Music Therapy: Cheryl Dileo, PAD, MT-BC

ETHICAL THINKING —
Aw
‘MUSIC THERAPY
Cheryl Dileo, PAD, MT-BC

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ETHICAL THINKING
MUSIC THERAPY
Ceryl Dileo,PhD, MT-BO

Temple Umiversity
vefrey Books
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Jeffrey Books
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Permission for the reprinting of their Codes of Ethics

has been granted to the publisher
by the following associations:
American Music Therapy Association, Inc.
Association of Professional Music Therapists
Australian Music Therapy Association, Inc.
Canadian Association for Music Therapy
Certification Board for Music Therapists
World Federation of Music Therapy, Inc.
Cover illustration and design by José Ignacio Castafio,
Copyright 2000 by Jeffrey Books
All rights reserved. No part of this book may be reproduced in any form
whatsoever, by photocopying, audio- or videotaping, by any electronic means, or
placed in information storage and retrieval systems. For written permission to
reproduce or reprint, contact Jeffrey Books.
Printed in the United States of America.

DEDICATION
to
My unforgettable father, Noble Joseph Diles, whe
My beloved mother, Drieda Habech Dileo, uhe taught me
My cherished
son,feffrey Dileo Marants, uheteachesme
CONTENTS
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About the Author POCO CeO Re eee HHT E HET O ESET EOE OTHE ESTEE ST HEHEHE EEEEFESOHE EEE EH EH EES xvi
a, Introduction to Ethical Thinking........00..00.00

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Why Professional Ethics?

Terminology
The Background: Research in Professional Ethics
Core Ethical Principles
Models of Ethical Development
Theories of Ethics
Codes of Ethics
Interface of the Law and Ethics
A Model for Ethical Decision Making
Situations That Pose Risk
Crisis Decision Making
Deterrents to Ethical Behavior
Chapter Summary
Additional Learning Experiences
2. The Virtuous Music Therapist...............cs<csssessoossrccssroonnaconecs
Caring
Empathy
Courage
Prudence
Chapter Summary
3. The Music Therapist as a Professional and Person.............
The Music Therapist as a Professional: Competence

Professional Competence in Music Therapy
vi
Competence in Groups Music Therapy Work

Personal Competence
Psychological Vulnerability and Impairment
Burnout
Professional Self-Care
Legal Aspects of Competence
Competence: Who is Responsible?
A Final Note on Competence
The Music Therapist as a Person: Values
Values and Religion/Spirituality
Therapists’ Private Lives
Chapter Summary
Ethical Dilemmas
Clients’ Rights and Therapists’ Responsibilities................
Introduction
Informed Consent
Information About Treatment
Information About the Music Therapist
Confidentiality and Its Limits
Financial Policies
General Policies
Clients’ Right to Refuse Treatment
Rights of Minors as Clients
Therapists’ Responsibilities Within the Helping
Relationship
Communication, Dignity and Respect
Non-Judgment and Acceptance
Facilitating Clients’ Autonomy & Responsibility
Therapists’ Responsibilities in Working with Groups
Therapists’ Responsibilities in Treating Difficult Clients
Therapists’ Responsibilities Regarding the Setting
Therapists’ Responsibilities in Preventing Harm
Therapists’ Responsibilities in Terminating Treatment
Chapter Summary
Ethical Dilemmas
2S: Ethical Thinking and Confidentiality Deere eee beer eee see eeeeeeseneeese
Definitions
Limits to confidentiality
Mandatory Reporting
The Duty to Warn and Protect 100
Protecting the Client from Self: Suicide 101
HIV/AIDS 104
Children 106
Groups 108
Safeguarding Confidential Information 109
Confidentiality in Record Keeping 110
Record Retention i13
Release of Records 114
To Clients 114
Subpoenas and Court Orders DTD.
To Insurance Companies oa5.
For Teaching Purposes 116
Informed Consent for Release 116
Chapter Summary 117
Ethical Dilemmas 119
Additional Learning Experiences 120
6. Boundaries and Dual Relationships..............0...0.ccceeeeeeeees 123
Boundaries 123
Boundaries in Music Therapy 124
Boundary Violations 125
Protecting Boundaries 126
Dual Relationships dz7.
Definitions and Prevalence 127
Social Relationships with Clients 128
Sexual Relationships with Clients: Sexual Exploitation 129
Prevalence 130
Characteristics of Therapists Who Sexually Exploit 130
Typical Reactions to Sexual Feelings 132
Dealing with Problems 133
Legal Aspects 135
The Use of Touch in Therapy 135
Accepting Gifts 137
Therapist’s Self-Disclosure 138
The Setting for Therapy 139
Dual Professional Relationships: Bartering 139
Post-Therapy Dual Relationships 140
Guidelines for Dual Relationships 14]
Chapter Summary 142
We Multicultural and Gender Perspectives.......................e 149

Vili
Need 150
The Present Problem 15]
Skills 154
Characteristics of Ethnic Groups i353
Identity Development 158
Models of Treatment 160
Feminist Therapy 160
Conscientizacao 161
Multicultural Group Work 161
Recommendations for Education & Training 163
Additional Recommendations 164
Chapter Summary 166
8. Ethical Thinking in Research and Publication................... 175
Background 17S
Informed Consent 175
Injury to Subjects LI?
Confidentiality 180
Competence 18]
Integrity and Objectivity in Research 182
Ethical Precautions Using Various Research Designs 182
Control Group Designs 183
Randomized Designs 184
Baseline-Treatment Designs 184
Longitudinal Designs 184
Deception in Research 185
Ethical Issues in Research with Specific Populations 186
Geriatrics 186
AIDS Patients 187
Children 188
Ethical Issues in Other Research Paradigms 190
Covert Observations 190
Qualitative Research 19]
Historical Research 19]
Ethical Issues in Research Publication 19]
Ethics and the Peer Review Process in Research 192
Research Fraud 193
Chapter Summary 194
9. Financial and Advertising Issues & Responsibilities
tothe Publier yin tena ae eaten 199
Part 1: Financial Issues 199

Fees and Informed Consent 199
Fee Splitting 201
Billing Practices and Fraud 202
Bill Collecting 203
Managed Care 204
Part 2; Advertising and Commercial Issues 205
Advertising/Announcing Services 205
Commercial Activities 209
Part 3: Responsibilities to the Public 211
Competence 212
Accuracy of Information 212
Precautions for the Control of Information Pa;
Television/Radio 215
Treatment Through the Media 216
Self-Help Materials 216
Chapter Summary 217
10. Responsibilities to Colleagues, Employees, Employers,

and the Professional Association.................0..c:cccceseceseseeeees ppd |
Responsibilities to Colleagues and Employees Let

Harmonious Relationships with Colleagues aoe
Cooperating with Colleagues 223
Preserving the Reputation of Colleagues 2o3
Concurrent Music Therapy Services 223
Sexual Harassment 224
Letters of Recommendation g20:
Responsibilities to Employers ef
Responsibilities to the Professional Association 229
Chapter Summary 230
Additional Learning Experiences oye
11. Ethical Thinking in Education and Supervision.................. 235
Definitions 233
Advertising and Recruitment 236
Admissions Pet
Program Design and Content 238
Competence in Education and Supervision 238
Dual Relationships in Education and Supervision 241
Dual Therapy Relationships in Education & Supervision 241
Experiential Training 243
Dual Sexual Relationships in Education & Supervision 246
Dynamics 246
Prevalence and Effects 247
Ethical Issues 248
Recommendations 250
Student Evaluations 251
Confidentiality 252
Teaching Ethics 252
Where Ethics is Taught and Learned 253
How Ethics Should be Taught 254
Ethics Competencies 255
Chapter Summary 256
£2; Promoting Ethical BERavion......030:...:c2ssssseccns

obsges cesxsueeteavaoss 261
Informal Resolution of Ethics Violations 261

Formal Resolution of Ethics Violations 265
A Model for Ethical Practice 266
Chapter Summary 267
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CES isc, <csecazicns te cette yee cs een? 269
Appendix: Codes of Ethics in Music Therapy...............0.0...:cceeee 291
American Music therapy Association 291

Certification Board for Music Therapists 298
World Federation of Music Therapy 304
Association of Professional Music Therapists 306
Australian Music Therapy Association ey |
Canadian Association for Music Therapy 314
PREFACE
To be good is noble, but to teach others to be good

is nobler and less trouble.
Mark Twain
I am passionate about professional ethics! Since the writing of my doctoral

dissertation on the topic almost twenty years ago, I have devoted a significant portion
of my professional energies to ethics: studying, conducting ethics research,
presenting ethics papers and workshops at conferences, chairing ethics committees,
contributing to the writing of ethics codes, and teaching ethics to students. This book,
then, represents an important step in the evolution of this passion.
Ihave learned many things about professional ethics during this time, and my
learning continues. The breadth of issues involved in professional ethics is
staggering, and although I would like to say that all of these issues are addressed in
this book, I realize that this is not the case. In every professional situation, there are
ethical problems, too numerous and unique to be included in any one volume.
I’ve learned that professional ethics is continually evolving. Practices and
standards change in response to new laws, new technologies, new ethical issues, etc.
For example, the emergence and widespread use of the internet during recent years
has posed new ethical considerations, which will invariably influence ethical practice
and standards in the near future.
I’ve learned that the acquisition of ethical thinking as a process is critical in
meeting the challenges of professional life. Ethical thinking is complex, active and
multi-faceted. It involves the whole of the person, including thinking, feelings,
values, self-awareness, beliefs, knowledge, attitudes, biases, judgment and virtues.
I’ve learned that a knowledge of ethical standards and laws is essential to
competence, however, these are insufficient in providing practical guidance for day
to day ethical dilemmas. Furthermore, they do not or cannot substitute for the
process of ethical thinking.
I’ve learned how necessary training in the process of ethical thinking is for
music therapy students and professionals. Whereas ethical dilemmas that arise in our
profession may often be similar to those of professionals in related fields, they are
sometimes quite different, due to the medium of our intervention, the intensity of the
music therapy process, the diverse and multicultural nature of our work, and the level
and types of training we receive.
Moreover, I’ve learned that ethical thinking is perhaps the most important
skill we can impart to students and colleagues, as it is the hallmark of the true music
Xll
therapy professional. Music therapists are regularly confronted with ethical problems
for which no clear or obvious solution is forthcoming. They face conflicts in needs,
rights, responsibilities and values. Negotiating their way through these ethical
quagmires requires caring, compassion, prudence, and courage.
Finally, I’ve learned that teaching ethical thinking requires a thoughtful, safe,
sensitive, encouraging, honest and allowing process. As ethical thinking calls upon
all parts of the person, including an acute sense of self-awareness, students (and
professionals) must be sufficiently supported in this endeavor. In addition, those who
teach and supervise must be capable of serving as ethical role models themselves.
Purpose and Structure of The Book
This book is written for undergraduate and graduate students and

professionals in music therapy. Its purpose is to provide exposure to a wide range of
ethical topics and issues therapists may encounter in all aspects of their professional
careers. Besides providing a brief review of recent literature on ethics, from both
music therapy and related fields, the goal of this volume is to facilitate the
acquisition of ethical thinking.
An ethical decision-making model is included in the first chapter, and this
may be applied in solving the ethical dilemmas included at the end of each chapter.
The existing music therapy codes of ethics (from the United States, from the World
Federation of Music Therapy, and from the English-speaking countries around the
world) are included in the Appendix. Readers may consult these standards as part of
the process of solving the various ethical dilemmas posed. It has been my experience
that using the codes in this way helps students and therapists learn their content most
efficiently. It also facilitates an awareness of how important the process of ethical
thinking is for those issues not addressed directly in the codes!
A particular emphasis of this book is on the need for self-awareness and self-
exploration. As it is impossible to think ethically without being aware of one’s
feelings, values, virtues, biases, attitudes, prejudices, and ethical blind-spots, there
are a number of self-assessment activities suggested at the end of the chapters for
more in-depth discussion and exploration within the classroom or supervisory
setting, or for the reader to complete in private. Readers are encouraged to maintain
a personal journal while using the book, and suggestions for journal entries are
provided at the end of the chapters.
In addition, a number of instructional activities are included at the end of
each chapter to be used for more detailed investigations of specific topics. These may
be particularly relevant for graduate students and professionals who may want to
learn more about particular issues that are relevant to their interests, needs, and
clinical practices.
Chapters are organized around specific categories of responsibility the music
therapist assumes as a professional. Whereas this organization works onaconceptual
level, it does not always work on a practical level. Issues and content may indeed
overlap, and often more than one issue is involved in an ethical problem. Cross-
referencing from chapter to chapter is used throughout the book to avoid obvious
Xill
redundancies.
As I mentioned above, the breadth of ethical issues that a professional may
encounter is staggering. Not all have been or could be included in this text. This is
not meant to imply that these issues are either unimportant or ethical just because
they do not appear. Choices of issues had to be made, and numerous ethics textbooks
in related fields were consulted concerning the topics they included or did not
include. The present text is considered to be relatively similar in content to the most
widely accepted texts in other professions.
Professional music therapists may use this book as a reference for the
numerous ethical dilemmas they encounter in their work. They may use the ethical
decision-making model to solve ethical problems in the “real world,” and they may
also benefit from specific guidelines for dealing with ethical issues. Helping
clinicians to become sensitized to and to anticipate ethical problems is also an
important mission of this book. For example, music therapists in private practice
may become more aware of the potentially enormous ethical and legal issues they
may encounter.
This book is intended to be a practical one, i.e., to facilitate ethical thinking
and to apply this thinking to potential ethical problems. Although there is some
information provided on ethical principles, theory and philosophy, this is not its
primary focus.
The relationship of the law to music therapy practice is emphasized whenever
possible, as this may impact significantly on ethical decision-making. However, it
is important to note two things in this regard: 1) laws affecting practice vary from
state to state, and it is not feasible in one volume to present all the laws from all the
states, and 2) music therapists may or may not be covered by or named specifically
in these laws, and there is little precedent for how these laws have been or may be
applied to music therapists.
Similarly, for readers who are from countries other than the United States, it
is essential to note that this book has been written from an American perspective
alone, particularly with regard to laws, No attempt has been made to address legal
issues for music therapists practicing outside the United States.
It is also critical for non-American readers to understand that ethics occurs
within a cultural context, and the cultural context for this book is strictly American
(multicultural as it may be)! Therefore, ethical issues that are addressed herein may
not be ethical issues at all within a different culture or country. Moreover, there may
be ethical issues not addressed in this book that are serious issues in another culture.
Teachers and supervisors from non-U.S. countries who use this book as a text, will
therefore need to interpret the issues for their students based on their own culture.
The Ethical Dilemmas
Various ethical dilemmas are presented at the end of most chapters in the
form of case examples. These dilemmas have been drawn from a variety of sources:
my personal experience (and all identifying information has been removed), from the
contributions and discussions of my students throughout the years, and occasionally
X1V
from ethics casebooks in other professions.

No direct solutions to these situations have been provided, as they are
intended to stimulate discussion, self-exploration and ethical thinking. From my
many years of experience in teaching within a case-example format, I can assure you
the discussions will indeed be heated ones (and students have always relished the
opportunity to disagree with each other and with the professor as well)!
Readers should attempt to apply all relevant aspects of the decision-making
model presented in Chapter 1 in arriving at a solution to the dilemma. In the past, |
have given students multiple-choice solutions to the problems with instructions to
choose from one of the responses (or “none of the above” options). I have found that
learning is enhanced without these choices, as it is more challenging for students to
develop their own alternatives. Ethical thinking is a unique process for each person,
and there should be no imposition of ideas or interpretations.
Readers are encouraged to think about the dilemmas in a personal way, and
to consider how they would respond as individuals to each of these. They should
observe their spontaneous reactions to the dilemmas, and to explore these responses.
For example, readers may feel uncomfortable, fearful, shocked, bored, sad, angry,
etc. when they read the scenarios. These reactions can lead them to a greater self-
awareness, as they connect their reactions to their own beliefs, values, attitudes,
cultures, and life experiences. It is not likely that all readers will react in the same
way to the content of this book, and sharing these reactions with colleagues can
provide fertile grounds for discoveries about self and others.
It is often the case as well that readers will have different perspectives
regarding how an ethical dilemma can be solved. They should be encouraged to
formulate their own ideas and opinions and to express these openly. Instructors may
further challenge students by modifying the dilemma in various ways, as even subtle
changes to the situation can drastically alter proposed solutions.
As some situations or topics may elicit personal and sensitive reactions from
readers, the environment created for discussion, exploration and discovery needs to
be a safe, encouraging, and supportive one. The instructor as well as the students
should share responsibility for creating this. This may be accomplished by assuring
confidentiality, by facilitating respect for the ideas of others and by aspiring to the
virtues of an ideal music therapist (see Chapter 2). Both students and instructor
should avoid indoctrination, ridicule, pressure to conform or any form of
disrespectful behavior. Additional guidelines for this type of experiential work are
provided in Chapter 11.
It is my “passionate” wish that this book will be useful to readers in learning
the complex and exciting process of ethical thinking. If only one ethical problem can
be avoided or resolved more successfully by using the information provided in this
book, it will have been well worth the effort indeed.
Acknowledgments
First, I would like to acknowledge the significant role that Mr. Charles
Braswell, Professor Emeritus of Music Therapy, Loyola University of the South, has
XV
played in my professional life, as my mentor, friend and most trusted advisor. He is

the person who first taught me professional ethics during my undergraduate studies.
A number of years later, he suggested that I focus my doctoral dissertation on ethics
in music therapy. Therefore, he is the person most responsible for my interest in and
knowledge on the topic. More importantly, however, he has never ceased to be my
foremost model of professional integrity. My gratitude to him cannot be expressed
in words. :
I would like to thank my students, past and present, who have helped me to
refine my ideas on ethics, who have challenged my opinions with their own, who
have provided new and innovative perspectives, and who have taught me more than
they’ll ever know.
I would like to thank Temple University and Dr. Jeffrey Cornelius, Dean of
the Esther Boyer College of Music, for the research leave that supported my work
on this book.
My appreciation is expressed to my graduate assistants, Joke Bradt, MMT,
MT-BC, Maria Scutti, MT-BC, and Michael Zanders, MT-BC for the countless
hours of article and book retrieval that helped to make this book possible.
Thanks to my colleagues and friends, Drs. Ken Bruscia and Darlene Brooks
for listening and advice.
My friends, Julia Marciante and Janice Judge gave me immeasurable support
during the preparation of this book. My thanks are expressed to them for always
being there and for continually showing me all that true friendship implies.
Most of all, thanks and love are expressed to the people who share my life
and who kept me going while writing this book: to my father, Noble Dileo, who is
always present in my thoughts and heart, and whose love goes on and on; to my
mother, Frieda Dileo and sisters Linda Dileo Cantrell and Dawn Brooks, for their
love, support, constant encouragement and belief in me; to my son, Jeffrey Dileo
Maranto, for continually reminding me that there are things in life, such as teenagers’
needs, that are much more important than writing ethics books; and to my partner,
José Ignacio‘““Natxo” Castafio, for the cover design, for his advice on the content and
technical aspects of the book, for cooking all of our meals, and for the many
wonderfully loving details of everyday life.
And as always, I thank my Creator for His many gifts and blessings.
Cheryl Dileo
August, 2000
XV1
ABOUT THE AUTHOR
Cheryl Dileo, PhD, MT-BC, is Professor of Music Therapy at Temple University in

Philadelphia, and has been involved there in the establishment of the first full PhD
program in Music Therapy in the United States.
She is a Past-President of the World Federation of Music Therapy, and also a Past-
President of the National Association for Music Therapy, Inc.,
She received her bachelor’s and master’s degrees in music therapy from Loyola
University of the South and her PhD from Louisiana State University, Baton Rouge.
She has held music therapy teaching positions at the University of Evansville and
Loyola University of the South, and served as a Consultant in the development of the
music therapy undergraduate program at the Berklee College of Music, Boston.
She has served in many leadership positions for the National Association for Music
Therapy, the World Federation of Music Therapy and other professional organizations
during the past 25 years. She authored the Model Ethical Guidelines of the World
Federation of Music Therapy, Inc. (1993), and also the Code of Ethics of the National
Association for Music Therapy, Inc. (1988).
She is the author/editor of 10 books and over 70 chapters and articles on music
therapy; her research specialties include: medical music therapy, professional ethics
and music therapy education and training. She is a consulting editor for the Journal
of Music Therapy, The International Journal of Arts Medicine, and The Arts in
Psychotherapy.
She is currently involved in clinical work and research at Temple University Hospital
with patients awaiting heart transplantation. She frequently consults with medical
facilities who are interested in establishing music therapy or music medicine
programs.
She is an active international lecturer having taught in 17 countries on 5 continents.

In 1995, she received the Merit Award from the National Association for Music
Therapy, Inc.
INTRODUCTION TO ETHICAL THINKING
Consider the following situations:
Joan, your music therapy colleague working at the same adolescent

inpatient treatment facility as yourself, is having an affair with Al, a
married co-worker. Although they have attempted to be discreet, their
relationship has become known to their professional colleagues, including
yourself. Steve, one of your adolescent clients, tells you that he heard
about the relationship between Joan and Al, and asks you ifthis is true.
Following a GIM session in which many disturbing images were

described, Alice, a 15 year old client, tells you that she has been molested
by her father for the past year. Alice is very depressed and tells you that if
you tell anyone, she will commit suicide.
As a music therapist working in private practice in a small community,

you have had an intense and stressful week. However, you and your
husband have planned a special evening at a restaurant to celebrate your
anniversary. During the romantic dinner, your husband presents you with
a beautiful diamond anniversary ring and leans over to kiss you. After he
does, you open your eyes and discover that one of your clients, Joe, has
just entered the restaurant and has observed this kiss. You have just begun
working with Joe and suspect that he is sexually attracted to you.
Music THERAPISTS, like most other professionals, are inevitably faced

with perplexing ethical problems and conflicts on a regular basis. Ethical dilemmas
occur when there is no one solution that will resolve the problem in a completely
appropriate way or when there are several possible solutions, all of which appear less
than satisfactory (Bailey & Schwartzberg, 1995). Most often these dilemmas
represent conflicts between or among the various areas of professional and personal
rights and responsibilities.
Because of the range and complexity of potential ethical dilemmas that may
challenge a music therapist throughout his or her career, it is quite impossible to
prepare anticipated “solutions” to all of these problems. More often than not, music
therapists must make ethical decisions by themselves, and frequently these must be
made hastily and involve heightened emotions and pressure. Even when they are told
what to do by supervisors, employers, etc., they alone must live with the
consequences of their decision.
Music therapists who have acquired the skill of “ethical thinking” can
approach ethical dilemmas objectively, can assess their own personal values and
feelings, can appraise and prioritize the rights and responsibilities of all parties
involved, can evaluate consequences of various decisions, can make the best decision
possible, can implement the decision, and can accept the consequences. Ethical
thinking is a style of making decisions that underlies truly ethical behavior;
moreover, it is the hallmark of professionalism.
The ability to utilize “ethical thinking” in making decisions is perhaps the
most important skill a music therapist can possess. Without this grounded and
incisive sense of ethics, no matter how musical, how clinically adept, or how well
prepared the therapist may be, he or she will never be a “good” music therapist.
Ethical thinking is at the core of music therapy practice, research, supervision, and
teaching. It is by far the most important content area of music therapy education and
training and the most valuable skill a student can acquire. A music therapist who
does not possess ethical thinking puts his or her clients, research subjects, students
and/or supervisees at risk, can compromise responsibilities to an employer, and can
jeopardize the reputation of the profession.
Ethical thinking 1s a process that draws upon all resources of the professional.
It requires: self-awareness of one’s beliefs, feelings, values, attitudes, and
motivations; knowledge of relevant codes, standards, principles, laws; sensitivity to
the cultural context and client’s values; good judgment; and the application of
personal virtues (see figure 1)
Figure 1
Empathy
Feelings & Motivations elf-Awareness
Therapist’s Valueg Client’s Values

Ethical
Ethical Codes Thinking
Core Principles
Knowledge/Judgment Contextual values

Why Professional Ethics?
Why should music therapists be ethical? There are two primary reasons.
Music therapists belong to the helping profession, individuals from a variety of
disciplines whose purpose it is to provide service to others. These services provide
an important function within society; helping professionals are bound to special
obligations to others, and enjoy special rights aswell. Their
s Society expects that these
individuals will exercise their professional and personal responsibilities in an ethical
manner, putting the needs of their clients above their own (Stein, 1990).
Secondly, ;
Music therapists have skills and
knowledge which translate into power. The ethical responsibility for therapists, then,
is to not exploit this power; to do so would imply a violation of the client’s trust, a
necessary component of helping. Furthermore, helpers have an ethical imperative to
be aware of themselves and their actions, and to promote the welfare of and
minimize harm to the client (Stein, 1990).
According to Pope and Vasquez (1998), ethics*impliesethreesfundamental
asks
admitting,the:significance
for therapists: 1) of the: lives of the individuals we’
pour pi
orneeeeie Te PT bilitwas P
Terminology
There are a number of terms used in professional ethics that must be defined
and clarified prior to further discussion. Although definitions abound for these terms,
the following definitions will be used in the current text.
The term, i e
a
eontexts. These standards “prescribe what humans ought to usually do in terms of
righis, obligations, benefits to society, fairness or specific virtues” (Andre, 1986, p.
2):
These principles are expressed as guidelines and comprise the Gedeof Ethics
for a profession. Holding a professional credential implies adherence to the
established ethical code. Ethical behaviors are those that conform to these accepted
professional standards of conduct.
Valieraresicubjentivel avd may be both emotionally charged and deeply felt by the
individual. “People’s values represent the totality of their prior experiences,
education, socialization, and reflection on choices made in other situations” (Stein,
1990, p. 23). As will be seen in this book, a music therapist’s own values often
influence “ethical thinking.” Furthermore, an individual’s personal values may be
in conflict with his or her professional ethics.
However, morals
involve an intrapersonal evaluation of behavior according to a static or evolving
cultural or religious framework (Corey, Corey & Callanan, 1998). Personal, religious
or cultural morals can influence and conflict with professional ethics.
- n
aninterdisciplinarystheoretical/and geographicalibasis” (Corey, et al., 1998, p. 3).
i i ;
Professionalism is indeed related to ethics. It is

possible, however, to be unprofessional and not unethical (such as in wearing sloppy
clothes to work). On the other hand, unethical behavior is a/ways considered
unprofessional as well.
hich Legal
d standards
! re those professional
refer tofessional. regulated by thely lawof
behayi behaviorsble wit
Prosecutions,
The Background: Research in Professional Ethics
The area of music therapy ethics has not received adequate attention from
researchers, clinicians or scholars in the field. What is known from the published
research will be briefly summarized in this section. In addition, selected research
results concerning ethical behavior in the field of psychology will be reviewed.
Reasons for the lack of attention to music therapy ethics were speculated by
Dileo-Maranto (1987c) who stated that music therapy professionals may
inaccurately assume that: 1) the use of music in treatment is not ethically
problematic, 2) music therapists are not called upon or involved in ethical or legal
decisions, 3) the existing codes of ethics are sufficient for ethical decision-making,
and 4) music therapists are by nature ethical in all areas of practice.
Dileo-Maranto (1981b, 1984, 1987c) performed a systematic comparison of
the Code of Ethics of the National Association for Music Therapy, Inc. with codes
of ethics from other creative arts therapy professions and from other health care
professions. She found notable differences in content and focus among codes of
various creative arts therapy professions (art therapy, dance therapy, etc.), with few
commonalities among them. In comparing the NAMT code with those of other
health care professions, she found several areas not addressed in the NAMT code.
These included statements concerning continuing education, fees, advertising and
private practice. The NAMT Code was subsequently revised (Dileo-Maranto, et al.,
1988) to include these issues. She recommended that there be an ongoing evaluation
of the NAMT Code to assure its relevance and timeliness (1987c).
In spite of the lack of attention to ethics in their literature, music therapists
regard ethical competence as very important in comparison to other entry-level skills
(Braswell, Decuir and Dileo-Maranto, 1980). In contrast, however, music therapists’
ethical problem-solving abilities are disparate. Dileo-Maranto (1981a, 1981c, 1987c)
asked 21 randomly selected music therapists to select one of four solutions to 56
hypothetical ethical dilemmas and also to rate the importance of each of the ethical
dilemmas on a scale from 1 (Unimportant) to 7 (Extremely Important). Results of
this survey showed a widespread disagreement among respondents concerning the
“correct” solution to each of the ethical dilemmas (there was unanimous agreement
on only 8% of the solutions). Ethical problems causing most disagreement among
respondents included: the relationship between supervisor/practicum student,
incompetent faculty, use of employer’s facilities, settings for private practice,
personal values of the music therapy with regard to treatment, advertising,
confidentiality, and emotional involvement with clients (see Dileo-Maranto, 1987c
for the complete list). Respondents also rated the following ethical issues as most
important: confidentiality, client welfare, and dual relationships; and the following
as least important: advertising, personal behaviors of therapists, and gifts from
clients.
In a similar survey, Dileo-Maranto (1981a, 1981c, 1987c) asked 11 music
therapy experts to select the correct response (from four possibilities) to 300 ethical
problem situations and to rate their importance. There was unanimous agreement
among experts on only 25% of the solutions, and there was no unanimous agreement
on any one of the 300 items regarding its importance.
Dileo-Maranto (1980; 1981c) and Dileo-Maranto & Wheeler (1984;1986)
surveyed all NAMT and AAMT music therapy university faculty to determine how
ethics is taught within the music therapy curriculum. Results showed that music
therapy is taught most often as part of another course (rarely as a full course), and
that faculty felt that materials available to teach ethics were insufficient.
Respondents indicated that music therapy students are often quite naive to ethical
issues prior to instruction, and that instruction in ethics should constitute a greater
portion of training. The breadth of ethical issues emphasized in teaching appeared
limited (perhaps due to time constraints), as one-third of faculty reported that
confidentiality issues were the main focus of teaching. Faculty rated themselves as
at least moderately successful in teaching ethics, and there was no general consensus
among respondents concerning the most difficult area of ethics to teach.
Dileo-Maranto (1990) reviewed 256 experimental articles appearing in the
Journal of Music Therapy between 1968 and 1988. The method section of each was
analyzed to determine the specific ethical precautions implemented in research
relevant to informed consent (e.g., voluntary status of subjects, risk-benefit
advisement, protection of confidentiality, etc.). In addition, each article was assessed
to determine if any potentially deceptive or injurious procedures were used (physical,
psychological, or social). Only 22 % of the articles reviewed contained any reference
to the use of ethical precautions, and 4.3% implemented procedures that could be
classified as deceptive or potentially injurious to subjects. The author recommended
that there be additional education regarding research ethics to students and
professionals, a review of publication policy by the Journal of Music Therapy, and
greater familiarity with the NAMT Code of Ethics.
All of these studies point to the need for additional, as well as more focused
and in-depth education of music therapy students and professionals regarding
professional ethics. This need is apparent in other fields, as well. Several studies
regarding the ethical behaviors of psychologists are reported below as an example.
Pope and Vetter (1992) conducted a critical incident survey of common
ethical dilemmas experienced by 679 practicing members of the American
Psychological Association. Respondents identified 703 problematic ethical issues
which were organized according to 23 different categories. Fifty-seven percent
(N=398) of the ethical issues reported fell into the following four categories (in
descending order of frequency): 1) confidentiality, 2) blurred, dual or conflictual
relationships, 3) payment sources, plans, settings and methods, and 4) academic
settings, teaching dilemmas and concerns about training.
Within the first area, confidentiality, there was ample evidence provided that
psychologists were indeed struggling with difficult decisions about whether to reveal
confidential information and to whom. Particular areas of difficulty included:
reporting risks to third parties, child abuse cases and HIV disclosure. Respondents
appeared to be concerned about the boundaries of confidentiality among multiple
caregivers and in group situations, as well as the conflicts between ethical codes and
the law.
Within the second area, blurred, dual or conflictual relationships,
psychologists reported difficulties in maintaining clear and appropriate boundaries
within the therapeutic relationship, for example, in therapist/supervisory roles, in
providing therapy to individuals with whom there was also a social relationship, and
in relationships with former clients. The authors suggest the need for clarification in
the ethical guidelines as to what constitutes dual relationships, the special problems
involving dual relationships in small or rural communities, and the issues of
accidental dual relationships.
Within the third area, payment issues, respondents were in large part
concerned about ethical responsibilities with regard to clients’ inadequate insurance
coverage, billing issues, and conflicts between the needs of the clients and financial
priorities of providers, employers and/or administrators.
Within the fourth category, academic and teaching issues, many respondents
reported ethical dilemmas in the pressures to assign inflated grades to students as
well as the issue of dealing with unqualified students.
Frequent problems addressed by the Ethics Committee of the American
Psychological Association reportedly involve issues of competence, poor
professional judgment, impaired practice (physical and emotional problems),
informed consent, confidentiality, dual relationships and financial arrangements.
Poor training is a possible cause of these phenomena (Peterson, 1996; Pryzwansky
& Wendt, 1999).
Other research regarding ethical issues in psychology and related fields will
be mentioned throughout this text. As will be seen, ethics education for students and
professionals continues to be cited as a possible preventive strategy for ethical
problems.
Core Ethical Principles
There are a number of core ethical principles which underlie professional

behavior in many disciplines which are also relevant to the practice of music therapy
(Bailey & Schwartzberg, 1995; Cohen & Cohen, 1999; Corey, et al., 1998; Koocher
& Keith-Spiegel, 1998; Pope & Vasquez, 1998; Scott, 1998). Ethical principles can
be the starting point for a discussion of ethics and represent what may and should be
internalized by the therapist, as these stimulate thinking and subsequent behavior
(Rosenbaum, 1982). These core ethical principles are listed below.
including the risks of injury) to others through either a specific action

or through neglect. The principle of wtiditystresses,the
intention. ofproviding, to
(Munson, 1988).
3) The principle of autonomy acknowledges the rights of individuals to make

choices and decisions regarding their own welfare, as.long asthese choices donot
impinge.upon.the.autonomy-ofothersy
Respecting the autonomy of others implies
allowing them
self-determination.
the freedom of
4) Justice stresses the concepts offairness and equality intreatment toall.
t
equality with which treatment is dispersed at the individual level (Scott, 1998).
According to the concept of equality, “all benefits and burdens are to be distributed
equally” (Bailey & Schwartzberg, 1995, p. 7).
5) Fidaliégzizoplinsetiaeslaliill ?
(Corey, et al., 1998).

6)MOT
Rbioadelineds rane cband ithof
10) Acknowledging accountability involves accepting theresponsibility for
personal and professional behavior and performing professional duties with integrity.
These core principles are significant goals to which the music therapist may
aspire, and are manifest in all of the music therapy professional codes of ethics. They
are extremely important principles to consider as a music therapist makes ethical
decisions, and as such, comprise one aspect, but not the totality, of ethical thinking.
Models of Ethical Development
Several authors describe the developmental stages or processes of moral

decision-making and behavior. Three of these models are included in this section, so
that the reader may gain an understanding of the possible developmental aspects
involved in ethical thinking.
The first'model isthat of Kohlberg (1984) ee ee
stages..of -moraldecision-making»based»primarily~on=the»concept»of
justice: |
. A behavior is moral if one does not receive punishment for it. Bad
behavior is punished. 2) /nstrumentalegoism. Behavior is good if it meets the needs
and wants ofa person. 3) Interpersonal concordance. Behavior is moral if it reflects
a consideration of others and meets with their approval. 4) L
order, What is moral is defined by fixed rules that all must obey. Individual beliefs
are subordinated to authority for the good of all. 5) Societal*eonsensus. Moral
behavior is voluntary, and rules for behavior are democratic. 6) Nonarbitrary social
cooperation: Moral behavior is a product of rational and impartial decision-making,
with a concern for the implications of behavior for others.
Kohlberg’s levels show a progression in moral development and moral
judgment from preoccupation with concerns of the self, to conformity to norms and
rules of one’s own social environment, and finally to concern for more universal
principles (Beabout & Wennemann, 1994).
Acknowledging that there is more to morality than moral judgment, a second
theoretical model is that of Rest (1994) who describes the processes involved in
inl itivity,) involving an
interpretation of the situation, an analysis of possible outcomes of actions, empathy
and role-assumption; 2) moral judgment, involving a determination of which course
of action is morally right or wrong; 3) morabmotivation involving a prioritization of
the importance of some moral values over others; and 4) moral'charatter, involving
the strength and courage to implement the morally correct course of action (pp. 23-
24). Moral behavior can be enhanced through education (Rest, 1994).
Whereas Kohlberg’s model of moral decision-making focuses on the concept
of justice (a male concept of morality according to Gilligan, 1977), it does not reflect
the experiences of women whose moral concerns comprise issues of care (Biggs &
Blocher, 1987). Gilligan (1977) thus proposed a three-level progression of moral
development in women. At the first level, egocentric, the woman is both self-focused
and powerless, morality is a function of societal sanctions, and “should” and “would”
are synonymous. During the transition to the next level, there is movement from self-
involvement to responsibility, the development of connections to others, and
increased self-esteem with the potential for making good moral choices. At the
second level, societal, morality is a function of social norms, and self-sacrifice and
responsibility for others (but not for self) is valued. During the transition to the next
stage, self-sacrifice is re-evaluated, and care for self and one’s own needs become
salient. Honesty, truth and self-responsibility are salient features. In the final stage,
universal, caring, nonviolence, and the obligation of not harming become universal
imperatives governing actions towards self and others (Biggs & Blocher, 1987;
Gilligan, 1977).
Although none of these models can necessarily be considered complete and
absolute, they provide information for both students and professionals concerning
the potential complexity of developmental issues and processes in ethical decision-
making. In addition, they also point to possible gender differences in moral
development which may impact on ethical judgment.
Theories of Ethics
It is also important to consider in this section several theories of ethics,

rooted in philosophy, that are sometimes used as a basis for making ethical
judgments. Several of the prominent theories are presented and considered. These
are organized according to theories involving consequentialism, non-
consequentialism, virtues and feminist ethics. The first two theories are considered
principle-based. In these, abstract ethical principles are enumerated, and the ethical
merit of choices is determined by how well these principles are adhered to (Howe &
Miramontes, 1992). Principle ethics emphasizes obligations and choices for behavior
to determine the right course of action.
Consequentialism (teleological approach) embraces the perspective that
right or wrong behavior is judged solely in terms of its consequences. Ethical
behavior maximizes what is good and minimizes what is bad.
Consequentialist theorists often differ with regard to the hierarchies of values
which form the basis for ethical judgments (Banks, 1999). Utilitarianism is one type
of consequentialism. Behavior is good when it maximizes the good of all.
Difficulties in applying this theory include that it is not always possible to define
what is the good which results, and that it is cumbersome to calculate how many
people will benefit from a given act (Howe & Miramontes, 1992)..
Nonconsequentialism (also known as deontological theory) emphasizes that
10
the ethical merit of actions is not determined by their consequences, but on the basis
of logically consistent, universal rules and principles involved in_ their
implementation (Schulte & Cochrane, 1995). For example, Kant stressed the
principle that individuals are intrinsically worthwhile, should be respected, and
should be autonomous (Banks, 1999). In contrast to consequentialists, non-
consequentialists affirm that maximizing the good does not imply a sacrifice of the
good for some so that others can benefit. In addition, non-consequentialists do not
need to know anticipated outcomes of actions before decisions are made. A problem
however with non-consequentialism is that there may be competing universal ethical
principles involved in any decision, and there is no means to prioritize these
principles. Consequentialists solve this issue by focusing on the principle that serves
the maximum good (Howe & Miramontes, 1992).
Critics of these two principle-based theories point to the problems in dealing
with abstract, universal principles. These appear to be difficult to apply in real-world
settings, are not sensitive to unique aspects of differing situations, and do not
enhance the creativity needed in addressing new ethical problems. Principle-based
theories also seem to ignore the histories and uniquenesses of the persons to whom
they are applied (Howe & Miramontes, 1992).
A thitd:category ofethical:theory involves those that are virtue-based. It is
wrong to assume that there are no principles involved in virtue-based ethics, as there
are indeed. However, these principles are abandoned when they are insufficient in
solving the concrete problem at hand. As such, principles are replaced with the
ideals of the “ethically virtuous deliberator.”"(Howe & Miramontes, 1992, p. 19).
Virtue-based theories thus pinpoint who is ethically virtuous. Decisions then are
evaluated in terms of how well they represent those of a virtuous decision-maker.
Virtue ethics is aspirational, relying on ideals, rather than on rules or principles.
“Simply stated, principle-based ethics asks ‘Is this situation unethical?’ whereas
virtue ethics asks ‘Am I doing what is best for my client’” (Corey, et al., 1998, p.
10).
According to Meara, Schmidt and Day (1996), a virtuous person can be
characterized as an individual
who (a) is motivated to do what is good, (b) possesses vision and
discernment, (c) realizes the role of affect or emotion in assessing or judging
proper conduct, (d) has a high degree of self-understanding and awareness,
and perhaps most importantly (e) is connected with and understands the
mores of his or her community and the importance of community in moral
decision making, policy-setting and character development and is alert to the
legitimacy of client diversity in these respects (pp. 28-29) (Pryzwansky &
Wendt, 1999).
Meara, et al., (1996), see virtue ethics and principled-based ethics as

supportive to each other and equally necessary to competent ethical decision-making.
Howe and Miramontes (1992) further suggest that the theory chosen is dependent
upon the characteristics and nature of the ethical question and ultimate decision to
be made.
cs. In this theory, ethical
decision-making is not based on a set of rules, but on a framework for thinking that
underlies all assumptions concerning theory and practice. This framework includes
the feminist principles of empowerment, collegiality, care, cultural diversity,
proactivity, and therapist competence and accountability (Brown, 1995; Coale, 1998;
Lerman & Porter, 1990). Feminist ethics is in direct rebuttal to rule-based models,
and involves “an ethic of multiplicity and mutuality, in which ail voices - client,
significant others, therapist, and community - are privileged” Coale, 1998, p. 205).
The feminist model of therapy is discussed in Chapter 7.
Codes of Ethics
Having a code of ethics is a necessary part of being a profession. According

to criteria presented by several authors (Fleming, Johnson, Marina, Spergel, &
Townsend, 1987; Richardson & White, 1995; Scott, 1998), music therapy can indeed
be classified as a profession. These criteria include: a defined body of specific
knowledge or expertise; autonomy and self-governance, including the
implementation of a code of ethics and standards of practice; formal educational
procedures for practitioners; research geared towards substantiating practice; a
professional organization which represents the professionals; and an
acknowledgment of competency through certification, etc. Thus, the development
and enforcement of a code of ethics for music therapists is an essential component
of its being considered a profession.
According to Levy (1993), professionalethics
perform several functions. As
, ethics provide the acknowledgment of what is acceptable in behavior in
specified contexts, and the understanding of these values is fairly widespread. As
aspirations, ethics function as ideal behaviors to which individuals can only attempt
to ascribe. As prescriptions, ethics function as nonvoluntary mandates, the violation
of which can impose censure.
lawsuits!(Lowenberg & ane ere cen 1996; Stein, 1990).

For whom are codes of ethics written? Certainly, codes are obviously
. “(C)odes are the canons
of the counselor’s profession. They govern the behavior of the professional. They
inspire ethical conduct and serve as the standard against which professional conduct
is measured. Moreover, they serve as a guide or reference for the counselor who had
a question about how to proceed after confronting a problematic situation” (Stein,
1990, p. 65). Codes are also intended for the general public. They inform the public
of the standards adhered to by its professionals, and of the quality of services that can
12
be expected from them (Stein, 1990).

There are problems, however, in relying solely upon codes for ethical
decision-making. Ethical behavior involves more than conforming to the mandates
of a code. Codes do not provide foolproof or perfect guidelines for several reasons.
First, codes tend to be ambiguous, vague, and overly broad in nature, and often do
not present specific solutions for specific problems (Bersoff, 1994; Hughes, 1986;
Jacob-Timm & Hartshorne, 1998; Keith-Speigel & Koocher, 1985; Kitchener, 1986).
Second, ethical principles contained in the codes may compete with each other in any
given situation, and it can be very unclear as to which principle should be observed.
Ethical principles in codes may also conflict with the law. Third, codes of ethics are
not proactive in terms of new ethical issues that emerge (Jacob-Timm & Hartshorne,
1998). Rather, principles are usually added some time after an ethical problem has
become salient, or after a law has been passed (Stein, 1990).
Codes are also limited in helping the professional determine solutions to
complex problems, involving conflicts between the ethical code and the
professional’s values and/or the standards of the employer, community or culture
(Corey, et al., 1998), Furthermore, Pope and Vasquez (1998) stress that codes of
ethics are insufficient in providing solutions for unique clients in unique situations.
Even in cases where the codes provide specific prescriptions for behavior,
they are not helpful in providing details concerning the process of making decisions,
i.e., making one choice over another, or in educating the professional concerning the
rationale for being ethical (Stein, 1990). Codes therefore, are only one part of ethical
decision-making, as ethical thinking comprises a larger and more involved process
for which the professional is ultimately accountable (Jacob-Timm & Hartshorne,
1998; Stein, 1990).
Coale (1998) vehemently argues for “context-based” rather than rule-based
ethics (1.e., codes of ethics), as the former facilitates the process of ethical thinking
based on the uniquenesses of the client and the therapist’s relationship with him or
her. The client’s context is defined as the system involved in therapy, the meaning
given to that system, and the meaning co-created through the therapeutic
relationship. Ethical decisions can only be made in this context, and therefore ethics
rules cannot be legislated.
Coale (1998), writing from a feminist perspective, further elaborates the
problems of rule-based ethics. First, the needs of humans are extremely variable;
rules imply that all clients are the same. Second, rules invoive ascribing “truth” to
professionals and their institutions over clients “voices” (p. 6). This over-empowers
the professional and disempowers the client. Third, rules present an ethnocentric
portrayal of what is normal. Fourth, rules can function as a substitute for thinking,
and can actually interfere with the process of ethical thinking. Fifth, rules imply that
therapists are by nature not deserving of trust, and abiding by external mandates
helps them to prove their worth. Sixth, every rule is grounded in a particular
theoretical framework which inevitably conflicts with another framework. Seventh,
protection of the professional and the profession, as opposed to the client, is an
obvious hidden agenda of rules. Eighth, because of the threats of litigation, lawyers
Is
have a growing role in establishing rules. And finally, managed care imposes a
“lens” for viewing the client-therapist relationship. Coale (1998) concludes that
“(e)thics cannot be de-contextualized from the professions that promulgate them.
And the professions cannot be decontextualized from the socio-cultural context in
which they exist” (p. 15).
In summary, it is important to realize both the necessity for codes of ethics
as guidelines for professional behavior, as well as their inherent limitations. Codes
of ethics are indeed not a panacea for ethical behavior, and they comprise only one
part of the process of ethical thinking.
Interface of the Law and Ethics
Legally speaking, helping professionals have a very unique responsibility to

their clients; higher standards for their behavior are therefore required (Pryzwansky
& Wendt, 1999). This is know as a
(Haas & Malouf, 1995). Awareness
of both ethical codes and the law is essential for the music therapist, as professional
practice is governed by both types of standards.
Laws represent the minimal requirements for behavior, and conduct below
this minimum standard is subject to legal action. There are foursources
of laws and
legal obligations: 1)constitutional law, from the United States Constitution and state
constitutions;
‘ 2)
; statutory laws,
; which: are written sitby Congress and state legislatures,
age
Scott, 1998, p. 7).

There are basically two types oflaws: civil andcriminal. Civil
law governs:
the.state (Malley & Reilly, 1999).
“©There are certain characteristics of all law: 1) A law is a rule or mandate
intended for an audience and can be either affirmative, requiring something active,
or prohibitive, forbidding particular behaviors. 2) Its intent is to control behavior. 3)
A law designates a range of punishments for its infraction. 4) A law is a declaration
of what is deemed morally right by a significant portion of society at a given time.
5) A law is a mechanism for declaring and preserving people’s rights (Kapp, 1999).
As minimal standards however, laws do not provide guidelines for what may
be “excellent” professional work beyond what is considered legally permissible
(Cohen & Cohen, 1999). Ethical codes, on the other hand, provide aspirational goals
for professional behavior, that is, the ideal conduct a professional strives to achieve.
“Laws and ethical codes, by their very nature, tend to be reactive, emerging from
what has occurred rather than anticipating what may occur” and simple obedience
to codes and laws does not guarantee solutions to all ethical dilemmas a professional
may encounter (Corey, et al., 1998, p. 4)
There are at least six interactions between the law and ethics (Thompson,
14
1990). These are shown in Table 1.
TABLE 1
INTERFACE OF THE LAW AND ETHICS
Legal Illegal Not a Legal

Issue
Ethical Obeying just Not following Doing right

law unjust law where there is
no law
Unethical Obeying unjust Not following Doing harm

law just law where there is
no law
Examples of these interactions may include the following (adapted from

Thompson, 1990, Clouser, 1973). As can be seen, there are indeed circumstances
when the law is consistent with ethical codes, when the law is in conflict with ethical
codes, and when the law is irrelevant to ethical codes.
*Ethical-Legal: Maintaining a client’s confidentiality where this is mandated

by law.
*Unethical-Legal: Using testimonials in advertising clinical services.
*Ethical-Illegal: Withholding a client’s confidential records when
subpoenaed by a court.
*Unethical-Illegal: Sexual relations with a client.
*Ethical-Not a legal issue: Offering pro bono services to clients who are
unable to pay.
*Unethical-Not a legal issue: Giving therapeutic advice on talk show radio.
Howe and Miramontes (1990) summarize therelationship between the law
minate the ne
aucidivanellinphpiapaseeastia huasicigas cance Se
implications, and 4) when law does not need interpretation, itpresupposes ethical
1S
responsibilities. Therefore, ethics and the law are neither separate nor the same.
There are no simple solutions to resolving conflicts between ethical codes
and the law. Different professions are subject to different laws, laws vary from state
to state, and there are a number of gray areas in existing laws.
Moreover, codes of ethics of various associations provide differing mandates
for resolving these conflicts. For example, members of the American Psychological
Association (APA, 1995) are required to seek solutions that conform to the law and
at the same time as closely as possible to the code of ethics. Members of the
American Counseling Association (ACA, 1995) are required to yield to legal
standards (Corey, et al. 1998). For music therapists confronting these ethical-legal
conflicts, consultation with a lawyer as well as knowledgeable music therapy
professionals is essential. Doing what is ethically reasonable may also be what is
legally acceptable as well (Howe & Miramontes, 1990; Thompson, 1990), but there
are exceptions to this rule.
The term, ice, i i Malpractice
refers to the a
a
suicide of a client, breach of contract, negligence, slander/libel, and breaches of
confidentiality. For a client (plaintiff) to win a malpractice suit, the following:musty
be:proven: “1) A legal duty of care was owed by the defendant to the plaintiff...2)
There isastandard of care, and the ...professional breached that duty, 3)The client
suffered harm or injury (demonstrated and established), and 4) The...professional’s -
breach’ of duty was'the proximate cause of the injury or harm...” (Malley & Reilly,
1999, p. 68).
In roalpeasteltete
motes ae eT eREETee PT evlisnreererimina!
prosecution, depending upon the complaint. If found liable in civil malpractice suits,
professionals receive mandatory fines to compensate injured plaintiffs, and are also
subject to paying punitive damages. In criminal cases, professionals found guilty are
subject to potential incarceration and monetary fines (Scott, 1998).
Because of the fear of ethical and legal sanctions in a litigious environment,
some therapists may take a “‘risk-management” approach to professional conduct and
painstakingly adhere to all relevant laws, standards, codes and policies. Whereas it
is commendable for professionals to be aware of and uphold these rules for
professional conduct, their motivation for doing so may be questionable. Therapists
who behave appropriately out of the fear of litigation and the need for self-protection
because others may be out to get them are indeed practicing from a defensive posture
and with a focus on their own needs. On the other hand, therapists who engage in
ethical conduct because it is the right thing to do are focusing on their professional
responsibilities and the needs of those they serve. “Holding high ethical standards
requires acting with benevolence and courage rather than donning protective armor
and running for a safe place to hide” (Koocher & Kieth-Spiegel, 1998, p. 4).
16
A Model for Ethical Decision Making
The following represents a model for ethical decision-making that may be

useful for music therapists in confronting and solving ethical problems. Based on the
concept and components of ethical thinking presented earlier in this chapter, this
proposed schema incorporates ideas from a number of other decision-making
models, (Bailey & Schwartzberg, 1995; Canadian Psychological Association, 1991;
Cohen, 1994; Cohen & Cohen, 1999; Congress, 1996; Corey, Corey & Callanan,
1998; Eberlein, 1987; Gambrill & Pruger, 1997; Haas & Malouf, 1989; Hill, Glaser
& Harden, 1995; Jacob-Timm & Hartshorne, 1998; Keith-Spiegel & Koocher, 1985;
Koocher, 1983; Levy, 1993; Malley & Reilly, 1999; Nagle, 1987; Packard, 1997;
Pope, Sonne, & Holroyd, 1993; Rest, 1984; Scott, 1998; Steinman, Richardson, &
McEnroe, 1998; Treppa, 1998; Tymchuk, 1986; and VanHoose & Kottler, 1987),
as well as from principle-based, virtues and feminist theories of ethics.
The process of ethical decision-making is not a linear one, as in solving a
problem in chemistry. It may be more an art than a science, but an art with forms and
frameworks to direct creativity (Cohen & Cohen, 1999). Ethical thinking implies
balancing many “voices,” which include: the therapist’s feelings and perceptions, his
or her self-awareness, his or her virtues and values, his or her knowledge and
judgment, the client’s values, the core ethical principles, the ethical codes, the
context of the situation and its values, and the law. As Cohen & Cohen (1999) so
elegantly state: “The individual ethical decision maker is left with the challenge of
conducting the chorus, with knowing when and where each voice is to be sounded”
(p. 26). Even so, there is no assurance that an ethical decision will be reached, but
sound ethical thinking is optimized when these perspectives are considered.
The proposed model is presented in a step-by step format, although the reader
should be advised that these apparently sequential steps are indeed artificial, and they
may be considered in any order deemed appropriate and revisited as often as
necessary. Some of the twelve steps are ongoing. For example, the examination of
the therapist’s values, beliefs and feelings should occur at each step, and should not
be considered a separate step. The steps for ethical decision making are as follows:
ETHICAL DECISION-MAKING MODEL
1. Identify the problem, issues and practices involved.

2. Assess the obligations owed and to whom.
3. Assess your personal/emotional response.
4. Consult core ethical principles, ethical standards and codes, relevant
laws, and institutional policies.
5. Consider the context and setting.
6. Identify your own beliefs and values and their role in this situation, as
well as those of the client.
7- Consult with colleagues, supervisors and all possible resources.
8. Consider how the ideal, virtuous therapist might respond.
9. Generate possible solutions, utilizing the input of the client when
feasible.
10. Evaluate each proposed solution in terms of possible consequences and
make a decision.
11. Implement the decision.
12. Evaluate the decision.
The thinking and feeling process that may be involved in accomplishing each
of the steps is may be as follows:
STEP 1. Identify the problem, issues and practices involved.
a) Decide ifthe problem is an ethical one or not.

b) Collaborate with the client in defining problem.
c) Collect and weigh the facts.
d) Determine who is involved and in what ways.
e) Gather information from the individuals or parties involved.
J) Formulate reasonable assumptions about the problem.
g) Make a decision to confront the problem (or not).
ROK KOK
STEP 2. Assess the obligations owed and to whom.
a) Evaluate the rights, responsibilities and vulnerability of all affected

parties, including the institution and general public.
b) Identify the loci of ethical responsibility.
c) Identify conflicts in these responsibilities.
KKK
18
STEP 3. Assess your personal/emotional response.
a) How do you feel about the problem?

b) What are your immediate emotional reactions?
26K KK
STEP 4. Consult core ethical principles, ethical standards and codes, relevant
laws, and institutional policies.
a) Identify any conflicts between core ethical principles, ethical standards

and codes, laws, and institutional policies.
b) Consider all possible sources that may influence the kind of decision you
will make.
26 AK OK 6 OK
STEP 5. Consider the context and setting.
a) Are there sociocultural considerations, including those involving gender,

race, ethnicity, sexual preferences, etc.?
b) Are there particular factors from this context or setting that should be
taken into consideration in making a decision?
28 KK KK
STEP 6. Identify your own beliefs and values and their role in this situation, as
well as those of the client.
a) Are the therapist's beliefs and values in conflict with those of the client?
b) Can the therapist integrate personal and professional beliefs?
38K KK
STEP 7. Consult with colleagues, supervisors and all possible resources.
a) Ask advice from others, while preserving the confidentiality of the

situation.
46 KK KK
STEP 8. Consider how the ideal, virtuous therapist might respond.
a) What virtues do you possess or aspire to that can be used to make an

ethical decision in this matter?
b) How would the ideal therapist respond?
KK KK
19
STEP 9. Generate possible solutions, utilizing the input of the client when
feasible.
a) Defer judgment or critical evaluation when attempting to generate

alternatives.
b) Produce as many alternatives as possible, allowing ideas to flow freely,
rather than to be governed by rules and practical matters.
c) Combine and improve solutions to create new solutions
a) Narrow list of solutions to realistic choices.
OK ICKCK
STEP 10. Evaluate each proposed solution in terms of possible consequences
and make a decision.
a) Creating scenarios for various solutions, imagine the best, worst, possible
and probable outcomes for each.
b) Determine who will benefit and who will be harmed (physically,
psychologically, socially, economically, etc.) by each proposed
solution, (including, the client, client’s family, institution, students,
research participants, colleagues, profession, society and self), Use
a risk/benefit analysis of the situation.
c) Assess consequences of various solutions in terms ofshort, continuous and
long-term effects.
d) Select one or two solutions that appear best for the situation, and further
analyze these according to the following criteria:
i) How the solution affects the dignity and the responsible caring for
all involved. Through actively empathizing with the client,
determine how the client will feel about the solution.
ii) The degree to which the solution(s) upholds the core ethical
principles, codes of ethics and the law.
iti) The degree to which the solution is consistent with the informed
consent of the client.
iv) Whether the solution is within your normal range ofprofessional
behaviors and within the bounds of your competence.
v) Your feelings about and motivations for choosing this solution. Is
the decision based on pleasing others or yourself?
vi)The provisions and precautions required to cope with the
consequences of the decision.
e) After making a final decision, review this decision with a colleague,
supervisor and the client.
f) Determine your commitment to act on the decision. If action is suspended,
what are the reasons for this? Are there fears of risks to self? Are
there financial, legal, professional and/or social obstacles and
20
pressures not to act? Does the therapist feel threatened by others

who may oppose the decision? (Treppa, 1998).
28K OK
STEP 11. Implement the decision.
a) Be prepared to assume responsibility for the consequences.

b) Maintain flexibility.
c) Identify areas in which you may be most vulnerable and strive to minimize
this.
d) Practice coping skills and assertiveness.
e) Identify and rely upon support networks to cope with stress.
J) Think through the short and long term effects for self and others in not
implementing the decision (Treppa, 1998).
KK KK
STEP 12. Evaluate the decision.
a) Monitor, review and follow-up on the impact of the action taken.

b) Obtain feedback from others, as well as the client.
c) If the ethical situation is not resolved, be prepared to become involved
again in the decision-making process.
d)Assume_ responsibility for consequences; correct any negative
consequences of the decision, ifpossible.
e) Continue to reflect upon the situation.
* KK KK
Situations That Pose Risks
Ethical therapists may often encounter situations that may contribute.to

oblem
impair ethical
ethicalypr s»or
decision-maki ng. 'These situations may is
categorized as follows:
£aaaespeeetinoee rauscasanianue wees eines alam oe
unavoidable problems, which. may. be-anticipated. but-cannot” be adequately
:
d : c
Spiegel, 1998; Sieber, 1982)

. .
fecocher & Keith-
cs
Crisis Decision Making
In reality, some ethical decisions need to be made very quickly, as in crisis

zi
situations. When time does not permit the appropriate collection of information for
making an informed ethical choice, when there is no opportunity to involve the
appropriate persons, when it is difficult to identify the party to whom primary loyalty
is required, when stress is high and objectivity is diminished, and/or when an
ongoing evaluation and modification of actions is not feasible, ethical decision-
making can be less than optimal (Babad & Salomon, 1978; Koocher & Keith-
Spiegel, 1998). Crisis situations areusually characterized bythepresence ofan
@te! (Koocher & Keith-Spiegel, 1998).
Codes of ethics may not offer much guidance in these situations, and several
authors have provided suggestions for therapists to prepare themselves for these
situations. These are particularly relevant for music therapists who work in private
practice.
tk
are
ski The therapist should
be familiar with codes of ethics, legal regulations and institutional policies in
advance, for example, procedures for reporting child abuse and suicide threats.
Continuing education, workshops, in-service education, etc. can provide therapists
with information and skill in crisis management. The therapist should also develop
and maintain current articles on various topics in crisis management for reference in
times of need. The therapist should locate a knowledgeable attorney who may be
contacted in times of emergency, and keep his or her number handy. A professional
support group can be helpful for exploring potential issues before they occur, and
individuals can make themselves available to others in time of crisis. Therapists
should have sufficient self-awareness to realize the limits of their competence in
handling any situation, especially those that involve client crises, and should
immediately seek help when demands of the situation exceed their abilities. The
therapist should avoid relying on memory, actively documenting decisions made and
the rationale for such and maintain careful records (Jacob-Timm & Hartshorne,
1998; Keith-Spiegel & Koocher, 1985; Koocher & Keith-Spiegel,1998).
Deterrents to Ethical Behavior
Koocher and Keith-Spiegel (1998) and Sieber (1982) identify a variety of

factors that can contribute to unethical behavior in the professional: being careless,
having insufficient training, deluding one’s self, having personal character flaws, not
anticipating potential problems, encountering unavoidable or ambiguous problems,
having inadequate guidelines for solving problems, and conflicts in loyalty.
Pope and Vasquez (1998, pp. 13-15) discuss the use of ethical denial in
justifying unethical behavior. Therapists may utilize a number of rationalizations to
avoid ethical accountability. For example, they may think, “It’s not unethical if’...
*You don’t mention ethics.

22
*You are not aware of a specific ethical standard you are violating.
*You can name others who are doing the same thing.
*Y our clients don’t complain.
*Y our client asked you to do it.
*Y our client, because of a specific condition, made you do it.
*You were not at your best on that day.
*You heard through a friend that an ethics committee member said it was
okay.
*You’re certain that the people who made up the code of ethics don’t
understand the difficulties of clinical practice.
*It results in more pay or recognition.
*It’s more convenient.
*No one will discover it or if they do, they won’t care.
*You’re observant of the majority of the other ethical standards.
*You’re not really trying to hurt anyone.
*There’s no definitive research proving what you did was harmful.
*You only did it one time.
*No one can say for sure or prove that you’ve done it.
*If you are famous, rich, accomplished, important, etc.
*If you are too busy to do otherwise.
Josephson (1991) provides a list of statement that may typically be used by

therapists to rationalize their unethical actions, including: “If it’s necessary, it’s
ethical”; “If it’s legal, it’s proper”; “I’m just fighting fire with fire”; “It doesn’t hurt
anyone’”’; It’s okay if I don’t gain personally”; “I can still be objective”; and, “I’ve
got it coming to me” (p. 6). Furthermore, Koocher and Keith-Spiegel (1998) add:
“Just this once” and “This time it’s different” (p. 10).
Cohen and Cohen (1999, p. 41) discuss some questions that therapists can ask
themselves to avoid the illogical thinking which may interfere with their ability to
make sound, ethical decisions:
*Am I thinking of clients in terms of stereotypes?

*Am I impulsively overgeneralizing from inadequate data?
*Am I catastrophizing over possible outcomes?
*Am | ignoring cultural issues?
*Am I being too perfectionistic?
*Am I following the crowd?
*Am I condemning or judging others and myself?
*Am I underestimating my ability to endure individuals or situations?
Steinman, Richardson and McEnroe (1998, pp.3-10) discuss several ethical

“traps” that can detract from clear ethical decision-making. The first involves the
notion that solutions to ethical problems take nothing more than commonsense and
objectivity. In reality, many decisions must be based on more, especially legal and
23
ethical standards. Objectivity is an unobtainable ideal in most situations; the therapist

cannot escape from his or her own distorted worldview or personal needs and is also
inevitably part of the ethical problem. Unacknowledged personal needs can often
influence the most “objective” decision-making, therefore it is essential that
therapists constantly monitor their own needs and also consult with others to be
aware of personal biases.
A second ethical trap involves the lack of distinction between professional
codes of ethics and personal values or morals. A therapist cannot use personal values
and morals to make ethical decisions in the professional arena, as sometimes these
are in conflict. When this is the case, personal values and morals must take a back-
seat to what is ethically mandated.
A third ethical trap involves the assumption that there are no ethical
absolutes, and that all ethical decisions are situation-specific. The reality of ethical
behavior is as follows: 1) there are some ethical problems that can only be solved by
a consideration of the circumstances in which they occurred, such as accepting gifts
from clients; 2) there are some ethical mandates that are fairly firm, but there are
designated circumstances under which exceptions are acknowledged, such as in the
area of confidentiality; and 3) there are some ethical mandates for which there are
never any exceptions, such as in sexual contact with client.
Chapter Summary
1. Music therapists will inevitably face challenging ethical dilemmas during the
course of their professional careers. Ethical thinking is considered to be the most
important skill a music therapist can acquire.
2. Ethical thinking is a process that draws upon all resources of the professional. It
requires self-awareness of one’s beliefs, feelings, values, attitudes, and motivations;
knowledge of relevant codes, standards, principles, laws; sensitivity to the cultural
context and the client’s values; good judgment; and an application of personal
virtues.
3. Music therapists have obligations to be ethical because of the special

responsibilities and privileges of their work in helping others who are vulnerable.
The power of their roles as helpers cannot be exploited or misused, and they must
protect their clients’ well-being. As helpers, music therapists assume accountability
for their actions.
4. The research on ethics in music therapy is limited, and existing findings reveal
contradictory results. Although music therapists may feel that competence in ethics
is quite important, there is little agreement among professionals concerning how
ethical problems may be solved, or concerning how ethics is taught. Furthermore,
insufficient attention has been given to ethical standards in the published music
therapy research literature. There is an apparent need for a more systematic approach
24
to ethics training within the profession.
5. The core ethical principles of beneficence, nonmaleficence, autonomy, justice,

fidelity, veracity, acknowledging dignity, acting with caring and compassion,
striving for excellence, and acknowledging accountability, are fundamental to ethical
behavior.
6. Codes of ethics provide important normative, aspirational and prescriptive

functions for professionals, although they are inherently limited in their ability to
help professionals solve ethical problems. Nevertheless, they do comprise one
essential part of ethical thinking.
7. Laws provide minimum standards for practice. The relationship between the law
and ethics is a complex one. Legal and ethical standards are sometimes consistent
with each other and sometimes not, and expert advice is often needed when there is
a conflict. Most professionals are extremely threatened by the notion of malpractice
litigation, although professionals may choose to practice in an ethical manner rather
than in a defensive manner.
8. A model for ethical decision-making is presented which involves a 12-step

process:
1) Identify the problem, issues and practices involved. 2) Assess the obligations owed
and to whom. 3) Assess your personal/emotional response. 4) Consult core ethical
principles, ethical standards and codes, relevant laws, and institutional policies. 5)
Consider the context and setting. 6) Identify your own beliefs and values and their
role in this situation, as well as those of the client. 7) Consult with colleagues,
supervisors and all possible resources. 8) Consider how the ideal, virtuous therapist
might respond. 9) Generate possible solutions, utilizing the input of the client when
feasible. 10) Evaluate each proposed solution in terms ofpossible consequences and
make a decision. 11) Implement the decision. 12) Evaluate the decision.
9. Music therapists should avoid situations that may pose increased ethical risks, and
at the same time prepare themselves strategically for decision making in crisis
situations.
10. There are a number of deterrents to ethical behavior, including personal

characteristics of the therapist and deficits in training or judgment, as well as various
(and common) forms of denial, illogical thinking and ethical traps.
1. As a beginning exercise, jot down some specific professional actions that you
consider to be clearly unethical. Consider whether these unethical behaviors are
25
“always” unethical or are “sometimes” unethical depending upon the circumstances.
2. Make a list of some of the ethical dilemmas you have encountered as a student or
professional. Rank order these in terms of frequency, and be prepared to discuss
these with your fellow students. Consider the aspects of ethical thinking, if any, you
used in coming to a solution regarding the dilemmas.
3. React to the current research findings concerning ethics in music therapy. What
do you think about the status of the profession in this regard, and what studies would
you consider as important for the future?
4. Skim through the codes of ethics provided in the Appendix. Classify various
statements as “normative,” “aspirational,” or “prescriptive.” What are your first
impressions of the codes? How do you feel the various codes are similar or different
in tone?
5. Apply the ethical decision-making model to an ethical problem presented at the

beginning of the chapter.
6. Go through the various statements in the section, “Deterrents to Ethical Behavior.”

Is there a particular rationalization or type of illogical thinking that you have used
in the past or may be prone to use in the future?
7. Investigate in more depth one model of ethical development that appears

consistent with your own life experiences. Write a short critique of this model.
8. Write a short paper on one particular theory of ethics that appeals to you or to
which you have had some exposure. Evaluate how this is consistent with your own
personal belief system.
9. Attempt to rank order the core ethical principles in terms of their importance.
Provide a justification for this ordering and discuss this with your classmates.
10. Keep a personal journal while studying this textbook, to be seen only by you.
After each chapter, describe your emotional reactions to a particular section or
sections. For example, in this chapter, what are your reactions to the possibility of
having a malpractice suit filed against you as a professional? What parts of the
chapter do you find most validating for yourself? What parts of the chapter
overwhelm you, and why?
THE VIRTUOUS MUSIC THERAPIST
APTTieWinniesiadhesapyeietnaperscnof thetharapiet The qualities,

virtues, and character of this individual are indeed central to the music therapy
process, and contribute to the ultimate success or failure of therapy. Music therapists
may be competent in their work and adhere to the tenets of rule-based ethics, but if
they lack the essential virtues that underlie the practice of music therapy, it is not
likely that they will make a significant difference in clients’ lives.
Being an excellent music therapist obviously involves more than learning the
established rules of professional conduct. The virtuous music therapist is one who
acts according to ideal principles, and who does what is right, because it is right, not
out of fear of professional or legal sanctions. Virtues are valued both for their benefit
to clients, as well as for their own intrinsic merit (Cohen & Cohen, 1999). The
virtuous therapist, must first have adequate knowledge, and then make a choice
regarding his or her actions, because they are virtuous in their own right. These
actions must emanate from his or her firm, internalized convictions which have
evolved from a history of virtuous acts (Cohen, 1994).
It is certainly possible to generate a long list of desirable qualities that various
types of peoresstouals wend ideally possess. Furthe e, there are several prevalent
‘ odel, and ] (Cohen, 1994).

In the trust- Penne model (Bayles, 1989; Cohen, 1994), therapist virtues
which place trust as central to the relationship are emphasized and include: honesty,
candor, competence, diligence, loyalty, fairness and discretion. Therapists who do
not possess all of these virtues do not merit the trust of the client. Trust is essential
to the therapeutic process because of the client’s vulnerability, the therapist’s power,
and the inherent potential for client exploitation.
The autonomy-facilitating model focuses on those therapist virtues that are
seen to enhance independence and self-actualization in the client, ideals not
addressed in the previous model. These virtues are prerequisite to therapists working
in humanistic orientations and include: congruence, unconditional positive regard,
and empathy (Rogers, 1977; Cohen, 1994).
In the human welfare model, therapist virtues emphasize the enhancement of
28
client welfare, from which both the elements of trustworthiness and client autonomy
are derived. These virtues include: respect for human worth and dignity, moral
autonomy, and caring for clients and other parties (Cohen, 1994).
Each of these models has important relevance for music therapy practitioners,
and all of the virtues listed in each of the models are deemed necessary for good
practice. The remainder of this chapter will focus on a “‘short list” of those therapist
virtues that are seen as essential to true helping in music therapy and to the
attainment of ethical thinking.
Caring
Caring is a cardinal and foundational virtue for music therapists. According

to Doherty (1995), “the caring bond therapists offer to clients isthe heart ofthc
. 118). The therapist’s ability
to establish an environment of caring may be a primary component of healing; its
absence can be viewed as a principal reason for failure (Patterson, 1985).
Caring is not an abstract attitude or isolated behavior; rather, it occurs in the
context of a therapeutic relationship (Noddings, 1984). Caring involves helping
another to grow as a person and implies both action and feeling (Hinman, 1994),
To be truly caring, the therapist must have: an openness to receive from the
client, an absorption in the client, and a willingness to go beyond the self to help the
client. >
(
understanding him,orher (Doherty, 1995).
Absorption iin the client puts him or her as the primary focus of attention,
while also . “Devotion characterizes your
response to the cared for person. Interdependence not independence, dependence or
codependence best characterizes this part/apart relationship” (Dokecki, 1996, p.
101).
The willingness to go beyond the self implies helping the client achieve his
or her goals, although these may sometimes differ from those of the therapist
(Doherty, 1995; Noddings, 1984). However, caring helps the therapistitolgrow..as
(Dokecki, 1996).
In addition, Dokecki (1996) and Mayerhoff (1971) elaborate on the
characteristics of the caring therapist: the use of alternating rhythms, patience,
honesty, trust, humility, hope, courage, and perhaps most importantly, knowing.
Caring on the part of the therapist is not linear, but involves alternating
hytl ; ) bari neeRperienee es , 7
ofit to evaluate its results, and taking various perspectives of the self, client and
caring behaviors.y Caring involves actively chosen )
develop at their own pace} to sustain uncertainty, and to allow the self to grow in the
mastery of caring. Honesty allows the therapist tosee the clients asthey truly are, to
The therapist
eaten {rarer cage armen ed
his
limitations.
or her
invdifficult'situations, and to ar neers praseorcy oa replete with potentially
positive outcomes that may be influenced by his or her action of caring. Courage
permits the therapist to take risks. Finally, knowing is the most important ingredient
Caring is not always natural or spontaneous in therapeutic relationships. A

distinction is made between “natural caring” and “ethical” caring. Natural caring
“stems from a spontaneous desire to receive and respond to the other” (Noddings,
1984, p. 5), such as the care that is shown by a parent towards a child. Natural caring
occurs most readily on the part of the therapist when the client is not dissimilar to the
therapist, when he or she is vulnerable, when he or she requests help, and when he
or she is grateful for treatment. Caring may not be spontaneous however for the
difficult client, who is different from the therapist, who is not open with his or her
problems, who resists help and who is not appreciative of the therapist’s assistance.
In these situations, therapists draw upon their sense of “ethical caring,” a caring ideal
and imperative that provides the motivation and resources for caring to occur.
Therapists encounter many clients they don’t like or who tur them off. Ethical
caring allows the therapist to strive to find some compassionate connection with the
client that will lead to natural caring. With an awareness of his or her reactions to the
client and with caring as a primary goal, the therapist tries various strategies to listen
and respond to the client in different ways so that this connection can be achieved.
Often the therapist utilizes his or her own memories of being cared for as a resource
in this process (Doherty, 1995; Noddings, 1984).
There are . It is sometimes impossible for
th 1 i
thatthicalcaring
may neverleadtonaturalcaring. The therapist has a responsibility
to be aware of the potential limits of his/her caring, and he or she should avoid
entering into a therapeutic relationship with those individuals for whom the lack of
caring will result in ineffective treatment Even more problematic are the situations
in which the therapist attempts to care for the client, but is ultimately unable to. This
should be discussed with clients in an ethical, caring way, and the clients should be
referred to another therapist if possible (Doherty, 1995).
Another ing 1
c
such. As a result, the person of the client becomes indiscernible. As this can often
happen with difficult clients, the problem is more telling about the therapist’s own
reactions and struggles than the client’s problems. When the therapist uses labels, he
or she attributes the difficulty to the client, and thus avoids responsibility for it.
Although it is normal to have irate reactions to clients, once these feelings are
acknowledged and expressed by the therapist, it is possible for the therapist to
reassume a caring stance. Objectifying the client lessens the potential for ethical or
30
natural caring to occur (Doherty, 1995). —

