…the idea was, basically, that the patient-preferred live performance element of the protocol was something that would help both rapport and help the patient talk to the therapist more and just kind of provide an “in,” so that you could get a conversation going…we know that music can be a very great way to initiate, develop, and facilitate social interaction in that if you see someone playing music and giving that experience to you, it can just open up a level of rapport that’s either just deeper or developed more quickly than you would otherwise be able to do in a hospital room. (A)

…PPLM is the easiest way to build rapport with someone and prove that you understand them and you’re not there to play music that you enjoy but that you actually play what they enjoy…I think having that buffer with the CID makes it…if I went in and just asked them point blank what their stressors were, I don’t think it would maybe come off as well…but I think having the CID sort of paired with the PPLM makes it easier to get it out… (M)

I really think the rapport is a really important part of this…it is in the beginning of the protocol to discuss music preferences…I felt that the music helped the therapeutic relationship grow and become comfortable in most situations. Playing a couple songs at the beginning of the session may "break the ice" and help patients open up…(R)

…ultimately it’s the therapist’s job to help the patient find his/her own coping strategy, because I can’t just come in with a list of coping strategies and tell the patient, “Okay, you need to choose this strategy or use that strategy,” because that’s not going to be functional for the patient. The patient needs to find a strategy that’s going to work for their own life. (A)

…but really my goal was just to help them identify some way of coping or identify ways that they already do it, anything like that…but I was always very cautious about coming in and not trying to fix anything but more just opening up the door for them to talk about it and allowing them, more than just suggesting new coping skills for them to use, more like let them talk about it and see, “Oh, this is something that I’m already doing that I do find as a good way to cope,” and identifying it in that way. (H)

So I think it works in the fact that it helps people simply think about it. And it’s a nice way to get people’s minds maybe realizing that “Oh, this is something that I could actually do something about” or “There is ways that I can take care of this at home.” So I think of, when people have the opportunity to see that it is changeable and that they’re not necessarily stuck with it, helps their minds figure out, “well, what are some options?”…So having, help people get that belief, I think, is simple in the fact that we’re not making them do anything but help them believe that they are capable of doing something…it’s not intended to be a deep “pull out all of your secrets” isn’t intended to happen within, you know, 20 to 30 minutes and then they have one or two things that they can consider, not ensured that they’re going to do, but something that they can consider implementing. (M)

And, in doing the dialogue with patients, for the most part, I wasn’t giving them new information, but focusing on having them identify what they already know and then reinforcing the coping strategies that they were identifying…(U)

…they really need someone to talk about these stressors with because the nurses on the floor are wonderful, but they don’t have just one patient, they have, you know, maybe four or five. So, having the time to sit down with them and chaplains can’t come every day because there’s maybe two chaplains or what not. (M)

I also thought it was a great outlet for the patients to just express themselves because they really just want someone there to listen to them and talk with them…at the end of the session some patients would tell me, “You know, I really appreciate you coming in here and talking to me and listening to me because this has been a very rocky experience.” Like someone going through their hair being shaved, that was really kind of terrifying for them and they weren’t sure who to talk to about it and so I would be in there and they would just kind of come and express to me what their stressors and by the end they would always say “I feel much more relieved and much more relaxed than I was at the beginning of the session.” So, some did express that, the dialogue did help to calm their nerves and some just said “Wow, that was really great. I just wanted someone to talk to.” (R)

But then I also think a lot of them, especially those who were maybe farther from home or who don’t have as many visitors, just really like having someone come in and talk to them, who’s not going to ask them to do stuff or be there to give them a shot or that kind of thing, but just to have someone who’s there to chat about their experience and actively listen. And I think that was helpful for a good portion of them as well…and I think the support was beneficial as well. As I said earlier, to have someone just come in who is just there to talk and play some music and actively listen. You know, maybe they don’t have a lot of visitors coming in, so it gives them an opportunity to talk about their experience. (U)

