Ethical reflections on social media use within music therapy: A conversational focus group study

ABSTRACT

Introduction

Social media has transformed how music therapists work, with numerous practitioners utilizing the affordances of social media in music therapy practice. So far, music therapy research has been significantly limited regarding the ethical implications of social media use. A better understanding of the ethics of social media use is needed to inform the continuous evaluation of professional ethical guidelines.

Methods

We conducted a systematic text condensation of transcripts from one conversational focus group consisting of five participants with diverse connections to music therapy and social media.

Results

The results highlight the many ways social media can facilitate both substantial value as well as serious risk in music therapy practice. Through the analysis, it has also become clear that music therapists must make complex considerations in working with social media to maintain a level of responsible practice.

Discussion

This study provides (a) insights and experiences from practice gathered in a conversational focus group, (b) discussions exploring the possible value and risks of social media use in music therapy, and (c) implications for practice including a summary of some ethical reflections.

KEYWORDS:

• Social Network Services (SNS)
• sharing
• public therapy
• privacy
• consent
• GDPR

Introduction

Social media¹ has transformed how music therapists work, with numerous practitioners utilizing the affordances of social media in music therapy practice. This became particularly apparent during the COVID-19 lockdown when one of the authors (EAS) contributed to the creation of multiple music therapy events in Norway where client performances were shared on social media. Music therapists do not only engage with social media as a means of communication with clients but also in ways that are similar to how the overall music industry uses social media for publishing music, music videos, concert videos and promotion. However, these practices, when applied within a health profession, are intertwined with ethical dilemmas that require careful attention. To date, only a few traces of social media publishing practices can be found within music therapy literature (Lydvo, 2017; Reid & Miño, 2021; Viega, 2019). Though we can look at the discussions on social media use from other disciplines (Baier, 2019; Boddy & Dominelli, 2017; Henderson et al., 2013), the unique facets of music therapy remain mostly unexplored (Sæle, 2022).

We believe that music therapy practitioners, educators, researchers, and clients should have access to content and literature that stimulate reflection on specific dilemmas regarding social media use within music therapy. A better understanding of ethical social media use is warranted to inform the continuous evaluation of professional ethical guidelines, standards of education, and training for music therapy students (Bates, 2014). The complexity of this area incorporates both individual, relational, institutional, and geographical layers. Dileo’s comprehensive book Ethical Thinking in Music Therapy (2021) not only emphasizes this complexity but also presents the ethical decision-making model on which the American Music Therapy Association’s Code of Ethics is based. In addition to this, Trondalen’s book Ethical Musicality (2023) stretches the scope of ethical considerations to encompass a broad conceptualization of music and relational approaches to ethics.

Drawing on the results of a conversational focus group conducted in Norway, this article discusses the potential values and risks of using social media within music therapy and calls for deepened ethical reflection that goes beyond general and/or restrictive guidelines.

Legal backdrop

As a response to the confusion about legal matters expressed by music therapists (Reid & Miño, 2021) and as a legal backdrop to the exploration of ethics, we will start by briefly reviewing some relevant aspects of the General Data Protection Regulation which is relevant for those working in Europe.

The General Data Protection Regulation

The General Data Protection Regulation (European Commission, 2016), abbreviated as the “GDPR”, is a regulation that was adopted by the European Union in 2018. Since this study is situated in Europe and as there are no worldwide privacy regulations available, the GDPR will be used to provide legal perspectives on consent and privacy. From 2018 onwards the GDPR has had a significant impact on how music therapists and all other institutional employees ought to manage personal data. Personal data are defined in the GDPR as any information that can be linked to a physical person (GDPR Info, 2016a). Examples of personal data in the context of this study include names, photographs, video, and sound. The main principles of the GDPR state that personal data must be processed with:

• lawfulness, fairness, and transparency

• purpose limitation

• data minimization

• accuracy

• storage limitation

• integrity and confidentiality

• accountability (GDPR Info, 2016b)

These principles are intended to ensure that data managers, in this case, the music therapist’s institution, collect, store, and share personal data with respect and integrity (GDPR Info, 2016a). In terms of the principle of lawfulness, there should always be a valid legal basis for collecting data before the processing of data starts (Intersoft Consulting, n.d.). While there are in total six different lawful bases (GDPR Info, 2016c), only the legal basis of consent is relevant to the focus of this study. Valid consent is characterized by being “freely given, specific, informed and unambiguous” (Intersoft consulting, n.d., para. 2).

