A description of a music therapy meta-model in neuro-disability and neuro-rehabilitation for use with children, adolescents and adults.

Daveson, Barbara A.

Abstract

Changes to therapy services in healthcare are constantly shaped and driven by government and professional requirements. Recently, the need for adaptable models of music therapy within neuro-disability and neurorehabilitation, alongside the need to demonstrate outcomes has been identified within music therapy literature. Additionally, the Department of Health has emphasised the need for patient-led and patient-centred care. This paper presents a flexible, tri-pronged meta-approach to music therapy practice that promotes service-user involvement, and allows for the measurement of outcomes through the use of a particular approach to goal-setting. The three approaches of the meta-model (i.e., restorative, compensatory and psycho-social-emotional approaches) are described, and case vignettes of work with those with brain injury and neurodegenerative disease are shared to illustrate how the model can be used to support these treatment approaches. An outline of the development of the model is provided, and comment about the potential challenges regarding the use of the model is included. This meta-model is applicable to practice in hospitals, residential and outpatient settings with children, adolescents and adults patients in neurology, neuro-disability and neurorehabilitation. Thus as a consequence, a response to the need for music therapy that is patient-centred, patient-led, able to be measured and adaptable is shared.

Keywords: disability, rehabilitation, neurology, music therapy, treatment, model, brain injury, neuro-degenerative disease

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A growing emphasis on patient-directed care is evident within healthcare (Department of Health, 2005; Galloway, 2006). Additionally, within the field of neuro-disability, there has been a call for the need for evidence of music therapy outcomes (Magee, 1999, 2006), plus the use of flexible models of music therapy practice (Jochims, 2004). Music therapy authors have also written about the lack of music therapy posts in the field of neuro-rehabilitation, both within Australia and the United Kingdom. They write that this shortage is due, in part, to a poor understanding about music therapy, plus an absence of clear communication about music therapy outcomes within the field (e.g., Tamplin, 2006a; Magee, 1999, 2006). The information presented in this article assists in addressing these issues through the sharing of a patient-centred and patient-led practice model that assists with clarity and specificity about treatment, along with a method to ensure measurement of outcome. As a consequence, there may be improved understanding about the scope and potential of music therapy practice.

A meta-model for music therapy practice in the field of neurodisability (including the area of neuro-rehabilitation) is presented in this article. The model can be used with adults, adolescents and children in hospitals, residential and outpatient settings. It is called the Meta-Model of Music Therapy in Neuro-disability (i.e., the MIND) and can enable patient-led care through a flexible approach to practice that involves the use of models that aim to restore function, compensate for loss, and/or attend to areas that are psycho-social-emotional in focus. The MIND results in the measurement of outcomes through the use of a standard approach to goal setting that ensures that the goal has specific criteria, namely that the goal is specific, measurable, attainable, relevant and time-related, or a SMART goal (see Maidment & Merry, 2002). Therefore, the MIND results in a music therapy service that is able to be patient-led and patient-centered, measured and inclusive of various models of music therapy practice. Details of this meta-model are presented in this paper, along with an outline of its development, the rationale concerning its development, and challenges associated with its use.

The Development of the MIND Model

The MIND was developed in six stages. First, a review of the literature with the aim of identifying approaches and models of practice within the field of neuro-disability was completed. Second, reflection upon my own clinical practice alongside reflection of the practice of those I managed and supervised within the field occurred. This process allowed for a comparison to be drawn between the content of published information with practice experiences that were evident within the field. Third, published works that referenced models of practice, constructs, or frames of reference that were being described by clinicians yet not able to be located by myself within the music therapy literature were located. This step involved looking within fields allied to neuro-disability where music therapy was practiced (e.g., special education), and outside the field of music therapy (e.g., in occupational therapy literature). Fourth, the development of a standards document that outlined the local standards of a music therapy service was developed. In this document the information gathered in stages one to three was synthesized into a meta-model. Fifth, the meta-model of practice was shared with three clinicians working in the field and their thoughts about the model were considered with the view to modifying the model. (1) Six, the model was introduced to clinicians working in the field of neuro-disability in a hospital to assist with clinical reasoning, practice development, use of consistent terminology regarding practice, communication about music therapy input and output within care team environments, and service development. As a consequence, the MIND was designed and integrated into practice.

