Supervision Demystified IV

This is our last of four posts about clinical supervision.  Thanks for joining in the conversation so far!  If you haven’t read our previous posts on this topic, you might want to go back and catch up!  In today’s post, we’re each going to describe our respective approach in providing supervision, whether as peer or individual supervisor.

Who are you as a (peer or private) supervisor?

Jillian: To me, supervising others is like helping them finish a puzzle.  They raise their issues, and the task of the supervisor is to identify what piece(s) might be missing.  Is it knowledge?  Is it a skill?  Is it self-awareness?  Is it another view or interpretation of the patient’s experience?  Are multiple pieces missing? We may not actually hold the correct piece or pieces, or if we do, we may have only a small part of one piece.  If we have something to offer, such as some bit of knowledge, then the next task is to offer that puzzle piece in a way that will allow them to receive it, put it into place, and grow from it.  Or maybe we suspect the supervisee already has the missing piece somewhere in their puzzle box, and then our task is to do what we can to help them discover that themselves.

Noah: My supervision approach closely parallels my therapeutic approach: bear witness, structure a safe and supportive space for exploration, and promote meaning-making through exploration. One significant adjustment I’ve made to my supervision style is to expand my thinking when a supervisee identifies no pressing issues at the time we meet. I do not assume that they are being avoidant, in denial, or thinking superficially. Instead, I consider one of two possible options:

(1) Supervisees are legitimately having a week of grounded and self-aware work that requires no further processing because they have developed the skills necessary to                   manage such issues

(2) Supervisees have moved beyond the need to process day-to-day issues to address deeper clinical, philosophical, and/or theoretical concerns, questions, and ideas.

Ideally, both conditions are in place, indicating that the supervisee has reached a level of competence sufficient for diving under the surface to tackle the less explicit but no less prevalent issues that confront experienced clinicians.

Kristen: When I work with students, I see myself taking on multiple roles depending on the student’s place in their developmental trajectory. Sometimes it is necessary for me to be a mentor, role model, parental figure, or teacher. As the student moves through the developmental phases, the role of supervisor shifts to one that accompanies the clinical journey, at times being provocative and other times providing support. I ascribe to the view of one that accompanies when providing clinical supervision to professionals. My role becomes that of a listener and fellow traveler, guiding supervisees towards accessing resources within themselves.

Meghan: I try to do what has most benefited me — empower my supervisees to find the answers within themselves, and help them to find the meaning in each clinical moment. In moments where they don’t know “what to do” we talk about different possibilities, and how to choose the one that feels right in the moment. If they bring me a confusing clinical moment that they find upsetting, we work to understand the patient, the therapist, and the co-created space in between, knowing that often there is no clear delineation of these three. Supervision is an intimate clinical relationship too — and in most cases, my supervisees and I find ourselves on a journey towards their own self-discovery, even as they are helping their patients with the same thing.

Cat Hospice

“We’re running a cat hospice”

I hadn’t really connected the dots in that way until my wife said it out loud to friends. While I had been aware of it on an intellectual level, it was jarring to hear it framed in that way. Suddenly, we weren’t curing our 18-year-old feline’s failing kidneys or reversing her ailing liver functioning. Rather, we were making her comfortable, bearing witness, and waiting.

Continue reading Cat Hospice

Mothering our Patients

We are excited to share with you this guest post from Miriam Sherk, a hospice music therapist at Mercy Hospice Trinity Health Care in Ann Arbor, Michigan. Here, Miriam reflects on the parallels and intersections of motherhood and music therapy in hospice, and considers how the roles of “mother” and “music therapist” inform one another. Please feel free to any thoughts, questions, or general comments for Miriam or about the post to help further this important discussion.

I walked into Ed’s room last winter, knowing that he would not greet me with recognition. Ed had a diagnosis of vascular dementia and his cognition had been slowly declining in his recent months in hospice. His nurse had shared with me that Ed had been crying throughout the morning “for no particular reason.” As I walked towards Ed’s bed he reached out his arms towards my 8 month pregnant belly, looked up at me and spoke the word “mother.” At this moment I felt a sense of vulnerability. Something so personal and cherished to me was being brought into the therapeutic space without warning. Feeling disarmed I hesitated briefly.