Though some would argue that publicly available personal data are not protected by the GDPR, this is not the case (Information Commissioner’s Office, n.d.b, para. 3). The GDPR requires that consent must be collected when recording and sharing to social media, even if the client performs in a public space or if these data are gathered from public web pages.

Study objectives

This study seeks to explore complexities regarding consent, privacy, and ethics within the context of music therapy with the research question: “How can music therapists and music therapy clients approach an informed practice of sharing on social media?” To explore the gap in knowledge regarding ethical dilemmas we chose to facilitate a discussion with people who have lived experience from practice where social media has been used in music therapy. The study also aims to present a concluding summary of some ethical reflections that can hopefully function as a tool for self-reflection for music therapists working with social media.

Methods

Due to the exploratory aim of the study, we selected a qualitative study design using a conversational focus group approach to facilitate a safe space for sharing experiences. Analysis of the conversational focus group was carried out using systematic text condensation as informed by Malterud (2012b).

The rationale for study design

Though it could be argued that a focus group does not gather data that are representative of a larger group or even the participants themselves, it can help understand norms and discourses, as well as how people react to, and think about a certain phenomenon (Malterud, 2012a). Furthermore, the use of focus groups offers the advantage of facilitating participant interaction by allowing them to pose questions from their unique perspectives and steering the conversation toward the topics they consider significant. Compared to a study design guided by the researchers alone, this dynamic engagement from participants can enrich the dataset beyond the researchers’ pre-existing beliefs and expectations. As a preliminary preparatory stage before the focus group took place, we collected relevant guidelines and legal documents to create a summary of the legal backdrop for the topic under consideration. This summarized overview is presented in the “Legal backdrop” section of this article and was handed out to the participants before the focus group. In this way, the legal backdrop provided an opportunity for the participants to deepen their knowledge about past experiences. In addition to this, handing out the legal backdrop before the focus group aimed at initiating thought processes on the study topic before coming together.

Participants

Five participants were recruited through purposive sampling. The main inclusion criterion was “personal experience from music therapy in conjunction with the use of social media”. The purposive sample included people with a connection to music therapy either in a professional role or as a client of music therapy. Potential participants were contacted through the researchers’ professional social networks. The final composition of the focus group consisted of two participants who had experiences as music therapy clients, two participants who had experiences as music therapists, and one participant who had experiences co-working with music therapists as a psychologist. Two of the participants had previously been in a client—therapist relationship. Additionally, several participants had existing connections from within the local music therapy community. Because of these overlapping roles and relationships, the group constellation was not only thoroughly discussed by the researchers, but the participants were also informed that they might have pre-existing relationships with other participants.

There were several considerations behind the decision to invite group members with such a complex web of relationships and power relations. Firstly, given that this study aimed to explore experiences rather than to generate quantifiable effects, a strategic and diverse selection of participants could help us achieve nuance and variation in the dataset (Knodel, 1993; Malterud, 2012b). Secondly, it is essential to realize that every group constellation possesses inherent limitations and advantages. In this study, we emphasised on creating a group based on familiarity, ensuring that none of the participants were exclusively talking to strangers. Barbour (2018) suggests that researchers should not necessarily avoid existing constellations of people due to pre-existing relationships and power relations, but rather seek to explore how these relationships come into effect through critical analysis. Consequently, our preliminary conversations with the participants informed the conclusion that including a prior client--therapist relationship could add a sense of safety to the group. Thirdly, there are inherent limitations tied to conducting research in a relatively small city and tightly woven music therapy community. It would be difficult in this context to conclusively ensure that none of the participants had some form of pre-existing relationship.

The moderator of the focus group (EAS) had professional relationships with several of the participants from making social media content as a filmmaker in the recent past. Though familiarity with the moderator could hold participants back from critiquing the moderator’s (EAS) work, this does not necessarily weaken the study results considering how the research topic is aimed at music therapists rather than the ethics of filmmakers. On the other hand, the previous common experiences supplied a foundation for the conversation.

