On Developing Music Therapy Goals and Objectives
Abstract
In order to address the treatment of deficits through music therapy interventions, clinicians who assess human behaviors from a physiological perspective can target treatment goals and objectives to address more than just the symptoms of diagnoses. Clearer understand of Goal and Objective can help identify and address possible causes of mal-functions. This is possible when clinicians observe patients with a keen clinical eye for associating presenting problems with unobservable physiological reasons for them. This paper discusses the differences between a goal and an objective, and suggests how a clinical eye might focus long-range goals and short-term objectives from a physiologic perspective for any diagnosis. A sample case of autism is presented for the purpose of illuminating the suggested approach and terminologies discussed. Although the case is of a child with an Autism diagnosis, the information presented is transferable to other diagnoses and age groups. Clinical observations and sample goals and objectives discussed are based on the hypothesis that behavior is rooted in physiologic function resulting from information that is, or is not, available, that is either well perceived or ill-interpreted, by the brain, which thus calls for what appears as less functional behaviors. In considering treatment with music, interventions based on observed behaviors and responses will yield goals and objectives for possible causes of identified areas of deficiency, including psycho-emotional issues.
Back To Basics: Understanding Goal and Objective
My experience as a music therapy educator has been that the terms goal and objective have been as widely and variously defined as the term music itself. Students training to work in psychiatric and other adult settings seem to rely in great part on feel good and social interaction goals. There is nothing wrong with goals for self-esteem, feel good or getting along with others. However, the underlying causes of psychiatric and neurological deficits for instance, high stress factors, slow information processing mostly due to chemical interventions, auditory and vision issues, traumatic brain injuries, sensory deficits, and many other underlying physical indicators often escape music therapy treatment plans. In the development of Music Therapy as a clinical treatment, there has been much emphasis on the client-therapist relationship as a healing element. With many diagnoses, this is irrelevant. A client-therapist relationship is a moot point with comatose patients, and often also with PTSD, Alzheimers, severe retardation, lower functioning and non-verbal Autism, and others. Obviously it is comforting to have a nice relationship with a health professional, but is it not also so that the relationship (given a higher-functioning patient) automatically evolves as a direct result of the music interaction, rather than it being a separate treatment goal? In addition, it seems to me that a relationship that does not generalize to other areas of human interactions and life skills can become superficial to the basic cause of a psychological problem. ("I have a great relationship with my therapist, but I still hate my mother..."). This is a simplistic view, of course, but something to consider. The "relationship" that is healing in music therapy is that between the client and the music.
Music Therapy students who have been training to work with children of various diagnoses, tend to rely predominantly on what are called IEP Goals (Individual Educational Plan goals developed by school administrators and teachers). In the United States, IEP goals apply to educational curricula but have little to do with functional behavior, other than the pursuit of compliance and following of adult-issued directives. Other countries may have different varieties of such educational goals. Music therapy is not educational, as such, so how can it be defended as a service in an educational setting? By preparing the system for learning a distinct physiological goal of music treatment. My question to my students has been, "Okay, thats what they are doing. But what and how can music seek to achieve positive functional adaptation? Why can music reach beyond speech, OT, curriculum, and other issues? What do we music therapists see as the underlying cause of the deficits, and, how can we develop discreet goals and objectives defining our treatment service? "
In several of my dictionaries, a goal is defined as "... the end to which a design tends...." It has been my experience throughout several years of clinical practice and teaching clinical thinking to music therapy students, that the approaches to developing goals often are intermingled or confused with those of objectives, (often defined as "... an aim or end of action"). The understanding of the difference between a goal, and an objective is key to the development of treatment interventions. Let us, therefore, define goal as the ultimate attainment of change or betterment of a presenting issue and its cause(s) over the long term (overall design) - the end of the road. An objective, then, would be the step-by-step, short-term strategy (actions) - the road to the destination - that is traveled to yield the attainment of the goal. Simple? To the more experienced clinicians, this explanation might seem obvious. However, in my experience, in practice, and certainly in the classroom, treatment goals and objective are poorly understood, hence the need to discuss and clarify the terms, regardless of how obvious it might appear to the seasoned music therapist. To clinicians who are already knowledgeable in physiologic function, are not discomforted by referring to music therapy as a treatment, and who are incorporating the knowledge into clinical work, this paper may simply substantiate what is already being done. For others, the information may be totally new and thus hopefully will encourage further dialogue, reading. and study of the development of goal and objective, and reading of literature and research in scientific journals in addition to those of music therapy. Let us continue to investigate the subject of developing goals and objectives with this in mind.
How Can Music Therapists Develop Clear, Articulate Goals and Objectives Based on Observations Through a Clinical Eye?
We begin by asking: What response deficits are observed and assessed by the clinician, and what do those imply about associated anatomic/physiologic afflictions? In The Music Effect: Music Physiology and Clinical Applications (Schneck & Berger, 2006), there is discussion of human physiologic function, homeostasis, the fear cycle, sensory systems, and how the individual elements of music can be, and indeed have been used clinically to address deficits. The hypothesis explores the possibility that music as a treatment can be employed to address more than just observable mal-adaptive behaviors. Music Therapy has the potential of addressing causes of certain deficits causes which may not be immediately discernable to the clinician with limited knowledge or experience in how the body works. With the growing fields of Music and The Brain neurosciences, and the call for rigorous scientific music therapy research, it seems beneficial for physiologic function to become part of clinical knowledge, training, and treatment protocol.
