Music Therapy and Pregnancy: nine months of change

I’ve waited to write this article; it feels like my most personal blog post yet. But I also think it’s an important topic to cover, as I’m not aware of any other Music Therapists that have written about their experience of working whilst pregnant, and some of the complex issues this can bring up. The current demographic of Music Therapists practicing in the UK is largely female; and many Music Therapists are recently graduated. Whilst I don’t want to make assumptions about this demographic and links to plans to have families, I do feel that this topic is particularly relevant to the profession and would be useful to explore here on my blog rather than in a more formal paper.

As I write this, I am on maternity leave, 39 weeks pregnant and expecting my first child. The reason I’ve waited until this point to write this is perhaps because finding the time to write whilst still working was difficult, but also it is an extremely personal experience to try and put into words. I’d like to try and cover the following topics here: how does being pregnant effect practice, boundaries, therapy content and also change circumstances? I am writing purely from a personal perspective, and all experiences here may well be unique to me, but I’ll try to tie in with current medical and clinical guidelines as I go. I’ve divided this article into the following sections:

  • The change in personal circumstances
  • Managing symptoms
  • Health and Safety throughout pregnancy
  • Announcing pregnancy to colleagues and patients
  • The growing bump, and the change in dynamics and limitations of practice
  • Managing the expectations of maternity leave

 

The change in personal circumstances

Hopefully for most, becoming pregnant is a happy and exciting experience. However, it is probably also the start of a huge emotional and psychological shift. Perhaps my shift was more pronounced due to the devastating loss of a family member at the same time, but I found myself feeling absolutely all over the place, and needed to spend a lot of time working through things to understand them so that I still go to work and be the ‘good enough’ Therapist. I’m not sure what was grief, what was hormonal, what was coming to terms with the start of a new life…I was full of excitement and hope, but very anxious about the high rate of miscarriage in the first 12 weeks of pregnancy. I couldn’t tell colleagues and patients about the pregnancy during this time, which led to me feeling that I wasn’t a particularly ‘authentic’ Therapist, and I found myself fighting to stay present in sessions and not become distracted by my own ‘stuff’. I’m wondering how much this ultimately changed the dynamic (unconscious and conscious) of sessions, and also how realistic it is that we can prevent dynamics from changing at all when the Therapist is experiencing something so life changing? I have written more about this in a later paragraph. I’m wondering how we can balance this fragile experience; are we prepared to take this sort of topic to supervision in such early stages of pregnancy, when we may not feel comfortable announcing the pregnancy to our Supervisor? I would suggest that Personal Therapy would be a good place to take this sort of topic and what it brings up, and I personally found a lot of support in my partner at this time too. Pregnancy has also been a good opportunity to practice self care, which I always feel must be high up on our list of professional and personal priorities.

 

Managing Symptoms

I have heard of the mythical ‘dream pregnancy’ where the woman experiences no negative symptoms and looks simply blooming throughout; however in reality I have not met another woman that hasn’t struggled at some point with symptoms caused by pregnancy. Personally, I have suffered with morning sickness (or ‘all day and night sickness’, as it should be more aptly called!) for the majority of the 9 months, and I had a short bout of sciatica around the 5-month mark. Both of these symptoms have been unexpectedly debilitating for me and caused increased emotional symptoms too. I would like to talk openly about them and the coping mechanisms / managing solutions that I developed in the hope that they might be useful for others:

Morning Sickness: My morning sickness started around the 2-month mark, which meant I couldn’t tell patients or colleagues. This was a real difficulty: Music Therapy is not the kind of profession where you can take prolonged air breaks outside, or just sit quietly until waves of nausea pass, or suddenly run out of a session to vomit (hopefully in a toilet). I was not prepared for the mental impact of such sickness too; I found myself becoming increasingly low in mood, lacking motivation or energy for work and simply not being happy with how I was managing working whilst being unwell. The thing is: there is just no way around it. You can’t be your best when you’re so poorly. So, what can you do? I started to find little coping strategies that really helped ease things: for example, I realised that on the days I ate oats regularly (porridge, flapjacks, oat cakes) I was less sick, and I also realised the foods that I couldn’t keep down and avoided them (meat, and all strong-smelling foods). I managed to move some session times around so that I could avoid late finishing days, and I also found that holding more sessions in the morning was better for me than holding more sessions in the afternoon. I was also able to negotiate some working from home days with the institutions I worked with; to write annual reports or reviews, and I inevitably did have to take some time off. There is also medication available (see your doctor) to help relieve the nausea and vomiting for severe cases, which I was offered but, for some reason I can’t explain, decided not to take.