Data collection

The conversational focus group was conducted in person during the fall of 2021. Despite the social distancing restrictions during the COVID-19 pandemic, we decided to facilitate an in-person meeting that complied with all necessary safety measures. The conversation lasted 75 minutes and was recorded using a digital audio recorder. After a brief introduction about the structure of the conversation and the study’s focus, the moderator invited the participants to share past experiences from music therapy in conjunction with social media. This was done using the open question: “Is there anyone who would like to share some of their previous experiences with music therapy and social media?” The participants were encouraged to talk freely, respond to each other’s experiences, be curious, ask questions, and dig deeper into topics they found interesting or important. As the participants participated actively, giving each other space, the first half of the conversation progressed without interruption from the moderator. Throughout the conversation, the moderator aimed to give all participants an opportunity to voice their experiences or thoughts on each topic discussed, thus requiring slight interruptions in the conversation. The moderator also ensured that the most central aspects of the study aim were addressed as described in a brief conversation guide.

Analysis

Data analysis was performed using a study-specific adaptation of systematic text condensation (Malterud, 2012b). To begin with, the audio recording was transcribed using naturalistic transcription (Bucholtz, 2000; Davidson, 2009; McMullin, 2021) which emphasizes the meaning of each sentence rather than the way it was performed. The text was read by the researchers independently, each thematizing the meaning units on their own before continuing the analysis cooperatively (Smagorinsky, 2008). Upon reviewing the initial themes together, we interpreted the focus group conversation arranged into meaning units while repeatedly discussing and further developing the units and themes. A selection of meaning units from the various themes were then collated thematically and are presented in the results section below.

Each theme has been given a generalized description to summarize core aspects of the content before the selection of meaning units is presented. To ensure confidentiality, the meaning units from each participant were given a letter rather than a name to help the reader not allocate specific gender expectations and gender biases to the comments. As well as not disclosing names or gender, the background of each participant has not been actively disclosed though it has neither been completely hidden. This has been done to emphasize that each participant is speaking on behalf of themselves rather than representing any larger group.

Ethical considerations

The research project was registered and approved by the Norwegian Centre for Research Data (NSD). Throughout the study, we engaged in a reflexive process regarding how our embodied practice and position impact and inform the research process.² One of the researchers (EAS) had individual conversations with all interested participants to explain why they had been invited, how the data would be processed and for what, and as well the practical implications of participation. Three of the originally invited participants declined the offer to participate as a result of these considerations. After the initial conversation, the participants received (a) an information sheet about the research project, (b) a summarized legal backdrop for the topic under consideration, (c) a consent form based on the recommended template from the NSD, and (d) a copy of the research project assessment as evaluated by NSD. Before the focus group conversation started, the moderator collected written consent from all participants and stressed that the participants were free to withdraw their consent at any time in the process. The confidential research data was stored on the research institution’s research database to ensure secure data management.

Results

Social media was tightly linked by all participants to the concept of difficult situations and ethical dilemmas. Three participants had experienced problematic situations themselves. The five topics elicited from the systematic text condensation and collaborative thematization are: “Problems with free consent”, “Dynamics of responsibility in the client-therapist relationship”, “Emotional support in sharing processes”, “Possible consequences of sharing”, and “Conflicts of interests”.

Problems with free consent

While there are many legal aspects of consent regarding social media use within music therapy, the participants of the focus group engaged intensively with the ethical complexities of freely given consent in the context of publishing music-related content such as songs, photographs and videos. A main theme throughout the discussions regarding consent concerned the implications of fear when dealing with consent. One participant remarked that the promise that consent can be withdrawn without any contradictions or consequences is often artificial. The participant claimed that no matter how much someone would say that there are no consequences of rejecting or withdrawing consent, there will always be some kind of consequence. Another participant explained how the same principle applies in group constellations where everyone except one wants to perform or share, suggesting that some form of group pressure can be inevitable. Participant F continued by affirming the claim that one cannot know for sure if consent is freely given or not:

Some people do not dare to say “no” when asked. They say it is all right to share photos of them, but they did not really have any intention of their own to share. Then they may end up anxious after the publication, reflecting on what people might think. (Participant F)

Here, Participant F did not seem to talk merely about the fear of saying no within a power relation, neither about the fear that a vulnerable relationship might be disturbed. Rather, it seemed like they pointed toward the kind of fear that someone might have against saying no in general, possibly because of personality traits such as being non-confrontational or shy.

