I was going to do another status update on what I've been up to (which has included some good stuff, like getting to observe speech, physical, and occupational therapists work with students), but I read an article tonight that I wanted to critique on here. It'll be a good change of pace. By the end of this week I'll be drowning in IEPs (that's Individual Education Plan) and writing goals, so I'm sure I'll have plenty to say then.
When I was in school, my math and science teachers would always tell me "show your work." I hated it. Sometimes, I could do things quickly in my head, and I didn't need to show my work. But that was the rule. The reason for this rule was that if I came up with an incorrect answer, I could see where I went wrong. This same adage can be transferred to music therapy. You must "show your work."
I found this article via Twitter. It was posted by a music therapist I follow, Rachelle Norman. Rachelle runs a private music therapy practice called Soundscape Music Therapy, running out of Kansas City.
Before reading my response, you may want to read the article. It's titled "The Illusion of Evidenced-Based Practices", by Michelle Dean. In the article, Dean takes issue with the heavy emphasis on evidenced-based treatment (EBT) in education and healthcare practices today, and how art therapy doesn't really fit into this model.
Before I begin, let me make my bias very clear. I am in full support of evidenced-based treatments. This is what I was taught at FSU, and it's what I believe is the best route. I feel that the only way you can administer a treatment fairly to a client, is to prove to them scientifically that it works.
Now I take several issues with this article. One of the first arguments Dean makes is that the success of art therapy is predicated upon the relationship between the therapist and the client.
"...when symbols or people in a relationship are taken out of context they lose their meaning...those relationship qualities that are so elusive to measure."
She claims that in order to measure the benefits of art therapy scientifically (without bias), one would have to remove the regular therapist that the client sees. Thus, the client/therapist relationship variable would be removed, and the effectiveness of the therapy would be stifled.
I take issue with this for several reasons. One is that just about every treatment and therapy you can think of, outside of chemical treatments, is reliant on a successful relationship between the client and the therapist. The health of the client/therapist relationship plays an essential role in the success of psychology, psychotherapy, speech, occupational, and even physical therapy. If you change the therapist in any of these fields, you will more than likely reduce the effectiveness of the therapy, at least until this new therapist establishes a relationship with the client. This is especially true with special needs children, who thrive on routine and structure.
All of these fields cannot simply disregard EBT and abandon having to prove and document the success of their treatments, just because they rely on the client/therapist relationship. In fact, I don't think you need to remove the therapist to scientifically measure the effectiveness of these therapies. Granted, this is a variable. It would be difficult to judge if it was solely the treatment having the positive or negative effect on the client. But you'll never be able to remove all of the variables in any kind of behavioral science. That's just the nature of the beast. There are far too many variables to control. How is the client feeling that day? Did they have breakfast? Did they sleep well the night before? You just can't control everything the way you can in a biology or chemistry lab. It's always been this way though, and that hasn't deterred behavioral science very much.
Dean also makes the argument that art therapy does not fit into the EBT model because it is very symbolic in nature. The creative expression is the therapy, and that is difficult to measure.
"Although objective observation may be desirable in evidenced-based therapies, it is not truly possible in this relational, creative, and symbolic context."
I believe this sells art therapy short. The benefits extend far beyond the opportunity for self-discovery or expression. Certainly this is very important, but look at the big picture. Look at the motor skills benefits, both gross and fine, painting has. Look at the object identification opportunities, or the academic and pre-academic lessons you can transfer into an art session. I feel that Dean is only focusing on one goal, and it's a very limited goal.
The Fulton County MT's all have a poster with their music therapy supplies that I love. It says "How can I use music to ________?"I believe the art therapy field can ask this same question: How can I use art to _______? To practice following directions, to increase social contact, to teach colors, to exercise fine motor skills, etc? Simply looking at the expressive aspect limits the field so much. It'd be like a music therapist who only ever worked on the goal of mood elevation. Just, "let's play some drums and talk about what we're feeling." This is definitely a very important goal in MT, but there are thousands of others that are equally important.
