Tuesday, December 22, 2009

12/22/09 Quote- a patient defines music therapy

Florence Tyson is one of the foremothers of music therapy. And, happily, I've been at this long enough to remember her presence at  conferences back when I was a baby music therapist (she died in 2001).

Her book, Psychiatric Music Therapy: Origins and Development, (1981) has a quote from a patient at the Creative Arts Rehabilitation Center (which has since closed). I put it up over my desk at work, because I think it captures the essence of music therapy so beautifully. Evidently, Florence Tyson felt the same way, because she included it in her book (pp. 71-72).
In music therapy, the music therapist, by the very nature of musical accompaniment, makes a profound psychological statement to the patient. He says: 'With this musical experience I will journey with you from the beginning of the piece (your struggle) to the end (transformation). I will go with you through anxiety, rhythm difficulties, fantasies, whether you finish or not. I will listen to you speak, even musically.' The good therapist becomes aware of this statement and when warranted becomes a guide, brother, sister, the good friend. There is the basic reality of patient and therapist coming together, one human to another. 
With accompaniment assured, the patient can explore strengths and weaknesses, realize his or her own potentials, and define problems. A patient even may become, in a monumental step toward maturity, responsible for his or her course. This reality also may occur in a highly structured session as long as the structure is always realized by the patient to be directed toward his growth, stability and self-discipline -- as long as the demand aims at the patient's eventual responsibility and individuation.

I think that pretty much captures it, don't you?

Monday, December 21, 2009

The joy and rapture of questions

QuestionsImage by Oberazzi via Flickr
People who read my blog know I'm a big fan of questions. And that I obsess over, well, everything


Because the only way to find out more is to ask more. And if we're not willing to ask ourselves questions, then we run the risk of walking around in life in a state of automatic. 

As music therapists, if we don't learn how to ask ourselves bigger and better questions (it really seems to be about learning how to ask ourselves better questions, I think), then our work stagnates. 

And we stop paying attention.

So I thought it was interesting (okay, yes, and delightful) that, in one day, I happened on two rather interesting items related to questions. I thought you might enjoy them as well, so I'm sending you along to have your own questioning party.

Here's where to go:

1. One is an excerpt from the book, The Interrogative Mood: A Novel? by Padget Powell. The entire thing  seems to be written in the form of a series of questions! And they're great questions! I've ordered it, and I'm awaiting it with great anticipation.

2. As if there weren't enough glorious questions in that bit of readery, I somehow discovered Jeffrey Tang's blog, The Art of Great Things. And, darn if he didn't just make a case in his most recent post for the good people of the world to ask the difficult questions

In keeping with the spirit of questioning, I have to wonder: What's next?

Tuesday, December 15, 2009

12/16/09 Quote- effortlessness, waiting, self-awareness

radiant effortlessnessImage by jhave2 via Flickr
From an article by Wayne Muller, "Effortlessness", in Unity Magazine, May/June 2003, pp. 4-6:
Deep within all things there is a natural rhythm, a music of opening and closing, expansion and contraction. Our heart, our lungs, the seasons, the oceans- all life expands and contracts, opens and closes, softens and hardens and then goes soft again. This potent opening and closing cannot be forced to happen, nor can it be stopped. It is simply the way of all things.
We need only remain clear and awake to listen for how things really are, to feel how the smallest changes of energy and attention move in us, in our relationships, in our work. We can learn to follow the spaces between things. Not to fight and push and cajole, but rather simply to wait until the true way reveals itself easily and clearly in this moment. 
My thoughts as I read this:
This seems to me a wonderful (and poetic) reminder of why it's so necessary for us, as music therapists (as any kind of therapists), to examine and to be aware of our own issues and motivations in our work. If we're not aware then we run the risk of "pushing, struggling and cajoling" our clients into getting better (behaving better, functioning better) instead of simply being with them and trusting that they will move forward at their pace. 

When I notice myself reacting in a session with a sense of urgency and "I must do something right now"  this passage reminds me: sometimes I just have to wait and be with my client(s) until s/he/the group is ready to move forward.

When I'm not willing to do that I know my focus has shifted to myself and to my own fear that I'm somehow not fulfilling this idealized (and delusional) notion that I have to be "the perfect therapist who can fix it all for her clients."

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Saturday, December 12, 2009

"I want to be here."

I noticed the word "here" came into my mind rather loudly as I accompanied W's breathing on the piano. Then..."I want to be here."