Dynamics of responsibility in the client-therapist relationship

Participants expressed that music therapists should take careful steps when working with someone in a difficult period of life. It was highlighted that some people who struggle psychologically or find themselves in a difficult period do not necessarily have control over what they are saying on their own social media accounts. This was exemplified by instances of participants regretting their own published content from when they were ill. Adding to the notion, Participant M stated that music therapists have a responsibility to be restrictive regarding social media use:

[…] It is not just about being positive and help facilitate the content sharing, but it is also about making considerations about when something should not be done or shared. For instance, to say: “You should not share this on social media because it is too close and personal.” And as the person might choose not to listen to you and share it anyway, it is an important dilemma to think about how much responsibility is placed at the role of the music therapist regarding what occurs in a therapeutic context. (Participant M)

Participant M highlighted the importance of declaring which responsibilities the music therapist should have, and that music therapists must be ready to face the consequences of taking on those responsibilities. Confirming this claim, Participant H shared an example where their own conductor carried out the exact opposite procedure of what Participant M suggested above. The conductor pushed Participant H into a performance situation which eventually led to a bout of severe anxiety and a withdrawal from music. Unexpectedly, Participant H then contrasted their own example with another personal experience in which they were gently encouraged by their music therapist to participate in a concert performance:

Though I am comfortable with performing my music, I have previously found it difficult to take the initiative myself, and I still think it is scary. At the same time, to be able to get on stage performing my music is probably the best thing I know. So, when my therapist took the initiative and suggested that I could perform on this music festival, and afterwards signed me up, it was hugely helpful to me. (Participant H)

Following these comments, one of the participants concluded that people are indeed very different regarding having photos of themselves published, thus highlighting the importance of individualized adaption as opposed to simply following rules. The participants seemed to agree on the importance of always ascertaining the client’s own motivation and initiative to share. Also, they noted that people’s preference for social media presence is not static, but dynamic and changes with time. Participant B confirmed the claim by giving examples of youths changing their social media preferences:

I have had several experiences with youths who have come to me long after they stopped participating in music therapy, wishing to take down content that was previously published on Spotify and Facebook. (Participant B)

As contrast to previous comments explaining how people can be afraid of rejecting or withdrawing consent, Participant B’s experience showed that the music therapist had strengthened the relational trust enabling the youths to actively withdraw their consent. While the conversation regarding the dynamics of responsibility in the client--therapist relationship so far had been mostly about the safeguarding of clients, Participant B now brought in a new sub-theme which was about safeguarding the therapists:

In the context of a psychiatric center and treatment, I have experienced patients recording activities in music therapy with a personal phone, and then sharing them on Instagram afterwards. (Participant B)

Several participants responded to Participant B’s new input with affirmation that ethics regarding music therapy and social media should apply just as much for therapists as for clients. One participant shared that all patients entering a mental health institution in Norway sign a consent form that states that both the recording of therapy sessions and the publishing of health-care workers on social media are not allowed. Participants acknowledged that behavior like the one described by Participant B can either directly or indirectly breach the therapist’s ability to maintain their duty of confidentiality.

Emotional support in sharing processes

One central aspect highlighted by several participants was the role of emotional support throughout music therapeutic processes of performing, sharing, and even afterward. It was important for the participants to address how performing and social media sharing can be done in the safest way possible. Participant M explored the potential risks of concert performances without proper support from peers:

Once when I had a concert performance as a vocalist with a band, I got exceptionally nervous. I get nervous every time, and when I get nervous, I also get overly self-critical. If I would not have the support which I had, consisting of good friends who supported me, or if I would have been more on edge while watching the performance afterwards, I would risk getting a panic attack or a depressive withdrawal. (Participant M)

Another participant continued in response to Participant M by elaborating on the feeling when social media content does not elicit the response that was hoped for. Their experience was that a disappointing number of responses quickly led to overthinking, anxiety, and a worsened self-perception. However, Participant C brought in a new perspective on the topic of emotional support in sharing processes by presenting an experience from music therapy showing how they dealt with challenging feelings constructively:

The artist I play with was very unhappy with a certain performance. However, the performance was recorded and shared in a private social media group. […] As members of the private group, we then wrote what we thought about the performance with encouraging comments, and with the evidence right in front of everyone in the group to watch. Then, it after all became a very enjoyable and proud experience for the artist to get the performance published later. (Participant C)

The comment exemplifies the importance of professional support in the process of sharing on social media. Also, the comment shows how a private social media group can facilitate a safe space to share positive feedback and to provide emotional support.

