Don’t forget your oxygen mask! Caring for ourselves so that we can better care for our clients

Abstract

Music Therapists face significant stressors at work which, if not adequately addressed, could lead to stress and burnout. Against the background of a final-year dissertation, this article discusses how Music Therapists use self-care to manage occupational stressors. While the small-scale qualitative research project focussed on how Music Therapists working in hospices in the United Kingdom manage work-related stressors, analysis of the data revealed themes which, it is suggested, seem to apply to the wider music therapy community. Findings indicate that Music Therapists would be well-advised to develop and use self-care strategies to mitigate work-related stressors and thus reduce the potential for ill-health. The article seeks to inform the practice of Music Therapists and concludes with the author’s recommendations.

Keywords

burnout music therapy occupational stress self-care well-being

Background

Every time passengers board a plane they are reminded to put on their own oxygen masks before assisting others. Similarly physicians need to be reminded that they can’t help others if they do not address risks to their own well-being.

(Atallah et al., 2016: 731)

This observation caused me to wonder whether, in the process of caring for clients, Music Therapists may neglect to put on their own metaphorical oxygen masks and overlook taking care of themselves. Against the background of my final-year dissertation, this article explores the significant and topical issue of Music Therapists’ self-care.

Beginning practice-based learning in a hospice, I had a burning question: How do Music Therapists working in palliative care manage their responses to their patients’ deaths? I sought to explore the question in my dissertation, the more general aim of which was to gain an understanding of how Music Therapists working in hospices in the United Kingdom manage work-related stressors.

My early research confirmed that death/dying is an unavoidable work-related stressor for palliative care Music Therapists (Rykov, 2001). However, it soon became clear that not only did the work give rise to other emotional demands, causing a risk of stress and burnout (Clements-Cortes, 2006), but also that many of these demands were faced by the wider music therapy community (Gooding, 2019). I became curious about how Music Therapists use self-care to manage occupational stressors.

Literature

Personality characteristics contribute to one’s vulnerability to stress (Vega, 2010), and an inability to deal successfully with occupational stress can lead to burnout (Maslach and Jackson, 1981). Particularly affecting helping professionals, Pines and Aronson (1988) observe that, ‘tragically, burnout strikes precisely those individuals who had once been the most idealistic and enthusiastic’ (p. 10), leading them to ‘experience a shift from passion for their work to barely burning embers’ (Richardson-Delgado, 2006: 30). The personal and professional consequences are significant (Pines and Aronson, 1988). The music therapy profession, too, suffers: burnout was the primary reason Music Therapists cited to Decuir and Vega (2010) for leaving their roles.

Gooding’s (2019) integrative study concluded that Music Therapists appear to be at average risk for burnout. However, it also found that Music Therapists may experience more burnout than other mental health professionals, especially with regard to emotional exhaustion. Common stressors were identified in Clements-Cortes’ (2013) review: low remuneration, work overload, severity of clients’ problems, intensity of the therapeutic relationship, professional isolation, role ambiguity/conflict and lack of understanding of music therapy. These two latter themes had been recognised in Hills et al.’s (2000) study of burnout and multi-disciplinary team-working among British Music Therapists. Their study also cited difficulties of working in a multi-disciplinary team as a potential stressor. Concerns reported by Music Therapists to Silverman (2014) included issues of boundaries and transference/countertransference. In addition, Trondalen (2016) highlighted the constant requirement to promote the profession together with the absence of recognition, poor working conditions, conflicting workplace philosophies and difficult relationships within multi-disciplinary teams.

Naturally, individuals differ in how they respond to stress (Fowler, 2006), but regardless of personal differences, ‘almost everyone will experience burnout if severe, uncontrollable, and unmodifiable chronic pressures are placed on them without adequate support’ (Pines and Aronson, 1988: 51). Berry’s (2017) crucial finding that those Music Therapists with a higher frequency of self-care practice had a lower degree of burnout underpins Posluns and Gall’s (2019: 4) assertion that self-care ‘is not a luxury but is a clinical and ethical imperative’.

Self-care practices may be grouped into overlapping categories of physical, support, psychological and spiritual domains (Richards et al., 2010). Swezey’s (2013) examples included:

Physical	Support	Psychological	Spiritual
Exercise	Relationships with family/friends	Work–life balance	Organised religion
Healthy diet	Professional relationships	Positive thoughts/affirmations	Meditation
Adequate rest	Personal therapy	Self-awareness	Relaxation
Yoga	Supervision	Use of humour

Other recognised self-care strategies for Music Therapists include the use of music and continuing education (Ferrer, 2017).