An Introduction to the Three Approaches to Care

The MIND, as can be seen in Figure 1, involves three approaches to practice that are located within music therapy literature. Here, these approaches are termed the restorative (e.g., Baker, 2000; Baker & Roth, 2004; Baker & Tamplin, 2006; Cohen, 1988, 1992; Magee, 1999; Thaut, 1999; Schauer & Maruitz, 2003), the compensatory (e.g., Baker & Roth, 2004; Lucia, 1987; Magee, 1995) and psycho-social-emotional approaches (e.g., Nayak, Wheeler, Shiflett, & Agostinelli, 2000; Magee & Davidson, 2002; Purdie & Baldwin, 1994; Wheeler 1983). It therefore entails a meta-modelled approach to music therapy, or a perspective that relies on more than one model of practice, as it allows for the integration of various approaches to music therapy work within the field of neuro-disability. (2)

The rationale for the need for such a multi-focused approach is that patients with brain injury and neuro-degenerative disease can present with various types of needs at one point in time (Kolb & Wishaw, 2004), and that such complexity of need cannot always be met through the use of one music therapy model (Jochims, 2004). This is the case as those with brain injury or neuro-degenerative disease may experience, as a result of their injury or disease process, changes in many areas including cognitive, behavioural, psychological, emotional, communication and physical realms. Also, the severity and intensity of these changes may vary (Kolb & Whishaw, 2004).

[FIGURE 1 OMITTED]

For example, a patient who has Broca's aphasia and therefore damage to the frontal lobe may, in addition to having communication difficulties, experience frustration due to insight about their difficulty, along with right-sided weakness or paralysis. Thus, improvisation might be used to decrease levels of frustration (i.e., the psycho-social-emotional approach), while therapeutic instrumental music performance (Thaut, 1999) might be required to assist with regaining strength in the right side (i.e., the restorative approach). Also, other strategies may be introduced within music therapy to overcome or compensate for language production difficulties. Song-collage [as described by various clinicians including

Tamplin (2006b)], for example, may be offered to the patient to enable communication about their response to their injury (i.e., compensatory approach). In this respect the MIND assists with promoting patient-centered care as the therapeutic approach is centered upon the needs and abilities of the patient at the time that the therapy is provided.

Patient-Centered and Patient-Led Care

In the interests of patient-centered care, the MIND requires the therapist to fulfill a duty of care that can, or is likely, to be addressed within the scope of the music therapy program. This means that the treatment offered remains centered or focused upon the care needs during the time of admission. This is ensured through two procedures. First, the patient is encouraged to identify areas to focus upon while participating in music therapy. Second, the area that the patient wishes to focus upon is considered further to result in the writing of goals that can be achieved within the duration of admission. When the patient is unable to contribute to this procedure, for example due to severity of damage from brain injury or lack of mental capacity to consent, the therapist takes primary responsibility for ensuring the development of a relevant treatment program based upon a number of considerations, including the aims of patient's admission to the care site, as negotiated with relevant care stakeholders (e.g., the next of kin and the multidisciplinary care team). Such goals are written to assist the therapist and patient to address target areas and to define the foci of practice. Plus, this procedure involves patients in the process of establishing the direction of their own care, and thus assists with patient-led care.

SMART Goal Setting (3)

The results of goals are described as the outcomes, and outcomes of goals are measured through the use of outcome measures (Johnson, 1997). When the MIND is used the outcome measure is the goal itself. There are many different approaches to goal setting as there are also many outcome measures available to clinicians. However, the SMART goal setting approach is one that features within neuro-rehabilitation and has been described as being relevant to practice within this field (McMillan & Sparkes, 1999; Wilson, 2003). The SMART goal setting approach underscores the MIND.

