By Aaron Lightstone

When we provide palliative care music therapy, or any kind of care for that matter (palliative or not, musical or not) we as caregivers do our utmost to engage directly with the individual person we are caring for.  We do our utmost to see that person and interact with each individual as a whole person.  On one level this means getting past a person’s cultural background and seeing them as the idiosyncratic, quirky, individual person that he or she is.   Providing culturally sensitive therapy/care also means having a strong awareness of how our own cultural identity  affects the dynamics of therapy and caregiving with the people we provide care to (Hadley, 2013).

When we start to speak about a person’s culture and account for it in the therapy setting, we risk responding to our consciously and unconsciously held perceptions, beliefs and stereotypes as to how a person from that particular culture is supposed to behave, think and respond.  For therapists, one function of good supervision with an experienced supervisor is to help bring these dynamics into one’s awareness.  Despite the risk, it is an important risk to take because culture is such a fundamental building block of our personal identity. Yet there are many complexities and dynamics to cultural identity.  Some people embrace their culture (to many degrees), others reject their culture (in many different degrees) and some are ambivalent or think they don’t belong to a particular cultural group. I find this latter group interesting, because it shows us that ethnicity plays such a large role in forming cultural identity.  In most societies members of the dominant/mainstream culture can be prone to thinking that they do not belong to any particular cultural group because they are not “ethnic”. 

Of course everyone belongs to a culture, everyone is part of some ethnic group, (even if it is an ethnic group that is so culturally dominant that it does not even register as an ethnic group), but if we learn about a patient’s ethnicity and think that we now understand her culture we are short changing her as a patient and ourselves as caregivers.  I think this is an important point, because in recent years care givers have been taught to pay a great deal of attention to cultural sensitivity, to providing care that is sensitive to and respectful off a patient’s cultural perspective.  This is a huge step forward in the interest in providing quality patient care, but I don’t think we often take enough time to understand what is really meant by respecting a patient’s culture or even what cultural identity really encompasses.  Most of the time caregivers think they are being culturally sensitive when they know something about the patient’s religion and/ or ethnicity.   Let’s take a moment to consider all the other factors that make culture a larger concept than religion and ethnicity [don’t get me wrong, taking time to understand how a person’s religion (or lack thereof)  and ethnicity (or perceived lack thereof) plays into their self-concept is a great place to start but we must go further].

Consider the following examples.

A teenager is in care with an illness that he has battled since he was 6 years old.  His parents were born into Hindu families in Rajastan, India and came to Canada before he was born where they live a relatively secular life only going to temple for the most important festivals.  He grew up in a suburban neighborhood of Toronto that is mostly populated by immigrants from China.  Most of his friends are Chinese.   He loves to make original Hip Hop music on his lap top and upload it to youtube, facebook,  and soundcloud.   Some of his friends are into this kind of music making and sharing as well, but he is the most skilled in his peer group.   This young man from Canada is of Indian heritage, identifies strongly with African-American music, has mostly Chinese friends, but spends a lot of time in hospital and “patient” may be part of his identity, he is also a digital native.    The point I am making with this vignette is that if we only pay attention to being sensitive to his religion and ethnicity we might not get many of the nuances of his cultural identity particularly the part that relates to music.  From his perspective his “Hip Hopness”  might be of equal or greater importance to his cultural identity than his “Indianess” For many teenagers musical preferences are not just about musical preferences.  They are also important markers of cultural identity.  As the sociologist Robin Sylvain (2002) points out, for some youth identification with a popular music subculture can be a more powerful point of identity building than the ethnic group they originate from.  Being a “deadhead” is not just about liking the music of the Grateful Dead, being a “raver” is not just about being interested in electronic dance music, and being a “Hip Hopper” is not just about liking rap music.   For the youth who are invested in these groups, the identification with the group can be extremely powerful in the formation of identity.  It truly becomes their tribe.   They have community, shared rituals and language and aesthetic conventions not just in music but in visual arts such as fashion (think of the baggy pants worn by many teens listening to Hip Hop).  Sylvain’s fascinating ethnography details how for many youth their affiliation with a popular music-based subculture provides many of the  social/cultural functions that membership in religious and ethnic groups provided to previous generations.   In this short example I have tried to add many nuances and variables to culture beyond the basics of ethnic group and religion.  I could have added many more important details such as which languages did his grandparents speak, what caste did they come from, what level of education did his parent’s achieve, or more  information about his socio-economic status.  These are all factors that play into the shaping of a person’s cultural identity.