Continue reading Mothering our Patients

Supervision Demystified III

This is our third of four posts this month on the topic of clinical supervision, borne of our collective enthusiasm for supervision processes and their value in each of our own journeys of clinical and professional development.  You may want to go back and read part I and part II before you continue reading below!  This week we will each talk a little bit more specifically about how and why we have found professional supervision to be an indispensable component to competent and satisfying clinical practice. Continue reading Supervision Demystified III

Supervision Demystified II

This is our second of four posts this month on the topic of clinical supervision (read Part I here).  We’ve observed that lots of music therapists aren’t familiar with supervision, what it’s for, and what it’s like to receive it. This series was thus borne of our collective enthusiasm for supervision processes and their value in each of our own journeys of clinical and professional development.

In this particular post, we want to address how supervision for a professional differs from the supervision that all music therapists are required to receive during internship.  Below you will read each of our answers to this question, which we all tried to address from dual perspectives — our personal experience as music therapists who have received supervision as both interns and professionals, and our professional experience as supervisors observing those that we have supervised. Continue reading Supervision Demystified II

Supervision Demystified I

For our last series of 2015, please join us in a conversation about supervision.  “Supervision” for professional music therapists refers to a specific process in which the music therapist pursues ongoing clinical guidance from another professional in the field (or a related field). The music therapist wanting supervision will seek out a clinician that they feel they can learn from, and pay them for regular meetings (usually 45 minutes to an hour in length, on phone/Skype or in the supervisor’s office) where the two discuss the music therapist’s cases, and sometimes other professional issues as well.  Sometimes music is used as part of this. Supervision is an opportunity to explore the dynamics of therapeutic relationship with various patients, as well as to develop greater understanding of one’s clinical identity.

Another valuable iteration of supervision is the peer supervision group, in which group members take turns sharing case material and providing feedback to each other. In private supervision, one gets the whole time to oneself to receive guidance and feedback, while in group/peer supervision, the time is shared and in addition to receiving one also reflects on others’ cases and shares impressions or suggestions.

This series of posts on supervision came about because of our collective observation that “supervision” is a foreign concept to a lot of music therapists. In my own personal experience, supervision was something that sort of appeared in my daily schedule as an intern, without any real explanation of what it was for or what I was supposed to do with it. Different schools and different internship sites seem to handle the concept of supervision differently: Some don’t mention it at all. Some consider it a time to go over practical matters, whereas others encourage deeper consideration of clinical issues. Some bill it as a part of internship only, whereas others encourage their students and interns to make supervision an ongoing aspect of their future careers.

We four are, of course, part of that last camp. We’ve all found supervision to be exceedingly helpful, and we all can hardly imagine our work without it. So we’re each going to share our thoughts on supervision this month, with another post on each of the next three Tuesdays.  Each week we will address a different question about supervision.

Introduction: What’s Your Supervision Story?

Jillian: I’m currently involved in a peer supervision group that includes music therapists working in hospice as well as other settings. As for our training and our theoretical orientations, while we are by no means clones, there are a lot of overlaps and similarities.  At times, that is a strength, and at times that may be a weakness. Regardless, the group is a professional lifeline.  We meet monthly, and have been doing so for a few years now.

I am not presently engaged in individual supervision, and I miss it.

At work, I supervise interns with whom I work individually.

Noah: I currently receive individual supervision from a music therapist in addition to peer supervision with a cadre of colleagues that, as Jill aptly described it, are a much needed lifeline. Each supervision I receive roughly once a month.

I find individual supervision to be at once one and all of the following: confounding, angering, relieving, and clarifying. Confounding because of the barriers that our explorations frequently uncover, angering because of my tussles with those barriers, relieving when those barriers are either dismantled or reconfigured into an access point, and clarifying because of the insights that emerge and evolve when granted more fluid access to my intrapersonal world. There are times when one characteristic will dominate over the others, but the most meaningful sessions are when all four balance each other out in what Joseph Zinker coined a multilarity.

A multilarity is when there are multiple outcomes, as opposed to “just” two outcomes in a polarity. As this diagram of a supervision multilarity shows, the balancing of these four experiences creates a dialectical tension. When I have been able to successfully use individual supervision to resolve this tension, it has given birth to deeper, more nuanced insights.

Peer supervision is like the good kind of high school reunion (I’m assuming they exist somewhere…) where you connect with friends that you feel like you haven’t seen for a while, and pick up where you last left off. Sometimes the explorations are as intense as in individual supervision, but what I have found to be the most invaluable aspect of peer supervision is the deeply embodied compassion and empathy for my process through work and school that I do not get anywhere else. These are truly a collection of my peers who have lived similar experiences as my own, and can extend supportive understanding through as simple a gesture as a head nod.