He was sitting in his usual partially reclined position on the couch and staring straight ahead. No eye-contact. Ignoring the instruments (although I think he tossed a mallet on the floor at one point). 

Just. Sat. 

I knew he was still not feeling all that well. We both had colds this past week. But he had been very clear that he wanted to come to his session.

"Breathe in; breathe out." I sang quietly, accompanying myself on the piano.

He waited until I was finished, and then he quickly tossed the maraca and the bells in rapid succession. 

Obviously something was bothering W. And as I watched him the song "Wish You Were Here" came to my mind. I found it in my folder, and I was all set to start playing when he stopped me, pushing my music folder to the floor.

Okay then. Kill the music. Better stick to just listening. 

"I'm wondering what's upsetting you so much today." 

W pushed the rest of the instruments off the bench next to his seat, making sure to send them into the distant regions of the Music Room. He watched them as they rolled off in various directions. He turned to me and tried to make sound with his voice. It came out as a quiet, brief hum. He waved his arms in frustration, unable to make me understand.

"I can't imagine how frustrating it must be for you to have so much to say and so few ways to say it. Can you go back to the music and use the instruments?" 

W got up and gave a few of the closer instruments, the ones he'd already sent to the floor, a shove with his foot, pushing them even farther away.

I looked at the clock and realized we only had five minutes left before the session ended. I let him know we would have to end shortly. 

I knew he wasn't finished. 

I recalled our previous session in which he kept picking up the bells when it was time to go (seemingly to let me know he wanted to take the instrument back to his cottage with him- like a transitional object). He didn't seem to feel finished then either. 

I asked him if perhaps his current upset was related to not wanting to let go of the bells and leave last time.

Eye-contact. Bingo!

"It is hard to leave a place where it's quiet and where you've developed a sense of safety. I know how much it means to you to be here."

Because I felt his helplessness, I went on and on. 

I reminded him that his worth does not come from me. That music therapy helps him remember and recognize his worth and value as a person. That we work toward his being able to go out in the world with the awareness that he is a worthy and valuable human being. 

I added that I realized this wasn't an easy task. We all struggle with it. "But, W, you have survived living in an institution for over 25 years. And you still care about people. Relationships still matter to you. That's a miracle!" 

He thought about this for a while. 

I gently noted again, "W, we need to stop for today." I got my coat on, brought his coat and hat over and began helping him get into his outer gear.

He paused midway through the process, flapping his left arm in his coat sleeve, not quite finished putting it on. In a second, he took off the coat, took off the hat, handed them back to me and pushed me gently backward in a clear gesture of "No."

He was staying "here". "I want to be here, Roia!" was what he seemed to clearly be stating with his actions.

I sat with him. 

"What do you think is making it particularly difficult for you to leave today? Is it that it's the holidays? Is this an anniversary date for you that I'm unaware of?" He paused and looked up and to the side to consider this.

"Perhaps you're feeling particularly lonely." Eye-contact.

We sat quietly, breathing together. "Loneliness is hard."

After a while he got up to push my tissue box off the piano. I brought him his coat again, and I let him know I thought he'd be okay. He is, after all, a survivor.

He hesitated, but he finally put on his coat and we walked out. 

Here is the song, "Wish You Were Here", that I would have sung for him in our session- mistakes, clunky piano keys and all. 

Wednesday, December 9, 2009

12/8/09 Quotes: Music therapy, observation, paying attention

The process of observing in a music therapy session: noticing what's going on with the client, with the music, how I'm reacting and responding, and the sorting it all out...this is the process of music therapy. 

And Ken Bruscia captures it beautifully:
Once therapist and client enter the therapy room, a steady stream of rich, complex encounters begins, encounters that invariably stretch and challenge the therapist.  Flowing in the steady stream are messages and cues from the client for the therapist to process, multiple physical and emotional reactions that the therapist has, and an unending current of thoughts and questions to ponder, relevant and irrelevant, lucid and fragmented. 
One of the most difficult things for new music therapists (in my opinion) is learning how and what to pay attention to in music therapy sessions

Someday, when I get myself organized enough to write an article about this topic, I'm starting it with this quote.

Bruscia, K. E. (1998).  “Techniques for Uncovering and Working with Countertransference” (pp. 93-119) in Bruscia, K.E. (ed.) Dynamics of Music Psychotherapy.  Gilsum, NH:  Barcelona Publishers.  

