Case Examples of Music Therapy for End of Life [1 ed.] 9781937440237

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Case Examples of Music Therapy at the End of Life Compiled by Kenneth E. Bruscia

Case Examples of Music Therapy at the End of Life Copyright © 2012 by Barcelona Publishers All rights reserved. No part of this e-book may be reproduced and/or distributed in any form whatsoever. E-ISBN: 978-1-937440-23-7 Distributed throughout the world by: Barcelona Publishers 4 White Brook Road Gilsum NH 03448 Tel: 603-357-0236 Fax: 603-357-2073 Website: www.barcelonapublishers.com SAN 298-6299 Cover illustration and design: © 2012 Frank McShane

Table of Contents CASE ONE Life Review with a Palliative Care Patient Cheryl Beggs CASE TWO Songs of Faith in End of Life Care Russell Hilliard Jenna Justice CASE THREE Music Therapy at the End of a Life Jenny A. Martin CASE FOUR The Courage to Die—Nathaniel, a Terminal Cancer Patient: A Case Analysis Chava Sekeles CASE FIVE Where Have All Our Flowers Gone? Music Therapy with a Bereaved Mother and Widow: A Case Analysis Chava Sekeles CASE SIX “Couldn’t Put Humpty Together Again”: Symbolic Play with a Terminally Ill Child Catherine Sweeney CASE SEVEN Songs In Palliative Care: A Spouse’s Last Gift Jane Whittall

Introduction Kenneth E. Bruscia Case examples provide very unique and valuable insights into how different forms of therapy are practiced, as well as how clients respond to those therapies. This e-book describes various ways that music therapy has been used to help individuals at the end of life. It has been compiled not only to provide practical information to students and professionals in music therapy and related fields, but also to inform all those affected by death and dying about the potential benefits of music therapy. This introduction is intended to help readers better understand and contextualize each case example presented in the book, not only within the field of music therapy, but also within the literature on end of life care. To do this, it provides basic information on end of life care, music therapy, and case examples. About Individuals at the End of Life Individuals at the end of life are persons of any age who are in the advanced stages of a life-threatening medical condition and in need of hospice or palliative care (Dileo & Loewy, 2005). Primary therapeutic goals under these circumstances include: ameliorating pain and suffering (physical, emotional, and spiritual), maximizing day-to-day functioning, maintaining the highest possible quality of life, assisting the person to gain closure wherever needed, and helping the person to derive meaning from his or her life. End of life care often includes loved ones, relatives, and caregivers in the treatment plan, not only because they can play a vital role in accomplishing the above goals for the person dying, but also because they too need the support and assistance of end-of-life professionals. The case examples in this book provide myriad perspectives on the different needs that individuals and their loved ones may have at the end of life and the ways that these needs can be met through music therapy. Because music experience involves the body, mind, and spirit, music therapy is ideally suited for helping individuals at the end of life address their physical, emotional, interpersonal, and spiritual needs. About Music Therapy (Based on Bruscia, 1993) Definition and Applications In music therapy, the therapist and client use music and all of its facets—physical, emotional, mental, social, aesthetic, and spiritual—to help the client improve or maintain his or her health. In some instances, the client’s needs are addressed directly through music and its intrinsic therapeutic properties; in others, they are addressed through the relationships that develop between the music, client, therapist, and other participants.

Music therapy is used with individuals of all ages and with a variety of conditions, including psychiatric disorders, medical problems, physical handicaps, sensory impairments, developmental disabilities, substance abuse, communication disorders, interpersonal problems, and aging. It is also used for self-development purposes, such as improving learning, building self-esteem, reducing stress, supporting physical exercise, and facilitating a host of other health-related activities. Given its wide applications, music therapists may be found in general hospitals, psychiatric facilities, schools, prisons, community centers, training institutes, private practices, and universities. Basic Premises The thing that makes music therapy different from every other form of therapy is its reliance on music as the primary medium for promoting the client’s health. Every session involves the client in a music experience of some kind. The main ones are listening to, recreating, improvising, and composing music. These will be described in more detail in the next few paragraphs; however, it is important to explain immediately that clients do not have to be musicians to participate in or benefit from music therapy. In fact, because most clients have not had previous musical training, the music activities and experiences used in therapy sessions are always designed to take advantage of the innate tendencies of all human beings to make and appreciate music at their own developmental levels. Of course, in clinical situations, music therapists may encounter clients who have physical or mental impairments that interfere with one or more of these basic musical potentials. Therefore, care is always taken to adapt music therapy experiences to the unique musical capabilities and preferences of each client. Music therapists also screen clients who may have adverse psychological or psychophysiological reactions to participation in music. Four Basic Music Experiences Used in Therapy To understand how music therapy works, it is necessary to examine the unique nature of each of the four types of music experience—listening to, recreating, improvising, and composing. In those therapy sessions that involve listening, the client takes in and reacts to live or recorded music in the style preferred by the client. The client may respond through activities such as relaxation or meditation, structured or free movement, perceptual tasks, freeassociation, story-telling, imaging, reminiscing, drawing, and so forth. Music listening experiences are used with clients who need to be activated, soothed, or further developed— either physically, emotionally, intellectually, and/or spiritually—as these are the kinds of responses that music listening elicits. In those therapy sessions that involve re-creating music, the client sings or plays precomposed music. This may include learning how to produce sounds, imitating musical phrases, learning how to sing, learning to read notation, participating in group sing-along’s, performing a song or piece, participating in a musical show or drama, and so forth. Re-creative experiences are most appropriate for clients who need to develop sensorimotor skills, learn adaptive behaviors, maintain reality orientation, master different role behaviors, identify with the

feelings and ideas of others, work with others cooperatively, or merely share in the joy of making music—as these are the main aspects of singing or playing pre-composed music that have therapeutic implications. In those therapy sessions that involve improvising, the client makes up his or her own music extemporaneously, singing or playing whatever arises in the moment. The client may improvise freely and spontaneously or according to the musical or verbal guidance of the therapist. Sometimes the client is asked to improvise sound portraits of feelings, events, persons, or situations that are being explored in therapy. The client may improvise with the therapist, with other clients in a group, or alone, depending on the therapeutic objective. Improvising music is most appropriate for clients who need to develop spontaneity, creativity, freedom of expression, self-awareness, communication, and interpersonal skills—as these are the basic components of improvising. In those sessions that involve composing, the therapist helps the client to write songs, lyrics, or instrumental pieces, or to create any kind of musical product, such as music videos or audiotape programs. Usually the therapist simplifies the process by engaging the client in aspects of the task within their capability (e.g., generating a melody, or writing the lyrics of a song) and by taking responsibility for more technical aspects (e.g., harmonization, notation). Activities involving composing music are used with clients who need to learn how to make decisions and commitments, or find ways of working in an organized way toward a goal. Most often, clients create compositions (especially songs) around significant events, people, or relationships in their lives, or to express thoughts and feelings that they are exploring in therapy. In addition to strictly music experiences, music therapists often engage clients in verbal discussions. Clients may be encouraged to talk about the music, their reactions to it, or any thoughts, images, or feelings that were evoked during the experience. Clients may also be encouraged to express themselves through the other arts, such as drawing, painting, dance, drama, or poetry. Music therapy sessions for children often include various games or play activities which involve music. The case examples that follow highlight the goals of music therapy for individuals at the end of life, and the different kinds of music experiences used to address these goals. Thus, a key to reading these cases is to pay close attention to how each type of music experience affords clients many different opportunities to not only confront their problems within the music, but also to explore healthier ways of dealing with or resolving them. This leads to the next important topic—the ways that case examples can be read or studied for greatest insight. About Case Examples For purposes of the present discussion, case examples can be divided into two main types: clinical cases, and research cases. A clinical case is a professional report written by the therapist, client, or observer to describe what transpired during and upon completion of the music therapy process with an individual client or group. The report is usually based on recordings of the session or notes and logs kept by the therapist and/or client. Efforts are made to present an accurate and unbiased account of the therapy process to the extent possible, and

theories are often used to substantiate or contextualize the therapeutic approach. Objective data may or may not be provided to verify or document the report. In contrast, a research case is a data-based report, provided by the therapist or researcher, to document or verify the specific therapeutic effects of a particular music therapy protocol on an individual client or group. As such, a research case operationally defines and measures how the independent variables (e.g., treatment methods used by the therapist) act upon the dependent variables (e.g., targeted treatment outcomes for the client), when all other relevant variables and conditions are controlled. Perhaps the best way to derive the most benefits from a clinical or research case is to read it from a particular perspective, and to interrogate the case or group of cases from that perspective. Essentially, the reader adopts a particular lens or viewpoint to study the case(s), and then asks questions that arise as a result. Three of the most helpful reading perspectives are: scientific, personal, and clinical perspectives, each of which poses very different questions for the reader to ponder. Reading from a Scientific Perspective Scientists usually look for answers to two basic questions when reading a case. First, is the case credible? That is, how accurate were the perceptions and interpretations of the writer, and how trustworthy are the findings and conclusions presented? Of course, this is not a question that only scientists pose. One’s natural propensity as a reader is to question the truth value of what is read. Certainly, if the reader is involved in some way with an individual at the end of life, the truth value of the case is of vital interest. That leads to the second scientific question: Can the information learned in this case be applied to other cases? Or even more rigorously, can the findings of this case be generalized to similar or matched cases? Here too, readers who are directly affected by individuals at the end of life are as interested in this question as scientists and researchers. Their interest is in whether these individuals in their own lives can derive the same benefits of music therapy as the client in this case did. Scientists or researchers can also glean other very important information from case studies. Because clinical cases provide rich descriptions of the therapy process, they usually provide myriad ideas for what needs to be studied scientifically. By describing what seemed to work and or not work for a particular client, a clinical case reveals to the researcher which clinical protocols and therapeutic outcomes warrant further research, while also suggesting specific hypotheses that might be tested. Moreover, because events unfold naturally in a clinical case as they do in real life, and because variables cannot be controlled as in laboratory research, the clinical case gives very important information on what specific variables must be considered when doing research, not only the most likely independent and dependent variables that are likely to be related, but also what extraneous variables need to be controlled. Of course, a research case can provide the same insights, to some degree, as a clinical case; they too offer valuable information on potential independent, dependent, and extraneous variables to consider. The greatest advantage of the research case is not only that it provides objective evidence of what works or doesn’t work in therapy, but also because it can reveal the “effect size” of the therapeutic change. That is, a single-case research study can show how big

an effect the independent variable had on the dependent variable, or the extent to which the treatment protocol was effective in inducing therapeutic change in the client. Though this effect and its size cannot be generalized, careful replication of research cases and meta-analysis can begin to build a case for the establishment of clinical cause-effect relationships. Reading from a Personal Perspective By their very nature, case examples invite the reader to identify with one or more characters involved in the case, and then move from identifying with one character to identifying with another. The characters may include the client, the therapist, other clients, loved ones, and so forth. Identifying with people involved in the case not only helps the reader to understand first-hand what each character is experiencing, but also gives the reader an opportunity to compare how the character reacted with how the reader would react. Here are some examples: 1) Identifying with the client: What must the client be thinking or feeling about the therapist, music, other clients, or loved one? If I were the client, would I think or feel the same? What does this client need and want from those involved in the therapy process, and would I need or want the same? These same questions can be posed for every client involved in the case. 2) Identifying with the therapist: What must the therapist be thinking or feeling about the client, the music, the other clients, or the client’s loved one? Would I think or feel the same? What kind of person would I be if I were working with this client? What is the therapist trying to do, and would I try to do the same? 3) Identifying with loved ones: What must the loved one be thinking or feeling about the client, the therapist, the music, and other clients? If I were a loved one, would I think or feel the same? What does this person need or want, and would I need or want the same? Does this person believe that music therapy will help, and would I? How does the loved one feel about the therapist, and how he or she is relating to the client? Does the therapist know what he or she is doing? The fascinating thing about taking an empathic position is that once one successfully steps into one character’s shoes, and becomes sensitive to who he or she is, an endless number of additional empathic positions arise, and one’s entire personal reaction to the case becomes enlivened. Reading from a Clinical Perspective A clinical perspective is concerned primarily with methodological questions that are most often posed by other clinicians. Clinicians want to know what does and does not work when working with a client in music therapy. Practically speaking then, they are most interested in the following kinds of questions:

1) Based on this case, what should I be looking for in clients? What client needs and resources do I have to address more in my own work? How can I assess these facets of the client in music therapy? 2) Based on this case, what kind of therapist-client relationship is best for this kind of client, and what is the best way of forming such a relationship? 3) What is the role of music in working with this clientele? What types of music experiences are most therapeutically relevant and effective? What styles of music are most appropriate? 4) Based on this case, what are the best ways of responding to the client when he or she is acting out, abreacting, resisting, or not progressing? 5) Based on this case, what clinical criteria should be used in evaluating the client’s therapeutic progress? Other Writings on Music Therapy at the End of Life The case examples in this e-book were taken exclusively from various books published by Barcelona Publishers. Thus, these cases, though typical, may not comprise a representative sample of all clinical practices in music therapy for individuals with at the end of life. Here is a list of other published case examples along with other writings on the topic. Aasgaard, T. (1999). Music Therapy as Milieu in the Hospice and Paediatric Oncology Ward. In D. Aldridge (Ed.), Music Therapy in Palliative Care: New Voices (pp. 29-42). London. Abrams, B., & Kasayka, R. (2005). Music Imaging for Persons at the End of Life. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. 159-170). Cherry Hill, NJ: Jeffrey Books. Aldridge, D. (1995). Spirituality, Hope and Music Therapy in Palliative Care. The Arts in Psychotherapy, 22(2), 103-109. Aldridge, D. (Ed.). (1999). Music Therapy in Palliative Care: New Voices. London, UK: Jessica Kingsley Publishers. Aldridge, D. (2003). Music Therapy References Relating to Cancer and Palliative Care. British Journal of Music Therapy, 17(1), 17-25. Beggs, C. (1991). Life Review with a Palliative Care Patient. In K. E. Bruscia (Ed.), Case Studies in Music Therapy (pp. 611-616). Phoenixville, PA: Barcelona Publishers. Bradt, J., & Dileo, C. (2010). Music Therapy for End-Of-Life Care. Cochrane Database of Systematic Reviews (Online), (1), CD007169. Bright, R. (1989). Developing Skills & Competencies in Music Therapy for Palliative and Hospice Care. In J. A. Martin (Ed.), the Next Step Forward: Music Therapy with the Terminally Ill (pp. 13-22). Bronx, NY: Calvary Hospital. Bright, R. (1979). Palliative Care at the Royal Victoria Hospital, Montreal. The Australian Music Therapy Association Bulletin, 2(4), 3-6. Brooks, M., & O’Rourke, A. (1985). Grief and Music Therapy. A Study into the Application of Music Therapy with the Dying and Bereaved. Annual Journal of the New Zealand Society for Music Therapy, 7(2), 16-24. Brown, J. (1992). Music dying. The American Journal of Hospice & Palliative Care, 9(4), 17-20.

Bruscia, K. E. (1995). Images of AIDS. In C. A. Lee (Ed.), Lonely waters: Proceedings of the international conference, Music Therapy in Palliative Care, Oxford 1994 (pp. 119-124). Oxford: Sobell Publications. Cadesky, N. (2005). The Clinical Use of Therapist’s Voice and Improvisation in End of Life Care. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. 203-210). Cherry Hill, NJ: Jeffrey Books. Cadrin, M. L. (2006). Music Therapy Legacy Work in Palliative Care: Creating Meaning at End of Life. Canadian Journal of Music Therapy, 12(1), 109-137. Cadrin, M. L. (2009). Dying well: The Bonny Method of Guided Imagery and music at end of life. Voices: A World Forum for Music Therapy, 9(1) Chestnut, M., Duncan, M., Gagnon, S., & Schreck, B. (2005). Music Meditation in the ICU. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. 211-218). Cherry Hill, NJ: Jeffrey Books. Clair, A. A. (2007). Prognosis Grim/Situation hopeless: Making a Difference with Music Therapy. Music Therapy Perspectives, 25(2), 76-79. Clements-Cortes, A. (2010). The Role of Music Therapy in Facilitating Relationship Completion in End-Of-Life Care/L’impact de la Musicothérapie sur le Travail de Séparation en fin de vie. Canadian Journal of Music Therapy, 16(1), 28-147. Colligan, K. G. (1987). Music Therapy and Hospice Care. Activities, Adaptation & Aging, 10(1-2), 103-122. Cortes, A. (2006). Occupational Stressors among Music Therapists Working in Palliative Care. Canadian Journal of Music Therapy, 12(1), 30-60. Daveson, B., & Kennelly, J. (2000). Music Therapy in Palliative Care for Hospitalized Children and Adolescents. Journal of Palliative Care, 16(1), 35-38. Dileo, C., & Loewy, J. (Eds.) (2005). Music Therapy at the End of Life. Cherry Hill, NJ: Jeffrey Books. Dimaio, L. (2010). Music Therapy Entrainment: A Humanistic Music Therapist’s Perspective of Using Music Therapy Entrainment with Hospice Clients Experiencing Pain. Music Therapy Perspectives, 28(2), 106-115. Erdonmez, D. (1995). A Journey of Transition with Guided Imagery and Music. In C. A. Lee (Ed.), Lonely waters: Proceedings of the International Conference, Music Therapy in Palliative Care, Oxford 1994 (pp. 125-136). Oxford: Sobell Publications. Fagen, T. S. (1982). Music Therapy in the Treatment of Anxiety and Fear in Terminal Pediatric Patients. Music Therapy, 2(1), 13-23. Flower, C. (2008). Living with Dying: Reflections on Family Music Therapy with Children Near the End of Life. In A. Oldfield, & C. Flower (Eds.), Music Therapy with Children and Their Families (pp. 177-190). London, UK: Jessica Kingsley Publishers. Forrest, L. (2000). Addressing Issues of Ethnicity and Identity in Palliative Care through Music Therapy Practice. Australian Journal of Music Therapy, 11, 23-37. Foxglove, T. (1999). Music Therapy for People with Life-Limiting Illness. Nursing Times, 95(18), 52-54. Frego, R. J. D. (1995). Music Movement Therapy for People with Aids: The Use of Music Movement Therapy as a Form of Palliative Care for People with AIDS. International Journal of Arts Medicine, 4(2), 21-25.

Gallagher, L., Huston, M., Nelson, K., Walsh, D., & Steele, A. (2001). Music Therapy in Palliative Medicine. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 9(3), 156-161. Gilbert, J. P. (1977). Music Therapy Perspectives on Death and Dying. Journal of Music Therapy, 14(4), 165-171. Groen, K. M. (2007). Pain Assessment and Management in End of Life Care: A Survey of Assessment and Treatment Practices of Hospice Music Therapy and Nursing Professionals. Journal of Music Therapy, 44(2), 90–112. Hartwig, R. (2010). Music Therapy in the Context of Palliative Care in Tanzania. International Journal of Palliative Nursing, 16(10), 499-504. Halstead, M., & Roscoe, S. (2002). Restoring the Spirit at the End of Life: Music as an Intervention for Oncology Nurses. Clinical Journal of Oncology Nursing, 6(6), 332-336. Hanser, S. (2005). Music Therapy to Enhance Coping in Terminally Ill Adult Cancer Patients. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. 33-42). Cherry Hill, NJ: Jeffrey Books. Hartwig, R. (2010). Music Therapy in the Context of Palliative Care in Tanzania. International Journal of Palliative Nursing, 16(10), 499-504. Hepburn, M. (2004). Meaning, Purpose, Transcendence and Hope -- Music Therapy and Spirituality in End of Life Hospice Care. New Zealand Journal of Music Therapy, 2, 58-82. Hilliard, R. (2001). The use of music therapy in meeting the multidimensional needs of hospice patients and families. Journal of Palliative Care, 17(3), 161-166. Hilliard, R. (2002). The Effects of Music Therapy on Quality of Life and Length of Life of Hospice Patients Diagnosed with Terminal Cancer (Ph.D., Florida State Univ., 2002). Dissertation Abstracts International Section A: Humanities & Social Sciences, 63, 1760. Hilliard, R. (2004). Hospice Administrators’ Knowledge of Music Therapy: A Comparative Analysis of Surveys. Music Therapy Perspectives, 22(2), 104-108. Hilliard, R. (2005). Hospice and Palliative Care Music Therapy: A Guide to Program Development and Clinical Care. Cherry Hill, NJ: Jeffrey Books. Hilliard, R. (2005). Enhancing Quality of Life for People Diagnosed with a Terminal Illness. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. 19-24). Cherry Hill, NJ: Jeffrey Books. Hilliard, R. E. (2003). The Effects of Music Therapy on the Quality and Length of Life of People Diagnosed with Terminal Cancer. Journal of Music Therapy, 40(2), 113-137. Hilliard, R. E. (2004). A Post-Hoc Analysis of Music Therapy Services for Residents in Nursing Homes Receiving Hospice Care. Journal of Music Therapy, 41(4), 266-281. Hilliard, R. E. (2006). The Effect of Music Therapy Sessions on Compassion Fatigue and Team Building of Professional Hospice Caregivers. Arts in Psychotherapy, 33(5), 395-401. Hogan, B. (1998). Approaching the End of Life: A Role for Music Therapy within the Context of Palliative Care Models. Australian Journal of Music Therapy, 9, 18-34. Hogan, B. (1999). Music Therapy at the End of Life: Searching for the Rite of Passage. In D. Aldridge (Ed.), Music Therapy in Palliative Care: New Voices (pp. 68-81). London, UK: Jessica Kingsley Publishers.