I currently provide individual supervision via phone and Skype to music therapists out of state. With some the focus is on clinical issues, while with others it is more focused on professional development.

Kristen: My current supervision situation could be described as “complicated”! Previously, I had participated in and greatly benefited from weekly clinical supervision from a music therapist that I highly regarded. When that relationship ended, I had a transitional period, consisting of a “grief” of sorts for a relationship that I highly valued. I felt myself wandering and trying to determine what to do next. I think it’s also important here to mention that my needs had shifted. I had taken on a management/administrative role, causing the main focus of my work to be on staff and program development and management. Currently, I receive weekly administrative supervision, monthly clinical supervision from a psychologist, and participate in a monthly creative arts therapy peer supervision group. This has been my supervision arrangement for the past year and a half. I am currently looking for a music therapist who has experience in providing supervision to supervisors and managers. Through my role as program director, I provide weekly or biweekly clinical supervision to a team of 7 creative arts therapists (music and art) and child life specialists in the workplace setting. I also provide clinical supervision to music therapy and dance therapy interns as a component of their clinical training.

Meghan: I have had a lot of different supervision situations over the years: private supervision with a senior music therapist (in my case Diane Austin); private supervision with a drama therapist in my workplace and concurrently with my boss at the time, a clinical nurse specialist; several iterations of peer supervision with other music therapists; and two iterations of peer supervision with a group of various creative arts therapists in private practice. Currently, I do peer supervision once a week with an art therapist and a peer consultation group once a month with a group of clinicians of various backgrounds who work with people with foster care histories (which is part of my private practice work). For the past three years I have also paid for weekly private supervision with a psychologist/Jungian analyst.

On the provider side, I have supervised practicum students, interns, and new professionals in on-site workplace supervision sessions for a number of years. Currently and for the last few years, I’ve provided private supervision to music therapists in my office or via phone or Skype. I’ve worked with MT’s who work in hospices, psychiatric hospitals, and private practice situations.

Thanks for reading this first post in our series.  We’re interested in your reactions as we continue on this topic!   What do you want to know more about?  What of our supervision stories surprises or intrigues you?  What would you like to share about your own supervision story?  Please share.

Sometimes, Music Therapy Isn’t Enough

What follows is an exchange that we (Noah and Kristen) had over email regarding two aspects of our work which caused us to ponder the limits of the work.

Neurological Irritability and Terminal Agitation

Kristen:

As another case presentation wraps up at our monthly palliative care committee meeting, the recurring question is raised: “What other services could this child benefit from?” We just sat through a case presentation of a 1-year-old who presented with one of the most difficult (in my opinion) symptoms to manage—neurological irritability. The question is almost rhetorical, as no one really does seem to know what else to do.

For those unfamiliar with the term, neurological irritability typically occurs in infants who are neurologically devastated and worsens over the first year. The theory is similar to neuropathy, where the nerves are firing spontaneously. This results in seemingly unending irritability which does not resolve with traditional soothing techniques, including (typically) music/music therapy. These babies have had poor brain development, and typically exhibit repetitive and unchanging crying, dysautonomia, and muscle spasms. A variety of medications are often trialed, along with positioning, vibration, music therapy, Reiki, massage, etc. You name it, we try it. But think about that—your baby cries endlessly until they fall asleep and does not respond to any of your attempts to comfort them.

Noah:

This really resonates with me, Kristen, and reminds of my work with terminal agitation. Terminal agitation emerges during imminent death, and is an intense restlessness frequently marked by virulent (sometimes violent) efforts to get out of bed, strained calls for “help”, and an inability to be soothed. While the majority of hospice patients will not experience it, for the minority that do it is a highly distressing experience for them, their loved ones, and any present healthcare professionals. So distressing is the experience that a particular focal point for me while educating new patients and their families is how to identify terminal agitation and what steps to take when it begins. We want to break the initial cycles of that agitation before it evolves into something more intense and unmanageable.

