for the relevance of music therapy within these cultural shifts and to summarise the evidence for the efficacy of music therapy in these settings; and, to provide recommendations on the ways in which music therapy advocates, researchers, and practitioners can continue to substantiate the credibility of the field given the policy and practice environment.

Methodology and Definition of Key Terms

An integrative literature review approach was used to allow for the inclusion of a wide range of pertinent literature including policy documents, efficacy studies, and theoretical papers (Whitehorse & Kneel, 2005). First, the key themes for the review were identified through broad reading of contemporary Australian policy documents related to service-provision to families and young children (Australian Government Department of Families, Housing, Community Services and Indigenous Affairs, 2009; Council of Australian Governments, 2009a,b). A panel of experts currently involved in the field as managers of family services or music therapists were then consulted and asked to confirm the validity of the themes selected. The three final themes were: hard-to-reach families; home visiting; and, integrated and place-based service delivery. These were selected because of their widespread representation within current Australian policy and practice discourse and because of the potential of music therapy to become more active in each of these areas.

Hard-to-reach refers to those families that are underrepresented, overlooked or resistant to support services (Doherty, Hall, & Kinder, 2003). Families that are underrepresented may be marginalized, disadvantaged or socially excluded. Families that are overlooked may be those families who never engage, or disengage from services when service providers fail to cater for their needs. Families that are termed service-resistant are those who choose not to engage with services or are highly wary of becoming involved (Curtis et al., 2009). Home visiting refers to services provided in the home of the family as part of assertive outreach efforts. Integrated service delivery refers to the break-down of individual services in favor of inter-agency, inter-departmental and/or, inter-disciplinary collaboration. Full integration at the end of the continuum is characterised by the merging of previously autonomous entities or organisations (Moore, 2009). Place-based service delivery is a related idea that can be conceptualized as a localized approach to the broader challenge of integrated service delivery (Burton, 2012). The two terms are therefore used interchangeably throughout this paper.

The terms for the themes discussed above are used throughout this paper even though it is acknowledged they may be unfamiliar to practicing music therapists in many instances. In advocating for music therapy it is essential to be cognizant of the current policy trends, cultures of service delivery, and associated lexicon. Use of the same terms that are embedded within policy frameworks will allow music therapy advocates to establish themselves as integral participants within contemporary practice and policy cultures.

A search of databases EBSCOHOST and Google using the themes as search terms yielded a wide range of empirical and grey literature. An additional search for peer-reviewed papers documenting theory or practice on music therapy with families was also undertaken through database and journal table of contents searches. This allowed the authors to synthesise the information gained from literature pertaining to the key themes with evidence from the music therapy field pertinent to this area of practice.

In this paper, each key theme is further defined before current knowledge is summarised. The relevance of music therapy within each area is then discussed with reference to existing evidence and theory. The concluding section presents the implications for the future of music therapy and makes recommendations to advocates, researchers, and practitioners.

Hard-to-Reach Families

The early intervention service system aims to engage with families early during the child-raising years so that initial parenting and child development difficulties can be addressed (Council of Australian Governments, 2009a). Further, if families can be successfully engaged with services early, it is more likely they will use available supports when future problems arise. Early engagement also corresponds with governments making the most of their investment in the early years in relation to the long term social and economic benefits for society (Heckman, 2011).

A policy and service focus on hard-to-reach families arises from the awareness that even if highly effective interventions are available, the degree to which change at a population level can be achieved will be hampered by a number of issues. In particular, the extent to which services successfully reach and engage with those families who are in most need of support will be a key determinant (Curtis et al., 2009). There is no clear consensus definition of what 'hard-to-reach' means and there are some tensions involved with the use of the term. Some authors in the area are quick to point out that the service must take some responsibility for its ability to engage with particular groups of families (Curtis et al., 2009). A recent Scottish report noted that 'hard-to-reach' as a term appears to place the blame on families for their lack of engagement and that a more helpful conceptualisation, particularly in the policy arena, might be that these groups are rather 'easy to ignore' (Matthews, Net to, & Bessemer, 2012).