Sciatica: With the sciatica I was able to ask for extra help with anything physical because I had announced my pregnancy to colleagues and patients by that point (this will be explored in a later paragraph) and I tried to be as honest as possible with everyone and make it something we could talk about in sessions. I wanted to be able to support my patients with anything that my pregnancy – and its limitations – brought up for them. I adapted my instrument set up and the way I used the therapy space so that my movements could remain limited to a comfortable range for me; for example, remaining seated in a chair and not crawling around on the floor!

Anxiety / Low Mood: interestingly, I almost didn’t write this paragraph about the emotional and psychological symptoms of pregnancy, but it really is equally important to the physical side of things and I believe that it often goes unspoken about in the pregnant community. Firstly, I feel it is incredibly important to state that regardless of any previous mental health history, becoming pregnant and emotionally preparing for a baby is going to be an emotional rollercoaster for every woman (and man). And that’s ok. As mentioned above, I found myself anxious about the high rate of miscarriage in the first 12 weeks – constantly worrying if my baby was ok because it was too early to know by feeling movements or seeing a bump. It was also a brand new experience – I didn’t know what was normal, what to expect, how to manage what was coming up. At the beginning of my pregnancy I was grieving for the family member recently lost, whilst trying to come to terms with the new life growing inside me. Then 5 months into my pregnancy I lost another very close family member and this added more grief into my circumstances. And then there was my sickness, and the hormones that I was producing… the result? An emotional minefield. However, this is where my Music Therapy training really helped me: I was able to really become aware of my feelings and think about them, explore them, and try to understand and work through them where possible. I often sought advice from my partner too; asking him if something I was feeling or thinking was particularly out of character for me or did he feel I was perhaps overthinking it? This was a great support to have, and also helped us go through the pregnancy together emotionally. As my pregnancy has continued, I have learned a lot more about myself and developed some coping mechanisms for emotional content coming up: I’ve made extra space and time for myself for reflecting, thinking and processing anything coming up, I’ve reached out more to family and friends and I’ve generally made more ‘me time’ – here we come back to self care and just how important it is when enabling us to carry on being our best, or maybe just ‘good enough’ for our patients.

Tiredness: This is a big problem for the majority of pregnant women (from my understanding) and I have felt very lucky to avoid this symptom. I have friends that have spoken about not being able to focus or remain engaged throughout the working day, and coming home from work to sleep for 12 hours straight. Although I can’t offer advice based on personal experience, I can suggest taking a similar approach to the morning sickness problem: if you can rearrange your sessions and working day to fit the pattern of tiredness you are experiencing, it would be helpful to do so. It may sound obvious, but your body is growing a human being. It’s exhausting! You need to look after yourself and your baby – remember SELF CARE.

 

Health and Safety throughout pregnancy

This section is probably quite obvious but still very important to write about, especially when thinking about how Health and Safety can tie into good self care! I feel it’s necessary to seek official guidance when writing this, and I think the most important thing is to firstly know your rights in the workplace as a pregnant woman. One problem I’ve found when writing this is that many Music Therapists are self-employed contractors and I’m not sure how being self-employed affects the below…can anyone advise?

‘When the employee tells her employer she’s pregnant, the employer should assess the risks to the woman and her baby. Where there are risks, the employer should take reasonable steps to remove them, eg by offering the employee different work or changing their hours. The employer should suspend the employee on full pay if they can’t remove any risks, eg by offering suitable alternative work. Pregnant employees who think they’re at risk but their employer disagrees should talk to their health and safety or trade union representative. If your employer still refuses to do anything, talk to your doctor or contact the Health and Safety Executive.’ https://www.gov.uk/working-when-pregnant-your-rights

My assumption for how this relates to self-employment is that we, as the Contractor, are responsible for carrying out risk assessments with the institution we are contracting with and negotiate adaptations as a result to any risks arising. Personally, I carried out additional risk assessments for each client I was working with where I felt my changing circumstances changed any element of risk during sessions. Some institutions also made sure things were put in place to do with room set up and instrument carrying so that I wasn’t having to lift or move anything unnecessary.

