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Music Therapy in Palliative Care: New Voices

br2004_043Aldridge, D. (Ed.) (1999) Music Therapy in Palliative Care: New Voices. London: Jessica Kingsley Publishers.

Reviewed by John A. Carpente, Temple University

David Aldridge has put together a wonderful collage of clinical stories written by several European and Australian music therapists, demonstrating a variety of music therapy approaches in palliative care settings. Authors of the book are David Aldridge, Trygye Aasgaard, Clare C. O’Callaghan, Beth Dunn, Bridgit Hogan, Wendy Magee, Susan Weber, Nigel Hartley, Lutz Neugebauer, Gudrun Aldridge, and Rob Finlayson; music therapists, who, as stated by the editor, have “no complete published volume to their names,” hence the title: “New Voices.” According to Aldridge, he has created this forum as a way to encourage and inspire music therapists to write and share their experiences, because, as he suggests, there is a “neglected tradition of clinical writing” (p. 9).”

The 175 page book, published by Jessica Kingsley contains 11 chapters, composed of short stories, brief case studies, and personal reflections of music therapists working with both children and adults living with HIV/AIDS, cancer, and other chronic degenerative diseases. Many of the authors write in their own personal voice. The book contains a thorough reference list and a subject index. In addition, the book’s introduction provides the reader with a brief synopsis of each chapter.

The focus of the book is diverse, highlighting several goals of music therapy in palliative care such as: creativity, communication, relationship, environment, personal expressiveness and meeting the client in music.

As a therapist who has experience in working with persons with AIDS, I can certainly appreciate the areas of focus, and the commitment that each author has to his/her clients and areas of interest. Although there were certain chapters of the book that I felt needed further elaboration, they each provided thought provoking ideas that allowed me, the reader, to begin to formulate opinions and develop my own ideas. What follows, then, are my own reactions to certain chapters in the book.

In the chapter entitled, “Music Therapy as Milieu in the Hospice and Pediatric Oncology Ward,” Trygve Aasgaard addresses the importance of “Environmental Music Therapy.” Being aware of the environment in a hospice care setting is so vital to the quality of life of the dying person. Aasgaard discusses how music therapy can create a therapeutic milieu in the hospice setting. Although his ideas, , have the potential to play an important role in the hospice setting, I felt that this topic required further exploration in music therapy practice, such specific techniques, the role of the music therapist, the clinical intent of the music, and its overall efficacy.. However, Aasgaard does touch on some very interesting questions: What can the role of music therapy be when it comes to creating favorable environments? And what are the realities of the environmental aspects of treatment and care?” Although these are important areas to focus on, I would have liked to have seen more clinical rationale and thoughts on the implications of environmental music therapy in regards to how the profession may be viewed.

O’Callaghan’s chapter provides some insights into the songwriting process in hospice care. The chapter presents a study of 39 clients in palliative care, two thirds of the clients had an advanced neurological disease and one third had cancer, using a song writing paradigm to facilitate composing their own music. An analysis of song lyrics of 64 songs highlighted the following themes: messages, self-reflections, compliments, memories, reflections upon sight of others including pets, self expression of adversity, imagery and prayers. She concluded that “song writing offers palliative care patients opportunities to creatively express themes significant to their life experiences, enabling them to live out there life, and avoid existing until death” (p. 58).

Although I found the eight themes and categories that emerged in her study to be of value, I began to formulate several questions in regards to the data: Where and how did the themes emerge? Did the themes emerge as a result of the creative process in music therapy between two people? According to category nine in her Song Writing Paradigm, the patients were given musical choices as to how they wanted their accompaniment and musical elements to be played: What type of music was being created (initiated) by the therapist, and how much did this influence the themes.

In Hogan’s chapter, “Music Therapy at the end of Life: Searching for the Rite of Passage,” I truly began to resonate with what she emphasizes: the importance of creativity, intimacy and being human through the aspect of live music. However, at the same time she discusses the use of musical elements in what seems to be a prescriptive format. For example, she writes, “If patients are physically or emotionally distressed and seem agitated and anxious, I may use music with a relatively narrow and moderately low pitch range in order to instill a sense of security, structure and support” (p. 72).” Music that is intimate is personal; it’s created with intent for another person. As a Nordoff-Robbins music therapist, it is unclear to me how she can use these prescriptive ideas to create personal, intimate music for her patients. It was also unclear how GIM (a receptive method) was incorporated into her musical ‘performances” of her patients.