Tuesday, December 8, 2009

Quotes I have known and loved: Coming soon to a blog near you

It's been a long time since my first posting of quotes I have known and loved. And that's a shame, because there are so many quotes from so many wonderful writers whose work has inspired and taught me over the years. 

You know? The more I think about this, the more I think it's time to start a weekly quote in this blog. 

Of course, knowing me (and I do), it will be awfully hard for me to limit it to one quote. But I'll do my best. At least I'll try to stick to just one author...or maybe just to one topic. 

Oh, who am I kidding? It's impossible for me to behave when it comes to quotes. 

So there. I think it's an official decision. One day of the week (since I don't blog all that regularly anyway) is dedicated to quoting some of my favorite authors on some of the subjects I spend a lot of time thinking about.

Comments? Opinions? 

Tuesday, November 24, 2009

Isn't that kind of messed up?

Those of you who regularly read my blog have probably come to realize that I'm not exactly someone who focuses primarily on behavior change as a goal of music therapy. (And, truly, I'm not trying to bash behaviorists here.)
Not Different Just SpecialImage by nickwheeleroz (on holiday) via Flick

My usual focus is on building the therapy relationship  and learning about my clients through interacting with them. Behavior change, I believe, comes about naturally because the person wishes to maintain relationships with other people.

As such, I spend a lot of time thinking about and trying to come up with some ways of understanding why certain "behaviors" (or ways of being) are so indelible and resistant to change. (Mind you, this is something I regularly try to hash out in my own life as well. But I digress.)

So I started to wonder whether some of my clients have gotten so accustomed to playing the role (in their families, in the institution, in their lives) of "the messed up one" or "the problem" because, on some level it affords them the opportunity (perhaps, from their perspective, their only opportunity) to be special? 

I'm not saying this in a mean-spirited way, believe me.

Here's the thing: a good large portion of the folks I work with often don't stop "doing behaviors" that get people grumbling at them (this in spite of years of behavior modification programs and, the ever popular in institutions, active treatment).

And it made me wonder. Why?

I know my clients always have some reason (whether or not the reason is obvious to me or to any of their other supporters) for choosing the actions and interactions that they choose. 

Okay. So.

In the absence of a clear or obvious reason as to why someone is acting in some unusual or less than sociable way (a reason such as physical discomfort that hasn't been discovered or addressed, or a reaction to something we may not yet know is happening- like hidden abuse), I ask myself (and my clients): 

What's preventing this person from moving beyond this behavior? What is it about this particular way of interacting, this way of being in the world, this way of behaving...that is working for this person in some way? Why might s/he be loathe to give it up?

So I come back to the question in my mind: what if this adopted behavioral style, or interactional style, is in some way fulfilling a wish to be "special"? 

And whose wish to be special is it fulfilling? Is it my client's wish? Or is it the wish of his/her family? By not playing out the role of "special" will s/he be disappointing her/his family? Or believe s/he will disappoint her/his family? 

Is it a way to be noticed at all? In an institution, unless you act out in some way, you run the risk of pretty much sitting quietly by yourself and not having much interaction with anyone, because you're essentially not getting on anyone's nerves. That's fine if you're not all that into interactions with people, but what if you're lonely. And your choice is to not be noticed at all or to be outrageous? Which might you choose?

Right about now you're probably thinking, "No wonder that girl doesn't get anything done all day, obsessing all over the place as she tends to do."

And you'd be right. 

Sunday, November 22, 2009

You don't know what people know when they can't tell you...

From the Daily Mail in the UK, here is yet another reason we can't decide we "know" what people who don't use speech know or don't. Thanks to Anne Barbano for tweeting it to my attention.

Patient trapped in a 23-year 'coma' was conscious all along
By Allan Hall
Last updated at 1:59 AM on 23rd November 2009
A man thought by doctors to be in a vegetative state for 23 years was actually conscious the whole time, it was revealed last night.
Student Rom Houben was misdiagnosed after a car crash left him totally paralysed.
He had no way of letting experts, family or friends know he could hear every word they said.
46-year-old Rom Houbne was trapped in a coma for 23 years and had no way of letting anyone know he could hear what they were saying (pictured posed by model)
Rom Houben was trapped in a coma for 23 years and had no way of letting anyone know he could hear what they were saying (pictured posed by model)
'I screamed, but there was nothing to hear,' said Mr Houben, now 46.
Doctors used a range of coma tests, recognised worldwide, before reluctantly concluding that his consciousness was 'extinct'.
But three years ago, new hi-tech scans showed his brain was still functioning almost completely normally.

