Sunday, February 22, 2009

Supervision: Part I: Professional Clinical Supervision

Here's the first part of an article I wrote for the 2009 Winter edition of the NJAMT News (NJAMT is the New Jersey Association for Music Therapy):

Supervision: Part I: Professional Clinical Supervision
Roia Rafieyan, MA, MT-BC
 What is “clinical supervision”?
“The focus of the supervision relationship is to address the complexities involved in helping supervisees in their ongoing (and never-ending) development as competent and compassionate professionals.  Supervision is a relationship, one in which both supervisor and supervisee actively participate and interact.  It is a process of unfolding- not simply following a recipe, but engaging in a rich and dynamic relationship.  Supervision then is also a journey, or odyssey of sorts, in which supervisor and supervisee learn and grow and from which both will very likely leave transformed in some way.”  (Forinash, 2001, “Overview” p. 1, in Music Therapy Supervision (Forinash, Ed.); Gilsum, NH:  Barcelona Publishers)
 We all receive some form of clinical supervision when we are students- either in our field placements or as a crucial element in our internships.  Many of us, however, are unaware of the benefits and availability of clinical supervision once we are finished with our schooling and begin our professional lives.
With the advent of licensure and an increased need for accountability, along with a desire to deepen understanding of music therapy and the various approaches which make up this complex field, supervision has begun to be recognized as a necessary and important part of the process of becoming a practicing music therapist.  
Common misperceptions about supervision:
§       The clinical supervisor will criticize me.
Some music therapists see supervision as being a continuation of their school experience, and they are concerned with being judged (i.e., expecting an encounter similar to that of being graded in school on their skills).  This is an unfortunate misconception. In fact, clinical supervision offers less experienced music therapists the chance to explore and develop their own professional identity. 
§       I’m finally on my own, and I want to try out some of my own ideas. My supervisor will expect me to do exactly what s/he does/says.
Supervision often involves learning from a music therapist whose work is admired and, at least initially, emulated.  Ideally, however, the supervisee is supported as s/he begins to discover and try new or different approaches that are adapted to his/her own personality and style. 
§       My supervisor will give me activity ideas.
In fact, the supervisory relationship is a rich resource, well beyond that of simply sharing ideas for new activities and music experiences.  A skilled clinical supervisor will help the music therapist to process difficult sessions (or relationships with challenging clients) by actively engaging the supervisee in music-making and self-examination.  The use of music during supervision serves as a way to model different ways to use music therapeutically.   
§       My supervisor will have all the answers.
Clinical supervision often follows a developmental process (not unlike the process found in providing music therapy) in which the supervisor offers guidance, not criticism.  It’s a relationship, and it develops in much the same way any therapy relationship develops; however, the focus is somewhat different than in therapy.  It is not uncommon for music therapists to wish for or hope that their supervisor will be able to offer them answers to their most challenging work situations.  One of the ways the clinical supervisor will help is by validating the music therapist’s experiences, reframing a particular problem, or, at the very least, helping to formulate new questions.
(Note: The chapter “Parallel Experiences” by J. Dvorkin and R. Rafieyan [in Inside Music Therapy: Client Experiences, edited by J. Hibben; 1999, Barcelona Publishers] describes the developmental process in the supervisory relationship as it parallels the music therapist’s developing relationship with one of her clients.) 
Who gets clinical supervision? How does one go about finding a clinical supervisor? 
Students get clinical supervision as a part of their schooling.  Professionals, at any point in their work, may choose to receive supervision.  Generally, the supervisory relationship is one in which the supervisee pays the supervisor for the service s/he provides.  Some music therapists work within a creative arts therapy department in their facility.  As such, they may receive clinical supervision within the context of their job.  Others may work under social workers, psychologists, psychiatrists, or psychotherapists.  Again, they may receive ongoing supervision as a benefit of their employment. 
Most music therapists, however, tend to feel somewhat isolated in their workplace, often being the only person providing this specialized service.  Furthermore, while professionals outside of the music therapy field may respect and even be intrigued by this specialized form of work, they may not fully understand what it entails, and they may not be able to offer the kind of support which may be needed. 
Some clinical supervisors advertise their availability in regional and state music therapy newsletters.  Another way to find a supervisor is to contact a music therapist whose work you admire and ask if s/he would be available to provide supervision.  Fees are generally negotiable, and most clinical supervisors will charge about the same fees a music therapist receives for providing private individual music therapy services.  
Additionally, there are ongoing music therapy supervision groups. These are different from peer supervision groups in that they are led by a clinical supervisor who is paid to offer this service.
Who provides clinical supervision?
Clinical supervisors are generally music therapists who have advanced training and experience.  Within the music therapy field, there are a number of specialization areas (Music PsychotherapyGIM, Nordoff-Robbins, Neurologic Music Therapy), and those seeking further training in these areas will often have supervision as a component of the learning. 
It may be helpful to note that clinical supervisors explore countertransference material which the supervisee brings to the supervision session. At times an issue may warrant further exploration which may go beyond the boundaries of the supervisory relationship.  When this happens, an effective supervisor will refer the supervisee to seek his/her own personal psychotherapy (some opt to receive music therapy from another therapist), thus maintaining the boundaries of clinical supervision.
 What does clinical supervision look like?
As you would imagine, clinical supervision is meant to be an interactive process.  Ideally, when supervision is done live, the supervisee is able to explore the clinical issues using music. Generally, the supervisee brings material from his/her work to the session (this may include, but is not at all limited to, work with particularly challenging clients, uncertainty as to how to proceed with a group, strong angry reactions to a co-worker or client, fears of burnout, secondary traumatic stress reactions, difficulty using music, finding oneself attracted to a client, etc.).  
The clinical supervisor helps the supervisee by creating a therapeutic framework within which to understand what s/he is experiencing as a therapist, what her clients(s) may be experiencing, how the music can be used, etc.  How this happens depends, of course, on the needs of the supervisee.  This is why the supervisory relationship is of such importance.  Without the relationship, which provides a solid base, it is difficult for the supervisee to feel safe in exploring all aspects of the work of therapy. 
The second part of the article (which I'll need to finish writing soon) will address peer supervision for music therapists. 

