I read Jeanette Tamplin's paper about the development of the programme in which she is involved with interest. Whilst Music Therapy (MT) in the UK is well developed in the area of mental health, with people with learning difficulties and with children with communication disorders, rehabilitation has been an area where the profession is still struggling to make its mark in the UK. I am responding to the Australian experience with an overview of MT in rehabilitation in the UK. Whilst I can make some comment on rehabilitation, my major focus will be neuro-rehabilitation as this is the area in which I've worked in the UK for 16 years.
Few rehabilitation facilities within the UK employ music therapists (MTs). A recent survey of rehabilitation units found that a total of 1.8 MTs are employed in four units across the UK (Andrews & Turner-Stokes, 2005). In the UK the majority of music therapy posts working with neurological clients tend to be in nursing homes where people with acquired brain injury and degenerative illness such as Multiple Sclerosis and Huntington's Disease live receiving long term nursing care. Since 1988 the Royal Hospital for Neuro-disability (RHN) has had the only full-time MT post in neurology in the UK, and since 1990 the only 'team' of therapists working in a neurological setting. This has expanded from 1.6 whole time equivalent (WTE) in 1990 to the current position of 3.2 WTE professional staff with additional assistant posts. The RHN is a national medical charity relying heavily on voluntary donations, and funding for the music therapy service is sourced entirely from charitable trusts and foundations. Currently the National Health Service (NHS) funds one permanent three day post in neuro-rehabilitation at Sheffield Northern General Hospital. Other music therapy service provision in general and neuro-rehabilitation funded by the NHS tends to be in the form of contracted service level agreements within established music therapy services such as that provided at St Ann's Hospital, Haringgay in North London. This provides one day in the elderly stroke rehabilitation unit and a further two days in general rehabiltation. Nordoff-Robbins Music Therapy UK funds another substantial three day post in a NHS neuro-rehabilitation setting at the Regional Rehabilitation Unit at Northwick Park in north London, which provides training placements for Nordoff-Robbins students. Nordoff-Robbins Music Therapy UK also funds several part-time posts through its outreach programme in facilities which care for people with neurological conditions, however, these posts tend to be predominantly in continuing care or community settings rather than rehabilitation facilities. Headway, a charity which provides support and services to people who have suffered a head injury and their carers, also has recently established a part-time music therapy post in its East London centre. Once more, this is funded through voluntary contributions. This overview of music therapy in rehabilitation has a particular focus on neuro-rehabilitation and is not meant to be authoritative. Some posts may have been omitted from this overview.
Thus, funding for music therapy posts in neuro-rehabilitation settings within the UK is widely variant. Sources for funding are predominantly from charitable trusts and organisations. Currently, very few MT posts in neuro-rehabilitation are funded by the NHS which funds other allied health and related professions such as physiotherapy and occupational therapy as part of standard care, and to a lesser degree speech and language therapy and clinical psychology. Several reasons underpin the funding source differences. Firstly, as Jeanette points out in her report, there is a shortage of rigorous research into music therapy in neuro-rehabilitation which justify its inclusion as part of standard care. However, it could be argued that our sister professions also lack a body of research evidence. Two other key reasons might contribute: a lack of understanding of the contribution MT has to play in neuro-rehabilitation; and a shortage of appropriately skilled music therapists to respond to posts when funding becomes available.
We have not yet reached the point in the UK where it is standard for funders to 'cherry pick' which services will be funded in a single rehabilitation package, however, this has been known in very complex cases. I have argued for many years that until the MT profession is able to clearly and concisely communicate its treatment outcomes, it will remain on the fringes of neuro-rehabilitation (Magee, 1999). As a foundation to further research, the profession need to communicate about outcomes expected of MT with greater clarity and uniformity. Where posts have sprung up in recent years in the UK, these have often been of such a part-time nature (e.g. one day per week or less) that it is impossible for the post holder to integrate with the treatment programme and contribute in any meaningful way. Combined with a lack of specialist skills in neuro-rehabilitation care, individual music therapists positioned in such posts are often vulnerable. In my experience, this has led to poor retention and the post not being readvertised as it has been difficult to demonstrate positive outcomes.
Andrews & Turner-Stokes (2005) surveyed units which included general rehabilitation units in addition to neuro-rehabilitation units. Hence, the figures they report of MTs working in publicly funded neuro-rehabilitation units may be an overestimation of the real number employed in these settings. However, nine units which were not providing MT expressed a perceived need for MT as part of service provision. Of these units, the majority were general rehabilitation units and two were spinal units. This should be of interest generally to the profession here in the UK as spinal rehabilitation is an area which has not yet employed MTs in the UK, and there are few posts in hospital settings across all populations. Perceived staff/ patient ratio is another interesting factor reported within the perceived need, estimated at 0.25 MT / 10 beds. This compares to a perceived need of approximately 2.2 OTs / 10 beds, and 0.8 SLT / 10 beds.
