"Truly there is a healing force in meaning." (Viktor Frankl)

When I saw the title of the book in the library, I knew I had to borrow it:

"The Unheard Cry for Meaning: Psychotherapy and Humanism"

Not surprisingly, it's by Viktor E. Frankl, the man who famously wrote "Man's Search for Meaning".

I haven't gotten very far into it, and now I have to dash off to get to a gig in Massachusetts, but here are some quotes I wrote down so far:

"The patient had not been taken as a human being, that is to say, a being in steady search of meaning; and this search for meaning, which is so distinctive of man had not been taken seriously at its face value, but was seen as a mere rationalization of underlying unconscious psychodynamics. It had been overlooked or forgotten that if a person has found the meaning sought for, he is prepared to suffer, to offer sacrifice, even, if need be, to give his life for the sake of it. Contrariwise, if there is no meaning he is inclined to take his life, and he is prepared to do so even if all his needs, to all appearances, have been satisfied." (p. 20)

And...

"...I think that, rather than exhibiting mental illness, someone worrying about the meaning of life is proving his humanness. One need not be a neurotic to be concerned with the quest for a meaning to life, but one does need to be a truly human being." (pp. 28-29)

And...

"If we are to bring out the human potential at its best, we must first believe in its existence and presence." (p. 30)

One more...

"...while food is certainly a necessary condition for survival, it is not sufficient condition to endow one's life with meaning and thus relieve the sense of meaninglessness and emptiness." (p. 33)

I absolutely must dash out of here, but I wanted to send along these thought-provoking comments. I'm sure you can see how music therapy fits into this nicely. And, having worked in an institution for so many years, you can, I'm sure, see how I might recognize how directly Frankl's comments speak to the experiences of my clients.

I'd be interested to hear how other folks relate to these quotes as well. It certainly follows appropriately on the tails of my thoughts with regard to whether or not my clients feel they're getting something out of being in music therapy.

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.