Health and Safety Executive released an e-leaflet in April 2013 about new and expectant mothers and how to manage health and safety factors occurring at work. From the risk factors they have identified in the leaflet these are ones I picked out as being particularly relevant to Music Therapists:

  • Lifting and carrying heavy loads
  • Exposure to infectious disease
  • Work related stress
  • Threat of violence in the workplace
  • Excessively noisy workplaces

For a full list of risks you can visit the leaflet here: http://www.hse.gov.uk/pubns/indg373.pdf.

I feel that it’s important to be extra sensitive to the above risk factors during pregnancy, particularly the exposure to infectious disease: before my pregnancy, perhaps I would have been more willing to see a patient with an infectious disease by taking hygiene precautions, however during pregnancy I have been much more strict about not seeing any patients with an infectious illness because ‘pregnancy suppresses the body’s immune system (to ensure the fetus isn’t rejected as something foreign) which means your body is less able to fight off infection and illnesses’ (http://www.motherandbaby.co.uk/pregnancy-and-birth/pregnancy/healthy-eating-in-pregnancy/the-top-foods-to-boost-your-pregnancy-immune-system).

Maternityaction.org.uk mention the heavy lifting health and safety concern specifically on their webpage about working during pregnancy. Again, I’m not sure how being self-employed or a Contractor affects the below (perhaps Contractors must take responsibility for carrying out the risk assessments and implementing all changes needed with the institution?) and if anyone can advise I would be grateful:

‘Your employer should follow the steps above and take reasonable action to ensure that you are not put at risk from having to do heavy lifting or offer you suitable alternative work. If necessary you may need to provide a letter from your doctor or midwife outlining the risks and a certificate confirming your pregnancy. If the lifting you do involves the risk of injury this may be contrary to the Manual Handling Regulations 1992. These regulations require your employer to take reasonable steps to ensure that employees do not undertake heavy lifting that could cause injury and to take appropriate steps to reduce the risk of injury.’ (https://www.maternityaction.org.uk/advice-2/mums-dads-scenarios/pregnant/health-and-safety-during-pregnancy-and-on-return-to-work/).

When it comes to thinking about work related stress, I think that as Therapists we’re already well equipped to identify and manage factors arising in this area, but it is important – as mentioned in the Managing Symptoms section – to be mindful that pregnancy brings a lot of emotional turbulence with it which can perhaps decrease our ability to manage work place stresses with our usual capacity. I would recommend extra supervision and personal therapy to manage these elements of practice if you feel it would be helpful.

Threat and violence in the workplace: I took a similar approach to this topic as with the infectious illness; I had a zero-tolerance policy. With patients that were potentially, or known to be, high risk of physical violence I ensured I had at least one other member of staff in sessions with me along with some kind of communication system such as a walkie-talkie, and I made it very clear that if there was any escalating behaviour or any incidents arising I would remove myself from the room immediately and the patient should be handled by the other members of staff (this is always the case, not just in pregnancy). This challenged many of my previous working approaches but it was the safest thing to do, and that had to be my priority.

Noise in the workplace: not something I ever thought about before becoming pregnant, but it came up at several of my workplaces. I became concerned at certain noise levels, or pitches / frequencies of sound, and whether this could be damaging to the baby’s developing ears and hearing systems:

‘Sound can travel through your body and reach your baby. Although this sound will be muffled in the womb, very loud noises may still be able to damage your baby’s hearing…some experts think that pregnant women should not be routinely exposed to noise louder than 115 dBA. This is roughly as loud as operating a chainsaw. Areas that are very loud (more than 115 dBA) should be avoided during pregnancy as much as possible, even if you are wearing hearing protection’ https://www.cdc.gov/niosh/topics/repro/noise.html.