Mr Houben describes the moment as 'my second birth'.
Therapy has since allowed him to tap out messages on a computer screen.
Mr Houben said: 'All that time I just literally dreamed of a better life. Frustration is too small a word to describe what I felt.'
His case has only just been revealed in a scientific paper released by the man who 'saved' him, top neurological expert Dr Steven Laureys.
'Medical advances caught up with him,' said Dr Laureys, who believes there may be many similar cases of false comas around the world.
The disclosure will also renew the right-to-die debate over whether people in comas are truly unconscious.
Mr Houben, a former martial arts enthusiast, was paralysed in 1983.
Doctors in Zolder, Belgium, used the internationally accepted Glasgow Coma Scale to assess his eye, verbal and motor responses.
But each time he was graded incorrectly.
Only a re-evaluation of his case at the University of Liege discovered that he had lost control of his body but was still fully aware of what was happening.
He is never likely to leave hospital, but as well as his computer he now has a special device above his bed which lets him read books while lying down.
Mr Houben said: 'I shall never forget the day when they discovered what was truly wrong with me - it was my second birth.
'I want to read, talk with my friends via the computer and enjoy my life now that people know I am not dead.'
Dr Laureys's new study claims that patients classed as in a vegetative state are often misdiagnosed.
'Anyone who bears the stamp of "unconscious" just one time hardly ever gets rid of it again,' he said.
The doctor, who leads the Coma Science Group and Department of Neurology at Liege University Hospital, found Mr Houben's brain was still working by using state-of-the-art imaging.
He plans to use the case to highlight what he considers may be similar examples around the world.
Dr Laureys said: 'In Germany alone each year some 100,000 people suffer from severe traumatic brain injury.
'About 20,000 are followed by a coma of three weeks or longer. Some of them die, others regain health.
'But an estimated 3,000 to 5,000 people a year remain trapped in an intermediate stage - they go on living without ever coming back again.'
Supporters of euthanasia and assisted suicide argue that people who have lain in persistent vegetative states for years should be given the opportunity to have crucial medical support withdrawn because of the 'indignity' of their condition.
But there have been several cases in which people judged to be in vegetative states or deep comas have recovered.
Twenty years ago, Carrie Coons, an 86-year-old from New York, regained consciousness after a year, took small amounts of food by mouth and engaged in conversation.
Only days before her recovery, a judge had granted her family's request for the removal of the feeding tube which had been keeping her alive.
In the UK in 1993, doctors switched off the life support system keeping alive Tony Bland, a 22-year- old who had been in a coma for three years following the Hillsborough disaster.
Dr Laureys was not available for comment yesterday and it is not clear why he thought Mr Houben should have the hi-tech screening when so many years had passed.

Tuesday, November 17, 2009

Why, yes, yes I DO know it all! Why do you ask?

DiaryImage by Barnaby via Flickr
I have finally come to the realization that every single one of us has the private belief that we know the right way to do things. And everybody else who does what we do (or something not even remotely similar to what we do)  does not know the right way to do things.

One would think having worked in an institution for, oh, almost twenty-two years now, that I'd have made this discovery a good solid age ago. But...no.

And how is it (you may well be asking yourself) that I have come to this awareness and chosen to share it with you all here? Now? In this very moment?

Hmm. There must be a way to express this kindly and gently.

Let's just say that it astonishes me how frequently non-music therapist co-workers feel inclined to tell me exactly how and what I should do to be a "proper music therapist" to the clients in their care. 

I can, of course, only presume that the advice is offered in the spirit of being helpful. (If only these same people would be so helpful as to tell me a client has a horrible cold before I invite the person to come to music therapy.)

So there I was yesterday, feeling all kinds of "Humph! Who the hell do you think you are!?" and so forth, having had yet another of those sorts of interactions with a staff member. And I had to stop.

Yes. I simply had to stop.

Because, as much as I hate to admit it, I harbor the same exact rotten belief. I am just as strongly convinced that I know better than she does

And it's not as if I don't go around regularly making all manner of judgments with regard to how people are interacting with my (yes, my) clients, harping on about what they should be doing  with the guys and how they should be doing it, and on and on. 