The Australian Government took a particular focus on engaging hard-to-reach families in its Stronger Families and Communities Strategy (2004-2009; Curtis et al., 2009) with the final evaluation report suggesting that hard-to-reach families include young parents, homeless or itinerant families, refugees or recent migrants, and families with child protection issues. In analysis of the quantitative evaluation data from the Australian Communities for Children initiative (discussed later in this paper), families (n = 2000) who met any of the following criteria were considered hard-to-reach: fatherless households (22%); jobless households (21.5%); parental income less than $500 per week (16.4%); maternal education of year 10 or less (17.5%); Indigenous (27.4%); or, parent born overseas (31%). Almost half of the families identified as hard-to-reach met at least two of the above criteria providing evidence of a clustering of disadvantage among families. Other reports of hard-to-reach families confirm that multiple barriers to self-sufficiency and family stability are the defining features of such families (Ellerbe et al., 2011). Such barriers may include: drug and alcohol addiction; intimate partner violence; mental health problems; learning problems; unemployment; poor education and physical health; unmet basic needs such as housing, transport and childcare; poverty and financial stresses; physical and social isolation; and, cultural and language barriers (Nulls, Mullis, Cornville, Mullis, & Jeter, 2010).

Further complexity to defining 'hard-to-reach' is added when service context is considered. For example, Australian service providers consistently identified that Indigenous families were hard-to-reach, however only if their service was not designed specifically for these cultural groups (Curtis et al., 2009). Similarly, services specifically designed for young parents may not find young parents particularly hard-to-reach, where other general services designed to cater for a broad range of parents do (Curtis et al., 2009).

Reported strategies for reaching and engaging with hard-to-reach groups include: assertive outreach strategies such as home visiting; offering non-stigmatizing 'soft entry' points for families within their own communities; using non-threatening, indirect and informal approaches; play-based interventions; relationship-based, client-centred and strength-based approaches; and, adapting interventions to meet local community needs (Curtis et al., 2009). Evaluation results for the Stronger Families and Communities Strategy in which many of these approaches were embedded, found interventions were equally effective for those identified as hard-to-reach and those not (Edwards et al., 2009).

Music Therapy and Hard-to-Reach Families

Many family-focused early intervention music therapy programs report targeting the kinds of families that would be considered hard-to-reach by any of the above definitions. For example, the Sing & Grow national evaluation (n = 850 families) included levels of single parents (23%), mothers with incomplete high school education (39%), and non-English speaking parents (17%) at comparable levels to those reported by the Communities for Children evaluation (Nicholson, Bethels, Williams, & Abad, 2010). Additionally 32% of parents in the Sing & Grow study gained their main income from government benefits and 7% of children were Indigenous. Similarly to the clustering of disadvantage within families found in the Communities for Children study, the families that participated in Sing & Grow reported experiencing at least two of the hard-to-reach indicators on average.

Outcome studies on the Sing & Grow music therapy intervention have found it to be effective in generating change in these hard-to-reach groups. Reported results have included improved self-reported parent mental health and improved clinician-observed parenting behaviours and child development. These results have been consistent across various risk groups including young parents (Abad, 2011), parents of a child with a disability (Williams, Bethels, Nicholson, Walker, & Abad, 2012), and multi socio-demographic risk groups (Nicholson, Bethels, Abad, Williams, & Bradley, 2008). These results have also been found to be relatively robust to variations in implementation conditions that occurred as the program was expanded on a national scale (Nicholson et al., 2010).

It is clear that music therapy interventions can be successful in engaging with typically hard-to-reach families and are also effective in generating change but little is known regarding why. Why does music therapy appear to be attractive to, and effective for these families that many services finding typically difficult to engage? The music therapy setting is often described as possessing many of the same characteristics identified by other fields as requirements for meeting the needs of hard-to-reach families (Curtis et al., 2009). Some of the earlier descriptions of family-based music therapy intervention include that it is non-threatening, informal, play-based, relationship-based, and a strength-based approach (Abad & Edwards, 2004; Abad & Williams, 2006). Perhaps the various levels of involvement possible within the structure provided by the music, from listener or observer to active participant (Procter, 2011), allow hard-to-reach families to choose their own level of comfort without feeling the pressure to comply with any particular expectations (Williams, 2011).