I was once asked by a school administrator to explain how music therapy fits into an educational setting and therefore why this service should be included; what are goals specific to this intervention that are not already covered through other services? My response was simply that music therapy goals are based on factors that prepare the mind and body for learning. Learning will not take place while the system and brain are busy elsewhere dealing with functional deficits. (Schneck & Berger, 2006; Tennant, 2005). Having said that, the question for us clinicians is --- " why does music prepare the mind and body for learning? How?" and "what are we doing that is different and goes beyond allied services?" Surely not academic goals ("... child will count; read;" etc). Surely not speech goals ("...child will pronounce th; will describe his clothing"... etc.). Surely not OT and PT goals ("...child will thread a chain of beads..."; "....child will toss ball into net...." ). While we may be supporting the goals of allied clinicians, or incorporating them into our treatment, we understand that music therapy addresses physiologic function in a more holistic manner or so we like to believe. That means that music, through the six elements of rhythm, melody, timbre, dynamics, harmony, form, can address many body/mind functions to regulate the system and prepare it to receive, process, and retain information more accurately. Why? Because music requires no semantic translations, and the elements immediately resonate with body functions (emotions, energies, tensions, etc.) which can be altered, depending on how music elements are applied.
Here we address the development of music therapy goals and objectives from the theory that before other areas of function can be developed top-down functions such as reading, writing, rythmetic, language the system must first function in a more adaptive (bottom-up) manner, in which the brain receives and perceives information accurately in order to call for functional physical and psycho-emotional responses. All that we are, think, and do, are based in physiology. Even psychology is physiology. That is, psycho-emotional responses do not function by themselves, outside of the human system. It is part and parcel of the entire (truly holistic) physiologic function. Responses and behaviors are the result of responses based on how the brain receives and interprets incoming sensory information if it is even receiving information accurately in order to call for appropriate responses. And appropriate is applicable to each individual system the modus operandi of that system, that systems finger print. Each system has its version of appropriate. And each systems appropriate responses are based on survival instincts and fear survival responses (fight/flight) (LeDoux, 2002; Berger, 2002; Schneck & Berger, 2006; Soukup, 1996; Mead, 2004; Bowler, 2001; Pontius, 2005; McGowan, 2007; Dubuc, 2008). Simply put, the HPA Axis (Hypothalamus- Pituitary-Adrenal), the Amygdala, and the rest of the Limbic Systems, are constantly monitoring t he internal and external environment for potential danger (LeDoux 2002; Damasio 1999; Schneck/Berger, 2006; Soukup, 1996; Mead, 2004; Bowler, 2001; Pontius, 2005; McGowan, 2007).
Biological chemistry and behaviors seen in diagnosed populations, from Autism and Alzheimers to Cancer and Schizophrenia, involve this monitoring cycle, a fear for lurking danger yielding the fight/flight response. Most of the time, we are not aware that this is occurring internally. Most of us think of fear and fight/flight in association with cognition, recognizing danger and shouting "FIRE!". But there are internal stressors predominantly yielding fear, stress, fight/flight behaviors, due to misinterpretation of information by the brain, all of which we are unaware. Occurrences such as sudden urges, palpitations, indigestion, ulcers, high blood pressure, immune deficiencies, dozens of symptoms unknown to the cognitive brain, tend to indicate that the brain perceived some kind of threat, real or ill-perceived, and called for some response.
This internal fight/flight drive is highly apparent in Autism (Bauman & Kemper 2006; Schetky & Benedek, 2002), although music therapy clinicians often tend not to perceive the behaviors in this manner. Satelliting about a room, running from sound, peripheral vision and ambient hearing, and other similar functions are fight/flight survival behaviors. Alzheimer patients who suddenly scream out or cry, who chaotically move about as if seeking an escape route, are displaying fight/flight fear behaviors. The brain, unable to differentiate a threat from safety, calls for survival behaviors. Autism and many other diagnoses, for instance, display a lack of top-down control of bottom-up information processing in the brain.
By fight/flight response related to the fear cycle, I am discussing this not as a cognitive awareness of the fear, but a physiological awareness that is knowledgeable to the instinctive, intuitive brain, but not necessarily to the cognitive brain (Bowler, 2001; Dubuc, 2008, LeDoux 2002, Schneck & Berger 2006). In other words, we may not know we are in a state of fear, yet our body chemistry is excreting fear hormones. The exploration of goals and objectives in this paper is based on this theory, and on my clinical work and qualitative research for over 15 years with diagnosed populations, as well as with Music Therapy teaching and lecturing engagements. My teaching experience has brought out the factor that the development of physiologically targeted goals and objectives is still in an amorphous state due, predominantly, to limited understanding of underlying physiological and neurological causes fundamental to many presenting problems (including those of psycho-emotional nature).
As a result, many music therapy goals are often reworded from allied interventions or school goals to which music is added almost as a pleasant succor, addressing symptoms but not possible causes. I suggest that music therapy can go further than many other interventions, by incorporating well-indicated physiological goals and objectives informing why and how music elements can address physiologic function, alter homeostatic references, and achieve better adaptive responses in preparing the mind and body for positive development.
Scientific and Clinical Understanding is The Best Assessment Tool
The approaches to assessments for determining music therapy needs are as diverse as there are music therapists. In many respects, this is still quite an uncharted, under-developed area, for many reasons. There is a myriad of books, pamphlets, forms, approaches, suggestions, adaptations, seminars, discussions, and training on assessment tools and products. The very existence of such variety attests to the fact that there is not one, clear, specific, uniform approach to assessment protocols for this profession, and those that are available serve limited uses.
As things currently stand, each therapist or therapy method, depending on the work sites, seems to develop (and has developed) his/her own versions of assessment. For children, there are many published assessments that mainly parallel educational goal formats from within school settings, often resembling objectives similar to music education classes for special needs students. Not to deliberate the point or change the scope of this paper, here are just few examples of music therapy assessments currently available for childhood diagnoses.
One type of evaluation specifically serves the needs of school IEPs (which should be the domain of the school rather than the music therapist). For instance, the Special Education Music Therapy Assessment Process, SEMTAP (Coleman & Brunk) basically addresses secondary school requirements, but seems to fall short of defining the music treatment process specifically detailing physiological needs for sensory integration, visual/auditory function, vestibular and proprioceptive interventions, and the like.
