Moving Toward Incorporation a Definition of the Quality of Life in the Practice of Music Therapy
Abstract
The concept of quality of life is a fundamental goal in the practice of music therapy, whether implicitly or explicitly defined in the philosophy of the practitioner. To improve the quality of life is often mentioned as one of the goals for music therapy treatment. However, the definition of quality of life has not always been clearly defined. Though music therapy literature expressing some of the important concepts surrounding the issue of quality of life, for example, the philosophical tenet that music is essential for human life, still no concrete and specific definition is expressed. The purpose of this article is to review the literature concerned with a definition for quality of life in other disciplines and to suggest a model for a more comprehensive definition of the quality of life for use in the practice of music therapy. Anecdotal examples are given to stir the issues toward a more comprehensive definition of the quality of life to be used in music therapy. As the title suggests, this article will not give a decisive answer for the definition of quality of life. However, this article will afford readers a chance to think and revisit their experiences as music therapists and define their own definition for quality of life.
The client had the equivalent cognitive functioning of an infant, documented as a cognitive age of “0” months old in his official facility chart. His workdays were spent at a wheelchair accessible workstation with large 10-inch red button. When the button was lightly pressed, a series of lights turned on and off, a fan made a gentle breeze, a floral scent was generated, and beautiful music played for 30 seconds. He loved these stimulations. When a member of the staff pressed the button, the man turned his head toward the fan, enjoyed the gentle breeze, and smiled. When the stimulation stopped, the light left the man’s face. He slouched down into his wheelchair with drooping shoulders and a sagging face. When the button was pushed again, the man became happy again. Unfortunately, he did not seem to make the connection between the big red button and what it activated. Cause and effect, the very basis of cognitive function in human beings, was beyond his level of understanding. Documentation of his efforts to accomplish the goal, “H correctly activates a mechanical object”, filled ten three-inch binders in the facility’s storage room. Year after year he worked on this task, every Monday through Friday, from 9 AM to 5 PM, without ever connecting the pushing of the button to the pleasant sensations. The task was designed to improve his quality of life and make him happy. But would the quality of his life have been better if he had been provided with these sensations for as long as he wished, rather than being tormented by endless 30 second repetitive cycles of contingency behavior modification?
The concept of the “quality of life” lies at the heart of the practice of music therapy, whether implicitly or explicitly defined in the philosophy of the practitioner. Regardless of the individual therapist’s approach, the goal is to make the client’s life better and to improve the very quality of their lived experiences. In the practice of music therapy, three major axes can be used by each practitioner: the individual client, the etiology of their disorders and diseases, and the therapist’s philosophy of the quality of life. Given that clients treated with music therapy most likely have limited abilities in one or more areas, sometimes their therapists have the duty to discern the client’s needs and desires and develop an understanding for how to cope with them. This responsibility is powerful but at the same time it can be problematic, or even dangerous because the therapist’s personal value system and philosophy directly affects the long-term goals involved in the client’s treatment.
A review of music therapy literature reveals that the goal of music therapy treatment is to improve the quality of life; this remains consistent from literature dealing with the beginning of life (premature babies) through to the end of life (hospice care). It seems that this phrase is often used as garnish and that it seems as though various authors expect their readers to contextualize it themselves using their personal values and interpretations. Farquhar (1995) points out that quality of life is “a powerful phrase” that has been “popularized, even clichéd” and “has become a journalist’s, politician’s and advertiser’s dream” (p. 502). As I am interested in this issue, whenever I encounter “to improve the quality of life” in a sentence, I attempt to understand that particular author’s context. Unfortunately, a more detailed definition is seldom offered. After a thorough review of music therapy literature including “well-being,” “psycho-social,” or “spiritual,” the author was unable to find any specific articles referring to “definition” of quality of life.
To improve the quality of life may be the long-term goal of the therapist, but it might not always match that of the client. If this is the case, what are the best options for clients who do not have the sufficient ability to communicate their needs? As some clients have very limited means of communication, at what point does the therapist decide for them? While it might be easy for a therapist to determine what immediately improves the quality of life, it is not as simple to know what will improve the client’s quality of life, nor even what will be the best possible treatment plan for the client. How, then, do we as music therapists determine what is best for our clients?
Each therapist’s quality of life philosophy creates a distinct and intricate approach to his or her practice of music therapy. Therefore, the construction of a comprehensive definition of the values and meanings involved in defining the quality of life in music therapy requires the examination of definitions drawn from other disciplines, including those of medicine and social science. Further anecdotal examples help focus the issues toward a more comprehensive definition of the quality of life to be used in music therapy. As we already understand and experience, music has its very unique power in human behavior and human experience in music can nurture and nourish very unique conceptions of quality of life. However, the purpose of this article is not to explore this in the context of this article, but to review the literature concerned with a specific definition for quality of life in other disciplines and to suggest a possible model for a more comprehensive definition of the quality of life for use in the practice of music therapy.