Another barrier to caring is the use and misuse of clinical techniques, which
when employed as “techniques,” without a sensitivity or connection to the needs of
the client, become empty, uncaring strategies (Doherty, 1995).
Final obstacles to caring are found in the workplaces and cultural milieus
where therapy occurs. Therapists must also be cared for to allow them to continue
to care. Non-supportive and isolating workplaces, extremely heavy client loads, the
pressures of managed care, and work with clients from different cultural/social
backgrounds, (who require more active efforts for understanding and caring), can
contribute to an erosion of caring on the part of the therapist. In these situations,
“therapists start to go through the motions, it shows, and we know it We become
negative about our clients, we hope for no-shows or cancellations, our natural caring
declines, and our ethical caring begins to feel like martyrdom” (Doherty, 1995, p.
133).
As important as caring is within the therapeutic relationship, there are some
risks and dangers for the therapist when caring is overemphasized or distorted. The
first involves the loss of boundaries for the therapist. This can result in an
overidentification with the client, an entrenchment in the client’s process, a
compromise of objectivity, or the establishment ofa dual relationship with the client
(sexual or otherwise) (Peterson, 1992).
The second involves the danger of paternalism, or the feeling that caring is
a “magical” tool from a perfectly virtuous therapist. This can result in an
underemphasis on clinical knowledge and skill and on the rigor required in
maintaining caring at the heart of therapy (Doherty, 1995).
A third risk in overemphasizing or distorting caring is the notion that caring
precludes confrontation, and always requires a supportive stance. The “toughness of
caring” (Noddings, 1984, pp.98-103) sometimes implies being firm, confrontive and
directive (Doherty, 1995).
A fourth risk involves the “potential to split the nurturing and the technical
aspects of therapy, the expressive and the instrumental, the intuitive and the rational”
(Doherty, 1995, p. 135). As mentioned previously, caring involves alternating
rhythms (Dokecki, 1996), including shifts between the rational/instrumental and the
feeling/intuitive. Therapists must select what is appropriate for their clients in the
moment. If either of these becomes polarized, the therapist can either overidentify
or underidenify with the client’s feelings (Doherty, 1995).
When therapists genuinely care, clients know it. Caring is not something
therapists do, but are. Caring is often conveyed in how therapists interact with clients
in the smallest of details both within and outside of the therapy session (Doherty,
1995).
Music therapists are fortunate in having access to music as a medium for
showing caring to the client. In music therapy, caring is demonstrated in the
receptivity of the therapist to the client’s music, his or her engrossment in it, as well
as his or her sensitive music or verbal responses to it. Caring is shown in the ways
therapists reflect and validate the client’s current state through music. Caring is
shown in the ways that music is co-created with the client. Musical experiences can
31
be inherently nurturing and caring for the client, and together with the care that
emanates from the person of the therapist, may be significant factors in the client’s
healing.
Empathy
Empathy is one of the most basic healing tools with which the music therapist
works. Empathy is motivated by caring, and indeed goes beyond it. It is both a virtue
and an innate capacity of the therapist, as well as perhaps the most essential part of
the therapeutic process.
Empathy involves opening oneself to the emotional experience of the client,
resonating with that experience, and thereby achieving a deeper understanding of and
connection with the client. Empathy is not sympathy or feeling for the client; it is
not solely an intellectual understanding of the client’s pain; nor does it entail an
emotional! identification with the client in which the therapist experiences the pain
in the same way as does the client. Empathy allows access to the most important
information about the client, and it provides the client with the most significant
resource for healing. The client’s experience of being profoundly understood and
acknowledged by the therapist is in itself transformative (Rivera, 1996).
Empathy involves intellectual understanding as well as feelings. As Rogers
(1980) states: “The therapist senses accurately the feelings and personal meanings
that the client is experiencing and communicates this understanding to the client” (p.
116)... the therapist is “a confident companion to the person in his or her inner
world” (p. 142).
Empathy involves “informed feeling.” “(A)ffect fuels understanding, and
understanding fuels affect” (Cohen & Cohen, 1999, p. 62). There is no clean division
between knowing and feeling in the therapeutic process. Empathy also involves the
therapist’s ability to allow the client’s experience to resonate within him or herself,
and to then use this experience and information to better help the client (Rivera,
1986).
To be empathic, therapists must be both aware and accepting of themselves
and others. They need to acknowledge when they are touched by the client. When
the client stimulates negative feelings, such as fear or disapproval, therapists must
acknowledge these responses as their own and not the client’s, they must
acknowledge the rights of both to have feelings, (Rivera, 1996), and they must
accept and work through these negative responses.
Empathy helps clients to feel secure, safe, and free to be themselves
(Hancock, 1997). By letting clients know that they are being empathically heard and
understood, they are then free to explore more closely their inner feelings (Rogers,
1980).
Miller, Duncan and Hubble (1997), through a thorough analysis of the
literature, found that the nature of the client-therapist relationship, i.e., when
involving empathy and caring, is one of the most accurate predictors of success in
psychotherapy, even more so than the influence of any single theoretical orientation.
For many clients, the therapist’s attempt to understand, connect and empathize with
32
them is more significant than whether they actually do or not. The virtues of empathy
and care help the therapist stay focused on the client’s needs; these are absent in
those therapists who exploit clients (Coale, 1998).
Not all clients will respond to the therapist’s empathy in a positive manner;
the therapist’s empathy can be met with suspicion, rejection, ambivalence or other
responses. When this occurs, the therapist has the responsibility to continue to
provide an empathic environment in which the client may choose to change (Rivera,
1996).
Empathy is not a light switch that can be turned on or off. Especially in long-
term therapy situations, empathy can wax and wane. The quality of empathy can
change from client to client and even within a single session (Rivera, 1996). The
ability to empathize also changes considerably during the therapist’s career. A
beginning music therapist, with few life experiences and much growth ahead, cannot
manifest the same quality of empathy as an older therapist, with greater maturity and
a significant amount of such experience. And even then, no therapists, however
seasoned, are without certain blockages that can interfere with their capacity for
empathy. As Rivera so aptly states, “Some degree of countertransference is part of
every therapy relationship...like the American Express Card...We don’t leave home
without it” (p. 185).
Empathy, especially sustained empathy, is very demanding and can imply a
great deal of psychological stress for the therapist; the degree of the stress varies
among therapists and often according to the types of clients with whom they work.
Working with clients who are in extreme psychological and/or physical pain can be
particularly difficult. Virtuous therapists strive to achieve a balance between over-
empathizing (which can lead to burnout) and under-empathizing (which can lead to
detachment and withdrawal). Sustaining empathy can be draining and depleting, and
this can influence the therapist’s relationships with his or her family (Coale, 1998).
The virtuous therapist realizes that empathy is crucial to healing and engages
in regular self-care to assure that his or her ability to empathize does not become
impaired.
Courage
Courage is the virtue that helps therapists to persevere, to take risks, and to
continue trying and caring. Courage allows therapists to assume firm positions and
confront very difficult and challenging clinical situations. The lack of courage often
results in an overly cautious approach to therapy, one that does not permit the client
to move forward. A lack of courage is apparent when the therapist knows and
believes in a “right” course of action, has the ability to implement the action, but
fails to do so (Waters & Lawrence, 1993; Doherty, 1995).
Courage is needed in many clinical situations. For example, with clients who
are very resistive to music therapy treatment and/or who express open hostility to the
therapist, courage is required to overcome the anxiety and insecurity that these
clients can sometimes instill in the therapist, and to take an appropriate course of
action. Having courage requires that the therapist make clinical decisions geared
33
towards addressing the client’s problems rather than the therapist’s own anxieties.
Confronting a client and/or the client’s anger requires courage; it involves the risk
of appearing unnurturing or uncaring, and also of losing the intimacy of the
therapeutic relationship. A lack of courage is seen when the therapist does nothing
(Doherty, 1995).
Likewise, situations in which clients are potentially suicidal require a great
deal of courage from therapists. Fear of losing the client combined with the fear of
malpractice litigation often motivates the therapist, especially one in private practice,
to prematurely or inappropriately request hospitalization. An excessively cautious
approach in these situations can be an indication of a lack of courage (Doherty,
1995).
Self-awarenessis a challenge in courage for all therapists. Identifying and
dealing with their emotional reactions to clients, including those that may interfere
with therapy, are hallmarks of virtuous therapists. Failure to honestly and
courageously examine the self inevitably is harmful to clients. Therapists who lack
the ability and willingness to do this may be unable to distinguish their clients’
needs, issues and problems from their own. Furthermore, they may be unable to take
needed risks with clients, if they can’t take the risk to be open to themselves. “The
dangerous therapists are not the ones who recognize and feel badly about their failure
to take an appropriate risk, but the ones who rationalize their lapses or put the
responsibility on the clients” (Doherty, 1995, p. 157)..
Courage is also an essential virtue in working with colleagues and in
institutions. Upholding ethica! standards and protecting the welfare of clients in
unethical circumstances may require the music therapist to confront colleagues,
insurance companies, employers and others. The risks in doing such can involve
litigation, sanctions and/or loss of a job. There are no easy answers to or assurances
for the risks the music therapist must sometimes take. Courage allows him or her to
persevere.
Prudence
Prudence can be seen as the virtue which balances all the others. Prudence
assures that caring does not lead to excessive client dependence, that courage does
not lead to vigilantism, and that empathy does not lead to the loss of boundaries.
Prudence involves knowing how to use virtues in the right way for the client.
Prudence involves both good judgment and wisdom. Because of the human
tendency to over-generalize new knowledge, therapists may be at greatest risk for
poor judgment when new information is obtained (Doherty, 1995). For example, this
is particularly true after music therapy students have taken their first course in ethics.
I have observed that there is a period of time following an ethics course when
students question all their behaviors as well as the behaviors of others. Judgments
of situations or actions as being “unethical” abound. Even when students are duly
warmed that this over-generalization of information will occur, it happens
nevertheless. Eventually, students are able to discern more clearly between those
actions, behaviors or situations that are unethical and those that are not relevant to
34
ethics whatsoever.
In addition to good judgment, prudence also involves good-timing in both the
big and small decisions therapists make each day (Doherty, 1995). There is an
essential element of truth in Kenny Rogers’ lyrics in““The Gambler.” Knowing when
to “hold ‘em, fold ‘em, walk away and run,” are important timing issues for music
therapists (although not literally). Music therapists must utilize good timing for
example, in knowing when to reflect back the client’s music or to initiate a change
in theme, in knowing when to implement a contingency or to ignore a behavior, in
knowing when to listen or to play, or in knowing when to process an improvisation
or to be silent.
Inconclusion, although it is difficult to admit, even virtuous therapists cannot
heal all clients. “Some problems do not get better, and sometimes progress in one
area is snuffed out by deterioration in another. If therapists cannot always promise
change, let alone miracles, we can promise to walk with people who entrust
themselves to us, to support and challenge them, and to never objectify them or
exploit them for our own purposes. In doing so, we enact the quintessential virtue
and the primary moral mandate of our profession” (Doherty 1995, p. 137).
Chapter Summary
The ideal music therapist will inevitably possess many virtues. Virtues are
considered both essential to ethical thinking and necessary components of an
effective therapeutic process. The virtues of caring, empathy, courage, and prudence
are discussed in this chapter as core virtues that music therapists should strive to
attain. Understanding what actions these virtues imply is essential, as an
overemphasis or distortion of the meaning of the virtues in real world practice may
be harmful to clients. The therapist’s self-awareness is crucial to becoming virtuous.
1. Within the context of your own personal life’s narrative, describe the following:
*The persons and experiences that have helped you to become committed to
caring for others.
*Describe the virtues (mentioned in this chapter or not) that you feel you
possess, how you acquired these, and significant role models.
*Describe how being virtuous impacts or may potentially impact on your life
at this time, both personally and as a professional.
*Describe the potential role of caring and other virtues for you in the future,
both personally and professionally. Are there any obstacles that you
can anticipate encountering?
*Describe additional virtues that you would like to acquire and their
significance and meaning in your life.
*Describe virtues that are valued in your particular culture and their role in
your personal and professional life.
35
2. List and describe the attributes a good music therapist should possess. Rank order
the five you consider to be most important. Describe which of these you
currently possess, or are striving to obtain. Describe your process for
acquiring these.
3. Reflect upon what it means to provide help to others and to receive help from
others. How are these both similar and different?
4. In your course journal, describe your feelings and reactions to this chapter in
general, and to specific parts that may have stirred emotional reactions in
you.
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THE MUSIC THERAPIST AS A
PROFESSIONAL AND PERSON
The Music Therapist as a Professional: Competence
Introduction
a=
Ghe concept of competence in music therapy, as in other related professions,
can be a complex one. Competence in music therapy practice is both an ethical and
legal imperative and involves knowledge, skills, judgment, self-awareness, and
psychological competence. The music therapist must have the knowledge and skills
to assess and to understand the client’s problems, judgment in knowing how to use
his or her knowledge and skills in implementing music therapy interventions and in
assessing their effectiveness, and self-awareness of those personal issues that may
influence the course of music therapy treatment with the client.
The issue of competence is multifaceted in music therapy because of the
breadth and depth of music therapy practice. Music therapists work with a wide
range of clinical populations of all ages, including but not limited to individuals with
the following diagnoses/problems: abuse, aging, Alzheimer’s disease, autism,
behavioral disturbances, cancer, chronic and acute pain, persistent vegetative states,
developmental disabilities, dual diagnoses, eating disorders, emotional disturbance,
forensics, head injuries, hearing impairment, learning disabilities, medical/surgical,
mental health, multiple disabilities, neurological impairments, Parkinson’s, physical
disabilities, post-traumatic stress disorder, Rett syndrome, speech impairments,
strokes, substance abuse, terminal illness, and visual impairments (AMTA, 1999).
Music therapists also work with “healthy” individuals as a way of promoting
continued well-being. Music therapists must be prepared at the bachelor’s level to
work with any and all of these clinical groups.
The goals of music therapy practice vary widely according to the population
served, the clinical setting, and the unique needs of each client. The music therapist
must be competent in implementing music therapy to achieve these clinical goals.
A number of areas of music therapy practice have been identified. Bruscia
(1998) categorizes these areas as: didactic, medical, healing, psychotherapy,
recreation and ecological. Dileo-Maranto (1993a, 1993b) identifies fourteen schools
38
of music therapy practice as follows: diagnostic, educational/developmental, music

therapy private instruction, music activity therapy, combined arts practices, music
therapy and healing, music therapy and performing arts medicine, music therapy in
academic and clinical training, rehabilitative music therapy, music psychotherapy,
biopsychosocial music therapy, palliative music therapy and preventive music
therapy. Competence in music therapy thus implies the ability to work effectively in
one or more of these areas of practice.
Within each of these areas of practice, music therapists can provide treatment
at different levels of depth: supportive, specific, or comprehensive (Dileo-Maranto,
1993a, 1993b), or auxiliary, augmentative, intensive, or primary (Bruscia, 1998).
Each successive level of practice requires additional competence gained from
education, training and/or experience.
Theoretical orientations of music therapists also vary; music therapists may
practice at various levels within each of these areas using different theoretical
frameworks, including behavioral, psychodynamic, biopsychosocial, humanistic,
transpersonal, to name a few. Competence for working in each of these theoretical
orientations correspondingly varies.
Finally, music therapists may implement a wide range of musical experiences
in their clinical work, again according to the depth and breadth of practice. These
musical interventions can be classified as: receptive, recreative, compositional,
improvisatory (Bruscia, 1998, Dileo-Maranto, 1993a, 1993b). A variety of music
therapy techniques/methods can be utilized within each category. The musical skills
needed to employ these techniques/methods in treatment vary considerably, as each
technique or method requires specific types and levels of competence from the music
therapist. Some techniques or methods necessitate specialized, advanced training,
e.g., the Bonny Method of Guided Imagery and Music, Creative Music Therapy, or
Analytic Music Therapy.
The professional music therapy associations in the United States have
developed and adopted entry-level competencies for the practice of music therapy.
The professional competencies of the National Association for Music Therapy, Inc.
(NAMT, 1996) and the American Association for Music Therapy (Bruscia, Hesser
and Boxill, 1981) require bachelor’s level music therapists to acquire knowledge,
skill and ability in the following areas: 1) Music Foundations (music theory, history,
composition, arranging, major performance medium, keyboard, guitar, voice,
nonsymphonic instruments, improvisation, conducting, and movement). 2) Clinical
Foundations (exceptionality, principles and dynamics of therapy, and the therapeutic
relationship). 3) Music Therapy (foundations and principles, client assessment,
treatment planning, therapy implementation, therapy evaluation, documentation,
communication, termination, professional ethics, interdisciplinary collaboration,
supervision, and administration). The reader is encouraged to examine the specific
competencies required under each of these categories.
Bruscia (1986) has developed advanced-level competencies for the practice
of music therapy which may serve as the basis of master’s and doctoral level study
and for advanced clinical or institute training in music therapy. These advanced
competencies are organized into eight categories: advanced clinical skills, creative
39
arts therapies, research, theoretical skills, advanced musicianship, clinical

supervision, clinical administration, and college teaching.
The National Association for Music Therapy (NAMT, 1988) has adopted
Standards of Clinical Practice which are designed to provide guidelines for quality
music therapy services. Standards for general music therapy practice (referral,
assessment, program planning, implementation, documentation, termination and
continuing education) are included as well as standards for practice in specialty areas
(adult psychiatry, consultant work, general hospital, geriatrics, physical disabilities,
private practice, and school settings).
Finally, the independent Certification Board for Music Therapists is
responsible for developing and administering the national certification examination
for music therapy. The examination measures competence (knowledge, skills, and
abilities) in music therapy, related clinical areas, music, and professional roles and
responsibilities. Persons who have completed an approved training program in music
therapy as well as the required music therapy internship are eligible to sit for this
exam Those who successfully complete the examination are awarded the title, “MT-
BC,” the official credential for music therapy practice in the United States.
Professional Competence in Music Therapy
In spite of the profession’s attention to the development of entry-level and

advanced competencies, standards of practice, and a national examination,
competence in music therapy, as in many other helping professions, still remains
somewhat of a struggle. Indeed, the profession has developed criteria for a
“reasonable standard of care” in music therapy. However, competence in music
therapy cannot be fully and completely assessed through a written examination or
through academic, supervisory, or self-evaluations. Competence, as defined above,
involves many other factors, such as personal self-awareness and psychological
competence. These factors cannot be measured either easily or objectively.
In related professions, competence is often assessed by asking other
practitioners what they would do under similar circumstances. If other professionals
determine that their actions would have been the same as the actions in question,
then it is concluded that the questioned actions have met a minimum standard of
competence. If the other professionals disagree with the actions in question, then it
might be determined that the actions in question fell below the minimum standard
of competence. This is known as the “reasonable man standard, that is ‘what would
a reasonable person similarly situated do?’” (Stein, 1990, p. 40).
As Stein (1990) point outs however, “there is a major difference between
being competent and being good” (p. 39). Competence is on a continuum, and
behaviors that can be referred to as competent vary widely, that is from marginally
competent behavior, to mid-range competence (good practice) to exceptional
competence. Incompetent behavior, on the other hand, is not only unacceptable
ethically, but also unacceptable legally, and implies the potential for litigation.
Problems regarding professional competence abound in the helping
professions. In the field of psychology, there are several problems which fall under
40
the rubric of competence: practicing outside the parameters of training, misusing

tests, working while mentally or physically unable to do so, neglecting to treat,
diagnose or refer when appropriate, and the breach of the duty to warn (Peterson,
1996). In a national survey, 24.6% of psychologists reported that they practice in
areas where they are less than competent (Pope, Tabachnik and Keith-Spiegel, 1987).
In another study, psychologists revealed that issues concerning competence are
among the most frequently encountered ethical problems. Furthermore, psychologists
reported the least consensus on solutions to competence dilemmas when compared
with other ethical issues (Haas, Malouf, & Mayerson, 1986).
Although there are no data available, it is suspected that a similar situation
exists in the field of music therapy. As described above, given the breadth and depth
of skills, knowledge, abilities and personal resources needed to work with so many
clinical groups according to various schools of practice, at varying levels of
intervention, in different clinical settings, within diverse theoretical frameworks, and
using a variety of musical experiences, methods and techniques, it is no easy task for
the music therapist to achieve competence. Also, given the inherent limitations of
what can be addressed in education and training programs, it is unrealistic to assume
that entry-level practitioners and even advanced practitioners can be fully competent
with all clients they encounter in music therapy.
There are many reasons why music therapists might work outside the bounds
of their competence, and indeed these reasons are interrelated. First, the music
therapist might not realize his or her own limits in knowledge, skill, abilities or
personal resources as these relate to the level/depth of practice. This may result from
a deficiency in training, where the levels of music therapy were not adequately
emphasized, and the limits of working with only a bachelor’s degree sufficiently
exposed. Or the music therapist, for whatever reason, may demonstrate an
unwillingness to accept skill limitations. So, the music therapist may not know any
better about his or her limitations, or may know better but refuse to accept these
limits.
Second, the music therapist may not have received adequate training in the
breadth of music therapy practice. Because of the many clinical populations with
whom music therapists may potentially work, it is virtually impossible to prepare the
therapist, both academically and clinically, to work equally well with all populations.
There is not enough space or time within the undergraduate curriculum to do this.
Correspondingly, most music therapy faculty do not have the clinical facility
themselves to work with all clinical populations. There will inevitably be gaps in the
educational process.
Third, because of the nature of the job market, the clinical area in which the
entry-level music therapist has interned frequently may not be the clinical area in
which a job is available. The music therapist often accepts a job involving a clinical
population with whom he or she has had no experience. The choice may be: accept
the job that’s available, or have no job at all!
Fourth, the music therapist may assume that the Board Certification
credential is a blanket endorsement of competence and the required breadth and
depth of skills, or that a short training course, such as Level I of the Bonny Method
41
of Guided Imagery and Music qualifies him or her to engage in this practice. Further,
music therapy clients may also incorrectly assume that board certification or an
advanced degree in music therapy assures that the music therapist specialized and
competent in work with autistic children, for example, is also competent in music
psychotherapy with adults.
Fifth, music therapists may be reticent to refuse pressures from an employer
for practice outside his or her limits for fear of losing the job and/or the respect of
colleagues. For music therapists in private practice, refusing a client who challenges
the therapist’s limits may imply losing a referral source.
Sixth, a new music therapist may feel compelled not to refer a client whose
clinical issues have intensified, especially when the client has unrealistic
expectations about what the therapist can do through music therapy.
Seventh, music therapists working in private practice in small communities
may feel unable to refer clients for whom they are not prepared clinically to other
music therapists, because there are none available.
Eighth, music therapists may demonstrate variable skills in different areas of
training. For example, the music therapist may have been a good musician, but may
have done poorly in his or her academic work. Subsequently, his or her musical skills
may be well developed, but he or she may not know how to use these skills
adequately with clients. Similarly, the music therapist may have been a good
musician and student, but may have emotional and personal limitations in clinical
work or may lack self-awareness. These personal limitations will inevitably impede
his or her competence. Thus, a minimal amount of competence must be demonstrated
in all areas.
Ninth, music therapists who do not engage in continuing education, receive
supervision for their work, attend conferences, read the literature, maintain self-
awareness and stay current in their field may have slowly (or quickly) diminishing
skills and competence.
Tenth, music therapists may lack caution with the methods and techniques
at their disposal and underestimate the power of their effects. For example, music
therapists conducting basic music and stress-reduction sessions may well encounter
powerful cathartic reactions from clients, which they may not be competent to
handle. One essential aspect of education and training, thus, is an emphasis on the
power of music therapy and the care with which all techniques and methods must be
used, .
Regardless of the existing limitations in assessing competence, and the
various reasons that might lead the music therapist to practice outside of the
boundaries of competence, the responsibility of the music therapist to achieve and
maintain competence in practice is a clear and absolute ethical necessity.
Competence thus implies the willingness and ability of the individual practitioner to
honestly monitor and evaluate his or her own professional and personal strengths and
weaknesses. Competence also implies making honest decisions about whether the
therapist can adequately offer treatment to particular clients and/or whether these
clients should be referred to another therapist. These decisions are seldom easy
(Pryzwansky & Wendt, 1999).
42
How does the music therapist know when he or she is working beyond his or
her limits of competence? How can the music therapist know when to either accept
or refer a client when he or she does not feel prepared to address the client’s
particular needs? (Corey, et al., 1998). As stated previously, neither board
certification, bachelor’s degrees or advanced degrees prepare the music therapist to
work competently in all areas and at all levels of practice.
It is important to realize that the process of honestly self-monitoring one’s
strengths and weaknesses will always uncover doubts regarding professional
competence, and it is not uncommon for these doubts to emerge (even among
seasoned professionals) when difficult clients are encountered. “Difficulty working
with some clients doesn’t by itself imply incompetence” (Corey, et al., 1998, p. 268).
The music therapist faced with these doubts and questions is not without
resources. Supervision may be a viable option, and one that is not emphasized
enough in professional work. Supervision can be provided by more experienced
colleagues in music therapy, by former music therapy professors, by music therapy
supervisors, by individuals from related professions, or through peer supervision
arrangements. Supervision allows the music therapist: to have objective feedback
regarding his or her own self-assessments and doubts, to have another opinion
regarding the need to refer clients, and to receive specific advice regarding how to
handle challenging clinical situations. Supervision can further expand the music
therapist’s self-awareness of competence and can help pave the way for additional
training. It is this author’s belief that supervision should be an ongoing process,
especially for beginning music therapists. Supervision is also a necessity when the
music therapist embarks upon work in new clinical areas, at different levels of
intervention, within different theoretical orientations, and/or with new music therapy
methods. Ongoing and regular supervision is one potential safeguard against
incompetence in music therapy practice.
Regular or occasional consultation with experienced colleagues in music
therapy or other professions is also a viable option that may provide similar benefits
for the music therapist.
Continuing education (recertification) is not only an option, but also a
requirement for music therapists who are board certified. The Certification Board for
Music Therapists has implemented specific and rigorous continuing education
requirements which music therapists must complete to maintain and recertify for
their board certification credential. “The basic goal of the Recertification Program
is to document the current clinical competency efforts of each Certificant” (CBMT,
1991, p. vii). As music therapy is a rapidly expanding and evolving profession,
continuing education is needed not only to maintain entry level competence in the
field, but also to prepare therapists for work with new clinical populations, methods,
and techniques. Continuing education helps the music therapist to keep current in
knowledge and skills.
The continuing education options for music therapists who recertify include:
educational activities (workshops and courses), graduate coursework, self-study
activities, professional activities, short-event activities or re-taking the national
examination. The music therapist may tailor these educational experiences to
43
remediate any deficiencies in his or her knowledge and skills.

Another option for music therapists to maintain and enhance competence is
specialized and/or advanced training. Many bachelor’s level music therapists
engaged in clinical practice soon realize the limits of their training in addressing the
breadth and depth of clients’ needs, and seek out training to improve their clinical
competence. Graduate study in music therapy offers training in advanced music
therapy methods, as well as specialized training with a particular clinical population.
Therefore, this training can help fill in the gaps for the music therapist who self-
assesses these particular weaknesses in competence. Institute training in particular
music therapy methods (e.g., The Bonny Method of Guided Imagery and Music,
Creative Music Therapy, etc.) can provide the therapist with skills in working within
a particular music therapy model of practice.
Music therapists can strive to maintain and enhance their competence through
conference attendance and through keeping abreast of the research and clinical
literature in music therapy and related fields. These activities are seen as essential
for professional development. Music therapists who fail to engage in these activities
may be in the dark as to current developments in the field.
It may be the case that music therapists who pursue one or more of these
options will still, in the best interests of the client, need to decline treatment or refer
him or her to another practitioner. This must be done in a sensitive and appropriate
manner, one in which the client is fully informed of the reasons for the decision and
provides consent for the actions.
Competence in Group Music Therapy Work
Music therapists working clinically with groups (as most music therapist do)
need to be competent in the use of music therapy approaches/techniques with clients.
Unethical practice can result, for example, in the following situations: when
therapists use techniques with which they are not familiar or skilled, when the
techniques selected address their own personal issues or needs for power, when
techniques are used to intensify feelings within the group, (and it is the therapist’s
own need to have this intensity), and when techniques are used to put pressure on
group members or diminish their dignity in any way (Corey, et al., 1998).
Corey et al., (1998) provide the following ethical guidelines regarding the
responsible use of therapeutic techniques with groups: 1) Techniques should be
theoretically grounded and have a specific therapeutic goal. 2) Techniques used
should be selected according to the needs of the clients and should support the
client’s self-exploration, awareness, and discovery of new behavior. 3) Techniques
should be adapted according to the clients’ cultural diversity. 4) Techniques are used
to enhance group process rather than hide the therapist’s incompetence. 5)
Techniques are implemented sensitively and carefully according to the group
process, and are discarded if they are ineffective. 6) The therapist invites
participation of the group members, but they are free to make a decision regarding
participation. 7) Therapists should have knowledge of and experience with the
techniques they use, as well as the possible impact of the techniques on the group.
44
It is a good practice for music therapists working with groups to have had
personal experiences (during their training or otherwise) with the techniques they
use. Furthermore, an awareness of a music therapy group process as a participant can
prepare the music therapist for what may occur when working clinically. Responses
to music therapy are often intense and powerful. The music therapist should be
prepared for these reactions from group members, and should be competent in
handling cathartic responses involving anger, rage, sadness, confrontation, etc. The
therapist should thus be aware of the potential power of the techniques used and be
most cognizant of his or her competence in dealing with these potential reactions. As
mentioned above, therapists need to be clear about the level of music therapy at
which they are competent to work.
The therapist should also have sufficient self-awareness to understand
whether his or her own needs, e.g., for intensity, expression of anger, etc., are a
factor in how he or she is implementing treatment. This is discussed more fully in
the following sections.
Personal Competence
As has been mentioned in other chapters, the person of the therapist is a

significant component of the music therapy process. One cannot consider the notion
of competence, therefore, without considering all that personal competence implies.
As music therapists are “asking clients to look honestly at themselves and to choose
how they want to change” they “must open their own lives to the same scrutiny.
They should repeatedly ask themselves the questions: ‘What makes me think I am
capable of helping anyone?’ ‘What do I personally have to offer others who are
struggling to find their way?’ ‘Am I doing in my own life what I urge others to do’”
(Corey, et al., 1998, p. 34). Therapists should indeed serve as models for emotional
health, well-being and growth. Psychological competence “reflects therapists’
acknowledgment and respect for themselves as unique, fallible human beings. It
involves self-knowledge, self-acceptance, and self-monitoring. Therapists must know
their own emotional strengths and weaknesses, their needs and resources, their
abilities and limits for doing clinical work” (Pope & Vasquez, 1998, p. 62).
Corey, Corey and Callanan (1988) have proposed useful qualities for mental
health professionals: 1) concern for others’ welfare; 2) awareness of one’s own
feelings and the subsequent capacity to be present for those of clients; 3) awareness
and acknowledgment of one’s strength and power; 4) the development of one’s own
personal therapy style; 5) the desire and courage to be vulnerable; 6) respect and
appreciation for self; 7) an interest in functioning as a role-model for clients; 8) the
ability to take risks and the ability to acknowledge mistakes; 9) an openness to
personal growth; and 10) the ability to laugh (p. 28-29).
Just as there is an absolute imperative for music therapists to be competent
in what they “do” with clients, there is the same ethical imperative to be competent
in how they “are” with clients. Psychological competence involves knowing oneself,
and is as important (or perhaps even more important) than knowing on intellectual
levels. Self-awareness is the key to being psychologically competent. Therapists’
45
self-awareness of their personal needs, issues from their life histories, and their
vulnerabilities is the first step in preventing these factors from interfering with the
process of therapy.
Self-awareness, then, is one of the key characteristics of effective therapists.
Hancock (1997) recommends that therapists ask themselves: “Who am I as a
thinking, feeling, relating and acting person?” (p. 96) as a starting point for self-
exploration. This question can open the door for evaluating one’s beliefs, values,
biases, self-perceptions, and needs. Self-awareness must be a continuous process
rather than a sporadic exercise (Hancock, 1997). It involves a constant vigilance of
the therapist’s need to engage in personal therapy to assure emotional competence
(Pope & Vasquez, 1998).
Music therapists, like all human being have needs. Corey and Corey (1990;
1993) describe common needs of therapists as follows: “1) the need for control and
power, 2) the need to be nurturing, 3) the need to change others in the direction of
(their) own values, 4) the need to provide answers, 5) the need to feel adequate,
particularly when it becomes overly important that the client confirm our
competence, and 6) the need to be respected and appreciated” (1990, p. 62; 1993, pp.
1-29). Self-assessment of one’s needs is essential for the exploration of personal
competence. Although the needs listed above may seem reasonable ones for human
beings, they may be devastating for therapists involved with clients. If unmonitored
and unchecked, they have the potential for seriously interfering with the music
therapy process. For example, the need for power and control can lead to client
exploitation. The need to be nurturing can foster client dependency. The need to
change others and provide answers can compromise client autonomy. The need to
feel adequate, respected and appreciated can lead to the lack of objectivity and client
manipulation.
Simply put, the place for therapists to meet these needs is not in work with
clients, as their own needs are of paramount importance. The question music
therapists must continually ask themselves in all aspects of treatment is: “Whose
needs am I meeting, mine or the client’s?” Psychological competence, therefore
involves honestly assessing one’s needs and how these needs are brought to bear in
the clinical situation. This is not to say that therapists can derive nothing from the
therapy situation to meet their own needs. People become therapists because they
want to help others, and music therapy can indeed be gratifying for this and for other
reasons. The important issue, however, is whose needs come first - the therapist’s or
the client’s?
The therapist’s emotional makeup is an important predictor, as well, of the
success of therapy (Sussman, 1992). It is thought by some authors that the theoretical
orientation therapists use, the type of therapy they prefer, and the clients with whom
they are either successful or unsuccessful are all related to their own histories
(Strean, 1993). The desire to become a therapist is often related to the therapist’s
need to find a resolution to his or her own problems (Sussman, 1992). A therapist’s
history and life experiences undoubtedly influence his or her psychological makeup
and competence, although the manner in which this influence is experienced and/or
resolved and the role it plays in the therapist’s clinical work is unique for each
46
person (Pope & Vasquez, 1998).

Pope & Feldman-Summers (1992) gathered data on psychologists’ self-
reports of the abuses they had experienced during their lives (childhood, adolescence
and/or adulthood). It was discovered that almost one-third of male therapists and
more than two-thirds of female therapists reported experiencing some type of abuse.
The types of abuse reported most frequently by male therapists during childhood or
adolescence (in descending order of frequency) included: nonsexual physical abuse,
sexual abuse by someone not related to them, and sexual abuse by a relative. As
adults, male therapists reported experiencing: nonsexual abuse by a partner,
nonsexual physical abuse by a stranger, sexual harassment or attempted rape. The
types of abuse reported most frequently by female therapists during childhood or
adolescence (in descending order of frequency) included: sexual abuse by a relative,
sexual abuse by someone not related, and nonsexual physical abuse. During
adulthood, female therapists reported experiencing: sexual harassment, attempted
rape, nonsexual abuse by a partner, nonsexual physical abuse by a stranger, and
acquaintance rape.
No implication is made here that there is a positive or negative connection
between the experience or non-experience of abuse and the emotional competence
ofa therapist. Therapists must determine how these life events, as well as a multitude
of other factors, influence them and their work.
No music therapist enters the therapy situation as a “blank slate,” and he or
she always carries emotional baggage and unresolved issues. If being a “blank slate”
were the requirement for being a competent therapist, there would be no therapists
anywhere! Music therapists are, like the clients with whom they work, in process.
It would be impossible to wait until all issues and personal problems in the
therapist’s life were resolved before practicing clinically, as the reality in life is, this
will never happen!
What is important, however, is for therapists to be aware of how these issues
and problems can impact their work. It may be that sharing common issues with a
client can lead to greater empathy and connection. On the other hand, it may be that
common issues can lead the therapist to try to solve his or her own issues through the
client, or give the client advice on how to solve these problems based on the
therapist’s own experience. In addition, it may be that common issues may cause the
therapist to retreat from the client emotionally because of the pain involved. Even
when the issues of the therapist and client are vastly different, the same reactions
may occur. Unless there is self-awareness, the therapist may unwittingly lead the
client to avoid issues and discourage self-exploration, as he or she may be doing, out
of fear, discomfort, disdain, etc.
It is not so much a question of whether the therapist is experiencing
problems, but how they are being dealt with that is significant. Does the therapist
take responsibility for his or her own part in the problems, or is there denial and
blame? Is there an awareness of potential solutions? Is there an openness for seeking
help with these problems if the therapist is not handling the problems effectively by
him or herself? Is the therapist willing to do what he or she would expect a client to
do? (Corey, et al., 1998).
47
Therapists who are unaware of their personal issues and needs run the risk
of engaging in destructive types of countertransference with clients. It is then that
countertransference becomes an ethical issue as well as a dynamic clinical issue.
Destructive countertransference can be manifested in a number of ways: 1)
overprotecting the client because of the therapist’s own fears, 2) treating clients
benignly and superficially because of the therapist’s fear of anger and confrontation,
3) rejecting clients because they may be needy or dependent, 4) requiring continuous
approval and validation from clients, because of the therapist’s need for acceptance
and liking, 5) overidentification with clients’ issues and behaviors resulting in a loss
of objectivity, 6) advice-giving, out of the needs for power and superiority, and 7)
exploiting clients emotionally or socially (Corey, et al., 1998).
In summary, therapists cannot help others understand themselves, until they
also do the same. Therapists cannot accept clients until they can accept themselves
and their own needs. Therapists can help patients heal only to the extent that they
have also healed themselves or are in the process of healing.
Psychological Vulnerability and Impairment
No matter what the music therapist’s theoretical orientation, the use of the
self in the therapeutic relationship is as significant as the use of music: these are the
only two tools the music therapist has at his or her disposal. Because psychological
vulnerability is a part of the self, it inevitably influences what occurs between client
and therapist (Coale, 1998).
There are a number of factors that impinge upon the therapist’s psychological
vulnerability, and these are discussed in this section.
All therapists have specific emotional areas in which they are predisposed to
be vulnerable. There are a number of issues which may predispose a therapist to
burnout as well: emotional and spiritual exhaustion, extreme idealism, loneliness,
overidentification with clients, perfectionism, authoritarianism, need for control,
unfulfilled needs for intimacy, traumatization, and unresolved childhood issues
(Coale, 1998; Farber & Heifet, 1981; Figley, 1995a; Grosch & Olsen, 1994). .
Isolation is an important factor that can increase the therapist’s psychological
vulnerability. Isolation results from a variety of factors, including: lack of contact
with colleagues, the necessities of confidentiality and avoidance of self-disclosure,
emotional energy given in a one-way direction, and the continual termination of
therapeutic relationships (Coale, 1998). Isolation can result either in the therapist’s
alienation from his or her own feelings, or in his or her becoming too involved with
the client and thus emotionally exhausted. He or she may extend the therapeutic role,
with the power inherent in it, into his or her own personal life and may become
detached and withholding (Guy, 1987).
At the same time the therapist is also in the public’s eye with his or her
personal behavior, and is responsible for not damaging the reputation of the
profession. Friends can impinge upon the therapist’s knowledge and ask for advice,
or create unnecessary distances because of fear of being assessed. The therapist’s
family may also be scrutinized and judged for their behavior. The therapist must be
48
on guard while in public, as there is always the possibility of encountering clients.

(Kottler, 1993).
The intensity of their work also makes therapists vulnerable psychologically.
Therapy involves deep and intense feelings for both the client and therapist.
Therapists thus both need to be prepared for this intensity and able to deal with these
feelings. If they cannot, their interventions may be ineffective or even harmful (Pope
& Vasquez, 1998). Several authors have studied the frequency and type of intense
feelings experienced by psychologists (Pope & Tabachnick, 1993; Pope, Tabachnick
& Keith-Spiegel, 1987). Results from these two studies have been combined, and
although the self-reported frequencies of the psychologists’ responses are not
included here, they all reflect a greater than 50% response rate. Some of the intense
feelings reported include the following (in descending order of frequency): fear that
a client will kill him or herself; fear for a client’s worsening condition; disclosing
your anger towards the client, experiencing sexual attraction for a client; fear that a
client may need resources that are not available; having a sexual fantasy about a
client; fear that a client may formally complain about the therapist’s services; having
angry fantasies about a client; crying while a client is present, expressing
disappointment to a client; and speaking in a raised voice to a client out of anger.
Dealing with clients’ issues of pain, turmoil and injustice can take its toll and
challenge the therapist on existential and spiritual levels. Even when attempting to
experience the client’s pain empathically, the therapist may become the target of the
client’s negative feelings. Trying to provide the extremely distraught client with
empathic support is extremely difficult when the therapy does not seem to be helping
or when the client ends treatment suddenly (Coale, 1998). It may then become even
more difficult for the therapist to sustain empathy with subsequent clients (Edelwich
& Brodsky, 1980). The therapist may experience dysphoria, referred to by a variety
of terms: compassion fatigue (Figley, 1995b), secondary traumatic stress disorder
(Dutton & Rubenstein, 1995; Figley, 1995a, 1995b), empathic strain (Wilson &
Lindy, 1994), and vicarious traumatization (McCann & Pearlman, 1990; Pearlman
& Saakvitne, 1995) (cited in Coale, 1998, p. 154). The therapist may also experience
burnout and emotional exhaustion, which will be described in more detail in another
section of this chapter.
Ambiguity can also play a contributing role in the therapist’s psychological
vulnerability. Therapy is fraught with contradictions. The client and therapist are
both equal yet unequal and hierarchical because of the power inherent in the
relationship. They are at the same time intimate in feelings, yet distant because of
boundaries (Kottler, Sexton & Whiston, 1994). In addition, it may be very
ambiguous to define success in therapy, as perceptions of success can be viewed
differently by both client and therapist (Coale, 1998; Farber, 1983a, 1983b). There
is also ambiguity in the conflicts between what the client needs and what the
therapist needs. Ambiguity exists in dual role relationships that may enter treatment.
There is ambiguity in the therapist’s balance of time between working with clients
and maintaining and improving competence. Finally, there is ambiguity in feelings
of making a difference to clients and not being meaningful at all in the bigger
scheme of things (Farber, 1983a, 1983b).
49
Psychological vulnerability is often exacerbated by external pressures of

managed care to help clients in a very short period of time. The therapist feels
accountable to clients, even though these feelings and expectations may not be
realistic. Further, when unable to help successfully, the therapist fears for his or her
job and may question his or her own competence (Coale, 1998).
Therapists become vulnerable as well due to influences of colleagues.
Pressures from workaholic colleagues to perform more and better can be very
stressful. Conversely, colleagues who are emotionally drained can cause chain
reactions in others working around them (Coale, 1998).
Therapists are vulnerable to common stressors within the therapy situation.
These include: threats of suicide, anger directed at the therapist, clients’ agitation,
apathy and depression, and premature termination of treatment ((Deutsch, 1984;
Farber, 1983b). In addition, feelings of not being able to help the client, not liking
the clients, seeing too many clients, experiencing self-doubts, and feeling isolated
can also serve as significant sources of stress (Deutsch, 1984).
Therapists may also be vulnerable to certain types of clients. Just as therapists
have the power to exploit their clients, there are also some types of clients who are
prone to exploit their therapist, resulting in an increased vulnerability for the
therapist. These clients are those who attempt to exploit the therapist financially, for
example in not paying for treatment, in trying to go “overtime” in sessions, in using
telephone calls between sessions to get “free” therapy time, or in taking the
therapist’s equipment or supplies without permission. Clients may also exploit the
therapist emotionally and professionally, for example, by making telephone calls at
inappropriate times, by pressuring or threatening the therapist to falsify records or
insurance claims, or by undermining the integrity of the relationship by offering
sexual favors or expensive gifts. There are also clients who can exploit the therapist
physically (by attacking or sexually assaulting him or her) (Epstein, 1994).
Epstein (1994) describes various ways that therapists can deal with client
exploitation. The author cautions that therapists should never collude with clients in
any unethical or illegal behavior out of fears of confronting them, of invoking their
shame or anger, or of losing them. Likewise, it is risky for the therapist to make
frequent exceptions to his or her policies for exploitive clients or to permit frequent
invasions of the therapist’s time and space. The author suggests that the therapist
discuss all boundary crossings with clients as soon as they occur, clarifying those
that may be the result of any type of emergency intervention, and also taking
precautions ahead of time for clients who have a history of exploitive or assaultive
behavior.
Therapists can become vulnerable to their own irrational belief systems and
perfectionistic tendencies regarding therapy. Therapists can illogically assume that
they can always work at their maximum capacity competently and enthusiastically,
that they are capable of handling any and all client emergencies, and that they can
help each and every client they see. Therapists can also believe that they alone are
responsible for client progress and behavior, that they cannot take time off of work,
that they should be continually on call because of clients’ needs, that work is the
main focus of their lives, that they must be perfect models of good emotional health,
50
and that they have the power to control their clients (Deutsch, 1984). (Itis interesting
to compare these irrational beliefs to the list of therapists’ needs cited in the previous
section)! According to Corey, et al., (1998), “the underlying assumption that creates
stress is: ‘If I do not live up to my high expectations, 1 am personally incompetent
and inadequate” (p. 60).
Various life situations and issues of the therapist can come into play in terms
of psychological vulnerability. For example, the therapist who is also a parent can
be influenced by his or her work with child or adolescent clients, and this can cause
the therapist to treat his or her own children differently (e.g., not setting limits) out
of fear that the same will happen to them. Being a parent requires some level of
denial concerning all that can happen to achild. Working with children to whom bad
things have happened can erode this denial (Coale, 1998).
The therapist, as with any other human being, inevitably experiences painful
life events, such as illness, losses through death or divorce, traumas, etc. When these
occur, does the therapist continue working or discontinue seeing clients? There are
no pat answers to these dilemmas. Again, it is not so much a question of whether, but
of how the therapist is dealing with these issues that is the key factor (Corey, et al.,
1998).
Some clients may feel particularly vulnerable when a therapist must cancel
sessions due to various life events or when they observe illness and/or distress in
their therapist. As it is often impossible to hide these things from clients, they often
and understandably want to know what is happening. They may blame themselves
for changes in the therapist and may require reassurance that this is not the case.
Some may fear that the therapist will leave them or they may even begin to question
whether the therapist’s competence is becoming an issue. Other clients may feel
guilty for dealing with their own issues in treatment, when they know that the
therapist is already excessively burdened. The therapist’s decision regarding self-
disclosure to clients is a sensitive one, and also one with no pat answers. If and when
self-disclosure is used, it must be for the benefit of the client and not the therapist,
and the therapist is responsible for this discernment and level of self-awareness
(Coale, 1998).
Vulnerability may lead to impairment. Pope, Tabachnick & Keith-Spiegel
(1987) found that more than half (59.6%) of psychologists surveyed reported
continuing to work when they were too distressed to do so effectively. A small
percentage (5.9%) indicated they had worked under the influence of alcohol.
Bouhoutsos (1983) found that frequent reasons for impairment included: substance
abuse, psychiatric illness, physical illness, and grief following the loss of a loved
one. Burnout is also a major cause of impairment, and will be discussed in the
following section.
Although no comparable data are available for the field of music therapy,
more than half (61%) of psychologists reported having had experienced serious
depression. Moreover, more than one-fourth reported having experienced the desire
to take his or her own life, with a small percentage (4%) having attempted it. The
same percentage indicated that they had needed hospitalization (Pope & Tabachnik,
1994). One study revealed that almost one-fourth of impaired psychologists had not
a4
undertaken personal therapy, citing reasons such as confidentiality issues, lack of

resources, and fear of judgment by colleagues (Deutsch, 1985),
Impairment implies more than not functioning effectively. Impaired
therapists may indeed harm their clients or further add to their suffering. They may
use the client to address their own needs or may actively exploit clients sexually or
emotionally (Corey, et al., 1998). Benningfield (1984) cites factors associated with
impairment which include: loss of empathy, feelings of being alone, inadequate
social skills and isolation, denial of responsibility for and consequences of their
behavior on clients, absorption with personal issues, and rationalization of actions.
Therapists who are affected by various factors to such a degree that their
work becomes impaired must put the needs of their clients first, continue their work
under supervision or discontinue their work. Making the assessment of what
constitutes impairment requires objectivity and self-awareness that the therapist may
not readily possess in these particular moments. Personal therapy, supervision and/or
consultation from trusted colleagues is often required. For professionals who are in
denial regarding their impairment, colleagues play an important role as well. It may
be necessary at times for colleagues to take an active part in confronting the
impairment, and to offer direction for remediation (see Chapter 12).
Burnout
Music therapists, as with other helping professionals, are not immune to the
risks of burnout. Oppenheim (1987) in a survey of music therapists, found that
18.4% of respondents who had worked 5 years or less scored in the medium range
of burnout on 5 (of 6) scales. Insufficient pay, lack of support and respect from their
administrators, and the demands of performing job duties outside of music therapy
were the most commonly cited reasons for burnout. In addition, music therapists who
had been working 5 years or more scored in the moderate range of burnout on one
of the six scales; 29% had high scores on one scale.
Burnout can be defined in a number of ways. Burnout is referred to as a state
of “utter despair and exhaustion resulting from the cumulative impact of a host of
stressors and aversive aspects related to therapeutic practice” (Guy, 1987, p. 253);
as an “erosion of the spirit” (Grosch & Olsen, 1994, p. 4); or as “a process in which
the professional’s attitudes and behavior change in negative ways in response to job
strain” (Cherniss, 1980, p. 5).
Burnout is to be distinguished from temporary states of fatigue, as these do
not imply more pervasive alterations in attitudes concerning one’s work and clients.
Burnout is also to be distinguished from the changes in attitudes resulting from the
socializing influences of colleagues and others in the work environment. Although
burnout also involves a change in attitudes and behavior, these are attributed to job
stress rather than to employment acculturation. Burnout is also distinguished from
staff attrition, as burnout does not always imply leaving one’s job (Cherniss, 1980).
Burnout has a negative impact on the therapist’s work performance and
effectiveness, as he or she loses enthusiasm, ideals, commitment and aspirations; the
therapist’s attitude inevitably influences his or her interactions with clients. All
oe
therapists are vulnerable to burnout at any time, although individuals in their first
two years of professional work may be most at risk, as this is the time when values
are formed that may endure throughout a career (Cherniss, 1980).
There are a number of sources of strain for new professionals; the first source
involves feelings of professional competence. Following many years of education
and training, professionals may still feel unprepared for the demands of clinical
work. There is indeed heightened pressure for the therapist to meet clients’ needs,
to establish their reputations among colleagues, and to live up to the implications of
their credentials.
A second source of professional stress involves frustration and
disappointment with clients’ responses, particularly clients’ lack of appreciation,
motivation, and cooperation. New professionals may have increased needs for client
validation and acceptance. However, the reality is that many clients view the
therapist’s competence as suspect, they do not value the services they receive, or
they expect more than the new therapist can reasonably give. To guard against these
client reactions, therapists must devote more time and care to their work, and more
emotional energy to deal with their fears and anxieties. Client behaviors, such as lack
of motivation, lying, manipulation, dependency, physical abuse, suicide, acting out,
etc., threaten the therapist’s security and self-esteem. Therapists are often unsure of
boundaries, and they may have difficulty in negotiating what they are capable of
achieving vs. what clients expect from them (Cherniss, 1980).
A third major source of strain involves the bureaucracy of the workplace.
New therapists are often appalled at the demands of paperwork, red-tape, procedures,
rules, and institutional politics. Many do not anticipate their lack of autonomy and
control, as well as the interference imposed by administrators and by the system in
general. There are inevitable value conflicts between the system, clients’ needs, and
professional standards, and new therapists do not yet possess the skills for
overcoming these impediments (Cherniss, 1980).
Understimulation and boredom in their work is another unexpected source
of stress for new therapists, as routines become established and variety diminishes.
Therapists yearn for the meaning and intellectual activity that had been present
during their training.
Finally, relationships with colleagues can imply a source of stress. As
colleagues can serve as a major buffer against strain and provide crucial support and
stimulation, when this does not occur (because of institutional politics and role
conflicts, differences in orientation and values, personality conflicts, mistrust, or
devaluing of music therapy), colleagues can become a further source of strain
(Cherniss, 1980).
New therapists adjust to job demands by changing their attitudes about work,
and six specific changes are noted: 1) they assume lower goals and standards for
work; 2) they assume less responsibility for their actions, attributing more blame to
the clients or system; 3) they let go of their idealism and adopt more cynical views;
4) they detach from their work emotionally; 5) they become less involved
psychologically with their work as a source of meaning and seek this meaning
elsewhere; and 6) they become more involved in their own self-interests and less in
a3
the intrinsic rewards of their jobs (Cherniss, 1980).

Professionals’ career orientations, i.e., their prioritization of what job rewards
are most significant and their future career goals, are related to their experience of
stress and burnout. Four types of career orientations are described by Cherniss
(1980). These include: 1) social activists, who see their work as a means of effecting
social change; 2) careerists, who are looking for success, prestige, advancement and
financial rewards; 3) artisans, who seek intrinsic rewards, challenge, new endeavors,
autonomy, and self-development; and 4) self-investors, whose primary interests are
in factors outside of work, such as family, personal development, etc. Cherniss has
found that self-investors and careerists are at least risk for burnout, whereas social
activists are most at risk.
The quality of life professionals maintains outside of the workplace is also
a significant and interdependent factor in their becoming susceptible to burnout.
Those most at risk for job-related stress include professionals who have unstable or
unfulfilling relationships or who are new to their communities. Conversely, job
burnout also can impact on personal lives as well (Cherniss, 1980).
Cherniss (1980) makes a number of recommendations to avert and/or deal
with professional burnout. These include the following for training: 1) curricula
designed to more effectively enhance competence and containing more practical
information and concrete guidelines for everyday situations, and 2) more emphasis
on psychological competence and interpersonal skills involving listening, leadership,
helping and conflict resolution. Within the work environment, a number of
interventions can be used to address burnout issues, and these include: professional
development activities and counseling, orientation procedures, burnout assessments,
professional support groups, modifications to the job to alleviate the intensity of the
workload and allowances for part-time work, provision of feedback, maintaining
connections among staff, management training, and clearly articulated goals and
procedures.
Professional Self-Care
The need for professional self-care is a frequent topic in the literature as a

means to avoid burnout and as an essential ingredient to continued therapeutic
effectiveness (Edelwich & Brodsky, 1980; Coale, 1998; Farber & Heifatz, 1981;
Grosch & Olsen, 1994; Guy, 1987; Kottler, 1993; Kottler, Sexton & Whiston, 1994).
There are a number of aspects of self-care: 1) time management (e.g., balancing
work and free time, allowing time for family and friends, efficient scheduling); 2)
emotional self-care (e.g., involvement in personal therapy, supervision, spiritual
pursuits); 3) leisure and recreational activities (e.g., hobbies, vacations, sabbaticals);
4) physical self-care (e.g., stress management, exercise, nutrition); and 5)
professional self-care (e.g., continuing education, supervision, involvement in
professional associations, balancing various professional activities, research,
conference attendance, self-directed study). Few codes of ethics however, include
the issue self-care as an ethical mandate, except in cases of therapist impairment
(Coale, 1998).
54
It is important to realize as a professional that helping others without

replenishment of the self is dangerous to both therapists and clients. Entering the
music therapy profession does not involve taking a vow of martyrdom! As a
university educator for many years, it has been my observation that many music
therapists (both students and professionals) have the tendency to ignore their own
needs and to avoid self-care. Whereas almost all would agree to its importance,
relatively few actually take the necessary measures. Without a doubt, there are many
extremely dedicated music therapists who give their all to their clinical work.
Perhaps, they should be reminded that giving their all to clients and doing their best
clinically also implies doing the best they can for themselves. Therapists need not
feel compelled to choose between their clients and themselves. If this choice is made,
the quality of therapy will undoubtedly suffer.
Self-care is on-going, and implies that the therapist stay attuned to his or her
needs, feelings and values, in addition to those of the client in each and all therapy
sessions. By doing this, therapists can more fully understand and be honest about the
“why” of their behavior and interventions with clients; this honesty maintains the
integrity of the relationship (Coale, 1998). Therefore, personal therapy, supervision,
and/or consultation can all play important roles in self-care. All can provide venues
for music therapists to deal with both personal and professional issues and problems,
and can serve as important, ongoing means for therapists to stay healthy. When
therapists’ problems are severe and they are at risk of impairment, the pursuit of one
or more of these options is essential.
Maintaining one’s personal connection to music can be particularly important
for music therapists. This can be achieved in any number of ways, through study,
performing, creative activities, using music for stress reduction, etc. Learning to
nurture oneself through music can be a significant and meaningful strategy for those
whose belief in its healing capacities is unrivaled!
Seeking peer support is also a significant part of self-care, and an option that
can reduce many of the risk factors for vulnerability and impairment.
It is also essential that training programs in music therapy prepare students
for the emotional demands of working clinically. Being a music therapist is replete
with joys, frustrations, satisfaction and disappointments. Students must be helped to
find ways to take care of themselves as professionals to avoid impairment and
burnout in their careers. They should be introduced to the risk factors, as well as
strategies to avoid these, such as coping and stress-reductions skills. Peer support
groups may also provide students with opportunities to have their feelings and
vulnerabilities acknowledged, validated and addressed. Personal therapy, including
personal music therapy, should be routinely encouraged for music therapy students.
Preparation in these ways represents an important step towards prevention.
Legal Aspects of Competence
Besides an ethical issue, competence is also a legal issue. Therapists who are
incompetent personally and/or professionally in their work are at risk for malpractice
litigation.
eh)
Malpractice litigation can stem from a number of therapist behaviors, and

those that present the greatest risk include: “negligence, improper diagnosis,
disclosure of information, sexual intimacy with clients, issues of informed consent,
and suicide or homicide by clients” (Pryzwansky & Wendt, 1999). Additional areas
that can be ripe for litigation involve incompetence, failure to consult or refer,
inadequate supervision of students, and patient abandonment (Stromberg, et al.,
1993a, 1993b). Furthermore, certain client groups, e.g., those with volatile
psychopathology, those who have been traumatized, abuse victims, and child custody
cases, may all present an increased risk for litigation (Koocher and Keith-Spiegel,
1998).
Behnke and Hilliard (1998) note that malpractice cases involve four Ds:
“Dereliction of Duty Directly causing Damages” (p. 10). If any of the Ds is not
involved, there will be no case.
Duty involves that owed to the patient as dictated by a standard of care.
Dereliction refers to the breach of this specific duty. Because of this, the patient
sustained damages or harm. The dereliction of duty is considered the direct cause of
harm to the client (Gable, 1983).
Although it is not the purpose of this chapter to create undue alarm among
music therapists concerning the risks of being sued by clients, litigation is always a
possibility insofar as incompetence is concerned. There are no data available
concerning the frequency of malpractice complaints against music therapists, and it
is indeed hoped that these are few and far between, if any! The music therapist who
maintains personal and professional competence for ethical reasons is likely also to
be practicing in a responsible manner legally. It is emphasized that music therapists
should practice in a virtuous, ethical manner as their primary motivation, rather than
out of fear of being taken to court.
Competence: Who is Responsible?
It is the opinion of this writer that competence is everyone’s business:

individual music therapists, music therapy educators and supervisors, as well the
professional music therapy association and certification board. Each has a specific
role in assuring and enhancing professional competence, as well as in safeguarding
the profession against incompetent practitioners.
Although. this chapter has focused primarily on the responsibilities of the
individual therapist, (e.g., in maintaining skills, self-awareness, etc.), this section will
emphasize the responsibilities of educators, supervisors and the professional
association in facilitating competence within the profession.
The responsibility of educators in promoting competence in students begins
as soon as potential students make contact with the educator and university.
Screening applicants for music therapy study is an important first step, and educators
have the responsibility of establishing and implementing criteria for admission (see
also Chapter 11). Educators may thus assess the student in each of the following
areas:1) academic record, 2) musical skills 3) personal suitability and potential
personal and interpersonal problems, 4) interest in and motivation for becoming a
56
music therapist, 5) past experience or contact with handicapped individuals, 6)

openness to learning, 7) particular clinical interest, 8) career goals, 9) reasons for
wanting to attend the specific university, etc. As admission to a music therapy
program is a two-way process, the educator also has the responsibility of fully
informing the applicant concerning the academic, musical and personal demands of
the music therapy program.
Educators are also ethically responsible for the content of their training
programs to develop and enhance competence in their students. Both the breadth and
depth of training is of concern at both undergraduate and graduate levels. Educators
are responsible for designing curricula and field experiences so that students can best
achieve the competencies established by the professional association. Educators are
also responsible for evaluating students’ competencies on a regular basis and for
providing feedback and support to the student in those areas where there are
deficiencies. Educators structure and monitor the pre-internship field experiences of
students, and determine if the student is adequately prepared for internship. Some
educators monitor and jointly supervise the internship experience of students as well
to ensure that clinical competence is acquired by the student. Additional details
concerning the ethical responsibilities of educators and supervisors are included in
Chapter 11.
Supervisors are responsible for structuring field experiences (both pre-
internship and internship), for providing regular feedback to students and academic
faculty regarding their acquisition of competencies, and for determining if the
students’ competencies are adequate for entry-level clinical work.
The music therapy association is responsible for: identifying the professional
competencies required for music therapy practice; for developing the educational and
clinical training standards to be implemented by educators and supervisors, as well
as the professional standards for music therapy clinical practice; and for both
developing and enforcing the professional code of ethics. The association is also
responsible for providing opportunities for the growth of professional competence
among its members through its journal publications, conferences, and other
educational endeavors.
The Certification Board for Music Therapists is responsible for the
development and implementation of a national examination to assess entry level
competence (and the awarding of the board-certification credential to eligible
persons), for the development and implementation of continuing education
requirements for board certified professionals, for the monitoring of professional
continuing education endeavors, and for the approval of continuing education
programs for professionals,
All professional music therapists, again, are responsible for their own
personal and professional competence, and are also ethically bound to be aware of
(confronting, if necessary) incompetence in music therapy colleagues (see Chapter
12).
Thus, the responsibility for personal and professional competence is both an
individual and shared responsibility among all music therapy professionals working
in the field clinically, in academic settings, in supervisory capacities, and/or on
57
behalf of their professional association.
A Final Note on Competence
Personal and professional competence is a day to day commitment of the

music therapist. As such it is both a process and journey to which all efforts must be
directed, rather than a destination to which anyone ever fully arrives. This continual
striving for greater competence is the essence of music therapy practice.
The Music Therapist as a Person: Values
One of the basic tenets of the practice of music therapy is the belief in clients’
Capacity to change, and in the potential for music therapy to facilitate that change in
their social, emotional, cognitive, physical, and/or spiritual functioning within their
particular environments (Linzer, 1999). Change involves the implementation of a
value system concerning the goals of the change, the nature of the change, and the
potential results of the change.
No music therapy relationship is value free. Values come to play in most
therapeutic decisions, in most client-therapist interactions, and in the therapy process
itself. Values are deeply imbedded, and both the therapist and client bring the values
they have accumulated throughout their lives into every therapy session.
Clients also have values regarding what change implies in their lives. They
may be resistant to change because of the anxiety this can create. For example, an
abused woman may fear leaving her abuser husband because of the fear of being
alone and of having to care for herself and her children (Linzer, 1999). Whereas the
client’s resistance to change may stem from a variety of factors, (financial,
emotional, social, etc.), it may also be based on cultural influences and may represent
a way for the client to adhere to his or her ethnic traditions. This conflict in values
often presents an important challenge to work in therapy, and may require the
relinquishing of the therapist’s own professional values (Linzer, 1999).
It is important for therapists: 1) to be aware of their own values and how
these impact on their work, 2) to understand the values of the client, and 3) to assess
when these values may be different or in conflict. They may not agree with their
clients’ values, but they must respect their right to have them (Corey, et al., 1998).
Ethical issues arise when the therapist does not respect the client’s right to his or her
values, when the therapist is unable to accept them, and when he or she attempts to
impose his or her own value system on the client. Other conflicts occur when the
therapist’s goals for the client differ from the client’s goals. It is most difficult for
the therapist to conceal his or her values, as these may be communicated in many
ways during therapy, and the client is unconsciously and covertly influenced to
accept these. In a similar manner, conflicts emerge when the agreed upon therapeutic
goal implies the client’s relinquishing of deep-seated values, such as a religious
belief (Steere, 1984).
The issue of values in therapy is a controversial and difficult one. Therapists
may be somewhat polarized in their stances concerning how to use or not use their
58
own value systems in therapy. On one hand, there are some therapists who feel it is
their job to influence their clients to accept the “correct” (therapists’) values in their
lives. It is highly questionable whether one human being can know what is right for
another, and it is clear that therapy is not a venue for preaching (Corey, et al., 1998).
On the other hand, there are therapists who use all their energy to keep their values
from being discovered by the client.
Corey et al., (1998) support a moderate position regarding the role of
therapists’ values in treatment. They contend that a client needs to know the
therapist’s opinions on issues so that the client’s own thinking can be tested. Bergin
(1991) states that therapists should be forthcoming with the client regarding their
views, cooperate with the client in setting appropriate therapeutic goals, allow the
client to make decisions autonomously and then take responsibility for the
consequences.
Corey, et al. (1998) further believe that it is not possible or desirable for
therapists to avoid their values within the therapeutic process, and it is appropriate
for therapists to express these when relevant to the client’s situation. Bergin (1991)
states “It’s vital to be open about values but not coercive, to be a competent
professional and not a missionary for a particular belief, and at the same time to be
honest enough to recognize how one’s value commitments may not promote health”
(p. 399). Bergin also emphasizes that the challenge for professionals is in the ways
they use their values to promote the process without using their power to inflict
them.
The present author believes that this is a most complex issue, and that there
are a number of complicating factors. The four basic questions to be considered in
this discussion include the following: 1) What values of the therapist are related to
the goals of treatment and process of therapy, and should these be shared with the
client? 2) Is it appropriate for the therapist to express his or her own values as they
relate to the client’s values? 3) Can therapists work with clients who have different
values? And 4) If therapists’ and clients’ value systems differ, what are the criteria
for client referral?
The first question is: What values of the therapist are related to the goals of
treatment and process of therapy, and should these be shared with the client? The
present author’s answer to this question is a resounding “yes,” and there are a
number of qualifying criteria for this response. The therapist’s own values (and
personal needs as well) are likely to be manifested first of all in the theoretical
orientation he or she has adopted, in the techniques he or she employs, and in his or
her personal style of therapy. As any theoretical orientation comprises basic beliefs
and assumptions about human beings, their relationship to the world, and their needs,
it is not surprising that music therapists will select an orientation that is most
consistent with their own values. Even though a music therapist may have been
trained according to one particular theoretical orientation, the orientation that he or
she ultimately adopts is likely to be the one that is most resonant with personal
beliefs and values. Moreover, the therapist’s personal style within this orientation
will be further refined to reflect these values as well. It is not believed that therapists
can work for a period of time in a particular orientation and use specific techniques
59
without experiencing difficulty and frustration, if this work is an inauthentic

expression of their own value systems. Some music therapists have had sufficient
training to be able to work within several orientations depending upon the client’s
needs. Although some may question the ability of any therapist to do this with
adequate skill and depth, it may indeed be possible for experienced therapists. The
therapist’s theoretical orientation and techniques should by no means be a secret to
the client, and as is emphasized in Chapter 4, informed consent requires that these
facts be disclosed to the client prior to treatment.
The needs of the client and goals for treatment are undoubtedly assessed and
established within the context of the therapists’s particular theoretical orientation.
Although these goals may indeed vary accordingly, there appears to be at least some
consensus regarding the goals implemented by therapists. A survey of mental health
practitioners revealed a number of basic values thought to be essential both to good
mental health and to be used as goals for psychotherapy. These include: self-
determination; sound coping strategies for stress; the capacity to give and receive
love; sensitivity to others’ feelings; the ability to be open, forthright and authentic;
satisfaction with one’s work; achieving one’s own identity and self-esteem; being
able to communicate effectively on interpersonal levels; possessing self-knowledge
and the propensity to grow; and taking care of one’s physical well-being (Jensen &
Bergin, 1988).
The establishment of therapeutic goals is not a unilateral process
accomplished solely by the therapist. The therapist may make an assessment of
potential goal areas, but these must be negotiated with the client through the
informed consent process. Goals developed according to the values of the therapist
may not be imposed upon the client, although the therapist may express his or her
viewpoint concerning the client’s needs, being open as well to the client’s viewpoint.
It is of course unethical for the therapist to have a hidden agenda regarding the goals
for treatment. Goals are always a matter of negotiation with the client and/or the
client’s parents/guardian. To do otherwise would compromise the client’s autonomy,
and violate his or her rights. In the event that these cannot be agreed upon by both
parties, informed consent does not occur, and the client may need to be referred to
another therapist.
The second question to be considered 1s. Js it appropriate for the therapist
to express his or her own values as they relate to the client’s values? As stated
previously, this is a most controversial issue, and there is no simple or pat answer.
However, perhaps the starting point for arriving at an ethical decision is the
therapist’s honest and brutal self-awareness. Because value systems of the therapist
are often emotionally charged and involve deeply imbedded phenomena, it is
essential for the therapist to question his or her own needs to share/express his or her
conflicting values with the client. Is it in the client’s best interest for the therapist to
express his or her own personal values? Or is this the therapist’s own need? And if
so, does the therapist have a need for his or her values to be
accepted/approved/validated by the client? Does the therapist need to feel power in
imposing values? Does the therapist feel that he or she needs to show
expertise/wisdom to the client, and that he or she knows better about the client’s life
60
than the client him or herself? Does the therapist need to share values to feel
competent, helpful, effective? Does the therapist need to test his or her own values
with the client? Are the therapist’s values so deeply held and compelling that he or
she feels obliged to share these? How will the client feel if the therapist’s conflicting
views are expressed? Will this serve to alienate the client and/or restrict his or her
freedom in the discussion of values? What impact will this have on the therapeutic
process? Does the client really care about the therapist’s values? The list of questions
may go on and on.
If on the other hand, the therapist’s values are consistent with those of the
client, is it in the best interests of the client to share this information as well (e.g., to
establish more of an empathic connection)? Or is this the therapist’s need? If so, does
the therapist have a need for acceptance/approval/validation from the client? Will the
client feel supported by this information, or more constricted in exploring other
values for him or herself? Again, the questions continue.
Aside from the first question posed, (i.e., “is it in the client’s best interest for
the therapist to do so?”), if the therapist’s honest answer to any of the
aforementioned questions is “yes,” the therapist should not share his or her values
with the client without first obtaining supervision, consultation, or personal therapy,
as his or her personal needs may in fact be coming into play, and may potentially
interfere with the therapy process.
If the therapist assesses that it is in the client’s best interest to share his or her
values, (and again brutal honesty is required on the part of the therapist), additional
factors should be considered before this is done. First, this sharing can never imply
an imposition of values. The therapist must assess whether he or she has the skill and
competence to share values in a way that does not imply coercion for the client to
accept these values, either explicitly or implicitly, overtly or covertly. Can the
therapist present his or her values in a manner in a way that is open and non-
imposing, so that the client does not feel judged or limited in further discussion of
his or her values?
Even if the therapist shares his or her values in a way that invites discussion
and is non-imposing, the therapist’s body language and nonverbal actions may imply
coercion (Corey, et al., 1998). Does the therapist subtly direct the client’s
conversation or change the subject? Does the therapist withdraw eye contact, shift
posture, grimace, change his or her tone of voice, etc. when disagreement exists? The
therapist needs to be very aware of these subtle messages that may, in fact, serve to
compromise the client’s autonomy and self-determination.
Before making the decision to share his or her values, the therapist needs to
carefully assess some the dynamics of the relationship with the client. Does the
therapist know the client well enough to do this? How helpful will this information
be to the client? Does he or she care or want to know? Can he or she anticipate to
some extent the client’s reaction? What is the power dynamic of the therapist’s role
with this particular client? What are his or her expectations of treatment? How
vulnerable is the client with regard to the therapist’s influence? Is the client
excessively dependent upon the therapist? Are there multicultural factors involved
(see Chapter 7) that may further exacerbate the client’s vulnerability?
61
Obviously there are many issues to be considered in making and

implementing the decision of the therapist to share his or her values with the client,
and the decision is not, nor should it be, an easy one. Because informed consent is
such an important factor in preserving the client’s autonomy, the therapist may
simply ask the client for his or her approval before doing this. In asking for the
client’s approval, the therapist may also clarify with him or her the reason for
expressing values, his or her intent not to coerce or influence the client, and his or
her willingness to have an open discussion of the values involved. The therapist
should be prepared to have the client refuse this information and to honestly be okay
with it, i.e., not feel rejected, angry, etc. If the therapist is aware of his or her needs
and feelings and is also respectful of the client’s right to self-determination, he or she
can allow the client to decide whether these values may be shared, and the client will
sense his or her own true freedom in making this decision in a non-coerced manner.
The third question to be considered is: Can therapists work with clients who
have different values? There is a seemingly simple response to this question: It
depends on the therapist, the client involved and the magnitude of their value
differences!
Therapists who work with clients having different values systems than their
own need to be self-aware of their competence and skill in this area, their personal
needs and issues which may impact on their work, their level of experience
(professional and personal) and maturity, their openness to those who are different,
and their willingness to go beyond themselves and grow in this area. Whereas many
music therapists will strive to have the necessary skills and qualities to work with
any client having any value system, few are capable of actually doing so, nor can this
be realistically expected. What is expected is that music therapists have the self-
awareness to know what they are capable of doing with these clients in terms of both
professional and personal competence. Whether working in facilities or in private
practice, music therapists will inevitably have clients referred to them with differing
value systems, and it is the responsibility of the music therapist to make the
determination of whether he or she can work effectively with them.
The expectations of the client are also of significance. Clients may prefer to
work with therapists who share the same values, culture, gender, ethnicity, life
experiences, and issues as the therapist. Clients want their values to be understood,
acknowledged and supported, and they may believe that therapists/individuals who
are similar to themselves may have the capacity to do this. The rapid emergence of
self-help groups in American society attests to this belief and need. Some clients
may screen potential therapists regarding life experiences, issues and values. As
these are important components of informed consent, the therapist has the
responsibility to respond honestly to client’s questions about these issues, so that the
client may make an informed decision concerning treatment.
The type and magnitude of the differences between the client’s and
therapist’s value systems is an important consideration in determining whether the
therapist and client can work together effectively. Differences in values may be
minor or major, or they may be diametrically opposed to each other. For example,
differences between individualistic or collectivistic cultures (see Chapter 7)
62
regarding self-determination and family allegiances may be striking. Likewise,

differences in religious values may be of major significance, for example with regard
to the issue of abortion. Political differences between extreme right wing and
extreme left wing parties are another example. The therapist must determine whether
the gap between his or her values and the client’s is too large or extensive to be
adequately bridged.
Another consideration concerns the familiarity of the therapist with the
client’s particular values. Even though the gap in values may be quite extensive, the
therapist may have had experience with previous clients who had similar values or
the therapist may have received specialized training in this area. The more unfamiliar
the therapist with the client’s values, the more insecure he or she may feel regarding
his or her personal and professional competence.
Therapists who are relatively secure in their own value systems may have
little difficulty in working with clients who are very different, whereas therapists
who are insecure about their values may be threatened by others that are only slightly
different from their own.
The therapist’s and client’s degree of tolerance for differences is another
consideration. Certain value systems comprise beliefs that are unyielding, rigid and
intolerant of diversity. The need for the therapist to remain true to his or her own
value system while working with clients who have radically different views may
present a real difficulty for the therapist. It is important for music therapists to re-
examine their own values if they expect the client to do the same (Corey, et al.,
1998).
Therapists may consider some of the aforementioned factors in deciding
when they are able to work with clients who have different value orientations.
Indeed, as a professional, the music therapist may often need to relinquish expression
of his or her values or neutralize these beliefs in work with clients, and yield to
professional ethics as the “dominant culture” (Linzer, 1999, p. 24). The client and
therapist involved, and the magnitude of their value differences are significant
factors in whether personal values can be suspended or neutralized.
The last question posed is: Jf therapists’ and clients’ value systems differ,
what are the criteria for client referral? In many instances therapists may be
successful in working with clients with diverse values. In other instances, there may
be serious doubt concerning the potential effectiveness of therapy. What then are
criteria that may be used in making the decision to refer or to defer treatment?
Tjeltveit (1986) suggests that the therapist may consider referring a client
whose moral, religious or political values are primary components of the client’s
problems and when: 1) the therapist has reached his or her limits of competence, 2)
the client’s values are extremely uncomfortable for the therapist, 3) the objectivity
of the therapist is compromised, or 4) the therapist has serious concerns about the
possibility of inflicting his or her values on the client. Therapists may also consider
referring clients with whom goals may not be successfully negotiated, or with whom
negative countertransferences cannot be adequately resolved. Under these
circumstances, it is advisable to refer the client to a therapist more suited to the
client’s needs. The mere presence of a values conflict between therapist and client
63
does not warrant a referral, as these may be worked through successfully.

Finally, therapists must be sufficiently self-aware to: 1) anticipate when their
values may compromise their objectivity in the therapy process, 2) understand their
feelings with regard to issues involving their personal values, 3) acknowledge their
limitations, and 4) be honest with clients when they feel that their value conflicts will
present a serious impediment to effective therapy (Corey, et al., 1998).
Values and Religion/Spirituality
For purposes of this discussion, “Spirituality refers to a personal inclination

or a desire for a relationship with the transcendent or God; religion refers to the
social or organized means by which persons express spirituality” (Grimm, 1994, p.
154). Whether the reader agrees or disagrees with these definitions is not necessarily
relevant to the present discussion. However, it is important to understand the
significant role of religion/spirituality in promoting health and in enhancing the
therapeutic process. Values involving religion and spirituality play an important role
in people’s search for identity and life’s meaning, and these values influence many
aspects of the person’s life experience. The therapist’s task, therefore, is to attempt
to comprehend the client’s religious/spiritual values and beliefs, and to use these as
a framework for therapeutic work. Both religion/spirituality and therapy may serve
as important sources of healing, strength and solace for the client (Corey, et al.,
1998).
It is the client’s right to bring his or her religious/spirituality issues into
therapy. Conflicts may arise, however, when there are important differences between
the client’s and therapist’s religious/spiritual beliefs. Therapists may have strong
religious/spiritual values and clients may have few, if any. What is clear in this
circumstance is that therapists may not impose their religious/spiritual beliefs on the
client. In the opposite scenario, when the client’s religious/spiritual values are
fervent, and the therapist’s are not, the therapist is ethically obligated to be sensitive
and open to these beliefs. Therapists must “listen to them (clients) and let them lead
the way, and (allow them) to talk about areas they indicate they want or need to
explore” (Corey, et al., 1998, p. 83). Therapists are thus challenged to find ways of
establishing empathic connections with these clients, realizing that they may not
impose their beliefs, no matter how divergent they may be.
The question of competence arises in the way music therapists are trained to
deal with issues in religion/spirituality in therapy. It is not known how many
university or clinical training programs include this topic in their curricula. Many
music therapists may thus feel uncomfortable or inadequate in this regard, and may
not feel that it is appropriate to respond to their clients’ religious/spirituality issues.
Those therapists who do feel comfortable may feel competent in addressing these
issues from the perspective of their own religious beliefs, which is potentially
problematic. In addition, because music is often associated with transpersonal,
religious and spiritual rituals, clients may expect the music therapist to support their
religious beliefs values through music.
As a first step in dealing ethically with this issue, music therapists must be
64
acutely self-aware: of their religious/spiritual beliefs or lack thereof, of their biases

against or towards certain religions or practices, of how events in their lives have
contributed to their current values, of their capacity to empathize with clients having
conflicting religious/spiritual values, of their ability to tolerate different value
systems, and of their personal and professional limits of competence in this area.
For music therapists who find it uncomfortable to work with clients’
religious/spiritual values, there are a number of professional options: 1) obtaining
additional training in the use of music therapy to support these needs, for example,
within the context of continuing education, graduate programs or institute training,
such as the Bonny Method of Guided Imagery and Music (which emphasizes
transpersonal and spiritual applications of music); 2) studying privately or in a
structured manner various world religions and practices; 3) pursuing self-experience
in music therapy for these issues; 4) seeking personal therapy or pastoral counseling;
5) obtaining supervision or consultation; and/or 6) referring the client to a different
practitioner.
For music therapy work with some clinical populations, a primary emphasis
or focus of treatment may involve the client’s spiritual/religious beliefs and needs,
as these may be the most significant sources of strength and coping available. Music
therapists working with AIDS, terminally ill, and cancer patients, for example, as
well as those working with the elderly confront these values on a daily basis.
Obtaining information concerning the client’s religious/spiritual values is thus an
important part of the music therapy assessment process.
The present author’s music therapy work with patients awaiting heart
transplants is another prime example of a clinical population for whom
religious/spiritual beliefs may represent the primary source of hope for survival.
Clients’ values and beliefs take a variety of forms, and the author, as therapist, must
be continually prepared to follow the their lead, honor and support their beliefs
through the music therapy process, and be open to any discussion about these beliefs.
It is felt that without acceptance and acknowledgment of the client’s
religious/spiritual values and without the capacity to follow the client’s lead
musically, it would be virtually impossible to establish an empathic connection with
him or her.
Therapists’ Private Lives
An important ethical consideration is the concern about behaviors of

professionals at those points in time when their private lives and professional lives
intersect. Therapists have the same right to their private lives as do other
professionals and non-professionals. However, ethical issues emerge when
therapists’ private behavior has the potential to reflect negatively upon the profession
(Stein, 1990).
There are expectations of society that members of professional organizations
serve by their example. For instance, there are expectations of lawyers to follow the
laws, there are expectations of physicians not to smoke, there are expectations of
therapists working in substance abuse not to get drunk or use drugs, there are
65
expectations of marriage counselors not to be divorced, and there are expectations

of family therapists not to have problems with their children. There are times,
therefore, when the private behavior of therapists is held to the same ethical
standards as is their professional behavior (Stein, 1990).
Are therapists ever off-duty, or must they be on duty 24 hours a day, seven
days a week? Are they like the grade school principal who lived in the same
community as her school and who felt the need to dress formally to do food
shopping, as she routinely encountered pupils and their parents and wanted to
maintain her image as principal? (Stein, 1990).
What then are the ethical expectations of the music therapist’s private
behavior? Must he or she behave in a way to reflect positively upon the profession
at all times even when off-duty? It may be safely stated that music therapists are
obliged to be law-abiding citizens, with all that this entails. Music therapists should
be examples of good mental health and of responsible community membership.
Private behavior should be in keeping with the standards of the community. Beyond
this, there may be additional responsibilities imposed by the type of clinical
population with whom the music therapist works. For example, music therapists
working in substance abuse should be cautious in their use of alcohol in public.
It is especially important for music therapists who live and work in small
communities, where there private behavior is more prone to observation by others,
to exercise responsibility in their private behavior, as this behavior is often a direct
reflection on their profession. This necessity may also at times extend to their family
members. There are no hard and fast rules concerning how this is done, but the music
therapist should anticipate what the community expectations are for him or her and
make every attempt not to violate them.
On the flip side of the coin is the responsibility of the therapist not to let
personal problems interfere with professional work. As mentioned earlier in this
chapter, therapists are as vulnerable to life issues and problems as any other human
being, and perhaps even more so because of the intensity and demands of their work.
Neither the music therapist nor any other person can shield him or her from these
problems or life events. The way music therapists respond to these problems and
how they prevent these problems from interfering with their work is what matters.
Chapter Summary
1. Competence in music therapy practice is a complex issue due to the range of

clinical populations seen, the breadth and depth of practice, the theoretical
orientations employed and the musical skills required. The professional associations
have developed both entry-level and advanced competencies, standards for clinical
practice and a national examination as guidelines for and assessment of professional
competence.
2. Competence is on a continuum and is also variable according to various

knowledge, skill and personal requirements for music therapy practice. There are a
number of reasons which may account for or compel music therapists to practice
66
outside of their areas of competence. However, self-awareness and assessment,

supervision, consultation, continuing education, graduate coursework and institute
training, conference attendance, and knowledge of the current literature may be
effective preventive strategies.
3. Music therapists working with groups should understand both the power of the
techniques they use and the dynamics of group process from a personal perspective.
The therapist should be prepared to handle intense group reactions, and be cognizant
of the boundaries of their competence.
4, Personal competence in music therapy requires self-knowledge, self-acceptance

and self-monitoring. The music therapist, as all human beings, has needs. An
awareness of these needs within the therapy session will help the therapist avoid
using the client to meet his or her own needs and to place the needs of the client first.
Therapists’ emotional makeups and life experiences may significantly impact on
their clinical work, and they must continually monitor this influence. If left
unmonitored, destructive countertransferences may result. Therapists cannot help
others, accept others or heals others unless they do the same for themselves.
5. There are a number of factors which may increase a music therapist’s vulnerability
to psychological impairment, including: isolation, being on public display, the
intensity of the work, ambiguity, external pressures, pressures from colleagues,
stressors within the therapy situation, clients themselves, irrational belief systems,
and life events. A therapist’s psychological impairment poses risks to the welfare of
clients, and therapists must make the decision regarding whether or not they are able
to continue working effectively.
6. Burnout is a state of exhaustion resulting from a host of work stressors with a

negative impact on one’s professional work. New professionals may be particularly
at risk for burnout. Causes that predispose professionals to burnout include: doubts
concerning one’s competence, frustrations and disappointments with clients,
bureaucracy, understimulation and boredom, and negative relationships with
colleagues. Burnout may also be related to the professional’s career orientations.
Burnout may be diminished by more effective training as well as specific
interventions within the workplace.
7. Routine professional self-care is considered essential in maintaining the quality

of music therapy services. Personal therapy, stress management, peer support, and
maintaining a personal relationship with music are suggested as effective self-care
strategies.
8. Competence is both an ethical and legal issue, and there are legal ramifications for
incompetent practice.
9. Competence is the responsibility of each individual music therapist, of music

67
therapy educators and supervisors, of the professional association and of the

Certification Board for Music Therapists. Each has a specific role in monitoring and
assuring professional competence.
10. No therapy is value free, and both clients and therapists bring their respective
value systems to each therapy encounter. Controversy exists as to whether and how
the therapist’s values can/should be shared with the client. Underlying any decisions
is the need for the therapist’s self-awareness regarding his or her values, and a
sensitivity towards the potential imposition of the therapist’s values on the client.
Four questions for discussion regarding values are presented, and guidelines for
ethical behavior regarding conflicts in values are discussed.
11. Clients’ religious/spiritual beliefs may play an important role both in the
therapeutic process and in healing, and this is particularly significant with some
clinical populations. The ability of the therapist to acknowledge and to respond to the
client’s belief system may be an important factor in establishing an empathic
connection with him or her. Ethical issues emerge when the therapist is not able to
do this, because of inadequate training, differences in belief systems or other reasons.
Therapists must assume responsibility for self-awareness of potential conflicts and
problems and for their limits in competence. Competence in this area may be
enhanced through supervision, training, and other endeavors.
12. Although music therapists’ have the right to their own private lives, there may
be community standards and expectations they must uphold or meet so as not to
reflect negatively on the profession. At the same time, music therapists have the
responsibility of not allowing their personal lives to influence their professional
work.
Ethical Dilemmas
A number of case examples of ethical dilemmas are presented in this and

subsequent chapters. You are likely to experience emotional reactions to some of
these. An honest recognition of these responses is important to ethical thinking and
self-awareness. Learning to discuss your feelings and reactions with others is
important to your professional growth now and throughout your career, as peers are
an important resource in the ethical thinking process and also in assuring your
personal and professional competence.
You may want to use all or parts of the ethical decision-making model
presented in Chapter 1 in arriving at an ethical course of action for the music
therapists involved.
1. Frank, a music therapist working at a large psychiatric facility is asked to conduct

psychodrama sessions for his adult clients. He has only had one university course
on the topic. He fears that his refusal to do so will impact on his promotion, which
is in process.
68
2. Steve, a music therapist in private practice, has attended a one-day continuing

education course on music in family therapy, and has also read some books and
articles on the topic. He would like to extend his practice, and has decided to involve
the family members of some of his individual clients in their sessions.
» 3. June, completed her master’s degree in music therapy during the 1970s, and has
been working ever since at a residential facility for the developmentally disabled
until recently. Because of a low census, her facility was closed. She applied for and
obtained a job as a music therapist in a facility specializing in closed-head injury.
Although this is an area of music therapy that emerged following her training, she
feels that she will be able to “catch-up” by attending the facility's orientation
program, as well as the 1-hour weekly in-service programs they provide to their
staff.
-4. Clara is a music therapist working in a medical setting. She is a conscientious and
dedicated therapist, and remains on call with clients’ families so as to be present at
times of crisis. During a 6-month period, she lost two clients to whom she had been
very close, her husband filed for divorce, and her daughter was diagnosed with an
eating disorder. She subsequently has become quite distant and detached from her
current clients and has stopped being on-call to their families. She has also begun
taking a prescription sedative that makes her lethargic and “spacey” in her work.
5. Pat, a new music therapy bachelor’s-level graduate, is working with a group of

adult clients who have acute psychiatric disorders. Normally, Pat uses music therapy
techniques aimed at providing support, and does not attempt to involve the clienis
in a psychotherapeutic process. However, because he had heard a presentation on
a special music and imagery technique at a recent conference, he wanted to see how
this would work with his group. What followed amounted to chaos for him. The
clients were deeply affected by the experience, and they had many intense emotional
reactions. Not knowing how to respond to these, he prematurely ended the group.
6. Sam, a gay college music therapy professor teaches ina small, religious-affiliated
college and lives in an adjoining small, conservative community. He is discreet about
revealing his sexual preferences to his students and colleagues, but frequents gay
bars on weekends. Recently, he had a close call when he saw one of his students at
the same bar, but was able to slip out the back door. He is very concerned about
what will happen ifhis sexual preferences are discovered.
7. Harriet, a music therapist in private practice attends a friend’s party and drinks
more than she should. When she returns home, she discovers an urgent message from
a client who needs to talk with her immediately.
8. Pete, a music therapist working in a treatment facility for alcohol abuse comes out
of a bar on a Saturday night, after having had quite a bit to drink, and meets the
parents of one of his clients.
69
9.Mary Ellen works as a music therapist in an outpatient treatment center. Stephanie

is a client with six children who is experiencing depression. Both Stephanie’s and
her husband's religious backgrounds are very conservative. Stephanie reveals to
Mary Ellen that she has just discovered she is pregnant again and is considering
having an abortion. Mary Ellen is a strong pro-choice advocate and encourages
Stephanie to make this decision.
10. Susan has worked for 6 years as a music therapists in a hospice setting. She is
deeply spiritual, and relies on her beliefs to help her cope with the losses of her
clients. She also helps her clients deal with their impending death by telling them
about the afterlife that awaits them where there will be no more suffering. She also
encourages clients to pray for hope and strength.
11. One of Susan's patients, Joshua, who is dying from multiple sclerosis, asks Susan
to accompany him musically during an assisted suicide at his home. He would like
Susan to use the music he loves to help him pass from this life to the next.
12. On his way to work, Frank, a music therapist working in an adolescent treatment
facility, has a car accident. He is not injured, but his car has been totaled, and he is
quite shaken. He is late for work, and when he arrives, he has to make the necessary
Phone calls to his insurance company, his wife and to a car rental agency. Miriam,
one of his clients, is waiting for him and their scheduled session when he arrives.
13. Christopher, a music therapist in private practice, has been working with Paul,
a client with relatively severe depression. Paul reveals to Chris that he has just
learned that he has AIDS. Christopher's brother, Cliff, has recently died of AIDS,
and Christopher had a very difficult time accepting his brother's sexual orientation,
disease, and subsequent demise. In addition, Christopher is phobic about contracting
AIDS himself. He is considering terminating his work with Paul.
14. Bob is a music therapist who works at a large state psychiatric hospital. He is
assigned to work with clients who have drug abuse problems. Bob has used a variety
of drugs in the past, i.e., marijuana and cocaine, and feels there is nothing wrong
with them.
15. Dee works as a music therapist in a residential facility for the developmentally
disabled. She often takes clients on field trips to hear concerts in the community. A
nurse at the facility gives Dee prescription medication for one of her clients with
epilepsy that must be administered during the field trip.
16. Paul is a music therapists who smokes marijuana in the privacy of his home to
“unwind.”
17. Dr. Jones, a music therapy professor at a large state university, is invited to a
student party. When she arrives, she discovers that alcohol and drugs are being used
70
by her students.
18. Brett, a music therapist in private practice, finds it difficult to work with clients
of different races, socioeconomic backgrounds and sexual orientations. Following
his initial meeting with some clients, he tells them that he is not sufficiently trained
to work with their particular problems and offers to refer them to another music
therapist.
19. Andrew discovers that Louis, his music therapy co-worker, sells marijuana and
cocaine outside of work.
1. Obtain copies of the AMTA listing of professional competencies. Go though the

list and rate your current skills using the following scale: 1 (no competence); 2
(minimal competence); 3 (moderate competence); 4 (good competence); and 5
(excellent competence). Make a list of the competencies that are rated as “1" or “2"
and develop an educational/training plan to address these competencies.
2. If you are graduate student or professional music therapist, obtain a copy of

Bruscia’s (1986) advanced competencies. Using the scale provided above, rate
yourself on each of the advanced competencies and develop an educational/training
plan to address those that have been rated as “1" or “2."
3. Review the AMTA Standards of Clinical Practice. Note strengths and weaknesses
in your current clinical work.
4. Obtain a copy of Dileo-Maranto’s (1993a; 1993b) and Bruscia’s (1998)

classification of music therapy practice. Identify the areas and levels of music
therapy practice. Using the scale provided above, rate your level of competence in
these areas and levels.
5. A number of factors may be related to psychological adjustment in life. Using the

following format, list those variables that you think are essential to psychological
well-being, the reasons for their importance, and how you would design music
therapy interventions to address these variable.
Variables Reasons for Importance Music

Therapy
Interventions
ae
6. Realizing that the information you provided in activity #5 above may reflect your
own values and theoretical orientation, write a short essay concerning the approach
to music therapy that appears to be most authentic for yourself.
7. In your course journal, reflect on the following question: “Who am | as a thinking,

feeling, relating and acting person?”
8. Based on the section in this chapter concerning psychological vulnerability,

impairment, and burnout, identify those factors in your life that you feel make you
most vulnerable to impairment (list adapted from Benningfield, 1994; Corey, et al.,
1998). In doing this, you might ask yourself the following questions:
~*Am I satisfied with my personal life and relationships?