Authors (including Bitcon, 1981; Clements-Cortes, 2013; Ferrer, 2017; Oppenheim, 1987; Trondalen, 2016) have periodically recommended that Music Therapists adopt wide-ranging strategies for self-care in each of the four domains. However, in limiting themselves to only offering recommendations, these writers did not explore the effectiveness or uptake of the suggested self-care practices.

Others have researched which strategies Music Therapists actually use for self-care. Salmon and Stewart (2005) reported that Music Therapists most frequently used music, support from family and friends, exercise, church and leisure activities. Fowler’s (2006) investigation into the relationship between personality, work environment and Music Therapists’ well-being revealed use of coping strategies from each domain. Notably, each of these studies was conducted well over a decade ago, at a time when self-care practices arguably differed from those used today.

More recently, Chang’s (2014) qualitative study into Canadian Music Therapists’ experiences of burnout addressed self-care. The participants, each of whom had experienced burnout, reported various strategies used in their recovery process. While their experiences of burnout may have given them a nuanced perspective, it is nonetheless noteworthy that all emphasised the importance of self-care.

In addition, some theses (including Chang, 2008; Murillo, 2013; Swezey, 2013; West, 2009) have investigated self-care strategies of Music Therapists, but while they provide valuable information and are occasionally cited in peer-reviewed literature (e.g. Gooding, 2019; Moore and Wilhelm, 2019), they have not undergone the rigour of their own peer review. Furthermore, as with Chang (2014), the studies were conducted in North America and do not specifically consider the self-care of Music Therapists practising in the United Kingdom.

Reflecting on how to integrate self-care into a busy life, Gredler (2018) observed that the ‘underlying necessity of self-care [is] that it is personal, original and easily implemented’ (p. 23). Jones (2005) recommended that hospice workers should create personalised self-care plans, while Posluns and Gall (2019) suggested that mental health professionals should be required to complete a self-care inventory on renewal of registration with their professional body.

Method and methodology

Seeking to investigate how Music Therapists working in UK hospices manage work-related stressors, I conducted a small-scale qualitative study. Wishing to explore how participants made sense of their lived experiences, I used an Interpretative Phenomenological Approach (Smith et al., 2009). Ethical approval was received in accordance with, and the research was undertaken following, the University of Roehampton’s (2014) research ethics guidelines. All information disclosed was treated confidentially, and anonymity was preserved.

The three participants had experience in working in hospices as Music Therapists. Their experiences were gathered using open questions in semi-structured interviews. Emerging themes were put into clusters of related superordinate themes with associated subordinate ones.

Results and discussion

I was struck by how many of the themes involved self-care and, except for one subordinate theme, could apply to Music Therapists beyond those working in hospices. Below I describe the themes, position the results within the literature and discuss their implications. To preserve confidentiality, all names used are pseudonyms.

Approaches to the concept of self-care

The first superordinate theme concerned participants’ experiences of approaches to self-care and arose in each interview. With the exception of ‘awareness of painful emotions aroused by working with the terminally ill’ (which need not be considered for the purposes of this article), each sub-theme has relevance to the general music therapy profession.

Personal responsibility for self-care

While everyone recognised the importance of self-care, not all took active responsibility for it. Maya’s acknowledgement of the need to ‘help yourself’ contrasted with Alex’s frank admission: ‘If you left self-care to me, I would end up like a bag of twigs’. Meanwhile, Becky’s recognition that she had not realised the need for self-care until she had experienced burnout and taken sick-leave was reminiscent of Murillo’s (2013) participant: ‘It is best to do ongoing preventive maintenance than to suddenly realise that you have nothing left and need to halt everything while you refuel’ (p. 124).

Balancing care for patients with care for self

One explanation for neglect of self-care may be that, like Rogers (1995), we are better at caring for others than caring for ourselves. Alex’s forthright declaration, ‘[we] need to be well enough ourselves in order to help others’ is abundantly supported in the literature (e.g. Atallah et al., 2016) and highlights the importance of Music Therapists ‘treat[ing] themselves as if they were their own client’ (Pines and Aronson, 1988: 153) to preserve their well-being.

Perspectives on self-care through supporting others

In the final sub-theme, all participants mentioned supporting others through, for example, running staff support groups or choirs. Analysis of the interviews reminded me of the concept of the wounded healer (Jung, 1951) and led me to wonder whether supporting others may have offered a means by which the participants were able to soothe their own emotional pain. Maya’s insight of finding ‘just’ sitting and playing on the inpatient unit ‘strangely helpful’ perhaps suggests that she, as well as the patients, was enriched in these moments. I would suggest that in such circumstances, it is imperative that the Music Therapist recognises their needs or motivations and does not defend against them.