Possible consequences of sharing

One of the main concerns in the group seemed to be the feeling of not knowing exactly which consequences might emerge after sharing music-related content performed by music therapy clients. The following narratives include vastly different perspectives and experiences, ranging from social media posing a serious threat that should be avoided, to social media playing a significant role in the therapeutic process. While some claimed that no one can predict the consequences of sharing on social media, others claimed that some clients are in fact aware of the consequences. Not only that, but also that they actively wish to share their own story both to help others as well as to process lived experiences themselves. Participant B elaborated:

Sometimes, sharing your story can help others. I have witnessed that songs co-created by me and other youths in therapy have become enormously valuable to other younger youths. (Participant B)

Some participants had experiences of how sharing on social media as well as a concert performance in general can facilitate the establishment of new friendships and social networking. One of them, Participant H, shared an experience of how the sharing of a concert performance arranged by music therapists opened new possibilities to them as a musician:

[…] I got contacted by a producer that had seen my contribution to a music festival on TV. Since then, possibilities have snowballed for me in a positive way which has opened new and unexpected doors. (Participant H)

Moving to the theme of potential risk, some participants seemed to be especially concerned that sharing songs created in therapy might publicly reveal personal information from a difficult period. They claimed that both the public connection to therapy resulting from the participation in a music therapy event, as well as the presence of personal content on social media, can follow you into the future as possible sources of stigmatization. Supporting that claim, one participant shared a case of stalking which resulted from content sharing in music therapy. A specific person, whom the client was being guarded from, was able to contact the client after a public Spotify account had been created to promote the client as an artist. The participant highlighted the lack of control when utilizing digital sharing technologies. Participant H responded to the current case of stalking with a concern about being discriminated against as a result of their own attendance at a public music therapy event on social media:

I am rather open when it comes to writing lyrics, and think it is nice when people are as open as possible about their lives if they are ready for it. However, even though I think it is a good thing to be open about my personal life, I then must endure the risk that others might have prejudices toward my previous life experience. This can come into effect for instance when I am applying for jobs. What happens if a potential new employer knows about my previous drug addiction treatment? (Participant H)

All participants expressed uncertainty regarding the dilemma about positive opportunities of sharing versus the risks of stalking and discrimination.

Conflicts of interests

During the conversation, some participants with professional experience of using social media when working with clients highlighted the complexity of navigating different and diverse interests. Though acknowledging that the health of clients should always be the primary priority in health contexts, participants expressed serious concern regarding how the interests of support organizations financing the music therapy sessions could possibly collide with the interests of the clients:

Previously when I have applied for financial support to run the music therapy project with youth, it was specified in the applications that the funding organization had to be featured through social media posts and on our website. The expectation to promote our funders pushed me to share our work as a music therapy organization and to show that we were active. […] Even though we had written consent, including consent from the primary caregiver when the youth was below age 16, it was not always easy to know what was really okay and not. (Participant B)

Exploring the topic further, Participant B added that the music therapy community seems too willing to get music therapy clients on stage, as well to promote music therapy through research and events. They uttered a concern regarding the surprising number of music therapy clients attending public music therapy stages. Another participant suggested that this might relate to the music therapy community’s desire to gain publicity and acknowledgement.

Discussion

Toward free consent

Based on the results of this study, we have selected six main considerations for the discussion of the process of facilitating free and informed consent.

Discussing implications

Starting out, the therapist and client should always, if the health state of the client allows for it, discuss the various implications of sharing music-related content on social media. As music therapists enter such conversations, they should be knowledgeable about the most recent versions of professional ethical guidelines, as well as their institution’s own social media guidelines. We will further discuss the possible consequences below under “Possible consequences of sharing”, as well as presenting them as a succinct list under “Implications for practice”.

