The Language of Guided Song Writing with a Bone Marrow Transplant Patient

By Emma O'Brien

Introduction

The music therapy literature often refers to music as a unique universal language - one that is able to connect with all human beings, from all walks of life. One of the unique skills of the music therapist therefore, is the ability to access music through language. This can be achieved either by representing musical concepts, experiences, or expression in approachable non-musical language, and/or through musically reflecting clients' spoken language.

The majority of people with whom we work are not trained musicians, yet they have their own music history and character. It is generally accepted that the skill of the music therapist is to tap into this musicality and give it a voice.

Six years of clinical practice using song writing with cancer patients and in particular patients undergoing bone marrow transplantation, led me in the direction of my research into the nature of the interactions (musical, verbal and non-verbal) between patient and therapist that occur when creating an original song. Guided song writing demands a high level of interaction through non-musical language between patient and therapist, to achieve the goal of creating an original song. This process of musical reflection of language has parallels with word painting, a technique used by composers throughout the ages, but it is the interactions between therapist and patient, and the constant musical reframing of the patients' language that is unique to music therapy.

The song writing method I use has been influenced by O'Callaghan's (1996) song writing paradigm and extended to encompass a range of possible styles and avenues of expression for the patients. The method aims to write an original song that is patient directed. The main purpose is to facilitate the patient's verbal expression, by brainstorming ideas and formulating lyrics, and then ultimately to set these lyrics to music. The patient is involved in every step of the method.

The song writing process I apply in practice follows four steps. They are as follows: 1) brainstorming, 2) reframing, 3) determining the style and key of the song, and 4) setting the melody and accompaniment (O'Brien, 2003).

1. Brainstorming

The music therapist encourages the patient to speak freely about any topic that interests him/her. During this process the music therapist transcribes the patient's words remaining as true as possible to his/her words. The music therapist uses techniques of open-ended questions and reflection to encourage the patient to elaborate on material presented and extend his/her expression verbally. The music therapist then guides the patient towards a main theme for the song by recounting his/her words and grouping the material into common theme units.

2. Reframing

In this next step the music therapist encourages the patient to think of his/her material in terms of sections of a song; a chorus, verses, and at times a bridge, or refrain.

The chorus represents the major theme. Once a theme has been established the music therapist begins to gather text that expresses or supports the theme, consistently referring back to the patient for validation. In this process the patient may wish to alter their original words into more poetic rhythms and meters and the music therapist acts as a guide offering solutions or variations when requested. The verses represent further explorations of the theme and may also aid in story telling.

The same process of reframing takes places when setting lyric lines for the verses. In some cases words strings or themes may not fit into either the verse or chorus, but may still be related to the theme of the song. The music therapist may suggest to the patient at this point to contain these word strings or lyric lines in the bridge of the song, or as a tag at the end of the piece. Again the process of reframing the lyrics is repeated here. Once the patient is satisfied with the overall structure of the song lyrics, the music therapist suggests setting the lyrics to music

3. Determining the style and key of the song

The music therapist confers with the patient regarding his/her preferred style and if no style is nominated the music therapist begins by illustrating different styles and tonalities on the guitar with verbal explanations of the examples. The music therapist attempts to musically represent any descriptions of style that the patient offers. Once the patient has chosen a style and key for the song the setting of the lyrics begins.

4. Setting the Melody and Accompaniment

The music therapist begins to speak the words with the patient listening to the natural melodic inflections that arise from the text. The music therapist uses these inflections in combination with the natural rhythm of the text to facilitate a melody. Verbal descriptions of melodic lines and parameters are offered to the patient followed by musical examples. The music therapist offers the patient various melodic settings at times underpinning the melodic choices with a simultaneous accompaniment. The music therapist encourages the patient to offer melodic examples and to complete melodic lines.

The patient is also encouraged to actively choose chord progressions, with particular reference to setting the lyrics in an appropriate mood, and utilizing chord progressions as an integral part of differentiating between the verses, chorus, bridge and refrain.