As highlighted by Maidment and Merry (2002), SMART goal setting means that when goals are written they have the features of being specific, measurable, attainable, relevant and time-related. There is a rationale for such an approach to setting goals. Specific and precise goals are easier to measure and achieve, while measurable goals allow for the therapist to evaluate whether or not the goal has been achieved. Attainable goals are ones that are realistic; and ideally these need to be set with patients otherwise the goal may not be relevant to the patients' circumstance or how they perceive their current situation. Also, goals need to be achieved within certain periods of time. The identification of timeframes assists with identifying how goals can be improved if the goal is not being achieved, and how resources can be co-ordinated within teams (within set time periods) to achieve the goal. In this respect, timeframes enable solid teamwork.

In essence, SMART goal setting assists with improving the quality of the standard of care provided to patients, and can be used to measure the outcome of music therapy input. In practice, this type of outcome measure can be supported by the use of validated scales or other outcome measures that can be administered by music therapists or others involved in the treatment program.

As treatment foci need to be realistic in nature, only treatment aims that are in accord with the patient's predicted prognosis and situation will be established. This principle ensures that treatment foci will always be in line with the abilities or needs of the patient at the time of the service being offered. For example, it is unlikely that restorative-type goals (i.e., ones that aim to restore function) will be set with someone who is experiencing deterioration as a result of a chronic neuro-degenerative disease. This is suggested as despite all efforts it is likely that deterioration will continue to occur, meaning function cannot be restored. In this situation, the restorative approach might lead to the opening of a duty of care that cannot be fulfilled, and the measurement of care would reveal an unrealized outcome from the intervention. Instead, compensatory or psycho-socioemotional approaches may be warranted here as the patient may be enabled to (a) learn new strategies to compensate for losses or deficits that result due to disease progression (e.g., compensatory approach), or (b) develop adaptive coping strategies regarding their deterioration or be assisted with adjustment to prognosis or disability (i.e., psycho-socioemotional approach). Similarly, if the patient is physically able to regain function, yet unable to attend therapy due to emotional or psychological factors, then initially a psycho-social-emotional approach may be required with the view to decreasing the impact of the emotional or psychological factors that have resulted in the patient's withdrawal from treatment.

In summary, when using the MIND to inform practice, music therapy intervention is patient-led and patient-centered, and guided by the use of the three overarching approaches to practice described above. Also, interventions must be measurable via the use of SMART goal setting. Therefore, as highlighted in Figure 2, this work involves a number of decisions at various points throughout the care pathway. These decisions are shaped by assessment outcomes, influenced by patient choice, informed by the relevant evidence-base that is available, and provided as per service constraints (e.g., duration of admission). The following section provides further explanation of the three approaches to practice.

The Restorative Approach

The restorative approach to practice aims to restore function toward a level that is similar or close to the level of functioning prior to injury (Baker & Roth, 2004). An example of a model of music therapy that is used for restorative work is the Neurologic Music Therapy Model (Thaut, 1999). Generally speaking, the restorative approach is driven by the belief that music is able to assist with restoring function through the use of the neurological, information-processing, and sensory components involved when music is used. This approach is underpinned by the view that the patient is a combination of neuro-physio-chemical-biological processes. The theoretical basis for this approach involves the theory that the brain can reorganize itself after neurological trauma to re-enable function. This theory is otherwise referred to as the neuro-plasticity theory, and means that new connections in the brain can be used to complete tasks that are initially unable to be completed by the patient post-injury or that undamaged parts of the brain may take over functions from damaged areas (see Baker & Roth, 2004, plus Baker & Tamplin, 2006, for an account of this approach).

The restorative approach is useful with patients who have active rehabilitation goals, those that are responding to and engaging with the rehabilitation process, and those aiming, and are assessed as most probably being able, to make functional gains. (4) This approach is characterized by frequent sessions that require the patient to actively participate in the achievement of goals.

