Abstract
There has been a long-standing debate around the relevance and usefulness of (standardised) assessment in music therapy. In my experience, Music Therapists sometimes feel that assessment in music therapy is reductionist and that, by trying to measure or analyse or quantify what happens in a music therapy relationship, it somehow takes something away from the spontaneous creativity and connection that comes from shared musical experience. This position reminds me of the famous quote ‘writing about music is like dancing about architecture’ (Sperrazza, 1979) that seems to express the challenge of trying to articulate what happens when someone has a musical experience.
As Music Therapists we have all had those experiences and understand, perhaps more than most, the capacity that music has to bring about observable, positive changes in clients that we work with. I would argue that it is our responsibility to be able to articulate these experiences coherently and concisely in order to be able to communicate with our clients, their families, our colleagues in other disciplines, employers and commissioners about the unique affect that musical experiences can have. Without assessment, how do we, as clinicians, know how to apply music in the most effective way in order to bring about positive change?
In the foreword to this book, Barbara Wheeler states, Assessment is essential to music therapy treatment, but Music Therapists’ understanding of assessment and methods of assessing have not always kept up with their clinical needs. (p. 11)
It is clear that current health, education and social care environments are increasingly driven by the need for evidence-based interventions. Cuts in funding, such as those that we have seen in the United Kingdom in recent years, mean that Music Therapists need to be able to demonstrate, not just subjectively through observable change but objectively through the use of psychometric evidence, the effectiveness of music therapy interventions if we are to survive economically motivated decision-making and keep our jobs. It would seem that now more than ever Music Therapists need to be working together to develop and standardise assessment tools that in turn serve to develop and sustain the integrity of the discipline of music therapy.
On their website, The International Music Therapy Assessment Consortium (IMTAC), whose members collected together and edited this anthology, state three clear objectives: Developing and standardizing robust and research-based music therapy assessment tools Increasing awareness of assessment within and around of the field of music therapy Implementing music therapy assessment in clinical practice. (https://www.musictherapy.aau.dk/imtac/)
The Consortium is currently coordinated by the team at Aalborg University in Denmark and its member organisations originate from Denmark, USA, Germany and the UK.
In chapter 1, two of the editors set the scene by exploring the history and practice of music therapy assessment across the world. The 16 tools that are included in this volume originate from Northern Europe and from the United States with the exception of one tool from Argentina. This is interesting in terms of how closely it matches the membership profile of IMTAC. It is highlighted that few publications on assessment in music therapy in Asia have been produced in English; however, it does come as something of a surprise that there are no tools from Australia included in this anthology although two are referenced here.
There is a useful discussion about the purpose and implementation of assessment in clinical practice. Some of the questions raised here certainly resonate with my own experiences, for instance, whether it is necessary to have music therapy–specific assessments or whether an assessment process should include music making. In my own clinical practice with children and adolescents particularly in educational settings, I have opted to use generalised tools that look at psychological attributes such as the Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997) or the Trait Emotional Intelligence Questionnaire Adolescent Short Form (TEIQues-ASF) (Petrides, 2009) a self-report tool for adolescents which looks at emotional intelligence. While somewhat useful, as these tools are familiar to professionals from many different disciplines and are standardised assessments that communicate change over time, any positive changes cannot be directly attributed to the music therapy intervention. As is pointed out in this book, using a music-specific assessment allows the therapist to measure the uniqueness and usefulness of music therapy and allows comparison between a client’s observable responses under music and non-music conditions (p. 25).
The purpose and methods of assessment are usefully summarised here and we are introduced to the acronym RIOT that stands for Reviewing, Interviewing, Observing and Testing which describes the procedures used in data-based assessment. Each of these terms is explored in detail and the purpose of assessment at each point of the therapy process (diagnostic/prescriptive, formative and summative) is also considered. In fact, it can be argued that assessment in some form shapes the entire music therapy intervention as therapists strive to understand better the emerging responses and needs of clients and modulate their own responses and behaviour accordingly, in order to promote increasingly healthy functioning.
A summary of the findings of the search by Waldon et al. (2014) and Waldon (2014) of English-language music therapy articles that feature the terms ‘test’ and ‘measure’ between 1980 and 2014 draws attention to the fact that ‘the number of assessment instruments in the prominent music therapy journals continues to be small’ (p. 36). In addition, many of the existing tools remain difficult to obtain, have not undergone repeated study and do not include psychometric factors.
This first chapter concludes, ‘Assessment in music therapy is necessary for quality treatment and provides a unique opportunity to use music to evaluate client functioning using the creative and flexible medium of music’ (Jacobsen, Waldon and Gattino, 2019: 37).