The text may require further refinement at this stage to fit the melodic line preferred by the patient and dictated by the style of the song. The music therapist seeks to involve the patient in every musical step and process, continually seeking verification and repeating musical material.

Once the song is completed, it is sung with the music therapist encouraging the patient to sing along. A tape recording of the song is then made for patient to keep.

The nature of the interactions between patient and therapist when writing a song in a bone marrow transplant ward, was the topic of my post-graduate research at the University of Melbourne (O'Brien, 2003). Qualitative research methods, derived from phenomenology and case study, were used to investigate the nature of the interactions between patient and therapist when writing a song on a bone marrow transplant (BMT) ward. Six BMT patients participated, nine songs were written, and the sessions were recorded, and transcribed. All six individuals were interviewed about their experience. Analysis of the interviews revealed distilled essences and general themes, which emerged as the experiential nature of the interactions. Four song writing sessions were selected for in-depth analysis of the interactions (including verbal, musical, and non-verbal interactions). In order to analyse the interactions, a "template" was devised showing the interactions initiated by the music therapist, and by the patient, and the "shared" interactions between the two. The 'template' revealed common and not common elements of the nature of the mechanisms of the interactions between patient and therapist, offering a unique insight into the process of creating an original song using therapist guided song writing techniques. (O'Brien, 2003).

The sub question of my research was "what is the nature of the verbal interactions between patient and therapist?" This question resonates with the theme of this edition of Voices. For the purpose of this article I will discuss only one song writing session, with the first participant of the study, Pina. I will discuss the nature of the verbal interactions used by both the music therapist (myself) and Pina when creating her song, through brainstorming ideas/themes for the song, reframing the expression into lyrics and when setting the lyrics to music.

Background Information About Pina

Pina was a 38 year old female of Italian descent with acute myeloid leukemia. She was married, with two girls aged 3 and 7. Pina was admitted for her bone marrow transplant in September 2001, with her older brother as her donor. Her initial contact with music therapy was during the early stages of her transplant and it began with relaxation to music and live music playing.

Pina created her song whilst in pain from severe graft verses host disease, (a serious complication that may arise from a donor transplant), that had eroded her bowel lining. The day before writing the song 'Milestones', Pina and her family had been told that her prognosis was poor, yet Pina maintained a hopeful outlook for her future. It was Pina's way to be positive about life and try to grasp the best of what the day had to offer. She always managed a smile that filled the room. She had a very warm personality, was gently spoken, and loved to sing. She had a very close knit family, bought up on sing-a-longs in the car during long trips. Her extended family was important to her lifestyle, as she often talked of big family occasions, and a great source of peace for her as they offered unfailing support throughout her treatment.

Pina's Experience of Songwriting

Following the song-writing music therapy session, a research assistant interviewed Pina about her experience of writing a song. The interview was transcribed, and using phenomenological thematic analysis, key statements, and themes emerged. The themes were then synthesised into a distilled essence of Pina's experience of writing a song. The essence retains Pina's original words as much as possible.

Distilled Essence of Pina's Song-Writing Experience.

Never in a blue moon did Pina think she would write a song in hospital, however she found the experience fantastic and it gave her the opportunity to express exactly what she was going through. In song writing Pina felt proud that she was able to express a lot of emotion regarding her feelings of the moment, and represent exactly what she was going through.

Pina felt that it was easier to put her feeling into a song to let people understand what she was going through. She wanted significant people in her life, her family and carers, to understand that without them she wouldn't be here.

She found the method just snowballed. At first she began talking about what was happening and then put it all together in verses, which she initially found daunting, but then it all sort of blended in and the next minute she had a song. There were a few things that were dropped out and a few things that were added once the words were set to music. The music just seemed to flow once she and Emma (the music therapist) had decided the style, which came out more as a mixture of styles than a ballad or upbeat song. This 'mixture', for her, represented more emotional music.