As fine an attempt as this assessment tool might be, the SEMTAP evaluation tool unfortunately often circumvents the real question: what is it, specifically, that music therapy treatment can achieve that other interventions miss or cannot easily provide ? For schools to require music therapy to follow along the lines of IEPs is akin to asking, say, a dentist to devise goals detailing why and how dental treatment will help Nicholas read! The idea of medical treatments to prepare the body and brain for learning as music therapy can do seems to be completely omitted in educational thinking! (Yes, fixing teeth, realigning over- bites, and alleviating gum disease and pain, certainly will contribute to the well-being, and therefore, the better learning abilities when the brain is not busy taking care of the body). These dental goals are clearly not parallel to educational goals! Music Therapy goals (when planned correctly), also involve preparing the body and brain for learning, and IEP teaching goals have nothing to do with this. Music can change what other interventions cannot. Where are the assessment tools that explain this?
Another interesting tool is the recent IMTAP: Individual Music Therapy Assessment Profile, (Baxter, Berghofer & MacEwan, 2007) which comes close to being one of the first most comprehensive approaches to discovering specific characteristics of behaviors through extensive cross-sections of observable characteristics. This assessment approach includes information on how to score and graph findings, basic to developing goals and objectives based on the findings, and provide a full report specific to findings. The IMTAP is an excellent across-the-board instrument addressing a variety of diagnoses, but is mainly applicable to childrens functions. It is quite inclusive, and can yield elegant information, but the music therapists must still be the one to amalgamate the findings and determine priority order for goals and objectives based on the findings. Erratic eye-movements? What does that indicate? Inability to track pitch? What does that mean? As comprehensive and ideal as the IMTAP assessment process appears to be, the IMTAP would probably not be useful for assessing certain types of adult diagnoses, geriatric behaviors, Alzheimers and Dementia patients, Pain Management and Stress Reduction issues, Psychiatric diagnoses, and many other functions which, by the way, could also be observed in younger diagnosed populations.
In various other clinical settings, there are hospital and institutional types of assessment formats most often dealing with problems that are "fixable" or stabilizing through pharmaceutical, verbal, or medical interventions. There are many other clinicians and assessment tools not mentioned here, which also include assessment of musical skills whether the child can sustain a pulse, can sing in pitch, and so forth. So it is discovered that the child cannot sustain a pulse. What does it mean that the child can or cannot sustain a pulse? Or that s/he can or cannot sing in pitch? Of what clinical consequence is the fact that a child likes music? The child might also like "ice cream" or bike-riding. How does music interest, skill, and intelligence correlate with systemic needs and deficits? That is the question.
Coupled with the limited amount of uniformity in music therapy assessment tools, and at that, none that take a truly comprehensive look at physiologic factors involved the vital signs of adaptive function, so to speak -- in behaviors and responses, is the fact that there is limited understanding on what defines a goal and objective, and how specifically to formulate a goal based on assessed findings, putting these in some order of priority. (For instance, a speech goal might be "...Child will enunciate sh" correctly disregarding the fact that perhaps the child simply cannot "hear" the sound of "sh" correctly!). In part the problem of goals and objectives may be due to a lack of substantial research in the areas of music therapy dose-response effectiveness. Dose-response refers to how much, how often, for how long, of what type of interventions, for which diagnoses, will music therapy treatment be effective in yielding changes and betterment.
Music Therapy should not be a trial and error intervention. Clinicians must understand what is being observed and what certain responses and behaviors indicate, or it becomes quite implausible to derive accurate assessments of needs allowing for specifically directed (especially scientific) goals, objectives, and approaches to which music therapy treatment can contribute and which can be clearly monitored and measured. The approaches of Neurologic Music Therapy (Thaut, 2007), Physiologic Music Therapy (Schneck & Berger, 2006), Biomedical Music Therapy (Taylor, 1997), Medical Music Therapy (Standley, 2005), and the growing field of Brief Therapy, are moving in the direction of dose-response research and application for specific goal attainment. But generally, there is still an overly dependent reliance on goals and approaches articulated by allied clinical professions (i.e., OT, Speech, etc.) and school teachers. Unfortunately, this results in music therapy being considered adjunct to other interventions, although music, itself, often is the strongest treatment intervention for inducing changes in vital signs (physiological) influencing all other responses.
Defining Clinical Goals Requires a Clinical Eye
In many respects, the six individual elements of music can be thought of as the pharmacological ingredients prescribed to address particular functional issues in a diagnosed client(s) assessed for music therapy treatment. These music ingredients are acoustic, serving primarily internal elements of function, but which can result in both internal and external alterations. It happens that these pharmacological ingredients are usually also quite pleasant to ingest and with which to interact. In effect, it is the "spoonful of sugar [that] helps the medicine go down..." , as Mary Poppins chimes (Richard & Sherman). But it is still medicine. And music therapy is a treatment modality. As with any medicine, the clinician diagnosing the ailment must understand the presenting issues, their possible causes and implications to bodily functions, and the types of medicines that could best address the problems and lead the system back toward health.
The music therapist, observing with a clinical eye, will identify existing problems, and understand how those problems can be treated with specific applications of music elements. This knowledge includes the perspectives of physiologic function followed by sensory processing issues, cognitive abilities, psycho-emotional demeanor (whether in a state of fear, distress, anxiety, self-injurious, etc.), and how these areas interact when attempting functional responses. Goals and objectives developed from this comprehensive (scientific and clinical), in-depth understanding of causes and deficits from both the physiological and music treatment perspectives, helps target the work specifically as treatment with music. (After all, music therapy is much more clinically based than music as therapeutic .
Information and interventions of allied services certainly plays a role in apprising the music therapist of areas identified as deficient in other therapies. Speech Pathologists may refer to oral-motor issues; OTs may indicate vestibular, proprioceptive, tactile and motor deficits; psychologists and teachers may note an inability of the subject to focus, sit still for lengths of time, follow directives, etc. This supportive information helps the music therapist to obtain a well-rounded picture of behaviors as observed by others. In the end, the music therapist must amalgamate this information, apply physiologic knowledge, determine wherein the causes may lie, and proceed to treat those in a manner unique to treatment protocol using music. Thus, Music Therapy goals and objectives may reflect treatment goals of others, but will be specific to how treatment with music can address both the cause and response.