If I look at the building blocks of my own culture, then I might describe my-self as a Canadian-Ashkenazi Jew (of East-European ancestry), musician (who identifies more with Sephardic music than Ashkenazi music), urban, white, straight, married (with children) male. Some might argue that some of these descriptives go beyond culture and start to get into the deeper, more personal concept of identity. I am making the point that culture and identity are intertwined and inseparable.  Being a musician is an important part of my personal identity, but I also belong to a culture of musicians in Canada.   So my point is simply that culture is much more complicated than ethnicity, or religion and that as caregivers we need to understand how nuanced it can be and then get to appreciate how these nuances manifest themselves in the people we care for.  Before thinking about this in terms of the culture of the people whom we provide care for, it can be useful for caregivers to beginning by examining the interplay and dynamics of all the different cultural groups that they identify with.  This is an important point for all caregivers but especially so for music therapists because we are using music which is such a powerful, cultural medium.

I remember at a very early point in my music therapy training reading something somewhere about the importance of having a repertoire of “ethnic” songs so that when I encounter a Greek client (for example) in my work, I will be able to connect to this person with a popular Greek song, or Jewish, or Tamil, or Cantonese or whatever.  I always had trouble with this notion as being a bit too simple and reductionist.  I would never discount the idea completely because I have seen (particularly with elderly dementia patients) how this technique can provide a valuable point of connection. Especially at the early stages of therapy with people who have advanced dementia for example.  I once had an elderly Lebanese patient in palliative care. We had no common language with which we could speak.   One day I showed up at her bedside with my oud and played an Uhm Koulsthum song.  Her face really lit up and her mood changed for the better.  But this was not an example of me learning a familiar Arabic song in order to make an initial connection with her.  I have a deep and genuine interest in this instrument and the music-culture associated with it, and I think that this shared and genuine interest might make all the difference.  A shared and genuine interest in a client’s music is communicated in very subtle and non-verbal ways and it is really hard to fake it.  Fortunately, I am a curious musician so I have a genuine interest in many music-cultures including reggae, calypso, and Caribbean folk songs, popular music of the 30s,40s, 50s,and 60s, blues, Sephardic folk songs, Bossa Nova, Choro, Samba and other Brazilian forms, Son, Afro-pop, Texas string bands, Klezmer, Indian Classical, Arabic Classical, Indian film music, Rock and Roll, most forms of Jazz, some forms of European classical music,  most forms of country music, Hip-Hop, and a few other kinds of music.  On the other hand here are a small number of musical forms that I have listened to and just can’t relate to or just find myself completely unmoved (they shall remain unnamed as I don’t want to offend those fans or practitioners).  My musical taste might seem rather broad, but if you think about I still have yet to explore  most of the world’s music which is still untested to my ears.  As a curious musician I probably have a broader musical palate than the average person, but my point is that especially in this post-modern age, a person’s culture (or a very basic description of it) may not give many clues for what type of music a therapist might use to establish a relationship. For example, if the year was 2062 and I was an elderly music therapy client in long-term care, what music would be a good starting point for this Jewish-Canadian born in 1973 (aged 89 years)?

Familiar music can be very comforting particularly in difficult situations such as palliative care, but novel experiences are fun, enriching, and stimulating.  (Depending on what the goals of the therapy are) I think we do our client’s a disservice if we only offer them familiar music experiences or music experiences that they are capable of requesting.  Think for a moment about a time you heard (for the very first time) a kind of music that was new to you that you really enjoyed.  A new song, a new band, or even a whole new genre.   This was stimulating, or fun, enjoyable, or exciting.  It can be easy for music therapists to fall into the mode of being a human juke box, playing requests for our clients, but we can also become guides for our clients and offer them a range of music experiences that includes novel ones.   I find that after I know a client I can predict with some accuracy which unfamiliar songs, music genres, or improvisational styles they will respond to, and I have seen important things happen when people are gently pushed or guided toward new musical experiences.  

