A Symphony of Life: Creating and
Preserving Legacy through Innovative
Medical Music Therapy Interventions
Brian Schreck, MA, MT-BC
Title of Program: Family Medicine Grand Rounds Title of Talk: A Symphony of Life: Creating and Preserving Legacy through Innovative Medical Music Therapy Interventions Speaker/Moderator: Brian Schreck, MA, MT-BC Planning Committee Members: John King, MD, MPH, Melisa Gibson, MD, Anne Morris, MD, Whitney Calkins, MD Date: November 17 , 2014 Workshop #:15-101-12 Learning Objectives 1. Synthesize current evidence based practices of the role of creative arts therapies in palliative and hospice care.
2. Identify the importance of medical music therapy in palliative and hospice.
3. Share/apply innovative medical music therapy interventions with multidisciplinary psychosocial teams
DISCLOSURE: Is there anything to disclose? Yes or No Please list the Potential Conflict of Interest (if applicable): ______________________________________________________________ All Potential Conflicts of Interest have been resolved prior to the start of this program. Yes or No (If no, credit will not be awarded for this activity.) COMMERCIAL SUPPORT ORGANIZATIONS (if applicable):
______________________________________________________________ The University of Vermont College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The University of Vermont designates this live activity for a maximum of 1 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Overview
• “creative arts therapies involve the implementation of an arts intervention by a trained, credentialed creative arts therapist; the presence of a systematic psychotherapeutic process; the use of individualized treatment interventions”
- JAMA vol 173 (no.11) June, 2013
Creative Arts Therapies
An Overview
• Specialties include art therapy, music
therapy, dance/movement therapy, drama
therapy, and poetry therapy.
• Can significantly reduce anxiety, depression,
pain, and improve quality of life
• Music therapy for cancer patients can reduce
anxiety, pain and improve mood
• Dance therapies can improve QOL
Individual CAT
Art- uses art media images and creative process to create projects of as reflections of development, abilities, personality, interest concerns and conflict.
A therapeutic means to resolve emotional conflicts, fostering self awareness and reduce anxiety. ( American Music Therapy Association)
Drama therapy is the systemic and intentional us of drama/theatre to achieve therapeutic goals of symptom relief, emotional and physical integration, and personal growth. It is an active approach that helps to tell the patients story, to solve problems, achieve catharsis, extend the breath and depth of the inner experience, understand the meaning of images, strengthen the ability to observe personal roles (National Drama Therapy Association)
Dance/movement therapy is based on the assumption that body and mind are interrelated and is defined as the psychotherapeutic use of movement as a process that furthers the emotional, cognitive and physical integration of the individual. (National Coalition of Creative Arts Therapies Associations)
Biblio/poetry therapy- the intentional use of poetry and other literature for personal growth and healing (National Coalition of Creative Arts Therapy Associations)
Definitions 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. It is an established health profession in
which music is used within a therapeutic relationship to address physical,
emotional, cognitive, and social needs of individuals (AMTA, 2011).
Active Music Therapy: Administered by a board-certified music therapist
and requires physical action by the medical patient and/or patient’s family.
Passive Music Therapy: Administered by a board-certified music
therapist and requires no or limited physical action by the medical patient
and/or patient’s family.
Music Medicine: Passive listening to pre-recorded music offered by
medical personnel (Dileo 1999).
Well-Being: Individual’s perceived health and quality of life based on
satisfaction with emotional, social, and physical life experiences.
Overview of MT Methods
• Receptive Music Therapy: Live music listening,
recorded music listening, song analysis, music guided-imagery
for relaxation.
• Improvisational Music Therapy: Instrumental, vocal,
storytelling and symbolic play.