There are many areas of the book that as a clinician reinforced many of my own ideas and philosophies. Aldridge’s passionate chapter, “Music Therapy and the Creative Act” discusses the creative relationship; linking creativity and the creative relationship to what seems to be existential, humanistic, and transcendental psychology. Aldridge writes, “.the therapeutic question is not “What am I?,” a question that lies in the realm of categorization and cognition, but “How am I?” which is one of being” (p. 22).”

In addition, Aldridge brings up a valuable point when describing artistic expression as an element that brings chaos to order. He explains that music takes on the role of an object that creates form and contains internal order for feelings. Personally, I feel that if there is to be any value in practicing the arts, it perhaps lies in the properties of the work of art that allow it to be an object onto which people can project their fears of chaos, loss of control, and loneliness.

While reading Dunn’s chapter, “Creativity and Communication in Working in a Children’s Hospital,” I could not help but link this approach to the Child Life programs here in the United States. Both programs focus on how the child perceives and internalizes the hospital environment; and “building” a creative and “healthy” environment for the child to “be” in. Dunn says: “Hospitalized children can become inhibited and withdrawn because of their illness and/or because the hospital environment is essentially an adult environment imposed on the child’s own creative world” (p. 60).” She then points out that one of the goals of music therapy is “enhancing the child’s own unique creativity and communication capabilities through influencing children’s perception of themselves within the hospital environment” (p. 60).” She describes how she accomplishes this goal through the use of songwriting and pre-composed songs.

In chapter 9, “Music Therapy with HIV Positive and AIDS patients,” Neugebauer introduces what seems to be a Nordoff-Robbins approach to his work. He discusses the use of live interactive music making in developing the therapeutic relationship (within the music). In addition, he suggests that each improvisation expresses the client’s condition and state of health revealing both his/her limitations and possibilities. Neugebauer believes that the musical experience gives the client the “possibility of bringing about active change” (p. 127).” He continues to state, “As a result there is active participation in the healing process. The patient becomes active instead of merely being given treatment” (p.127).” This is a stimulating concept. This idea alone can create meaning and give purpose to a dying person’s existence, as they are activating their will and co-creatively participating in something with someone that is larger then they are. In addition, it can provide a sense of hope.

I thoroughly enjoyed Hartley’s chapter, “Music Therapists’ Personal Reflections on Working with Those who are Living with HIV/AIDS.” I appreciated his honesty, and his ideas in regards to “change” within the client. And although my opinions differed in the area of “change,” it gave me the opportunity to think about my own perceptions regarding”change” within the client.

On page 107 Hartley discusses one of the facility’s policy which states,”. situations will not be tolerated where the aim of one person is to change another.” He continues by saying “therapy will not work, therefore, if the therapist sets out to change his patient” (p. 107).” According to Hartley, change can occur, but it is not the focus. The focus is embarking on a journey through the unknown; discovering and encountering adventures. Personally I feel that if the goal is to enter into a journey, then the goal is to change, because any new journey demands a new perspective or a new response.

Continuing with Hartley’s chapter, I came across an interesting passage on page 121, regarding how we as therapists listen to clients. He states,”.”out of frustration I (Therapist) stood up and, taking a beater hit the marimba, directly cutting across his (client) playing. He stopped: Is that a therapeutic technique? He (client) exclaimed. (A moment of silence) Are you upset because I invaded your space? I asked. No, he answered, only because what you did had nothing to do with what I was playing” (p. 121).” I so greatly appreciate Hartley’s honesty in discussing this experience. It is a difficult situation, as we as therapists go into sessions with certain expectations, consciously or unconsciously. By doing so, are we allowing the process to naturally unfold? Are our expectations taking the client onto his journey based on what we think the correct path is?

Music Therapy in Palliative Care: New Voices is filled with personal experiences, ideas, concepts and perspectives in working with the dying. Although the book is well-written and easy to read, because it is not a comprehensive look of music therapy in palliative care, I would not recommend this book as an appropriate learning tool for beginning music therapy students. However, based on the book’s diversity, and “real life” experiences, I would highly recommend it to music therapy professionals and advanced students who are already working with clients in hospice care.

In addition, because the book provides the reader with various ideas and concepts that need to be further explored and developed, this collage of work will continue to inspire and promote dialogue between music therapists throughout the world. This book is certainly a sign that music therapy in hospice care is growing, and will continue to grow.

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