[FIGURE 2 OMITTED] (5)

Case Vignette

 A patient sustained brain injury following a haemorrhage resulting
 in complex neuro-disability, including ataxia, dysphonia and
 dysarthria. The speech and language therapist assessed potential
 for the patient to regain functional speech and a referral to music
 therapy was made to assist with this. After a music therapy
 assessment was completed, the restorative approach was selected to
 support the patient with this goal. This led to the use of aspects
 of the Neurologic Music Therapy Model described by Thaut (1999).
 More specifically, regular sessions were conducted to (a) improve
 articulatory control and respiratory strength through the use of
 oromotor respiratory exercises, (b) extend voice control abilities,
 namely inflection, pitch, and breath control, through the use of
 vocal intonation therapy, and (c) facilitate initiation,
 development and articulation in speech and language through the use
 of therapeutic singing. The following is an example of a type of
 goal that was set with this patient: that the patient will increase
 breath control (as demonstrated by increased length of phonation)
 from three to five beats in a sung phrase three out of five
 opportunities twice weekly, with the view to ultimately restoring
 speech.

The Compensatory Approach

The second approach to music therapy practice in the MIND involves work to develop compensatory strategies (as described by Baker & Roth, 2004). Compensatory work involves the therapist working with the patient to develop strategies that compensate for losses that have occurred. Such strategies enable the patient to retain their role as related to their social identity. Therefore, this type of approach requires the therapist to assess the patient's needs from the perspective of functionality as related to their role within their social ecology. In this respect, this approach is underpinned by an understanding of the patient as a socially situated being over time, despite changes in functionality or ability. It is informed by various frameworks including Bronfenbrenner's Ecological Framework (1977). The compensatory approach is useful in assisting those with neuro-degenerative disease to compensate for losses due to disease progression, such as deterioration that occurs throughout Huntington's disease.

Case Vignette

 Nursing staff referred a patient diagnosed with Huntington's
 disease to music therapy because of the patient's increased levels
 of frustration resulting from communication difficulties. The
 speech and language therapist identified that the patient's speech
 intelligibility was severely compromised and that withdrawal from
 social contact was a risk, as was isolation and/or low mood. During
 music therapy assessment it was assessed that the patient was able
 to (a) express herself via improvisation and recreative playing,
 (b) vary her musical output and choose moods and themes to
 improvise upon, and (c) experience a lift and consolidation of mood
 as a result of music-making (as verified through the use of
 self-report measures). The assessment led to the identification of
 a need for compensatory work to enable expression of feelings and
 mood through the use of music, despite deterioration of verbal
 abilities. It was also predicted that music therapy could assist
 with enabling social relationships. The compensatory approach was
 identified as needed as it was known that further disease
 progression was likely and continuing, as evident by the patient's
 ongoing loss of function due to the disease. A typical long-term
 goal for this patient was to maintain the ability for
 self-expression. Shorter-term SMART goals included that the patient
 will (a) choose one song once per session (from a choice of two
 songs contrasting in musical style and lyrical content) to express
 her mood, and (b) improvise music to express her emotions within
 every music therapy session and report that the improvisation
 enabled expression of feelings.

The compensatory approach can also be used when patients have achieved many of their rehabilitative goals or have little or no potential for rehabilitation. This is sometimes the case for those experiencing deterioration due to chronic neuro-degenerative disease yet admitted to a hospital for the management of symptoms.

The Psycho-Social-Emotional Approach

The third approach in the MIND stems from an understanding of the use of music to convey emotions, alter emotions, enable socialization and social-skill development, and shape psychological functioning. This approach is informed by research and clinical work that has reported benefits in the field of neuro-disability in achieving various outcomes, including (a) the maintenance of skills in satellite areas despite overall decline in function (Davis & Magee, 2001), (b) communication and social relationship maintenance (Magee, 1995), (c) the use of music to lift mood despite physical decline or loss of ability (Magee & Davidson, 2002), and (d) the use of music to impact upon mood while also assisting with engagement in rehabilitation (Nayak et al., 2000). There are many different models of work that are available for use when this approach is used. Detail of two levels of practice from a multi-levelled model of practice as described by Wheeler (1983) is provided in Table 1.

