Boundaries

bound·a·ry n. pl. bound·a·ries

1. Something that indicates a border or limit.

2. The border or limit so indicated.

 

Boundaries are important. Boundaries are healthy. In mental health, this is a big issue. Many of our patients are here because they have violated boundaries in some way, and most of our patients have had their boundaries violated at some point in their lives, often traumatically. It's no surprise that many of them have difficulty maintaining and building appropriate boundaries in their own lives. 

Therefore, it is important for clinicians and mental health care workers to initiate and maintain firm boundaries with their clients. Boundaries are ethical. Maintaining boundaries is important for everyone's safety, especially with clients who are vulnerable or "at risk". But what does it look like to have good boundaries? It's not the same for each clinician, nor is it the same for each client. 

 

There is no book I can read that outlines the proper boundaries that work for EVERY client in EVERY situation with EVERY practitioner. I don't want to treat every client the same way, nor do I want to be less authentic with clients (authentic meaning real, or genuine - this does not mean I'm going around self-disclosing to clients or treating them like peers, just that I treat them like real people). 

 

I thought I had been mindful about these issues with clients and that I had created and maintained these boundaries. However, this past week, a client talked to me about some feelings he has developed towards me, about a whole slew of misconceptions he had made about our relationship. I talked to him about boundaries: our relationship is therapeutic, not anything more; our relationship will never be more than therapeutic; I think you're a good person but you are my client and I will never reciprocate those feelings; etc. 

This was totally unexpected for me and out of the blue. At first, I kept racking my brain to try and figure out what I had done wrong, how I had caused this, what I had done... and after processing with my supervisor, writing up a note in the client's chart, and talking to this client's IDT, I know that it's not something that I did wrong. I didn't cause this, and I didn't see it coming. However, it's a good wake-up call to continue to be mindful of boundaries and parameters to set with people. It's also a good reminder that this job is full of surprises, and that working with this population is about expecting the unexpected.

In conclusion, I haven't really come to any final conclusions. This is an issue that will consistently be a part of my job and that I'll probably deal with for the rest of my life. I have no concrete, take-away message from this post, except for this: all therapy is about what the client needs; "the welfare of the client is of the utmost importance".

As of 10/28: ~670 hours complete

Building Rapport

For the past couple of weeks I've been doing individual music therapy sessions as part of my case study requirement for my internship. So far, I've really enjoyed doing individual sessions. The dynamic is SO totally different than having a group... for one, it's just me and my patient, instead of 5-10 patients and 2-3 staff.  Not only can we work a lot more on music stuff that is pertinent to this person individually, but also, it's a good opportunity (as well as a necessity) to build good rapport with the individual I'm working with.

The Merriam-Webster online dictionary defines rapport as "a friendly relationship; relation; especially:  relation marked by harmony, conformity, accord, or affinity". In school and while starting practicums and clinical work, we are reminded over and over how important it is to build solid rapport with our clients. This setting has really caused that message to hit home for me. If you don't have good rapport with your clients, your therapeutic relationship deteriorates really quickly. Conversely, if you are too friendly with your clients, this also causes your therapeutic relationship to deteriorate. 

In music therapy, we have the added advantage of being able to use music or music making as a way to build rapport with our clients. Making music together, allowing someone to express themselves musically in a safe environment, creates a cohesion or a connection with someone pretty quickly. 

My individual sessions have been focused on teaching this patient guitar so far. Honestly, if you just took that at face value, it wouldn't necessarily be music therapy - anyone with a certain level of guitar skills could do it. But I know that the conversations we have during sessions, the verbal processing that takes place, takes us a step beyond just learning guitar and into the realm of music therapy. As I build rapport with this patient, I hope to further incorporate music and expression into our sessions and combine that with emotional and verbal processing of what's really going on. But more on that later :) 

As of Friday 10/18, I am at 640 hours! 400 to go!

Motivational Interviwing (Week 13)

Last Thursday I got to attend a training in something called Motivational Interviewing.  This is a method for conversation or counseling with clients that focuses on drawing clients out as opposed to putting our ideas into clients. MI is client centered and directive, and it focuses on "exploring and resolving ambivalence" and "centers on motivational processes within the individual that facilitate change". 

Basically, instead of attempting to externally motivate change or imposing change on clients that they might not be ready for, motivational interviewers meet the client where they're at and respect that 1) motivation to change comes from within and 2) readiness to change is a process that is always fluctuating.

The acronym used to summarize techniques used in this method is OARS.  Here's a short breakdown of what these mean:

• Open-ended questions: These are questions that gather more information than just a simple yes or no.  These often start with words like "how" and "what". These types of questions give clients a chance to explore their own ambivalence to change.
• Affirmations: Compliments.  Praise positive behaviors and support clients in whatever stage of change they may be.  This builds rapport with clients and gives them a safe place to be more open with you.
• Reflective listening: This is a way of checking that what they're meaning is what you're understanding, rather than assuming you know what they meant. It strengthens the empathic relationship, and demonstrates that staff are actually listening and trying to understand the problem. Usually, these are the most commonly used technique, with about 1-2 reflective statements made for every question.
• Summarizing: Pulling together what happened in a session or an interaction. This is like a special form of reflective listening used to concisely wrap up what was said and focus on the important parts. 