The inherent flexibility in the way that many family music therapists (and music therapists in general) approach their work appears to also allow for the adaptation of interventions to meet local community needs (Day, Teggelove, Morse, & Stephensen, 2012; Sherwin, 2011; Williams & Abad, 2005). Because a music therapy intervention may not be designed with any particular risk group in mind, it is adaptable to each unique client group. This avoids any stereotypes or stigmas that may be associated with being a service for a particular kind of parent or family.

Further, the medium of music has often been described as a "universal language" with emotions portrayed in music recognizable across cultures (Fritz, 2009, p.165). The use of music as the main mode of intervention negates any requirement for high level written or verbal language skills in any particular language. Family music therapy that primarily uses childhood repertoire may also alleviate the sense that families are attending a parenting intervention, leading to a less stigmatizing environment.

Music therapy and musical play have been described as natural environments in which both parent and child can engage with in-situ hands-on practice in relating (Williams, 2009). The great synergies between musical interactions and parent-child relationship development have been covered elsewhere particularly in the fields of communicative musicality, infant-direct singing, and music therapy for parent-infant bonding (Creighton, 2011; Edwards, 2011; Malloch & Trevarthen, 2009; Trainer, 1996; Rehab, 2003). It may be that these natural, yet often unarticulated relationships between parenting and musical play are what attracts hard-to-reach families to activities involving the use of music.

Home Visiting

One key strategy widely used to engage with hard-to-reach families is assertive outreach into homes, known as home visiting. Traditionally home visiting refers to a long term relationship developed by a child health nurse to support families through the early years of parenting and assist in removing barriers to effective parenting and positive child outcomes (Howard & Brooks-Gunn, 2009). However, many discrete intervention programs, usually of eight to 10 weeks duration, have also been delivered in the home by a range of interventionists (McDonald, Moore, & Goldfield, 2012). Hence, the term 'home visiting' is often now used to describe any intervention delivered in the home.

By taking an intervention to the family in their own home, barriers such as transportation, child care, and a lack of social confidence are overcome (McDonald et al., 2012). There is evidence that assertive outreach into homes leads practitioners to have greater contact with families considered hard-to-reach by nature of their higher levels of multiple disadvantage than the general population (Rots-de Varies, van de Good, Strokes, & Garretson, 2011a). However, findings on the effectiveness of home visiting for instigating and sustaining positive change are mixed. Differential findings may relate to what is delivered, how much is delivered, to whom, and by whom.

Recent reviews of sustained home visiting applications for vulnerable families make clear that 'what' is delivered in the home should be evidence-based and known to be effective (McDonald et al., 2012; Moore, McDonald, Sanjeevan, & Price, 2012). Null findings are more commonly found in studies where a general home visiting protocol, rather than a documented intervention was followed. A review of nine home visiting programs internationally found that there was no evidence that home visiting was likely to decrease child maltreatment (Howard & Brooks-Gunn, 2009). However, an intervention that included weekly visits for eight weeks focusing specifically on parental sensitivity, attachment behaviours, and behavioural outcomes for children within the child protection system showed significant outcomes when compared to a control group (Moss et al., 2011).

The varying results regarding the effectiveness of home visiting may also reflect variations in 'how much' is delivered, to whom, and how outcomes are measured. In a meta-analysis, more frequent home visits (three or more a month) created larger effect sizes regardless of whether visits were conducted by health professionals, nurses or Para professionals (Never, van Green, & Pollard, 2010). Another study compared early home visiting to a control group at follow up (school age) and found no lasting effects overall (Kerstin-Alvarez, Holman, Riksen-Walraven, van Dorsum, & Hoefnagels, 2010). However, for those families that had experienced a high number of life stressors, children in families who had received the home visits were less likely to have developed problem behaviours. This indicates that there may be a buffering effect provided later in life for particular groups of families, even when there are no apparent direct results from the intervention. Home visiting may influence parenting behaviours that have a much later effect on child outcomes than is measured by most evaluations.

