[Original Voices: Essay]
By Masako Otera
The author discusses what music therapists must work on to establish Evidence-based practice (EBP) in music therapy by referring to Saito’s discussion of the misunderstandings and various interpretations of Evidence-based medicine (EBM), the issue of Empirically Supported Treatments (ESTs) in EBP in psychology (EBPP), and related discussions. Although the EBP movement tends to be recognized as a threat to music therapy, some recent discussions of EBM and EBP are encouraging for the development of EBP in music therapy. This paper shows that an integration of evidence of multiple types with clinical expertise and the individual needs in clients has become a consensus of EBP. However, the issues related to conducting Randomized controlled Trials (RCTs) and employment of standardized treatment protocols in music therapy have persisted as difficult problems. Because the issue of EBP is very complex and easily biased, effective learning of this issue should be promoted among music therapists so that they can successfully relate to the EBP movement and bring benefits to the field of music therapy. The author suggests that incorporating the ideas of EBP positively into the field of music therapy and constructing methodologies and theories will enhance EBP.
Keywords: evidence-based practice, evidence-based medicine, randomized controlled trial
In 2010, the American Music Therapy Association (AMTA) endorsed the definition of Evidence-Based Music Therapy Practice (EBMTP) as follows: “Evidence-based music therapy practice integrates the best available research, the music therapists’ expertise, and the needs, values, and preferences of the individual(s) served” (AMTA, 2010). According to this definition, Evidence-based practice (EBP) in music therapy is a practice based on clinical decisions integrated not only with research results, but also clinicians’ expertise and clients’ individual needs.
Nevertheless, the need remains for the development of more concrete and explicit ideas of EBMTP that reflect the needs and circumstances unique to the field of music therapy. Bradt (2008) has called for an active discussion related to this EBP issues among music therapists. The author responds positively to the discussion related to EBP in music therapy and hopes to promote the sharing of common understandings about the EBP issue among music therapists. The author also agrees with Bradt’s suggestion that it is not the issue of whether or not music therapists relate to EBP, and agrees that it is rather the issue of how they deal with it. However, the author has remained aware of the needs of music therapists to learn more about basic ideas of Evidence-based medicine (EBM) and EBP to promote effective discussions about EBP in music therapy. A history of confusion has continued in the public’s understanding of EBM and EBP in other related areas. Music Therapists should be careful about some of those typical misunderstandings. While developing our discussion related to EBP, learning more about EBM and EBP might prevent repetition of the same mistakes and unproductive discussions.
The author found that Saito, a Japanese physician, produced some discussions related to EBM and EBP that were insightful and helpful (S. Saito, 2012a; S. Saito, 2012b). Saito has been an active practitioner and researcher of Narrative-based medicine (NBM) in Japan. NBM, which emphasizes the value of narratives and discourse between a patient and a medical practitioner during clinical practice, is frequently recognized as an idea that conflicts with EBM (Saito & Kishimoto, 2003). Saito (2012a) reported that “EBM and NBM are theories and methodologies aimed at maximizing a state of well-being in an individual patient [author’s translation]” (p. 16) and maintained the need for both EBM and NBM in a patient-oriented medical practice by expressing them as “wheels on a cart [author’s translation]” (p. 74). The author agrees strongly with Saito’s standpoint. Therefore, the discussion presented in this paper is intended to avoid a dichotomy such as music therapy vs. medicine or quantitative research vs. qualitative research. Rather, the author hopes to use Saito’s and related discussions to re-explore our understanding of EBP and related issues in music therapy and to promote productive discussions among music therapists. Herein, the author would like to present some of Saito’s discussions of the misunderstandings and various interpretations of EBM and the issue of Empirically Supported Treatments (ESTs) in EBP in psychology (EBPP) while reflecting on previous EBP discussions in music therapy. Thereafter, the author suggests some future directions of EBP in the field of music therapy.
EBM is classifiable as one field in EBP because EBP refers to practices in various fields (S. Saito, 2012b). Therefore, EBM might be expressed as EBP in medicine, but EBM is used in this paper because this terminology is widely accepted.