My opinion is that all of the above has to be managed on a case-by-case basis and judged by the Music Therapist in each setting they go into. If you are a Contractor, I think it’s realistic to expect the institution to work with you to ensure that they are providing a suitable workplace and you can work together to implement any changes necessary in response to the risks identified. The bottom line is: if you feel there is any risk to your baby due to your working environment you must make the necessary changes and safety must come first.

 

Announcing pregnancy to colleagues and patients

Generally, pregnant women are advised not to announce their pregnancy in general until after their first ultrasound scan, which is around the 12-week mark. However, I felt it was very important to talk with my immediate colleagues sooner than this, as I was already struggling to manage my caseload with my recent family bereavement and needed to put changes in place as soon as possible. There is no rule as to how early you tell your employer or colleagues, other than by law it must be at least 15 weeks before the date the baby is due. This means that you could choose to wait as long as 25 weeks (around 6 months) before announcing your pregnancy – although I imagine it might become pretty obvious before that point! There is advice here on telling employers about pregnancy: https://www.gov.uk/working-when-pregnant-your-rights but again I’m not sure what guidelines are in place for self-employed contractors. If anyone can advise, please do so in the comments below.

But what about announcing it to patients? This is something I spent a lot of time thinking about and I felt a lot of guilt around the concept of going off on maternity leave and handing over to a new Therapist. There will be more on the dynamics of pregnancy and patients in the following paragraph, but one thing I would advise when thinking about when to tell your patients you are expecting a baby is that each patient needs to be thought about on an individual basis in line with their individual needs. Some patients may need much longer notice period than others, or the use of a visual aids, or perhaps your work is finishing with them imminently and you make the decision not to tell them. Whatever the decision is, the patient’s needs should be at the top of the list along with how best to approach the concept of pregnancy, a baby, the impending discharge or change of Therapist, and what else could be put in place throughout the transition.

 

The growing bump, and the change in dynamics and limitations of practice

The growing bump may be one of the first visible indications to a patient that their Therapist is pregnant. For me, my morning sickness made it impossible to wait for too long after the 12-week mark to tell my patients why I had been absent, or why their session might be at a different time or why I might be a little different because I was feeling very poorly. I made the decision that authenticity, openness and honesty (within therapeutic boundaries set around the needs of the patient) should be prioritised so that my patients would be able to explore any arising issues my pregnancy brought up. This also ensured that we that we had plenty of time to work through issues and themes before my maternity leave started. Of course, I also had to balance this with the needs of my patients and whether they would or would not be ready to receive this kind of news. I wanted to introduce things in the most thoughtful, supportive and structured way I could.

Clinical Example: I was working with several children at a SEN school, seeing each child 1:1, all of whom were involved in high level child protection measures. I felt that I needed to be able to give the children as much time and space as possible to bring any issues surrounding the pregnancy, the potentially upsetting idea of a ‘perfect baby’ (projection) and comparisons they may make to their own circumstances, and impending end to our sessions. I told them as soon as I could whilst putting their needs at the centre of the decision-making process with timing, and ensuring I wasn’t encountering any breaks in the session schedule e.g. half terms. I therefore told them around the end of November or the beginning of December (depending on each child’s individual needs) that I was expecting a baby and that in 4 months’ time I would be going on leave and they would have a different Music Therapist. I decided to do this verbally whilst using visual countdown calendars that rolled out in a long line, incorporating any planned breaks such as Christmas, half term and Easter, and each week we crossed the session off and counted down how many weeks left. I also made sure that in each session I gave the children space and time to ask me any questions they had about me or the baby whilst we were looking at the countdown chart, or if they had any feelings about me leaving. I had visual aids such as emotion picture cards and charts called ‘I have something to tell you’ so that they could point to an image without saying the words if that was too difficult. This approach worked well with all of the children, and I was surprised about the kinds of thoughts and questions they had about the baby (e.g. “can it hear me now?”, “can we sing a song for the baby?”) and additionally it gave us a very long countdown period with lots of time available to bring up and explore any feelings they had. For some of the children, it took the visual countdown and my growing tummy to really help them understand and process the impending change or the concept of a baby, whilst others straight away understood and could think about the time we had left together quite easily.

