Tuesday, June 30, 2009

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?


The Little Jewelry Box said...

interesting blog:)

karen monroy said...

Some times, it is helpful to stop all the considering and re-considering and just be the space your clients can be appreciated and valued.
In the end, if a Client was being "fed" through the music therapy--you'd know it, you'd feel it, they would "show" it.

Who cares which method is being used, as long as it is heart-led and spirit re-deeming?

Reminds me of that study done at Stanford University a few years ago : those that worried if they were doing the "right thing" tended to be overwhelming ethically and morally centered. Those who didn't seem concerned --not so much.

Blessings for the wonderful work you do. I know you earn at least two angel stars daily!

Roia said...

Well, gosh, who would I BE without all my obsessing and thinking? :-)

Karen, I absolutely agree that my clients do let me know (eventually) whether being in music therapy has meaning for them or not. The truth is though that I don't know that it's usually the music therapy that keeps them coming back or if it's the relationship they have with me.

Yes, I know you're probably thinking, "well, who cares? The point is that something about being there is satisfying" and you would be right in one sense.

But is it really "effective" music therapy to have someone appear to be so dependent on me?

I hadn't heard of the study you mentioned. It sounds nifty, and I'll see if I can find a reference to it somewhere online (behold the power of Google!).

Thanks to you both for reading and commenting! Also for the stars!