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.

Week 10!

This week was the Arts Festival at the hospital.  It was an amazing day that took months to plan and lots of people to make it happen.  I’m so glad I got the experience of getting to be a part of it.  There was lots of patient art displayed and fun stuff to do, from arts and crafts to temporary tattoos to visiting bands to basketball games.  I got to spend the day playing music, listening to others share their musical talents, and connecting with people on a different level.  Having fun is so therapeutic in so many ways, and I got to know both staff and patients better through this experience.

One of the patients I’ve been working with is getting discharged soon and wants to record a song that she wrote in one of our sessions before she leaves – which is awesome, except that I feel like I’m fighting with the recording equipment we have.  I don’t claim to be tech savvy, necessarily, but I have rarely felt as technologically challenged as I have with this particular piece of equipment – every time I think I’ve figured it out, something new goes wrong! Recording is something I’d never really thought would be an issue for me, but it’s something I’m struggling to learn anyway.  At least I’m learning! I just feel like this has taken SO much more time than I thought it would.

I feel like a broken record saying that I’m getting the hang of the way things are going here because I tend to say or think it every week.  The thing is, I genuinely do feel like I get the hang of what I’m doing, and then I get new stuff to take care of and learn and get the hang of… it feels like I’m a snowball racing down a hill sometimes when I look back on it.  I can’t believe it’s been almost 3 months since I’ve been here.  

Last week, I talked about how I tend to focus on the negative aspects or the things I do wrong when reflecting on sessions.  My homework for supervision from this week was to think of 3 good things that happen throughout the week, or things I do well.  Stay tuned :) 

Hours completed: 426ish by Friday the 13^th!    

An amalgamation of thoughts - Week 9

(This was supposed to post on Saturday but somehow got stuck in my drafts)

 

This week I have been struggling with remembering that I am learning.  I am having trouble being OK with where I am now, and with the learning process; instead, I’m coming down hard on myself for not knowing how to do things now, or being fabulous at what I do compared to people who are way ahead of me and have been doing this for years.  I think that I’ve been afraid to mess up to the point that it’s affecting my ability to ask questions, and to the point that it’s made me nervous to lead.    

I have also been discouraged when I feel like clients are not “responding” to what I’ve done – which, as I was reminded this week, isn’t really a valid indicator of whether I’ve actually done well – you can do everything right here and lead an amazing session, and sometimes that won’t seem to make any difference.  Remembering this will hopefully help my confidence when I’m not getting any feedback from group members.

One topic I’ve been reflecting on the delicate balance of being real and genuine while maintaining proper boundaries, of treating the clients here as the unique human beings they are without crossing any lines or losing authority.  This topic has come up a couple of times, not in relation to anything that has happened with me or since I’ve been here but just in general, and it has reminded me to constantly be mindful of this issue.  I know this is brought up in school and in trainings and things, but it has been interesting to watch and listen to interactions between staff and patients – sometimes seeing therapeutic qualities of staff which I’d like to imitate, and other times knowing what I want to avoid replicating.

Even though this was a short week, I feel way more tired than I have previously and am starting to feel emotionally fried.  This might be due to a number of factors, but I’m hoping that a little R&R will be what I need and that I’ll get that.

Some things I’d like to do well for this coming week:

• Preparation for groups
• Taking care of myself – avoid more tiredness, emotional exhaustion, etc.
• Confidence, confidence, confidence – tied in with not beating myself up for not being an AMAZING MUSIC THERAPIST when I’m still learning. 

 To close, here's another blog I enjoyed reading this week: 73 Things I Wish I'd Known as a New Therapist.  Numbers 23&24, 42&43, and 72&73 are especially pertinent to this post. Enjoy :) 

Hours completed as of Friday, September 6^th: 378 1/3

Two months down!

The past couple of weeks have been the first two of a new term of groups at the hospital.  I've  begun co-leading and even leading some of my groups.  It's been easier than I expected this week.  The first week of term was pretty nerve-wracking, even though I had been here several weeks; it felt like a big step to start taking authority in groups instead of assisting the therapist in charge or observing.  But this second week felt more comfortable.  It has still felt busy - but not bad busy.  I feel like I'm getting more into the "meat" of my internship, and I'm just starting to delve in.

I feel like I'm getting to know patients better, as well as staff.  Getting to work with a variety of different music therapy styles and techniques has been interesting and informative.  Working with a lot of different diagnoses and functioning levels in a variety of group styles has been good too.  This past week I got to have my first individual experience with a client here.  She is hopefully moving out of the hospital into a group home and wanted to write a song before she left.  We sat down and worked together on the song, and I was really impressed with the insight she had into her issues and hospitalization.  It was an ideal first session, and definitely a good reminder of why we're doing this. 

Although in some ways this past week felt productive, I also felt some pressure to make decisions.  I had to decide on a "special project", a case study, and a few other things that will determine a lot what I work on for the rest of internship.  More on that next time.  

As a side note - I also started applying for part-time, weekend jobs this past week.  Wish me luck! 

344 hours completed as of Friday, August 30th (696 to go)