A presentation at the recent conference of the Mid-Atlantic Region of the American Music Therapy Association (March, 2008) has inspired me to focus this column on evidence-based practice. During a 4-hour lecture, Cheryl Dileo (Professor of Music Therapy and Director of the Arts and Quality of Life Research Center, Temple University, USA), Brynjulf Stige (Professor of Music Therapy, University of Bergen; Head of Research at GAMUT, Norway), Brian Abrams (Director of Music Therapy, Immaculata University, USA), and myself (Assistant Director of the Arts and Quality of Life Research Center, Temple University) presented on principles and perspectives of evidence-based practice in music therapy. The presentations and the discussions that ensued were truly fascinating and inspiring to me. At the end of the lecture, several attendees shared a similar sentiment and strongly encouraged us to continue the dialogue about evidence-based practice in music therapy.
During the past couple of years, we have seen several publications as well as conference presentations on evidence-based practice and music therapy. Many interesting ideas have been shared but what is missing is a continuous and dynamic dialogue. The challenges we face as practitioners in an evidence-based era are many and our voices need to come together in proposing potential solutions to these challenges. Although our countries have unique political, socio-economical, and healthcare demands that drive policies concerning funding and service provisions, I believe that an active and ongoing international dialogue and debate on how to best answer to the EBP demands is urgently needed. Therefore, I would like to invite all of you to contribute your voice to this debate. Let’s begin sharing our experiences, opinions, fears, suggestions, and strategies related to EBP. An excellent place for such dialogue is the discussion forum of this journal. With this column, I am following others who have published and presented on this topic but am adding an urgent call to jump on the EBP wagon not as a passenger but as a driver!
Because EBP is rooted in medicine, it has resulted in many objections in non-medical fields (including music therapy) and has caused a lot of anxiety. Many view EBP as a dogmatic paradigm that is out to destroy us. As a result, EBP is rejected rather than critically evaluated for potential advantages and disadvantages. We cannot afford not to engage in EBP (Gilroy, 2006). EBP is not a phenomenon that will soon disappear; it is a social movement and it is here to stay for quite a while (Sturdee, 2001). As a result of critical evaluations and identification of its shortcomings, the EBP model will most likely shift but the demand for evidence of the effectiveness of treatments will remain. Just yesterday, I received an e-mail from a colleague asking for evidence from controlled clinical trials on the effects of choir singing on psychiatric patients. Without evidence, the current program will not be able to continue. I know that many of you have been faced with the same demands for evidence and your programs have been threatened. Therefore, the question we need to consider is not whether to engage in EBP but how to engage in it. If we, as music therapists, cannot provide an answer to the how, the answer will be provided for us and we will find ourselves in a situation that will indeed be damaging to the practice of music therapy and our clients. We will have contributed to making EBP that destructive force we fear it may become.
A major issue in EBP is the current hierarchy of levels of evidence. This hierarchy was directly borrowed from the evidence-based medicine levels of evidence with ‘meta-analysis of randomized controlled trials’ being considered the top standard. In contrast, ‘qualitative research’ as well as ‘expert opinion’ find themselves at the bottom of the pyramid. We all know that this is not a good situation for our field. The goal of an RCT is to be able to generalize the findings and make the claim that a particular intervention is (the most) effective in addressing a certain issue. I do not need to convince you that demonstrating the effectiveness of a music therapy intervention is not a matter of just conducting some randomized controlled trials (RCTs). Music therapy is not prescriptive in nature. Clinical decision-making in music therapy does not parallel treatment decisions in medicine. So should we condemn RCTs as far as music therapy concerns? Definitely not! Should we claim that we cannot provide outcome-based research because it violates the values of music therapy? Absolutely not! We need outcome research to answer certain questions in music therapy. When I am working with a child who is in pain, I want to know if my intervention results in pain reduction. Likewise, health administrators want to know if our interventions will result in health benefits for the patients in their settings. RCTs can help provide this information. However, we cannot accept RCTs as the gold standard to inform our clinical work. We need to understand not just the what but also the how and the why! And we need to educate others that the outcome of music therapy is not answered by only asking the what question. I wholeheartedly agree with Gilroy (2006) when she states in her book on evidence-based practice in art therapy:
Rather than acceding to the prerogatives of orthodox EBP, I argue that art therapy should develop a pluralistic evidence base appropriate to the discipline, one that challenges the implicit hierarchies and beliefs that underpin EBP (p.2)
The presenters and participants in the lecture at the recent Mid-Atlantic Regional conference posed many interesting questions we need to consider. I am listing them here because I hope they will help stimulate a dialogue amongst all of us (so thank you Cheryl, Brynjulf, Brian and participants!):
Making music therapy evidence-based will require a lot of work and for many of us it brings new ways of thinking and challenges. In addition to our own dialogue, we should look at how other non-medical professions have responded to the perceived threat of EBP. For example, I highly recommend Gilroy’s book Art Therapy, Research, and Evidence-Based Practice. Her critical evaluation of EBP and her suggestions to art therapy for how to deal with EBP are excellent. We can learn a lot from the ongoing debates in nursing journals as they too are presented with many challenges related to EBM and EBP.
Gilroy urges art therapists not to reject EBP but to critically evaluate it and adapt it to the needs of their discipline:
Reviewing the EBP’s underlying assumptions and the systems that continue to drive its implementation [...] enable the paradigm to be understood as a contemporary social movement, as a product of history, as a process. Entering the EBP arena able to challenge and trouble the paradigm, its values, research priorities and blinkered view of evidence will contribute to a shift in the paradigm and enable art therapists to adapt its framework to the discipline (2006, p 25).
Let’s get ready to contribute to this shift. Let’s become active participants and respond in a way that is meaningful to the field of music therapy.
Gilroy, Andrea (2006). Art Therapy, research, and Evidence-Based Practice. London: Sage Publications.
Sturdee, P. (2001). Evidence, influence or evaluation? Fact and value in clinical science. In C. Mace, S. Moorey,&B. Roberts (Eds.), Evidence in the psychological therapies: A critical
guide for practitioners (pp. 61-79). London: Brunner-Routledge.
Bradt, Joke (2008). Evidence-Based Practice in Music Therapy: Let’s Continue the Dialogue. Voices Resources. Retrieved January 08, 2015, from http://testvoices.uib.no/community/?q=colbradt210408