Definitions of the Quality of Life in Other Disciplines
The debate regarding the quality of life can be traced back centuries. One of the earliest sources is that of the philosopher Aristotle and the definition of εύδαιμονία (eudaimonia), commonly translated as happiness. Eudaimonia can be summarized as saying that the good life is achieved when we fulfill or realize our natural goals by developing our full potential (Ackrill, 1975; Barnes, 1982). Harris Rackham (1926) noted that a more accurate portrayal of eudaimonia would embrace “well-being” (cited in Fayers & Machin, 2000), but Nordenfelt (1993) pointed that eudaimonia is not “…a state of a person but an activity. Aristotle does not regard happiness as a state that one is in possession of, nor is happiness an experience. Instead happiness consists in a certain type of active life” (p.17). Eudaimonia is a final goal within which being self-sufficient is the end of an action, rendering it a process that is an end unto itself.
The contemporary phrase “quality of life” emerged after World War II. Initially it was used to make the distinction that “the good life depends upon more than material affluence encompassing instead a wide range of factors such as employment, housing, the environment, the visual arts and health”(Holmes, 2005, p. 493). Now “quality of life”, “human well-being”, and “welfare” are often used interchangeably although each has slightly different meanings and connotations. The fields of politics, medicine, and social science often attempt to quantify aspects of the human condition in order to define the “quality of life.” For example, quality of life may be defined in terms of household income in the case of socio-economic class or the level of physical function as in the case of medicine. This quantitative approach is used to present an objective view towards the effectiveness or prospects of policies, medical services, and specific initiatives or projects. There is a wide range of questionnaires and instruments that have been developed to quantitatively measure and assess specific attributes of this objective quality of life in a variety of settings.
Since the late 1970s, there has been a growing inclination to inquire into subjective well-being as a more robust understanding of the individual quality of life, defined as a person’s experience and evaluation of his or her life (Campbell, 1976; Nord, 2005). David Aldridge (2000), a philosopher in music therapy, points out the importance of this subjective view and states that “[i]t is possible to have a disease but not be distressed. Indeed, it is possible to be dying and not be distressed” (p.21). In other words, subjective well-being is derived, in part, by the individual’s perception of his or her successes and status in life. Such well-being defies standardized quantitative measures. Regardless of the many different interpretations of the definition and meaning of quality of life, it can be concluded that an individual’s happiness and satisfaction with life are considered as the two major building blocks in defining quality of life.
There are numerous efforts that have not been successful in recognizing or defining the subject of the quality of life. Due to individual differences in the understanding of the importance of life, results from several studies converge on the finding that there are many definitions of the quality of life as there are people studying the subject of the quality of life (Baker & Intagliata, 1982; Cummins, McCabe, Romeo, & Gullone, 1994; Felce & Perry, 1995; Liu, 1976). According to Farquahar (1995) there are four main types of definition; global, component, focused, and combinational. The global is the most commonly used in defining quality of life, as it allows for encompassing many different facets of the quality of life, however, it over generalizes and does not allow enough specificity of the major components to use it practically. The component definition attempts to break down the quality of life into specific elements in terms of dimensions and characteristics dependant on specific purposes, such as the research topic and measurement for long-term project or policy. The limitation of the component approach is the reliability and validity of each component in the measure of quality of life. Focused definitions use only one or a small number of components to define the quality of life. This component approach is often used to define a very specific quality of life, such as that of a cancer patient, or one in hospice care. The drawback to this is that it is a very narrow definition and in some cases authors use it too broadly and attempt to extend it into a broader interpretation of the quality of life. Therefore, it increases the probability of seeing the trees as the forest. The final version, the combination or hybrid, is created by combining global and component types, including the attendant advantages and disadvantages of both.
The World Health Organization (WHO) defines quality of life, using a combination type definition, as:
[I]ndividuals’ perceptions of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, personal beliefs and their relationships to salient features of their environment (WHO, 1997).
Bowling (2003) defines health-related quality of life as “a collection of interacting objective and subjective dimensions. Quality of life is also a dynamic concept; values and self-evaluations of life may change over time in response to life and health events and experiences” (p. 3). The issues concerning the quality of life have been extended to include the disability critique of prenatal testing (PNT). Consumerist and perfectionist attitudes reinforce the notion that children with difficulties are an encumbrance to themselves, their parents, and society (Asch & Wasserman, 2005). Sometimes medical professionals recommend abortion based on test results. Along these same lines, hospice care, long-term care units, and vegetative-state patients are discussed in terms of their quality of life. This illustrates the complexity of defining quality of life.