Kristen:

Interesting parallel, Noah. I had never considered the commonalities of both of these issues. The impact both have can be highly distressing to caregivers (families and staff).  Let’s consider, for a moment, the ways in which parents typically establish bonds with their children. Early on, there is a reciprocity that is established through the caregiver—care receiver dyad whereby the caregiver learns to interpret and respond to the baby’s cues, and the baby responds to those caregiving efforts to indicate that the caregiver has successfully met their needs. Thus, bonds are established and strengthened. The caregiver also becomes more secure in their abilities to care for their baby and doesn’t necessarily need the reinforcement of these positive responses every time, as they can feel confident that they will eventually figure out how to soothe their baby. What an amazing circle of communication this is! Now, let’s consider the description of the baby with neurological irritability—the baby who is either asleep or appears to be writhing in pain. Imagine the difficulty this begins to pose over time.

Noah:

Right – when this degree of distress manifests, it impacts loved ones and becomes an interpersonal issue in addition to an intrapersonal one. Nobody wishes to die experiencing so much dissonance within and around them, and no caregiver wishes to bear witness to their loved one, who has already struggled with so much, struggle even further. Compounding this caregiver stress is their bearing witness to the struggles of hospice professionals attempting to treat it. That is perhaps the most disheartening and frustrating element of terminal agitation: we experience the “what” but do not know the “why”. Kathy Murphy once wisely intoned to me that the only people who know what it’s like to die are dead, and here that barrier looms large. It’s impossible to determine what exactly causes terminal agitation given that those who have experienced it are unable to share, so we’re left with a lot of conjecture.

Biomedical explanations range the gamut, from infections, to unmanaged wounds, to a natural restlessness brought about by organs shutting down. No true point of origin is known, and accordingly pharmacological treatment largely focuses on administration of anti-anxiety and anti-psychotic psychotropics. The goal of these medical interventions is not to alleviate the agitation but to override it under a mountain of sedation. I find this is troubling as I understand terminal agitation as an existential condition far more than a physiological one.

For me, terminal agitation is an existential condition to a much larger extent than a physiological one. Terminal agitation does not discriminate, occurring for both the most anxious and the most actualized of patients. It’s point of occurrence during imminent death, that critical 24-72 hour window of time when the patient is actively transitioning into death, is key. It suggests that during this time when the patient is readying him/herself to let go of this life and move onto what comes next, their unresolved content (e.g., past traumas, fractured interpersonal patterns, etc.) rises to the surface to essentially say “Hey, what about me?” For some, the re-introduction of that content into their consciousness hits hard and furious, and at a time when their psychic resources are compromised, a primal desire to “fix” that unresolved content can take place. At such times I believe terminal agitation sets in.

What Can We Do?

Kristen:

It’s the inability for any of us to “fix” the situation and resolve the symptoms that make it so challenging.  In the facility I work for, we care for a large number of children who are minimally responsive. These children receive round-the-clock care from nurses and therapists skilled at interpreting the subtle cues they present and responding accordingly. Even a child who seems to have almost no discernable responses can experience comfort through a nurse positioning them perfectly, strengthening the feeling of success that the nurse caregiver experiences in providing care. Each time we admit a child who is experiencing neurological irritability, there seems to be a silent groan. There is a collective effort to do everything we can, get every service involved, rack our brains and spend endless amounts of time trying to soothe this baby with typically minimal results. Eventually, the baby grows a bit older and moves into a more minimally responsive, less irritable state. But for that year or so, the toll the irritability takes on the staff is palpable. The longer the baby stays, the more the phrase “oh [name] cries all the time; that’s just the way he is.” is uttered. This is the resignation to the fact that, no matter how much we tried, we just couldn’t help this baby. That is very difficult to acknowledge.

Noah:

You’re calling it for what it is, Kristen: sometimes, no matter the strengths of our craft, the skills of our practice, or the intuitiveness of music as a healing medium and experience, there’s very little we can do to impact meaningful and substantive positive change. For hospice music therapists, our charge is to help people more fully and intentionally engage with that unresolved content, to interact with it in the interest of constructing a resolution and/or closure that helps facilitate movement through this life into the next. Are we able to do that with somebody so overwhelmed with their internal experience and so out-of-reach from their surrounding environment? I can’t imagine how. Music, as a relational phenomenon, is predicated on reciprocity and shared experience, and there is little chance of those integral facets taking root here. So when I’m called out to a terminal agitation event, what tools do I have at my disposal?