Observing Presenting Problems, Designing targeted Goals and Objectives
Consider this brief case description of an Autistic young boy:
Nicholas is an 8-year old Autistic, non-verbal child. His delays include functioning at a cognitive level of a 5-years old; presents with uncontrolled body movement; requires much non-purposeful movement (satellite activities) about the room; displays stereotypic stimming behaviors such as hand-flapping and odd noises; non- existent eye contact; inability to attend to task without prompting; inability to relate to others; is generally "compliant" though predominantly in a world of his own; displays age- appropriate receptive language skills but is non-verbal and presents with expressive language deficits; dislikes participating in activities (such as drumming in which he constantly drops mallets); tends to be labile emotionally, fluctuating between laughter and tears; Nicholas attends a special program in his school, and receives speech pathology services, occupation and physical therapy, activity of daily living (ADL), and ABA (Applied Behavioral Analysis) behavioral program. He is also included in a regular class room with an aid to assist. IEP listed goals include learning to identify alphabetical letters, numbers, colors, shapes, relationships between objects, social norms, two to three verbal exchanges with another, responses to "yes" and "no" choices, appropriate responses to choice- making: "do you want this or that?" etc., various other typical educational curricular goals.
In Nicholass school IEP (Individual Educational Plan), teachers indicate an interest in having him understand certain academic concepts, attainment of which could be measured at the conclusion of the school year. Academic information is based on curricular considerations for his age level (3rd grade at best) reading, arithmetic, spelling, etc. That is the role of the school to teach.
The Occupation Therapist (OT) indicates goals of fine-motor development for writing skills, with objectives including the holding correctly of writing implements, developing eye-hand coordination (through threading beads), aiding sensory integration for centering and body awareness (through various OT activities of swinging, brushing, etc.), and some additional OT concerns, including flexion and relaxation of muscle groups, muscle toning, and motor-planning. This is the role of Occupation Therapy to apply physical activities able to prepare the body for the occupation of navigating the environment successfully.
The Physical Therapist is concerned with spatial and gross-motor activities (running, walking, etc.), along with various sports proficiencies (throwing/catching balls, basketball, etc). This is the role of Physical Therapy: to train or retrain the body for appropriate behaviors and responses.
The Speech Pathologist is concerned with oral-motor function, proper deliverance of word articulation, pragmatics (conversation and description of events), verbal interactions, language comprehension (appropriate responses to questions and answers; choices, etc). Tasks are specific to these symptomatic deficits. That is the role of Speech Pathology.
The Music Therapist is asked to join the team and provide an assessment, including goals and objectives that indicate and justify the contribution of music therapy treatment to other interventions being provided to Nicholas. He or she is specifically asked to define ".... what is it that music therapy can contribute that other 'pull-out' interventions are not already addressing?" Indeed a tough question to answer, unless the clinician fully understands how music therapy differs and goes beyond other treatments. So, what, specifically, is the role of Music Therapy in this triage?
Observing Nicholas
The first thing that the music therapist must consider when assessing a client in order to determine goals, is the putting of things in an order of treatment priority based on observed needs and responses. That is, of all the presenting issues, which deficits would require more immediate treatment, and which can be put on temporary hold. In assessing Nicholas, for instance, (based on the sketchy information provided here), certainly his frenetic behavior, the inability to use expressive (vocal/verbal) language, or to control body movement, register vestibular and proprioceptive sensory information required for self- and body- awareness, sense of body in space, muscle tone, body dynamics, and general movement, would be high priority areas for investigation, goal-setting and treatment. Music therapists know that unless sensory information is registered (coded) and interpreted correctly, and unless the fear response associated with the brains inability accurately to process incoming sensory information is calmed, cognitive information will not reach important brain destinations (Tennant, 2005; Schneck & Berger, 2006). In an on-going fear spiral, the Hippocampus shuts down, vision is peripheral, auditory is ambient, movement is fight-flight mode (thus the satelliting about the room in erratic movements), and the subject presents with a restless, fearful mode of behavior. This knowledge can translate into priorities for establishing goals and objectives specifically for music therapy interventions for these presenting behaviors. (Berger, 2002)
As an example, let us consider two prominent characteristics of the diagnosis mentioned above, that define Nicholass autism and presenting issues. What needs to be considered?
A). ....presents with uncontrolled body movement; requires much non- purposeful movement (satellite activities) about the room; displays stereotypic stimming behaviors such as hand-flapping and odd noises, etc;
Since behavior is communication and information, what do these behaviors communicate? In the above case, satelliting about a room, and undertaking excessive non-purposeful movements indicate a fear response -- the fight-or-flight, anxiety response. Are these behaviors really part of a fear response? Is Nicholas trying to flee? Probably yes. In fact, given the sensory stimulation overload of instruments, sounds, faces, environmental noises and input, and an inability to process and integrate sensory stimulation, nor understand his body, Nicholass brain is most probably unable to sort or adequately process the environment, considers the situation threatening, and calls for survival responses to all that is going on. Having lived with the inadequacies all of his young life, his systems homeostatic set points are now most likely set to a perpetual (habitual) state of fear fight or flight -- due to an inability accurately to assess whether sensory input is threatening or not. His brain calls for actions associated with a threatening environment. This has become habitual (homeostatically set).