And it's not as if I haven't opened my big yappy mouth about it often enough either. 

[Insert uncomfortable silence here.]


So. There we are. 

More therapy anyone?

[In the spirit of common decency, I have to say that I also work with a lot of very supportive and cool people who seem to respect the way I do my job and expect me to know what I'm doing. But I still maintain that in our secret identities as "the one who knows", we all entertain this belief in some way or another. Which was really my point.]

Friday, November 6, 2009

What does it all mean?

The movie, "Precious", is opening tonight in various major cities. I don't think it's playing anywhere near me. I've been listening to bits about it on NPR, on Oprah and it was reviewed on the evening news. It's based on the book, "Push", written by a woman by the name of Sapphire

Needless to say, it's been getting a lot of good reviews in spite of being a very graphic and painful film to watch. 

The thing is, I'm not sure I really want to see it. 

And I wondered, as I watched an interview with one of the cast members, "what does the fact  that I don't want to see this film mean about me as a music therapist?"

I work with a lot of traumatized people. People who have intellectual and developmental disabilities have often experienced severe and chronic trauma. I hate that my clients have and continue to suffer this way. I hate that anyone suffers, frankly. 

It made me wonder, "Am I obligated, as a music therapist, to go and watch a film that portrays a young woman who is brutally abused by her family?"

It's not as if I'm in denial that people are abused. 

I guess it's pretty obvious I'm having some ambivalence (and guilt- ah, yes, the ever-present guilt) about my decision to not see this movie. 

The best explanation I can give (not that anybody was asking for one) is that I can only bear witness to so much trauma. I have a larger obligation (if we're talking obligations here- and I seem to be) to not expose myself to so much trauma that I can't even function as a therapist to my clients. 

Anyone else want to weigh in on this? Or am I the only one who obsesses about such things? 

Sunday, October 25, 2009

Violence in the lives of people with disabilities

Gosh, I hardly finish publishing a blog about music therapists getting hurt on the job and I hear this on the news. It's truly a horrible, often hidden epidemic, and it must be stopped.

FLATBUSH (WABC) -- There are allegations of abuse Sunday against a state-certified care facility in Brooklyn.

The family of a 43-year-old mentally and physically challenged man claim he was brutally assaulted at the Institute of Community Living in Flatbush, and no one is saying how it happened.
Kimberly Creary is determined to get to the bottom of things, how and why her mentally challenged brother, Colbert, ended up hurt.
"His eye was closed, purple and burgundy, it was horrible," she said.
Colbert, who has limited speech, has lived at the Institute of Community Living for 15 years. The small, state-run facility houses those with mental and physical disabilities.

Kimberly got a call from staff on September 23, saying Colbert had been rushed to Kingsbrook Jewish Medical Center, suffering from an eye abrasion. But when she saw him, she was stunned.
"They don't know what happened," she said. "They told me he got up in the morning, took a shower and was fine and came to downstairs with eye like that."
Darrel Creary remembers his uncle being very agitated.
"He was very angry, pushing everyone away," he said. "I tried to feed him, and he wasn't trying to have that."
Frustrated, Kimberly called police. Officers from the 67th Precinct went to the facility, but Kimberly says staff told them that Colbert was not able to talk and was sleeping. So the officers left.
Then, a preliminary investigation by the state indicated that a worker had been placed on administrative leave, although it's not clear why.
The facility says that because of confidentiality laws, it could not discuss the matter. But Kimberly believes there is more to this story, possible criminal negligence and assault. She is meeting with the district attorney Monday.

No matter how many people in staff and support positions get hurt doing this work, folks with disabilities are way more vulnerable to abuse. I'm not saying it's okay that anyone gets hurt, but this is a difficult reality, and it needs to keep being noticed and brought out into the open so it can stop happening.

When we are injured by our clients

One of the scarier things about being a music therapist is that sometimes we get hurt on the job by our clients.

This is something I've been meaning to write about for some time now, but I've been procrastinating. I mention it now, because, recently Todd Henry, a man identified as a music therapist, was actually killed by one of his students.

It's a real issue when we provide services to people who are not always able to control their behavior. Or those who have gotten used to using violence as a means of communication. Or who have serious mental illnesses and aren't able to distinguish between what is reality and what is generated in the mind.