Horne-Thompson, A. (2003). Expanding from Hospital to Home Based Care: Implications for Music Therapists Working in Palliative Care. Australian Journal of Music Therapy, 14, 3849. Horne-Thompson, A., Daveson, B., & Hogan, B. (2007). A Project Investigating Music Therapy Referral Trends within Palliative Care: An Australian Perspective. Journal of Music Therapy, 44(2), 139–155. Houck, A. (2008). The Development of a Music Therapy Protocol for Determining the Spiritual Needs of Hospice Patients (Ph.D., Univ. of Minnesota, 2007). Dissertation Abstracts International Section A: Humanities & Social Sciences, 68(8), 3207. Ibberson, C. (1996). A Natural End: One Story about Catherine. British Journal of Music Therapy, 10(1), 24-31. Jonas, C. (1994). True Presence through Music for Persons Living Their Dying. NLN Publications, (15-2670), 97-104. Knapp, C., Madden, V., Wang, H., Curtis, C., Sloyer, P., & Shenkman, E. (2009). Music Therapy in an Integrated Pediatric Palliative Care Program. The American Journal of Hospice & Palliative Care, 26(6), 449-455. Krout, R. (2001). The Effects of Single-Session Music Therapy Interventions on the Observed and Self-Reported Levels of Pain Control, Physical Comfort, and Relaxation of Hospice Patients. The American Journal of Hospice & Palliative Care, 18(6), 383-390. Krout, R. (2003). Music Therapy with Imminently Dying Hospice Patients and Their Families: Facilitating Release Near the Time of Death. American Journal of Hospice & Palliative Care, 20(2), 129-134. Krout, R. (2005). The Use of Therapist-Composed Song in End of Life Music Therapy Care. In C. Dileo, & J. Loewy (Eds.), Music Therapy at End of Life (pp. 129-140). Cherry Hill, NJ: Jeffrey Books. Krout, R. E. (2004). A Synerdisciplinary Music Therapy Treatment Team Approach for Hospice and Palliative Care. Australian Journal of Music Therapy, 15, 33-45. Lee, C. A. (1996). Music at the Edge: The Music Therapy Experiences of a Musician with AIDS. London, UK: Routledge. Lindenfelser, K. (2005). Parents’ Voices Supporting Music Therapy within Pediatric Palliative Care. Voices: A World Forum for Music Therapy, 5(3). Retrieved June 30, 2011 from https://normt.uib.no/index.php/voices/article/view/233/177 Lindenfelser, K. J., Grocke, D., & McFerran, K. (2008). Bereaved Parents’ Experiences of Music Therapy with Their Terminally Ill Child. Journal of Music Therapy, 45(3), 330–348. Lloyd-Green, L. (1998). Palliative Medicine in the Nineties. In R. R. Pratt, & D. E. Grocke (Eds.), MusicMedicine 3: MusicMedicine and Music Therapy: Expanding Horizons (pp. 238-241). Saint Louis, MO: MMB Music, Inc. Loewy, J. (2005). Preface: Preparing for the Passage. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. xv-xviii). Cherry Hill, NJ: Jeffrey Books. Loewy, J., Altilio, T., & Dietrich, M. (2005). Lift Thine Eyes: Music Used as a Transitional Element in Passage. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. 95-102). Cherry Hill, NJ: Jeffrey Books.

Loewy, J., & Stewart, A. (2005). The Use of Lullabies as a Transient Motif in Ending Life. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. 141-148). Cherry Hill, NJ: Jeffrey Books. Magill, A. (2001). The Use of Music Therapy to Address the Suffering in Advanced Cancer Pain. Journal of Palliative Care, 17(3), 167-172. Magill, L. (2005). Music therapy: Enhancing Spirituality at the End of Life. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. 3-18). Cherry Hill, NJ: Jeffrey Books. Magill, L., & Berenson, S. (2008). The Conjoint Use of Music Therapy and Reflexology with Hospitalized Advanced Stage Cancer Patients and Their Families. Palliative & Supportive Care, 6(3), 289-296. Mandel, S. E. (1993). The Role of the Music Therapist on the Hospice/Palliative Care Team. Journal of Palliative Care, 9(4), 37-39. Marom, M. K. (2008). “Patient Declined”: Contemplating the Psychodynamics of Hospice Music Therapy. Music Therapy Perspectives, 26(1), 13–22. Marr, J. (1998-1999). GIM at the End of Life: Case Studies in Palliative Care. Journal of the Association for Music and Imagery, 6, 37-54. Martin, J. A. (1991). Music Therapy at the End of a Life. In K. E. Bruscia (Ed.), Case Studies in Music Therapy (pp. 617-634). Phoenixville, PA: Barcelona Publishers. Maue-Johnson, E. L., & Tanguay, C. L. (2006). Assessing the Unique Needs of Hospice Patients: A Tool for Music Therapists. Music Therapy Perspectives, 24(1), 13-21. Mramor, K. (2001). Music Therapy with Persons Who Are Indigent and Terminally Ill. Journal of Palliative Care, 17(3), 182-187. Mondanaro, J. (2005). Interfacing Music Therapy with Other Arts Modalities to Address Anticipatory Grief and Bereavement in Pediatrics. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. 25-32). Cherry Hill, NJ: Jeffrey Books. Munro, S. (1993). Music Therapy in Palliative/Hospice Care. St Louis, MO: MMB Music. Munro, S., & Mount, B. (1978). Music Therapy in Palliative Care. Canadian Medical Association Journal, 119(9), 1029-1034. Nakayama, H., Kikuta, F., & Takeda, H. (2009). A Pilot Study of Effectiveness of Music Therapy in Hospice in Japan. Journal of Music Therapy, 46(2), 160-172. Nakkach, S. (2005). Devotional Music Therapy: Contemplative Vocal Music and the Passage. In C. Dileo, & J. Loewy (Eds.), Music Therapy at the End of Life (pp. 189-202). Cherry Hill, NJ: Jeffrey Books. Nicholson, K. (2001). Weaving a Circle: A Relaxation Program Using Imagery and Music. Journal of Palliative Care, 17(3), 173-176. O’Callaghan, C. (1984). Musical Profiles of Dying Patients. The Australian Music Therapy Association Bulletin, 7(2), 5-11. O’Callaghan, C. (1988). Music Therapy in Palliative Care, What’s Happening Now?. Fourteenth National Conference of the Australian Music Therapy Association Inc. “Music Therapy: A Community Resource”, Melbourne, 78-83. O’Callaghan, C. (1989). Isolation in an Isolated Spot: Music Therapy in Palliative Care in Australia. In J. A. Martin (Ed.), the Next Step Forward: Music Therapy with the Terminally Ill (pp. 33-46). Bronx, NY: Calvary Hospital.

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West, T. (1994). Psychological Issues in Hospice Music Therapy. Music Therapy Perspectives, 12(2), 117-124. Whittall, J. (1991). Songs in Palliative Care: A Spouse’s Last Gift. In K. E. Bruscia (Ed.), Case Studies in Music Therapy (pp. 603-610). Phoenixville, PA: Barcelona Publishers. Whittall, J. (1989). The impact of music therapy in palliative care: A quantitative pilot study. In J. A. Martin (Ed.), the Next Step Forward: Music Therapy with the Terminally Ill (pp. 69-72). Bronx, NY: Calvary Hospital. Wlodarczyk, N. (2007). The Effect of Music Therapy on the Spirituality of Persons in an InPatient Hospice Unit as Measured by Self-Report. Journal of Music Therapy, 44(2), 113122. Wylie, M., & Blom, R. C. (1986). Guided Imagery and Music with Hospice Patients. Music Therapy Perspectives, 3, 25-28. Yaya Kelleher, A. (2001). The Beat of a Different Drummer: Music Therapy’s Role in Dementia Respite Care. Activities, Adaptation & Aging, 25(2), 75-84. References for Introduction American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition, Text Revision. Washington DC: American Psychiatric Association. Bruscia, K. (1993). Music Therapy Brief. Retrieved from temple.edu/musictherapy/FAQ. Dileo, C., & Loewy, J. (Eds.) (2005). Music Therapy at the End of Life. Cherry Hill, NJ: Jeffrey Books.

Case Examples of Music Therapy at the End of Life

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE ONE Life Review with a Palliative Care Patient Cheryl Beggs Abstract This case describes the use of life review with an 86-year-old amateur violinist in palliative care. Given the patient’s rich musical past, the life review process involved reviving his love for playing the violin, encouraging him to play his song repertoire for the therapist, his family and other patients, and eliciting personal memories through song reminiscence. A videotape was produced of a life review session, and a special musical evening with his family was held as he neared death. Background Information At the time of this case, Mr. H was an eighty-six year old man in palliative care. He was born on June 25, 1889. He was married with five children, and served as patriarch and provider for his family. Mr. H’s illness began in 1958 when he had a cancerous growth removed from his colon. Then in 1975, he was hospitalized for a prostate operation. Shortly before this time he had confided in his family that he had cancer of the prostate. In 1985, he entered the hospital because of a loss of bladder control. After this, he was primarily bedridden and unable to control bodily functions. He again entered the hospital in late January 1986 with the diagnosis of prostate cancer with metastasis. It was at this time that he was referred to weekly music therapy sessions for the following goals: to promote independence, to increase acceptance of his limitations, and to encourage him to communicate musically. A music therapy assessment designed by the author was conducted during the first session. It revealed that he was a native of Nova Scotia of English/Scottish descent and a member of the Church of Latter Day Saints. He had worked for Ford Motor Company before retirement. His family has been very supportive throughout his illness. As for his musical background, Mr. H was a violinist who loved old time music. He had learned to play the fiddle when he was a teenager in Calgary, and as a country boy played it for amusement. In his mid-twenties, he put the violin on the shelf for a while, and did not touch it again for thirty-five years. Then in the late 1950’s he went to a fiddle contest and decided to give it another try. He won a prize in the class of sixty-year-olds and over.

In the 1980’s, after his wife had succumbed to Alzheimer’s Disease, Mr. H made a practice of visiting the “old folks homes” around Windsor and playing for “the poor old souls,” as he called them—many of whom were younger than he. Since being hospitalized in January of 1986, Mr. H had regressed to the point of dependence on staff and family for his daily needs. He had essentially given up on himself and lost the will to live. It was decided that a caring humanistic approach was needed to encourage him to resume some responsibility for his life. Treatment Process Music therapy was scheduled on a weekly individual basis with sessions lasting from 30 to 90 minutes. The sessions were held in a typical double room in a general hospital. Since Mr. H was clear in mind, and enjoyed talking about and playing music, the technique called “life review” was the logical choice of treatment method. It allows for a natural pairing of music and verbal discussion in exploring important life events. This combination also led to many creative musical experiences for both him and the therapist. The life review was accomplished through singing, playing, and listening to music that was important in Mr. H’s life, and talking about any associations and memories that were triggered by the music. Rediscovering the Violin The first session began with Mr. H mistaking the music therapist for the dietician. He immediately began to complain about the hospital food. I proceeded to tell him that I was the music therapist, at which time he promptly pushed his food away and said: “Music is the best medicine.” He then told me that he was a violinist, and asked if I could play the violin. I replied that piano and voice were my main instruments, but that I had played a little on stringed instruments. He then asked me to get his violin from the closet and tune it for him. I proceeded to do so (quite poorly), until he took the violin from me and began to tune it himself. This was an important step because he had done so little for himself in the past, and this was at least an attempt to begin regaining some control over his present situation. Mr. H was then encouraged to get out of bed to play, but he refused and instead played lying down with the bed raised. Reactivation through Music During subsequent sessions, music played a role in encouraging Mr. H to get dressed and to use the wheelchair to come to music therapy. By this time, we had moved from his room to a larger space down the corridor to give him a change in environment. Playing the violin kept his mind alert, and he often commented that the more he played the more the titles of songs came back. Mr. H requested music therapy on a daily basis, but eventually accepted that sessions were only available on a weekly basis. Actually, this motivated him to find other ways of making music during the week. He soon began entertaining everyone with his playing, and was praised enthusiastically by other patients and the nursing staff. He also brought tapes of his own playing to listen to during his physiotherapy sessions.

In the music therapy sessions, Mr. H invited me to accompany him on the piano. He would select the songs (many of which were unknown to me), and before starting would tell me the key and chord progressions for the song. Sometimes he gave me tapes of his old band playing so I could learn the style of a song from listening. He took great pride in sharing these tapes with me, and would often say, “With all the letters beside your name, you’ll have no trouble learning these songs. Psychologically, his playing increased his emotional well-being, while also promoting a sense of accomplishment and self-worth. A Videotaped Life Review Session By June of 1986, Mr. H was confined to bed, but despite intravenous tubes in his left arm and weakening muscles in his right arm, he continued to play the violin, bowing as best he could. He reported having some pain, but often refused pain medications in the morning, and he never complained of physical discomforts during music therapy sessions. Once he commented, “The only pain I have are tears of joy in my eyes when you come to see me.” He also reported that his pain and discomfort lessened by the end of music therapy sessions. The musical life review was conducted on June 12, 1986. Mr. H agreed to have the session videotaped so that others could see the importance of music therapy. The life review was conducted by posing questions to Mr. H about his musical past. Questions were sequenced chronologically, beginning with songs Mr. H remembered from his childhood and youth, and then songs important during his adult years. We discussed the most significant musical works and styles, and his specific preferences. Mr. H also talked about what his life would have been without music. As we moved into the present, I asked him what the value of music had been in hospital. He replied that he would have felt weak and helpless. Mr. H and I also played some of the music we discussed. The music selections ranged from old-time jigs, reels, and waltzes to pre-1900 songs, spirituals, and hymns. The Final Stage When it became increasingly obvious that Mr. H had little time left to live, a special evening was held in his honor by his family, a palliative care volunteer and myself. Mr. H played the violin, and his family sang while I accompanied on the piano. Mr. H’s daughter also gave him a special tribute by singing “Somewhere My Love” from the film, “Dr. Zhivago.” Mr. H had often played a tape for the therapist of his daughter singing this song. It was a very touching evening to hear such music coming from his hospital room. Music therapy sessions drew to an end when Mr. H became too weak. When the final stage of dying came, the head nurse told me that I should say my goodbyes. I went to see Mr. H for the last time. We thanked one another for the times we had shared. Few words were needed. He died shortly thereafter, on September 25, 1986. After his death, Mr. H’s family donated a portable keyboard for use in music therapy. A gold plaque inscribed with “In memory of Mr. H” was placed prominently on the keyboard, and to this day serves as a constant reminder of our special relationship. Discussion

Music therapy provided Mr. H with an outlet for self-expression, while also motivating him to become more independent and to communicate with and relate to others. This also helped him to maintain feelings of dignity, self-accomplishment and self-worth. The music also facilitated reminiscence and evoked memories of significant events and people. The main factors contributing to these results were the strong and open relationships formed between the patient, his family, the palliative care team and the music therapist. Music therapy also helped the family by giving them opportunities to share in Mr. H’s music, and to have positive memories of him during the last few months of his life. These memories will be enhanced for years to come by the life review videotape documenting Mr. H’s involvement in music throughout his life. Glossary Life Review: A musical profile of a person, consisting of selections of music which have special meaning for the person at various stages during life. Palliative Care: A program of active, compassionate care of the terminally ill aimed primarily at improving the quality of life. It is delivered by an interdisciplinary team that provides sensitive and skilled care to meet the physical, psychological and spiritual needs of both patient and family.

Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case Study Perspectives. Gilsum NH: Barcelona Publishers.

CASE TWO Songs of Faith in End of Life Care Russell Hilliard Jenna Justice Introduction For those living with an advanced illness and a prognosis of six months or less, hospice care is often utilized for pain and symptom management (Ripamonti, 2005). Under hospice care, patients elect to forego aggressive curative treatment and opt for palliative medicine, also known as comfort care (Connor, 2009). The primary goal of this type of care is to enhance quality of life in a holistic manner (Fine, 2008). To accomplish this, hospice employs a variety of professionals to assist the patient and family. This interdisciplinary group includes physicians, nurses, nurse aides, social workers, chaplains, volunteers, bereavement counselors, and adjunctive therapies (including music therapy). Hospice care can be provided in hospitals, long term care settings, private homes, and in-patient hospice units (Stoddard, 1992). Since 1995, the hospice industry has seen a dramatic increased utilization of music therapy in end of life care (Hilliard, 2005a). In part, this is due to the growth of hospice and the need for agencies to offer innovative services that set them apart within the market place. Hospice administrators have used music therapy programs within their marketing of the agency to increase the hospice census and encourage referral partners to use one agency over another, arguing that offering music therapy demonstrates the agency’s commitment to quality end of life care (Hilliard, 2001, 2005a). This growth is also due to an emerging body of evidence supporting music therapy in end of life care. There are now at least seven empirical research studies in the literature that show significant differences in variables such as mood and pain, anxiety, dyspnea, comfort, relaxation, quality of life and spirituality with the treatment of music therapy in end of life care (Hilliard, 2005b). Because music therapy enhances the quality of clinical care and also provides support from a business perspective for the hospice agency, it is likely that music therapy will continue to blossom throughout the end of life care continuum. This chapter provides a foundational framework for the utilization of music therapy in end of life care and offers a case study demonstrating the benefits of music therapy for this population. A theoretical orientation of cognitive behavioral music therapy combined with a humanistic approach, are presented, and the case study provides an example of assessment, treatment planning and the achievement of therapeutic goals. Foundational Concepts

There are a variety of theoretical orientations guiding the practice of music therapy in patient care, and this diversity is what enriches the field and its clinicians. While some music therapists hold true to one or more theoretical orientations, others describe themselves as eclectic, pulling from multiple theories to meet patient needs (Hilliard, 2005a). Whatever the theoretical foundation of the clinician, hospice care requires therapists to uphold ethical standards interpreted by the industry to include: • • • • •

Patients’ rights to autonomy. Hospice workers respect the self-determination of the patient, even though the worker may not agree with the decision. The experience is whatever the patient says it is. This relates to all experiences, the most prevalent of which is pain. Upholding non-malfeasance, the hospice worker is guided to ‘do no harm’ and consistently guides treatment based on the patient and family’s value systems. The hospice worker is benevolent, always seeking to ‘do good’ for the patient and family. Hospice patients and families are richly diverse, and the hospice worker remains non-judgmental, forever seeking to understand and respect patients’ beliefs, lifestyles, values, cultures and religious/spiritual practices (Hilliard, 2005a).

While the aforementioned can be descriptive of many therapeutic relationships, it is vitally important in end of life care. Most practitioners recognize the dying process as one that is entirely unique for each individual and that the grieving process is unique among and between family members. Additionally, the average length of time patients utilize hospice services varies greatly from a few days to months. Depending on the community and hospice agency, the average length of stay for a hospice patient may only be 45 days (Connor, et al., 2007). Given this brief period of time to provide treatment within a therapeutic relationship, goals of care must be clearly defined. Given that the hospice philosophy is so greatly patient centered and provides for a relatively short period of time for the provision of care, we have found cognitive behavioral music therapy (Hilliard, 2005a), combined with humanistic or person-centered therapy (Hilliard, 2005a), to be highly effective as a theoretical approach for music therapy in end of life care. This type of treatment has been tested in the literature, and the data support its use in enhancing quality of life for people diagnosed with terminal cancer in an in-home hospice program (Hilliard, 2003). Cognitive Behavioral Therapy (CBT) was developed primarily through a merging of cognitive and behavior therapies (Simos, 2002). The common ground between the two theoretical orientations of treatment is the alleviation of symptoms and the focus on the “here and now” (Rachman, 1997). CBT evaluates how thoughts, actions and feelings work together to affect one’s mood, mental health, ability to adjust, among other specific mental health needs or disorders. Specifically, CBT evaluates the patient’s inner dialogue (thoughts expressed through one’s inner voice), behaviors engaged that are guided by the inner dialogue or shape the inner dialogue and the emotions experienced within the thought-behavior-emotion paradigm. Because of the body of evidence supporting its efficacy in treatment, CBT has become the

psychotherapy treatment of choice for mood disturbances such as anxiety and depression, sleep disturbances such as insomnia, and other mental health needs (Gould, et al., 1997; Gosselin, et al., 1996; Keller, et al., 2000; Siversten, et al., 2006). In addition to adult clients, children and adolescents respond successfully to CBT treatment for depressive disorders, anxiety and post-traumatic stress disorder, among others (Kendall, 2005). Humanistic therapies challenge the therapist to relate “as one human being to another with utter concentration and utter sincerity” (Fromm, 1964, p. 184). Client-centered therapy (also referred to as person-centered therapy), founded by Carl Rogers (1961), holds at its core the belief that each person has a natural tendency to strive to make the very best of his or her experiences. This innate motivation Rogers called the actualizing tendency (Rogers, 1961). Among the things we value as humans are love, affection, attention, connection, nurturance-Rogers labels these things as positive regard (Rogers, 1961). In the therapeutic relationship, it is important for the therapist to provide unconditional positive regard for the client and the client’s situation. The following are what Rogers (1961) considers essential for success in the therapeutic relationship: • • •

Congruence: The therapist displays a genuine sense of care and concern and remains honest with the client. Empathy: The ability of the therapist to convey that the client’s experiences are heard and understood through validation and reflection. Respect: Total acceptance conveyed by the therapist for the experiences of the client.