The importance of boundaries

Establishing boundaries in a variety of respects appeared to have become an effective self-care strategy for all participants.

Boundaries around patients

Each interviewee appreciated that the unique aspects of working in palliative care presented a challenge to set clear boundaries around patients. This was particularly true when they identified with their patients. Becky was concerned that, in the past, she had overstepped a boundary when her relationship with a patient of a similar age ‘was more like a . . . friendship’, causing her to become ‘devastated’ when the patient died. Certainly, emotions surrounding death and loss may heighten one’s susceptibility, but identification with clients is not a concept unique to hospice work (see, for example, Short, 2017). The findings of the study indicate that Music Therapists’ self-care should include cultivation of and awareness of boundaries around clients, striking an appropriate balance between emotional connection with and professional distance from them, particularly those with whom the therapist identifies.

Separating work from home

The sub-theme of maintaining a boundary between work and home was a significant one for all participants. The vivid imagery of Alex’s striking metaphor, ‘you don’t want to roll through the door dragging the coffin behind you’, was rich in meaning. Time spent commuting allowed Maya to unwind and ‘leave [her] work at work’. Tellingly, and corresponding with experiences of participants in Chang’s (2014) study of Music Therapists’ burnout, it was Becky’s illness that led her to ‘make a point of not taking work home . . . that’s been one way that I’ve freed up a bit of space for myself’. Thus, both the data and literature suggest that separating work from home is a crucial self-care strategy.

Music in therapy/recreational music

Similar to Chang’s (2014) distinction between ‘the musician self and the music therapist self’ (p. 79), everyone described the value of regular music-making with others outside work. Alex felt ‘safe’ while Maya cherished playing music ‘that was purely for me’. Echoing the latter, Becky underlined her boundary between work and home, playing music with friends ‘in a completely different way’.

Reflecting Priestley’s (1994) advice that to be effective as practitioners, Music Therapists must tend their own musical needs, examples of participation in music outside the workplace for self-care are found extensively in the literature. A total of 84% of Salmon’s (2003) palliative care music therapy participants used music for self-expression/pleasure, and each of Clements-Cortes’ (2006) interviewees used music for themselves. It is, therefore, vital that Music Therapists do not overlook their own music-making as part of their self-care.

Being outdoors, away from physical boundaries

Without exception, the participants extolled the benefits of being in nature, un-hampered by physical boundaries. Alex reported running regularly, and Becky and Maya each reported walking in fresh air. Declaring ‘open space is very good for me’, Maya’s use of evocative language (‘there are lambs everywhere . . . daffodils and blue skies’) painted a contrasting picture to the confines of the music therapy room. Open space provided psychological space for participants to ‘recycle the day’ (Alex), take ‘time out’ (Becky) and ‘clear my head’ (Maya).

It is well-established that time spent in nature has a positive impact on well-being (Howell et al., 2011). Indeed, many of Fowler’s (2006) respondents mentioned being outdoors to reduce stress and Runningdeer (2013) described being in ‘nature’s beauty’ (p. 141) for self-care. Therefore, spending time in natural settings may be a valuable self-care tool.

Experiences of barriers to and enablers of the management of work-related stressors

Participants’ various experiences were identified from analysis of the data. Two barriers to managing stress featured highly.

The perceived need to appear to be ‘professional’ may have impeded participants’ capacity to self-care, not least because such an image could not always be sustained. Everyone referred to suppressed emotions sometimes unexpectedly seeping out. Becky felt she was being ‘unprofessional’ if she got ‘upset’, as she was ‘supposed to be the strong one’. Perhaps this illustrates that beneath ‘chronic niceness’ (Speck, 1994: 97), ‘there boils a chaos of death denied [and] fury at the helplessness’ (Nimmo, 1997: 137).

It may well be that an expectation to sustain an outward professional appearance is shared by Music Therapists working in fields other than hospices. The potential harm of this avoidant strategy should be recognised. There is a fine line between necessary and healthy psychological defences against emotions aroused by the work and those which constitute barriers to effective management of such emotions (Wood, 1998). As hiding emotions is a risk-factor for burnout (Stensland and Landsman, 2017), finding appropriate times and ways to acknowledge and process painful feelings aroused by the work is a crucial self-care strategy.

Another potential barrier was a feeling of needing to be busy. While all participants referred to this need, only Alex articulated a potential rationale for it: ‘the more stressed I become the more I go to work . . . [I would] overwhelm . . . myself with so much work that I didn’t have to feel it almost’. Music Therapists should be aware of the potential to employ relentless busyness as a defence mechanism to protect themselves from processing painful emotions (Doe and Katz, 2016), for if done habitually, there may be negative consequences for their well-being.