*How am I caring for myself both physically and emotionally?
*Am I open to disclosing my vulnerabilities to colleagues and peers?
*Can I admit my mistakes and limitations as a professional?
*How consistent am I in my work ?
*What are the primary sources of stress in my life?
*Is it possible that these stressors can lead to burnout or impairment?
*Are there steps I can take to deal with these stressors before impairment occurs?
*Am I open to supervision?
*Am I open to requesting assistance from others?
*Am I open to pursuing personal therapy?
*What is my current personal relationship to music?
9. Reflect upon your personal needs:

*for control and power
*to be nurturing
\\*to change others in the direction of your own values
—"*to provide answers
*to feel adequate
*to be respected and appreciated (Corey & Corey, 1990)
*Other needs, e.g., to feel loved, to be taken care of, to be approved of, etc.
Describe how you meet these needs in your life, how you are unable to meet
your needs, and which needs may come or have come into play in your clinical work.
10. Describe your religious/spiritual orientation and the basic tenets of your beliefs.
Reflect upon how these beliefs evolved and significant persons who influenced them.
Assess how strong your convictions are, and how difficult it may be for you to put
these aside in a therapy situation.
11. Rate your ability to work with the following types of clients as follows:
1. Yes, with minimal difficulty
2. Yes, with some difficulty
3. No, not at all
72
Client Rating
*A client with fundamentalist religious beliefs who disavows
your own beliefs.
*A client who proselytizes his religion to you.
*A client who feels that her problems are the result of the lack of fortitude
in her religious beliefs.
*A client who asks you to pray with him.
*A client who is cut-throat in business, who uses others to advance himself
and who has no qualms about doing so.
* A gay couple who want to address their relationship and
sexual problems.
*A lesbian couple who want to address their relationship and
sexual problems.
*A man who is having an affair and wants to find ways to stay in this
relationship as well as his marriage.
*A man who wants to leave his wife and family to
pursue his sexual freedom.
*A woman who wants to leave her husband and children to pursue
a lesbian lifestyle.
*A teenager who wants support in having an abortion.
*A teenager who engages in unsafe sex practices with multiple partners.
*A man who believes women should be subservient and submissive to their
husbands’ commands.
*A client who believes that feelings are illogical and irrational, and
that emotions are to be avoided.
*A man who believes that sparing the rod spoils the child.
*A convicted child-molester.
*A convicted rapist.
*A serial killer.
*Parents of an interracial couple who oppose the marriage
of their children.
*A client who is extremely prejudiced towards all minority groups,
including your own.
*A member of a neo-nazi group (skinhead).
*A gay couple wanting to adopt a child.
*A lesbian couple who are seeking artificial insemination.
*An interracial couple wanting to have a child.
*A couple who practice “swinging.”
*A man who is involved in an alternative sexual lifestyle,
bondage, domination, etc.
*A man who is exploiting the welfare system.
*A woman who has abandoned her children.
*An abused wife who wants to stay with her husband.
*A man who has had a number of extramarital affairs and
feels no remorse.
ef,
*A gay man who wants the therapist’s support to inform his parents
about his having AIDS. =
* An intravenous drug user who has AIDS els
12. In your course journal, describe your emotional reactions to any issue or ethical
dilemma discussed in this chapter.
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CLIENTS’ RIGHTS AND
THERAPISTS’ RESPONSIBILITIES
Introduction
‘
Crients who come to music therapy are vulnerable for any number of
reasons: their physical, mental, social, emotional, developmental, and/or economic
problems are usually sufficiently severe to warrant their need for help. They are
vulnerable because they are in need. Most clients are new to the use of music
therapy as a treatment, which can further contribute to their vulnerability. They may
be confused about what it is, what is expected of them, what the music will do, what
the outcome may be, and if it will work. Clients who are vulnerable and in need are
sometimes desperate for a treatment that will help them with their problems. They
may look to the music therapist as a magical healer who is capable of curing their
ills, or, on the other hand, they may approach music therapy with some scepticism
about the potential of music to do anything, aside from perhaps, helping them to
relax!
An important responsibility of the music therapist is to reduce clients’
vulnerabilities by providing them with information about what music therapy is and
involves. Informing them of their rights within the clinical music therapy process
and providing them with the option of accepting or refusing music therapy based
on the clear information provided, is a significant part of acknowledging the
following: 1) clients’ worth and dignity as human beings, 2) their autonomy in
making decisions for themselves, and 3) the commitment of the music therapist to
be a responsible and ethical provider of services. Therapists’ responsibilities to
provide this information, as well as a number of their other responsibilities to
clients, are discussed in the present chapter.
Informed Consent
“Informed consent is a legal term referring to a person who, in possession

of suitable information, grants authority to someone else to take actions affecting
that person” (Beach, 1996, p. 22). Providing informed consent opportunities to
clients is both an ethical and legal requirement and responsibility of music
76
therapists. The purpose of informed consent is to provide information to clients

about what music therapy involves, so that they may make a knowledgeable
decision concerning its appropriateness as a treatment modality for themselves.
There are three necessary components of informed consent: 1) Competence-
the client has sufficient mental and emotional capacity to make rational decisions
for him or herself. When this is lacking, a parent or guardian is required to make
decisions. 2) Informed. The client receives sufficient information in a clear manner
to comprehend the matter to be decided. Sufficient information refers to the amount
of information a reasonable person requires prior to making a decision. 3) The
consent is voluntary. Consent is obtained without coercion or pressure on the client
to make the decision; he or she acts freely (Haas & Malouf, 1989). All three
components must be present for the consent to be considered truly informed.
Informed consent is both an ethical requirement as well as a technical skill
(Haas & Malouf, 1989). Therapists who provide information to clients using written
consent forms as a substitute for dialogue with the client are missing the opportunity
for providing meaningful and ethically beneficial information to the client in a
usable manner. Written consent forms may often be difficult for the client to
understand. Some studies have found that typical consent forms used in the practice
of psychology are written at a level understandable only to those with 14+ years of
school (upper level college) or graduate education (Grundner, 1980). Further studies
have indicated that clients have poor recall of the contents of consent forms (Pope
& Vasquez, 1991).
Corey et al., (1998) recommend that therapists take an educative approach
with clients concerning informed consent, by explaining information to them in a
clear manner and by encouraging them to ask questions. Therapists should be
willing and prepared to answer questions at the beginning of treatment concerning
the following issues: goals of therapy, services provided, expected behavior from
the client, risks and benefits of treatment, the qualifications of the therapist,
financial commitment, length of therapy, limits of confidentiality, and mandatory
reporting requirements. To view clients as partners in the process, not only with
informed consent procedures, but also throughout treatment, supports them in
deriving more benefits from therapy, as well as helping to diminish any power
disparities in the relationship (Corey, et al., 1998).
Therapists should be especially sensitive to clients’ vulnerabilities, as
mentioned in the beginning of this chapter, and be skilled in intuiting the client’s
own frame of reference (Koocher & Keith-Spiegel, 1998). Clients from culturally
diverse backgrounds, as well as individuals who may have experienced
socioeconomic and cultural pressures, e.g., women, children, the economic
disadvantaged, the elderly, and the institutionalized, may have experienced a
socialization process in which their autonomy and rights have been compromised
(Liss-Levenson, Hare-Mustin, Maracek, & Kaplan, 1980). These clients may be
reluctant to ask questions or address their own needs and issues (Koocher & Keith-
Spiegel, 1998).
The concept of “empowered consent” (Brown, 1994) is one that may
facilitate true and competent informed consent. In empowered consent, the therapist
ee
carefully structures the information and manner of presentation to remove any

pressures of coercion or imposition that might be sensed by vulnerable clients.
The general content areas of the consent form for treatment are included
below (with information included from Corey, et al., 1998; Koocher & Keith-
Spiegel, 1998; Peterson, 1996; Wheeler & Bartram, 1994). ‘The types and amount
of information, the specific content of informed consent, the style of presenting
information, and the timing of introducing this information must be considered
within the context of legal requirements, work setting, agency policies, and the
nature of the client population” (Corey, et al., 1998, p. 118). Some content areas
are relevant only to music therapists in private practice (e.g., fee information).
Private practitioners should develop their consent forms in consultation with an
attorney to include information relevant to the laws in their jurisdictions.
For music therapists working in treatment facilities, general informed
consent for treatment may be obtained from the client by the facility upon
admission. However, it is a good policy to obtain consent for music therapy
treatment specifically, and the consent form used by the music therapist should be
approved by the facility before its implementation.
Information About Treatment. In general, therapists should include relevant

details concerning the following: 1) Music therapy assessment - the types of
procedures involved in assessment, sources of information, and procedures for goal-
setting. 2) Music therapy treatment - goals, length, how and when treatment will
begin and will be terminated, types of music therapy interventions and techniques
employed, the clinical process, how the therapist and client will work together, what
is expected from the client, what will be provided by the therapist, the client’s rights
in treatment, (including the nght to voluntarily consent and to withdraw at any
time), potential benefits of treatment (and the fact that no guarantees can be
offered), potential risks and effects of treatment, and alternative treatments
available. 3) Music therapy evaluation - what procedures will be involved in
evaluating treatment progress, and if/how this information will be conveyed to the
client.
The influence of managed care on the treatment process, if relevant, should
be discussed with the client. As managed care may limit the number of sessions
reimbursed and/or the length of treatment, therapists are often required to provide
short-term interventions for clients’ problems. These may not always be in the
client’s best interests. The client should be informed concerning the appropriateness
of short-term procedures for his or her presenting problems (Richardson & Austad,
1991; Smith & Fitzpatrick, 1995).
Information About the Music Therapist. The therapist can provide

information regarding his or her education and training, certification, registration,
and/or licensing, specialty certifications, clinical specializations and experience,
theoretical orientation, and approach to treatment. The therapist should also inform
the client if he or she is being supervised, the reason for supervision, and the
procedures used for maintaining the client’s confidentiality. The therapist may
k:)
provide the name of the supervisor involved upon the client’s request. The therapist
should indicate if he or she regularly consults with other professionals regarding
case materials, and the procedures used for maintaining confidentiality. The
therapist may mention also the professional code(s) of ethics by which he or she is
governed
Confidentiality and Its Limits. The therapist should provide information

concerning how confidentiality will be handled and maintained, and whether the
client enjoys privileged communication (see Chapter 5). Special policies regarding
confidentiality/privilege with regard to parents/guardians of minor children or
legally incompetent adults, as well as in group, couples or family treatment should
be included, when relevant. Procedures for the release of confidential information
and for obtaining the client’s consent for its release should be detailed. The therapist
should indicate whether information will be shared with the client’s referral source,
if relevant, and the content of the information shared.
In addition, the therapist should carefully detail and educate the client
regarding the limits of confidentiality, including: 1) how information will be shared
with third-party payers and the potential risks involved, and 2) the legal
requirements for disclosure of confidential information, (i.e., when there is
suspicion or evidence of child and elder abuse, when there is a duty to warn and
protect if the client endangers self or others, when a crime is threatened, and when
records are ordered by a court of law) (See Chapter 5).
The therapist should also provide information concerning the content of
clinical records, how they will be maintained and safeguarded, how long they will
be retained, and how they will be disposed. The same information should be
provided concerning the use of video or audio tape recordings involving the client
(See Chapter 5).
The therapist may also include his or her policy regarding the client’s access
to his or her records, and the procedures involved (e.g., reviewing records with the
therapist present) (See Chapter 5).
Financial Policies. A full disclosure is made to the client regarding the costs
of treatment sessions, how payments are handled (e.g., billing procedures, insurance
reimbursement, filing insurance forms, co-payments), sliding scale fees available,
who is responsible for payment, how late or delinquent accounts are handled and
the additional fees required for such, and how financial records are handled and
maintained (see Chapter 9).
General Policies. The therapist should also include his or her policy
regarding the following issues: 1) access to the therapist in an emergency, 2) access
to the therapist in-between sessions, 3) access to another therapist when he or she
is ill or unavailable, and 4) session cancellation policy (the amount of notice
required, and the fees imposed for late cancellation).
The written informed consent form, covering the topics mentioned above,
should also include a statement that the client understands the information provided
72
and has been afforded the opportunity to ask questions of the therapist. The form
should include the client’s and therapist’s names and should be signed and dated by
both. The client should receive a copy, and the therapist should also retain a copy
for the client’s files.
Clients’ Right to Refuse Treatment
Clients who are not satisfied with the information concerning any aspect of
treatment, indeed have the right not to consent or to pursue an alternative treatment
option. Clients who are committed to an institution involuntarily, prisoners, and
minors may have their rights compromised both to provide true informed consent
and to refuse treatment. There are no easy answers to these situations, and music
therapists are often obligated to follow policies of their employers concerning
whether or not unwilling clients are required to participate in music therapy
sessions.
Rights of Minors as Clients
Music therapists in private practice may confront issues regarding the rights
of children and adolescents with regard to informed consent, specifically the rights
of minors to seek treatment independently and without parental consent, and their
rights to refuse treatment even though their parents have provided informed consent
on their behalf. Music therapists working with minors should be familiar with laws
in their jurisdictions regarding the treatment of minors, as these vary according to
State.
Only a small number of states (e.g., Virginia) permit minors to enter into a
therapeutic relationship without parental consent, and this involves treatment which
addresses substance abuse, birth control, sexually transmitted diseases, or crisis
situations. In most states, however, parental consent is required (Corey, et al., 1998;
Koocher & Keith-Spiegel, 1998).
It is possible that the need for privacy may an motivating issue when minors
seek treatment independently, as the parents themselves might play a part in the
presenting problems. The therapist who encounters the dilemma of whether to treat
self-referring minors without parental consent must consider the level of
competence of the minor, the potential harm caused by not treating him or her, the
severity of the problem, and the legal implications for the therapist in entering into
this relationship. Music therapists should seek consultation as well as legal advice
in these situations (Corey, et al., 1998). It may be ethically required to attempt to
balance the minor’s right to treatment against the parent’s right to refuse treatment
for him or her (Stein, 1990).
In cases where the minor refuses treatment to which his or her parents have
provided consent, including hospitalization, there may be no other options for the
minor (Melton, Koocher, & Saks, 1983; Koocher & Kieth-Spiegel, 1998; Weithorn,
1987), except when the minor’s welfare is jeopardized, and the courts are called in
to make the final decision (Stein, 1990).
80
Although legally the child may not have the right to refuse treatment, this
does not imply that he or she should not be afforded the right to make decisions
about the nature of treatment. The therapist should attempt to obtain assent from the
child, and this is both an ethically required and clinically sound practice (Corey, et
al., 1998; Stein, 1990). Minors can be encouraged by the therapist to become active
participants in establishing goals and in making treatment decisions, according to
their ability to do so, and resistance to treatment may be diminished when the
minor’s self-determination is recognized and validated (Corey, et al., 1998).
Therapists’ Responsibilities within the Helping Relationship
A number of virtues of the ideal music therapist were discussed in Chapter

2. The virtues of caring, empathy, prudence and courage are considered to be
essential to the helping process. Other responsibilities of the therapist and rights of
the client, considered necessary for effective therapy to occur, are discussed in this
section.
Communication, Dignity and Respect. Communication, the conveying of

one’s thoughts, feelings and attitudes, is one of the key components of heiping.
Communication is a two-way process. Therapists communicate both from their own
personal experiences and from their training. They are responsible for a self-
awareness of who they are both as people and as therapists; the manner is which this
is transmitted to their clients is essential. Clients, on the other hand, communicate
according to their own life experiences. These experiences may be vastly different
from those of the therapist, and honest communication involves the attempt by the
therapist to make sense of the client’s worldview. This implies going beyond the
roles that are played as client and therapist, and recognizing the shared and common
humanity between them. The therapist is first and always a person, one who brings
his or her personal assets and limitations to the therapy situation, both of which may
contribute to the quality of communication achieved in the therapeutic relationship.
(Malley & Reilly, 1999).
Besides attempting to understand the world through the client’s eyes, the
therapist must communicate as a genuine human being with the client, be present
to the client’s experience, and remain transparent both to self and to the client. This
involves assuming a non-judgmental stance and just listening (Malley & Reilly,
1999).
Acknowledgment of the innate dignity, worth and value of the client is a
cornerstone of music therapy practice. The client is respected as this human person,
not just a human person (Hancock, 1997). This is unconditional in the sense that it
is unrelated to the person’s behavior, qualities or limitations. The therapist, then, is
capable of separating the client as a human being from the problems, behaviors and
needs that bring him or her to therapy. Respect for the client can have positive
implications for the therapy process as well, as it can help reconstruct the client’s
impaired self-esteem. Respecting the client as a person unconditionally can be the
starting point for his or her ability to change. Respect is demonstrated in all of the
81
therapist’s words and actions, as well as in the manner that the therapist “says” and
“does” throughout the process (Hancock, 1997).
As therapists respect the client’s dignity, clients are helped to experience
themselves more completely and to come to understand their potential for growth.
The therapist’s “being there” for clients affords them the opportunity to explore this
potential. “Being there” also involves the therapist’s being a real person whose
primary concern is understanding the client’s world and experiencing it with him
or her. (Malley & Reilly, 1999),
Non-judgment and Acceptance. The therapist’s responsibility for not

judging the client and for accepting him or her naturally flows from the preceding
section: when the humanity of the client is respected for its inherent dignity, non-
judgment and acceptance are readily implied.
Clients come to therapy for many reasons, and by virtue of their humanity,
each is entitled not to be judged (Hancock, 1997). The power ascribed to the
therapist in the relationship requires some level of judgment, however, and it is
quite common for therapists to feel they are not doing their job well unless they are
judging what is right or wrong, good or bad about the client. In playing the role of
judge, the insecure therapist may feel more competent, more effective, and more
distant from the world of the client.
Therefore, it is essential for the therapist to make the following distinction:
the judgment required as a therapist is of the client’s behavior and not of the person.
Any and all judgments are made from the perspective of assessment and treatment
planning, and never from the perspective of placing blame or guilt on the client
(Hancock, 1997).
Non-judgment does not imply abandoning societal, moral and legal
standards for the safety and well-being of individuals and property. The therapist
is obligated to uphold and adhere to these standards with the client. In a similar
manner, the therapist is not forced to abandon his or her own personal values and
standards. However, these values and standards should not serve as the criteria for
anyone other than the therapist him or herself, and these should not be imposed on
the client (Hancock, 1997).
A therapist must convey his or her stance in maintaining a non-judgmental
attitude with the client early in the therapy process, and restate this whenever he or
she senses that the client is feeling judged. Clients may misinterpret the therapist’s
praise as judgment, and this may create pressure for them to adhere to the
therapist’s perceptions of what should be. Likewise, a therapist’s overly quick
assessment of a situation or offering of advice can also make the client feel that a
judgment was made on minimal information. Clients can feel that the therapist is
not respecting them enough to listen patiently and completely. Clients can also feel
that the therapist is acting im a judgmental manner when he or she appears
condemning of others who have injured or harmed the client.(Hancock, 1997).
Therapists should exert caution in buying into classifications of persons or
groups as not worthy of respect and treatment (Hancock, 1997). For example,
several years ago my colleague and I were conducting research concerning the
82
musical projective responses of imprisoned child molesters and rapists (repeat-

offenders) (Bruscia & Dileo-Maranto, 1985). We were extremely excited and
intrigued about working with this population and in understanding them more
completely via the music therapy assessment we had developed. We were
nevertheless quite shocked by the reactions we received from other colleagues when
we described our research plans. Many questioned our rationale for wanting to
conduct research with these groups, whom they felt were not entitled to any type of
further understanding or treatment because of the heinous crimes they had
committed. We believed differently, however, and were able to appreciate and
respect the clients’ humanity, and to approach the situation with a non-judgmental
perspective.
Non-judgment, of course, obviously extends into an acceptance of the client.
The ability to accept clients is related to one’s level of self-awareness and ability to
use the self as a therapeutic agent. The result of client acceptance has implications
for the process of therapy as well. Acceptance facilitates the client’s exploration of
thoughts, feelings and behaviors, and enhances the establishment of an empathic
connection with him or her. Acceptance of clients as human beings of dignity and
value uccurs, even though they may have characteristics that are unappealing or
problematic, and acceptance does not imply a condoning of these behaviors.
Acceptance acknowledges the therapist’s belief in the client’s ability to grow and
change, as well as the pace with which this occurs (Hancock, 1997).
Both feelings and thoughts comprise acceptance, and these factors must be
balanced to achieve the therapeutic goal. The therapist must monitor his or her own
biases, attitudes and feelings that present obstacles to accepting the client, and
pursue supervision or personal therapy to remove these obstacles (Hancock, 1997).
Facilitating Clients’ Autonomy and Responsibility. Clients’ behaviors may

sometimes be difficult to comprehend. However, attempts by the therapist to
understand the choices they make, according to their worldviews, can help clients
obtain greater self-awareness, and the realization that choice is always possible
regardless of the situation. Autonomy implies the ability to make choices and also
the responsibility for their consequences. Therapists help empower clients with the
skills of self-determination and autonomy, whatever their limitations may be
(Malley & Reilly, 1999).
Clients may enter therapy with inappropriate expectations of the functions
of the therapist. For example, they may expect the therapist to be a friend, to give
advice, or to be able to remove the their problems. These inaccurate expectations
can serve as a detriment to the client’s autonomous functioning in treatment.
Expectations of both client and therapist should thus be shared at the beginning of
treatment (and the informed consent process is an excellent venue for this
discussion) to clarify these expectations (Thompson, 1983).
The therapist can also implement therapeutic practices or procedures which
may inadvertently diminish the client’s autonomy within the relationship. By
mystifying what the therapeutic process entails, the client does not have sufficient
information about what is happening and why, and he or she may be unable to
83
function autonomously. In a similar manner, an extreme lack of structure or too

much structure creates ambiguity for the client. The client cannot glean from the
therapist what is expected, and he or she may be dependent on clues from the
therapist for what may constitute a “correct” response (Thompson, 1983).
Some therapeutic techniques also may promote client dependency. These
include: hypnosis, some behavioral or Gestalt techniques, and any step by step
procedures that are directed solely by the therapist. These techniques may also
include therapist-directed music and imagery procedures or relaxation procedures.
Also, cognitive therapy techniques that are implemented in a manner in which the
client relies on the therapist’s judgment for what is rational or irrational, and it is
implied that the “therapist knows best” for the client, may also promote
dependency. The giving of advice to the client may do the same. This is not to say
that these strategies should not be employed or that they are ineffective! However,
when they are used, informed consent is required, so that the client is provided with
a description of the procedures used, their purpose, potential results, and possible
alternative treatments (Thompson, 1983).
To enhance the client’s autonomy, the therapist should also be careful in his
or her use of reassurance and evaluative judgments with the client. These practices
convey to the client that the therapist knows what is true for the client, and is the
“expert” concerning what will happen; these may inadvertently undermine the
client’s reliance on his or her own feelings and judgment. Even seemingly positive
statements such as “you did better with that issue than last time” or ‘“‘you’ve made
a lot of progress” reinforce the position of the therapist as judge, expert and
authority, and of the client as a dependent receiver of this expertise (Thompson,
1983).
Finally, attempts by the therapist to intercede for the client with other
parties, when the client is capable of doing this for him or herself may diminish the
client’s autonomy. Likewise, any use of deceptive or paradoxical treatments (i.e.,
the client is told to do something that is in his or her best interest, even though it is
virtually impossible to accomplish) that are intended to help the client confront and
renounce a maladaptive behavior, may also impinge on autonomy (Thompson,
1983).
Informed consent, as stated above, is an essential factor in enhancing the
client’s autonomy and self-determination. The focus of sessions as well as their
content and procedures are negotiated with the client. The client is consulted for his
or her permission to use new techniques (Thompson, 1983).
One approach to facilitating autonomy encourages the client to become his
or her own “personal scientist,” i.e., an individual skilled in analyzing and
improving his or her own behavior (Mahoney, 1974). The therapist’s role in this
particular process is as a technical consultant, assistant or support to the client’s
attempts to change. Rather than providing the client with directions and answers,
the therapist may employ Socratic dialogue procedures to help the client explore
and examine his or her feelings and beliefs. Hypotheses, as opposed to
interpretations of behavior, may be offered by either the therapist and client, and
these are subjected to challenge and revision. A number of possible solutions to
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clinical problems are generated by the client and therapist, and the client is
encouraged to experimentally test them. Towards the end of this particular
treatment, contact with the client is faded, and there is a transition to independent
functioning (Mahoney, 1974; Thompson, 1983).
Protecting the client’s rights to autonomy and self-determination is related
to the therapist’s use of his or her power within the therapeutic relationship. The
therapist can choose the type of power used. For example, he or she can use
“directive power,” relating to clients as objects, exerting control over them, and
thereby rendering them powerless in the relationship (directive power).
Unfortunately, directive power dis-enables clients, and diminishes their capacity to
accept responsibility for their actions and to believe in their own effectiveness as
human beings (Craig& Craig, 1973; Dokecki, 1996).
On the other hand, the therapist may choose to relate to the client as a person
and exercise “synergic” power. In this manner, clients are considered partners and
allies with whom a collaborative relationship is established; energies of both parties
are focused on co-creating. The goals of this partnership are to enhance clients’
feelings of self-determination and empowerment in influencing their own destinies,
and to reinforce their capacity to work effectively with others.
~“Synergic power cannot take place within the traditional, paternalistic model
of therapy, but requires a ““we-relation” of interdependence between the therapist
and the client as a person, not as an object. This type of power implies an awareness
of the client and his or her personal narrative, goals, and life’s meaning; the
therapist does not use his or her power to impose meaning on the client (Dokecki,
1996).
Therapists’ Responsibilities in Working with Groups
Competence issues for music therapists in group work are discussed in

Chapter 3 Similarly, the special considerations required for protecting
confidentiality in group situations are discussed in Chapter 5. Other ethical
responsibilities for music therapists working with groups are discussed in this
section.
Group members should be afforded the same access to informed consent
procedures as clients in individual music therapy. Group members have the right to
know what is expected of them in the group, as well as the potential risks and
benefits to them, before a decision is made regarding participation. Therapists
should take the time to explore participants’ preconceptions about the group and
provide guidelines to them for effective behavior (Yalom, 1995). It is helpful if
therapists explore members’ fears regarding participation, and assist them in
developing goals for themselves (Corey, et al., 1998).
Group participation may pose risks to participants, and these should be
enumerated for the clients. Risks may include: disruptions to the members’ lives;
the invasion of privacy and vulnerability in revealing personal information;
pressures from the group to explore difficult issues or to participate in particular
group experiences; scapegoating, involving projections and blaming from other
85
group members; confrontation by others; and the lack of assurance regarding the
maintenance of confidentiality outside the group. These risks can be minimized to
some extent through the informed consent agreement, which establishes
responsibilities and expectations for both the therapist and group members. Specific
rules for group participation may be included. In addition, therapists need to be
competent and skilled in working with groups, as this is a primary safeguard for
members’ well-being and emotional safety (Corey, et al., 1998).
Therapists have the responsibility for screening potential group members,
to ascertain that this particular group may be beneficial for this client with this
particular therapist at this particular moment (Corey, et al, 1998). Group music
therapy is not for every client. According to Yalom (1995), the following types of
clients may not be appropriate candidates for intensive therapy groups on an
outpatient basis: individuals with neurological damage, paranoia, hypochondriasis,
acute psychosis, antisocial personality disorders or addictions to substances.
Conversely, groups may be very helpful for individuals who have interpersonal
difficulties, (such as loneliness, and problems with intimacy, assertiveness or
dependency), as well as those who have existential issues, who are highly anxious,
who have identity issues, who fear success, or who are workaholics (Yalom, 1995).
When group participation is not voluntary, as is the case with some clients
who are hospitalized, the therapist must take particular care to inform the clients
about their rights, including: the group’s nature and goals, procedures used, the
limits of confidentiality, their choice of response in the group, and how their
participation in the group will be shared with others outside the group (Corey, et al.,
1998).
Policies for attendance of group sessions, as well as procedures to be
employed when a member wants to withdraw from the group, need to be established
and shared with the group as part of the informed consent process. Because a
member’s sudden withdrawal from the group can be disruptive to the group process
and to group cohesion, it is advisable that members commit to informing and
explaining to other members their reasons for leaving prior to withdrawing. This is
important so that potential misunderstandings can be resolved, that negative
experiences within the group can be shared, and that closure can be obtained for the
client and group (Corey, et al.,1998).
Therapists have the responsibility of providing additional help and support
for any group member who remains in distress at the end of a session. Therapists
are not free to abandon these clients just because the session is over. Therapists
should be careful in timing interventions during the session to make sure that
adequate time remains for processing the feelings that emerged during the
intervention (Corey, et al., 1998). Clients should not fall apart and then be
dismissed!
As in all music therapy practice, therapists working with groups need to
realize the limits of their competence, and refer clients for required services when
needed.
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Therapists’ Responsibilities in Treating Difficult Clients.
It is very difficult to define characteristics of “difficult” clients, as these

definitions vary according to the therapists involved, their particular areas of
clinical expertise, as well as their own personal issues and values!
However, some characteristics and behaviors of clients may present more
challenges to therapists than others, and include: threats of suicide, threats of danger
to the therapist or others, intimidation, acting out behaviors, overdependency, verbal
abuse and sarcasm, extreme withdrawal, substance abuse, borderline personality
disorders, pedophilia, and failure to attend sessions and pay for services (Koocher
& Keith-Spiegel, 1998). These behaviors can create many stressors for therapists,
and pose serious ethical dilemmas.
The most important issues to be considered for the therapist who encounters
these clients are those of personal and professional competence and the limitations
of such. Therapists must be aware of these limits before agreeing to treat certain
clients and assist them in finding appropriate services early on in treatment before
serious problems ensue, and the client’s further discomfort is at stake (Koocher &
Keith-Spiegel, 1998).
It is not expected that music therapists are personally and professionally
competent to work with every client they may encounter during the course of their
careers, in spite of their honest efforts to regularly maintain and improve their
competence. Self-awareness of personal and professional competence is a key issue
in this regard. The most difficult client is one who not only presents a clinical
challenge, but whose issues also provoke strong emotional reactions from the
therapist (Koocher & Keith-Spiegel, 1998).
Is the music therapist unable to work with difficult clients because of a
deficit in education, training or experience? Or is the music therapist’s own
countertransference issues rendering the assessment of a difficult client even more
difficult? Are the therapist’s values in conflict with those of the client? Are personal
biases, prejudices and discrimination issues being disguised as professional
competence issues? These are serious considerations for the music therapist, and
require honest responses and an ethical course of action. Supervision and/or
consultation may be required to assist the therapist in achieving greater self-
awareness and in facilitating ethical decision-making.
Difficult clients can make therapists angry. Therapists must exercise
appropriate self-awareness in these situations, own their personal reactions, and be
able to separate these reactions from the pathology of the client. The therapist must
also not abuse his or her power within the therapeutic relationship to act out this
anger or to cause harm to the client. These feelings need to be vented in supervision
or consultation, along with an exploration of whether professional competence or
the therapist’s own personal problems are the issue (Koocher & Keith-Spiegel,
1998).
Sometimes difficult clients threaten the therapist’s personal safety. The
therapist should take all such threats seriously, and not assume they will stop by
themselves. A re-analysis of the client’s problems, history and plan for treatment
87
is required, and even though clients may not have a history of violence, there may
indeed be a first time for everything, (and as a preventive measure, therapists should
routinely screen clients for potential violence). The therapist should be clear in
conveying limits to the client, i.e., that threats will not be tolerated, and that the
relationship could be terminated if they persist. The therapist should also document
the client’s threats and his or her responses to them, as the duty to warn and protect
also applies to the therapist as well as third parties (Koocher & Keith-Spiegel, 1998)
(see Chapter 5).
When a client threatens harm to the therapist, the therapist should seek
consultation from his or her lawyer, from expert colleagues and/or from supervisors
within the facility. If the client is to be retained, the therapist should develop a
careful treatment plan to address the client’s anger, should determine clear limits
for behavior that will be tolerated, and should assure safety for him or herself, (e.g.,
notifying security at the facility, or not being alone with the client in his or her
private office) (Koocher & Keith-Spiegel, 1998).
Therapists’ Responsibilities Regarding The Setting for Therapy
Ethically speaking, music therapy should take place in a setting that provides
safety and privacy for the client. It is the responsibility of the music therapist to
assure that the setting poses no threats of harm to the client, i.e., that it be physically
safe. Music therapists working with hyperactive children, for example, should
ascertain that there are no potential dangers to clients, such as harmful materials,
loose wiring, open electrical sockets, etc., within the environment.
The music therapist must also assure that there are no threats within the
setting to the client’s emotional safety. Therapy should be held in a private place
that is not accessible to interruptions by other clients or staff during clients’
sessions. Because music therapy is often more “noisy” than other types of treatment,
sessions should be held in settings where the voices and music of the client and
therapist cannot be easily overheard by others.
Unfortunately, this is an ethical standard that is not often achieved by music
therapists working in treatment facilities. There may be little choice for the therapist
as to where the music therapy sessions are held, and the therapist will often have to
choose the “best” space from the less than satisfactory spaces allotted. Music
therapists may need to work at a client’s bedside in a nursing home or hospital and
may have little control over intrusions by other staff. In spite of the realities of
clinical work, it is important for the music therapist to at least attempt to find the
best conditions available for music therapy work, realizing that the limitations of
the setting often impose restrictions on the clinical process.
Music therapists in private practice also need to strive for safety and privacy
in their practice settings. A number of music therapists conduct music therapy in
their homes. This arrangement may be appropriate for some types of clients and
music therapy interventions, but it is obviously not appropriate for all. A primary
risk of using an office in a therapist’s home involves the potential establishment of
dual relationships with the client, as the client has access to the therapist’s personal
88
information, lifestyle, etc. (Herlihy & Corey, 1992). Also, there are also risks for
intrusion by the therapist’s family on the privacy of the client. On the other hand,
it is not always fair for the therapist’s family to be banished from their home during
session time. If a home office is used, it should occupy a private space within the
home (Richards, 1990).
As stated above, it is not appropriate to work with some types of clients in
ahome office. The therapist should avoid seeing potentially dangerous clients in his
or her home setting because of threat of harm that this may pose for the therapist
and/or the family (Herlihy & Corey, 1992).
Therapists’ Responsibilities in Preventing Harm to the Client
As stated in Chapter 1, a core ethical principle is non-maleficence, or “do

no harm.” An important ethical responsibility of the music therapist thus is to
prevent harm to the client.
It is possible that music therapy can have negative effects on the client,
although few contraindications for music therapy appear in the literature. Some
contraindications and negative effects mentioned in using music therapy for stress
management, for example, include: cathartic reactions, musicogenic seizures, and
increased tension (Dileo-Maranto, 1993c).
Robitscher (1978) discusses some of the potential direct negative results of
psychotherapy, which may also be relevant to music therapy practice as well. These
include: the exacerbation of the client’s problems and symptoms; the development
of new symptoms and problems; the misuse or abuse of therapy by the client, for
example, in becoming overly dependent on the therapist or process; the client’s
overestimation of his personal resources, undertaking tasks prematurely or without
sufficient capacity to do so; and disenchantment with and loss of confidence in the
therapy process or the therapist. The client may feel that he or she has wasted both
time and resources in treatment, may experience cynicism in pursuing other types
of treatment, and may lose faith in human relationships in general.
It is important for music therapists to acknowledge the fact that negative
effects may be the result of music therapy interventions. Once this awareness is
achieved, the music therapist can take appropriate action to prevent these effects
from occurring and to remediate the problems.
In addition to safeguarding the client against potentially harmful effects of
treatment, the music therapist has a more general responsibility of protecting the
physical, psychological and social welfare of clients entrusted to them (as well as
all clients within the facility in which they are employed), and in preventing any
type of harm to them. This goes beyond the responsibilities described in the
previous section, regarding the setting for treatment, as clients may also need to be
protected from individuals and actions within a particular setting.
Therapists’ Responsibilities in Terminating Treatment
Therapists have an important ethical responsibility not to abandon clients in

89
treatment. Even when there are external pressures, e.g., managed care limitations
on treatment (see Chapter 9), therapists may still have an ethical obligation to find
ways to continue the client’s treatment, if there is a pressing clinical need to do so
(Pope & Vasquez, 1998).
When the client no longer benefits from treatment, however, other ethical
obligations exist. This may be problematic in the sense that there are no specific
guidelines for the music therapist concerning the duration of treatment or the
criteria for terminating treatment. This is indeed determined by both the subjective
judgment of the therapist as well as the objective data regarding progress. For music
therapists working in facilities, it may also be determined by the consensus of the
treatment team or by managed care requirements. For private practitioners in music
therapy, a contract for a designated number of sessions may be negotiated with the
client, after which time progress can be evaluated, and a decision made regarding
further treatment.
Therapy does not continue indefinitely. An important ethical responsibility
of the therapist, as well as an important right of the client, is to terminate treatment
when it is no longer beneficial or when there is harm to the client from treatment.
The client may have reaped all the potential benefits of what music therapy has to
offer. Or, there may be other reasons for the lack of progress, including, personality
clashes between the client and therapist, the client’s resistance to comply with
treatment, or the therapist’s competence in handling new clinical problems that
emerge (Woods, Marks & Dilley,1990).
For whatever reason, the therapist is obligated to take appropriate action,
prepare the client for termination, discussing his or her needs and views regarding
the conclusion of treatment, referring the client to another therapist and attempting
to assure continuity of care, and helping the client make the transition in a safe and
supportive manner. The therapist should make every attempt to prevent a lapse in
care that could prove detrimental to the client (Woods, et al., 1990).
Ethical problems may arise when the decision to continue treatment that is
no longer of benefit is made based on the client’s issues of fear, insecurity or
dependency (Koocher & Keith-Spiegel, 1998). The therapist is obligated to discuss
with the client the reasons that therapy is no longer warranted, to present to the
client a plan of action, and to allow the client to make an informed choice
concerning this plan (Hare-Mustin, et al., 1979).
When there is a question as to the client’s needs for continued treatment, or
there is a disagreement between the client and therapist regarding treatment, the
therapist should discuss this with the client openly. An external consultation can be
arranged with another therapist who could provide an additional opinion regarding
the appropriate course of action (Koocher & Keith-Spiegel, 1998).
The termination of treatment, irrespective of the reason, requires a concerted
effort on the part of the therapist to understand its meaning for the client. The
termination process must be carefully planned and structured so that it can be a
positive experience for clients, including those who have benefitted from music
therapy, and those who have not (Hancock, 1997). Clients should not be left with
unfinished business at the end of treatment if appropriate closure procedures have
90
been implemented.
In a similar manner, music therapists working with groups need to provide
sufficient support to help members transition away from the group experience.
Termination is an important component of the group/therapeutic process, as it
provides the opportunity for members to reflect on the meaning of their experiences,
to identify the progress they’ve achieved, to integrate what they’ve learned about
themselves, and to make decisions concerning their future behavior (Corey, et al.,
1998).
Group members may be reluctant to terminate and deny that it is about to
happen (and similar issues can exist for the therapist). These issues notwithstanding,
it is the therapist’s responsibility to keep the group focused on issues of closure.
Termination is a significant part of the process, which when carefully handled, can
be a major factor in promoting and maintaining therapeutic growth (Yalom, 1995).
Chapter Summary
1. Providing clients with opportunities to give informed consent is both an ethical

and legal requirement in treatment. Its purpose is to provide information to clients
about what music therapy involves, so that they may make a knowledgeable
decision concerning its appropriateness as a treatment for themselves. Consent may
be considered “informed” when clients are competent, when they are given
adequate information, and when their consent is completely voluntary. Content
areas for informed consent include: information about music therapy assessment,
treatment and evaluation, information about the music therapist, information
concerning confidentiality and its limits, and information concerning financial and
general policies.
2. Some clients’ rights to provide informed consent or to refuse treatment may be

compromised because of their status or age. Laws regarding minors’ rights to enter
into treatment without parental approval vary according to state. Music therapists
working with minors who refuse treatment, even though their parents have provided
consent, should attempt to obtain the client’s assent for treatment, and involve him
or her in decisions regarding the nature of treatment.
3. Therapists have responsibilities and clients have corresponding rights within

treatment: to communicate effectively, to afford dignity, respect, non-judgment,
acceptance, and to facilitate the client’s autonomy and responsibility.
4. When working with groups, music therapists have the responsibility to provide
the members with opportunities for informed consent with a description of the
possible risks involved, screen group members to ascertain that this type of
treatment is appropriate for them, establish policies and procedures to minimize
risks, realize the limits of their competence, and make provisions for supporting
members who remain in distress following the group.
1
5. Clients who are viewed as “difficult” to treat often present clinical challenges as
well as evoke strong emotional reactions from the therapist. Therapists must
carefully distinguish their own countertransference and competence issues from
treatment issues, and supervision or consultation may often be required to
accomplish this. Therapists’ anger towards clients should be dealt with outside of
the therapy situation. Clients should be screened for potential violence. For those
who may potentially threaten the therapist’s personal safety, clear behavioral limits
should be imposed, and the therapist should implement a variety of measures to
protect him or herself.
6.Therapists are responsible for clients’ physical and emotional safety and privacy
in selecting a setting for music therapy treatment. This may be quite difficult when
space within an institution is limited. Therapists who establish offices in their
homes need to consider potential problems, such as the establishment of dual
relationships, invasion of the client’s privacy, and threats to safety, as well as the
inconveniences for their own family members. Therapists also need to protect
clients from emotional, physical and social harm within a particular setting.
7. Music therapists should be alert to any potential negative effects of and

contraindications for music therapy, although these have not been routinely
documented in the literature.
8. Music therapists may not abandon clients who require continued treatment, even
when there are external pressures to do so. On the other hand, clients who no longer
benefit from treatment, for a variety of reasons, should not be allowed to continue
in music therapy. Sometimes, referrals to other therapists may be required, and a
smooth transition provided to assure continuity of care. When there is a question
regarding the client’s need for continued treatment, an external consultation may be
needed. Termination procedures sheuld be carefully planned and implemented to
assure a positive experience for the client; no unfinished business should remain.
With groups, supportive termination procedures may represent an important stage
of the group process, and further facilitate members’ growth and change.
Ethical Dilemmas
Using relevant sections of the model for ethical decision-making as a framework

(Chapter 1), determine an ethical course of action for the music therapists in each
of these dilemmas.
1. Sebastian, a 16-year old attending a public high school, was involved in a fight
with another at his school. His school suspended him with the requirement that he
receive therapy before he could be readmitted. Sebastian’s mother contacted Lynn,
a music therapist in private practice. When Lynn saw Sebastian, he admitted that
he had been wrong in fighting with his peer, but had been provoked by this
particular peer who called his family, “white trash,” his mother, “a drunk,” and
92
his father, “a maniac.” Lynn explored his feelings about his family members
through various musical improvisations. She came to realize that Sebastian's issues
indeed stemmed from his enormous family problems. Lynn asked Sebastian's mother
if she and her husband would be willing to attend Sebastian’s improvisation
sessions. Lynn refused and said that she had decided to bring Sebastian to another
therapist.
2. Helen is a music therapist who works on a forensic unit. Seymour, a client, has
been assigned to her song/lyric-discussion group. Seymour is most uncooperative,
stating that he thinks music therapy is stupid, and that he would prefer to be
elsewhere, but “they are making him come”’ ifhe wants to keep the few privileges
he has. During the groups, Seymour sits in the corner with his arms folded, and
occasionally makes comments about wanting to leave. His presence in the group is
disruptive to the others. Although Helen has done everything possible to try to
engage Seymour in the group, these efforts have been unsuccessful.
3. Shirley, a 14-year old, calls Eric, a music therapist in private practice and
requests an appointment with him. One of her friends had seen Eric in the past, and
she obtained his number from her. In her phone call, she tells Eric that she just
found out she was pregnant and can’t tell her parents about this because they will
kill her. She is having difficulty eating, sleeping, and concentrating, and feels she
is in a real crisis. She can’t tell her parents about the therapy, because they will
want to know the reason. Eric states that he cannot work with her without her
parents’ consent. Shirley becomes despondent.
4. Jim, a music therapist in private practice, conducts an intake evaluation with

Jason and his mother, Pam. Pam reports to Jim that she is very concerned about
Jason's behavior as he has been smoking pot, is doing poorly in school, is not
accepting responsibility for his behavior at home, is rebellious to his parents, and
lies continually. Jim works with Jason privately, (without the inclusion of his mother
in the sessions), and uses a variety of music therapy interventions. Pam assumes
that Jim is addressing the issues she identified during the intake session. Pam has
called Jim several times in between sessions, and she is told that Jason is doing
fine. Jason’s behavior continues to deteriorate, and Pam, after the 10" session calls
Jim. Jim tells her that he doesn't feel that Jason has any severe problems, that the
problems she reported are only normal adolescent issues, and that she is the one
who is the problems by not “letting go.”
5. Fred, a music therapist in private practice, has been working with Janelle, a
client who has had many difficulties in her interpersonal relationships. Fred feels
he has made progress with Janelle, and that the goals of therapy have been
achieved. He begins to prepare Janelle for termination. Janelle is unwilling to
terminate, and she tells Fred that, without him, she would have no one to whom she
could express her feelings.
93
6. Monica, a music therapist working in a facility for the developmentally disabled

momentarily turns her back on a large client and is struck by him.
7. Rachel runs a music therapy group for adult clients who have acute psychiatric
disorders. During the session, Dan, becomes verbally abusive to her, accusing her
of incompetence and mistreatment, and also begins an argument with Shawn,
another client who comes to her defense. A fight breaks out between Dan and
Shawn, and other clients, because of their proximity, appear to be at risk for injury.
8. Michelle, a music therapy student completing her field requirements in a nursing

home, observes an orderly striking an Alzheimer’s patient.
9. Helen, a music therapists working at a large psychiatric facility discovers two

adult clients having sex in an unoccupied building.
10. Brian, a music therapist working in a facility for adolescents allows clients to
use the restroom during sessions ifthey need to. When two clients do not return in
a timely manner, he looks for them and finds them having sex in a secluded area
outside the music therapy offices.
11. Sabrina, a music therapist who has just completed her third level of GIM
training is attending a party where her co-workers in music therapy and from other
departments are present. They are very interested in GIM, both personally and
professionally, and ask her many questions about the method. One of the guests, a
psychologist, asks if Sabrina will conduct a group GIM session with the guests,
assuring her that they will keep all information confidential.
12. Gretchen, a music therapist in private practice works with “normal” adults who
have stress problems and also with couples who are preparing for childbirth. She
uses the den of her home for sessions, because she is unable to afford a private
office, and because her clients feel more comfortable (and less like therapy clients)
in a home-like atmosphere.
13. Jonathon, a music therapist working with substance abuse clients, demands
strict discipline in his music therapy sessions. He verbally reprimands clients ifthey
are late for sessions, and occasionally makes sarcastic or degrading comments to
them ifhe feels they are denying their issues.
14. Louise, a music therapy working with clients who have chronic psychiatric
disorders, feels that many ofher clients are over-medicated, fatigued and indifferent
to music therapy sessions.
15. Clifford works as a music therapist in a prison setting. He works with Hal, a
prisoner who is serving a 30-year sentence for aggravated rape. Clifford is
convinced that Hal is innocent of the crime and has been imprisoned unjustly.
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16. Fran is a music therapist in a private inpatient treatment facility for children.
She meets with the treatment team to discuss Sally. The team recommends that Sally
be transferred to a state facility because she hasn’t made sufficient progress, and
because her insurance benefits have run out. Sally disagrees with this decision, but
is in the minority. The day after the team meeting, Sally’s mother calls Fran and
asks Sally for her opinion regarding the team’s recommendation.
1. Either by yourself or in a small group, design an informed consent agreement for

a client (real or imagined), using the criteria provided in this chapter. After
completing the agreement, submit it to another person or group to read, ask for
feedback, and entertain questions they may have regarding its content.
2. Using a role-playing situation, present the information in the informed consent

agreement to a “client” verbally. Ask for feedback concerning: your language, your
style of presentation, the completeness of the information, your willingness to
entertain questions and your method of answering questions.
3. Role-play a situation in which your “client” is a child or adolescent. Verbally

present the information required to obtain the “client’s” assent.
Pe
4. In a short essay, describe what you consider to be the most important aspects of
the music therapy relationship.
5. In your course journal, reflect on the types of clients who might present the most
difficulty for you, in terms of your current level of competence and your own
personal issues, values, etc. Also, reflect on the characteristics of clients who might
make you angry (or have made you angry in the past). Can you find a connection
between your own issues and the clients’ issues? Discuss both of these topics with
your peers.
6. In your course journal, describe any reactions, fears, frustrations, etc. you may
have about potentially harming clients, or in being ineffective with them as a
therapist.
7. Discuss with a peer or small group your reactions to saying “goodbye” to clients
in the past, for example in your clinical experiences. Is this easy or difficult for you?
Do you have a tendency to hang on or let go too quickly? Do you try to avoid the
situation? Do you experience guilt, relief, etc. in saying goodbye? What issues can
you anticipate having in the future concerning making decisions about and
implementing termination procedures with clients?
8. Complete the following chart to include your ideas on what the rights of clients
are in music therapy and what your responsibilities are as a music therapist.
25
Describe any rights or responsibilities that may be in conflict.
Clients’ Rights Therapists’

Responsibilities
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ETHICAL THINKING AND CONFIDENTIALITY
Definitions
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Conddentinlity is a core concept within the client-therapist relationship in
music therapy. For clients to establish trust in the therapist, confidentiality must be
assured to the fullest extent possible, and the maintenance of confidentiality is both
an ethical and legal responsibility for the music therapist. As such, however,
confidentiality is a very complex issue, fraught with potential conflicts between
ethical requirements and legal mandates.
The issue of confidentiality is considered very important by music
therapists. Fifty music therapists were asked to rate the importance of 56 ethical
problem situations, and the situations concerning confidentiality were rated highest
of all situations in the survey (Dileo-Maranto, 1981a; 1981c; 1984; Dileo-Maranto
& Ventre, 1984,1985). Issues in confidentiality are also significant in the field of
psychology. Several studies revealed that confidentiality issues are the most
frequently occurring ethical problems (Haas, et al., 1986; Pope & Vetter, 1992), In
another study, 61.9% of psychologists reported having unintentionally broken a
client’s confidentiality (Pope, et al., 1987). Furthermore, experienced psychologists
reported that the most frequent intentional breaches of ethical or legal standards
involved confidentiality dilemmas (Pope & Bajt, 1988).
It is important to distinguish between the three most common terms used in
reference to the protection of the client’s information: confidentiality, privacy, and
privileged communication. Confidentiality refers to the ethical obligation of the
therapist to protect the client’s information from disclosure to anyone, without
express permission from the client to do so. Confidentiality is not absolute,
however, and there may be circumstances (discussed in later sections of this
chapter) that may necessitate this disclosure. Therefore, confidentiality is limited,
and the client must be informed of these limits at the beginning of the treatment
process.
Privacy is the broadest term of the three defined here, and refers to the
constitutional right of all persons to determine the extent to which they will share
personal information with another. The right to privacy is considered an essential
component of human dignity and autonomy (Koocher & Keith-Spiegel, 1998).
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Privileged communication (or privilege) is a legal term, granted to a client,

that specifies that the information shared by the client in certain relationships is
protected from disclosure in courts of law without the client’s permission. Laws
vary from state to state as to which relationships are specified for the client as
privileged, but may include attorney-client, physician-patient, husband-wife, and
priest-confessor relationships. When the professional is specifically mentioned in
the law, the client is afforded privilege in relationships with this professional
(Koocher & Keith-Spiegel, 1998; Pryzwansky & Wendt, 1999). Clients in
psychotherapy relationships may be protected by privilege in most states if their
therapists are licensed, certified or registered, but the details of this privilege vary
accordingly. Thus, if these professionals are summoned to testify in court regarding
personal information provided by the client, or to furnish the client’s records to the
court, they may refuse to do so (Corey, et al., 1998). There are no known laws
which provide for privileged communication for clients in music therapy
relationships.
As privilege is a right of the client, and not the professional involved, and
the client may choose to waive this right. When this occurs, the professional must
provide the information required by the court and/or testify. Judges, in the interest
of justice, may also override the client’s privilege in civil or criminal cases,
depending on law. In addition, there are circumstances which may override
privilege, including: the mandatory reporting of child or elder abuse, the duty to
warm or protect another from harm, in emergency situations, for certain
reimbursement issues or legal requirements, or when the client files a lawsuit (e.g.,
malpractice) (Stromberg, et al., 1993a, 1993b; Koocher & Keith-Spiegel, 1998).
These issues will be discussed in the following sections.
Limits to Confidentiality
There are a number of circumstances, both ethical and legal that limit the
extent to which confidentiality can be maintained. Under normal circumstances, for
example, confidential information may need to be shared for purposes of: 1)
receiving supervision or consultation (in which cases the identity of the client is
disguised as much as possible), 2) providing information to other professionals, e.g.,
in communicating about a client who was referred, or 3) being processed by clerical
staff for third-party reimbursement. There are also a number of exceptional
circumstances in which the breaching of confidentiality is mandatory: 1) when the
client presents a danger to self or other persons, 2) when the client reveals the intent
to commit a criminal act, 3) when there is suspected child, elder or handicapped
abuse, and 4) when there is a court subpoena for a client’s records (Corey, et al.,
1998).
The music therapist must anticipate both these normal and exceptional
circumstances, and duly inform the client as to the limits of confidentiality prior to
the initiation of music therapy services. With these limits in mind, the client then
has the option of choosing the information he or she wishes to disclose. As the
clinical population with which the music therapists works may require more
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potential limits of confidentiality (e.g., AIDS patients, clients at risk for suicide,
children), it is the responsibility of the music therapist to become familiar with the
laws of his or her jurisdiction governing confidentiality, privilege, mandatory
reporting of abuse, and duty to warm, prior to working with these populations.
Mandatory Reporting. All states have adopted mandatory reporting laws for
child abuse. Child abuse is defined as follows: “the physical or mental injury, sexual
abuse or exploitation, negligent treatment, or maltreatment of a child by a person
who is responsible for the child’s welfare under circumstances which indicate that
the child’s health or welfare is harmed or threatened” (The Child Abuse Prevention,
Adoption and Family Services Act of 1988; Pub.L. 100-294-14). Individuals in
various professions (e.g., teachers, medical doctors, psychologists, social workers,
and other health and social service professionals) are required to report suspected
child abuse to authorities. It is not necessary for these professionals to prove the
abuse, as this is to be determined by the child protection agency (Pryzwansky &
Wendt, 1999). Although music therapists may not be mentioned specifically in the
list of professionals who are required to report child abuse, music therapists who
work with children should be familiar with signs of potential abuse as well as
reporting procedures. Whether this information is disclosed by the children
themselves, by adults who are abusing, or by a relative, or whether the abuse is
current or past, this matter may need to be reported according to the individual state
law (Corey, et al., 1998). As laws vary from state to state, it is essential that music
therapists are familiar with the laws of their particular jurisdiction.
Designated professionals who fail to report suspected child abuse are subject
to substantial fines, imprisonment, and civil litigation. In addition, professionals
who are licensed by the state may be subject to having their licenses revoked or
suspended. The majority of state laws stipulate that the professional must know
about the abuse and willingly fail to report it in order for liability to be present, and
this protects the professional from situations in which honest mistakes are made.
The Pub.L. 93-247 (The Public Health and Welfare Act) requires states to provide
immunity to designated professionals who make incorrect reports in good faith
(Corey, et al., 1998; Pryzwansky & Wendt, 1999).
In a similar manner, all states have mandatory reporting laws for elder
abuse, but not all have laws for mandatory reporting of handicapped abuse
Reporting suspected abuse, while clearly required by law, poses a number
of ethical and therapeutic dilemmas. It is clear that disclosing confidential
information may irrevocably damage the therapeutic relationship. Further, therapists
may fear that the reporting of suspected abuse, when they are not completely certain
that it has occurred, may increase their vulnerability to litigation (Kalichman &
Craig, 1991).
In situations where the therapist is uncertain about reporting abuse, he or she
should document observations and the reasons for reporting, and consult with other
professionals, including his or her supervisor. The therapist may also choose to
make the report with the family present, to discuss this decision with them, to
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clarify his or her requirements to do so, and to process their feelings. This procedure
may help preserve the integrity of the therapeutic relationship, if this is at all
possible (VandeCreek & Knapp, 1993).
Cohen & Cohen (1999) provide guidelines for therapists in reporting
suspected child abuse: 1) Therapists must inform clients of the limits of
confidentiality regarding mandatory reporting of child abuse at the beginning of
treatment. 2) Therapists must comply with these laws, unless there is clear and
imminent danger to the child resulting from the report. 3) If the alleged perpetrator
of the abuse is a client, the therapist informs him or her of the intent to report (if this
does not involve an additional threat to the safety of the child). If the child is a
client, the therapist seeks consent from him or her.
The Duty to Warn and Protect. A number of court decisions in recent years
have repeatedly emphasized the need for therapists to protect third parties from
actions of their potentially dangerous clients. When clients disclose an intent to
harm another person, may or should this confidentiality be breached to protect the
third person at risk of harm? The answer may be, “Yes.” A description of a
landmark case, Tarasoff v. the Board of Regents of the University of California,
follows.
Poddar, a student at the University of California, was an outpatient at the
student health service. Poddar revealed to his therapist (Moore) that he intended to
kill another student, Tatiana Tarasoff, who had spurned his affections, and that he
intended to purchase a gun. Moore felt Poddar was dangerous and contacted the
campus police who interviewed Poddar and later released him after he promised to
stay away from Tarasoff. Podar discontinued treatment, and two months later, shot
and killed Tarasoff. Tarasoff’s parents sued the university and its Board of Regents
for not having notified their daughter of this danger. Their case was dismissed by
a lower court, and later the Supreme Court of California ruled in favor of their
appeal (Corey, et al., 1998; Koocher & Keith-Spiegel, 1998).
The implications of this decision for therapists are as follows: 1) therapists
must breach confidentiality to warn persons whose welfare and safety are at risk,
and 2) there is a duty to protect third parties from clients who present danger to
them. Thus, therapists have duties both to their clients as well as to society, and
these duties may often be in conflict (Corey, et al., 1998).
The Tarasoff decision remains a controversial one. There have been few
reported cases of liability for therapists who have failed to warn third parties; it may
not always be possible for therapists to predict the likelihood of a client actually
causing harm to another. In addition, other states have not consistently upheld this
decision in similar cases. In the Tarasoff case, the intended victim was identifiable;
in other cases, the victim was not. What then is the responsibility of the therapist
regarding aclient’s general statements of aggression? (Corey, et al., 1998). The duty
to warn and protect must be exercised when the following three criteria are
involved: 1) a therapeutic relationship exists, 2) based on the client’s history,
violence can be reasonably predicted, and 3) the potential third-party can be
identified (Costa and Altekruse, 1994).
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What is clear for therapists is that they need to exercise a reasonable

standard of care in assessing client dangerousness, in treating these clients, and in
protecting others from potential harm by these persons. Careful record-keeping and
consultation are essential components of meeting the standards of this adequate care
(Bednar, Bednar, Lambert & Waite, 1991). In addition, therapists working with
potentially dangerous clients should gather adequate case history information,
inform clients of the limits of confidentiality, keep detailed records of any threats
of harm made by the client, obtain consultation, and document efforts made to
inform third parties (Stromberg, Schneider & Joondeph, 1993b). Documentation of
the rationale for all actions and of the actions taken is critical if the therapist is to
minimize his or her risk of liability (Monohan, 1993).
Therapists may also rely upon one or more of the following options for
action: attempting to manage the client therapeutically, discussing the issue with the
client, warning third parties, notifying the police, seeking involuntary commitment
for the client, referring the client to a physician for medication, seeking help from
other professionals, clergy, and/or friends of the client, directly involving the
client’s family (and others) in dealing with and resolving the threat (Reaves &
Ogloff, 1996), removing instruments that are harmful, or modifying treatment
Many states require therapists to warn and protect others of potential harm
to them, and a number of states grant immunity for breaches of confidentiality made
in good faith (Stromberg, et al., 1993a, 1993b; Haines v Bellissimo, 1977 ).
Therapists should always obtain legal advice when confronted with the duty to
warn.
Protecting the Client from Self: Suicide. Just as there is a duty to warn and
protect third parties of potentially dangerous client behavior, there is also an ethical
and legal responsibility to protect clients from harming themselves and from taking
their own lives. The breaking of the client’s confidence is often necessary when the
therapist suspects that hé or she may commit suicide, if this will assist in
prevention.
Some might question the right of the therapist to undermine the client’s
autonomy and self-determination with regard to his or her decision to commit
suicide (and this will be discussed in further detail later in this chapter). When these
decisions are “far-reaching, potentially dangerous and irreversible...(when they are)
made under extreme psychological duress, or (when they involve) dangers not
adequately understood or appreciated by the client” (Cohen & Cohen, 1999, p. 252),
there may need to be a paternalistic restraint of the client’s freedom.
As it is often impossible to reliably predict suicide, assessing the risks
involved is an extremely stressful task for therapists. The therapist is indeed
challenged in determining when the client may be serious in his or her intent to do
this. The issue of suicide summons many personal issues for the therapist:
competence, degree of control, responsibility, and capacity to deal with life-
threatening situations (Corey, et al., 1998).
A therapist who experiences the suicide ofa client is usually devastated. The
102
experience evokes issues of self-doubt and second guessing about what he or she
could have done better to prevent the suicide; anger, pain and guilt may be
overwhelming. In addition to his or her own feelings, the therapist frequently must
try to cope with the feelings of the client’s family, which may involve intense anger
at the therapist (Pryzwansky & Wendt, 1999). Fear of litigation is real, as suicide
is one of the leading causes for successful malpractice claims against therapists
(Szasz, 1986).
Assessment of suicide risk involves the identification of typical crises that
may precede such an attempt. Therapists must have skill in being alert to warning
signs and in implementing competent treatment aimed at prevention. Depression,
suicidal thoughts, intent, and plans need to be assessed early on (Fujimura, Weiss
& Cochran, 1985; Pope, 1985; Pryzwansky & Wendt, 1999; Sommers-Flanagan &
Sommers-Flanagan, 1995; Wubbolding, 1996). In addition, there may be other
signs of risk, including: verbal statements about suicide; previous attempts at
suicide; sleep disruption (which can exacerbate depression); feelings of
hopelessness-helplessness, guilt and worthlessness; extreme anxiety and panic;
specific plans to execute the suicide; alcohol and drug abuse; previous psychiatric
history; long-term chronic illness, including HIV infection; sudden changes for the
better in mood or impulsivity; behaviors that are associated with finality/dying
(giving away possessions, making a will, making closure in business); and
withdrawal from sources of support (cited in Corey, et al., 1998). In addition, some
demographic factors are associated with increased risk for suicide, including: sex
(men, especially those under 35 and over 65 are more likely than women to commit
suicide), marital status (single people are more likely than married persons), and
employment status (the unemployed are at greater risk) (Corey, et al., 1998).
To determine the seriousness of the client’s intent and the need for
intervention, Wubbolding (1996) recommends that therapists explore with the client
both overt and subtle references to suicide through an open discussion which
emp.oys the following questions: 1) Are you contemplating suicide? 2) Have you
attempted suicide previously? 3) Do you have a plan? 4) Do you have the means for
suicide at your disposal? 5) Are you willing to make a unilateral no-suicide pact to
remain alive, 1.e., to avoid killing yourself either intentionally or unintentionally for
a designated period of time? and 6) Is there anyone in your life who could dissuade
you from suicide and to whom you could talk if you had the urge to commit
suicide?
Even given all this information, the decision about the client’s risk still
remains within the subjective analysis of the therapist (Corey, et al., 1998).
Suicide may be prevented if the client’s cry for help is heard, and if support
is given to him or her in managing or coping with the presenting crisis. If therapists
can anticipate suicide, there may be an opportunity to prevent it. When a client is
assessed to be at risk, the therapist is both ethically and legally obligated to break
the client’s confidence and implement a prevention plan. When the therapist does
not take appropriate action, or if she or he exacerbates the client’s situation, liability
may result (Corey, et al., 1998), and a valuable life may be lost.
As with the duty to warn and protect potential victims of the client, the
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therapist must exercise a reasonable standard of care to safeguard the client’s life.
A number of authors (Austin, Moline & Williams, 1990; Bednar, et al.,1991;
Bennett, Bryant, VandenBos, & Greenwood., 1990; Bonger, 1991; Fujimara, et al.,
1985; Pope, 1985; Pope & Vasquez, 1991; Sommers-Flanagan & Sommers-
Flanagan, 1995; Wubbolding, 1996) (cited in Corey, et al., 1998) have
recommended possible courses of action for suicide prevention which include the
following: 1) The therapist should be cognizant of his or her personal limits, and
also recognize the stress involved in working with suicidal clients. 2) The therapist
should strive to create an atmosphere of support for the client. 3) The therapist
should work to obtain a commitment from the client to refrain from intentional or
unintentional suicide. 4) The therapist should consult with colleagues on client
cases. 5) Clients should know the therapist’s availability and how to contact him or
her between visits. 6) The therapist should receive specialized training in suicide
prevention and crisis-intervention and stay abreast of the latest developments in
these areas. 7) The therapist should fully assess his or her own competence and refer
clients when needed. 8) The therapist should consider client hospitalization as an
option with an awareness of its benefits and liabilities. The therapist should also
monitor the client closely following hospital discharge, as this is a time of increased
suicide risk. 9) The therapist should communicate with the client clearly and firmly,
and avoid being manipulated by the client’s threats. 10) If working within a facility
or agency, the therapist should ascertain clearly the lines of responsibility for
clients. 11) The therapist should avoid allowing the client access to dangerous
instruments within the clinical setting, making certain that the client’s personal
weapons are given to another person. 12) The therapist may need to schedule the
client for more frequent visits. 13) The therapist should emphasize the client’s
strong points and will to live, 14) The therapist should convey his or her caring,
with its accompanying limits and actions, as well as his or her realistic aspirations.
15) The therapist should be willing to share responsibility for the client with the
client. 16) The therapist, with the client’s assistance, should establish a network of
friends and family to support the client. Although as in Tarasoff there is no duty to
warn specific individuals of the client’s intent to commit suicide, if warning others
will help prevent the suicide, it is then the therapist’s obligation to do so (Swenson,
1997).
Self-awareness is crucial in work with suicidal clients. Coale (1998) presents
an example of how her own self-awareness manifests itself in her work with these
clients:
“T often talk about my needs to a suicide contract with them so that J do not
have to worry constantly about them between sessions. The contract is
clearly to help them stay alive, which they generally want to do or they
would not be in therapy in the first place; but, once I have entered into a
relationship with them and care about them, the contract is also for my
needs. I have been struck with how readily most clients will agree to such
a contract when I am honest about my need for it as well as theirs....I have
also let clients know, from time to time, that their violent or illegal behavior
is intolerable to me. Not just that it is not in their therapeutic best interests
104
or is in violation of the law, but that it goes beyond the bounds of my

tolerance” (p. 214).
To avoid liability, therapists must use appropriate documentation of the

client’s behaviors as well as their own actions towards prevention, and seek
consultation with other professionals on a regular basis. The therapist should
carefully document all aspects of the client’s assessment process, including his or
her case history and treatment records and his or her suicidal ideation, as well as the
provision of informed consent regarding the limits of confidentiality. The therapist
should also document the preventive and treatment measures utilized with the
client, the resources provided and the individuals contacted for imminent risk.
Consultation provides the clinician with the needed support to cope with the stresses
of work in this area and also feedback concerning the standard of care being
implemented (Sommers-Flanagan & Sommers-Flanagan, 1995). The reasonableness
of the professional judgment exercised by the therapist is a strong determinant of
liability. If for example, the client gave no indication whatsoever that he or she was
considering suicide, liability is not an issue (Pryzwansky & Wendt, 1999).
Can suicide involve a rational decision for the client? Some authors will
argue for the client’s right to autonomy and self-determination, even if this involves
suicide. Obviously, both the therapist’s own values as well as legal requirements are
influential in how he or she approaches this issue. Szasz (1986) argues that
therapists should not employ the power of the state to coerce individuals into
staying alive. Moreover, it is the individual who is accountable for his or her own
actions, and this should not be assumed by the therapist.
Some authors argue as well that individuals who are fully rational have the
right to make this decision, for example, individuals living in chronic pain, with
little hope for relief. The responsibility of the therapist then is to ascertain that the
individual is making this decision with full cognitive awareness. Battin (1995) has
proposed five criteria to be used in determining whether suicide is rational; all of
these criteria must be satisfied: 1) The individual’s ability to reason-does the
individual make logical errors in thinking, and can he or she assess the
consequences of actions taken? 2) Does the person have a realistic worldview? Are
claims made justifiable within a relevant culture? 3) Does the person have complete
and accurate information for making decisions? 4) Is the intent of the suicide to
avoid harm or irremediable mental or physical pain? 5) Is the suicide inconsistent
with the person’s fundamental values?
HIV/AIDS. The maintenance of confidentiality with clients who are HIV-

infected or who have AIDS is of utmost importance, as the disclosure of a person’s
HIV or AIDS status may seriously jeopardize his or her social, familial and
economic well-being. The Confidentiality of Medical Information Act protects the
individuals’s right to privacy by preventing the disclosure of information related to
his or her mental or physical condition without specific authorization. The
disclosure of information concerning an individual’s HIV status is specifically
prohibited in some jurisdictions (Woods, et al., 1990). In many clinical situations,
105
music therapists may not have the right to information concerning whether or not
clients have HIV or AIDS.
When a client who has AIDS or is HIV seropositive is aware of his or her
condition and fails to make this fact known to sexual or needle-sharing partners, or
engage in safe sex practices, a most difficult ethical situation arises for the therapist
(Pryzwansky & Wendt, 1999; Stewart & Reppucci, 1994). This may be one of the
most controversial issues a therapist ever confronts. The therapist must choose
between protecting the client’s confidentiality and the therapeutic relationship or
protecting other individuals at risk; a moral, ethical, legal and professional dilemma
results (Corey, et al., 1998).
The laws have not yet clearly or universally defined the ethical and legal
responsibilities of therapists who become aware of the potential dangers that these
behaviors imply for the HIV-client’s partners. State laws vary concerning the
disclosure of HIV-related information, and these may also be different for
physicians and therapists. Some states may not permit therapists to disclose this
information to warn and protect others, and they are mandated to attempt to
persuade the client to do so voluntarily (VandeCreek & Knapp, 1994). Some states
expressly forbid HIV disclosure, whereas other states allow physicians to disclose,
but not those in mental health practice. Furthermore, in many states, therapists who
disclose this information may be subject to criminal and civil (e.g., malpractice)
charges. Other states have not yet developed specific laws (Corey, et al., 1998).
Duty to warn and protect guidelines may be relevant in these cases (Woods,
et al., 1990). In making the decision concerning whether he or she has the duty to
warn others, the therapist must ascertain whether there is imminent danger to an
identifiable person, such as a spouse, or if the potential victim is an anonymous
sexual/needle sharing partner.
Therapists working with HIV-infected or AIDS patients must have current
knowledge of the disease and its risks for transmission, as well as knowledge of the
relevant state laws as a starting point (Spiegel, 1998). Therapists should also have
adequate self-awareness of their own values and attitudes towards the disease. As
a next step, therapists are obliged to discuss the risks of transmission frankly with
the client; this alone may be sufficient to encourage the client to adopt safe sex
practices or warn partners. In some cases, the client may be resistant to doing this,
and the therapist will need to consider his or her duty to warn and breach the client’s
confidentiality. The therapist should make every attempt to secure the client’s
permission to do this, and should seek expert advice before taking a course of action
The working group on confidentiality with HIV-infected clients (specifically
maternal and pediatric HIV-infection) at Creighton University’s Center for Health
Policy in Omaha (1992) has recommended guidelines for decision-making
regarding these disclosures: “When the risk of infection is significant, the identity
of the third party is known, (when) warning is likely to be effective in preventing
infection, and every reasonable measure to convince the patient to disclose has
failed, professionals have a strong ethical obligation to warn those at risk.” (Cited
in Reaves & Ogloff, 1996, p. 123).
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Cohen and Cohen (1999) also enumerate five conditions which must all be
satisfied before a therapist may breach the HIV or AIDS client’s confidentiality: “1.
The therapist is aware of medical evidence indicating that the client is HIV
seropositive. 2. The third party is engaging in a relationship with the client such as
unprotected sexual intercourse, which according to current medical standards,
places the third party at high risk of contracting HIV from the client. 3.The client
is not likely to disclose his or her HIV status to the third party in the near future, nor
is anyone else likely to do so. 4.The third party can be identified and contacted by
the therapist without the intervention of law enforcement or other investigative
agencies. 5. The third party is not engaging in high-risk sexual activity (such as
promiscuous sex without the use of a condom) for which he or she can reasonably
be expected to foresee or comprehend the high risk or harm to self” (p. 217). The
risk to a third party must be compelling and imminent for therapists to breach the
client’s confidentiality.
The same authors also detail specific procedures to be used by the therapist
in warning persons at risk of HIV infection. The therapist should make the
disclosure in a timely manner to minimize the risks involved. The therapist
encourages and supports the client in making this decision by him or herself. Before
the disclosure is made, the therapist notifies the client that he or she intends to do
so. The therapist should avoid deceiving, manipulating or coercing the client in any
way, such as by making continued treatment contingent upon the client’s disclosure.
The therapist is direct (avoiding answering machines, etc.) in making the disclosure
to the person at risk or to his or her parents/guardians if the person is a minor. The
therapist limits the content of the disclosure only to the information needed to
convey the risk involved; the therapist protects the client’s identity if possible. The
therapist employs reasonable safeguards for the client’s well-being, for example, to
prevent the client from harming him or herself. The therapists offers support or a
referral to the third party (Cohen & Cohen, 1999),
In addition to these recommendations and procedures, the therapist should
document the rationale for his or her actions, as well as the evidence for the risk to
the third party. Legal advice should be obtained to ascertain that the planned course
of action is advisable. Consultation with expert colleagues at every step in the
ethical decision-making process is essential.
Children. The therapeutic relationship can evolve only when there is trust;
it doesn’t matter if the client is an adult or a minor child. Unfortunately, children are
not treated the same as adults. Small differences in age result in vast differences in
comprehension and maturity. Children may not be deemed independently
competent to enter into a contract involving therapy and to provide informed
consent. In most states, the parent or guardian must execute this contract for the
child, (Corey, et al., 1998), and consequently, the rights to confidentiality are vested
also with the parent/guardian (Peterson, 1996). Exceptions do exist in some states
however, and adolescents may have the right to enter into therapy for designated
reasons (e.g., substance abuse, birth control) without parental consent. Therapists
should be cognizant of the laws in their individual states regarding the rights of
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minors to enter into therapeutic relationships without parental consent (Corey, et al.,
1998).
There are several other factors which complicate this issue. The posture of
the legal system historically is to assign most if not all decision-making rights of the
child to the parent. There has been little precedent for recognition of the
emancipated rights of children (Peterson, 1996). In addition, the costs for therapy
are most often borne by the parent/guardian. These individuals may feel entitled to
have access to the confidential information of the child, or even have influence over
treatment because of this financial commitment. In addition, in situations where
parents are divorced, the rights of noncustodial parents may present a further
complication (Biggs & Blocher, 1987). Overall, however, parents have the right to
general information about their child’s progress in therapy (Stromberg, et al., 1993a,
199sb).
The threat of malpractice is often a consideration for the therapist working
with children, because of the inability of children to provide informed consent. The
therapist who yields to the wishes of the child and is in conflict with those of the
parent may be at risk. The professional codes of ethics often do not provide clear
guidance for therapists in these situations (Peterson, 1996).
The following recommendations for protecting the confidentiality of child
clients are offered by Zingaro (1973), APA, (1981), and APGA, (1981). 1)
Communication between child and therapist should be considered confidential
because of the nature of the therapeutic session itself. 2) Whereas consultation on
a specific case is not a violation of confidentiality, informal discussions of the
client’s case with colleagues should be focused on helping the client, and his or her
identity should be protected. 3) If the therapist must provide written reports for
evaluation purposes, these should be limited to the necessary information only, with
all attempts made to avoid an invasion of the child’s privacy. 4) If the minor child
reveals behavior that is potentially harmful to self or others, the therapist should
attempt to dissuade the client from participation in this activity, and explain his or
her responsibilities to inform others. If the client persists in this behavior, the
therapist should take reascnable action to inform the appropriate authorities. The
determination of the individuals to be informed should be determined by the
situation and the therapist’s judgment. 5) If the therapist is subpoenaed to testify in
court regarding the client and is unwilling to breach confidentiality, the therapist
may attempt to become an agent of the client’s attorney. That is by revealing the
information to the attorney, the therapist may be able to assume this privilege. To
be protected under this privilege, the attorney must raise this privilege in the court.
The therapist may also request that the information be disclosed to the judge in his
or her chambers rather than in the courtroom. Neither of these strategies, however,
guarantee that the information will be considered privileged.6) When the therapist
is unsure of a course of action to be implemented, he or she should seek
consultation from experts in the field. And 7) If parents or school officials request
confidential information from the therapist, the therapist should attempt to uphold
the child’s rights to confidentiality. If the therapist feels that it is in the child’s best
interest for these individuals to have information, the therapist may provide them
108
with suggestions about what they can do or not do to help the child. In this manner,
confidential information may be protected (Zingaro, 1973). In addition, therapists
can indicate in the informed consent agreement their policy for providing
information concerning the child to his or her parents. Therapists may also seek
permission from the child to release confidential information to parents and provide
the child with the information to be discussed. The therapist may also include the
child in his or her meeting with the parents (Corey, et al., 1998).
Laws governing confidentiality for counselors working in school systems
are different from those governing therapists in private practice. The Family
Educational Rights and Privacy Act of 1994 governs policy in schools that are
federally funded. School counselors are not required to contact parents of children
under 16 who seek their services. Moreover, school counselors are not required to
disclose information to parents from counseling sessions or allow parents access to
the child’s records (Corey, et al., 1998).
It is important for schools and agencies to have written policies and
procedures for responding to problems involving suicide risk and substance abuse.
Policies for suicide risk should contain procedures for referring the child to a trained
professional or agency, and for involving the parents in the process (Poland, 1995).
Regarding substance abuse in the schools, some states have implemented laws
requiring that parents be notified of their child’s behavior. The therapist may be
responsible for distinguishing experimentation from use and abuse. Written policies
and procedures are again required to protect the child as well as the professional
involved (Peterson, 1996).
Groups. Privileged communication does not generally apply to group

therapy settings, except i several states (Corey, et al., 1998). Although the therapist
is bound by professional ethics and the law not to reveal confidences obtained
during treatment, the confidentiality of group members can be breached by any
individual group participant. Therapists have the responsibility to inform groups of
these inherent limits in confidentiality, i.e., that confidentiality cannot be
guaranteed. Informed consent procedures detailing the limits of confidentiality
should be provided to all members.
Therapists also need to inform the group about their own limits in
maintaining confidentiality, e.g., the duty to warn and protect. Also, if working
within an institution, the therapist must inform the group members that he or she is
obligated to document individual and group behavior and progress in their charts.
Clients should also be informed that this information may be shared with other staff
in team meetings (Corey, Williams & Moline, 1995).
At the same time, therapists have a responsibility to encourage group
members to maintain confidentiality regarding what occurs in the group situation
as well as the identity of other group members. This information bears repeating at
various times during the group process, as members may nonmaliciously want to
share their experiences with family and friends (Corey, et al., 1998).
Because there is rarely privileged communication in groups, a client may be
summoned to testify in court concerning what was revealed by another member
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(Bernstein, 1977).
When groups involve minors, consent should be sought from parents. In the
consent form, a description of the purposes of the group, the need for
confidentiality, and the therapist’s policy regarding his or her intent to uphold
confidences of group members should be included. Parents may be given general
information about their child (and no other group members) without violating the
child’s confidences (Corey, et al., 1998)
The therapist should work with the group members in addition to their
parents/guardians to reinforce the concept of maintaining confidentiality within the
group, and encourage discussion of these issues as they arise for the members
Confidentiality also needs to be maintained within experiential music
therapy group training sessions in academic settings. Group members should be
aware of the need to safeguard private information of their fellow classmates. In the
academic setting as well, students who receive group supervision for their fieldwork
(practicum) or internship experiences are also mandated to preserve client
anonymity in their case discussions, and to refrain from any discussion of client
material (their own clients, or clients of other students) outside of the supervision
setting.
Therapists working with families or couples need to be clear in informing
clients of the limits to which confidentiality can be maintained. For example, if a
couple in therapy later files for a divorce, the therapist may be summoned to testify
in court regarding either party (Peterson, 1996). In a similar manner, the therapist
working with families may be compelled to submit therapy records to a court ina
custody battie.
Safeguarding Confidencial Information
Appropriate safeguards needs to be considered in maintaining the

confidentiality of the client’s personal information. The basic requirement is that
information be handled in a manner that acknowledges the dignity and privacy of
the client, and all others mentioned in the information (Biggs & Blocher, 1987).
Threats to confidentiality are posed when confidential information is treated
carelessly or casually, or mishandled in any way. There are many examples.
Conversations between professionals concerning a client, as well as telephone
conversations with or concerning a client, should not occur in places where they can
be overheard, e.g., in elevators, hallways, waiting rooms, etc. These situations may
be more common than one imagines. The present author recently visited a friend
who was in the hospital. A large sign was posted in the elevator warning
professionals not to discuss patients in this space! Without a doubt, conversations
about a client should never occur in social situations or public places.
Modern technology may contribute significantly to careless handling of
confidential information. Messages left on answering machines, conversations on
cell phones, and information inputted into computers are all subject to access by
unauthorized individuals (Pope & Vasquez, 1991). The storage of confidential
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information on computer floppy disks, hard drives, etc., must be carefully

safeguarded from unauthorized access. Any communications of client information
via e-mail cannot be relied upon for security.
Confidentiality also involves protecting information about the client in
treatment, as well as the fact that the client is in treatment. This information is
compromised, for example, when secretaries take phone messages for therapists,
and these slips of paper (with the client’s name) are treated carelessly.
Client records, which will be discussed in more detail in the following
section, need to be stored in secured, locked places, and only designated
professionals may have access to these records. Clients’ files may not be left on
desks, in cars, in typewriters, or on lunch tables! Records of client appointments,
calls, and insurance or financial accounts should be treated in a similar manner.
Anyone besides the therapist who has access to client information, including
secretaries, clerical workers, accountants, etc., should be trained regarding
procedures to maintain confidentiality. If these individuals have access to clients’
names and data, they must also be bound by policies of confidentiality.
The setting of therapy, including waiting room situations, may also
contribute to breaches in clients’ privacy. Especially in small communities, clients
may not feel comfortable in running into people they know in therapy waiting
rooms. Provisions should be made, if possible, for privacy for those waiting for
therapy sessions. Poor office soundproofing poses an additional risk Therapists who
have offices in their homes that are not adequately set apart from their living
quarters may expose clients to invasions of privacy by the therapist’s family
members.
In small communities, as well, clients’ checks deposited by a therapist may
breach privacy, as tellers can have access to the names of individuals receiving
therapy. Alternate prov:sions should be made in these circumstances (Corey, et al.,
1998).
Clients’ records reviewed in quality assurance procedures may breach
confidentiality. Client information provided to insurance companies also poses the
same risk (Dileo-Maranto & Ventre, 1985).
Therapists in private practice who turn delinquent clients’ accounts over to
collection agencies may be invading the privacy of these clients. Privileged
communication is not upheld by the Internal Revenue Service, who may summon
the tax records of a therapist (Dileo-Maranto & Ventre, 1985).
The list of potential threats to confidentiality goes on and on, and therapists
should monitor all potential risks to confidentiality on a continual basis.
Confidentiality in Record Keeping
Record keeping presents a challenge to all health care professionals, and

music therapists are not exempt by any means. This challenge is created by the
various potential uses of a therapist’s records. From one perspective, records
document client assessment, treatment, and progress towards established goals, and
in this regard, they are of obvious benefit to the client and the therapist, and may
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contribute to the quality of treatment offered. Threats to the confidentiality of these

records need to be avoided as discussed in the previous section.
From another perspective, records are used to meet the requirements of the
therapist’s facility, accrediting agencies, and third-party providers (Peterson, 1996).
In this regard, records may potentially present a threat to the client’s confidentiality.
From a third perspective, good record keeping helps protect the therapist
from the client in potential malpractice litigation (and if a malpractice suit is filed,
privilege no longer exists).
From a final perspective, client records may be summoned by a court of law,
breach the client’s confidentiality and perhaps be used against the client!
From all of these perspectives therefore, record keeping presents threats to
the client’s confidentiality. Meeting the potentially conflicting demands of
persons/agencies who may have access to clients’ records, and at the same time
safeguarding the welfare of the client and the therapist, is indeed the challenge.
Appropriate record-keeping practices are indeed essential for the music therapist.
Failure to do so creates both ethical and legal risks for the therapist.
The Standards of Clinical Practice of the National Association for Music
Therapy (NAMT, 1988) provide guidelines for documentation in music therapy.
The following should be included in the client’s records: referral, assessment,
placement, program plan, and ongoing progress. These should be recorded
according to federal, state and facility requirements. The therapist should also
record the client’s functioning level in relation to the established goals and
objectives for him or her. Important interventions and client’s responses to these
shall be noted in the evaluation of progress. The language used in the client’s record
should be objective and professional and based on observable data. The
documentation should include the date and the therapist’s signature and professional
credentials. Music therapy documentation is confidential, unless as appropriate
release is authorized, and should become part of the client’s file. This document
should contain referrals made to other sources, and also plans for music therapy
interventions if not initiated immediately. Finally, contacts with other persons in the
client’s life outside of music therapy should be included.
In addition to the aforementioned information, music therapists working
with patients in the general hospital setting shall also include the date of the client’s
referral, confirmation of the physician’s orders, and services requested. For
inpatients, documentation must be done no less frequently than once per week.
Music therapists in private practice must document the client’s payment for
services, and forward a periodic evaluation to the referral source as appropriate
(NAMT, 1988).
Music therapists may also consider including documentation of the informed
consent process with the client, including the risks and benefits of treatment,
instructions regarding the limits of confidentiality, financial information (billing,
insurance, etc.), dates and times of sessions, a discharge summary, details of the
termination process, consultations obtained, and forms for authorizing the release
of information (Corey, et al., 1998; Peterson, 1996).
For music therapists in private practice, financial records should be
big
maintained separately from clinical records to avoid the disclosure of sensitive

information to clerical staff, and insurance payers (Hall, 1988).
The content and style of the client’s record may be dictated by the institution
in which the therapist works. The amount of detail included is usually determined
by the therapist (Corey, et al., 1998). Records should contain factual information,
and therapists should avoid the inclusion of hypotheses, subjective impressions or
unsubstantiated information. Notes for each session with the client should be
recorded, including interventions and progress (Peterson, 1996). Documentation
should be thorough, yet to the point. If information is not recorded, then it can be
assumed it never occurred (Corey, et al., 1998).
As mentioned earlier in this chapter, it is important for the therapist to
carefully document the client’s risk for suicide, the treatment options both
considered and employed, precautions taken, persons notified, etc. (Peterson, 1996).
Meticulous documentation is required in any cases requiring the disclosure of
confidential information to others.
At the same time, therapists must realize that clients’ formal records may be
subpoenaed by court, may be viewed or accessed by clerical personnel, by the client
him or herself or by regulatory or insurance agencies. For this reason, it is important
to safeguard particularly sensitive information, such as the client’s HIV or AIDS
status. The use of strategic documentation may preserve the confidentiality of this
information. For example, the therapist may chart this diagnostic information
separately in an envelope attached to the client’s file. If records are accessed,
diagnostic information is not readily available. The therapist might also include
diagnostic information in the file using a code. Furthermore, if the therapist wishes
to make note of any subjective information regarding the client, these should be
addressed as “memoranda to him or herself” (Biggs & Blocher, 1997) or “working
- notes” (Koocher & Keith-Spiegel, 1998) and kept exclusively in the therapist’s
possession, and r,ot accessible to any other person. These personal memoranda are
not generally subject to subpoena, although this is always a possibility. Further, the
therapist may be required to testify in court concerning their contents (Biggs &
Blocher, 1997). Working notes include conjectures, subjective impressions and
incomplete ideas that may be worked into a report at a later time, information that
might be the basis for discussion with a supervisor, or ideas that are discarded as
new information emerges. Working notes involve interim documents; information
is reworked into less sensitive formal reports and destroyed (Koocher & Keith-
Spiegel, 1998). It is important for the therapist to regularly review and summarize
these sensitive working notes. If these notes are subpoenaed, they may not be edited
Therapists who work in clinical facilities must be especially careful to
adhere to the standards for record keeping, storage and disposal of the facility.
Failure to do this may result in disciplinary and legal action for the therapist
(Peterson, 1996).
Once the therapist’s notes are entered into the client’s records, they should
not be altered. To do so after the fact can imply tampering. The therapist should
document information soon after each session and include the date and his or her
KES
signature (Corey, et al., 1998),

