“Oh no! It’s the Therapist.” Managing institutional dynamics as a contractor

Hearing sounds from within, I knocked politely on the door of my session room; an unused classroom. A brief moment of waiting before the door opens and a child peers out of me. Turning to the class teacher, he shouts “Oh no! It’s the Therapist” in an exasperated tone. He shuts the door in my face. I hear the sound of clattering and chairs scraping from behind the door and shouts from the teacher for the children to get their coats. These noises form the soundtrack to my thoughts of what to do or say in this situation: ‘this room is booked for me…’ ‘I use it every week…’ ‘we give additional notice that I’m coming…’ ‘why do I feel so humiliated?’ The thoughtfulness turns to frustration: ‘I have a session in 15 minutes…’ ‘I have so many bags to load in and set up the room….’ ‘why am I known as the Therapist as eyes are being rolled and voices become tense?’ As the children file past me and the teachers avoid eye contact, I feel a sense of helplessness: I feel like I have no voice here, and that my role is misunderstood.

In the months since this incident, I have thought a lot about the theme of the Music Therapist – or any health professional or contractor for that matter – being an outsider in a large institution if they only visit a few hours a week. I would like to ask other Music Therapists and other health, care and education professionals the question: how do we manage dynamics like these when we might only be in that one place for a few hours a week?

We all work differently, and every setting has a different working culture, attitudes and personalities. The following thoughts and suggestions are how I am thinking about my past and present work settings, and I would welcome your thoughts, feedback and experiences.

 

What might the dynamics be within staffing groups and institutions?

I don’t want to dwell too much on the theoretical underpinning of what happens psychodynamically within group of people, but it is important to acknowledge some of the theories that can help us think about what might happen when a sole-worker, an individual contractor, enters an already established staffing team. Yalom established 11 therapeutic factors that happen in groups and one of which is particularly relevant and transferrable to any group of individuals, including working teams, is his theory of imitative behaviour: individuals may be influenced by patterns of behaviour that others in their group are modelling, and may model themselves on others within the group (Yalom: 2005, p17-18). Therefore, for the independent Therapist or professional coming into that group may feel very separate, and therefore be treated as an outsider if they do not fit in with the behaviours the existing group exhibit. This also reminds me of something I wrote about briefly in one of my MA Music Therapy assignments when describing group processes; individuals within the group lose their ‘individual distinctiveness’ (Freud, 1921, p9) in order for the group to function. An individual contractor or professional entering this group will exist very much as a separate individual and therefore stand out from the rest of the group, again separating them. It is no wonder it’s so easy to feel completely separate from a staffing team if you enter for a small number of hours a week, with limited opportunities to form relationships. Being separate, or an ‘outsider’, also makes it likely for the contractor to become a target for any negativity to be projected onto, which is then identified with and experienced by that contractor as with Klein’s 1946 definition of projective identification.

 

Whilst thinking about psychodynamic theory can be incredibly useful when reflecting on how it feels to enter a group and some of the dynamics that may be present, I’d like to put forward some of my own ideas about how we can proactively deal with this. I’ve come up with some suggestions in the following categories: developing a presence in the institution, developing relationships with staff, and developing understanding about the professional’s role within the setting.

 

Developing a presence in the institution

One of the first lines that comes to mind here is: minimal hours, maximum presence. Whilst this may unfortunately sound a little like a slogan for a quick-fix PR company, I think it really does apply to many Music Therapists working in freelance, multi-institutional roles. I certainly often spend a very small number of hours in a school, hospital or home each week but I have a certain level of expectations from that setting:

  • to know what I do
  • to be prepared for my visit
  • to provide me with an appropriate space for the therapy
  • to provide handovers
  • to refer patients to me
  • to allow me to link in with other health and care professionals
  • to enable me to do my job

It’s no surprise that, due to me being in that school, hospital or home for a handful of hours each week, my expectations are regularly not met. Or maybe I don’t manage them properly? What could I, or we as a profession, do to ensure that we enable the setting to provide us with the above working environment? Whilst thinking about this I’ve put together a little list of things I could do to enable the above to be smoother:

  1. When setting up a new clinical service in a new institution, ask the Manager to arrange a staff meeting that I can attend to introduce myself and Music Therapy. Make my introduction informative and interactive; practical demonstrations of musical activities, maybe some visual information in a PowerPoint presentation, and some handouts for people to take away with them.
  2. Spend the first ‘shift’ in any given setting being present: spending time with staff and patients. Get to know them; let them get to know me and what I do. Be authentic and transparent. Encourage warm and friendly, yet professional, interaction. Ask the staff and patients if there is anything I can do to help make my presence better known before clinical work starts and my time becomes limited.
  1. Make an extra effort to attend meetings or Skype in to the meeting if I can’t attend in person. Failing that, provide a written update to be read out. Sometimes this might mean attending meetings outside of working hours which means it would not be paid? Something to think about.

