[Position Paper]

Considerations for Therapeutic Boundaries When Using the Intimate Medium of Music

By Laura Medcalf

Abstract

Conventional understanding of therapeutic boundaries is a common concept present across a range of health care practices. Many therapists in music and health care work adopt these ideals to govern their ethical behaviour in practice. For some therapists, these practices may still be extremely appropriate. However, music practitioners working in newer therapeutic models or more contemporary contexts, such as community music therapy, may value a much more intuitive and reflexive approach to boundaries. In addition, the influence of culture and context are also important, as well as the impact of music. Music practitioners experience powerful moments of connection through music making with people. Music is a medium that invites intimate and personal interactions, and should also be considered in the context of therapeutic boundaries. The new term musical intimacy may help therapists to be aware of the intimate nature of making music with people and the potential vulnerabilities that it can reveal. In addition, this may encourage therapists to explore and reflect upon the boundary complexities that can be present when using music in health and well-being work.

Keywords: therapeutic boundaries, musical intimacy, music therapy

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Editorial note: In 2016, Voices hosted a special edition to accompany the launch of a Massive Open Online Course (MOOC) on the topic of "How Music Can Change Your Life". Thirteen authors agreed to develop position papers for the MOOC, with two articles being developed to accompany each of the six topics within it. Each author has highlighted the theorists and researchers who have influenced their thinking, and included references to their own research or music practices where appropriate. These papers have been written with a particular audience in mind—that is, the learners who participate in the MOOC, who may not have had previous readings in any of the fields being canvassed. We hope that you find these articles interesting, whether reading as a MOOC learner, a regular VOICES reader, or someone who is discovering VOICES for the first time.

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Introduction

Using music with people can be intimate, personal, and revealing. In the practice of music therapy we experience profound moments of connection through our musical interactions, which can be powerful and challenging for both the therapist and person they are working with. In these moments, there is a vulnerability that is revealed. As a result, it is important to consider how these powerful moments can impact the therapeutic process, and to reflect on how we can keep these moments safe for the people we work with. The concept of therapeutic boundaries is often used as a framework within many forms of psychotherapy, particularly by therapists who draw upon psychodynamic methods. Interestingly, the particular influence of music on boundaries has not been explored in any great depth. For music therapists, it is imperative to examine the influence of music, given it is a medium that is personal, cultural, spiritual, social, and is influenced by each individual context that it is used in. The term musical intimacy is proposed as a useful concept to shape this reflection, and captures the intimate and personal nature of music making, while also highlighting the vulnerable and potentially challenging nature of the musical experience.

Common Understandings of Therapeutic Boundaries

The notion of therapeutic boundaries has its roots in psychodynamic theories, with much of the early development and research conducted in psychotherapy (Gutheil & Gabbard, 1993; 1998). Boundaries are defined as the parameters of practice between the health professional and their clients (Fronek, et al. 2009), and relate to every aspect of practice, such as the time, place or setting for therapy, how much the therapist discloses about themselves (often described as self-disclosure), ideas on the exchange of gifts, and ideas about the therapeutic relationship itself. Essentially, boundaries provide a way of thinking intended to protect the client and the therapist from harm by establishing ground rules that govern ethical and safe practice.

Langs (1979;1978) described how boundaries are constructed within a therapeutic frame that “provides safety, care and holding for clients in psychotherapy work” (p. 8). He also outlined particular ground rules for boundaries in psychotherapy, which included description of the ideal office environment, specifics about the session, the time, fees, privacy, and confidentiality. He provided a perspective that may be useful, however these ideas may also lead to a narrow view of what is appropriate, making the therapist feel that they must follow this particular set of guidelines. In fact, this particular way of interacting with their clients could also limit the interpersonal connections in practice, potentially leaving therapy feeling distant or clinical. Indeed, they reflect a particular approach that is contextually situated – influenced by issues related to the culture, the gender, and the training of Langs himself.

However, many others described similar perspectives, and refer to issues such as boundary crossings and boundary violations (Gutheil & Gabbard, 1998). In fact, there is little literature about therapeutic boundaries that does not reference these ideas in some way. Boundary crossings have been defined as minor deviations from conventional processes in therapy that do not harm the client or therapy process, and may even be beneficial (Gutheil, 2008). Similarly, Wheeler (2014) described boundary crossings as “behaviours, practices or decisions that are clearly different from usual therapeutic practice” (p. 70). However, behaviours described as boundary crossings can sometimes lead down the “slippery slope to boundary violations” (Coe, 2008), since they establish conditions where boundaries are not being managed according to the widely accepted standards. However, authors such as Lazarus (2013) suggested that boundary crossings can be valuable in building the therapeutic relationship and may even help the therapeutic process. Clearly, opinions vary on this topic.

