The trouble with "quality" when one starts to think about it for too long

In my quest to figure out whether or not I'm providing quality services to my clients (because at this point, let's face it, it's become something of a quest), a lot of questions and thoughts have emerged for me.

It all sounded so easy on paper...

Obviously, on one level, this is clear-cut, and there's no real need for a lot of thought. We ("we" being music therapists) have certain elements in place to make sure we are doing what we're supposed to be doing.

We start by doing an assessment, from that we develop goals and objectives, we provide music therapy, and we evaluate the outcomes. Then, presumably, we can articulate "yes, the client met this objective" or "no, the client did not meet this objective."

When the goals and objectives are met we, ideally, proceed toward termination. When they're not, we either have to re-think what we're doing in order to help the person to be more successful or we decide that the goals and objective we originally set may not have been appropriate and we adjust them accordingly.

You'd think that would be the end of the story, but if we're really talking quality, it's not.

For a lot of reasons.

Meaning what? Or what meaning?

First of all, If I used a straight behavioral approach or a skill development approach in my work, then, sure, when my client achieves an objective that hopefully implies the effectiveness of the music therapy intervention I used. But it doesn't necessarily mean my client is happy with the service I'm offering or feels that s/he made some change that was important to her/him. It just means that s/he performed a specific action based on a specific objective/goal which may or may not have meaning for him/her.

Here's why I say that:

I work with people who not only don't use speech, but they're not usually the ones who decide they'd like to receive music therapy ( at least not initially). Furthermore, they may or may not understand what music therapy is, how it can benefit them, what is the process, and what the point of it all is (again, at least not initially).

This is how my caseload evolved: I either inherited my clients from former music therapists who worked at the institution, or I ended up working with people because I was assigned to provide music to their whole group and at some point I realized this particular person could use some individual intervention, or the team (that would be the treatment team who writes the "person-centered plan") makes a referral and asks me to work with someone.

More often than not, my clients never "request" music therapy, at least not with a clear understanding of what music therapy is and what it isn't. (And, to be truthful, people are often referred to us for music therapy because they "like music".)

Who/what determines quality in this context?

So I'm left wondering how is "quality" defined when I am providing services to people with severe disabilities who live in an institution, and when I use a relationally-based music therapy approach, the focus of which is not necessarily on developing specific skills?

Whose definition of quality do I use? The institution's definition (which is usually based on the rules and regulations provided by funding sources as well as a series of "core indicators")? Or the clients' definition?

I'm inclined to use my clients' definition, but how do I go about determining, when my clients don't use speech and their ways of communication can be confusing, what their perceptions, understanding, and preference for quality is? How can I figure out whether they are satisfied with the music therapy they're getting? And, given their histories, are they settling for, or being satisfied by, less than they should be?

On the other hand, it's important to respect the standards set by the institution as well. I can't very well ignore the context within which I'm working. As such, it's necessary to take that aspect into account as I move forward in this process.

And let me not fail to mention that, as a Board-Certified music therapist, I am expected to provide services with an awareness of the standards set forth by the Certification Board for Music Therapists (CBMT for short) and the American Music Therapy Association (AMTA).

Obviously, there's still more to say about this subject. On to the next post, eh?

What makes us great? And are we even as great as we think?

I've been obsessing about whether or not I'm providing meaningful and quality services to my clients of late. It started when I read an article in the Psychotherapy Networker on Supershrinks: What's the Secret of Their Success (written by Scott Miller, Mark Hubble, and Barry Duncan).

In 1974, researcher David F. Ricks coined the term supershrinks to describe a class of exceptional therapists—practitioners who stood head and shoulders above the rest. His study examined the long-term outcomes of "highly disturbed" adolescents. When the research participants were later examined as adults, he found that a select group, treated by one particular provider, fared notably better. In the same study, boys treated by the "pseudoshrink" demonstrated alarmingly poor adjustment as adults.

The authors did research, based on the work of K. Anders Ericsson, (a Swedish psychologist), trying to figure out how one becomes a supershrink, and they came up with this "formula for success":

(1) determining your baseline of effectiveness, (2) engaging in deliberate practice, and (3) getting feedback—depends on and is informed by the others, working in tandem to create a "cycle of excellence."

To me, this "formula" sounds a lot like quality improvement, which is something we really don't do a lot of- at least not consciously and deliberately- in the Music Therapy Unit at our facility.

The article further pointed out:

...you shouldn't be surprised or disheartened when your results prove to be average. As with height, weight, and intelligence, success rates of therapists are normally distributed, resembling the all-too-familiar bell curve. It's a fact: in nearly all facets of life, most of us are tightly clustered around the mean. As the research by Hiatt and Hargrave shows, a much more serious problem is when therapists don't know how they're performing or, worse, think they know their effectiveness without outside confirmation. Unfortunately, our own work in tracking the outcomes of thousands of therapists working in diverse clinical settings has exposed a consistent and alarming pattern: those slowest to adopt a valid and reliable procedure for establishing their baseline performance typically have the poorest outcomes of the lot.

Gosh. I started to wonder whether or not I was thinking I was doing a pretty decent job when maybe I wasn't. Hm.

So this has me thinking a lot about how I can go about determining whether or not I'm providing a service that's going to make a difference in my clients' lives in the long term.