This is a pretty cool technique that I hadn't really heard much about before. Since taking the class, I've tried to incorporate MI into my interactions with clients, especially a few in particular. This method seems like it would be beneficial for a wide variety of music therapy settings - even MTs who aren't working in psych could benefit from these methods for building rapport and maintaining a client-focused relationship.

For more detailed information, see www.motivationalinterviewing.org :)

Oh, hey, I'm halfway!

Since I missed a post last week, you're lucking out and getting two in one day!

This past week I hit the 3 month mark and I am super close to the halfway point as far as hours go.  I had my midterm last week, which (as far as I could tell) went well.  There is a lot that I can see I've improved on, and a long way I have still to go. 

In the spirit of positivity, here are some things I think I've learned or improved on:

• Confidence: Ever since I led my first ever music therapy group in my first practicum, I've been super nervous to lead groups.  I know I can do it, I'm just much more comfortable co-leading.  I'm not a very good authority figure. Since I've been here, this has been something I've been actively working on trying to change.  I've definitely seen improvements in my own ability to assert myself and gain authority over a group, and I attribute that to improving my confidence. 
• Documentation: In school, they sporadically drilled into our heads how important documentation and clinical writing are. We talked about it and practiced it, but not consistently, and every place does documentation differently, so this was something I felt some trepidation about. However, I have received positive feedback about my documentation so far, and am feeling pretty comfortable with it.
• Time Management: This is something that will be a life-long battle for me.  I am naturally a procrastinator.  However, I have improved on it greatly, and have done OK since I've been here.  I know I can continue to improve, but I think I've improved since I've been here - especially as I've had to juggle more and more responsibilities. 

Sometimes I think that six months for an internship is a SUPER LOOOONG TIME and that I don't know how they expect us to do this and and and........ and then other times, I don't feel like I'm at all ready to be 100% on my own and be a hardcore profesh music therapist yet, so then I'm like, oh good, I have three months left to figure this out.  I feel like this halfway point has come really quickly, and at the same time like I've been here for a long while.  I am not quite sure how to feel about it.  But I'm excited about the next 3ish months and look forward to what they bring.

The Universal Experience

The topic on which I have chosen to focus my main internship project is trauma informed care.  According to the U.S. Department of Health and Human Services, 85-95% of women in the public mental health system report a history of trauma, with trauma most commonly occurring in childhood.  Not all individuals with a trauma history have or develop a mental illness, but most individuals who suffer from mental illness have also experienced trauma, and most of the patients I have interacted with have experienced some kind of trauma.

Historically, people who suffered from mental illness were not expected to recover, nor were they treated as individuals.  The mental health care system in the US has been improving steadily, from improvements to facilities and inpatient institutions in the mid 1800s to deinstitutionalization (moving individuals from asylums and hospitals to homes and community-based care) since the 1950s. However, it has only been during the past 30 years or so that an interest has been taken in the impact of traumatic experiences on mental and behavioral health, and it did not become a direct focus in direct mental health care until a few years ago.

A trauma-informed approach to treatment is one in which the focus of healing is sensitive to the root or underlying trauma causing symptoms.  Trauma-informed caregivers recognize the signs and symptoms of trauma in staff, patients, and families, and their treatment is sensitive to the continuing effects of trauma in individuals.  

This approach focuses on a set of principles rather than a list of rules for treatment.  It offers a new paradigm in which the premise of treatment shifts from asking, "What's wrong with you?" to asking "What happened to you?" 

Trauma-informed interventions focus on the safety, empowerment, and support of individuals.  Trauma-informed staff focus on building trust and transparency, on collaboration with patients in treatment, and on the unique nature of each patient's needs.  

I chose this topic to do my project on because I believe the shift towards trauma sensitive care and trauma-informed services is an important step in mental health care.  I want to work in this setting because I believe individuals can and do experience recovery from trauma, and that understanding the experience of individuals is part of the foundation of a therapeutic relationship.  

One of the things I've seen mentioned several times while I've been researching trauma-informed care has been the importance of offering services that allow patients the time to build trust and the safety to share their story, to share about what happened.  This especially resonated with me.  Before I had ever heard of trauma informed care, I wrote a paper for a counseling class about my motivations for working as a counselor.  In this paper, I used a metaphor of each person's life as their own personal story that is being written, and about my desire to see individuals share their stories and "make their next chapter better than the last".  

Because of this, I chose to use the theme of story sharing in my "special project" for internship as well.  I'm working on writing a program plan tying story sharing in with music therapy; specifically, giving group members an opportunity to build trust and write songs telling a part of their story.  I am hopeful that this project will be meaningful for participants in this group and for my internship. 

One of the prompts on the description for what this journal could be about is, "Why have I chosen this path?" This is a question I've been reflecting on throughout my internship so far.  The truth is, there are many reasons why I chose this path, but I think that this project and trauma-informed care in general play a big part in why I've chosen this path.  I have chosen this because, as the National Center for Trauma-Informed Care states on their web page, "people with lived trauma experience can and do recover and heal".  

Among other things, I am continuing to learn how to practice this kind of care and will continue to do so throughout my internship and career.  Next week I will also have the chance to attend a special training about Trauma-Informed Care, which I'm really excited about.  I'm hopeful that the hospital is making steps in the right direction towards having a trauma-sensitive environment where people can and do heal.