Music therapists often employ audio or videotaping of clients’ sessions for
assessment and evaluation purposes. Clients must be informed of the nature and
purpose of taping, how the tapes will be used, who will have access to them, how
they will be stored, and how long they will be retained at the beginning of treatment
in the informed consent agreement (Corey, et al., 1998). Music therapists must take
special care when reviewing these materials (so others do not have access to their
contents).
Record Retention
As mentioned previously, clients’ records must be kept securely, in locked

storage spaces, where they cannot be accessed by unauthorized persons. Even after
the therapist terminates work with a client, records must continue to be stored ina
secure manner. Music therapists working within facilities need to be aware of
policies concerning record retention.
Clients’ records may be needed in the future by other professionals who treat
the client, by insurance providers, by courts of law, or by the therapist him or
herself in the event of legal action (Haas & Malouf, 1989).
The length of time a client’s records need to be retained may vary according
to the type of record kept, the type of client’s need for documentation, the likelihood
of the client’s requirements for future treatment, validity and relevance of the
record’s contents, and governing state or federal requirements (Koocher & Keith-
Spiegel, 1998).
Facility policies or local statutes may dictate the length of time that records
should be maintained according to their type, i.e., business, clinical, school or
research records. These laws may differ according to whether the therapist is in
private practice or employed by a facility. Therapists in private practice should also
be aware of the seven-year requirement for maintaining tax records, as these may
be needed in the event of an audit of the therapist and/or the client (Koocher &
The therapist should consider the client’s welfare as well as legal
requirements when deciding the appropriate length of time for retaining records.
Obviously clients may benefit from information in previous records when seeking
future treatment, however, obsolete and invalid data contained therein may also
present a risk for the client (Koocher & Keith-Spiegel, 1998).
When there are no laws or policies governing the time frame for record
retention, the therapist may opt to keep complete records for a seven year period
(Corey, et al., 1998). The American Psychological Association (1993a)
recommends that the therapist retain complete records for 3 years, and case
summaries for an additional 12 years following termination of services (Pryzwansky
& Wendt, 1999).
Consideration may be given to storing separately abbreviated records
containing minimal client information (names, addresses and phone numbers) in the
event of a fire (Hall, 1988). For therapists who are retiring, records can be kept in
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their possession and made available upon request. Therapists should also make
arrangements for the disposition of records to another professional in the case of
their death (Pryzwansky & Wendt, 1999). When records are disposed of, this should
be accomplished in a way that protects the client’s confidentiality. Shredding,
burning or destroying documents may be required (Koocher & Keith-Spiegel,
1998).
Release of Records
To Clients. Whether or not clients have the right to access their clinical
records is somewhat controversial, and also related to the type of record requested,
i.e., institutional record, records of a private practitioner, or working notes. Access
to institutional records is governed by law and facility policy. The federal Freedom
of Information Act of 1966 and state laws concerning patients’ rights may mandate
the client’s right to this access (Koocher & Keith-Spiegel, 1998).
Client access to records maintained by therapists in private practice may or
may not be dictated by state law, and the therapist should be familiar with relevant
laws in his or her jurisdiction. The client’s right to access a therapist’s working
notes is not usually governed by law (Pryzwansky & Wendt, 1999).
Who owns a client’s records? Koocher & Keith-Spiegel (1998) assert that
records are the property of the facility or private practitioner, even though clients
may feel that they “paid for them.” Whereas clients may have access to copies of
records, the original records belong to the facility or practitioner. The working notes
are the property of the therapist.
Institutional records are the property of the facility, not the client or
therapist. Any documents in a file that can be accessed by other staff within the
facility are considered the property of the institution. The therapist’s working notes,
maintained separately and privately, are the property of the therapist (Pryzwansky
& Wendt, 1999)
Whether or not the client “owns” his or her records, he or she will likely
have the right to access them whether these are institutional records or records of
a therapist in private practice. Therapists should always keep this fact in mind in
their record-keeping. If these documents are prepared appropriately, clearly and
professionally, and contain factual versus speculative information, therapists should
not feel threatened (Koocher & Keith-Spiegel, 1998).
The therapist should establish a policy concerning how the client’s records
are shared with him or her, and this should be a part of the informed consent
agreement. For example, the therapist may insist on being present when the client
reviews records to answer questions, clarify terms or process reactions. The
therapist in private practice should also determine ahead of time whether he or she
will charge the client for the time involved in reviewing the record together, and if
so, there should be a consideration of the client’s ability to pay for this (Koocher &
Parents/guardians may also request access to a minor client’s records. The
therapist should establish a policy prior to treatment, as part of the informed consent
115
agreement about what types of information may be shared to protect the

confidentiality of the client. Family members who seek access to records of a
competent adult client may be denied this access, unless there is a compelling
reason, e.g., danger to self or others, that may necessitate this (Koocher & Keith-
Spiegel, 1998).
Subpoenas and Court Orders. Even in the event of privileged

communication, and clients of music therapists are unlikely to have privilege, client
records may be subpoenaed by a court of law. The therapist’s working notes are not
usually subject to disclosure in civil cases, but may be summoned in criminal cases
(Koocher & Keith-Spiegel, 1998).
It is important to distinguish between subpoenas and court orders for client
records. Subpoenas can be put out through an attorney’s request (either the client’s
attorney or the opposing attorney) to the clerk of courts for records or for an
appearance. A court order is issued by a judge based on a hearing (usually in
criminal cases). Responses to court orders are required, and submission of records
is also required, unless an appeal to a higher court is approved. The court then
decides on what information is privileged or not (Koocher & Keith-Spiegel, 1998;
Pryzwansky & Wendt, 1999).
If a subpoena for information arrives, the therapist should first consult his
or her attorney to determine what is legally required. If the subpoena is from the
client’s own attorney, the therapist should then consult with the client for
permission to release the information, and to review information with the client that
may be damaging to him or her. Therapists may offer to submit a summary of
working notes to the court if these are requested (Koocher & Keith-Speigel, 1998;
If the subpoena is from the opposing attorney, the therapist may contact this
attorney, and say “‘I cannot disclose whether or not the person noted in the
subpoena is now or ever was my client. If the person were my client, I could not
provide any information without a signed release form from that individual or a
valid court order’” (Koocher & Keith-Spiegel, 1998, p. 131). The therapist should
then contact the client with the details of the situation and request permission to
speak with his or her attorney. The therapist may ask this attorney to consult with
the opposing attorney regarding the issues of privilege or attempt to quash the
subpoena. The therapist should also consult with his or her own attorney in the
matter, but the therapist must respond in some way to the subpoena. If the therapist
must release documents, he or she should provide notarized copies and not original
documents, as these may be lost (Koocher & Keith-Speigel, 1998). For further
information on this subject, the reader is directed to the publication prepared by the
APA’s Committee on Legal Issues (1996).
To Insurance Companies. When clients’ treatment is paid for by a third-

party provider, claims for reimbursement require the therapist (or client) to provide
confidential information regarding the client, including: diagnosis, type of service,
dates of service, length of treatment, etc. The insurance provider may seek
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additional details from the therapist including the client’s presenting symptoms,
treatment procedures, or other sensitive information (Koocher & Keith-Spiegel,
1998).
Insurance companies may use or share this information in a variety of ways,
perhaps to the detriment of a client who may be denied future insurance benefits,
or who may have this information provided to his or her employer if self-insured.
Clients may not be aware of these implications when signing release of information
forms so that treatment may be reimbursed, and it is often difficult for the therapist
to fully inform clients in this respect, as the control of information is out of his or
her hands once it leaves the office. In refusing to have information released to
providers, the client may need to pay for treatment him or herself. The therapist
should attempt to determine how the information is used/shared by insurance
companies to be able to inform clients who rely upon third-party payers (Koocher
& Keith-Spiegel, 1998).
For Teaching Purposes. Therapists who use client information, especially

audio or videotapes from clinical work, for teaching purposes must have the client’s
full consent before doing so. All information that could lead to the identification of
the client should be removed from the materials, and case information should be
appropriately disguised.
Informed Consent for Release. Prior to releasing any confidential

information, therapists must obtain written consent from clients. Consent must be
obtained following the provision of adequate information to the client, and without
any hint of coercion. The therapist has an important role in exposing all the
potential risks and benefits to the client concerning the release of information, how
the information will be used, and the potential effects for the client this may imply
(Koocher & Keith-Spiegel, 1998; Pryzwansky & Wendt, 1999).
Informed consent agreements for the release of information should contain
the following information: 1) name of the person receiving the records, 2) a
description of the specific records to be forwarded, 3) the intended use of the
information, 4) the date the form is signed, 5) the date the consent will expire, 6)
any modifications/limitations to the materials send, 7) the client’s-parent’s-
guardian’s name and signature and relationship to client, and 8) signature of a
witness, if not signed in the presence of the therapist. The client retains a copy of
the consent for release form, and the therapist retains a copy for the client’s records.
The therapist should also document which information was sent and to whom it was
forwarded. Materials sent should be clearly identified as confidential, the recipient
should be notified as to restrictions on how they are used, and only the designated
and relevant materials should be forwarded. (Koocher & Keith-Spiegel, 1998).
When information in a client’s record may violate the confidentiality of other
persons, such as in group therapy, this information may need to be removed prior
to the forwarding of materials (Pryzwansky & Wendt, 1999).
hw
Chapter Summary
1. The maintenance of confidentiality within the therapeutic relationship is both an

ethical and legal responsibility of music therapists, as well as a prerequisite for the
establishment of trust. According to available data, both music therapists and
psychologists view confidentiality as one of the most important issues in ethics.
Confidentiality refers to the ethical obligation of the therapist to protect the client’s
information from disclosure to anyone, without express permission from the client
to do so. There are inherent limits to confidentiality in every therapeutic situation.
Privileged communication (or privilege) is a legal term, granted to a client, that
specifies that the information shared by the client in certain relationships is
protected from disclosure in courts of law without the client’s permission. Privacy
refers to the constitutional right of all persons to determine the extent to which they
will share personal information with another.
2. There are a number of exceptional circumstances in which the breaching of

confidentiality may be mandatory: 1) when the client presents a danger to self or
other persons, 2) when the client reveals the intent to commit a criminal act, 3)
when there is suspected child, elder or handicapped abuse, and 4) when there is a
court subpoena for a client’s records. Laws in all states require that therapists report
suspected child abuse or elder abuse. Failure to do so may result in legal action
taken against the therapist.
3. The duty to warn and protect third parties who may be in danger from a client
mustbe exercised when the following three criteria are involved: 1) a therapeutic
relationship exists, 2) based on the client’s history, violence can be reasonably
predicted, and 3) the potential third-party can be identified. Therapists need to
exercise a reasonable standard of care in assessing client dangerousness, in treating
these clients, and in protecting others from potential harm by these persons.
4. A reasonable standard of care must be exercised for clients who are at risk for
suicide. The therapist is responsible for assessing this risk, for breaking
confidentiality if necessary, and for implementing a plan to prevent the action.
5. Laws protect the confidentiality of an individual’s HIV or AIDS status. Clients

with HIV or AIDS who endanger the well-being of third parties present an
enormous ethical dilemma for therapists. The laws have not yet clearly or
universally defined the ethical and legal responsibilities of therapists who become
aware of the potential dangers that these behaviors imply for the HIV-client’s
partners. Specific criteria must be present before a therapist may breach the client’s
confidentiality, and if a decision to warn a third-party is made, specific procedures
and additional safeguards must be implemented.
6. In most states, the parent or guardian must execute the informed consent contract
for his or her minor child, and consequently, the rights to confidentiality are vested
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also with the parent/guardian. Nevertheless, therapists should make every effort to
continue to maintain the confidentiality of the information the child provides in
treatment, develop policies for this which may be communicated through informed
consent procedures, and obtain the child’s assent for the release of information.
7. Privileged communication rarely exists in group therapy situations. Participants

need to be informed of the limits of confidentiality, and educated concerning the
necessity of maintaining the confidentiality of information revealed during
treatment by group members. Precautions should also be taken to protect
confidentiality in experiential music therapy training groups, as well as in couples
or family therapy.
8. Therapists must advise clients of the limits of confidentiality prior to treatment.

Therapists should be familiar with laws in their respective states governing
confidentiality.
9. Appropriate safeguards needs to be considered in maintaining the confidentiality

of the client’s personal information. The basic requirement is that information
should be handled in a manner that acknowledges the dignity and privacy of the
client, and all others mentioned in the information. There are many threats indeed
to the confidentiality of this information.
10. Record keeping presents threats to the client’s confidentiality. Meeting the
potentially conflicting demands of persons/agencies who may have access to
clients’ records, and at the same time safeguarding the welfare of the client and the
therapist, is often a challenge.
11. Procedures for maintaining confidentiality in clients’ records are numerous and
detailed. There must be adequate, objective documentation so as to benefit the
client, and at the same time, an avoidance of information, which if revealed, may
be potentially harmful to him or her.
12. The therapist should consider the client’s welfare as well as legal requirements
when deciding the appropriate length of time for retaining records. Obviously
clients may benefit from information in previous records when seeking future
treatment, however, obsolete and invalid data contained therein may also present
a risk for them.
13. Clients may have the right to access their clinical records, but their rights may
vary according to the type of record requested, i.e., institutional record, records of
a private practitioner, or working notes. Access to institutional records is governed
by law and facility policy.
14. Informed consent must be obtained from clients prior to releasing any
confidential information. The release of clients’ records may be mandated by courts
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of law, by insurance providers, or by other parties.
Ethical Dilemmas
1. Patricia, a music therapist working in a psychiatric facility accidentally leaves

her file cabinet open overnight. When she returns to work the next morning, she
discovers her files out of order.
2. A relative of Josephine, a music therapist, is hospitalized in a psychiatric facility

where Josephine works. The therapist is aware of the client's progress although she
does not work directly with him. The relative's spouse calls Josephine at home daily
to check on her husband’s progress.
3. Sarah, a music therapy intern completing clinical training takes photographs of

her clients for his personal scrapbook. The intern has not obtained permission from
the administration or clients’ families.
4. Sam is a music therapist in private practice. Gregory, one of Sam’s clients with
paranoid tendencies, asks Sam to allow him to read his music therapy file.
5. Charles, a music therapist in private practice, works with Rosie and Harry, a
couple who have pursued music therapy to assist in their communication
difficulties. In an individual session, Harry revealed that he was having unprotected
sex with gay men and at the same time, unprotected sex with his wife. Harry does
not want to be tested for HIV or to tell his wife about his gay affairs because he
thinks she will divorce him.
- 6. In the situation above, Rosie finds out about Harry’s sexual activities and files
for divorce. She asks Charles to testify in court on her behalf.
7. Sid is a client of Marina, a music therapist who works in a psychiatric facility.

Sid has been hospitalized because of a manic episode. He discloses to Marina that
he is HIV positive, and that he does not plan to stop his sexual activities, involving
unprotected sex with numerous anonymous partners, as he wants to ‘get even.”
Marina is scheduled to meet with the treatment team who is making a decision
regarding Sid’s discharge.
8. Jon, a music therapist in private practice, shares office space with a psychologist
and social worker. A common waiting area is used, and there are often a number
of clients waiting to see the three therapists. Jon meets his clients in the waiting
room when it is time for their appointment. When he has a new client, he will often
walk into the waiting room and announce the new client’s first and last name.
9. Darla, works as a music therapist in a medical hospital. One of her clients,

Florence, has been suffering from multiple sclerosis for many years, and has been
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hospitalized for a medical crisis. Florence tells Darla that she will not likely see her
again, as the disease has become too much for her to bear, and that she plans to
commit suicide when she leaves the hospital.
10. Theresa, works as a music therapist in a facility for the developmentally

disabled. Marge, one of her adolescent clients, tells her that her mother’s boyfriends
used to pay her 25 cents to have sex with them. She describes in detail the sexual
activity.
11. Paul, a music therapist has been working privately with Stanley in his practice.
Stanley was recently arrested for assault and battery. The district attorney learns
that Stanley has been receiving music therapy and subpoenas Stanley's records from
Paul.
12. In the situation above, Stanley continues to receive music therapy from Paul
while he is on bail and awaits his case to come up in court. He feels he is innocent
of the charges, and states that he will “kill whoever lied to the police about his
involvement in the crime.”
1. Do a literature search to find out the laws in your state regarding: confidentiality,
privileged communication, the duty to warn, confidentiality with regard to minors,
confidentiality and AIDS/HIV, and/or the reporting of child abuse, elder abuse and
handicapped abuse. If you know an attorney, you may consider talking to him or her
about these issues. Write a summary of your findings and how they might relate to
_ music therapy practice.
2. Write the confidentiality section of an informed consent agreement, detailing the

limits of confidentiality.
3. Write a release of confidential information form for a potential client.
4. Pick a topic that may have intrigued you in this chapter, do further research, and
write a short to moderate length paper. Present this to the class.
5. Role play telling a client about the limits of confidentiality. Get feedback.
6. Role play a scenario in which you tell a client that you must breach confidentiality
for any of the reasons mentioned in this chapter. Ask for feedback, and discuss your
reactions to doing this.
7. In your course journal, reflect upon the meaning of confidentiality within the
therapeutic relationship and how it may contribute to trust.
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8. Reflect upon an instance from your past when your confidentiality was breached
by someone else. Describe your reactions then and now. You may want to discuss
this with a partner or in a small group in class, or log about it in your journal.
9. In your course journal, explore your feelings of competence in working with

clients who present a danger to themselves or others or who have been abused.
10. Discuss with your classmates various institutional policies for record-keeping
they have encountered in their clinical work. Formulate general guidelines for
documentation that meet with the requirements of these policies, with the music
therapy Standards of Clinical Practice, and with the need to protect the client, in the
event records need to be released.
11. Discuss with your classmates confidentiality policies that may be implemented
by music therapists working with groups.
12. Discuss with your peers additional threats to a client’s confidentiality (or the
confidentiality of his or her records) not included in this chapter. Are there any
particular threats to confidentiality relevant specifically to music therapy work?
Generate additional ethical dilemmas and provide an ethical solution to these.
13. In your course journal, reflect upon any issue discussed in this chapter to which
you may have had strong reactions (and there may have been many)! For example,
what are your feelings about perhaps not having the right to know which of your
clients is HIV or AIDS infected? How would you feel about having your clinical
records subpoenaed by a court? How would you feel about having to testify in court
concerning a client? What would be your reactions if one of your clients committed
suicide or wanted to end his or her life because of a devastating illness? What are
your feelings about preserving the confidentiality of minors when their parents
request this information? How would you react if your had to report child or elder
abuse, or if you had to warn others concerning a potential suicide, about a potential
threat to themselves, or concerning their risk for HIV/AIDS? How would you feel
about one of your clients reading his or her records?
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BOUNDARIES AND DUAL RELATIONSHIPS
Boundaries
|| epee are part of every relationship. Boundaries serve to define

relationships, to help the people involved in them to discern where their realities
begin and end, and to allow individuals to establish their own separate identities.
Physical, as opposed to, psychological boundaries are easier to define;
psychological boundaries involve feelings, perceptions, etc., and are less tangible.
Individuals with good boundaries are cognizant of where their own boundaries end
and those of others begin, and are aiso sensitive to when their boundaries are
transgressed (Friedman & Boumil, 1995).
Individuals with a poor sense of boundaries have difficulties discerning
themselves as separate from others, and have problems in identifying their own
thoughts, feelings and needs. They may be at a loss in making decisions, because
their sense of self is impaired, and they tend to rely on others as external points of
reference. They also have difficulties in establishing and maintaining healthy
relationships, as limits are not determined, and boundaries are easily crossed
(Friedman & Boumil, 1995).
It is thought that the process of defining one’s boundaries occurs during
childhood. When children express needs and are cared for appropriately, they learn
to rely on their own experiences, feelings and thoughts. When their needs are not
met or in opposition to those caring for them, they do not rely on their own
experiences and needs, but on the needs of others. Hence, boundaries become
ambiguous, and children are not able to distinguish self from other. Abuse, assault,
and other violations have serious further implications for children’s boundaries
Examples of impaired boundaries are manifested throughout life and may
include the following: difficulty is asking for things to meet one’s needs as well as
difficulty in saying no to others; greater ability to take care of others than oneself;
reliance on others rather than oneself for knowledge about the self, including what
is real and true; problems with decision-making because of the lack of awareness
of one’s own needs and feelings; inability to modulate emotions when they are
experienced, as they are felt as overwhelming; development of one-way
relationships in terms of giving, and the inability to leave these relationships;
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oversensitivity to and feeling responsible for other’s emotions and moods; the
experience of unexpected and unpleasant memories, thoughts and sensations;
difficulty in focusing attention; and the inability to learn from one’s mistakes
Boundaries in Music Therapy
Boundaries are a significant component of the client-therapist relationship

in music therapy. The ways boundaries are established can be key factors in the
development of trust and safety within the relationship and also in how the client
responds to and progresses in treatment. The careful observance of boundaries helps
maintain the integrity of the client and therapist as separate persons, and the
therapist’s healthy modeling of boundaries to the client is most helpful within the
process (Epstein, 1994).
Epstein (1994) discusses the “frame” of therapy which consists of
information concerning boundaries, roles of the client and therapist, and the
therapeutic process that are communicated both explicitly and implicitly to the
client. The frame helps the client navigate through painful issues and distress.
It is important for therapists to have an insightful awareness of their own
personal boundaries and boundary problems, as the transgression of boundaries with
a client creates a host of ethical problems. The negotiation of boundaries in therapy
is sometimes difficult, and therapists must first be aware of their own boundary
issues before clinical boundary issues can be addressed.
Epstein (1994) emphasizes the significance of the therapist’s self-awareness,
psychological functioning, and ego boundaries. Therapists who have self-esteem,
who can distinguish their own needs from the client’s, and who have the capacity
to acknowledge autonomy in others, are much less at risk for boundary problems.
Appropriate ego boundaries help the therapist discern what is inside him or her and
what is inside the client. These boundaries need to be both adequately flexible to
allow adjustment to change and the client’s needs, and adequately consistent to
maintain coherence in the relationship.
The setting of boundaries can seem paradoxical in therapy. As stated in
Chapter 2, creating an empathic connection with the client is a key component in
healing. There are however limits to this connection; to ignore or to be unaware of
these limits places the therapist at ethical risk and jeopardizes the integrity of the
therapeutic relationship. To maintain too rigid a boundary does the same.
However, therapeutic relationships are indeed paradoxical. They involve an
attempt to establish equality in an inherently vertical relationship and to empower
clients in a situation where the therapist is singularly empowered. Similarly, it is a
challenge for the therapist to negotiate boundaries equitably with the client when
it is the therapist alone who is ultimately accountable for these limits (Coale, 1998;
Kottler, Sexton & Whiston, 1994). Moreover, there is no one boundary that fits all
clients.
What is significant in negotiating boundaries in therapy is balance, between
detachment and union and between distance and proximity. This balance is different
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for various points in a relationship with one client, as well as from client to client.
Determining factors are the needs of the client and the capabilities of the therapist.
The balance of boundaries is always an issue (Coale, 1998). “Although a healthy
frame has coherence and consistency, it must also be adaptable in a moment-to-
moment way. Ideally, the therapist will be able to fine-tune the frame into an
empathic, dynamic structure that is sensitive to the patient’s changing needs”
(Epstein, 1994, p. 17). Boundaries must also be adapted according to the ethnic,
gender, and multicultural needs of the client.
Coale (1998) emphasizes that it is not so much the nature or the structure of
boundaries that is significant, but “the way in which boundaries facilitate or impede
the therapeutic process on behalf of the client” (p. 99). Coale further states that the
therapist must honestly and accurately assess the following: if the client is being
used or exploited in any, if the therapist is sensitive to the client’s perception of the
boundaries, if the therapist is self-aware of his or her own boundary needs, if the
therapist is flexible enough to respond to different clients’ boundary needs, and if
the therapist is using the client to meet his or her own needs.
Boundary Violations
Boundary violations “refer to any behavior that infringes upon the primary
goal of providing care, and that might harm the patient, the therapist or the therapy
itself’ (Epstein, 1994, p. 2). Boundary crossings are distinguished from boundary
violations. Boundary crossings refer to deviations from normal practice; these could
be either beneficial or harmful to clients. Boundary violations usually imply
exploitation of or harm to clients (Gutheil & Gabard, 1993). Boundary crossings,
however, can lead to boundary violations when they contribute to a distortion of the
parameters of the therapeutic relationship.
Boundary issues in therapy are pervasive. Boundary violations are
frequently associated with sexual misconduct, inappropriate touching, and the
establishment of dual relationships with clients, as will be discussed later in this
chapter. However, other forms of nonverbal communication are also implicated in
boundary crossings and violations, including: body language, location and
arrangement of the therapy room, seating, and musical instruments, long pauses in
conversations, and so forth (Coale, 1998).
Clients come to music therapy because they have problems and are
vulnerable. Music therapists, on the other hand, are trained and skilled and have the
capacity to address clients’ needs.
“The potential for boundary violations derives from the space that exists
between the knowledgeable professional and the vulnerable client. The
inequality between us, the power differential, creates the need for
protection. Boundaries define formally and informally how professionals are
to exercise their power inside the relationship. When professionals maintain
these limits, the power differential presents no problems. However, when
professionals abuse the privilege of their power, they violate the boundary
that protects the space and place us (clients) in jeopardy” (Peterson, 1992,
126
p. 34).
Sources of professional power include that which is ascribed to the therapist
by society, the therapist’s expertise and skill, the client’s expectations and
dependency, as well as the professional’s own sense of power. Notall therapists are
comfortable with this power and responsibility within the therapeutic context. To
deal with this, therapists sometimes attempt to achieve more or less control with the
client: “tightening or enlarging the space in the professional-client relationship
undoes the controls on the relationship and thus paves the way for exploitation”
(Peterson, 1992, p.58). When this space is expanded, there is often a reversal of
roles between client and therapist. When this space is tightened, the therapist
maintains too great a distance in the relationship to protect him or herself for
whatever reason, and attributes this distance to the needs of the client (Coale, 1998)
In these violations, the therapist’s needs become the matter of concern rather
than the client’s, there is an implicit secrecy about the role reversal, there is an
inability of the client to extricate him or herself from the situation (and he or she
loses either way), and there is always a misuse of the therapist’s power (Peterson,
1992).
Protecting Boundaries
Singer (1992) discusses certain rituals/boundaries that need to be maintained

to prevent violations and to preserve the integrity of the client-therapist relationship.
1) Time: therapy occurs within a certain period of time, and both therapist and client
agree to containing work within this designated limit. 2) Space: therapy takes place
in a designated place and only in this place. 3) Intent: therapy is conducted at a
designated time and in a way that distinguishes it from other types of social,
personal or professional encounters. 4) Exclusivity: there are no other relationships
that exist between client and therapist besides that relating to treatment. 5)
Subsequent Relationships: even after the therapy relationship is terminated, the
client and therapist are not free to develop other types of social, business, or
personal relationships.
Rutter (1992) also discusses the need for “inner boundaries,” specifically
with regard to sexual feelings about clients. Internal boundaries represent the subtle
distinction between fantasy life and desire within the therapist. The therapist’s
ability to entertain fantasies as such about a client, but not cross the boundary to the
actual experience of desiring to implement the fantasies is an example of the
internal boundary at work. The presence and awareness of these inner boundaries
allows therapists to identify and work on an internal boundary violation before it is
acted upon. The reliability of this inner boundary is an essential quality in assuring
ethical behavior. A healthy inner boundary may be visible to clients who are
observing the therapist to determine their own safety with him or her. Furthermore,
the model the therapist provides in working with his or her own inner boundary may
be most significant to the client who will learn more from how the therapist is than
from what the therapist says.
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Dual Relationships
Definitions and Prevalence
“Dual relationships occur when professionals assume two roles

simultaneously or sequentially with a person seeking help” (Herlihy & Corey, 1992,
p. 3). The second role assumed by the therapist can involve 1) an additional
professional role or 2) an additional nonprofessional role (Herlihy & Corey, 1992).
Examples of the first type of dual relationship include: therapist/teacher,
therapist/supervisor, therapist/business partner, therapist/employer,
therapist/employee, educator/mentor, etc. Examples of the second type of dual
relationship include: therapist/friend, therapist/family member,
therapist/acquaintance therapist/lover, educator/friend, former therapist/friend,
former therapist/lover, etc. Dual relationships can also be created ‘through the
following: bartering for professional services, therapist self-disclosure, attending
clients’ social events, accepting gifts from or giving gifts to clients and touching
clients.
Dual relationships are pervasive and are often difficult to recognize and
avoid, especially when they are sequential. These relationships imply many risks.
For the professional therapist, these risks can include: damage to the therapeutic
relationship, loss of public confidence, violation of ethical codes, loss of credentials,
and potential litigation. For the client involved, there is a loss of trust, exploitation,
betrayal, confusion, anger, and a loss of therapeutic benefit. For other clients or
consumers, there is a loss of trust in and regard for the therapist’s professional
abilities. For the profession, there is a diminishing of credibility and prestige. For
the therapist’s professional colleagues, there is the difficult situation of having to
confront his or her unethical behavior (Herlihy & Corey, 1992).
Pope and Vetter (1992) found that dual relationships were among the four
most common ethical issues reported by psychologists. Epstein, et al. (1992)
surveyed psychiatrists and asked them to report on their behavior with patients
during the previous two years. Respondents reported the following incidences of
potential boundary violations and dual relationships: |) touching patients (besides
a handshake) (45%); 2) treating family members or persons known socially (32%);
3) having personal relationships with patients after termination (19%); and 4) self-
disclosing personal information to patients.
Whether dual relationships are a/ways harmful to the persons involved is
controversial (Herlihy & Corey, 1992; Pope & Vasquez, 1991). Harm in dual
relationships can often assume the form of some type of exploitation, although other
types of harm are possible, resulting from impaired therapist judgment, conflicts of
interest, ambiguous boundaries, and distortions in the relationship (Pope &
Vasquez, 1991).
Kitchener and Harding (1990) suggest that dual relationships may be
considered only when there are minimal risks for the individuals involved and when
there are also potentiallly greater benefits from this relationship. They suggest three
criteria for evaluating risks: 1) the degree that expectations are incompatible
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between the persons (the greater the incompatibility, the more potential risk), 2) the
discrepancy in responsibilities (the greater the discrepancy, the greater potential for
conflicts in loyalty and objectivity), and 3) the amount of power and status the
professional possesses (the more power and status, the more potential for harm).
The problem of dual relationships is complex, and there are often no simple
solutions, formulas, or pat answers obtainable from the codes of ethics. The
therapist’s level of self-awareness may be the most significant factor in finding the
appropriate solutions to these problems.
Social Relationships with Clients
There are many ways in which dual therapeutic-social relationships can be

established, such as: inviting clients to social events, accepting as clients individuals
with whom the therapist has had a previous social relationship, having coffee/meals
with clients after sessions, running into clients outside of therapy sessions,
accepting clients’ invitations to attend special events (e.g., graduations, weddings,
parties), or having any contact at all with clients outside of therapy session. Risks
of entering into social relationships with clients are always present, and may be
even more so for music therapists working in small communities.
Are social relationships with client inherently bad? The clarity in boundaries
between client and therapist is a major factor in helping to avoid dual relationships.
If therapists are ambiguous, clients will be even more so concerning the nature of
the therapeutic relationship. Because of the closeness inherent in therapy, clients
can sometimes view the therapist as a close friend, and attempt to involve him or
her in the social aspects of their lives. Painful feelings can result when this
involvement is refused by the therapist. Clarification of roles and expectations at the
beginning of therapy can help the therapist avoid these circumstances (Herlihy &
Corey, 1992).
Some theoretical orientations in treatment are inherently structured to
disallow dual social relationships, e.g., psychodynamic intervention, which
emphasizes the need for clear boundaries and the awareness of transference and
countertransference (Borys, 1988). Also, guidelines for social involvement with
clients may be viewed as more or less stringent depending on the client population
with whom the therapist works, as well as the setting. For example, music therapists
working with developmentally disabled children and their families may not feel it
inappropriate to be part of a social ritual honoring some developmental milestones
of the client. Music therapists working with the terminally ill in hospice care may
not deem it inappropriate to attend a client’s funeral. Music therapists working in
institutions may be required as part of their jobs to accompany clients in social
functions outside the institution. Music therapists working in small communities
cannot help but encounter clients or clients’ families in their neighborhoods or
churches. Music therapists working in private practice with couples may find it
validating to attend the renewal of marriage vows for a couple successfully
completing treatment. There are numerous examples. What is important to consider,
however, is the potential for these activities to change the nature of the therapeutic
129
relationship itself by creating a conflictual or competing relationship with the client.
Sexual Relationships with Clients: Sexual Exploitation
Sexual exploitation of clients and the establishment of dual sexual-

therapeutic roles can assume a number of names, e.g., sexual misconduct, sexual
boundary violations, undue familiarity, etc. For purposes of this chapter, sexual
exploitation is defined as the “manipulation or coercion of vulnerable persons by
professionals in whom they have put their trust, resulting in sexual relationships; or
any sexual activity between a professional and someone with whom she or he has
a professional relationship” (Ragsdale, 1996, p. xi). Whereas sexual exploitation
involves any type of erotic contact (i.e., touching body parts directly or through
clothes, nudity, kissing, etc.), it can also involve sexual conversations, expression
of sexual fantasies, gestures and sexual gazes, provocative dress, nonverbal
behavior, seductive behavior, etc. for purposes of meeting the therapist’s needs
rather than the client’s (Pope, Sonne & Holroyd, 1993).
Sexual exploitation is differentiated from sexual harassment, which is
defined by the U.S. government as “‘(t)he use of one’s authority or power, either
explicitly or implicitly, to coerce another into unwanted sexual relations or to
punish another for his or her refusal; or the creation of an intimidating, hostile or
offensive working environment through verbal or physical conduct of a sexual
nature” (Ragsdale, 1996, p. xxii). For purposes of this text, sexual harassment is
used to denote inappropriate sexual demands, suggestions, behavior, etc. from one
who is in power to another in a subordinate position. This can involve professional
colleagues, faculty and students, supervisors and supervisees, employers and
employees, etc. This topic is discussed further in Chapter 10.
Sexual exploitation of clients is one of the most serious ethical issues. The
damage done to clients can be immense, as the therapist violates the core ethical
principle of maleficence. “Exploitation” is indeed the correct term for this
phenomenon, as the therapist takes advantage of the client’s vulnerability and trust,
and uses the power the of therapeutic role to satisfy his or her emotional and
physical needs.
Understanding the profound consequences to clients can help with
prevention (Herlihy & Corey, 1992). Pope (1988) terms this harm, the “‘therapist-
patient sex syndrome,” with characteristics similar to other types of abuse and
posttraumatic stress disorders. These include: “ambivalence, guilt, emptiness and
isolation, identity/boundary/role confusion, sexual confusion, impaired ability to
trust, emotional lability, suppressed rage, cognitive dysfunction, and increased
suicidal risk” (Herlihy & Corey, 1992, p. 23). An earlier study found that 90% of
patients who had become sexually involved with their therapists had experienced
harm from the experience (Bouthoutsos, 1983). Therapist-patient sexual
exploitation has been associated with the following problems in clients:
posttraumatic stress disorder, exacerbation of an eating disorder,(Schoener &
Gonsiorek, 1988), difficulties in marital/family relationships, loss of trust in
professionals, and increased hospitalizations for psychiatric reasons (Collins, et al,
130
1978).
There are numerous consequences to this type of violation for the
professional as well, including: loss of professional credentials, loss of membership
in the professional organization, loss of employment, and court action, both civil
and criminal (Vasquez & Kitchener, 1988). Supervisors of trainees who engage in
these violations can also be held accountable (Austin, Moline & Williams, 1990,
cited in Herlihy & Corey, 1992).
Prevalence. The prevalence of sexual exploitation of clients by therapists

has been the topic of several early studies (Gartrell, et al., 1986; Holroyd and
Brodsky, 1977; Kardener et al., 1973; Perry, 1976; Pope & Bouhoutsos, 1986).
These results revealed that from 5.5 to 13.7% of male therapists admitted to having
had sexual contact with clients. Women therapists reported this contact about three
times less often than their male counterparts. More recently, this percentage has
declined somewhat; only 0.5% of responding psychiatrists, psychologists and social
workers admitted engaging in sexual activity with current clients, and 3.9% with
former clients (Borys and Pope, 1989). Although these results appear encouraging,
the relatively high rate of nonresponse could imply a much higher rate of violation,
as nonresponders may be less inclined to admit to sexual exploitation, given the
current trends in litigation for this activity (Cited in Epstein, 1994).
Further studies reveal that therapists often begin to break boundaries
gradually with clients, e.g., through self-disclosure, gift exchange, and meetings
after hours, before sexual contact actually takes place (Simon, 1989; Epstein, 1994).
Characteristics of Therapists Who Sexually Exploit. As the literature on

this serious topic is large, there have been numerous attempts to describe
characteristics of therapists who exploit their clients. It is clear that most violators
are male. Beyond that factor, various authors have categorized perpetrators in
various ways.
According to some authors (Brodsky, 1989; Gabbard, 1989; Strean, 1993;
Sussman, 1992; Twemlow & Gabbard, 1989), the typical therapist who sexually
exploits clients is a middle-aged male about 15 years older than his victim. He is
dissatisfied with and unsuccessful in his romantic and personal relationships with
women, and he maintains sexual involvements with several clients simultaneously.
This therapist tends to establish other dual relationships with clients (e.g., business,
social), and frequently crosses boundaries with self-disclosure. In addition, the
therapist is often very isolated from colleagues.
Therapists who engage in erotic contact with their clients are also quite
vulnerable and inept at dealing with their own emotional issues, They frequently
choose to share their problems with clients and, in a sense, engage in role reversal
(Smith, 1989). These therapists can be seen as “wounded healers” in that they look
to their clients to meet their needs of feeling loved and whole (Gabbard, 1989;
Marmor, 1976; Rutter, 1989; Sussman, 1992).
Epstein (1994) discusses therapist risk factors associated with sexual
exploitation: the therapist attributes his or her own need for love as that of the
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client; the therapist believes that love can cure the client’s problems; and his or her
zeal to assist the client is translated into romantic energy.
Golden (in Schafer, 1990) identified three classifications of therapists who
exploit clients sexually: 1) those who are unaware of ethical mandates, 2) those who
are aware of mandates, but who are compelled towards receiving the romantic
benefits of dua! relationships, and 3) sociopaths who are aware of the mandates and
who deliberately violate them.
Schoener and Gonsiorek (1988) and Gonsiorek (1995) classify the
pathologies of therapist-perpetrators according to six categories. 1) Naive therapists,
who are uninformed about ethical standards and boundaries, and have problems
with discerning the nature of the professional relationship. 2) Neurotic therapists,
who are aware of ethical mandates, and who may involved in limited sexual
contacts with clients due to personal stress. They typically end these relationships
deliberately, show remorse for these actions, and actively seek help. 3) Severely
neurotic therapists, who have chronic and deep psychological issues, and may
experience depression, impaired self-concept, and isolation. Emotional boundaries
in their therapeutic relationships are incoherent and trespassed. They may
experience remorse for their behavior, but they do not have the capacity to end the
relationship, and may rationalize or deny their responsibilities. 4) Therapists with
character disorders and impulse control issues have chronic disturbances,
inadequate judgment, and may have experienced litigation initiated by clients. Often
they commit a number of offenses; they respond remorsefully when their behavior
is uncovered, but are not able to appreciate the serious consequences of their
actions. 5) Therapists with sociopathic or narcissistic character disorders are similar
to the previous category, but are more skillful in their behavior and more removed
emotionally. They are successful in manipulating others to avoid discovery. 6)
Therapists who are psychotic or borderline exhibit inadequate judgment and contact
with reality.7) Therapists who are classic sex offenders engage in repeated contact
with children and/or adults, In spite of rehabilitation, the context of therapy may
needlessly put their clients at risk, and they should not be allowed to continue to
practice. 8) Medically disabled therapists, who may sexually exploit clients because
of a medical problem. (There are two salient subcategories of these therapists: a)
therapists who are neurologically impaired and who may exhibit inappropriate
judgment and impulse control which may contribute to sexual exploitation. Because
of their age and status, their behaviors may not be questioned by colleagues and
may escalate in severity; and b) therapists with bipolar disorder who may be without
boundaries during a manic phase and engage in sex with clients).9) Finally,
therapists with masochistic or self-defeating behavior may outwardly appear to be
workaholics, however, they are incapable of setting boundaries with clients. Often,
they will exhibit other self-defeating behaviors, such as not being paid by clients,
and not taking appropriate care of themselves.
Finally, Pope and Bouhoustos (1986) present the ten most familiar scenarios
for therapist-patient sexual exploitation: 1) A patient-therapist role reversal exists,
and the needs of the therapist becomes paramount. 2) The therapist uses sexual
intimacy as a treatment for the client’s problems. 3) The therapist regards the
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transference as unrelated to treatment. 4) The therapist encourages the client to be

over-dependent. 5) The therapist employs drugs or alcohol as part of the seduction
ritual. 6) The therapist forces him or herself on the client and/or may threaten or
intimidate. 7) The therapist frames the sexual exploitation as true love. 8) The
therapist does not treat the emotional intimacy of the relationship with sufficient
care and responsibility. 9) The therapist ignores the boundaries of the relationship
in terms of time and place. 10) The therapist takes advantage of the client’s needs
for physical closeness.
Typical Reactions to Sexual Feelings. Therapists’ sexual feelings towards

clients have been considered a taboo topic. Although these sexual feelings are quite
common occurrences, therapists have not been forthcoming in recognizing,
acknowledging and creating opportunities to work through these feelings. To avert
acting out on these feelings, therapists need a safe, nonjudgmental context in which
these can be addressed.
Therapists can experience a number of reactions to their sexual feelings
towards clients. Pope, et al. (1993) have identified an extensive list of these
reactions. |) The therapist may experience surprise or shock, with a corresponding
impulse to either blame the client or escape from the therapeutic relationship. 2)
Because of the taboo against sexual feelings towards clients, therapists may
experience a great deal of guilt. 3) Therapists may experience anxiety concerning
their existing personal issues as well as increased vulnerability. 4) Therapists may
feel as if they are losing control of the situation, as if they are incompetent
therapists, and that they can potentially harm the client. 5) Therapists can fear
‘criticism and rejection. 6) Therapists can experience a great deal of frustration in
not being able to address their sexual feelings directly with the client, or in not
being able to act on their feelings (even when committed to not doing so), 7)
Therapists can feel confusion over the needed tasks of treatment, and their roles and
boundaries (characterized by an obsessive preoccupation with the client, a shift in
emphasis from the client’s needs to their own, and the erosion of therapeutic
boundaries. 8) Therapists can experience confusion concerning their own or client’s
actions (which may involve misinterpretations of the client’s behavior). 9)
Therapists can feel anger with themselves and with the client’s sexuality (which can
be extremely damaging to the therapeutic relationship). 10) Therapists may
experience fear in not meeting the sexual demands of the client (e.g., the client may
feel rejected, unattractive, or may be self-destructive).
When therapists’ reactions to their sexual feelings goes unacknowledged and
unaddressed, a number of damaging results can occur. Pope, et al. (1993) discuss
the clues that may indicate that something is wrong within the therapeutic
relationship: 1) The therapist may treat the client in a dehumanized manner (e.g.,
as just a diagnosis) or dehumanize him or herself (e.g., through excessive
intellectualization). 2) The therapist avoids contact with the client, misses sessions,
or plans to terminate the relationship. 3) The therapist becomes obsessed with
thoughts of the client, fantasizes about the client during sexual activities with
others, and makes “telling” mistakes and slips. 4) The therapist affords the client
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extra, special treatment. 5) The therapist attempts to isolate the client from his or
her personal relationships for various reasons (e.g., jealousy, to create over-
dependency, to manipulate the client’s feelings, or to avoid potential discovery). 6).
The therapist isolates him or herself from colleagues and friends. 7) The therapist
imposes a bond of secrecy on the client concerning therapy. 8) The therapist
searches for blanket reassurances from other professionals. And/or 9) the therapist
is bored, sleepy or lacking concentration during sessions with the client (to avoid
his or her distressing feelings or impulses).
Dealing with Problems. Pope, et al. (1993) state: “...1n any and all
circumstances, the therapist must never engage in sexual intimacies with the patient,
and it is the therapist who always bears sole responsibility for ensuring that this
fundamental prohibition is never violated (p. 100). Sexual exploitation of clients is
never permitted under any circumstances. There is never any justification for this
behavior no matter how much mutual consent is present, how demanding the client
is, or how intense the therapist’s feelings may be. It is never the fault of the client.
With this unwavering mandate aside, it is necessary for therapists’ sexual
feelings to be adequately acknowledged and addressed. In doing this, it is important
to differentiate feelings from behavior: sexual contact with client’s can never occur,
but sexual feelings can be openly shared and resolved. Unfortunately, the few
therapists who have violated this mandate have rendered the discussion of sexual
feelings dangerous for those who would never transgress a sexual boundary.
Therapists can thus feel very alone, guilty, confused and frustrated by these feelings
(Pope, et al.,1993). As Coale (1998) states, “(t)he vast majority of us should be
made aware as part of our training and ongoing supervision and consultation that
we afe ail potentially vulnerable, in the right combination of circumstances, to act
out our own issues (either sexually or otherwise) in our.relationships with clients.
This means being totally free to own and discuss sexual and other feelings for and
fantasies about clients with colleagues, supervisors and teachers” (p. 91).
In acknowledging and exploring sexual feelings for clients, therapists may
learn a great deal about themselves, about the client and about the therapeutic
relationship. Failing to admit these feelings, on the other hand, will render any self-
exploration incomplete, and possibly jeopardize the client (Pope, et al., 1993).
It is important for therapists to also acknowledge and come to terms with
the inevitable frustration of their sexual feelings towards clients, as this can grow
and become dangerous if unaddressed. A big price is paid for acting ethically, and
the therapist cannot downplay the amount of fortitude needed to resist unethical
behavior, as this may lead to his or her yielding to temptation. In a similar manner,
when therapists are not at risk for acting out sexually with the client, the failure to
acknowledge these frustrations can lead the therapist to act out these reactions with
the client or significant others in his or her life. “Denial of or discounting the
feelings resulting from blocked attraction, desire or arousal can result in anger,
bitterness, hostility, or self-pity that the therapist may find surprising and difficult
to understand” (Pope, et al., 1993, p. 92).
The exploration of sexual feelings towards clients should be an important
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aspect of the academic and clinical experiences of music therapists in training as

well as of continuing education experiences for professionals. ‘“(W)here sexual
attraction to patients and other sexual feelings are concerned, it is crucial to avoid
avoidance” (Pope, et al., 1993, p. 8). This exploration is most effectively done in
classrooms, in individual and group supervision settings, in peer supervision and in
consultation. The atmosphere created must be one of support, safety, and
nonjudgment (Pope et al., 1993).
Several authors have offered additional guidelines for dealing with sexual
attraction towards clients. Edelwich and Brodsky (1982) have suggested the
following: 1) It is important to acknowledge feelings and to separate the therapist’s
feelings from those of the client; 2) The therapist should refrain from taking on the
client’s problems personally and should not ask the client to take on his or hers. 3)
The therapist should be open to confiding in trusted others and have the courage to
confront the issues involved directly. 4) The therapist must avoid rejecting the client
and should also be able to express caring in a nonsexual fashion. 5) The therapist
should avoid unnecessary self-disclosure. 6) The therapist should realize that
reactions to clients are common and avoid denial or repression. 7) Therapists must
accept that feelings are not actions, and avoiding unethical sexual behavior is a
mandate.
Collins (1989) adds that the therapist should avoid unnecessary physical
contact with the client and engage only in that contact that could be done under
public scrutiny. Sexual behavior on the part of the client should be dealt with as a
therapeutic, not personal, issue.
: Should the therapist discuss his or her sexual feelings with the client
involved? In rare cases, this may be appropriate, but it is always risky. The therapist
needs special skills to do this, it must be in the client’s best interest to do so, and at
all costs, it must not be interpreted by the client as an attempt at seduction (Collins,
1989; Pope, et al., 1993). Alternately, the therapist should work through these
feelings in supervision or consultation.
Even when therapists use their available resources for dealing with these
issues (€.g., introspection, supervision, consultation, study, personal therapy), they
may still confront an impasse, where the proposed plan for action is potentially
harmful to him, her, or the client, and not implementing the plan may be equally
damaging. Under these circumstances, Pope et al., (1993) suggest that the therapist
evaluate the plan of action using the following considerations and questions: First,
having sex with the client is not an option. Second, is a “slippery slope” being
created? Does this plan pave the way for more dangerous behaviors to occur at a
later time? Third, has the therapist consistently communicated the ground rules of
therapy to the client regarding sexual behavior? Fourth, can the plan be delayed
until there is a clarification of the sexual issues involved? Fifth, is the plan in
accordance with what is best for the client’s welfare? Sixth, is the plan in
accordance with the informed consent provided to the client? Seventh, how will the
client understand and react to and feel about the plan? Eighth, does the therapist
have the required competence to implement the plan? Ninth, is the plan consistent
with the therapist’s normal repertoire of behavior and therapeutic approach? Tenth,
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is there a reason not to consult with another concerning this plan? Is there a hidden
cause for this reluctance? Is the consultant chosen appropriate?
Legal Aspects. Therapists are among the professional groups who serve as
fiduciaries to their clients, i.e., persons in whom trust is placed. Because there is
power for the therapist inherent in this relationship, therapists must uphold higher
standards of practice and work only towards the best interests of those they help.
Sexual exploitation is a breach of the fiduciary responsibility, as many clients are
seriously harmed by this (Jorgenson, 1995).
Sexual contact between clients and therapists is forbidden by professional
associations. Moreover, therapists who sexually exploit have been judged liable for
damages courts of law. Therapists may be prosecuted on civil and/or criminal
charges.
Therapists may be accused of negligence/malpractice in these cases. Even
if the therapist claims that the sexual contact was consensual, courts have not
considered this a valid defense against these charges, as the proper standard of care
was breached. Reversal of therapist-client roles and other types of dual relationships
(business, social, etc.) may also constitute a breach of care in courts of law (Simon,
1991). .
Thus, dual relationships, especially with regard to sexual exploitation,
represents an area where ethical standards and the law converge. Besides violating
ethical standards, therapists can likely be prosecuted by law.
The Use of Touch in Therapy
Touch is a controversial topic, as it can be associated with the loss of

therapeutic boundaries, dual relationships and sexual exploitation. The use of touch
in therapy is considered by some to be a stepping stone down the slippery slope of
sexual misconduct (Pope, 1988). It is further argued by some that touch can enhance
dependency and can be misinterpreted by clients (Corey, et al., 1998). On the other
hand, touch can be an important part of the therapeutic process, and a means to
express genuine care for the client.
The use of touch is not addressed, per se, in the music therapy codes of
ethics, although it is strongly discouraged by the American Psychological
Association regardless of the therapist’s intentions, client’s needs or its role within
psychotherapy. If nothing further, touch is suspect (Coale, 1998).
Touch is a “touchy” topic for discussion, but perhaps less so than sexual
exploitation. “Yet the risk of not talking about these things....is that the therapist has
no reality check other than himself and his clients to ensure that he is using/or not
using touch in an appropriate manner. Denial, concealment, and making taboo the
issues of touch, sexual feelings and fantasies increases the risks to both therapists
and clients” (Coale, 1998, p.92).
Aside from the use of touch as a prelude to inappropriate sexual contact,
there appear to be no clear guidelines about the appropriateness of touch in music
therapy. Obviously, the use of touch varies according to the age group and clinical
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population with whom the music therapist works. In addition, the use of touch can
vary with the clinical music therapy technique used. Policies within facilities also
vary from strict “never touch” client policies to no policies at all.
Appropriate types of touch in music therapy mat or may not include the
following: the playing of instruments by client and therapist (where the therapist
prompts the client to play in a hand-over-hand method, for example), the Bonny
Method of Guided Imagery and Music (where touch is used to ground the patient
following a particularly intense session), or hugs at the end of sessions.
Touch between client and therapist may be contraindicated in psychiatric or
prison settings, but may be a necessary component of treatment in other settings,
such as in work with the physically disabled. The use of touch appears to be more
acceptable in work with children, the elderly, and some medical patients who rely
on touch to feel connections to others (Coale, 1998), but less than acceptable or
controversial in work with adolescents, adults, abuse victims, etc. Also, the use of
touch may be defined by the gender and culture of clients, for example, women
clients may have a propensity towards touching, and certain ethnic groups, such as
Mediterranean cultures, may use touch extensively in interpersonal relationships.
Other cultures may avoid its use.
Touch should never be used with clients who do not want to be touched and
who would feel invaded by it. It is also contraindicated for clients who could
misconstrue its purpose as sexual (Coale, 1998).
Touch should not be used by therapists who experience discomfort with it,
even when so requested by the client. A less than genuine response will occur
otherwise, and this is readily obvious to clients. “Rather than force a nongenuine
“ response, it is far better for the therapist to tell her client that his need is valid but
tnat she is unable or uncomfortable in responding to it in the way he has requested.
Out of this conversation, other ways of responding to the client’s need can then be
negotiated” (Coale, 1998, p. 93).
Also, the gender of the client and therapist as well as the context of therapy
are also relevant factors in the use of touch. Even though the use of touch may be
appropriate and needed by the client, and the therapist comfortable with its use, it
may be contraindicated for an adult client and therapist of different sexes. The
meaning of the touch could change (Coale, 1998). Touching may be more
appropriate in groups where it can be witnessed by others (Corey, et al., 1998).
When touching is used in therapy, clients should be informed beforehand,
and their reactions sought. Touching can sometimes produce opposite effects, such
as distracting clients from their current feelings. Therapists must assess their own
reasons for wanting to touch the client as well as the client’s readiness for this, the
client’s cultural background, the level of trust established, and the effect on the
client (Corey, et al., 1998).
Therapists must be free and comfortable in embarking upon the discussion
of touch with other colleagues without fear of judgment or recrimination. “It is in
openness, not secretiveness, that ethical thinking and behavior occur” (Coale, 1998,
p. 94).
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Accepting Gifts
Accepting gifts from clients can create the semblance of a dual relationship,
and thus this topic is considered in this chapter. As mentioned in Chapter 1,
accepting gifts from clients is an ethical problem that can only be solved by a
consideration of the circumstances in which it occurs (Steinman, et al., 1998). It is
difficult to generate hard and fast ethical rules that will apply to all circumstances.
There are indeed, however, specific factors to consider in making this decision.
The price/value of the gift is one factor to consider, but certainly not the
only one (Borys, 1988; Herlihy & Corey, 1992). Is there a magic price beyond
which a gift is considered too costly? (Stein, 1990). It would be difficult for a
therapist to arbitrarily make this determination. If price alone were the
consideration, then it would seem acceptable for therapists to accept handmade gifts
from clients or gifts of minimal monetary value. Even these types of gifts are not
without ethical consequences, and other factors need to be taken into account.
The nature of the gift to the music therapist is a second consideration (Stein,
1990). Is the gift a monetary one, or one that implies some monetary gain (such as
a stock tip), one that involves a service from the client (such as lawn-mowing), an
intangible gift (such as prayers), etc.? The type of gift must be considered in making
a decision concerning its acceptability. Remembering that the music therapist is
already compensated for his or her work with the client, and no additional
compensation is appropriate through gifts, however tempting the gift may seem and
however well deserved it may be by the therapist.
A third consideration is the intended beneficiary of the gift. Gifts can be for
the personal benefit of the therapist, for the benefit of other clients (such as musical
instruments or tickets to a concert), or for the benefit of the facility in which the
therapist works (a building improvement, a cash donation or memorial fund in a
client’s name). Again, the person(s) or institution who will benefit from the gift
needs to be assessed, with more or fewer ethical implications depending on the
circumstances.
A fourth factor and perhaps the most significant is the motivation of the
client. Gifts can be given for any number of reasons, e.g., in appreciation for work
done well, as a way to gain particulars favors from the music therapist (e.g., extra
sessions, special attention, and/or continuance of treatment when this is
contraindicated), or as an attempt to manipulate the therapist and/or treatment. All
of these motivations contain ethical issues, and the following are questions to
consider: Does accepting the gift have implications for the future client-therapist
relationship? Is the therapist compromised in making future decisions regarding the
client? Are the therapist’s ethics compromised in any way? Are false expectations
being created? Will the therapist feel obligated to pay back to the client in any way?
(Stein, 1990).
An honest and open discussion with the client concerning the implications
of accepting gifts and of the therapist’s reactions to doing so may be needed when
gifts are offered. Flatly refusing gifts, especially those offered as tokens of
appreciation can sometimes be hurtful to clients (Herlihy & Corey, 1992).
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To avoid these difficult situations, some therapists make it a policy with

clients not to accept gifts, and clients are so advised at the beginning of treatment
(Herlihy & Corey, 1992). It is also essential to understand the ethical implications
of receiving gifts before the situation arises, as it will be too late after the fact
(Stein, 1990).
Ina similar manner, due care must be exercised when a therapist chooses to
give a gift to a client. The four considerations mentioned above may also be applied
in making ethical decisions about this issue. Most importantly, the motivation/needs
of the therapist in giving gifts must be examined, with a careful scrutiny of the
implications of the gift for the therapeutic relationship.
Therapist’s Self Disclosure
The use of self-disclosure by the music therapist in treatment will vary

according to his or her theoretical orientation. Self-disclosure is an issue included
here because of its potential to change the nature of the therapeutic relationship. Not
all self-disclosure is seen as ethically problematic. However, there are a number of
issues (content and otherwise) to be considered in its use.
Clients engage music therapy services because they need help with their
lives, not because they need to listen to the therapist’s own problems! Thus, the
purpose of the use of self-disclosure is one that must be assessed before it is used.
Is self-disclosure being used for the therapist’s benefit or the client’s? The therapist
must honestly evaluate this goal, as it is easy to distort intent when the therapist is
not self-aware. Even when addressing the client’s needs is the therapist’s goal, the
client may respond uncomfortably, and the therapist must be sensitive to the client’s
\
reactions. Self-disclosure, when used, must be well-timed and relevant (Herlihy &
Corey, 1992).
The content of self-disclosure is another consideration. Sometimes, clients
may benefit from hearing the therapist’s reactions to them and their music, how he
or she is responding to the relationship with the client, etc. These may be
appropriate types of self-disclosure, 1) if the client is poised to receive this
information, 2) if the therapist shares these reactions thoughtfully and sensitively,
and 3) if they are relevant to the therapeutic process at the moment. Self-disclosure
is only a part of the process, and not a goal in and of itself (Herlihy & Corey, 1992).
Epstein (1994) classifies the content of self-disclosure as 1) indicated, 2)
risky, and 3) contraindicated. Indicated types of self-disclosure include details of
the therapist’s training, clinical orientation, and treatment methods. Also, self-
disclosure may be appropriately indicated in the discussion of the details that may
impinge upon the client’s decision regarding treatment or those that may be
necessary to clarify a client’s anxious distortions. Risky self-disclosures include
the discussion of items concerning the therapist’s personal life, especially when this
discussion is not for the immediate benefit of the client (e.g., to impress the client,
to gain his or her sympathy, etc.). Contraindicated disclosures involve those
concerning the therapist’s problems, issues, relationships, and conflicts.
The use of self-disclosure can easily violate boundaries. Role reversal can
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occur, and the client can be subtly (or not so subtly) drawn into the role of the
therapist and care-giver. Again, the therapist must be acutely self-aware of his or
her own needs, and not use the client to take care of these needs.
Another risk in the use of self-disclosure is that it can appear as advice-
giving by the therapist, who may use his or her own experience to tell the client how
he or she solved a particular issue. This obviously can threaten the client’s
autonomy, make the client very uncomfortable, and put unneeded pressure on the
client to conform to what was right for the therapist. It can never be assumed that
the solution to the therapist’s problems is the right one for the client.
Lastly, sometimes it is the client who asks the therapist to disclose personal
aspects of his or her life. In these situations, it is important for the therapist to
openly discuss with the client his or her motivations for asking this information.
The therapist always reserves the right to make the ultimate decision about these
disclosures after determining if this information is indeed helpful to the client, if it
is irrelevant, or if it can cause an unwelcome shift in the relationship.
The Setting for Therapy
The setting for therapy should be considered as a potential problem in

boundary violations and dual relationships. This is of particular significance when
music therapists establish music therapy offices in their homes. Although this
practice is not necessarily unethical per se, it is replete with problems, one of which
is the potential! for creating conflictual relationships (Herlihy & Corey, 1992). Other
issues regarding the setting for therapy have been discussed in Chapter S.
- Clients who see the music therapist at his or her home are often privy to the
deta‘ls of the therapist’s personal life and lifestyle. There are several implications
to this knowledge. First, the client gets to know the therapist (and possibly the
therapist’s family) on a more intimate, personal level than when therapy takes place
in a neutral setting. Because of this knowledge, the client can come to make
inaccurate assumptions about the nature of the relationship, i.e., that it is a social
one. Second, because the client is received into the therapist’s home, the climate for
therapy can inadvertently become more social in nature. The seriousness of the
work that transpires can be compromised.
Dual Professional Relationships: Bartering
Bartering involves exchanging a client’s goods or services for therapy, and

this may be viewed as an alternative by the client who is unable to pay for therapy
services. This form of exchange is common among some cultures and in some
(often rural) communities.
Bartering implies the creation of a professional dual relationship. In
bartering, the therapist assumes the role of the client’s employer (i.e., the client
essentially works for him or her) in addition to the therapeutic relationship.
Bartering is ethically questionable both for financial as well as dual
relationships reasons. The value of goods or services is usually questionable and
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cannot be easily equated with therapeutic services. When there is a difficulty with
the goods or services, e.g., if they are not satisfactory to the therapist, a financial
conflict is introduced into the therapy relationship, and the relationship can be
seriously disrupted (Peterson, 1996). The therapist may in fact expect better than
average services from the client (Pope & Vasquez, 1991). Conversely, when the
value of the goods or services is more than the value of the therapy services, the
client can easily be exploited.
Bartering can be particularly problematic when the therapist uses the client’s
services for personal matters, such as house painting, car repair, etc. In these
situations, there is also the possibility of the client having access to personal details
of and becoming involved in the therapist’s life, which can lead to a dual social
relationship.
Therapists may suggest alternatives to bartering arrangements for clients
who are unable to pay the usual fees for services. These can include the use of a
sliding scale for fees based on the client’s income, or as a last resort, referral to
another therapist (see Chapter 9).
Although bartering is considered an unethical or questionable practice at
best, therapists, because of the cultural context in which they work, may need to
consider the use of bartering as an option for payment. In doing so, they need to
consider the following: 1) the potential impairment of judgment or impact on the
therapist’s performance the bartering may create, 2) the determination of the value
of the goods or services clearly and openly with the client, 3) the amount of time
involved in the agreement, 4) documentation of what transpires, the value of the
goods or services, and a date on which the agreement will end (Hall, 1996).
Fost-Therapy Dual Relationships
Does the music therapy relationship end with the termination of treatment?
And what social, business, or sexual relationships with clients are possible after that
time? Clients or therapists can sometimes entertain the idea that because of the
closeness that has been established, they will remain part of each other’s lives once
therapy has ended. It is not unusual for clients and therapists to grow to appreciate
each other as human beings, and to want to continue involvement with each other
following therapy. In small communities, social contact both during and following
treatment is sometimes unavoidable (Herlihy & Corey, 1992).
Social relationships following therapy should be avoided. Progress made in
treatment may be threatened when a social relationship is added. In doing this, the
therapist closes off all possibilities for the re-establishment of a therapeutic
relationship in the future, should the client need intervention. And it may well be
that the client needs a therapist more than another friend.
As Herlihy and Corey (1992) state,““(O)nce someone has terminated his or
her ...relationship with us, our contract to help them ends. No one would suggest
that because we have once seen a person in therapy we have a lifelong obligation
to help them. But it is equally implausible to suggest that just because our contract
has ended we ought willfully to engage in activities that will undo the benefits that
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have accrued from our services” (p. 146).

Pope (1993) in a review of the literature, suggests that approximately 10%
of therapists reported engaging in sexual relationships with former clients. Codes
of ethics vary on this topic. For example, the APA Ethical Principles and Code of
Conduct (1992) mandates a two-year period of time after therapy is terminated
before the therapist may establish a sexual relationship with a former client (cited
in Pryzwansky & Wendt, 1999). No such guidelines are provided in the music
therapy codes of ethics.
However, even when sexual relations with former clients are permitted
following the mandated waiting period, various professional organizations agree
that it is incumbent upon the therapist to assure that no exploitation exists. Other
factors that need to be assessed include: the amount of time since termination
occurred, the type and length of treatment, the factors surrounding termination
(coercion, deception), the client’s history, the client’s mental status, who terminated
the relationships and for what reasons (e.g., to initiate a sexual relationship), who
initiated the contact following therapy, and the possibility of harm to the client
Difficulties abound in therapists’ dual relationships with clients following
treatment. Transference does not end when treatment stops, and the change in the
relationship could cause harm years after. Also, clients who experience difficulties
are prevented from returning to the therapist they trusted (Pryzwansky & Wendt,
1999). In addition, in some jurisdictions these relationships are illegal.
Once having served as a therapist, some obligations remain. Because the
therapist has special knowledge of the client, this factor will influence the nature of
their relationship even subsequent to treatment. The client is free to choose to have
no further therapeutic contact, and the therapist is restrained from pursuing social
contacts (Collins, 1989).
Guidelines for Dual Relationships
Cohen and Cohen (1999) offer several criteria for assessing the potential
problems of dual relationships: 1) the potential loss of the client’s and/or therapist’s
autonomy and judgment; 2) the adverse effects of the relationship, and 3) the
possible misuse of confidential information. In addition, Herlihy and Corey (1992)
offer a model for decision-making regarding the ethics of dual relationship. When
dual relationships are unavoidable, informed consent should be secured from the
client, consultation should be sought, details of the relationship should be
documented and self-monitored, and supervision should be undertaken. When dual
relationships are avoidable, their risks and benefits should be assessed. If the risks
outweigh the benefits, the relationship should be avoided. If the benefits outweigh
the risks, the aforementioned steps (informed consent, etc.) should be utilized.
Collins (1989) makes specific recommendations for dealing with dual
relationships as follows: 1) if the therapist must rely upon institutional policy to
dissuade dual relationships with clients, then his or her countertransferences should
be subject to review; 2) the use of self-disclosure and the sharing of the therapist’s
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experiences, when needed and appropriate, should be drawn from past rather than
present issues; 3) new developments in the therapeutic relationship that the therapist
would like to keep secret are cause for alarm and should be subject to supervision;
4) the information one gains from a therapeutic relationship cannot be erased in any
future relationship with the client; and 5) job satisfaction and gratification should
be derived in large part from the self and from colleagues. Relying solely on
patients for this can cause problems.
Epstein (1994) also suggests that four basic principles be provided to
patients at the beginning of treatment:
1. Your mind and body belong to you. No one (not even I, your therapist)
is allowed to take liberties in this regard. 2. The sole purpose of this
treatment is to foster your health. Its purpose is not my gratification. 3.
There is an enormous difference between feelings and actions. It is possible
to have strong desires and not act on them. There are other ways of handling
such feelings without being swept away by them. 4. Our relationship is
solely for your treatment, and regardless of any emotions either of us might
experience, it must never lead to a direct life involvement like that between
friends, acquaintances, relatives or romantic partners (p. 206).
Chapter Summary
1. Boundaries help in defining the self as separate from others. Individuals with a
poor sense of boundaries have difficulties in relationships with others and are often
unable to discern their own thoughts, feelings and needs.
2. Appropriate boundaries are an important component of a healthy therapeutic

process. Therapists must have an awareness of their own boundary needs and issues
before attempting to negotiate boundaries with a client. Healthy boundaries are both
flexible and consistent at the same time. Setting boundaries with clients and at the
same time finding empathic connections with them may appear paradoxical,
however the quest for balance is significant in this process.
3. Boundary crossings refer to deviations from normal therapeutic practice and may
lead to boundary violations, behaviors and practices which detract from the purpose
of therapy. Boundaries define how the therapist’s power is used within the
relationship. When boundaries are overly-expanded or overly-constricted, the client
is in danger of exploitation, and a reversal of client-therapist roles is likely. Both
external limits and internal boundaries can contribute to a safe environment for the
client.
4, Dual relationships involve the establishment of a second role with the client,
either personal or professional, at the same time or sequentially. Dual relationships
imply risks for the therapist, client, public, and profession.
5. Opportunities for creating social relationships with clients abound and are often
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related to the theoretical orientation of the therapist, the client population served,
the clinical setting and the type of community in which music therapists live. Dual
social relationships have the potential to change the nature of the therapeutic
relationship.
6. Sexual exploitation involves the manipulation or coercion by therapists of their

vulnerable, trusting clients resulting in sexual activity. This is one of the most
serious types of ethical violations and can result in enormously damaging
consequences for both parties. Sexual exploitation unfortunately occurs more often
than one would imagine, and there are a number of classifications of therapists who
engage in this behavior. Therapists who sexually exploit clients are subject to
ethical as well as legal sanctions.
7. The use of touch in therapy is often both determined and limited by: the type and
age of the client, gender, culture, and need, as well as the therapist’s comfort with
touching and his or her motivation and self-awareness. Touch can be a first step
towards inappropriate sexual activity, and its intent can be misinterpreted by clients.
Touch is a particularly powerful and healing intervention, however, precaution must
be exercised in its use.
8.Accepting gifts from clients can contribute to the establishment of dual

relationships. In considering whether or not to accept gifts, therapists should
consider: 1) the value of the gift, 2) the nature of the gift, 3) the intended
beneficiary, and 4) the motivation of the client.
9. S2lf-disclosure by the therapist should be used cautiously and always with the
’ client’s (not the therapist’s) needs in mind. The timing, content and motivation of
the self-disclosure are important considerations.
10. Therapists who provide treatment in their homes must be careful to avoid the
creation of dual relationships.
11. Bartering clients’ goods or services in exchange for therapy presents several
ethical and financial problems, and should be avoided whenever possible.
12. Dual relationships (social, business and sexual) with former clients should be
avoided as they are potentially harmful to the client for a number of reasons.
Therapists can use procedures to actively avoid dual relationships, and to assess
their risks if they are unavoidable.
Ethical Dilemmas
1. Celine, a music therapist working at a large psychiatric hospital often visits

clients during weekends and non-working hours to check on them and to make sure
they are okay.
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2. Bruce, a music therapist working in a community mental health center has a very
good relationship with Michael, an adult male client suffering from depression.
Michael requests that Bruce visit his home occasionally, not only for social reasons,
but also for “minimal” therapy.
3. Sharon, a music therapist at a facility for the developmentally disabled, often

brings clients, especially those with no families, to her home for holiday dinners.
She uses these opportunities to both reward the clients and also to teach them social
Skills in a normalized environment.
4, Julia works as a music therapist with substance abuse clients. Frank, one of her
clients is quite persistent in asking her questions about her personal life, marital
status, previous boyfriends, salary, etc.
5. Barry is a music therapist in private practice. He works with Misty, a

developmentally delayed client. Misty’s single mother, Karen, accompanies her to
all the sessions. Barry and Karen have much in common, and Barry decides to ask
Karen out on a date.
6. Paul works as a music therapist in a medical setting. Mindy, one of Paul’s former
girlfriends with whom he has had a sexual relationship becomes a patient on the
unit where Paul works.
7, Lauren works in an extended care facility. One of her clients is Ruth, a woman
-who is in deteriorating physical and mental health. Lauren has established a very
close, empathic relationship with Ruth. Ruth asks Lauren to assume the duties of
her power of attorney and manage her financial assets. Ruth trusts none of her
family members to do this.
8. Dianne, a music therapist working at a psychiatric facility attends a dinner party

with her friends. Upon arrival, she notices a former client also at the party.
9. Cecilia, a psychiatric music therapist, and Roland, her husband, are enjoying
dinner at a nice restaurant. Cecilia notices Bert, one of her former clients, having
dinner alone at the restaurant. Bert comes to their table, sits down, and proceeds
to tell Cecilia the details of his life since his discharge from the psychiatric hospital.
10. Jason works in private practice in a small midwestern community, and is the
only music therapist for miles around. Rev. Masterson, the minister at Jason’s
church, makes an appointment with Jason to deal with his issues of stress and
depression.
11. Jason, from the situation above, needs a new lawn mower. Randall, one of his
clients owns a hardware store, and Randall’s store is the only place in town to buy
a lawnmower. Jason is considering going to the next big town (40 miles away) to
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purchase one, but he is afraid that he will offend Randall.
12. Jason, from the situation above, is married and has an 11 year old daughter,
Nancy. Nancy comes home from school one day with her new friend, Jessica.
Nancy asks Jason ifJessica can stay for dinner, and Jason agrees. Jessica’s mother
comes to the door after dinner to pick up Jessica, and Jason realizes that she is one
of his new clients.
13. Penny, a music therapist working at a psychiatric facility in a small town has
been working with Wally, a client with substance abuse and psychiatric problems.
She has met Wally’s wife, Monica, who visits him regularly, although she travels
a substantial distance to do so. As the time grows closer for Wally to be discharged,
Monica tells Penny that she has just purchased a home closer to the hospital, so
that Wally can attend A.A. meetings and also continue his treatment on an
outpatient basis. As Monica continues to tell Penny about her new house, Penny has
the awkward realization that Monica has purchased the house right next door to
her.
14. Arthur, a music therapist at a facility for the developmentally disabled, receives
a hand-made Christmas gift from one of his young clients, Suzie.
15. Roger, a music therapist working in a school for autistic children, has made
considerable progress with Darrell, which has far exceeded all of his family’s
expectation. Darrell’s family is extremely appreciative for Roger’s work, and
present him with a substantial check. In addition, because they own a car
dealership in the community, they offer Roger the opportunity to purchase a car at
any time at their cost. Roger, is a struggling music therapist, and desperately needs
a new car.
16. Jolene, a music therapist, works with Melissa, a young woman who has
experienced abuse and rejection from her schizophrenic mother. Melissa buys
Jolene a beautiful silver necklace for Christmas, with a note that reads: “I hope you
will accept and enjoy this gift and think of me when you wear it. Iknow you won't
refuse and dislike my gifts like my mother always did.”
17. Jonathon, a music therapist in private practice works in an office building in

which there are a number of other complementary therapist practitioners. Belinda,
a massage therapist, is one of those professionals. She would like to begin music
therapy with Jonathon to deal with her relationship issues, but because her business
has been very slow, she cannot afford it. She asks Jonathon ifshe can provide him
and his parents with massage therapy in exchange for music therapy sessions.
18. Gay is a music therapist working at an extended care facility. One of her clients,
Bertrand, has Huntington’s Chorea, and frequently elopes from the facility. Bert is
a large man, and often puts up a struggle with staff. On this particular day, Bert has
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again eloped. He refuses to return to the facility unless Gay drives him back in her
own car. The staff knows that Bert means what he says, and Bert is only a few
blocks away from the facility.
19. Marilyn, a music therapist in private GIM practice is working with Sam. She
begins the GIM induction, and instructs Sam to tense and relax various muscle
groups. As she instructs Sam to focus on the muscles of his hips and buttocks, she
notices that he has become sexually aroused.
20. Tony, a music therapist working at a facility for children, has Jerome on his lap,
and they are playing the drum together. Jerome loves to play instruments, and
reaches for one after the other. As Jerome moves around on his lap, Tony notices
that he is becoming sexually aroused.
21. Davis works as a music therapist in an acute psychiatric setting, and Madge is
one of his new clients who suffers from depression and suicidal ideation. During a
music therapy improvisation session, Madge tells Davis that she had a sexual
relationship with her former music therapist.
22. Joe, a music therapist in private practice, enters the waiting room to meet his
new client, Cheryl. Joe stops dead in his tracks when he sees her. She is a dead
ringer for Heather Locklear, the woman of his fantasies. As he begins to interview
Cheryl, his mind races, and he cannot stop thinking about how it would be to go out
with her, have a relationship with her, etc. etc. He is trying to think of a way to stop
- this therapeutic relationship before it begins. He knows he cannot see her socially
or be involved with her romantically ifhe agrees to be her therapist.
N.B. The author apologizes profusely for this obvious self-indulgence.
23. Ted, a music therapist, and his girlfriend, Patty are enjoying a particularly
romantic evening sitting on a blanket on the beach, drinking Pina Coladas, and
watching the sun set. Tonight is the night that Ted intends to ask Patty to marry him.
As he leans over to take the ring out of his pocket, he begins to speak.
Unfortunately, the name “Patty” does not come out of his mouth. Rather, he says,
“Maureen,” the name of one of his clients.
24. Frank, a music therapist working at a facility for substance abuse, has weekly
group music therapy sessions. At the end of the sessions, which are often quite
intense, he encourages his clients to go around the room and hug each other, as a
gesture of support. He gives each client a hug as well. Verna, a new client, gives
Frank along hug and doesn't quite let go. At the next group session, Verna sits next
to Frank, in the circle, and makes suggestive remarks.
1. Discuss with classmates your feelings about the following:

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*self-disclosure to clients, e.g., telling a client you are angry with him or
her.
*establishing social relationships with clients during or after therapy.
*bartering with clients who can’t afford music therapy services.
*accepting gifts from clients
Do you think music therapists should engage in these behaviors, and how might
they influence the therapy process?
2. Discuss with your peers the client populations for whom touch might be an
important aspect of therapy, and for whom it might present risks.
3. In your course journal, reflect upon your own needs for touching as a therapist,
and your comfort or discomfort in touching clients.
4. Complete the following self-assessment checklist, circling those feelings or

actions that might be relevant to you as a therapist (adapted from Epstein, Simon
and Kay, 1992, pp. 150-166 and Menninger and Holzman 1973, pp. 91-92).
* Recurrent feelings of affection towards clients ©

