Episodes of Relationship Completion Through Song: Case studies of music therapy research in palliative care
Amy Clements-Cortes, BMT, MusM, MTA, PhD, Senior Music Therapist, Baycrest Centre for Geriatric Care, Toronto, Board Member: Canadian Association of Music Therapy, Room 217 Foundation
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This article has been reprinted with the kind permission of author Amy Clements-Cortes.
Personal Motivation for This Investigation
My Position as a Musician, Music Therapist, Music Teacher, and Researcher
My artistic experiences have taught me that the arts are widely valued in our culture even if not so explicitly stated. For example, music’s continued prevalence and availability in today’s society reinforces for me that it is something that we crave as humans, and something that we need indirectly for survival. I think of music as a basic need because it has the power to satisfy emotional needs such as relationship, communication, as well as intellectual, spiritual, and aesthetic needs which are purely as important to a person being whole as is the satisfaction of our physiological needs. In fact Sloboda (2005) maintains that “music serves a major psychological function in many people’s lives, closely connected to the explicit purposes of many forms of psychotherapy” (p. 216).
The arts including music are a key source of knowledge and meaning about ourselves as human beings and the world around us. They have taught me about beauty, passion, happiness, emotions, and pleasure. I charge that music teaches us, and is a very powerful way of learning about relationships. I believe that the ultimate defining quality and value of music that makes it so vital is its power to make us feel, become aware of, and express our feelings and emotions in a way that we are often not able to do through words alone. Sloboda (1992) confirms that strong and valued emotions appear to be at the heart of engagement with music.
Music creates sacred spaces and provides me with feelings of fulfilment and privilege. I do not believe that the meaning of music is solely inherent in the music, but that it is a combination of both music’s intrinsic properties and its external associations. Interestingly, Bigand, Filipic, and Lalitte (2005) report that while our emotional responses to music may be conditioned by memory, the emotional character of musical excerpts are easily recognized and consistent among listeners independent of their backgrounds in music and culture.
Being both a music teacher and music therapist I think my view is unique, and for me it is vital to be connected to the value of music in my life and in the lives of my students and clients. This is critical to my understanding of why it is so essential to teach music and practice music therapy principles. It is in the past twelve years working as a music therapist, music teacher, and performer that my connections to the arts and in particular music have grown stronger, and the power of music has never been more alive for me. There are days when I question why I have chosen to be a music therapist and wonder if I am really helping anyone, but then I think of some of those healing and transformative moments. I have been given the gift of music and I am fortunate to be able to share it on a daily basis either by inspiring young students or helping patients at the hospital with a copious variety of goals.
Intentionality and Researcher Presence
As a music therapist and researcher working in an inpatient palliative care program, I initially became interested in investigating if music could help patients with their physical pain, and in turn, enhance their comfort. I am pleased to say that I have been able to witness such benefits of music first-hand through my provision of live music at the bedside, and through the results of a research study I conducted which looked at the effects of live music versus taped music on patients’ perceived pain and physical comfort (Clements-Cortés, 2005). There are several theories that explore why music might be useful in reducing pain perception. For example, Beck (1991) theorized that music might alter the perception of pain through affective and cognitive effects that stimulate endorphin production and the endogenous mechanisms for pain modulation. She concluded that “music therapy is a non-pharmacological method which helps manage pain and suffering in patients with long-term and life threatening illnesses” (p. 1335) and additionally that music therapists working in collaboration with other medical approaches could maximize a patient’s pain control. Brown, Chen, and Dworkin (1989) proposed that there are two distinct attributes of music that may be useful in developing effective pain coping skills: attention-distraction, and an affect dimension. They state that music has the potential to hold one’s attention, modify one’s emotional state, and evoke moods. Magill-Levreault (1993) proposed that music therapy could change the perception of pain in patients by distraction, alteration of mood, enhancing control, use of prior skills, and promoting relaxation.
Psychological pain refers to pain that is the result of psychological stress and/or emotional trauma. It is “pain having mental, as opposed to organic, origin” (Thomas, 1997, p. 1390). Thinking of patient care and pain in a more holistic manner, people experience not only physical pain, but also psychological pain, and some of the physical pain may in fact be expressions and manifestations of psychological pain. Zimmerman, Pozehl, Duncan, & Schmitz (1989) explain that pain is a complex phenomenon produced by the interaction between physiological, psychological, social, cultural, and spiritual components. According to Brown, Chen, & Dworkin (1989) today’s researchers and clinicians concur that physiological and psychological factors interact to produce pain perceptions and pain behaviours. In my pain research study (cited above) I learned that music was helping patients, but how was it helping? Was it providing them with a more peaceful frame of mind, therefore enhancing comfort and reducing psychological pain? Was music helping by diverting attention away from pain and providing a tiny escape? What were the issues affecting the experience of pain? What was the source or cause of the pain? In a subsequent study I would add a qualitative component in terms of answering some of these questions, and obtaining a more descriptive account of pain.