Wednesday, February 18, 2009

A step in a new direction

I have recently had the opportunity to become a clinical supervisor- not a practicum supervisor this time, but I am now someone who is regularly consulted by a professional music therapist for ongoing support and learning.  This is so thrilling and exciting to me!

I certainly haven't made any secret of the fact that I'm a great big fan of clinical supervision, having had my own supervision (with the same clinical supervisor) for the past fifteen years (did I just say fifteen years?  Yikes!). 

I have, on more than one occasion, stated that supervision saved my music therapy life. I'm not being melodramatic in saying that- it's true. Receiving clinical supervision from a more experienced music therapist has given me the confidence to share my work in presentations and in writing, and it's created a deep passion in me for the work that I do. Now it's given me the courage to learn how to support other music therapists as they develop their own professional identity.

I'm finding that being a clinical supervisor asks much the same things of me that being a clinician does. There are many of the same elements- the need to pay attention, slow down, sit quietly sometimes, notice my own reactions, and, of course, there is the ever-present experience of uncertainty.   

I have noticed how much I look forward to these weekly sessions. Even when I don't know the answer, I love the effort it takes to think about how to respond and pondering the cases my supervisee has shared with me after we finish talking.  

More than anything I'm waiting for the day when we can do live clinical supervision, so that we can more easily use the music as a part of the process.  

What an honor to be able to share in another person's journey toward becoming a music therapist.

Saturday, February 7, 2009

Where have all the music therapists gone?

Since I've been sick all week I only actually worked about a total of 9 hours.  As such, I've been roaming through other people's blogs.  

While roaming, I found this interesting post by Ryan Howes on the topic of therapist burnout.

Music therapists have only recently begun to talk about the fact that we burn out. A lot. So many music therapists end up getting advanced degrees outside of the field- or they simply move into other, completely unrelated fields.

I've thought about some of the reasons for this, and here are some of my ideas:
  • Music therapists often work in isolation.  We're usually the only creative arts therapist in our facility. Or, if we have a private practice, we may be one of the very few music therapists we know. 

  • There is a frequent lack of awareness, respect for, or understanding of the education and training it takes to do the work we do.  I can't even begin to tell you how many times I've had musicians or therapists say to me that they do "music therapy" in this facility or the other, and "no, of course, I don't need a degree in music therapy."

