Transitions from Clinical Experiences to Clinical Questions and then Research

Songwriting with Bereaved Pre-adolescent Children

By Melina Roberts |Author bio & contact info|

Abstract

The purpose of this article is to describe the author's personal transition from her clinical experiences working with bereaved children and adolescents, to clinical questions that arose during this time, and then to her current phase whereby she has commenced research to examine songwriting with bereaved children. This article includes relevant literature that discusses bereavement in childhood, songwriting in music therapy, and music therapy support for bereaved children and adolescents. A description about the author's current research, that integrates the three areas highlighted in the literature, is also discussed.

Keywords: music therapy, bereavement, children, songwriting, research.

Introduction

There is a cyclical process in music therapy between clinical work, the clinical questions that arise from this work, and the questions that form the basis for research (Wheeler,1983 as cited in Wheeler, 2005). The results from research inform and shape our clinical practice and so the cyclical progression continues. The purpose of this article is to describe my own personal transition from clinical experience, to clinical questions, and then to my current research. Currently I am undertaking the Masters by research degree at the University of Melbourne and am in the process of designing my research project. This article will provide information about the various elements of my ongoing transition from music therapist to student researcher.

Background

Shortly after completing my undergraduate music therapy degree at the University of Melbourne I commenced work at a palliative care hospital. During my first year as a music therapist I conducted music therapy programs in aged care facilities and also a program on one of the adult patient palliative care wards in the hospital. In 2003 I was offered the opportunity to facilitate a home-based music therapy program for bereaved children and adolescents. This was a very exciting opportunity as I had thoroughly enjoyed my clinical placements with children. The child and adolescent music therapy bereavement program was conducted through the palliative care hospital and had commenced in 2001. When I started this program I experienced a range of thoughts and feelings. As this program was home-based, and this was unfamiliar to me, I didn't know what to expect. My thoughts at the time were: How would I go about conducting a session in a child's home? What needs would these children have? How was I going to be able to provide them with music therapy that would best assist them with their grief? I felt as though I was walking into the unknown. I do enjoy being challenged in my clinical work so this 'unknown' was exciting for me. With some personal reflection, I identified that my feelings included elements of excitement, eagerness, and intrigue. Over the next three years I facilitated many sessions with different types and ages of bereaved children and teenagers. It seemed to me that, although these youngsters presented with and expressed similar responses to grief, each of these children used music therapy in their own unique way.

My observations informed me that these children used music therapy sessions for:

diversion and fun - to escape the grief that had impacted their lives and their homes
self expression - to explore and express what thoughts and feelings had been evoked by grief
an opportunity to ask questions - particularly questions about grief that the children couldn't ask of their Mum or Dad for fear of making them cry
an opportunity to remember their loved one - to express memories about their deceased loved ones
an opportunity to speak about being excluded from bereavement activities - for example, when two children, a brother and sister, were not allowed to attend their grandmother's funeral
an opportunity to explore and express spiritual beliefs - opportunities to make music, sing and draw about what happens to loved ones after they die
an opportunity to talk about the impact of grief - opportunities to highlight the past and the present and how grief had caused changes in their lives.

Each of these children and teenagers had experienced losses, and grief had significantly impacted their lives. Despite promoting the full gamut of music therapy interventions, that we as music therapists tend to store in our therapeutic bag of tricks, song-writing seemed to be the most appealing and satisfying intervention for these children and teenagers. For most of these youngsters, once songwriting was included in sessions there was seldom any interest in returning to other music therapy interventions, which had been introduced in previous sessions.

Through assisting children with lyric composition, I noticed that these children and teenagers were presenting in a different way during songwriting. They were reflecting on their experiences, were engaged with the process, and shared very personal, meaningful and profound messages that had not arisen during other music therapy interventions. The process of songwriting was eliciting a new and more profound focus for these children in music therapy.