* Reticence to deal with clients who act out
* Laxness in dealing with clients who don’t pay their fees, cancel sessions or extend
their length
* Attempts to impress the patient with personal information about yourself
* Attempts to impress your peers abcut a client’s special characteristics
* Tardiness in beginning therapy sessions
* Permitting sessions to go overtime when there is not a pressing need to do so
* Unnecessarily reassuring clients to relieve your own anxiety
* Drowsiness during sessions
* Fears about clients’ discontinuing therapy
* Inclinations to ask clients for personal favors
* A need to argue your point with clients and to impose your viewpoint
* Being a therapist to your family members or friends
* Your experiences of gratification with your power in controlling clients
* Feelings of excitement or longing when you think about a client.
* Openness to seductive behavior from a client as a sign of your own sexual
attractiveness
* Disclosing sensational aspects of your clients’ lives to others (even when
maintaining their anonymity)
* Making exceptions to clients’ treatment because you feel sorry for them, because
they are so distressed/disturbed that you have no other option, or because
you are afraid they will become angry or self-destructive
* Telling a client about your personal problems with an expectation of empathy
from him or her.
Reflect on your reasons for any of the feelings or behaviors you checked
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above. Discuss these reasons with a peer, faculty member, or supervisor.
5. In your course journal, reflect upon your boundaries as a therapist. What issues
can you identify that might be helpful or problematic to you in the future? Explore
how you might work through potential problems.
6. Pick a topic from this chapter that is of particular interest to you. Do a literature
search and write a short paper summarizing your findings.
MULTICULTURAL AND
GENDER PERSPECTIVES
e
Ftice can be defined in many ways. Broadly speaking, culture refers to
those beliefs, actions and behaviors associated with: sex, age, location of residence,
educational, status, socioeconomic status, history, formal and informal affiliations,
nationality, ethnic group, language, race, religion, disability, illness, developmental
handicaps, lifestyle, and sexual orientation (Cohen & Cohen, 1999; Corey, et al.,
1998; Ivey, Ivey, & Simek-Morgan, 1993; Pedersen, 1994). Culture ultimately
represents the many ways that people adjust to their environments (Das, 1995) as
influenced by these variables. Cultural influences are both obvious and subtle.
When culture is defined broadly as above, then it can be assumed that
cultural issues are present with a// client in all settings. Moreover, the unique
interplay of these variables within each client, makes his or her relationship to the
environment unique and in need of special consideration. Thus, a// clients bring to
music therapy a blend of cultural factors, and can be considered multicultural.
Further, a// music therapy work can be considered multicultural. The term,
“multicultural,” as used in this chapter refers to the blend of cultural factors within
an individual that influences his or her relationship with and adjustment to the
environment. Multicultural issues become significant when the individual must
relate or adjust to an environment in which his or her cultural issues are not shared,
acknowledged, or understood by others.
It is important to understand that the client’s unique blend ofcultural issues
influences all aspects of music therapy treatment. How the client (and family)
conceptualizes both his or her problem as well as treatment is an essential
consideration in the therapy process.
In addition, the music therapist 1s influenced by his or her own blend of
cultural issues with regard to music therapy treatment. An important ethical
implication, thus, is the therapist’s self-awareness of these issues when working
with all types of clients.
Problems arise when the music therapist works with clients whose cultural
variables are significantly different than his or her own. Special skills in
understanding, in accepting, and in working with these clients are needed. A
therapist’s self-awareness is needed to understand how his or her own cultural
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issues (i.e., being culture bound) may possible inhibit client understanding and
acceptance. Special awareness of the potential for ethnocentrism, the propensity for
viewing others according to one’s own values, is essential. Ethnocentric therapists,
when approaching conflicts in cultural values, generally assume that their values are
the better or correct values.
Multicultural work implies issues of meaning for both clients and therapists.
In order for music therapy to be effective, therapists must understand and accept the
individual meaning of both the client’s problems and of therapy to him or her. The
implications of these meanings are broad and impact upon all interactions between
the client and therapist, as well as all music therapy approaches and techniques
used.
However broadly or narrowly the reader chooses to define culture, it is
essential to realize that even though it is possible to learn and understand both
general and specific cultural characteristics, each person within a culture remains
to be discovered and understood as an individual, with a unique blend of these
variables. Furthermore, it is not enough to understand clients’ multicultural issues
from “our” perspectives, but according to “their” realities and ways of knowing
(Ballou, 1990).
Obviously, when all music therapy treatment is conceptualized as
multicultural work, there are numerous treatment issues involved which are above
and beyond the scope of this chapter (which is by necessity focused on ethical
issues). However, the issues of clients’ needs and therapists’ competence in working
multiculturally are indeed primary ethical issues. A number of these topics will be
discussed as a starting point for ethical thinking. In addition, some concrete
information regarding clients’ needs and therapist competence in this area is
presented according to obvious cultural variables, specifically ethnic, race,
language, and nationality issues. A// potential cultural issues (as defined above),
both obvious and subtle, are not addressed herein. However, a sensitivity to,
awareness of and acceptance of these many client and therapist issues is
emphasized.
Need
Clients receiving music therapy in the United States can most often be
described as “multicultural.” Even with the exclusion of nationality, racial, and
ethnic cultures (and these are indeed ubiquitous), cultures created by age, gender,
disability and socioeconomic factors, to mention a few, create the need for music
therapists to develop an awareness and understanding of their clients’ special needs
and vulnerabilities. When nationality, racial, language, ethnic and other cultural
factors are superimposed as considerations, the need for client understanding and
awareness becomes even more acute.
Multiculturalism is a reality in working as a music therapist in the United
States, and can be more or less so for music therapists working in other countries.
Multicultural issues are present for music therapists working in relatively
homogeneous, small communities (where more subtle cultural issues may come into
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play), as well as in large urban areas with diverse populations (where more obvious
cultural issues may be involved).
Things are moving quickly and evolving in our societies, as demographics
continue to change. It is anticipated in both the short and long term that there will
be shifts in the composition of minority cultures, with Hispanics, Asians, and others
comprising the largest numbers in these categories. The implications for music
therapists and for music therapy treatment are enormous.
The Present Problem
Multicultural theories seem to imply “that psychological services may be for

the people but not of or by the people they ascribe to serve” (Malley & Reilly, 1999,
p. 107). As the predominant psychological theories utilized in psychology (and to
some extent in music therapy) stem from western European/American male culture
(Malley & Reilly, 1999), one wonders how relevant these theories are and will
continue to be.
“Western psychological structures value the individual, assertiveness,
nonconformity, competition, freedom, individual responsibility, expression
of feelings, innovation, and individualized morality. Non-Western
psychological structures, on the other hand, may emphasize the primacy of
relationships, compliance, conformity, cooperation, security, collective
responsibility, control of feelings, conservatism and morality” (Malley &
Reilly, 1999, pp. 107-108.).
As conceptualizations of wellness in therapy are based on these structures, major

conflicts become apparent. For example, the Western/American perspective
emphasizes “rugged individualism” (Das, 1995), whereas non-Western structures
emphasize collectivism. Applying Western/American standards to an Asian client,
for example, may result in the labeling of his decision to avoid shame to his family
as lacking autonomy or assertiveness. Obviously, these cultural values cannot be
ignored in therapy (Cohen & Cohen, 1999).
These Western/American values are present as well in client assessment and
diagnosis, and as such determine the criteria for judgments concerning the presence
of pathology. It cannot be ignored that cultural factors are implicated in the
formation of personality and in the manifestation of psychological problems, as well
as in the manner in which clients seek out help for these problems. The
Western/American criteria used in assessing pathology thus may be considered
inappropriate for use with various multicultural groups; behaviors stemming from
multicultural beliefs and values are likely not to be recognized as being culturally
appropriate, and may be misdiagnosed as pathological.
Gender issues are also of concern using the Western/American approach to
treatment, which has emphasized the male characteristics of assertiveness over the
female characteristics of nurturance, caring and emotional expression (Cohen &
Cohen, 1999).
Sue and Sue (1990) have suggested that traditional therapy interventions for
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minority clients are often ineffective. These authors found that one-half of minority
clients leave treatment after the first session. They also found negative stereotypes
of minority cultures common among therapists.
There may be other reasons for the ineffectiveness of therapy for
multicultural clients. Besides the most basic fact that the underlying theoretical
models used in treatment may often be irrelevant or contrary to cultural assumptions
regarding health and illness, these models may emphasize goals or forms of
treatment that are contradictory to established cultural behaviors. In addition, there
are various conceptualizations of psychological problems attributable to culture. A
number of cultural groups view emotional problems as physical in nature and
believe that these problems can be overcome by will and positive thinking.
Therapists may also be unaware of their biases towards, lack of sensitivity
to and stereotypes of multicultural groups with whom they work. Often
multicultural clients have experienced some type of discrimination or oppression
from the mainstream society, and these issues are brought to the therapy situation.
When the therapist further reinforces these issues with clients and is not sensitive
to the power inherent in his or her role, it is impossible for trusting relationships to
develop, as the therapist represents for them more of the same problem and not the
solution.
It is also difficult for trust to develop when the therapist is unable to
understand and appreciate the client’s unique values and worldview. Some of these
values directly relate to attitudes towards therapy. For example, clients of some
cultures (e.g., Hispanic) rely on themselves and family members to solve
difficulties. Therapy may be the last rather than the first option. The role of the
therapist also varies according to cultural expectations. For some Asian cultures, the
therapist is expected to be an advising “expert,” whereas in work with women, the
therapist may more adequately function in a partnership role.
It is difficult to establish ethical standards that are relevant and appropriate
to multicultural therapy (Glass, 1998). As Pedersen and Marsella (1982) so
accurately state, “A serious moral vacuum exists in the delivery of cross-cultural
counseling and therapy services because the values of a dominant culture have been
imposed on the culturally different consumer. Cultural differences complicate the
definition of guidelines even for the conscientious and well-intentioned counselor
and therapist (p. 498).”
The problem is not solved by referring the client to another music therapist,
one whose cultural background is more consistent with the client’s culture. As this
is rarely possible in many music therapy situations, it is not a realistic option. Nor
is the problem solved by warning the therapist against being prejudiced, as this
implies that the therapist will be adequately self-aware to detect all possible and
subtle demonstrations of prejudice. “Furthermore, it ignores the reality that the
ethics code itself, in the process of defining what constitutes correct, appropriate,
and ethical behavior, reflects normative values characteristic of the dominant
culture” (Glass, 1998, p. 119).
The ethical implications of working with multicultural clients are clear and
involve two primary issues. The first concerns the protection of clients’ rights.
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Clients of various cultures are often more vulnerable and have been oppressed (and
this oppression may often bring them to therapy). They require special protection
because of this vulnerability. Failure to address diversity issues is an infringement
upon clients’ rights and autonomy. Power issues in treatment need to be carefully
monitored.
The second involves the competence of the therapist. Working with
multicultural clients requires increased self-awareness concerning potential biases,
as well as multicultural awareness. Therapists must also have a clear recognition of
the limitations of their skills, and actively pursue additional education and training
to achieve competence (Bass, 1996). Both of these factors relate to the
establishment of effective therapeutic relationships which is the overriding ethical
principle involved.
The music therapy profession is gradually realizing the importance and
significance of addressing the issues involved in work with multicultural clients,
and the music therapy literature reflects a growing interest in multicultural issues
and in multicultural training. Troppozada (1995) surveyed 500 music therapists to
examine their opinions on the need for multicultural training in music therapy.
Results revealed that the vast majority of music therapists take the client’s culture
into account when selecting music for use in therapy, and 78.2% indicate the need
for multicultural training. Similarly, Darrow & Molloy (1998) examined clinical
practices, educational curricula and the music therapy literature in an attempt to
identify the current status of their concern with multicultural issues. The authors
found that multicultural education is generally provided to students through general
education courses and electives. Many respondents felt that their educational
background was not sufficient in this area, and they (75%) had acquired their
knowledge through their own experience. The authors also found that greater
attention is being given to multicultural issues at music therapy conferences.
Moreno (1988) has continually emphasized the need for multicultural
training within the music therapy curriculum. Bradt (1997) has described some of
the ethical issues in multicultural music therapy, and Flores (1966), Hanks (1992),
Henderson (1991), Moreno (1966), have all studied multicultural influences on
music therapy practice.
The Standards of Practice of the National Association for Music Therapy,
Inc. (1988) state that “All music therapy assessment methods shall be appropriate
for the client’s chronological age, functioning level, and cultural background” (p.
9). NAMT defines culture as involving those factors related to the “client’s
geographical origin, language, religion, and family experience” (p.14).
The Essential Competencies for the Practice of Music Therapy of the
American Association for Music Therapy (Bruscia, Hesser & Boxill, 1981) require
“Understanding of the elemental, structural and stylistic characteristics of classical
and popular music from various periods and cultures” (p. 4). The Advanced
Competencies of the American Association for Music Therapy further require “In-
depth understanding of different musical cultures and sub-cultures, and their
implications for music therapy” (Bruscia, 1986, p. 63). In addition, the Professional
Competencies of the National Association for Music Therapy (1996) require that
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music therapy students: a) “identify the elemental, structural and stylistic

characteristics of music from various periods and cultures” (p. 1), b) “select, design
and implement effective culturally based methods for assessing the client’s assets
and problems through music...c) Select design and implement effective culturally
based methods for assessing the client’s musical preferences and level of musical
functioning or developmentand ” d) “Develop and maintain a repertoire of music for
age, culture and stylistic differences” (pp.3- 4).
It is interesting to note that a survey of recently registered music therapists
in 1995 revealed that at least 38% had not learned the first competency mentioned
above. Further, it was reported that 53% of newly registered therapists had not
learned the second competency, 56% had not learned the third competency cited
above, and 47% had not acquired the fourth competency during their academic
training (NAMT Subcommittee on Professional Competencies, 1996).
Skills
Several authors in fields related to music therapy have provided lists of the
specific knowledge and skills required to work with multicultural clients. These
competencies are also relevant to music therapists.
According to the American Psychological Association (APA,1993b),
therapists involved in multicultural therapy need: 1) an awareness of cultural
diversity; 2) an understanding of the part that culture (in its broadest sense) plays
in the psychological and economic development of these individuals; 3) an
awareness of the relationship between socioeconomic and political factors and
psychosocial development in various cultures; 4) an understanding of the need for
clients to be aware of, maintain, and come to terms with their culture identities; and
5) an understanding of the interconnection between culture, gender, sexual lifestyle
and individual’s needs and actions (cited in Bass, 1996). These guidelines also
recommend therapists’ self-awareness to ascertain the role of their own cultural
backgrounds, biases, etc., in the ways they approach clients. Therapists are thus
asked to continuously question whether their approaches are congruent with the
ways they treat clients from cultures similar to their own. The guidelines also stress
the need to acknowledge the roles of the client’s family, community, values and
beliefs as these relate to culture.
Sue, Arredondo, and McDavis (1992) contend that therapists with
multicultural competence should demonstrate the following: 1) a sensitivity to the
culture of clients and its impact on their lives; 2) a comfort in working with people
from diverse cultures and a respect for their differences; 3) an awareness of their
own biases which originate within their own culture and the impact of these on their
work; 4) a knowledge of the cultural and familial structures of their clients and the
barriers they encounter; 5) the willingness to seek consultation when needed; 6)
knowledge of the research; and 7) good verbal and nonverbal communication skills.
Further, Sue and Sue (1990) recommend the development of therapeutic approaches
that can accommodate the needs of culturally diverse clients.
Corey, et al., 1998 stress that therapists must refrain from using their own
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cultural beliefs as reference points for culturally diverse clients. Within cultures as
well, therapists must be sensitive to imposing their own experiences on others.
Herr (1991) challenges therapists to come to terms with some of following
issues: 1) the integration of Western and Eastern approaches to treatment; 2) ways
to become familiar with various worldviews; 3) methods to assist multicultural
clients in learning about mainstream cultural norms without substituting these for
their own; 4) ways to help majority clients deal with their cultural biases and racist
issues and learn more about minorities; 5) ways to assist minority therapists in
becoming aware of their own prejudices; and 5) methods to promote effective
multicultural treatment when client and therapist are from divergent cultures.
Sue (1996) states that becoming multiculturally competent is a long-term
endeavor requiring continuing training. Realizing that it is impossible to acquire an
in-depth knowledge of all cultures, it is very important for the therapist to be aware
of the limitations in his or her knowledge and skills, addressing these through
referral, consultation and additional education.
In addition to all of these recommendations, music therapists must also
cultivate an awareness of, sensitivity to and acceptance of the diverse musical styles
and idioms clients bring to therapy. As connections to the client are often first made
through his or her own music, it is expected that with multicultural clients, this will
also be the case. However different, unappealing or foreign this music may appear
to the music therapist, he or she must realize that the openness to entering into the
client’s musical expression will serve to establish the initial components of a
trusting relationship. Understanding the personal and unique meaning of the music
for each client is an additional necessity.
To accomplish this, the music therapist must: 1) develop an intellectual
understanding and knowledge of music from various cultures; 2) understand the
context of music within various cultures; 3) understand the musical healing
traditions of diverse cultures; 4) acquire experiential learning of various musical
traditions; and 5) acquire sufficient musical skill to be able to participate in and
structure these musical experiences for clients.
Characteristics of Ethnic Groups
Major differences between cultures can be categorized according to their

emphasis on individualistic versus collectivistic values. Corey, et al., (1998)
attribute these differences to Western versus Eastern assumptions, however, these
assumptions may go beyond geographic location. Whereas mainstream North
America and parts of Europe may adhere to Western (individualistic) values,
Eastern (collectivistic) values may also be assumed by Hispanic, Native American,
African Americans, Asian (Corey, et al., 1998) and feminist cultures. For purposes
of identifying some fundamental differences between these cultural value systems,
the present discussion will classify these differences as either “individualistic” or
“collectivistic.”
Individualistic values emphasize the role of the uniqueness of the individual
who functions independently and who 1s responsible for him or herself as well as
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his or her own needs. To accomplish goals, the individual may need to exercise
assertiveness and compete with others; conflict is an anticipated part of this process.
The individual strives for freedom and participates as an individual democratically.
He or she need not conform to others’ wishes if these are in conflict with his or her
own needs to self-actualize. The energy and power of youth is valued (Corey, et al.,
1998; Ho, 1985).
On the other hand, collectivistic values emphasize the primacy of the group,
relationships within the group and the interdependence of all within the group.
Group members’ first responsibilities are to the group and the group’s needs.
Working together in harmony and cooperation is needed to achieve group
actualization and security for its members. Compliance, conformity, cooperation
and uniformity are essential components of the group process. Deference to
authority, especially to figures who are older and wiser, is required (Corey, et al.,
1998; Ho, 1985).
It is strongly noted that the intention of this classification is not to perpetuate
stereotypes among various cultural groups. Rather, it is meant to expose some of the
concrete differences in values, thinking and beliefs that may exist among certain
cultures. It is strongly emphasized again that each person within a culture is an
individual with a blend of many cultural factors, and must always be approached as
such rather than through any artificial or over-generalized “category” system. It is
also stressed that the designations of “Asian,” “Hispanic,” etc. are indeed overly
broad, as these are not homogeneous cultures. Rather they are comprised of
heterogeneous groups, each having a unique language, history and culture (Leong,
1992) (e.g., Chinese, Vietnamese, Japanese, Korean, etc.; and Spanish, Argentinian,
Mexican, Cuban, etc.).
Information for this classification is taken from a variety of authors:
Attneave, 1985; Brammer, 1985; Corey, et al., 1998; Devore, 1985; Henkin, 1985;
Ho, 1985; Itai & McRae, 1994; Ivey, 1988; Ivey, et al., 1993; Ridley, 1984; Sue &
Sue, 1985; Sue & Sue, 1990; Sue & Sue, 1991. Characteristics of individualistic and
collectivistic worldviews and examples of cultural groups to which these
characteristics may apply are presented in Table A.
TABLE A
INDIVIDUALISTIC COLLECTIVISTIC CULTURE
Relationships with
Family
Nuclear structure Extended family structure

Communication via roles
or status Chinese
Respect of parents/
Obedience Chinese
Japanese
FS
Career Orientation
Academic Achievement Chinese
Career development Chinese
Emotional Communication
Some openness in Control of feelings Asian

expressing feelings Emotional Harmony Asian
Avoiding loss of face Asian
Express only with family Chinese
Issues in Therapy
Relationships formed Relationships formed Asian

quickly slowly Hispanics
Native Am.
Discuss problems easily Speak when spoken to Asian

Hispanics
Native Am.
Family/friends first resource Asian

Hispanic, etc.
Healing occurs within family Native Am.

& community context
May not react well to “talk” African Am.

therapy Asian
Use of probing, personal Probing is Offensive and Many cultural

questions invasive Groups
Relationships develop
through silence Native Am.
Vertical Relationships Egalitarian Relationships Women
Locus of control-internal Locus of control-external Women

Oppressed
Cultures
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ee
Communication Issues
Direct eye contact Direct eye contact implies

lack of respect Asians
Native Am.
Agressiveness-sexuality Native Am.
Physical gestures Physical gestures

may be intrusive
Direct eye contact when Direct eye contact when

listening, less while speaking; less while
speaking listening African Am.
Directness Indirectness Japanese

Nonverbal communication
Silence is uncomfortable Excessive talking is impolite Japanese
Moderate speech Rapid speech, varied vocal Hispanic

Some vocal tone with tone
emotionality
Slight incline facing person Sit side by side Eskimo, Inuit
Handshakes common Handshake-sexual intent Eskimo, Inuit
Conversational distance 6-12" conversational Arab, Mid-

arm’s length distance Eastern
Structured, linear view Casual view of time South

of time; prompt American
Precision of written word _—_ Oral traditions African
Identity Development
An awareness of one’s identity as a member of a particular culture may be

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an important consideration for both clients and for the music therapists who work
with them. Models which illuminate the developmental stages of the acquisition of
identity in persons who represent minority cultures add to this awareness.
One model of identity development (i.e., for African-Americans) is briefly
presented in this section as an example of the ways that cultural awareness grows
and develops. This development is described according to five stages, with a brief
description of how the stages are manifested in therapy. This theoretical model was
developed by Jackson (1975) and Jackson & Hardiman (1983) (cited in Ivey, et al.,
1993). Components of this model may also be relevant to identity development in
other cultures.
Stage 1) Naivete. The black individual is unaware of his color asa
distinguishing feature, as is common in children.
Stage 2) Acceptance. The individual is defined by the “other” as being “‘non-
white.” Identity is formed as a reaction against being white rather than as an
embracing of being black. The individual is cooperative and subservient to his or
her white therapist. Acceptance can be passive or active in nature.
Stage 3) Resistance and Naming. The individual experiences an important
transformation and acknowledges and names his African-American identity as such.
He or she faces the implications of being black in a white society, and may turn
away from white culture as he or she reflects on African American history. Anger
may be experienced, and the individual may prefer to work with an African-
American therapist.
Stage 4) Redefinition and Reflection. Awareness of the meaning of being
an African-American continues to evolve, and a secure African-American
consciousness is established.
Stage 5) Multiperspective Internalization. The African-American person
emerges with pride in him or herself and also a respect for and awareness of others.
Both positive and negative aspects of the predominant culture are assessed; the
individual is prepared to oppose aspects contributing to African-American
oppression. The individual is able to utilize a multitude of perspectives in looking
at and interpreting his or her world.
Jackson (1975) and Jackson & Hardiman (1983) contend that this model
provides two essential principles for working with African-American clients in
therapy. The first principle involves the need to ascertain the client’s worldview and
offer a treatment approach consistent with this. The second principle involves
gaining an understanding of the development of the client’s evolution as related to
those around him or her and society at large. When societal oppression is a reality
for the client, he or she may fluctuate among denial, acceptance and action,
depending on which most readily facilitates survival and well-being.
The authors also stress that this model is relevant to specific developmental
tasks, and the individual may return to earlier stages of development as new tasks
emerge.
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Models of Treatment
Two models of treatment that address issues in multicultural therapy are

presented in this section. Those included are feminist therapy and conscientiza¢ao,
the development of critical consciousness according to the stages of identity
development. What is implicit in both of these models is the focus on issues of
cultural oppression and the need for the client to view him or herself within his or
her own cultural context.
Feminist Therapy. Traditional theoretical approaches to therapy, as

discussed above, may contain sexist assumptions about women. Countering these
presumed male-dominated theories, the feminist approach to therapy embraces
several essential components: 1) external factors are considered the source of the
female client’s difficulties, 2) therapy occurs within an egalitarian relationship
between client and therapist, and 3) the client’s strengths as well as weakness are
emphasized (Ballou & Gabalac, 1984). The “self-in-relation” is an essential
construct in therapy. Relationship implies mutual understanding, thus the self is
formed, exists and manifests itself only within the context of relationships. The self
consequently requires another person for fulfillment, and a goal in treatment is to
move from this dependency to interdependency (as opposed to independence)
(Miller, 1991). The responsibility for change is seen as a balance between the client
and environment (Ballou & Gabalac, 1984).
The major themes in feminist therapy are provided by Ballou & Gabalac
(1984) as follows:
1. Egalitarian relationship. The client and therapist work as partners in
therapy, and thus the power of traditional therapy relationships is diminished. The
therapist uses self-disclosure of her own personal experiences as a woman as a
significant component of treatment.
2. Community resources. As therapy does not end with the session, clients
are actively referred to a number of resources and services in the community,
including support groups and legal aid.
3. An active, participatory counseling style. This involves the stimulation
of client insight and the use of confrontation when needed. The therapist’s stance
is one of caring and support which is used to help the client progress in independent
thinking. Techniques, such as as assertiveness training, are used within the feminist
therapy framework.
4. Information giving. Education is an important part of feminist therapy,
which includes providing information to the client relevant to sexism, the impact
of culture, etc. Education is used to foster awareness of the manner that clients have
been conditioned by society to react in specific ways.
5. Personal validation. Clients are validated for their worth as valuable and
unique individuals by the therapist. The client’s oppressive environment may have
precluded an adequate self-assessment of her worth.
6. Modifications of traditional theories. Traditional theoretical approaches
to therapy are modified and shaped to become more sensitive to multicultural and
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gender issues,
Conscientizagdo: The development of critical consciousness. Working

with cultural groups who have been oppressed involves the need to help them
experience themselves and understand themselves from a socicultural perspective.
Conscientizagao (Freire, 1972), or the development of critical consciousness, is
considered a metagoal of treatment, allowing clients to be freed from sel f-blame and
to accurately view themselves in relation to others and to their cultures.
Ivey, atal., (1993) use the stages of cultural identity development (Jackson,
1975; Jackson & Hardiman, 1983) presented in the previous section to develop a
treatment approach that can facilitate the client’s acquisition of a critical
consciousness (conscientizagao).
Some of the stages of this treatment model are as follows (Ivey, et al., 1993):
Acceptance: The therapist thoughtfully attends to the client’s situation and
helps the client make connections to his or her cultural experience. As the goal of
this stage 1s the development ofcritical awareness, practical help is provided, and
the reality of the situation is confronted.
Naming and resistance: The therapist uses active listening and empathy to
further confront issues in the client’s experience. The therapist may support the
client in the acquisition of more assertive behaviors and skills in anger management.
Attention to the client’s needs and feelings is a focus, realizing that their fulfillment
may involve an opposition to oppressive realities.
Reflection and redefinition. Anger towards society is often present, however
clients will often retreat to their cultures for reflection. Responsibility for self is
internalized, and the understanding of self is more important than action. The
therapist will often educate the client at this stage concerning cultural identity
theory to enhance the client’s reflection.
Multiperspective integration: The client alternates between anger,
acceptance and reflection at this stage, and in doing so, achieves a balance in
responsibility between internal and external factors. The client is able to use a
variety of reference points, and achieves a clear awareness ofthe impact ofculture
on his or her own situation. The therapist helps the clicnt to manage stress, to
acquire feedback from others, and to balance needed action.
As in all types of treatment, empathy is considered a critical intervention in
this treatment model. Empathy is given to the client, empathy is expressed
concerning the client’s development within his or her family, and empathy is shown
for his or her cultural heritage (Ivey, et al., 1993)..
Multicultural Group Work
As has been discussed throughout this chapter, working with multicultural

clients requires an enhanced sensitivity to and understanding of clients’ cultural
issues, as weil as the therapist’s self-awareness concerning his or her own culture
and potential attitudinal and value biases. Working with multicultural groups is no
different, and the issues involved can become even more complicated.
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Music therapists working with multicultural groups may be inclined to

assume that the traditional theoretical assumptions underlying group music therapy
are appropriate for all clients and can be used irrespective of the multicultural
characteristics of group members or therapists involved. However, multicultural
issues, as broadly defined at the beginning of this chapter, can exert an important
influence on the development of group process and cohesion, on interactions
between the therapist and group members, and on whether or not goals are achieved
(Lewis & Ford, 1991).
It can not be assumed that aspects of group process are equally valued
among members as they are by the therapist. For example, issues such as emotional
expression, conflict and confrontation, etc. are culturally determined. Music therapy
group leaders who belong to an individualistic culture, and trained according to
these parameters, can predetermine expectations for group members’ behaviors, and
these may be quite unrealistic for and opposed to those of the group members
themselves (Hurdle, 1991). As a result, group members often become nervous and
confused about what to expect and how these experiences can meet their needs. This
situation is exacerbated when the therapist is highly directive and probing of
reticent group members’ feelings. For the insensitive therapist, clients’ behaviors
can be attributed to resistance; for the vulnerable clients, the therapist’s behaviors
can appear invasive, disrespectful, and intrusive.
When groups are similar according to cultural characteristics and when
therapists belong to a different or dominant culture, cultural tensions can be
projected onto the leader, or the leadership of the therapist may be rejected by the
group because of feelings of not being understood. Also, within the group process
itself, “confrontation can be misrepresented as racially based and a form of
discrimination. Stereotyping, scapegoating, and polarization can easily occur”
(Hurdle, 1991, p. 66).
When groups are comprised of members from differing cultural
backgrounds, additional issues of bias and prejudice can emerge. Therapists can
facilitate a positive experience by first, understanding their own prejudices, and
second, by encouraging a frank discussion of group members’ attitudes and feelings
(Glass, 1998). Therapists must further serve as role models of respect and
acceptance of multicultural clients and have an awareness of the realities of the
clients’ experiences of belonging to a minority culture (Hurdle, 1991).
Therapy groups have the potential for allowing multicultural clients to
experience a reaffirming of their cultures, as well as their identities, power and
pride, and for providing the skills to move fluidly among various cultures. In fact,
given the current realities of society, these potential outcomes of group therapy may
become significant goals for this work in the future (Glass, 1998; Chau, 1991).
Hurdle (1991) also stresses other unique potentials of multicultural group therapy:
the facilitation of discussion concerning culturally based values and behaviors, and
the acquisition of skills in relating to members of different cultures. ‘““Multiethnic
groups become a laboratory for learning about cultural differences and human
similarities, as well as a forum to address personal life issues” (p. 59).
Thus, multicultural group therapy can help enhance both individual
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adjustment as well as cultural understanding. As group therapy is preferred to

individual treatment for multicultural clients (Henrie, 1993), and “(w)hen conducted
in a culturally relevant and respectful manner, there is nothing inherently alien in
group approaches that make them categorically inappropriate to any culture. Group
therapy with nonmajority cultures does not require radical alterations of general
principles of group process” (Glass, 1998, p. 122).
Music therapy group intervention, besides being the most common approach
in music therapy, is also one that requires particular attention when multicultural
clients are involved (and as stated previously, all music therapy work can be seen
as multicultural). Besides the considerations for group work offered in this section,
music therapists may have unique opportunities to contribute not only to the
individual well-being of group members, but also to their understanding and
acceptance of each other’s cultures through the medium of music. The sharing and
understanding of clients’ diverse musical expressions within a group can greatly
enhance cultural understanding and reinforce an acceptance of the uniqueness of the
individual. As shared musical experiences can inherently bring clients closer
together, the same results can be expected when clients share their diverse musical
idioms and styles with others. Thus, musical experiences can transcend cultural
differences when group members participate in a universal expression of their
humanness.
Music therapy, as a nonverbal communication tool, also allows for more
flexible participation within a group, permitting members to express their feelings
in ways other than through verbal means, which may indeed be inconsistent with
their cultural traditions. Music therapy group leaders are thus encouraged to be
models for multicultural acceptance, and to be flexible in adapting the music
therapy group techniques used for their multicultural clients.
Recommendations for Education and Training
Ponterotto (1988) has presented a model of identity development for white

therapy students. When confronted with multicultural issues, students may go
through the following stages:
1) Preexposure. The student may not have conceptualized therapy as
multicultural in nature and may be naive to its implications. For example, the
student may assume that there need be no differences in the ways clients are
approached, or may be unaware of his or her biased attitudes and behaviors.
2) Exposure. When exposed to information and issues concerning
multicultural phenomena, including oppression, the student realizes what she or he
doesn’t know, and is aware of potential deficiencies in his or her educational
background. The student may become confused and disturbed.
3) Zealotry and defensiveness. In realizing the many issues connected with
multiculturalism, the student may respond in one of two fashions: 1) he or she may
become indignant and engage in activist behavior, or 2) he or she may feel passively
defensive and further adhere to tenets of the dominant culture and therapeutic
traditions.
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4) Integration. The student gains a respect and appreciation of

multiculturalism, with knowledge of how these factors influence treatment. He or
she acknowledges the impossibility of knowing everything there is to know at one
time and identifies ways to acquire additional knowledge in the future.
With these stages in mind as a reference point, the quality and intensity of
education and training regarding multicultural phenomena can be considered both
significant and critical. A number of recommendations are proposed to ensure that
students receive adequate training in this area.
First of all, multicultural competencies need to be established by the music
therapy profession, both on entry and advanced levels to serve as guidelines for
education and training. These need to be integrated into the profession’s current
entry-level competencies and assessed by faculty, internship supervisors and the
CBMT.
Music therapy faculty and internship supervisors need to be culturally aware
and competent to teach/supervise in this area. This may necessitate special courses,
conference offerings, and continuing education programs designed for both these
groups as well as for practicing music therapists.
Information on multicultural issues should be integrated throughout the
music therapy undergraduate and graduate curricula. Music therapy courses should
contain special sections on how theories and techniques may be adapted to meet the
needs of multicultural clients. Both didactic and experiential learning strategies
should be used to convey this information. As a critical component of competence
in working with the culturally diverse involves self-awareness, students should be
given opportunities for self-exploration to identify and work through their own
cultural biases that may impede their work. Faculty are responsible for identifying
those students who lack the necessary self-awareness, who are unable to work
through their biases, or who are adamant in imposing their own cultural values on
their clients, as all of these factors may preclude their work with multicultural
groups.
Students should also have opportunities for practicum experiences with
diverse cultures whenever possible, and receive adequate supervision specifically
concerning these issues.
World and multicultural music courses should be required as part of the
music therapy curriculum. As stated previously, these courses should assist students
in understanding diverse musical idioms and the cultural and healing contexts in
which these occur through both lecture and experiences. Students should also
acquire the musical skills needed to participate in and structure these experiences
for clients.
Additional Recommendations
Besides the numerous recommendations offered throughout this chapter,

additional suggestions are provided for therapists engaged in multicultural therapy.
It is essential that therapists acquire self-awareness of their own cultural
heritages as well as all possible biases and prejudices. Therapy is not value-free;
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both the therapist and client bring their respective values into the therapy setting.
With multicultural clients, these values may be more or less difficult for the
therapist to understand and accept. It is important that music therapists come to
terms with this reality. It is only then that the therapist and client can create together
a value system for their work.
Ivey, et al. (1993) emphasize the need for a “dialectic coconstructivist
approach” (p. 129) between client and therapist which acknowledges the reality of
the influence they exert on each other. This approach has four basic premises. 1)
The client and therapist have separate and unique cultural backgrounds that
influence their perceptions and their respective “meanings” in therapy. 2) In
therapy, client and therapist influence each other and learn from the other; they
construct together their reality. 3) Therapist and client are influenced as well by
their links to their cultures. 4) Both client and therapist are not only bearers of
culture, but have the capacity to change and co-create culture within their
environment, and are in essence “a multiplicity of One” (p. 129).
Cohen and Cohen (1999) provide recommendations for the virtuous
therapist working in multicultural therapy. According to these authors, virtuous
therapists have unconditional positive regard and respect for clients of all cultures
and remain neutral so that the clients’ expression of values (even if very different
from those of the therapist) enhances his or her self-determination and autonomy.
Although the concept of autonomy may belong to the individualistic value system,
it is used here to refer to a therapeutic context in which the client can determine
independently the cultural aspects and values that he or she wishes to uphold, even
if they are indeed collectivist values.
These authors also provide six specific recommendations for multicultural
work: 1) Therapists should be vigilant to avoid creating a divisive situation between
varying cultural or religious beliefs of parents and children. 2) Children need
protection by the therapist when parental cultural views threaten their welfare. 3)
Clients’ levels of acculturation and assimilation need to be assessed. 4) Therapists
can provide support to client’s ethical decisions by exposing them to various ethical
perspectives. 5) Therapists should be cognizant of discriminatory practices that may
impact on clients, and work to minimize these effects. 6) Therapists must be aware
of the different definitions of family among cultures and the individuals included
in these definitions.
Finally, Henrie (1993) also offers a number of specific suggestions for
therapists involved in multicultural group work: 1). Therapists need to be informed
about various cultures but need not be experts on all cultures. It is more important
for them to express openness in learning about cultures from their clients.2) Goals
for group work should be articulated according to cultural needs. 3) Clients should
be informed as to ways to use the group most effectively. 4) More structure and
therapist involvement within the group is preferred to less structure and ambiguity.
5) The clients’ perceptions of the authority and power of the group leader are
significant. Too much authority can contribute to mistrust and further oppression;
lack of authority may be insufficient for clients expecting hierarchical relationships.
6) The therapist should stress and model group standards of respect. 7) The therapist
166
should emphasize members’ cultural strengths and assets, rather than liabilities and
weaknesses. 8) At the beginning of group work, the therapist should focus
specifically and intentionally on cultural issues (rather than waiting for this to
emerge from the group), and encourage discussion of issues concerning similarities,
differences, expectations, biases, prejudices, and communication characteristics
among clients and therapist. 9) The therapist should emphasize interpersonal as
opposed to psychodynamic interpretations of therapeutic work. 10) If possible, a
therapist from a culture similar to that of the group should co-lead. 11) Activity-
oriented experiences, rather than verbal therapy should be used with clients who
have low levels of acculturation.12) Clients who have been oppressed should be
encouraged to share these experiences with the group as a way of establishing group
cohesion and trust. 13). The therapist should not overgeneralize or stereotype
clients, but ascertain what is true for each client as a unique person.
Even after all of these recommendations have been provided, the reader may
still wonder if it is indeed possible for therapists of one culture to work with clients
of another! This is a valid question that needs to be addressed. Therapists who have
serious misgivings about their abilities, who are overly self-conscious and
analytical, who are fearful of acknowledging the differences present, who regard
these differences as problems, or who are basically uncomfortable, may not be able
to work successfully with multicultural groups (Corey, et al., 1998).
These authors further state that therapists can learn how to work effectively
in this area if certain conditions occur. 1) Therapists must receive specific training.
2) A working relationship needs to be developed between client and therapist, 3)
The therapist must be flexible in applying theories and techniques to appropriate
treatment goals. 4) The therapist should be able to be tested and challenged and to
experience clients’ mistrust without reacting defensively. 5) The therapist must be
self-aware of values, prejudices and biases (Corey, et al. 1998).
Chapter Summary
1, Broadly speaking, culture refers to those beliefs, actions and behaviors

associated with: sex, age, location of residence, educational, status, socioeconomic
status, history, formal and informal affiliations, nationality, ethnic group, language,
race, religion, disability, illness, developmental handicaps, lifestyle, and sexual
orientation. It can be assumed that cultural issues are present with ail client in all
settings. The client’s unique blend of cultural issues influences all aspects of music
therapy treatment. Multicultural work implies issues of meaning for both clients and
therapists. Ethical issues in multicultural work involve issues of clients’ needs and
therapists’ competence.
2. Most music therapy work can be considered multicultural in nature.

Western/American approaches to therapy are often irrelevant to or may be
ineffective with multicultural clients. The music therapy profession is gradually
realizing the importance and significance of addressing the issues involved in work
with multicultural clients
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3. Anumber of specific therapist skills are required for competence in multicultural

work. In addition, music therapists must: 1) develop an intellectual understanding
and knowledge of music from various cultures; 2) understand the context of music
within various cultures; 3) understand the musical healing traditions of diverse
cultures; 4) acquire experiential learning of various musical traditions; and 5)
acquire sufficient musical skill to be able to participate in and structure these
musical experiences for clients.
4. Major differences between cultures can be categorized according to their

emphasis on individualistic versus collectivistic values. Individualistic values
emphasize the role of the uniqueness of the individual who functions independently
and who is responsible for him or herself as well as his or her own needs. On the
other hand, collectivistic values emphasize the primacy of the group, relationships
within the group and the interdependence of all within the group. These two value
systems are manifested in a number of issues relevant to therapy.
5. Developmental models of cultural identity along with specific models of therapy

geared to cultural issues, e.g., feminist therapy and conscientizacao, are useful in
understanding the needs and the issues of oppression of minority clients within a
dominant culture.
6. Multicultural group work can be ineffective or detrimental to multicultural clients

if procedures are not sensitively and competently implemented. On the other hand,
these experiences may prove extremely effective for clients when used as
opportunities for sharing and understanding. Music therapy may have an important
role in this process.
7. Students of a majority culture who receive multicultural training may also

undergo a process of identity development. Specific multicultural competencies
should be developed and implemented for music therapy students.
8. Therapists can learn how to work effectively with multicultural clients if certain
conditions are met: 1) Therapists must receive specific training. 2) A working
relationship needs to be developed between client and therapist, 3) The therapist
must be flexible in applying theories and techniques to appropriate treatment goals.
4) The therapist should be able to be tested and challenged and to experience
clients’ mistrust without reacting defensively. 5) The therapist must be self-aware
of values, prejudices and biases (Corey, et al. 1998).
Ethical Dilemmas
1. Donna, a GIM fellow, is conducting an introductory GIM session with Beth,

whose religious beliefs may be characterized as “‘fundamentalist.”” As Donna begins
the induction procedure to facilitate an altered state of consciousness, Beth
becomes terrified, stating that, according to her religion, an altered state of
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consciousness makes one susceptible to the influence of the devil.
2. Dr. Matthews is a music therapy professor at a large university. Hong-Chin, one

of her students, has just been assigned to her first fieldwork experience in an
extended care facility with geriatric clients. Hong-Chin comes to Dr. Matthews’
office in tears, stating that she cannot work with these clients or tolerate the way
that Americans treat their elderly. She is extremely distressed by the fact that the
clients have been placed in an institution (they should be cared for by their
families), and that they are treated with no dignity or respect.
3. Dr. Matthews (from the situation above) feels that one of her Asian students,
Hiroshi, is not suited for the music therapy profession. Hiroshi is very distant from
his clients, is doing poorly in his classes, and lacks interest in and motivation for
the clients he sees in fieldwork. Dr. Matthews suggests to Hiroshi that he might be
happier in music performance study, because of his considerable piano talent, and
that he might consider changing majors. Hiroshi tells Dr. Matthews that his family
has decided he should be a music therapist, has sent him to America to study, and
to change majors would represent a disgrace for them. Dr. Matthews emphasizes
with Hiroshi that it is his life and his career, and that he should pursue goals that
are consistent with what he wants to do, no matter what his family has decided.
4. Crystal works as a music therapist with women who are victims of marital abuse.
In Crystal's culture, women are seen as subservient to men, are married for life, no
matter what the circumstances, and must always put the needs of their husbands
and children before their own. In discussions following music improvisation
experiences, her clients offer each other support to become independent from their
abusive husbands and to start their lives over. When this discussion occurs, Crystal
immediately cuts it off, and reminds them that their husbands are expecting them
to return.
5. Ramon is a music therapist who works in a facility with clients who are
experiencing depression. In response to a lyric discussion activity, the clients talk
about their life circumstances and the problems and difficulties that have
contributed to their depression. Ramon often uses his own experience of cultural
oppression to reassure the clients that things could be a lot worse for them, and that
he has survived his own oppression, and they, who are experiencing less severe
problems than he has, will do just fine.
6. Marlene works as a music therapist conducting groups for clients who have
bipolar disorders. Sook-Li is one ofher clients, who rarely contributes to the groups
and who appears to be embarrassed when group members display emotion.
Marlene knows very little about Sook-Li because she is so quiet. Marlene is quite
frustrated with her “resistance.” Marlene badgers her with questions and tries to
involve her in the group. On day, Marlene, out of feelings and frustration, tells
Sook-Li, “Why can’t you just talk about what you are feeling? Everyone else does,
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and they distrust you because you are so private. They feel you are better than they
ore,”
7. Mark is a music therapist who has been working in an inner city psychiatric
hospital for 2 months. He routinely sees clients of many diverse cultures. His
supervisor has suggested that Mark take some graduate courses in multicultural
approaches to therapy and music therapy, but Mark insists that “clients are all the
same, no matter what their problems may be. The most important thing you have to
do is listen.”
8. Helene is a music therapist who works in a small psychiatric hospital in a small

community. Rashid, is one of her new clients. Rashid is new to America and has a
lot of difficulty in expressing himself in English, and his accent is quite heavy.
Helene feels very frustrated in working with him, as it takes an enormous amount
of time to listen to him and to try to figure out what he is saying. The rest of the
members of the music therapy group in which he participates also get quite
impatient waiting for him to complete a sentence. Helene asks that Rashid be
transferred to art therapy, in place of music therapy.
1. Identify the influence of your own cultural heritage on your attitudes, values and
beliefs in the following self-assessment exercise (adapted from Ivey et al, 1993).
A. Identify your ethnic background, according to the following categories:
*Nationality: Citizenship as well as current residence

*Race
*Ethnic Heritage (countries from which your ancestors came)
You may want to include a family tree
*Religious heritage
*Gender
*Disability
*Significant Group Affiliations
*Sexual Orientation
*Socioeconomic Classification
*Primary Language
B. Review this information and make note of what you consider to be the core
cultural influences in your life. Do you classify yourself as monocultural, bicultural
or multicultural?
C. Identify significant messages (beliefs, attitudes, values, expectations) you have

received from each of these cultures according to the designated categories below.
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D. Make note of any conflicts in the messages you have received from your various
cultures. Identify whether these messages are indicative of an individualistic or
collectivistic value structure (or combination of both, or other value system).
E. As you go though this self-assessment, you should be aware of how you may
have internalized the messages, have synthesized them (conflicting messages), or
have abandoned them altogether. If you are aware of specific messages, you may
have already departed from them. If you are unaware, these messages may be very
deeply ingrained in you, and may require further exploration.
Culture I Culture 2 Culture 3 Ete.
*Life Expectation Messages:
Conflicts:
Synthesis:
*Roles and Responsibilities

of the Individual
Conflicts:
Synthesis:
*Role of the Family
Conflicts:
Synthesis:
*Gender Roles
Conflicts:
Synthesis:
*Meaning of Marriage
Conflicts:
Synthesis:
ee
*Use of Language
Conflicts:
Synthesis:
*Roles of Children and

Responsibilities
Towards Them
Conflicts:
Synthesis:
*Role of Elderly
Conflicts:
Synthesis:
*Emotional Expression
Conflicts:
Synthesis:
*Seeking Help When in Need
Conflicts:
Synthesis:
* Attitudes Towards Those

Different From Self:
Prejudices
Conflicts:
Synthesis:
*Religious values (and what

religion is valued/devalued?)
Conflicts:
Synthesis:
L7Z
*Occupations that are valued/

devalued
Conflicts:
Synthesis:
*Cultural groups valued/

devalued
Conflicts:
Synthesis:
F. Reflect on how any or all of these messages can impact on your work as a music
therapist, either positively or negatively.
2. It may be argued that all clients are multicultural in some respect, and that if an
overemphasis is placed on culture, there will be a decreased sensitivity to the
uniqueness of the individual. Agree or disagree with this position in a discussion
with your peers.
3. Use the following questions as topics for discussion: As it is virtually impossible

to include characteristics and needs of a// cultures in music therapy training
programs, what criteria may be used in decisions regarding the specific cultures to
be included? Should multicultural issues be addressed in all music therapy courses
or in one special course on the topic?
4. Identify and describe your current stage in the model for student identity
development: 1) preexposure, 2) exposure, 3) zealotry or defensiveness, or 4)
integration. What would be helpful for you to move to the next stage of
development?
5. Using the model of identity development as a framework ( Jackson, 1975;

Jackson & Hardiman, 1983) , trace the stages of your own cultural identity
development.
6. Develop a list of specific multicultural competencies for entry-level and/or

advanced music therapists.
7. Select a particular culture (your own or one that interests you). Gather
information on: specific behavioral characteristics and values of this culture
relevant to therapy (you can use Table A as a guide), prominent musical idioms, and
the role of music in healing. Identify specific considerations that should be given
in designing and implementing music therapy with persons of this culture. Prepare
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a paper to present to the class along with an excerpt of this culture’s music. Also,
provide a demonstration of a music therapy experience with persons of this culture.
8. In your course journal, reflect upon any personal issues, values, prejudices,
beliefs or attitudes (from question #1 above), that may hamper your work in
multicultural music therapy. Explore possibilities and options that may be used to
address these issues.
9. In your course journal, reflect upon your own feelings of competence for
multicultural music therapy work. Identify what you may do to improve your level
of competence.
10. Identify one conceptual or theoretical approach to therapy/healing within a

specific culture (e.g., traditional Chinese medicine, Ayurvedic medicine, etc.).
Explore details of this approach through additional readings and/or literature
searches. Compare and contrast this model with the traditional Western/American
theoretical model of therapy.
11. Obtain additional information on the feminist model of therapy. Describe your
reactions to this model.
12. Go through one code of ethics included in the Appendix. Identify those
statements that are relevant to a multicultural approach to music therapy. Identify
those statements that may be in conflict with this approach (and which may reflect
a Western/American theoretical orientation). Draft a list of ethical standards that
may be relevant to multicultural music therapy practice.
ETHICAL THINKING IN RESEARCH
AND PUBLICATION
Background
Che current emphasis on the need for ethics in scientific research can be
traced back to the Nuremberg Code (1946), the first document to address the ethics
of experimentation with human subjects. Formulated in response to the Nuremberg
war crimes, it contains ten declarations which stress the core ethical principles of
beneficence, justice and autonomy in research. It was the first document in
contemporary history to articulate both the concepts of informed consent and
risk/benefit analysis, (i.e., the degree of risk involved in the experiment should not
exceed the potential humanitarian benefit of the research problem). It also
emphasized the ethical principle of utilitarianism, i.e. , doing the greatest good
possible (Beach, 1996).
In more recent history, the United States Government mandated the
establishment ofInstitutional Review Boards in institutions receiving federal funds.
Their purpose is to monitor and safeguard the rights and welfare of human subjects
in research (Dileo-Maranto, 1995). The National Institutes of Health have provided
regulations for the composition and function of the IRB (National Institutes of
Health, 1983).
For approval ofany research proposals, Institutional Review Boards (IRBs)
must ascertain that the following requirements are met: (a) risks to the subjects are
reduced as much as possible, (b) there is an appropriate relationship between risks
and benefits, (c) subject selection is fair, (d) informed consent procedures are
documented, (e) safety precautions are appropriate, (f) privacy and confidentiality
are protected, and (g) vulnerable subject groups are protected” (U.S. Public Health
Service, 1984, cited in Dileo-Maranto, 1995, p. 83). These issues will be discussed
in the following sections ofthis chapter.
Informed Consent
Informed consent in a research context is a legal term which refers to the

decision a person makes freely and independently to participate as a subject in a
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research project after having been fully informed of all pertinent information, as
well as all potential risks and benefits to him or her. Informed consent is based on
the core ethical principle of autonomy, and requires that the person be provided
information prior to his or her participation in the research (Beach, 1996).
Three important principles underlie informed consent: 1) the capacity of the
individual to comprehend the information provided, 2) the completeness of the
information provided and the effectiveness with which this information is presented,
and 3) the freedom with which the individual makes the decision (Dileo-Maranto,
1995).
Informed consent involves much more than asking a subject to read and sign
a consent form. Factors that may influence the individual’s capacity to provide
informed consent include 1) age (the individual must be 18 years of age or older),
and 2) his or her emotional, physical and intellectual functioning. Individuals who
are below the legal age of 18 or are impaired in the any of the aforementioned ways
may not be judged able to provide consent for themselves, and consent must be
given by a parent or legal guardian.
The investigator has the sole responsibility for assuring that the information
regarding subjects’ participation is as comprehensible as possible to them. Subjects
should be able to understand what the study is about, the nature of the risks
involved, and what is expected to occur. Subjects must also clearly understand that
the nature of their participation is voluntary, that they have the right to either agree
or not agree to participate, and that they may withdraw their consent to participate
at any time during the study, if they so choose. Although this sounds fairly straight-
forward in theory, it is not so in practice. Many subjects do not understand research
or statistics. Subjects who are especially vulnerable with life threatening illnesses,
for example, may be over-anxious about the possibility for a cure, and this may
interfere with their understanding of the risks. Subjects may also not be able to
discriminate between what is treatment and what is research, especially when the
experimenter is the one who provides both. Procedures for providing information
to the subject in a way that can be fully understood should be part of the research
design; (Beach, 1996).
The skill of the researcher in communicating information is essential.
This means that the researcher must be aware of and able to apply all of the
following communication skills: appropriate eye contact, which shows
respect; active listening, which allows participants to ask questions and
express concerns; empathy, which is the ability to understand the subject’s
state of mind; tone of voice, which should be gentle, and should
communicate respect and concern; and professional appearance, which
signifies responsibility and commitment to the research (Beach, 1996, p.
23).
Several factors may compromise an individual’s freedom to provide consent
to serve as a research subject. Besides impaired capacity or age, these factors may
include: the existence of dual relationships, coercion and vulnerability. Because of
the power inequity in various dual relationships, the pre-existence or establishment
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of these relationships with potential research subjects is very risky. For example,
music therapy students who are recruited by their music therapy professors as
research subjects may feel unable to refuse, because of fear of recrimination through
grades or through compromised letters of recommendation. Similarly, music
therapy clients may feel undue pressure to participate in research conducted by their
own music therapist because of the fear of loss of services from the therapist or
facility if they refuse. Thus, dual relationships that involve a power inequity
between subject and researcher may preclude free and voluntary consent from
subjects. Neither students nor clients can ever be required to participate in research
(Dileo-Maranto, 1995).
To avoid these situations, music therapy faculty should avoid recruiting
students from their own classes as research subjects. However, students from other
classes for which they are not the professor may be used. If participation in research
is a necessary part of learning in a particular course, students should have other
options for this learning, e.g., participation in the research projects of other
professors, or other optional requirements, such as papers or projects in lieu of their
research participation (Dileo-Maranto, 1995),
Music therapists may recruit clients of other music therapists for research,
providing that clients’ privacy is not violated in the process, or they may use their
own clients if it is extremely clear that clients will receive their “regular” music
therapy services even if they decline to participate in the research. The researcher
has the sole responsibility of honestly monitoring the influence of his or her power
with the client; if the therapist assesses that the client agrees to participate in the
research out of dependency needs, out of the need for therapist approval, or for any
other dynamic issues in the therapeutic relationship, the consent to participate is not
completely voluntary.
The coercion of subjects to participate in a research project can be both
obvious and subtle, and needs to be carefully and honestly evaluated. Coercion may
be obvious when the researcher uses excessive financial compensation for
participation, for example, to low income subjects. In such cases, this might
represent “an offer they can’t refuse.” Coercion may be subtle when the urgency to
recruit subjects for a required thesis, for example, is conveyed to the subjects by the
researcher. Coercion may also be used to dissuade subjects not to withdraw from
a study once it has begun, because of pressures on the researcher to complete the
study (Dileo-Maranto, 1995).
The more vulnerable the client, the more the voluntary aspects of research
participation may be compromised. For example, subjects who are in a great deal
of pain may feel they have no choice but to participate in a music therapy research
project which may represent the only potential relief from their situations. Similarly,
individuals who are incarcerated in prisons have diminished rights to begin with.
Care must be taken by the researcher to assure that their lack of autonomy is not
exploited in the informed consent process.
Informed consent is documented with subjects in writing using a carefully
designed consent form. The information provided to the subject in the consent form
is fairly standard and should include most or all of the following:
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1) a heading indicating that it is an informed consent document,

2) the names of the institution/facility and primary and co-investigators,
3) the title of the research project and funding agencies or sponsors (if
applicable),
4) the purpose of the study, the reasons the subject is asked to participate,
and the number of subjects to be included,
5) a description of the study, including the procedures to be used, what is
expected from the subject, the time commitment involved and
duration of the study, and any use of control procedures,
6) all possible benefits that may reasonably result from the study to the
subject directly or to others,
7) all foreseeable risks involved for the subject, including potential side
effects, discomforts, stresses, lack of effects, and potential future
effects,
8) any alternate treatment procedures available that might benefit the
subject, including the option to receive standard treatment,
9) statement of procedures used in protecting the confidentiality and privacy
of the subject and his or her data, who will have access to the data,
how the data will be used, to whom the data will be disclosed, and
if the subject will have access to study results and/or his or her
individual data,
10) any remuneration, financial or otherwise, for participation in the study,
including the policy for remuneration if the subject withdraws from
the study,
11) information regarding the costs of the research, including any additional
costs to the subject, or payments by other parties,
12) statement of policy regarding compensation for any injury sustained
during the research and who will be responsible for compensation,
13) a statement regarding the voluntariness of participation, including the
fact that refusal to participate or to withdraw participation will not
involve any penalty or loss of benefits to which the subject may be
entitled otherwise, and a statement regarding procedures for
withdrawing,
14) a statement indicating that any new information obtained during the
research that may influence the subject’s willingness to continue
will be shared with him or her, and that the researcher may terminate
the subject’s participation in the study if required, even if consent
has been provided,
15) the name and telephone numbers of the person(s) to contact with
questions about the research itself (usually the investigator) or
concerning the subject’s rights,
16) a statement (that the subject signs) indicating that he or she has been
informed, has had the opportunity to ask questions, has received a
copy of the consent form, is cognizant of the risks, benefits and
alternative treatment options, and freely grants consent to participate
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(this section must be in the subject’s native language if he or she

does not speak English),
17) a statement signed by the researcher certifying that to the best of his or
her awareness, the subject comprehends the requirements, purpose,
risks and benefits of the study,
18) a statement, included at the bottom of the form on the copy that the
subject retains, that the study and consent form have been reviewed
and approved by the IRB for a one-year period,
19) when the subject does not understand English or the language used in
the consent form, a summary of its content must be translated into
the subject’s native language, and the subject must receive a copy of
this summary,
20) a statement of the subject’s assent to participate, if a minor child,
21) a statement signed by the interpreter (if the subject does not speak
English or the language of the document) that the subject
understands the information and agrees to participate in the study,
22) signatures of the researcher(s), subject, and witness with dates (Beach,
1996, Dileo-Maranto, 1995).
When pictorial, audio or video data are taken from the subject during the
study, an additional consent form is often used to provide information concerning
the use, storage and disposal of these data, along with safeguards to protect the
subject’s anonymity and confidentiality.
Injury to Subjects
Injury to subjects is one of the most important ethical issues in research. In

assessing potential injury to subjects, the researcher must consider the type of injury
possible, its duration, intensity, and potentiality as well as subject vulnerability
(Dileo-Maranto, 1995). Music therapy research is not often associated with a
serious potential for risk. However, less obvious types of risk may be difficult to
determine, observe and evaluate according to their long-term effects (Koocher &
There can be many types of injury to subjects: psychological, physical,
intellectual, social, economic, and itegal. Also, breaches of confidentiality or
privacy, coercion and deception and invalid research findings also constitute
potential sources of injury (Beach, 1996; Dileo-Maranto, 1995).
The duration of the injury involves how long the injury will be sustained,
i.e., for the duration of the study, following the study or on a permanent basis. The
intensity or severity of the injury may range from minor to profound. It is the
researcher’s sole responsibility to deliberately minimize risks of injury, according
to type, intensity and duration (Dileo-Maranto, 1995).
The potentiality of risk involves how likely it will be that a subject will
sustain injury: is the potential for risk minimal, moderate or substantial? As
mentioned previously, a careful assessment of this potential must be provided to
subjects in the informed consent process. The researcher is responsible for reducing
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the potential for harm; if there are risks involved, they should be as minor,
reversible and as short-term as possible (Dileo-Maranto, 1995).
Many factors may contribute to subject vulnerability in research. The mere
fact that many subjects in music therapy research have conditions that depart from
what is considered “normal” makes them more vulnerable to risks for injury.
Subjects who have hidden psychological or physical conditions may be more
susceptible to risks. Subjects who have diminished verbal skills may be incapable
of articulating distress or discomfort during research procedures. Careful screening
of subjects is required to anticipate potential hidden factors that may interact with
the treatment. In addition, low verbal subjects should be carefully monitored to
detect any potential distress during the procedure (Dileo-Maranto, 1995).
When there is a doubt concerning the potential for risk, or if the researcher
is unable to anticipate risk potential, it is advisable for him or her to conduct a small
pilot study to assess risk factors before implementing the study (Koocher & Keith-
Spiegel, 1994).
How do the potential benefits of a particular study compare to its potential
risks for subjects? This is a difficult and controversial topic.“The dilemma created
for researchers is this: How does one go about developing generalizable knowledge
for the welfare of society (the greater good), while maintaining respect, privacy, and
confidentiality of individual subjects, whose autonomy and protection from harm
must also be maintained?” (Beach, 1996, p. 19). The researcher and the IRB
inevitably assume responsibility for this decision.
Researchers are called upon to assure that the benefits of research outweigh
its risks through a risk-benefit analysis. Benefits include those for the subject and
for society at large, (and the subject is duly provided the necessary information via
the informed consent process if there are no potential benefits for him or her
directly) (Dileo-Maranto, 1995).
Risk-benefit analyses may involve statistical calculations, wherein the
study’s potential benefits are multiplied by the probability of their occurrence. This
number must be greater than the product of the potential risks for harm multiplied
by their probability of occurrence. This calculation results in a risk-benefit ratio,
which is included in the informed consent document (Beach, 1996).
Confidentiality
Maintaining the confidentiality of research data may be the most sensitive

ethical issue in research. As Loue (1995) states: “It is important to recognize the
tension between the need to protect research participants’ privacy and the need for
information in research” (p. 79).
The right of the subject to decide if information about him or herself will be
shared with others, as well as the type of information to be released, is paramount.
If this right is compromised, the welfare of the subject is in jeopardy (Beach, 1996;
Dileo-Maranto, 1995). In a sense, the research process itself, which aims at
discovering and sharing information, is in conflict with the rights of the individual
to privacy (Drew, 1980).
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This is especially true in research with certain types of subjects, such as with
children and with AIDS patients. In the latter case, for example, release of
information concerning the presence of the disease could harm family relationships,
threaten jobs or potential employability, and impact on financial issues. Preserving
confidentiality thus requires special safeguards, and just as in clinical work, subjects
must be cognizant of the limits of confidentiality in order to make an informed
choice regarding participation (Beach, 1996).
The sensitivity of the information collected in research may require
additional precautions regarding confidentiality. Some types of information are
arguably more sensitive than others (e.g., musical preference versus sexual
preference), although the researcher cannot make blanket judgments for the subjects
about how sensitive this information may be for him or her personally. The subject,
in the informed consent process, is given the opportunity to make this decision for
him or herself (Dileo-Maranto, 1995).
Methods of data collection influence the need for additional precautions to
protect subjects’ confidentiality. Data that are gathered via anonymous testing
procedures or through mail-in anonymous surveys present less of a risk for
disclosure than do methods which rely upon pictorial, audio- or videotaping of
subjects’ responses. The latter may imply a direct identification of subjects and their
data by anyone who has access to these materials. Additional informed consent
procedures are needed when these data collection procedures are used (Dileo-
Maranto, 1995).
Any and all persons who have access to the data must be accountable for
protecting the subjects’ confidentiality, and it is the responsibility of the researcher
to monitor that this is done. Research must be designed to include “administrative,
management and technical safeguards to control the use and disclosure of
information” (Beach, 1996, p. 26). When information identifying the subject does
not need to be included with the data, it should not be. When there is identifying
information concerning the subject included in the data, it should be maintained
separately from results and stored under lock and key. All data should be coded
whenever possible to prevent anyone handling the data from identifying individual
subjects and their results.
The subject has the right to know and approve of who will have access to the
data and for what reasons, how the data will be stored, maintained and disposed of,
and how the results of the research will be disseminated. Research data presented
in aggregate form in a professional journal, where no individual results of subjects
are identified, present much less of a threat to confidentiality, for example, than
does a case study. Subjects must also approve in writing of the release of any
information that could possible identify them to any person or agency (including the
funding source) within or outside of the research project (Beach, 1996).
Competence
Just as in clinical work, music therapy researchers must possess both

professional and personal competence to carry out the intended research study. They
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may not use or test music therapy methods in which they have insufficient abilities,
skills or training. They must also be competent in the research process itself. New
researchers should conduct their studies with supervisory guidance and consultation,
if needed.
Competence implies that research studies are conceptually sound with
appropriate designs and statistical analyses. Competence in research, as in clinical
work, demands a continuing commitment to learning and development.
Integrity and Objectivity in Research
The term, research data, includes the various methods used in measuring and
recording data as well as the measurements themselves; these can take a multitude
of forms. Research data provide the basis for reporting research findings.
Appropriate management of the data and adherence to specific values in a research
study are needed to assure the integrity and credibility of the research process and
the researcher. “There is a fine line between sloppy science (questionable research
practices) and misconduct” (Beach, 1996, p. 49). Thus, objectivity, (the avoidance
of bias), and integrity are core values in making decisions about the research
methods that will be used, how the information will be communicated, and how the
data will be managed.
Objectivity also implies the ability of the researcher to use self-awareness
and self-evaluation to monitor against injurious or deceptive practices. Objectivity
is essential in making decisions about the inclusion or exclusion of data, and in the
decisions regarding publication. Objectivity requires truthfulness and honesty in
sharing data. Without objectivity, the intent of research is obstructed (Beach, 1996).
Integrity in the research process implies the communication of all
procedures actually used in the experiment, the details of how the data were
collected, etc. The goal is to provide sufficient detail so that others may replicate the
study. To report procedures and methods not used, to include data that have not
been measured (fabrication) or the alteration of data in any manner (falsification)
represents research misconduct (Beech, 1996).
The U.S. Department of Health (1994) has issued data management
guidelines for NIH researchers; and these represent a model for exemplary practice
in research. These guidelines require that: 1) research results be recorded, annotated
and indexed in a manner that permits continuous review by others, including
research collaborators; 2) all data, even those not intended for publication should
be treated in the same manner, and 3) data should be maintained long enough so that
the study may be replicated, analyzed, or challenged by others.
Ethical Precautions Using Various Research Designs
There are a number of ethical implications for various designs used in

research, and these are discussed in this section. No matter what designs are used
in research however, their quality can present ethical problems. Poor designs
provide results that do not add to the scientific knowledge base in the field, and in
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fact can diminish this knowledge. Poor designs result in useless studies, waste the
subjects’ time, and put them at risk without need. Invalid results, if relied upon, can
diminish the effectiveness of treatment in the future. “Overall, the scientific
knowledge stockpile has been contaminated” (Koocher & Keith-Spiegel, 1994, p.
60).
Control Group Designs. Control group designs, however meritorious for

scientific reasons, can present ethical issues for researchers. When a control group
is used in research, participating subjects receive all other types of treatment
available, except for the experimental one. From an ethical perspective, no-
treatment control groups can be used only when the control subjects are not in need
of the experimental treatment, and when not receiving this treatment presents no
loss to them. Subjects, through informed consent, may also agree to the possibility
of participating either in the control or experimental group, even when the treatment
could be beneficial to them. No-treatment control groups may also be used when the
resources of the study render the experimental treatment available to fewer
participants than available, when no other resources for the treatment are obtainable
to subjects, when the control subjects understand the situation and agree to
participate, when the treatment has not yet been demonstrated to be effective, and
when the placement of subjects into control and experimental groups is done fairly
(Koocher & Keith-Spiegel, 1994)..
The use of a no-treatment control group design is ethically questionable
when the music therapist has used the method to be tested on a clinical basis, and
it is has been effective, or when other studies have demonstrated the method’s
effectiveness, and for example, it is being tested with a new population. Music
therapists in this situation may consider other, more ethical design options for the
research. First, a wait-list control group may be used, In this design, the treatment
is given to the experimental group, and the treatment is withheld from the control
group until after the treatment period. Following the experimental period, the
control group is given the same treatment. Therefore, both groups receive the
experimental treatment, only the treatment for the control subjects is delayed
(Dileo-Maranto, 1995). Of course, this option is not ethically sound when the
subjects involved are in a crisis situation, or if the music therapy treatment would
not be relevant if delayed. For example, the use of a wait-list control group would
be inappropriate if music therapy was being used to reduce anxiety in patients
undergoing surgery, assuming that subjects will undergo surgery only once!
Another ethical option is to use a design in which each subject receives both
experimental and control conditions. In this manner, comparisons can be made
among treatments, and no subject is denied access to treatment. Again, the nature
of the study determines whether this option is feasible or not (Dileo-Maranto, 1995).
A third option involves the use of a treatment comparable to music therapy
for the control group, with a comparison made of the effects of the two types of
treatments.
No matter what design is used, subjects must be fully informed concerning
their opportunities to receive treatment, with an estimation of the likelihood of their
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assignment to experimental or control conditions (Dileo-Maranto, 1995).

A final issue to be considered concerns the control of confounding variables.
To effectively assess the influence of music therapy on dependent variables, it may
appear necessary to withhold other types of treatment that the subjects may be
receiving simultaneously. For example, if subjects receiving music therapy are also
receiving art therapy or dance therapy at the same time, the effects of music therapy
as a treatment might be more effectively assessed if the other treatments were
withheld during the music therapy treatment period. Again, this may make good
sense from a scientific perspective, but not from an ethical perspective; any
treatment that could benefit subjects may not be withheld (Dileo-Maranto, 1995).
Alternately, a sound design may result if all subjects (both experimental and
control) experience the same confounding variables equally, e.g., dance therapy.
These extraneous variables (treatments) are then considered as additional
independent variables, and it is then possible to assess the effects of music therapy.
Randomized Designs. Randomization involves the assignment of subjects

to groups, wherein each subject has an equal and independent opportunity regarding
the assignment, Randomized designs are ethically appropriate when the type of
study involved does not involve a therapeutic treatment, when the subjects are not
selected on the basis of need for the treatment, and when there is no potential risk
involved. These designs may also be ethically appropriate when the study involves
a treatment, but it is not known at all if this treatment will be effective or better than
any other treatment (or no treatment). The use of randomized designs, on the other
hand, may be ethically questionable when subjects have a presenting problem in
need of treatment, and when there are risks inherent in assigning subjects to a
particular group. Randomized designs do not permit subjects to be placed in the
group that would be most beneficial for them, and therein lies the ethical dilemma
Baseline-Treatment Designs. The use of baseline-treatment designs can

create ethical issues for researchers as well. These designs generally involve
observations and measurements of an individual’s behavior as it occurs in its natural
state before treatment is applied (baseline condition) and also during treatment.
Comparisons between these two conditions are then made to assess the
effectiveness of treatment. Ethical issues associated with these designs involve the
risks for subjects during baseline conditions. For example, subjects who are self-
injurious present risks to themselves if allowed to engage in these behaviors without
intervention or restraint. Allowing the subject to remain self-injurious without
intervention for the sake of research is ethically inappropriate. Alternatives to
baseline observations need to be considered under these circumstances. If baseline
conditions are required, they should be extremely short, with all possible safeguards
implemented to reduce risks to the subject (Koocher & Keith-Spiegel, 1994).
Longitudinal Designs. Longitudinal designs involve the repeated collection

of data using the same subjects over an extended period of time. There are several
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ethical issues involved in these designs. Relationships between the researcher and
subjects are often created, because of the length of their association, and may also
involve subject dependency issues. Procedures for termination of the study must be
similar to those implemented in clinical work, especially when treatment/therapy
was a part of the experiment. The needs of the subjects may not be consistent with
the timetable of the experiment. Abandonment of subjects, when they are still in
need, may cause more harm to the subjects than if the study had never been initiated
Another ethical issues involved in these studies includes the enhanced risks
of breaches of confidentiality, because of the extended time frame involved. Also,
subjects who decide to withdraw from these studies cannot be easily replaced, and
the researcher may exert undue pressures on subjects not to terminate their
participation (Koocher & Keith-Spiegel, 1994).
Deception in Research
Deception in research can be defined as the “misrepresentation of facts

related to the purpose, nature, or consequences of an investigation” (Drew, 1980,
p. 49). Deception involves one or more of the following: 1) providing false
information, 2) the deliberate withholding of information relevant to the study, or
3) failing to inform the subject that he or she is participating in one. Debriefing, i.e.,
the provision of accurate information about the study to subjects is usually done as
soon as possible after its completion. Researchers attempt to justify their use of
deception by stating that a full disclosure to subjects concerning the purpose of a
study beforehand would negatively affect its results. Obviously, deception is not
consistent with the requirements of informed consent. (Dileo-Maranto, 1995).
The use of deception can potentially harm subjects in two ways. First, the
deceptive procedure employed can be embarrassing or anxiety-provoking for them.
For example, false feedback regarding subjects’ negative performance can make
them feel badly about themselves. Second, when subjects are debriefed regarding
the study’s real purpose, they may experience various negative responses. In either
case, the literature reveals that a number of reactions may occur, including:
“feelings of degradation, loss of self-esteem, embarrassment, anger, disillusionment,
anxiety and mistrust” (Koocher & Keith-Spiegel, 1994, p. 62). Children may be
even more at risk for the negative effects of deceptive research procedures, and may
experience these reactions more intensely.
Alternatives to the use of deception may include: providing general,
nonerroneous, partial disclosure information to subjects before the study, and a
complete debriefing following. Role-playing and simulation experiences may also
be appropriate, and although these options may be more problematic from a design
perspective, they are less controversial ethically. Subjects may also be warned prior
to the study that it may involve some deception, and that they will receive a full
debriefing afterwards. In this manner, the subjects may consent to being deceived
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Ethical Issues in Research with Specific Populations
This section presents information regarding ethical issues that may arise in
music therapy research with specific clinical populations. Although not all clinical
populations with whom music therapists may conduct research are discussed here,
many of the ethical issues mentioned can be generalized. It is important to
understand that the vulnerability of various populations makes individuals more
susceptible to risk as research subjects.
Geriatrics. Geriatric populations, especially those residing in nursing homes,

may present various problems that can interfere with their ability to provide true
informed consent. Researchers should be aware of these factors and take additional
measures to ensure that their rights are both maintained and maximized.
Many elderly individuals, because of the culture of their age group, are more
yielding to authority than persons of younger generations (Kapp, 1999). A
researcher, because of his or her degrees, titles, or position, may represent another
type of authority figure. The elderly person may thus relinquish or suspend his or
her decision-making regarding informed consent to the researcher, who may be
perceived as an “expert” and more capable of deciding what the person should do.
This tendency to yield decision-making to authority is exacerbated when the
elderly reside in a nursing home facility. Dependency on caregivers is both a reality
and a factor that can greatly contribute to coercion (Kapp, 1999). The elderly will
therefore not be very willing to refuse participation in a research study conducted
by music therapy staff, for example, if they feel their care may be threatened in
doing so.
Many elderly persons are alone in life, and may have few family or friends
to provide support and feedback regarding their decisions (Kapp, 1999). This
support is important, as they may feel insecure about making important decisions
for themselves. Again, without objective feedback from others, they are more likely
to defer to authority, or to feel coerced into decisions because they feel their
security and care are threatened.
Related to this is the fact that their cognitive capacities may vary
considerably (Kapp, 1999). Alertness, reasoning skills, comprehension, and
memory may fluctuate from day to day. They may “forget” that consent was
provided from one day to the next. The presence of depression may also play an
important and interactive role in their cognitive functioning.
Participating in a research study may be something they have never
experienced in their lives, and this notion alone can be quite anxiety-provoking.
When they are asked to sign papers (i.e., to provide informed consent), their fears
can further escalate (Kapp, 1999).
Because of these factors, as well as others, the elderly may need special
considerations with regard to informed consent. Particular care is required in
explaining the study to them. The language used by the researcher, the volume of
his or her voice (with patients who have hearing impairments), and the clarity and
readability of the consent form may all help in communicating information (Kapp,
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1999). Being aware of variations in cognitive and mood states, providing clear
information about the voluntary aspects of research participation, using care to
avoid any type of perceived coercion, offering support, and avoiding an
authoritative posture will help reduce their vulnerability.
AIDS Patients. Confidentiality is a primary ethical issue in the conduct of

research with AIDS and HIV-infected persons. As stated earlier in this chapter,
breaches of confidentiality with AIDS research subjects may put them at risk
socially (e.g., through discrimination), economically (e.g., through loss of
employment) and legally (e.g., reporting of illegal drug use). These realities may
deter AIDS patients from participating in research which could be of benefit to them
personally and also to society as a whole (Loue, 1995).
Confidentiality issues can occur in many ways when conducting research
with AIDS patients. Some states may require that an individual’s HIV or AIDS
status be revealed (to monitor the status of the disease). Courts may require that
research records for an AIDS subject be surrendered. The “duty to warn” an
intended victim may require the release of information about a subject. Research
funding sources may require information to be disclosed. Furthermore, study data
may be mismanaged, allowing others inadvertent access to it (Loue, 1995).
Physicians are required to report cases of AIDS to a health department in all
states, and some states also require the reporting of HIV seropositivity (see Chapter
5). Researchers who are non-physicians are not governed by this mandate, however,
if the research involves HIV testing procedures, individuals performing this testing
may be required to report the information. This is very controversial ethically, as
researchers’ reporting requirements could seriously diminish subjects’ trust, and this
factor may preclude experimental treatment for individuals who are adamant about
not having this information disclosed. A number of states, however, allow subjects
to be tested blindly for HIV seropositivity (wherein individual identities and test
results are not linked together) (Loue, 1995).
Specific circumstances that may necessitate a breach in confidentiality for
AIDS patients also apply to all clinical populations in research as well (see Chapter
5). Child abuse/neglect reporting by professionals is mandatory in all states. When
confronted with evidence of child abuse or neglect in pediatric or adult HIV
research, the researcher is compelled to report these circumstances to the designated
authorities, even at the risk of betraying the subject’s confidentiality. In some states,
definitions of child abuse also include behaviors which expose unborn children to
the risk of HIV (through high-risk sexual behaviors) or drugs (through maternal
drug injection). Likewise, the researcher may be required to report these behaviors
of research subjects to the authorities, thereby breaking confidentiality (Loue,
1995S).
Partner notification laws, i.e., the requirement to alert sexual or needle-
sharing partners of HIV-infected individuals to their potential HIV-exposure, vary
according to state, as do the procedures involved and the voluntary nature of such
notification. These laws are distinguished from contact tracing, which involves the
contacting of all such known partners, as a type of medical investigation (Falk,
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1988). It may be the case that researchers, according to the laws of their state, may
be required to notify subjects’ partners who may be at risk of infection.
Finally, individuals who serve as subjects in HIV research may provide
informed consent at the beginning of the study and may later lose capacity because
of the progression of the disease. If the individual no longer remembers giving
consent, an ethical dilemma results concerning the subject’s continued participation.
Children. Research involving children as subjects presents a host of ethical

issues, in terms of potential risks, research design, and confidentiality. The issues
discussed in this section, although of particular relevance to minor subjects, can be
generalized as well to other clinical populations who are vulnerable.
It should be realized that children who are used as subjects in research often
possess additional sources of vulnerability besides age (e.g., intellectual, physical,
emotional, developmental or social problems), and these factors render them more
susceptible to risk. These children may experience more distress as a result of
research procedures (e.g., adverse conditioning) than do “normal” children (Fisher
& Tryon, 1988). Similarly, research procedures that are innocuous for “normal”
children may not be so for more vulnerable children. For example, a survey
concerning one’s family background may elicit no reaction from a “typical” child,
but may produce a great deal of discomfort for the adopted child (Koocher & Keith-
Spiegel, 1994), Similarly, a study involving music and touch may evoke very
negative reactions from the child who has been sexually abused (Koocher & Keith-
Spiegel, 1994).
Risks for children in research can be minimized by researchers through a
complete analysis of all aspects of the study, as well as a consideration of the
potential risks involved from several perspectives. Levine (1978) recommends that
researchers ask themselves the following questions: What is the potential for risk
according to the developmental stage of the child? Can the researcher draw upon
his or her knowledge of the procedures used to comprehend potential risks? What
are the characteristics of the subjects, and what factors might contribute to their
vulnerability? Unanticipated risks may occur much more frequently with children
than adults (Pearn, 1981).
To minimize risks also, researchers must insure comfort and safety in the
physical environment of the research setting. For procedures that involve stress, fear
or anxiety for the child, it is important to have a parent or trusted person accompany
the child during the research (Koocher & Keith-Spiegel, 1994).
There are a number of issues involving the privacy and confidentiality of
children in research. Ethically speaking, the confidentiality of research subjects,
including children, must be protected. Parents of children involved in research
studies, however, often expect that the researcher will provide them with details of
their child’s data. This can be a most complicated issue. It is ethically permissible
to share research data if the subject’s permission is obtained beforehand. However,
are children capable of giving free and informed consent for the researcher to do
this? Even if the researcher is relatively certain that the child is duly informed and
understands what is being asked, the child may not be “free” in making this
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decision. If the child refuses to allow his or her data to be given to parents, how can
the researcher inform the parents of this decision in a way that will protect the child
from being pressured by them? Children in abusive situations may be particularly
at risk (Koocher & Keith-Spiegel, 1994).
If the child refuses permission for data to be shared, must the researcher lie
to parents (which is ethically questionable as well)? In this situation, the researcher
may decide to terminate the child’s participation in the study, using the rationale
that the child does not meet the study’s requirements. This solution may be ethically
appropriate, as the researcher is protecting the subject from risk and/or injury, and
the subject may well wish to withdraw. In addition, this solution may protect the
subject from parental retribution (Koocher & Keith-Spiegel, 1994).
Parents may also attempt to get specific information about their child’s data
by stating that they have the right to ask questions concerning the study (according
to the informed consent agreement that was signed). To avoid this situation, the
researcher should be clear at the outset of the study (and include this policy in the
informed consent agreement) that parents may receive general study results, but not
the results of their individual child. Parents and children must be given the
opportunity to consent/assent to this policy. Parents may agree not to be informed
of their child’s results, or if the subjects know that their parents will be privy to their
information, they may modify their participation accordingly (Koocher & Keith-
Spiegel, 1994).
Some parents may make receipt of their child’s data a contingency for
providing consent to participate. This can be a most uncomfortable situation for the
researcher, and he or she may either choose not to include this child in the study, or
offer the parents only aggregate results (Koocher & Keith-Spiegel, 1994).
On the other hand, sometimes it may be counterproductive to withhold
findings from persons who could assist the child, such as.in the case of assessment
studies aimed at identifying problems that put children at risk, In these situations,
the policies for sharing this information (i.e., the type of information to be shared
and the specified recipients of the information) will need to be detailed in the
informed consent agreement (Koocher & Keith-Spiegel, 1994).
Researchers conducting case studies (for publication) with children need to
make every effort to disguise the materials so that the individuals involved may not
be identified. In spite of how well this is done, there is always the possibility that
a reader may be able to identify the individuals described. This fact must be
disclosed during the informed consent process (Koocher & Keith-Spiegel, 1994).
Besides parents, there may be pressures on the researcher to disclose
information to other persons or agencies, or the researcher may feel it is necessary
to share some information with others for the benefit of the child. As stated
previously, any type of information disclosure must be approved by the parent and
child before this can occur (Koocher & Keith-Spiegel, 1994).
There may be situations where sensitive data collected by the researcher are
of interest to various agencies who, for example, may be involved in gang activity
or drug use prevention. Researchers working with very sensitive data may consider
applying for a certificate of confidentiality from the Public Health Service; these
190
certificates render the data immune from court subpoena, and provide a high, but
not absolute degree, of confidentiality for the data (Koocher & Keith-Spiegel,
1994).
In some types of research with children, researchers may need to solicit
information from third-parties, e.g., the children’s teachers, classmates, etc. The
risks inherent in third-party involvement are twofold: 1) the third-party sources may
reveal information that the child/parents would not want known, and 2) the
researcher may inadvertently reveal sensitive information to the third-parties, e.g.,
that the child has been sexually abused. Having the consent and assent of the parent
and child is essential, however, with this type of data-gathering method, there are
still serious risks. The researcher and the parents/child must ascertain if the benefit
derived from the study outweighs these risks (Koocher & Keith-Spiegel, 1994).
Similar to the need to inform clients of the limits of confidentiality in
clinical work, researchers must also advise (in informed consent procedures), the
limits of confidentiality in research. For example, confidentiality cannot be
maintained when there is suspected child abuse or neglect, when there is an
awareness of potential harm to the subject, or when the subject threatens the welfare
of another (duty to warn).
Ethical Issues in Other Research Paradigms
Ethical issues may exist when one conducts research using other paradigms
and methods, such as qualitative or historical. These issues are presented in this
section.
Covert Observations. Covert observation involves the observation of

individuals for a period of time by a researcher who assumes a false identity with
them. The individuals being studied are not aware that they are participating in a
research study or that they are being deceived with regard to the researcher’s
identity (Bulmer, 1982). Covert observation is an ethically controversial research
practice.
Erikson (1967) provides a number of ethical arguments against this type of
research: researchers have responsibilities to subjects, and as there are potential
(and often unforeseeable) risks involved for subjects in being secretly observed,
they must have the right to provide consent to these risks in advance. Deception
involves betraying the trust of others; when the personal relationships established
in covert observation are based on this falsehood, injury to them is likely. He
further stresses that both the misrepresentation of the research as well as the
researcher’s identity is unethical.
Because of the potential methodological flaws in applying covert
observation practices, one can neither justify their use nor the invasion of privacy
created for those observed. For example, data resulting from covert observation are
often faulty, as the researcher is unable to evaluate the disruptive effects he or she
causes within the setting and with the individuals observed. Bulmer (1982) argues
that the same research objectives may be obtained using other, more ethically
19]
acceptable methods. For example, besides the covert-insider role assumed by the
researcher in covert participation, researchers may opt to function as: 1) an overt
outsider (the researcher keeps his/her own identity and does not enter the world of
the participants), 2) a covert outsider (the researcher assumes a false identity, but
does not enter directly into the participants’ world), or 3) an overt insider (the
researcher assumes a new role with the knowledge of the participants being
observed) (Bulmer, 1982).
Qualitative Research. Ethical issues in qualitative research may be

essentially different than in quantitative research. Bruscia (1995a; 1995b) identifies
three primary issues: 1) It is impossible for researchers to provide all details of the
study to the subjects beforehand, because methods and data collection may
“emerge” according to each subject. 2) Dual relationships, with their potential
conflicts of interest, may be involved when the therapist and the researcher are the
same, 1.e., clinical decisions regarding the client thus may be influenced by research
necessities. 3) When collaboration (seeking advice and assistance from research
subjects) involves subjects who are also clients, dual relationships may again result.
With regard to the third issue, collaboration can involve the client’s having access
to research data which may be potentially harmful to him or her or to the process
of therapy. Collaboration may injure the client-therapist relationship, or contribute
to role reversal. Collaboration may also require more from the client than he or she
is capable of contributing. To avoid these difficulties, Bruscia (1995b)
recommends: 1) supervision during the research process, 2) the separation of
research and therapist roles, 3) collaboration with individuals who are familiar with
the subjects, rather than the subjects themselves, and/or 4) collaboration with
subjects who do not function as sources of data.
Historical Research. Ethical issues in historical research are also somewhat

different than in quantitative research, as humans are not used as subjects.
Nevertheless, the historical researcher is bound to exercise ethical thinking in
reporting sensitive information (Dileo-Maranto, 1995). In addition, researchers have
the responsibility to safeguard their sources of information and to allow others
access to this information (Solomon, 1995).
Ethical Issues in Research Publication
Publication and/or presentation at professional conferences is usually the