In fact, EBP originated in the idea of EBM, which was introduced in the early 1990s (S. Saito, 2012a; Straus, Glasziou, Richardson & Haynes, 2011). As it is beyond the topic of this paper, the author will not discuss the history of the development of EBM. One of the original ideas of EBM was to integrate research results into clinical work. It has triggered various misunderstandings and criticism (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996; S. Saito, 2012a). Sackett et al. presented the paper titled “Evidence based medicine: What it is and what it isn't.” The definition of EBM in this paper indicated, “Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (p. 71). Thereafter, Straus et al. endorsed the definition saying “Evidence-based medicine (EBM) requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances” (p. 1) in the standard EBM textbook titled “Evidence-Based Medicine: How to Practice and Teach EBM (Fourth edition).”
Saito (2012a) pointed out three types of naïve misunderstandings about the quality of evidence in EBM. The first type of misunderstanding is “to recognize information traditionally valued as ‘scientifically validated’ such as fundamental medical research or animal studies as ‘high-quality evidence’ while leaving the hierarchy of the quality of evidence out of account [author’s translation]” (p. 21). Saito remarked that EBM was originally undertaken to integrate research findings of clinical epidemiological studies into clinical situations. Therefore, research findings from fundamental research are less valued as evidence in EBM. The second type of misunderstanding is “to naïvely trust research results as high-quality evidence as long as the source information are expressed quantitatively [author’s translation]” (p. 21). Saito noted that examining quantitative data by statistical critical reviews only secures their reliabilities and validities. In other words, research results expressed in numbers do not always mean that they are reliable as evidence. The third type of misunderstanding is “to accept only research results of Randomized controlled trials (RCT) as the most valuable evidence and recognize other research results having no value [author’s translation]” (pp. 21-22). Saito argued that EBM is a practical process based on an individual patient and useful evidence for each case can be different. Therefore, the rank order of the quality of evidence differs according to each case and the results of RCT are not always ranked at the top of the hierarchy. In fact, Straus et al. (2011) suggested that “Proponents of EBM would acknowledge that several sources of evidence inform clinical decision-making” (p. 7). They valued RCT findings or systematic reviews of RCTs as the most reliable answer to the clinical questions regarding efficacy of a certain treatment method, but stressed that “they are not usually the best sources for answering questions about diagnosis, prognosis, or the harmful impact of potentially noxious exposures” (p. 7).
In addition, Saito (2012a) pointed out a misunderstanding related to treatment guidelines. Treatment guidelines are presumably one tool for clinical decision-making, but clinicians may be confused with the idea of implementing a practice by following the treatment guideline of EBM. This misunderstanding may engender practice without flexibility, which is disadvantageous for patients and is even against the idea of EBM stating “The practice of EBM is not a ‘one-size fits all’ approach” (p. 7) (Straus et al., 2011).
In addition to the misunderstandings of evidence in EBM, various interpretations related to the concept of EBM also exist. Saito (2012a) divided them into three groups which share some common ideas related to EBM, but their emphases differ. A brief description of Saito's categories follows.
The first group is called the “EBM orthodox school” (S. Saito, 2012a, p. 29). This school values the practice of EBM by going through a series of five steps starting at a formulation of clinical questions. The “PICO” or “PECO” (S. Saito, 2012a, pp. 31-32; Straus et al., 2011, pp. 15-16) format is often used to formulate clinical questions. PICO or PECO is an abbreviation of four elements that must be identified at the beginning of the EBM process: P, patient; I or E, intervention or exposure; C, comparison; and O, outcome. After formulating the clinical questions, four more steps must be completed: 1) searching and tracking down the best available evidence, 2) exercising critical appraisal of evidence, 3) integrating the evidence with clinical expertise and patients’ individual needs, and 4) evaluating the executed process (S. Saito, 2012a, p. 31; Straus et al., 2011, p. 3). This school is regarded as a standard method in the EBM education.