Questions, Reflections and Theories Transpiring from Clinical Work

Reflecting on my work with bereaved children and teenagers, I have explored several questions. Many of these questions arose when I was facilitating the home-based bereavement program. However, I now continue to work with bereaved children and teenagers through a children's hospice and many of the themes and questions that I identified previously are being reinforced in my current clinical work. What follows are some of my questions, reflections, and theories that have transpired from this work.

Question: Why do I Enjoy Working With These Children so Much?

Reflection: Because I feel challenged by the needs that these children present and I believe that music therapy can provide them with something meaningful, appealing, and unique. This uniqueness may be due to the notion that most people have not heard of music therapy before. Many children I have worked with openly expressed "Music therapy. I haven't even heard of that before. What is it!" As music therapy is a 'new' option for these children, it sparks interest for them. As music therapists we get quite skilled at answering the very reasonable and predictable question "What is music therapy?" In my clinical work with bereaved children, and whilst visiting their homes to meet them for the first time, I experimented with various ways to explain music therapy to these children. A typical response to their question: "What is music therapy?" was "Well . the reason that I am here is because someone in your life has died . and when this happens, people may have a mix of thoughts and feelings. Because something like this has happened, many people think that if we talk about the things that have happened, ask questions about what happened and talk about our feelings, that this can sometimes make us feel better. In music therapy I can come and visit you at home and if you want to we can play musical instruments, play games, sing favourite songs, write songs and heaps more - whatever you like to do really. The idea is that if you play music it might make you feel better and it might be fun. Music can also sometimes help us to talk about and express our feelings. Some people find it hard to talk about feelings and so if you don't want to, you don't have to. It's really up to you to choose what you do and don't want to do." Often this type of explanation was followed up with other questions and these continued until all of the questions were discussed so that the children understood the rationale for music therapy. I found that this transparent an up-front approach was welcomed and understood by the children and by their families.

Question: Why does music therapy with bereaved children work?

Reflection: Children present with multiple responses to grief. Grief can impact many areas of a child's life. These may include the emotional, physical, psychological, cognitive, and developmental parts of their life. Music therapy is appropriate for bereavement work for reasons discussed below:

Music therapy fosters choice making and when working with bereaved children, activities can foster multiple opportunities for choices. Music therapy allows clients to choose from a number of musical interventions and within these choices, there is flexibility to adapt to the needs of the individual. Music therapy provides me with useful and flexible resources that allow me to use the tools that these children can profit from. In music therapy, bereaved children have multiple opportunities to make choices. They can choose activities, songs, how much or little to participate, whether to initiate or follow the music therapist - the possibilities are endless and this seems to be a source of strength and empowerment for these children. Music therapy can be what the client needs and what the client wants. This in itself may be interpreted by the client as a source of control and empowerment during a time when control and empowerment have been greatly impacted by grief.
Music therapy can provide flexibility to meet the complex and diverse needs of all children and teenagers. Because music therapy is individually adapted to the person's needs and to their developmental stage, this is what keeps children engaged. Children seem to approach the world as a continual learning experience and usually are open-minded to different ideas and approaches that are presented to them. In my approach with bereaved children and teenagers I often plan sessions in relation to the assessment of the child's needs. Despite the potential for addressing specific needs and providing structure in sessions, I have observed that children respond with engagement to an environment that promotes flexibility and spontaneity. When a child initiates an idea and a music therapist supports this musically and/or verbally, the child usually responds spontaneously perhaps with the realisation that "Oh. I have some power over what can happen in our music therapy session." However there also needs to be an even balance between freedom and structure. Structure can ensure that the music therapy sessions contain a process and are focussing on allowing opportunities to address the grief-related needs of the children. Working within this structure, children should be encouraged to initiate ideas and these ideas should be supported and reciprocated by the music therapist. This empowering and supportive environment for a bereaved child can promote opportunities to: a) accept the loss of loved ones, b) memorialise and remain connected to loved ones, c) express thoughts, feelings, memories, and spiritual beliefs, d) experience activities that increase self-esteem and empowerment, e) play and sing their stories of loss and grief, and f) develop coping strategies (Roberts, 2006). Due to the impact of bereavement, these identified needs that may be supported by music therapy can provide a positive experience during a time of adversity.
Music is often associated with fun and something that children can relate to. Music is familiar, and this sense of knowing about music gives children permission to become involved in music-based activities. Although the term 'therapy' may be unfamiliar or maybe have negative connotations for a child or teen, the term 'music therapy' seems to greatly interest children. If this interest can be sustained and if a description about music therapy is provided effectively, children will be likely to engage in music therapy for grief support and will benefit from this. I think that through music therapy in grief work, children can feel normal, they can feel important and heard, they can experience choices and control and they can after some time feel supported enough by the music therapist, to express themselves and the complex thoughts and feelings that result from grief. They can have their 'voices' heard. For children, this experience may be new. As new or unfamiliar experiences may be regarded as either positive or negative, I think that we need to be cautious about the assumption that music therapy is 'non-threatening'. I believe that music therapy may actually feel unfamiliar, intimidating, and potentially threatening to some clients. I do believe that the therapeutic skills that music therapists use in sessions are paramount when introducing music therapy, and I do believe that music therapy activities may be non-threatening, however I also believe that at first, 'music therapy' as a concept may be quite intimidating or threatening to a client. How many times when introducing music therapy to clients have we heard statements such as: 'But I can't play music', 'I'm not good at music'.
Music therapy can provide support for the whole family that is experiencing grief. Bereavement often affects the whole family unit where the child is living. Music therapy, in home setting programs, may provide an environment whereby the child can escape from the grief focussed environment for some time. While some children will respond quite well to talking about and expressing their grief, other children may not have the developmental ability or the emotional availability to articulate and express grief. In this type of scenario, music therapy can provide a positive source of diversion. Family members who are also grieving may be invited to participate in music therapy sessions. This participation in music, which is often associated with enjoyment, may provide a positive experience for the whole family. Alternatively, family members may wish for the child to have music therapy for themselves as their 'special time'. In my experience parents also seem to welcome the opportunity to have some 'time-out' when music therapy sessions are taking place. Music therapy can meet the needs of the child within the overall needs of the family unit. Music therapy may be experienced as a source of positive strength and this may assist the family with coping.

Research to Investigate the Questions that Arise During Clinical Work

As I have discussed above, my clinical experiences have led to questions about music therapy with bereaved children, and beliefs about what may be occurring. An investigation to thoroughly explore some of these questions requires a methodical approach. Commencing a research project, that provides a methodical approach, is the next step for me in this cyclical progression (Wheeler, 2005).

Currently I am undertaking a Masters by research degree, under the supervision of Dr. Katrina McFerran, at the University of Melbourne, Australia. This research will target the area of songwriting with bereaved children and will focus on the question: What themes occur in the song lyrics of songs that have been written by bereaved pre-adolescent (7-12 year old) children?

To better contextualise my research project, I am going to highlight the literature that discusses bereavement in childhood, songwriting in music therapy, and music therapy for bereaved clients. Aspects of my research project, and my current theories, will be discussed within the literature review. Following this section, I will outline the research design of my project.

Literature: Bereavement in Childhood

There is countless literature discussing childhood bereavement. Due to the multitude of literature available, the following section of this article will highlight only the most significant aspects about children and grief.

The importance of supporting bereaved children with grief has gradually gained recognition within the last five decades. Researchers, bereavement specialists and the general community have acknowledged that children are exposed to, rather than shielded from grief, and these children should be recognised and supported through these types of experiences (Baker & Sedney, 1996; Silverman, 2000; Worden, 1996).

How children understand death has a great impact on their responses to bereavement and much of the literature has focussed on children's concepts of death (Busch & Kimble, 2001; Christ & Christ, 2006; Oltjenbruns, 2001;Yang, 2006). With access to information about how children understand death, clinicians have greater information and insight into how to help these children. Studies have revealed that children react to grief in a number of ways depending on their development stage and age at the time of the loss (Worden & Silverman, 1996). School age children have been known to react to grief with regression, denial, anger and aggressive behaviours, feelings of guilt, feelings of sadness, withdrawal, sleeping and eating disturbances, disruptions at school, and expressions of wishing to die to be reunited with the deceased (Christ, 2000; Christ & Christ, 2006; Worden, 1996; Worden & Silverman, 1996).