I read with interest the results of the evaluation of the first year of the Royal Talbot MT Programme, particularly comparing the reasons for referral to MT with a study of referral patterns at the RHN. Severe service cuts at RHN in 2001 demonstrated the need to monitor music therapy service referrals, response times and outcomes more closely in order to justify the service. This resulted in a revision to the documentation used for referral and the inclusion of information to assist with data monitoring.
Referral to music therapy at the RHN focuses on six categories of health need, drawn from the multidisciplinary documentation system (see Table 1). It is interesting to note the differences between these and the reasons for referral used at the Royal Talbot. In particular, the combination of 'social and emotional' together at the Royal Talbot differs from the RHN system, which incorporates 'social relationships' with 'communication skills'. The combination of 'Communication skills and social relationships' was the outcome of a long process negotiating with the multidisciplinary team at the time when we were devising a single multidisciplinary documentation system. Hence it should be noted that the resulting categories reflect a multidisciplinary rather than a unidisciplinary system. It was a key priority, however, to find optimal integration of the music therapy system into the wider service delivery. The revised system allowed for the collection of both quantitative data and qualitative data. Quantitative data included the frequency of referral for each category of health need, the priority given to each health need by the referrer, and timeliness of completion of assessment. Qualitative data was collected from key stakeholders such as the professional who made the referral, the patient themselves if they were able to provide feedback, and the family. Analysis and reporting of the qualitative findings resulted in the reinstatement of a 0.6 whole time equivalent post, the funding for which had previously been cut.
Review of referral patterns over a two year period produced results which contrast with those reported at the Royal Talbot (Magee, 2005). The aims of the RHN review were to identify reasons for referral to music therapy within multidisciplinary neuro-rehabilitation teams, and to identify patterns in those disciplines referring to music therapy. As the results of this review are currently submitted for publication (Magee & Andrews, submitted for publication), a brief report on the results only can be provided here.
Table 1: Reasons for referral to Music Therapy
| Categories of health need | Selected examples of specific goal areas |
|---|---|
| Physical presentation |
|
| Occupation |
|
| Cognitive function |
|
| Communication skills and social relationships |
|
| Emotional expression |
|
| Behaviour |
|
During the two-year period from which data were collected, 110 referrals were received across three rehabilitation units. The most frequent single source of referral was from multidisciplinary groupings, particularly forums such as case reviews, but also from other subgroups of the MDT e.g. SLT/OT. Examination of the MDT subgroup referrals demonstrate that combined speech and language therapy and occupational therapy referrals were the next most frequent source of MDT referral. Speech and language therapy most frequently made referrals as a single discipline, followed by occupational therapy.
Categories for referral (See Table 1) were reviewed both for their overall frequency but also for the priority attributed to each category. The referral system allowed referrers to prioritise the goals of MT assessment from 1 – 6, with priority one being the most important aspect to be addressed by assessment. Thus, indication is given as to whether physical aspects are the key reason for referral, or whether emotional expression is considered a priority need.
Communication skills and social relationships was the most frequent reason for referral to MT, and the most frequently rated Priority 1 (26.8% and 36.7% respectively). Emotional Expression was the second most frequent reason for referral (23.6%), and the category with the second highest rating of Priority 1(26.6%). Behaviour and Cognitive function followed consecutively with nearly parallel results. Behaviour rated as the third most frequent reason for referral (17.9%) and the third highest priority for referrals (16.5%). Cognitive function was the fourth most frequent reason for referral (16.1%) with the fourth highest priority (12.8%). Physical presentation was referred as a priority goal in only 5.5% of cases, although was given as one of the reasons for referral in 8.9% of referrals overall. Occupation was the least frequent reason for referral to music therapy (6.8%), with only 1.8% referrals outlining this as a priority goal area.
Whilst comparison between referral patterns in the two settings can only be anecdotal given the information provided, the similarities between the two reports is of interest. The reported findings of the social and emotional impact of MT with the Royal Talbot may indicate the level of functioning of the patient population. The level of clinical complexity typical of the population at RHN prevents this type of data being collected. Functional levels of disability have not been given by either report, and so comparisons between the two can remain only speculative.