In contrast, three potential enablers for managing stress were identified. First, consistent with Vachon’s (1995) findings, each participant valued the support of colleagues. Maya’s summary, ‘collectively as a staff we all look out for each other’, seemed to encapsulate everyone’s experiences. However, these participants’ positive experiences of the multi-disciplinary team are not universal. The literature indicates that while the collegial community may be a protective factor for work-related stressors, conversely difficulties within the team may actually be a source of stress (Hills et al., 2000). Thus, the findings emphasise the importance of supportive colleagues as an enabler to meet the demands of the work.

Second, everyone spoke of the beneficial impact of peer support networks, using them as a way of connecting with their professional community. Becky particularly valued the opportunities to share mutual experiences with like-minded colleagues (‘people have put emails out saying, “Has anybody experienced this?”’). This accords with the literature. Citing Stewart’s (2000) finding that peer support positively correlates with job satisfaction, and while recognising that ‘maintaining a support network can be a draining addition to our clinical week’, Sutton (2002) warned that ‘we fail to acknowledge our need for support at our peril’ (p. 62).

The third potential enabler was supervision. Similar to Music Therapists in Stewart’s (2000) survey who recognised ‘the prime importance of supervision to therapist survival’, Alex was ‘fastidious about supervision’. However, Alex and Becky had starkly contrasting experiences of its ‘safety net’ (Katz, 2016: 218). Whereas Alex’s supervisor was alert to and addressed episodes of sadness, Becky had the opposite experience with her early symptoms of burnout apparently going un-heeded by her supervisor.

Brown’s (2009) ‘major areas for Music Therapy supervision’ (p. 123) encompass crucial areas for Music Therapists, but well-being is strikingly absent. Perhaps reflecting present culture, Ashby’s (2017) suggestion that ‘well-being should be a key component of supervisory practice if Art Therapists are to remain able to function at their best long-term’ (p. 245) must surely apply equally to Music Therapists. It may include the development/monitoring of self-care plans (Merriman, 2015).

Limitations and further research

The study had several limitations. Significantly, given the constraints of the project’s size, important themes including additional self-care strategies, enablers (especially support from family/friends) and management of work-related stressors within the organisational domain were not discussed. Nor was there space to explore the fact that, notably, none of the participants talked about having their own therapy (albeit one mentioned a short, unsatisfactory course of counselling). Notwithstanding its limitations, the study provides some insight into how Music Therapists working in UK hospices manage work-related stressors through self-care. It underlines the need for further research into the work-related stressors faced by Music Therapists generally in the United Kingdom and how they are managed.

Recommendations

Informed by the study, my recommendations are threefold:

(a) Manage work-related stressors

Music Therapists should be encouraged to cultivate awareness of their work-related stressors and to create systems to manage them. This may include habitually reflecting on the feelings that those stressors give rise to, and accepting and working through such feelings when they arise.

(b) Practice self-care

Making a list of one’s own self-care strategies and regularly re-visiting that list is highly recommended. While the participants gave their own examples, the list could usefully be tailored to one’s individual needs and budget. A personalised self-care plan, perhaps setting out a timetable, may assist.

Identification of one’s enablers to self-care is paramount. These may well include supportive working relations and peer support networks. To that end, Music Therapists may wish to integrate themselves into their multi-disciplinary team, giving and seeking support, and endeavouring to foster formal and informal discussions. As for peer support networks, geographical location no longer presents a barrier, as video conferencing has opened up possibilities of connecting everyone irrespective of where they live.

Equally importantly, Music Therapists should be encouraged to explore barriers to self-care. If they include adoption of negative coping mechanisms, more functional coping styles can be developed.

It is proposed that supervisors should be encouraged to be alert to symptoms of burnout and to routinely address self-care in supervision. This may include providing space for creating and monitoring self-care plans. It is further proposed that Health and Care Professions Council (HCPC) may wish to consider requiring submission of a self-care inventory on renewals of registration.

Conclusion

Music Therapists can face a real risk of burnout, as illustrated by the experience of one of the participants. The personal and institutional effects of burnout are costly, and the associated risk to the profession of losing practitioners is significant. Reinforced by the professional requirement to understand the importance of maintaining one’s own health (HCPC, 2013: section 3.2), the time and money invested in affordable self-care will reap rewards in mitigating burnout and increasing career longevity.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ali Rowley

Author biography

Ali Rowley qualified as a Music Therapist in 2020.

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