In the following two chapters, the editors take us on a journey through the theories and concepts that define assessment and the way in which it is applied in music therapy. Chapter 2 provides a comprehensive guide to the different concepts that inform psychometric testing and how it relates to music therapy theory. It also explains how theory ‘underlies the processes of collecting, interpreting and applying assessment information’ (Jacobsen, Waldon and Gattino, 2019: 42). I found this chapter particularly useful as it provides clear definitions of terms such as bias, validity, evidence, consistency and reliability. As a Music Therapist who has been more involved with in-service design and delivery rather than research, these definitions are both accessible and invaluable. I found myself looking back at them for reference when reading the psychometric aspects of the assessment tools that are included in detail later in the book, in order to improve my understanding of what was being described. Many helpful references are made here to Kenneth Bruscia’s (1987) seminal text on improvisation in music therapy and the work of Tony Wigram (2007, 2019)
One concept that I found particularly useful was around a broader understanding of treatment validity or the extent to which any assessment process contributes to the design of treatment programmes. For me this answers the ‘so what?’ question that I sometimes find myself asking when confronted with a complex set of data. In my opinion, it goes without saying that assessment data should be used in a way that is of maximum benefit to the client. Arguably it should guide the clinician in being able to apply music therapy interventions in the most effective way. While Music Therapists are not in the business of conferring diagnoses, some music therapy assessments can provide additional information to existing diagnostic assessments. For example, the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC) (referenced in Chapter 20) evidences increased sensitivity for functioning in the auditory and visual domains for those with disorders of consciousness as compared to other assessment tools.
Chapter 3, by Gustavo Gattino, Stine Lindahl Jacobsen and Sanne Storm, provides us with a detailed literature review of non-test tools in music therapy. Using the RIOT acronym once again, this refers to assessments that use Reviewing, Interviewing and Observing as their main means of gathering data but do not use a formal test. Of the 29 case studies that met the inclusion criteria, 16 cited observation as their main means of gathering data and a further 6 used observing alongside reviewing. What follows is another very useful breakdown of the different types of observation and how these relate to theories that inform music therapy practice. The three different types of observation that are explored are listed below:
Behaviour observation
Tactile and body observation
Interaction and communication observation
Under each of these headings there is a helpful section on what to observe. Most of these techniques would require detailed analysis (micro-analysis) of video recordings of clients in music therapy sessions in order to elicit valuable assessment data. It is interesting then to consider how these data are subjectively interpreted in the context of theoretical understanding. For instance, the authors reference Antonio Damasio’s (1999) work on ‘background’ feelings – unconscious feelings that may be incongruent to what we are expressing verbally but that can be observed through our posture, the tone of our voice and the prosody in our speech.
The chapter concludes with a step-by-step guide to building an assessment tool, which is invaluable for any clinician working without a pre-developed tool. Overall the first three chapters provide a concise yet thorough guide that builds one’s understanding of the context, theory and concepts that shape music therapy assessment in a way that is helpful and easy to follow. This goes some way to meeting the objectives of the IMTAC.
The following 16 chapters make up the main body of the text, with each one describing a different assessment tool. Chapter 4 presents the template that each author was asked to follow when preparing their chapter for publication: the context and motivation behind the tool, how it was developed, how it can be administered and how data are collected. The psychometric properties of the tool are discussed and its application in clinical settings is considered alongside any training requirements. While not every author covers every aspect of the template, it gives an overall structure that makes them all clear and easy to follow. The 16 tools (chapters) are not grouped by client group or country of origin but seem to follow quite a random order. The editors acknowledge here that this compendium contains only a selection of tools and that there are more that could have been included. They also direct the reader here to the catalogue on the IMTAC website that contains short descriptions of these tools and more.
Before discussing the tools it would seem appropriate here to raise one of my few grievances with the text, which is the number of acronyms that it contains. I found myself frequently having to flip back and forth through the text to remind myself what each acronym stands for. I am not sure that this is avoidable when discussing multiple assessment tools; however, at times, it certainly disrupted the flow of the writing (and my thinking!)
While not all of the 16 tools were developed for a defined client group, most were designed with a particular population in mind. These include children with autism; children, adolescents and adults with psychiatric disorders; older adults with dementia; adults with acquired brain injury; and adults with prolonged disorders of consciousness and vulnerable families. The motivation, for the majority of the tools, was to assess for unique observable behaviours within the music condition that could add to our understanding of the way in which the client presented.
In chapter 8, Penny Roberts describes in detail the differences in priorities between the different members of the clinical team when it came to designing the Individual Music Therapy Assessment Profile (IMTAP) tool. For instance, one Music Therapist prioritised emerging language skills while another was more concerned with observable pre- and post-data. In the chapter conclusion, she quotes an e-mail from one of the co-authors of the tool that states, . . . our goal was to produce a ‘. . . usable, functional multi-domain assessment that gave clear indications for goals, provided a quantitative means to assess client progress, and allowed therapists of all levels (from entry to master therapist) to use it’. (p. 172)
My own experience of developing an assessment measure resonates with these experiences. Between 2009 and 2011, while providing music therapy with children and families at Coram, I was lucky enough to be involved in building, piloting and publishing the Music Therapy Outcome Star (MTOS) (Burns and MacKeith, 2011). This process included extensive consultation with a range of multi-disciplinary colleagues and parents about what changes as a result of music therapy intervention and then about how that ‘what’ changes. Although initially everyone had different priorities, eventually we were able to agree on five domains that were supported by music therapy and psychological theories and to create a journey of change that could be applied to each of those five domains. As the tool is completed by parents (considering behaviours observed at home), by the teacher (behaviours observed in the nursery/school setting), and the Music Therapist (behaviours observed during the music therapy session), we were able to identify differences in presentation between the different conditions and how these changed over time. This allowed us to identify strengths that were only demonstrated in the music condition, for instance, an innate sense of rhythm. We communicated about these unique abilities with parents and teachers through sharing carefully selected video extracts of sessions. We did not include a scale that specifically looked at musical behaviours and how they changed over time. Unfortunately, the psychometric properties of the MTOS have yet to be established.