Seeking the initiative of the client

When working with clients one-on-one, some therapists approach digital technology and sharing on social media by allowing the process of recording and sharing to be guided by the client’s initiative (Derrington, 2019). If it is the client who takes control of both the recording and the sharing process, only with support from the therapist, many legal issues concerning power relations and the institution’s management of personal data can be avoided. On the other side, letting the client take control of the process might also add to the complexity of the therapist’s ethical responsibility, thus making it difficult for the therapist to maintain a sense of control throughout the sharing process. Nevertheless, in cases where the sharing process could not, or should not, be led entirely by the client’s initiative, the therapist should be cautious to always seek the client’s inner motivation rather than simply asking if they want to consent or not.

Managing consent changes

It is imperative that the therapist should be prepared to manage changes to consent as time passes. The therapist could emphasize how withdrawing consent is a decision that deserves respect, and that the consequences for the rest of the project will be solved positively and acceptably for all involved parties.

The case of youths withdrawing their consent to published music on social media, as presented in the results section, provides a clear example about the relevance of consent withdrawals. This case prompts a crucial question for music therapists engaged in content sharing: “Could there be any clients who might wish to withdraw consent but lack the relational trust to communicate this to me?” On the other hand, several factors might lead a music therapist to refrain from encouraging content take-down instead of occasionally renewing consent as has been recommended elsewhere (Sommers & Bohns, 2019). First, music therapists are sometimes co-creators of the published content and can be emotionally and professionally invested. Second, the process of attending to consent changes in the published content could be time-consuming, not to mention resource-demanding if other professionals are needed in the editing process. Finally, taking down cooperative social media content could potentially affect the other involved clients negatively.

Dynamic consent

Through adapting the concept of dynamic consent (Mascalzoni et al., 2022; Schuler Scott et al., 2019), we acknowledge the need for individualized and granular consent management. That means proposing variations of consent to demonstrate how it can be modified to the client’s preference, for example by sharing only the first name, or limiting the duration of publication. Maybe the content could be publicly available for only one week before it could be taken down again, resulting in a restricted duration of the digital footprint (Jamal & Zain, 2022). Among the variations proposed by the therapist, there should be different suggestions for how the content could be presented, whether anonymously or with the connection to therapy concealed.

Mediating group pressure

If consent must be sought where there are multiple people involved, the therapist should not represent a naive positive attitude but should rather act as a moderator regarding the participants’ willingness to share. This moderation is important to facilitate an open space for anyone who might not have their own reasoned intention to share. When considering group pressure, it is useful to consider the pioneering psychological experiments done by Asch (1951) in which individuals often conformed to the consensus of the majority even though they initially held a more personally rationalized alternative. Considering that similar effects have been found in several replication experiments since the original 1951 study (Franzen et al., 2023), it is crucial to seek the inner motivation of the silent or vulnerable voice in group decisions.

Protecting the privacy of the therapist

As well as problematizing clients’ safety, the findings of this study highlight how the privacy of the therapist can also be challenged in therapeutic settings. One specific case revealed how a client disclosed the client-therapist relationship by filming parts of the music therapy session without asking the music therapist, thus making it impossible for the therapist to keep their duty of confidentiality. Issues of consent and fear can become reversed when the client wants to share collaborative content while the therapist does not wish to partake on social media. The topic of music therapists’ privacy and safety on social media processes clearly requires further examination in future research.

Dynamics of responsibility in the client-therapist relationship

Both Yalom’s (2002) exploration of relationships in therapy and Dileo’s (2021) ethical decision-making model in music therapy affirm the complexity of collaborative decision-making within the client--therapist relationship which was emphasized in the results. As Yalom urges the need for individualized therapeutic approaches that honor the uniqueness of each person, so too should the responsibilities taken on by the music therapist be adapted to every client. The findings of this study presented two stories from the same participant of how they had gotten pushed into participating in performances – one eliciting a negative experience and one eliciting a positive experience. Dichotomies such as these illuminate the kind of tensions that music therapists must deal with and highlight the importance for all professional music therapists to be engaged in the theme of social media processes (Dileo, 2021; Trondalen, 2023).

