Balance

The past couple of weeks here have been a different sort of challenge than what I've experienced so far. Instead of trying to figure out how to focus on everything and keep myself from getting overwhelmed, I'm able to handle things - but I'm trying to find my own voice, my own music therapy style, my identity as a music therapist.

One of the challenges for me is that of finding balance at this time. My supervisor and I have talked a lot about this balance that I feel like I have in some groups, but not in others. I am working on finding the balance of being comfortable and confident, instead of too timid... without overcompensating and being too overly assertive or even aggressive. I tend to give too many options and too much freedom to patients, and I need to balance that by being more decisive and direct in my leadership, but in the past I've sometimes overcompensated and been a little too in-your-face about it.

I also am working on how to handle patients with really different functioning levels being in the same group and how to account for that. It's not always easy figuring out how to accommodate for everyone's vastly different goals and needs. I've got a group this term with folks all over the spectrum so it's been interesting and challenging for me to figure out how to help reach their needs and help everyone be successful in group.


My individual music therapy sessions with my case study client have been going tremendously well! This client has had an extensive history of substance abuse problems for around 10 years prior to being arrested and hospitalized. He has identified music as a sober leisure skill for himself and as a coping skill to use when he's out of the hospital to keep him sober. When we had an initial meeting, I asked him why he thought music would be useful to him. He answered, "I've had more fun playing music than I ever did doing drugs. When I get out of here, I'm going to have a lot of time on my hands. It would be so much better to use music to keep me from getting bored than what I used to do."

For the first month or so, most of what we worked on was just on playing guitar. The past few weeks, however, have delved a little deeper into what's going on. The past two sessions have been really great as far as talking about the patient's insight into his mental illness and substance abuse issues, as well as him opening up to me more on a personal level and showing me some stuff he's written (which he refused to do before!). I had a chance to do a music therapy assessment on him - which I felt like went pretty well - and have been learning lots of new songs on guitar to teach him. He has been really excited about learning guitar and has also been really insightful on a deeper level. Overall, I think it has been a really successful experience for both of us.

 As of yesterday I have less than 200 hours left! Currently I am at 847 hours completed. I'm excited to be seeing my family who is coming to visit for Thanksgiving and getting in today :)

Stories & Journeys

A few weeks ago, I talked about my internship project. The topic I chose for my project is a paradigm that people are starting to implement in mental health care, trauma-informed care.You can read more about it in my post here.

As I touched on in that post, one of the core principles of Trauma-Informed Care involves a shift in the way mental health caregivers relate to their patients. An aspect of this shift involves listening to the stories of trauma survivors and providing them with a safe way to express their stories. A medium that has been proven effective for individuals to express their stories in a safe way has been through creative arts, including music, visual arts, movement, and other art forms. Trauma-informed expressive arts therapy (including MT) is based on the idea that using art forms as a medium for expression is helpful in reconnecting implicit and explicit memories of trauma.

For my project, I'm doing research as well as leading a group that focuses on this idea of trauma survivors sharing their stories. It's a music therapy group, so the way that group members are asked to share their story is through writing songs about it.

This group has met 2 times so far. The first week, we started with a mindfulness excercise with music. We took a few minutes to introduce ourselves, then spent most of the group discussing our expectations and purpose. I felt like it was important for group members to build some rapport with each other and with me, as well as to lay down some ground rules for group members. Most of these ground rules involved things like confidentiality and respect of each other - which most people probably know, but I know that if I was going to share intimate details about my story, I would like some reassurance that I could trust the individuals I was sharing it with. The first week, some people were pretty quiet while others were more talkative. Most group members required a lot of questions or prompts to participate in discussion. At the end of group, everyone filled out a set of questions, including "What does recovery mean to you?" "What comes to mind when you think of sharing your story?" and "What are your expectations of this group?"