A number of years ago I went to a workshop at a music therapy conference given by Richard Scalenghe (who is both a music therapist and a quality assurance professional) called, "So You Think You Provide Quality Care? Quality Improvement for Music Therapists". I found it thought-provoking then, and as soon as I read the supershrinks article I rummaged through my collection of papers and handouts so I could look at this subject again.

I'm going to do some more reading and see where I can go with all this. In the meantime, if you are a music therapist (or a psychotherapist or a person who has experience with quality assurance/improvement), I'd love to hear what approaches you've used to determine the effectiveness and quality of the services you're offering.

"I need to be still"

Today, at a little after 5 PM, Mn died. 

I met Mn back in 1988 when I started working at the developmental center. She was a teeny little woman who didn't use speech. When she was feeling better (she died of cancer), she used to come and sit on my music book while I was playing music in her group. It always made me chuckle.

Mn was surrounded by Mg, Ib, Dn, the nurse who turned off her vent, and me. 

The nurse and chaplain at the hospital told us to let them know when we were ready, and they would ask us to step outside while they removed the machines which were keeping her alive, and then we would be allowed to come back in and be with her as she died.

Before we called the nurse to disconnect her ventilator and prepare her, Mg, Ib, and Dn gathered around her, each holding her hand, rubbing her leg, and touching her long hair, crying. I sang:

I need to be stiIl and let God love me
I need to be still and let God love me
When this old world starts to push and shove me
I need to be still and let God love me

I need to relax and let God take over
I need to relax and let God take over
He'll take this load off my shoulders
I need to relax and let God take over

(Written by: Archie P. Jordan and Naomi Martin)

~~~~~~~~~~~~~~~~~~~~

We were all set to go back in the room when the nurse told us it was okay (we'd gotten rid of our dirty gowns and put on new ones in anticipation).  There was a lot of crying. Even the nurse was sniffing as she watched. 

I mostly stood at the foot of the bed, and I alternated between watching Mn take her last breaths and watching the machine register "0".  

It wasn't that I didn't want to touch Mn. It just seemed important that the people who had taken care of her should have the physical space they needed to say "goodbye". I knew I'd have room when it was time.

When everyone was finished and had begun to wash their hands, I moved closer to her. I took her left hand in mine, and I put my right hand gently on her forehead for a moment, and I wished her well on her journey.

We filed out, thanked the nurses, and left the Intensive Care Unit. 

I was struck by how little I cried, how honored I was to be present for her death, how humbling and quiet it all felt. 

As I drove home, I found myself feeling teary, but it was a gentle tearfulness. To Mn I offer James Dillet Freeman's beautiful "Prayer for Protection":

The light of God surrounds you

The love of God enfolds you

The power of God protects you

The presence of God watches over you

Wherever you are God is.

Death, Loss, Love

We held K's memorial service this past Wednesday.

His morning shift staff asked me to sing "I'll Fly Away", "Amazing Grace" and "The Wind Beneath My Wings". I made it through without crying, which surprised me, because the staff had put up a big collage of pictures of K.

At his service, I learned that K was abandoned by his family at a hospital when he was four months old. He was in his early 60s when he died. Wow. That's a long time to live in an institution.

Toward the end of the memorial, A, the minister said to us,

You're going to go about your daily business, and then some time, maybe in the coming weeks, maybe a couple of years from now, you're going to think of K. When you do, thank him. And remember him, not as a body and not in the form he took when he was alive. Remember him as his true self. As a spirit connected to you.

Yes, just as I remember R, I'll remember K. A lovely smiling spirit for whom I had the privilege of being music therapist.

Oh, THAT's why you're still standing!

It was gorgeous out today (in spite of my itching and sneezing and generalized whining)! TE was sitting outside with his group when I picked him up for his session. He was more than happy to flit along with me, because- well, because we go way back (we've been working together for almost twenty years now) and there was a really loud radio playing right near him. Noise is not his favorite thing (and, oy, can I relate!).

Anyway, we got to the Music Room, and he took off his baseball cap and put it carefully on my cart (which is where we usually put our outer gear when we arrive), but he didn't go and sit down (which is what he always does). 

I thought he might need a toilet, so we headed off the bathroom down the hall. I sent him on in, and I waited. And waited. There didn't seem to be anything happening, so I asked him to come out if he was finished. The door opened, and he appeared. We headed back to the Music Room. 

And TE was still flitting around the room, not sitting. Hm. 

"Maybe you don't want music therapy today? Perhaps a walk instead?" I was about to start heading for the door when it hit me. 

I bought TE a couple of big dog chew toys, because he likes, no, he needs to chew on things. When he doesn't have anything to chew on, he keeps a hand in his mouth or he chews on his shirt. 

Ergo, dog chew toys. 

Hey, they're big, they come in different textures, and he really seems to like them. And usually my neurons are firing, and I remember to leave them out for him when I set up the room before I go and pick him up from his cottage. It being Monday and such, I had forgotten. 

And evidently TE was kindly trying to remind me, "Um, something's missing here, lady."

I went to my desk, got them out, and brought them on over. As soon as I handed them over, he sat down.

"OK, Roia, now we can begin."

I love when I actually get it once in a while.