The second school is called the “EBM guideline school” (S. Saito, 2012a, p. 30). This school places value in employing clinical epidemiological information as evidence and exercising a critical review of evidence similarly to the EBM orthodox school. However, the EBM guideline school emphasizes “the presentation of practice guidelines and promotion of standardized clinical practice [author’s translation]” (p. 32). To achieve the purpose for this school, the hierarchy of the quality of evidence and the level of recommendation are crucially important. The research results of RCT are ranked at the highest level, whereas case reports and experts’ opinion are regarded as the lower level in the hierarchy of the quality of evidence. Making the hierarchy of the quality of evidence and setting up the level of recommendation enables the inclusion of evidence of multiple types into EBM even if some evidence cannot be supported by the critical examination in the EBM orthodox school.
The third school is the “EBM conventional scientist school” (S. Saito, 2012a, p. 32), which emphasizes scientificity, “the quality of being scientific; scientific character” (Oxford English Dictionary, n.d.), and objectivity in medical research. Whereas the first two schools mainly examine specific clinical epidemiological information as evidence, this school includes research findings from fundamental medical studies including biomedical and pathophysiological research. Furthermore, no subjective data such as those related to the psychological state and quality of life are regarded as evidence, even if they are expressed in a quantitative manner.
Saito (2012a) gave some examples of individual differences in perspective that can explain the different emphasis in EBM. Those who are willing to spread their treatment methods or guidelines by promoting EBM might find value in the ideas of the EBM guideline school. Researchers who strictly pursue scientific research might only believe the ideas of the EBM conventional scientific school. Different viewpoints are unavoidable. In fact, the quest for the most correct view among those will engender unproductive controversies (S. Saito, 2012a).
To date, EBM has mainly focused on clinical outcomes that were determined using quantitative research techniques. However, the EBM textbook by Straus et al. (2011) also has a section discussing qualitative research as follows: “Qualitative research can help us to understand clinical phenomena with emphasis on understanding the experiences and values of our patients” (p. 110). Saito (2012a) asserted that knowing “How patients experience their illnesses and find meanings in the process” (pp. 22-23) is also valued in EBM because it cannot be separated from pursing treatment outcomes. Saito also noted the need for establishing an effective method to include research findings of qualitative studies as evidence.
A history of confusion and misunderstandings persisted in relation to the concept of EBP in psychology (EBPP) in the United States. Saito (2012b) described the history of the development of EBPP and a salient problem triggered by the establishment of Empirically Supported Treatments (ESTs) in history. In the early 1990s, the American Psychological Association (APA) undertook the establishment of ESTs: a list of treatment methods that are validated by empirical studies and standardized treatment procedures under certain clinical conditions. Because the list was dominated by treatment methods related to cognitive behavioral therapy, this standardized approach created an unfair situation for treatment methods that were not listed in the ESTs. In addition, the establishment of ESTs gave the impression that practicing treatment methods listed in ESTs meant practicing EBPP (Saito, 2012b).
The APA (2006) recently explained that the concepts between EBPP and ESTs differ. The ESTs concern the efficacy of a certain treatment method under a specific clinical condition, whereas EBPP is a clinical decision-making process with the integration of evidence of multiple types to individual practices. Therefore, EBPP’s methodology is a higher level concept over the ESTs; ESTs are merely a recommendation that might be relevant to the corresponding case. The APA also emphasized that treatment methods that have not been empirically studied are not validated as ineffective.
The APA (2006) recognized the importance of inclusion of research evidence of multiple types such as “efficacy, effectiveness, cost-effectiveness, cost-benefit, epidemiological, treatment utilization” (p. 274) and the contribution of multiple research designs including qualitative research. The APA stated that “Psychological practice is a complex relational and technical enterprise that requires clinical and research attention to multiple, interacting sources of treatment effectiveness” (p.275). As the history of EBPP and ESTs implies, a movement is taking place in a direction toward comprehensive practice in psychology, which is in an opposite direction to the limiting evidence in EBPP.