The second week, group members began brainstorming and jotting down ideas of what their song was going to be about. My supervisor wasn't there so I led this group solo. After they brainstormed for 15-20 minutes, we spent time discussing it. At first, discussion was hard. I felt like I was having to pull information out of people and like they didn't want to talk to me. I was especially struggling with phrasing one question. I had relayed it to the group 2 or 3 different ways and only one person answered. I was feeling harried at this point and wasn't sure how to ask this in a way that people would respond to.

Then, one of the group members (the one who had already answered) was super forward (which is pretty normal for her) and asked me if I was nervous. I thought about what you learn in counseling classes about self-disclosure: will it be beneficial for the patients? Also, I thought about what I was asking of them... I was asking them to be super honest with me and share things about themselves. So, I decided I should be honest about this. I told them that sometimes internship is hard, but I really love it too. I told them that I'm not always nervous, but sometimes I get nervous leading groups because I don't know whether what I'm doing is working, especially when I'm the only one talking. The patient who brought it up said I should just breathe and ask my question again, so I did.

Giving that little bit of self-disclosure was a huge turning point for the group: everyone in the group started sharing about times when they were nervous to talk to people or nervous that they were doing something wrong, and some of them reassured me that they were in this group in particular because they want to be there (it was an optional group that they had chosen specifically). After several people had shared about that, one person started talking about his song topic, which led to discussion about that, and then someone else did, and eventually everyone in the group was discussing and sharing with each other. Two of the group members said they really want to record the song that they write so that they can include it in books they plan on writing!

This session ended up being phenomenal. Even after I dismissed group members, everyone stuck around and chatted, helped me clean up, and talked about their songs and their ideas.

Anyway, that was my awesome session yesterday. I have a really good feeling about my project now. I am super excited to see what the end product of people's songs are. 

Winding up, winding down

Last Monday marked the start of a new term here at the hospital. This term is the big one for me - I started leading a full schedule (mostly) on my own. Some of the groups I am leading are ones slowly took over leading last term, and some are new ones. I am also continuing to do individual music therapy sessions with a client as part of my case study. 

Here is an overview of some of the groups and interventions I'm doing. (Some of these descriptions are taken from program plans that I've written as part of my internship that I'm implementing now.)

• Songwriting: This group focuses on using songwriting to allow participants to express themselves, to increase self-esteem, to facilitate therapeutic discussion, and to improve both self-awareness and interpersonal awareness. Participants are given the chance to learn several methods to use to write songs both as a group and individually. A lot of the stuff I use for this group comes from some awesome resources that I got at the AMTA National Conference in St. Charles last October. 
• Personal Wellness through Music: This group is designed for patients who have an interest in learning basic instrumental skills or improving their advanced skills. Participants set their own musical and wellness goals at the beginning of term and track them each week. This group will engage in discussion about the relationship between music and wellness and people's progress in each area. It will focus on frustration tolerance, communication styles, desire and level of motivation, importance of practice and repetition, setting goals for self, acknowledgement of successes and failures, and personal wellness. 
• Band: This group gives participants the opportunity to build personal and professional relationships with one another while building their musical skills.  Some goals focused on in this group are involve improving communication skills, improving social tolerance, and beginning to conquer performance anxiety.  Group members get the chance to be creative and expressive, develop healthy leisure skills, accept responsibility, and build self-esteem.
• "The Meaning Behind the Music" (Song Discussion): This group uses song discussion, or lyric analysis, to facilitate therapeutic discussion, the improvement of clients’ self-awareness and interpersonal awareness, and the identification of healthy behavior patterns. This technique involves listening to songs and discussing both the lyrics and the music, including the rhythmic, tonal, and expressive elements of the music, as well as the relationship between the two.  In addition to discussing song elements, the group will discuss the relevance of the themes and messages found within the music and the lyrics, and their relevance or meaning to each individual.
• Healthy Rhythms (drumming & stuff): This group explores the use of rhythm, improvisation, and creative expression to relieve stress, promote wellness, and develop coping skills. Group members actively engage in music making, regardless of their musical skill level.  The group explores a variety of rhythmic interventions, including cultural drumming techniques, community aspects of drum circles, group cohesion, and/or the effects of rhythms on overall health and wellness.  This group also provides a safe place for members to express themselves verbally and non-verbally, as well as to discover and create personal rhythms and styles. 