 

Developing relationships with staff

When time in a setting is limited, my priority is to deliver the clinical sessions and ensure my patients are receiving what they need. However, this does sometimes leave little time for getting to know the team around that patient or getting to know the wider staff network in the setting. For example, there was one school I worked in where unfortunately the only staff members that knew me were the receptionist and the SENCo. To this day, it makes me feel really sad and brings up horrible worries that I didn’t do my job properly (even if the patient was at the centre of everything I did), but I do also know that it was perhaps not me that was totally to blame; relationship building has to be two way between the institution and the contractor coming in. Here are some thoughts about building relationships with staff:

  1. Begin with the staff team directly involved with the patient: the other professionals that work with them. Set aside specific time to link in with them regularly; monthly update meetings or phone calls, email correspondence after a session, outcome measuring and therapy aims planning at frequent intervals.
  2. This might sound condescending and I apologise if so: be approachable. Encourage small talk. Ask how someone’s weekend was, what they’re doing this evening, how their day is going. Keep it professional, but be friendly. Be confident and feel like you belong there; because you do!

 

Developing understanding of the professional’s role within the setting

This is perhaps the trickiest area of integrating into an existing staff team; we work with sensitive, confidential patient material and we are restricted by regulations and guidelines when talking about our work. So how can we develop an understanding of our role and what other staff members can expect from us? I suppose the simplest form of developing other’s understanding of our role within an institution is to talk about what we do without giving specific information about patients unless it’s in the form a case-study and we have permission to share the information? Here are some thoughts about how to stay within the boundaries of good practice whilst helping others understand what we do:

  1. Talk about Music Therapy generally; who can we work with? What are the common reasons for referral? What are some general activities we do in sessions? What don’t we do?
  2. Relate other therapies to Music Therapy, e.g. ‘I noticed the Physiotherapist working on hand grip and finger movement earlier, I have a fantastic musical instrument called the Cabasa that exercises the same parts of the body, just let me know if you’d like me to show you!’
  3. If you have permission for a case study or video clips to be shown to other health and care or education professionals for training or marketing purposes, don’t be afraid to show them to the staff team working with your patients so they can understand more about what happens in a Music Therapy session.
  4. If you don’t have the above permissions or materials, why not write an anonymous case study for the setting you’re in? It doesn’t have to be about a specific patient within that setting, but it would be useful to have a case study about someone that might have a similar diagnosis or therapeutic aims, from a similar but separate institution.
  5. Invite the staff team to come and see your Music Therapy space when it’s all set up so they can see the range of instruments you bring and have a visual idea of the space you’re working in. Invite them to play the instruments and see what they sound like!

 

A final note

One thing I feel is really important and relevant whilst writing about this topic is to really emphasise that in order to be respected in an institution we need to have respect for ourselves. If we want to be taken seriously as professionals, we need to take ourselves seriously as professionals. We, as Music Therapists, are highly trained specialists and have a wide, varied, extensive knowledge of many clinical areas as part of our training. And we are highly trained musicians! We know what we’re doing (most of the time!). If you have confidence in your work, this will be communicated to those you interact with whilst doing the work.

I would love to know if any other Music Therapists – or other health and care professionals or contractors – have had any experiences like my one in that school I wrote about at the start of this post? Please comment and share your experiences!

 

REFERENCES

Freud, S. (1921) Group psychology and the analysis of the ego London: The International Psychoanalytical Press

Yalom, I. with Leszcz, M. (2005) The theory and practice of group psychotherapy (5th edition). New York: Perseus Books Group.

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ellieruddock Written by:

Ellie received her MA in Music Therapy from Roehampton University, and undertook additional training to receive certification as a Neurologic Music Therapist. She is a full-time member of the Chiltern Music Therapy team as well as the Therapy Manager for the organisation, and has experience of working individually and running groups with adults, older adults, children and infants across a number of health and social care sectors, including learning disabilities, ASD, mental health, brain injury and dementia. Alongside her music therapy work Ellie was previously a Trustee for the British Association for Music Therapy.

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