As children move through different developmental stages, they may re-visit grief (Worden, 1996) and need ongoing help to confront grief-related issues (Corr, Nabe, & Corr, 2006). In recent times, authors within the bereavement field have been advocating for research to adopt a developmental lens (Christ & Christ, 2006; Oltjenbruns, 2001; Schoen, Burgoyne, & Schoen, 2004). By identifying children's reactions and perceptions of grief within a developmental framework, bereavement support clinicians can provide better interventions to assist children with coping.

Based on the cognitive development system developed by Piaget (Corr et al., 2006) children aged 7-11 or 12 years of age are classified by the stage of concrete operations. Regarding children and bereavement and according to the Royal Children's Hospital (Melbourne, Australia):

School age children gradually acquire and refine the capacity for logical thought. During these years, they develop a more complete understanding of death. At first, they see it as something that happens only to other people. From the age of six, children start to develop the death concepts of irreversibility, causality, and universality. There is considerable variability in the ages at which these concepts are acquired so it is important when speaking with children to make some individual assessment of their level of understanding. School aged children become increasingly curious about the causes of death and are interested in details and death rituals. Explanations should be tailored to the child's developmental level, cognitive ability and previous life experience (Hynson, Sutton, & Jurisch, 2006).

Author's Reflections

For the purposes of my research I will focus on bereaved pre-adolescent children (7 to 12 year olds) as the grief responses of these children are fascinating. In my clinical work I have noticed that children within this age group have moments of profoundly exploring and openly expressing grief. As quickly as these moments appear they soon disappear again. Children are engaged in writing a song about the memories of their deceased loved one and within a moment these children request to move on to another music therapy activity or to play. It seems that children of this age group are fluctuating between confronting the grief and then avoiding the grief.

Stroebe & Schut (1990) developed the dual model theory for coping with bereavement. This theory outlines that bereaved individuals oscillate between two groups of stresses in order to cope with the effects of grief. These dual models are loss oriented stressors and process oriented stressors. The loss orientation stressors are whereby the individual focuses on the loss, whereby the process orientation stressors are those whereby the individual focuses on learning mechanisms and deals with new tasks (Stroebe & Schut, 1990). Stroebe and Schut proposed that adapative coping is achieved by oscillating successfully between the dual models. At times the bereaved individual confronts their grief, at other times they avoid their grief. This theory, relevant for children, was described by Moody & Moody (1991) who described that children ". may be playing spontaneously one moment, than be terribly sad the next" (p. 593).

Worden (1996) and Silverman & Worden (1992) have reported on their study known as the Harvard Child Bereavement Study. This study was developed to analyse the impact of the death of a parent on children, and incorporated a longitudinal study design whereby the researchers interviewed 125 bereaved children between the ages of 6 and 17 years of. The outcomes from this research revealed that bereaved children expressed that they require:

Adequate information about the death
Fears and anxieties to be addressed
Reassurance that they are not to blame for the death
Careful listening
Validation of feelings
Assistance with overwhelming feelings
Opportunities for involvement and inclusion in event e.g. funerals, memorials
Continued routine activity
Modelled grief behaviours through adults
Opportunities to remember their deceased loved one (Worden, 1996).

Bereaved children require opportunities to express and resolve grief-related issues (Moody & Moody, 1991) with the assistance of interventions that are familiar, developmentally appropriate, and effective. Creative arts therapies, considered to be effective for bereaved children, have been regularly reported (Goodman, 2002; Webb, 2002). Worden (1996) referred to mourning as 'the process of adaptation to loss' (p. 31) and suggested that grieving children may adapt to grief by participating in creative art activities. "Children speak in their own language of play, art, and story" (Doka, 2002, p. xiv) so it is rational that reports reveal how bereaved children are responding both positively and effectively to creative interventions for grief support.

