Exploring Contemporary Aspects of Supportive Music Therapy in Addressing Client Grief and Loss

Reflections with Australian Author Ruth Bright

By Robert E. Krout |Author bio & contact info|

In 1983, I traveled 600 miles by bus from Melbourne to Sydney, to experience a short music therapy student placement with Ruth Bright in psychiatry and psychogeriatric settings. Ruth drove me from ward to ward and hospital to hospital, with a small keyboard, piano accordion, and song books in her car boot (trunk). I was fascinated to witness Ruth practice techniques she had described in her books, such as the empty chair technique when someone was invited to express an important message to a deceased relative. I was moved to witness how she used familiar songs to �switched the lights on in the eyes of bed bound patients, and supported a young man with Huntingtons Disease to imagine a life worth living. I will also never forget, sitting in the sunshine while eating our sandwiches, feeling amazed as Ruth described the lengths she went to, to access literature which extended her therapeutic skill base and provided theoretical informants for her work, much of which was honorary. Ruth was also contributing to that knowledge: in 1966 she published "Music and Mental Health" in the journal Mental Health in Australia (Bright & Grocke, 2000).

Perhaps the greatest challenge faced by music therapists is adapting academic knowledge and music techniques acquired during training into our work environments. Ruth Brights pioneering work as a practitioner academic built bridges between theory and practice, encouraging many of us to practice creatively, tailoring and developing methods that seemed appropriate for idiosyncratic vulnerabilities amongst people in our varied clinical settings. Ruths countless books, articles, and conference and workshop presentations pivotally inform music therapy practice in aged care and grief work. Australian music therapists are indebted to Ruth and are proud of her remarkable contribution to the international music therapy community, and the fields of gerontology and bereavement. Ruths generous sharing of her practice wisdom, and leadership in theoretically framing clinical work has inspired my own work in palliative care, and I am very grateful.
- Clare OCallaghan -

Ruth Bright

Ruth Bright is a pioneer of music therapy in Australia and a world-known author and presenter. She was Founding President of the Australian Music Therapy Association, serving in that inaugural role from 1975-1978. She also served as President of the World Federation of Music Therapy from 1990-1993. Her groundbreaking work and writing on music therapy in the fields of dementia, psychiatry, and grief has led to numerous publications, and The University of Melbourne conferred an Honorary Doctor of Music degree upon her in 2002 to recognize her many contributions both to the profession of and literature in Australian music therapy.

One of Dr. Bright's areas of specialization is grief counseling, and she has made many valuable contributions to the literature. Her 1996 book Grief and Powerlessness: Helping People Regain Control of their Lives (London: Jessica Kingsley), examines how and why people grieve, considering the experiences of bereavement and loss across a wide range of contexts. These include aging, death and dying, AIDS, disability; cultural loss, and illness. In that book, she also shares many practical ideas for treatment approaches and solutions, presenting strategies for facilitating change and empowering clients to aid themselves in regaining control of their lives. Especially important for music therapists was her 2002 book Supportive Eclectic Music Therapy for Grief and Loss (St. Louis: MMB). This practical 12-chapter volume considers the many and varied uses of music therapy to address grief and loss needs across a broad range of client and patient populations. It embraces an eclectic attitude in considering a variety of treatment approaches and clinical interventions.

Addressing Grief and Loss Using Music Therapy

In March, 2009 I had the pleasure of sitting down with Dr. Bright at her home in Wahroonga, one of Sydney's northern suburbs, to discuss some aspects of and issues relating to the uses of music therapy in addressing grief and loss. The four main questions I asked addressed several aspects of supportive music therapy, ones both of interest to me and hopefully relevant to other music therapists working in a variety of settings. The final question also looked at the emerging grief and loss needs resulting from the current world economic challenges.

Robert Krout: Good morning. It's a pleasure to visit and speak with you about the uses of music therapy in supporting grief and loss and you many years of experience in this area.

