All Things Must Pass: Utilizing Music Therapy in the Transition of a Dying Loved One
By Jacob Beck
Abstract
Even as a Music Therapist with some knowledge and experience with hospice, I was yet unprepared for the intimate passing of one of my own loved ones. This is the story of how I used music to help relieve my father’s and my own anxieties surrounding his transition, and the challenges and successes that I found in offering that music to him.
Keywords: hospice, end of life care, music therapy with family, songs, dual relationships.
All Things Must Pass Away
On the evening that former Beatle and rock music legend George Harrison passed away, my father came home from work, changed out of his suit, and dusted off his phonograph well enough to put on Harrison’s eponymous triple record album, "All Things Must Pass." He invited me, without having to ask, to participate with him in this unique tribute to a musician and cultural icon that we both greatly admired—I joined him in the living room as the album played in its entirety, not a word spoken between us. Looking at this experience through the lens of music therapy, one could argue that the tribute to Harrison was a musical intervention, created spontaneously, yet successful towards reaching a goal or objective, although it is not clear of course who the client was or who the therapist was during the "session." No matter how one chooses to argue the spontaneous intervention’s professional merits, though, it is clear that a positive musical experience was shared and nurtured between father and son across at least three therapeutic domains: social; emotional; and spiritual.
It was in that very same living room just more than 9 years later that my father lay ill, eventually passing away from an aggressive form of colon cancer with his family by his side. The music and the musical tributes that I felt compelled to provide were then for and about him, and so it was more academically clear who was classified the "therapist" and who was the "client," but the therapeutic dynamic that we fostered for one another remained very similar to that which we shared in 2001, after HarrisonÂ’s death: spontaneous; having little need for speech; therapeutic elements arising as instinctively called for; therapeutic elements temporarily unrecognized and seen in hindsight. At that time, as a music therapist young in the profession, I wondered what my professional expertise was adding to my fatherÂ’s experience, while also keeping close to heart and mind the fact that I was soon to be a grieving child.
Involved in a most disparate of dual relationships (grieving son vs. music therapist), I know fully which relationship came first and foremost (son). Yet in his final days on this earth, I acted consciously as a caregiver, sometimes with the intention of providing therapeutic music experiences for him, and drew on my education and scant experience as a music therapist during the two weeks I spent with him prior to his ultimate transition. Have I grown as a Music Therapist as a result of the experience? Were the methods I employed even considered Music Therapy? What are some of the successes and challenges that were brought to bear by my education and professional experience? And most importantly, was my father comforted and helped in traditional or untraditional ways by the music experiences that I chose to give him in his final days?
To Therapy or Not to Therapy
One of these questions—Was Music Therapy actually performed—is clearly answered in the negative: no, I was not my father’s Music Therapist. The American Music Therapy Association’s official definition of Music Therapy is this: "Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program" (American Music Therapy Association, 2010). My musical relationship with my father in his last weeks and days bears scant resemblance to a clinical one, and besides that, the ethical dangers of being a Music Therapist to a family member are outlined clearly in such texts as "Ethical Thinking in Music Therapy" under the section of dual relationships (Dileo, 2000, p.127). I wasn’t paid for any work or clinical progress rendered, and I wasn’t expected or obligated to report to his hospice providers or work as part of any interdisciplinary team, nor had I the desire to act in any professional capacity in my preternatural mourning. However, I did utilize known "music interventions to accomplish individualized goals" and I am a "credentialed professional who has completed an approved music therapy program," and these facts were certainly influential in establishing my role as a caregiver, one that I relished and felt responsible for. If not charged professionally with musical duties, I felt impelled strongly to use my musical gifts, training, and experience to accomplish personally generated goals with my father; the term "quality of life" kept rising in my mind as I proposed with myself the ways in which I could help. Also, there was on my part a certain and powerfully felt confusion throughout his short end of life care pertaining simply to my own needs and feelings surrounding my father’s impending passage from this world. In both my father’s and my cases, music and musical intervention on my part represented a clearly defined method to deal with the myriad challenges that we both faced.
The literature on music therapyÂ’s effect on oncologic patients and end-of-life care is many-faceted and proves clinically to be at least moderately statistically successful in many cases (Aasgaard, 2001; Brodsky, 1989; Ezzone, Baker, Rosselet, & Terepka, 1998; Beck, 1991; Burns, 2001). The main treatment areas across spectrums of care for a cancer patient are generally as follows: reduction of pain; reduction of stress; increase of coping skills and mechanisms; increase of social support; and increase in self-expression and communication (Hanser, 2005). Music Therapy aimed at reducing pain, stress, and providing social support for those grieving a major loss is an entire area of study unto itself and will not be addressed in this essay to a large degree; in fact, the musical work that I am doing to cope with my own loss is ongoing and personally studied thus far to a lesser degree. It is fair to mention, though, that any interventions done in the home setting where my father transitioned almost always involved other members of our nuclear family; his wife, his 3 sons, their wives, and his grandson (my progeny) were intimately involved in all aspects of his care, and the delivery of music was no exception.