From that point I became interested in using music to help facilitate emotional expression in the terminally ill, and I began to see that music used in this way was a potential avenue to help clients cope with psychological pain. The concept that music and emotion are linked is discussed by Salmon (1993) who explains that music and emotion: contain multiple themes simultaneously; are made up of an interplay between tension and resolution; use symbolic expression; move through time and are defined largely by time; and, exist in the realm of relationship. Music acts as a non-verbal catalyst of our feelings, which helps evoke an emotional response, in turn releasing information stored in memories and facilitating the expression of feelings both pleasant and more difficult to deal with. When a patient experiences strong emotional reactions, he/she chooses music that will reflect his/her spiritual and emotional state, and thus the music becomes a mirror into the emotions.
Once again I was privileged to see that music could have an impact in helping patients express emotions that were too difficult to communicate verbally. Sometimes this expression centred on conveying feelings of anger and frustration regarding their illness; other times music helped clients express sadness over their losses. One of the key sources of psychological pain appeared to surround relationships. Patients worried about loved ones they were leaving behind, strained relationships, and grieved the loss of: long-time relationships with spouses, children, parents, and friends; and, the future losses of missing life events such as weddings and grandchildren. For example, Bailey (1984) found that songs selected by patients tended to reflect a variety of themes including hope, pleasure, relationships, needs and desires, feelings, loss, and death and peace. Reminiscing allowed families to reconnect together over music that brought up significant memories, and/or to discover unresolved issues that were subsequently addressed with the help of the music therapist. The use of songs in music therapy allowed patients and families to experience increased connectedness and the song theme that focused on relationships was a useful tool in helping patients and family members process unresolved feelings about various relationships.
Magill (2005) presents the case of Michael, a 34 year old male diagnosed with prostate cancer who was referred to music therapy by the psychiatrist due to his self-imposed isolation. When approached by the music therapist, Michael was hesitant but eventually agreed to listen to music and consented to future sessions. Music therapy provided him with the opportunity to vent his feelings of sadness and fear, and most importantly to express the sadness he felt about “abandoning” his brother. His feelings of guilt were preventing him from receiving the much needed support that was being offered to him in his relationships with his family, friends, and the health care team.
In Kugelman’s (2000) hermeneutical-phenomenological analysis of pain narratives he found that every narrative of psychological pain began with the end of a relationship, thus reinforcing the fact that incomplete relationships are a key source of psychological distress.
Dying persons are also challenged by ending the relationships with themselves and spiritual figures. Research is needed to assess what therapies and techniques may be helpful in facilitating and enhancing relationship completion for the dying and how this may be accomplished.
I am thankful that in my practice I have been able to use music to help clients express these emotions, and in turn, ease their anxiety. In order to continue to develop as a clinician and to work in greater depth with my clients, and improve their overall care and comfort, I need to know how I can continue to help my clients once they have expressed these emotions. I want to broaden my understanding of how music can be used to help a person cope with issues surrounding relationships of an intrapersonal, interpersonal, and/or transpersonal nature, specifically, ending relationships with themselves and significant others (family, friends, pets, spiritual figures/connections.) I am becoming increasingly more aware that songwriting is a powerful tool that can facilitate emotional expression, and that the songs themselves often become very meaningful to the patient and those with whom they share the songs. Once introduced to songwriting and engaging in this form of creative expression many patients choose to write songs as gifts for their loved ones, songs that reflect feelings and messages that they would like to share with their families, and ultimately songs that help them to complete relationships with various persons including themselves. Dileo and Magill (2005) state:
When facing their end-of-life, individuals naturally review their lives and tend to want to come to terms with unfinished business and unresolved issues in relationships. Songwriting offers patients the opportunities to express their feelings of remorse, gratitude, hopes and appreciations. These expressions can enhance feelings of closure, often resulting in feelings of relief and resolution. (p. 226)
Byock (1997) elucidates that there are five sentiments that permit relationships to reach completion once they are expressed. These are: “I love you,” “Thank you,” “Forgive me,” “I forgive you,” and, “Goodbye.” According to Dileo and Parker (2005) “Songs can convey these messages more powerfully and completely than words alone,” (p. 45) and Dileo and Magill (2005) assert that various clinical methods could be used to facilitate the expression of these sentiments including song choice, song improvisation, song discussion, song dedication, song narrative, creation of song legacies, and songwriting. The present study built on the findings of Dileo and Parker to investigate the effect that various music therapy techniques may have in facilitating relationship completion in the ways outlined by Byock (1997).
VIEW Artistic Excerpt: Music to Shatter The Silence
VIEW Review By: Kevin Kirkland, PhD, MTA
The Author: Amy Clements-Cortes, BMT, MusM, MTA, PhD is Senior Music Therapist at Baycrest Centre for Geriatric Care in Toronto, working with clients in the Rehabilitation, Behaviour Neurology, Complex Continuing Care and Palliative Care units. She also serves on the Board of Directors for the Canadian Association of Music Therapy, conducts numerous research projects and is a frequent presenter and author. Amy owns and operates a private studio and has produced CDs and videos used in music recreation programs. Amy also offers her broad range of experience in both the arts and healthcare as a member of the Room 217Foundation Board of Directors. To purchase Episodes of Relationship Completion Through Song visit Amazon.com
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