Robert Krout & Ruth Bright Ruth Bright: Well actually, this is my 50th year of being a music therapist, and I've been a music teacher for a few years before that, and although I haven't worked a lot in palliative care, in a formal sense, I've worked with many people who have been facing death, either in the very near future, or have been told that they haven't got long to go. And I think that my experience as a teacher working with children, although they were ordinary children in school, gave me an understanding of how music reaches all sorts of things that are hidden below the surface. And I also think that doing a counseling course was a great help. I learned not to ask questions, but to make statements, which people could either ignore or take up on those things. So, it's been a wonderful 50 years, well I've not quite completed 50 years, but this is the 50th year. And it's really been a very great privilege I think, to use music to support people, and to strengthen them to face whatever the future holds for them.

RK:What was your first introduction to using music therapy to support grieving for those who had losses?

RB: Well, I think that the visit to Canada probably was the key event in my life in the late 1970s when I went to Montreal to spend a few weeks working with Susan Munro in the palliative care unit of the Royal Victoria Hospital, which was a huge active treatment hospital, a freestanding palliative care unit. And I think they've probably had more influence on people there, and on me as well, seeing how palliative care was part of the continuum of medical and health care, not something in which doctors need to get the patients who were dying who they were ashamed of, because they hadn't managed to cure them.

RK: In the opening sentence of the preface to your 2002 book Supportive Eclectic Music Therapy for Grief and Loss, you write "This is a practical handbook with a theoretical substratum, rather than a theoretical treatise with occasional ideas for action." Is this theoretical substratum in essence another way of defining or supporting an eclectic approach, as opposed to viewing music therapy work in grief and loss from a single theoretical position? How would you describe or define an eclectic approach to this work?

RB: My aim in writing something whether an article or a book - is to make it as practical and useful as possible, rather than simply a theoretical discussion of an idea. But I also see it as vital to give a theoretical basis to my work, with references to relevant literature, in order to demonstrate that there is a sound rationale both for the casework that I describe and the ideas I suggest. To describe my approach as eclectic ensures that readers know that I shall be describing the results achieved through a range of different methods, depending on the needs of the individual concerned. I have always used an eclectic approach, and there were various reasons for this. I realized very early on that individuals are different, and that a particular approach which works for one person does not necessarily work for everyone. In other words, one approach doesn't suit everybody. I also realized that a single individual may need different approaches at different stages in the management or treatment of their condition. Someone who is coping with a difficult grief may need initially to explore all the reasons why the loss has hit so hard the relationship with the person, their own self-esteem and whether this has been impaired in some way, and so on. But for many people there comes a stage when the analytical approach is no longer appropriate because the person is at risk of getting stuck in introspection, and needs to put things in the cupboard intellectually, allowing full expression of feelings - but then start to work out new ways of living and relating to others. At this point, the cognitive, practical method is more useful.

The rightness of this opinion was confirmed when in the mid-1970s - I started to visit various places around the world to observe music therapy in action, and found that methods used by music therapists in different places seemed to be determined more by the philosophical approach on which their training had been based than on the needs of the individual, and that in some instances the chosen approach did not meet those needs. Thus in some places, psychoanalytical methods were considered to be essential, but in other places (such as USA at that time) behaviorism was the approach. In some facilities, improvisation on instruments was the only method used whether with children or adults almost without any conversation or discussion, but in other places discussion of music played on records was an acceptable therapeutic approach. In one German mental hospital, where improvised music was the chosen activity, the staff met for discussion after the session and I heard such comments as "I knew he was angry when he played so loudly" without any attempt having been made either to verify this assumption by discussion with the patient, or to talk over the reasons for the anger (if that is what the loud playing had in fact symbolized - and not excitement!) It is possible, of course, that this was a regular feature of the patient's behavior, so that the assumption was justified, but nevertheless my own practice is to check things out anyway (and virtually all Australian therapists would do this).

In adopting an eclectic approach, I was perhaps fortunate in that I started work 18 years before any music therapy training was established in Australia, so that rather than doing a set course of study - I gradually developed my own program, helped by discussion with many professional colleagues, and studies supported by hospital librarians. This background study included much practical experience, gained by:

sitting in on a leading neurologist's out-patient consultations,
attending neurology and psychiatry presentations,
talking with the psychiatrists, social workers and other staff who were looking after the patients with whom I worked,
learning about all kinds of childhood disabilities and handicaps, and working in group homes, and in a children's unit for permanent care,
doing some investigations on using music to enhance co-ordination of gait and hand movements at a centre for multiple sclerosis,
working with aged people, in rehabilitation, long-term care, dementia and psycho-geriatrics,
joining the Australian Association of Gerontology and, in 1970, giving a major conference paper for that organization,
working in children's wards, spinal and head injury units,
attending seminars on a wide range of topics,
joining (1978) the newly-formed National Association for Loss and Grief,
and travelling overseas to see music therapy in various hospitals, special school and educational facilities.