Stereotypic behaviors of hand-flapping and stimming, along with satelliting about a room with no apparent purpose, are indicative of fear behavior. This is not the conscious "Im afraid" cognitive fear, but the sub-cognitive, instinctive Amygdala-HPA axis-driven systemic response resulting from inaccurate sensory registration (coding) and interpretation. The brain is confused with information. This causes Nicholas to move about in an unstructured, unpaced, (non-rhythmic), restless manner. His system must be in motion in order to protect itself. His nervous system is not in a relaxed, calmed state, but instead, probably due to an overactive Amygdala, his emotional responses are not in sync with external factors in the environment (i.e., the non-threatening room, etc.) or the safety realities of the circumstance. Music Therapists aware of these probable physiological constraints will seek two distinct priority goals: one that deals with calming and centering the system; and one that seeks to rhythmically pace the system and provide purpose and structure to Nicholass movements, easing systemic stress. Goals, therefore, might read:
GOAL 1. Reduction of physiological stress and anxiety (possibly due to sensory misinterpretation)
This is a long-range goal. How will this goal be attained in smaller (shorter-term) increments of treatment? What would the objectives be in order to help achieve reduction of stress and anxiety? Some of the following might be applicable, with the dose-response based on pre- and post- treatment results in the initial period of treatment:
Objective 1. In an environment with limited visual distraction (e.g., low lights, few instruments, etc.) Nicholas will undertake 10-minutes of a calming, centering activity (e.g ., Brain Gym (Dennison & Dennison), and quiet, slow background music) with therapist prompt
Objective 2. Nicholas will sit or lie quietly for 5 minutes following opening centering activity, and continue listening to quiet music;
Objective 3. Nicholas will breathe in an out slowly, (blow his recorder similarly), for 3 or more minutes, while quiet music plays in background.
Treatment interventions to address the objectives (tasks) would be added beneath each objective, to map how the objectives are to be addressed. In the interest of space, the intervention approaches here are suggested parenthetically within the objectives.
In the above examples, the time (dose) allocations for the objectives are based in part on the recommendations of the Brain Gym system of stress reduction (Dennison, http://www.braingym.org.) Brain Gym Educational Kinesiology is a mind-body system developed some 30 years ago by Paul and Gail Dennison to help organize the human system toward relaxation and learning. It involves a series of mental/physical exercises recommended to be undertaken for a minimum of 10-minutes. The system actually recommends 20-minutes for objective number one, but given Nicholass high anxiety behavior, the activity is best introduced in shorter increments of time, and expanded as treatment progresses over time. These three objectives are developed because, before anything else can be fixed, the system needs to be quieted. Deep breathing tends to bring that about, and using recorder brings sound (auditory awareness) to the breathing, maintaining the brains interest in the activity.
The quiet listening of music while lying or sitting in a comfortable position further induces muscular relaxation and reduction of hyperactive amygdala (fear) activity. These interventions, administered on a regular basis, could eventually alter homeostatic set-points away from fear responses resulting from erroneously interpreted sensory information. Dose-responses listed in the objectives are based on actual clinical work that has been observed to yield changes in behaviors resulting from music therapy interventions that followed these prescribed routines (Berger, 2002; Schneck & Berger, 2006). The above objectives are developmental. Repetitions and length of time for activity can be increased to the point where the systems ability to sustain calm, focus, and task attention comfortably, for longer periods of time, is seen to have peaked and become habitual, having reached a plateau at which continuation of activities at peak performance reinforce and sustain the adaptive behaviors. (Actual clinical work with this case has shown that this, indeed, has been the best procedure for this case. It has taken approximately 12 sessions to increase the interventions to longer periods of time).
Continuing with the first priority (erratic body movement), another goal can be added:
GOAL 2. Organization of Self: Body movement pacing and controlled, purposeful movements; upper/lower body coordination.
Objective 1. Nicholas will master jumping on trampoline while simultaneously beating tambourine, for 5 minutes, or through 4 completions of supportive jumping song. (Will drink water between mounting trampoline)
Objective 2. Nicholas will learn to march to tempo of Yankee Doodle, displaying accurate rhythmic marching movement and beating hand drum during marching, responding to musical cue for changing direction. (March tempo to be determined by therapist) Duration of task: 5--10 minutes or 100% organized movement.
Objective 3. Nicholas will be able to sustain slow pulsing rhythm on drums, using bilateral parallel and alternate arm movements, stopping and waiting each time music stops. Activity duration: 15- minutes, 3 different songs. 100% sustaining of task.
These objectives are directed at muscular and general body control, motor-planning, upper-lower body coordination, and rhythm internalization. Dose-response, once again, is based on assessment and clinical observations, and are also developmental, as stated above. The interventions subscribe to the philosophy that entrainment to rhythm (rhythm internalization) can reorganize compulsive movement into structured and purposeful movement, based on the precept that by pacing the system through specific rhythmic activities, homeostatic set points can be altered toward organized functional adaptation, replacing undirected, chaotic behaviors of the body. And one further goal for this area of physiologic consideration, might include:
GOAL 3. Develop Awareness and Redirection of stimming arm movements.
Objective 1. Nicholas will reach for maracas or hand-bells (or other shaking instruments) when stimming instinct is sensed;
Objective 2. Nicholas will shake maracas in organized, rhythmic manner commensurate with music being played. Task duration: continued shaking of instrument throughout two different childrens songs
Once again, goal and objectives are designed to further organize upper body compulsive behaviors, such as stimming and erratic arm movements, by bringing the behaviors into conscious awareness by the child (his brain), in a rhythmic manner. Since we cannot absolutely determine why the brain is calling for these stimming, erratic behaviors, we best not seek to extinguish them, but rather, to redirect them into purposeful actions. This could provide a new option to the brain, for deciding whether to continue the behavior, or extinguish it as unnecessary. The clinical assumption is the possibility that by reaching for an object that will organize and give musical purpose to the stimming, and enabling the brain to hear the sounds of the behavior (sounds of maracas), the brain may become aware of new options for response, and either continue to pursue further adaptive actions, and even extinguish the chaotic behavior altogether.
As the above samples indicate, there are clear distinctions between Goals and Objectives. The Goals are planned as long-term, overall, end results. Objectives, and the interventions to direct the objectives, are the short-term means to reach the long-term Goals. The above three sample goals result from the observation that fear and stress modes are what Nicholass behaviors appear to be communicating. The goals and objectives are designed to calm the system, organize (redirect) its behavior with purpose, and as such, bring systematic comfort and reorganization to an otherwise distressed system. The goals and objectives also provide proprioceptive and vestibular sensory needs most obviously malfunctioning (per clinical observation and allied therapists assessments), causing much of the distress to the system.