end result of the research process. In this manner, the sharing of scientific data
contributes to the growth and development of the discipline. Publication is also the
beginning of another process, one that involves the larger scientific community of
professionals who evaluate and further develop the study’s results (U.S. Department
of Health, 1994), It is important that publication be done in a timely manner to
promote the state of knowledge within the field. It is inappropriate to fragment the
publication of results, or to publish the results of one study in more than one source
(Beach, 1996).
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Authorship. Authorship involves the assignment of credit to individuals

involved in the research when publication and/or presentation of the results occurs.
Authorship acknowledges the researcher’s scientific contribution to the field, and
as such implies both a benefit for the individual and a responsibility to the discipline
(U.S. Department of Health, 1994).
Authorship is a privilege and should be attributed only to those who have
made significant contributions by completing at least two of the following tasks:
conception of the study, design, implementation/execution, analysis and
interpretation of data, and/or writing the final manuscript (Lafollette, 1992).
Authorship should only be assigned to those who are willing to take responsibility
for the study (Beach, 1996), and some journals require that all authors sign consent
to publish forms.
Practices vary as to how the primary author is assigned or “Who’s on first?”
(Lafollette, 1992). In some studies, the person who writes the paper is credited with
primary authorship. In others, the senior author’s name is placed first, and in others,
there is an alphabetical listing of authors. Under ideal circumstances, however, the
listing of authors should be according to their contributions. Even when authors
have been given university credit or have been paid for their contributions, these
efforts should still be acknowledged through the assignment of authorship
(Lafollette, 1992).
Individuals who have contributed to the study by providing advice, space,
support, etc., do not merit authorship, but may be acknowledged for their assistance
within the text of the paper (Beach, 1996). “Free rides,” or assigning authorship
without an appropriate contribution to the research, for example, as a means to
bestow an honor on someone, should be avoided (Lafollette, 1992). Whether or not
individuals who have served as mentors, professors, and research advisors should
be assigned authorship may be a delicate issue. It is the opinion of this author that
these individuals should not share authorship in a study completed by a student.
Each author is responsible for reviewing the study and for supporting its
findings. The primary author may accept the responsibility of competing the report,
submitting the study for publication, and for coordinating communication among
the authors, for example, if the study needs revisions before publication. The
primary author also makes sure that each author approves and authorizes its
submission for publication (U.S. Department of Health, 1994).
Ethics and the Peer Review Process in Research. Peer review, as it relates
to the research process, involves complete, objective and honest scrutiny by
recognized experts of research papers, publication submissions, grant proposals, etc.
Peer review is a critical component of the research process. Although it may be a
time-intensive procedure, researchers have the responsibility to participate as
reviewers to advance knowledge in the discipline (Beech, 1996; U. S. Department
of Health, 1994),
Conflicts of interest, including existing or potential competitive,
collaborative or close relationships between reviewers and the authors of the
research may jeopardize a reviewer’s objectivity. Ethically speaking, the reviewer,
193
under these circumstances, should return the materials unread (Beach, 1995; U.S.
Department of Health, 1994).
Research under review is considered privileged, and as such, it may not be
used to the advantage of the reviewer, nor should ‘t be given to other persons to
read, unless necessitated by the review process. Maicrials may not be photocopied
and retained by the reviewer, or used in any way without specific permission to do
so by the journal and the author (Beach, 1995; U.S. Department of Health, 1994).
Additional guidelines for competent and ethical peer review require
reviewers to: 1) remain anonymous, 2) accept only those materials for which they
may provide an expert review, 3) maintain objectivity towards and confidentiality
of the material at all times, 4) be honest in uncovering any potential conflict of
interest, 5) carefully provide documentation for negative reviews, 6) attempt to be
fair and reasonable in request for additional information, and 7) return reviews in
a timely manner (Panel on Science, 1992-1993).
Research Fraud. Research fraud can be defined as those actions that

represent a deliberate intention to deceive others for ari unethical reason. Fraud may
occur when an author, editor or reviewer uses a falsehood or deception (e.g.,
inauthentic data or authorship, decisions regarding publication) to obtain an unfair
benefit (e.g., to promote one’s own career) or to intentionally harm the rights or
interests of others (Lafollette, 1992).
Fraud is distinguished from other types of unintentional actions, such as:
honest mistakes in typing, calculations, typesetting, referencing, etc., that often are
the result of sloppiness or carelessness on the part of the authors,
There are a number of ways in which authors can commit fraud: by using
data that are non-existent, by falsifying or distorting real data, by using other
authors’ ideas without citations or by violating copyright laws, by falsifying
authorship (eliminating or including authors), or through the falsification of the
status of publication (Lafollette, 1992).
In a similar manner, reviewers may commit research fraud in the following
ways: by deliberately falsifying information in a review, by intentionally biasing a
review (often involving a conflict of interest), by falsifying the authorship of a
review, by deliberately delaying a review for some type of gain (e.g., to allow self
or others to publish first), by failing to disclose conflicts of interest, and/or by
pilfering ideas from a manuscript they are reviewing (Lafollette, 1992).
Journal editors as well may be involved in research fraud by: falsifying the
authorship of a review (e.g., a review by editorial staff rather than by peers),
providing false information to an author concerning the review process, utilizing a
personal or political agenda for decisions regarding publication (unrelated to the
material’s scientific merits), and/or pilfering ideas from a manuscript (Lafollette,
1992). Editors can also “stack the deck” politically for or against a manuscript by
sending it to reviewers that they know will either accept or reject it.
Besides being ethically unacceptable, there are several types of research
fraud that are also illegal: intentionally publishing false or nonexistent data, deceit
in authorship, forgery of an author’s signature (real or fictitious), copyright
194
offenses, and plagiarism (Lafollette, 1992).
Chapter Summary
1. The Nuremberg Code of 1946 outlined the ethical principles that are currently
used in scientific research. The United States Government has also mandated the
establishment of Institutional Review Boards in all institutions receiving federal
funds. Their purpose is to approve and monitor research and assure that subjects’
rights are protected.
2. Informed consent in a research context is a legal term which refers to the decision
a person makes freely and independently to participate as a subject in a research
project after having been fully informed of all pertinent information, as well as all
potential risks and benefits to him or her. Three important principles underlie
informed consent: 1) the capacity of the individual to comprehend the information
provided (which may be compromised by age or physical, emotional or intellectual
functioning), 2) the completeness of the information provided, and the effectiveness
with which this information is presented, and 3) the freedom with which the
individual makes the decision (which may be compromised by dual relationships,
coercion and subject vulnerability). There are necessary components that must be
included in all written consent forms.
3. There can be many types of injury to subjects: psychological, physical,

intellectual, social, economic, and legal. Also, breaches of confidentiality or
privacy, coercion and deception and invalid research findings also constitute
potential sources of injury. The intensity, duration and potential for risks to occur
must be minimized by the researcher. Researchers are called upon to assure that the
benefits of research outweigh its risks through a risk-benefit analysis.
4. Maintaining confidentiality of research data may be the most sensitive ethical

issue in research. The right of the subject to decide if information about him or
herself will be shared with others, as well as the type of information to be released
is paramount. If this ght is compromised, the welfare of the subject is in jeopardy.
Additional precautions for maintaining confidentiality are required when data are
sensitive, when subjects are vulnerable, when certain data collection methods are
used, and when other parties have access to data.
5. Researchers must be competent in the methods being tested and in the research
process itself. Objectivity and integrity are core values in making decisions about
the research methods that will be used, how the information will be communicated
and how the data will be managed.
6. There are a number of ethical issues involved in the use of various research
designs. Sound scientific designs may not always be sound in an ethical sense, and
researchers must consider the welfare of subjects as primary. The use of deception
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in research is inconsistent with the requirements of informed consent.
7. Clients’ specific vulnerabilities pose additional risks when they participate in

research. Issues of coercion, confidentiality, and injury may be amplified by these
vulnerabilities, and researchers must be cognizant of the need to exercise additional
precautions and safeguards in obtaining informed consent and in implementing the
research.
8. Ethical issues may also arise in the conduct of research within qualitative or
historical paradigms. When human subjects are involved, their rights in research
remain the same as in a quantitative paradigm.
9. Dissemination of research results through conference presentations or

publication is the end of one part of the research process and the beginning of
another, wherein the scientific community has the opportunity to study and evaluate
the research findings. Authorship involves the assignment of credit to individuals
involved in the research. Authorship acknowledges the researcher’s scientific
contribution to the field, and as such implies both a benefit for the individual and
a responsibility to the discipline. Authorship should be assigned according to
contributions made to the research.
10. Peer review involves complete, objective and honest scrutiny by recognized
experts of research papers, publication submissions, grant proposals, etc. Peer
review is an essential component of the research process, and necessitates
competence, objectivity, and confidentiality on the part of reviewers.
11. Fraud may occur when an author, editor or reviewer uses a falsehood or
deception to obtain an unfair benefit or to intentionally harm the rights or interests
of others
Ethical Dilemmas
1. Mary Jane, a music therapist working with clients who have problems with
substance abuse, conducts a research study which examines the effects of music
therapy in reducing stress. She employs a treatment which combines music and
progressive muscle relaxation and compares this to a treatment using music alone.
While implementing the study, two of her first three subjects have extreme cathartic
reactions to the procedures. She is surprised by these results, but considers them
to bea “fluke” and decides to continue with the research.
2. George is hired to conduct a music therapy study with patients in intensive care.
He plans to examine the effects of music therapy on heart rate and anxiety using an
experimental-control group design. His research protocol has been approved by the
hospital’s Institutional Review Board. As he meets with potential subjects to obtain
their informed consent, the vast majority of them state that they are very interested
196
in participating in the study, but will only consent to participate ifthey are assigned
to the experimental group and not the control group.
3. Bert is conducting a study involving the projective music responses of

adolescents with psychiatric problems. In this study, subjects listen to short excerpts
of music and sounds and are asked to write a story about what they hear. He
protects the subjects’ confidentiality by not attaching names to their stories;
subjects include only their age and sex on their story forms. After he has completed
the testing procedure and begins to read and analyze the stories, he becomes
extremely concerned. One of the subjects, identified only as ‘‘male” and “17,” has
written a vivid story in which the main character plans and executes a mass
shooting at a high school. He is especially worried because, in the story, the subject
writes in the first person.
4. Simone, works as a music therapist in a school for children with psychological

difficulties; many are very shy, quiet and withdrawn. She is conducting a research
study that examines the effectiveness of specially-designed group music
improvisation experiences in facilitating subjects’ assertiveness with others. The
treatment procedure is designed to last for six weeks, and subjects receive music
therapy three times a week. After the fourth week, one of the subjects comes to the
session very upset. He tells her that he would like to withdraw from the study, as his
parents had punished him severely for “not listening to them” and for “‘answering
back.”
5. Gilda previously worked as a music therapist with terminally ill patients in

another part of the country. She receives an invitation to write a chapter for a book
on music therapy in palliative care. The editor of the book asks that she emphasize
the music therapy approach she used with her clients and also include case
examples. She wants to include two very moving case examples in particular from
her work. Because she does not know how to contact the clients’ families for their
permission to publish the examples, and because the clients involved are no longer
living, she feels that it is ethically acceptable to include their cases in her chapter.
6. A very wealthy music therapy graduate student, Gregory, (yes, readers, this one
is definitely a fictitious example), is trying to complete his thesis which involves the
use of music therapy to enhance the self-esteem of economically disadvantaged
children. He has had a great deal of difficulty in recruiting subjects for the study,
and decides to offer subjects’ parents $500 for allowing their children to
participate.
7. Pedro, a music therapist working at a large state institution, has assisted his
colleague, Selma, with a research project. The research was completed, and Selma,
as first author, wrote up the final paper. Selma submitted the paper to the Journal
of Music Therapy, and it was accepted for publication. Pedro, as second author,
received the required forms from the Journal to sign before the study is published.
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As he reads through the final paper, he is shocked to find that Selma has falsified
some of the data.
8. Rose Marie has received grant funding to conduct a longitudinal study involving
the use of music therapy to minimize the developmental delays of children who were
born prematurely and to provide support to their families. The study design requires
a weekly music therapy session with the children and their families in their homes
for a period of three years. Needless to say, she becomes very familiar with
research subjects and also quite involved in their lives. As the three-year period
comes to an end, she begins to implement termination procedures to obtain closure
with the subjects. Several of the families are still experiencing a great deal of
difficulty in coping with the problems that resulted from their child’s low birth
weight, and are very distraught with the idea that Rose Marie will “abandon” them
when they need her the most. In addition, many of the children have made
significant progress in music therapy, and the parents are afraid that they will
regress significantly if they do not continue to receive music therapy services.
9. Dr. Fierov Tenure, is a music therapy professor at a large university. He has

been supervising the master’s thesis of Padma, and has devoted a significant
amount of time and energy to the project. Padma has achieved some nice results
concerning the use of music therapy as a treatment for clients with eating disorders,
and would like to submit her paper for publication. Dr. Tenure insists that his name
be included on the paper as a second author, because of the extensive amount of
time he has devoted, and because this has detracted from his work on some of his
own research projects.
10. Carolyn is an experienced clinician and researcher who serves as a consulting

editor for Music Therapy Perspectives. Because she is an expert on the use of music
therapy with autistic children, she receives an article on that topic to review. She
is extremely surprised when she reads the article, « it is very similar to the article
she is currently preparing for publication. She also s .;pects that she knows who the
author is (it’s a small world), and that this particular author stole the idea for this
article from a presentation she made at a recent music therapy conference.
11. Dr. X. Perimental, is a music therapy professor « a midwestern university and

teaches the music therapy research course that a:i of his graduate students must
take. Dr. Perimental strongly believes in experiential learning, and that students
cannot learn to be good researchers unless they actively participate as subjects
themselves. For this particular semester, he is requiring his students to participate
in his personal study which involves the use of drumming to induce trance-like
states. Students who don’t participate or who do not complete the study are docked
one letter grade for the course.
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1. Using the criteria provided at the beginning of this chapter, design a research
consent form for a study you would like to undertake, or for a study already
published in a music therapy journal. Share this with a peer and solicit his or her
feedback and questions.
2. Design a special consent form for a study with children, geriatrics, AIDS patients,
or another vulnerable population, taking into consideration the particular risk factors
involved.
3. Pick an area of research ethics, e.g., confidentiality, the potential for injury, etc.,
or research ethics with a particular clinical population, e.g., prisoners, for further
study. Consult textbooks and do a literature search on the topic. Write a short to
moderate length paper and include specific implications for music therapy research.
4. Have a discussion with your classmates concerning how you might ethically
conduct research as a music therapy clinician. Discuss the similarities and
differences between research and clinical practice.
5. Have a discussion with your classmates concerning what might constitute risk or
injury to subjects in music therapy research, and precautions that may be exercised
to avoid these.
6. In your course journal, explore any reactions you might have to particular
sections of this chapter. Reflect upon how it might be for you to participate as a
subject in music therapy research and to conduct music therapy research with
subjects yourself. What would your needs be as a subject? What would you like to
provide for your subjects as a researcher?
FINANCIAL AND ADVERTISING ISSUES
& RESPONSIBILITIES TO THE PUBLIC
ser
Che first part of this chapter presents information particularly relevant for
music therapists who are engaged in private practice, contractual work and/or
consulting. Ethical standards obligate the music therapist to establish sound
financial practices. Problems associated with managed care are also discussed.
The second part of this chapters is devoted to issues concerning the
advertising of music therapy services and to the various commercial activities in
which music therapists might be engaged.
The third and final section ofthis chapter includes a discussion ofthe ethical
issues involved in providing information about music therapy to the general public
and through the media.
Part 1: Financial Issues
Fees and Informed Consent
The establishment offees for music therapy services by private practitioners

is a task that combines (and sometimes juxtaposes) issues ofclient welfare, business
needs, qualifications, types of services offered, the professional’s self-esteem as
well as the client’s ability to pay. Fees for private music therapy services vary
across the United States, and appear to be influenced by issues such as: location
(e.g., costs in the Northeast and West Coast may be somewhat higher), length and
type of session (e.g., Guided Imagery and Music sessions may typically last two
hours, whereas sessions with developmentally disabled clients may be less than an
hour), clinical population served (e.g., psychiatric, normal, developmentally
disabled), and training of the therapist (e.g., bachelor’s or master’s degree or
specialized training).
According to the most recent data (AMTA,1999), approximately 7% of
music therapists work with the job title, “Self-Employed/Consultant,” and
approximately 26% of music therapists report some type of private practice
activities. The average fee for group and individual sessions 1s a little less than $50
per hour, and rates for consultation are higher. AMTA states “As the healthcare
market manages and monitors costs more carefully, music therapists must be
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accountable for the full range of cost factors involved in delivering services”
(AMTA, 1999, p. 239). In the United Kingdom, there are established minimum
hourly fees for music therapy services (see APMT Code of Ethics in the Appendix).
Whatever the case may be, therapists are ethically bound not to exploit the client's
vulnerability in financial matters (Koocher & Keith-Spiegel, 1998),
Not all clients can afford to pay the entire cost of private music therapy
services! Professional music therapy codes of ethics in Canada and the United
States require music therapists to take into account the client's ability to pay, as the
client’s needs and welfare are more important than financial considerations.
Although data are not available, it is likely that at least some music therapists in
private practice may offer sliding-scale fees for clients (based on income) who are
unable to pay the full rate. Therapists may also consider payment schedules over a
more extended period of time for clients experiencing financial difficulties,
Some clients are not able to pay even the smallest amount for music therapy
services! Although not specifically required by codes of ethics in the music therapy
profession, other professional codes (e.g., psychology) require therapists to provide
some pro bono (free) services to clients who are unable to pay. The therapist
continues to be obligated to ethical and legal standards when providing these
services (Peterson, 1996). When pro bono services are offered to some clients, these
arrangements should be determined prior to the beginning of treatment. Unpaid
accounts that are considered pro bono after the fact make the therapist vulnerable
to professional sanctions (Bennett, et al., 1990). For some professions, clients who
are completely unable to pay for treatment, may be referred to other sources (¢.g.,
community agencies) for more affordable services. Whereas this may be an ethical
practice technically, the present author contends that this practice is indeed ethically
questionable in music therapy, especially given the lack of potential sources of
music therapy treatment in many locales. It is hoped that music therapists will
negotiate payment options, including the possibility of pro bono work, external
funding, etc., so that the client in financial distress may have access to music
therapy treatment. Bartering with clients, 1.e., exchanges goods for services, is not
an ethically sound practice because of the risks of the establishment of dual
relationships. This issue is discussed in Chapter 6.
Certainly, ethical practice necessitates a consideration of the clients’ welfare
insofar as fees are concerned. Thus, the ways that fees are established and
communicated to the client, as well as how fees are handled and collected are
important ethical considerations. As discussed in Chapter 4, therapists are obliged
to provide a full disclosure of the fees required for services, as well as their payment
and collection policies as part of the informed consent process, so that the client
may make a responsible decision regarding treatment. Besides making this
information available at the beginning of therapy, an open discussion of costs may
occur at any time during treatment (Koocher & Keith-Spiegel, 1998). Therapists
should also inform clients of any potential requirements and limitations of third-
party reimbursements, e.g., the number of sessions, deductibles, exclusions and
copayments (Keith-Spiegel & Koocher, 1985).
Consideration should be given to the client whose insurance reimbursement
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runs out in the middle of treatment or who experiences an unexpected financial

crisis during treatment. In the former situation, it may be possible to anticipate in
advance the number of sessions required and estimate the limits of insurance
coverage, and to inform the client of this through informed consent. When done in
advance, there are no financial surprises for the client, and other types of financial
arrangements can be made for additional payment. In the latter case, it is certainly
not possible to anticipate that the client may become unemployed and unable to pay
for treatment! And it is also the ethical responsibility of the therapist not to abandon
the clicnt in the midst of needed treatment, especially for financial reasons;
abandonment is an issue that increases the therapist’s vulnerability to litigation as
well (Koocher & Keith-Spiegel, 1998).
Therapists should be very careful about raising fees during treatment,
especially when the client has agreed to a particular fee at the beginning of
treatment. He or she has the right to expect that there will be no excessive increases
(Koocher & Keith-Spiegel, 199%).
Therapists should provide information to clients during the informed consent
process about his or her policies regarding payment for missed sessions or sessions
cancelled on very short notice. If the policy of the therapist is to charge the client
in these situations, he or she must explicitly provide these details to the client in
advance.
Therapists should be very careful in using “‘soft-sell” or “hard-sell” tactics,
e.g., “Music therapy will help you get better, and it 1s an important investment in
your well-being” or “You can’t afford not to have music therapy for your problem”
to coerce or pressure potential clients into entering treatment (Koocher & Keith-
Spiegel, 199%). Besides implying a guarantee for treatment, which is an unethical
practice in and ofitself, it represents an exploitation of the therapist’s power and the
client’s vulnerability.
Fees impact the client financially, personally, emotionally and sometimes
transferentially within the therapeutic relationship, and as such may become a
therapeutic issue warranting discussion. Thus, it is especially important for
therapists to consider informed consent regarding financial issues, not as a single
occurrence, but as a process throughout therapy (Koocher & Keith-Spiegel, 1998).
Fee Splitting
Fee splitting refers to the practice ofproviding part of the sum a client pays
for services back to the person/source who referred the client (1.¢., a kickback).
This is usually done by prior arrangement between the parties. For example, in a
music therapy private practice, the music therapist may pay part of the client’s fec
for services to the psychologist who referred the client to him or her. This practice
may exploit the client, who is usually unaware that this is happening. The referral
may be in the best interest of the client, or it can be made simply for financial
reasons, in which case the service is not needed by the client. Further, fee splitting
may result in increased costs to clients for services. Fee splitting by music therapists
is prohibited by a number of the professional ethics codes.
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Ethics codes of other professions have generally prohibited fee-splitting

(Dileo-Maranto, 1981b; 1984). However, significant changes in regulations by the
Federal Trade Commission regarding fee splitting, prompted revisions to the Ethics
Code of the American Psychological Association (Koocher & Keith-Spregel, 1998),
no such changes have been reflected in the codes of ethics of the music therapy
professions. The current APA Ethics code now permits fee splitting, as long as tts
based on the services provided and not on the referral itself. In addition, fee splitting
is permitted in employer-employee relationships (APA, 1995), Clients also need to
be informed about fee splitting arrangements.
In employer-employee relationships where there is fee splitting, employers
take a percentage of fee paid by the client. When actual services are rendered by the
employer, such as in supervision of the employee, this practice is considered to be
appropriate. When no services are provided by the employer, this practice may be
unethical (Koocher & Keith-Spiegel, 1998). The AMTA Code of Ethics permits
music therapists to accept payment for services rendered directly by themselves or
under their supervision. Similarly, the CAMT Code of Ethics requires that music
therapists who subcontract work to another therapist are entitled to appropriate fees
for the services they provide.
Billing Practices and Fraud
For music therapists whose services are covered by third-party payment (and
according to AMTA 1999 data, approximately 23% of music therapists receive third
party reimbursement, although it is not known how many of these therapists are in
private practice), there are a number of issues that may constitute unethical and
illegal billing practices and/or fraud.
In the field of psychology, the majority of legal and/or disciplinary actions
taken against professionals, including license revocation, are the result of
inappropriate billing practices, such as the alteration of a diagnosis and the failure
to collect the required copayment (Peterson, 1996). Psychologists report financial
issues as among the top three ethical problems in practice (Pope & Vetter, 1992),
In addition, Pope et al., (1987) found several common high-risk business practices
reported by psychologists, including: changing the client’s diagnosis so that
reimbursement could be obtained (61%), bartering with clients (25%), and loaning
clients’ money (26%).
Most health insurers require a diagnosis of the client’s problem for payment
to be issued (Koocher & Keith-Spiegel, 1998). Music therapists, with the exception
of those who hold an additional license to do so, are not able to provide an official
diagnosis. Therefore, another professional may be required to do this for the music
therapist.
Moreover, insurance carriers often reimburse for specific services and
procedures. Billing companies for services not actually rendered to clients, or
deliberately concealing the service provided, is a fraudulent practice. Fraud is
legally defined as an act committed with the intent to deceive and which causes
harm or injury. There are four basic requirements for classifying a behavior as
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fraudulent: “First, a false representation is made by one party, who either knows it
to be false or is knowingly ignorant ofits truth...Second, the misrepresenter’s intent
is that another will rely on the false representation. Third, the recipient of the
information is unaware of the intentional deception. Fourth, the recipient of the
information isjustified in relying on or expecting the truth from the communicator.
The resulting injury may be financial, physical or emotional” (Koocher & Keith-
Spiegel, 1998).
Some therapists charge clients a reduced rate for services that are not
covered by insurance (and paid for in cash), and a higher rate for those services that
are covered. Although this practice is questionable and may be in violation of
companies’ contracts with providers, it is rationalized by some in legal terms by the
fact that less paperwork is involved, and hence a lower fee may be charged. Other
contractual violations may include failing to collect clients’ copayments (and
essentially lowering the fees that are claimed to insurance companies), billing
clients for the difference between what the insurance company pays and what the
therapist’s fee is, even though there is an agreement with the insurers not to do so,
and misstating his or her charges on insurance claims forms (Koocher & Keith-
Spiegel, 1998). Additional fraudulent practices include billing insurers for missed
sessions, misstating the actual provider of services, and misrepresenting family or
group treatment as individual services (Peterson, 1996).
Bill Collecting
Disputes regarding fees comprise the most common type oflegal complaints
taken against psychologists (Bennett, et al., 1990; Woody, 1988). Therapists
working in private practice may find themselves in a position to pursue payment for
services when clients fall behind in what they owe. Because of the sensitive nature
of the client-therapist relationship, and the vulnerability of the client, this matter
warrants special handling. Therapists should discuss the situation frankly with those
clients who are still involved in treatment. However, most often debts are owed by
clients who terminate (Koocher & Keith-Spiegel, 1998).
In extreme circumstances, some professionals have taken their clients to
small claims court. The fact that the identity ofa client is revealed in a public forum
is a serious matter for concern regarding confidentiality, and indeed it is necessary
to give the client sufficient warning that this will occur. Other professionals have
used fee-collection agencies, which operate as an agent of the therapist in procuring
the amounts owed. Although this procedure is more private, the therapist is held
responsible for any abusive, threatening, inappropriate collection strategies or harm
to the client (Koocher & Keith-Spiegel, 1998). Therapists may indeed have the right
to use these agencies, but they also have the responsibility to inform clients about
this practice during the informed consent procedure. Therapists are also obliged to
find other solutions for delinquent accounts and also to adequately notify clients
before collection agencies are employed.
It is not uncommon for clients to file complaints against therapists who use
these types ofbill collection strategies (Peterson, 1996), and there is also evidence
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that threats and probability of malpractice litigation increases for clients who are
seriously in arrears in their debt payments (Woody, 1988). Therapists must avoid
using their power in the relationship and their knowledge of the client to collect
debts (Koocher & Keith-Spiegel, 1998)!
Managed Care
Managed care is a method for the delivery of health care services which has
emerged during the past decade (Scott, 1998). The managed care system stresses
prevention and cost-containment, as well as short-term, cost-effective interventions.
(Corey, et al., 1998). The advent of managed care has implied profound changes for
all health care professionals (Scott, 1998) and has created a host of ethical issues
within patient care. To say that managed care has been controversial among both
consumers and professionals is a true understatement! Several of the ethical issues
which have emerged within the managed care system are discussed in this section,
although it is not the present author’s intent to provide a comprehensive review of
the issue.
Because of the overriding necessity of cost-containment, one implication of
managed care for professionals has been an expansion of their roles and
responsibilities, into supervision, administration, education, research, and
consulting, to name a few (Scott, 1998). Another implication is the requirement for
professionals to become skilled in formulating treatment plans rapidly, in limiting
the scope of treatment goals, and in using methods that achieve rapid results with
the client (Foos, Ottens, & Hill, 1991). Therapists must do more with less (Scott,
1998). Austad (1996) reports that some professionals feel that managed care
systems are unethical because they provide a financial motivation for professionals
to limit or withhold care. Within this system, therefore, there are inherent incentives
for: refusing and restricting access to long-term treatments, limiting clients’ choices
of providers, interfering with the continuity of treatment, using less-qualified
professionals for treatment and for reviewing services, breaking the patient’s
confidentiality in review procedures, and relying on business ethics instead of
professional standards.
Thus, some of the primary ethical issues for therapists working in managed
care include the following: 1) competence; 2) conflicts of interest, 3)
confidentiality, 4) continuity of care, and 5) informed consent. These issues are
interrelated.
Competence. Therapists need to have skill in implementing effective time-
limited treatment. As they must be able to respond to a variety of clinical problems
in an effective manner, an eclectic approach is required (Haas & Cummings, 1991).
Additionally, therapists must guard against assuming responsibilities dictated by
managed care organizations that are beyond their competence, and must also be
vigilant concerning the competence of others providing treatment and review.
Conflicts of interest. Managed care may require therapists to choose
between what their clients need and the restriction of interventions and goals to
maintain costs; these may be vastly different concerns (Haas & Cummings, 1991).
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The therapist’s primary consideration is the client’s welfare, first, foremost and
always. Helping to create a profit for the insurer is not a high priority when
balanced against the client’s needs.
Confidentiality. Managed care often requires therapists to submit diagnoses
and confidential client information for reimbursement and for external review. The
therapist cannot assure that this information is protected once it leaves his or her
office. The therapist must take every precaution necessary, including limiting the
amount of information provided (but not fraudulently altering it) to the bare
minimum, informing the client of the possible risks involved in submitting this
information, and obtaining his or her informed consent to do so.
Continuity of care. Insurers may dictate for example, that a client is entitled
to 5-6 sessions of reimbursed coverage for his or her problem. What happens when
the reimbursement ends and the client’s problem persists? The therapist is ethically
and legally obligated not to abandon the client, especially during a crisis situation,
and the therapist is responsible for making provisions for the client’s continued
care, for example, through reduced rates, through pro bono arrangements, through
referral, etc.
Informed consent. Clients are entitled to know about the limits of treatment,
referrals and confidentiality imposed by managed care companies. This information
must be clearly communicated during the informed consent process prior to
treatment. The client may be informed that the managed care coverage may not be
sufficient in terms of the number of sessions reimbursed to treat the client’s
problems. Clients have the right to decide for themselves how they will approach
therapy in light of these known restrictions and limitations.
Part 2: Advertising and Commercial Activities
The manner is which music therapists in private practice announce/advertise

their services has important ethical implications for the profession. As the nature of
amusic therapist’s advertisements reflects directly on the integrity of the profession
and influences the public’s perceptions of music therapy, caution and restraint are
necessary to assure that this information conforms to professional, rather than
commercial standards.
In a similar manner, music therapists may be involved in or consulted on a
number of commercial activities, involving products for music therapy, equipment,
CDs, cassettes, books, etc. The manner in which these products are presented to
professional or public audiences again can contribute to their perceptions about
music therapy in either positive or negative ways.
Advertising/Announcing Services
What is clear in advertising and announcing services is that professional

standards change over time, and what is allowed today may be quite different ten
years from now. Requirements for ethical advertising have become more liberal
during the past twenty years, as a result of federal and state regulations.
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For example, in 1989, the field of psychology, in an emergency action taken

in response to decisions and regulations of the Federal Trade Commission, removed
previously existing prohibitions from their Code of Ethics. The prohibitions lifted
have permitted psychologists to use the following in advertising: testimonials from
patients, claims for unique or one-of-a-kind services, appeals to patients’ fears if
they do not obtain services, statements regarding the desirability of one service over
another, and direct solicitation of clients. In spite of the liberalization of this code
regarding advertising, however, psychology state licensing boards may implement
more restrictive advertising requirements (Koocher & Keith-Spiegel, 1998;
The codes of ethics of the various music therapy associations have not
liberalized their requirements for advertising as has the field of psychology. The
Code of Ethics of the American Music Therapy Association (1999 - see Appendix),
is quite specific regarding what is permitted. Ethical standards for advertising listed
in the AMTA code (1999) are included in the following sections with a brief
explanation of each statement.
*“The MT will adhere to professional rather than commercial standards in
making known his or her availability for professional services. The MT will offer
music therapy services only in manner that neither discredits the profession nor
decreases the trust of the public in the profession.” (AMTA, 1999, 10.1). “The MT
will make every effort to ensure that public information materials are accurate and
complete in reference to professional services and facilities” (AMTA, 1999, 10.3).
Professional standards are those used by members of various helping professions,
including medicine, psychology, social work, etc. Commercial standards are those
relied upon by businesses and companies that are selling a service or product, e.g.,
carpet-cleaning, food products, etc. When one considers the dissimilarities in the
intent of professionals versus commercial businesses, the differences in the
requirements for advertising become striking indeed!
A most important consideration is the vulnerability of the individuals who
might comprise the intended consumer groups for professional services (although
these persons cannot be solicited directly), and their need for accurate information
about the professional who is offering these services. Whereas potential consumers
may be relatively unfamiliar with the profession of music therapy, generalizations
from one inappropriate advertisement can easily extend to and color perceptions of
the entire field.
*“The MT will avoid the following in announcing services: misleading or
deceptive advertising, misrepresentation of specialty, guarantees or false
expectations, and the use of the Association’s logo” (AMTA, 1999, 10.4). The
information contained in advertisements for music therapy services, for example
regarding its applications and efficacy, should be based only on current research
findings, and even then, should be stated very cautiously. Even though a music
therapist may have had substantial clinical success in using music therapy to treat
a particular clinical problem, to make these claims without the support of controlled
research is unethical. Also, as there are no data yet which indicate overwhelmingly
that music therapy is 100% effective with all clients who have a particular clinical
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problem, the information provided in advertisements should not mislead the reader
to assume that this is the case. Likewise, advertisements which suggest that there
are guarantees for music therapy services or unrealistic expectations for success are
both inappropriate and unethical, e.g., “Money-back guarantee!”
The music therapist must accurately represent his or her specialty in
advertising materials. For example, if he or she has completed a six-month
internship with autistic children, this does not constitute a claim for a specialization!
Although there are no hard and fast guidelines regarding what does constitutes a
specialty, one might reasonably assume that specialized training and certification
in a music therapy method or approach, such as the Bonny Method of Guided
Imagery and Music, Analytical Music Therapy or the Nordoff-Robbins approach,
or a non-music therapy approach, such as biofeedback, would be appropriate.
Advanced degrees in music therapy and/or substantial clinical experience with a
particular clinical population or problem, might be acceptable as a stated
specialization as well.
The music therapist should not imply any endorsement of the professional
association in his or her advertisements. For example, using the logo of the
association or including his or her membership or function in the association
(beyond what is implied through professional certification) is unethical. The music
therapist may of course use his or her professional credentials obtained through an
association or organization, such as “MT-BC,” but not the statement, “professional
member: American Music Therapy Association.” For example, the present author
could not ethically use her positions as Past-President of the National Association
for Music Therapy or the World Federation of Music Therapy in her announcements
of private practice, as this might imply an endorsement of these organizations, and
an inappropriate and irrelevant claim for particular skills or specialization.
*“The following materials may be used in announcing services (all of which
must be dignified in appearance and content): announcement cards, brochures,
letterhead and business cards. The MT may include the following on these
materials: name, title, degree, schools, dates, certification, location, hours, telephone
number, and an indication of the nature of services offered” (AMTA, 1999, 10.6).
The following information is an example of an ethically appropriate advertisement:
Cheryl Dileo, PhD, Music Therapist-Board Certified

Bachelor’s and Master’s in Music Therapy,
(Loyola University of the South, 1971;1975 )
PhD in Music Education for College Teaching,
(Louisiana State University, 1981)
Specializing in the treatment of adults with medical problems.
Humanistic music therapy approaches used to address
physiological, psychological, and social aspects of illness.
Individual and group sessions available.
110 Locust St. Philadelphia, PA 19140
Hours: Monday-Wednesday-Friday, 10:00AM - 6:00 PM
Phone: 215-665-2903
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It is important to include only the academic degrees relevant to music

therapy practice. To list as a credential an M.A. (in business for example), is not
relevant and may be misconstrued as advanced training in music therapy. (Note that
the author listed specifically the focus of her PhD above, to emphasize that this
degree was not in music therapy). Only music therapy degrees from universities
approved by the American Music Therapy Association should be included. In
addition, such titles as, A.B.D. (all but dissertation, or PhD candidate) should be
avoided, as these are not earned degrees.
Contrary to what is currently acceptable within the Code of Ethics of the
American Psychological Association, music therapists may not use testimonials
from present or former clients in their advertising, e.g., “This worked for me, it will
definitely work for you!” Likewise, music therapists must not use any competitive
types of advertising, e.g., “You’ve tried the rest, now try the best,” “Music therapy
is more effective than traditional stress-management procedures” or “I’ll beat any
one’s rates: guaranteed lowest prices!” Moreover, music therapists may not appeal
to clients’ fears regarding the services offered, for example, “Stress kills; stress
reduction through music therapy is a must!” or distinguish themselves as offering
unique or one-of-a-kind services, for example, “I’m the only music therapist in this
state who is specialized in and qualified to treat children with Rett’s syndrome.”
(The author apologizes for the glaringly unethical examples used to stress the
intended points). The music therapist should also refrain from “tacky” slogans, e.g.,
“The music therapist who really cares” misleading names of their practices, e.g.,
“Music heals,” or special offers, “First session free!” The use of testimonials as well
as the making of claims regarding the superiority of music therapy or the music
therapist over other music therapy or non-music therapy professionals, is expressly
prohibited by the Australian Music Therapy Association.
*Announcing services through the mail (to other professionals) and through
listing in the telephone directory are acceptable. No advertisement or announcement
will be rendered in a manner that will be untruthful and/or deceive the public”
(AMTA, 1999, 10.7). To whom does the music therapist advertise? The music
therapist may announce services to other professionals or professional agencies who
might serve as referral sources for his or her private practice. Music therapists are
not permitted to send announcement directly to potential clients or clients’ families.
The only type of direct advertising may be through a listing in a telephone directory,
and only the information specified above may be included.
Of course, the music therapist may develop brochures describing his or her
services, and these may be distributed to persons who request further information.
For example, a referring psychologist may direct a potential client to a music
therapist, and the music therapist may ethically send him or her a brochure.
According to the restrictions stated in the AMTA code of ethics (1999), it
is therefore implied that music therapists are not permitted to advertise in
newspapers, through the media (radio or television), or through the internet. Of
course, as ethics codes are reactive more than proactive (see Chapter 1), the whole
issue of the internet has yet to be explored in the music therapy codes. This is
described in more detail later in this chapter.
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*As stated in the ethical codes of the American, Australian, and Canadian
Music Therapy Associations, the music therapist is not permitted to solicit clients
receiving music therapy from other music therapists. Furthermore, the codes state
that music therapists are not permitted to solicit clients for their private practices
from the agencies in which they are employed.
Finally, according to the American and Australian music therapy codes,
music therapists who also maintain a private music teaching studio must distinguish
between the two services they are offering and the different natures of the
professional relationships established with their students and clients. They may not
offer music therapy to the students who come for music instruction and visa-versa.
In summary, the music therapist is accountable for the way that he or she,
as well as the profession in general, is represented to the public and to other
professionals in advertising and announcing services. Music therapists who are
developing advertising materials are strongly advised to seek feedback from expert
music therapy colleagues before these materials are published. It is important that
these materials are factual, accurate, dignified and professional, and that the music
therapist exercises appropriate caution and good judgment both in their content and
in their dissemination.
Commercial Activities
In recent years, there has been a burgeoning interest within the public sector
for products, including equipment, CDs, cassettes, and books, related to music self-
help strategies. These products have been developed by music therapists
themselves, by music therapists in consultation with various companies, by non-
music therapists, or by various companies and manufacturers who have sought
endorsements from music therapists to promote sales. There has also been a surge
in equipment and products designed for use by music therapists and other
professionals in their work with clients.
There are a number of both distinct and interrelated ethical issues involved
in these commercial activities, including: 1) the potential conflict for music
therapists in developing and promoting self-help products, as self-help with music
is clearly different from the process of music therapy, 2) the claims made about
these products, many of which have not been tested empirically for their
effectiveness, 3) the conflict created when music therapists are given financial
incentives by the developers of these products to test them, 4 ) the conflict created
when music therapists are asked to provide testimonials or endorsements (paid or
unpaid) of these products/equipment to the general public and to other
professionals; and 5) the potential conflict of interest for music therapists who
dispense products/equipment to clients. Unfortunately, these issues are not clearly
addressed in many of the music therapy codes, and the music therapist may feel lost
when confronting these situations.
Music self-help products are ubiquitous. The number of tapes, CDs, books
and equipment available in various catalogues and/or on the internet is astonishing.
Although there are sometimes superlative claims made about the effectiveness of
210
these products (from reducing stress, to alleviating headaches to curing cancer), in

reality, it is suspected that few have undergone rigorous testing to assess this.
Whereas most professionals, such as myself, try to remain open to these new ideas,
a great amount of scepticism is always present in the absence of scientific data. The
aforementioned issues regarding commercial activities are discussed below.
* Music therapists themselves may be the persons who develop
equipment/materials for self-help use by the general public, and may use their
degrees and credentials to promote sales of these. This is a most controversial area,
and there are two issues involved. First, do music therapists have the nght to
develop materials/products for the general public? Of course they do. However, in
doing so, it is important to refrain from identifying these products/materials as
music therapy materials/products. It is an ethical imperative to provide accurate
information to the public concerning music therapy; identifying music therapy as
a self-help process is a serious ethical mistake. This issue is discussed further in the
following section.
Second, music therapists must also be very cautious about using their music
therapy credentials or place of employment in the promotion and sales of these
products/equipment. They must consider if these credentials are relevant to the
products/equipment being sold, or if they are being used by the therapists to
promote their own financial gain. There should be no implied endorsement of the
products by the credentialing organization or the employer whatsoever.
* Music therapists should be alert to unsubstantiated claims regarding the
effectiveness of products/equipment being marketed to the public or to other
professionals, and should refrain from making such unsubstantiated claims for
products/equipment with which they have some involvement. As stated previously,
the current marketplace is flooded with these products/equipment, and the music
therapist has the responsibility of distinguishing between those that have been
appropriately tested in a scientific manner and those for which no data are available.
Music therapists would also be unethical in making claims for the effectiveness of
products/equipment that they have developed themselves without having tested
them adequately.
* Conflicts of interest may emerge when music therapists are paid by
manufacturers to test products that have been developed. As there is certainly no
ethical issue involved in whether these products should be tested, the financial
incentive given for testing may compromise the therapist’s judgment; it may be
unclear for him or her as to where loyalties lie, 1.e., to the potential consumers of the
product or to the manufacturer. If a music therapist were to engage in this type of
product testing, it should be done in a rigorously scientific manner, and it should be
clear to the manufacturer that only the objective results will be reported, whether
these results support or do not support the product’s effectiveness.
* Endorsements by music therapists of self-help products/equipment
intended for the general public are not appropriate, particularly when payment is
made to the therapist for doing this. The Code of Ethics of Australian music
therapists addresses this issue most directly: “The music therapist shall not allow
his/her name to appear in any advertisements for equipment (including musical
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instruments); The music therapist shall not give testimonials regarding equipment
or instruments” (AMTA, 1994, 3.6.ii, 3.6.iii). The other music therapy codes of
ethics do not prohibit endorsements per se.
In allowing one’s name to be used in a product endorsement, there are
several issues to be considered: 1) the intended audience of the
marketing/advertising, i.e., general public or professionals, and 2) whether the
music therapist is paid or not paid for the endorsement. In the field of psychology,
for example, endorsements by psychologists of products to the general public are
not considered appropriate for two reasons: 1) if the product is related to the field
of psychology, its merit should hinge upon the scientific data which support its
effectiveness, and not the word of the endorsing professional, and 2) if the product
is not related to the field, the endorsement is irrelevant (Koocher & Keith-Spiegel,
1998).
The endorsement of products to a professional audience may or may not be
considered ethical, depending on the accuracy of the endorsement and the intent of
the person endorsing. If he or she does so merely for financial gain, this practice is
questionable (Koocher & Keith-Spiegel, 1998).
Endorsements of products can occur even without the music therapist’s
knowledge or consent! For example, the present author was quite shocked and
dismayed to see a quote by her (which had been published in another source), along
with her name, and her position as President of the World Federation of Music
Therapy appearing on an advertisement for a new age CD! The quote (about the
potential relaxing effects of music) and her position were apparently intended to
imply her endorsement of the CD and attest to its effectiveness. Needless to say, the
present author did not ignore this situation!
* There are several potential ethical issues involved when music therapists
recommend purchase or dispense materials/products/equipment to clients. Both the
American and Australian codes of ethics address provide guidelines for such
practices. These guidelines can be summarized as follows: 1) commercial activities
of the therapist should not interfere with his or her responsibilities to the client or
colleagues; 2) the client must have a genuine need for the product and should be
allowed to make a free and uncoerced choice regarding its purchase; 3) the music
therapist should make no profit from this transaction, nor should he or she receive
a fee or commission from this transaction; and 4) charges for products should be
billed to the client separately from services rendered. In addition, music therapists
are not allowed to profit or receive a fee or commission for the sale of equipment
or instruments to their facilities or schools.
Part 3: Responsibilities to the Public
Several music therapy codes of ethics discuss the ethical responsibility of

the professional to increase public awareness of music therapy. As this ethical
principle appears sound and straightforward, however, it is not so in practice. When
the music therapist enters the world of mass media, (i.e., print, broadcast and
electronic media), he or she inevitably confronts a hotbed of ethical problems.
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Whereas music therapists are inevitably delighted to have the opportunity

to spread information about their beloved profession to large numbers of people,
there are many ethical risks inherent in doing this. Some of the primary ethical
issues are discussed in this section and include: competence, accuracy, control of
information, and offering treatment through the media.
Competence. There are many risks involved even when one provides
accurate, competent information to the general public (and these will be discussed
in more detail later in this section). These risks are exacerbated when the music
therapist providing the information does so in an incompetent manner.
The music therapist should have sufficient expertise to address the
publicized topic, and if not, should ethically refer the interviewer to another music
therapist. Because interviewers are often pressed for time, they may exert pressure
on the therapist to provide this information, and the music therapist should resist
yielding to this urgency. The present author has had many requests for information
from the media throughout the years, and has always been acutely aware of the
limits of her expertise. For example, requests for information on music therapy for
medical problems would most certainly be answered; information regarding music
therapy for the hearing impaired would be referred to another therapist. The present
author has had occasional urgent phone calls from former students and other
professionals who have been asked to do media interviews and have no idea what
to say on the topic! If the music therapist does not know a music therapist who has
expertise on the topic, it is a safe practice to refer the interviewer to the American
Music Therapy Association. The AMTA office staff are skilled in directing the
media to experienced music therapists in a variety of clinical areas.
The music therapist should accurately state his or her credentials and should
ascertain that these are cited correctly in the media materials. For example, it is
irresponsible ethically to allow oneself to be identified as “Dr.” when this credential
has not been earned.
Furthermore, the music therapist should be most cautious in providing
information on behalf of any person or organization other than him or herself
personally. In other words, unless specifically authorized to do so, the music
therapist may not serve as the spokesperson for the music therapy profession or
association. Direct and repeated statements to this effect to the interviewer are
appropriate.
Accuracy of Information. This is perhaps the area that poses the most
numerous ethical issues for the music therapist, no matter what type of media (e.g.,
print, broadcast, or electronic) is involved. The present author could include a long
list of her own media horror stories on this subject!
Even when the music therapist has the expertise and competence to provide
information to the media on a particular subject, an enormous amount of caution
needs to be exercised. The therapist must be acutely aware of the tendency of some
media personnel to sensationalize, distort, take statements out of context, exaggerate
or overgeneralize data, use irrelevant or unrelated comments, or treat information
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in a biased, superficial or casual manner.

When speaking to the media, the music therapist must avoid personal
opinion and rely primarily on current scientific information for the content of the
interview. This may often imply the need for the therapist to prepare for the
interview by reviewing the most recent research on the topic. Even when this is
done, it is extremely important to provide this information with a great deal of
caution. For example, even though the research may point to the effectiveness of
music therapy with a particular clinical population or problem, the therapist must
emphasize that these are the current research findings, are limited as such, and may
not be overgeneralized. The therapist should avoid absolute, definitive and
sweeping statements regarding the effectiveness of music therapy, and should be
most careful about the choice of words used, for example, using “may” “possibly,”
etc. When there are only limited data, the music therapist should represent this
information honestly and accurately, and not be afraid to state that the information
is not yet known.
The music therapist may have knowledge about the effects of music therapy
from his or her own professional experience. Again, the therapist should frame this
information as his or her personal observations and emphasize that these results
have not been empirically tested. The interviewer may prompt the therapist to draw
conclusions about music therapy, and the therapist should stress that this cannot be
done.
For a number of reasons, music therapists may intentionally distort
information about music therapy to the media. This is considered a serious breach
of ethics, and often the damage caused by this distortion is very difficult to undo.
Precautions for the Control of Information. As just stated, once inaccurate

information is disseminated, it is very difficult to retract, and the harm to the
profession may have already been done! Therefore, the music therapist should make
every effort beforehand to exercise control over the information provided. These
precautions are not always easy to implement, and the music therapist may
sometimes need to make a decision not to provide the requested interview if he or
she feels that no control over its content can be exerted. The music therapist’s
attitude toward professionalism, accuracy of information, and caution should be
conveyed to the interviewer from their first moment of contact.
When contacted by the media, the music therapist should first determine the
purpose of the article or interview, the interviewer’s approach to the information,
and how the information will be used and disseminated. The therapist should
attempt to screen the interviewer for any possible sensationalistic predispositions
or approaches to the music therapy information. The therapist should also screen the
interviewer for general knowledge about music therapy. Sometimes interviewers
have “done their homework” and are able to pose thoughtful questions. When
interviewers have no knowledge about music therapy whatsoever, their questions
can be rather uniformed and unfocused, and there may be more chances for having
accurate information distorted. The therapist may sometimes provide the
interviewer with general background information on music therapy in written form
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before the interview is scheduled.

If the information will appear in print, it is very important for the therapist
to know about the nature of the publication, book, magazine, newspaper, etc. and
make the determination about the appropriateness of this publication to carry
information about music therapy. Indeed, the reputation of the publication may be
such that its mere association with information on music therapy could be damaging
to the profession, even if the information were accurate! The present author has
sometimes been contacted by freelance journalists who are writing articles which
they are attempting to sell to a publication, and they cannot identify at the time of
the interview where the article will appear. It is often risky to conduct interviews
without knowing where the article will ultimately appear, and the music therapist
would not be pleasedto have his or her quotes appear in a magazine with a
centerfold!
It is also risky for the music therapist to do interviews on the spot. As
stated previously, the therapist should prepare for the interview and review the
current literature. The present author always delays phone or other types of
interviews and sets appointments that allow her adequate time to prepare. If
interviews cannot be delayed until this is done, they are refused.
For interviews that will appear in print, it is highly advisable for the music
therapist to provide a written summary of his her statements to the interviewer
immediately following the interview. In this manner, the interviewer has this
information as a reference point for writing the article. Further, the interviewer may
also use this information to assure the accuracy of the quotes used. This practice
may serve to avert problems and misunderstandings.
It is also very important for the therapist to insist on having a copy of the
article (or at least the relevant section involving his or her input) for final approval
(and possibly revision) prior to its publication. The present author has learned to
make this her policy before a request for an interview is granted. If the interviewer
is not able to commit to this agreement, the interview is often refused. This practice
can prevent a number of problems: it can assure accuracy in the therapist’s
statements and allow for correction of any errors by either party, and it can prevent
information from being taken out of context. It can also prevent any irrelevant
information from being printed. If the information conveyed by the music therapist
is not presented in an acceptable manner, the interviewer should be notified (and it
is always important for the therapist to have a way to contact the interviewer should
the situation arise).
The present author has also been involved in situations where she has
conducted lengthy interviews with a journalist and provided a substantial amount
of information for specific articles. When the articles appeared in print, much of the
author’s information was used, and she was not given credit for any of it! Even
when an agreement to see and approve the article is established beforehand with the
interviewer, this may not happen, and there may be no way to prevent this situation
from occurring.
There are several other caveats for music therapists when conducting
interviews. The music therapist should universally refrain from making derogatory
215
comments about anyone. Even though these may be mentioned in passing, they may
later appear in print. The same rules apply to other offhanded remarks, comments,
jokes, gestures, etc. no matter how comfortable the therapist feels with the
interviewer or how trustworthy he or she may seem (Koocher & Keith-Spiegel,
1998). The music therapist would be greatly surprised and dismayed to see these
remarks in printed form for posterity to view.
Music therapists may also be asked to author mass media articles for
magazines or for the internet. In these situations, the music therapist may be able
to exercise a greater degree of control over content, although editors may change
this information in ways that would be unsatisfactory. In any of these situations, the
music therapist must be able to exert control over the final copy before it is
published. If any pictorial, video or audio representations of the therapist’s clinical
work are used, express permission must be sought from the client(s) involved, and
every effort should be made to protect confidentiality.
The music therapist should also exercise good judgment concerning the
topics for these articles (again using the aforementioned guidelines to assure
competence and professionalism and to avoid sensationalism, exaggeration, etc.) as
well as the venues for publication. Obviously, it would seem ethically unsound for
the music therapist to author an article on how to use music to improve one’s sex
life for a magazine that might be considered sexist in orientation. Although this may
be an extreme example (or maybe not), the reader undoubtedly gets the point being
made.
Music therapists may also author trade books (as distinguished from self-
help books which will be discussed in the following section), which are geared to
providing information on music therapy or specific topics therein to the general
public. The focus of these books is on providing scholarly information and research
in a manner that is easily accessible to the non-professional. When executed in a
competent, objective and cautious manner, these books may make important
contributions to the knowledge base of the general public and pose few ethical
issues.
Music therapists, like any other citizens, are free to write letters to the editor
of newspapers, magazines, or via the internet, expressing their opinions on topics
not related to music therapy, e.g., politics, social injustices, etc. In doing so,
however, they speak for themselves and not their profession, and therefore should
not include their professional status or credentials.
Television/Radio. Whether in live or pre-recorded television or radio

broadcasts, a similar amount of caution and control must be exercised. For example,
because of time constraints, the music therapist’s responses may be cut off even
before providing the appropriate information, and information may be edited so that
statements are taken out of context. Distortions may readily occur, and
sensationalism may be emphasized.
It is important for the music therapist to request informed consent
procedures from the show’s host and producer. A clear agreement on the ground
rules needs to be reached, including the show’s purpose and intent, the role of the
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therapist, the questions to be posed, a clarification of what the therapist is either

willing or not willing to discuss, and the names and roles of other guests and
experts. If such an informed consent agreement is impossible to negotiate, the
therapist may be well advised to decline participation (Pryzwansky & Wendt, 1999;
Stein, 1990).
Treatment Through the Media, Although it may not be a common practice

at the present time, music therapists may be asked to participate in call-in radio or
television shows or through the internet or printed media where either advice is
given concerning music self-help procedures or music therapy assessment or
treatment is provided. This is a highly controversial area, and it is important to
distinguish among the various practices of providing general information to the
public, giving advice to specific persons about how to use music for themselves, for
example, in stress management, or in conducting assessment/treatment for
listeners/viewers/internet users, for example, in designing and implementing mass
media programs to assist with health problems.
As indicated previously, the provision of appropriate, accurate, competent,
and cautious information to the public is an ethical responsibility. But the
parameters of this information-giving need to be clearly contained so that this
information is not misconstrued as advice-giving or assessment/treatment; the first
practice is ethically questionable, whereas the latter is clearly unethical. Distinctions
between the two practices may be quite fuzzy.
Although this issue is not directly addressed in the music therapy codes of
ethics, the codes are emphatic concerning the therapeutic relationship, i.e., music
therapy can only be offered within this context. This implies a face-to-face, person-
to-person relationship; this is not the case when advice or treatment is given through
the internet or media. Although music therapists may view these situations as
opportunities to increase public awareness of music therapy (and become the
pioneering “Frazier Crane’s of music therapy), the ethical implications of offering
advice or treatment are enormously negative, and the practice for malpractice
litigation abounds. Moreover, even if advice, assessment or treatment is not the
intent, music therapists may not take advantage of these media/internet
opportunities to solicit clients.
Self-Help Materials. Self-help materials, including books, CDs, cassettes

and other programs involving music are ubiquitous. For the present discussion,
these self-help materials are defined as those that: are created by credentialed music
therapists, are offered as an alternative to procedures implemented by a therapist,
are completely self-administered, and are readily available without the consultation
of a professional. Self-help materials can be classified according to the following
categories: how-to improve, how to control, and how to cope (Koocher & Keith-
Spiegel, 1998).
Some professionals may contend that these products provide a needed
service to individuals who may not have the time and resources for or access to
professional music therapy help, and who may be so motivated to use them. These
2417
products may indeed be beneficial. Obviously, members of the general public who
are interested in self-care have the need and right to have access to the most
potentially helpful materials designed by persons who are competent and expert in
doing so. As many of the self-help materials in the marketplace are of dubious
benefit and are designed by unqualified persons, music therapists may provide an
important service in this regard.
At the same time, there are always risks when members of the general public
use these materials in inappropriate ways (and there are of course no controls over
this), when the self-diagnosed problem does not necessitate the self-help procedure,
when a more serious problem exists (and the self-help materials can mask or
exacerbate this problem), and when there are clear contraindications for their use.
It is not possible to guard against harmful effects, either minor or serious, from
these materials in spite of specific instructions and warnings (Koocher & Keith-
Spiegel, 1998).
Before these self-help materials are offered to the public by music therapists,
it is essential that they be adequately tested to demonstrate their efficacy. It is also
essential that any claims for effectiveness made by the author(s) be both based on
available data and cautious in their generalization. Disclaimers should be used
where appropriate. This may be difficult to accomplish, as the publishers of these
materials may indeed want to make unrealistic assertions to promote sales.
Therefore, the music therapist should make it a part of his or her contract with the
publisher to review and approve of all advertising and promotional materials
regarding the book (Koocher & Keith-Spiegel, 1998).
In summary, music therapists need to exercise a great deal of caution in their
dealings with the media; the reputation of the profession is always on the line.
Therapists are ultimately responsible for how their names are used and for the
information provided. The goals of the media and the goals of the music therapist
and his or her profession may likely be incornpatible (Koocher & Keith-Spiegel,
1998; Stein, 1990).
Chapter Summary
1. Clients’ welfare is of primary important in the setting of fees for private music
therapy services. The client’s ability to pay or not pay should also be considered.
Therapists should provide a full disclosure regarding fees and fee policies to clients
through the informed consent process.
2. Fee splitting refers to the practice of providing part of the sum a client pays for
services back to the person/source who referred the client. This is usually done by
prior arrangement between the parties, and is an unethical practice in music therapy.
3. There are a number of identifiable fee handling practices that are unethical and/or
illegal, some of which may be classified as fraud. Therapists must use caution in bill
collection procedures for clients who are in arrears in their fees for services. Threats
to clients’ welfare and confidentiality are primary issues.
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4. The managed care system stresses short-term interventions with methods that are
cost-effective, and emphasize prevention. Some of the primary ethical issues for
therapists working in managed care include: 1) competence; 2) conflicts of interest,
3) confidentiality, 4) continuity of care, and 5) informed consent. These issues are
interrelated.
5. The manner is which music therapists in private practice announce/advertise their

services has important ethical implications for the profession. As the nature of a
music therapist’s advertisements reflects directly on the integrity of the profession
and influences the public’s perceptions of music therapy, caution and restraint are
necessary to assure that this information conforms to professional, rather than
commercial standards. In a similar manner, music therapists may be involved in or
consulted on a number of commercial activities, involving products for music
therapy, equipment, CDs, cassettes, books, etc. The manner in which these products
are presented to professional or public audiences again can influence their
perceptions about music therapy in either positive or negative ways.
6. When providing information to the general public, the music therapist must be
concerned about ethical issues involving: competence, accuracy, control of
information, and offering treatment through the media.
Ethical Dilemmas
1. JoBeth, a music therapist in private practice, conducts an intake interview with

Martin, a client who is extremely depressed and in a relationship crisis. Martin is
unable to pay for music therapy services, although he feels that they can be quite
beneficial for him. JoBeth offers Martin several options: 1) he can pay a reduced
fee for a time, and allow the remainder of the fee to accumulate until he is better
able to pay for services, 2) she can refer him to a community mental health center
to meet with a less-expensive counselor, or 3) he can paint her office in exchange
for treatment.
2. Seymour, a music therapist in private practice, has worked with Ernie forayear.
Ernie has terminated music therapy services because he is so behind in his fees, and
he is afraid he will never catch up if he continues in treatment. Seymour is
considering turning Ernie’s account over to a private collection agency, but does
not want to pay the fees to do this. So, he decides to call Ernie himself on a regular
basis to remind him that his fees need to be paid. He also sends him weekly
reminders of his account balance.
3. Frances is a music therapist in private practice who is reimbursed for her

services through her client, Joshua’s HMO. The HMO allows for the reimbursement
of 20 sessions a year, after which time, no payments are provided. Frances decides
to bill the HMO for fees much higher than she normally charges. In this manner,
she can use the additional funds as payment for the additional sessions that Joshua
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will likely require.
4. Frances, in the situation above, works with another client, Peter, whose HMO
pays for his music therapy treatment. However, Peter’s HMO will only cover 5
sessions per year. Peter is experiencing a major crisis in his life, and his coverage
has just stopped.
5. Samantha has resigned her job as a music therapist in the community mental
health center where she has worked for 5 years with the intent of building her
private practice in music therapy. She knows that the center will not hire a music
therapist to replace her, and she would like to continue working with some of her
clients. She prints a brochure describing the types of services she will offer in her
practice, and mails the brochures to clients’ homes.
6. Miguel, a music therapist working in a school for children with developmental

disabilities, is asked by a client’s parent to provide extra music therapy outside of
the school setting.
7. Patricia, a music therapist who is establishing a private practice, announces her

services to other professionals through a dignified brochure. She also contacts the
local Association for Retarded Citizens and tells them that if they refer clients to
her, she will make a donation of a portion of the clients’ fees back to the
association.
8. Hilda, a music therapist establishing a private practice, announces her services

through a dignified newspaper ad.
9. Gretchen, a music therapy professor, routinely receives unsolicited materials,

tapes, CDs, etc. free from individuals or companies who ask her to test their
effectiveness. Gretchen keeps the materials, but does not comply with their requests.
10. Frederick, a music therapist with considerable experience and expertise, is

asked by a major record company to design a series of CDs for use by persons who
may be experiencing health problems, e.g., stress, pain, heart disease, etc.
11. Frederick, from the situation above, is also asked to design a CD series that can
improve intelligence in infants and children. The series will be launched through
an “infomercial” which will include testimonials for the products by both
celebrities and professionals.
12. Rolando, a music therapist working in a medical hospital has done very
impressive work with coma patients. Gene, the hospital administrator contacts the
local newspaper and conducts an interview in which he makes a number of
sensational claims about Rolando’s work. Rolando sees the article in print and is
horrified.
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13. Larry, a specialist in the use of music therapy for various stress and health
problems, is asked to produce and host a late-night radio program for people who
have sleep problems, e.g., insomnia. Larry would select music that people could
listen to to help them get to sleep, and at the beginning of the program, he would
answer questions of people who could call-in with specific issues.
14, Werner, a music therapist has become famous for his work with developmentally
delayed and autistic children and who possess extraordinary musical talent on the
piano. He has presented some of his clients on television programs, where they have
performed. He maintains a web-site, and is frequently contacted by children’s
parents who e-mail video clips of their children playing the piano. He evaluates
them and makes recommendation to their parents.
15. Erica, anew music therapy graduate, is asked to pose for a centerfold photo for
a popular men’s magazine. Because this magazine publishes “good articles,’ she
feels that this would be an interesting and unusual way to “stimulate interest” in
music therapy.
1. Discuss with your classmates how you would establish and handle fees for your
music therapy private practice, taking into account the ability of clients to pay,
billing procedures, and fee collection procedures.
2. Conduct a “mock” newspaper interview with a classmate extemporaneously on

a particular topic in music therapy. Take notes of what the classmate says, and read
these back to him or her at the end of the interview. Make a decision if you would
want to have this information appear in print.
3. Prepare a 15-minute general presentation on music therapy that you might be

asked to deliver to interested persons. Present this in class and ask for feedback.
4. Pick a topic from this chapter that interested you, and do additional research
using books and articles. Write a short paper.
5. Consult various codes of ethics in health care (e.g., psychology, family therapy,
counseling, etc.). Note their ethical standards for advertising, fees, and commercial
activities. Determine similarities and differences between the codes. State how you
agree or disagree with these standards.
6. In your course journal, reflect upon any strong reactions to the chapter’s topics..
RESPONSIBILITIES TO COLLEAGUES,
EMPLOYEES, EMPLOYERS,
AND THE PROFESSIONAL ASSOCIATION
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Che responsibilities of music therapists to their professional colleagues and
employees are clearly delineated by the music therapy codes of ethics. Professional
relationships should be characterized by integrity and respect, with the realization
that the quality of these relationships invariably influences services to clients. The
codes also specify the responsibilities owed to the professional music therapy
associations in general, as well as the duties implied when members serve as
officers of the professional association. This chapter presents a discussion of the
various ethical issues that may frequently arise in these professional relationships.
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Responsibilities to Colleagues and Employees a
Summary of Professional Codes
The responsibilities of music therapists to professional colleagues, as

outlined in their professional codes are summarized as follows:
1. Therapists must establish harmonious relationships with their professional
colleagues. Colleagues are to be treated with fairness, integrity and honesty, and
their divergent viewpoints and values are to respected.
2. Cooperation with colleagues is essential particularly where the welfare
of the client is involved. Music therapists employed by facilities frequently
participate as members of interdisciplinary teams and must collaborate with other
professionals in establishing, implementing and evaluating plans for clients’
treatment. Obviously, the client is best served when members of the team put his or
her needs first.
3. Music therapists are ethically bound not to damage the reputations of
other professionals, and at the same time, are required to discourage incompetence
in music therapy practice. Furthermore, they must assure that professionals working
with them or under their jurisdiction, i.e., students, employees, are working within
their respective limits of competence based on their training and experience.
222
4, Music therapists working in private practice must refrain from accepting

clients who are receiving treatment from another music therapist, except when this
is agreed upon by both therapists, or after the client terminates treatment with the
original music therapist.
5. Music therapists are prohibited from engaging in any type of sexual
harassment of coworkers, students, supervisees or employees. Persons who have
either initiated or who have been the subject of sexual harassment charges are to be
afforded dignity and respect by the music therapist.
Harmonious Relationships with Colleagues
One might assume that music therapists and other professionals working in
any of the areas of health or education would have a greater awareness of the
intricacies of interpersonal relationships that would assist them in establishing and
maintaining effective connections with their colleagues in the best interests of their
clients. This is sometimes the case, and (unfortunately) sometimes not. As any
human beings may have the tendency to do, they may put their own needs first, and
a variety of inter- or intra-professional disputes may ensue. These clashes may
involve any number of professional or personal issues, including territoriality,
institutional politics and finances, theoretical or methodological differences,
professional competition and rivalries, as well as personal styles and disagreements
(Koocher & Keith-Spiegel, 1998). Regrettably, disputes among professionals are
ubiquitous, sometimes escalating to virtual wars among them.
Koocher & Keith-Spiegel (1998) discuss workplace risk factors that may
contribute to conflicts among professional colleagues. These include: competition,
sparse resources, lack of advancement opportunities, low morale, ineffective or
unclear management strategies, inequities, envy, and bias. Inadequate working
conditions, including high noise levels, insufficient privacy, excessive work loads,
and inadequate furnishings may further add to the professional’s stress and
irritability. In addition, the evaluative power of one professional over another, poor
communication of role expectations, and poor feedback contribute as well to
interpersonal strife. These authors further describe personality variables of
professionals that may contribute to disharmony. Persons who are emotional labile,
unstable, arrogant, narcissistic, critical, impulsive, angry, demanding, obnoxious,
and/or rude can often cause havoc in the workplace.
It is unrealistic to expect that music therapists will never encounter or
experience these conflicts, or that “harmonious” relationships with colleagues will
prevail at all times. What is important to understand, however, is that these battles
may often, if not always, impact negatively on services to clients. For this reason,
conflicts should be addressed professionally, and war tactics should always be kept
out of the workplace. Colleagues will frequently criticize and disagree with each
other on professional issues; this is normal, and often they will “agree to disagree.”
However, when these disagreements become personal vendettas, a line has been
crossed, and professional ethics are at stake. When other professionals are drawn
into taking sides, the matter can become even more dangerous.
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When informal attempts to resolve disputes are ineffective, it is important

to have more formal procedures or rules available upon which to rely. Due process
may protect the individuals and neutralize the powerful emotions involved. When
conflict occurs with a person in a superior position, there is an inherent threat to the
professional in the subordinate position. He or she may need to rely upon formal
procedures, realizing the potential risks involved (Koocher & Keith-Spiegel, 1998).
Music therapists are indeed called upon to work with their colleagues in the
most professional manner possible, with the awareness that this may be one of the
most challenging of all the areas of professional ethics!
Cooperating with Colleagues
Cooperation with colleagues implies both the intent to be helpful as well as

timeliness in responding. Lack of cooperation can be viewed then as either an active
refusal to help or a passive delay in helping. When the welfare of clients is at stake,
music therapists have a responsibility to cooperate with others to the fullest extent
possible and to avoid delays in fulfilling the requests of others, even when they are
very busy. Sometimes if the therapist is unable to respond to a request immediately,
he or she can at least promptly convey to the colleague when and if the response
can/will be provided (Koocher & Keith-Spiegel, 1998).
Preserving the Reputations of Colleagues
Colleagues deserve to be treated respectfully, and all efforts should be made

not to damage a colleague’s professional reputation. No matter how annoyed, angry,
etc. the music therapist may be with a colleague, he or she may not express these
views publicly or let personal feelings motivate professional attacks. Besides the
fact that comments damaging the professional reputation of others may make the
therapist vulnerable to litigation, they are ethically unacceptable.
When music therapists become aware that another is practicing
incompetently, and there is ample and objective evidence for this, this information
is not to be shared in a public manner, but with the person involved as a first step
(see Chapter 12). If this matter is not resolved between them, then the music
therapist must follow the appropriate steps in reporting the matter in the prescribed
manner. In no case is the music therapist allowed to damage this person’s reputation
publicly.
Making negative comments about other professionals through electronic
means, such as the internet, professional chat rooms, etc., is likewise unethical.
Even though the professional may assume that he or she is doing so anonymously
and that this information is confidential, this is rarely the case.
Concurrent Music Therapy Services
Music therapists in private practice may not accept clients for treatment who
are receiving music therapy from another professional. Furthermore, music
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therapists may not solicit private clients of another therapist for his or her own
practice. Clients have the right to choose their own therapist. If clients want to see
two music therapists simultaneously, for example, those specialized in very
different methods of music therapy, these music therapists should confer to
ascertain whether this would be in the best interest of the client involved.
On the other hand, if a client currently in treatment with one music therapist
(MT1) approaches a second music therapist (MT2) and conveys dissatisfaction with
MT] and the desire to change therapists, MT2 may refer the client back to MT1,
asking him or her to address these issues directly. MT2 may also ask the client’s
permission to confer with the MT1. If the client is unwilling to do this, it may be
risky for MT2 to accept him or her as a client.
A music therapist (MT 1) may refer a client to another music therapist (MT2)
for a consultation or assessment. In these cases, MT2 may not accept this client for
more than the original purpose, i.e., consultation or assessment, and may not enter
into a therapeutic relationship with him or her.
If music therapists are asked to make referrals for clients to a music therapist
in another location, they should do so with the client’s best interest in mind. They
may refer the client to someone they know is competent, or they may rely on the
professional directory to identify names of credentialed therapists. It either case,
because the choice and potential effectiveness of a therapist are highly personal
matters and are influenced by many factors, it is important to warn the potential
client that there are no guarantees for success in the referrai. In making referrals, the
therapist puts his or her own reputation and credibility on the line, so referrals
should be done thoughtfully, carefully and with the appropriate caution conveyed
to clients (Koocher & Keith-Spiegel, 1998).
Sexual Harassment
Sexual harassment is defined by the U.S. government as “(t)he use of one’s

authority or power, either explicitly or implicitly, to coerce another into unwanted
sexual relations or to punish another for his or her refusal; or the creation of an
intimidating, hostile or offensive working environment through verbal or physical
conduct of a sexual nature” (Ragsdale, 1996, p. xxii). For purposes of this text,
sexual harassment is used to denote inappropriate sexual demands, suggestions,
behavior, telling dirty jokes, presenting sexually explicit materials, etc. from one
who is in power to another in a subordinate position. According to the U.S.
Government’s definition, sexual harassment involves: 1) sexual favors to obtain an
advancement or prevent a job termination, or 2) the creation of an inappropriate,
hostile or offensive environment for working. Sexual harassment can occur between
professional colleagues, faculty and students, supervisors and supervisees,
employers and employees, etc.
Except for the most obvious, extreme acts of sexual harassment, sexual
harassment and its subsequent harm may sometimes be difficult to define. Factors
involved include: the motivations of the person committing the act, the
interpretation of the victim, the nature of their relationship, and the context in which
225
the behavior occurs. There are differences between what men and women may
Judge as unacceptable behaviors (Koocher & Keith-Spiegel, 1998).
“Gender harassment” is another type of abuse involving statements directed
at one’s sex, but not at individuals specifically (Fuller, 1979). Not all types of
gender-directed behavior can be considered harassing, however, those behaviors
which result in humiliation, discomfort, exclusion, or ridicule, or that are intended
to keep members of one sex in a subordinate position may potentially be considered
so (Koocher & Keith-Spiegel, 1998).
The AMTA Code (1999) protects individuals who have filed a sexual
harassment charge or who are the recipient of such a charge. Music therapists are
obligated to afford these individuals respect and dignity, and to not base their
decisions on this factor. For example, decisions regarding admission to a graduate
program, employment, tenure, promotion, etc. may not be influenced by this status.
DeAngelis (1991) recommends that before making a statement or engaging
in a particular behavior, therapists ask themselves if they would feel comfortable
in doing so if the recipient were a supervisor. If there is any hesitation, the intended
statement or behavior is likely inappropriate.
Music therapists should be particularly sensitive to and make every effort
to avoid and prevent both subtle and overt forms of sexual or gender harassment.
Letters of Recommendation
Music therapists are often contacted for letters of recommendation regarding

colleagues, employees, supervisees, etc. These letters may be used to assist the
recipient in discriminating among applicants for a particular position, and as such,
should provide information that may be helpful in the selection process. Letters of
recommendation should also contain information that the music therapist him or
herself would want to know if he or she were in the position of making a choice
among applicants (Koocher & Keith-Spiegel, 1998). Music therapists are ethically
accountable for the letters of recommendation they write, and there are a number
of ethical issues associated with this topic.
Music therapists can never assume that the letters of recommendation they
write will not eventually be seen by the applicant, even if this individual has waived
his or her right to confidentiality. Thus, the music therapist should be most careful
in including negative comments in these letters. If these negative attributes are
included and have not previously been shared with the applicant, a lawsuit may
ensue. On the other hand, it is also clear that any hint of an unfavorable evaluation
of the applicant, even if included in an otherwise positive letter, will often result in
his or her rejection for the position desired (Koocher & Keith-Spiegel, 1998).
Music therapists may be asked in advance by an applicant to write a letter
of recommendation for him or her. If the music therapist has reservations about the
applicant’s abilities, he or she should discuss this with the applicant, and suggest
that he or she contact another referee. In some cases, the music therapist is not
asked in advance by the applicant and is contacted by letter or phone to provide a
letter of recommendation. If the music therapist has reservations about the
226
applicant, he or she may opt to write a non-committal letter, stating only factual
information about the applicant, e.g., length of time employed, position,
responsibilities, etc. In a similar manner, the therapist may not assume that negative
comments made in a phone conversation will not eventually be disclosed to the
applicant.
If negative information needs to be conveyed, this information should be
presented in a most factual and concrete manner, devoid of personal opinion. It is
then up to the recipient how to use and act upon this information. Furthermore, this
information should have been shared with the applicant in the past, and should not
represent a surprise to him or her (Koocher & Keith-Spiegel, 1998).
In writing letters of recommendations, music therapists are often caught in
a conflict of loyalties to the applicant versus the profession. For example, does the
therapist have the primary responsibility to an employee who is applying for
graduate studies or to the university involved? Could it be that these studies would
help the employee improve his or her skills and become a better professional? Or
should the music therapist’s allegiance be to the profession? Is it responsible to
recommend someone for graduate training who may not ultimately be suitable for
professional work? There is no easy answer to this conflict. |
Being asked to write letters of recommendation for employees or coworkers
with some questionable attributes often presents another interesting
personal/professional conflict for music therapists: if the music therapist does not
recommend the person for another position, he or she may likely be stuck with this
person indefinitely! Although there is humor in this dilemma, it is indeed one that
requires a careful consideration of allegiances.
Music therapists may be asked by several employees, students, or coworkers
applying for the same position to provide them each with a letter of
recommendation. This can present a difficult situation for the music therapist in
light of the fact that the same recipient/employer will receive several letters from
the same referee concerning different individuals. This certainly is a situation where
the referee can misuse his or her power by recommending most highly the person
he or she thinks should get the job, creating a clear disadvantage for the other
applicants requesting letters. On the other hand, the music therapist may lose his or
her credibility with the recipient if all candidates receive outstanding letters of
recommendation. In a sense, they will cancel each other out, and not permit the
recipient to discriminate among these applicants. The music therapist has at least
several options in this situation: to write carefully crafted letters describing the
attributes of each candidate and avoiding the recommendation of one over the other;
limiting the number of letters written, e.g., for the first person who asks; or refusing
to write any letters whatsoever.
Failing to provide a letter in a timely fashion, or not supplying a letter at all,
if one has agreed to do so, is another ethical problem. In essence, this is a passive.
way of assuring that a person will not be considered for a position, whether the
evaluation is positive or negative. The applicant may never be informed that his or
her file is incomplete in time to request a letter from another referee, or the recipient
may assume that the lack of response was due to the applicant’s questionable
eeh
abilities. In any case, this practice is cruel and punishing to the applicant. If the
referee is too busy to write a letter, he or she should say so when asked for one,
rather than inadvertently sabotaging the applicant’s chances. Applicants who are
students or supervisees may be uncomfortable in “bugging” the therapist for the
letter. Therapists always have the ethical right to refuse to write a letter of
recommendation for various reasons; however, once a commitment has been made,
it is unethical not to do so according to the designated time lines (Koocher & Keith-
Spiegel, 1998).
Individuals/employers/institutions who are advertising to fill a position may
not contact individuals who may know the applicant unless the applicant has
authorized them to do so, e.g., through a list of potential references. It has been
recently observed that potential employers, graduate school faculty or universities
may take the liberty to contact their friends or professional colleagues who may be
familiar with the applicant without authorization to do so. For example, music
therapy search committee faculty at one university may feel justified in contacting
music therapy faculty at an applicant’s university to inquire about his or her
professional competence, even if these colleagues have not been specifically listed
as references for the applicant. This practice is highly controversial and potentially
unethical. Obviously, this can be an uncomfortable and damaging situation for the
applicant, who may not have informed his employing institution that he or she has
applied for a position elsewhere. Moreover, if the applicant does not get the job
offer or refuses the job offer, the fact that he or she has applied for another position
remains.
Music therapists certainly have the right to apply for other jobs even when
currently employed, and there is no ethical obligation to inform employers of this
unless another position is accepted. At that point, it becomes an ethical obligation:
to inform his or her employer of this fact, to give the employer sufficient time to
hire another music therapist, to cooperate fully in the search process if needed, and
to provide for a smooth transition.
Responsibilities to Employers
Music therapists are ethically obliged to act with integrity as employees of

a facility. According to several of the music therapy codes of ethics, the
responsibilities implicit in this ethical behavior include: providing services in an
ethical manner, observing the employer’s policies, procedures and regulations,
informing the employer of any conditions that may limit the effectiveness of music
therapy services, informing the employer of any conditions that could compromise
ethical practice, protecting the property, reputation, and integrity of the employer,
using the employer’s facilities and resources only as authorized, and representing
the employer accurately when authorized to do so, distinguishing personal from
employer’s views. Furthermore, music therapists may not use their positions with
employers to solicit clients for their own private practices, unless this is authorized
by the employer. Music therapists may not ask clients to pay for private music
therapy services when they are entitled to such services through the music
228
therapist’s employing agency. Some clients may want to continue music therapy
services privately following discharge from a facility. Any such arrangements with
clients need to be approved by the facility (AMTA, 1999; CAMT, 1998).
However clear and direct these responsibilities to employers may appear,
there can be conflicts which arise between these and other ethical responsibilities
of music therapists, for example to clients. Several of these conflicts are described
in this section, although this discussion is by no means complete or comprehensive.
The most common ethical conflicts may occur when responsibilities to abide
by the policies, procedures and regulations of employers are contrary to the needs
of the music therapist’s clients. There are a number of examples. Music therapists
may feel that their client case loads or schedules are inappropriately heavy or
restrictive, and they are not able to deliver optimal services to clients. Music
therapists may feel that they do not have sufficient time for documentation. Music
therapists may object to treatment priorities and additional services provided (or not
provided) to clients. Music therapists may be in conflict with the treatment
philosophy or orientation of the facility. Music therapists may object to clients’
discharge policies resulting from managed care regulations, etc., etc. In some cases,
the policies of the employer may be in direct conflict with the music therapist’s
code of ethics. In other cases, music therapists may feel the need to advocate for
clients, perhaps actively opposing the employer’s policies.
When these conflicts occur, the music therapist has the responsibility to
address these issues with the employer. Sometimes, the conflict can be resolved
easily and readily. Sometimes, an adversarial situation is created, and the music
therapist may be put in the difficult position of potentially risking his or her job.
When clients’ needs and rights are involved, the decision must be made as to
whether it is in their best interest for the music therapist to lose his or her
employment. Can the music therapist work within the system, maintaining his or her
employment and still effect the needed changes? There are no easy answers, and the
process of ethical thinking will indeed be required.
Although rare and extreme, there may be situations where the music
therapist may need to contact external agencies to solve the problem, in other
words, to engage in “whistle-blowing.” In these cases, music therapists must need
to consider how complete and accurate their information is concerning the situation
and practices, the potential harm of these practices, the extent to which they can
resolve the problem within the system, and the rules, laws and ethical principles
violated if the music therapist either reports the situation or does not report the
situation. Once a decision has been made to report the situation to external agencies,
the music therapist must decide how this should be done (e.g., anonymously or
overtly), and whether the music therapist should resign from his or her position
before doing so. The music therapist should also attempt to anticipate responses
from the employer and the external agency as well as the potential results to be
achieved (Nader, Petkas & Blackwell, 1972).
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Responsibilities to the Professional Association
Music therapists have responsibilities to their professional association in

their roles as professional members and also in their positions of leadership within
the association. The music therapy codes of ethics specifically address these
responsibilities, and these are summarized as follows:
As Association members:
1. Music therapists have the ethical responsibility of observing and

respecting the rights and rules of the professional association and
of protecting its reputation.
2. Music therapists have the responsibility of contributing to the growth of
the profession and association, enhance its standing in the
community, and of increasing the level of knowledge, skills and
research within the profession.
3. Music therapists represent the profession only when specifically
authorized to do so.
4. Music therapists will not permit the use of their membership status in the
Association inappropriately.
As leaders within the Association:
1. Music therapists distinguish between personal views and professional

views when acting on behalf of the Association.
2. Music therapists do not misuse their official positions within the
Association.
3. Music therapists exercise integrity and confidentiality in their
Association duties.
4, Music therapist ensure that the activities of the Association promote the
highest standards of practice.
5. Music therapist provide others with opportunities for continuing
education, as well as resources for ethics and clinical work.
6. Music therapist support the development of competence and ethical
practice among music therapy students and new professionals
7. Music therapists are accessible to Association members and the society
for consultation on ethics.
8. Music therapists routinely evaluate established ethical standards.
9. Music therapists respond to unethical practice according to established
policies.
10. Music therapists assist members in identifying competent peers for
consultation and supervision.
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Chapter Summary
1. Establishing harmonious relationships with their colleagues in the workplace is

often a challenging task for music therapists. Workplace and administrative factors
often exacerbate conflicts. Because difficulties with colleagues inevitably impact
on services to clients, music therapists must avoid conflicts, handle them
professionally when they occur, and rely on due process procedures when possible.
2. Cooperation with colleagues implies both the intent to be helpful as well as

timeliness in responding. Colleagues deserve to be treated respectfully, and all
efforts should be made not to damage a colleague’s professional reputation.
3. Music therapists in private practice may not accept clients for treatment who are
receiving music therapy from another professional. Furthermore, music therapists
may not solicit private clients of another therapist for his or her own practice.
4. According to the U.S. Government’s definition, sexual harassment involves: 1)

sexual favors to obtain an advancement or prevent a job termination, or 2) creation
of an inappropriate, hostile or offensive environment for working. Sexual
harassment is both unethical and illegal.
5. Music therapists who are asked to write letters of recommendation for colleagues,
employees, supervisees, etc., may be faced with a number of ethical dilemmas.
Realizing that the letters they write may ultimately be seen by applicants, it is
necessary to include factual information in these letters. Conflicts may exist
regarding loyalties to applicants versus the profession.
6. Music therapists are ethically obliged to act with integrity as employees of a

facility, and the responsibilities implicit in this ethical behavior include: providing
services in an ethical manner, observing the employer’s policies, procedures and
regulations, informing the employer of any conditions that may limit the
effectiveness of music therapy services, informing the employer of any conditions
that could compromise ethical practice, protecting the property, reputation, and
integrity of the employer, using the employer’s facilities and resources only as
authorized, and representing the employer accurately when authorized to do so,
distinguishing personal from employer’s views.
7. Music therapists have very specific responsibilities to their professional

association as members and as leaders within it.
Ethical Dilemmas
1. Olga and Stephanie, two music therapists working at a psychiatric facility, co-
lead group sessions. They begin to have serious personal conflicts. Olga has been
very critical of Stephanie, and the two barely speak to each other. Their lack of
231
communication is definitely interfering with their planning ofgroups and discussion

of group members following the sessions.
2. Faith is a music therapist working at an acute psychiatric facility. She regularly

attends team meetings which are led by Dr. Arrow Gant. Dr. Gant has little regard
for music therapy or for Faith’s competence, even though she is excellent in her
work. At team meetings, he ignores her input, argues with her about her assessment
of the needs of particular clients, and disregards her recommendations. Because
Dr. Gant is a very powerful staff member, the other team members are reluctant to
challenge him and support Faith.
3. Nina, amusic therapy intern, becomes the sounding board for discontented music
therapists at her facility. The therapists are displeased with the working situation
and the administration.
4. Heather, a music therapist who is attending a party with coworkers, overhears

Jill, a music therapy colleague, making derogatory remarks about other staff
members and about the music therapy profession.
5. Lee, a music therapy supervisor at a large state hospital, frequently comes to

work late and leaves work early. He asks Glenn, one of his interns, to punch his
time card for him. Glenn fears recrimination if he refuses.
6. Cynthia works as a music therapist in a nursing home and is also completing her
master’s degree at a nearby university. She is doing the testing for her thesis during
the weekends. Cynthia borrows the nursing home's CD player, electronic keyboard
and guitar on Friday evenings and returns them on Monday morning.
7. Silvia, a music therapist in private practice, works with Melissa, an adult client
who has cancer. Silvia uses a variety of music improvisation approaches in
therapy. Melissa is benefitting from her work with Silvia, but also wants to try GIM.
Melissa explores GIM practitioners in the area. She asks Silvia for advice on
whether she should pursue GIM with Walter, a GIM fellow. Silvia knows Walter,
but has little respect for his GIM work.
8. Russell is an administrator of an institution which employs Joy, a music therapist.

