General

On Boundaries

Boundaries can be difficult in any therapeutic context – some would argue they are troublesome in any context period – but there is a particular quality to boundaries in this work.  Where do the boundaries fall in music therapy end-of-life care, and what does it mean when we cross them?  I think of two main places where they feel tricky to me in end-of-life work.  One is in answering questions regarding my personal biographical information, and the other is in the context of stepping outside my “role” as the person who talks about feelings and plays music for and with patients.

When I first began to work in home hospice, I was startled by the ways that I was forced to confront my own feelings about boundaries, and the decisions that I was pushed to make about how to draw them.  Something is different when you are visiting people in their homes.  Some of this might be the culture of the hospice team – people would sometimes be confused about why the nurse, aide, and pastoral counselor might be willing to tell them about where their kids go to school and how long they’ve been married, but I would not.  Social convention is also part of this, as we are all taught that we must be polite when we have guests to our home, and thinking of hospice workers as “guests” rather than “people who are coming to help me die” is a sort of unconscious emotional choice that lots of patients and family members make.  That’s why I would find myself sometimes arriving to homes where a spread of cookies were laid out on the coffee table just for me, or how I would end up with offers from patients to set me up with their son or nephew.  These are efforts to avoid the reality of the situation (that I am paid to be here, that I’m a therapist who is part of the team that comes to help people die), and tries to reframe the whole interaction as social and pleasant, rather than clinical and potentially difficult.

That said, I don’t believe that it’s always necessarily the right choice to disabuse patients and family members of this perspective.  I think many music therapists who work in home hospice would agree with me.  Sometimes it is the right thing to eat a cookie or accept some tea.  Sometimes it’s okay to choose to truthfully answer questions about my biographical details.  The nuances of when this is a good idea and when it’s not are really a topic for supervision rather than a blog entry.  The only generalization that I can think of about this is that we must always be conscious and curious about why everyone is making the choices they make in the moment.  Why do we accept a cookie from one patient’s family member and not another?  Why do we tell one patient our marital status and not another?  These are serious questions that help to keep our practice ethical and also help us to work on understanding ourselves, our countertransference, and our clinical identity more deeply.

We can also understand our patients more deeply by tuning in to what might be behind their questions.  Are they struggling to relate to us in the absence of evidence that we have something in common?  Are they avoiding talking about themselves?  Do they feel mistrustful and are they thus scraping for something that will make them feel more comfortable?  Once we start asking ourselves these questions, of course, we can make the choice to respond to the underlying purpose of the question rather than just answering the question outright.  I would say that this is probably the best default position.  But again, there are nuances in individual cases, and these are best discussed in supervision, where colleagues or mentors can help us to see the places where we might have blind spots.

Working in more acute care, as I do now in the medical hospital, I find that boundaries take on a completely different shade of gray.  My supervisor in my first hospital job, a highly intuitive Clinical Nurse Specialist, told me when I asked her a question about boundaries, “This is very personal work.  Sometimes there are moments where we need to let it be personal.”  I think our work, as music therapists, is perhaps even more personal because when we are playing music with our patients we are already sharing so much of ourselves.  We are putting our souls right there on the table between us sometimes.  Paradoxically, this reality implies an argument for more stringent boundaries and, occasionally, for more diffuse boundaries as well.  Again, supervision.

