By Audrey Weatherstone, MusicWorx Intern

I am fortunate to have a music therapy internship with a wide variety of populations and settings. Over the past several months, I have worked with pediatrics, older adults and hospice, mental health groups with adolescents, children with developmental disabilities, and adult medical and palliative care. I am becoming a versatile and well-rounded music therapist, influenced by my many supervisors and their differing approaches to music therapy. Having this variety has helped me to discover my style as a music therapist, and find what I am truly passionate about. Along with benefitting from all of these differences, I have also discovered parallels between all of these settings. In developing my own approach to music therapy, I find that I am applying some of the same tools to my work with infants all the way through my work in end of life care. One parallel that I didn’t expect was to find ways to apply elements of a DIR®Floortime™ model anywhere. 

For the first three months of my internship, I worked with 4 children and teens with Autism Spectrum Disorder (ASD) once a week. Each client brought entirely different personalities, interests, goals, and needs to the sessions. In this placement, I learned how to view music therapy from a DIR®Floortime™ model, and rewired my perspective from the more behavioral approach my education background instilled in me. I personally find a lot of value in the perspective of this model, and its universal foundation.

What is DIR®Floortime™?

For a detailed description of DIR®Floortime™, check out these blog posts by my supervisor and a previous intern:

For now, here is a quick recap:

DIR®:

• Developmental capacities
• Individual differences
• Relationship-based

These three categories work together to create a foundation for understanding human development. Each person perceives and interacts with the world differently, driven by social and emotional relationships. “Through a deep understanding of the “D” and the “I” we can use the “R” to promote healthy development and to help every child and person reach their fullest potential” (DIR® – ICDL – DIR Floortime)

Floortime™

• Follow the child’s lead
• Bring them into a shared world to help achieve developmental milestones

By following a child and meeting them where they are physically, emotionally, sensorially, and socially, we can begin to address developmental milestones. When we exist in a shared world with others, we are able to open and close circles of communication. DIR®/Floortime™ has become widely known as an approach to working with children with ASD, and most commonly addresses educational, social and emotional, and developmental goals (Greenspan, 2004).

Why This Model Is So Versatile:

I initially began to discover parallels between my sessions with children with ASD and my work in adult medical care when I realized: Everything starts with regulation. In order to exist in a shared world with anyone, whether in a music therapy context or simple day to day interactions, our bodies and emotions need to be stable. Regulation is similar to homeostasis, or a state of steady internal conditions. Our bodies achieve homeostasis to maintain stable fluids, temperature, blood sugar, and more, in response to ever changing external conditions. Regulation refers to the same concept in a broader sense, and involves our bodies, sensations, and emotions. 

When I begin an adult medical session, my first task to to make sure the patient is regulated. Are they in pain? Are they having trouble breathing? Are they experiencing anxiety or stress that is affecting their ability to interact with others? If so, these become the primary needs. Before we can move onto more complex interventions with patients, such as songwriting, interactive music making, or verbal processing, we have to first address these basic needs. If an infant in the NICU is crying and unable to self-regulate, the music therapist must first stabilize their emotions. If an adult with dementia is agitated and disoriented, the music therapist must first help to regulate them physically and emotionally, and orient them to a shared world. Once these goals are met, we can move up the ladder to more complex objectives.

Beginning sessions with this in mind helps to create a more stream-lined assessment process. Walking into a hospital room with minimal information about a patient and having to assess their pain, stress, dyspnea, orientation level, music preferences, goals, and objectives all within the first few minutes of a session is a lot! By breaking assessment and treatment planning down into pyramid steps, we can clearly and effectively assess the client.

The Hierarchy of Needs:

Utilizing pyramids to understand priority of needs is not unique to DIR®Floortime™. Maslow’s Hierarchy of Needs shows similarities in the importance of meeting basic needs before excelling in other aspects of life. If we do not have food, water, and safety, we cannot survive as humans, and cannot engage in meaningful relationships and accomplishments. If we are not regulated, we cannot engage in these aspects of life either.

Another aspect of Floortime™ is following the client’s lead. Working without structure has been an important learning curve for me, and it has enhanced my work in pediatrics and adult medical care. Taking time to let the patient show you what they need allows for much deeper connection than bringing music selections, conversation topics, or interventions to the table. Autonomy is a crucial part of building a functional therapeutic relationship. When given the opportunity, people have a natural desire to climb the hierarchy of needs, and as therapists we must give the space to allow clients to show us the way.

The Developmental Ladder

This image represents the developmental milestones addressed in the DIR®Floortime™ model, specifically with individuals with developmental and intellectual challenges. However, I believe these categories can be adapted or interpreted to meet the appropriate needs for any population. Here is a comparison between what meeting these needs has looked like in my experience with clients with ASD and adult medical care:

• Regulation and Shared Attention
  • Clients with ASD: address physical and emotional needs, provide or take away sensory stimulation, meet the client where they are in the room, use music to express and redirect emotions.
  • Adult Medical and Hospice: address agitation, provide grounding and calming music to stabilize vitals and distract from pain.

• Engagement with Others
  • Clients with ASD: build rapport, initiate social interaction and connection through music.
  • Adult Medical and Hospice: build rapport, discuss music preferences, begin individualized music experience and receptive music.

• Two-Way Purposeful Communication
  • Clients with ASD: maintain emotional and sensorial regulation through music making or listening, engage in client music making.
  • Adult Medical and Hospice: maintain regulation, stable vitals, and pain distraction through music, engage in patient music making.

• Shared Social Problem Solving
  • Clients with ASD: opening and closing circles of communication verbally, gesturally, or musically, following directions or steps to interventions.
  • Adult Medical and Hospice: engage in reciprocal music making, music guided reminiscence or beginning verbal processing.

• Creation of Ideas
  • Clients with ASD: engage in pretend play, communicate via symbols.
  • Adult Medical and Hospice: participate in songwriting, lyric analysis, visual arts.

• Logical Thinking
  • Clients with ASD: identify and express emotions, learn new concepts or address academic goals.
  • Adult Medical and Hospice: recognize themes through verbal processing, generalize coping skills learned through music therapy.

Consider how these categories can be addressed and adapted to the population you work with! Think about what primary regulation looks like in the population you work with, and how these needs can be addressed first, and with music.

References:

DIR® – ICDL – DIR Floortime. (n.d.). Retrieved from http://www.icdl.com/dir/

Greenspan, S. I. (2004). Web-Based Radio Show. Floortime TM: What it Really Is and What it Isn’t. Retrieved from: https://tinyurl.com/yy3hafel

Mcleod, S. (2018, May 21). Maslow’s Hierarchy of Needs. Retrieved from https://www.simplypsychology.org/maslow.html