#3 Assessments and Goals:
A few months ago, I received my formal training in Neurologic Music Therapy (NMT). I had been taught and supervised by Neurologic Music Therapists throughout my career and had a fairly secure understanding of the techniques before arriving. What I unexpectedly experienced during this training was a bit of an identity crisis. I had not realized until that training how many of my mentors were subtly practicing from an NMT approach.
During formal NMT training, we discussed how to assess and determine goals for our clients. This seems like a standard part of music therapy and certainly not specific to NMT. What was discussed instead was a particular way to determine your goals, using the Transformational Design Model, which is the foundation to all NMT practice.
When you consider what you learn about writing assessments, goals, and objectives in undergrad, often what comes to mind for most students are session plans, formal assessments, and music-based assessments. I distinctly remember learning how to assess clients from a formal, music-based assessment form and revisiting that form after a few sessions of music therapy. Much of our practica work in undergrad is also based on group sessions, with little practica being offered for individual work. As a student, there are so many skills to learn and apply that learning in this way makes a lot of sense.
However, assessing clients inside of music or writing goals before arriving to our client does not always make sense for the real world. When I got to my internship, I was overwhelmed with the amount of information I was required to learn about an individual based on reading their medical chart, talking with the interdisciplinary staff, attending rounds, and maintaining this information solely in my head before meeting the patient. Alternatively, sometimes I knew absolutely no information about the patient before walking into the room to introduce myself. How in the world was I supposed to assess this patient without any previous knowledge and then implement a treatment plan in the moment without any planning time?
This is the greater reality to music therapy, especially within the medical setting. While at NMT training, our discussion of assessment and goal writing was facilitated by the NMT approach of the Transformational Design Model (TDM). TDM sounds like a really fancy and complicated way to describe assessment and goal implementation but it’s relatively straightforward. I, however, sat through the presentation entirely dumb-founded because the entire presentation put into words what I’ve been trying to explain to others (students especially) for years.
Using the TDM is how I practice music therapy. And I had no idea. There was a moment during the presentation when the audience was asked how often they arrive to a client prepared with their “bag of tricks [interventions]” that always work for them no matter what. Approximately half of the room raised their hands and I almost fell out of my seat. I immediately became alarmed, inwardly questioning how a music therapist is meant to address the needs of their clients in the moment if they instead apply a collection of successful interventions on them instead like a bandaid? What work is being done through this approach? I was confused in the moment because I had not only found the language to describe my approach to medical music therapy but I also felt that my mentors had neglected to inform me over the years that I was practicing under a specific music therapy philosophical approach without any knowledge of doing so.
When learning to balance how to assess a patient immediately when entering room, designing a treatment plan/goals in the moment, and implementing the treatment plan immediately, I was taught to make these decisions based on evidence gained in the moment. I could assess someone by reading clues around the room, asking questions of the patient and family, implementing an intervention based on my determined goal and making adaptations as needed in the moment. I could improvise, utilize original songs, adapt existing songs, and implement all of those music therapy interventions based on the needs that I recognized occurring at that time in the room.
While sitting in the TDM presentation, I learned that all of those factors had a name and an official order of processes. I just didn’t know them until that presentation. Below is a brief synopsis of how to implement the TDM (in my own words/understanding).
The Transformational Design Model:
1.Pre-assessment – Determine a pre-assessment to be used outside of the music before implementing any music interventions. Ask questions (gain knowledge), be aware of clues around you, gather information from the client, family, team members, use a pre-established non-music assessment form, etc.)
2.Goal: Establish a goal(s) based on the above pre-assessment. What are the needs that you identified from the pre-assessment? What goals address the identified needs in the moment?
3.Implement treatment plan: Provide music therapy interventions that directly impact the goal and need areas.
4.Post-assessment: Utilize the same assessment used during the pre-assessment to measure changes that occurred within the session. Ex. Measuring a pain level from 0/10 pre- and post-music therapy intervention and session if lowering pain was the identified need area and distracting from or establishing non-pharmacological pain management was the goal.
5.Transformation: Implementing the transfer of skills gained, changes made, progress to regular life or activities of daily living outside of music therapy. This is the key to the approach of NMT. How does what occurred in the session transfer to everyday life skills?
This particular model of practicing music therapy is the only application that makes sense to me. It is the only approach to implementing music therapy that I believe addresses non-musical goals with a transfer to every day life. It aligns with PT, OT, SLP, psychology, child life, etc. and how they practice. Why would we worry about making changes within and only within music therapy when the point of music therapy is to utilize music as the medium to facilitate change in everyday life? I believe the lack of practicing music therapy in this way is one of the biggest reasons why we have not moved forward further in our profession.
My work has lended itself more to an adapted version of TDM throughout the years, mostly because some populations blur the lines of the processes. In my opinion, this is perfectly appropriate because I consider myself to follow an eclectic approach, choosing to blend many approaches rather than adhere only to one. Adapting the TDM also fosters a more client/patient-centered and provides you as the therapist with flexibility.
I now teach my interns about the TDM a little ways into their internship. It can be an overwhelming phenomenon to learn about, especially since it is contrary to many things taught in undergrad. I give them this language to study and consider so that they can begin to see a shift in their thinking when they assess patients. I have seen the change in my students’ thinking and it alters their focus from addressing surface level issues with patients to being able to dive in deep and make significant therapeutic progress.
Transferability is key. We are not practicing music therapy to have our clients be great in music therapy. We are using the music to cause a therapeutic change that transfers into their everyday life. You do not need to be an NMT. You do not have to say you follow the TDM. You should however meet the needs of the clients in the moment and help guide them towards growth, progress, and therapeutic change all within the music.