I've been hurt at times by my clients. I've been smacked, bitten, scratched, had my hair yanked, my fingers squashed, I've been head butted, grabbed, in a headlock, pushed, kicked, and pinched. Depending on the day, the situation, the context, and how violent the situation was, I've felt varying levels of distressed.

In general when I get hurt, my immediate reaction is that I feel uncomfortable, angry, frightened, ashamed, uncertain, violated, powerless, and with a general sense of not being sure how to proceed after it has happened (other than to say, "we need to stop the session for today.").

Because I work the way I do (using an object relations approach), I absolutely believe that the feelings I experience in reaction to getting hurt are more than likely the feelings my clients either are, or have, experienced in their lives (hello, projective identification).

As such, part of moving forward with my clients after violent behavior is addressing what happened in the following session(s), talking about how it impacted me and what I think my client may have been trying to communicate to me (i.e., that s/he was feeling powerless, ashamed, angry, frightened, etc.).

I work with people who live in an institution. By that very fact alone, they have experienced trauma. Never mind the many other forms of physical, sexual, emotional trauma they've likely endured over the years. When a person doesn't use speech, and doesn't feel as if s/he's being listened to, and s/he is fresh out of coping skills, violence is sometimes the result.

This issue isn't talked about much, if ever, when we're in school and learning to become music therapists. It's also not a topic that I see coming up in music therapy conferences either.

One of the reasons I don't usually bring it up is that it scares people. Another reason is that I don't like the idea that people see my clients' violent behavior as being a factor of their disability. I don't think most of my clients are violent (and not all of them are) because they have autism or some other intellectual or developmental disability. I believe it's usually a result of their life and not having learned better ways to cope with extremely challenging situations.

So I'm bringing it up today. And I'm wondering what your experiences (whether you're a music, creative arts, or other sort of therapist or supporter/caregiver) have been with this issue.

Sunday, September 13, 2009

Battling inertia one session at a time

From the Random House College Dictionary Revised Edition (1984), the definition of "resistance" and "resist":
Resistance: n. 1. the act or power of resisting, opposing, or withstanding. 2. the opposition offered by one thing, force, to another....4. Psychiatry. opposition to an attempt to bring repressed thoughts or feelings into consciousness. 5. (usually cap.) (esp. during World War II) an underground organization working to overthrow the occupying power, usually by acts of sabotage, guerilla warfare, etc.

Resist: v.t. 1. to withstand, strive against, or oppose. 2. to withstand the action or effect of. 3. to refrain or abstain from, esp. with difficulty or reluctance.--v.i. 4. to make a stand or make efforts in opposition; act in opposition; offer resistance. --n. 5. a substance that prevents or inhibits some action, as a coating that inhibits corrosion.

I didn't think D was going to be attending music therapy today. When I arrived in his cottage to pick him up he was sprawled all over his chair napping. But, I'll be darned, he got up and put on the rain poncho with some help from me, and we walked over to the Music Room, even more slowly than usual. He seemed so sluggish it was watching someone moving through a vast and entangling substance.

When I saw him the previous week, he was so exhausted, I'd given up early and walked him back.

After removing his rain gear and handing it to me, he went to lie down on the couch, appearing quite beat.

I asked him what he needed from the music, inviting him to look toward me when one of my suggestions sounded right to him. Did he need the music to express something he was having trouble saying? Did he need music to soothe him? To energize him? He chose "energize him" (looking at me directly rather than looking away as he had done when I offered him the other options).

I played "We Are the Champions" for a couple of reasons: first, it starts out quietly and builds (following the mood-iso principle of matching the person's general state musically and moving the music in the emotional direction one is trying to achieve). Second, the lyrics (to me anyway) offer a powerful commentary about struggling to overcome difficulty and standing firm in one's truth.

The song didn't seem to do much for him (although he seemed to be listening behind his closed eyes).

"D, I'm not sure what to offer you. You're letting me know you're very tired. I don't know whether it's because you don't feel well physically, or if you're feeling downhearted. If you truly don't feel physically well, then please let me know by standing up and going to the door, and we'll go back to the cottage so you can rest. If you're feeling downhearted or depressed, it may help if you take the first step by sitting up."

I played an energetic riff on the guitar, and I improvised a song in which I presented him, again, with this choice: stop for the day or make an effort by sitting up. I pointed out that I can't make him stay awake, and if he wants my help he needs to meet me halfway (by not lying down and at least trying to engage in the session).

