Placements lie, of course, at the centre of student learning in music therapy, and I am regularly sobered to remember that however impressive we might be in choosing lecture topics, improvising, or facilitating discussion at the University or Conservatoire, it is out in the field, with patient needs and inspiration that student therapists-in-training find their feet and learn to think like music therapists – putting frameworks, ideas and methods into action.
In New Zealand, we are in the process of building our profession and the number of practitioners has grown in the last five years from 17- registered to 52 registered music therapists at most recent count with Music Therapy New Zealand, September 2010. Wellington, Dunedin, Auckland and Christchurch music therapy supervisors have been generous with their time and energies in visiting second year thesis students on a nine-month internship and our two-year Master of Music Therapy Programme has been much enriched by this therapist diversity and clinical expertise. As a result it has been possible for recent students to experience a wide variety of practice: for example a transitional health school for teenagers with mental health difficulties, a visual resource service for children, drug and alcohol programmes, a hospital paediatric ward, a local hospice, a specialist unit for Huntington’s Disease, a dedicated music therapy centre and allied health professions’ service, special schools, and a rehabilitation unit for people with neuro-disability.
Our first year students are sometimes lucky enough to attend placements with on-site music therapists, but our Wellington colleagues are busy supporting and visiting second years, and so there are not enough qualified music therapists to go round yet! So generally they are their own pioneers, often introducing music therapy to the setting at the same time as having their first encounter with patients. No small challenge I think. They do have a clinical liaison (including teachers, visiting neuro-developmental therapists, speech therapists, occupational therapists, centre managers and so on) but no one on site to specifically model their practice or offer detailed feedback or planning schemes. So obviously this does have some impact on the choice of supervision style offered by our programme.
A few years ago I watched a film on training and support for family therapists in the UK, which demonstrated a striking technique of the supervisor to a practitioner family therapist observing the therapist in a next door room working with a family, through a one-way mirror and giving suggestions and possible actions and words to the therapist through a head-set. The family, I presume, knew that the supervisor/trainer was there observing, but the discussion and actions were not affected by the physical presence of another person directly in the room, (though obviously the supervisor was very clearly in the consciousness of the therapist-in-training). It struck me at the time that the trainee therapist was being a bit like a television presenter, working on screen but with the producer giving updates, ideas and instructions in the presenter’s ear, but out of hearing of the audience at home. It gave a very literal version of Casement’s ‘internal supervisor’ (Casement 1985), and rather an alarming, though interesting way of keeping your practice focused and safe as a new practitioner in a complicated field of work. It did intrigue me at the time, and I have recently been thinking about it again, as I have been preparing to write this column about some supervision and assessment practice that my colleague, Daphne Rickson and I have been engaged in on our training programme with our Year 1 Masters’ students on their first placements.
As we have developed things so far, Daphne and I go out to the community placements to supervise and assess our first years on-site, and also run fortnightly supervision groups at the University, where the students share their experiences together. However the visiting supervisor/assessor role is a very different one than I had been used to in the UK, where I was either supervising students on-site in my own place of work, or hearing from students and supervisors at college as they reported on or played tapes of their practice (the second being more like traditional supervision of experienced workers too). The visitor-to-the-placement allows a very live and vivid experience of student practice (rather than the student’s selected reports, or even tapes). You get a picture of the sights, sounds and smells, and the student’s relationships with the team, plus a feeling for the support, or lack of it that is available. Obviously you can also get in the way, be over-protective or intimidating, and so the role is rather delicate and complex in my experience in the past few years. However, one of the real benefits is that the student is more knowledgeable than you in the setting, they know the patients and staff over time, and though as supervisor/tutor, you bring experience and ideas, the student can inform you and just be more confident than they might be if they were with you in your workplace.
Unlike the experience in family therapy described above, we are most usually in the room with the student and their patient(s), and while this has a dynamic effect on everyone, I think there are some interesting advantages to this approach at times, though we will always need to ask permission of the patients first (and students will generally choose situations where they think the patient will not be adversely affected by a visitor, or where they have been able to give their own consent). Quite often patients quite enjoy the novelty of another person, and I will often invite patients with some language to say something to us both about their experience of music therapy sometime during the visit, which gives the student the opportunity to hear what their clients think about the work. Sometimes this can be eye-opening and very moving.
I would like to give some examples of experiences of some work I have shared with students recently in both supervision and assessment of their first experiences on placement in the New Zealand community. I would like to thank the students for their agreement in describing a perspective on their work, and note that specific identifying details have been changed, and the names of the students altered to protect confidentiality. In both cases, being in the room during the music therapy work seemed to encourage the students on in their work, and perhaps to build ideas and strategies for interaction in particular ways. I will offer an example from a children’s hospital ward and a psychiatric unit for elderly patients.