The quality of life in social science is sometimes defined using a definition verging toward the component-type. The components selected can include: happiness, life satisfaction, and subjective well-being as “the basic building blocks of quality of life,” and “the actual sensations of pleasure and pain that are the foundations of feelings of happiness” (Phillips, 2006, p. 15). Numerous efforts have emphasized that the important factor in the individual’s perception of the quality of his and her life is how he or she thinks, feels, and perceives current events and situations (Phillips, 2006). According to Philips, there are several different ways to determine the components of the quality of life: utilitarianism, the basic needs approach, Doyal and Gough’s (1991) theory of human need (THN), prudent values, and capabilities. Utilitarianism refers to the importance of mental states of happiness and satisfaction; prudent values are “values which make any human life go better and are predicated on a notion of the good life based on our essential humanity” (Phillips, 2006, p.70); capabilities refers to an approach to well-being in terms of degree of freedom to choose within various choices in life: “being happy; achieving self-respect; taking part in the life of the community” (Sen, 1993, p.36). Phillips (2006) states that core attributes in these discussions include moral expectations from the society, a basic understanding of human nature and the extent to which these factors are to be taken into account.
The client did not have enough strength to use a wheelchair. He lay on the bed as the nurse rolled it to the music therapy group session. His participation was not noticeable in the beginning. However, because this client signaled his involvement with such a euphoric smile, the therapist thought something was going on, but she could not figure out what had made him so happy. As she moved closer to him, she could detect that he participated in the group sing-along by moving his lips, but produced no sounds discernable by the main group. After she noticed his enjoyment, she visited him at his bedside and found many songs that he already knew. When she sang songs that he knew, he gave a big smile and responded by mouthing the words. The smile indicated gratification and happiness in the moment, although it may not have been a part of any long-term benefit and did not make any permanent environmental change.
Toward a Definition of the Quality of Life in Music Therapy
Aristotle thought that human happiness was based on human nature. When we fulfill our deepest desires and needs by performing an activity, or using our minds with excellence, we can achieve Aristotle’s eudaimonia (Washburn, 2003). Consequently, the question becomes one of what are our most basic and deepest desires and needs? Although there are many theories and opinions about what the basic needs of human beings are, in music therapy, we must question the basic and fundamental needs and desires of human beings regardless of their level of function.
There is a great deal of controversy surrounding the varied opinions of what constitutes basic human need. Different ideas compete with each other regarding what is the crucial and absolutely necessary ‘thing’ in life, depending upon the discipline, philosophical orientation, culture, and individualized situations involved. There may never be total agreement over the issue of a basic human need, though a consensus may be possible. Depending on each individual’s situation, the desires and needs are in constant flux; for example, the wish to return home might be the first and foremost desire for someone who has stayed in a hospital for several months. If somebody suffers from chronic pain, he/she may just want to end the pain or not be in pain. If someone is in perfectly good health, has financial security, a happy family, and is satisfied with his job, but is always anxious about failure, what is his desire? Is there a fundamental theme underneath these different desires? The analysis of three basic and innate needs might offer insight into this issue.
According to some motivational researchers, competence, autonomy, and relatedness are the three innate basic psychological needs (Connell & Wellborn, 1991; Deci, Vallerand, Pelletier, & Ryan, 1991; Ryan & Deci, 2000). The term ‘basic’ implicates that the satisfaction of the need leads toward health and well-being, but if the need is not satisfied, it can predict diminished well-being and pathology (Ryan & Deci, 2000).
Competence is defined as “feeling effective in one’s ongoing interactions with the social environment and experiencing opportunities to exercise and express one’s capacities” (Ryan & Deci, 2002, p. 7). The desire to create something by whatever means available, as illustrated in the anecdotal example, seems to be a vital need for humans. Human beings tend to have a wish to create something tangible and visible, and to share it with others. The desire to succeed, to create artifacts, and to seek challenges that maintain and enhance their current skills and capacities appears to be intrinsic to most humans (Ryan & Deci, 2002). Competence appears to be not a state which is an attained skill or capability, but as a sense of confidence and effectiveness in an active process (Connell & Wellborn, 1991; Ryan & Deci, 2002). Bunt (1994) mentions that “Music and music-making can be a focus of real beauty and transformation, helping us to define our humanity and all that is vibrant in living to our creative potential” (p.187). When appropriate accommodations are provided, music and music making can be accomplished with very limited physical and cognitive functioning, fulfilling the basic human desire to demonstrate competence.