Joy discovers inadvertently that Russell has been embezzling funds intended for
clients, when she overhears him discussing this in a phone conversation.
9. Heidi is Darren’s administrator at a residential facility for the developmentally

disabled. Darren is the only music therapist at the facility, and Heidi believes that
as many clients as possible should receive music therapy. Thus, Heidi schedules
Darren for six 1-hour music therapy group sessions with clients per day. He is
allowed one hour for lunch, and also one hour for a team meeting. Darren is very
concerned about his schedule, because there is no time for documentation. Heidi
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contends that direct contact with clients is much more important than writing about
them.
10. Dale, a psychologist, is the Clinical Director at the psychiatric facility where
Amy, a music therapist is employed. Amy is a lovely, energetic woman and Dale,
her supervisor, often arranges for meetings alone with her in his office. He
occasionally teases her about her figure and “jokingly” mentions he would like to
date her. He also frequently comments and teases about his sex life.
11. Kelly works as a music therapist in a psychiatric facility which has no air
conditioning. Because the temperature in her music therapy office is so
uncomfortable during the summer, Kelly often wears shorts, halter tops, and similar
types of summer wear to work.
12. Belinda, a music therapist and former supervisor of Sean, receives a request for
a letter of recommendation from an employer to whom Sean has applied for a job.
Belinda is surprised by this request because Sean never asked her in advance to
provide such a letter. Belinda was not at all pleased with Sean’s work when she was
his supervisor. In fact, after his initial six-month probationary period had come to
an end, she was forced to dismiss him. Belinda decides to write a non-committal
letter to the employer, stating only the fact that Sean had been employed and the
dates of the employment. Several weeks later, Sean calls Belinda and threatens her
with a lawsuit because she had defamed his character.
13. Lucy is a music therapy internship supervisor and the only music therapist
employed at her facility. Duane, her intern, has completed three months of his
clinical training. Lucy applies for and receives a job offer from another facility with
a salary almost twice that of her current salary.
14, Phillip is the Chairperson of the Education Committee for his music therapy
association. He applies for a teaching position at a university that is developing a
new music therapy program. During his interview, he mentions to the search
committee that he is responsible for the association’s review of new university
programs, and assures them of approval ifhe is hired.
1. Role play various scenarios with classmates regarding “difficult” colleagues,

using real or fictitious examples (no names please). Discuss with classmates ethical
and professional ways that a music therapist may respond to these colleagues.
2. Investigate the sexual harassment policies for your university or place of

employment, and the procedures for reporting these behaviors. Discuss these
policies with your peers.
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3. Role play the following with peers: 1) telling a colleague that you are unable to
provide a letter of recommendation for him or her; 2) discussing with your
supervisor difficulties you are having with his or her policies and how these are
negatively affecting your work, and 3) discussing with team members your
objections to a particular treatment or discharge plan for a client. (You may
certainly add other scenarios). Solicit feedback from your peers, and summarize
general ideas and strategies you have gained from this experience for future
reference.
4. Do some reading on assertiveness training. Present a report to the class,

distinguishing between assertiveness and aggressiveness. Role play various
situations with peers in which you might practice assertiveness.
5. Discuss various practical ways that you can be ethically responsible to: 1)
colleagues, 2) your employer, and 3) your association.
6. Do further research on a topic from this chapter that has captured your interest.
Using relevant books and periodicals, write a short paper and present it to the class.
7. In your course journal, reflect upon your own strengths and weaknesses in
dealing with difficult situations with colleagues, employers, etc. Explore ways to
improve any weaknesses.
ETHICAL THINKING IN
EDUCATION AND SUPERVISION
a=
Ghere are vast numbers of ethical issues related to the area of music therapy
education and supervision, too many to include on any one chapter. However, an
attempt is made here to discuss a number of the more common issues and dilemmas,
with a mention of those that may occur less frequently. The following topics related
to music therapy education programs and clinical training facilities are included:
advertising, admissions, program design and content, faculty and supervisor
competence, dual relationships, experiential training, student evaluation,
confidentiality, and advising. There is indeed some overlap in content between these
two areas, as supervision may occur within the academic setting, and education may
occur within clinically supervised settings. The issue of teaching ethics in both of
these situations is also emphasized.
Definitions
Music therapy education is defined as comprising the academic experience

of preprofessional music therapists, whether on the undergraduate or graduate
equivalency levels, or graduate studies (master’s and doctoral) for professionals
already certified as music therapists. This definition of education also includes
specialized, institute training in music therapy, e.g., Guided Imagery and Music, and
in some instances, continuing education programs for certified music therapists
offered in a number of venues.
Music therapy supervision is defined as the guidance and feedback provided
to preprofessional or professionals regarding clinical work. Supervision may be
offered by university faculty or clinicians in university or clinical settings.
Supervision always involves a triad comprised of supervisor, supervisee and client.
The ethical imperative of both faculty and supervisors is to provide training
and facilitate growth in three essential areas: ethical functioning, professional
competence and personal functioning (Vasquez, 1992).
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Advertising and Recruitment
The music therapy codes of ethics do not discuss the topics of advertising
and recruitment with regard to educational and training programs. In spite of this,
the following ideas are offered as to what may constitute both ethical and unethical
program advertising and recruitment practices.
It is ethical to think that catalog and advertising materials describing music
therapy university curricula, continuing education programs and clinical training
facilities should be accurate, current and cautious in their content. For example,
university catalogues should contain details concerning entrance and program
requirements, faculty, clinical/theoretical/research emphases, course requirements
and descriptions, practica/internship requirements, experiential training offered,
musical requirements, research/thesis requirements, and any additional requirements
needed for successful completion of the program. As catalogs represent a contract
between the university and the student, these requirements must be up-to-date and
accurate. For example, a student entering a music therapy graduate program to study
with a particular faculty member should not discover, following matriculation, that
the faculty member retired three years ago. A student entering a clinical training
facility with the desire of working with a specific clinical population should not find
out that opportunities to work with this population are no longer available.
Likewise, course syllabi represent a contract between the professor and
student regarding the expectations and requirements of the course (informed consent
procedure). When there is a large discrepancy between the course description in the
catalog and the course syllabus the first day of class, or a large discrepancy between
what is included in the syllabus and what actually occurs during the course, students
have reason to be frustrated and to complain.
Professors should provide as much detail as possible in the course syllabus
(in writing), including its goals, objectives, requirements (papers, exams, etc.),
books/readings, assignments, course schedule, and policies regarding grades,
absences, etc. The professor should also include his or her office hours, appointment
policy, and phone/e-mail contacts. Specific consent procedures for experiential
training must also be included, and these are discussed in a subsequent section.
Clinical training programs should be accurate in their descriptions of the
clinical experiences available to interns, types of supervision offered and specific
internship requirements. All aspects of the internship, including experiences and
requirements should be disclosed in advance, so that an informed choice can be
made by the student regarding the suitability of this placement for him or her.
Continuing education programs should also be as accurate and current as
possible in their advertising information. Any changes in or alterations to the
programs, e.g., guest speakers, should be communicated to those registered prior to
the program, and an opportunity provided for withdrawal from the program with no
penalty.
Other issues related to advertising concern the degree to which university
programs can be aggressive in their advertising, and how persuasively faculty
members can recruit students. What are the limits to the content of university
ZT
advertising beyond which it may be considered inappropriate? For example, it may

be questionable for programs to include data on their students’ job procurement and
scores on the Certification Examination (CBMT), as these practices may constitute
competitive advertising. The use of testimonials from former students may be
similarly questionable (Dileo-Maranto, 1987).
The recruiting of students already enrolled in another music therapy
academic program may be an unethical practice, particularly when students have not
expressed an interest themselves in changing programs. For example, contacting a
graduate student enrolled in university X in an unsolicited manner and offering an
assistantship for him or her to attend university Y is questionable at best.
Faculty members must exercise caution and professionalism with those
students already enrolled in a particular music therapy program (university X) and
interested in transferring to another (university Y). Faculty from university X must
not exert undue pressure on students to remain in the program, and must not
disparage the reputation of university Y. Similarly, faculty from university Y should
make no derogatory comments to the student regarding university X in an attempt
to recruit him or her.
Sometimes, students who are considering transferring to or enrolling in a
music therapy program ask music therapy faculty members their opinion of another
music therapy program being considered. Music therapy faculty should only
provide factual information, e.g., location of the program, type of program, etc., if
they are certain that this information is accurate. It is more appropriate to decline
comment on any program other than their own. To comment negatively or
inaccurately about another music therapy program or its faculty is a breach of ethics
(see Chapter 10).
Admissions
Although not directly addressed in the music therapy codes of ethics, it is

an ethical responsibility of music therapy faculty and supervisors to develop
appropriate criteria for student admission into music therapy training programs and
Clinical training facilities. At the undergraduate levels, students should be screened
during the admissions process to ascertain that they possess the necessary
motivation, musical skills, intelligence, and personal qualities that may lead them
to successfully complete the program, acquire the designated music therapy
competencies, and work effectively as music therapists. Thus, admissions criteria
may be both objective and subjective in nature.
There are no magic formulas, nor are there steadfast and universal criteria,
for predicting which students will succeed and which students will not, and the
undergraduate experience as well as the internship can be times during which
significant change and maturation occurs in the student.
At both the undergraduate and graduate levels, program admission is a two-
way process, and ina sense, resembles an informed consent agreement. Students are
given detailed information regarding the program for purposes of making decisions
about whether the program is suitable for their needs and appropriate for their career
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goals. At the same time, faculty screen the students to determine if they are suitable
for the program, advising the student of any potential limitations that may interfere
with successful completion of the program.
It is important to stress, however, that students who are blatantly unsuited
for the music therapy program should not be admitted. It is unethical to permit
students entrance to a program when there is only a remote chance that they will be
able to complete it successfully. Given the enormous amount of time, energy and
financial resources university education requires, this is only fair to the student.
Unsuitable students should not be admitted solely to meet enrollment quotas.
Admissions criteria should be applied equally to all students, and admissions
procedures or criteria that are biased or discriminatory in any way are clearly
unethical.
Program Design and Content
According to the music therapy codes, faculty and supervisors have an

ethical responsibility to design and establish curricula and training programs which
will adequately prepare students to acquire the necessary competencies for music
therapy practice. Curricula should include preparation in academic, research,
clinical and ethical areas of practice. Faculty should expose students to a wide range
of music therapy methods as well as current literature in the field. Methods and
theories taught should be current and consistent with the most recent advances in
music therapy and related fields (AMTA, 1999).
Specific standards for academic curricula and clinical training programs in
music therapy have been established by music therapy associations, and it is the
responsibility of faculty and supervisors to comply with these standards.
Competence in Education and Supervision
In order to prepare competent music therapy practitioners, music therapy

faculty and supervisors must also be competent both in music therapy and in
teaching/supervising. The music therapy codes of ethics enumerate ethical standards
for those involved in preparing students for clinical work. Faculty and supervisors:
1) will use their skills to help others acquire high levels of professional competence;
they must remain current in the field, 2) will not teach in areas in which they have
not had adequate preparation, 3) will assure that students’ clinical work is
performed under adequate supervision, and will provide such supervision to
maximize the student’s competencies, 4) will ascertain that students understand the
values and ethical standards of the profession and abide by these standards, 5) will
arrange for satisfactory working conditions and opportunities for experience, regular
evaluations and constructive feedback, and 6) will encourage an exchange of ideas
between the students and themselves.
Corey, et al., (1998, pp. 292-293) enumerate some of the specific
responsibilities of supervisors to those they supervise. These responsibilities fall
into several categories: 1) competence in supervision; 2) providing adequate
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information regarding supervision; 3) shared decision making regarding supervision

needs; 4) selecting the appropriate role as supervisor (consultant, instructor, etc.)
and clarifying this with the supervisee; 5) fostering clinical and ethical competence;
6) utilizing an informed style of supervision consistent with one’s own style; 7)
holding regular meetings and providing timely feedback; 8) providing supervisory
interventions in a way that enhance personal awareness, clinical decision-making
and self-confidence; 9) advancing abilities to work with culturally diverse groups;
10) helping supervisees identify the boundaries of their abilities; 1 1) monitoring the
clients involved assuring that clients are not at risk and maintaining confidentiality
in record-keeping; 12) instructing and demonstrating appropriate professional and
ethical standards; and 13) monitoring techniques and methods used in treatment.
Unfortunately, many students may be unable to determine when their
educators or supervisors are not current in the field, are relying upon dated,
inaccurate, subjective and/or incomplete information, or are not adequately prepared
for teaching or supervision. Faculty and supervisors thus are ethically obliged to
have a personal commitment to maintaining their knowledge and skills (Koocher
& Keith-Spiegel, 1998).
Faculty and supervisors will sometimes be in a position where they are
required to teach or supervise in areas in which they have not been adequately
prepared. In these situations, these professionals should strive to acquire additional
training, as well as consultation and supervision if needed (Koocher & Keith-
Spiegel, 1998).
Academic freedom is a right of college professors, and most professors are
not completely objective or without their own personal values. Professors’
discussion of potentially controversial or sensitive topics, particularly when a bias
is obvious, should be disclosed to students in advance so that students may make
an informed choice regarding their own participation in this discussion. Professors
should be aware of their potential biases and controversial views and acknowledge
these to students, and at the same time attempt to present other viewpoints. Students
should also be allowed opportunities for discussion and disagreement, and they
should be respected for such (Koocher & Keith-Spiegel, 1998)..
The music therapy supervisor has the ultimate responsibility for the client’s
welfare and may be the most important individual in helping the supervisee to make
therapeutic decisions about the client. Over-directive supervision, however, presents
an ethical problem, as
...the imposition of the supervisor’s beliefs about what is best for the client
can take the shape of unbending directives that the supervisee then feels
impelled to deliver for fear of failing in supervision or personally insulting
the supervisor. Although the supervisor might be acting on beliefs that are
manifested because of unclear personal feelings towards the supervisee or
the supervisee’s client, the supervisee and the client can be compromised
(Kurpius, Gibson, Lewis & Corbet, 1991, p. 51).
In both professional and preprofessional supervision, there is always the

potential for a conflict of values according to different theoretical orientations. The
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music therapy supervisor must be aware of supervision that is imposing or overly-

directive, must be mindful of the limits of his or her expertise in various theoretical
orientations, while also remaining open to other perspectives, and must maintain
clear communication with the supervisee regarding his or her own approach to
music therapy to best address the needs of the supervisee (Dileo, in press).
Jacobs (1991) provides the following list of questions to help students
identify “dysfunctional” supervisory experiences and relationships, and these are
also relevant to students’ relationships with educators.
*Is the student having any feelings about his or her supervisor that the
student feels uncomfortable about or that may be interfering with the ability
to work comfortably with the supervisor?
*Does the student feel comfortable with the ways his or her supervisor
interacts with the student?
*Does the student find himself or herself reacting to his or her supervisor in
confusing ways or differently than the student normally reacts to other
people?
*Is his or her supervisor generally available to the student? Will the
supervisor find time for the student if he or she communicates that
something important has come up?
*Does the student ever feel judged or labeled by his or her supervisor? Does
the supervisor make the student feel like there is something wrong with him
or her?
*If a conflict arises, can the supervisor acknowledge a role in the difficulty,
or does the student tend to feel blamed or identified as the cause of the
problem?
*Does the student ever feel exploited or abused by his or her supervisor?
*Does the supervisor ever discourage the student from sharing information
with his or her fieldwork advisor? (p. 134).
Faculty and supervisors should be cautious in their teaching styles, in their

use of potentially offensive language or innuendos, and in their disclosure of
personal information. Humiliating, insulting, shaming, ridiculing, or degrading
students is ethically inappropriate (Koocher & Keith-Spiegel, 1998).
Psychological impairment may occur in faculty and supervisors (see Chapter
3). Emotional distress is experienced by everyone from time to time, and the
professional must make the decision about whether he or she is able to fulfill his or
her responsibilities competently in these instances. More long-term problems, such
as burn out, severe emotional problems, vindictiveness, etc., can seriously
compromise students’ welfare, especially when these are either intentionally or
unintentionally directed towards the student. Students may be placed in a Catch-22
situation, and fear recrimination through grades, letters of recommendation, etc., for
reporting such troubling behaviors.
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Dual Relationships in Education and Supervision
As discussed in detail in Chapter 6, dual role relationships and boundary

violations are indicative of exploitation. Dual role relationships are created when
an educator or supervisor takes on an additional role with the student (and for this
discussion the term, “student” will include supervisees, as well), a role which
creates conflicts in responsibilities for him or her (Stout, 1987; Kitchener, 1988).
The power differential between educator/supervisor and student is of concern, and
because of this, students are not able to provide true, voluntary consent to enter into
these dual relationships (Jacobs, 1991). The effects of dual relationships may indeed
be devastating and can include: an erosion of trust, breaches in confidentiality,
impairment of the student’s autonomy, reduced objectivity, damage to the
educational or supervisory process, conflicts of interest, and the distortion of
priorities regarding responsibilities and needs (Dileo, in press).
A number of dual relationships can be created within academic and
supervisory settings. Examples may include: 1) establishment of financial
relationships with students, 2) the acceptance of gifts from students, 3) social or
emotional relationships or friendships with students, 5) the use of students as
research subjects, 6) providing therapy for students, and 7) engaging in sexual
relationships with students. In this chapter, attention is given to the two of the more
common and serious types of dual relationships: dual therapeutic relationships and
dual sexual or romantic relationships (Dileo, in press).
There is more danger inherent in some types of dual relationships than in
others. Some dual relationships are extremely unethical. Others may be less so, if
unavoidable and handled prudently (Kitchener, 1988). Dual relationships can be
viewed as problematic when: 1) the expectations inherent in the two roles become
increasingly incompatible, 2) when the responsibilities of roles becomes more
disparate, and 3) as the power and prestige between the roles is amplified. The
potential for harm, exploitation, and compromised objectivity corresponds with the
degree that each of these three areas is violated (Kitchener, 1988).
On the other hand, when the potential for a conflict of interest is minimal,
such as former students becoming friends with the educator or supervisor, some
dual relationships may not be viewed as unethical. However, even in these
situations, the educator or supervisor assumes responsibility for maintaining an
awareness of potential role conflicts and minimizing their impact if they occur
(Kitchener, 1985). |
Dual Therapy Relationships in Education and Supervision. In music

therapy, both educational experiences (particularly involving experiential learning)
and supervision can be “therapy-like.”As the facilitation of self-awareness and
personal development in students is an important component of both education and
supervision, there is sometimes a thin line between this and therapy, and boundaries
may indeed be crossed if the educator or supervisor does not exercise thoughtful
caution.
A distinction is made between the facilitation of self-awareness and personal
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development, and the direct intent of supervisors and educators to provide therapy
for their students. The latter practice is both inappropriate and unethical, as a dual
relationship with the student is intentionally established. The focus of this section,
therefore, is on educational and supervisory experiences that are not directly
intended to be therapy, but which may violate boundaries nonetheless.
There is an inherent conflict of interest between serving as a student’s
educator/supervisor and serving as his or her therapist. Educators/supervisors serve
in an evaluative capacity with regard to the student, and as such have power and
authority over the student. They must assess various competencies of the student,
including cognitive abilities, musical skills, clinical skills, interpersonal skills and
degree of self-awareness. When these competencies are judged to be inadequate,
they have the responsibility of recommending remediation, and when this cannot
be done, the student’s termination from the program may be required. Faculty and
supervisors have the ethical responsibility to protect the profession and public from
incompetent practitioners.
On the other hand, the responsibilities of a therapist to a client involve acting
in his or her best interest, and although there is a power disparity between client and
therapist, the therapist does not have the authority and power over the client in
terms of evaluations, grades, letters of recommendation, etc. In other words, the
therapist does not have the obligation of evaluating the client’s professional
competence and of having influence over his or her career, as is the case in
education/supervision. Further, information obtained from the student as a client of
the educator/supervisor could be potentially used against the student in terms of
evaluation. How then can the student feel safe when he or she enters into a therapy
relationship with an educator/supervisor? It is impossible to do so.
It is important for educators and supervisors to define the goals of
educational experiences and supervision, e.g., skill acquisition, personal growth,
professional development, etc., and to be clear about how this learning will be
implemented. For example, a goal of supervision may be to address the impact of
the music therapist as a person on the therapy process. Supervision then may be
used to help the student to acquire awareness of personal limitations and unresolved
issues that may interfere with his or her work. However, boundaries must be
imposed on this self-exploration, and the focus of supervision should be on the
supervisee’s relationship to the client. Self-exploration should also be limited to an
identification and clarification of issues that warrant exploration. The process of
going into these issues and resolving them within a therapeutic process is
inappropriate in supervision and will most likely create a dual relationship. The
student should be referred to a therapist for this work. Because the boundaries of
educational/supervisory relationships may often be ambiguous, and not as clear cut
as the example above may imply, it is the responsibility of the professor/supervisor
to be continually alert to this potential for duality and to actively and clearly prevent
this from occurring (Herlihy & Corey, 1992).
Aside from the academic and supervisory relationship, professors and
supervisors may be called upon informally by students to give them personal advice
on non-academic topics. The professional should exercise caution in doing this, as
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dual relationships can result.
Experiential Training. Experiential training methods are used fairly

frequently in music therapy education and supervision. The purposes for which they
are used can generally be classified as follows: 1) for music therapy skill acquisition
(with personal growth a secondary goal), 2) to enhance personal growth and
development and self-awareness (with skill acquisition a secondary emphasis) and
3) to facilitate supervision. Experiential training may indeed help the student to
acquire self-knowledge of his or her strengths and weaknesses as a therapist. It may
facilitate a critical examination of the student’s attitudes, beliefs, values, prejudices
and characteristics that may either enhance or hinder professional work (Herlihy &
Corey, 1992). Experiential training may also help students acquire skills in
promoting change in others, and in understanding the power of music therapy ona
first-hand basis. It provides a safe place for students to practice their skills (Dileo,
1999).
Experiential training methods may be led by either faculty/supervisor or
students, and may include the following: 1) client role playing, 2) demonstrations
of music therapy techniques, 3) inauthentic participation (wherein the student role
plays him or herself, deliberately choosing to be “in character” and making
decisions regarding how this character will respond to the experiences) or 4)
authentic participation (wherein the student participates as he or she truly is) (Dileo,
1999).
Students’ authentic participation in experiential training methods may
include an identification or clarification of personal issues, the giving and receiving
of interpersonal feedback, an attempt at greater self-awareness, and also self-
disclosure of personal information in the here and now. Whereas authentic
participation may offer the student the fullest academic and personal learning
experiences, it also poses the greatest number of ethical risks and dilemmas. These
may include the creation of dual therapy relationships/unclear boundaries with the
professor or peers, and an invasion of privacy. Further ethical issues can arise when
the instructor abuses his or her power and authority in the situation, when authentic
participation is mandated (and no informed consent is given for the experience), and
when the student’s personal work is evaluated, e.g., through grades (Dileo, 1999).
Because of the nature of experiential training, it may be difficult to establish strict
boundaries between academic and personal types of learning (Herlihy & Corey,
1992).
Dual relationships, in which the instructor also assumes the role of therapist,
and the students assume the roles of clients, may occur relatively easily in
experiential training, and a concerted effort must be made to avoid them. There are
different expectations of a therapist versus a professor, different responsibilities
implicit in these roles, as well as a true power differential (Herlihy & Corey, 1992).
In these dual relationships, the conflicts between roles and responsibilities
as a therapist and instructor may be potentially harmful to students. As the
instructor may have access to the personal information about the student and his or
her personal issues, this information creates a conflict with the instructor’s
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responsibility to evaluate the student, via grading and letters of recommendation.
As the instructor is responsible to the profession for training competent therapists
and for safeguarding the field against incompetent therapists, it is a difficult and
challenging task for the instructor to keep the student’s personal information
separate from professional information in making these evaluations. Also, students
are acutely aware of the instructor’s power with regard to these evaluations, and
may be hard pressed to feel safe in revealing personal information. In addition, there
may be a more subtle conflict for the instructor in attempting to facilitate the
student’s personal development, and at the same time assessing his or her personal
effectiveness.
There are inherent differences between therapy and experiential training,
according to Herlihy and Corey, (1992). Therapy focuses on resolving pathology,
and requires safety for the client to explore issues that interfere with health. On the
other hand, training begins with a healthy person and focuses on increasing that
person’s sensitivity and social skills so that he or she may be more effective in
working with clients. Therapy and experiential training also differ with regard to the
depth and intensity of the exploration undertaken, the techniques used, and the
nature of the relationship between the two parties.
Experiential training within a group process format may yield therapeutic
benefits to participants, although this is not its intent. In these groups, students have
opportunities: 1) to become aware of their feelings and express them, 2) to identify
and examine their beliefs, attitudes, values, as well as their patterns of thinking and
feeling, 3) to gain an understanding of how they are perceived by others, 4) to
develop an awareness of how they affect others and how others affect them, and 5)
to make decisions about aspects of themselves they would like to change. (Herlihy
& Corey, 1992).
Group experiential training, however, can easily become therapy, and
instructors must use extreme caution to prevent this from occurring. Instructors
should carefully avoid the following practices: 1) exerting pressure on students to
reveal personal information that may cause embarrassment, 2) attempting to break
down students’ defenses, 3) interpreting students’ responses in an attempt to
uncover unconscious material, 4) using strategies/techniques to actually treat
problems, e.g., depression, eating disorders, etc., and 5) attempting to resolve deep-
seated problems. It is always the responsibility of the instructor to maintain
appropriate boundaries, and when students are in need of personal therapy they
should be referred to appropriate professionals outside of the program (Herlihy &
Corey, 1992).
In spite of the risks inherent in experiential training, there may be many
benefits for students, as described above. One can go so far as to question whether
it is ethical not to include experiential training in the music therapy curriculum. For
the present author the question is not so much ifthese methods should be included
in training, but how they can be implemented in an ethical manner.
A number of variations on experiential training are available to reduce risks
to students. These variations include:1) the mandatory nature of student
participation, 2) the leadership of the group, 3) the type of experiences involved, 4)
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the context of training, 5) modification of grading procedures, and 6) the use of

informed consent. These variations may be used in combination (Dileo, 1999, in
press).
Students may be given the option of participating or not participating in
experiential training. Experiential courses may be electives within the curriculum,
and students may opt not to take them. In this way, students do not feel forced into
participation if they do not feel safe in doing so. In addition, students may be given
options of how they choose to participate in experiential courses, for example
authentically, inauthentically, through role playing, through observation, or not at
all. This option may be used as well for different experiences offered within a given
course, i.¢., students may select how they want to participate based on the nature of
the experience.
Students are most at risk when the instructor leading or participating in the
experiential training is also the one who assigns grades or has other types of power
over the student. Variations on this include the use of an external instructor who
does not have authority over the students involved in terms of grades or letters of
recommendation (and who maintains the confidentiality of the students’ responses),
or the use of a leaderless or self-directed group experience.
As stated previously, students are most at risk when they participate
authentically. When other types of participation are allowed, e.g., inauthentic, role
playing, demonstrations, or simulated experiences, students may personally distance
themselves from the experiences. If authentic participation is used, the instructor
may limit students’ self-disclosures to here and now responses.
The context in which experiential training occurs may also be modified to
reduce risks to students. For example, students may participate in a non-credit
experiential course off-campus led by someone other than a faculty member. When
this training occurs outside the university context and without imposed evaluation
procedures (e.g., grading), students may be exposed to less risk.
When experiential training is used within a “‘for-credit” course, grades must
usually be assigned. The instructor may modify grading procedures however,
keeping them separate from both the choice and content of participation in
experiences. In other words, grades are not attached to whether or not the student
participates or to his or her level of participation (as described above). Grading may
be limited to, for example, the student’s skill acquisition with regard to the
experiences, or to didactic components of the course, such as papers and
examinations. Grades should not be based on whether or how a student self-
discloses or the content of such. Instructors may implement blind grading systems,
wherein a faculty member not involved in the course reads students’ course logs
anonymously and assigns grades. Experiential courses may be offered as “credit-
only” or “pass-fail.” Furthermore, students’ responses in experiential training
should be kept separate from other types of evaluation, such as for admission to or
continuation in the program.
No matter what variations of experiential training are offered, instructors
should always obtain informed consent from students at the beginning of the course.
It is preferable if informed consent is obtained in writing, so that students may keep
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a copy to refer to during the course. The informed consent agreement may include
the following information: 1) risks and benefits of participation, 2) options for
participation, how participation may be modified, and how participation is related
or not related to grading procedures, 3) confidentiality precautions for the instructor
and students, 4) boundaries for the content of students’ disclosures, 5) distinctions
between experiential training and therapy, and 6) procedures for referring students
who are in need of personal therapy.
A special mention is made of requirements for written assignments by
students, such as personal logs or journals, that may ask them to record their
personal feelings and reactions. Care should be taken, through informed consent,
to explain to students the purpose of these assignments, boundaries for their content,
how confidentiality will be maintained, etc. Again, grading procedures for these
assignments must not be based on the nature of the student’s self-disclosure.
Dual Sexual Relationships in Education and Supervision
Dynamics. Sexual relationships between faculty members or supervisors and

students likely exist on most if not all university campuses, and perhaps in clinical
training facilities as well. The inherent lure of the professor or supervisor as a
pinnacle of knowledge and admiration among students is well known. At the same
time, professors and supervisors are encompassed by attractive, energetic young
people who treat them with reverence and awe. This presents a tempting situation
for both parties who may enter such relationships for a variety of reasons, including:
sexual encounters, career advancement, or love (Koocher & Keith-Spiegel, 1998).
Pope (1989) describes seven common scenarios, each with its distinct
dynamics and process, into which faculty-student or supervisor-student sexual
relationships may be categorized:
1. Aladdin’s magic lamp. The student looks to the professor/supervisor as
the source of many things he or she desires, such as good grades, positive letters of
recommendation, abundant attention, and financial support (scholarships,
assistantships, etc.). To get what is desired, the student may use sex, romance, etc.
2. An offer that can’t be refused. In the absence of potential rewards for the
student or when rewards are not effective, the educator/supervisor can make indirect
or implied threats of what is expected/required of the student. Students catch on to
this ploy quickly.
3. Don Juan. The educator/supervisor is a lover and “party-animal.” The
university or facility affords him or her a new stock of students to be pursued
annually. He or she avoids any emotional involvement with the prey, and when a
student becomes emotionally involved, the student is blamed for immaturity and/or
emotional problems.
4. The Fountain of Youth. Professors/supervisors in this category are often
going through some type of personal age-related crisis, are dissatisfied, discontent,
regretful, and derive little pleasure from teaching or clinical work Although they are
not deliberate predators, occasionally a student appears who is young and energetic
and who is able to renew their interest in life. Their vulnerability renders them
247
unable to resist the temptation. These relationships are not generally one-night
stands, but are generally short in duration.
5. Frozen roles. This relationship involves a student and educator/supervisor
who are seeking to preserve the imbalanced roles of power/dependency
characteristic of their teacher/student dynamics. Both parties have been
unsuccessful in previous intimate relationships with persons who were their equals.
Because both are comfortable with these dynamics, these relationships can be
enduring and may result in marriage.
6. Before I realized what was happening. Learning is an emotionally charged
experience, one that can stimulate attraction and transference. Some
professors/supervisors tend to exploit this phenomenon, not adequately respecting
the student’s vulnerability or managing the intensity of the situation. Students can
get lost in the transference and intensity, and this can lead to a gradual or rapid
sexualization of the relationship.
7. The objective and _ fair-minded educator/supervisor. Some
professors/supervisors feel that they are endowed with the power of objectivity, and
distinguished by such powers from their mortal colleagues. They engage in sexual
and/or romantic relationships with students, claiming that their judgment is
unaffected, and that they are still capable of making objective and fair decisions
about the student, e.g., regarding grades, letters of recommendation, assistantships,
etc.
Prevalence and Effects. Because of the increase in awareness of sexual

harassment issues in higher education and in the attempt to avert potential litigation,
many universities have established policies that prohibit or strongly discourage
sexual or romantic relationships between professors and their own students. The
issue is a most controversial one among faculty and students alike (Koocher &
What is the prevalence of sexual encounters between faculty and students?
Although there are no comparable data in the field of music therapy, several studies
have been conducted which examined the incidence of self-reported sexual
involvement between student psychotherapists (psychologists or psychiatrists) and
their instructors. Results revealed the following: 0-3.9% of male respondents and
4.1-17% of females reported sexual involvements with their educators (Carr, et al.,
1991; Gartrell, et al., 1988; Glaser & Thorpe, 1986; Pope, Levenson & Schover,
1979). Also, 55% of female medical students reported being the subject of advances
from their instructors (Sheehan, et al., 1991). Forty-five percent of female
respondents indicated that they were punished by their educators for refusing sexual
involvement (Glaser & Thorpe, 1986), and 9.7% of female students reported being
harassed by their faculty (Carr, et al., 1991). In addition, 11% of psychology
educators reported sexual involvement with their students, and 28% felt this
behavior was ethical (Tabachnik, Keith-Spiegel & Pope, 1991).
The immediate and long-term effects of these relationships are likely quite
damaging. Research suggests that students who engage in sexual relationships with
faculty subsequently engage in sexual relationships with clients at a higher rate
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(Pope, et al., 1979). In another survey, 96% of female students who had experienced
sexual relationships or harassment involving faculty indicated that this had been
harmful to them and/or to the faculty involved (Robinson & Reid, 1985). Also,
attitudes towards the sexual relationships appear to become more negative over time
(Glaser & Thorpe, 1986).
Ethical Issues. Although the topic may be controversial in other fields, it is

quite clear and straightforward in the field of music therapy. The Code of Ethics
of the AMTA (1999) expressly prohibits: the exploitation of students, sexually,
physically, financially, or emotionally; and the establishment of dual relationships
with students that interfere with judgment and objectivity and which may involve
competitive or conflicting interests.
The ethical issues involved in establishing sexual relationships with students
are similar to those involved in therapist-client sexual relationships (see Chapter 6).
There is power inherent in the role of the educator/supervisor, and he or she has
power and authority over the student’s grades, status in the program, career
advancement and perhaps even financial status; the student is correspondingly
vulnerable to this power. There is also an inherent conflict of interest involved for
the educators or supervisors who sexualize relationships with students, in other
words, they put their personal needs ahead of those of the student.
Some would argue that because both educator/supervisor and student are
adults, if mutual consent is given for a sexual/romantic relationship, no ethical issue
is involved. One may question, however, how free the consent may be for the
student. The professor/supervisor has various types of power over him or her, as
described above, and this unequal status does not permit true voluntary consent.
Furthermore, students may not be free to leave these relationships, once established,
for fear of recrimination. When the relationships between students and
professors/supervisors do not work out for whatever reason, there are both personal
and professional implications for such. The resulting feelings of sadness,
humiliation, fear, and vindictiveness can be superimposed on the professional
relationship, making for a potentially volatile situation. Professors/supervisors can
endanger their careers, become the target of litigation and administrative action, and
can lose their credibility and reputations. Students may also endanger their status
in the program, their financial support, their grades, and their careers (Koocher &
The role of the educator, supervisor and academic program is to facilitate
the intellectual, career, personal and ethical development of the student. Can
teaching/supervisory relationships become sexualized and retain their integrity at
the same time? The introduction of sex produces a scenario that is the complete
opposite of what this role and intent should be. Even when the results of sexual
relationships are not devastating for the student on a personal level, one can
seriously question what the student is able to learn from this environment.
Obviously, students learn, through the direct modeling of their professor/supervisor,
that it is acceptable for professionals to put their needs ahead of students’ needs, to
satisfy these needs in any way they choose, and to thereby discount the need for
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(Pope, et al., 1979). In another survey, 96% of female students who had experienced
sexual relationships or harassment involving faculty indicated that this had been
harmful to them and/or to the faculty involved (Robinson & Reid, 1985). Also,
attitudes towards the sexual relationships appear to become more negative over time
(Glaser & Thorpe, 1986).
Ethical Issues. Although the topic may be controversial in other fields, it is

quite clear and straightforward in the field of music therapy. The Code of Ethics
of the AMTA (1999) expressly prohibits: the exploitation of students, sexually,
physically, financially, or emotionally; and the establishment of dual relationships
with students that interfere with judgment and objectivity and which may involve
competitive or conflicting interests.
The ethical issues involved in establishing sexual relationships with students
are similar to those involved in therapist-client sexual relationships (see Chapter 6).
There is power inherent in the role of the educator/supervisor, and he or she has
power and authority over the student’s grades, status in the program, career
advancement and perhaps even financial status; the student is correspondingly
vulnerable to this power. There is also an inherent conflict of interest involved for
the educators or supervisors who sexualize relationships with students, in other
words, they put their personal needs ahead of those of the student.
Some would argue that because both educator/supervisor and student are
adults, if mutual consent is given for a sexual/romantic relationship, no ethical issue
is involved. One may question, however, how free the consent may be for the
student. The professor/supervisor has various types of power over him or her, as
described above, and this unequal status does not permit true voluntary consent.
Furthermore, students may not be free to leave these relationships, once established,
for fear of recrimination. When the relationships between students and
professors/supervisors do not work out for whatever reason, there are both personal
and professionali implications for such. The resulting feelings of sadness,
humiliation, fear, and vindictiveness can be superimposed on the professional
relationship, making for a potentially volatile situation. Professors/supervisors can
endanger their careers, become the target of litigation and administrative action, and
can lose their credibility and reputations. Students may also endanger their status
in the program, their financial support, their grades, and their careers (Koocher &
The role of the educator, supervisor and academic program is to facilitate
the intellectual, career, personal and ethical development of the student. Can
teaching/supervisory relationships become sexualized and retain their integrity at
the same time? The introduction of sex produces a scenario that is the complete
opposite of what this role and intent should be. Even when the results of sexual
relationships are not devastating for the student on a personal level, one can
seriously question what the student is able to learn from this environment.
Obviously, students learn, through the direct modeling of their professor/supervisor,
that it is acceptable for professionals to put their needs ahead of students’ needs, to
satisfy these needs in any way they choose, and to thereby discount the need for
250
department, as it may not be possible to predict future roles with the student that
may involve power, authority or evaluation. The same situation exists for faculty
who are considering dating former students. Will their former role involving power,
authority and evaluation come into play in the future with the student? It may be
that the student will need a letter of recommendation from the faculty member for
employment. Or perhaps, the student may decide to return to the university for
graduate studies. These relationships therefore require careful thought and foresight.
Finally, there may be situations where spouses or partners of faculty (or
other family members) decide to enroll for study in programs where the faculty
member teaches. Although these relationships may be pre-existing (i.e., they did not
evolve while the parties were in a student-teacher relationship), they nonetheless
have similar ethical implications. Because of the obvious inherent conflict of
interest and lack of objectivity of the faculty member regarding this particular
student, he or she should avoid any type of evaluative, power or authority
relationship with him or her in the academic setting. The faculty should not allow
the spouse/partner/family member to take his or her courses, and should excuse him
or herself from any departmental decision making role involving the student. Even
when taking these precautions, however, it is not possible to control the possible
biases of other faculty members towards the student, and the faculty member should
be extremely cautious in appearing to exert any pressure on colleagues regarding
grades, special privileges, etc. for the student. Needless to say, both faculty and
student will be in an awkward situation that should be handled very cautiously.
Recommendations. Because sexual/romantic relationships between

faculty/supervisors and students are unethical, they should be avoided at all costs.
Serious consequences for the faculty or supervisor involved, the student, other
students, the program and perhaps the university or clinical facility are likely
outcomes. Faculty members/supervisors who are contemplating or engaged in such
relationships should seriously consider seeking supervision or consultation with
trusted colleagues or engaging in personal therapy to deal with their issues and
needs in a more effective manner.
Similarly, Gabbard (1989) offers a number of recommendations for students
who feel pressured to engage in sexual relationships with educators/supervisors: 1)
decisions should be made based on informed choice rather than a feeling of
inevitability, 2) a log should be kept in which inappropriate behaviors are
documented, 3) connections should be made with other individuals to overcome
feelings of isolation, 4) it is important to respect one’s own feelings, even those that
may be uncomfortable, 5) if the professor/supervisor involved acted unethically, it
is important to assess whether other students may be similarly at risk, 6) a
determination should be made whether the student can resolve the issue in private
with the professor/supervisor, 7) if the matter cannot be resolved privately, it may
be necessary to find another faculty member or professional to mediate, 8) the
student should determine procedures for filing grievances, 9) other avenues for
resolving the problem may be explored, including consulting an attorney regarding
one’s legal rights.
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Student Evaluations
The music therapy codes of ethics acknowledge the responsibility of the

educator or supervisor to evaluate the student’s competencies according to sound
educational practices. They are likewise required to identify those students whose
weaknesses are such as to impair their performance as competent therapists. Implied
in the evaluation process is fairness and timeliness. Evaluations should be as
objective as possible, without bias, and provided in manner that will permit the
remediation of weaknesses. Established observable and behavioral criteria for
evaluation rather than personal judgments (Koocher & Keith-Spiegel, 1998) should
be employed. Furthermore, the same evaluation criteria should be applied equally
to all students.
Identifying impairment in students is a challenging issue for educators and
supervisors, as this impairment may be serious enough to interfere with clinical
work. For example, signs of impairment in the student may include: psychiatric
disturbances and depression, substance abuse, excessive grief, recurring medical
problems, loneliness, and marital discord (Deutsch, 1985; Pope, Tabachnick &
Keith-Spiegel, 1987; Thoreson, Miller & Krauskopf, 1989; Vasquez, 1992). This
type of impairment should be distinguished from the distress which results from the
developmental tasks of becoming a professional, which may be more amenable to
interventions from faculty and supervisors (Vasquez, 1988).
Lamb, Cochran & Jackson (1991) and Lamb, Presser, Pfost, Baum, Jackson
& Jarvis (1987) have developed procedures for assessing and responding to
impairment in psychology interns. Based on the three broad aspects of professional
functioning (knowledge and application of professional standards, competency and
personal functioning), they define impairment as:
interference in professional functioning that is reflected in one or more of
the following ways: a) an inability or unwillingness to acquire and integrate
professional standards into one’s repertoire of professional behavior; b) an
inability to acquire professional skills and reach an accepted level of
competency, and c) an inability to control personal stress, psychological
dysfunction or emotional reactions that may affect professional functioning
(Lamb, et al., 1991, p. 292-293).
These authors also provide criteria for discriminating problem behaviors

from impaired behaviors. Problem behaviors are those that require attention and
remediation but are not unusual or excessive for students. Examples include:
anxiety regarding clinical work, discomfort with diversity in clients, and lack of
understanding or compliance with agency requirements. Impairment, on the other
hand, involves the following:
a) the intern does not acknowledge, understand or address the problematic
behavior when it is identified; b) the problematic behavior is not merely a
reflection of a skill deficit that can be rectified by academic or didactic
training; c) the quality of service delivered by the intern is consistently
negatively affected; d) the problematic behavior is not restricted to one area
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of professional functioning; e) the problematic behavior has potential for

ethical or legal ramifications if not addressed; f) a disproportionate amount
of attention by training personnel is required; g) the intern’s behavior does
not change as a function of feedback, remediation efforts, or time; and h) the
intern’s behavior negatively affects the public image of the agency (Lamb,
étal., 1987, p. 599).
Furthermore, Lamb, et al., (1991) recommend additional criteria that may

be used to distinguish problem from impaired behaviors:1) the specific behaviors
manifested, where they occurred, and whether these behaviors are included in
evaluation criteria; 2) negative consequences of the behavior for clients and the
agency; 3) who witnessed the behaviors in question and their frequency; 4) self-
awareness of the preprofessional and his or her response to feedback; 5)
documentation of feedback; and 6) the seriousness of the behavior on the
professional/ethical continuum.
Vasquez (1992) emphasizes the need for supervisors and educators to
provide adequate feedback to students, to recommend strategies to solve the
difficulty, and if necessary, to terminate the clinical work of the student. The latter
is a most difficult decision for the supervisor to make, and one which “requires
social assertiveness, integrity, moral commitment, and ego strength,” and there may
be a “tendency to collude or avoid these important ethical responsibilities that exist
to protect the student, clients and the profession’’(p.200).
Confidentiality
One of the music therapy codes states that faculty and supervisors must
respect the confidentiality of the student with regard to his or her progress, sharing
such information only with the appropriate persons. Appropriate persons should be
considered only those who have immediate responsibility for training or evaluating
the student.
Other information about the student obtained by the faculty or supervisor
through the course of their interactions in class or in private discussion should be
maintained as confidential whenever possible. This information should not be
revealed as case materials in lectures or in casual conversations with colleagues or
others. When professors or supervisors must consult with others concerning a
student who is having difficulty, the student’s anonymity should be maintained. In
emergency situations, it may be necessary for the faculty or supervisor to break
confidentiality to protect the student or others (Koocher & Keith-Spiegel, 1998).
Teaching ethics
According to the music therapy codes of ethics, it is an ethical responsibility

for music therapy faculty and clinical supervisors to teach students the ethics of
music therapy practice, and to serve as an exemplary role model for ethical conduct
and enforcement of the professional code. This statement is not aspirational in
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intent! As the gatekeepers of the profession, they must first model what they intend
to teach.
Where Ethics is Taught and Learned. Data are available concerning how
ethics is taught and learned in academic and clinical training settings. Although
these studies were not conducted recently, and their results may not be
representative of how ethics is taught and learned in academic and clinical training
settings currently, they are national in scope, and they do provide some information
as to how the situation used to be (and may still be).
Dileo-Maranto & Bruscia (1988) asked music therapy educators and
supervisors where music therapy competencies, including ethics, were most
efficiently learned. Results from 37 music therapy educators revealed that ethics is
most efficiently taught in undergraduate courses (60%), practica/internship (28%),
graduate and coursework (12%). Results from 82 internship supervisors revealed
that ethics is most efficiently taught in undergraduate courses (40%),
practica/internship (36%), graduate courses (6%), and on the job (15%). On the
other hand, music therapy clinicians nationwide were asked where they actually
learned ethics. Results from 1,323 clinicians revealed that they learned ethics in
undergraduate coursework (30%), in practica/internship (20%), in graduate
coursework (10%), on the job (30%), and in training outside of a university or job
setting (11%).
Regarding who teaches ethics in the academic program, 72% of educators
reported that ethics is taught by music therapy faculty, 6% by non-music faculty,
and 21% by clinical supervisors. Educators also rated the success with which ethics
was taught as fairly high.
On a scale of 1 (least breadth/depth) to 5 (most breadth/depth), educators
rated the breadth and depth given to their coverage of ethics in their curricula as
2.77 and 2.43 respectively. Using the same scale, clinical supervisors rated the
breadth and depth of their coverage of ethics in clinical training as 3.58 and 3.53
respectively. Clinicians rated their own competence in ethics as 3.68 at the end of
their training, and 4.31 at the time of the survey.
In addition, Dileo-Maranto (1980; 1981c) and Dileo-Maranto & Wheeler
(1984;1986) surveyed all NAMT and AAMT music therapy university faculty to
determine how ethics is taught within the music therapy curriculum (and again,
these may or may not represent current practice). Results showed that ethics is
taught most often as part of another course (rarely as a full course), and that faculty
felt that materials available to teach ethics were insufficient. Faculty reported that
their students were often quite naive to ethical issues prior to instruction, and
recommended that instruction in ethics constitute a greater portion of training. The
breadth of ethical issues faculty emphasized in teaching appeared limited (perhaps
due to time constraints), as one-third of faculty reported that confidentiality was the
main focus of teaching. Faculty rated themselves at least moderately successful in
teaching ethics, and there was no general consensus among respondents concerning
the most difficult area of ethics to teach.
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How Ethics Should be Taught. There is an inherent risk involved in

teaching ethics in an unsystematic manner. Without structured, formal coursework
within the academic experience and without relevant learning materials, the student
may not be exposed to the breadth and depth of ethical issues. From the available
data cited above, it seems apparent that faculty members rated their coverage of the
breadth and depth of ethical issues only as average (and indeed there are many more
topics to be considered in ethics besides confidentiality). Students may be
dependent on the faculty member’s knowledge of ethics, especially when there are
no relevant instructional materials. Teaching ethics implies maintaining current
knowledge of both ethics and the law. As professional ethics is constantly evolving,
a considerable amount of work and study is required to maintain competence in
teaching.
Instruction which relies solely on the emergence of issues within supervision
is also very limited. Again, there can be no assurance that the necessary breadth and
depth of coverage will be provided in this approach, which Handelsman calls
“ethics training by ‘osmosis’” (1986a, p. 371).
It is the present author’s position that ethics needs to be afforded sufficient
instructional time within the music therapy curriculum, and that ethical thinking and
problem solving should be addressed explicitly in both undergraduate/graduate
coursework and clinical training in music therapy. The field of psychology has
taken a similar position regarding ethics instruction (Haas et al., 1986; Handelsman,
1986a, 1986b; Tymchuk, 1985; Tymchuk et al., 1982).
What is the best way to teach ethics? Currently, studies in the field of
psychology have shown that students were able to improve their skills in both
identifying ethical issues (Baldick,1980) and in problem-solving (Gawthrop and
Uhlemann, 1992) following various instructional strategies. However, several
studies, have reported a gap between students’ abilities to identify an appropriate
course of action and their willingness to follow through with the action (Bernard &
Jara, 1986; Smith, McGuire, Abbott & Blau, 1991). There are also no real
comparative data demonstrating the efficacy of one teaching method over another.
Therefore, research is needed concerning which instructional strategies help
students to best develop ethical thinking and to implement their ethical decisions
(Nagle, 1987; Tymchuk, 1985; Welfel, 1992).
In the field of psychology, there is an emerging consensus that ethics
instruction should be systematic and offered through a multilevel approach which
includes both structured classroom coursework and supervised discussion within
practica and internship settings (Fine & Ulrich, 1988; Meara, Schmidt & Day, 1996).
Ethics coursework provides the student with an introduction to ethical principles,
codes and decision-making strategies (Eberlein, 1986; Fine & Ulrich, 1988;
Handelsman, 1986b; Tymchuk, 1986). In addition, there are a number of
instructional strategies for teaching ethics, for example, instruction in problem-
solving, discussion of case examples, role playing (Bersoff, 1995; Gawthrop &
Uhlemann, 1992; Kitchener, 1986; Plante, 1995), self-assessment, lecture, directed
readings, independent research, clinical rounds, and video analysis.
Za
Ethics Competencies. The specific competencies to be imparted in teaching

music therapy ethics have yet to be defined, although this question may certainly
arise. At the present time in the field of music therapy, there are no detailed
competencies for ethical behavior; the current competencies are as follows: “(the
music therapist will) adhere to professional codes of ethics..Interpret and apply
ethical standards of the music therapy profession...Interpret and apply laws and
regulations regarding the human rights of clients” (NAMT, 1996). Realizing that
the professional codes may be quite inadequate in providing specific guidance for
ethical decisions, and that ethical thinking as a process may occur neither
spontaneously nor “by osmosis,” it seems essential to delineate more detailed
professional competencies in ethics. In this manner, music therapy faculty and
supervisors may develop more precise goals for their academic and supervision
efforts regarding ethics.
The following list represents the professional competencies that are
emerging in the field of psychology and are drawn from various recommendations
from their professional literature (Jacob-Timm & Hartshorne, 1998). These are
considered to be relevant as well to the field of music therapy.
1. Ethical therapists are sensitive to the ethical aspects of their work and are
cognizant that their behavior has ethical implications that can be both helpful and
harmful to others (Kitchener, 1986, p. 307; Rest, 1984; Welfel & Kitchener, 1992)
2. Ethical therapists have an adequate and working knowledge of the codes
of ethics, professional standards and laws as they relate to practice (Fine & Ulrich,
1988; Welfel & Lipsit, 1984).
3. Ethical therapists are proactive as opposed to reactive in their ethical
thinking and behavior (Tymchuk, 1986). The utilize their knowledge of ethical
codes, professional standards and the law in conjunction with ethical decision-
making skills both to foresee potential problems and to prevent them.
4. Ethical therapists are competent in assessing the ethical aspects of a
situation and exhibit skill in utilizing ethical reasoning and judgment (Kitchener,
1986). They utilize and have mastered an effective problem-solving model
(Tymchuk, 1981, 1986).
5. Ethical therapists demonstrate an awareness of their own feelings and
values and the role of these in the ethical decision-making process (Corey, Corey
& Callanan, 1993; Kitchener, 1986).
6. Ethical therapists acknowledge the complexity of ethical dilemmas and
decisions and are able to withstand uncertainty and ambiguity. They realize that
there may be more than one appropriate ethical decision (Kitchener, 1986).
7. Ethical therapists have the courage and fortitude to implement decisions
and assume accountability for their actions (Kitchener, 1986).
In addition, Rest (1984) has identified four components of moral or ethical
behavior which include: 1) the ability to observe and envision consequences and
effects of behavior and to frame sequences of events of potential causes, 2) making
decisions about what ethical solutions are appropriate, just and consistent with one’s
ideals, 3) making the decision by choosing among conflicting and competing
values, and 4) implementing the course of action. According to this model,
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educators and supervisors should focus on students’: development of empathy,

decision-making (versus rule-following), self-awareness of motivation and values,
and personal confidence and assertiveness (Dileo, in press).
Chapter Summary
1.Ethical advertising for education and clinical training programs necessitates

accuracy in the information provided, and the use of competitive advertising
strategies is questionable. Faculty and supervisors should not disparage the
reputations of other programs or actively recruit students who are matriculated
elsewhere. Students entering into music therapy education and training programs
should be adequately screened to determine their suitability and potential for
success. Faculty and supervisors have an ethical responsibility to design and
establish curricula and training programs which will adequately prepare students to
acquire the necessary competencies for music therapy practice.
2. In order to prepare competent music therapy practitioners, music therapy faculty

and supervisors must also be competent both in music therapy and in
teaching/supervising. Faculty and supervisors should be aware of and acknowledge
their values and biases, should avoid imposing these on students, and should
monitor their personal competence in teaching and supervising.
3. Because of power differentials and conflicts of responsibilities, the establishment

of dual relationships with students can have devastating effects. There are more
risks inherent in some dual relationships than others. Dual therapy or dual
romantic/sexual relationships with students may be particularly risky. Music
therapy education and supervision may be “therapy-like” when an attempt is made
to increase the student’s self-awareness and personal development; boundaries need
to be constantly monitored. This is distinguished from the practice of providing
therapy to students directly, which is unethical because of the power and authority
issues and evaluative responsibilities involved.
4. Experiential training methods are commonly used in education and supervision

to enhance a student’s self-awareness and skills as a therapist. Experiential training
may take a variety of forms, and the purpose of this training must be clearly
articulated. Variations on how experiential training is implemented may reduce
risks to students. Informed consent procedures should always be used.
5. Dual sexual relationships between educators/supervisors and students are

expressly prohibited by the music therapy codes of ethics. The ramifications of
these relationships are numerous and damaging to both parties.
6. The music therapy codes of ethics acknowledge the responsibility of the educator
or supervisor to evaluate the student’s competencies according to sound educational
practices. Faculty and supervisors must discriminate normal problems from
25,7.
impairment and take appropriate action for remediation.
7. According to the music therapy codes of ethics, it is an ethical responsibility for

music therapy faculty and clinical supervisors to teach students the ethics of music
therapy practice, and to serve as an exemplary role model for ethical conduct and
enforcement of the professional code.
8.There are no current data concerning how music therapy ethics is taught or
learned, and no detailed ethics competencies have yet been developed. However,
ethical thinking involves: the development of empathy, decision-making skills
(versus rule-following), self-awareness of motivation and values, and personal
confidence and assertiveness
Ethical Dilemmas
1. Dr. Martinson, a music therapy professor learns that his music therapy student,
Monica, is having an affair with a colleague, Dr. Clinton, whose course she is
taking.
2. Dr. Stevens, a music therapy professor at a large university, often receives

unsolicited complaints from her students about other faculty members.
3. Dr. Mack Kismo, a music therapy professor, often delivers provocative and
controversial lectures to his students. He does not attempt to disguise his feelings
concerning how the field of music therapy is dominated by women, how they leave
the field as soon as they get married and have children, and how male music
therapists are ultimately more qualified to assume university teaching and clinical
administration positions. When challenged on these views, he refers to the existing
data in the field, and also mainiains the right to exercise his academic freedom in
interpreting and applying these data.
4. Dr. I.M. Intolerant, teaches music therapy at a small college. She is very abrupt
and impatient in her dealings with students. She discourages students from making
contributions in her classes, by using such comments as “Couldn't you think of a
more intelligent question than that?” “That’s the type of response I would expect
from a second-grade child,” “You’re an idiot,”” You don’t belong in music
therapy,” etc.
5. Dr. Connie Cernd has several undergraduate students in her music therapy
program who have personal and emotional limitations and a lack ofself-awareness.
These issues will likely hamper their competence as music therapists.
6. One ofDr. Cernd’s students, Lucy, (from the situation above), asks Dr. Cernd for
a letter of recommendation to a clinical training facility. Lucy cannot obtain an
internship without this recommendation.
258
7. Dr. Intensa, a music therapy professor at a local college, requires all of her
students to enroll in the Music Therapy Methods 3 course. The course is completely
experiential, and students must participate in an ongoing music therapy group for
personal development. Students are “technically” graded on their skills in leading
the group, and on their verbal and interpersonal skills as both leaders and
participants. The course is quite intense, and no consent form for students is used.
In the past, students who have taken this course and who did not work “in-depth”
on their personal issues, received poor grades. In fact, other students jokingly
remark that “grades are based on the number of tissues you use during the course.”
8. Tammy, a music therapy intern at a psychiatric facility, has received a poor

three-month evaluation from Amy, her supervisor. Dr. West, her faculty advisor, has
also received a copy. Tammy believes that the evaluation is unfair and contains a
number offalse statements.
9. Bessie, a master’s student and music therapy intern at a facility for the
developmentally disabled, disagrees with the methods used by her supervisor, Ruth
(a bachelor’s level therapist). Their theoretical orientations are totally different,
and Bessie feels that her training and skills are more sophisticated that Ruth’s.
What’s more, Bessie feels that Ruth is condescending in her approach to clients
both verbally and musically. Ruth tells Bessie that unless she does as she’s told, she
will never pass her internship.
10. Dr. Studman, a music therapy professor, and his graduate assistant, Gloria have
worked very closely for two years. Gloria has assisted Dr. Studman in teaching his
classes, has helped him with his research, and has even done personal errands for
him. They have also become very good friends, and see each other frequently for
meals, drinks, etc. outside of campus. They call each other with their personal
problems, and Gloria even stays in Dr. Studman’s house when he attends
conferences. Gloria is quite enamored with Dr. Studman and would like to pursue
a romantic relationship with him. She will be graduating in a few months, and
hopes that they can begin this relationship as soon as she completes her studies.
1], Ally, a music therapist, interviews for two music therapy graduate programs in
the same locale. She is undecided about which one will better meet her needs.
During the interview, she asks each faculty member for information about his or her
own program. She then asks him/her to comment on the other graduate program she
is considering. She assumes that because the schools are close in proximity, the
faculty know each other's programs very well, and it would be good to get an
objective opinion.
1. Consider what types of information about academic music therapy programs and
music therapy clinical training programs would be most valuable for you to have
Pe
in making an informed choice. Also, consider what type of information would be

valuable to you, but would not be ethically permitted!
2. How do you think academic and clinical training programs can ethically screen
students for admission? What criteria may be used?
3. Reflect upon the use of experiential methods in music therapy education and
supervision. Do you feel these are valuable tools for learning?
4. In your course journal, reflect upon what you would need from an experiential
course to derive the most benefits in terms of personal awareness and development,
and also in terms of music therapy skills.
5. Write a “mock” student consent form for an experiential training course. Include
in it what you would need personally (from #4 above). Discuss this with your
classmates, and perhaps also with your music therapy faculty.
6. In your course journal, reflect upon the type of feedback you need from faculty
and clinical supervisors that would most help you grow, both personally and
professionally, when you experience difficulties in your training program. Be as
specific as possible. Keep these ideas and add to them from time to time. If you do
experience difficulties in the future, they will be there to help you ask for what you
need. You may also want to have a discussion on this topic with your classmates
and faculty/supervisor. Input to faculty from students concerning their needs within
the program is often invaluable.
7. Think about the issue of dual relationships in education and supervision. Are
there dual relationships that seem to you to be more or less risky than others? What
boundaries should be implemented for both parties to avoid risky dual
relationships? What boundaries do you implement (or need to implement) to avoid
these risks?
8. Reflect upon what it might mean for you to be “an exemplary model of ethical
conduct” for the students you may supervise or teach in the future. What are the
implications for you in the present if you aspire to this?
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PROMOTING ETHICAL BEHAVIOR
husic therapists have an obligation to be familiar with their professional

code of ethics and to abide by it, even when there are external pressures, e.g., from
employers, to violate ethical standards. The music therapist is at all times
responsible for his or her ethical behavior or lack thereof. At the same time, music
therapists have a responsibility to monitor the behavior of their professional music
therapy peers or co-workers, students, interns and employees.
Should a music therapist serve as a watchdog for the profession? Although
“watchdog” is a strong term, it is the music therapist’s responsibility to protect
clients, employers, students and the profession from the unethical activities of
others. Unethical behavior may go unchecked, and may continue unless someone
notices and intervenes (Koocher & Keith-Spiegel, 1998).
Koocher & Keith-Spiegel (1998) categorize characteristics of professionals
who may be prone to act unethically, unprofessionally or questionably: 1) those
who are uneducated, unaware or naive to ethical standards, 2) those who are
incompetent because of inadequate training, emotional impairment, etc., 3) those
who are insensitive to the needs of others, e.g., because they lack empathy, have
excessive needs for control, are overzealous, are biased or prejudiced, etc., 4) those
who exploit their power, authority or the trust given them, and put their own needs,
e.g., financial, sexual or otherwise, over the needs of those to whom they have an
ethical responsibility, 5) those who are irresponsible or careless in the execution of
their professional duties and who may abandon their responsibilities, 6) those who
are vengeful and who are driven by intense emotions rather than sound professional
judgment, 7) those who are fearful of retaliation or liability for previous behaviors,
8) those who rationalize or distort their behavior, and 9) those who slip and make
mistakes, but who are otherwise ethical. Furthermore, professionals may act
unethically when they utilize ethical denial or illogical thinking, when they are
uninformed or when they are caught in various types of ethical traps (see Chapter
1).
Informal Resolution of Ethics Violations
Upon learning of or observing another’s unethical behavior, the music

therapist has the responsibility of bringing this behavior to the person’s attention,
262
and of requesting action(s) to correct this behavior, i.e., attempting an informal

resolution. According to the music therapy codes, this is usually the first step
required. The therapist should be given a chance to become aware of and to
remediate the action voluntarily and informally, and the music therapist may discuss
with the individual various possibilities for correcting the behavior. The music
therapist should document in writing his or her actions, as well as the response of
the person involved. The music therapist should then ascertain that the behavior has
been corrected, if the therapist has voluntarily agreed to do so, and should document
this as well.
When the individual who is involved in the ethical violation is a student,
intern or employee, the music therapist may feel relatively comfortable in providing
feedback to him or her regarding the behavior in question and in asking for
corrective actions. As the music therapist may have some authority over these
persons, he or she also has some level of responsibility in assuring that their
behavior is ethical.
When the individual involved in the ethical violation is a co-worker,
colleague or person who has some authority over the music therapist, he or she may
feel less inclined to confront the person for many reasons, e.g., because of personal
discomfort, because he or she does not want to get involved, and/or for fear of
recrimination, legal action, retaliation, physical or emotional harm, or job loss. The
seriousness of the violation may also influence a music therapist’s willingness to
handle the violation on a person-to-person basis. For example, violations that are
relatively minor may be ignored, and at the same time, violations that are extremely
severe may pose excessive danger for the therapist.
There may be compelling reasons for music therapists not to attempt an
informal resolution of the ethical violation on a person-to-person basis. For
example, the music therapist may not be able to directly confront a colleague who
is sexually harassing him or her. Or, the music therapist may believe that the
colleague poses a threat to his or her well-being and safety, or he or she may be
fired out of recrimination. Some colleagues may be impaired in some way, e.g., by
drug or alcohol abuse, stress or physical or emotional disability, and these factors
may render the individual potentially volatile if a direct confrontation is attempted.
When there are extenuating circumstances such as these or others, the music
therapist may file a formal ethics complaint with the professional association
directly without attempting to informally resolve the ethical violation. In doing so,
the reasons for doing this must be provided to the ethics committee to which the
complaint is made.
Koocher and Keith-Spiegel (1998) provide specific guidelines for
therapists who attempt an informal resolution of ethical violations with colleagues.
1) An attempt should be made to determine the specific ethical standard or
principle or law that has been violated. When in doubt concerning whether the
situation is an ethical one or not, colleagues or the professional association may be
consulted. If no standard or principle can be identified, the matter may be a
professional issue, but not an ethical one, e.g., a colleague with an abrasive
personality or with views out of the mainstream of current thought.
263
2) A determination should be made regarding how strong the evidence is

that a violation has been committed. Evidence may be categorized as follows: a)
direct observation of the colleague committing the offense, b) intentional or
unintentional admission by the colleague that the offense has taken place, c) direct
observance of a colleague’s suspicious behavior that is not readily interpretable, d)
a convincing and credible secondhand report from another who is seeking assistance
in dealing with the infraction, e.g., a client, or e) informal hearsay or gossip.
The validity and credibility of evidence should be weighed carefully. The
therapist should attempt to speculate why the individual involved would have
committed the particular offense, and if there could be alternative explanations for
the behavior. If evidence comes from a secondhand source, the motivations of the
individual reporting this should be examined, as well as the likelihood that the
information has been distorted (Koocher & Keith-Spiegel, 1998).
The type of evidence available is likely to help determine a particular course
of action. If the evidence is relatively shaky, the therapist may choose to remain
alert to and monitor the situation, but not take immediate action. If a secondhand
source is reliable, and the source is seeking assistance with a problem, the therapist
should try to be as helpful as possible, and has the option of becoming involved in
the situation or not. If he or she does become involved, he or she must have
permission from the source to reveal identifying information.
3) The therapist should explore his or her motivation in dealing with or not
dealing with the violation. Anger may be a motivating force if the therapist is him
or herself the victim of the violation. However, the therapist should honestly
determine whether the colleague’s unethical behavior poses potential harm to the
profession, clients, etc., and if this is the case, he or she must pursue the resolution.
An exception to this obligation may occur if confronting the colleague places the
therapist at risk (Koocher & Keith-Spiegel, 1998).
4) The therapist should consult with colleagues expert in ethical issues,
maintaining the confidentiality of the person who has committed the violation
5) The therapist should make a decision regarding a plan of action and the
best strategy for confronting the colleague, using an ethical decision-making model.
The therapist should avoid the temptation to deal with the situation in an indirect or
covert manner. For example, he or she may decide to spread the information to
other colleagues as a warning. This action may not remediate the problem, and may
indeed be unethical for a number of reasons. The therapist should also avoid an
anonymous confrontation, such as an unsigned letter, an anonymous phone call, or
forwarding a copy of the code of ethics to him or her. The colleague may be
oblivious to the intent of the message, or if aware, may become more secretive or
paranoid, and the violation may persist (Koocher & Keith-Spiegel, 1998).
6) Face-to-face encounters with the colleague are preferred to phone calls
(unless the parties are at a distance geographically), letters or electronic
communication (which may pose additional threats to confidentiality). In-person
encounters may permit constructive interaction. The therapist should schedule an
appointment with the colleague in advance in a manner that does not appear overly
264
threatening. The encounter should take place ina professional setting that protects
privacy and confidentiality (Koocher & Keith-Spiegel, 1998).
7) The therapist should prepare for the meeting so that he or she can
maintain a sense of calm and confidence, even in the face of the colleague’s
potentially intense reactions. It is helpful for the therapist to assume as
nonthreatening a stance as possible, avoiding righteousness, and a moralistic
approach. For example, the therapist may expression concern or confusion and ask
for clarification on the problem, allowing the colleague ample time to offer an
explanation for his or her behavior (Koocher & Keith-Spiegel, 1998).
8) The tone of the conversation should be both constructive and educative.
The therapist may attempt to establish a partnership with the colleague so that they
may confront the situation together. The therapist should avoid a vertical,
accusatory or judgmental posture (Koocher & Keith-Spiegel, 1998).
9) The therapist should describe his or her ethical responsibilities in the
situation, and should be prepared to state his or her concerns for the ethical
standards that have been violated, if necessary. Directness, openness and honesty
are important, and the therapist should not attempt to trick the colleague into an
admission or to play detective (Koocher & Keith-Spiegel, 1998).
10) The therapist should assess his or her relationship with the colleague. Is
the colleague a subordinate or superior, a friend or an adversary, or someone the
therapist knows well or not at all? The approach taken with the colleague is often
directly related to the nature of the existing relationship, or lack thereof. If the
colleague is a friend, the confrontation may be more comfortable, as a caring
relationship may already exist. Although, the therapist who confronts may indeed
jeopardize the friendship, however, if the therapist acts in and conveys good faith
to help the colleague, the friendship will likely survive. If the therapist does not
know the colleague, the confrontation will likely become more formal, although
caring and concern may still be expressed. If the confrontation is with an adversary,
and no confidentiality issues regarding the violation are involved, the therapist may
ask another party to deal with the confrontation or to be present at the time. Because
emotional issues such as anger, revenge, etc. may come into play, care should be
taken so that the confrontation does not become a personal vendetta. If the therapist
is confronting the individual on behalf of another person, the therapist must be
honest regarding his or her indirect knowledge of the situation and his or her reason
for intervening, e.g., on behalf of a student. Following the meeting, the therapist
may want to arrange a meeting with all persons present, and may agree to mediate
such an encounter (Koocher & Keith-Spiegel, 1998).
11) If the colleague becomes extremely agitated, abusive, aggressive or
threatening, the therapist should stay grounded and attempt to redirect the colleague
to a calmer state. If the behavior persists or if the therapist feels unsafe in the
situation, he or she may suggest that the discussion be postponed until a later time
and that the colleague contact him or her within a certain time frame. If the
colleague does not contact the therapist for another meeting, the therapist may need
to pursue additional or more formal action. Consultation with an expert colleague
would be helpful prior to filing formal charges. If charges are filed, the colleague
265
should be so informed of the action (Koocher & Keith-Spiegel, 1998).

It is important to note (from the music therapy codes) that music therapists
should not file or support the filing of formal complaints that are frivolous, or which
are intended to cause damage to a colleague, rather than to protect the public and
profession. The music therapist, whether the person filing a complaint or the
recipient of such, is also ethically obliged to cooperate fully in any ethics
investigations, proceedings or hearings.
Formal Resolution of Ethics Violations
When music therapists have unsuccessfully attempted to resolve unethical

behavior in an informal manner, i.e., through a confrontation with the colleague
involved, or if an informal resolution is not feasible for reasons cited previously, the
therapist may decide, after consultation with expert colleagues, to file a formal
ethics complaint through the professional association and/or certifying body. Civil
and criminal charges may also be filed if the matter is a legal one as well.
Music therapy associations who provide ethical standards for members
usually have detailed procedures for filing and processing formal ethics complaints.
These procedures vary according to the professional music therapy association, and
may be a part of the code itself. When no formal procedures are in place, the music
therapist may contact the association for direction on how to proceed. The reader
should refer to the code of ethics of his or her professional association (see the
Appendix) for specific details. A time limit for filing a formal ethics complaint after
the violation has occurred may be imposed, e.g., one year.
After an ethics violation has been filed, processed and heard, a decision is
made by the association regarding the violation. If there is insufficient evidence of
an ethics violation, or if the individual is found not to have committed the
infraction, exoneration is usually recommended. If the individual is found to be
guilty of the unethical behavior, sanctions may be imposed on the individual.
Sanctions may include the following: temporary or permanent withdrawal of the
individual’s membership in the association; mandatory rehabilitative activity, such
as personal therapy, education or supervision; and/or a written reprimand for the
violation to be retained in the individual’s permanent association records. In
addition, the individual may be denied eligibility for the professional credential, or
the credential may be suspended for a time, not renewed or revoked. The
association may have provisions for the individual to appeal the decision, or to
reapply for membership or the professional credential if suspended.
It is noted that an association’s code of ethics applies only to its members
and/or those persons who are certified by the association. Individuals who are non-
members or who are not credentialed by the association are beyond the jurisdiction
of the association. For example, music therapists are not able to file charges through
the music therapy association against a person who is practicing music therapy
without an appropriate credential and who is not a member of that professional
association. Other means for filing complaints may or may not be available, unless
civil or criminal activity is involved.
266
A Model for Ethical Practice
Many recommendations for ethical behavior have been made throughout this
text. As a summary, the following recommendations are offered for day to day
music therapy practice to both prevent and deal with ethical problems. These have
been adapted from the following authors: Canter, Bennett, Jones and Nagy (1996);
Haas and Malouf (1995); Pettifor, 1996; and Pryzwansky and Wendt (1999).
1. Be familiar with the music therapy code of ethics of your association. It is hoped
that you have become more familiar with this code in solving the ethical dilemmas
presented in this text. However, it is important to keep the code handy and refer to
it often. As the music therapy codes of ethics may be revised, become familiar with
new documents as well.
2. Become familiar with federal laws and state regulations which are applicable to
music therapy practice. Identify an attorney who may be available to you and
provide consultation when difficult or crisis situations arise.
3. Be familiar with the rules, regulations and policies of your employer. Remain
alert to any rules, etc. which may conflict with the ethical standards of the music
therapy profession, and inform employers of these conflicts in advance. Prevention
of such conflicts can greatly enhance your work situation.
4. Seek out continuing education in ethics, at conferences, through specialized

course work, or through directed self-study. Access libraries, bibliographies and/or
online resources with current information on ethics. Encourage the development of
workshops and seminars on ethics at your workplace or at conferences of your state,
regional or national music therapy association.
5. Engage in efforts to enhance your own self-awareness. This can occur through
personal therapy, supervision and/or consultation. Keep a journal of your thoughts
and feelings, particularly with regard to the clients you see. Pursue options for self-
care that are most meaningful and relevant to your own needs, as discussed in
Chapter 3. Work actively to deal with excessive stress.
6. Use all available opportunities to enhance your professional and personal

competence. Pursue continuing education through graduate courses, workshops,
seminars, self-study, etc. Seek out supervision when the limits of your competence
are tested.
7. Develop a peer support network, particularly if you feel isolated in your work.
Among peers, you can have opportunities to share clinical experiences, strategies,
techniques, concerns and information. Peers can also provide opportunities for
supervision.
267
8. Maintain a list of professionals with whom you may consult for expert advice on
ethics, such as members of your association’s ethics committee, former faculty
members or supervisors, etc. Use them for advice and feedback!
9. Identify when there is the potential for an ethical problems, and remain aware of
your blind spots, biases, weaknesses, limits and vulnerabilities. Develop skill in
applying a model for ethical problem-solving, such as the one presented in Chapter
Chapter Summary
1. The music therapist is at all times responsible for his or her ethical behavior or
lack thereof. At the same time, music therapists have a responsibility to monitor the
behavior of their professional music therapy peers or co-workers, students, interns
and employees. Therapists should be aware of characteristics that may predispose
persons to act unethically.
2. Upon learning of or observing another’s unethical behavior, the music therapist

has the responsibility of bringing this behavior to the person’s attention, and of
requesting action(s) to correct this behavior, i.e., attempting an informal resolution
The music therapist should undertake this action with appropriate sensitivity, a
well-grounded strategy, and caring. Guidelines for accomplishing this are provided.
Person-to-person confrontations about ethical violations may not always be
possible, for example, if in doing so, there are risks to the safety/welfare of the
therapist.
3. When informal attempts to resolve the ethical violation are unsuccessful, the
music therapist may use more formal procedures, i.e., the filing of a formal charge
against the person. Associations each have their own detailed procedures for how
this process is handled.
1. Select a variety of ethical dilemmas from the previous chapters of the book, and
make a decision about whether and how the music therapist involved (or his or her
colleague) could implement informal attempts at resolving the ethical problem. If
informal attempt are not advisable, state the reasons why.
2. Role play with a peer a confrontation with a colleague for an ethical violation
(you may use a particular situation provided in the book). Go through the guidelines
provided in this chapter, and receive feedback on how you handled the situation.
3. Read through the procedures given in the music therapy codes for attempting
formal resolutions of ethics violations. What are your reactions to these procedures?
Compare these procedures with those provided in ethics codes of related
268
professions.
4. Read through the list of characteristics that may predispose individuals to acting
unethically. Take a hard look at yourself to examine if you may have any of these
characteristics.
5. Based on what you have learned in this ethics course, you may have additional
suggestions to be included in the section, “A Model for Ethical Practice.” Discuss
these with your classmates.
6. In your course log, reflect upon your strengths, weaknesses, feelings, etc. in
handling informal and formal resolutions to ethical violations. Are there specific
strengths you may have in dealing with these confrontations? Are there specific
feelings or weaknesses you can identify which may prevent you from doing so if the
situation required it? Explore possible options for addressing these feelings and/or
weaknesses.
7. Develop your own plan of action for preventing and dealing with ethical
problems in the future (you may want to use the list of suggestions as a guideline)
as well as your course logs.
8. In a short paper, summarize the most important things you have learned about
ethics and yourself in this course, using your course logs as a starting point.
9. Go back to the beginning of the book and the first ethical dilemmas presented in
Chapter 1. Provide solutions to these problems again. No matter what solution you
provide the second time around, reflect on how your process for solving the
problem may have changed as a result of having studied ethics.
10. Define what ethical thinking means for you at this point in your career. What
implications may ethical thinking have for you in the future?
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APPENDIX: CODES OF ETHICS
AMERICAN MUSIC THERAPY ASSOCIATION CODE OF ETHICS
Preamble
The members of the American Music Therapy Association, Inc. hereby recognize and publicly
accept the proposition that the fundamental purposes of the profession are the progressive
development of the use of music to accomplish therapeutic aims and the advancement of training,
education, and research in music therapy. Our objectives are to determine and utilize music
therapy approaches that effectively aid in the restoration, maintenance, and improvement in
mental and physical health. To that end, we believe in the dignity and worth of every person. We
promote the use of music in therapy, establish and maintain high standards in public service, and
require of ourselves the utmost in ethical conduct.
This Code of Ethics is applicable to all those holding the MT-BC credential or a professional
designation of the National Music Therapy Registry and professional membership in the
American Music Therapy Association. We shall not use our professional positions or
relationships, nor permit ourselves or our services to be used by others for purposes inconsistent
with the principles set forth in this document. Upholding our right to freedom of inquiry and
communication, we accept the responsibilities inherent in such freedom: competency, objectivity,
consistency, integrity, and continual concern for the best interests of society and our profession.
Therefore, we collectively and individually affirm the following declarations of professional
conduct.
1.0 Professional Competence and Responsibilities
1.1 The MT will perform only those duties for which he/she has been adequately trained, not
engaging outside his/her area of competence.
ee The MT will state his/her qualifications, titles, and professional affiliation(s) accurately.
13 The MT will participate in continuing education activities to maintain and improve
his/her knowledge and skills.
1.4 The MT will assist the public in identifying competent and qualified music therapists and
will discourage the misuse and incompetent practice of music therapy.
LD The MT is aware of personal limitations, problems and values that might interfere with
his/her professional work and, at an early stage, will take whatever action is necessary
(i.e., seeking professional help, limiting or discontinuing work with clients, etc.) to
ensure that services to clients are not affected by these limitations and problems.
1.6 The MT respects the rights of others to hold values, attitudes, and opinions that differ
from his/her own.
Neel The MT does not engage in sexual harassment (as defined by U.S. law).
1.8 The MT accords sexual harassment grievants and respondents dignity and respect, and
does not base decisions solely upon their having made, or having been the subject of,
sexual harassment charges.
1:9 The MT practices with integrity, honesty, fairness, and respect for others.
1.10 The MT delegates to his/her employees, students, or co-workers only those
responsibilities that such persons can reasonably be expected to perform competently on
the basis of their training and experience. The MT takes reasonable steps to see that such
persons perform services competently; and, if institutional policies prevent fulfillment of
this obligation, the MT attempts to correct the situation to the extent feasible.
2.0 General Standards
zl The MT will strive for the highest standards in his/her work, offering the highest quality
of services to clients/students.
2.2 The MT will use procedures that conform with his/her interpretation of the Standards of
Clinical Practice of the American Music Therapy Association, Inc.
Z.3 Moral and Legal Standards
2.3.1 The MT respects the social and moral expectations of the community in which
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he/she works. The MT is aware that standards of behavior are a personal matter
as they are for other citizens, except as they may concern the fulfillment of
professional duties or influence the public attitude and trust towards the
profession.
2.3.2. The MT refuses to participate in activities that are illegal or inhumane, that
violate the civil rights of others, or that discriminate against individuals based
upon race, ethnicity, language, religion, marital status, gender, sexual
orientation, age, ability, socioeconomic status, or political affiliation. In
addition, the MT works to eliminate the effect on his or her work of biases
based upon these factors.
Relationships with Clients/Students/Research Subjects
The welfare of the client will be of utmost importance to the MT.
The MT will protect the rights of the individuals with whom he/she works. These rights
will include, but are not limited to the following:
-right to safety;
-right to dignity;
-legal and civil rights;
-right to treatment;
-right to self-determination;
-right to respect; and
-right to participate in treatment decisions.
33 The MT will not discriminate in relationships with clients/students/research subjects
because of race, ethnicity, language, religion, marital status, gender, sexual orientation,
age, ability, socioeconomic status or political affiliation.
3.4 The MT will not exploit clients/students/research subjects sexually, physically,
financially or emotionally.
35 The MT will not enter into dual relationships with clients/students/research subjects and
will avoid those situations that interfere with professional judgment or objectivity (e.g.,
those involving competitive and/or conflicting interests) in their relationships.
3.6 The MT will exert caution in predicting the results of services offered, although a
reasonable statement of prognosis and/or progress may be made. The MT will make only
those claims to clients concerning the efficacy of services that would be willingly
submitted for professional scrutiny through peer review, publication in a professional
journal, or documentation in the client’s record.
nt The MT will offer music therapy services only in the context of a professional
relationship and in a setting which insures safety and protection for both client and
therapist. The MT will avoid deception in representations of music therapy to the public.
3.8 The MT will inform the client and/or guardian as to the purpose, nature, and effects of
assessment and treatment.
39 The MT will use every available resource to serve the client best.
3.10 The MT will utilize the profession’s Standards of Practice as a guideline in accepting or
declining referrals or requests for services, as well as in terminating or referring clients
when the client no longer benefits from the therapeutic relationship.
3.11 In those emerging areas of practice for which generally recognized standards are not yet
defined, the MT will nevertheless utilize cautious judgment and will take reasonable
steps to ensure the competence of his/her work, as well as to protect clients, students and
research subjects from harm.
3.12 Confidentiality
3.12.1 The MT protects the confidentiality of information obtained in the course of
practice, supervision, teaching and/or research.
3.12.2 Confidential information may be revealed only under the following
circumstances:
a. when under careful deliberation, it is decided that society, the client, or other
individuals appear to be in imminent danger. In this situation, information may
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be shared only with the appropriate authorities or professionals. The client is

made aware of this when possible and if reasonable.
b. when other professionals within a facility or agency are directly related with
the case or situation.
c. when the client consents to the releasing of confidential information.
3.12.3. The MT informs clients of the limits of confidentiality prior to beginning
treatment.
3.12.4 The MT disguises the identity of the client in the presentation of case materials
for research and teaching. Client or guardian consent is obtained, with full
disclosure of the intended use of the material.
3.12.5 All forms of client records, including, but not limited to verbal, written,
pictorial, and tape recordings will be acquired with informed client or guardian
consent and will be maintained in a confidential manner by the MT. Also,
adequate security will be exercised in the preservation and ultimate disposition
of these records.
3.12.6 Information obtained in the course of evaluating services, consulting,
supervision, peer review, and quality assurance procedures will be kept
confidential.
Relationships with Colleagues
The MT acts with integrity in regard to colleagues in music therapy and other professions
and will cooperate with them whenever appropriate.
The MT will not offer professional services to a person receiving music therapy from
another music therapist except by agreement with that therapist or after termination of
the client’s relationship with that therapist.
The MT will attempt to establish harmonious relations with members from other
professions and professional organizations and will not damage the professional
reputation or practice of others.
The MT will share with other members of the treatment team information concerning
evaluative and therapeutic goals and procedures used.
Relationships with Employers
The MT will observe the regulations, policies, and procedures of employers with the
exception of those that are in violation of this code of ethics.
The MT will inform employers of conditions that may limit the effectiveness of the
services being rendered.
When representing the employer or agency, the MT will differentiate personal views
from those of the profession, the employer, and the agency.
The MT will provide services in an ethical manner and will protect the property,
integrity, and reputation of the employing agency.
The MT will utilize the agency’s facilities and resources only as authorized.
The MT will not use his/her position to obtain clients for private practice, unless
authorized to do so by the employing agency.
Responsibility to Community/Public
The MT will strive to increase public awareness of music therapy.
Responsibility to the Profession/Association
The MT respects the rights, rules, and reputation of his/her professional association.
The MT will distinguish personal from professional views when acting on behalf of
his/her association. The MT will represent the association only with appropriate
authorization.
The MT will strive to increase the level of knowledge, skills, and research within the
profession.
The MT will refrain from the misuse of an official position within the association.
The MT will exercise integrity and confidentiality when carrying out his/her official
duties in the association.
Research
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8.1 The MT establishes a precise agreement with research subjects prior to their participation
in the study. In this agreement, the responsibilities and rights of all parties are explained,
and written consent is obtained. The MT explains all aspects of the research that might
influence the subject’s willingness to participate, including all possible risks and benefits.
The MT will avoid any deception in research.
8.2 Participation of subjects in music therapy research will be voluntary. Appropriate
authorization will be obtained both from the subjects involved (or specified guardians)
and the facility. The subject is free to refuse to participate or to withdraw from the
research at any time without penalty or loss of services.
8.3 The MT is ultimately responsible for protecting the welfare of the research subjects, both
during and after the study, in the event of aftereffects, and will take all precautions to
avoid injurious psychological, physical, or social effects to the subjects.
8.4 The MT will store research data in a secure location accessible only to the researcher.
The researcher will determine a set period of time after completion of the study by which
all research data must be shredded or erased.
8.5, The MT will be competent in his/her research efforts, being cognizant of his/her limits.
8.6 The MT will present his/her findings without distortion and in a manner that will not be
misleading.
8.7 Publication Credit
8.7.1 Credit is assigned only to those who have contributed to a publication, in
proportion to their contribution.
8.7.2. Major contributions of a professional nature made by several persons to a
common project will be recognized by joint authorship.
8.7.3. Minor contributions such as editing or advising, will be recognized in footnotes
or in an introductory statement.
8.7.4 Acknowledgment through specific citations will be made for unpublished as
well as published material that has directly influenced the research or writing.
8.7.5 The MT who compiles and edits for publication the contribution of others will
publish the symposium or report under the title of the committee or symposium,
with the therapist’s name appearing as chairperson or editor among those of the
other contributors or committee members..
Fees and Commercial Activities
The MT accepts remuneration only for services actually rendered by himself or herself or
under his or her supervision and only in accordance with professional standards that
safeguard the best interests of clients and the profession.
The MT will not take financial advantage of a client. The MT will take into account the
client’s ability to pay. Financial considerations are secondary to the client’s welfare.
Private fees may not be accepted or charged for services when the MT receives
remuneration for these services by the agency.
No gratuities, gifts or favors should be accepted from clients that could interfere with the
MT’s decisions or judgments.
Referral sources may not receive a commission, fee, or privilege for making referrals
(fee-splitting).
The MT will not engage in commercial activities that conflict with responsibilities to
clients or colleagues.
The materials or products dispensed to clients should be in the client’s best interest, with
the client’s having the freedom of choice. The MT will not profit from the sale of
equipment/materials to clients. Charges for any materials will be separate from the bill
for services.
10.0 Announcing Services
10.1 The MT will adhere to professional rather than commercial standards in making known
his or her availability for professional services. The MT will offer music therapy services
only in a manner that neither discredits the profession nor decreases the trust of the
public in the profession.
220
The MT will not solicit clients of other MTs.