Regardless of the degree to which home visiting is effective as a stand-alone intervention in creating change in families, it appears that it may be successfully used as a bridging strategy to other supports for hard-to-reach families. If ongoing, sustainable support, and community connectedness and resilience are goals of prevention and early intervention programs, then the potential of home visiting to transition hard-to-reach families into other types of support holds promise. A recent study found that an intervention group who received up to 11 home visits had higher rates of referral to, and take up of, early intervention services compared to a control group of mothers who received no home visits (Schwarz et al., 2012). Others have also documented the ways in which home visiting was successfully used to build links between families previously not accessing services and the mainstream service system outside of the home (Rots-de Varies, van de Good, Strokes, & Garretson, 2011b).

Home visiting can be seen to work in conjunction with centre-based support, rather than as an alternative strategy. One study compared home visiting to a centre-based group program to improve attachment behaviour between parents and children (Niccols, 2008). The intervention modes were found to be equally effective in creating change. Drop-out rates were higher for the centre-based group program, though this program was also more cost effective. It may be that centre-based and home-based interventions function in a differential fashion for families depending on parent motivation, parent goals for change, and experience of disadvantage (Bloomquist, August, Lee, Piehler, & Jensen, 2012). It appears then that neither centre- or home-based care is more superior to the other, but that they may be used in conjunction and relative to individual family needs. Service providers must balance the competing demands of cost effectiveness, and issues of reach, dose, and efficacy in making decisions about the delivery of support via home visits and/or centre-based services.

It is important to note that availability of resources for home visiting does not necessarily guarantee that engagement with families will be easy. In one program, five contact attempts, including two home visits per participant, were required following referral before a response was received (Ellerbe et al., 2011). Once families are engaged, retention also varies. The Early Head Start home visiting program found that drop out was related to home visits being less focused on child development and being less engaging to parents (Ragman, Cook, Peterson, & Rakes, 2008). Families experiencing multiple risks were also more likely to drop out.

These findings reflect the need for home visiting programs to not only focus on the 'what' and 'how much' of delivery, but also the 'how', if hard-to-reach families are to be engaged in this kind of support. A recent Australian review found that key elements of effective home visiting include: being relationship-based; involving partnerships between professionals and families; having goals that are meaningful to parents; building parenting skills; and, being non-stigmatizing (Moore et al., 2012). Other recommendations included staff being highly trained and supported given the complex nature of the work. Constant monitoring of program fidelity is also recommended. This ensures that evidence-based interventions remain true to their core elements in order to maintain effectiveness (Moore et al., 2012).

Music Therapy and Home Visiting

Established music therapy programs would appear to be in a position to meet many of the recommendations for home visiting as made by Moore and colleagues (2012), however home-visit music therapy has a limited documented history. A recent review included a total of 20 international publications with a focus on home-based music therapy (Schmidt & Oysterman, 2010). These likely represent only a small amount of the music therapy clinical work actually occurring in client homes as evidenced by other publications not included in the review (Horne-Thompson, 2003; Lindenfelser, Hense, & McFerran, 2011; Roberts, 2006). Documented cases of home-visit music therapy to date have primarily been with elderly or palliative care patients, with only a few focusing on families with young children (Pascal, 2011, 2012a).

There is evidence that music therapy conducted as home visits allows greater reach to families who would not normally attend centre-based interventions, and that home visits can be used as a 'soft entry' point prior to families transitioning to group music therapy in a community setting (Williams, 2011). Home-visit music therapy also provides the clinician with the opportunity for direct observation in a naturalistic setting and minimizes the need to transfer skills learned in centre-based therapy to the home environment (Pascal, 2011). It appears then that there is the potential for music therapy to be delivered in the home, as a stand-alone intervention, but perhaps more importantly, as a way to introduce hard-to-reach families to services found out of the home, as one part of an integrated service delivery system. Given the limited extent to which home-visit music therapy is represented in the published literature, increased documentation and additional research on its effectiveness is warranted.