I also interpret Dean's words as saying that you cannot measure these expressive and symbolic benefits of art therapy, and I disagree with her here as well. I don't believe there is anything wrong with good 'ol self report. Doctors in the hospital use it all the time. Think about every hospital room you've been in. I know all the rooms I've seen have a Likert scale on the wall, usually numbered 1-7 or 1-10, of the patient's current pain perception. The doctor asks how the patient's pain is that day, and they let him know on that scale. The lowest number would be "little-to-no pain" and the highest would be "unbearable pain." This is a very important tool in helping doctors assess a patient.
You can use the same concept to judge the effectiveness of an art therapy session on a clients emotional state. A simple pre-post self-assessment using a Likert scale. This isn't any less valuable than any other data collected in an experiment. It's a simple, fast, and effective way to collect quantitative data on a phenomenological experience.
I don't think you'll find many music therapists who will belittle the importance and impact that the Journal of Music Therapy has had on our field. Having research support our field opens up jobs and new opportunities for music therapists everyday. It may be inconvenient at times, but the only way to protect and expand our career field is to back it up.
Show your work.
Photo courtesy of Flikr user Kevin H.
So I have gotten a lot of experience working with various art therapists at the BHC. The ones I work with say, "it is not about the product but the process." This is completely different from our practice in music therapy... for us, it is ALL ABOUT the outcome. I agree with you that, if an AT wants to measure a client's progress, there are certainly ways that they could do so. However, it seems to be that this is not the type of therapy they practice. I have enjoyed collaborating with these ATs @ BHC, and teaching them a thing or two about behavior mod.
ReplyDeleteThe other thing I think we differ from in MT vs. AT, is that a MT session could certainly be successful even without a happy/perfect relationship from patient to client. I have had a couple patients @ BHC say they don't like me because I told them "no..." Well, that is the nature of behavior mod, and whether they see a gain or benefit from me saying "no," it is indeed there. I didn't say no to make them hate me, I said no to influence their non-functional behavior.
So... I feel you on this one, Andrew. Nice article review. It is just the nature of MT vs. AT... there is just not much research out there in AT because they just don't believe in the evidence-based model (I speak generally).
(MT rocks!)
Thank you for your post, Andrew. The topic of research in music therapy (and other creative arts therapies) is a complicated one, precisely because of the many facets involved in the therapeutic relationship and the wide range of needs/goals that MTs address. Like you said, I doubt anyone would deny the importance of research to the growth of our field and improving the effectiveness of our clinical work. The problem, as I see it, is producing quality research.
ReplyDeleteThe standards of "evidence-based practice" would like us to produce double-blind, placebo studies, as is standard in the pharmaceutical world. This is obviously impossible in music therapy research. Once you start making concessions from there, though, the quality of the evidence would seem to suffer, both from an "outsider's" perspective and from a music therapist's perspective. For example, to control interventions to the point that they are truly replicable, you really do have to take out the person of the therapist and the therapeutic judgments we all should be making in clinical work. Thus, we end up with music therapy studies that measure participants' responses to a particular CD or to a protocol that might not look like music therapy at all. We could say that the other forms of music therapy simply aren't valid, but that denies the real benefits that many clients get from working with music therapists.
Another problem is the tools we use for measuring various phenomena. For one, self-report measures are often considered pretty weak, even when those research tools have been validated in previous studies. Staying confined to self-report measures will not get us that much more respect from the scientific community. The next step, then, is to measure directly observable data, like heart rate, stride length, gait, etc. This is the strength of NMT research. Those types of measurements leave out many emotional, spiritual, and cognitive components, however, not to mention any sort of understanding of the music that is created in a session. Maybe brain scans will be a solution in the future to show concretely what is experienced emotionally. That technology is not accessible yet, though.
I think many therapists and clients know on a personal, experiential level that music therapy has an effect on many areas of living, too, but we have not found a stellar way to quantify them. We have to "show our work" in other ways, too. This is why all of the rigorous forms of qualitative research are also important to our field.