Though the client--therapist relationship sometimes allows for a significant amount of collaborative decision-making through the course of therapy, we wish to note that this is not the case in a variety of practice contexts. Some illnesses and life situations come with some form of lack of insight regarding one’s own health state. If these individuals wish to share aspects of their own life on social media in these periods, extra attentiveness and even guarding is required from the therapist. Examples of such contexts are dementia care, traumatic brain injuries, psychotic illnesses, and work with children. Dealing with a lack of insight regarding one’s own health state, including severe forms such as anosognosia, calls for extensive insight into symptoms combined with professional discernment.

Possible consequences of sharing

Let us look closer at the possible consequences of sharing to stimulate further reflections on sharing processes. As noted in the introduction, the continuous evaluation of the possible consequences of sharing is an important step during the approach to informed consent. The results highlighted several values and risks identified with social media publishing while in therapy which we discuss in the following sub-sections.

Unwanted attention

The risk of getting unwanted attention or even stalking has received little attention in music therapy literature. Still, the results suggested that content shared on social media as a part of a music therapeutic process can increase the risk of getting unwanted attention. A study of voluntary self-disclosure on social media (Chen, 2013) confirms what is noted in the results, namely that social media has become a place where a significant amount of the world’s population live out much of their lives as well as developing their identity.

We recognize that minimizing the risk of receiving unwanted attention requires a highly sensitive approach to sharing. Any information shared in a music therapeutic process that is not already publicly shared on social media will contribute to the enduring digital footprint of the client. Consequently, Bates and Wheeler (2015) urge music therapists to be very careful with sharing personal information that can be connected to the physical person, and in addition, to use diverse privacy settings on different platforms actively.

Stigmatization, de-stigmatization, and discrimination

The results demonstrated the risk that a client can potentially be stigmatized by a future employer who might discover their connection to music therapy, or perhaps worse, details of the reason for referral such as a personal story of drug addiction. Goffman (1963/2009 describes stigma as “[…] a special kind of relationship between attribute and stereotype […]”. Accordingly, stigma is something that happens within a person, a thought connection between an attribute and a stereotype, and will therefore seldom be registered, neither its consequences.

A survey by Bråten (2016) showed that 4 out of 10 employers in Norway check their applicants’ Facebook profiles as a standard procedure in the employment process. Such social media examination is claimed to be justified in that it will improve the business’ work management and increase the safety of their employees (Bråten, 2016). Other studies affirm the concern expressed in the results section of how employers can “hold negative attitudes toward people with mental health illness” (Brouwers et al., 2020), and as a result “engage in discriminatory behaviour” (Hipes et al., 2016). These studies imply that a certain stigma in the workplace can quickly manifest itself as an invisible discriminatory influence on the employment process.

On the other hand, the results also introduce an optimistic perspective in the context of stigmatization regarding the opportunity to partake in de-stigmatizing movements by sharing on social media. One participant highlighted that the present level of societal awareness concerning mental health would not have been achieved without the significant contribution of the multitude of individuals actively engaging in the movement to openly share their personal experiences with mental health conditions. In this way, social media can be regarded as a tool to voice an activist statement based on life experience, not only to expand the views of those around the client in a wider cultural and geographical context.

Conflicts of interest

We now turn to the topic of conflicts of interest to think critically about the possible interests underlying the trends of our social surroundings. In the results, secondary interests (Thompson, 2009) that were identified as potential conflicts of interest when working with social media included the interests of the support organization, the music therapist, and the music therapy community. The first possible conflict from the results was the support organizations. A participant who had applied for funds to run a non-profit music therapy organization explained how the funder required that they were explicitly mentioned on social media posts. The participant seemed to feel pressure toward publishing based on this requirement from the funding organization.

The latter potential conflicts of interest concerned the promotion of the music therapist and the music therapy community. In addition to the fact that most music therapists are familiar with advocating their own practice, Norwegian music therapists are also explicitly called to assist in the implementation and authentic integration of music therapy within the health contexts (Stige et al., 2019). As Norway is a social democratic welfare state which provides public health services³, the strategic implementation of a health profession also needs to be grounded in the wish of the democracy and the voice of the general public (Dalton, 1996).