Integrated Service Delivery and Place-Based Approaches

Integrated service delivery and place-based approaches have recently become prominent features of the policy documents within Australia that aim to address social disadvantage, particularly in the early years (Australian Government Department of Families Housing Community Services and Indigenous Affairs, 2009; Council of Australian Governments, 2009a, b). It is important to note that integrated and place-based service delivery may or may not mean co-location of services. Children's or family centres are an obvious example of this kind of service delivery but they are only one example. While there is some evidence that parents prefer co-location of services (Office for Standards in Education Children's Services and Skills, 2009), being co-located may not necessarily mean that professionals are working in a truly integrated manner. An alternative mode is virtual family centres where services are seamlessly integrated without the need for co-location (Moore, 2009).

Place-based policies have arisen from the recognition that socio-economic deprivation often clusters within particular communities and therefore implementing policy and intervention at a local level may be an effective way to reach this population and address the many interlinked challenges faced by families (Matthews et al., 2012). At the practice level, interest in place-based service delivery has arisen from broad contemporary recognition that a one-size-fits-all model for service delivery is unlikely to be effective given the unique characteristics pertinent to each community (Centre for Community Child Health, 2012). Each community is likely to have unique needs, motivations, resources, and family characteristics.

Although the agenda for integrated service delivery in Australia is well underway, this kind of work is still very much 'cutting edge' (Centre for Community Child Health, 2012; Moore, 2009; Moore & Fry, 2011; Moore & Skinner, 2010) with local examples of evaluation findings rare. International evidence for the effectiveness of integrated and place-based approaches to service delivery is currently sparse and inconsistent, with evaluation challenges and methodological inadequacies leading to a difficulty in synthesizing and interpreting results (Moore & Fry, 2011; Siraj-Blatchford & Siraj-Blatchford, 2009). One recent example of a successful approach to integrated service delivery involved the positioning of on-site case managers who worked cross-departmentally with vulnerable families in a state of America. This lead to promising decreases in mental health problems, substance abuse, and intimate partner violence for low-income mothers over a twelve month period (Ellerbe et al., 2011). No child outcomes were measured.

Perhaps the most significant national investment in place-based approaches in Australia has been the Communities for Children program first implemented as part of the Stronger Families and Communities Strategy in 2004 (Muir et al., 2009). A number of communities across Australia were identified based on the clustering of poor outcomes for children and high levels of disadvantage. Substantial funds were allocated to each community with the mandate of providing local and integrated solutions and supports to families with young children. Evidence from this strategy was considered by a recent round table of leaders in the field to be 'reasonable' (Centre for Community Child Health, 2012). Evaluation results indicated that this localized approach did improve service coordination and collaboration and increased the number of services available for young children and families (Muir et al., 2009). While effect sizes for parent and child outcomes were negligible, the strategy did improve engagement of hard-to-reach families (Muir et al., 2009).

Key authors have drawn consistent inferences regarding the requirements for successful integrated service delivery, despite outcome evidence being sparse. These are: strong leadership; shared decision making; appropriate shared governance arrangements; a highly skilled and flexible workforce (often requiring the blurring of professional boundaries); a shared vision and philosophy; and, evidence-based practice and ongoing evaluation (Centre for Community Child Health, 2012; Centre for Community Child Health & Murdoch Children's Research Institute, 2012; Moore & Fry, 2011; Siraj-Blatchford & Siraj-Blatchford, 2009). It is important for services such as music therapy, wishing to engage in integrated ways of working, to be mindful of these factors.

Music Therapy and Integrated Service Delivery

It is clear from recent music therapy history that the field is ideally placed to engage in integrated service and place-based delivery models, and many therapists may already be doing so to some extent. However, this has not yet been articulated clearly or often. Like most other professions it may be that many of the essential components for integrated service delivery including collaborative team work, the blurring of professional boundaries, shared governance arrangements, and a highly trained and flexible workforce exist in various pockets of work. However all of the sufficient components for full integration do not yet appear to be developed in any one site. This would be expected within a broader early intervention practice environment that is still coming to terms with how to define, undertake, and evaluate integrated and place-based service delivery models.