The concepts inherent in client-centered therapy pair well with the general practices of hospice care providers. Within the end of life care community of practitioners, the concept of “meeting the patient where the patient is” parallels Roger’s approach of empathy and unconditional positive regard. Respect from a Rogerian perspective is akin to the recognition of non-judgment by the hospice worker. Understanding that the patient and family are the true experts in their own care is similar to Roger’s understanding of the actualizing tendency. Combining CBT for its utilization in treating symptoms in short-term therapy with person-centered therapy for its use in providing unconditional positive regard is the basis of Cognitive Behavioral Music Therapy (CBxMT) in hospice care. Within CBxMT, the therapist strives to alleviate symptoms in end of life care such as anxiety, depression, and insomnia in the briefest amount of time. The concept of time is of great importance at the end of life, as patients seek to optimize quality of life by alleviating symptoms to enjoy the remaining precious moments they have with their loved ones. Further, the therapist strives to provide empathy, congruence, and respect while treating these symptoms, leaving the patient with a sense of validation for his or her own personal meaningfulness. Within this approach, the relationship between the therapist and patient is significantly important. Often times, patients will come to call members of the hospice team “family” because of the depth of relationship that is built during this intimate time of life. The role of the music is to treat symptoms while simultaneously affording opportunities for deeper human connectedness or communion with the patient’s higher power. What follows is a case study describing how CBxMT meets the

multidimensional needs of a patient diagnosed with a life-limiting illness, highlighting the central elements of this approach. The Client David was a 62-year-old man with a diagnosis of head and neck cancer. At the time of the music therapy assessment, David had been receiving hospice care in his home for less than one month and was receiving additional agency services from the hospice physician, registered nurse, chaplain, and social worker. His physical symptoms included a visible growth on his neck (roughly the size of a golf ball), compromised speaking abilities resulting in a whispered tone, pain, productive cough of both phlegm and blood, and occasional dyspnea (shortness of breath). Throughout his treatment and hospice care, David refused all medications, utilizing instead diet, prayer, and vitamin supplements to combat his symptoms. David had been married for 22 years, had no children, and was an active member of his church. Upon assessment, David reported that his spiritual journey was the most important task of his end-of-life experience, and that he wished to explore it further with the therapist. His wife reported that there had been significant changes in David’s relationships in the year since his diagnosis, and that she had seen a softening in his personality, resulting in fewer disputes in their marriage and friendships. Based on the music therapy assessment, the following treatment goals were developed: 1. Patient will experience increased spiritual support. 2. Patient will evidence increased quality of life. 3. Patient will report lowered pain perception. Additional sessions with the patient resulted in the addition of the following treatment goal: 4. Patient will develop alternative communication skills. The Therapeutic Process Sessions with the patient were held on either a weekly or bi-weekly basis. When the music therapist first met David, the patient was able to speak, although he was frequently interrupted by long bouts of coughing. As rapport was developed, David spent a great deal of time talking about his faith and his church experiences, commonly turning to Biblical scriptures to support his dialogue. His descriptions of his church experience during these early sessions were overwhelmingly positive. He spoke often of the important relationships he had developed at the church, and indicated that these relationships had been positive throughout his lifetime. He described his male friendships in particular as significant relationships and told stories indicating that these friendships had been longstanding and stable throughout the years. As the sessions progressed, however, David began to disclose that his relationships had weathered difficult times, and that he held regrets about what he perceived to be his “overbearing” personality in these relationships, and his relationship with his wife. In separate dialogues with his wife, she confirmed this description of his personality. Through verbal

counseling and musical validation, the music therapist explored the complexities of these relationships with David. At times, he was very forthcoming about his regrets and engaged in frank exploration of the difficult behavior patterns that he had exhibited in his relationships. He spoke of being “dominant,” and rarely giving others’ opinions credence or a full hearing. David cried occasionally during these difficult revelations and almost always embedded his stories with a scriptural reference that spoke to his search for positive and loving closure. At each session, the music therapist provided live music, accompanied either by guitar or keyboard. This music was almost exclusively spiritual in nature and was most frequently Christian choruses that directly utilized the scripture he discussed, or held the meaning of the scripture therein. David reported that this music felt “supportive” to him, and gave him a different way to think about the scriptures he had memorized. On occasion, the music therapist made recordings of David’s favorite scripture choruses after the session for him to use during his private devotional times. As David’s illness progressed over the next several weeks, speaking became more difficult, and he began to write most of his dialogue to me and other visitors in small notebooks. His writings were vivid and detailed, and did not seem to indicate a desire to reduce communications, but rather simply find a different way to communicate. When asked about his stamina to continue to write, David seldom expressed a desire to limit this communication, and instead wrote more voluminously. In addition, his other physical symptoms also increased. He experienced greater and more regular pain levels. Utilizing the iso-principle (Hilliard, 2005a) of matching the dynamics and tempo of David’s preferred music with his perceived pain level the music therapist was able to assist him in decreasing his pain perception. His tumor began to rupture with increasing frequency, resulting in increased pain and blood loss. He reported significant weakness when walking and began limiting his trips outdoors. It was during an increase in these negative symptoms that David expressed suicidal ideation to the music therapist. He wrote of having a gun, of not being afraid to use the gun, and of being tired of his body’s breakdowns. When further pressed, together with his wife and one of his friends, David acknowledged that he didn’t believe he had the “courage” to actually perform the suicide. He agreed to give the gun to his friend for safekeeping, to be returned to his wife after his death if she wished to have it. While David expressed some embarrassment during this intervention, he asked the music therapist to stay after the dialogue with his wife and his friend was complete. He then wrote a note expressing that he hadn’t understood how profoundly discouraged he was, and how troubling his suicidal ideation had been to his wife and friends. He also wrote of his love and appreciation for his wife and friends, acknowledging that they had his best interests at heart. He was very moved by their caring, and by the music therapist’s role in the intervention. At the closing of this session, the music therapist improvised a song expressing David’s feelings of being cared for and deeply loved by his wife and friend. Clinical Songwriting As a result of this catharsis, the music therapist suggested to David that he work with the music therapist to find a way to communicate to his wife and friends the depth of his feelings for them, and for the roles that they have played in his life. Further counseling led David to believe that this process would also allow him to rebuild any broken parts of his

relationships, and to allow him to leave a “legacy” that was more powerful than any negativity he had displayed in his friendships up to that point. He spoke of how unexpected it was to have so many male friends in his life now, when he had never had male friends throughout his life. He reported that this brought him an enormous amount of joy. Together, the music therapist and David created a list of six friends to whom David wished to write songs. In addition to this list, he wished to write a song for his wife and a song for his church family expressing his fervent spiritual experience and hope that others may experience God as he had. For each friend, David discussed two things: 1) how that friend had impacted him, and 2) the most important thing David wanted to tell the friend. Each song had a heavily spiritual overtone, as this was David’s request. His overall intent was to communicate how he wanted his life to be remembered. The themes that emerged during these discussions, subsequently painted in the songs, were: Friend A: 1. You were the first male in my life to say “I love you” to me. 2. Thank you for being the one friend who called me every day of my illness. Friend B: 1. You led me to Jesus. 2. We are about to meet and celebrate in eternity. (Friend had predeceased David.) Friend C: 1. You are a soldier for God. 2. You taught me to be a Christian warrior. Friend D: 1. Your difficult times are in God’s hands. 2. You will never be alone. Friend E: 1. You have taught me a love of nature. 2. Thank you for being my oldest friend. Friend F: 1. Laughing with you has been so important to me. 2. Though we will meet in eternity, I feel like I will miss you terribly. Wife: 1. Our love is a gift from God. 2. His comfort will surround you after I am gone. Church: 1. You have been my family. 2. This is my vision of heaven.

The music therapist and David spoke at length about each individual person. David discussed the difficult parts of his relationship with each, and explored not only what he wanted to “leave” for them, but also what he believed his relationship to be with them now. These were intense dialogues, utilizing a great deal of musical validation for his experiences. This musical validation was provided in the form of hymns and spiritual songs that the music therapist performed live with guitar or keyboard accompaniment. She used songbooks and lyric sheets so that David would be able to follow the lyrics as she sang. They would analyze the lyrics, drawing parallels between the messages of the songs and David’s experiences and emotions. During these emotionally intense discussions, the music therapist also used music as a specific relaxation tool to combat any coughing bouts that he experienced in these sessions. After discussing each relationship, the music therapist asked that David provide characteristics of the person for whom the song was written, and together they translated these characteristics into musical elements that would be part of the songs. For example, one song had an Irish lilt, honoring his friend’s Irish heritage and love for Celtic music. Another song was written as a military march, reflecting his friend’s stoicism and military countenance. The song for David’s wife was written as a love song/ballad. Upon completion of each song, the music therapist recorded the final product onto a digital minidisk recorder and burned it onto a CD. David took the lyrics for each song and put them into a document that he then printed and framed. Two of the six men were invited individually to the patient’s home, where he asked the music therapist to perform his song for his friend, then proceeded to tell the friend the impetus for the song. These were heavy, tearful and powerful sessions. David reported to the music therapist that the experience was exactly what he had hoped it would be. Some three months after they began working together, David died in his home, surrounded by his wife and friends. His wife reported that he experienced some shortness of breath as he began to weaken, but that he appeared comfortable until the end. She also spoke of his use of the recordings that had been made during his music therapy sessions, both the individual songs as well as the relaxation music that had been recorded for him, to combat any restlessness or pain during his last two days. Legacy After David’s death, his wife asked the music therapist to sing at David’s funeral. The music therapist provided the hymn that David had requested most frequently during his music therapy sessions, and then the song that he had written for his church, which described what he believed heaven was going to be like. At the reception after the service, his wife had placed all eight of David’s framed songs on a table for his friends to share, and made copies of the CDs to give to each one, including the wife of the friend who had predeceased David. Conclusion Within the CBxMT theoretical framework, the music therapist provided an atmosphere of unconditional positive regard. Through this, the patient was able to express aspects of his

personality that led to relationship issues he wanted to review as he approached the end of his life. The therapist’s approach of congruence, empathy and respect fostered a relationship that afforded the patient an opportunity to review his life in a way that encouraged him to deepen relationships with those whom he loved. This positive regard for David allowed him to be vulnerable with the music therapist and admit his own “domineering” personality, share his spiritual beliefs, and even disclose at one point that he was experiencing suicidal ideation. Through Cognitive Behavioral Music Therapy techniques, the therapist was able to meet a variety of short-term therapeutic goals (such as pain and symptom management) with a variety of music therapy interventions. Table 1 provides a summary of these goals, along with the corresponding intervention.

Quality of life is an all-encompassing concept in end of life care that includes social, emotional, physical, and spiritual needs. Music therapy is highly beneficial in holistically treating the patient and his or her family, and is therefore a natural choice as a treatment option for enhancing quality of life throughout the dying process. Utilizing CBxMT techniques, the music therapist can address behaviors, physical symptoms, thoughts, emotions and relationships within a relatively brief therapeutic time. Because hospice care, by nature of its end of life treatment, is often brief in nature, CBxMT can be regarded as a viable treatment for those facing multifaceted needs at the end of life. References Connor, S.R. (2009). Hospice and Palliative Care: The Essential Guide. New York: Routledge. Connor, S.R., Pyenson, B., Fitch, K., Spence, C. & Iwasaki, K. (2007). Comparing hospice and nonhospice patient survival among patients who die within a three year window. Journal of Pain and Symptom Management, 33(3), 238–46. Feist, J. (1990). Theories of Personality (Second Edition). Fort Worth: Holt, Rinehart and Winston, Inc. Fine, P.G. (2008). The Hospice Companion. Oxford: Oxford University Press. Gosselin, P., Ladouceur, R., Morin, C. M., Dugas, M. J. & Gaillargeon, L. (2006). Benzodiazepine discontinuation among adults with GAD: A randomized clinical trial of cognitivebehavioral therapy. Journal of Consulting Clinical Psychology, 74(5), 908–919. Gould, R. A., Ottow, M. W., Pollack, M. H. & Yap, L. (1997). Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: A preliminary meta-analysis. Behavior Therapy, 28(2), 285–305. Hilliard, R. E. (2003). The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer. Journal of Music Therapy, 40(2), 113–137. Hilliard, R. E. (2005a). Hospice and Palliative Care Music Therapy: A Guide to Program Development and Clinical Care. Cherry Hill, NJ: Jeffrey Books. Hilliard, R. E. (2005b). Music therapy in hospice and palliative care: A review of the empirical data. Evidence-Based Complementary and Alternative Medicine, 2(2), 173–178. Keller, M.B., McCullough, J.P. & Klein, D.N. (2000). A comparison of nefazodone, the cognitivebehavioral analysis system of psychotherapy, and their combination in the treatment of chronic depression. New England Journal of Medicine, 342(20), 1462– 1470. Kendall, P.C. (2005). Child and Adolescent Therapy: Cognitive Behavioral Procedures (3rd edition). New York: Guilford Press. Rachman, S. (1997). The evolution of cognitive behavior therapy. In D. Clark, C. Fairburn and M. Gelder (Eds.) Science and Practice of Cognitive Behavior Therapy. Oxford: Oxford University Press. Ripamonti, C. (2005). Prognostic factors in advance cancer patients: evidence-based clinical recommendations. Journal of Clinical Oncology, 23, 6240–6248. Rogers, C. (1961). On Becoming a Person: A Therapist’s View of Psycho-therapy. London: Constable. Simos, G. (Ed.) (2002). Cognitive Behaviour Therapy. Hove: Brunner-Routledge.

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE THREE Music Therapy at the End of a Life Jenny A. Martin Abstract This case describes music therapy with a woman dying of cancer and her family. Phases in the therapy process are described, and the techniques of “Song Choice” and “Life Review” are illustrated. Personal thoughts and feelings of the therapist are presented. Introduction Dying is never easy, neither for the dying person nor their family. While it can be a very frightening experience, one which involves facing many painful changes, it can also be a time of warm, intimate sharing. Music therapy can play an integral role in this time of transition. Music, because of its capacity to give voice to the ineffable, its capacity to express beauty and pain simultaneously, and its ability to transport us to another time and place, provides the music therapist with a particularly well-suited tool with which to help dying patients and their families cope with the difficult challenges they face. This case describes music therapy with a woman dying of cancer and her family. I will illustrate how various music therapy techniques are used, and I will share what it is like to do this kind of work from the therapist’s perspective. Although music therapy with the terminally ill can be very brief, people approaching death can be open to others in a way that is most unusual It can be a singularly touching experience to enter so intimately into someone’s life at the very end, and especially when joined by a lifelong friend—music. Background Information Medical History Sarah was admitted to Calvary Hospital with a diagnosis of breast cancer with metastases to the lungs, other breast, lymph nodes, and skin. Calvary is a 200 bed hospital which provides palliative care to those with advanced cancer. Sarah had been diagnosed with breast cancer approximately two years previously. At the time of diagnosis, she had received radiation therapy, and four months later, she had a mastectomy which was followed by additional radiation therapy. She responded fairly well until a year later when she had a recurrence. Chemotherapy was attempted, but the tumors continued to grow, and Sarah started experiencing shortness of breath.

When she was admitted to Calvary she had a massive infiltrating right chest lesion, and edema of the right arm. She was experiencing intermittent pain, and had a fever secondary to infection in the chest lesion. She was increasingly lethargic and essentially bed-bound. The admitting physician also noted that Sarah was experiencing anxiety. He also documented that she did not want to be resuscitated, that a Do Not Resuscitate (DNR) order had been in effect at the previous hospital. Sarah was receiving a variety of medications, including Morphine Sulphate (MS) for pain, antibiotics, Xanax for anxiety, and oxygen to help with the shortness of breath. Psychosocial History At the time of admission Sarah, a Caucasian woman of the Protestant faith, was in her early fifties. She had three children, two sons and a daughter, all in their twenties. Her youngest son, who was living at home, had a problem with substance abuse, and her daughter was described as having “multiple problems.” Sarah’s husband had died suddenly two years earlier. Within the last two years her brother had also died, thus she had experienced much grief in the recent past. Her sister, Jane, in her early forties, was her primary means of support. Sarah’s and Jane’s relationship had gone through many significant changes. As they were growing up their mother (who was an addict) was unavailable to them, thus Sarah, being ten years older than Jane, took on the role of mother in many ways. In adulthood, Jane had become an alcoholic and Sarah had stepped in to help care for Jane’s family. There had been a period of estrangement between the sisters, attributed to Jane’s alcoholism. When Jane joined Alcoholics Anonymous and became sober, around the time of Sarah’s diagnosis, the rift was bridged. The social work admission note stated that Sarah was aware of both her diagnosis and her prognosis. The social worker also noted that Sarah was coping by using many facades to keep going, and that she expressed concern about not wanting to be a burden on her family. Sarah acknowledged having come to depend on her sister, Jane. Treatment Process Preparation Sarah was referred for music therapy one week after she had been admitted to the hospital. She was referred by the social worker, the reason being that the “patient could benefit from additional support.” The social worker also mentioned that Sarah was interested in making a tape for her children, and wondered if I could provide her with the necessary equipment. Before going to see the patient I reviewed her medical chart in order to gain an understanding of her basic history. While all the patients at Calvary have advanced cancer, they vary greatly in terms of age, ethnicity and religious background, how recently they have been diagnosed as well as the course of the disease and treatment. All of these factors will influence a person’s pattern of coping.

In addition to the above medical and psychosocial history, I looked for information regarding how the patient was adjusting to the hospital and any changes in her medical and/or psychosocial status since admission. The nurse’s notes described her as “friendly and cooperative,” and noted that she appeared “to be adjusting well.” Three days after admission she had refused her Xanax and the routine Xanax had been discontinued as the physician noted her anxiety had lessened. She was receiving the oxygen continuously and had periodically been complaining of pain. Introducing Music Therapy When I first meet a patient I usually begin by explaining what, as a music therapist, I do at Calvary. This allows the patient to make an informed decision whether it is something they would want. When I entered Sarah’s room (all of the rooms as Calvary are private rooms), I saw a rather large woman, lying in bed, the head of the bed raised, breathing with the help of an oxygen mask. I introduced myself and told her why I had come to see her, stating that the social worker had mentioned to me that she would like to have access to a tape recorder. Sarah answered that yes, she would. There were things that she would like to say to her children, and she was now too weak to write. I sensed that even speaking to me now was somewhat of a strain. Sarah, while not exactly reserved, also struck me as someone who would need some time to get comfortable enough with someone to open up to them. I therefore decided that this first meeting would be relatively brief, focusing on the concrete task of operating the tape recorder. I showed her how it worked, and left it within reach of the bed so she would be able to use it if she felt strong enough. Two days later I visited Sarah to see how she was doing and how things had gone with the tape recorder. She said that she had not yet tried to use it. She just had not felt up to it. I had the foreboding feeling that this was a task that, though important to her, might be left undone. Wanting to have something to base our interactions on other than the tape recorder which she might never have the strength to use, and feeling that Sarah could certainly benefit from music I introduced some other aspects of music therapy. I explained that much of what I did was to play guitar and sing for the patients, adding that some patients like to sing along, some want only to listen, others fall asleep while I play, and that others simply are not interested in music. In my brief description of music therapy, I strive to get the idea across that our use of music is quite flexible, and that the music is available to patients to use in whatever way suits their needs at any particular time. Most people have no experience with or understanding of music therapy; they have not chosen to come to music therapy. It is important to help them understand how it is different from entertainment, which is most people’s experience of music, and to take away the pressure for them to respond in a certain way. Sarah liked the idea of my playing for her, but did not want any music at that time. During the next week I stopped by to see Sarah several times, but she was sleeping each time. I chose not to wake her. Ten days after having left the tape player with Sarah, we had our first session. During this time she had gotten somewhat weaker, her arm was more swollen and in general she was experiencing more pain. Her sister, Jane, and a friend, Emily, were also

present. There was a warm feeling in the room, I got the sense that these three women cared about and understood each other deeply. Song Choice: The First Encounter The music therapy technique I used during this session was “Song Choice,” allowing the patient and her two visitors the opportunity to choose songs, which I then played. Song Choice on the surface can appear simple, yet when it is sensitively used, it can be a very rich therapeutic technique (Bailey, 1984). It is often difficult for terminally ill patients and their families to recognize and express their feelings directly through words, yet they often choose songs in which the lyrics clearly express what they are experiencing. Whether this process is conscious or unconscious, it provides an excellent means of self-expression, which is important at this time. Often patients and families can be encouraged to discuss the themes and feelings presented in the song material. Song Choice also provides an excellent means for patients and families to appropriately exercise control. This is important because terminally ill people have lost control over so many aspects of their lives. They can decide if they want to hear happy, sad, nostalgic, silly or sacred music. The feeling of being in control may also help them to have the courage to broach difficult topics. Song Choice is also a powerful assessment tool. As therapist, I am keenly aware of the kinds of songs which are chosen, as well as those which appear to be avoided. I also am sensitive to patient’s reactions, both verbal and nonverbal, to the songs, both the music and the lyrics. During this session Sarah asked to hear two songs, “Amazing Grace” and “Morning Has Broken,” both religious songs. It was interesting because Sarah had not discussed religion very much up to this point, and there had been no mention of religion in the Social Worker’s notes or conversation. Sometimes chart notes comment that patients’ religious beliefs are a source of strength and/or comfort for patients. Jane asked for the last song, requesting “When Irish Eyes Are Smiling.” My sense was that she wanted to finish on a lighter note. The next session, again with the three women, took place one week later. Before going into Sarah’s room, I reviewed her chart for information regarding changes in her condition and relevant psychosocial information. The nurse’s notes documented that Sarah was complaining of increased pain, and that the lesion was worse. The Social Worker reported that Sarah was slowly opening up to her, and that Sarah spoke of how it is difficult for her to be in such a dependent, helpless situation, and that she feels that she has no control over anything. I continued using music therapy in a similar fashion as in the first session, allowing Sarah, Jane and Emily to choose songs that they would like to hear, and discuss the feelings and memories evoked by these songs. I would periodically ask questions to help expand and clarify what they were feeling or expressing. Towards the end of the session Jane asked to hear the song “Puff the Magic Dragon” (Lipton & Yarrow, 1965). This is an interesting song in that while it is a children’s song filled with fantasy it also very vividly deals with the issue and feelings of loss. Puff is devastated by the loss of Jackie Paper:

PUFF THE MAGIC DRAGON – EXCERPT His Head was bent in sorrow Green scales fell like rain Puff no longer went to play Along the Cherry Lane Without his lifelong friend Puff could not be brave So Puff that mighty dragon Sadly slipped into his cave. As I played this song, which starts off so cheerfully and then turns quite sad, I could feel the atmosphere in the room change as the song progressed. Jane, standing at the foot of Sarah’s bed, was singing along with the song. Towards the end both she and Sarah were crying, as was Emily. After a period of gentle silence, I commented that that was quite a song. Jane started speaking of what the song meant to her, and why she thought that she may have chosen it. She acknowledged that when she first asked for it she had not remembered the ending. At the same time, she felt on some level that she must have known, and that she really had chosen it because it expresses how she will feel when Sarah is gone. She went on to say that one of the reasons the song is so meaningful is because it clearly depicts the different stages of Puff’s and Jackie’s relationship, and clearly demonstrates that it was because of the love and good times that Puff had shared with Jackie that he was so sad when Jackie was gone. She again related this to her and Sarah, acknowledging that it was because of the love that they shared that it was so hard for her to lose Sarah. I left this session having a great deal of respect for both Sarah and Jane, as well as the music therapy process. I admired the way Jane was able to both identify and share her feelings about Sarah’s impending death. I was also once more appreciative of the power of music to evoke and express difficult feelings. Music Therapy Assessment The procedure at Calvary is to write a music therapy assessment following the second music therapy session. In the assessment I examine the patient’s amenability to music therapy, as well as possibilities for various levels and kinds of participation. I describe the ways the patient has used the music thus far. I identify some of the needs of the patient that can be addressed in music therapy, as well as possible methods and techniques that could be used to meet these needs. I also write about any involvement in the sessions by family members. Following is the assessment I wrote for Sarah: Sarah is a XX year old woman with Cancer of the Breast with metastases to the lung. She experiences shortness of breath and her arm is quite swollen, thus she would not be a good candidate for music-making during sessions. She is very amenable to and appreciative of music. I have seen Sarah two times in music therapy along with her sister Jane and a friend. She participated through song choice, follow up discussion, and

singing along some, to the extent that she was able given her shortness of breath. Sarah, her sister, and their friend, openly express enjoyment of the music and use it as a springboard for discussion of a variety of topics, including memories and feelings regarding Sarah’s illness and expected demise. Sarah is very open and articulate, and her sister is very supportive and communicative. Song Choice is a good means of selfexpression for Sarah, sister, and friend; they consciously choose songs depending on what they need, choosing religious, happy and sad songs on different occasions. This also provides a sense of control. Sarah will mention her difficulties, but thus far has not wanted to discuss them in any detail. The treatment plan will be to see Sarah one to three times per week in music therapy until further modification. Interventions will focus on: (1) Facilitating self-expression via song choice and follow up discussion; (2) Diminishing anxiety through use of soothing, familiar music; (3) Facilitating communication with sister through use of song material; (4) Providing opportunities to appropriately exercise control via song choice; (5) Providing support to Sarah and sister through involvement in music therapy. The overall goal is to help Sarah and her sister adjust to Sarah’s deteriorating condition. Intimate Sharing The next music therapy session took place five days later. This time I saw Sarah alone. I had decided that while continuing to have joint sessions with Sarah and Jane I also wanted to see Sarah privately a few times. This was because I had noticed that Sarah appeared reticent to discuss any of her difficulties, and felt that it might be easier for her to be more frank and open if Jane was not present. It is often easier for patients to delve into painful or frightening material when family members are not there. As Sarah appeared to have a need to keep up a facade for her family, I wanted to provide her with the opportunity to discuss some of her feelings and concerns when we were alone, when she did not have to protect her family. Sarah’s medical chart documented that she was experiencing increased shortness of breath, was using the oxygen continuously, and had increased pain accompanied by pressure on her chest. Her morphine dosage had been increased. There was greater edema in her arm and she had complained of feeling nauseous. There was give-and-take during this session: Sarah picked the first song and then insisted that I pick the next, and we rotated back and forth like this during the session. Although I generally encourage patients who are alert to choose all the songs, they often want me to choose some of my favorites also. Sometimes they feel that it is selfish for them to choose all the songs. With Sarah, I felt that a more likely interpretation of this was that, given the in-depth discussion of the significance behind the choice of songs which had taken place in previous sessions, Sarah felt that she was sharing a lot of herself through her song choices, and wanted the exposure to be a little more equal. The desire to know something about the therapist is not unusual, and I find that, in general with this population it is therapeutically beneficial for the therapist to disclose more about him/herself than is the norm in therapy. Before starting the music I asked Sarah how she was doing. She told me how she had been feeling nauseous lately, and that the shortness of breath was getting worse. She was somewhat anxious and concerned about this, both because it is extremely unnerving not to be

able to get one’s breath, and because she interpreted these symptoms as a sign that the disease was progressing. After talking about these concerns I asked her if she would like to hear some music. The first song that Sarah asked to hear was “His Eye is on the Sparrow.” This song is an encouraging spiritual, the chorus being: “His eye is on the sparrow and I know He watches me.” While being hopeful, this song also discourages feelings of hopelessness or frustration because of the promise that God is watching. For Sarah it seemed like an interesting song choice in that it signified her need for hope in the face of her worsening symptoms, as well as the message that, on some level, maybe she should not be feeling what she was feeling. She seemed to have trouble taking care of herself and accepting that her feelings and needs were o.k. Sarah asked me to pick the next song. I decided to support her need for hope, and chose a song called “Song of Hope.” This song speaks of how we can be overwhelmed by hardship and asks for help to come to a more positive place. I changed the words somewhat so as to be more appropriate to palliative care. The first verse, as I sing it at Calvary is: SONG OF HOPE - EXCERPT When the darkness overwhelms us To dim our sight and mind When all roads lead to confusion And hope’s impossible to find Free our minds for dreaming Of a time when pain shall ever cease Free our eyes for vision That leads us to the ways of peace. The next song that Sarah asked for was “Raisins and Almonds,” a Jewish lullaby describing a child being tucked into bed and sung to by his mother. When Sarah asked me to pick another song, I stayed with the theme of childhood and comfort, and sang a song called “Dolphins and Mermaids.” This song presents nice images of dolphins and mermaids swimming in the sea, and also points out that our bodies and the various limitations are not as important as what we have inside us, our minds, and our hearts. I have found that imagery is often useful in relieving anxiety and thus diminishing the perception of pain. The last song that Sarah asked to hear in this session was “Erie Canal.” In this case, I did not have a clear understanding of the significance of this song for Sarah other than knowing that for many people the timelessness of folk songs seems to provide some sense of comfort. When we were ending, I asked Sarah what the music sessions were like from her perspective. She spoke of how she had always enjoyed music, often felt very peaceful when listening to music. She said that she had never expected to find that enjoyment and source of peace here in the hospital. Recalling the sessions we had had with Jane and Emily, Sarah found that she was listening to the words of songs more now than ever, and that sharing the music with her sister and friend was very touching. She commented that she had never expected to depend on her sister as she was now, and that the music sessions somehow “took the edge off of that. She described the music as “a real source of enjoyment.” She also spoke of the comfort

provided by the music and how the lullaby “Raisins and Almonds” made her think that some people might never have known what it was like to be tucked in. The next session took place one week later. Sarah’s general condition was about the same: she continued to be weak, with shortness of breath and her arm quite swollen. This session, like the previous one, was with Sarah alone. Again we went back and forth, Sarah picking one song and me choosing the next. Sarah asked to hear “Let There Be Peace on Earth,” and “I’ve Just Seen a Face.” I chose “I Believe” and “Perhaps Love.” Sarah spoke somewhat more openly of the feelings and memories evoked by the music, as well as the changes she was going through in her relationships to others, these changes being precipitated by her worsening condition. Sarah spoke of life when she and Jane were growing up. Since she had been like a mother to Jane in many ways, it was a struggle now to be so dependent on her. Speaking of her children, Sarah expressed concern about them, especially the younger two. At the same time, she was able to acknowledge that she had honestly done all that she could, and that it was time to trust and let go. Sarah also spoke of how tiring visitors were. With gentle probing, she admitted that she felt the need to “keep up a front” with her family and friends. She did not want to bring them down with her. We discussed what a strain this was on her, and whether this was really how she wanted to spend what little energy she had. I asked her if Jane was aware of how she felt about this, and she acknowledged yes. While Sarah seemed to be able to see the other perspective, at the same time I got the impression that she felt the need to take care of others, and that this was one way she felt she could still do this. She had spent her whole life taking care of others, thus much of her self-concept was tied up in this role, and she needed a way to reinforce it. This was a source of frustration for Jane, yet it seemed important to Sarah. Over the next two weeks, Sarah had music therapy three times, once alone and two times with Jane and Emily, as well as some other visitors. Her condition continued to deteriorate. As the shortness of breath became more acute, Sarah became more anxious. The Xanax was started again but then discontinued because Sarah said that it caused “bad dreams.” She complained of greater pain, and her pain medication was increased. She was started on intravenous fluids because her oral intake was no longer adequate. As Sarah’s condition deteriorated her spirits also seemed to deteriorate. She admitted to feeling “down” and then “depressed” but did not want to talk about it. Earlier Sarah had told me that she had prepared herself emotionally for death, but she had not realized how difficult dying would be physically. She had not anticipated such pain and discomfort. It all seemed to be taking its toll on Sarah. The music therapy sessions continued along the same general course. Jane and Emily started choosing more of the songs as Sarah became weaker. She would often close her eyes and listen during the music and she stopped singing along. Their pastor was often visiting and he also participated in the sessions. I played “Dolphins and Mermaids” which became a favorite of Jane’s, and she asked for a copy of the words, which I gave her. Dealing with Pain

Sarah’s condition continued to deteriorate, and slightly less than two months after she had been admitted she was placed on the critical list. The physician’s note stated that the patient “is markedly short of breath, receiving morphine and oxygen continuously.” Her pain medication had again been increased. Early that afternoon I went to see her; Jane had not yet arrived. Sarah was alert and responsive, though experiencing severe pain. I went out and told the nurse that Sarah was asking for pain medication. The doctor went in to see her. She had only recently received an injection of morphine, but clearly she was still suffering and the doctor gave her another. I acknowledged Sarah’s pain to her and explained that sometimes music could help, was she willing to give it a try? She said yes and I sat down to play, instructing Sarah to try and listen to the music. I chose not to improvise at that time, I wanted to provide greater structure and familiarity. Instead I played many of the songs which we had played over the past two months, gradually moving to more quiet, soothing music as the session progressed. I also gradually lengthened the phrases of the music after having coordinated the rhythm of the music with Sarah’s breathing. Sarah, though still uncomfortable, appeared somewhat more relaxed at the end of the session. This was an extremely difficult session for me. For some reason Sarah’s pain and anxiety affected me deeply. Perhaps it was because I felt so helpless. It is difficult to witness someone in such acute distress, and as a professional, I felt that I was supposed to be able to help. While music could and did help, I wanted it to do more, to take away Sarah’s pain and breathing difficulties. I began feeling uncomfortable and anxious myself. I also knew that for the music to be most beneficial it had to be steady and grounded yet flexible, which was certainly not how I was feeling. I wanted to provide a calm presence. Being able to play the music helped. At first I focused on the music until I felt a little stronger, and then I was gradually able to focus more on Sarah and meet her in the music without losing my sense of groundedness. I spoke with Jane later in the afternoon. She was concerned and anxious, but appeared to be coping well. She had worked hard at preparing herself for Sarah’s death, and I agreed with the social worker that Jane seemed to have made peace with Sarah and was accepting of her impending death. Life Review The following day Sarah, though responsive, was sleeping for long intervals, and was described by one nurse as “slightly confused.” She had also started to drift off during conversation. I went to her room, and found Jane, Emily, and their pastor there. When asked, Jane and Emily both wanted me to stay and play some music. When working with someone who is dying, an important goal is to help someone to bring their life to a close. One way to do this is to encourage the patient to engage in the life review process, to look back over their life. Music because of its uncanny ability to evoke memories, can play a key role in this process. In this session, the music was used to stimulate a “life review” of the music therapy life which Sarah, Jane, Emily, and I had shared. They chose many songs which we had done in the past and shared memories of previous sessions, including the joy and the sorrow which the music had

evoked. I had not planned this, yet once started I encouraged it as I recognized it as a meaningful and fruitful way to spend what we expected to be our last session together. That night Sarah’s family stayed at the hospital, staying at her bedside. Sarah was lethargic but responsive, moaning at times. The next morning the physician’s note read: “Anxiety and pain. Wants to die.” I spoke with Jane, listening, and offering support. She also seemed ready for Sarah to die. I would not be at work for the next two days thus when we said good-bye we knew it might be for the last time. Sarah’s condition continued to deteriorate over the next two days. She was poorly responsive, but she hung on. Her family stayed at her bedside. Upon return to work I went to Sarah’s room. Her youngest son, her daughter, her daughter’s boyfriend, and Jane were all in the room. They all looked a little ragged; it had been a long vigil. As a patient’s condition deteriorates, the focus for psychosocial care often shifts from the patient to the family. I will often play music for a family that I have worked with when the death of the patient is imminent. While I had worked very closely with Jane, I had never met Sarah’s children before. I did not want to intrude, yet I also felt that they all might benefit from a directive, supportive activity. This can be a very hard time for family members. They both want to and feel that they “should” be at the bedside of the dying person, yet often they feel that there is nothing that they can do. I offered to play some music, and Sarah’s family all appeared quite relieved at the idea. Jane asked to hear “Dolphins and Mermaids” and stood at the foot of the bed as I played. After that song she left Sarah’s room. I wondered about her relationship with Sarah’s children, sensing that it might be somewhat strained. Sarah’s son, daughter, and daughter’s boyfriend chose the remainder of the songs. Most of them were spiritual or religious in nature and included: “Amazing Grace;” “Let There Be Peace on Earth;” “Rock of Ages;” and “Old Rugged Cross.” The three of them seemed very young and somewhat lost, not knowing which songs to ask for, trying to do the “appropriate” thing. I wondered how they would do after Sarah had died. Many of the songs they asked for evoked memories from their childhood. I had the image of the rug being pulled out from underneath them, and that they were clutching at things to hold them up. I noticed and felt glad that the music provided a needed structure, along with some emotional and cognitive connections to their past. Still I left the room feeling sad for the family. Sarah died at 2:00 that afternoon, surrounded by her family. The next morning Jane called me and asked if I would be willing to sing at Sarah’s funeral. It can be a strange experience to be so intimately involved with a family and then, not being present at the moment of death, you return to the floor and the patient and the family are gone. I welcomed the opportunity for closure and also to provide some continuity for Jane’s sake. The Calvary staff had been very involved with her over the two months that Sarah had been a patient, and I was glad that we would be represented at the funeral. Jane chose three songs for me to sing at the funeral. During the service the pastor introduced me and spoke of the meaningful role music therapy had played at the end of Sarah’s life. The first song I sang was “Let There Be Peace on Earth,” chosen because it exemplified Sarah’s spirit. Second was “Dolphins and Mermaids” which held such meaning for Jane. Last was “Amazing Grace” which speaks so deeply to so many. It was very moving, both painful and beautiful, to sing these songs at Sarah’s funeral. It was a profound and meaningful experience for me to be there. .

Discussion and Conclusions I have come to believe that music therapy can help the terminally ill in two ways. First, it can be used to accomplish what we traditionally regard as “therapeutic” or “clinical” goals, (e.g., reduction of anxiety, strengthening of self-concept, and much of what was discussed in the assessment). Second, music can be a source of deep, meaningful interaction—between patients and families, patients and patients, and patients and me. Music therapy provided Sarah and Jane the opportunity to express themselves through the use of songs. At times the songs, such as “Puff the Magic Dragon,” brought to awareness feelings and reactions which hitherto had been unconscious. Sarah and Jane both used the music as a springboard to discuss a variety of topics, including some that were quite difficult and painful. Other times the significance of the song choice remained unclear, and the value remained primarily in the expression. How was this expression helpful? I will first look at the benefits from the sessions when I was working with Sarah alone. For Sarah it was difficult for her to state her needs, ask for help, and accept help from others. However she could do this, indirectly, through the song material. By choosing a song she could express either what she was feeling or needing. By my choosing to play songs which reflected what Sarah had expressed I could meet the need and let her know that I understood. For Sarah and Jane together one result of this self-expression was enhanced communication and understanding between the two sisters, which, I believe, helped them to adjust to the changing roles in their relationship. The necessity for Sarah to move from the one who took care of others to the one who needed to be taken care of was a difficult change. One of the music therapy goals was to facilitate this adjustment, and I believe music therapy did play a beneficial role here. The music also helped enhance the feeling of closeness between Sarah and Jane. They shared many memories evoked by the music, experiences of childhood and their lives together. They also shared other thoughts and feelings they had experienced as they listened to the various songs. The music also proved to be a real source of enjoyment for both Sarah and Jane. A terminal illness is difficult for both patients and families because it usually involves one difficult situation after another. An enjoyable experience provides a period of respite and can serve to “recharge the batteries” thus enabling the person to better deal with the next stressful situation. Sarah herself said the music helped to “take the edge off.” As a pleasurable experience, it also provided the opportunity for Sarah and Jane to enjoy some of their remaining time together, which is not always easy in a hospital. This was important, as it could help Sarah to feel that it was not always a drain or imposition on Jane to come see her. These fun times also provided Jane with some wonderful, meaningful memories. Just as an enjoyable experience can be a source of added strength for coping, so can a religious experience. It is common for people with a terminal illness to turn to their religions as a means of comfort and strength. Some people are more open and direct about expressing their spirituality than others. As Sarah did not address this topic directly, and I chose not to ask, I cannot know for certain whether the spiritual music provided comfort and strength. My sense was that Sarah’s desire to hear religious music was indicative of her desire for spiritual support.

I learned from Jane that Sarah had sung in her church choir, thus Sarah had a meaningful relationship to religious music. Another goal I had with Sarah was to diminish her anxiety. Familiar music is helpful in doing this. A hospital room can be transformed from an unfamiliar environment to a familiar one through the use of music that the patient knows. In this general way, I believe the music therapy was effective in diminishing Sarah’s anxiety, even if it did not take it away entirely. There were times when Sarah was anxious and in pain in spite of my intervention. While this does not mean that music therapy was a failure, this is a time when I wish it could have been more effective. Jane clearly reached a good level of acceptance regarding Sarah’s death, through hard work on her part with the help of music therapy, social work, and other disciplines. Music therapy helped in this in the ways described above. In addition, the music played throughout Sarah’s hospitalization at Calvary, as well as my playing at the funeral, provided a real sense of continuity through Sarah’s physical deterioration and death. A death can be extremely disorienting, and some sort of continuity is crucial. I was reassured that “meaningful interaction” had taken place when I received from Jane made it clear that it had occurred. Jane wrote: “Words do not suffice in my telling what an integral, important part you played in Sarah’s life and her death. Because of the wonderful memories we were able to build my loss is lessened. Your participation in the funeral helped me to close the circle on a wonderful part of loving Sarah, and I will ever be grateful.” That is clear enough for me. Glossary Edema: Abnormal retention of fluid, swelling. Lesion: An open wound. Metastases: The spread of the disease from its primary site to other parts of the body. Palliative Care: Care which serves to alleviate the symptoms of a disease but does not strive for a cure. People usually receive palliative care when a cure is thought no longer possible. References Bailey. L.M. (1984). The use of songs in music therapy with cancer patients and their families. Music Therapy, 4, 5-17. Lipton, L., & Yarrow, P. (1963). Puff the Magic Dragon. Los Angeles: Pepamar Music, Warner Brothers.

Taken from: Sekeles, C. (2007). Music Therapy: Death and Grief. Gilsum NH: Barcelona Publishers.

CASE FOUR The Courage to Die—Nathaniel, a Terminal Cancer Patient: A Case Analysis Chava Sekeles “We are not condemned to meet death with empty hands. To begin with, we have to find a meaning in our life.” (Sogyal Rinpoche, 1993, The Tibetan Book of Living and Dying) Dedicated to Dr. Jaacov Avni and Dr. Alma Avni1 Introduction “After receiving my diagnosis, I was shocked. I could not react. I could not discuss it with my wife and children. I had nightmares and daytime horror-fantasies in which I could see the cancer cells moving from my lungs, creating settlements everywhere, becoming larger and larger. Then, suddenly, a huge vacuum cleaner entered my blood vessels and sucked up all the malignant cells as well as all my internal organs, till I was left empty, clean, and dead.” Nathaniel told of this dream (or perhaps fantasy) when he was first introduced to music therapy by his oncologist. She had given consideration to the fact that he had loved music since childhood, played the French horn in his free time, and participated in an amateur orchestra. Nathaniel had finished high school (specializing in natural science), the army (prestigious unit), and university (majoring in natural science). He was married, with four children; had a job in science; and, in addition, showed impressive personal development. Then, at the age of 45, he began to cough heavily and had some shortness of breath and bronchitis. He was sent for medical examinations and was found to suffer from lung cancer. Nathaniel was an emotionally and physically healthy person. He had smoked heavily from age 17, but like many others had not considered the possible consequences. He had fairly good knowledge of medical issues and seemed to be emotionally capable of confronting the bad news. In reality, he was shocked to hear the news from the oncologist and had responded by isolating himself in his room for a few days. After a while, he was able to collect himself and collaborate with the specialist and with his family. Meanwhile, his wife had difficulties digesting the bitter pill and explaining it to the children (ages 10, 14, 16, and 20). The medical team at the hospital clinic (physician, nurses, social worker, and psychologist) was of great help, and the family, supported by Nathaniel himself, found the courage and the means to deal and cope with the situation. It is important to mention that compared to doctors who commonly used standard distancing techniques and tactics to cope with the emotional burden of treating the

terminally ill (Maguire, 1985), Nathaniel was fortunate to have an empathic oncologist who knew how to talk to him in a straightforward manner. She informed him of his illness, though in those years doctors preferred to conceal the truth from their patients (Buckman, 1996). Nathaniel was referred to music therapy following a few months of chemotherapy, after his condition had deteriorated and it was clear that a metastatic process was already active. In accordance with the family’s request, he was sent home to spend his last weeks/months in a supporting, loving environment.2 Backer, Hannon, and Gregg (1994) discuss the desire of many patients to return home and die there. They mention the difficulties in executing this wish, such as the family’s exhaustion of physical and emotional energy, financial problems, and more (pp. 60-62). In addition, due to the intimate and intensive situation at home, a severe illness--in this case, terminal--might arouse all sorts of unfinished business and conflicts. To treat a person in an optimal way requires a lot of patience, calmness, a systematic approach, courage, and, above all, love. Nathaniel’s family decided to do their best. They had the support of the medical fund, they had each other, and they had friends who were able and willing to help. As abovementioned, music therapy commenced by the oncologist’s recommendation and was administered at the patient’s home on a private basis, with some financial support from the medical fund. Due to Nathaniel’s condition, it was obvious that the approach should focus on receptive music therapy in which most of the work is done through the patient listening to music and not by creating the music as is done in active music therapy. In receptive therapy, the listening material is played according to the patient’s choice and request. For example: • • • • • •

Pre-composed music played by a tape recorder (cassette, CD, records). Pre-composed music performed by the therapist. Music improvised by the therapist. Music and fantasizing. Music and reading poetry or reacting with movement or painting. Music accompanying the last moments of life.