Webb (2003) described that expressive arts therapies in grief work give permission for grieving children to non-verbally express and process their thoughts and feelings. In an earlier report Segal (as cited in Moody & Moody, 1991) suggested that children commonly avoided discussing their grief-related emotions. It was considered that this suppression of feelings would be detrimental to the grieving children as it may delay their acceptance of grief. With the use of symbolic creative activities, bereaved children may take these opportunities to communicate and expel grief-related thoughts and feelings (Moody & Moody, 1991).

Literature: Songwriting in Music Therapy

Baker & Wigram (2005) have recently provided a comprehensive overview about songwriting in music therapy. They suggest that songwriting has been used to: "assist people to reflect on their past, present or future, to make contact with unconscious thought processes, to confront difficulties within their interpersonal experiences and their interpersonal relationships, and to project their feelings into music" (p. 11).

Focussing on the last decade (1996-2006) of music therapy literature, there have been many reports about songwriting in music therapy practice and research. In these reports the clients' ages and clinical settings have been diverse. Some of these reports have discussed songwriting with the following child populations: hospitalised children and adolescent patients (Abad, 2003; Cowell, Davis, & Schroeder, 2005), paediatric and adolescent oncology patients (Aasgaard, 2000, 2005; Ledger, 2001); children in the bone marrow transplant unit (Hadley, 1996); abused and traumatised children (Day, 2005); child and adolescents within psychiatry assessment units (Oldfield & Franke, 2005); and for children & adolescents in grief & bereavement (Dalton & Krout, 2005; Krout, 2005b; Roberts, 2006).

Music therapy literature has revealed that songwriting has been demonstrated to foster a variety of therapeutic aims including: emotional changes (Jones, 2005); increased self awareness (Aasgaard, 2000); self expression (Aasgaard, 2000; O'Callaghan, 1990; Turry & Turry, 1999); achievement, self-esteem, mastery and control (Aasgaard, 2000); psychosocial support for coping and adaptation (Aasgaard, 2000); reduction of anxiety and increased sense of security (Hadley, 1996); self reflection (Baker et al., 2005a); opportunities to express grief & memorialise loved ones (Roberts, 2006); and opportunities for patients to gain greater insight and express messages that are relevant to their lives (O'Callaghan, 1996).

The music therapy literature has included discussion about the diversity of songwriting models being used by music therapists. Songwriting methods have included: song parody, also known as lyrical or word substitution (Abad, 2003; Hadley, 1996; Jones, 2005; Ledger, 2001); cloze, fill-in-the-blanks technique (Baker, Kennelly, & Tamplin, 2005a); blues songwriting (Hadley, 1996); original, or freely composed songwriting (Baker et al., 2005b; Hadley, 1996; O'Callaghan, 1990, 1996); spontaneous or improvised songs (Robb, 1999; Turry, 1999; Turry & Turry, 1999), adding new verses to songs (Baker et al., 2005b); computer music program composition (Cowell et al., 2005; Roberts, 2006); and songwriting with verbal processing (Nolan, 2005).

In Songwriting: Methods, Techniques and Clinical Applications for Music Therapy Clinicians, Educators and Students, Baker and Wigram (2005) focused on the various, systematic methods of songwriting that music therapists have developed and use in their clinical work. They state:

Here, the process and product of writing a song within therapy sessions is the therapeutic intervention. The therapeutic effect is brought about through the client's creation, performance and/or recording of his or her own song. The therapist's role within the music therapeutic relationship is to facilitate this process ensuring that the client creates a composition that can be felt as owned by the client and expressive of his or her personal needs, feelings and thoughts (p. 14).

Author's Reflections

Question: Why does songwriting appeal to clients in music therapy?