These are just a handful of the groups I'm leading. I'm also doing an engagement group, a group based on my special project (Trauma-informed MT - which I posted about earlier and will post on again soon!), a guitar group, a social skills group, a relaxation group, and choir. 

Leading groups completely has been interesting. It could definitely have gone better in some cases, but some went pretty well. I think that one thing that I definitely need to work on is my confidence and my assertiveness, which I've had to work on since the beginning and will probably continue to work on for my whole career. 

It feels like each day, I'm either scrambling to keep up and feeling flustered, or feeling super relaxed and working on stuff that won't be due for another week or two. I am pretty sure it's more about my perception than about the actual amount of work varying from day to day.

In non-internship-related accomplishments, I finished an entire tube of chapstick without losing it or running it through the wash. I'm pretty sure this is like, the second time in my life that's ever happened.

Other than that, life has been pretty average out here in Oregon. I'm torn because I want to keep exploring and meeting people and making a home for myself, but I'm nervous to do so because I don't know where I'll be or what I'll be doing in 2-3 months. Will I find a job nearby? Will I move to somewhere completely different? I don't know. I'm trying to not let that effect how I interact with people or build relationships and how fully I put myself into the present.

I get to see my family in two weeks so that's pretty exciting!

Signing off now...By the end of today I'll have finished 782 hours and have 258 left. 

Break Week & DBT

The last week of October was a break from groups for us here at the hospital. I took a much needed day off on Monday of break week, then dived right in to two full days of DBT training!

DBT stands for Dialectical Behavioral Therapy. It is a therapeutic style that was derived by a psychologist named Marsha Linehan when CBT did more harm than good at treating certain patients, especially those with intense emotional dysregulation or trauma histories. DBT is most commonly used as a treatment for Borderline Personality Disorder, or BPD.

I had heard of and had some experience with DBT before, but this training was really useful for me. I learned a lot about patients with BPD as well as about dialectics and DBT techniques.

I learned that BPD is the personality disorder most associated with both attempted and completed suicide, while an estimated 80% of people with BPD self-harm (or NSSI - non-suicidal self-injury) in some way. These patients have a pervasive disorder of their emotional regulation system; behaviors such as self-harm are their way of attempting to emotionally regulate, a "solution" to regulate their emotions.

DBT seeks to change thoughts and behavior patterns, and emotionally validate individuals receiving services. It balances clients' need for acceptance and validation and their need to change behavior patterns. DBT services include Skills Groups, individual therapy sessions, consultation to therapists and facilitators, consultation or coaching to the clients, and Behavior Change Protocol.

Some of the aspects I really liked about DBT:

• How client-centered it is: This whole therapy style validates and accepts clients where they are at, while still encouraging them to change maladaptive or ineffective behaviors. It validates the person as separate from the disorder they have been labeled with. 
• The goal of DBT is to help clients create a life worth living. In reality, that's all anyone wants, but a lot of clients in the psychiatric system have lost hope of that happening. 
• Focus on intervention  rather than prevention. We help clients learn the skills they need to cope and to emotionally regulate, rather than doing everything for them. 
• Studies on DBT programs show significant reductions in NSSI, treatment dropout, anger, depression, substance abuse, anxiety, dissociation, etc. etc. etc. for patients AND reduction of staff burn-out and hostility towards staff. It's super effective!

As in every kind of therapy, this obviously won't work for everyone. And it's not all sunshine and rainbows - clients still experience different rates of change and a multitude of behaviors during DBT treatment. It is not always implemented correctly, leading to poor outcomes in those cases. But in general, I'm just excited that the psych community is leaning towards more humanistic, client-centered therapies with recognition of the hope of recovery for everyone.
 

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 :)