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Within the supportive domain, it can act as a distraction from physical and psychological suffering.
Within the communicative/expressive (emotional) domain, it can have a cathartic influence, creating a safe channel through which patients can express repressed emotions.
Within the transformative (spiritual/existential) domain, it can support the search for meaning and transcendence, and can facilitate the creation of a lasting legacy.
Within the social domain, it can help strengthen social bonds with loved ones.
To identify mechanisms contained in the music therapy intervention.
To compare these with the mechanisms identified in the literature.
To identify pertinent mechanisms embedded in the social and organisational context.
To examine the ways in which different individuals respond to music therapy
To illuminate individual experiences of music therapy of patients, their families and the professionals caring for them.
Therapeutic programme mechanisms
Supportive (physical and psychological domain)
I think it’s a distraction for some people. So instead of focusing on the illness, they’re focusing on music and something else that’s enjoyable, so it’s a positive for them and takes them away for a period of time to that other place, and actually, another patient said that to me, that that’s what it did. So, for that period of time that they had the music therapy, they did not think about their illness at all. (AHP 1)
They don’t see it (music therapy) as therapy. They see it as something enjoyable and about something other than their bowels and their pain. It treats them as a human with interests and loves and dislikes and a past, as opposed to, okay, let’s just discuss how medication is helping them today. (Physician 1)
I think it can be a by-product, distraction, but it’s (music therapy) very much about them as a person, their personality, their choices, their family and a focus on them and living. Reminiscing has been a huge part of sessions, and like I’ve said, it’s not all about music in the sessions. Sometimes it’s about me listening to them, and about all the things they have done in their life. (Music Therapist)
Patients reported that music therapy helped them to relax, which in turn helped lift their mood. They found the music therapy sessions gave them something to look forward to, lifted their spirits and provided a ‘fun’ space for them and their families/friends which improved their emotional wellbeing.Sometimes the cameras come out and they take videos if there are a lot of instruments involved and there are songs that they associate with happy memories as a family. They would record this as well, especially if they see their loved one playing an instrument and they never thought this would happen, especially not in the hospice or anytime throughout their life, and they’re having fun together. (Music Therapist)
While intuitively clear to practising music therapists, patient reports further highlighted that the music alone was not the key therapeutic resource, but that the music therapist in combination with the music was central to meeting therapeutic outcomes. The key therapeutic mechanism appeared to be the relationship between the patient and music therapist. This is consonant with the music therapist’s primary aim at the start of the therapeutic process, which is to facilitate clinical goals for each patient. Patients reported feeling a deep connection with the music therapist that surpassed the expectations they had of the therapy. The act of sharing and creating the musical experience together appeared to strengthen this connection, along with the therapist’s ability to help them feel listened to, be comfortable with themselves and to have fun.Sitting listening to her (the music therapist) sing and play music helped me feel relaxed. It lifts you. You [are] normally sitting moping but it takes my mind off the monkey (cancer) and gives me something to focus on. (Patient 4)
With music therapy it’s all about building up that relationship, through creativity and giving that alternative experience. The clinical aims could be relaxation, it could be legacy, it could be pain management, alleviating anxiety, working with families and making new memories for them. But it very much depends on the client and the client-led approach. (Music Therapist)
I found the music therapist really helpful and caring. She talks away and asks how I’m feeling and plays different music to help lift my mood, and it does. She’s very jolly and picks happy music that lifts my spirits. (Patient 5)
Communicative/expressive (emotional domain)
Being able to tell my story about my children, how I feel about them, how proud I am of them, to be your mum. Music therapy helps me put it on paper, expressing my love for them, my legacy of love for them. Gives me comfort to know they will have something to go back to (Patient 4)
Music therapy also aided communication between patients and practitioners.Rather than having conversations focused largely on medical care, music therapy appeared to encourage a more personal avenue of conversation with practitioners around their background and loved ones., This also appeared to help facilitate patient-centred care in terms of knowing the patient’s preferences, needs and values.Another patient wrote lyrics based on her family, and then the music therapist put that to song. So that lady had said, “This is my thank-you to my family and this is how I want to express myself”. It was difficult putting those things down into words, but she found a way to express herself through the music and she said… “I don’t know if I would be able to say these things, but because it’s put down in a song…” (Physician 5)