Based on Saito’s discussion described above (S. Saito, 2012a; S. Saito, 2012b), the author would like to move on to a discussion of EBP in music therapy. During the more than 10 years before the AMTA’s endorsement of the definition of EBMTP in 2010 (AMTA, 2010), Madsen and Madsen (1997) reported that therapeutic applications of music in music therapy needed to be based on scientific evidence. He intended to discuss how music therapists answer questions of the effectiveness of music therapy. While his statement was not made in the context of EBM and EBP, Madsen and Madsen’s statement was an indication of the future issue of EBP in music therapy. Extensive discussions of quantitative vs. qualitative research have been conducted in terms of showing the effectiveness of music therapy (e.g. Rolvsjord, Gold and Stige, 2005).
Vink and Bruinsma (2003) emphasized the importance of EBP in terms of accountability in music therapy. They maintained the use of scientifically validated evidence, especially a systematic review of the Cochran library, and valued the hierarchy of the quality of evidence to underscore the effectiveness of music therapy to people in other areas and to promote beneficial practices for clients. EBP with progression through the five steps was exercised and the decision-making process was described in their paper. They did not exclude research findings of qualitative studies from the list of evidence, but rather considered research results of those types as supplemental information to scientific evidence. Their view of EBP integrates the mixed idea of three schools described earlier and reflects their intention to follow the idea of EBM precisely to music therapy. Many discussions among both clinicians and researchers have led to expressions of anxiety and fear for the movement of EBP in music therapy.
Aldridge (2003) and Edwards (2004) expressed their unease about limiting the inclusion of evidence to research results of quantitative studies and questioned the promotion of standardized treatment protocols in music therapy. Several difficulties of making RCTs applicable to music therapy research in palliative care and pediatrics were pointed out by O’Callaghan (2005, 2009) and Edwards (2004), including the varied client population and a flexible and individual-based nature of clinical practice. These points made by these researchers are relevant not only to the area of palliative care and pediatrics but also to other clinical areas in music therapy. It is likely, therefore, that many music therapists working with a large variety of populations would agree with their points.
There are two main concerns discussed above. The first concern is about limiting the types of evidence, while the second one involves the difficulty of conducting RCTs in music therapy. Although the latter issue persists as a difficult problem (this issue will be discussed later), the first concern may no longer be relevant. As described above, the integration of evidence of multiple types with clinical expertise and the individual needs in clients has become a consensus of EBP. In addition, EBP refuses overdependence on using standardized treatment because EBP is an individual-based treatment process. Bradt (2012) recognized EBP as “the biomedical hierarchical model” (p. 121), which is constructed with RCT findings and meta-analysis, and suggested that the model was not fully applicable to EBP in music therapy. Her view is the very reflection of that of the EBM guideline school. The author agrees with her point suggesting the model’s unsuitability to music therapy, but questions whether fixing the idea of EBP as “the biomedical hierarchical model” is necessary. The scope of evidence in EBP has now expanded considerably and is moving in a direction of accepting evidence of multiple types with more flexibility.
What should music therapists work on with this EBP issue? The need exists for theoretical work for defining evidence of multiple types in EBP as Abrams (2010) did; merely naïvely claiming the inclusion of evidence of multiple types is not convincing for critics who believe the limited type of evidence in EBP to accept evidence of other types. Theoretical frameworks are also needed to conduct such theoretical studies. The involvement of multiple types of evidence invariably engenders the necessity for coexistence of different epistemological frameworks. Epistemology is “the theory or science of the method or grounds of knowledge” (Oxford English Dictionary, n.d.). A need exists for a meta-theoretical framework to integrate different epistemological frameworks.
Kyougoku (2006) theorized the existence of multiple types of evidence in EBP using Structural Constructology (Saijo, 2005) as a meta-theoretical framework. Structural Constructology is a new philosophy developed by Saijo (2005). According to Saijo, one constructs structures from our reactions to our experienced phenomenon. Saijo gave an example of this by saying “For example, when one sees ‘muddy water’ on the ground, he/she may recognize it as ‘drinkable water’ if he/she is dying of thirst [author’s translation]” (p. 53). In this example, “muddy water” and “drinkable water” are constructed structures. Saijo asserted that everything around us turns into constructed structures according to one’s intention and therefore, the multiplicity of the existence of structures is unavoidable. Kyougoku (2006) used this principle to theorize the existence of multiple types of evidence in EBP while he also accommodated the idea of determining superiority between evidence in accordance with a purpose of practice. The author suggests that Kyougoku’s idea might be useful and that it has potential to resolve the issue, and eagerly anticipates discussion on this topic.