Autonomy refers “to being the perceived origin or source of one’s own behavior” (Ryan & Deci, 2002, p. 8). The word “autonomy” originated from the Greek, autos (self) and nomus (rule), therefore it can be translated “self-rule” which implicates ‘living according to laws one gives oneself, or negatively, not being under the control of another” (Haworth, 1986, p. 11). The natural tendency to have control over our own environment can be found in daily experiences. Human beings do not like to be controlled and constrained. There is a burning sensation to decide what, when, where, and how to do my activities alone, to have self-agency. During music therapy group sessions, it is often observed that a client or clients attempt to dominate the group and control the group dynamics. Considering music therapy group sessions as a micro representation of a larger society, this power struggle can be found in almost any group setting. How can music therapy interventions allow the fulfillment of the need for autonomy?
Relatedness can be defined as “the desire for frequent, positive, and stable interactions with others (Williams & Sommer, 1997) and is fulfilled primarily through positive affiliation and acceptance from others (Gardne, Pikett, & Brewer, 2000)” (Carvallo & Pelham, 2006, p. 95). The desire to be connected with others, to belong to a group, and share the moment with other human beings seems to be a fundamental tenet of human psychology. In addition, human beings desire to communicate with others; to be known and to be understood by others is another core element of the human experience. Langer (1942) and Meyer(1956) claim that the aesthetic experience in music gives us opportunities to explore the self and to express ourselves far beyond what is available through language alone. This desire to express can be understood as a sub-category of the relatedness. Zimmer (2004), a German Music therapist, has worked with 426 premature babies and their mothers to promote bonded and attached relationships between them despite physical and emotional separation due to medical and psychological demands. After her project, Zimmer claimed that “We are only able to truly live if we are able to form relationships with other human beings” (p.128). Her conclusion supports relatedness as a basic human desire.
Music therapy environments can allow and enhance satisfaction of the three basic needs which can be a prerequisite for supporting a healthy function. Consequently, using eudaimonia as a basic global definition, and including these three basic desires, will be a good starting point towards creating a definition of quality of life for use in music therapy. Music therapy improves the quality of life of a client when it helps the client realize his/her intrinsic goals of interpersonal relationships, communication, and creativity as s/he attempts to fulfill full potential.
The documentary, What an Amazing World (순간포착 세상에 이런 일이; by SBS, Korea on original broadcasting date August, 3rd, 2001) was about a person who was a quadriplegia due to cerebral palsy. He could do nothing alone; he could not eat, nor rise; and he only had control over his mouth. Somehow, he began practicing origami using a plasticized paper, such as wrapping paper. He folded and even cut this paper inside his mouth. On a video clip from the documentary, when somebody put a small one-and-half-inch square piece of this paper in his mouth, he could turn it into flowers, butterflies, and cranes. When he spit out his creation, he looked like he had the whole world in his hand and glowed with pride. What made him proud? What made him so happy? Was it the affectual relationship with others when he gave these as gifts or the fulfillment of the basic human desire to create?
Conclusion
A music therapist can be a voice for someone with no voice. Music Therapy has a mission to nurture the seeds - the natural goals - inside each client. Unlike typically developed individuals, people with disabilities have additional obstacles to the development of their potential abilities without the help of special encouragement and intervention. The goal of the therapist is simply to find these dormant seeds, and to help them germinate and grow to their full potential.
It is important to acknowledge the role of the therapist’s views of the quality of life, both in a general and therapeutic setting, because these values direct treatment and restrict or enable the potential goals of the client. Treatment given with no thought toward the quality of life of the individual client is like building a house without a blueprint. Clients have only limited time and resources, and some clients’ ability to learn and apply skills are challenged; therefore treatment that establishes these skills must be highly effective and succinct.
Francis, a gifted, middle aged pianist with AIDS talked about his music therapy sessions, with music therapist Colin Lee, in the book Music at the Edge (1996) Francis said, “When I’m doing these sessions [improvisation] with you I am actually living a moment; I’m actually living with somebody and producing something and revealing myself” (Lee, 1996, p. 78). Without realizing it, Francis had emphasized the three crucial aspects of music therapy: interrelationships with other people (living with somebody), creativity (producing something), and self-expression (revealing myself).
A music therapist is present for a client who has a limited ability to communicate, to provide interpersonal relationships, to facilitate his or her creativity in music, and to promote self-expression through music. We might not, could not, and do not need to have the ultimate answer for the definition, value, and meaning of the quality of life. However, like Colin Lee (1996) states that “[A]nswers are intrinsically less important than questions; questions themselves are enlightening; questions hold the key to a greater understanding of music therapy” (p.148). Our continual inquiry will lead to the means of its future improvement in the practice of music therapy. Philosophy involves not only a thinking process, but also provides a guideline for this practice; therefore, inquiries into the quality of life are not only explored in the broad sense, as an area of inquiry about music therapy, but also as a principle guideline for practicing music therapy. We cannot expect other disciplines such as psychology, economics or philosophy to produce the value and meaning of the quality of life for us. This is our responsibility that we must accept.
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