• Re-creative Music therapy: Song singing
• Compositional Music therapy: Songwriting
-Lindenfelser, 2013
MT Goals
Pt/family will exhibit increased
• Comfort/relaxation
• Increased coping ability, esteem, well-being
• Decreased anxiety
• Decreased shortness of breath
• Report decreased pain/discomfort
• Express loss and grief
• Verbalize spiritual or cultural needs
• Plan music for memorial/funeral
-Lindenfelser, 2013
MT Interventions
• Provide music for relaxation/comfort
• Provide music for decreased pain/agitation/anxiety
/discomfort
• Encourage emotional expression and response
• Provide music and guided imagery
• Assist Pt/family in songwriting or song analysis
• Encourage Pt/family participation in improvisation
play
• Provide music to validate and support Pt/family
spiritual beliefs
• Provide music to validate Pt/Family’s cultural heritage
-Lindenfelser, 2013
Why is the music meaningful
• It takes on deeper significance during times
of loss and grief
• An art form that is universally valued
• Has cultural and spiritual significance
• Personal significance to specific events,
rituals and traditions (Magill, 2009)
-AMJHPM vol 26 2009
The significance of the music for as
perceived by surviving caregivers Strategies used:
• Precomposed songs- reminiscence, life review, lyrics can guide thoughts
• Song composition – use of familiar melodies, life stories, enhances sense of personal value, attributes about the self, messages to significant others, opportunity for resolution
• Imagery in music for symptom relief, use of peaceful images
• Music listening-live music in sessions with caregivers, familiar music, connection to transformative events in life (Magill, 2009)
Clinical Aims
Reengage children with their environment using
CAT to create three elements of contextual
support:
• Structure: To provide Pt’s with opportunities for successful
mastery over their environment.
• Autonomy Support: To afford Pt’s opportunities to
make choices and direct activities
• Involvement: To express unconditional acceptance of Pt’s
and reinforce their efforts and actions. (Robb, 2003)
-Bradt, 2013
1. Listening to live, therapist-composed,
improvised music
• I invite you to imagine you are sitting in a
hospital room with a loved one. You are
holding their hand and it is very quiet.
Everyone present is thinking of the right
things to say, but no one is saying anything.
Gentle music is offered…
2. Performing on an Instrument
Functional (Re)Creation!
3. Improvising
Re-Creative &
Compositional MT
• Song: Singing/playing familiar songs
to normalize the experiece and to
validate patient’s interests and identity.
• Songwriting: Can help facilitate
communication of the patient’s
experiences and feelings –often a
treasured and tangible part for the
family (Lindenfelser, 2013)
E.
• E. is a 13-year-old with spinal cord astrocytoma,
secondary quadriplegia
• At approximately 5:30 3/9/10 respirations stopped and
HR slowly decreased. Time of Death 5:48 AM.
• Legacy theme/intervention: Preserving E.’s voice by
utilizing and celebrating her physical expression/Live
music for comfort care post-mortem
E.
Continue living in the midst of letting go
E. was
an artist
and wanted to
be a fashion
designer
These sketches
were designed
before E. lost
the use of her
arms
These images were
used to label the Cd’s
of our recordings
created for her family
Tell Me A Story
Family-Centered Synergy • "On the day it became evident that Critter would lose his
battle, Brian stayed with him and his family in the ICU,
playing the songs that Critter loved, singing with the family
and providing them with CD copies of the recordings. As we
walked Critter back to A5 South in his bed, still on the
ventilator, Brian was there, playing the music that meant so
much to Critter. "When the family gathered around Critter's
bedside to say a final goodbye, his father requested that
Brian come and be close to the family. He was an essential
part of Critter's care team, and his presence and music at
the end of the journey provided such a comfort to the family.
Critter's mother asked Brian to provide the music at his
funeral, and Brian did a fantastic job.”
• She added, "Critter's best friend is a current patient, and at
the funeral, he wanted to sing a song he had written. Brian
assisted him in playing, and I believe that in the difficult
months ahead for this child, Brian will also bring comfort
through the love of music that all three share."