Music therapy has a history of collaborative work with other professions (Rout, 2004; Magee, Buffet, Freeman, & Davidson, 2006; O'Dell & Coffman, 2007; Wheeler, 2003). Most of the literature discussing integrated ways of working as a music therapist arises from the medical field where research is primarily concerned with establishing the validity of a role for music therapy within such team settings (e.g. Knapp et al., 2009). Within the family music therapy field, various research has established the role of music therapy within team practice settings to include not only direct service provision, but also providing a unique assessment of family strengths and weaknesses (Old-field, 2006; Wigwam & Gold, 2006) and offering a 'soft entry point' and connection to other services (Abad et al., 2013; Williams, 2009). Still, much of the family music therapy literature mentions collaboration with referring organisations and staff only as a sideline to other discussions (Day & Borderer, 2011; Nicholson et al., 2008; Nicholson et al., 2010; Williams et al., 2012).

Research within an integrated service for paediatric palliative care patients suggests a further important role for music therapy. Knapp and colleagues (2009) compared those families who had participated in music therapy and those who had not and found that music therapy participation was the greatest predictor of parental satisfaction with the service as a whole. Parents who had accessed music therapy for their child were 23 times more likely to report that they were satisfied with the overall integrated service than those who did not access music therapy (Knapp et al., 2009). This finding suggests that music therapy may support the overall appeal, acceptability, and accessibility of holistic integrated services and may have implications for attracting hard-to-reach families to services.

A recent pilot project within Australia indicated that the introduction of a music therapist to an integrated service supporting hard-to-reach families improved the reach of the service to those families most in need of support (Williams, 2011). Home visits were used as an assertive outreach and 'soft entry' strategy, whereby highly isolated families were able to initially engage in musical play in the home environment until capacity and confidence to join community support groups (including but not limited to group music therapy) was developed (Williams, 2011). Similarly to the points made by Moore and Fry (2011), the process evaluation of this pilot project also found that ongoing communication, positive and strong relationships and highly flexible and competent clinicians were vital when working in this integrated fashion (Williams, 2011).

Many music therapists are also skilled in molding their ways of working to the 'place' and community in which they find themselves. This is very clear in the literature from the growing field of Community Music Therapy where theory and case studies exemplify and highly value the constructs of communication, culture, and collaboration (Pavlicevic & Ansdell, 2009; Stige & Aaron, 2011; Stige, Ansdell, Elefant, & Pavlicevic, 2010). These constructs are essential ingredients for place-based and integrated service delivery, though they alone are not sufficient for full integration. Full integration would be signaled by the merging of previously autonomous entities and the merging and blurring of professional boundaries (often arbitrary in any case) between music therapist, case manager, counselor, educator and social worker (for example). The extent to which music therapists are currently engaged at this end of the integration continuum is unclear due to a limited focus on such process-related aspects within the literature.

Implications for Music Therapy

This paper has used recent, primarily Australian literature to review three constructs of current importance to policy-makers, researchers and parishioners in the early intervention and family-centred practice fields. Current policy mandates that hard-to-reach families are heavily targeted and successfully engaged in supports early in a child's life, and that most services, if not all, strive for a more integrated approach to service delivery with place-based strategies attracting significant funding. Home visiting is one assertive outreach option that is receiving increased attention within Australia for its potential to both deliver evidence based services within homes, and to draw isolated families out into the community where supports can be accessed as and when they are needed. The music therapy field is already invested in many of these approaches, yet further developments in the areas of advocacy, research and practice will continue to improve both the standing of the profession and the quality of the music therapy and early intervention services on offer to families.

Advocacy

In advocating for music therapy, it is essential to be cognizant of the current policy trends and associated lexicon. Use of the actual terms 'hard-to-reach', 'integrated service delivery', and 'place-based approaches', will allow music therapy advocates to establish themselves as participants within the current practice and policy agenda. Advocates must also be aware of the issues presented in this paper. Music therapy does have an evidence base that is relevant to these ways of working which should be articulated at every available opportunity. Further, music therapy is on the cutting edge of this work and there are many indicators from both research and practice, that the field holds substantial potential to contribute meaningfully, and even take on leadership, as these new service delivery cultures develop.