The benefits provided by my musical relationship with my father are more clearly seen in retrospect; that is, the delivery of interventions at the time of my fatherÂ’s end-of-life care were not preordained and were made during a period of my personal experience absolutely overwhelmed with confusion, emotional pain and joy, anticipatory grief and mourning, and concern for myself, father, and nuclear and extended family. There was no professional pressure for me to perform musical duties; my musicking with my father was motivated purely by a personal need to define my role as caregiver and simply to help my father in any way that I could. The interventions that I chose throughout any day or night were created semi-spontaneously and with a marked creativity. I drew on the considerable personal musical information that I knew about my father to generate rough approximations of clinical music therapy interventions, and these included: music listening to preferred recorded music; music listening complimentary to healing massage; live musicking involving acoustic instrumental guitar; religious hymn singing with him and family members; song-singing of preferred songs from a "safe" aural distance; generating song lists from my father of preferred religious songs; and musicking during periods of his relative sentience.
Songs of Mercy
In attempting an analysis of the effectiveness of the music that I delivered my father in his final days, I find it useful to reference Cheryl DileoÂ’s list of clinical approaches for delivering songs to oncology patients (Dileo, 1999). Songs, both in active and passive listening, formed the backbone of my unofficial but important work with my father and family during this time. Working backwards (approaching an understanding of effectiveness after the fact), I realize the possibilities that "songs" naturally afforded me (as they were somewhat spontaneously delivered) as a modified "treatment" tool, and their effectiveness illustrates not only a personal gratification but a tangible proof of music therapyÂ’s overall effectiveness in easing his and any cancer patientÂ’s challenges. All following quotes are from DileoÂ’s list of clinical song approaches.
Songs accompany us through our lives and often become associated with various difficult life events. Songs then become tools for recall and re-experiencing those events that may be relevant to a therapeutic process and, at the same time, provide resources for resolving conflicts. (p. 152).
Songs and special singers followed and enriched immensely my fatherÂ’s experience throughout his entire adolescent and adult life: Led Zeppelin perhaps his remnant of a brief feeling of rebellion; The Beatles as a culturally felt phenomenon and lasting astounding musicality; Harry Nilsson as his honey-voiced clown prince; Emmylou Harris as his absolute favorite and a flashpoint for his life with his wife of 34 years, and this is just to name an important few. His musical tastes ranged dramatically from pop music (both new and old) to jazz to a variety of classical music, especially the Romantic period. I then had a wealth of musical material from which to draw in attempting to comfort him in his final days, and recreating songs live using guitar and voice, or choosing recorded music for him to digest when he could no longer physically choose for himself, was the "easy" part, as I was so intimate with his preferences. My father taught me to love recorded music, and I feel that I was simply returning the favor. Music was a constant in his house normally, and became even more so in his final days; it contributed to his quality of life and also the quality of life for his family, under emotional siege. It should be noted that as emotionally gratifying as preferred recorded music could be, it also presented some unique and unexpected challenges. Some favorite music was simply too difficult to listen to at certain junctures for his family, the songs being so connected emotionally to the dying loved one and causing visible distress for them; also, at points when my father was too cognitively depressed to understand the music aurally, the delivery of his favorite and closely held music was contraindicated.
Songs are capable of influencing all aspects of the individual simultaneously, i.e., physical, emotional, cognitive, social, and spiritual. (p. 153).
Preferred music was often utilized to accompany other events or processes during my father’s last days, as in the case of his therapeutic massage sessions, which continued until the day before his transition. He would ask me to choose music to be played during his massage sessions; I obliged by picking a preferred, appropriate CD, and care was taken to marry the situation with the music—a favorite was Miles Davis’ jazz album, "Kind of Blue." The music has a very sparse instrumentation (a jazz quintet) and "space" between the melodies and solo playing, lending itself quite well to a sort of energized relaxation on the part of the listener; it also happened to be an album that my father and I shared in reverence before his illness. The music was a conduit, along with the massage, for touching on all the major domains of his experience, and was presumably effective in appropriately increasing or decreasing values in some of the main areas of end of life treatment: the physical decrease of pulse; an increase in sense of well-being; a diversion from anxiety about life circumstances; a lifting of the spirit.
Songs provide a mechanism for examining and reinforcing an individualÂ’s spiritual life. (p. 153).