All this added to my theoretical understanding and enlightened my practical work, which gave strong support to my eclectic philosophy. (Incidentally, although in the early years I was still a volunteer because music therapy was not yet established as a profession, I was appointed as Honorary Music Therapist so that there were no problems about confidentiality - I had full access to files, and contributed my own notes.)

RK: As a bit of a follow-up, has anything about your eclectic approach changed for you in your work since the publication of the book in 2002?

Ruth Bright RB: In one sense it has, since I've retired from doing a lot of the work that the book was based on. I retired from working in psychiatry in 1999, and so I'm now only working with nursing home people, many of whom have dementia, and also with their families. I think where the grief and loss the eclectic approach is relevant is in the work with the families. Most of the people with dementia and too far advanced really to have a sense of grief. You may see depression and general low mood but not enough for them to be able to think "Why am I like this?" I had actually hoped to do a formal research project at this particular nursing home with family members and music therapy, but in fact there weren't enough to make it justifiably a proper thesis. But certainly the work that I do with relatives gives them the opportunity not only of doing something positive in sharing (with usually the spouse rather than the parent), but also expressing some of their sadness in the real moment. They are seeing the person restored temporarily but also seeing the person gradually disappearing. I know it sounds strange to say you see one grieving when they see a loved one restored. But although they may cry or have tears in their eyes when they see their spouse or their mother singing and moving to music and so on, I think that the grief really is that this is really something that is lost from the past. And it's usually shown very unobtrusively with just tears in the eyes, or you get that sort of faraway look in someone's face. As I said in that book, I never ask questions, I always make statements. Like, you know "It can be quite strange to see someone restored to how they used to be." I've found the statements are much more useful because it gives the person freedom either to answer or say "Really?", or perhaps talk about it then or the next time.

RK: You have visited the Palliative Care Unit of the Royal Victoria Hospital in Montreal several times, and had the opportunity in 1979 to work for several weeks there under the guidance of Susan Munro, a pioneer in music therapy in palliative care. In your eyes, how have the applications of music therapy in supporting grief and loss changed over these past 30 years?

RB: These visits arose from the visit to Australia of Professor Balfour Mount, Director of that unit, and - in his lectures he spoke of the vital importance of music therapy. After discussion at home, it was decided that I would ask to go to the unit for a few weeks; interestingly, Mount had to get permission from the rest of the staff for this because the normal rule was that anyone who came to the unit had to spend the first 3 months emptying bedpans, because it was found that this gave people a true understanding of life in a palliative care unit. (And this rule held, whether the visitor was a professor or a nurse!) However, because of personal circumstances, my brief visit was approved. I found that music therapy permeated the life of the unit, with music therapy sessions for staff as well as patients, and it was wonderful to see the equality of staff one day when the chairs ran out before Professor Mount arrived at a Case Review, he insisted on sitting on the floor, refusing to allow anyone to give up a seat for him.

Another interesting, unusual feature was that the cleaners were regarded as important people because it had been found that frightened patients would sometimes confide thoughts and fears to the person sweeping under the bed, things that they had hidden from professionals. Volunteers were also key people in the unit, with a tape-recorded hand-over for them to listen to on arrival for their day of duty. If someone volunteered to join the team who had recently had a bereavement in the unit, the person had to wait 12 months, because there was otherwise the risk that either they would be coming only out of gratitude to the unit for the help they had received in their own grief, or that they were working out some hidden feelings by volunteering with possibly detrimental results for the unit as a whole.

All this may sound irrelevant to music therapy, but it showed me that the unit truly worked as a team, that music would never be seen (as it still is in some places) as an optional extra, an entertainment. The aspects of the unit which most changed my career path was the way in which therapists were able to (encouraged to) expand their role, on the basis that the patient opens up to the person he or she trusts, that official titles do not matter we were all encouraged to talk about anything the patient brought up, and NOT to say "You must talk to the doctor about that!"