Dual Relationships

One type of behaviour that is commonly considered to be a significant boundary crossing is dual relationships. A dual-relationship is when the therapist has other connections with their client outside of the client-therapist relationship (Moleski & Kiselica, 2005). Reamer (2013) described a dual relationship as something to be avoided for social workers, since creating other relationships can diminish the therapy process and potentially lead to boundary violations. Dileo (2000) similarly described the complexities with dual relationships, stating:

The problem of dual relationships is complex and there are often no simple solutions obtainable from the codes of ethics. The therapist’s level of self-awareness may be the most significant factor in finding the appropriate solution to these problems. (p. 128)

In some approaches to practice, there is strong advocacy for avoiding dual relationships, and this is the prevalent stance within psychodynamic frameworks. However, in more contemporary approaches to music therapy, such as community music therapy (CoMT), multiple roles and relationships are often described as essential to the therapeutic work. Inherent to the principles of community music therapy is a commitment to collaborative relationships, which stands in contrast to the expert-client dichotomy that is established by a psychodynamic approach (Ansdell, 2002; Stige, 2001). This is particularly conspicuous when performance is integrated into the therapeutic process, since the therapy then moves beyond the seemingly safe bounds of the therapy room and in to the public domain. The therapist is then required to not only respond to the private and individual needs of the client, but to also manage the performance, and to consider the needs of the audience and other stakeholders (O’Grady & McFerran, 2012).

Bolger (2012) provided one example from CoMT practice that illustrated how the Western concept of boundaries is not always suitable. She described a music therapy project she co-constructed with participants in Bangladesh. This project was located in a refuge for women and children, where Bolger lived and worked for one year and where self-disclosure and dual relationships were essential for the work to be authentic. Although trained to establish traditional boundaries in therapy practice, Bolger described how she instead developed a flexible and intuitive approach in order to respond to the contextual conditions. Of particular interest, was how she described sharing musical experiences, which expressed “Bangladesh’s rich musical culture” (Bolger, 2012, p. 28). Bolger described one such experience, which occurred after the death of one of the women in the village.

One of the older women in the group started to sing a slow, drone-like song, a Muslim song of mourning. The women covered their heads with their saris… and listened. Some women rocked gently, others joined in the song. This song lead into an hour of almost continuous singing by different members of the group, and the feeling created in the room was one of calm and sharing, the women coming together in their traditional music to express their loss. (p. 28)

In this example a profound sense of intimacy emanates through Bolger’s descriptions. This level of intimacy, experienced between the group members and Bolger, reflects a relationship that contrasts to the traditional dichotomy of the therapist-client dyad. This collaborative relationship reflects CoMT principles, where the conventional concept of a dual relationship may not be so relevant. Experiences like this create deeper connections between therapist and client, which are particularly emphasized through the use of music. This example demonstrated how the concept of therapeutic boundaries in this context, appear rigid or clinical. In practice, moments like these are common and demonstrate the uniqueness of music making, to create powerful moments of connection through personal music making. In addition, these moments challenge traditional notions of therapeutic boundaries through their naturally connecting nature.

Foster (2007) explored the complexities of friendship within the therapeutic relationship. One main theme that emerged from his interviews with three music therapists was about ‘boundaries, ethics and therapist fears’ (p. 17). The participants described the need to be flexible and adaptable with their boundaries. One participant commented, “I’m quite elastic round the edges… what therapy is about is an encounter between two human beings” (p. 17). Within the boundary theme the three participants also stressed the importance of flexibility in response to each unique context, rather than adhering to a strict set of rules. Another main theme to emerge was ‘balancing the personal and professional’ (p. 18), where overlaps between professional relationships and friendships were quite common. They described how music “brings a unique dimension to relationship, helping to forge strong connections between people” (p. 19). The intricacies of a therapeutic relationship can be expanded by the inclusion of music, as it adds other layers to the relationship and can act as a vessel for unique emotional, social, cultural, and personal experiences.