When using the psycho-social-emotional approach in neuro-disability it is important to be mindful of the time constraints around the work, as this will avoid opening up duty of care responsibilities that cannot be fulfilled during the length of admission. To aid with this consideration, the therapist may need to ask questions such as: What can be achieved with this patient within this length of admission? Is this psychological need a result of the brain injury or is it a premorbid characteristic that the patient brings to this context? If this need is indicative of a long-standing pattern of response, then is it possible to address this within the time constraints of this admission? When considering such questions it becomes clear what approach is suitable for use, and when using Wheeler's (1983) levels of intervention the therapist is aided in determining the level of input that is required. Additionally, consideration of such constraints are aided through the use of SMART goal-setting, as only goals that can be achieved during the duration of admission are established.

The psycho-social-emotional approach is applicable with patients who are withdrawing from restorative and compensatory opportunities or cannot engage in rehabilitation due to psychological, social or emotional complications. It is also relevant to those who have psycho-social-emotional needs that are related to their neuro-disability and can be addressed to a degree during the length of their stay at the care-site (e.g., psychological adjustment to disability). It is contraindicated for use with patients with no insight or awareness of themselves or their environment, such as those in vegetative state (see Giacino, 1997, for information about vegetative state).

Case Vignette

 A patient had sustained a severe brain injury as a result of
 bilateral ischemic cerebral insult secondary to an infection. After
 a period of coma and non-responsiveness, she was beginning to
 demonstrate responses that indicated she was aware of her self and
 environment, as indicated via reproducible eye-pointing to indicate
 choice and slight head turning to stimulus. There were times when
 the patient became upset as evidenced by weeping and crying during
 music therapy (as related to the context within the session).
 Additionally, others working with the patient had reported
 instances of the patient crying when the patient's children were
 mentioned. It was evaluated by the care team that this behaviour,
 at times, inhibited the patient's ability to engage in
 rehabilitation, plus was indicative of a need for
 psycho-social-emotional work. Thus, in addition to the need for
 compensatory work, the need for psycho-socio-emotional work to
 enable self-expression about feelings of loss/change and a
 subsequent re-engagement in rehabilitation was identified. An
 example of a short-term goal with this patient was: that the
 patient will experience decreased feelings of distress through
 selecting one song (from a choice of two songs with contrasting
 moods) to express an aspect of emotion(s) experienced during the
 day of the session, as indicated through self-reporting a decrease
 in level of distress from 4/5 to 2/5 each session.

Combined Approaches

Practically speaking, and as indicated in examples provided within this article, there may be overlap between the approaches, however it is advisable that the therapist practice with one approach for a period of continuous time with patients. This avoids confusion and promotes a strong and clear approach to treatment. However, patients do make changes and thus changes in approach may be warranted. Additionally, there may be times when patients present with complex and varying needs requiring the therapist to blend together different approaches to address different areas simultaneously. However, combining different approaches requires advanced skills of clinical competency as there is a risk that with specific clinical situations one approach may compromise the other.

Considerations regarding the Use of the MIND

In addition to the considerations involved with using multiple approaches within programs, there are a number of other items for consideration that can assist with the use and development of the MIND model. Three are highlighted here.

First, there is a risk that if the MIND model is used prescriptively (e.g., to pre-determine a course of treatment), rather than to support (a) communication about practice, (b) clinical reasoning processes and (c) the identification of the treatment that is required, the creative processes involved in music therapy practice may be compromised. This risk is similar in kind to the one that Edwards (2006) highlighted regarding the risk of music therapy practice becoming marginalized when research enquiry is valued over and above clinical practice. It is also similar to the risk that Wilson (2003) highlighted regarding the use of test results to plan and evaluate treatment, as compared to the use of goals to assist with keeping rehabilitation work real, relevant and useful. Awareness of this consideration may ensure that the model is used to support practice rather than to pre-determine or prescribe practice. With this in mind, it is hoped that this model assists with addressing Shoemark's (2006) call for clinicians to translate (i.e., communicate) their practice into a form that can be known by others.