The music therapy sessions continued for four months, mostly twice a week in the patient’s home, up until his death. Additional music was performed at the graveyard during the ceremony of the 30th day;3 this was done in accordance with Nathaniel’s request. As aforementioned in the first chapter, during the past years, many families have chosen to sing or play music at the burial ceremony and on the forthcoming traditional days. Nathaniel planned it in advance, and I had to promise him to honor his request. The Meaning of Music in Nathaniel’s Life First Meeting In the first meeting, I already knew several details: the medical condition, the treatment and Nathaniel’s perspective; his musical background; his life history; the family constellation;

the physical space in which we would spend the music therapy sessions; and some theoretical and practical ideas concerning music therapy with terminal cancer patients. When I first entered Nathaniel’s house, I saw him sitting on an armchair in a spacious area, flowers on the table, a black upright German piano in the corner, shelves with books and cassettes, a good-quality tape recorder, and a window facing a small, lovely garden. Nathaniel was a tall man, very thin at that stage, pale, breathing somewhat heavily, not very talkative, but the expression in his black eyes was welcoming. The suggestion of music therapy had come from his physician, but he had willingly agreed to try it. I presented myself shortly and told him that the path we would take would be in accordance with his wishes and needs. “Good,” Nathaniel had responded. He showed me his recorded music collection, and it was clear that he liked instrumental and vocal compositions from the Renaissance to the Romantic era. I wondered if he disliked music of the 20th century. However, this was not the immediate issue at hand. He told me of his instrument playing, admitting that he had had to quit because of his breathing problems.4 Though Nathaniel could still speak at that stage, use his hands, walk, eat alone, etc., he quickly tired and clearly stated that he would prefer to listen to music rather than do something active. He asked me if I would play the piano for him, and I agreed. During this initial meeting, his illness was mentioned through the nightmare he described, but he did not want to talk about it any further, and the general feeling was one of “he is examining me.” Half an hour went by, and we were still conversing on different subjects concerning his work, his family (I had met only his wife), and specifically his children. He very much wanted me to meet his children, and I promised to do so as soon as possible. Before leaving, I asked his permission to try the piano. He willingly agreed, and I played Schumann’s “Dreaming” (Träumerei) which is short and calm. He thanked me and we parted. When I stood at the door, he said: “Next time, please bring me music of your choice that I probably do not know.” I promised I would. Therapeutic Considerations After becoming aware of my personal feelings concerning this first meeting and linking them to my general approach to death and dying, I was more prepared to think about the possible therapeutic process. The use of receptive musical experiencing is completely legitimate in music therapy and is not worth less or more than the active experience. This issue, which sometimes troubles beginning music therapists, did not concern me. I entirely agree with Bruscia’s (1998) explanation of the role of the musical experience in music therapy and the balanced importance he places on both processes: active and receptive (pp. 107-125). The facts were that Nathaniel could hardly use an active musical experience, and I had to support his decision in favor of receptive music therapy: It is the client’s experience that is at the center of therapy, not the therapist’s actions, and because of this, all methodological decisions are based on what the client needs to experience through music (ibid., p. 108). Conversely, many questions passed through my mind: What should the content of the music be? What emotional material might it elicit? What would the result of a psychodynamic

approach be? Would it be wise to go into depth? When was it the right moment to delve into Nathaniel’s psyche? When was it appropriate to facilitate comfort, calmness, and the ability to accept death as a continuation of life? Bright (2002) recommends an examination of our own feelings and attitudes while working with terminal patients. Among other important points, she mentions the possible cultural or religious differences between the patient and the therapist (p. 67). For example: In my country, a religious Jew abides by strict rules and customs, which guide his steps and even his verbal expressions concerning death and mourning. If the therapist is religious and the patient is agnostic, or vice versa, it might arouse difficulties when dealing with such a sensitive stage of life. As therapists, we have to be flexible and work with different populations, but theory doesn’t always coincide with emotions and practice. Therefore, we have to doublecheck our positions, ethics, and honesty. In Nathaniel’s case, we came from approximately the same cultural-religious background, so I could remove these obstacles from my mind. Concerning the depth of the therapeutic process, my psychological education, supported by hospital practice, taught me to follow the patient’s lead and to consider his ego strength when considering the extent of depth he was ready and able to enter. Accordingly, I decided to allow myself considerable breadth and long-term patience, even though the oncologist had warned that Nathaniel’s days were numbered. As for Nathaniel’s illness, my tendency is to go over medical and psychological reports when embarking on therapy with a new patient. This is due to the notion that we can never know enough and that there are always new developments. Consequently, I again reviewed material concerning lung cancer and psychological approaches for dealing with terminal illness, material dealing with families of terminal patients, and approaches through and the possible contribution of music therapy. In addition, I mobilized my own experience of working with cancer patients. While doing so, it occurred to me that knowledge is in a way a coping mechanism and specifically serves to facilitate a sense of mastery; mastery that is much impaired when facing death. This was also surely true for Nathaniel, whose illness, pain, and fear presented him with a feeling of frustration and loss of mastery. It reinforced his need to be enabled to choose his own musical material and model of music therapy and by that to achieve a certain amount of mastery. Concerning his medical condition, as a music therapist, I certainly did not get a mandate to supply the patient with information. The Family in a Crisis of Cancer Blanchard, Albrecht, and Ruckdeschel (1997) discuss the psychological impact of cancer on the patient’s family. The research they cite indicates that the spouse becomes as distressed as the cancer patient and that the major concerns are the fear of the cancer’s outcome, fear of death (even if the prognosis is good), the loss of mastery, and not being prepared to meet the patient’s demands or understand his/her behavior. In addition, the disruption of the family balance and the daily routines requires a new alignment of life. Factors influencing family distress include the disease status and treatment; individual variables, such as spouse age, gender, and possibly caregiver optimism; perceived coping efficiency and adequacy of social support; and variables reflecting the functioning of either the patient-spouse dyad or the entire family unit (ibid., p. 193).

Sharon Manne (1998, pp. 188ֲ02) reviewed the literature dealing with cancer in the marital context and examined four questions: • • • •

What is the cancer’s psychological impact on the healthy spouse and on the patient? What impact does the cancer have on the quality and communication in the marital relationship? How does the social support of the spouse influence the patient’s adjustment? Does the marital relationship have an impact on the survival of the cancer patient?

Dr. Manne’s suggestions place emphasis on the need for a good assessment of the patient’s support network, evaluation of the spouse’s psychological functioning, the need to provide the spouse with information about the partner’s illness and how to care for him, and the importance of encouraging him to participate in a support group. Nathaniel’s wife obtained very good psychological support and was guided in how to deal with the children. After the initial shock, she and Nathaniel began to accept the situation and mobilized their mutual love and friendship for each other and for the children. From time to time crises arose, but each of them did his best to find a solution. We should consider that Nathaniel’s physical alteration from an active man and a successful family supporter could have had some bearing on his psychological condition and trigger deterioration. Nonetheless, Nathaniel did not become bitter or demanding. Rather, he attempted to cling to life and in a way found beauty in his existence: his wife and children, music, poetry, his room, and friends. Children, in general, are less interested in the details of the illness and more in the future of the ill parent, in the success of the treatment, and in their own future. Still, many times the children mirror the concerns of the parents and feel frustrated when treated in a childish manner by having the truth concealed from them. As Ratenaude (2000) says: When they feel they are being left out of important family discussions, even young children experience tension and distrust. This does not mean that all information and fears about cancer diagnosis or illness should immediately be shared with the child (p. 241). Indeed, imagination may sometimes be very frightening in comparison to the truth told to the child in a way adequate for his age, developmental stage, and emotional maturity. Nathaniel’s three eldest children (14, 16, and 20) received the grave news in a clear, simple way. The youngest (10) was told in a gradual, slower manner, with fewer details concerning the terminal phase of his father’s illness. We ought to remember that the youngest son was at his latency stage of development, in which children have both abstract and concrete ideas and concerns about cancer as well as about death. In addition, the schoolteachers of the three younger children obtained information from them regarding their father’s illness, and the mother directed them not to be ashamed and not to keep it secret from their friends. In this way, it was anticipated that the family cohesion could survive and that at the same time each child would maintain his/her own activities without guilt feelings. Nathaniel’s wife served the

children as a good example of honesty with respect to her ability to talk about her difficulties while coping through the help of love and friendship. Ratenaude (2000) claims that the emotional stress is greatest on a child when the parent of the same sex is ill. In Nathaniel’s family, the youngest (10) and the two eldest (16, 20) were boys. The 14-year-old was a girl. She obviously identified with the role of her mother and helped her as much as possible. She also helped her youngest brother with his homework. The eldest was in the army, that is to say, outside the house, and occupied as a combat soldier. When he came home, he demonstrated a “buddy” relationship with his father and through this supported him. The 16-year-old son was a very good student in school and an outstanding basketball player. He no doubt used his busy life to protect himself, as he had more difficulties than the other three in observing his adored father’s deterioration. The 14-year-old girl was more interested in visual arts and in nature. She supported her mother and, through that, her father as well. She was a sensitive girl and contributed femininity to the family constellation. The youngest son, a 10-year-old, was by nature a jolly, active boy with many friends, verbal and communicative. I had the feeling that in his distinctive way he was coping with the situation very well. His mother confirmed this idea. Nathaniel’s wife told me that she was very worried about her husband’s emotional reaction. Generally speaking, he was a tough person, a hero type. However, what had occurred in reality was that his illness had softened his personality and exposed traits of delicacy and sensitivity. She was also worried about the anger and bitterness she felt concerning his many years of smoking, fearing unnecessary conflict. However, she discussed this with him and in a way ventilated her anger. To summarize the family situation: In spite of the disaster that overwhelmed them, they continued to function and managed to preserve the family cohesion in a remarkable way. At this point, I return to the music therapy process. Music Therapy: 29 Sessions In Nathaniel’s case, I will describe and analyze the entire process of music therapy without dividing it into stages as was done in the first chapter. To emotionally prepare myself for the following music therapy meeting, I did what I always do, a practice learned from Indian medicine men: I improvised freely, both instrumentally and vocally, to find peace of mind and courage. As promised, I brought a musical composition to the second meeting: a vocal piece sung in the Regina Pacis convent in Holland where my friend Christina served as a nun. This unisono female vocality was recorded by me in the convent and has a pure, silver-sounding character. Nathaniel listened attentively for 10-minutes and requested to hear it again. He did so three times and then asked to keep it for himself. As I had already prepared a copy, I left it for him. Beyond the music therapist’s intentional work and professional thinking, there is always place for intuitive guess and emotional planning. I mention this in relation to the choice of the music. Of course, there was also an element of logic to it: The music was Gregorian, the character was calm and pure, and Nathaniel could not recognize this specific music. Conversely, there were also other possibilities that I did not select. I would like to once again accentuate the power of intuition at certain moments when knowledge is not the only element in life. Perhaps the nearness to death and to a mysterious world, vague and cloudy, compels us to

employ intuition in addition to knowledge. After listening to the piece three times, Nathaniel began to talk about his illness, described his fears of death and of leaving his family alone, and said: “For a short time, I felt peace of mind. This was while I listened to the music. I hope that’s what our meetings will generate. Next time, I’ll think about my music collection in this respect of tranquility and peace of mind.” This was a positive example of meeting Nathaniel’s therapeutic needs and of the path that began to form itself. It was good that he resumed making his own choices through which he derived a certain amount of mastery and that he was able to talk about his feelings. After 45-minutes, he looked tired but not worried. He closed his eyes and fell asleep. A month passed by, throughout which Nathaniel chose his own music for mutual listening. When the music stopped, Nathaniel would talk about his feelings or discuss the music. In the meantime, I had met his wife and four children. They seemed to be very interested in what we were doing. I explained briefly but could not invite them into the room, as Nathaniel was opposed to the idea. The three elder children understood what his wife and I explained to them. The youngest son had difficulties; therefore, I requested permission from Nathaniel’s wife to invite the children on one occasion to my clinic and give them a separate session. After the parents agreed, they indeed came to my place and we had an active as well as a receptive experience. The eldest son could not come, as he still served in the army, but the other three were very attentive and cooperative. From their musical and verbal reactions, I was under the impression that it was a good decision. They had enough mysteries to deal with concerning their father’s condition and death anxiety. By presenting them with an example of music therapy, they could be less anxious. This was specifically true since dealing with musical experiences is to deal with something normal, compared to what transpires during medical treatment. I imagine that it could have been very constructive to continue music therapy with the children, but it was impossible to do so both technically and therapeutically. Meanwhile, Nathaniel told me that the mutual listening experience was new to him, though he always listened to music at concerts, alone at his work, and at home. Since music therapy is based on interactions between patient and therapist through the experiencing of music, this might explain the change that Nathaniel felt was brought on by the mutual listening and its verbal results. Music to which someone listens at home, or plays at home, can be extremely moving for the listener or for the performer. This does not mean, however, that it necessarily opens up a window for self-awareness or for a strengthening of personality. In reality, people tend to cling to a professional analytical frame of mind (especially musicians) or to float on clouds of emotional experience so there remains no evidence of a therapeutic process, or the essential linkage which therapy seeks between emotion and intellect. (Sekeles, 1996, p. 43) Nathaniel was 45 years old, that is to say, at the midpoint stage in his life. Although they have typically established their family and economical security, those who face death at this age have great concerns: They grieve missing out on experiencing new horizons and watching the development of their children and grandchildren and are anxious about how their spouse will manage after their death. Indeed, the social worker guided Nathaniel’s wife to reassure him of her independence as well as to demonstrate for him the ability and strength of their children

to cope with the situation. I, on the other hand, took the task of reducing the fear and anxiety aroused by his impending death through our specific modality. Again, the religious Jew would have trusted in God and would have prayed for His mercy. This in itself might diminish fear and anxiety. Being an atheist, Nathaniel had other support: • • • •

Listening to music in a protected atmosphere. The verbal conversations we had afterward. The use of imagination and dreams in a soothing fashion. The identification with poetry.

Reading poetry of his choice began to accompany the listening to music. Subsequently discussing the content broadened the scope of therapeutic elaboration. He asked for poetry in Hebrew and in English. We read the poems of Yehuda Amichai (1983, 1985), who is one of the best 20th-century Israeli poets. Examples of his work translated into English can be read in Poet Healer (Spann, 2004), pp. 99, 175, 200. We also read from Emily Dickinson’s Favorite Poems (1890), Moshe Dor’s Maps of Time (1978), and Ruth Finer Mintz’s (translator and editor) bilingual anthology of Modern Hebrew Poetry (1968). I would like to bring forth one example from this phase: Nathaniel wanted me to read one of Amichai’s poems for him and recalled that he once enjoyed the Travels of the Last Benjamin of Tudela. After reading the poem, I asked him which part or idea was the most meaningful for him, and he immediately pointed at: A child who got hurt or was hit, as he was playing, holds back his tears and runs to his mother, on a long road of backyards and alleys and only beside her will he cry. That’s how we, all our lives, hold back our tears and run on a long road and the tears are stifled and locked in our throats. And death is just a good everlasting cry. Ta-daaaaaa, a long blast of the shofar,5 a long cry, a long silence. Sit down. Today. (The Selected Poetry of Yehuda Amichai, 1996; translation: Stephen Mitchell) It occurred to me that this poem was filled with symbolism related to Nathaniel’s manhood, which didn’t allow him to show any weakness or to cry. He might be willing to do so just like a child who finds shelter and the ability to cry in his mother’s arms. The cry is locked in the throat, which now symbolized a sensitive area. The notion of breathing a wind instrument to life is well recognized in magical thinking. Here it is being accentuated by the shofar, an ancient, mighty instrument used only in restricted times of danger and holiness. The shofar was also related to his own musical instrument, the French horn. I wondered how conscious and aware Nathaniel was to the emotional content of the poem. When I asked him what he liked in this part of the poem, he answered: Perhaps the relationship between the child and the adults. Indeed, I feel like a little infant, unable to master my life anymore and not even able to cry out unless I find mother’s lap. When we resumed our conversation, Nathaniel said: “I wish I could blow my horn and again feel the power of my breath.” I suggested listening to a composition played by the horn, and he asked if I could improvise on the subject. This was an interesting challenge. With his permission, I decided to use the sound and the rhythmical patterns of the shofar as a motive for

development. While playing the piano, I imagined the unique atmosphere of the synagogue on The Day of Atonement with all the people dressed in white, which is the color of pureness, festivity, and the deceased’s shroud in Judaism. It helped to attain inspiration. To improvise for the benefit of another person in therapy differs from free improvisations for your own sake. It requires from one much concentration and to be tuned into the other person’s expression, body language, and tone. This was an example of employing poetry and turning it into music, according to the wishes and needs of the patient. The piano is a very descriptive instrument with a wide range of implementations, from the most subtle content to orchestral strength. In such moments of therapy, one is relieved to have it as a main instrument. Nathaniel listened and for a very long minute did not utter a word. He reacted only in the following session, by shortly commenting, “Last time, I received a present from my therapist.” In the last month of therapy and of life, Nathaniel’s health deteriorated. He was rushed to the emergency room several times, but his family and he himself wished for him to remain at home. Before what was meant to be our final meeting, he entered a coma, and while lying in bed “listened” to Faure: Sicilienne. The entire family surrounded his bed. He died an hour later. At his funeral, there was no music except for the traditional prayers. A month later, at the 30th ceremony, I brought the same Sicilienne played on a tape recorder to the graveyard. In a way, this was the closure of the life-death circle of a man who knew how to gracefully carry himself through life, terminal illness, and death. Notes 1. Dr. Jaacov Avni was a prominent Israeli psychiatrist and psychoanalyst. For the past 22 years, he was head of the psychiatric unit at the Hadassah Medical Center, Mount Scopus, in Jerusalem. He was an open-minded person, interested in the art therapies and accommodating in the treatment of mutual patients. Dr. Avni died recently (March 2006) of an illness and left everybody who knew him in deep grief. Dr. Alma Avni passed away in August 2006. She was an internist and had a deep practical and theoretical knowledge of music. Our lifelong friendship began in 1952; ever after, we accompanied each other in our personal and professional lives. Alma offered me medical knowledge, personal warmth, and love. God bless her soul. 2. In such cases, the patient is sent to home care with the essential resources: home visits by a physician, nurse, physiotherapist, and occupational therapist. It is subsidized and supervised by the medical insurance fund in which the patient is a member. In Nathaniel’s case, he had a visiting physician, a nurse, and a physiotherapist. 3. Jewish people visit the grave seven days after the funeral, then after 30 days and each year on the date of death. These basic bereavement customs are kept by the religious as well as by most secular Jews. Each of the official visits to the graveyard adds new closure to the death, and its importance is that it is done in the company of family and friends. 4. Generally speaking, lung cancer does not cause symptoms when it is at its early stages. This is why it might be in an advanced condition when diagnosed. This was the case with Nathaniel: He was a heavy smoker and began coughing when the tumor began to

irritate the lining of the airways and caused a shortage of oxygen. In such a case, it is not logical to try a wind instrument even if it is the patient’s personal preference. 5. The shofar is the ritual instrument of the ancient and modern Hebrews. It was a priestly instrument in Biblical times. It was made either of ibex horn, its bell ornamented with gold and played on the New Year, or of ram’s horn, with silver ornamentation, used on fast days. Its tone was to be preserved unaltered. The shofar is closely connected to magical symbolism: Its blast destroyed the walls of Jericho, and in the Dead Sea scrolls it is written that during battles, shofar blowers sounded a powerful war cry to instill fear in the hearts of the enemy, while priests blew the six trumpets of killing. In our times, its liturgical use is restricted to the New Year (Rosh Hashanah) and the Day of Atonement (Yom Kippur). References See end of Case Five

Taken from: Sekeles, C. (2007). Music Therapy: Death and Grief. Gilsum NH: Barcelona Publishers.