Deficient motor-planning is quite a fearful experience for the brain, since it is in a constant state of anticipating physical disaster due to its inability accurately to process and organize appropriate and timely reactions to external events. Most music therapists surely are able to develop similar, or better, goals and objectives addressing erratic movements, stimming, fear responses, and organization of self. Although these goals appear to be similar to goals of OT, they are only similar in that the physiological deficits are involved. However, targeted instrumental playing, marching, sustaining rhythmic movement, and so forth, are music therapy interventions to address physiological deficits. Treatment tasks are designed directly to alter physiologic malfunction through music. The music resources of rhythm, dynamics, timbre, for instance, when directed toward physiological regulation, contribute to body dynamics, self-pacing, acoustic tolerance, motor-planning, and much more through the entrainment processes.
Looking further into Nicholass case, a second major priority in treating Nicholas is based on the following observed behavior:
B) ..... Nicholas is a .............. non-verbal child. In assessing "non-verbal", the music therapist must investigate at least some the following functions (which are often not indicated by speech and language pathologists):
i) the auditory system: What/how does Nicholas actually hear ? What does his brain perceive in sound? Does he track sound accurately, sequentially? Is the brain able to accurately reproduce and blend sounds (sound linking), or does he hear disparate, chaotic sounds? Can he process inflective sounds (high/low pitches)? Can he repeat (mimic) inflective sounds? Is he able to follow melodic contour and recognize a song? Can he match pitch vocally? Does he vocalize? Sing? Can he inflect vocally? (sing non-verbal pitches such as glissandos, highs and low tones, la-las, etc). Do timbres (of various speaking voices) impact on how/what he hears in spoken language? Is it possible that Nicholas has "perfect pitch", which may be impeding language comprehension?
Music therapy, being an acoustic intervention, is in a good position to illuminate auditory information processing issues in a clinical setting. Auditory deficiencies such as central auditory processing or auditory brain stem deficiencies that may not have been as yet observed nor investigated by audiology exams, could be primary contributing factors to expressive language deficits beyond that of oral-motor articulation. If Nicholas is not accurately processing auditory information or imitating sounds, how would he learn to speak or to understand language, since it is something learned originally by audio/visual imitation, auditory recall and prosody proficiency? (Infants obtain language by imitating sounds coordinated with visual observation of the process). Careful investigation of auditory function would be an imperative priority for the music therapist. (Musiek & Chermak, 2006; Chermak & Musiek, 1997).
ii) breath-control, oral-motor and tactile sensitivities (mouth, tongue, etc): Since expressive language is an exhalation of sounds, it seems plausible that breath-control along with oral-motor planning are deficient. Using ones diaphragm to expound verbal sounds begins in the process of imitation, becoming second-nature as it is rehearsed by the system. An infant exhales laughter, and coos to his mothers cooing. These are exhalations practiced by the brain once it experiences the event. To what extent did Nicholas "coo" when he was an infant? Does he use his voice in any way? Scream when agitated or upset? Breathing is also part of movement coordination, therefore erratic movement could provide clues signaling breath control and coordination issues. Furthermore, if Nicholas had language which he lost by the age of two, is it possible that somewhere in the brain, the information is still stored and can be pried loose?
iii) Further investigation of ability to make purposeful vocalizations: sound imitation and repetition capacities, vocalization and inflective processes, sound linking, visually attentive mimicry of facial expressions, and more. Therefore, it would seem plausible that a music therapist has the tools and observation capacities that a speech pathologist may lack. For instance, auditory tracking : will the child blow into the recorder and copy the type of rhythmic blowing of the clinician? Is the child comfortable holding a recorder in his mouth? Is his breath-control functional that is, can he blow slow, long tones, alternating with short rhythmic pulsations of tones? Which can he do, not do? Does he lose "concentration" if task exceeds a few short moments? Does he become over-stimulated when taking deep breaths and exhaling slowly? (Does he try to escape the task?).
When presented with a kazoo, will Nicholas hum long breaths through the kazoo? Will he hum a tune into the kazoo? Will he inflect high and low pitches when humming into kazoo? Will the vibrations of the kazoo over-under-stimulate his oral-motor? His lips? Can he close his lips around the recorder or the kazoo appropriately? Can Nicholas imitate the humming sounds of the therapist? Accurately? Can he imitate a high pitch? Low pitch? Two connecting pitches? Will Nicholas be able to identify the familiar tune being played on recorder by therapist? Being played on piano by therapist? (Tune such as Twinkles)? Is there a sign of recognition that Nicholas identifies with the tune? (Tune is presented non-verbally, no lyrics to obscure the hearing process). Will Nicholas recognize if tune is played incorrectly? Can he produce vocalizations, long and short tones on "la-a-a-a"? Variations thereof? Or, "hoooooo"? Or other presented oral abstract sounds? Clicks of the tongue? "RRRRR" with the tongue? "Hee Hee" sounds? Can Nicholas tune out intrusive extraneous sounds and focus on select auditory information? (Auditory Figure-Ground)
These areas in question, and the itemizing of possible areas for treatment, indicate the checking-in for vital signs relevant to stress, language acquisition, the auditory processing system, and possible deficits that music can address. Obviously the music therapist will not skip over these and go directly to presenting a fill-in song, without supportive information on the childs physiologic auditory processing. To do so would be to circumvent the therapy of the treatment, and go straight to a task based on unclear reasons for undertaking a task. (Music therapy cannot be just about an activity.) The activity is the approach or means of addressing an objective which is based on attaining a goal, which is based on assessment of needs through a clinical eye. There is no easy, quick way around this. Now that the therapist has articulated some questions involving the language deficit, the results might look like this:
Result of observations: Nicholas demonstrates an inability to sustain long exhalations into the recorder; he is unable to render short, rhythmic patterned exhalations into recorder; Nicholas cannot successfully imitate high and low hums into the kazoo; he has difficulty humming glissando tones up and down, into the kazoo; Nicholas is not comfortable holding recorder with both hands (at mid-line) and maintaining it appropriately in his mouth (he keeps inserting the recorder deeply toward the back of his throat); Nicholas is not comfortable with the general sound of the recorder, and is restless in his seat while therapist blows along with him. Nicholas resists humming into the kazoo (could be a sign of discomfort with the vibratory oral-motor stimulation provided by the kazoo sound); Most tones hummed by Nicholas are low-pitched, low placed vocal tones. Nicholas shows limited awareness of familiar tune ("Twinkle"). When asked to hum along, Nicholas appears not to understand command, nor imitate therapists humming along with the tune.
