Risk, Indemnity and Social Responsibility in Music Therapy Training

By Mercédès Pavlicevic

The HIV/AIDS pandemic has become associated with much of the African continent, and the South African media is saturated with facts, figures, and reports on how the pandemic affects various parts of this large and diverse country. Since the most devastating impact of HIV/AIDS is undoubtedly in the poor rural parts of the country, those of us whose lives and work orbit around metropolitan spaces get by with thinking about the pandemic only when the death of someone has a peculiar silence about it. The silence that loudly says "don't ask" has come to signal that the cause of death was most likely AIDS. In terms of the University of Pretoria's music therapy training programme, the pandemic is very close indeed - mainly the result of clinical placements addressing the needs socially disadvantaged communities. Although many music therapy clients - both adults and children - are not formally diagnosed, it is likely that a substantial proportion is HIV positive, reflecting regional trends. Moreover, thanks to poverty and malnutrition, tuberculosis, cholera and other diseases are rife. However, it is the stigma and silence of AIDS that is the most sinister - and infectious - aspect of the pandemic. The "real" risk of infection may be slight, but the risk of mental contamination much higher. This brings me to consider risk and indemnity in terms of music therapy training.

Indemnity against students becoming infected is addressed in a formal document, drawn up by the University's legal / insurance department, and vetted by the Deans of Medicine and the Humanities. The document asks students to confirm that as part of their clinical training placements, they agree to work with clients who may (or, more likely, may not) be formally diagnosed as suffering from tuberculosis, HIV/AIDS, and/or hepatitis C. The document then asks students to agree to be indemnified by the University, in case they become infected as a result of their training placements. The process of reading through the indemnity form together with students has brought into sharp focus the issues of danger, risk, and social responsibility in music therapy training.

For example, after a recent exercise of reading through the indemnity document, I noticed that one form was missing when the time came for signed indemnity forms to be returned. The student concerned voiced her unease about the danger of becoming infected. Prior to the forms being handed out, a medical practitioner had presented a profile of the pandemic, the (very low) risk of infection, as well as hospital strategies in case of "needle stick" injuries - unlikely given the nature of music therapy work. In my discussion with this student, we soon approached notions of "safety" and of "danger" in general, and it transpired that her neighbours had recently being targeted by a gang of robbers, while she was at home and unaware that this was happening. She could not get this episode out of her mind, and, since then, had been feeling "unsafe" both within herself and externally. Unsurprisingly, music therapy practice felt dangerous, and the risk of possible infection aggravated her sense of fragility. Risk and danger seemed to be everywhere, and "viruses" were out there, apparently waiting to "rob" her of her health and safety. Indemnity was clearly not going to alleviate these anxieties.

Before thinking further about indemnity, it may be useful to begin with thinking about the nature and flavour of risk - which affects all music therapy work, whatever our national, regional, or working contexts.

The Safety of Risk

We can sometimes choose to be in a position of risk - in the sense that we can choose to gamble, invest in the stock market, enter political life or, practice a caring profession. In the world of gambling, markets and investments, the primary motive is the possibility of profiting, of seeing one's investments grow (and becoming wealthy) - and the risk, of course, of losing. In health related practices, however, the possibility of gaining or profiting in some way is minimised, partly thanks to the notion of "health" being a cover-up for illness, disability or problems. In other words, in health related practices, health is what needs to be (re-) gained, usually from a position of ill-health, lost health or absent health, for instance, you consult a medical doctor because you are unwell and want to regain a state of health. The treatment offered carries a risk: that there might be side effects or that you might not become less ill than you are. The scenario is not that different if you think of consulting a social worker, a physiotherapist or even a music therapist: as in any risky business, the outcome is unpredictable. However, in the health professions, even if the probabilities are weighed evenly between positive or negative outcomes, the notion of risk has a flavour of possible loss. "Can I live without my illness or problem? How much money will this cost me? The treatment might hurt literally or figuratively. It might not cure me at all, and I might become worse."

For those who live in parts of the world that are unsafe, there is no choice about being at risk. Daily life is a risky business. In war zones, bullets or bombs might turn us into targets. In South Africa, with its horrendous record of road safety - or rather, road accidents - driving is one of the riskier aspects of daily business. Since nobody can avoid driving or being a passenger, risking becomes habitual, and most of us become blunted to its hazardous possibilities. In other words, we push the risks to the back of our mind, and apparently manage to live in relatively safe states of mind.

However, even living in comfortable, safe parts of the world seems to carry risk in the sense that the global climate "feels" more dangerous than a year or two ago. Danger has, possibly, become more prominent and less avoidable. The irony is that as long as we are in a position to be thinking about risk, we are still relatively safe.