CASE FIVE Where Have All Our Flowers Gone? Music Therapy with a Bereaved Mother and Widow: A Case Analysis Chava Sekeles “I have a hole in my bosom. Never knew of its existence. ...Here in the center of the bosom, a private hell occurred to a woman who just wanted to hold again and again to her love.” Adi Lelior, 2004, Till Death Do Us Part, p. 51) Dedicated to Anetta and Reuven Shari1 Introduction Naama, a mother in her forties, had lost her eldest son in a military action behind the “green line.” Though this occurred at a time of war, it was not the enemy who killed him, but, as they say in the army, “The fire of our own forces.” Throughout the first two years after this accident, Naama continued to function to some extent, though her motivation and efficacy had obviously deteriorated. Then, another blow struck the family, and her husband, following a short period of illness, passed away. Naama was left with her adolescent son David, who was on the verge of finishing high school. The everyday activities faded away, and her depression was accompanied by selfnegligence: From a beautiful, well-dressed, and preserved wife, she turned into an indifferent woman, could not execute her household duties, neglected her son, did not care to eat, and slept very little. After a year in psychotherapy accompanied by antidepressant drugs, she was referred to music therapy, where the work with her continued for three years. Two years after concluding music therapy, she married a widower who brought two daughters to the family nest. Throughout time, all the children left home and Naama’s life as part of a couple continued reasonably. Why was Naama referred to music therapy? The psychiatrist who treated her had claimed that the medication had helped her but that the verbal therapy had not been effective. Conversely, she had told him of her love for music, of the fact that she was moved by music, and of her readiness to try this medium. Intake and Observation Naama entered the room, did not look around, collapsed into an armchair, and stayed there. In the short conversation we had, Naama expressed enormous rage concerning the army, her fate, the dead, her losses, herself, and what awaited her in the future. She was very

ambivalent and unsure that any therapy might help her. Interestingly enough, she displayed all of this rage while sitting in the armchair in a bent over position, making hardly any movement and as though spitting the words to get them out of her system. Moreover, she did not raise her voice above mezzo piano. Thus, there was a disparity between the content and the vocal elements of what she said. At a certain moment, this rage content turned into a deep feeling of helplessness, loneliness, and emptiness. Her vocabulary changed, but the musical features remained approximately the same. The conversation turned to what she expected from music therapy. After a long silence, Naama asked, “Can it energize my body and soul? Can it pour something that will purify my being?” This was a high mountain of expectations. Was it, indeed, possible? What does music enable, and where are its limitations? How much would Naama cooperate, and how flexible was she? Specializing in the developmental-integrative model, I asked myself what approach and technique I should choose and implement. Therapeutic Considerations In the mourning process that Naama had undergone, the past, present, and future had been felt as an empty space, creating a deficiency, deep pain, helplessness, and hopelessness. The fact that Naama could not find a channel for consolatory activity caused me to contemplate her role in the matrimonial relationship: Naama had always had this conflict of developing her professional life versus being a wife and a mother. She chose the second role and became very dependent on her husband and children. After the death of her eldest son and her husband, as I had found with other dependent widows, she could not so easily rebuild a new meaningful life and was not able to care for the remaining youngest son. Generally speaking, the elaboration of personal grief either positively aids in the adaptation of the rest of the family to the bereavement process or influences it negatively. Death in a family causes changes in hierarchy, in re-sharing duties, in communication, and more. As long as Naama’s husband had lived, he had supported her and they had both taken care of the younger child. Though she had not reverted to her former self after her soldier-son was killed, she had nonetheless hung on in a way. When her husband died, the burden became too heavy and she could not prevent her own disintegration. Avigdor Klingman (1998) says that the death of an offspring is among the most difficult and painful experiences of parent’s, always perceived and felt as too early and unjustified. A child is an additional part of the parents’ egos, specifically in mother’s emotional worlds. In the Israeli society, where many young soldiers are killed during military service, there is also a kind of emotional differentiation between soldiers who had a “heroic death,” and soldiers who were killed in an accident. There is a lot of anger (in this case, anger toward those who killed Naama’s son). Remarks such as: “Nothing to be proud of,” and “He gave his life to the country for nothing,” can be heard from people, including the families of the deceased.2 Klingman (ibid.) says that according to the general literature on children’s deaths, the following factors must be considered: the parents’ personality, the age of the child, the cause of death, and the context in which it transpired. As aforementioned the transformation from a bereaved mother to a bereaved mother and widow led to Naama’s deterioration. Moreover, we can add a bereaved brother and son

who needed her to function both as a mother and as a father to the constellation. She needed to deal with her son’s grief as well as with her own, to organize all the official arrangements, to cope with her loneliness, and to find new meaning in life, as she did not even have a profession or job to get back to. All this was too much for her personality’s strength, and she sank into depression, including all the clinical signs. To confess to the truth, I had no idea as to what would happen in her music therapy sessions, and the fact that verbal psychotherapy had not helped her troubled me a lot. I did not think that music was the answer to all of her problems, and I did not feel omnipotent. With these feelings, I met Naama for the second session. Tied to a Coffin Naama entered the room, fell once again into the armchair, and said, “To tell you the truth, I don’t think I can do anything. Most of the time, I feel tied to a coffin, as if I were lying in a grave, unable to breathe. I cannot even concentrate on my youngest son, and I think that he may not need me.” This image of “tied to a coffin,” and the idea that her son might not need her, opened a narrow window for work and elaboration through music. I suggested that she transfer this feeling of lying in the coffin, unable to breathe or think, into music. She immediately responded, “No way! But if you can find recorded music that fits this situation, I’ll try to listen to it.” I screened my “inner library” of art music (which was the category she preferred), in an effort to find the image of “tied to a coffin.” After a few minutes, I suggested Lukas Foss’s Echoi (1961, 1963), an aleatoric improvisation for percussion instruments, cello, piano, and cembalo.3 The composition begins with a very low cluster played in a quick tremolo style. After a few minutes, percussion and piano notes are inserted, followed by Baroque themes, which sounds like a fantasy of distortion. I let Naama hear 10-minutes of the beginning, which was intense enough. Naama’s reaction was mixed, “This was awesome music. I could hardly stand it, but it perfectly portrayed the horrible stress I feel in the suffocating coffin.” Indeed, my choice of Echoi led to a similar feeling of stress and horror, probably due to the realistic sound of the roaring noise. Another reason was the improvisational features of Foss’s composition, which could show Naama that this approach exists in the work of wellknown artists. In music therapy, improvisation has a respectful position and acts as one of the main therapeutic languages. It enables one to dare, even without a preliminary experience. Thus, the expression of feelings is not necessarily accompanied by words. In addition, improvisations act as a chain of associations, freed from the mastery of reason and logic (Sekeles, 2002). In the third session, we turned back to the theme of being tied to a coffin, and Naama was ready to try to describe it through piano improvisation. Naama used to play the piano when she was young, but she did not spontaneously improvise. I, therefore, suggested that she choose one note and let me play it on the bass section of the piano. Naama suggested the note of E, and when she felt comfortable with this note, she carefully added her own improvisation. This one note was played in a constant rhythm (basso ostinato), served as a container, and symbolized the narrow space of the coffin. Naama began to play in a stiff, repetitious style, and gradually developed the melodic line, the dynamics, and the range of the music. I looked at her

face and saw the expression of a child playing with a new toy. This improvisation continued for about 10-minutes and allowed me, at a certain point, to develop the one note into a melodic counterpoint. After finishing, I suggested listening to the recording. Naama consented. She listened intently and afterward commented: “I have never improvised on the piano, and I never felt free to play in such a way. I reckon that the one note held me in a manner that allowed me to stay in the coffin without being suffocated. At the end, I even stepped out and felt quite good. I would not suspect that I’d be able to describe a feeling like that through music.” Therapeutic Considerations The ability to ”play” with any material; change its shape; remodel it; think about it in an unconventional way; be active, imaginative, and innovative, is the basics of creativity. Musical improvisations enable us to use “any mate thinking,” which is characterized by fluent production, multifaceted solutions, spontaneity, and freedom from logical thinking. From our discussions, I learned that Naama was not comfortable without a well-defined framework and that even while cooking she had to use recipes. From this point of view, strengthening her creativity meant providing her with more self-confidence and freedom. Symbolically, improvising on a holding pattern is to cast your own ideas on a sound ground. This is one of the advantages of mutual playing (in this case four-hand piano) and using techniques that do not require professional competencies. The holding frame is typically a repetitious parameter: rhythmical pattern, harmonic pattern, basso ostinato, an interval, a melodic line, and others. These are phenomena that exist in musical compositions and give the listener a feeling of consistency and confidence. I thought that we might work on broadening Naama’s improvisational and emotional horizons by listening to compositions that develop from a narrow space to a wider one and to correspondingly improvise in a similar fashion. Holding and Containing Hector Berlioz demonstrates a type of holding frame in the “Pilgrims’ Procession,” which is the second movement of Harold in Italy,4 by sounding a repetitious note. Though this note does not resound in an intensive way, it does so very clearly. Naama enjoyed listening to it, noticed the internal counterpoint voices and melodious lines, and in her imagination developed an entire conversation with her late husband. She divulged the content to me after the music was finished. I suggested that she employ a gestalt technique of two chairs and converse again by playing both roles: her husband and herself. In this conversation, Naama gently blamed her husband for deserting her, leaving her alone with her suffering. Though it was said in a very soft voice, I had the feeling that she had partially ventilated her anger. She moved from chair to chair, even changing her voice a bit, and used painful vocabulary to ease her burden, completely ignoring my presence. This is merely one example of holding parameters in music, which contain the sorrow of the patient and elicit verbal content. Another example was Ravel’s Bolero, in which the melody

is repeated from beginning to end (for 15- to 18-minutes) with changes in texture and dynamics. In addition, there is a repetitious rhythmical pattern typical to the Bolero dance.5 From a therapeutic point of view, this composition contains elements of ecstatic music, specifically the graduate crescendo and varying of the melodic instruments, versus the fixed rhythmical pattern:

There is, however, no accelerando, and thus the musical excitement in ecstatic traditional rituals (Sekeles, 1994), which elicit ecstatic dancing, is far more restricted and diminished in the Bolero. Naama reacted to the Bolero by deciding to adopt the rhythmical pattern and drummed it on the timpani for nearly 10-minutes. In the beginning, she could not sound the crescendo, but kept the tempo very well. After about three minutes, she added crescendo and acceleration, which are a natural physiological phenomenon. Naama commented on the feeling this kind of drumming gave her, “I felt high as if I was dancing and not playing. Amazing how a simple repetitious melody may have so much strength and the power to energize the listener. It was good.” Returning to the intake meeting, I thought about Naama’s response when I asked her what she expected from music therapy, “Can it energize my body and soul? Can it pour something that will purify my being?” Perhaps she had begun to open herself to simple physiopsychological activity and felt the music not only in her head but also in her body and soul. I remembered that I had Ravel’s arrangement of the Bolero for solo piano. I decided to use it the next session. After a week, Naama arrived and asked to listen to the Bolero again. I took the opportunity to suggest that she play the rhythm, just as she had already done, while I played the solo piano. Naama agreed to try this idea. We played it once from beginning to end, and she then suggested, “We can use the same rhythm and improvise a new composition on it.” We did this while alternating roles. That is to say, once she improvised and I kept the rhythm, and vice versa. I felt a positive procession of development, and while she was busy playing I observed a mild expression of satisfaction on her face. Therapeutic Considerations Both terms, holding and containing, originate in physiology and were adapted to psychology. The fetus is held and contained in his mother’s womb, which gives him comfort and confidence. Subsequent to birth, the mother’s body and hands carry on this posture and function, which gradually obtains a double meaning: physiological and psychological. Generally speaking, a holding frame or a frame “inclines to stabilize the therapeutic process and protect the client and the therapist from being over flooded and carried away by situations and actions that they are not yet ready for or unable to cope with” (Rosenheim, 1990, p. 46). In psychotherapy, the frame may be a set therapeutic time and structure, ethical rules, and more, which enable the therapeutic process to develop within it a proper amount of

flexibility. In music therapy, we also have specific techniques that supply a holding frame and, at the same time, allow freedom for improvisations. This is a duality, typical to music as an art form, which is present in almost all musical categories. With each patient, the holding frame may be a different structural element: rhythm, melody, harmony, etc. We therefore need to find the most effective element and work with it while internalizing, conversing, reflecting, augmenting, clarifying, and more. Naama was able to listen in a sensitive way, gradually represented actual life events through music, and used it to suit her particular needs. An example of this is the conversation she held with her husband in which she ventilated her anger toward him for the very first time. An additional sign of progress was her growing ability to improvise freely and to feel good about it. Besides its other advantages, playing freely may sometimes impart on the improviser an elated feeling of happiness. Indeed, this linguistic connection in English (and in some other languages) between “playing” and “playing” a musical instrument has great meaning. A smiling expression, which was uncommon for her, gradually began to appear on Naama’s face. A tiny light at the end of the obscure tunnel through which we walked together seemed to appear. It is significant to, again, emphasize that musical interaction in music therapy is perceived as analogous to life itself. I felt that Naama had gradually learned through the musical interaction that experiencing death, as difficult as it might be, was also a universal experience of life. One might develop personal meaning concerning life and death even when it seems as though life has lost its value and that we are imprisoned with the dead in their graves. Naama also began to understand that the worn-out term “coping” contains sub-terms such as adaptation, indulgence, giving, and the need to change life molds in order to establish psychological and spiritual independence. Mother-Son Music Therapy At a certain therapeutic moment, Naama brought her relationship with David, her youngest son, to therapy. She conveyed it verbally and described her guilt feelings and the minimal care she was able to provide him, “I expect him to understand my condition and most of the time to forget his young age and own needs.” During this conversation, we discussed a possibility she suggested, of mother-son music therapy. At that moment, it seemed a good suggestion and we decided to try it. This therapeutic process lasted until the conclusion of therapy and exposed many layers of pain and anger on both sides. By this time, David had already finished high school and had obtained a deferment from the army for the purpose of pre-military studies. I would like to present a few examples from this period and demonstrate the role music therapy played in this voyage: Togetherness. David entered the music therapy room with his mother, who informed him that he was allowed to freely explore the musical instruments. From this point on, I observed the two and the musical and extra-musical interaction that transpired between them. David had no problem trying the drums, the bells, the wind, the string, and self-made instruments. At first, Naama just watched him without any interference, but at a certain moment she gently joined him. He was playing the lyre, and she added Japanese bells. In a moment of intermission, I requested permission to record their mutual creation, and they

agreed. Naama and her son David spent the entire hour improvising without a directing subject, rules, or instructions. I did not see any reason to join in or to interfere. Re-listening. Next session, I suggested listening to some parts of their improvisations from the previous week. They agreed and did so very carefully. I noted that David had good concentration qualities in addition to his creative freedom. Following the listening exposition, he declared, “It is fun but we have to practice a lot if we want to be together.” His mother responded, “Yes, you are right, but here in music therapy we are not provided with corrective instruction. We have to find our way together.” Improvisations: David and Naama improvised with musical instruments for an entire month. During this period, they showed no inclination to describe a situation, a feeling, a figure, etc. Neither did they use their voice musically, although it is the closest element to speech. On the other hand, the improvisations became more and more developed and clearly structured, with dynamical changes; at times, they were even divided into semi chapters. It was amazing to see how a musical interaction could develop without planning or words. My role at that time was to let them be and work together in a way and through a modality foreign to them, to allow them to experience mutuality detached from everyday life. They occasionally asked for my help, mainly on technical matters, or requested that I replay their improvisations. Clinical Improvisations: After about a month, Naama told David that in her music therapy sessions she also experienced conversing, representing, describing her feelings, and more through improvisations. Coming from Naama (and not from the therapist), this was undoubtedly a turning point. Where would it lead them? Us? David suggested, “I like jazz and rock, you certainly prefer your classical music. Perhaps we can first represent ourselves through pre-composed music?” Naama accepted this idea, and for several sessions they listened to their musical choices, after which they developed interesting conversations. They gradually began to request my involvement, and we entered a phase in which Naama and I improvised together on the piano and David and I played his material. I would play the piano and he the drums and other percussion instruments. This process did not bring David any closer to his mother’s preferences, but drew Naama closer to her son’s music and she joined in his playing, showing new interest. Where Has All Our Anger Gone? The final segment of music therapy with Naama and David was the longest, and dealt with bitter feelings, anger, grieving for the deceased brother and father, and confronting mother-son emotions and each other, as difficult and painful as this was. The musical work they had invested in so far was very efficient in building a mutual relationship of confidence, and thus the ground was ripe for embarking on this new level. Once again, as in previous cases I have analyzed, patience was the key ingredient. In his chapter on dealing with anger and guilt, Parkes (1972) emphasizes the notion that: “Until the reality of the loss has been fully accepted, the greatest danger is the danger of the loss itself. The bereaved person still feels that the dead person is recoverable, and anything that brings home the loss is reacted to as a major threat. Relatives and friends who try to induce a widow to stop grieving before she is ready to do so, or even those who indicate that grief will pass, are surprised at her indignant response. It is as if they are obstructing the search for the one who is lost.” (p. 80)

I felt that since her mutual therapy with her son, Naama was on the verge of a better insight due to her revitalizing experiences and elicited more energy and acceptance. Developing insight mostly requires interference and guidance on the part of the therapist. With the therapist’s encouragement, Naama and David began to learn to express those parts in each of them that were silenced and distorted for a long time. Confrontation was necessary in order to begin an intra and inter dialogue. This therapeutic process was technically prompted through both musical and verbal conversations. At that point, they also began to employ musical vocality, which seemed uncomfortable to each of them. David was the first to realize that singing can increase the emotional possibilities of the vocal expression, as it holds many possibilities less exploited in speech: accentuation through many repetitions of one motive, rich emotional expression by using a wide vocal range, and more. Despite the embarrassment, the vocal dialogues they began to develop deepened the process of peeling away their protective layers of armor. David expressed his anger at his mother for investing all of her emotions in his deceased brother and later in his deceased father, though before her stood her surviving son, who was faced with overcoming a difficult period of matriculations, grieving, and mourning, “You barely asked me about my examinations, not to mention my feelings. You hardly ever cooked; you neglected every motherly function and walked around the house like a zombie.” Naama’s response was a cry that she was unable to end. A week later, she collected herself and said to David, “You were always the strongest in the family, stronger than your brother and father and surely stronger than me. I had the feeling that you did not need me, but it was also very convenient for me to think so, as I had no energy to invest or share.” At moments such as these, the therapist’s role was to facilitate a reassuring atmosphere, relating that the world continues to exist and that we do not come apart or dissolve when we discharge our conflicts with our beloved ones. The second step was to discuss the son-brother and husband-father deaths. It appeared that David had experienced many conflicts with his elder brother, but felt that he was not allowed to desecrate his mother’s memories or the memory of the dead. He missed his brother in an “unfinished business” dynamic and desperately needed to elaborate on the subject. I initially suggested working on it by representing the family members through musical instruments and voice. He first worked alone and later with his mother. Since his relationship with his father was very good, it was easier for David to express the immense anger toward his brother. I must admit that these recordings are among the most touching pieces I ever experienced in therapy. The more David and Naama externalized their emotions, the better they began to feel. Concerning Naama, her everyday functioning became nearly regularized, and the termination of music therapy painted the horizon. Music and Poetry. During this stage, singing became part of the sessions, including Israeli songs accompanied by the therapist. This soon led to the writing of poetry and sometimes to the composing of music to it. The latter process had many faces: Sometimes each of them wrote a poem with regard to him/herself without or with music; other times, Naama wrote a poem and David composed the melody or vice versa. Their style was very different, but the mutual feature was the discovery of a personal talent and artistic satisfaction. I would like to present the translation of Naama’s final poem, to which David composed accompanying music. We must of course take note of the fact that the translation from Hebrew to English changes the musical intonation of the text itself, but I tried to stay true to the original meaning:

Death bit crudely at my heart Left me in my grave dead-alive Bless God for opening my eyes to beauty and to the sounds of music Bless God for a compassionate last moment of salvation Bless God for purifying my heart to feel the pain and to accept the joy. Bless my life-friend for leaving me the sweet memories of the dead and the alive. Summary Sometimes we title a therapeutic process as though it were a musical form, such as a sonata, rondo, etc. In Naama’s case, I received the impression of a “case/form” due to the fact that we walked through endless curves, turned in all directions, experienced regression, and gradually felt new drops of life and insight. From the stage that Naama understood the urgent need to work through her relationship with her son David, the road turned from a stony, thorny path to a paved one. Music improvisation and receptive music therapy from time to time were the modalities that paved this road and the intra and inter mother-son relationship. Through this work, the relationship with the deceased became clearer, and Naama was able to open her heart to grief and bereavement without fearing the disintegration of her own personality. As mentioned in the introduction, Naama remarried two years after concluding music therapy. During this period, she dedicated time to the piano, which she had ceased to play upon concluding elementary school. She resumed lessons and spent time improvising. Her son, David, completed his studies and his army service (unharmed). It is essential to mention that the process of music therapy was concluded with the consent of both patients and therapist. It seemed like the right moment, though as Rosenheim (1990) says, sharpening the coping tools do not guarantee a “security certificate” for resisting future pressures (p. 204). It does, however, increase the likelihood of coping better, with reduced anxiety, when encountering a new obstacle in life.

Notes 1. Anetta (1903-1978) and Reuven Shari (1902-1989) were born in Russia. They were both among the compelled “numerous clauses” in their high school, which they finished “cum laude” at a very young age. Reuven studied further and became a young lawyer; Anetta studied dentistry and played the piano. The anti-Jewish pogroms, which had not ceased since 1821 (1859, 1881-1884, 1903-1906, 1917), left hundreds of thousands of Jews dead. In the 1917 Russian Revolution alone 250,000 civilian Jews died, many were wounded, and two million emigrated, mainly to America and partly to Israel (Rubinstein, Chon-Sherbok, Edelhei, & Rubinstein, 2002). Anetta and Reuven were young parents of their first baby daughter when they immigrated/escaped in 1925 to Israel. In the new country, they had to stop their intellectual activities and work like other pioneers in agriculture, in paving roads, in building Israel. In the forties, Reuven turned back to law and contributed intensively to the public life of Israel. In 1948, he became a member of the Knesset, head of civil service, and more. By decision, Anetta took responsibility for the home and the raising of her three daughters. This chapter is dedicated to my beloved parents, Anetta and Reuven Shari, who taught us the meaning of family, of work, of art, and of a motherland. 2. Comparing the grieving of mothers to that of fathers: Mothers display their grief more openly than fathers. There is less research concerning the grief of fathers, but in Israel they take on the role of the strong family member. It is important to remember that most of them served in the Israeli army and had experienced death-related situations as soldiers. They tend to be in more of a position of denial, their mourning period is shorter than that of the mothers, and they go back to work as soon as possible. On the other hand, there were several cases in Israel in which fathers (including some high officers) committed suicide at the grave of their soldier-son. 3. Lukas Foss is a German-born composer who immigrated to America. In 1956, he began to work on improvisations with his students at UCLA, which led him to form the Improvisation Chamber Ensemble. They did a lot of aleatoric work and contributed important new concepts to art music. 4. Harold in Italy was ordered by Paganini in 1834 as a viola concerto for his Stradivarius instrument. Berlioz remained one year in Italy and adored the landscape. The composition, ready in 1835, was influenced by these images. Paganini was not satisfied with the results, as the viola role in this composition did not show enough prominence. Still, it presents a special intrinsic relationship between the orchestra and the viola. 5. Maurice Ravel (1875ֱ937) composed the Bolero for ballet based on the traditional Spanish form. It consists of a repetitive melody, a counter-melody, gradual crescendo, a large orchestra, and changes in instrumental texture with condensation towards the end. Therapeutically speaking, it has a stable frame, which includes the rhythmical pattern and the melodic line. Changes of orchestration and volume occur on this foundation. Based on my clinical experience, most patients feel good with this composition. There are those who need repetitions and others who can perceive the gradual changes and enjoy them. Some patients like to express this music in movement or graphically, imitate the rhythm, and more. While working with dance therapists, I

instructed them to translate the Bolero’s musical components into movement. The videotaped results were very interesting, as we could observe unusual interactions between limbs, interesting choices of body parts to express the rhythm, difficulties in keeping the tempo solid while the dynamics changed, etc.