To my surprise, he did sit up as I sang, and he remained sitting for the final ten minutes of the session!

I invited D to use the instruments or his voice to give me an idea of what it's like for him to move right now (to go from lying down to sitting up). He chose his preferred instrument, the tube shaker, and picked it up and put it down a number of times. He began to use his voice, and there was a quiet, low, somewhat whimpering quality.

We (okay I) talked about resistance, and I congratulated him for pushing through his inertia to be able to sit up and take a (figurative) step forward.

Yet another way in which my clients amaze and impress me.

Wednesday, September 9, 2009

How do we cope when our clients are in terrible emotional pain?

My supervisee brought up a very important question/comment in supervision tonight. We were talking about dealing with clients/patients who are extremely ill, or whose families are coping with very difficult medical news.

One of the most challenging aspects of being a therapist is that it's so hard to see our patients/clients in terrible emotional pain. We, with our images of ourselves as caring music therapists, and as people who tend to be sensitive to the turmoil in other people, want to fix it. We want to come up with the "right" music, the "right" words, the "right" intervention.

We want to do this, but we can't.

We can't always figure out how to be with, come to terms with, help, support our patients (and their families) when they are in the midst of dealing with devastating news, when they are coping with trauma, when we send them back to hellish living situations, and so on.

What I suggested was the usual:
1) We need to trust that what we have to offer may be helpful in ways we can't know.
2) We need to take care of ourselves musically, emotionally, so we can come to terms with this sort of thing.
3) Sometimes having a some sort of spiritual way of understanding things helps.

As I thought about it further (after my supervisee and I said goodnight), it occurred to me that we tend to think we know what our clients/patients need.

We forget that we only see them in a particular setting, in a particular venue, in one specific context, in a specific and painful moment in their lives. And we forget that we don't have the context of the person's whole life and all the many intricate elements that make up someone's complex relationships and experiences.

Because we don't have that, we can easily fall into the trap of thinking (along with our clients/patients) that this is the only moment they're going to have. This terrible thing, moment, or experience is what is going to define them forever and ever.

And, yes, it may. Some people do define themselves by their most painful moments.

But it also may be true that the pain, sadness, fear and struggle are exactly what that person needs to go through at exactly that moment in his/her life in order to become who they came to be in this earth. In order to evolve and grow in some important way.

I try to remind myself (when I'm in the midst of feeling as if I'm never going to do/be enough for a client) that I don't know what my client needs (within the context of his/her life),

But I can offer what I have to offer: my presence, my caring, empathy, music, compassion, and maybe even love (okay, a therapeutic love). And it's important that, on some level, I recognize that what I have to offer is enough, and it may be exactly what the person needed in that specific moment. No one else but me could have offered it in the same way.

By the same token, there will be other people in our clients' lives who offer them what they have to offer them.

For all we know, it could be that our clients' real need is to learn how to receive. Well, we don't know the answer to that. But we do offer ourselves and what we do know. That our clients matter to us.

And our presence matters to them. Somehow.

And so it goes.