How does all this implicate goal-setting? First, it seems possible that his auditory tracking of vocalized sounds is problematic, in as much as he seems unable to imitate tonal vocal sounds through his kazoo. He is also unable to produce vocalizations on "la", "hooo", "hee hee", or clicks of the tongue. Does he hear these sounds correctly? Does he hear them but cannot retrieve them appropriately? Is he unable to oral-motor plan in order to produce these vocal sounds? Is there a problem with tonal memory and retrieval? Obviously these would have major impact on his ability to hear and link word sounds, and produce expressed language.
Based on the observed probability that Nicholass auditory system appears not to be registering (coding) or retrieving sounds well, nor is his tonal memory enabling him to recall and reproduce sounds using his voice, one of the first long-range goals might entail helping to regulate his breathing so that he becomes comfortable and paced in purposeful exhalations into the recorder, and to learn to hum inflective tones through the kazoo. Humming into a kazoo also provides vibrational feedback to the oral-motor system, which then induces tongue movements and oral awareness.
Therefore, some of the initial music therapy goals might perhaps include portions of the following:
GOAL 1. Regulate breath control for language development. (and efficient body movement).
Objective 1. Achieve the blowing of long, sustained tones on recorder for 2 (or more) repetitions of 4 long tones;
Objective 2. Achieve blowing short pulsed tones on recorder for 2 repetitions of 8 short pulsed tones.
Objective 3. Imitate 6 different therapist-presented kazoo sounds with an accurate repetition of at least 4 of the 6 sounds
Objective 4. Create 2 different novel hummed sounds on kazoo with 2 repetitions.
Examples of possible Approaches and Strategies for this Goal:
- Provide Nicholas with a recorder of his own, colorful, and easy to blow
- Develop intervention requiring purposeful blowing of tones on cue: e.g., "This is how we say Hel-lo....... toot....toot" (Mexican Hat Dance) in which Nicholas has time to prepare to blow the "toot..... toot" on cue; Repeat "hello" task for several minutes;
- Develop intervention requiring short-pulsed tones to be blown into recorder therapist role-models task playing and blowing rhythmically to rhythm such as "Hot Cross Buns", inviting Nicholas to follow along and imitate. This provides a variety of long-short blowing.
- Kazoo fun sounds to be imitated, perhaps to "Old MacDonald Played Kazoo, E I E I O; and when he played, he made this sound........... (and inflective sound is made) ".......
As with Priority (A) above, dose-response is based on previous clinical sessions and observation of progress. Objectives again are developmental in that applications can be increased to arrive at a peak performance level, and continued at the attained level for sustaining and reinforcing achieved level, increased expressive language, and organized body movement (walking, running, etc). Each client will display different rates of progress and abilities. These must also be considered. Observation of base-line performance, on-going tracking of progress and feedback from other therapists and family members, will yield and support the functional dose-response indicator in order to set task paces, repetitions, length of treatment routine, and related considerations (mood, health, etc).
Continuing with the language development area, goals and objectives might include:
GOAL 2. Regulate Vocal projection and tonal (verbal and non-verbal) expression.
Objective 1. Sing "la la la la" to pitches and rhythms of "Hot Cross Buns", combining long/short "las" singing one time loud; one time soft for duration of tune; (inflection exercise)
Objective 2. Vocalize "Hee Hee Hee Hee " or "mee mee" "Mary Had A Little Lamb" once through for duration of tune, with accuracy of melodic contour and rhythmic pattern. (diaphragm exercise)
Objective 3. Imitate vocalization sounds of therapist (glissandi, high and low tones) minimal 3 out of 5 different presented sounds.
Objective 4. Supply gibberish lyrics to familiar song, using correct melodic contours, vocal projection, and rhythm, in two different songs with up to 6 silly words in each song. Provision of at least 4 varied "gibberish" lyrics per song.
Approaches and Strategies:
- Face to face contact, therapist provides simple pulse on bongo drum placed between Nicholas and therapist, eliminating other "tonal" instruments so that only the voice becomes the main "pitch" tonal stimulus, and the brain can try to register and repeat heard vocal sounds, while coordinating observed articulation with heard sound. In addition, using arms on drums stimulates the relationship between auditory and motor cortex, influences of right hemisphere on left hemispheric activities, and more. Since Brocas area (speech and possibly also some movement) sits in the left hemisphere, the right hemisphere (left hand activity) can coax functional activity in the left hemisphere (Brocas area, right hand activity, etc).
- Approaches for Goal 2 can at times be combined with approaches to Goal 1, alternating, for instance, recorder with voice, or kazoo with voice, depending on motivation and progressive ability of Nicholas to attend and attempt to imitate.
Keep in mind that these are only samples of defined Goals, Objectives, and treatment strategies to demonstrate addressing expressive language and auditory deficits through music therapy resources, and are specific to the needs observed and assessed in session (as listed in case study above). A well-trained, astute music therapist can develop any number of strategies and tasks to address the Goals and Objectives, provided the clinician understands what is being presented by the client, and that Goals and Objectives must be clearly defined, based on information resulting from the clinical observations. Although speech pathologists may be working in these areas, the music therapist has the advantage of being able to fully address auditory function, apply exercises, targeted musical accompaniment and musical instruments to motivate, support and enhance brain attention and auditory information processing. Use of various timbres, melodic instruments, singing (especially without use of lyrics), rhythmic language (syllabic) expression, and face-to-face articulation can often achieve expressive language progress supplemented by speech pathologists
We can continue to discuss development of Goals and Objectives based on the above case, that would approach book-length! For now, the idea of what constitutes Goal vs. Objective, and how to approach these with a clinical eye, should be quite clear. One obviously cannot emphasize enough, that the music therapist must first understand how to observe, interpret what is being communicated through the behavior vis a vis physiologic constraints, and which and how music elements could best be applied as treatment to address those.