Of course, the above approach meant that I had to reconsider my boundaries within sessions. I realised that it’s incredibly difficult to continue a tight boundary around the giving of personal information when I was visibly changing from week to week; my patients would comment on how much my bump had grown, and ask questions about the baby. Staff and other professionals used it as a real talking point and wanted to talk about their experiences, sometimes in front of patients.  It felt wrong to shut down these avenues of communication, and instead I made the decision to build them into the therapy process and use it as a chance to explore what it meant for my patients so that I could support them accordingly. This felt strange to me; being open about me and the baby. It felt like it went against the psychodynamic approach of my training, but it also felt instinctively the right thing to do for my patients.

As my pregnancy developed, the physical limitations of sessions inevitably changed. Whilst I have usually been very active and had no problem being on the floor or running around the room with patients, I started to become physically less able to do these things as I got bigger, and also when I had sciatica. This meant that the physical experience of my patient’s sessions might have also changed, as well as the emotional experience. I tried to take the same approach as with the emotional transition of pregnancy and remained transparent about why I could not roll around the floor on that day, and how did that make the patient feel? What could we do to problem-solve the scenario together? I would try and bring their experience of it to the forefront of the session and support them to be able to work through and process it with me.

In summary; patient centred authenticity, honesty, time and visual aids really helped me manage the changing dynamic in sessions, and this change in dynamic was inevitable. I would really appreciate knowing how other Music Therapists managed this, and what approach they took with their patients! Please comment below.

 

Managing the expectations of maternity leave

Throughout my pregnancy, I put in a lot of preparation for maternity leave and counting down with clients, but knowing when to set my finishing date was difficult for two reasons: Music Therapy is a physical job and I had no idea when I would start to find things really difficult or too tiring, and being self-employed means that the decision had a considerable financial impact on me and my partner. I had a lot of advice from friends about finishing early to allow myself time to prepare for the baby and give myself a rest because work becomes difficult in the later stages of pregnancy. Unfortunately, I didn’t heed the advice I was given and decided to stop at 36 weeks, which in hindsight was too late. In reality, I found that at around 32 weeks I was very ready to stop: I was tired, the practicalities of the physical side of work was difficult to manage and I constantly needed help with instruments, and mentally I was a lot slower and found it difficult to focus for extended periods of time. I would urge other Music Therapists to consider a finishing date earlier than 36 weeks for the above reasons. Financially, as a self-employed Contractor, I am entitled to statutory maternity allowance from the Government which totals just under £140 a week: https://www.gov.uk/maternity-allowance/overview. Because I am self-employed, this is the only income I will receive throughout my leave, and has definitely altered my decision as to when to return to work. All being well, I plan to return to work 1 day a week in September and then 2 days a week in November (because I can do 10 days back at work before my statutory maternity allowance is stopped). This is all I have planned for now, because I feel it’s important to see how I manage this return to work when the baby is here.

When I was preparing for maternity leave, I had a very black and white approach about the cut off from work, and being completely uncontactable from the day I stopped work until the day I return. However, this has turned out to be unrealistic because there have been certain situations where my input has been needed or I have had to make contact with colleagues. And before I do return, I will have to lay the groundwork for carrying out sessions and negotiating clinical hours. I found that once I had been on maternity leave for a couple of weeks, I had relaxed and I was able to manage the idea of sporadic work related content throughout my leave as being a positive thing: keeping me in touch with my professional side, keeping my links and friendships with colleagues, and helping me prepare for when I do go back to work.

 

In summary

The topic of pregnancy and Music Therapy practice is important to explore because of the current demographic of Music Therapists and the clinical issues arising. It is a time of real change not only for the Music Therapist but for their colleagues and patients, and there are many elements to consider such as managing symptoms, health and safety, announcing the pregnancy, managing the changing clinical dynamics and arranging maternity leave. It is difficult to provide very specific information within this article because many Music Therapists are self-employed and therefore aren’t covered by employee rights in the same capacity as an employed Music Therapist would be. This article has taken a self care and patient centred approach to the topic of pregnancy and Music Therapy, and has provided links to medical and legal guidance where possible.

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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.

One Comment

  1. Bethan Fitzsimons
    July 26, 2017
    Reply

    So pleased to see you share your experience! This was the topic for my Masters dissertation and I couldn’t find anything written by Music Therapists!! Such an important issue to think and write about. Thank you for being willing.

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