The Battlefield “The Battlefield”
My Cancer’s like a battlefield
That I just keep on rockin’ through
Every day and night I fight
And I just keep on rockin’ through
Fartin’ and makin’ it right
Hoagies, fries and sprite
I just keep rockin’ through
My Cancer Is A Battlefield
Cancer is a battlefield
IV pumps and hospital beds
That I just keep on rockin’ through
Doctors and nurses all around
That I just keep on rockin’ through
Pepsi, steak, & corn
That I just keep on rockin’ through
Battlefield, battlefield
My cancer is a battlefield!”
Continuum Of Care/Legacy Work
The Battle Field
Movement 4: The Voice of home
• “Music From An 8 X 8 Room” Inspiration from Diego Stocco’s “Music From A Tree”:
http://www.youtube.com/watch?v=fY-ZoVMwGKM
5. Music combined with other modalities
(i.e., movement, imagery, art)
Search Strategy
• Keywords: music therapy, medical music therapy,
pediatric music therapy, music therapy and: quality of
life, pediatrics, hospitalized children, pain, inpatients
• Databases: MEDLINE/PubMed, CINAHL,
PsychInfo, Cochrane Library, Alt Healthwatch,
OhioLink, GoogleScholar, &
• National Association of Children’s Hospitals and
Related Institutions (NACRHI) electronic mailing list
The Evidence Summary • Peutz- meta-analysis CATs effect on psychological
symptoms and QOL in patients with cancer during and
after treatment, 27 RCTs
• During treatment, CAT significantly reduced anxiety
(Δ = 0.28 [95% CI, 0.11-0.44]), depression (Δ = 0.23
[0.05-0.40]), and pain (Δ = 0.54 [0.33-0.75]) and
increased QOL (Δ = 0.50 [0.25-0.74]). Pain was
significantly reduced during follow-up (Δ = 0.59 [95%
CI, 0.42-0.77]).
• Exposure to CAT can improve anxiety, depression,
and pain symptoms and QOL among cancer
patients -Peutz, et al (2013)
Evidence Synthesis
Effect MT may have on Well-Being in Pediatric Patients
Emotional:
• Reduces trauma
• Lowers maternal anxiety
• Less crying in neonates
• Reduces distress before/during/after blood tests
• Increases positive affect
• Active MT reduces anxiety
• Music medicine reduces pain/fear for pediatrics
undergoing lumbar punctures.
Evidence Synthesis continued
Social:
• Facilitates coping strategies
• Reduces maladaptive behaviors
Evidence Synthesis continued
Physical:
• Influences physiology
• Reduces migraine frequency
• Decreases pain during burn debridement
• Reduces the amount of pharmacological
interventions in neonates: Increases feeding rates,
increases quiet sleep states, reduces heart rate
Evidence Synthesis Continued Other Findings • May enhance cognitive abilities
• Facilitate non-verbal/verbal communication
• State of science is underdeveloped
• Consistent outcome measures
• Consensus on research priorities
Other palliative care outcomes/functions
• Preloss grief
• Postloss grief
• Means for expression for decision-making and goals
• Dignity and identity
• Expression of emotions
Encouraging decision-making
No one is quite like you
Or can be all you are
So loving, so caring
And always by my side
When I see your face
It makes me happy
You make me strong
You give me faith
With every song we sing
You are in my heart
You are my family
We’ll never be apart
“No One is Quite Like
You” Written for Mom
I’ll always be with you
I’ll always be your friend
I’ll always love you
And be your baby girl
Focus on Family-Centered-Care
Case: 30 yr male w NF-1
Severe neuropathic pain unresponsive to :
Opioids
Anticonvulsants
Benzodiazepine
Tricyclic antidepressants
Topical Local Anesthetic patches
TENS
Culinary Arts: Finding Control
Leaving a legacy
• http://www.shutterfly.com/custompath/viewEdi
t.sfly?fid=55b8e05dd84b633626cd1d30d33b
21f1
“If I don’t make fun of it, then who’s
gonna?”
• My goal is to approach living
with cancer with humor,
optimism, and yes indeed
sarcasm (that is a part of who I
am.) I look forward to many,
many more years of accidental
distaste, but I hope to fail
miserably in that department
and continue to teach
optimism, patience, how to
laugh in despair, and to never
give up.