When I returned to Sydney, I went to the medical director of the psychiatric hospital where I worked and said that I must change my mode of working to focus on individuals rather than groups, and to engage in discussion with the patients. His reply was "Right we will have a meeting at which you can talk to all the psychiatrists, and we will work out a referral system." From then on, people were referred to me for music therapy who had difficulties with grief. Sometimes this was the diagnosis of a mental illness and the effects this diagnosis had on their hopes for life, community stigma etc, but sometimes it was a bereavement or other loss which because of mental illness the person was not able to deal with. People who had attempted or were thought to be about to attempt suicide were referred to me, for individual work.

Forensic patients were also referred to me, people who had committed a major crime, usually murder, as the result of a delusional belief but who gained insight when medication dealt with their delusional beliefs, with the consequence of unbearable grief and guilt at what they had done. In all these situations, my notes on the interactions were regarded as vital reading by other staff members. (Later, staff turned to me for their own problems, and I was also asked by administration to lead de-briefing sessions after suicides.) So - that visit to Canada was of the utmost importance in shaping my career and also, I believe, in shaping the attitude of psychiatrists to the value and function of individual music therapy by referral. (I was invited to present papers to the New South Wales Chapter of the College of Psychiatrists, and gave papers on music therapy at some international congresses on psychiatry.)

Regarding changes in palliative care practice, I think that song-writing has developed strongly in Australia - and now in the UK with the employment of some Australian therapists. And song-writing involves quasi- or actual counseling, as people bring out the deepest thoughts, hopes, fears etc.

RK: To explore that a bit more, have you incorporated any of these experiences in your own work with dying patients?

RB: Although that was the only time I specifically worked in a unit for palliative care, I have done a lot of work with people who were in some other sort of healthcare facility who actually were dying. I think that music can open up a channel of communication between people when it's been impaired, either from the long distant past or because of the illness. For example, I remember a woman sitting up in bed facing forward, and her husband in a chair next to her, and they're just looking at each other, with a sort of silent distance between the bed and the chair. And I said to her, "Did you used to go to dances together?" And she said "Yes." And I said "Did you ever dance to this?", and I played the one about having the last dance. And they suddenly turned and looked at each other, burst into tears, and flung their arms around each other. So I just pulled the curtains around the bed and left them alone. But obviously something had gone wrong which had separated them, and it may not have been the illness. The music was able to bring them back together at that moment.

RK: In a 2008 address to The Brotherhood of St. Laurence in Melbourne, Australia, you talked about the "if onlys" and what influences our responses as therapists to the adverse changes in the people we care for? Can you relate this topic to music therapists working with bereaved clients?

RB: The "if onlys" are part of almost (probably of every!) separation, whether this is by distance, divorce or death bereavement. If the relationship has been stormy, the feelings may be "If only we had been able to sort things out " or "If only we had never met", or "if only I had been more patient, maybe things would have been OK" , "if only she/he had been different", and so on. (This applies both to parent/child and siblings.) If the relationship has been parental, the feelings will be modified by the mode of death - if by a motor accident in which the person was killed by a stranger, then, "If only she had been somewhere else", or similar thoughts. But if the death was through illness, then the response is frequently a feeling of guilt - "If only I had realized that he was so ill, and taken him to the hospital sooner" (or whatever is appropriate to the circumstances of the death.) Or there is anger, blaming a health professional - "If only that so-and-so doctor had known what he was doing, she need not have died."

But there are similar thoughts following any loss or disaster, whether it was a natural crisis such as fire or flood, or a man-made disaster such as loss of employment (anger with the employer or the state of the economy). I have found that to allow people to express these difficult, feelings is helpful, even though as an outsider one can see that in fact nothing would have made any difference. But it seems to be a natural part of being human to have these thoughts and feelings. If the child was difficult or disabled, there may well be hidden feelings of relief; these will, however, NOT be disclosed by our asking questions but by making statements (another major feature of all my work!). Of course kids can be difficult and I had often found that parents have a tiny feeling of relief "O well, I won't have to cope with THAT any more", and it really is quite normal for parents to feel like that sometimes! This tells the parent that they are not unique, not monsters, and although there may not be an instant response, it may well turn up n subsequent sessions or just privately bring the person some inner peace. So I never try to argue someone out of their feelings and remarks, but try to express the underlying emotions (sadness, confusion, anger, bewilderment) through reflective improvisation.