It can tell you a lot about a patient because of their choice of songs. You’ve got those who like religious music, hymns and things ... And others will choose like the Beatles songs and different things like that. You can tell a lot about a person and their background… (Nurse 2)
Sometimes it opens up a conversation as well. So, a particular lady, who made a song, she brought up sometimes, if she’d had that session, and she brought up then talking about her children. (Physician 6)
My husband has been present [at the music therapy sessions] and gave lots of suggestions, like the music of our first dance at our wedding. He really enjoyed it and it really lifted his spirits too. (Patient 5)
My husband thinks it (music therapy) is a bright spark in a dark environment. (Patient 2)
Transformative (spiritual/existential domain)
Music therapy helped me get onto that higher plane and transcend what I’m dealing with. (Patient 7)
Music therapy lifted me. Making the legacy CD helped me to see my life has been very worthwhile. (Patient 1)
One of my patients used it as a time – her husband was always there and involved, but she valued time with her sister, so it was kind of their time together - that was separate and ringfenced off from anything medical or anything about getting better or getting stronger. It was entirely relationship-building, and they would sing songs together, and it was just such a joy for them. So, I think it really…confirmed that relationship and probably strengthened it at the end of her life as well. (Physician 7)
One of our patients, like he never would have spoken about feelings and stuff, and like I mean he composed a whole song for his wife and literally handed her the CD and was like “Listen to that on the way home”, and she was just like “That’s the nicest thing you’ve ever done for me”, and it was all about her, so it was lovely. (AHP 5)
Legacy work really gives them (patients) a sense of purpose and captures the person’s personality. Their loved ones can listen to it (songs written by patients) and remember their character and possibly help them through the grieving process. And for relatives to know this was made for them to listen to after they (loved one) had passed away. They are still connecting with them. (Music Therapist)
The patients here are quite isolated because they’re in single rooms. They don’t tend to mix as a group, and yet, something like that, it draws them out into a more communal setting. There’s something that goes on outside the room for them. (Nurse 5)
Well, I just think of XX (music therapist) in the summer when she was out in the garden…all of our rooms then just on that side, everybody heard, so we all benefited from the music therapy in relation to that. It’s very calming I thought. We’ve all benefited from it. Just had that lovely…a nice atmosphere… (AHP 4)
I do feel it’s had an impact personally and professionally because it lifts you out of…sometimes the spiral of sadness that you can…go into here, and it just is a reminder [half-laughs] of…just…something maybe a wee bit more uplifting and happy. I know that sounds really simple, but that’s how I’d describe that. (AHP 2)
We are respectful of when she’s (the music therapist) with that patient and we let them have the time for the music therapy. (Nurse 6)
Our findings also suggested that first hand reports to clinicians from patients and families reinforced their belief in the effectiveness of music therapy and hence their support for it as a significant therapeutic interventionYeah, that was what was good (being aware of what music therapy is), because she came and she told us what it all about, and actually, that first couple of weeks, when we saw her on the ward… you then just got very familiar with the types of things that she did. (AHP 1)
So you would go into a room and somebody would say to you “No, I’ve got my music therapy”. …wouldn’t miss it for the world, so sent me off [laughing] until they’d done their music, so that’s how important it was to people! (AHP 1)
I know some patients, when they knew that XX (music therapist) was coming, you could see them brightening up and looking forward to a visit. (Nurse 3)
It’s another thing on our portfolio that we could offer patients, so it’s a positive thing to happen in the unit. I think it has added value. I think, if we’re seeing patients enjoying something, it’s good for everybody. (Physician 4)
As far as I can see, the staff have been very supportive of the music therapy, you know, because, it’s just like, oh, no, you can’t interrupt in that room because they’re having the music therapy – it’s being seen as a vital part of their treatment. (Nurse 6)
I don’t think it would be best use of their time (the music therapist) to sit through two MDMs. I think they’re better used seeing patients, and as long as they liaise with one member of staff, they can then pass it on. (Physician 3)