Reflection: I believe that songwriting is an exciting, stimulating, and potentially challenging intervention for clients. Songwriting seems to engage clients of all ages and can provide both methodical processes and aesthetic outcomes that seem to appeal to our clients. A methodical process can simplify the process of writing a song with clients and this may reduce potentially overwhelming feelings experienced by the clients. When clients commence writing a song there is a purpose to complete the activity. The drive to finish the song may be a source of motivation for the clients. On completing the task clients may experience a sense of achievement that may counteract other areas of their life that they are lacking achievement in. Also, I believe that there is romantic appeal to the notion of writing a song. I think this is shared by clients, their family member and also by the music therapists that facilitate these sessions. When the notion of writing a song is suggested in therapy, I have found that it is often received with interest from not only the client, but also the client's loved ones and carers. Through my experience with bereaved children who are writing songs, children express excitement and great pride in their song calling out things such as: 'Mum. Mum quick come and listen to my song' or 'Can I make some copies of my song to take for my friends'. In these cases, the loved ones of the bereaved children often respond to the creation of a song with expressions of admiration. At the end of the songwriting process the client may be presented with the song lyrics and/or a recording of the song and these tangible objects may symbolise the therapeutic process that has taken place during music therapy.

Literature: Music Therapy in Bereavement Work

In recent years, several research studies and clinical reports have discussed the use of music therapy with bereaved population (Dalton & Krout, 2005; Hilliard, 2001; Krout, 2005a, 2005b; McFerran-Skewes, 2000; McFerran-Skewes & Erdonmez-Grocke, 2000; Roberts, 2006; Skewes & Erdonmez-Grocke, 2000). Of these studies, there has been some discussion about songwriting with bereaved children and adolescents (Dalton & Krout, 2005; Hilliard, 2001; Roberts, 2006). However there is a lack of research investigating songs written by bereaved pre-adolescent children. In order to address this problem, the current author is in the midst of designing a research project to explore this area.

A research project investigating song lyrics composed by bereaved pre-adolescent children In order to gain insight into the experiences of grief for this age group, I want to closely examine the types of messages (thoughts, feelings, memories) that children are expressing in songs that have been composed during music therapy. I hypothesise that these song lyrics will reveal valuable information about what this population are able and willing to express about bereavement.

The aim for this research is to gain greater insight into the experiences of bereaved children and also to address a gap in the music therapy literature. This project will investigate the question: What themes occur in the song lyrics of songs written by bereaved pre-adolescent (7-12 year old) children?

The current author will gather song lyrics that have been composed by this population and this will form the data set for the research project. Following the data collection phase, the author will analyse the song lyrics using content analysis strategies that have been employed in other music therapy studies (Baker et al., 2005b; O'Callaghan, 1996 ;McFerran-Skewes et al., in-press). Content analysis is a research method that allows researchers to discover messages and forms of communication through the analysis of textual data (Krippendorff, 2004; Neuendorf, 2002). The song lyrics in this research will be analysed using conventional content analysis methods (Hsieh & Shannon, 2005). This method of content analysis involves the researcher immersing themselves in the data to gain a sense of the overall data set. The researcher then analyses the text word-by-word to detect the codes that capture key concepts. This process continues whereby similar words are merged into comparable categories. Words within the text continue to be organised into clusters of meaningful categories until the major themes of the analysis are unveiled and a subjective interpretation is prepared (Hsieh & Shannon, 2005). A secondary form of analysis will involve quantifying the key words that appear in song lyrics. This will provide information about the prevalence of key words and significant themes within the song lyrics of bereaved children.

Conclusion

The evolution of music therapy practice involves a cyclical and progressive nature whereby the clinical experiences of the music therapist lead to clinical questions and these questions can be thoroughly investigated through the process of conducting research (Wheeler, 1983 as cited in Wheeler, 2005). As I have observed in my clinical work, songwriting with bereaved children and adolescents can elicit powerful and profound reactions from these clients. This clinical outcome has inspired me to undertake research. By conducting research about songwriting with bereaved children I anticipate that I will gain greater information about the efficacy of this intervention with these clients. By conducting an analysis of the messages that occur in song lyrics written by bereaved children, information about what children are expressing in songs will be revealed. I anticipate that the information arising from this research will provide me with further insight into the needs of these children and the use of songwriting within this context. The results from this research will influence my future clinical practice and then the cyclical process will begin again.

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