Research

There are clear and exciting opportunities for further research in this field. The evidence base for family music therapy, both group and individual, is somewhat established. Such interventions have been associated with positive parent satisfaction, high levels of parent and child engagement, improved parent-child interactions, improved parental mental health, increased parenting skills, enhanced child developmental skills, and strengthened social networks (All good, 2005; Mackenzie & Hamlet, 2005; Nicholson et al., 2008; Old-field, 2006; Old-field, Adams, & Bounce, 2003; Shoe mark, 1996; Stanley, Walworth, & Nguyen, 2009; Walworth, 2009). These findings have been found to hold across geographic locations (Nicholson et al., 2010) and specialised populations (Abad, 2011; Williams et al, 2012), establishing that evidence-based music therapy programs can be designed, evaluated, and disseminated on a wider scale. This is a strong basis from which music therapy can build a greater presence within this sector, though further investigation in three broad areas is clearly needed.

First, as family music therapists move into more nuanced and different ways of working within the integrated service delivery framework, the efficacy of the direct clinical work undertaken will need to be continually evaluated. There is currently very limited documentation in relation to family-centred home-visit music therapy, its processes and outcomes and so this is a clear avenue for future investigation. What is being delivered in home-visit music therapy and how? What kind of therapeutic outcomes can be expected and actually achieved?

Also, while there is an established evidence base for short-term (six to 10 week) group family music therapy, little is known about the impact of single-session or very short-term music therapy contact for families. A recent Australian pilot indicated that this kind of short-term contact may become more frequent for music therapists working within integrated services if one of the main roles of the music therapist is to provide a soft-entry point to other services, or if contact with very hard-to-reach families is fleeting, yet still needs to be highly valuable (Williams, 2011). Evidence on single-session music therapy with adults suggests it can have positive therapeutic benefits (Curtis, 2011; Horne-Thompson & Grocke, 2008; Lin, Hsieh, Hsu, Fetter & Hsu, 2011; Silverman, 2011a, b). Solution focused single-session psychology (two hours duration) with children and adolescents with a range of mental health problems has also been found to be effective in reducing parent- and clinician-observed psychopathology at one-month follow-up (Perkins, 2006), with results maintained at 18month follow up (Perkins & Scarlet, 2008).

There is therefore promise that single-session family music therapy may be effective in stimulating ongoing change. Measuring the effectiveness of such single-session or very short-term intervention is difficult particularly when immediate physiological or psychological markers are not expected. New ways to measure the efficacy of very short-term family music therapy will need to be developed. Abad (2013) made the pertinent argument that direct changes in parent and child behaviours may not be the only outcomes worthy of note in this kind of work. Even limited exposure to the intervention may result in capacity building in families, and in stimulating links to the wider service environment and social support systems available. Further research in particular on the ways in which music therapy participation builds social capital (Procter, 2011) and is effective in linking hard-to-reach families to other services and supports would be highly valuable.

Second, it is unclear as to how participation in music therapy is related to positive outcomes for families. The mechanisms of change in regards to some programs with an established evidence base have yet to be fully explored (Williams et al., 2012). Recent detailed work with individual families has explicated the particular ways in which family music therapy supports mutually responsive parent-child interactions by providing opportunities to rehearse adaptive ways of interacting, bonding, and playing together (Pascal, 2012a). The same author has also theorized on the ways in which family music therapy with a focus on play might support adoption and the development of resilience in children (Pascal, 2012b). This work is highly relevant and might be used as the basis for the development of a theory of change for other music therapy interventions. Similarly, literature from family music therapy occurring in other settings such as with hospitalised infants (Shoe mark & Darn, 2008) and with older children and their parents (Old-field, Bell & Pool, 2012) may also be drawn upon. More in-depth and detailed qualitative studies would also provide further insight into the mechanisms of change for families participating within family music therapy and participant views of music therapy as part of broader integrated services. This kind of work might also address questions such as: Do hard-to-reach families find music therapy particularly attractive and why? What is the appeal of music therapy for other professions working within the integrated model? What kind of value does music therapy add to integrated service systems?

Finally, music therapists should more consistently collect demographic data that allows comparison to other programs. The extent to which music therapy interventions are successfully reaching families defined by policies as hard-to-reach can only be evidenced by collecting the same demographic markers used by government and large early intervention and prevention programs. These include maternal education level, main income source, maternal age, marital status and cultural identity.