For the melody Pina felt that she and Emma just tried a few options to find what would fit with the words, making the song more upbeat towards the end. She discussed with Emma what she was after but Emma was the person who put it all together for her. Pina chose to make the song more up beat at the end so it wasn't so emotional. She felt the process just flowed as she was offered different concepts of the song and chose what she liked.

Pina has played the song to her family and they absolutely loved it, everyone was excited and some family members cried when they heard the song. Pina found the lyrics represented her journey especially the chorus of "Milestones" and the final refrain of 'Next year is going to be our year". She felt that was her main focus and once she was over the illness the next year was going to be a very special year.

Pina felt that the song said it all, her past, present and future; and because of its significance, she will certainly be playing the song a lot. She believed she would return to the song time and time again to bring her back to what she and everyone else has been through to help them appreciate their life a lot more. She felt that being able to express herself in song was going to help her recover much quicker

The Lyrics of Pina's Song

(The lyrics and music were written within one music therapy session).

Milestones

Milestones with family, Milestones with friends
Throughout the illness, Reaching different steps
Each day is getting better, Next year will be our year,
Our family together, Next year will be our year
The illness was a shock, like being rolled over by a big boulder
We're all going through this together and were determined to fight.

Milestones with family, Milestones with friends
Throughout the illness, Reaching different steps.
My husband has been a rock, that inner strength by my side.
Friends they can't do enough, and the truth comes to light.

Milestones with family, Milestones with friends
Throughout the illness, Reaching different steps.
I watch my children and I feel that I've missed out on their lives,
I want to say how strong they've been, and it's helped me get through.

Milestones with family, Milestones with friends
Throughout the illness, Reaching different steps
Each day is getting better, Next year will be our year,
Our family together, Next year will be our year
Without all the care, I wouldn't be here
Each day is getting better, Next Year will be our year.

The Analysis of Verbal Interactions While Writing a Song

In the second part of my research study, I analysed the verbal, non-verbal, and musical interactions that took place while writing a song in music therapy. For the purposes of this article I will only present the verbal interactions that took place during Pina's song-writing session.

The verbal interactions were taken from the transcription of the audio tape of Pina's song writing session, and placed within the "template" (mentioned above) of music therapist initiated interactions, Pina's initiated interactions, and the "shared" interactions between the two of us.

I will present the analysis of the interactions parallel with the 4 stages of the song-writing session: brainstorming ideas, reframing, determining the style and key, and setting the words to melody and accompaniment.

Verbal interactions when brainstorming ideas/themes for the song: initiated from the music therapist

Four types of verbal interactions originating from the music therapist were found to be: establishing rapport, facilitating exploration of ideas for Pina, allowing for space within the process, and reflecting Pina's verbalizations and consequently affirming her self expression.

When establishing rapport with Pina, elements of humor were used within the session. This means of establishing rapport may have contributed to Pina's description of the session, where she described that writing a song was 'fun' and an enjoyable experience. Other common means of establishing rapport included positive affirmations (such as 'mmmm', 'yes', 'okay') and positive descriptions and validations of Pina's verbalizations that also contributed to the overall positive experience of song writing described by Pina.

The music therapist used varying levels of questioning to help Pina explore ideas. They can be classified as: 1) open questions, to extend her expression 2) yes or no choice questions, to clarify her expression, and 3) direct questions, to further extend her expression once a point had been clarified. These questions were often preempted by the music therapist quoting Pina's ideas from the brainstorming phase.

Space, silence, and pauses are common elements of music, and were present in Pina's song-writing session. Bunt (1994) describes silence as an integral part of music therapy as it allows for patients to process different aspects of a session. This is particularly true for patients undergoing bone marrow transplantation as they reflect on the vast number of feelings and experiences involved in their hospitalisation.