Ella has been working on a paediatric ward of a local hospital, with short stay medical and surgical patients in the open playroom, alongside members of the play specialist team. She had been working there for around eight weeks (one day per week) of a fourteen –week placement at this visit, and it was a second attendance I had made for supervisory support. Referrals that morning included :
- the Dad and two-year old sister of a young baby who was very sick (currently with her mother on the ward) and who had been admitted late the previous day; the family members might need some support at a stressful time for the family; and
- Sally, a twelve year old girl who was on 24 hour monitoring by nursing staff following admission for low mood and a recent overdose. This young girl had been there a few days, was calm and using the computer, but was quite bored and finding it quite hard to know what to do with her time.
Ella was interested and enthusiastic about making contact, but said she was finding it easier to engage the younger children, and she was little unsure if she could help Sally much from previous experience. The referral sounded daunting. We thought I could back her up and observe in the room. There were two moments that morning where it was, I think helpful to have an additional pair of experienced hands and listening ears. Firstly, Ella found a song which the toddler knew – ‘Twinkle Twinkle Little Star’ – but the little girl was rather fleetingly engaged. I was chatting at the side to the Dad as friendly support and he was holding the ward guitar and experimenting shyly. While Ella sang the song again, I prompted Dad with the appropriate chords, and was surprised at how delighted and involved he was. He was then able to play to support fairly quickly (as he knew some guitar chords) and he allowed numerous repetitions of the song while he practiced. Ella had meanwhile followed the little girl elsewhere in the playroom and was experimenting with keyboard. With Dad’s new found confidence, I suggested we invite the toddler to sing with her Dad, which I think Ella might not have done as it was hard to keep track of both together. The little girl was able to be drawn back to sit down and sing with her Dad very easily and Dad kept repeating how good it would be to sing more songs with his daughter. They sang it through a few times, the little girl looking at her Dad all the time. (This seemed especially pertinent for them both, as they were waiting around in hospital whilst the baby had tests and treatment, which was hard for everyone.) Ella had begun to value how much help it can be to work with parent and child, as in the previous week by singing songs with the mum of a child, the little boy quickly sat on Mum’s lap and wanted to join in, so it continued that thread of thinking.
Secondly, just as I was thinking it was time for me to go on to a next appointment, I noticed Sally (the twelve year old) stop her computer session. I was picking up my mandolin I had brought and she was looking at unusual curved case of the round-backed instrument. I asked if she wanted to take a look and she smiled, and sat next to her nurse, so we got it out, she looked at the shape and strings and said it looked a bit like ukulele which they were playing at school. The nurse then had a little chat with her about the ukulele playing, I played her a few chords with the plectrum/pick, and again Sally said they used picks for the ukuleles. As I had to go shortly, I thought I could create a little segue for Ella by offering Sally a spare plectrum that was in my case, and wondered if she might play the guitar with Ella when she finished. She beamed, and I understand Ella went on to share a few chords with Sally and have a useful shared chat with the nurse during the morning which gave the 24-hour-monitoring pair something a bit more to share and talk about.
I made a practicum assessment visit to Daniel, who was working individually with patients on an acute ward for elderly patients with mental illness. (My colleague Daphne and I share the support and assessment, so she had supported Daniel previously and on this occasion, I was coming to listen, evaluate practice and write a mid semester report). We arranged that I would watch Daniel’s session with Bob – a man in his early seventies who had been on the ward for a few weeks. Bob was diagnosed with bi-polar mood disorder, had a recent history of psychotic episodes and very severe depression following bereavement. Daniel had been having sessions with Bob for four weeks, and had been successful in building a meaningful connection with him with the piano, as Bob enjoyed listening to classical music and had been willing to attend. On my visit I witnessed Daniel walking a few circuits round the outside garden with Bob, whilst he reminded him about my visit and checked permission, and then a forty-minute session which was almost exclusively piano improvisation. When I talked with the senior nurse later, she was really struck by how important the short period of engagement with Bob had been. She commented that Daniel’s one-to-one sessions ‘had been significant in that this person had had great difficulty in concentration and has often sought to avoid engagement with others.’ The staff team was glad to report to family about Bob’s willingness to link with another person through music.