For example, a music therapy student expressed anxiety about the danger involved in driving to one of the training placements. The placement is in an outlying community, the road filled with vehicles that are not roadworthy, and a stretch of road just before the institution passes a 'taxi-rank'. The high concentration of pedestrians, the traffic congestion, as well as the fact that this is a poor area with notable absence of 'law-and-order' made her feel vulnerable, and anxious about the risks involved. She felt that there was a much higher likelihood on this journey (than on journeys to other placements) of being hi-jacked, robbed, or traumatised in some way, and requested that her placement be changed. In exploring this, we touched on both the external risks - which are part of the 'reality' out there in the world - and of her internal experience of danger and of being a victim. Not much could be done about the physical reality of the journey since there was no other road to the placement, and even when travelling with her student partner, the journey 'felt' unsafe. I then remembered a similar setting, when I worked in Zola Clinic in SOWETO. The journey to the clinic felt unsafe: I learnt from other clinic staff, some of the tricks of driving in SOWETO (slow down so that you don't need to stop at red lights; constantly check who is behind you; don't indicate, and so on). After some months of 'safe' travelling, I became annoyed at the coercive and paralysing urban myths of the dangers of this journey - although I maintained my vigilance.

The locus of exploring the risks of travelling with the music therapy student shifted to how avoiding this situation altogether might impact her commitment to a community placement. We also explored the possibility that the journey was, not especially dangerous. The point, here, is that it was through her well-developed sense of safety that she was able to 'spot the risk' and make decisions before putting herself in risky situations. At the same time, as the director of the programme, I was faced with the possibility that 'something' might happen to any of the students on their placements, and felt burdened by the responsibilities of the training placements. I sought advice from various Heads of Department, and learned that I was not alone in my concerns. Some disciplines have withdrawn their programmes from the more risky placements, because of similar issues.

Safety, Security, Indemnity and Illusion

If we now consider our work as music therapy teachers, I suspect that most of us wonder, from time to time, how effective we are as teachers. Does the theory we teach "fit" the practice? Can we find appropriate papers "at the right time" in terms of students' shifting experiences on placements? Is our supervision "good-enough" for students to grow into their work? Can we manage to contain students' anxieties? Can we all manage the internal and external risks to do with the notion, for example, of working and supervising work with a severely ill child who might deteriorate or die any time, thanks to because of insufficient treatment or malnutrition?

Now let us re-think indemnity. In other words, what we do about protecting ourselves, as music therapists, supervisors and students, from external and internal danger, if indeed, this is a desirable avenue for any of us. Indemnity (Latin: indemnis) means to be unharmed, to be safe from danger, damage or loss. Legal indemnity suggests that we might be compensated for injury, and that we are not liable for any injury or damage that we might inflict on others. Also, having to sign a legally binding document brings the notion of harm, hazard or peril under the spotlight. Music Therapy now seems to have a sombre ring to it, bringing us rather quickly to new edges of our comfort zones. Also, thinking about danger, risk and indemnity within the context of therapy feels somewhat peculiar! Indemnity is to do with harm, and with protection, while therapy has to do with healing, safety and growth. Why, then, this concern with harm and danger?

Perhaps notions of danger, risk and indemnity are illusions, in the sense of being private and idiosyncratic. In each of the students' concerns, the dangers that they experienced had to do with the "realities" of the placements as well as linking with other experiences in their lives. If, we think of danger and safety as internal states of mind - then why indemnity forms and what's the fuss? (And is there a risk of pampering music therapy students?). Also, is there not a risk of making danger more important than safety or comfort?

Two things have helped me to make sense of danger, risk and indemnity. The first is that danger seems to emerge mainly from the insistence, by the media, that living is dangerous, life is risky. If viruses don't get you in clinical placements, then missiles, the stock market or driving will annihilate you. Even if none of these actually happen, there is the mental and emotional erosion from relentless reminders of how important danger is. It seems that we are meant to be concerned - and deeply worried - about economic trends and world safety (or is it world danger), so that many of us feel less safe, more vulnerable, for all kinds of complex reasons. Music Therapy students, in my experience, are especially vulnerable during training - which brings me to the second point.

One of our roles as teachers (as I understand this) is to take "reality" - whether real, imagined, deluded or inconsistent - as a pivot for learning; musing around any event (no matter how trite or unspectacular) in order to give it meaning, in order to "learn" from it. Also, in taking seriously and exploring a student's concern about travelling to a placement, or becoming infected by HIV/AIDS (or by her imagination), we model listening to our inner voices. However out of sync these might be with the prevailing dubious order of the world, and we model listening with imagination.

I began this paper with the HIV/AIDS pandemic in South Africa, suggesting that the risk of contamination in music therapy practice is minimal. Yet my experience of visiting people dying of AIDS in squalor and starvation resulted in a consuming re-assessment of music therapy training and practice. It was not the virus that caught me, but something else: an understanding that it is not enough to decontextualise fragility and fear and explore these as internal, private issues. Contexts speak to us, and to be indemnified against their less savoury aspects feels unsatisfactory - and rather deaf. The illusion, perhaps, is that in South Africa we can practice music therapy without being contaminated by danger, despair and fear in society. It seems to me that these need to be linked, so that we can begin to knit together professional and social responsibilities as music therapists, as music therapy teachers, and as "caretakers" of the profession. And so, in South Africa, for as long as is possible, music therapy students will continue working in community placements with people suffering from poverty and disease. And they will continue to sign indemnity forms.