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Sekeles, C. (1996/7). Music and Movement in Moroccan Healing Rituals. In K. Hörmann (Ed.), Yearbook of Cross–Cultural Medicine and Psychotherapy (pp. 55–63). Berlin: Verlag für Wissenschaft und Bildung. Sekeles, C. (2000). Shamanic Rituals: Origins and Meaning. Therapy Through the Arts, The Journal of The Israeli Association of Creative and Expressive Therapies, 3 (1), 90–107. Sekeles, C. (2002). Musical Improvisation as a Therapeutic Language. Jerusalem: Ministry of Health. (unpublished presentation for clinical Psychologists). Sekeles, C. (2005). Voice and Silence. In A Desert Time: ICET General Conference 17–19 April 2005, Arad. (unpublished presentation). Sekeles, C. (2005). From Passive Mutism to Creative Inner Song (A Therapeutic Process with a Chronic Schizophrenic Patient). Florence, Italy: Shir Association Conference, 26.9.2005. (unpublished presentation). Shahar, N. (1999). The Israeli Song—Its Birth and Development in the Years In Z. Shavit (Ed.), Structuring a Hebrew Culture in Israel, (pp. 495–533). Jerusalem: (Hebrew). Siegel, J.P. & Spellman, (2002). The Dyadic Splitting Scale. The American Journal of Family Therapy, 30 (2), March–April, 93–100. Silverman, P.R. & Worden, J.W. (1992). Children’s Reaction in the Early Months after the Death of a Parent. American Journal of Orthopsychiatry, 62, 93–104. Siepmann, J. (1995). Chopin: The Reluctant Romantic. London: Victor Gollancz. (Read in: http://en.wikipedia.org/wiki/chopin) Slavson, S. (1964). A Textbook on Analytic Group Psychotherapy. New York: International University Press. Smilansky, S. (1981). Children’s View of Death. Haifa: Ach (Hebrew). Stein, D. & Avidan, G. (1992). The Unconscious Effort of a Parent to Preserve the Psychopathology of his Child. Bat–Yam: Abarbanel Psychiatric Hospital. Sogyal Rinponche (1993). The Tibetian Book of Dying and Living. New York: Harper Collins Publishers. [Hebrew translation 1996, Tel Aviv: Gal Publishing Ltd.]. Spann, Ch. (2004). Poet Healer. Contemporary Poems for Health & Healing. Sacramento, Cal.: Sutter’s Lamp. Strunk, O. (1950). Source Readings in Music History. From Classical Antiquity through the Romantic Era. New York: Norton & Company. Tatelbaum, J. (1984). The Courage to Grieve. New York: Harper & Row. Wiess, C. (2004). Using Israeli Songs in Music Therapy to Build Inner and Interpersonal Communication with Youths Suffering from Various Disabilities.Therapy through the Arts, The Journal of The Israeli Association of Creative and Expressive Therapies, 3 (2), 77–85. Wigram, T. (2004). Improvisations. Methods and Techniques for Music Therapy Clinicians, Educators and Students. London: Jessica Kingsley Publishers. Wigram, T. (2005). Song Writing Methods—Similarities and Differences: Developing a Working Model. In F. Baker & T. Wigram, (Eds.), Song Writing. Methods, Techniques and Clinical Application for Music Therapy Clinicians, Educators and Students (pp. 246–265). London: Jessica Kingsley Publishers. Wilde, O. (1998). The Critic as an Artist, Collected Works of Oscar Wilde. USA: Wordsworth Edition. 3TU

U3T

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Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE SIX “Couldn’t Put Humpty Together Again:” Symbolic Play with a Terminally Ill Child Catherine Sweeney Abstract This case gives an overview of the development and ethos of the children’s hospice movement in Britain. It presents a case study of some short-term work with a young boy in the terminal stages of a brain tumor and looks at the way in which he used embodiment within symbolic play to express and come to terms with his illness and his impending death. Introduction In Britain today there are an estimated twenty thousand children suffering from lifelimiting conditions. The majority of these children have metabolic disorders or neuromuscular degenerative conditions, with only approximately 20 percent suffering from cancer. The children’s hospice movement is a recent development, which began less than twenty years ago. The first children’s hospice was founded in Britain, and although the movement has spread throughout the world, Britain remains very much at its forefront. The first hospice, Helen House in Oxford, was founded in 1982 by Mother Frances Dominica, the Superior General of the Anglican Society of All Saints. She began a close friendship with Jacqueline and Richard Worswick when their daughter, Helen, developed profound and multiple disabilities following an operation to remove a brain tumor in 1978, when she was just two years old. Out of this friendship was born the idea of a small unit, akin to a family home, which would provide care for up to eight children with life-threatening illnesses or disabilities. At present there are twenty-two operational children’s hospices in Britain with a further fifteen hospices planned. These figures reflect a remarkably rapid development in the children’s hospice movement, when one considers that five years ago there were only a half dozen open. They are individually planned, but all offer support to children with life-limiting or lifethreatening illnesses, and their families. Many childhood terminal illnesses can have a longterm prognosis where deterioration occurs over many years and may involve profound physical and cognitive damage. Therefore, the children’s hospices offer respite care as well as terminal care and bereavement support. Remaining true to the original vision of Helen House, they are all small units, with none having more than eleven beds. Each child has his/her own room and the hospices also provide some family rooms or flats [apartments], so that parents can stay with their child if they wish.

The hospices seek to engender a home-away-from-home environment, with high levels of staffing (usually one-to-one) and a non-institutional approach. Most hospices have a wide range of facilities, including a swimming pool, computer room, soft-play area, music room, multisensory room, and art or play room. Some have nondenominational chapels where funerals can take place, and most have at least one temperature controlled room where the bodies can stay after death until the time of their funeral. The provision of music therapy in children’s hospices throughout Britain began in 1994 with the foundation of a charity called Jessie’s Fund in memory of a young girl named Jessica George who died of a brain tumor at the age of nine. Jessie’s parents started a fund to raise money to send Jessie to America for alternative treatment when her tumor failed to respond to conventional radiotherapy. Her parents are both professional musicians and their friends gave numerous concerts for what came to be known as Jessie’s Fund. Unfortunately, Jessie’s condition deteriorated quickly and she did not live long enough to have the treatment. Five months after diagnosis she died at a children’s hospice in Yorkshire. Although Jessie was only at the hospice for a week before she died, the one thing that she and her family really missed there was music. After her death, her parents decided to use the money raised to start a fund to provide music therapy in children’s hospices. Jessie’s Fund equips hospices with instruments, runs training courses for nursing and care staff in music-making, and gives hospices initial funding for a part-time music therapy post over three years. By the end of 2001 there were sixteen children’s hospices throughout Britain with part-time music therapists. This case study is based in one of the two children’s hospices in which I work. I set up the post there at the end of 1997 and work there one day a week. Although most of my work is with children who are staying for respite or terminal care, I also offer music therapy as a daycare provision and a few children and their family’s access music therapy on a weekly basis. As the majority of the children at the hospice have conditions that leave them with profound and multiple disabilities, much of my work involves using music to promote relaxation and pain management, and to provide these very damaged children with a means of nonverbal communication. With more able children, however, my work has a psychodynamic orientation. Initially I found some difficulties working psychodynamically within the hospice. I was viewed as someone who was going to entertain the children with music and “cheer them up.” The hospice itself can seem almost fiercely cheerful with its bright colors, large toys, and happy pictures. While this can be reassuring to families and children who may have had fantasies of a children’s hospice as a gloomy place with rows of dying children lying in beds, it also means that difficult and negative emotions can seem strangely out of place. I first had to establish a space for what Kuykendall (1998) terms “shadow:” an accepting space where children and families could bring their difficult and dark emotions that conflicted with the cheerful surroundings. In order to establish myself as someone willing to work in this way, I undertook education work with the staff to explain the function and processes of psychodynamic music therapy. I was aware that because children came to stay for up to two weeks at a time and because I would be working just one day a week, I would need the support of the staff to be able to work in such a way. In such a friendly home-away-from-home atmosphere, it took some time to establish the music room as a private space, where staff, parents, or other children cannot come and go

as they please while I am working, or interrupt a session to show visitors around or to inform me of a phone call. The other problematic aspect of working within a psychodynamic framework at the hospice is the irregularity of sessions. As only a small number of children come for regular sessions, I see the majority of the children on a very infrequent basis. They have sessions with me while they are staying for respite care and therefore these sessions need to be viewed as “one-offs.” It may be months or even years before I see them again, or they may die in the meantime. There is little opportunity to work through a therapeutic process and I cannot offer the safety of a regular therapeutic space. Due to these constraints, much of my psychodynamic work at the hospice takes place under the guise of play. As children naturally use play to explore and make sense of their world, working through play is a nonthreatening way of dealing with difficult issues and expressing emotions associated with them. Working in this way with a terminally ill child in music therapy gives him/her the opportunity to explore different scenarios and emotional states without the need to acknowledge verbally that he/she is actually experiencing them. The children that I work with often have limited verbal capacity due to either physical or cognitive disabilities associated with their illness. Even children with language can find words too threatening, too precise a vehicle with which to address profound and emotionally charged issues around their impending death, and they often show resistance to acknowledging issues verbally. This resistance occurs when the child is not consciously aware of his/her situation, or when he/she has learned that open communication about his/her illness cannot be borne by his/her family and others around him/her. Much has been written about children’s awareness of death and the means by which they communicate it (Kübler-Ross, 1969, 1981; Bertoia, 1993). While Kübler-Ross (1981) notes that children as young as three are aware that they are going to die and can talk about it, most communication by children about their impending death is at either a symbolic verbal level or a symbolic nonverbal level. In the case study discussed here, all of the material fell into these latter categories. The distancing process involved in symbolic musical play is an important aspect of music therapy with this client group. When a child explores his/her situation through musical play, the instruments that he/she uses and the music that he/she creates form transitional objects (Winnicott, 1971) through which communication of unconscious material occurs. These transitional objects may represent people and situations around the child, or can be used to express an aspect of the child him/herself through a kind of embodied musical play. In my experience, roles taken on in musical play are already familiar to the child, such as Disney characters, animals, or role models from television or films. Communicating through these various characters is less threatening than direct self-expression and reduces the level of resistance within the therapeutic encounter. Children often revisit characters and scenarios over long periods of time, even when there are significant breaks between sessions, reassimilating experiences and emotions according to their needs and abilities. In the case study I have chosen, a five-year-old child appeared to choose a single instrument to represent his situation and to communicate the knowledge and emotion of his illness, and employed nursery rhymes to facilitate an understanding of his dying.

Background Information At the turn of the twenty-first century, active treatment of cancer is far more successful than it was even ten years ago, with some cancers, such as leukemia, seeing an increase in survival rates from four percent in 1962 to 90-percent today.1 Yet, apart from accidents, cancer still accounts for more deaths in children between ages one and fourteen than any other illness. Brain cancers account for approximately 15-percent of pediatric cancers, with an average of 300 children developing brain tumors each year in the United Kingdom. Matthew was born in 1993 and was by all accounts an extremely lively child, who was able to read and count to beyond a hundred before he started school. Shortly after his fifth birthday his parents began to notice a subtle change in his coordination. The staff at Matthew’s school had also seen a slight problem with his balance when playing ball games, and they reported that he had some impairment in his attention span and that he had been falling asleep in class. Matthew’s parents decided to send him for tests to identify the problem, and in August, 1998, he was referred to the consultant pediatrician. His first NMR scan revealed a highly malignant tumor of the brain stem. Its size and position were such that although doctors recommended treatment, they could give no guarantee that it would be effective. Shocked and terrified by the news, Matthew’s parents agreed to a course of radiotherapy. The course lasted for six weeks, followed by a further six weeks spent waiting to see if it had shrunk the tumor. When at last the results came, they showed that the treatment had been ineffective in reducing the tumor or even in arresting its growth. Further treatment was offered, but chances of survival were deemed to be extremely slim. At that point, the family made the decision to not pursue further treatment and they were encouraged to look around their local children’s hospice. At the end of November the family first visited the hospice. I was not there that day, but the following week I heard reports of an engaging young boy with a mischievous sense of humor and some eccentric habits. With the growth of his tumor, and the resultant steroid treatment, Matthew was reported to have developed some challenging behaviors. These included pinching bottoms, stealing shoelaces, and covering people with stickers from a large collection that he kept with him. At times he could be aggressive toward others, which upset his parents as they felt that this was so unlike his normal character. Matthew spent that first visit energetically exploring the hospice, which he termed a “Fun House.” This unusual naming of a hospice was typical of Matthew’s determination to enjoy life, but also represented a defiance of his situation. I met Matthew the following week. I had the impression of a very strong character, who on only his second visit, seemed to have organized the hospice in the way that he wanted it and who had most of the staff at his beck and call. He appeared unable to focus on any activity for long and was very restless. He was testing the boundaries of this new environment, pinching the bottoms of new people that he met and showing some aggressive and demanding behavior. Some of this behavior was quite regressed and seemed to stem directly from neurological deterioration, such as his increasing fascination with urine and feces. Yet he had an awareness

of his own behavior and on our first meeting he told me that he was allowed to be as naughty as he liked because he was “poorly.” On the other hand, I was presented with a young boy who seemed to be really struggling with his situation. He was suffering from nausea, his balance was poor, his eyes squinted because of his tumor, and he was increasingly unable to hear and keep up with what was going on around him. Matthew’s speaking voice was gradually becoming louder as he was unable to hear himself speak, so that he tended to shout at everyone. As a means of selfpreservation in the midst of his failing abilities, Matthew blamed this problem on everyone around him. According to him, we were all inexplicably moving faster and talking quieter just to annoy him. He was having difficulty managing to play the computer games that he loved and was losing some of his intellectual sharpness. Treatment I was asked to assess Matthew for music therapy and, after speaking with his parents, offered him an individual session. His parents informed me that Matthew seemed unaware of how ill he was and had never asked about dying, although they would be open and ready to communicate with him if he initiated it. Later that day, Matthew had his first music therapy session. The music room in the hospice is quite small, with a good selection of instruments including a piano, guitar, metallophone, drums, cymbal, and many small percussion instruments. Matthew immediately made himself at home in the music room and began to explore several instruments at once. I noticed again how he was flitting from one thing to another, almost as if he was afraid of staying still, which seemed to be an attempt to mask the deterioration of his abilities. When asked how he would like to spend the session, he said that he wanted to sing. However, he immediately asked me to join him at the piano and “singing” turned out to mean playing piano duets. I was unsure as to whether this misplaced terminology was due to Matthew’s deteriorating capacity to use words, or simply the inability a five-year-old to differentiate between vocal and instrumental music. We played a lot of “songs” during that first, long session, all in a cheerful, childish style. Matthew was very much the leader in these improvisations, organizing me in the natural way that he organized everyone in his life. Matthew used eye contact and physical gesture to give me instructions as to how to play or how to finish playing. He showed an ability to communicate through the music he played, with an awareness of turn-taking and musical humor. Despite Matthew’s ability to engage in reciprocal play, I felt as though I was not being perceived musically as a separate other. It was as if I was being used as an extension of Matthew’s physical body with no individual input into the improvisations apart from my role in following his instructions. He was very structured in the way he approached these improvisations, which were all of roughly equal length and clearly demarcated. There was a short break after each “song” during which Matthew gave it a title. He named the first one “Myself,” and in many ways it did seem to reflect his personality: full of dotted rhythms and flamboyant, confident gestures that covered the whole range of the piano. Its energy and scope belied the physical fact of

Matthew’s deterioration, which did not seem to be addressed. Other titles included “The Weather” and “Friends,” but he did not elaborate verbally on any of them. These “songs” showed none of the anger or frustration that I might have expected from a young boy who was deteriorating so rapidly. Indeed, all of the improvisations sounded quite similar and undifferentiated. They seemed to embody an attempt to remain in an innocent, childish world of happy events and people, where nothing nasty or frightening occurred. I was aware that Matthew’s negative emotions were perhaps being projected through “naughty,” but childish, behaviors such as bottom pinching, biting, and kicking. After Matthew had finished all of his piano songs, he moved to an alto metallophone which was on the floor, instructing me to stay at the piano. He told me that we would play another song and began to play with the by now familiar dramatic flourishing of his arms. Again, Matthew’s music sounded cheerful and untroubled. As we played, I suddenly felt overwhelmed by a deep sense of sadness and loss. I turned to look at Matthew and saw that he had carefully removed the top bar of the metallophone and laid it on the floor without interrupting his improvisation. I realized that the effect of the removal of the bar was to handicap both him and his music. I wondered if this was Matthew’s attempt to reflect the physical situation that he was experiencing. I changed my accompanying music to acknowledge this change in affect even though Matthew’s cheerful physical stance and music remained unchanged. Matthew looked up briefly in acknowledgment but did not stop playing. After about another minute, he removed the next highest metallophone bar, again without ceasing his playing, thus further restricting himself. This continued until approximately half of the bars from the metallophone were lying on the floor. I felt very moved by this visual communication from a young boy who was gradually dying from the top down and losing his abilities as he did so. Although he could not speak about his experience of dying, or even directly express it in his music, it appeared that Matthew could use the alto metallophone to communicate the knowledge of his deterioration. As soon as this improvisation ended, Matthew jumped up and cheerfully said good-bye, leaving the room before any of the material could be addressed. After this session, I was left having to hold and process Matthew’s unmanageable feelings. I felt irrationally annoyed that he had skipped out of the room so lightly after playing, leaving me to replace the bars of the metallophone and to try to digest the material that he had communicated. It appeared that at this time Matthew needed to use me as a container for the awareness of his situation that he was as yet unable to assimilate. While Matthew could openly admit that he was “poorly,” he was not ready to accept that he was dying. Although he visited the hospice several times with his family after this, Matthew was often not there on the day I worked. On a few occasions when Matthew was in the hospice on the day that I was there, he chose not to come for a session, either because he did not feel well enough (at this stage he was suffering debilitating “headaches in his tummy” which made him very inactive) or, alternatively, because he felt very well and preferred to be outside playing. I felt some frustration at not being able to follow up on the first session, which had been so intense, but felt that he would return when he needed to.

Matthew’s other session with me took place three months later, just three weeks before he died, and ten days before his final visit to the hospice. We began with musical games where Matthew controlled my playing. He was taking the role of conductor, giving me nonverbal instructions as to how to play: pointing at me to tell me to start playing, and controlling the speed and volume of my playing through physical gesture. I was constantly directed to play fast and lively music and felt that here I was being used as a kind of transitional object, a vehicle for the music that he would have liked to play. Matthew was quite weak at this stage and was not capable of the sustained physical effort needed to play that he had managed three months earlier. He therefore needed to use me to express the energetic and healthy aspect of himself that he had lost. After this initial activity, Matthew again chose to play the alto metallophone, instructing me to accompany him on the piano. As in his first session, he began by removing the top bar a short time into the improvisation and went on to dismantle the instrument from the top down. The music itself was calmer and more introverted than it had been the previous time, with less drive and flamboyance. Again, I accompanied his playing by musically reflecting the emotion that I felt. This time, however, I felt less overwhelmed than I had in the previous session. On reflection this could partly be explained by the familiarity of Matthew’s actions, but there was also a sense that he had less need to project the emotion but could now survive its assimilation. During this improvisation, Matthew did not stop when half of the metallophone bars were lying on the floor as before, but continued until all of the bars had been removed. As we looked together at the metallophone frame lying on the floor, stripped of its bars, I was struck by how like a small coffin it looked. Both the shape of the box and the material it was made from, unpainted wood seemed suddenly, shockingly, coffin-like. Matthew then asked me to help him as he carefully placed all of the discarded bars and the beaters inside the shell of the metallophone. As we worked, I asked Matthew what had happened to the bars and he replied that they had got stuck inside the box. I wondered if that was a frightening place to be stuck, but he told me very seriously that they were happy in there. It seemed as though the coffin box could be a place of refuge for all of the worn-out, broken bars that could not play anymore, and for the beaters that no longer had anything to resonate against. Matthew seemed tired after all of this activity, and so we sat in silence for some time. He then asked to sing the nursery rhyme “Humpty Dumpty.” I played it on the piano while we both sang. In a child’s language and symbolism he seemed to be acknowledging the fact that he was now, like the metallophone, irreparably broken. There was no means of restoring him to health, despite all of the traumatic medical interventions he had experienced and the desperate wishing of his parents. In the end, not even the concentrated efforts of a king’s entire army could repair one cracked egg. Humpty Dumpty sat on a wall, Humpty Dumpty had a great fall, All the King’s horses and all the King’s men Couldn’t put Humpty together again.