My father was a very comfortably religious man, effectively and judiciously integrating his deeply held beliefs with the importance and gravity of his situation. A comforting aspect of his end of life care was the presence of his pastor, who came every day for more than a week to deliver spiritual care. Also comforting were favorite hymns; I generated a musical intervention that involved writing down my familyÂ’s most deeply preferred hymns, as well as my fatherÂ’s, and made an effort to learn as many as possible for a sing-along. As my fatherÂ’s health declined, a formal event did not materialize, but the songs accompanied many other activities, including his supposed last rites (he would not transition until 2 days later). These were very powerful moments in my familyÂ’s experience as we sang "Amazing Grace," "How Great Thou Art," "Be Still My Soul," "Simple Gifts," a couple of which were enriched in experience by their marriage with my fatherÂ’s most favored classical music (the melody of Simple Gifts, for example, embedded beautifully in CoplandÂ’s Appalachian Spring). There was a special transitory place reserved for the hymn "All Creatures of Our God and King," as my father specifically requested it; besides singing it for him and family during this time, I also worked up my own version to be played during his church funeral. In the last case, therapeutic success was reached both before and after my fatherÂ’s passing, as evidenced by his ability to thank me for the specific song and by the very positive emotional reaction from funereal participants; the lovingly held hymn represented a song of transition into the honoring of his memory and of grieving. Hymns are often central to the treatment of the spiritual therapy domain, and my expertise in quickly learning unfamiliar melodies and settings (born of music therapy training and experience) proved to be a highly useful and effective skill.
Songs allow opportunities for individuals to listen to the message/wisdom of the illness. (p. 153).
My father handled his illness for the 10 months he was acutely aware of it and his subsequent transition with extreme maturity and self-reliance. Hospice care was provided only in the final week of his life, and although it was immensely important to his comfort and quality of life, the bulk of his psychological, emotional, and spiritual healing through the point of death was conducted by himself and my mother with dignity and fierce determination. He and my mother dealt with his illness and the realizations of his sure fate with all of the finer points argued in the book "Dying Well: Peace and Possibilities at the End of Life," by Dr. Ira Byock; in deference to his self-reliance, he even handed over his bodily care to me and my mother when it finally became necessary, without complaint and with great dignity. He kept out of hospital as much as possible, knowingly took on alternative treatments including massage therapy, naturopathy, and specialized diets, and died as comfortably as humanly possible in his own home, surrounded by his reveling and loving family and in the sure presence of his God.
My role as a music maker here, then, could only be considered peripheral, yet his early lessons for me in what makes inspired music so inspirational were of use to both himself and me. Culling from his vast array of musical tastes, and being careful to use the "iso-principle" (Shatin, 1970, though I modified it to meet the environment and circumstances where they were, as a singular entity, as opposed to meeting a single person), I was compelled to choose songs to be delivered ambiently or from an aural distance, using them just as peripherally as my metaphorical role-playing. "Many Rivers to Cross," as sung by Linda Ronstadt; "All Things Must Pass," by George Harrison; "Walk Like a Man," by Bruce Springsteen; all favorites of his that took on a wealth of meaning and poignancy during his near transition, and could be argued to have the necessary lyrical "message/wisdom of the illness." How his quality of life was enhanced from these live arrangements at a distance is unknowable (him not receiving a questionnaire and not self-reporting), but measurable in the sense that he enjoyed or appropriately brooded over them from his near constant bed-rest. My father was intensely interested in explaining to himself his unique circumstances, and venerated for hours under his breath as to what was transpiring in his entire existence, and more so, the ways in which he could transition successfully; I sincerely feel that I was able to enrich that journey with some of his favorite transformative songs.
The Sound of Sentience
Ambience as opposed to directness, in fact, formed a very important element of my musicking with my father. Being sensitive to his personality and needs, it became quite apparent that he was not searching for a direct therapeutic contact, or even a therapeutic element of any kind (beyond his beloved massage sessions); this owed to his sustained and fierce self-reliance, as well as perhaps his struggles in allowing his closest family to see him in his condition. I had several months earlier (May 2009) attempted my first tentative foray into therapeutic relationship with him as he was passing a painful physical night following major surgery; he listened as I sang and played guitar, me moving in and out of familiar songs. He allowed me thanks, and the next morning asked if I would "sing less next time," a preference that I perhaps should have noted given his remarks about my non-music therapy playing for him in the past (he always enjoyed my instrumental playing more than my singing). He was uncomfortable with the directness of the singing and of it being so pointedly about and for him, and rather than feeling that he didnÂ’t deserve it for some reason (some hospice patients report feeling unworthy of care or that they are a burden for their loved ones [Byock, 1997, p. 159), he felt that he didnÂ’t need it for the improvement of his health. There is a remarkable difference between hearing that the music one has provided wasnÂ’t exactly appropriate from a client or emotionally distanced patient and hearing it from oneÂ’s own father. Nonetheless, in subsequent attempts to follow a therapeutic path, I made sure to provide music for him in a less direct way, by playing strictly instrumentally on an acoustic guitar, and more importantly by not making a big deal out of the "session"; this included playing in an adjacent opening of the room he was in, playing with my back towards him, or avoiding intensive eye contact that would suggest any semblance of "therapy." My music therapy training did not exactly call for this methodology, but a learned therapeutic sensitivity was definitively utilized in forming an intervention that was effective, that he reported to have enjoyed, and in which he took psychological, emotional, and spiritual pleasure .