  • Music therapy training is comprehensive, but no matter how much one learns in school, there's only so much an academic program can do to prepare someone to be a therapist. 
  • Most music therapists aren't aware of what clinical supervision is, let alone that it exists. When I present my work I often share the fact that, in the first six years of being a music therapist, I went to work with a knot in my stomach every single day. I felt like I didn't know what I was doing, that I was somehow not doing a very good job, that I should always know what to do and how to intervene, but I didn't, and on and on. Deciding to get clinical supervision from a more experienced music therapist saved my music therapy life! I think if more music therapists knew about clinical supervision, they'd make use of it and be more likely to stay in the field.

  • Music therapy isn't exactly lucrative. Economic realities sometimes force clinicians out of the field. Back in 1987, when I was initially searching for a job, I found myself applying for a full-time job that paid $13,000 for a music therapist with a bachelor's degree and $15,000 for someone with a master's degree. Yikes!

  • It's also sometimes rather difficult, depending on one's location, to find music therapy jobs.  There's an awful lot of educating and demonstrating that needs to go on in order to create job opportunities in this field.
  • I know some music therapists who've gotten advanced degrees outside of the field have told me they wanted more knowledge in a particular area specific to the populations they served (i.e., they became speech therapists or occupational therapists, or they got a master's degree in social work or special education).  More often than not, though, I think it's because there are better job prospects in those fields. I had thought about the same thing, but, again, because of clinical supervision, I decided to get my master's degree in music therapy.
None of this, of course, is meant to be judgmental.  I just find it sad that our field often seems to be shrinking almost as fast as it grows.

Wednesday, February 4, 2009

Well, *there's* the way to cure your insomnia, man!

When I went in to pick up W from his cottage this afternoon, he was trying to nod off while sitting at "the table" (a very popular place for staff to have people sit- partly to make sure their clients look like they're doing something, partly to make sure that the staff look like they're doing their job so their supervisors won't yell at them, and so their supervisor's supervisors won't start writing people up, and so on and so on). 

Behind him, his staff person was grumbling at him to "wake up, W!" To me she said, "This is the first time he started nodding off today. [It was 3:15 PM- that unholy hour when almost every living being on earth wants to take a nap- except maybe three-year-olds.]  W didn't sleep last night, and I've been keeping him awake all day, because otherwise he's up all night!"  

Then she turned her attention back to W, giving him an annoyed look. 

Again, loudly, "Wake up, W!  You're not staying awake all night again!  Get up!  Go with the music therapist!"

Evidently, his intentional bout with insomnia from the previous night was distressing her.

I'm not surprised.  I wasn't kidding about supervisors and grand-supervisors all coming down hard on the direct care when the folks they're "in charge of" look like they're just sitting around, doing nothing or sleeping all day.

I'm sad, however, to say that I reacted with some sarcasm.  I'm always torn between sense- I mean, I highly doubt W purposely stayed awake all night so he could feel like crap the entire next day- and the awareness that most of the people who work in direct support are put into these ridiculous no win positions of "You must keep the clients in active treatment at all times. Every moment is teachable. Blah, blah, blah. This is why CMS funds this institution. Blah, blah, blah. Written up. Blah, blah, blah. Fired."

Somehow, through his apparent haze, W caught sight of me approaching him, and he decided to stand up and walk with me (sort of- he was a bit wobbly) to get his meds before we left.

He was so tired that he actually tapped my arm for a moment while we were waiting for the nurse to get his meds organized, and then he went to find a chair to sit down.  

Now, the thing about W is that he is NOT a morning person.  

As such, both of his music therapy sessions are conducted in the afternoon. It's a pretty obvious thing. Whenever I show up in the morning he's dragging all over the place (if he's even awake). In the afternoon, he's Mr. Pleasant and Let's Go! 

Clearly there were no naps happening this morning!  Ahem!

We got his meds, he paused, and I asked him if he wanted to stay in today, and we could try doing this again on Saturday.  There was some nonverbal hemming and hawing on W's part, and he put on his coat, and we slogged on over to my building.

I guess he decided it would be quieter to sleep in the Music Room.