A comparison between the Royal Talbot programme evaluation and the audit of referrals at the RHN provide food for thought for the profession, particularly considering the need for greater evidence of the effects of MT in rehabilitation.
Considering both reports, the findings suggest that
Collection of this type of data across a greater number of sites would make an interesting and invaluable study in terms of examining the role of MT in the rehabilitation setting. I am currently exploring collaboration with another regional rehabilitation unit providing MT to see whether we can combine data in a meaningful way, using standardised functional measures to allow applicability of any results. Although service evaluations and audits such as those examined here do not qualify as rigorous research, the possibility to formulate patterns of MT service delivery in rehabilitation can assist the profession in presenting a persuasive argument about its role within complex and costly multidisciplinary programmes of care. It would be of even greater value if we could collect these types of statistics on music therapy services from international units.
Andrews, K., & Turner-Stokes, L. (2005). Rehabilitation in the 21st Century: Report of three surveys. London: Institute of Complex Neuro-disability.
Magee, W. (1999). Music Therapy Within Brain Injury Rehabilitation: To What Extent Is Our Clinical Practice Influenced By The Search For Outcomes? Music Therapy Perspectives, 17 (1), 20-26.
Magee, W.L. (2005). Patterns of Music Therapy Referrals in a Neuro-rehabilitation Service for Complex Disabilities. Presented at British Society for Research in Medicine, Pan-London Annual Audit Meeting, January, 2005.
Magee, W.L. & Andrews, K. (Submitted for publication). Multi-disciplinary Perceptions of Music Therapy: A Study of Referral Patterns in an Established Service.
After reading Wendy Magee’s article regarding her perspective of music therapy (MT) in rehabilitation from the UK, I felt compelled to make known the position of a music therapist working in a rehabilitation hospital in Ireland, as they are one of the very few therapists practicing in this area in the republic. One must be aware that Magee’s voices article was submitted in 2006 and I suspect that there have been great advances in establishing music therapy’s role in rehabilitation in the UK since then. However, when Magee describes rehabilitative MT in the UK at the time as “struggling to make its mark”, one can see a strong similarity to the present role of MT in rehabilitation as a profession in Ireland. Whilst I cannot comment on an overall view of MT in rehabilitation in Ireland, I can give a detailed synopsis from a trainee’s perspective of a recently established permanent music therapy post in a rehabilitation hospital in Ireland.
An Overview of a Music Therapy Position in Rehabilitation from Ireland: A Perspective from a Trainee Music Therapist
This rehabilitation hospital provides a comprehensive range of specialist rehabilitation services to patients who, as a result of accidents or illness have acquired a physical or cognitive disability and require professional medical rehabilitation. Three categories of patients are referred to this hospital, which includes people who have brain injuries, spinal injuries and patients who require prosthetic, orthotic and limb absence rehabilitation. The facility also has a small paediatric rehabilitation department which takes referrals of patients under the same diagnosis.
The music therapy position was initially set-up at this hospital as a pilot program in 2009 with the costs of running the program being covered by fundraising and charity donations. When comparing this article to Magee’s, it is noteworthy to see the similarity in funding sources for MT between Ireland and the UK, as Magee states when talking of how music therapy is funded in the UK that, “sources for funding are predominately from charitable trusts and organizations”.
As the pilot program came to a close in 2011, and the music therapist was set to leave the facility, feedback from service users, their families and the staff indicated that there was overwhelming support of an appeal for a music therapy post to be established on a permanent basis. In 2012, a permanent senior music therapy position was set up at the hospital employed under the health service executive (HSE) of Ireland. Magee states how in 2006, there were very few MT posts in neuro-rehabilitation funded by the National Health Service (NHS) in the UK. Comparing this to the position in Ireland six years later in 2012, this newly established post at this hospital became the only MT post working in neuro-rehabilitation employed by the HSE in Ireland. This comparison between the UK and Ireland displays how music therapy in rehabilitation is an innovative service in this area.
Team Working
An inter-disciplinary team forms the basis for the programs available at this hospital. Within the paediatric department, the music therapist works as part of a team of occupational therapists, physiotherapists, speech and language therapists, teachers, social workers, psychologists, nurses, doctors and others which contribute and work together on each child’s rehabilitation goals. A main feature of the paediatric program at this hospital is a transdisciplinary approach, where therapists for example will run joint occupational therapy (OT) and speech and language therapy (SLT) sessions with a patient. Music therapy is fully involved in this joint approach where the music therapist will regularly run sessions alongside an OT, a physiotherapist or an SLT where each professional will assist each other in achieving similar or identical goals. In addition to this collaborative working approach other members of the team may observe music therapy sessions in order make assessments of patients. (Twyford & Watson 2008).