Verbal interactions when brainstorming ideas/themes for the song: initiated from the patient (Pina).

Five types of verbal interactions from Pina in the brainstorming process were found to be in the domains of: rapport, response, exploration, space and focus.

In the domains of rapport, common verbal interactions of laughter and humor were present. Pina instigated and partially completed a short nonsense song with the music therapist before the music setting of her original lyrics began. The nonsense song was spontaneously created in response to an interruption by a nurse in the session. The music therapist accompanied the nonsense song and sang along.

Pina responded to the music therapist with positive affirmations, but also at times she chose to respond negatively to suggestions offered by the music therapist. Pina responded quickly to exploratory prompts from the music therapist, speaking freely about her issues and song themes.

Elements of space within the session were present, with the number of pauses decreasing as the session progressed, suggesting that the session picked up momentum as the verbal interactions between Pina and the therapist became closer and at times simultaneous.

Verbal Interactions During Reframing Into Lyrics

Once the first level of free brainstorming had come to a close, the focus of the session moved towards structurally reframing the expression into lyrics for the song. O'Callaghan (1996) explains that this step in her song writing protocol is about how the ideas that emerge are grouped into related themes, usually by the therapist, in what will become a chorus or verse.

In this study, reframing helped Pina group similar concepts into either the chorus, verse, or at times a bridge. In Pina's song, the chorus related to the milestones in her life and her illness. The verses were structured around the members of her family and their response to her diagnosis. The first verse talked of the family's general response to her illness, the second verse, of her husband and friends' response, and the third verse talks about her children. Consistent verification was sought from Pina, whilst structurally reframing her themes and ideas.

At the beginning of the reframing, the music therapist began to recount Pina's text in prose-like form, drawing together word strings and themes that are common. Following each suggestion, the music therapist sought confirmation from Pina and paraphrased, or offered word-ordering suggestions, only when requested. Pauses were used mid -line when reframing text to encourage Pina to offer suggestions. Once common themes were found and agreed upon, general formats for the chorus and verses were established. The reframing continued past this process as Pina refined, and at times replaced, her original brainstorming material.

Pina also became more directive in the internal structure of the verses and chorus as the session progressed, enhancing feelings of control and subsequent feelings of pride in the process. For example, she becomes more word specific as the lyric lines took shape, in order to correctly convey her intended story. Pina deliberated over whether to call her cancer 'the illness' or 'my illness' in the third line of her chorus. She chose 'the illness' indicting her view of cancer as detached from her sense of self.

Verbal interactions when setting the lyrics to music

Determining Timbre and Style of the Song

The music therapist's verbal interactions change in focus from the exploratory and structural nature, in the first section of the session, to a more explanatory and interpretative nature that is music centered. The method of applying music to the words is explained to Pina (explanatory) prompting her to actively interact musically and to be verbally directive in the music selection. The music therapist attempts to represent technical musical terms, using descriptive emotional and textural words (interpretative) to explain the timbres being played on the guitar, either before they are played, after they are played, and sometime even while they are being played. Exploratory direct questions are still used to gather information about style preferences, but they are focused on the musical setting of the song as opposed to being focused on gathering information about the individual's experience in the brainstorming section.

Pina's verbal interactions maintain a directive nature, which began to evolve during the structural reframing section, when discussing the music timbre and style of the song. Pina requests further demonstrations of music timbres and styles on the guitar, and at times rejects what is offered. She also draws parallels between the style she chooses and it's appropriateness in representing the lyrics. This insight by Pina into the process is interesting. It suggests she is able to identify the significance of the music in enhancing their verbal expression.

Pina uses descriptive language to communicate the timbre of the song for example, she describes an augmented major chord, in its second inversion, voiced in the upper register of the guitar, as 'dreamy'. Further into the session she also describes other selections, such as root position major chords, as 'serious'.