Self-disclosure

Self-disclosure is another concept that is described in conventional literature about therapeutic boundaries. The term self-disclosure refers to instances when the therapist reveals personal information about themselves to their clients (Constantine & Kwan, 2003). Hill and Knox (2001) explored the notion of self-disclosure in psychotherapy by conducting a literature review of 18 studies. In these studies, they found 14 examples of positive perceptions of therapist self-disclosure. As a result, they suggested that self-disclosure might be useful in building the therapeutic relationship, helping the therapist to appear more human. There is considerable debate about whether self-disclosure is helpful or harmful to the process of therapy, however, Audet (2011) explained the complexities of self-disclosure succinctly, stating:

On the one hand, therapist disclosure is viewed as a boundary violation that deviates from the ‘normal’ therapeutic stance. On the other hand, it is accepted as a viable therapeutic technique that loosens client–therapist boundaries and significantly humanizes the therapist to the client’s level. (p. 88)

Audet’s (2011) research examined self-disclosure from the client’s perspective. She interviewed nine clients about experiences where their therapist shared personal information. Before knowing personal information about their therapist, five of the participants described them as rigid, clinical, impersonal, and authoritative. After personal information had been shared, all of the participants described the therapist’s self-disclosure as adding a human dimension to the therapy. However, two of the participants described experiences where the self-disclosure from their therapist seemed to compromise the therapeutic process. One participant reflected on how they did not agree with what their therapist had shared with them. This diminished the clients’ view of their therapist and left them questioning the entire process, which supports the traditional notion of disclosure as harmful to the therapeutic process. Once again, the therapeutic relationship is a complex domain and perhaps a more reflexive stance that takes into account the individual’s context, culture, views, and values should always considered, although the possibility of over-sharing should be carefully monitored.

Evolving Discussions in Therapeutic Boundaries

A number of experts have begun to question the rigidity of therapeutic boundaries, in particular the idea of boundary crossings and violations. (Coe, 2008; Kroll, 2001; Lazarus, 2013; Martinez, 2000; Pope & Keith-Spiegel, 2008). Not only are new scholars and approaches demanding reconsideration, but some authors who have previously held firm views have also softened. For example, Gutheil (2008), who originally presented ideas about boundary crossing and violations, has more recently suggested that, "a therapist who is too fixated on boundary violations may be risking liability for other forms of substandard or unethical practice" (p. 7-8). He then described the previous stance as an obsessive preoccupation that reflected the politics of his country in the 1990s.

The difficulty with conventional boundary notions is that they rely on understandings of “usual therapeutic practice” (Wheeler, 2014, p. 70), which may not reflect contemporary approaches. When these concepts first emerged around 30 years ago, therapy was often confined to the therapy room behind closed doors, with existing ideas about how therapy should be conducted. With the constant questioning and evolution of practice, therapy is moving out of the therapy room into new contexts, such as the community. As such, it is timely to question therapeutic boundaries and explore how relevant they are to contemporary approaches to practice.

Although the presence of conventional therapeutic boundaries is strong, there has been some development in contemporary frameworks for boundary management. One notable addition is from feminist therapy (Brown, 1994; Root & Brown, 2014; Shonfeld-Ringel, 2001). Brown (1994) noted:

Appropriate boundaries in therapy are a reflection of race, class, culture, setting, and most importantly the specific and unique relational matrix among and between the human beings in the therapy room. (p. 31)

She further stated:

A way to reduce the risks for boundary violations does not lie in the identification of concrete rules regarding boundaries. Rather is rests in our ability to understand the characteristics of boundary violation and then to learn to ask if those characteristics are, or are highly likely to be present in a particular instance. (p. 5)

This responsive and flexible approach to boundaries provides a perspective that is useful for contemporary methods in therapy.

Within music studies, the development of CoMT has demanded a critique of therapeutic boundaries and a questioning of their relevance to contemporary music therapy work. O’Grady and McFerran (2007) explored the interface between music therapists and community musicians, and were one of the first to consider how the two disciplines might approach boundaries differently. These authors recommended that music therapists might learn from the approach of the community musicians interviewed in their study. These Australian musicians described adopting reflexive, context-specific approaches to therapeutic boundaries. The authors were led to suggest that “music therapists working in community contexts may have to negotiate appropriate boundaries with their participants rather than work from a pre-defined set of rules” (p. 23).

New Considerations For Therapists In Relation To Boundaries

There are some aspects of therapeutic practice that, in particular, reflect the more modern considerations that need to be taken into account when developing a contemporary holistic understanding of therapeutic boundaries. These include the impact of the individual’s context and culture, and specific to music and health work, the need to understand the multilayered experience of music and its influence on relationships and boundaries.

Context

Contextual influences on therapeutic boundaries should always be considered, since each individual process has unique elements that influence what kinds of boundaries need to be maintained, when, and how. In addition, there is not a single context in which therapists work, but rather interacting contexts, all of which include subtle and elusive boundaries embedded within them. Rolsvjord and Stige (2013) proposed that the use of the word context in music therapy approaches should include: 1) music therapy in context, 2) music therapy as context, and 3) music therapy as interacting contexts.