Matthew then chose to finish the session by singing “Twinkle, Twinkle Little Star.” Having worked through an experience of dying and accepting it without fear, he then seemed to be able to contemplate what things might be like after death. Twinkle, twinkle little star, How I wonder what you are. Up above the world so high, Like a diamond in the sky. Twinkle, twinkle little star How I wonder what you are. Unlike the previous session, when I had been left with Matthew’s unmanageable feelings as he skipped out the door to play computer games, I felt that he had completed a process of integration of knowledge about his death. It seemed as though he had come to an acknowledgment and an acceptance of his fate via a journey of symbolic play and children’s rhymes. That was the last time I saw Matthew. He visited the hospice once more for day care, but was extremely poorly. He died peacefully on May 11, 1999, at home in bed, with his mother, father, and sister around him. Discussion and Conclusions The course of Matthew’s therapy was not untypical of children’s palliative work. Several aspects of the therapy were significant: the unusual structure of his therapy in terms of timing; the use of instruments in symbolic play; the role of countertransference; and the function of nursery rhymes. Temporal Aspects Working with people close to death can be challenging when one is used to working within a process involving regular therapeutic encounters. With this client group temporal boundaries of engagement can be more fluid than with others. Aldridge (1996) has differentiated linear time (chronos) and creative time (kairos), pointing out that much interaction within music therapy takes place within the latter. Bunt (2001) notes that for people close to death who no longer have a daily routine of work or school, the chronological delineation of time becomes less important and they tend to inhabit the world of kairos. The physical condition of clients can also impinge on the therapy space, and sessions may need to be altered due to external factors such as medication, nausea, tiredness, and pain. Therapeutic meetings therefore often take place in an ad hoc fashion without significant prior arrangement. In this case study, each of Matthew’s two sessions provided a space where he was free to explore both fantasied and real scenarios. Milner (1952) sees temporal boundaries in psychoanalysis as a kind of picture frame within which an altered reality, a creative illusion, can develop, and notes that it is this illusion that facilitates an adaptation to the world. Despite the sporadic and limited nature of his engagement, Matthew approached the sessions in a

linear way and completed a process of integration and adaptation within them. For a child of five with deteriorating memory, this was astonishing. It made me realize that my wish for consistent sessions did not originate in Matthew and that he simply did not need the security of a regular encounter. The Use of Instruments in Symbolic Play Matthew used the vehicle of an instrument as the transitional object of communication and exploration of his illness in his two sessions. The metallophone was employed in a directly symbolic way. It became a character that was given voice within the drama acted out within our improvisations. Bunt (1994) suggests that an instrument can become a bridge--a “field of play” within music therapy. Here Matthew was using one specific instrument to embody his physical being. The physicality of the metallophone meant that it could be used and reused within representational play, allowing Matthew to make sense of and assimilate his experience. The Role of Countertransference Although Matthew knew that he was very ill, he could not integrate that with a cognitive understanding of his death. Speaking about drawing with children suffering from leukemia, Bertoia (1993) notes that, even though children have an inner awareness of their prognosis, they may not be able to understand it in the context of their own experiences. Therefore, she suggests that providing opportunities for creative self-expression can be an important means of developing insight with terminally ill children due to the ability of creative arts to access unconscious expression. Initially, Matthew’s knowledge about his dying was split off and unassimilated. The music that he played held nothing of the emotion attached to this knowledge. It was only through his embodiment of an instrument as a transitional object that I could gain insight into his inner world and he could come to understand and express what was happening to him. In the first session the feelings to do with this understanding were projected and my initial insight stemmed from a countertransference reaction, which had nothing to do with the music that he played. In the second session, Matthew seemed to be able to process this emotion without the need to split it off into me. This was then borne out by his request to sing nursery rhymes that dealt directly with these issues. The Function of Nursery Rhymes Nursery rhymes form a modality of interaction for children and are learned and sung from a very young age. Yet they often contain disturbing imagery of violence and death. As such, they have a useful function for children as familiar containers for frightening material. Matthew’s choice of “Humpty Dumpty” perhaps charts his physical fall from health, which must have seemed quite sudden to him. The nursery rhyme is to do with the hopelessness of broken things and the uselessness of interventions. In “Twinkle, Twinkle,” the image is more hopeful. The bereaved siblings that I work with often refer to their brother or

sister as a star in heaven, and it is an image that young children seem comfortable with. Matthew’s choice of this nursery rhyme reflects a hopeful and calm approach to his fate. Final Thoughts Matthew’s engagement in music therapy was sporadic and because of this our work together could be said to have lacked a process. As issues were not dealt with in a direct way verbally, one can never be sure of Matthew’s awareness of death. However, the way in which he used these two short sessions suggests that he had explored profound existential themes using the transitional phenomena of children’s play and had come to an acceptance of his fate. Glossary NMR: Nuclear Magnetic Resonance. A scan which uses magnetism to build up a picture of internal organs. References Aldridge, D. (1996). Music Therapy Research in Practice and Medicine: From Out of the Silence. London: Jessica Kingsley Publishers. Bertoia, J. (1993). Drawings from a Dying Child: Insights into Death from a Jungian Perspective. London: Routledge. Bunt, L. (1994). Music Therapy: An Art beyond Words. New York: Routledge. Bunt, L. (2001). Collaborative Research into Music Therapy and Cancer Care. Seminar, Musicspace, Bristol, UK. Kübler-Ross, E. (1969). On Death and Dying. New York: Macmillan. Kübler-Ross, E. (1981). Living with Death and Dying. New York: Macmillan. Kuykendall, J. (1998). Master Class for Help the Hospices, London. (Oral Presentation). Milner, M. (1952). “Aspects of Symbolism in Comprehension of the Not-Self,” International Journal of Psychoanalysis, 34, 181-195. Winnicott, D. W. (1971). Playing and Reality. London: Tavistock. ________________ 1 Statistics from St. Jude’s Children’s Research Hospital, Memphis, Tennessee, 2001.

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE SEVEN Songs In Palliative Care: A Spouse’s Last Gift Jane Whittall Abstract This study describes music therapy with a 42-year-old woman with terminal cancer, who had her wedding on the palliative care unit. Through her choice of songs, she was able to gain insight into her own feelings during the dying process, and by listening to them, she worked through the pain of leaving her husband. A songbook and tape of these songs provided her husband with a last gift of her love. Background Information Claudette was a 42 year-old woman with a metastatic brain tumour that had been diagnosed 18-months prior to her admission to the palliative care unit. As a result, she had a transient left hemiplegia and lacked the balance to sit in a chair unless she was well supported with pillows. In an effort to control her seizure activity and pain, she was on high doses of anticonvulsant medications (which caused drowsiness and made long visits impossible) as well as steroids (which caused edema, mood swings, and increased appetite). She had had neurosurgery at the time of diagnosis to excise the tumour but it was too extensive. Her hemiplegia set in almost right after surgery. In the subsequent 18-months, Claudette had remained at home and was relatively symptom-free, but was becoming increasingly troubled by seizures, pain, and dysequilibrium prior to her admission. Claudette’s mother came to the hospital at least twice a week and appeared to have a close and supportive relationship with her daughter. Her father had died some time ago. She had been living with a man in common law for many years before she became ill, and decided to marry him as she was arranging her admission to palliative care. Claudette appeared to be adapting well to her illness by developing an interest in activities that could be done in bed, maintaining her sociability, and focusing on those things that were important to her emotionally. She was seeing the art therapist regularly, but was not viewing these experiences as therapeutically oriented. She was concentrating on drawing for enjoyment. She was very articulate about her needs, though she did not dwell on her difficulties—almost to the point of denial. Although there were no contraindications for music therapy, Claudette did tire very easily due to her progressive weakness, increased seizure activity, and increased anticonvulsant medications. Music therapy sessions, therefore, were usually limited to twenty or thirty

minutes twice a week. Claudette was referred to music therapy in a general way, mostly so that she could use music as an activity in bed and plan her wedding music. Treatment Process Gaining Rapport I became acquainted with Claudette in an informal way: by planning the music for her wedding together (the wedding was scheduled to take place three weeks after her admission to the hospital), and by providing her with a radio by her bedside. Although she enjoyed talking with me, she assured me that she had no areas of difficulty, and that her real interest in music was to listen to the radio and attend concerts for pleasure. I respected her request, always included her in concerts, and always stopped to chat on my way to see other patients in the hope of building a rapport with her. The wedding took place and was an extremely emotional event for everyone involved. This had been such a priority for Claudette that she became very fatigued afterwards for about one week. At this point, I wondered whether she would feel the need to process some feelings about being so ill, married, and admitted to palliative care. When the excitement of the wedding had passed, I noticed that Claudette was beginning to ask me more about my role on the unit; she was also telling other patients about me. In the weeks following her wedding, she asked me if I had ever heard of a song called “Chapel of Love.” She was glad to learn that I had, but she had asked very casually, and said that it was not really important. In fact, I was unable to find the song and might not have followed through on it, had she not continued to ask me about it on a number of occasions. At long last, I found the song. Its lyrics depict the innocent joy of love. Below is an excerpt: CHAPEL OF LOVE Spring is here, the sky is blue Birds would sing if they knew Today’s the day we say, “I do” And we’ll never be lonely again Because we’re going to the chapel and we’re Gonna get married.... I made a tape of this song for Claudette and gave her a copy of the words. She designated it as her wedding song (even though it was not sung at her wedding), and began to play it over and over. She said it was a song of simple beauty, and that so was her wedding. She then asked the art therapist to help her to draw a “chapel of love” from the song in her diary. Phase One Claudette asked me if I could find another love song for her called “L’amour, C’est Etc.” Again, she did not attach much importance to it, but told me it was a pretty song and she

wanted me to hear it. She identified with several phrases in the lyrics. Among them were the following (translated from French): LOVE IS ETC. Love is like a bird - it travels great distances and falls from great heights... Only when the sun does not rise will you know that you never existed for me... Love is like a child - you give him everything and he leaves when he is grown. Love is like the summer - we need autumn to miss it. Again, I taped this song for her (following “Chapel of Love”) and gave her a copy of the words. This time, we looked at the words together, and she pointed out to me the strong similes for love and the impact of the last line. “Love is like the summer - we need autumn to miss it.” She focused more on the romantic content of the lyrics than on the implication that love is transient. She did, however, ask me for another copy of the words to give to her husband. As we continued to talk and to develop a relationship, Claudette began to reflect on her relationship with her husband, its beginnings, and its importance to her life. She expressed interest in hearing what she called “their song,” and asked me if I could find it for her. She remembered only the title (“L’été Indienne” or “Indian Summer”) and main melody, but not the words. The verses with which she identified strongly were (translated from French): INDIAN SUMMER Today, I’m very far away from that autumn morning It feels as if, were I there, I would think of you Where are you? What are you doing? Do I still exist for you? I’m looking at this wave, and, you see, I, like it, am rolling backwards I, like it, sleep on the sand and remember, I remember The high tides, the sun, the happiness here by the sea An eternity, a century, a year ago I added this song to the tape and gave her a copy of the words. Claudette was surprised in listening to the song and in reading its lyrics to find such a nostalgic tone. She had remembered only the sense of commitment and romance. It was only upon reflection and discussion of the lyrics with me that she began to identify with the sense of loss and longing that is inherent in the song. She began to talk more about how things had changed since she became ill, and no longer assured me that everything was fine. She often cried while listening to this song, saying, “Isn’t this ridiculous? It’s only a song about someone else and here I am crying. Denis [her husband] tells me not to listen to these songs if they make me cry, but I want to.” I let her know that I had noticed a trend in the songs she had requested and asked her if she had. With encouragement and guidance, she was able to articulate that the songs reflected her recent life path and unexpressed feelings of loss, and she was relieved to find that other people had had similar feelings.

Phase Two This new insight came at a time of many physiological changes caused by the disease process, and Claudette became more fatigued and weepy. She did, however, ask me to find another song to add to her tape and song book. Below are excerpts from the song that reveal the main theme (translated from French). GOOD-BYE LOVERS I guess it’s not always enough to love each other, because we weren’t made to live together... And now that you have to leave, we have a hundred thousand things to say That are too close to our hearts - given such a short time... We’ll leave each other just like we loved each other Without thinking about tomorrow... We’d forgotten something though It’s hard to say goodbye And I know very well that sooner or later today, or tomorrow, maybe I’ll tell myself that all is not lost from this unfinished book I’ll make up a fairy tale, but I’m too old And I wouldn’t believe it... A simple story like ours - one we’ll never write Come, little one, we must go, and leave our memories here We’ll go down together if you like Once again, Claudette knew the title and the melody, but did not know the words. When I presented them to her, she was astounded to see how related to death they were and asked “Why am I choosing such depressing death songs?” We talked about the possibility of her having an unconscious notion about the theme of these songs, and talked about speaking through metaphors in song lyrics. I assured her of the progress she had made and of the wealth of her resource—music—in coping with her illness. She then said she had never been much of a talker, and wanted a way in which to include her husband in this process without upsetting him. It was at this point that I suggested making a booklet of all the songs in the order of her choice that could be left as a legacy for her husband as well as an accompanying tape. I emphasized the importance of her telling her husband about our sessions so that he would not find such a legacy to be depressing during his own grief process. I relied upon her to talk to him about these things, as her husband’s visits almost never coincided with my time at the hospital. By this time, Claudette was much weaker and I was not able to see her as often. However, she asked me for one more song whose title she knew and said it was a sad song. The following excerpts were taken from the end of the song, and give its main message: HONEY, I MISS YOU ...I came home unexpectedly and found her crying needlessly in the middle of the day And it was in the early spring when flowers bloom and robins sing, she went away... One day while I wasn’t home, while she was there all alone, the angels came

Now all I have is memories of Honey, and I wake up nights and call her name Now my life’s an empty stage where Honey lived and Honey played and love grew up And Honey I miss you, and I’m being good And I’d love to be with you, if only I could. Once again, Claudette was surprised at the death-specific theme of this song, how she came to choose it without consciously knowing the words, and how it reflected her recent process. This was the last song that was included in her legacy tape and song book. Until this point, she had been keeping her husband updated on our sessions and had prepared a song book for him with me. Shortly after we worked with this song, Claudette had a severe seizure and was no longer lucid enough to process at this level. Although this occurred during her third month of hospitalization and she lived another three months, I left the hospital soon after this episode and, consequently, was not involved in her husband’s bereavement process. Discussion and Conclusions Claudette’s case points out several important factors to consider when working with the terminally ill. Many of us have come across countless references to the stages of dying, and, therefore, sometimes rely on our assessment of a particular stage instead of on the patient’s appraisal of the situation. In this case, perhaps there was some denial; but it appears to have been a valuable coping mechanism for Claudette’s emotional survival. This is why it is important to give the person space, and to take cues from him/her as to the content and depth of music therapy sessions. I believe that this respect is an essential element in gaining rapport and in establishing a relationship in which the therapist does very little other than support and encourage the patient. Working from a planned theoretical orientation, in this case, would have gotten in the way of my ability to give Claudette the space she needed. I would not have “been there” for her—I would have “done something” to her. The selection of songs and their order reflects the process of moving from denial of emotional turmoil to the gradual identification of the main issues that were of concern to Claudette. This process also gave her insight about the opportunity to reach some emotional resolution about leaving her loved ones. The making of a tape of these songs helped Claudette to slowly process this newly acquired insight (because she listened to the tape very often), and to provide her loved ones with a gift that would outlive her. This was perhaps one of the most personal gifts she had ever given, as it shared the inner emotional turmoil of her last days of living, as well as providing her loved ones with a legacy of her life. In the bereavement process, this might serve as a transitional object for those who are grieving since it is a real presence of Claudette’s personhood, yet it is also very soothing. This process will, hopefully, live on in memory of Claudette, whose husband now has her legacy tape and song book.

Glossary Metastatic: Spreading. Transient Hemiplegia: Paralysis on one side that comes and goes, in this case, because of pressure from the tumour on the spinal cord. Transitional Object: An object that is treasured (often because of its association with loved ones) and therefore a source of comfort when separated from loved ones.

Other E-books in this Series Available from: www.barcelonapublishers.com

Case Examples of Music Therapy— For Alzheimer’s Disease For Autism and Rett Syndrome In Bereavement For Children and Adolescents with Emotional or Behavioral Problems For Developmental Problems in Learning and Communication At the End of Life For Event Trauma For Medical Conditions For Mood Disorders For Multiple Disabilities For Musicians For Personality Disorders For Schizophrenia and Other Psychoses For Self-Development For Substance Use Disorders For Survivors of Abuse

Barcelona Titles by Topic Available at www.barcelonapublishers.com Analytical Music Therapy • Essays on Analytical Music Therapy (Priestley) • Music Therapy in Action (Priestley) • The Dynamics of Music Psychotherapy (Bruscia) • Group Analytic Music Therapy (Ahonen-Eerikäinen) Case Studies • Case Studies in Music Therapy (Bruscia) • Inside Music Therapy: Client Experiences (Hibben) • Psychodynamic Music Therapy: Case Studies (Hadley) • Developments in Music Therapy Practice: Case Study Perspectives • Case Examples of Music Therapy: A Series of 16 e-books Children with Special Needs • Alike and Different: The Clinical and Educational Uses of Orff-Schulwerk – Second Edition (Bitcon) • The Miracle of Music Therapy (Boxill) • Music for Fun, Music for Learning (Birkenshaw-Fleming) • Music: Motion and Emotion: The Developmental-Integrative Model in Music Therapy (Sekeles) • Music, Therapy, and Early Childhood (Schwartz) • Music Therapy in Special Education (Nordoff & Robbins) • Therapy in Music for Handicapped Children (Nordoff & Robbins) Infancy and Early Childhood • Music, Therapy, and Early Childhood (Schwartz) • Music Therapy for Premature and Newborn Infants (Nöcker-Ribaupierre) End of Life • Music Therapy: Death and Grief (Sekeles) Feminism • Feminist Perspectives in Music Therapy (Hadley) Fieldwork and Internship Training • Clinical Training Guide for the Student Music Therapist (Wheeler, Shultis & Polen) • Music Therapy: A Fieldwork Primer (Borczon) • Music Therapy Supervision (Forinash) Group Work • Music Therapy: Group Vignettes (Borczon) • Music Therapy Improvisation for Groups: Essential Leadership Competencies (Gardstrom) Guided Imagery and Music (Bonny Method) • Guided Imagery and Music: The Bonny Method and Beyond (Bruscia & Grocke) • Music and Consciousness: The Evolution of Guided Imagery and Music (Bonny) • Music and Your Mind: Listening with a New Consciousness (Bonny & Savary) • Music for the Imagination (Bruscia) Guitar Skills

• Guitar Skills for Music Therapists and Music Educators (Meyer, De Villers, Ebnet) Improvisational Music Therapy • The Architecture of Aesthetic Music Therapy (Lee) • Essays on Analytical Music Therapy (Priestley) • Creative Music Therapy: A Guide to Fostering Clinical Musicianship – Second Edition with Four CDs (Nordoff & Robbins) • Group Analytic Music Therapy (Ahonen-Eerikäinen) • Healing Heritage: Paul Nordoff Exploring the Tonal Language of Music (Robbins & Robbins) • Improvising in Styles: A Workbook for Music Therapists, Educators, and Musicians (Lee & Houde) • Music as Therapy: A Dialogal Perspective (Garred) • Music-Centered Music Therapy (Aigen) • Music Therapy: Improvisation, Communication, and Culture (Ruud) • Music Therapy Improvisation for Groups: Essential Leadership Competencies (Gardstrom) • Paths of Development in Nordoff-Robbins Music Therapy (Aigen) • Playin’ in the Band: A Qualitative study of Popular Music Styles as Clinical Improvisation (Aigen) • Sounding the Self: Analogy in Improvisational Music Therapy (Smeijsters) Music for Children to Sing and Play • Distant Bells (Levin & Levin) • Learning Songs (Levin & Levin) • Learning Through Music (Levin & Levin) • Learning Through Songs (Levin & Levin) • Let’s Make Music (Levin & Levin) • Music for Fun, Music for Learning (Birkenshaw-Fleming) • Snow White: A Guide to Child-Centered Musical Theatre (Lauri, Groeschel, Robbins, Ritholz & Turry) • Symphonics R Us (Levin & Levin) Nordoff-Robbins Music Therapy (Creative Music Therapy) • The Architecture of Aesthetic Music Therapy (Lee) • Being in Music: Foundations of Nordoff-Robbins Music Therapy (Aigen) • Conversations on Nordoff-Robbins Music Therapy (Verney & Ansdell) • Creative Music Therapy: A Guide to Fostering Clinical Musicianship – Second Edition with Four CDs (Nordoff & Robbins) • Healing Heritage: Paul Nordoff Exploring the Tonal Language of Music (Robbins & Robbins) • Here We Are in Music: One Year with an Adolescent Creative Music Therapy Group (Aigen) • A Journey into Creative Music Therapy (Robbins) • Music Therapy in Special Education (Nordoff & Robbins) • Paths of Development in Nordoff-Robbins Music Therapy (Aigen) • Playin’ in the Band: A Qualitative study of Popular Music Styles as Clinical Improvisation (Aigen) • Therapy in Music for Handicapped Children (Nordoff & Robbins) Music Psychotherapy • The Dynamics of Music Psychotherapy (Bruscia) • Essays on Analytical Music Therapy (Priestley) • Emotional Processes in Music Therapy (Pellitteri)

• Group Analytic Music Therapy (Ahonen-Eerikäinen) • Guided Imagery and Music: The Bonny Method and Beyond (Bruscia & Grocke) • Music and Consciousness: The Evolution of Guided Imagery and Music (Bonny) • Music and Your Mind: Listening with a New Consciousness (Bonny & Savary) • Music Therapy: Group Vignettes (Borczon) • Psychodynamic Music Therapy: Case Studies (Hadley) Orff-Schulwerk • Alike and Different: The Clinical and Educational Uses of Orff-Schulwerk – Second Edition (Bitcon) Periodicals (Free Downloads Available) • International Journal of Arts Medicine • Qualitative Inquiries in Music Therapy: A Monograph Series Profound Mental Retardation • Age-Appropriate Activities for Adults with Profound Mental Retardation – Second Edition (Galerstein, Martin & Powe) Psychodrama • Acting Your Inner Music (Moreno) Psychiatry – Mental Health • Music Therapy in the Treatment of Adults with Mental Disorders: Theoretical Bases and Clinical Interventions (Unkefer & Thaut) • Psychiatric Music Therapy in the Community: The Legacy of Florence Tyson (McGuire) • Psychodynamic Music Therapy: Case Studies (Hadley) • Resource-Oriented Music Therapy in Mental Health Care (Rolvsjord) Research • A Guide to Writing and Presenting in Music Therapy (Aigen) • Multiple Perspectives: A Guide to Qualitative Research in Music Therapy (Smeijsters) • Music Therapy Research: Quantitative and Qualitative Perspectives – First Edition (1995) (Wheeler) • Music Therapy Research – Second Edition (2005) (Wheeler) • Playin’ in the Band: A Qualitative study of Popular Music Styles as Clinical Improvisation (Aigen) • Qualitative Inquiries in Music Therapy: A Monograph Series (Free Downloads Available Here) • Qualitative Music Therapy Research: Beginning Dialogues (Langenberg, Frömmer & Aigen) Supervision • Music Therapy Supervision (Forinash) Theory • Culture-Centered Music Therapy (Stige) • Defining Music Therapy – Second Edition (Bruscia) • Emotional Processes in Music Therapy (Pellitteri) • Music and Life in the Field of Play: An Anthology (Kenny) • Music as Therapy: A Dialogal Perspective (Garred) • Music-Centered Music Therapy (Aigen) • Music Therapy and its Relationship to Current Treatment Theories (Ruud) • Music Therapy: A Perspective from the Humanities (Ruud) • Music Therapy: Improvisation, Communication, and Culture (Ruud) • Music—The Therapeutic Edge: Readings from William W. Sears (Sears)

Voice

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The Music Within You (Katsh & Fishman) Resource-Oriented Music Therapy in Mental Health Care (Rolvsjord) The Rhythmic Language of Health and Disease (Rider) Sounding the Self: Analogy in Improvisational Music Therapy (Smeijsters)

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Authentic Voices, Authentic Singing (Uhlig) Psychiatric Music Therapy in the Community: The Legacy of Florence Tyson (McGuire)