The MT will make every effort to ensure that public information materials are accurate
and complete in reference to professional services and facilities.
The MT will avoid the following in announcing services: misleading or deceptive
advertising, misrepresentation of specialty, guarantees or false expectations, and the use
of the Association’s logo.
The MT will differentiate between private practice and private music studio in
announcing services.
The following materials may be used in announcing services (all of which must be
dignified in appearance and content); announcement cards, brochures, letterhead and
business cards. The MT may include the following on these materials: name, title,
degrees, schools, dates, certification, location, hours, telephone number, and an
indication of the nature of services offered.
Announcing services through the mail (to other professionals) and through a listing in the
telephone directory are acceptable. No advertisement or announcement will be rendered
in a manner that will be untruthful and/or deceive the public.
Education (Teaching, Supervision, Administration)
The MT involved in teaching establishes a program combining academic, research,
clinical, and ethical aspects of practice. The program will include a wide range of
methods and exposure to and application of current literature.
The MT involved in education and/or supervision will use his/her skill to help others
acquire the knowledge and skills necessary to perform with high standards of
professional competence.
11.3 Theory and methods will be consistent with recent advances in music therapy and related
health fields. The MT involved in education will teach new techniques or areas of study
only after first undertaking appropriate training, supervision, study, and/or consultation
from persons who are competent in those areas or techniques.
11.4 The MT involved in the education of students and internship training will ensure that
clinical work performed by students is rendered under adequate supervision by other
music therapists, other professionals, and/or the MT educator.
The MT involved in education and/or supervision will evaluate the competencies of
students as required by good educational practices and will identify those students whose
limitations impede performance as a competent music therapist. The MT will recommend
only those students for internship or membership whom he/she feels will perform as
competent music therapists and who meet the academic, clinical and ethical expectations
of the American Music Therapy Association, Inc.
11.6 The MT involved in the education of students and internship training will serve as an
exemplary role model in regard to ethical conduct and the enforcement of the Code of
Ethics.
11.7 The MT involved in education and training will ensure that students and interns operate
under the same ethical standards that govern professionals.
12.0 Implementation
12.1 Confronting Ethical Issues
12.1.1 MT’s have an obligation to be familiar with this Code of Ethics.
12.1.2 When a MT is uncertain whether a particular situation or course of action would
violate this Code of Ethics, the MT should consult with a member of the Ethics
Board.
12.1.3. A MT will not disobey this code, even when asked to do so by his/her employer.
12.1.4 The MT has an obligation to report ethical violations of this Code by other
MT’s to the Ethics Board.
12.1.5 The MT does not file or encourage filing of ethics grievances that are frivolous
and are intended to harm the respondent rather than to protect the public and
preserve the integrity of the field of music therapy.
12.1.6 The MT cooperates in ethics investigations, proceedings, and hearings. Failure
296
to cooperate is, itself, an ethics violation.
12.1.7. Neither the Chair nor any other member of the Ethics Board will take part in the
informal or formal resolution procedures is s/he has a conflict of interest.
1222 Informal Resolution of Ethical Violations
12.2.1 Upon observing or becoming aware of alleged violations of this Code of Ethics
by an MT (hereinafter referred to as the respondent), the observer will consult
first with the respondent involved and discuss possible actions to correct the
alleged violation when such consultation is appropriate for the resolution of the
ethical violation. The MT should document these efforts at informal resolution.
In some instances, the individual consultation between the observer and the
respondent may be either inappropriate or not feasible. In such instances (which
may include, but are not limited to: sexual harassment, fear of physical
retaliation, and imminent threats to the observer’s employment), the observer
should file a formal grievance with an explanation of the reason why individual
consultation was not appropriate or feasible.
123 Formal Resolution of Ethical Violations
12.3.1 If.an apparent ethical violation is not appropriate for informal resolution or is
not resolved through consultation, the observer (herein referred to as the
grievant) will submit a written report (herein referred to as the grievance)
describing the alleged violation(s) to the Chairperson of the Ethics Board. The
written report will consist of the following: (a) a signed, dated summary, not
longer than one page, of the principle allegations (hereinafter referred to as the
charge) against the respondent; (b) a thorough explanation of the alleged
violation(s); (c) a summary of informal resolution attempts, when such have
been made; and (d) collaborative documentation, including signed statements by
witnesses, if available.
12.3.2 The grievance must be made within one year of the last instance of the alleged
violation(s) of this code.
12.3.3. Upon receipt of the grievance by the Chairperson of the Ethics Board
(hereinafter referred to as the Ethics Chairperson), the Ethics Chairperson will
advise the MT respondent, in writing and within 45 days, that an ethics
grievance has been made against him/her. Included in this notification will be a
copy of the signed charge. The Ethics Chairperson will invite the respondent to
submit a written defense within 60 days, including corroborative documentation
and/or signed statements by witnesses, if available.
12.3.4 The Ethics Chairperson, or his/her designee from the Ethics Board, will conduct
an initial inquiry into the grievance to confirm (a) the seriousness of the charge
and (b) the possibility of resolution of the issue without a formal hearing.
12.3.5 After the initial inquiry, the Ethics Chairperson or designee may, at his or her
discretion, negotiate a resolution to the grievance that will be presented in
writing to the grievant and the respondent. If both parties agree to this
resolution, they will sign and abide by the terms therein stated.
12.3.6 The initial inquiry by the Ethics Chairperson or designee, and negotiated
attempts at a resolution will be conducted within 45 days following receipt of
the respondent’s defense.
12.3.7 If agreement to a negotiated resolution is not reached, or if 45 days have passed
following receipt of the respondent’s defense, the Ethics Chairperson will
initiate the formal procedure. At that time, the Ethics Chairperson will inform in
writing the Ethics Board, the Executive Director of AMTA, the President of
AMTA, the grievant, and the respondent that the formal hearing procedure has
begun.
12.4 Formal Hearing Procedures
12.4.1 No member of the Ethics Board who has worked toward the informal resolution
of a charge will be part of the Review Board for the formal resolution
297
procedures. The Ethics Chairperson will send copies of the grievance and the
written defense to all members of the Ethics Board, along with a written report
of the initial inquiry and any attempts at resolution. The Board will review these
materials until the formal hearing. This hearing will be scheduled to take place
within 90 days of the Board’s receipt of all materials. All members of the Board,
as well as the grievant and the respondent, must agree to appear at this hearing.
A schedule for (a) the exchange of document and witness lists between parties
and the Ethics Board and for (b) any pre-hearing meetings will be set by the
Ethics Chairperson. The schedule will be developed in order to assure adequate
preparation time and a fair hearing procedure for all parties.
12.4.2 At the hearing the grievant and the respondent will both have the right to present
witnesses and other evidence, examine and cross-examine witnesses, and
employ an attorney or other advocate, if so desired, to represent him/her in all
matters.
12.4.3 The AMTA Executive Director will ensure that a transcript of the hearing is
made. Copies will be made available to either of the parties at a reasonable cost.
In addition, either of the parties may, at their own initiative and expense, have a
transcript made by a licensed court reporter.
12.4.4 The Ethics Board, after due deliberation, will rule upon the grievance. The
ruling will require a 3:2 majority. The decision of the board will be
communicated, in writing, to the grievant, the respondent, and the Executive
Director of AMTA, and the President of AMTA. The written report of this
decision will include specific recommendations and time limits for the
correction of violations, as well as possible sanctions. This report will be sent
via registered mail. Time limits for the correction of violations and/or sanctions
will begin upon the parties’ receipt of the report.
2.5 Group Grievances
12:5e1 If more than one individual wishes to file a grievance against the same party,
each individual will file a separate grievance. If the Ethics Chairperson
considers the grievances related in a substantive way, the Chairperson may
choose to combine the grievances into a single hearing, as long as there is no
objection to such combination by the individual grievants. In this instance, the
procedures heretofore established will remain the same.
1232 An employing agency may charge a MT with a violation of this Code of Ethics
in the same manner as an individual grievant does so. The employing agency
will appoint a representative to function in the role of grievant.
12.6 Corrective Actions
12.6.1 If the individual takes no corrective action within the designated time-limit, the
Ethics Board will recommend sanctions to the Executive Board for action.
Possible sanctions may include, but are not limited to: (a) permanent or time-
specific withdrawal of the individual’s membership in the Association; (b)
rehabilitative activity, such as personal therapy; (c) a binding agreement by the
respondent to limit practice, education/training or research; (d) a written
reprimand; (e) recommendation to the National Music Therapy Registry or the
Certification Board for Music Therapists (as appropriate) for the withdrawal of
professional designation or credential. The MT may appeal the decision of the
Ethics Board to the Judicial Review Board.
298
CERTIFICATION BOARD FOR MUSIC THERAPISTS

CODE OF PROFESSIONAL PRACTICE
PREAMBLE
The CBMT is a nonprofit organization which provides board certification and
recertification for music therapists. The members of the Board of Directors comprise a diverse
group of experts in music therapy. The Board is national in scope and blends both academicians
and clinicians for the purpose of establishing rigorous standards which have a basis in a real world
ractice,
‘ The CBMT recognizes that music therapy is not best delivered by any one sub-specialty
or single approach. For this reason, the CBMT represents a comprehensive focus. Certification is
offered to therapists from a wide variety of practice areas, who meet high standards of the Practice
of Music Therapy. To the extent that standards are rigorously adhered to, it is the aim of the
CBMT to be inclusive, and not to be restrictive to any sub-specialty.
Maintenance of board certification will require the adherence to the CBMT Code of
Professional Practice. Individuals who fail to meet these requirements may have their certification
suspended or revoked. The CBMT does not guarantee the job performance of any individual.
i: ELIGIBILITY FOR CERTIFICATION OR RECERTIFICATION
As a condition of eligibility for and continued maintenance of any CBMT certification,
each candidate or certificant agrees to the following:
1. Compliance with CBMT standards, Policies and Procedures
No individual is eligible to apply for or maintain certification unless in
compliance with all the CBMT standards, policies, and procedures. Each
individual bears the burden for showing and maintaining compliance at all
times. The CBMT may deny, revoke, or otherwise act upon certification or
recertification when an individual is not in compliance with all the CBMT
standards, policies and procedures. Nothing provided herein shall preclude
administrative requests by the CBMT for additional information to supplement
or complete any application for certification or recertification.
2. Complete Application
The individual shall truthfully complete and sign an application in the form
provided by the CBMT, shall provide the required fees and shall provide
additional information as requested. The individual shall notify the CBMT
within sixty (60) days of occurrence of any change in name, address, telephone
number, and any other facts bearing on eligibility or certification (including but
not limited to: filing of any criminal charge, indictment, or litigation;
conviction; plea of guilty; plea of nolo contender; or disciplinary action by a
licensing board or professional organization), A candidate or certificant shall
not make and shall correct immediately any statement conceming the
candidate’s or certificant’s status which is or becomes inaccurate, untrue, or
misleading.
All references to “days” in the CBMT standards, policies and procedures shall
mean calendar days. Communications required by the CBMT must be
transmitted by certified mail, return receipt requested, or other verifiable
methods of delivery when specified. The candidate or certificant agrees to
provide the CBMT with confirmation of compliance with the CBMT
requirements as requested by the CBMT.
3. Property of the CBMT
The examinations and certificates of the CBMT, the name Certification Board
for Music Therapists, and abbreviations relating thereto are all the exclusive
property of the CBMT and may not be used in any way without the express
prior written consent of the CBMT. In case of suspension, limitation,
revocation, or resignation from the CBMT, or as otherwise requested by the
CBMT, the individual shall immediately relinquish, refrain from using, and
299
correct at the individual’s expense any outdated or otherwise inaccurate use of

any certificate, logo, emblem, and the CBMT name and related abbreviations. If
the individual refuses to relinquish immediately, refrain from using and correct
at his or her expense any misuse or misleading use of any of the above items
when requested, the individual agrees that the CBMT shall be entitled to obtain
all relief permitted by law.
4. Criminal conviction
An individual convicted of a felony directly related to music therapy and/or
public health and safety shall be ineligible to apply for certification or
recertification for a period of seven (7) years from the exhaustion of appeals or
final release from confinement (if any), whichever is later. Convictions include
but are not limited to felonies involving rape, sexual, physical, or mental abuse
of a patient, client, child, or coworker; actual or threatened use of a weapon; and
prohibited sale, distribution, or possession of a controlled substance.
Il. SCORE REPORTS
The CBMT is concemed with reporting only valid scores. On rare occasions, misconduct
or circumstances beyond the individual’s control may render a score invalid. If doubts
are raised about a score because of these or other circumstances, the CBMT expects all
individuals to cooperate in any CBMT investigation or any investigation carried out by a
CBMT authorized testing service. The CBMT reserves the right to cancel any
examination score at any point in time, if, in the sole opinion of CBMT, there is adequate
reason to question its validity. CBMT in its discretion will (i) offer the individual an
opportunity to take the examination again at no additional fee, or (ii) proceed as
described below.
Il. APPLICATION AND CERTIFICATION STANDARDS
CBMT may revoke or otherwise take action with regard to the application or certification
of a candidate or certificant in the case of:
1. Ineligibility for certification or recertification; if a candidate or certificant has
not successfully completed the academic and/or clinical training requirements
for music therapy, or their equivalent, as set forth by AMTA; or if a candidate
does not qualify for an alternate admission consideration due to lack of or
inadequate training, which may or may not include applicants from countries
outside of the United States; or if a recertification applicant has not maintained
his or her quota of CMTE credits within the five year cycle;
2: Irregularity in connection with the CBMT exam or failing to maintain required
CMTE’s in a five year cycle;
3; Failure to pay fees required by the CBMT;
4. Unauthorized possession of, use of, or access to the CBMT examinations,
certificates, and logos of the CBMT, the name “Certification Board for Music
Therapists,” and abbreviations relating thereto, and any other CBMT documents
and materials;
3: Obtaining or attempting to obtain certification or recertification by a false or
misleading statement or failure to make a required statement; fraud or deceit in
an application, reapplication, representation of event/s, or any other
communication to the CBMT;
6. Misrepresentation of the CBMT certification or certification status;
qT: Failure to provide any written information required by the CBMT;
8 Habitual use of alcohol or any other drug/substance, or any physical or mental
condition which impairs competent and objective professional performance;
9, Failure to maintain confidentiality as required by law;
10. Gross or repeated negligence or malpractice in professional practice, including
sexual relationships with clients, and sexual, physical, social, or financial
exploitation;
11. Limitation or sanction (including but not limited to revocation or suspension by
300
a regulatory board or professional organization) relating to music therapy
practice, public health or safety, or music therapy certification or recertification;
The conviction of, plea of guilty or plea of nolo contender to a felony or
misdemeanor related to music therapy practice or health/mental health related
issues. This includes but is not limited to a felony involving rape, physical,
mental or sexual abuse of a patient, client, child, or coworker; actual or
threatened use of a weapon or violence; and the prohibited sale, distribution, or
possession of a controlled substance;
13: Failure to timely update information to CBMT; or
14. Other violation of a CBMT standard, policy or procedure as provided in the
CBMT Candidate Handbook, Recertification Manual, or other material provided
to candidates or certificants.
IV. ESTABLISHMENT OF SPECIAL DISCIPLINARY REVIEW AND
DISCIPLINARY HEARING COMMITTEES
A. Upon the recommendation by the Chair, the CBMT Board of Directors may
elect by a majority vote (i) a Disciplinary Review Committee and (ii) a
Disciplinary Hearing Committee, to consider alleged violations of any CBMT
disciplinary standards set forth in Section III. 1-14 above or any other CBMT
standard, policy, or procedure.
Each of these Committees shall be composed of three members drawn from the
CBMT certificants.
A committee member’s term of office on the committee shall run for three years
and may be renewed.
A committee member may serve on only one committee and may not serve on
any matter in which his or her impartiality or the presence of actual or apparent
conflict of interest might reasonably be questioned.
At all times during the CBMT’s handling of the matter, the CBMT must exist as
an impartial review body. If at any time during the CBMT’s review of a matter a
CBMT member identifies a situation where his or her judgment may be biased,
prejudiced or impartiality may be compromised, (including employment with a
competing organization) the member is required to report such matter to the
Executive Director immediately.
Committee action shall be determined by majority vote.
am When a committee member is unavailable to serve due to resignation,
disqualification or other circumstance, the Chair of the CBMT shall designate
another individual to serve as an interim member,
REVIEW AND APPEAL PROCEDURES
A. Failure to Meet CBMT Deadlines
As a rule, CBMT expects its certificants to meet all deadlines imposed by
CBMT, especially in regard to submission of fees, recertification applications,
required evidence of continuing education, and sitting for its examinations. On
rare occasion, circumstances beyond the control of the certificant or other
extraordinary conditions may render it difficult, if not impossible, for the
certificant to meet CBMT’s deadlines. Should a certificant wish to make appeal
of a missed deadline, the certificant should transmit a written explanation and
make request for a reasonable extension of the missed deadline, with full
relevant supporting documentation, to the CBMT office, to the attention of the
CBMT Board of Directors. A certificant shall pay a filing fee when filing such a
request. The Board of Directors will determine at the next meeting of the Board,
in its sole discretion and on a case-by-case basis what, if any recourse, should be
afforded to such individuals based on the circumstances described and the
overall impact on CBMT. No other procedures shall be afforded to certificants
who fail to meet CBMT deadlines.
Submission of Allegations
301
Allegations of a violation of a CBMT disciplinary standard or other

CBMT standard, policy or procedure are to be referred to the Executive
Director for disposition. Persons concerned with possible violation of
CBMT’s rules should identify the persons alleged to be involved and
the facts concerning the alleged conduct in as much detail and
specificity as possible with available documentation in a written
statement addressed to the Executive Director. The statement should
identify by name, address and telephone number of the person making
the information known to the CBMT and others who may have
knowledge of the facts and circumstances concerning the alleged
conduct. Additional information relating to the content or form of the
information may be requested.
The Executive Director shall acknowledge receipt of allegations and
forward to counsel for review within sixty (60) days.
The Executive Director shall make a determination of the substance of
the allegations after consultation with counsel.
If the Executive Director determines that the allegations are frivolous
or fail to state a violation of CBMT’s standards, the Executive Director
shall take no further action and so apprise the Board and the
complainant (if any).
If the Executive Director determines that good cause may exist to deny
eligibility or question compliance with CBMT’s standards, the
Executive Director shall transmit the allegations to the Disciplinary
Review Committee.
Procedures of the Disciplinary Review Committee
hs The Disciplinary Review Committee shall investigate the allegations
after receipt of the documentation from the Executive Director. If the
majority of the Committee determines after such investigation that the
allegations and facts are inadequate to sustain a finding of a violation if
CBMT disciplinary standards, no further adverse action shall be taken.
The Board and the complainant (if any) shall be so apprised.
If the Committee finds by majority vote that good cause exists to
question whether a violation of a CBMT disciplinary standard has
occurred, the Committee shall transmit a statement of allegations to the
candidate or certificant by certified mail, return receipt requested,
setting forth the applicable standard and a statement:
a. Of facts constituting the alleged violation of the standard;
b. That the candidate or certificant may proceed to request: (i)
review of written submission by the Disciplinary Hearing
Committee; (ii) a telephone conference of the Disciplinary
Hearing Committee; or (ili) an in-person hearing (at least held
annually proximate to the annual meeting of the CBMT) for
the disposition of the allegations, with the candidate or
certificant bearing his or her own expenses for such matter;
C: That the candidate or certificant shall have fifteen (15) days
after receipt of such statement to notify the Executive Director
if he or she disputes the allegations, has comments on
available sanctions, and/or requests a written review,
telephone conference hearing, or in-person hearing on the
record;
d. That the candidate or certificant may appear in person with or
without the assistance of counsel, may examine and cross-
examine any witness under oath, and produce evidence on his
or her behalf;
302
e. That the truth of allegations or failure to respond may result in
sanctions including possible revocation of certification, and
f. That if the candidate or certificant does not dispute the
allegations or request a review hearing, the candidate or
certificant consents that the Committee may render a decision
and apply available sanctions. (Available sanctions are set out
in Section VI., below.)
Procedures of the Disciplinary Hearing Committee
i If the CMTEs of a certificant are determined deficient after a certificant
has exhausted his or her remedies under CBMT’s then-existing
reconsideration process, the certificant may proceed to request: (i)
review of written submission by the Disciplinary Hearing Committee;
(ii) a telephone conference of the Disciplinary Hearing Committee; or
(iii) an in-person hearing (held at least annually proximate to the
annual meeting of the CBMT.)
If the candidate or certificant disputes the allegation or available
sanctions or requests a review or hearing, the Disciplinary Review
Committee shall:
a. forward the allegations and response of the candidate or
certificant to the Disciplinary Hearing Committee; and
b. designate one of its members to present the allegations and
any substantiating evidence, examine and cross-examine
witness and otherwise present the matter during any hearing
of the Disciplinary Hearing Committee.
The Disciplinary Hearing Committee shall then:
a. schedule a written review, or telephone, or in-person hearing
as directed by the candidate or certificant,
b. send by certified mail, return receipt requested, a Notice of
Hearing to the applicant or MT-BC. The Notice of Hearing
shall include a statement of requirements violated and, as
determined by the Disciplinary Hearing Committee, the time
and place of the review or hearing (as indicated by the
individual). The candidate or certificant may request a
modification of the date of the hearing for good cause.
The Disciplinary Hearing Committee shall maintain a verbatim audio
and/or video tape or written transcript of any telephone conference or
in-person hearing.
The CBMT and the candidate or certificant may consult with and be
represented by counsel, make opening statements, present documents
and testimony, examine and cross-examine witnesses under oath, make
closing statements, and present written briefs as scheduled by a
Disciplinary Hearing Committee.
The Disciplinary Hearing Committee shall determine all matters relating
to the hearing or review. The hearing or review and related matters
shall be determined on the record by majority vote.
Formal rules of evidence shall not apply. Relevant evidence may be
admitted. Disputed questions shall be determined by majority vote of
the Disciplinary Hearing Committee.
Proof shall be by preponderance of the evidence.
©90 Whenever mental or physical disability is alleged, the candidate or
certificant may be required to undergo a physical or mental
examination at the expense of the candidate or certificant. The report of
such an examination shall become part of the evidence considered.
The Disciplinary Hearing Committee shall issue a written decision
303
following the hearing or review and any briefing. The decision shall
contain factual findings, conclusions of law and any sanctions applied.
It shall be mailed promptly by certified mail, return receipt requested,
to the candidate or certificant.
E. APPEAL PROCEDURES
iP, If the decision rendered by the Disciplinary Hearing Committee finds
that the allegations are not established, no further action on the appeal
shall occur and the individual shall be notified.
2s If the decision rendered by the Disciplinary Hearing Committee is not
favorable to the candidate or certificant, the candidate or certificant
may appeal the decision to the CBMT Board of Directors by
submitting a written appeals statement within thirty (30) days
following receipt of the decision of the Disciplinary Hearing
Committee. CBMT may file a written response to the statement of the
candidate or certificant.
2 The CBMT Board of Directors by majority vote shall render a decision
on the appeal without oral hearing, although written briefing may be
sumbitted by the candidate or certificant, and CBMT.
4, The decision of the CBMT Board of Directors shall be rendered in
writing following receipt and review of any briefing. The decision shall
contain factual findings, conclusions of law and any sanctions applied
and shall be final. (Available sanctions are set out in Section VI. 1-8
below.) The decision shall be transmitted to the candidate or certificant
by certified mail, return receipt requested.
VI. SANCTIONS
Sanctions for violation of any CBMT standard set forth herein or any other CBMT
standard, policy or procedure may include one or more of:
l. Exoneration;
a Mandatory remediation through specific education, treatment, and/or
supervision;
3; Written reprimand to be maintained in certificant’s permanent file;
4. Suspension of board certification with the right to re-apply after a
specified date;
5 Denial or suspension of eligibility;
6. Non-renewal of certification;
Ue Revocation of certification;
8 Other corrective action.
VII. SUMMARY PROCEDURE

Whenever the Executive Director determines that there is cause to believe that a threat of
immediate and irreparable harm to the public exists, the Executive Director shall forward
the allegations to the CBMT Board. The Board shall review the matter immediately, and
provide telephonic or other expedited notice and review procedure to the candidate or
certificant. Following such notice and opportunity by the individual to be heard, if the
Board determines that a threat of immediate and irreparable injury to the public exists,
certification may be suspended for up to ninety (90) days pending a full review as
provided herein.
VIII. RELEASE OF INFORMATION
The individual candidate or certificant agrees that CBMT and its officers, directors,
committee members, employees, and agents, and others may communicate any and all
information related to the alleged individual’s application or certification and review
thereof including but not limited to pendency or outcome of disciplinary proceedings to
state and federal authorities, licensing boards, employers, other certificants, and others.
IX. WAIVER
304
The individual releases, discharges, and exonerates CBMT, its officers, directors,
employees, committee members and agents, and any other persons for any action taken
pursuant to the standards, policies, and procedures of the CBMT from any and all
liability, including but not limited to liability arising out of (i) the furnishing or
inspection of documents, records and other information and (ii) any investigation and
review of application or certification made by the CBMT.
X. RECONSIDERATION OF ELIGIBILITY AND REINSTATEMENT OF
CERTIFICATION
If eligibility or certification is denied or revoked, eligibility of certification may be
reconsidered on the following basis:
A. in the event of a felony conviction directly related to music therapy practice or
public health and/or safety, no earlier than seven (7) years from the exhaustion
of appeals or release from confinement, whichever is later,
B. in any other event, no earlier than five (5) years from the final decision of
ineligibility or revocation.
In addition to other facts required by the CBMT, such an individual must fully set forth
the original circumstances of the decision denying eligibility or revoking certification as
well as all current facts and circumstances since the adverse decision relevant to the
reconsideration of eligibility or the reinstatement of certification. When eligibility has
been denied because of felony conviction, the individual bears the burden of
demonstrating by clear and convincing evidence that the individual has been rehabilitated
and does not pose a danger to others.
Adopted: February 8, 1997; Effective date: January 1, 1998; Revised: February 7, 1998
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WORLD FEDERATION OF MUSIC THERAPY, INC.

MODEL GUIDELINES FOR ETHICAL CONDUCT
(adopted July, 1993)
A. PREAMBLE
The World Federation of Music Therapy strongly urges each member association to
develop its own codes of ethical standards for professionals. This process also involves defining
in each respective country the definition of music therapy and the designation of professionals to
whom this code applies.
This document has been developed to provide guidelines for the development of
professional codes of ethics.
B. RESPONSIBILITIES TO THE CLIENT
The welfare of the client is of utmost concern and responsibility for the music therapist.
In offering music therapy services to clients, the following principles should be upheld:
iy The music therapist respects the rights and dignity of the client and at all times acts in the
client’s best interest.
2. The music therapist does not discriminate in relationships with clients on the basis of
race, sex, creed, color, national origin, age, sexual orientation, or clinical problem.
3, The music therapist does not exploit the client for sexual, financial or emotional reasons,
nor for personal gain.
4, The music therapist delivers services only in the context of a professional relationship
and in settings which assure safety for the client. The music therapist adheres to the
highest standards of clinical practice.
3 The music therapist assesses both the strengths and weaknesses of the client and
develops appropriate treatment goals to meet client needs; the progress of the client is
continually evaluated.
6. Every available resource is utilized to effect treatment goals.
ee The therapist restricts his treatment to those areas where he or she is adequately trained
305
and does not practice outside of his or her area of competence; qualifications and titles of
the therapist are accurately stated.
The music therapist terminates treatment when the client no longer benefits from
services.
The music therapist protects the confidentiality of the client at all times, including verbal,
written, audio and pictorial information regarding the client.
The music therapist maintains his or her own personal mental and physical health. He or
she monitors any personal limitations which may interfere with the quality of work and
takes whatever actions necessary to ameliorate these.
The music therapist routinely engages in continuing study to maintain and improve
knowledge and skills.
RESPONSIBILITIES TO COLLEAGUES
The music therapist acts with integrity in regard to colleagues in music therapy and other
disciplines.
When a music therapist conducts an initial assessment of a client, he or she shall
ascertain which other therapies the client is receiving, if any, and shall strive to maintain
communication with the therapists involved.
The music therapist does not offer professional services to a person currently receiving
music therapy from another professional except by agreement with the therapist or after
termination of the client’s relationship with that therapist.
The music therapist shall not damage the professional reputation of any other therapists.
RESPONSIBILITY TO THE PROFESSION
The music therapist accepts the responsibility to contribute to the growth of the
profession and professional organization and enhance its standing in the community.
The music therapist attempts to increase the level of knowledge, skills and research
within the profession.
The music therapist distinguishes personal from professional views when acting on
behalf of the association. The music therapist represents the profession only when
authorized to do so.
The music therapist respects the rights, rules, and reputation of the professional
association.
RESPONSIBILITY TO THE COMMUNITY/PUBLIC
The music therapist attempts to increase public awareness of music therapy and
represents the profession accurately.
The music therapist respects the social, legal and moral standards of the community in
which he or she works.
The music therapist assists the public in identifying qualified music therapists.
RESPONSIBILITY TO EMPLOYERS
The music therapist observes the policies of the employer.
The music therapist shall inform the employer of any conditions that may interfere with
the quality of music therapy services.
FEES AND REMUNERATION
The music therapist accepts fees only in accordance with professional standards.
No gifts or favors should be accepted from clients which could compromise a therapist’s
decision or judgment.
RESEARCH
The music therapist protects the welfare of subjects participating in music therapy
research. :
Appropriate authorization from subjects and the facility should be obtained prior to
undertaking research.
Participation in research by subjects is voluntary following an explanation to subjects (or
guardians) of all of the potential risks and benefits possible from participation in the
study. The subject is free to withdraw from the study at any time.
The confidentiality of the subject should be maintained in reporting research results.
306
5: In publications or professional presentations, the music therapist shall assign credit to

those who have collaborated in the work in proportion to their contribution.
6. The music therapist reports findings in a way that is accurate and in a manner which
avoids distortion and will not be misleading.
I. RESPONSIBILITIES TO STUDENTS/SUPERVISEES
1. The music therapy educator or supervisor maintains current knowledge of the profession.
Z. The music therapist educator/supervisor evaluates students’ knowledge and skills and
identifies those students whose limitations may interfere with their performance as a
music therapist. The educator/supervisor shall not undertake therapy with a student for
various problems, but shall refer them to qualified professionals.
3 The music therapy educator/supervisor provides adequate feedback and supervision
necessary to train competent professionals.
4. The music therapy supervisor does not assign responsibilities to unqualified persons
without adequate supervision.
St The music therapy educator/supervisor maintains confidentiality with regard to a
student’s progress or failure to progress, discussing this only with appropriate persons at
the student’s academic institution.
J. ENFORCEMENT OF CODE
— If a breach of ethics occurs, the music therapist shall follow the enforcement procedure
developed by the music therapy association. If needed, the association shall take
whatever disciplinary action is warranted. These procedures typically involve the
following:
a. direct confrontation of the person in violation of the code by a fellow
professional in an attempt to rectify the problem.
b: if the breach of ethics is not rectified, the professional will contact the ethics
committee of the association with a report which provides documentation of the
alleged violation and attempt(s) to rectify it.
Cc. the committee will then ask for a complete report from the individual against
whom the allegations have been made.
d. the committee will determine if a violation to the code has occurred and the
appropriate measures to be taken if the individual is found to be in violation.
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ASSOCIATION OF PROFESSIONAL MUSIC THERAPISTS

A.P.M.T. CODE OF PROFESSIONAL ETHICS AND DISCIPLINE
1, Code of Ethics:
i) A member of the A.P.M.T. in the United Kingdom shall agree in writing to and thereafter abide
by the following code of ethics:
A. A Music Therapist shall always act in the best interests of the client. Among other
things this should include:
1. Refraining from disclosure of confidential information obtained from or
about a particular client except within the multi-disciplinary team responsible
for treatment. Confidential information may be disclosed to students on
placement, but only with the agreement of the relevant authorities (e.g. hospital,
school).
2. Music Therapists should be aware of and agree to abide by their relevant
Area Child Protection Committee (ACPC) Inter-agency Guidelines, as Child
Protection is an important issue for all music therapists regardless of whether
their work routinely brings them into contact with children. Music Therapists
have a duty to pass on information relating to suspected adult to child, or child
to child, abuse and therefore should ensure their adequate training in its
recognition. Music Therapists should read the relevant literature in the APMT
Information Book (pages C.20 and C.21).
307
3. Before using any verbal, written or recorded information acquired within the
therapeutic relationship, for the purposes of publication, public presentation or
broadcasting, the nature of the use of such material should be explained to the
client (and/or guardian), and his/her permission obtained. The use of case
material for articles in professional journals would not fall under this clause. In
all cases anonymity should be respected.
4. Maintaining the client relationship on a strictly professional basis.
B. Maintaining communication with doctors and other relevant professionals and
advising them of the nature and progress of treatment.
C. Seeking advice as necessary from other appropriate professionals.
ii. Music Therapist shall ensure that a satisfactory standard of professional competence is
maintained. Among other things this will involve responsibility for:
A. Restricting his/her practice to within the limits of his/her own training and
competence.
B. Undertaking when possible to attend any courses, conferences, lectures, etc., offered
by appropriate organisations in order to extend his/her range of skills and knowledge.
C. Maintaining his/her own musical skills at the highest level of professional
competence.
D. Ensuring he/she receives supervision of his/her clinical practice.
(iii) A. When undertaking private treatment, a Music Therapist should ensure that a referral
from a medical practitioner or from other professionals involved in the treatment of the
client is obtained, unless this is judged to be inappropriate. In all cases, whether in
private practice or other, the therapist should liaise as closely as possible with those
involved in the treatment of the client and a case history should be obtained.
B. Dept. of Health circular hc77 33 Sept. 1977 reads as follows:
In asking for treatment by a therapist, the doctor is clearly asking for the help of another
trained professional, and the profession of medicine and the various therapies differ. It
follows from this that the therapist has a duty and a consequential right to decline to
perform any therapy which his professional training and expertise suggests is actively
harmful to the patient. Equaily the doctor who is responsible for the patient has the right
to instruct the therapist not to carry out certain forms of treatment which he believes
harmful to the patient.(Summary Para.2 (ii)).
(iv) A Music Therapist shall conduct his/her affairs in a satisfactory manner. Among other things
this will include:
A. Maintaining a fitting level of inter-colleague relationship, both within the profession,
with those in other professions and with his/her employer.
B. Refraining from giving treatment whilst under the influence of alcohol or drugs
unless as prescribed by a medical practitioner.
C. Refraining from giving treatment unless mentally and physically fit to do so.
D. Refraining from delegating duties to unregistered persons, except in the case of
Music Therapy students in training, in which case full responsibility must be assumed by
the therapist for that delegation.
E. Refraining from committing any criminal act in the practice of his/her profession.
F. Providing suitable premises and conditions for the treatment of clients.
G. Insuring the clients against all risks while on the therapist's premises. Therapists
working in private practice should have malpractice insurance.
H. Acceptance of the minimum current rate recommended by the A.P.M.T. for private
sessions.
I. Ensuring absolute hygiene of instruments and equipment, both for the therapist's and
client's benefit. Advice about current hygiene practices should be sought from the
A.P.M.T., hospital pharmacy or other appropriate source.
J. Legacies and Gifts: Music therapists should not solicit for personal financial gain.
They should neither offer nor accept tokens such as favours, gifts, legacies or hospitality
which might be construed as seeking to promote undue influence. Where relevant they
308
should adhere to guidelines or procedures published by Employing Authorities.

2. Disciplinary Procedure:
Breaches of the code of conduct may be dealt with by a disciplinary sub-committee of
the Executive; this committee will include the Chairperson of the A.P.M.T. Membership of the
A.P.M.T, may be terminated. August 1999.
PRINCIPLES OF PROFESSIONAL PRACTICE FOR MUSIC THERAPISTS
The following has been written as a basis for negotiation to use either at work or before
securing work. It outlines what a music therapist needs in order to work effectively. It should be
used in conjunction with the Code of Ethics.
1. MANAGEMENT
i)Music Therapists should be directly represented on an institutional management
structure.
ii)The Music Therapist should obtain and agree a comprehensive and viable Job
Description. Managerial and clinical responsibility should be clearly defined and
understood.
iii)The therapist must establish and uphold clinical and ethical standards.
iv)Music Therapists should have control over a financial allocation for
instruments/equipment and assume maintenance of equipment levels as their
responsibility’.
2. SELF-EMPLOYED MUSIC THERAPISTS
i)Music Therapists should adhere to professional rather than commercial standards in
making known the availability of their service.
ii)Music Therapists should communicate the availability of their service to related
professions and referring agencies.
iii)Music Therapists in private practice should ensure they receive adequate clinical
supervision and are advised to carry suitable insurance.
3. MINIMUM CONDITIONS
Music Therapists should have adequate facilities within which to practise. This would
necessitate the availability of a self-contained room large enough for individual/group work,
storage of musical instruments and equipment, an administration area and a telephone.
4. THE REFERRAL SYSTEM
1) The Music Therapist should be responsible for dealing with referrals, assessment and
subsequent treatment of clients on an equitable basis.
\ : ; ‘
proveohon ofCheats endtherapistsaiiket Pen noua be ensured for the
ii) A written referral should be sought from an accountable agent where possible. In the
case of self-referrals a written referral would follow after the initial contract where
possible.
iii) Music Therapists should retain the right not to treat certain clients following an
agreed assessment procedure, especially in cases where his/her professional training and
expertise suggests that therapy may be actively harmful to the client.
5. CASE LOAD
i) Music Therapists should have adequate time to attend ward rounds, staff meetings,
case conferences, etc. and should negotiate one full half day per week (or pro rata) for
the administration of the Music Therapy Department (Item 6. also refers).
ii) Music Therapists, while liaising with other disciplines, should ultimately specify their
own case loads to suit the needs of the clients and that of their place of work, i.e.
balancing individual and/or groups of individuals. The number of clients within a group
will be determined by the physical environment, the specific needs and disabilities
(physical, behavioral, emotional, etc.) of the clients and the need for assistance/escort
from other staff.
309
iii) There should be adequate time between sessions for preparation and record keeping
and some record should be kept of all sessions.
6. RECORD KEEPING
i) A daily audit of attendances should be kept, specifying reasons for any cancellation of
sessions through client or therapist absence.
ii) Accurate observations and records of all clinical work are kept. Evaluation of clinical
work (including analysis of taped material) is an essential aspect of the therapeutic
process. Recordings should be named, dated and stored during the therapeutic
relationship. It is advisable that Music Therapy case notes and relevant tapes should be
kept for a minimum of three years.
7. CONFIDENTIALITY
i) The Music Therapist should always act in the best interests of the client.
ii) Transactions between client and therapist should refrain from disclosing confidential
information obtained from or about a particular client, except within the multidisciplinary
team responsible for treatment.
iii) Communication should be maintained with doctors or other professionals, advising
them of the nature and progress of clients’ treatment programmes.
8. TRAINING
i) The Music Therapist should ensure that a satisfactory standard of professional
competence is maintained and should endeavour to keep up to date with new and current
trends in therapy and overall philosophies of care. Continuing A.P.M.T. membership
raises awareness of such issues.
ii) It is desirable that Music Therapists should have study leave and financial
support from their employment in order to attend in-service training programmes,
lectures, workshops and professional conferences.
ili) Music Therapists contributing to training programmes for colleagues or students
should receive a training allowance.
9, SUPERVISION/PROFESSIONAL SUPPORT
i) It is in the interests of Music Therapists to receive regular clinical supervision, ideally
within the workplace. This may take the form of individual or group sessions, preferably
conducted by an experienced Music Therapist. Music Therapists should also seek
support from other institutions, regional groups of the A.P.M.T. or other related
professions.
ii) The Music Therapist must at ali times restrict his/her practice to within the limits of
his/her own training and competence.
ASSOCIATION OF PROFESSIONAL MUSIC THERAPISTS

COMPLAINTS PROCEDURE
1. INTRODUCTION
1.0 The Association of Professionai Music Therapists recognises that effective management of
complaints can instill confidence in the Association by the membership and/or general public.
1.1 The Association wishes to be pro-active in its response to, and handling of, complaints.
1.2 An agreed procedure to respond to complaints with maximum efficiency and clarity has
therefore been established.
1.3 The purpose of the procedure is to enable officers of the Association to:
i) evaluate the performance of the Association in response to complaints from within the
membership.
ii) be pro-active in seeking to arbitrate in situations of dispute between Association
members.
iii) be willing to investigate complaints received from the general public.
iv) give advice on behalf of the profession as a whole on issues of dispute between an
APMT member and his/her employer. This role should be distinguished from the
310
representation of the member.

1.4 The Complaints Procedure should not be regarded as a disciplinary procedure.
Recommendations arising from the investigation of a complaint may, however, include the
activation of the APMT disciplinary procedure.
1.5 The evaluation, arbitration, investigation and giving of advice referred to in paragraph 1.3
should be as open as possible, but decisions on this matter will be for each Panel to make on the
merits of the particular complaint it is considering.
1.6 The remit of the Complaints Panel shall be limited to clinical matters and other matters upon
which the APMT has a policy or has issued advice (e.g. grading and terms and conditions of
employment).
2. PROCEDURE
2.0 Complaint received by the APMT Chairperson. The complaint must be in a form that can be
passed promptly, without alteration, to the respondent.
2.1 If complaint in writing, Chairperson acknowledges receipt in writing within 14 days.
2.2 Chairperson assesses if complaint can be resolved informally or activates Complaints
Procedure. If any of the issues fall to be considered under paragraph 1.3 iv), the complainant
should produce evidence on whether internal employment channels have been used in an attempt
to resolve them. It is not automatic that failure to use or exhaust internal channels will preclude
activation of the Complaints Procedure, but it is an issue that the APMT Chairperson should take
into account. The complainant should also inform the Panel of any recourse to any external
advice or representation.
2.3 Chairperson appoints three members of the Executive Committee/Advisory Council,
including one person nominated as Panel Chairperson, to act as a Complaints Panel. All relevant
documentation is sent to the Panel members. The APMT Chairperson and the Panel Chairperson
should agree which aspects, if any, of the complaint are beyond the remit of the Panel and the
complainant and respondent should be informed accordingly.
2.4 Panel Chairperson contacts all parties involved to gain the fullest information. Deadlines for
the receipt of replies are set (not to exceed 21 days).
2.5 On receipt of information, the Panel Chairperson calls meeting of the group to assess
information and form conclusions based on the available evidence. It may be necessary for the
Panel to interview individuals involved in the complaint.
2.6 The conclusions/recommendations of the Panel will be conveyed in writing to all parties
involved with the complaint and the APMT Chairperson within 14 days of the Panel meeting.
The Panel will indicate the degree of openness/confidentiality associated with the report in the
light of paragraph 1.5. Documents and other information provided to the Panel under paragraphs
2.3, 2.4 and 2.5 will remain confidential to the Panel and will not be passed to the parties or to the
APMT Chairperson, unless the authors of this additional material agree otherwise, or unless the
Chairperson of the second (and final) Panel (see paragraph 2.8) agrees otherwise.
2.7 The Complaints Panel should strive to provide as full and sympathetic a response as possible,
using plain English. The APMT Chairperson will decide on any further
publicity, after taking advice from the Panel Chairperson.
2.8 All complainants and defendants hold a right of appeal. They should write to the APMT
Chairperson within 14 days of receiving the Panel's recommendations. The Chairperson may:
a) Review the work of the Complaints Panel and uphold their decision.
b) Appoint a second (and final) Complaints Panel to review the case. The
recommendations of a second Complaints Panel will be final.
2.9 The Chairperson must inform the complainant of the outcome of the appeal within 14 days of
receiving the request for appeal. If a second Complaints Panel is formed, they should follow the
same procedure and timescale as for the original Panel.
March 1995
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AUSTRALIAN MUSIC THERAPY ASSOCIATION, INC.

Code of Ethics and Rules of Professional Conduct
(Rev. 1994; additional revisions in progress, 2000)
Preamble
This document comprises the Code of Ethics and Rules of Professional Conduct of the Australian
Music Therapy Association, Incorporated, hereinafter referred to as The Association. The Code of
Ethics and Rules of Professional Conduct have been revised and re-issued in 1994 to all members
with the approval of the Ethics committee and the National Council of the Association.
1. GENERAL PRINCIPLES OF ETHICS
Io This Code of Ethics and Rules of Professional Conduct shall be applicable to all
Members of The Association; that is all Members who join under the classifications of
“general,” “student,” and “Registered Music Therapists.” However, certain of these
requirements will apply only to those Members who are Registered Music therapists
(RMTs).
t2 a) A Music Therapist is a person
i) who has undergone appropriate training and has had adequate clinical
experience, and
11) whose qualifications and experience are accepted by the National
Registration and Education Board of The Association as leading to the
professional qualification of Registered Music Therapist (RMT). The letters
RMT shall only be used by such persons who hold current Registration granted
by The Association.
b) “General membership of AMTA, Inc. does not confer upon an individual the right to
call himself/herself a Music Therapist. A professional Music Therapist is a person
granted Registration by the Registration Board of AMTA Inc.” (By-Law #1, The Rules
and Constitution of AMTA Inc., rev. 1991)
1.3 Music Therapists are required to renew their Registration annually by payment of the
annual fee as determined by the National Council of The Association. Failure to pay the
fees shall lead to a lapse of Membership and Registration.
No Member of The Association shall describe himself or herself as a Music Therapist
unless accreditation has been approved by the National Registration and Education Board
as above. Nor shall any Member of the Association describe his or her work as Music
Therapy, unless he or she holds current Registration as a Music Therapist.
ETHICAL PRINCIPLES OF REGISTERED MUSIC THERAPISTS
A Registered Member of the Australian Music Therapy Association Inc. shall at all
Respect the rights and dignity of the individual, serving all in need without consideration
of colour, culture, nationality, religion, politics, wealth or social status.
Provide, or cause to be provided an appropriate service for all patients/clients who come
under his/her care.
Maintain the highest standard of professional competence, striving continually to up-date
personal prcfessional skills and competence.
Maintain a high standard of personal conduct and professional practice, recognising the
need to safeguard the client’s physical, mental and emotional health as the primary
consideration. Music Therapists shall not be under the influence of alcohol, drugs or any
other substance which adversely affects the performance of their duties, thus brining
discredit upon the profession of Music Therapy, and be a potential danger to
patients/clients. Improper association with a patient/client shall not be allowed to
develop.
Treat all information regarding a patient/client as strictly confidential. Confidential
information should only ever be discussed in the context of liaising with other
professionals directly involved in that person’s care. Confidentiality does not override
the obligation of a Music Therapist to report any of the following to the appropriate
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authorities, where there are reasonable grounds for belief that they are occurring: a
criminal offence has occurred/is occurring (e.g., child abuse, incest, financial fraud,
exploitation or other abuse of a vulnerable person); notifiable diseases. Case material for
teaching, publication and/or research must be adequately disguised and all clinical
records must be maintained, stored and ultimately disposed of securely.
2.6 Recognise the extent and limitations of professional expertise, undertaking only those
methods of treatment which are within the therapist’s own competence, and referring to
the appropriate professional any person who presents with a problem or condition which
is outside that competence and expertise.
Co-operate loyally with colleagues and members of related professions. Such loyalty
shall not, however, override the moral or legal responsibility to uphold professional and
community standards of behaviour.
Strive to extend awareness of the value of music therapy, attempting always to maintain
and improve the provision of health services in the establishment and/or community.
RULES OF PROFESSIONAL CONDUCT
Music Therapists may accept referrals from: qualified medical practitioners; other
professionals; individuals seeking treatment for themselves; parents or legal guardians
who are seeking treatment for minors or legally incompetent persons in their charge.
oud In the case of referrals from the person concerned or from the parents/guardians the
Music Therapist shall, where appropriate, inform and consult with the person’s medical
practitioner and/or other qualified professionals such as the teacher, school counselor,
social worker, psychologist. The person shall be informed of any such consultation.
3.3 The Music Therapist shall terminate treatment in cases where it is reasonably clear that
the patient/client will not benefit from further intervention. A discharge summary should
be sent as soon as possible to the referring professional or to the parent/guardian. For
those who are self-referred, explanation should be given as to the reasons for the
cessation of music therapy, together with a summary of the work done. Separation from
the patient/client is part of the therapeutic process and must be planned.
3.4 No Member of The Association shall bring undue influence to bear upon a patient/client
or the family for purposes of bringing about a change in medical or paramedical
practitioners.
35 Except with the written agreement of that professional or after the termination of
treatment by that professional, no Music Therapist shall enter into a professional
relationship with a client who is already receiving music therapy from another Music
therapist. Following a locum tenens appointment, no Music Therapist shall enter into a
professional relationship with a client treated in the course of that appointment unless
with the written agreement of the original therapist or until a reasonable time has lapsed-
normally six months.
3.6 A Music Therapist shall not:
i) discredit any other professional
ii) allow his/her name to appear in any advertisements for equipment
(including musical instruments);
iii) give testimonials regarding equipment or instruments;
iv) profit from the sale of equipment or instruments to clients;
v) receive any fee from an agency regarding the supply or sale of
equipment or instruments to clients/patients/hospitals/schools or any
other individual or organisation;
vi) knowingly permit his/her name or any other publicity to appear in
unseemly coverage by the media;
Vil) utilise testimonials from clients;
Vill) make claims as to the superiority of the therapist over other Music
Therapists, nor the profession over another profession. If there is any
doubt concerning professional conduct, the Ethics Committee of The
Association can advise regarding such matters.
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mtd A Registered Music Therapist may advertise in accordance with the guidelines laid down
by the Australian Physiotherapy Association. Any RMT wishing to advertise their
services should consult this document which is available on request from the
Administrative Officer of The Association.
3.8 When a Registered Music Therapist in private practice is also involved in music
teaching, it is essential that the client (or parent/guardian for a legally incompetent person
or a minor) shall be fully informed as to the nature of the professional relationship which
is being established. A Registered Music Therapist shall not undertake any therapy under
the guise of teaching and if, when working as a teacher, a Registered Music Therapist
becomes aware of a client/pupil’s need for therapy, a clear statement on this must be
made in writing to the client/parent/guardian, an exact copy of this being kept by the
Music Therapist for reference.
ee] a)A Music Therapist or Member shall consult with the local branch of The
Association before speaking on behalf of The Association.
b) A Music Therapist or Member shall not permit his/her Membership or
position in The Association to be included in any professional publication
without written permission of The Association’s National Council or State
Executive Committee.
c) The name of The Association shall not appear in any publication without
written permission from the Chairperson of the Ethics Committee. The
Chairperson may request that the text be submitted in order to determine
whether there is any infringement of The Association’s policies.
GUIDELINES FOR ETHICS IN RESEARCH INVOLVING HUMAN SUBJECTS
All persons intending to carry out research shall make themselves familiar with the
Guidelines published by the National Health and Medical Research Council (NH and
MRC, PO Box 9848, Canberra, ACT, 2601)
Before starting a research project, a Registered Music Therapist must submit to the
appropriate person or persons within the facility full information as to the hypothesis to
be investigated, the methods to be adopted and the possible risks to the physical, mental
and emotional health of the subjects involved in the research.
Registered Music Therapists working in private practice or a facility which lacks a
standard for approval of research shall submit details (as listed in 4.2) to the Ethics
Committee of The Association for approval before starting any research programme.
Participation of Subjects in research shall be voluntary, with general signed clearance
forms. Subjects must be allowed to withdraw from a research project at any time.
All Subjects shall be informed of the nature of the research before being asked to sign a
clearance form which includes information on and explanations of:
*length of time the project will take, and time of individual sessions;
*any possible risks involved;
*any possible benefits involved;
*confidentiality;
*publication of results;
*for control groups, whether there are any risks in being deprived of treatment
in order to constitute a control group.
6 Signed clearance forms must be obtained from the Subjects themselves, or from
parents/legal guardians of persons deemed to be legally incompetent.
In all research, as in all Music Therapy practice, the rights and dignity of the individual
must be upheld.
INFRINGEMENTS OF THE CODE OF ETHICS
Any persons, whether a Member of The Association or not, who becomes aware of any
infringement of these ethical principles, or of the rules of professional conduct, shall
bring the infringement to the notice of the person or the organisation concermed, and ask
that the matter be corrected.
If the infringement continues or there is a refusal to comply with the request, the matter
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shall be brought to the attention of the Chairperson of the Ethics Committee of The
Association.
53 a) The National Council of The Association shall, under the following conditions
have the power to deprive any Member of his/her Membership. In the case of a
Music Therapist, the National Council may decline to renew the Registration,
and also, if applicable, Membership of The Association.
b) Failure to comply with any of the conditions and requirements of the National
Registration and Education Board, and/or the National Council, and/or the
Ethics Committee, shall lead to a lapse of Registration, provided that two
reminder letters have been sent to the last known address of the person
concerned, warning them of the possible lapse of registration.
c) On the recommendation of the Ethics Committee of The Association, a Music
Therapist may be deprived of Registration if the National Council decides, by a
two-thirds majority vote, that the individual’s breach of the Code of
Professional Ethics or of Professional Conduct, and/or failure to maintain
professional skills and competence, or failure to annually renew Registration,
make it inappropriate for Registration to be continued.
5.4 Applications for restoration of Membership and of Registration after deprivation or lapse
of Membership shall be dealt with by the National Council, and/or the National
Registration and Education Board, and/or the Ethics Committee of The Association.
Each case shall be considered on its merits. Music Therapists applying for renewal of
their professional status will be required to show cause why an application for renewal of
status should be received, and may be required to complete further courses of study or
supervised clinical work before the application for renewal is approved.
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Canadian Association for Music Therapy

CODE OF ETHICS
PREAMBLE
Introduction
The Canadian Association for Music Therapy (CAMT) recognizes that the purpose of the
profession is to promote the use of music to accomplish therapeutic objectives, and the
development of training, education, and research in music therapy. In doing so, the CAMT
advocates adherence to the principles of Respect for the Dignity and Rights of Persons,
Responsible Practice, Integrity in Relationships, Extended Responsibility, and Responsible
Leadership.
Membership in the CAMT commits members to abide by the CAMT Code of Ethics. In
addition, music therapists and students who are not members of the CAMT should be aware that
the Code establishes expectations for conduct and could be applied to them by courts or other
public bodies.
The Code articulates ethical principles, values, and standards to guide all members in
their everyday conduct and in the resolution of ethical dilemmas; that is, it advocates the practice
of both proactive and reactive ethics. The principles and values are stated broadly, in order to
apply to the various roles and contexts in which music therapists work. The Code is not
exhaustive, and therefore conduct that is not specifically addressed by the Code is not, by its
exclusion, necessarily ethical or unethical.
Structure of the Code
Five ethical principles, to be considered in balance in ethical decision making, are
presented. A statement of those values, which are included in and give definition to the principle,
follows each principle. Each value statement is followed by a list of ethical standards, which
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illustrates the application of the specific principle and values to the activities of music therapists.
In the margin to the left of the standards, values are listed to guide the reader through the
standards and to illustrate the relationship of the specific standards to the relevant principle.
The Principles and Values
Principle I: Respect for the Dignity and Rights of Persons
Music therapists accept as essential the principle of Respect for the Dignity and Rights of
Persons; that is, they uphold the fundamental rights of each person, and accept that an individual
should be treated primarily as a person, not as an object or a means to an end. Music therapists
acknowledge that all persons have a right to their innate worth as human beings, and that this
worth is not enhanced or reduced by their culture, nationality, ethnicity, colour, race, religion,
gender, marital status, sexual orientation, physical or mental abilities, age, socio-economic status,
and/or any other preference or personal characteristic, condition, or status. In adhering to this
principle, music therapists are specifically concerned with the values of General Respect, Privacy,
and Informed Consent.
Principle IT: Responsible Practice
Music therapists accept as essential the principle of Responsible Practice; that is, they
ensure that all activities occurring in the course of music therapy practice will maximize benefits
and minimize the harm to clients and others. Music therapists also accept the notion that
responsible practice involves a commitment to self-awareness, development, and care. Further,
music therapists ensure that their practices do not impact negatively on their peers/colleagues. In
adhering to this principle, music therapists are specifically concerned with the values of General
Caring, Competence, Self Knowledge and Care, Minimizing Harm, Confidentiality, Responsible
Record Keeping and Management, Fair Access, Ethical Research, and Ethical Business Practice.
Principle IT: Integrity in Relationships
Music therapists accept as essential the principle of Integrity in Relationships; that is,
they ensure that all interactions demonstrate integrity and a concern for the personal well being of
others. This includes taking reasonable steps to promote healthy relationships while avoiding
relationships that pose risk for harm. In adhering to this principle, music therapists are
specifically concerned with the values of Honesty and Responsible Relationship.
Principle IV: Extended Responsibility
Music therapists accept as essential the principle of Extended Responsibility; that is, they
recognize that they have responsibilities to the societies within which they live and work. This
includes promoting ethical behaviour within and beyond the music therapy community. Music
therapists also accept the responsibility of promoting and participating in the professional
development of music therapists. In adhering to this principle, music therapists are specifically
concerned with the values of Promoting Ethical Practice, Professional Development, and Respect
for Society.
Principle V: Responsible Leadership
The Directors of the Canadian Association for Music Therapy accept as essential the
principle of Responsible Leadership; that is, they acknowledge their responsibilities to the music
therapy community and society. This includes to providing to the CAMT membership education
and resources relating to ethics and music therapy practice to the CAMT membership. Further,
the CAMT is committed to monitoring the ethical practices of its membership. In adhering to this
principle, the Directors of the CAMT are specifically concerned with the values of Promoting
Ethical Practice and Professional Development.
Ethical Decision-Making Model
The ethical decision-making process may occur very rapidly, leading to an easy
resolution of an ethical issue. This is particularly true of issues for which clear-cut guidelines or
standards exist and for which there is no conflict between principles. On the other hand, some
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ethical issues (particularly those in which ethical principles conflict) are not easily resolved and
might require time-consuming deliberation.
The following basic steps typify approaches to ethical decision-making: *Identification
of ethically relevant issues and practices, and the related standards specified in the Code.
*Identification of individuals or groups who are, have been or are likely to be affected by the
issue and subsequent decision (e.g., client, client’s family, employees, employing institution, co-
workers, students, research participants, colleagues, the discipline, society, self).* Development of
alternative courses of action, beginning with consultation that is consistent with the values of
Privacy and Confidentiality.* Analysis of likely short-term, ongoing, and long-term risks and
benefits of each course of action on the individuals or groups involved.*Choice of course of
action after conscientious application of existing principles, values, and standards.*Evaluation of
the results of the course of action.* Assumption of responsibility for the consequences of action,
including correction of negative consequences, if any, or re-engaging in the decision-making
process if the ethical issue is not resolved.
Definitions
Accredited Music Therapist: Means any person, hereafter referred to as “music therapist,” who
has been awarded accreditation by the CAMT, and who is a member in good standing of the
CAMT. Music Therapy Student/Intern and Non-accredited Music Therapist: For the
purposes of this code, “music therapist” refers to those persons included in this definition who
have completed, or are in the process of completing a CAMT approved music therapy training
program.Music Therapy: Music therapy is the skillful use of music and musical] elements by an
accredited music therapist to promote, maintain, and restore mental, physical, emotional, and
spiritual health. Music has nonverbal, creative, structural, and emotive qualities. These are used
in the therapeutic relationship to facilitate contact, interaction, self-awareness, learning, self-
expression, communication, and personal development (CAMT, 1994).Music Therapy Practice
and Service: Music therapy practice and service includes all activities as described in the
aforementioned definition applied in an any setting (e.g., institution, agency, private practice,
internship or practicum setting).Client: Client means anyone (individual, group, family,
community, or association) for whom the music therapist has agreed to provide services.
CODE OF ETHICS
PRINCIPLE I: Respect for the Dignity and Rights of Persons
In adhering to the principle of Respect for the Dignity and Rights of Persons music therapists
would:
General Respect i Demonstrate respect for the dignity, worth, experience, and
knowledge of all people
r2 Acknowledge clients’ rights to self-determination and
autonomy, and the right to participate in decisions that affect
them.
1.3 Use language that conveys respect for the dignity of others
(e.g., gender-neutral terms) in all written or verbal
communication.
1.4 Not practice, condone, facilitate, or collaborate with any form
of unjust discrimination.
1.5 Not engage publicly (e.g., in public statements, presentations,
research reports, or with clients) in demeaning descriptions of
others, including jokes based on culture, nationality, ethnicity,
colour, race, religion, gender, sexual orientation, health status,
etc., or other remarks which reflect adversely on the dignity of
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others.
1.6 Abstain from all forms of harassment, including sexual
harassment.
Privacy sez) Take care not to infringe, in service or research activities, on
the personally, legally or culturally defined private space of
individuals or groups unless explicit permission is granted to
do so.
1.8 Explore and collect only that information that is relevant to
the subject of treatment, unless otherwise requested by the
client.
1.9 Inform clients of (a) the purpose for obtaining personal
information, (b) who will have access to the information, (c)
how it will be stored, and (d) the right of the client to have
access to the information in their records (see article II.28 and
II.29 for elaboration).
Informed Consent 1.10 Ensure that informed consent is obtained from clients or their
legal guardians before commencing service or research. When
clients are unable to give informed consent (e.g., young
children, the cognitively challenged), music therapists would
continue to respect the autonomy of the individual by
attempting to inform and involve them.
Provide, in obtaining informed consent, as much information
as a reasonable or prudent person, family, group, or
community would want to know before making a decision or
consenting to an activity. The music therapist would relay
this information in language which the persons understand
(including providing translation into another language if
necessary) and would take whatever reasonable steps are
necessary to ensure the information was in fact understood.
[1.12 Establish and use signed consent forms which specify the
dimensions of informed consent, or which acknowledge that
such dimensions have been explained and are understood.
Music therapists would use their discretion in obtaining
explicit consent, doing so for services involving the exchange
of highly personal information (e.g., research) or activities
that potentially could compromise client confidentiality (e.g.,
transfer of client information to a third party).
1.13 Assure, in the process of obtaining informed consent, that at
least the following points are understood: (a) purpose and
nature of the activity; (b) mutual responsibilities; (c) likely
benefits and risks; (d) alternatives;(e) the option to refuse or
withdraw at any time, without prejudice; (f) over what period
of time the consent applies; and (g) how to rescind consent if
desired.
[.14 Recognize that informed consent is the result of a process of
reaching an agreement to work collaboratively, rather than of
simply having a consent form signed.
1 Take all reasonable steps to ensure that consent is not given
under conditions of coercion or undue pressure.
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1.16 Respect the right of individuals to discontinue participation or

service at any time and be responsive to non-verbal
indications of a desire to discontinue if the individual has
difficulty communicating such a desire.
LA? Not use persons of diminished capacity to give informed
consent for participation in music therapy or research studies.
The music therapist would carry out informed consent
processes with persons who are legally responsible or
appointed to give informed consent on behalf of individuals
who are not competent to consent on their own behalf.
PRINCIPLE II: Responsible Practice
In adhering to the principle of Responsible Practice, music therapists would:
General Caring 1.1 Demonstrate an active concern for the welfare of any
individual, family, group, or community with whom they
relate in their role as music therapists. This concern includes
both those directly involved and those indirectly involved in
their activities.
1.2 Avoid doing harm to clients, students, research participants,
colleagues, and others.
IL.3 Accept responsibility for the consequences of their actions,
including the responsibility to correct any harm done in the
course of practice and research.
Competence 11.4 Deliver services to the best of their ability in all situations.
IL.5 Monitor and evaluate on an ongoing basis the effectiveness of
services provided.
11.6 Perform only those services for which they have established
competence through adequate training and supervision. In
providing services for which there are no established
standards, music therapists would inform clients that such
services are not professionally recognized, and take
appropriate precautions to protect the well being of the client.
I.7 Keep themselves up to date with relevant knowledge, research
methods, and techniques, through the reading of relevant
literature, peer consultation, supervision, and continuing
education activities.
I1.8 Refer clients to other music therapists or professionals when
the client requires services that are beyond the competency of
the music therapist.
11.9 Seek appropriate help or discontinue services for an
appropriate period of time when conditions (e.g., health,
stress) or circumstances (e.g., personal bias, inadequate
training) could potentially compromise the quality of service.
Self Knowledge IL.10 Evaluate how their experiences, attitudes, culture, beliefs,
and Care values, social context, individual differences and stresses
influence their interactions with others, and integrate this
awareness into all efforts to benefit and not harm others.
I.11 Engage in self-care activities which help to avoid and alleviate
conditions (e.g., burnout, addictions) that could result in
impaired judgement and interfere with their ability to benefit
ty
and not harm others.
Minimizing Harm I.12 Take appropriate steps to avoid harming others, including
ensuring that services are provided in a place that protects the
security and privacy of clients.
IL.13 Terminate an activity when it is clear the activity is more
harmful than beneficial, or when the activity is no longer
needed.
11.14 Seek an independent and adequate ethical review of human
rights issues and protections for any service or research
involving vulnerable groups and/or persons of diminished
capacity.
I1.15 Do everything reasonably possible to stop or offset the
consequences of actions by others when these actions are
likely to cause serious physical harm or death. This may
include reporting to appropriate authorities (e.g., the police) or
an intended victim, and would be done even when a
confidential relationship is involved.
11.16 Maintain adequate professional liability insurance when not
covered by an organization or institution.
Confidentiality 11.17 Take appropriate precautions to ensure the confidentiality
rights of clients and others, acknowledging that limits of
confidentiality may be established by a variety of sources,
including law and institutional regulations.
11.18 Never release the personal information of clients except in the
following instances: (a) with the client or legal guardian’s
written consent; (b) when there is reason to believe that a
client is in danger of harming him/herself or someone else; (c)
when there is reason to believe that a child has been or is
likely to be harmed; (d) in compliance with a court order,
subpoena, or requirement of an act or regulation of Canada;
(e) when providing information to an employee or co-worker
if the information is necessary for the performance of duties
of, or for the health, protection or safety of the employee or
co-worker; (f) when exceptional or emergency situations
require consultation with another professional.
19 In serious situations (as in standard IJ.18 [b] and [c]), bear the
responsibility of ensuring that appropriate action has been
taken. This may include reporting to the appropriate
government ministry, work supervisor, police, and potential
victim as required by the situation. Music therapists would
bear in mind that notification of family members may not
always be in the best interest of the client.
11.20 Make every effort to inform clients and/or their legal guardian
and obtain consent in situations requiring the breach of
confidentiality (see article II.19).
11.21 Inform clients of the limits of confidentiality prior to
providing music therapy services whenever personal
information is collected in the course of providing those
services. Exceptions could be made when the employing
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institution or agency has already informed the client of the
limits of confidentiality that apply to music therapy and/or all
services offered within the institution/agency. Music
therapists would keep in mind that they bear the responsibility
of ensuring that the client has been informed of the limits of
confidentiality.
11.22 Obtain written consent from the client or legal guardian for
the release of information to third parties. Music therapists
would ensure that an appropriate degree of confidentiality and
records security would be provided by third parties.
11.23 Make reasonable attempts to obtain consent to share client
information in public forums (e.g., conference presentations,
practicum seminars). When consent cannot be obtained,
music therapists would take appropriate action to conceal all
identifying information.
11.24 When working with groups, inform group members of the
importance of maintaining confidentiality, and elicit an
agreement to refrain from discussing the personal information
of group members outside of the therapeutic context.
Responsible ZS Keep one file on each client. The music therapist would
Record Keeping record only that personal information necessary for
Management continuous coordinated service.
Il.26 Ensure that all client records, including case notes, cassette
and video recordings, etc., are kept in locked filing cabinets,
that information stored in filing cabinets or computer files is
accessible only to the music therapist or those who have a
legitimate need to know the information.
11.27 Ensure the appropriate and complete destruction of outdated
client files, and devise adequate plans for records in the event
of incapacity, death or withdrawal from practice. Adequate
record retention practice would include destroying those
records that are no longer needed for services being provided
and/or client files seven years after termination of services
(seven years past age of majority for minors).
Fair Access 11.28 Inform clients, as appropriate, about their right to read and
have a copy of the information in their file, in accordance with
federal and provincial legislation.
11.29 Respond as soon as practical, but no later than 30 working
days, to requests for access by providing: (a) a copy of the
information to the client or legal guardian, including clients
under the age of majority who have given consent for
treatment, or who, in the music therapist’s opinion are capable
of understanding the subject matter of the record; or (b) access
to portions of the record that do not include information about
third parties; or (c) written reasons for the refusal of access to
the information in the client’s file.
Ethical Research II.30 Design and conduct research in accordance with established
ethical standards.
11.31 Establish, prior to participation, an agreement with research
321
participants specifying the responsibilities and rights of those

involved. Included is the client’s right to withdraw from the
research. Music therapists would describe elements of the
research that might influence the subject’s willingness to
participate, including potential risks and benefits.
11.32 Not use persons of diminished capacity to give informed
consent in research studies.
11.33 Avoid the use of deception in research.
11.34 Debrief research participants in such a way that the
participants’ knowledge is enhanced, and the participants have
a sense of contribution to knowledge.
Ethical Business 11.35 Not solicit the clients of another music therapist.
Practices II.36 Not solicit clients for private practice from agencies or
institutions with whom they are employed. If a client requests
that services be continued in private practice, the music
therapist would obtain the consent of the employing agency or
institution before fulfilling the client’s request.
11.37 Disclose the fee schedule and method of payment at the
commencement of the music therapy relationship.
11.38 Only ask for a just salary, which will be determined according
to the time involved, nature of the service, and level of
competence and experience. Music therapists can lower the
rate given to a client based on the client’s ability to pay.
11.39 Make all reasonable efforts to obtain payment before legal
action is taken. In cases where legal action is necessary, the
music therapist would inform the client of the impending
action and provide opportunity for prompt payment of monies
owed.
11.40 Accept from clients only gifts of minimal monetary value.
When offered a gift by a client a music therapist would
consider the possible consequences of accepting and refusing
the gift and make a decision in accordance with the principles
of Respect for the Dignity and Rights of Clients and Integrity
in Relationships. When refusing a gift, a music therapist
would make reasonable attempts to explain the reasons for
his/her decision to the client.
11.41 Refrain from requesting a fee for referrals made to other
music therapists.
11.42 Refrain from sharing their workload or salary with other
music therapists except by written agreement, and with the
fully informed consent of the client and/or employer. When
work is subcontracted to another music therapist, the
subcontractor would collect fees that are commensurate with
the service he or she is providing.
PRINCIPLE III: Integrity in Relationships: In adhering to the principle of Integrity in
Relationships, music therapists would:
Honesty H.1 Not participate in, condone, or be associated with dishonesty,
fraud, or misrepresentation.
III.2 Represent accurately their own and their associates’
S22
qualifications, education, experience, competence, and
affiliations, in all spoken, written, or printed communications,
being careful not to use descriptions or information which
could be misinterpreted.
HI.3 State honestly the efficacy of services, and acknowledge the
limitations of their knowledge, skills, and interventions,
including the potential for harm.
TI].4 Take credit only for the work and ideas that they have actually
done or generated, and give credit for work done or ideas
contributed by others (including students) in proportion to
their contribution.
III.5 Present instructional information accurately, avoiding bias in
the selection and presentation of information, and publicly
acknowledge any personal values or bias, which influence the
selection and presentation of information.
Responsible III.6 Not exploit any relationship established as a music therapist to
Relationships further personal, political, or business interests at the expense
of the best interests of their clients, research participants,
students, employers, or others.
Ill.7 Be acutely aware of the potential difficulties and challenges of
dual relationships (€.g., with students, employees, or clients)
and other situations that might present a conflict of interest or
which might reduce their ability to be objective or unbiased.
Music therapists would avoid dual relationships to the best of
their abilities or seek appropriate supervision when such
situations are unavoidable (e.g., when working in a small
community).
I1.8 Be acutely aware of the power relationship in therapy and,
therefore, not engage in sexual intimacy with clients, neither
during the time service is provided, nor for that period
following, during which the power relationship reasonably
could be expected to influence the client’s personal decision
making.
Iil.9 Inform all parties, if a real or potential conflict of interest
arises, of the need to resolve the situation in a manner that is
consistent with the principles of Respect for the Dignity and
Rights of Persons and Responsible Practice, and take all
reasonable steps to resolve the issue in such a manner.
III.10 Terminate services in such a way that does not abandon the
client. This includes (a) providing reasonable notice, (b)
discussing the reasons for termination, (c) discussing client
needs, (d) suggesting alternative service providers as
appropriate, (e) taking appropriate steps to facilitate transfer
of service to another service provider, and (f) ensuring that
discontinuation will not cause harm to the client.
H.11 Terminate the professional relationship when it becomes
evident that the client is no longer benefitting from the
service.
II.12 Inform an employer of any conditions that would compromise
323
ethical practice as described in this code, or other relevant
professional codes (e.g., provincial codes). In such instances,
music therapists would provide the employer with a copy of
the relevant code.
HT.13 Provide services in a manner that protects the integrity and
reputation of the employer.
IIT.14 Make use of the employer’s property and resources only as
authorized.
III.15 Act on their obligation to facilitate the professional
development of their students, interns, and employees by
assuring that these persons understand the values and ethical
standards of the profession, and by providing or arranging for
adequate working conditions, timely evaluations, constructive
consultation, and opportunities for experience.
III.16 Assume responsibility for the professional activities of their
students, interns, and employees. This includes ensuring that
students and interns identify their status (as students or
interns) to clients and others.
IIN.17 Encourage the free exchange of ideas between themselves and
their students.
PRINCIPLE IV: Extended Responsibility: In adhering to the principle of Extended
Responsibility, music therapists would:
Promoting Ethical IV. Address the unethical and/or harmful activities of colleagues,
Practice co-workers, students, and employees. This may include
bringing the activity to the attention of the individual, the
client who is being harmed, and/or the relevant professional or
lega! body.
IV.2 Report violations of this code by other music therapists to the
Ethics Committee of the Canadian Association for Music
Therapy.
IV.3 Engage in regular monitoring, assessment, and reporting (e.g.
through peer review, and in program reviews, case
management reviews, and reports of one’s own research) of
their ethical practices and safeguards.
IV.4. Help develop, promote, and participate in accountability
processes and procedures related to their work.
Prof. Development IV.5 Contribute to the discipline of music therapy through a free
pursuit and sharing of knowledge, and the critical evaluation
of self and the discipline, unless such activity conflicts with
other basic ethical requirements.
IV.6 Promote the highest standard of practice by soliciting or
providing peer consultation as required.
IV.7 Participate in and contribute to continuing education and the
professional growth of self and colleagues.
IV.8 Represent accurately the profession in all formal and informal
public statements.
Respect for IV.9 Abide by the laws of the society in which they work. If those
Society laws seriously conflict with the ethical principles contained in
this code, music therapists would do whatever they could to
324
uphold the ethical principles. If upholding the ethical

principles could result in serious personal consequences (¢.g.,
jail or physical harm), decision for final action would be
considered a matter of personal conscience.
IV.10 Consult with colleagues if faced with an apparent conflict
between keeping the law and following an ethical principle,
unless in an emergency, seek consensus as to the most ethical
course of action and the most responsible, knowledgeable,
effective, and respectful way to carry it out.
IV.11 Convey respect for and abide by prevailing community mores,
social customs, and cultural expectations in all activities,
provided this does not contravene any of the ethical principles
of this code.
IV.12 Acquire adequate knowledge of the culture, social structure,
and customs of a.community before beginning any major
work there.
IV.13 Not contribute, condone or engage in an activity or research
which contravenes international Jaw, including destruction of
the environment and violations of human nghts.
Principle V: Responsible Leadership
In adhering to the principle of Responsible Leadership, the Directors of the Canadian Association
for Music Therapy would:
Promoting Ethical V.1 Ensure that all activities of the Association promote the
Practice highest standard of music therapy practice.
V.2 Provide to music therapists ongoing education and resources
relating to ethical issues and practice.
V3 Assist in the development of those who enter the discipline of
music therapy by helping them to acquire a full understanding
of the ethics, responsibilities, and needed competencies of
their chosen area(s), including an understanding and critical
analysis of the uses, and possible misuses, of music therapy
practice and research. ™
V4 Make itself accessible and available to the members of the
Association and society at large for consultation on ethical
matters.
V.5 Engage in ongoing evaluations of established ethical
standards.
V.6 Address unethical practices by members of the Association in
accordance with the procedures outlined in the Canadian
Association for Music Therapy’s Policy and Procedures
Manual.
Professional V.7 Provide opportunities for continuing education for music
Development therapists.
V.8 Assist music therapists in finding peers who can provide
appropriate consultation and supervision.
Acknowledgments: Portions of the Canadian Psychological Association’s Code if Ethics were adopted and/or tailored for
use in the Canadian Association for Music Therapy’s Code of Ethics: Copyright. Canadian Psychological Association.
Reprinted with Permission.OO

Music Therapy: Cheryl Dileo, PAD, MT-BC

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ETHICAL THINKING —

Cheryl Dileo, PAD, MT-BC

Ceryl Dileo,PhD, MT-BO

Permission for the reprinting of their Codes of Ethics

Cover illustration and design by José Ignacio Castafio,

Copyright 2000 by Jeffrey Books

Printed in the United States of America.

My unforgettable father, Noble Joseph Diles, whe

My beloved mother, Drieda Habech Dileo, uhe taught me

a, Introduction to Ethical Thinking........00..00.00

Why Professional Ethics?

2. The Virtuous Music Therapist...............cs<csssessoossrccssroonnaconecs

3. The Music Therapist as a Professional and Person.............

The Music Therapist as a Professional: Competence

Competence in Groups Music Therapy Work

Clients’ Rights and Therapists’ Responsibilities................

6. Boundaries and Dual Relationships..............0...0.ccceeeeeeeees 123

We Multicultural and Gender Perspectives.......................e 149

8. Ethical Thinking in Research and Publication................... 175

Part 1: Financial Issues 199

10. Responsibilities to Colleagues, Employees, Employers,

Responsibilities to Colleagues and Employees Let

11. Ethical Thinking in Education and Supervision.................. 235

£2; Promoting Ethical BERavion......030:...:c2ssssseccns

Informal Resolution of Ethics Violations 261

Appendix: Codes of Ethics in Music Therapy...............0.0...:cceeee 291

American Music therapy Association 291

To be good is noble, but to teach others to be good

I am passionate about professional ethics! Since the writing of my doctoral

Purpose and Structure of The Book

This book is written for undergraduate and graduate students and

The Ethical Dilemmas

from ethics casebooks in other professions.

played in my professional life, as my mentor, friend and most trusted advisor. He is

ABOUT THE AUTHOR

Cheryl Dileo, PhD, MT-BC, is Professor of Music Therapy at Temple University in

She is an active international lecturer having taught in 17 countries on 5 continents.

Consider the following situations:

Joan, your music therapy colleague working at the same adolescent

Following a GIM session in which many disturbing images were

As a music therapist working in private practice in a small community,

Music THERAPISTS, like most other professionals, are inevitably faced

Feelings & Motivations elf-Awareness

Therapist’s Valueg Client’s Values

Knowledge/Judgment Contextual values

Professionalism is indeed related to ethics. It is

Core Ethical Principles

There are a number of core ethical principles which underlie professional

including the risks of injury) to others through either a specific action

3) The principle of autonomy acknowledges the rights of individuals to make

4) Justice stresses the concepts offairness and equality intreatment toall.

(Corey, et al., 1998).

Models of Ethical Development

Several authors describe the developmental stages or processes of moral

It is also important to consider in this section several theories of ethics,

Meara, et al., (1996), see virtue ethics and principled-based ethics as

Having a code of ethics is a necessary part of being a profession. According

lawsuits!(Lowenberg & ane ere cen 1996; Stein, 1990).

be expected from them (Stein, 1990).

Interface of the Law and Ethics

Legally speaking, helping professionals have a very unique responsibility to

Scott, 1998, p. 7).

1990). These are shown in Table 1.