Ambient music became in itself a challenge as well, and at some points music of any nature was contraindicated or simply unnecessary. At one juncture 3 days before his transition, my father was reclining in a hospital bed that hospice had provided in our living room, a respite from his unending time in his own bedroom. The house environment was relatively quiet and I decided on playing recorded ambient music, a collection of cello pieces by Yo-Yo Ma. The musical choice was made carefully to appeal to his preferences and perceived mood, to dynamic appropriateness, and also to the need for ambience instead of directness. Eager to formalize an opinion as to its effectiveness and after a few of the long, gorgeous songs, I asked him what he thought of the music. "ItÂ’s somewhere over there," he said quietly, pointing with his hands somewhat ethereally towards the source of the music. Comfortably lost in his thoughts and cognitively deteriorating, the cello music for him was a non-issue, as probably any music short of very loud punk music would have been. At that point a musical intervention was unnecessary, and while it certainly did no harm (being unremarkable to him), his gentle rebuttal was a distinct reminder of the individuality and impermanence of any one personÂ’s end of life experience.
The Importance of Being Musical
Music therapy has long thrived as an effective mode of interdisciplinary treatment with people suffering from end-stage cancer, claims a special professional relationship with hospice care, and in my mind, is in most cases absolutely essential in fostering that all-important standard of measurement, quality of life. The challenges faced by loved ones of cancer victims are immense, important, and varied, and I can only add my personal struggle as being in a dual relationship (son and music therapist) to the endless litany of the needs perceived by us survivors. However, music has forever been for me an important coping mechanism, proving long before I was a music therapist the value that it provides to lifeÂ’s domains of experience; and I feel strongly that in the case of my fatherÂ’s transition and because of his apparent and deep love for music, it was sorely needed in some fashion to enrich his and his familyÂ’s experience. My music therapy education and short professional career, though necessarily truncated and devalued to a large degree to accommodate the pressing needs of the situation, brought an added layer of purpose and integrity to the profundity of the passage of my father. I never saw him as a client, yet worked under the auspice that he was first and foremost a person in need and could be delivered a service that I was uniquely entitled to provide in some form. Music therapy has provided for me a lens in which to view human suffering and our responses to it, and I felt qualified on a conscious level to partake in my fatherÂ’s healing, and ultimately my own. My mother and I were sitting on either side of him one day not long before his transition, playing on the stereo Emmylou HarrisÂ’ "Luxury Liner," a seminal album in my mother and fatherÂ’s life, one that I encouraged her to choose for his unconscious listening pleasure. "You know," she said, "Emmylou will sing him to sleepÂ…and so will you."
References
Aasgard, T. (2001). An ecology of love: Aspects of music therapy in the pediatric oncology environment. Journal of Palliative Care, 17(3), 177-181
American Music Therapy Association. (2010). Definition of music therapy. Retrieved June 7, 2010, from http://www.musictherapy.org
Beck, S.L. (1991). The therapeutic use of music for cancer-related pain. Oncology Nursing Forum, 18(8), 1327-1337
Brodsky, W. (1989). Music therapy as an intervention for children with cancer in isolation rooms. Music Therapy, 8, 17-34.
Burns, D.S. (2001). The effect of the Bonny Method of Guided Imagery and Music on the mood and life quality of cancer patients. Journal of Music Therapy, 38, 51-65.
Byock, I. (1997). Dying well: Peace and possibilities at the end of life. New York, NY, USA: The Berkley Publishing Group.
Dileo, C. (2000). Ethical thinking in Music Therapy. Cherry Hills, NJ: Jeffrey Books.
Dileo, C. (1999). Songs for living: The use of songs in the treatment of oncology patients. In Dileo, C. (Ed.), Music therapy & medicine: Theoretical and clinical applications (pp. 151-167). Silver Spring, MD: The American Music Therapy Association, Inc.
Ezzone, S., Baker, C., Rosselet, R., & Terepka, E. (1998). Music as an adjunct to antiemetic therapy. Oncology Nursing Forum, 25, 1551-1556.
Hanser, S.B. (2005). Music therapy to enhance coping in terminally ill adult cancer patients. In Dileo, C. & Loewy, J.V. (Eds.), Music therapy at the end of life (pp. 33-42). Cherry Hill, NJ, USA: Jeffrey Books.
Shatin, L. (1970). Alteration of mood via music: A study of the vectoring effect. The Journal of Psychology, 75 81-86.
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