…with that rapport that you can develop in a matter of minutes rather than a matter of days, the theory or idea behind the protocol is that you’re able to dig deeper into conversation within a half-hour to forty-five minute time span that you wouldn’t otherwise be able to. So, the idea of short, efficient treatment is one of the hallmarks of the CID-PPLM. A music therapist comes in, establishes rapport quickly through a prescribed patient-preferred music model, and then is able [to] talk about the challenges and life issues that maybe no one else in the treatment team can get within a half hour time span. And then from that point, the coping-infused dialogue is really meant to, be the open conversations where patients feel safe and they feel welcome to talk about things that are difficult for them, why they’re in the hospital, and then things that they might be struggling with outside of the hospital and just helping the patient identify what coping strategies may be effective for some of those problems… (A)

I think that prepares the patient, starting where they’re at and starting small. And then, if they’re willing to go with you, you go into maybe some deeper issues and deeper stressors…(H)

…it’s nice to have an opportunity to do something that’s more than just one of your favorite songs/what concerts have you gone to. It’s nice to have a pool to pull from that lets you go a little deeper…it’s a great way to think about “what are your stressors – locally, globally” but incorporate in more harmoniously/congruently within the session so it doesn’t feel so abrupt…because even when I was in my internship, I still felt the things at the hospital were still pretty PPLM-based; but to add an extra layer or even just add an opportunity to talk about stressors and things that they can possibly deal with is just a nice thing to add on when you have the right client and have the rapport established already. (M)

And another thing that I liked about it is that the patients can direct how in-depth they want it to go…And so they can direct what level they want to take the dialogue to and then I have room within the protocol to respond to where they’re going…one of the things that they probably like about the protocol is that it is non-invasive…and they can choose where they want that conversation to go…Again, patients choose how deep they want the dialogue to go. (U)

But at the same time, it’s somewhat a flexible or living document which provides you a helpful guideline without necessarily locking you into a predetermined script of what you have to say to the patient…that’s one of the strengths and weaknesses of the protocol, is that the flexibility gives you the opportunity to adjust the intervention based on how your patient responds…I probably adjusted the amount of talk about coping skills and/or verbal processing based on the mood of the patient or body language I was getting, just with the understanding that everyone is kind of in a different place and they have a different level of willingness to participate in this kind of activity. (A)

…what I like about the mechanisms is that it doesn’t say how much talking, I mean, it says to alternate talking and the song, but it doesn’t really say how long the discussions have to be. So, if there needs to be more music, the little conversations in between can be shorter, and if it needs to be more conversation, uh, the dialogue parts can be longer…there’s a little bit of flexibility built into it. (H)

And also, if they don’t feel comfortable sharing with me and I force them to share with me then that’s not an appropriate way to establish therapeutic rapport. And I think that’s true with really any approach you take, that you’re not gonna go into a setting and just use a cookie cutter approach…you have to see what they have and what they present with… (M)

…so just having those main tasks and goals within the protocol was good but I could also kind of elaborate upon it or even if the local stressors came first or the global came first, whatever the patient is ready to talk about… it has a nice outline that can also be diverse within itself…I think it provides a really great guideline, which can also be really flexible at the same time…So, I sometimes kind of framed the wording a little bit differently depending on the patient… (R)

… if they’re just not opening up and I’ve given them a couple prompts and they’re sort of indicating to me that they’re not feeling confident, I can go back to the music. That doesn’t mean that the protocol is ineffective. I liked having the structure and having a guideline for where I want to go with the conversation…Yes, I like that it has structure but also flexibility and it’s not rigid and it’s not, you know, it’s not a script…So, it’s not “ask this question and then ask this question and then follow up with this”…I was able to adapt it in each session. (U)

…in terms of protocol, one of the things that I really like about it is that it provides a very clear guideline for clinicians. It has a goal in mind that I think most people who read the protocol can instantly understand – “Oh yeah, this is where the therapy session should be going and this is where the dialogue that I’m choosing to use should be going”…And, while some of these potential scripts or statements about what the goal of the conversation should be…while that may seem very intuitive or obvious to experienced clinicians or to clinicians who, understand therapy very clearly, this guideline, I think, can be very useful for younger clinicians who maybe go into a hospital room and don’t know what to say to someone. (A)