Kristen:

Yet, it seems like others have that belief that relief would come from either the music, the music therapist, or both. Inevitably, someone from music therapy is called to assess the baby. Surely the baby WILL respond to music! Although I wish this were true, often there is honestly no discernable difference. However, that certainly doesn’t mean that music therapy is not necessary. I may argue that it is vital. What becomes important when music therapy is not actually helping is the perception that music therapy is helping. If you’re thinking “Emperor’s New Clothes”, you are not far off. Think about this… baby cried all the time; no one can help; helpless feelings turn to apathy/lack of bonding/diminished investment/compassion fatigue/etc. What if music therapy could break that cycle simply by altering the staff’s perception of the baby’s experience? Could that impact compassion fatigue? Could that promote bonding? Possibly.

No matter how many times I work in this environment, I continue to find it exhausting. The baby’s crying cycles so I cycle with them in the music. My voice rises and falls and, although I am almost certain that this would have happened in spite of me, the baby eventually falls asleep. The nurses respond so positively. They seem relieved, perhaps even comforted themselves. I also watched a nurse linger in the door with a slight smile as I was singing with the baby. I realize that I am speaking about a half hour compared to an entire day. However, the positive feedback from the nurses continue with each session. They even call to request sessions at times, possibly when they themselves required that musical reprieve.

Noah:

And the question that arises for me while reading this, Kristen, is what if music therapy is unable to break that cycle? Such an unfair expectation impacts all parties: the clinician (who feels shamed for being unable to help in the way advertised), the caregiver (who feels disgruntled and disappointed that their loved one remains in an uncomfortable state), and, most importantly, the patient (who remains in a distressed state). This is where commonly held assumptions about what music should do and our continued difficulties communicating what music therapy can do are in conflict and creates discord. There are two issues here:

(1) The lack of distinction between music, which is a medium, and music therapy, which is a practice. Given our (generally) poor articulation of music therapy as a practice in end-of-life care,  non-music therapists’ poor understanding of this distinction makes sense. And in lieu of that understanding, it’s easy to see how non-music therapists could equate the medium (music) with the practice (music therapy) that employs the medium. When “medium” and “practice” are enmeshed in this way,  any assumptions an individual carries with him/her regarding what music should do is projected onto music therapy should do.

(2) Our poor understanding of what music therapy can do with patients experiencing terminal agitation. What’s our role, and what’s the role of the music? What symptoms do we focus on and how? Who do we focus on – the patient or the caregiver(s) – and how do we balance that focus? What theoretical precepts do we draw upon to inform this work? This is a phenomenon we haven’t explored yet, and it leaves us fumbling to conceptualize the clinical process as much as it leaves us questioning what best practices are.

My own practice with the terminally agitated tends to be vocally-centered with supplemental multisensorial interventions. Most sessions, this means I hold a patient’s hand or rub his/her shoulder in rhythm with carefully selected songs sung using varying voice qualities. Song selection involves sequencing into a song cycle centered around musical and lyrical themes. One cycle that I frequently draw upon is:

  • Amazing Grace (Traditional)
  • Let It Be (The Beatles)
  • The River (Garth Brooks)
  • Bridge Over Troubled Water (Simon & Garfunkel)
  • Come Thou Found (Traditional)

This cycle employs water imagery and themes of passage that assists patients and caregivers to jointly move through this period of imminent death. The voice qualities that I strive for are prayerful (intimate, nurturing, holding) and ministerial (guiding, facilitating). The intensity, timbre, and inflections of each of these qualities are adjusted to attune with the presenting emotional, spiritual, and physical needs in the room at the time.

Kristen:

Likewise, I find myself drawn towards using my voice almost exclusively combined with loving presence and touch. I often use the pediatric massage technique of “resting hands” over or on the baby while improvising or singing precomposed lullabies. Themes I look for are safety, holding, caregiving, love and nurturing. The transition here would be sleep, or hopefully, a quiet alert state.

Where Do We Go From Here?

As noted above, this conversation emerged from an off-the-record discussion between about the limits we have recognized in our practices and how we negotiate those limits in the pursuit of best practices with our patients. Looking back on how this conversation evolved, we recognize that follow-up discussion could focus on either (1) the boundaries of music therapy practice in end-of-life care or (2) work with patients experiencing neurological irritability or terminal agitation.

With that in mind, we invite you to share your thoughts, ideas, and experiences regarding either or both of those topics.  In what ways have you questioned the extent to which music therapy can help? Where do you think the constraints of our work are at the end of life or in the spectrum of palliative care? Have you had a time where you wondered if you were really effecting change? When working with neurological irritability or terminal agitation, what approaches have you used? What theoretical constructs have been helpful for you? Please leave a comment and keep the dialogue going!

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