Our awareness of context is crucial to the stories we tell about therapy; how we perceive the people we work with, how we understand health and illness, how we conceptualise therapy and change, and how we design research. (p. 59)

Considering the contextual influences on therapeutic boundaries demands a reflexive approach that considers the unique combination of factors for each individual and requires the therapist and client to respond accordingly.

Culture

Culture has been explored extensively by some scholars in the music therapy literature, particularly through the notable writings on culture-centred practice by Stige (2002). Stige noted:

Music therapy grows out of and interacts with culture. Music therapy is different in different places and at different times, not just because science moves forward, but because therapy is embedded in culture. (p. 121)

Since therapy is rooted in culture, our interactions and the boundaries that surround it, are influenced by the cultural context in which they take place. Papadopoulou (2010) explored cultural influences on therapeutic boundaries by interviewing three music therapists from Greece (two were trained in the United Kingdom). The main themes that emerged included: 1) boundary issues, including protection, responsibility, physical and internal boundaries, 2) cultural influences, 3) training influences, 4) flexibility in relationship, and 5) difficulties in relation to boundaries. One participant described the importance of acknowledging boundaries that were relevant to the client’s culture.

I believe the way we learn about personal and physical boundaries in the course is based on the British culture. Then we have to change all this to the Greek version. (p. 28)

All of the participants believed that their culture and their client’s culture influenced how they approached and managed boundaries in their work. One participant described the process of adjusting to a new culture:

… the patient comes in, walks straight to the piano, sits very close to me, claps my back and says what are we going to sing today? I nearly fainted. Working in the UK I found myself totally unready to face this when it happened… it took me some time to get back to Greece – not physically – but culturally. (p. 30)

The influence of culture on therapeutic boundaries is complex, and requires on-going reflection. In addition, as music and culture are so inextricably linked, the use of boundaries in music and health work particularly need to be considered within their cultural context.

Musical Intimacy

Musical intimacy is a new concept introduced through my doctoral investigation of the ways that music therapist negotiate therapeutic boundaries in practice (Medcalf & McFerran, 2016; Medcalf, 2016). I interviewed music therapists from the USA, Europe, and Australia, about their perceptions, experiences and understandings of musical intimacy. Surrounding this, I inquired about their approach to boundaries, particularly around their use of music. Through this exploration, a multilayered description of the experience of musical intimacy emerged. The essential features captured moments when the therapists experienced powerful moments of connection in and around the music, which triggered an acute sense of vulnerability and revealed the need for boundaries.

The participants in this study described both challenging experiences and powerful moments of connection through their descriptions of musical intimacy. The challenging experiences included intense emotion, vulnerability, and even loving feelings. These moments were often confronting for the therapists and their responses revealed varying responses to these situations. Despite this diversity, the powerful moments of connection were described by all 20 participants and included moving descriptions of magic moments, deeper connections, and moments where time stood still. These moments were sometimes experienced as challenging, however they encouraged deeper connections for the therapists and the people they worked with.

The notion of musical intimacy illuminates some of the personal and intricate ways that we connect with people when we share musical experiences. In addition, it alerts music and health practitioners to be aware of the vulnerability that can emerge through shared music making. The therapists in my study described carefully and consciously negotiating boundaries in ways that were reflexive, flexible and adaptive to the multiple layers of experiences in and around music. Conventional perspectives on boundaries were often not considered relevant, and many of the therapists relied on their intuition and past experiences to guide their decision making about boundary issues.

Conclusion

The very nature of musical interactions is social, cultural, personal, and intimate. As a result, conventional perspectives about therapeutic boundaries may be difficult to adhere to in some forms of music and health work. For therapists working in psychodynamic contexts, guidelines about boundaries that relate to therapy that occur in private spaces and addresses unconscious material may still be extremely relevant. However, music practitioners working in more contemporary contexts in community, or in newer therapeutic models, may benefit from much more nuanced and reflexive approaches to boundaries. Notions of context and culture have been highlighted in this article as particularly relevant. Finally, the particular challenges to traditional notions of boundaries that occur because of the intimate nature of making music with other people may provide a unique challenge to these concepts from psychotherapy that are based on verbal encounters. My thesis explored this particular phenomenon by exploring and articulating the concept of musical intimacy. This phrase points to multilayered experiences in music, in particular, the powerful moments of connection and the challenging experiences. Naming the idea of musical intimacy may help therapists be aware of these vulnerabilities in shared music making and highlight the need to negotiate and adapt boundaries within this space. These findings may be helpful to other practitioners using music for health and wellbeing in ways that incorporate reflections of the psyche.

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