The thing I like about the protocol is that the clinician or researcher always kind of has a next step in mind…I think it gives the researcher or clinician an idea; they always have the next step in mind. So, it kind of acts as a safety net for you. I like the idea of starting with the local and going to the global stressors and coping…I consider myself an inexperienced clinician and from personal experience I think it’s good and I’d use that idea…I mean, I definitely use that idea of starting shallow and going deep with whatever topic you’re on. But yeah, you’re talking about specifically this protocol, and I do think any handbook approach is going to make it easier, especially for real beginners. (H)

…it’s simple in the fact that it gives you two things to talk about. So, if you don’t feel that you have a lot of, I think, a bag of tricks of helping with therapy or how to talk to people and some of those talk-therapy type things. I think it’s a good way to ask questions that could dig deeper if you follow up with the right questions…I think it’s a good way to have some springboard and something for music therapists with less experience to have two questions that they could at least ask and have some options to follow up with…I do believe this is a nice tool for newer/less experienced music therapists who don’t have the counseling skills yet. Experienced music therapists can definitely use it, but I think it’s a nice use for newer music therapists want to go deeper than PPLM, but haven’t had years of experience yet with talking to people. It would have been nice to use during my internship for sure not only in the hospital but hospice as well. It’s a nice gateway to deeper counseling skills and discussions, but it can also be just about stressors and thoughts/actions too. (M)

I think for those that maybe are in school and not as experienced as a clinician in the field already, possibly in the medical field specifically…So, I think it’s definitely adaptable for those that aren’t as experienced, just because it is laid out so nicely and it’s also simple to understand what the target is and what the end result should be. (R)

…it was really helpful for me as an inexperienced clinician to have the structure and the prompts that it provided…Again, certainly the structure for someone who doesn’t have as much clinical experience. (U)

It’s great for a second session but it also feels a bit invasive for a first session…I don’t think the PPLM itself would be invasive if it was a second session or a third session but a lot of these people, when I would go in and introduce myself, I’d have to say my affiliations, say I was a graduate student…I also look really young so I don’t know how much they trust me and there’s no therapeutic rapport established whatsoever…but I still think it seems really sort of invasive for a first session as a meeting with someone and figure out what their music is but also, kind of pull out of them what’s stressing them…so if we had done it a second session or even a third, it would have had a greater opportunity to work and see what would happen. (M)

So, maybe having a day dedicated to that or maybe a longer time period dedicated to that, maybe discussing some areas that we could start plugging in how to build rapport at the beginning of the session, even more than what was already done because some patients were super ready to just jump in and talk where others I could tell they weren’t as comfortable and then I would go back and visit them on day two or day three just on my own time and it would be a little bit different compared to the first time I saw them… (R)

I have half an hour to forty-five minutes to build that relationship, use the music, and open up their dialogue. And it was enough time, but there were times when I felt like more time would have been helpful, you know. If I had had either a little longer with each patient or an additional session so that I could focus on building rapport with the music before getting into the dialogue… (U)

Yeah, that would definitely be an option and a very, sort of, multi-linear path that clinicians could follow if they didn’t quite know how to keep the dialogue moving just based on the existing protocol. (A)

There were times when I think the patients really just wanted to just hear music and not even dialogue at all between songs and you can feel that pretty quick. You know, after the first song and you start conversing with them a little bit, it would seem like they were just ready to get back to the music…when they didn’t want the discussion component. (H)

… those trouble spots that I ran into (patients not wanting to talk, difficulty transferring music/lyrics to the discussion, etc.) needed more preparation or back up options to work from…just when a patient isn’t ready to discuss, their life with you or their experiences with you…but if that ever does happen within the protocol, what’s the next step that could be done in case patients are ready for that – should I just go straight to PPLM, should I continue to talk and include the talking? … But, yeah just something to kind of have as a backup if that does happen – where’s the next step in the flow chart to go if it’s not working? (R)

…maybe they were taking too many pain medications, or whatever, to be able to participate in the dialogue… (U)