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Music therapy, online issues, ethics over commercialism

Well, I do risk my professional life here to some extent.   Something is troubling me a lot – and increasingly so as Covid continues to exercise its control over our lives and work.

Online music therapy.   As the country went into the first lockdown in March, we all had to think about whether our own caseloads and work environments carried within them the possibility for continuation over a period in which many of us faced fully closed schools, music centres and therapy rooms.   Of course, there were, and continue to be, services where music therapists continued to work “as normal”, often with a requirement for regular Covid tests.   My own caseload at the time spanned residential care homes in adult learning disability, individually referred children in music centres and work in a mainstream primary school – all set within a county music service.  The first was in complete lockdown with no visitors (social or professional) allowed; the music centres which mostly had admin staff only at times I worked, were fully closed and none of the families of the children I worked with sent them to school, even though some did have entitlement to attend.   

Music therapists can adopt many different ways of working, theoretical principles and different models for delivery of a service.  We play a wide range of instruments and come to music therapy from different backgrounds, since UK music therapy is a postgraduate profession.   One may primarily be a singer-songwriter, using a guitar as harmony instrument; another may be a classical pianist, cellist or violinist, yet another a jazz saxophonist.  

A therapist in dementia care, for example, may base their work around alleviating social isolation, accessing long term memory and enhancing quality of life.  They may choose to do this with songs, a guitar and participation through using songs as a prompt to memory and enjoyment.   This can, perhaps, be done through an online platform quite successfully and a return to live work achieved smoothly without major effects on the therapeutic relationship. 

However, a therapist working with challenging behaviour, non-verbal clients, serious mental illness or young people at risk of abuse in their home situation is more likely to work with a range of instruments, to need to observe facial expression and non-verbal cues and to be alert to transference and counter-transference in their work.   For any of these, a screen could become a source of distress, incomprehension or paranoia. 

This does bring me to a big question, and a concern that “online music therapy” is taking on a discrete identity of its own.  And from that, a worry grows that the door is open to create a fully online practice as a means of job creation, working with clients from disparate geographical areas without knowledge of local services, support systems, multi-disciplinary teams.   We do not exist in a vacuum, and music therapy is not a panacea, but it can significantly enhance life and bring about positive change when used in partnership with other interventions in education and healthcare settings.  So, for me, there are some baseline questions that need to be asked before a shift to online, or a referral taken for online sessions:

What is the bottom line for effective music therapy in terms of environment, equipment and privacy for both therapist and client?

Where is the line drawn between both parties compromising future therapy by virtually entering each other’s homes?   And is this clinically the best decision to make at the time?   For example, a client who is close to finishing therapy would benefit from having closing sessions online and the compromise is not highly significant, whereas a client whose therapy is at an earlier stage or much more long term may be destabilised by having been “invited” into the therapist’s home life and later needing to move back to the neutral ground of an institution. 

A priority here would be to consider the best clinical decision for each client, with the therapist’s own home situation also taken into account. 

Is the therapist able to give their undivided attention to the client/s?

From where I sit writing this, I can see two guitars, a piano, a cello, a small djembe, and a small basket of percussion bits and pieces.   So yes, there are instruments here with me at home.   But at the same time there are two university students needing Wifi and quiet for much of the day and a husband in virtual meetings in another room, often for long full days.   So while I, for one, had enough instruments, I could not deliver the full attention and reliability needed as a basic tenet of a psychotherapeutic relationship.   Working at home is surely one of the better things to come out of Covid for some, but given that we work with many who have experienced little reliability and attention in their lives, is it, empathically, the right approach?

Is the technology really up to it?

Like many others, I have taught my private pupils online with some success over the last few months – returning to safe live teaching when restrictions were lifted.  Of course, we’re back to online now.  There are some very key differences between teaching and therapy.  If the connection is bad for either party, we can stop and reschedule – no problem.   We can give one week a miss – in one case a laptop was being shared between several members of the family and wasn’t always available.  I knew all the pupils well – their technical weaknesses, the pianos they own and their family situations.   If I didn’t hear or see something well, my knowledge of them enabled me to hazard a reliable analysis of which technical quirk was letting them down!  But I will not take on new pupils online – a relationship needs to be built and I need to understand more about their technique in order to do this.  I charge a lesson rate – and my part of the contract is to deliver high quality piano teaching.   If I cannot do this, my professional integrity is compromised.  Not just right now, but for the foreseeable future.

Unless a therapist has a very high level of technological expertise and a room set up that can work, and the client has equally reliable technology, some of the primary tenets of therapy, such as reliability, full and undivided attention and close listening and observation, struggle to be met.   

So here’s the crunch – the bit that needs to spoken about openly.  

Would it be possible to undertake face-to-face work with this client at a suitable venue when restrictions are lifted? 

Does the therapist have time for this and can they manage the logistics?  If the answer is an honest no, is offering online music therapy a commercial opportunity rather than best, or even adequate, clinical practice?  Temporary and necessary should be the guiding factors in assessing viability of online work. 

If the ending of therapy at a clinically appropriate time creates a drop in a therapist’s income due to zero hours contracts there is inevitably a flip side.   Extending or setting up sessions without local professional liaison, supervision and a venue local to the client is commercially possible – but is it ethical?   The question is not can we do it, but should we do it?

January 2021

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