Eight weeks have gone and passed;
I wasn't sure if I would last.
But the time has come to raise the mast,
Sail along and continue this blast
Of a ride my life has been.
I believe that news will be great, .
But a few months I have to wait,
And during that time I appreciate
The value of patience and an optimistic state
Of mind.
I cannot fall behind
I remind
Myself to find
All the beauty in this seemingly cruel world
Into which we've all been hurled.
Like a flag coming unfurled,
My heart becomes twirled
With thankfulness and gratitude
That I have a positive attitude
And that I'll travel to any latitude
To keep on being that dude.
This radiation treatment is coming to an end,
It made my body contort and bend.
A painful round each day would send,
But I was greeted each day with a smile from a
friend.
The people I met who have taken care of me,
Who have always seemed to want to be
There doing their best to make us tumor free ...
I will leave here optimistically.
optimistic
02.02.11
Legacy
• “Brian, there are no words to express what
the time you spent with Q meant to him and
to me. We received this email (of the
recording) from you before we even got home
and the cd immediately thereafter. I am so
grateful to you and to whomever summoned
you to our room.”
TAB
StoryCorps
Our Principles StoryCorps is built on an uncompromising
commitment to excellence across all aspects of the
project, from collecting, sharing, and preserving
people’s stories; to organizational management; to
maintaining an extraordinary work environment
where respect and dignity are paramount.
The interview session is at the heart of StoryCorps.
We treat participants with the utmost respect, care,
and dignity.
• Metastatic desmoplastic round cell
tumor, diagnosed in 2/07. DOD: 1/3/09
• 27 years of age, two children at home
• Lullabies for two children
• Legacy theme/intervention: Creating
consistent night rituals for coping &
comfort
M.
M.
HEARTBEAT MUSIC THERAPY
Re-Creative &
Compositional MT
• Song: Singing/playing familiar songs
to normalize the experiece and to
validate patient’s interests and identity.
• Songwriting: Can help facilitate
communication of the patient’s
experiences and feelings –often a
treasured and tangible part for the
family (Lindenfelse 2012, Bradt 2013)
doppler
infant
toddler
Infant
Rock
School
aged Pt.
12 mo +
parents
Rock with
Sibling
Hip
hop
Infant +
parents
First
Birthday
http://cincinnatichildrensblog.org/patient-family-
experience/and-the-beat-goes-on/
http://abcnews.go.com/blogs/health/2014/05/26/therapist-
turns-heartbeats-of-dying-patients-into-music/
http://www.huffingtonpost.com/2014/07/02/recorded-
heartbeats-brian-schreck_n_5552019.html
http://wvxu.org/post/using-dying-heartbeats-make-music
Future Challenges
• Can a deceased person’s legacy intensify
loss associated with a complicated
relationship?
• How to assess the potential impact of a
legacy work on the recipient? Will they be
comforted?
• How to assess the emotional consequences
of the work in progress?
“This is the voice of home.”
-Clive Robbins
“One of the last things that Paul Nordoff said to a
colleague when he was dying in hospital was, ‘You
know, the greatest mystery of all is that we’re made
of music.’”
Ansdell, G. (1995). Music For Life. P.8 ISBN 1-85302-299-3
Let’s Dance
References
• Ansdell, G. (2000). Music For Life: Aspects of Creative Music Therapy with Adult Clients (p.8). 325 Chestnut Street, Philadelphia, PA 19106: Jessica Kingsley Publishers Ltd.
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• Cincinnati Children’s StarShine Program: http://www.cincinnatichildrens.org/service/s/starshine/default/
• Cincinnati Children’s Hospital Medical Center (2010): “Tell Me A Story” http://www.youtube.com/watch?v=JEXxVG550bs
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• ZoVMwGKM
References
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MT in the Seacrest Studio
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complex-conditions/heart-
conditions/seacrest-studios-performance-
was-my-victory-lap/#.Uqn5ERZyHww
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