It is also important to clarify one’s position in dealing with the EBP discussion. As described above, misunderstandings of evidence and various interpretations of EBM typically occur among people in different situations and standpoints due to individual interests and expectations toward evidence and EBM (S. Saito, 2012a). The same issues occur in the context of EBP. For example, individuals such as researchers, clinicians, administrators in hospitals or public institutions, all have different views about EBP according to their interests and expectations to assure that EBP become more beneficial for their positions. Defining one’s own position in the EBP issue by reflecting on one’s own view can be beneficial for oneself, but it is also helpful to understand the perspective of others. This disclosure might also prevent a person from triggering unproductive arguments and conflicts among different views (Kyougoku, 2011; Saijo, 2005). Moreover, the most important fact to note is that music therapists share a common understanding of the fact that EBP is for clients’ benefit in music therapy.
Saito (2012a) urged that “presenting one’s clinical decisions and the decision making process explicitly during EBM is extremely important [author’s translation]” (p. 37). Clients are the priority as recipients of such information. Music therapists are responsible for that information provision. As professionals, music therapists must explain what made us decide to do what kind of intervention and under what circumstances regardless of the type of evidence used for the explanation. The issue of accountability is a different matter from defining evidence of multiple types or defending the rationale for employing a standardized treatment protocol.
The issue related to conducting of RCTs in music therapy has persisted as a difficult problem. This issue relates not only with showing the effectiveness of music therapy but also the use of standardized treatment protocols. Rolvsjord, Gold and Stige (2005) presented a use of a guideline including principles of “a contextual approach to resource-oriented music therapy” (p. 17) for their RCT study instead of using a manual or protocol particularly addressing standardized treatment techniques and procedures. The author greatly acknowledges their effort as a first step for incorporating the guideline into their RCT to maintain the flexibility and spontaneous nature during the therapeutic process. However, the use of their guideline in RCT has not overcome the epistemological contradiction they described. RCT is an established research method, which is epistemologically informed using a positivist’s view. The positivist’s view hypothesizes the existence of objects in one’s outer world and research methods informed by such a view are useful to explain the causal force of pre-structured objects (Bruscia, 1998; Kyougoku, 2006). Therefore, RCT requires the pre-structured manual and is suitable for examining the efficacy of a pre-structured treatment method. The idea of positivism does not accommodate Rolvsjord, Gold and Stige’s guideline based on a constructivist’s view hypothesizing the emergence of different matters in one’s inner world. Music therapists must conduct RCTs if they want to ascertain the efficacy of a certain treatment method. The author’s determination to date is to conduct RCTs on treatment methods that are applicable for standardization as specific treatment protocols. Although this would result in conducting RCTs on the limited number of treatment protocols, knowing their efficacy is nonetheless beneficial for clients as well as music therapists. The crucial point to note is not to exclude research findings other than those of RCTs by remembering the ESTs issue in EBPP (Saito, 2012b); rather, to constitute a theoretical scaffold for evidence of multiple types in music therapy.
The author re-emphasizes that the issue of EBP is extremely complex and is easily biased as presented in Saito’s discussion (2012a, 2012b). Therefore, music therapists should attentively and actively learn more about EBP. Such effective learning will enhance research related to EBP in music therapy. In other words, EBP can bring benefits and risks to the field of music therapy, depending on how music therapists relate with this EBP movement (Bradt, 2008).
As described in this paper, the author discussed what music therapists need to work on to establish EBP in music therapy by referring to Saito’s discussion of the misunderstandings and various interpretations of EBM and the issue of ESTs in EBPP (S. Saito, 2012a; S. Saito, 2012b). The movement of EBP tended to be accepted as a threat to music therapy, but this paper showed some favorable trends. Although music therapists commonly share the idea that providing beneficial practices to clients is always the first priority, the author urges incorporating the idea of EBP positively to music therapy practices and constructing methodologies and theories will enhance EBP in the field of music therapy.
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