In many cases, the authors spoke about identifying unique strengths through including musical items in the assessment process. For example, in chapter 8, while describing the inclusion of the ‘musicality’ domain in every assessment, Roberts states, ‘We felt – and feel – strongly that music therapy is unique in its ability to recognise, assess, elicit and develop these talents and abilities . . .’ (p. 165). Similarly, in the conclusion of chapter 9 on ‘Event-based analysis’, Tony Wigram and Stine Lindahl Jacobsen state that ‘children often reveal unexpected abilities and potential’ (p. 193).
The authors draw on a variety of theoretical frameworks to inform the construct of their tools. These include those based in a behavioural approach, a phenomenological approach or a psychodynamic approach. Several cite the theories of Daniel Stern (1985, 2000, 2009, 2010) – affect attunement, vitality affect, non-verbal communication – and Malloch and Trevarthen (2009) – communicative musicality, in shaping their understanding of observable phenomena, and several more draw on the Improvisation Assessment Profiles developed by Bruscia (1987).
As an example, both the Assessment of the Quality of the Relationship Tool (AQR) described in chapter 10 and the Intramusical Relationship Scale (IRS) in chapter 11 focus on the intramusical development of children who struggle to form relationships. Both use different theoretical models to demonstrate how intramusical development precedes intermusical development. In other words, children must explore and develop their ‘musical singularity’ (Ferrari, 2013) before they can explore music in relationship with another. The AQR references Stern’s ‘layered model of development’ (2000) and the need to moderate over- and under-stimulation in music therapy to allow intramusical development to take place. Data collection for both tools is through the micro-analysis of video. This method of data collection is very time-consuming making it challenging to apply it in clinical practice; however, the data that it produces could be invaluable in shaping the musical interventions of the therapist in order to bring about change in the client.
‘The Music-based Scale for Autism Diagnostics’ (MUSAD) described by Thomas Bergmann in chapter 7 and MATADOC by Wendy Magee in chapter 20, both contribute unique data about the clients’ responses to music conditions that can assist in diagnosis. Both tools are designed to incorporate items that test domains related to diagnostic criteria rather than being based on theoretical constructs. They both have clear protocols for the administration of the assessment making them easy to apply in clinical situations once training has been received. While neither tool is sufficient alone to make a final diagnosis, both demonstrate high levels of content and construct validity and provide unique data that could not be assessed outside of the music therapy setting.
In order for assessment tools to be integrated widely into clinical practice, I would argue that they must be both easy to administer and to score. The number of items scored varies hugely between the 16 tools described in detail here, and I would suggest that the more complex the scales and subscales included in the tool, the less likely it is to be widely used.
Of the 16 tools described here, 7 state that they require the Music Therapist to undergo specialist training in order to be able to use them effectively. This has both a time and cost implication and in most cases it is not clear how widely available training is. Of the others, the Individual Music-Centred Assessment Profile comes with a CD-Rom that generates a quantitative report. Carpente (2013) anticipates updating this with an online version in the future making it more widely accessible. Several of the tools have manuals that are available from the author and do not require additional training. The Residual Music Skills Test is included in the text and the author states her wish that this will lead to its use in clinical practice. Unfortunately, the Music Therapy Toolbox (MTTB) computer analysis tool is not yet widely available.
In summary, in its opening chapters, this text provides extremely valuable exploration of the context and theory that shape the practice of assessment in music therapy. Useful and accessible definitions and descriptions of psychometric factors and of constructs such as observation serve to improve the reader’s understanding and provide a helpful point of reference when reading the later chapters dedicated to the individual tools. These early chapters will also be extremely useful for introducing music therapy students to assessment and encouraging them to incorporate this into their practice (Cassity, 2019). The tools themselves demonstrate a wide range of assessment styles and applications across diverse clinical populations. While it is unlikely that a Music Therapist would read this anthology from cover to cover, the clear structure of the chapters relating to individual tools makes this a very useful text for anyone who is looking for an existing tool that they can incorporate into their clinical or research practice, or who is looking to develop their own music therapy assessment.
It is very clear to me from reviewing this book that music therapy assessment has an integral part to play in sustaining the integrity and demonstrating the uniqueness of the discipline of music therapy.