This is one of my normal ways of approaching individual work, to reflect back to the person the emotions which are intrinsic to the life-story I have been told. The improvisation validates the person's hidden emotions and is almost always successful in building the essential therapeutic alliance. Suddenly the relationship and the conversation become real! So you can see that the "if onlys" are an important aspect of all grief work, and may be helpful in bringing to the surface things that are otherwise hidden.

RK: My last question again relates to your book Supportive Eclectic Music Therapy for Grief and Loss and your discussion of music therapy in response to "disenfranchised bereavement." Could you describe what that is for you in your work and how music therapy can address the needs of those with disenfranchised bereavement?

RB: The term Disenfranchised Grief was used by Ken Doka in his book with that title, published in 1989, and soon afterwards he lectured in Australia. By that term he meant the grief which was in some way seen as shameful so that the person felt that grief needed to be hidden. Two examples from my work, one was unsuccessful but the other had a wonderful outcome:

An elderly lady, whose son had died from AIDS, was in a general hospital with frailness and depression; she was able to tell people that he had died from cancer but unable to tell people that the cancer was part of AIDS, and also unable to talk about her shame that he was homosexual. (The fact that he had not married and thus had no children, was I considered, part of her grief but also unacknowledged.) Her blocking of grief had damaged her health, and although she was willing to talk about her sadness at his death, there were no signs of sadness as such, but rather a sense that there was, below the surface, a deep angry distress, which she was never able to acknowledge. I asked about music she had sung to him, but she was so afraid to show her grief that she would not sing nor even let me play the songs for her to listen.

Another elderly lady was in a psychiatric unit for depression and her psychiatrist noted that it was always at the same time of year, so referred her to me, to elucidate this if possible. It proved to be the anniversary of the forced adoption of her illegitimate baby. She had never seen the baby, was forbidden by her angry and ashamed parents to grieve or to tell anyone about this. It took a while to establish trust so that she told me of this, but eventually she told me her story. I asked her what lullaby she would have liked to sing to that baby. We then sang Brahms' Lullaby together or we started together until tears prevented her from singing more than a few words. One more session followed the next week to a transformed lady who was discharged that day and never again admitted. I knew this from the community nurse who was assigned to make occasional visits during the first few years after her discharge to see how she was progressing, and had feed-back 10 years afterwards that she was still well!

These are just two examples of disenfranchised grief but there are many more I could describe such as the middle-aged woman, the lover of a married man who felt unable to attend his funeral. Trust-building comes first, but once a therapeutic appliance is established - music associated with the relationship can be used to facilitate grief-work, with further counseling interactions.

RK: As a final follow-up, I'd like to ask something in relation to the previous question. With the current economic problems and the number of job losses, families are really having to adapt and change their lifestyles. Do you see disenfranchised grief-related issues evolving out of these financial losses?

RB: I don't know if it's so much disenfranchised grief, because I think that they are allowed to grieve over it. I think that the community as a whole is so distressed and angry for them that it's okay for them to feel stressed. I think that anger is the thing one sees on television, but I'm sure that there also must be enormous grief in the family, and probably a whole lot of "if-onlys." For example, a person may have changed jobs recently to what they thought was a better position and then been sacked because of cut-backs. The spouse may think "If only he'd stayed with that other company, he wouldn't be out of a job." And I guess that could almost tie in with family conflict. Perhaps the person that has now lost their job maybe is the only one in the family who wanted to make the change to a new job, and so they feel responsible for this loss. The loss of a job, one's possessions, status, sense of self-worth, it's a tremendous source of grief, anxiety, anger, a porridge pot of difficult emotions.

RK: Ruth, I really appreciate you sitting down to chat and share your thoughts. On behalf of music therapists throughout the world, thank you for the pioneering work that you have done and continue to do in using music therapy to support the unique and often challenging grief and bereavement needs of clients who have experienced losses in their lives. Your work is an inspiration to us all.