Within an integrated service delivery framework, music therapy researchers will need to consider the ways in which these investigations can be undertaken with a multidisciplinary approach. In this way research resources and skills can be pooled and findings will be of mutual benefit to each profession involved as well as contributing to the broader evidence on integrated service delivery. This idea reflects that of O'Grady and Skews (2007) who urged Community Music Therapy researchers to conduct investigations that would both inform music therapy, and the disciplines from which it draws, thereby reducing the isolation of the music therapy profession and having it connect more fully to the wider world of research.

Practice

Music therapy clinicians will need to carefully consider a number of factors in moving forward within this policy and practice environment. With integration comes the blurring of professional boundaries that have been hard fought by many in the profession and may seem initially threatening to the ongoing growth of the music therapy industry. In truly integrated ways of working, music therapists will be constantly up-schilling other professionals in the therapeutic use of music and gaining and using alternate skills themselves that may not always include the use of music. While this may be considered endangering to the identity of music therapists, one could posit that their creativity, conscientiousness, open-mindedness and their music, will make music therapists highly attractive for the new blended roles that will become more the norm as integrated service delivery continues to grow within Australia. Integrated working will also require an evolution of confidentiality practices if seamless service delivery across professionals is the aim. The implementation of continual support structures and high level professional supervision may be beneficial for music therapists in both accepting and embracing such notions. Additional education by way of recently available graduate certificates in integrated service delivery may also be of use.

Individual music therapists, along with each unique service, must consider where their work currently sits and how to clearly articulate its place on the integrated service delivery continuum between multi-disciplinary collaboration through to complete merging of previously autonomous entities. Only then can decisions be made in relation to integration goals and changing practices. This must be done while understanding that integrated service delivery must be a means only to the end of providing more timely and effective support to Australian families, rather than an end unto itself. Integrated service delivery will not be suitable for every clinician or every service. By considering and articulating the benefits and disadvantages within each clinical context, music therapists will become more articulate in communicating with others in the field. As we attempt to more clearly define the role of music therapy within integrated service delivery, we must also seek to define the different methods of service delivery, such as home-visit music therapy. Is it conducted in the venue because of convenience or is it a treatment modality in itself with unique outcomes such as reaching clients who otherwise would not be reached, and/or integrating the family into broader community supports?

It is also important to weigh the merits of flexible ways of working, highly valued in place-based services, against the cost and time effectiveness of rolling out already established interventions. Continuing to build on the existing evidence base will likely have strong positive implications for future funding opportunities for music therapy. Designing and implementing brand new intervention approaches in each setting makes the building of an evidence base more difficult, along with being highly time-, energy- and resource consuming. While each site and each music therapy participant is unique, it is not necessary that each intervention be unique and music therapists should not feel the need to 'reinvent the wheel' in each new setting. The way forward may be a careful combination of evidence based practices and those more flexible, site-specific approaches, which can be adapted to best suit each clinical setting.

Conclusion

The current culture of family service delivery is defined by integrated and place based approaches with a particular focus on hard-to-reach families and assertive outreach approaches. While direct research into music therapy in the context of integrated service delivery is sparse, there are many indicators among the theoretical, research and clinical literature that signal the potential of the profession to excel in these areas. The inherent flexibility and creativity of music therapy modalities allows for responsiveness to the needs of individuals, family units, and communities concurrently. The less intrusive nature of music therapy offers appeal for families otherwise more difficult to engage in community services. The evidence base strongly highlights the capacity of music therapy to stimulate change or growth in its participants. Further embracing the policy and practice language, and greater development and articulation of research findings and integrated practices, will better illustrate and embed the music therapy profession within this setting. This is likely to broaden access to funding opportunities that favor a place-based approach within communities of high need, and so is worthy of the profession's time and effort.

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Kate E. Williams PhD, RMT

School of Early Childhood, Queensland University of Technology, Australia

Kate Teggelove BMus(Thrpy), RMT

Sing & Grow, Playgroup Queensland, Australia

Toni Day MPhil, RMT

Sing & Grow, Playgroup Queensland, Australia

Corresponding author: Kate E. Williams Email: k15.williams@qut.edu.au