The primary motivation of the music therapists and politicians who work to strategically implement music therapy is the equal access to well-founded health services, including music therapy, for people across life situations and geographical location (Bauder et al., 2016; Peacock et al., 2016; Stige et al., 2019). The secondary motivational factors could include an increase in music therapy positions, as well as a protected and acknowledged position in terms of finance and status within health care. With this in mind, it is important to consider how our professional discussions might influence the pressure to publish on social media (Bandura, 2001). The results indicate that music therapists might feel a wish or pressure toward making music therapy visible to the general public, possibly grounded in the notion of how the ripple effects of showcasing music therapy can benefit multitudes of people in the future. Though hardly anyone would go through with social media publishing if there were any explicit doubt about ethics, future research should further examine how our discussions and social media norms influence music therapists’ willingness to use social media in therapy.

Implications

As a response to the results, the following implications for practice and future studies present an overview of recommended considerations that apply to music therapists and researchers who use social media.

Implications for practice

To maintain a responsible practice and to act consciously in the digital world, the following questions are proposed for consideration by everyone involved in social media sharing within music therapy. The questions are based on the GDPR (Information Commissioner’s Office, n.d.a) and the discussions of this study.

Social media publishing

1. How can sharing on social media improve and/or worsen the client’s health?

2. How can the client’s openness about own health and lived experience impact other people positively?

3. Does the client wish to keep their music therapy attendance confidential? If so, which steps must be carried out to properly anonymize this relationship in a publication process?

4. Which aspects of the music therapist’s and the client’s private lives should and should not be publicly accessible on social media?

5. Which ways could information disclosed on social media be used against the client in discriminatory ways?

6. How can explicit and informed use of restrictive privacy settings limit the public digital footprint and decrease the risks of unwanted attention?

7. How can the music therapist ensure emotional support throughout the publishing process, including follow-ups in the future?

Consent for publication

1. How could the music therapist’s power position influence the client’s decision to consent for the publication of music related content onsocial media?

2. Are there indications that the client’s capacity to consent may be impaired or restricted?

3. How can the music therapist reduce the fear of declining and withdrawing consent to make the consent decision as free as possible?

Conflicts of interest

1. How can the interests of support organizations, the music therapy community, and the music therapist hinder focus on the client’s best interests?

Implications for future studies

In this study, we have constrained the comparison of diverse models regarding ethical decision-making and personal, relational, and institutional ethics to primarily those in the country in which the study has taken place. As highlighted by one of the manuscript reviewers, we also think that a comprehensive and culturally sensitive international study of this topic would generate unique and valuable insight into current practices and future considerations and consequences. Although ethics guidelines are often based within organizational, national, and less frequently multi-national boundaries, access to the internet and social media is a global system accessible to individuals who may or may not be knowledgeable about the guidelines, laws, and consequences in their place of abode.

Conclusion

This study explores consent, privacy, and ethics in the context of music therapy and social media. The study discusses ways in which consent for publishing can be as informed and freely given as possible within the client-therapist relationship. The results point toward how music therapists must make complex considerations in work with social media to maintain a level of responsible practice. Finally, as a continuation of the discussion, we proposed a series of implications for practice and future studies.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

No funding was received for this study.

Notes on contributors

Eirik Sæle

Eirik Aurlund Sæle holds a Master’s degree in Music Therapy from The Grieg Academy – Department of Music at the University of Bergen, Norway.

Simon Gilbertson

Simon Gilbertson is Associate Professor at the Grieg Academy – Department of Music, University of Bergen, Norway. He began working in 1993 as a state-registered music therapist primarily in early neurosurgical rehabilitation with people with idiosyncratic biographies and also in residential, educational and institutional settings. After this first decade of practice and two decades of transdisciplinary learning and teaching, Simon is now committed to practice, education, and research related to significant-but-difficult-to-access issues at crossing points of critical thinking, health, and the arts. To do this work, Simon engages in uncommon, and at times idiosyncratic material-collaborative research processes that aim at i) exposing unexpected and novel claims and their oppositions and ii) promoting the necessity of methodological diversity within phenomena-responsive discourse.

Notes

¹ The term “social media” will here be used as an umbrella term for web based social networking services.

² A comprehensive overview of the critical reflections and discussions made throughout the project can be found in the master’s thesis “Komplekse avveininger innen musikkterapi og sosiale medier” (Sæle, 2022).