In my own experience, I have learned that I can make the choice to relax my boundaries with patients, but there will be consequences.  Sometimes the consequences impact the therapeutic relationship, and sometimes they most notably impact ME.  Years ago in the hospital, I worked with a woman in her 30’s who was newly diagnosed as HIV positive.  She had immigrated to New York from Eastern Europe, alone, and had then had a one night stand that led to her contracting the virus.  Her disease was significantly progressed – she was looking at nearing the end of her life already – and she was completely alone because her family abroad could not afford to visit.  She and I did some significant work in the music, mostly singing Fleetwood Mac songs together as a path for externalizing and working with her anxiety, but I crossed the boundary one day when I chose to put down my guitar and help this woman brush her own hair.  Her hair was about as knotted up as you could imagine, the kind of knots that you need spray-on conditioner and a significant time investment to sort out on your own, and she was distraught by her seeming inability to care for herself.  I felt overwhelmed by my feelings of compassion and I spent the remainder of the session perched behind her on the bed, gently working the brush through the tangles. This was a boundary violation, of course — a true step outside of my role — and I could have left this job for the nurse’s aide, but I didn’t. She cried a little bit as I worked, and I felt a tremendous emotional connection to her as I touched her.  And I think she was grateful — but I’m telling this story because violating that boundary opened up a piece of me that I wasn’t anticipating. I was physically trembling when I left her room, and barely made it to my office before I began to weep. I felt so sad for her that I couldn’t see any more patients that day, and I struggled to go back and see her again. I was reminded that the boundary isn’t there for no reason; one of the reasons it’s there is to protect me, to make it possible for me to do my work by creating optimal conditions in which the work can happen.

Have I chosen to violate those kinds of boundaries again? Yes. Not for years later, though. And when I did it (choosing to spend several hours feeding and attending to various non-music therapy-related needs of an oncology patient in extreme distress), I had a similar experience of emotional flooding. I remembered why I don’t usually do this sort of thing. My job has boundaries like everyone else’s in the hospital. Perhaps if you were in this situation, the impact on you would have been different — but that is part of the point. We all need to be aware of what boundary violations could mean to us, as well as what they might mean to the patient, so that we can treat our choices about boundaries as distinctly clinical.

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6 thoughts on “On Boundaries”

  1. Meghan, you’re right – so often we think of boundaries as being merely confining, but they’re protective as well. I often forget that boundaries protect myself, and not just the patient. Of course, like you pointed out, by protecting ourselves we protect other patients by maintaining our ability to be present with them, too.

    I don’t think we can talk about this topic enough. Boundaries are a day-by-day, session-by-session, moment-by-moment necessity. And they’re so, so gray in EOL care.

    – Jillian

  2. Fabulous blog, very sensitively written, with the “real-ness” of the work openly presented – thanks for writing this.

  3. Jillian, thanks for commenting. I’d love to read about your own experiences with boundaries, because I completely agree that it’s a topic we need to address more! Next post, perhaps?

    Grace, thank you so much for reading and letting me know how you feel about the piece. I’m so glad that it felt relevant for you and I appreciate your praise!

  4. Meghan – You do “reflective practice” so well. It’s a skill, along with self-care, that I find so crucial to our success as therapists. I feel that boundaries fall right into the intersection of these two issues.
    As a first year intern at a women’s safe house, I put in too many hours, bought supplies with my own money, and spent a lot of time thinking about how to make these women’s lives better. As you might imagine, in short order I experienced an episode of vicarious traumatization. Violating these boundaries was a blessing in disguise, because it taught me a hard and fast lesson about how to care for myself in this field. It’s a lesson about boundaries that protects me everyday.
    Later when I worked in home based with Latinos, and when I worked in residential with traumatized adolescents, the boundaries shifted again, and again.
    Your reflections about the mindfulness in boundary setting reminds me that while some boundaries should never change or move, there are large categories of boundaries that change depending on the context, client, or culture. I am a huge advocate of strong, thoughtful boundaries, but I also think that being too black and white means potentially missing some important therapeutic opportunities.
    Thank you for illustrating this point with so much care. The image of you detangling your client’s hair, and the grief that followed, will stay with me, as will your future successes.
    Cheers,
    Amy

  5. Thank you, Maya and Amy. I’m so glad you’re reading. Amy, I think boundaries start to really mean something important when we have situations like the ones that you’ve described and we have the self-awareness to really take note and reflect on them. Those memories of being overtaken can be so powerful when we make ourselves available to feel the brunt of them, wonder why, and move forward more mindfully.

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