Setting the Melody and Chord Timbre of the Song

The music therapist's verbal interactions continue to interpret music selections and suggestions either before or after playing and then singing them. The verbal interactions are also explanatory and now have become more rhythmic and melodic as the music therapist quotes Pina's lyrics. Verbal interactions are then used to confirm Pina's choices and offer positive reinforcement of any ideas presented by Pina.

There is also a 2nd level of structural reframing across the chorus and verses as the melodies chosen start to influence the lyrics previously set. This reframing is done musically, (singing) and also verbally. Verbal interactions in the domains of space and reflection are reintegrated into the process to encourage Pina to participate in the musical reframing of the lyrics.

At this stage Pina's verbal interactions are also becoming more rhythmic and melodic as she participates in recounting her lyrics and reframing them to fit the melody. At times there is no response from Pina, and the silence is left until the music therapist initiates further verbal interactions. Pina suggests melodic and harmonic changes using descriptive language, requesting that the texture become 'more serious'. She also uses structural language requesting different shapes of melodic lines; Pina requests an example of a 'moving' melodic line and variations in setting of lyric lines ('It needs to change here'). Although Pina offers further lyric concepts, they are now guided by music parameters, particularly melodic phrasing, word painting, chord progressions, climatic expectations in song, and the character of the music.

Conclusion

It was found that the interactions between client and therapist when writing a song in this setting were positive, self affirming, enjoyable, expressive and musically creative; with the music therapist as a guide, offering a broad music palate and a non-threatening therapeutic intervention to clients in this setting. The mechanisms of the interactions, although specified as verbal, non-verbal and musical, were all influenced and guided by the music and the expectation of the song.

The nature of the interaction when writing a song in MT on a bone marrow transplant ward is a music-centered unfolding of the individual's experience represented in song. It offers unique therapeutic interventions and interactions that may increase the quality of life of patients experiencing bone marrow transplants.

The details from these interactions contribute to the literature on song writing as reviewed by Krout (2000), who noted that the method of song writing has been described either from the clinician's behavioral observations, self-reports, or lyrical analysis. In this study, the patient's experience has been captured in the patient's own words, and this enables music therapists to better understand the process of song writing from the patient's perspective.

This in-depth representation of the process supports research by Anne Turry (1999), O'Callaghan (1996), and other music therapists who use lyrical analysis as a means of understanding a patient's experience of illness and treatment. However this study makes a seminal contribution to music therapy, by describing verbal interactions between therapist and patient that take place during the writing of the song on a bone marrow transplant ward.

Within the scope of the sub question of my research "what is the nature of the verbal interactions between patient and therapist?" the verbal interactions with Pina offered a base line from which a template of analysis of verbal interactions in further music therapy sessions was created.

Furthermore this study into the verbal interactions between patient and therapist highlights the unique use of language in music therapy to represent music, a medium that often goes beyond words, within our practice to our patients. It also gives an insight into how patients may represent their music experiences and expression in language.

References:

Bunt, Leslie (1994). Music Therapy: An Art Beyond Words. London. Routledge.

Krout, Robert E. (2000). Hospice and Palliative Music Therapy: A Continuum of Creative Caring. American Music Therapy Association (Ed). Effectiveness of Music Therapy Procedures: Documentation of Research and Clinical Practice. 3rd edition. p 323-411. Silver Spring: MD.

O'Brien, Emma (2003). The Nature of the Interactions Between Patient and Therapist when Writing a Song on a Bone Marrow Transplant Ward. Unpublished Master's thesis. Melbourne: The University of Melbourne.

O'Callaghan, Claire (1996). Lyrical Themes in Songs Written by Palliative Care Patients. Journal of Music Therapy, 33 (2), 74-92.

Turry, Alan (1999). A Song of Life: Improvised Songs with Children With Cancer and Serious Blood Disorders. In T. Wigram & J. De Backer (Eds.) Clinical Applications of Music Therapy in Developmental Disability, Pediatrics and Neurology. London: Jessica Kingsley.