Monday, July 20, 2009

Supervision: Part II: Peer Supervision

(This is the second part of the article I wrote for NJAMT News on professional clinical supervision for music therapists. The first part is here.)
Supervision: Part II: Peer Supervision
Roia Rafieyan, MA, MT-BC
The previous article looked at professional clinical supervision, addressing common misunderstandings about the role of the supervisor and describing what one might expect when one seeks the services of a clinical supervisor.
Another avenue for growth as a professional music therapist is peer supervision. This article will discuss the benefits of this way of learning and offer the author's experiences with her peer supervision group as one example.
What is peer supervision? How is it similar to/different from supervision with a clinical supervisor?
In contrast to professional clinical supervision, where a therapist with more experience acts as a mentor to another music therapist or a group of music therapists generally for a fee, peer supervision refers to both formal as well as informal connections between therapists who draw on each other's strengths and abilities as a means of developing their competence and effectiveness as music therapists.
Peer consultation/supervision can be as simple as posting a request for information on a music therapy email list or having a conversation with a trusted fellow clinician about a particularly difficult case. Some music therapists choose a more formal option. This involves working with a consistent group of people setting aside a specific time and place, agreeing on areas of focus and having a mutual commitment to ongoing professional growth. This piece will focus on my experience as a participant in a formal peer supervision group.
Where does it happen?
Our group chose to alternate meeting at the work sites of two of our members. Having enough physical space and access to a variety of instruments was important to us because we all felt a strong desire to use music-making as a part of our process. Just as significant was the need to find a central location since the group was spread out over a large geographic area.
How often? How long?
While meeting once a week or twice a month would be ideal, peer supervision groups can meet as often as is practical. The best our group was able to accomplish was to meet once a month. Meeting for about an hour and a half seemed to be a reasonable timeframe for our group which ranged in size from three to five people. This allowed each person to present case material and look at issues and gave us an opportunity to use the music to explore various aspects of our selves which affected the way we work with our clients.
What happens in a peer supervision group?
The group will develop its own rhythm. Ours gathered, checked in with each member, trying to find a common theme and come to a group consensus regarding the issues we wanted to focus on for that particular meeting. If no theme emerged, we did some musical exploring and improvising, starting with where we were and how we were feeling about our work. The music helped to initiate discussions through the act of listening to each other, analyzing our own musical experiences and observing the group process. Sometimes this would lead to more music-making with a more specific focus.
Different groups, because they are made up of different music therapists, will choose different approaches. While it could be a simple as a sharing of ideas and resources for music therapy experiences, it can also be a deep as supporting members to cope with profound feelings of helplessness or secondary traumatic stress and burnout.
How does this process help us increase our effectiveness as music therapists?
Music therapists have a unique opportunity to develop the skill of self-observation and to experience first-hand the dynamics and processes involved in group work when they engage musically and verbally in a self-examining peer supervision group with other music therapists.
By exploring our own feelings about and reactions to the work we do with our clients and our work situation(s) using music, we learn how to better engage our clients in a similar process. This enables us to become more effective in our work.
Helpful tips (based on our group's experience):
§ Let one or two people take responsibility for initiating, organizing and maintaining the group.
§ Meet in music therapy rooms in group members' workplaces (with permission) because it gives access to a variety of instruments (melodic and non-melodic) as well as freedom from distractions. It also provides the space needed to work.
§ Establish a date for the next supervision group before the end of each meeting (or set out a long-term schedule). This helps to create a commitment to the group and to the process. It is also helpful to send out email reminders.
§ Do not allow the group time to become a gripe session about how awful workplaces can be. Use music to explore and identify areas in which your own resistance may make it difficult to understand and support your clients.
§ Look for common themes in the stories that you share, or begin by improvising music based on what is currently being experienced by group members.
§ Watch out for the tendency to avoid using the music and to steer clear of difficult topics.
In summary a peer supervision group is one in which a group of professional music therapists come together on a consistent basis, and they use the skills they have to help each other grow as music therapists. By engaging in this process they are able to learn to be self-examining and may then, by extension, be able to take their work with clients to a deeper level.
Music Therapy Supervision (2001, Barcelona Publishers; M. Forinash, Editor) has three chapters describing peer supervision as well as experiential music therapy groups.
Chapter 12: Peer Supervision in the Development of the New Music and Expressive Therapist (E. Baratta, M. Bertolami, A. Hubbard, M. MacDonald, and D. Spragg) Chapter 14: Experiential Music Therapy Group as a Method of Professional Supervision (G. Langdon)
Chapter 15: Peer Supervision in Music Therapy (D. Austin and J. Dvorkin).
Additionally, of course, there are the many remaining chapters which focus on supervision of students during practicum experiences and internships, professional supervision, and institute training/supervision.
The Dynamics of Music Psychotherapy (1998, Barcelona Publishers; K. Bruscia, Editor) is a helpful read. While the chapters don’t specifically address clinical or peer supervision, there is a clear focus on the dynamic processes of therapy, and there are a number of chapters which focus on uncovering unconscious countertransference reactions to clients and working with elements of resistance within the therapist.
Online resources
“Models of Clinical Supervision” by George R. Leddick: http://www.ericdigests.org/1995-1/models.htm
“Peer Consultation as a Form of Supervision” by James N. Benshoff: http://www.cyc-net.org/cyc-online/cycol-0801-supervision.html
“Peer Group Supervision”- presents a model of peer supervision for those in the business world as well as in social services. It lists six phases of peer group supervision. Some of the ideas may be useful in getting your own peer supervision group started: http://www.peer-supervision.com/index.html
Specific to a particular approach to psychotherapy, but it could be very useful: http://www.contextualpsychology.org/running_a_peer_supervision_group