Magee’s describes in her article sources of referrals to music therapy across three rehabilitation units in the UK, where referrals came from multidisciplinary groupings such as case reviews, joint therapist referrals such as a combined referral by an OT and an SLT, and single therapist referrals from an SLT or a physiotherapist. The source of referrals to music therapy at this facility in Ireland are comparable to Magee’s account, as referrals at this facility come from similar professional team groupings and therapists.
The music therapist at this rehabilitation hospital also works using a method of clinical practice which they developed alongside another music therapist over a 13 year period working in a day center in London prior to their move to this Irish hospital in 2009. They called this approach collaborative approach music and attuned movement therapy. At this hospital the music therapist employs this method with certain patients where they will work closely with another professional, (usually a therapist such as those mentioned above) who acts as a movement facilitator for the child. During the therapy communication is on a pre-verbal level where patterns of breathing, vocal sounds and bodily movements are acknowledged by reflective improvised music and attuned movements. (Fearn & O’Connor 2008).
Expansion and Moving Forward
Since the MT pilot program was started in 2009 and a permanent music therapy position was founded in 2012, the service has moved from strength to strength and is continuing to expand. At first the music therapist solely worked with the paediatric patients which could range from birth to eighteen years of age. However, the prompt expansion of the music therapy service is evident as the music therapist now receives referrals from across the hospital. Along with their paediatric work the therapist now sees a number of adults in the hospital and they have also been integrated into the team, working with adult patients who have neurological damage, mainly with patients who are in altered states of consciousness.
From a trainee’s perspective it is clear that music therapy services are in high demand at this hospital and as knowledge of MT’s contribution and benefits to patients grows among the hospital staff, the service can only continue to expand in the future. However, as only a single music therapist is currently employed at this hospital, there is a definite limit to the amount referrals and workload this single therapist can manage with the hours available to them.
However, the music therapist at this hospital recently achieved a major step forward in the expansion of the music therapy department. They submitted a proposal to the ethics review board of the hospital to carry out a research study to assess the new music therapy assessment tool for awareness in disorders of consciousness (MATADOC),(Daveson et al, 2007). They proposed to identify its benefits in assessing patients level of response which would contribute to diagnosis and treatment planning as well as monitoring change in disorder of consciousness patients. Ethical approval was awarded in early 2013 and the research study is now in the final stages of preparation before the work can finally commence. If the study begins it will run for a period of two years and will result in the expansion of the music therapy department by an increase of employment hours for the senior music therapist and the addition of a second music therapist to the department to work on the research study.
In Conclusion
In Magee’s conclusions she considers findings from two different hospitals about MT’s role within the medical rehabilitation environment and its benefits to a rehab and neuro-rehabilitation programs. However she suggests as part of a future study that the findings “would be of greater value if we could collect these types of statistics on music therapy services from international units”. (Magee, 2006, para. 6).
From a trainee’s perspective the similarity between Magee’s findings in her conclusion and the music therapy program at this rehabilitation hospital in Ireland is unmistakable in terms of the process of establishing an MT post in this area, sources of referrals, music therapy’s relationship with other therapists and the contribution and role of MT within a rehabilitation team. A future evaluation or an audit of the music therapy service at this Irish rehabilitation hospital would be of great value to Magee’s proposal to collect data from international MT departments in rehabilitation and as she suggests, “would make an interesting and invaluable study in terms of examining the role of MT in the rehabilitation setting”. (Magee, 2006, para. 6).
References
Daveson, B. A., Magee, W. L., Crewe, L., Beaumont, G., Kenealy, P., (2007) The Music Therapy Assessment Tool for Low Awareness States. International Journal of Therapy and Rehabilitation. 14(12) (pp. 544-549)
Fearn, M. C., & O’Connor, R., (2008) Collaborative Working at the Cheyne Day Centre London. In Twyford, T., & Watson, T. (Eds), Integrated Team Working: Music Therapy as part of Transdisciplinary and Collaborative Approaches. (pp. 55-61) London: Jessica Kingsley Publishers
Magee, W. L., (2006) Music Therapy in Rehabilitation: A perspective from the UK. Voices: A world forum for music therapy. Retrieved from http://voices.no/?q=content/music-therapy-rehabilitation-perspective-uk
Twyford, T., & Watson, T. (2008) Integrated Team Working: Music Therapy as part of Transdisciplinary and Collaborative Approaches. London: Jessica Kingsley Publishers.