Music Therapy as a Discreet Intervention and Team Player
The information presented thus far, that the Goals and Objectives suggested above are based on the case assessment of music therapists. While they may be using similar terminologies to other therapies, these do not imitate those of allied clinicians. Rather, they complement and address issues that are of interest across the board of behavioral responses by this diagnosed child. This is an important factor in helping others to understand how music therapy works in conjunction with, but distinctly separate from, other therapies, and should provide essential information for administrative teams responsible for including music therapy treatment on their sites.
The bottom line, for music therapy, is that this treatment enables the brain, physiology, emotion, and various areas of function, to take hold and alter responses for the better i.e., to attain physiological functional adaptation, as a result of the music therapy process. So, if a speech pathologist is working on verbal enunciation, the music therapist is adding melodic contour which translates into prosody and inflection, thus supporting but not "copying" the speech pathologist. The same is true for the work on the body, which can help the system to organize and become paced, even as the Occupation Therapist is looking for muscle tone and motor-planning. Thus, the music therapist is a team player, but not a copier of what others are doing. In fact, it has been my experience that most often, other clinicians seek the advice and input from music therapists, to help with their problem solving interventions.
Summary Review
The process of having a clear understanding and development of music therapy goals and objectives depends on the ability of the clinician to understand the derivation and messages of behaviors, observe these with a clinical eye, and develop goals long term overall interest to better function and objectives short term achievements and activities, that will ultimately result in the attainment of possibly permanent physiologic/psycho-emotional and cognitive changes for the better (long-term goal). Therefore, one can specify goals as describing what needs to be changed and be different at the end of the road, objectives as the various roads to be taken in order to reach the end location, and the vehicle(s) -- employment of specific music elements as treatment strategies and approaches that will navigate the road of addressing deficits and reaching the end goal. (see Figure 1).
Figure 1: Hierarchy Relevant to Development of Goals and Objectives
The importance of understanding how to define and develop goals and objectives cannot be underestimated. These are precisely what makes the difference between music as a therapeutic recreation, or an entertaining pass time, or an education, or a performance, and music as therapy. Therapy defines as a treatment protocol to reach a long-term end result. Music Therapy is the means to reach the end the Goal -- through Objectives using music elements designed to be important roads and vehicles to reaching the positive end result the functionally adaptive behavior.
The music therapist more often can provide insight and information to allied clinicians. Since music therapy is basically a non-verbal treatment protocol, it reaches directly into the instinctive, intuitive organs of the brain where sensory information is coded, interpreted, and sent for cognitive processing in the upper neo-cortex. This process is unique to the Music Therapy intervention. Developing Goals and Objectives that demonstrate this uniqueness in its ability to attain change, is precisely what the music therapist must master. And this requires having a keen "clinical eye."
Final note; Not everyone will agree with what has been presented here. Neither will everyone have the essential background or training with which to apply a clinical (scientific) eye for developing treatment protocol based on physiological findings and assessments possible causes of malfunctions. Others may already be well-trained and experienced in working in the manner suggested above, and may find this paper quite simplistic and unnecessary.
The objective of this paper is to present anew, (or for those seasoned clinicians, to reconfirm) the issue of goal development in the hopes that my end result (my Goal) will be met that being the theory that ones ability to observe presenting problems with a clinical eye, to clearly define goals, differentiate objectives from goals, and develop both toward adaptive function, will attain that end result functional adaptation of client behaviors. This paper is asking clinicians to think more deeply about how the elements of music can be specifically targeted to address presenting behaviors that are caused by information processing deficits. What has been presented here as Goals, Objectives, and approaches to treatment, are just examples of possibilities, to emphasize the points being made, specific to music therapy treatment of physiological deficits that cause physical, cognitive and psycho-emotional stressors to the system. Clinicians can develop individual treatments based on observations. As for specific details regarding the measurement of interventions and progress, -- the dose-response factors of the above Objectives -- there is limited research in dose-response to inform how many, how much, what kind, for how long, a treatment should be provided in order to reach the designated goal. That is, there appears not be a codified protocol approach informing the dose-response factor affecting positive adaptation for specified goals. Thus, to state that after so many repetitions, some progress will be observable or achieved, is still quite arbitrary. Indeed one must monitor and track progress, but that is still an ambiguous aspect of current music therapy clinical practice. Perhaps progress could mean development of proficiency in a skill; perhaps in making fewer behavioral mistakes. Perhaps progress is manifest in sustaining a behavior and avoiding regression to less functional adaptation.
We are still at the beginning. One hopes that eventually, Music Therapy research will become better standardized and codified, to inform clinicians more accurately about dose-responses, thereby eliminating misleading assumptions At the very least, we can possibly make some educated, observation-based determinations of what it is we see, and hope to see at the end (goal) of music therapy clinical treatment. Music Therapy training and practice will continue to require the clinical eye in order to understand and establish clear treatment Goals, Objectives, Strategies, and Tasks. This will pave the way to better dose-response intervention strategies to support progress obtained from music therapy treatment.
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Additional Recommended Reading
Buss, K.A., Davidson, R.J., Kalin, N.H., Goldsmith, H. Hill. (2004). Context-Specific Freezing and Associated Physiological Reactivity As A Dysregulated Fear Response. Developmental Psychology, 40, 4, 583-594
Buzsaki, G. (2006). Rhythms Of The Brain. New York: Oxford University Press
Panzer,A., Viljoen, M., Roos, J.L. (2007). The neurobiological basis of fear: a concise review. South African Psychiatry Review, 10, 71-75
Patel, A. (2008). Music, Language and The Brain. New York: Oxford University Press
Schneck, D.J. (1990). Engineering Principals Of Physiologic Function. New York: New York University Press.
Thaut, M. H. (2008). Rhythm, Music, And The Brain: Scientific Foundations and Clinical Applications. New York: Routledge.
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