Our findings have allowed us to identify an additional theory related to the importance of flexibility when delivering music therapy to palliative care patients. In this context, flexibility refers to having a more flexible approach to timing of sessions rather than flexibility of approaches used within the music therapy session which is standard practice. For example, sessions were structured around the music therapist’s availability, which was limited by the amount of research funding available for the intervention in the randomised trial. Practitioners felt that more flexibility was required in terms of sessions in response to the unpredictability of patients’ disease trajectory.Very often I’d be getting my hand over I would find out a little bit about the patient, and what their needs might be? (Music Therapist)
The inflexible timing of sessions indicates a key barrier not raised previously in the literature, but highlighted in the findings of this study related to resources. While all practitioners saw the value of music therapy to the overall care of their patients, they also recognised that funding was the key barrier to implementing music therapy within the hospice setting.I think you need to be a bit more flexible with the availability of sessions and things to suit the patients. It’s just a little bit more unpredictable how the patient is going to be on the day. If I was only here on Tuesday and Thursday afternoon, I wouldn’t be able to see all of my patients. I’d only be able to see maybe half of them. The appointment system maybe works for some patients but not all. (AHP 5)
As long as someone’s going to pay for one (a music therapist), I can’t see there being an issue. It’s funding, isn’t it? (AHP 5)
Responses and experiences of participants
It’s across the board, across the age spectrum, because XX (music therapist) was able to cater for any taste and actually respond to the person’s need (AHP 4)
However, it is important to note that while practitioners’ often viewed ‘fun’ as a key outcome of music therapy, other outcomes, such as expressing repressed emotions better represent key clinical goals for the music therapist.I think music is universal, and different types of music will appeal to different people, but in everybody’s life, there has been some significant music. I’m not sure that we could say it only works for certain types because, you don’t have to be active, you don’t have to be a high-performance status to enjoy it. You know, enjoyment is a very individual thing, so, in that sense, it makes it a fairly universal option. (Physician 4)
Respondents also alluded to certain types of patient who may derive specific benefits, such as those whose religious beliefs were very important to them. For patients whose faith was a great comfort to them, music therapy appeared to help them strengthen that faith and continue spiritual practices while in the hospice setting.Fun is a by-product and that’s why it’s so important for staff to know what music therapy is about because they hear the music through the wall and ‘oh that sounds like fun’ and it usually is fun, but the other things are the important things. I will be thinking is this what this person needs, maybe we need to focus on these things that they’re repressing. Like after playing a song and they become really emotional, I’ll be there to support them and help them work through the underlying why are these words so significant for you? (Music Therapist)
A lot of the kind of ones I suppose who have sort of a religious faith seem to get a lot from it because I suppose they’re maybe not getting to church and stuff on a Sunday and they would get so much from that (AHP 5)
Music therapy helped me with praise and worship which raised me up. Helped me get onto that higher plane and transcend what I’m dealing with. (Patient7)
Those who had a longer prognosis appeared to benefit from legacy work and song writing that gave them an alternative focus between music therapy sessions.And it’s not so much about who might benefit the most, but from a kind of a clinical perspective, the people that I’ve really wanted to access it for before are the people who don’t like talking, or they feel themselves “I’m not a good talker” so for people who just…failing to engage them on a kind of…an emotional level or about their psychological needs…that it can be useful for easing their suffering. (Physician 4)
I think the patients who were with us for a longer time – they had time to write a song or they tend to delve into it beyond the superficial. There’s the other layers of therapy (legacy work and song writing) that a patient with a longer prognosis got to benefit from. (Physician 1)
One of the patients… very shortly before the patient died, the music therapist had… found out what childhood songs they’d all sung together, and the whole family all sang these songs together, and they all described it as being hugely emotional, and that was almost like a way of…saying goodbye. So, that was very powerful for that particular family. (Physician 6)
And I think with legacy-building as well, for their kids to have that in the future, the story of their life together, it’s pretty amazing to have that in the future… (Physician 6)
the ones who said they didn’t want it... can find it (the hospice setting) a little tiring. It is a very busy day, in a hospital or a hospice. Your door opens and you’ve no control over it. (Physician 3)