I have often used my oud and sitar in palliative music therapy sessions. Some might assume that the oud is particularly useful with people from the Middle-East and the sitar with people from India.  What is so intriguing is that this is not necessarily the case.  People who are not from those cultural backgrounds often can have just as strong (or often stronger) a response to the sound of those instruments.  Both are very resonant instruments with very rich tones.  I find that people who have cultural familiarity with them appreciate the effort of trying to meet their culture.  People who don’t have that connection also have strong responses.  I think the novelty of the exotic looking and sounding instruments has something to do with it but I think they have a very powerful sound that touches people in a deep way. 

 A couple of years ago I had the opportunity to do music therapy for trauma recovery with a veteran of the Canadian military.   He had done his military service in the Middle-East so I thought that if I brought my oud to our sessions that I might be adding an unnecessary layer of complexity and that (at least at the beginning)  I should avoid the oud and stick to the guitar as my primary clinical instrument.   After about seven sessions he asked about what other instruments I played and I felt I would be inauthentic for me not to tell him about my involvement with the oud.  He insisted that I bring the oud to the following sessions and he had very powerful responses to my playing on the oud, and he developed a very strong preference for my use of the oud in our sessions (as opposed to my playing guitar).  Much of his therapeutic progress seemed to occur as result of the improvisations we did together where I played oud and he played percussion.  Other than his year of military service in the Middle-East he had no prior exposure or cultural connection to this instrument.  He describes its tone as “earthy, spiritual, and grounding”.  He often spoke about being “ungrounded” and needing to get “grounded”.  He felt that the timbre of this instrument helped ground him and helped him process his trauma in ways that the sound of  guitar was not able to.  

So while I think a nuanced understanding of our client’s culture can be vitally important to the success of therapy, we also have to be careful that knowledge of culture does not blind us to bigger possibilities. I never would have thought that my oud would become an essential ingredient in the trauma therapy of a Caucasian, middle-aged male from North Ontario.  He challenged some of my notions of culture and I learned a lot from the experience of working with him.

As an afterword I would like to make readers aware of a related article that I collaborated on with Susan Hadley (2013) for her very important new book Experiencing Race As A Music Therapist: Personal Narratives.  This book is a response to the fact that in our training and professional lives as caregivers and music therapists, we may not adequately reflect on how our race (and our experience of it) affects our perceptions of ourselves and impacts our clinical work.  We often try to be color blind but in many situations race/ethnicity can be the elephant in the room.  Hadley worked with music therapists from all over the world, getting them to examine this issue in their own lives and clinical work and then she co-wrote a different chapter with each contributor.  Jewish, Maori, First-Nations, African, White, Aboriginal (Australian), African-American, Asian (Korean) are some of the ways in which the various authors identify themselves.  My chapter is called Reflections on the Paradoxes and Complexities of Identity.  In this chapter I reflect in greater detail how my identity as a Jewish-White-Male-Straight person impacts my work as a clinician. This book can be purchased in hard copy or as an ebook from http://www.barcelonapublishers.com/experiencing-race-as-a-music-therapist-personal-narratives/


Hadley, S. (2013). Let’s Talk About Race in Experiencing Race as a Music Therapist: Personal Narratives.  (Hadley, ed).  Barcelona Publishers, Gilsum NH.

Lightstone A.J, Hadley (2013). Paradoxes and complexities of identity in Experiencing Race as a Music Therapist: Personal Narratives (Hadley, ed).  Barcelona Publishers, Gilsum NH.

Sylvan, R. (2002). Traces of the Spirit: The Religious Dimensions of Popular Music. New York University Press, New York  NY.

About the Author: Aaron Lightstone MMT, MTA  is a music therapist, musician, composer, and ethnomusicologist who has been practicing in the Toronto area for the past 16 years  (www.musictherapytoronto.com).  He has extensive experience working with a wide range of clinical populations including; addictions, autism, geriatrics, psychiatry, palliative care, and has occasionally taught music therapy courses at Wilfrid Laurier University.   Research he conducted  for his Master's degree was recently published in the first Music Therapy book on the clinical uses of Rap music (Therapeutic Uses Of Rap and Hip Hop, edited by Susan Hadley and published by Routledge Press).    He plays guitar, oud and related string instruments with  the award-winning world music band Jaffa Road who have recently received their second JUNO award nomination. (www.jaffaroad.com).