One of the most important issues in early placement work clearly is making a meaningful connection with your participating client or patient, and Daniel was doing this naturally and effectively. He is an experienced improviser and particularly interested in using this mode to work in psychiatry. As I listened to the music in the session at the side of the room, I noticed that Bob was calm and appeared comfortable playing at the bottom of the piano while Daniel used the higher notes. Bob settled into a pattern of moving up and down about two octaves, choosing arpeggio-like figures on white and black notes that had a kind of modal-feel, and had some variety. Daniel demonstrated very clear skills at being able to match and attune to his patient’s music, through playing little melodic and rhythmic figures at the top section of the piano, which wove in and out of Bob’s playing. He kept carefully to Bob’s pace, but found some ways to emphasise musical aspects, playing in the spaces, and periodically changing the rhythmic orientation, which was subtle and sensitive. Daniel also showed remarkable patience - as Bob continued in a similar way for about 20 minutes. Towards the end of this period, I began to get quite uncomfortable listening, and was aware that this was initially just me (I would certainly have introduced some pauses or more obvious changes if I had been the therapist, and I needed to let Daniel work in his own way.) However, I also gradually began to think more carefully about Bob, who seemed increasingly intent in his own pattern, and was (I thought anyway) perhaps getting a little stuck in his up and down ‘pacing of the piano’ (it indeed seemed a little like Bob’s circular walking round the garden earlier on). I increasingly had the feeling of distancing, and remoteness, and was wondering if I should say something, or make an intervention, but I really did not want to mess up the relating between the two participants in the session.
I decided to make an intervention a bit like the supervisor through the head set! I started to sing – wordlessly some pulsed notes, in kind of two-bar bursts, with pauses, so that the piano music was punctuated and was modeling stopping my music as well as making sound. I am not sure how much Bob was affected by this, but Daniel noticed immediately and I think the music suddenly became a bit more personal for Daniel. I don’t quite remember exactly the sequence now, but after a while I dropped back and remained quiet, but finally just sang to Daniel that the music might finish soon (this time with words). In their own way they finished the session - by Daniel stopping and speaking to Bob, and inviting a quick cup of tea, before they progressed back to the main ward and some group music which followed in Daniel’s timetable.
When we discussed the session later, it was clear that Daniel had made more interventions and structured events in previous sessions but that the free, shared use of piano had been the most calming and engaging for Bob. This improvisation was a natural extension of that positive connection, and so Daniel’s thinking about this was still developing. However, my intervention did give an opportunity for us to think together about boundaries - musical and personal - in Daniel’s work, and how to move on from initially engaging patients, to making the developing relationship helpful and supportive to therapeutic change. Daniel has reported that Bob (after some up- and- down times in recent weeks) has recovered substantially and went home recently. The ward team is very clear that the music therapy input provided by Daniel has contributed significantly to helping him make links with people and environment, and they have been very appreciative of this student placement.
Daniel commented in a later piece of writing about the case work that the non-directive style in improvising had been very important in their work, in making Bob not worry about playing correctly, and to be able to enjoy his own playing without judgment. Daniel could value and confirm his own decision here. However my feedback (singing in the session and discussion later) had helped him think more clearly about his goals with Bob, and to be aware of using his own music to make boundaries for his patient. He described singing himself as a punctuating device in the last session before Bob went home and Daniel finished his placement, and Daniel recognised himself when he might need to offer shape and direction in his sessions.
I think for both the student visits described above, there was a particular benefit in being able to think together in the moment about people’s needs, to have an extra ‘musical body’ in the room to provide support and ideas, and ultimately to develop the students’ own thinking about their work as it was experienced. I think students are reassured by the supporting presence of an experienced music therapist sharing their work with them in person (as long as we do it in an empathetic way and have a chance to discuss this later). It has often been observed that beginning practical therapy on placements is a challenging time and promotes considerable anxiety for students (Hawkins and Shohet 2006, Madsen and Kaisler 1999, Thomas 2001, Wheeler 2002). Being able to witness students making meaningful contacts and supporting patients effectively as their tutor, can make them feel much better about how they are managing their casework, and can also give ready opportunities for help with development, and making the next step. For my colleague Daphne and I, it has provided many inspiring opportunities to see our students making progress, putting concepts into action, and also a chance to re-direct or change things that do not seem so useful. By being in the room, we can do this through music as much as through talking about the work, and it has been a very enjoyable and meaningful part of being a student trainer in New Zealand. Although it is partly to do with expediency – we do not yet have enough music therapists in the field – it does bring teaching about the work and practising it into close allegiance: for me this feels honest, valuable and moreover an exciting way to do my job.
Casement, P. (1985) On learning from the patient. London/New York: Tavistock Publications.
Hawkins, P. & Shohet, R. (2006) Supervision in the helping professions (3rd Ed). Maidenhead: Open University Press.
Madsen, C. K., & Kaiser, K. A. (1999) Pre-internship fears of music therapists. Journal of Music Therapy, 36 (1), 17-25.
Thomas, C. (2001) Student-centred internship supervision. In M. Forinash (Ed.) Music Therapy Supervision. Gilsum: Barcelona Publishers, 135-148.
Wheeler, B. L. (2002). Experiences and concerns of students during music therapy practica. Journal of Music Therapy, 39 (4), 274 – 304.
Hoskyns, Sarah (2010). "Hands-on" Supervision and Assessment in the Music Therapy Room for Students in Training. Voices Resources. Retrieved January 14, 2015, from http://testvoices.uib.no/community/?q=fortnightly-columns/2010-hands-supervision-and-assessment-music-therapy-room-students-training
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