Second, although the model described in this paper aims to ensure patient-led care, not all patients are able to consent to treatment, as they may, for example, lack the mental capacity to do so. With this in mind, adequate patient representation, advocacy and involvement regarding the planning of treatment needs to take place. Accordingly, the patient group involved (e.g., children, adolescents or adults) and the context of the care provided (e.g., community or hospital settings) will influence how these issues are approached. Third, another consideration for the use of this model is the difficulty with translating phenomenological experiences into discursive forms (see O'Callaghan, 2001), or in this situation translating music therapy treatment into measurable goals. This is a challenge that is presented to music therapy practitioners and others (e.g., psychologists) who work with psychological, social and emotional realms. Perhaps this is an area that requires further attention within music therapy research and practice and more generally within healthcare.

Conclusion and Recommendations

In this article, one way of working that enables a response to patient's diverse and complex needs, abilities and aspirations, has been presented. The MIND enables a structure to support and guide clinical reasoning as related to the patient's presentation, plus it promotes patient-centered and patient-led care within the field of neurology, neuro-disability and neuro-rehabilitation.

The MIND was developed primarily from practice experience alongside the consideration of research findings and relevant clinical literature from music therapy and allied professions. Therefore, while a useful tool to support practice, the model is yet to be researched and its use is recommended as a way to (a) support clinical practice, (b) assist with clinical reasoning processes that involve consideration of the relevant evidence-base available to the practitioner, (c) assist with clarity of communication about music therapy work, (d) enable measurement of outcomes, and (d) facilitate patient-led and patient-centered care, rather than pre-determine treatment.

The use of the MIND can assist with understanding the role of music therapy, as it potentially provides a template for auditing music therapy work. Accordingly, practice areas that require further research and attention will be identified through this process. It also follows that work assisted by this model can aid with the development of practice standards, as explorations into the scope and breadth of music therapy practice will occur.

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Barbara A. Daveson, PhD RMT, The Royal Hospital for Neuro-disability, London, United Kingdom

(1) The comments made by Jackie Lindeck, Holly Hitchen and Gemma Lenton-Smith are acknowledged here. It is also acknowledged that the thoughts contained in this paper were presented and developed within a lecture at Roehampton University (i.e., Daveson, B. (June 15, 2005). Music Therapy With People Living With Neuro-disability. Music Therapy Department, Roehampton University, London.)

(2) See Purdie & Baldwin (1995) for an account of various approaches to practice in this field.

(3) The work of the Goal Planning Working Party at the Royal Hospital for Neurodisability is acknowledged here. This work led to the development of this SMART goal setting information presented here. In particular the work of Hayley Ramsey, Megan Bishop, Philippa Williams, Gary Derwent and Ian Mobsby is acknowledged.

(4) At times the patient's appraisal of their restorative capability may be different from that of the multidisciplinary team's appraisal. It is recommended that careful consideration and negotiation, as to whether restorative goals are realistic, needs to occur during the assessment period.

(5) See Bruscia (1989) for an explanation of the difference between methods and method variations, along with examples of these.

Table 1
Examples of Two Different Levels of Practice within the
Psycho-Social-Emotional Approach

Practice Levels Features of Work

Music therapy as an (a) Goals achieved through activity
activity therapy rather than insight; (b) Aims to bring
 about changes to behaviour;
 (c) Understanding why the behaviour is
 occurring is not emphasised
 (Wheeler, 1983)

Insight music therapy (a) Focuses on the "relatively conscious
with re-educative goals material" (Wheeler, 1983, p. 10); (b) In
 this level of practice there is a focus
 on the here and now, feelings, and
 interpersonal responses--which then leads
 to insight, which in turn results in
 improved functioning (Wheeler, 1983)