Music Therapists Do It Differently: Verbal Interaction

In this series, we are exploring how music therapists do live music differently than other musicians, even though it may not be easy to see. This is part eight of a ten-part series. You can find an introduction and links to all ten posts here.

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Music therapists talk a lot.

At least, we don’t spend ALL our time playing music, at least not usually. Verbal interaction is a crucial part of what happens in music therapy sessions. And, music therapists do verbal interaction differently from other professionals.

#8. Verbal Interaction

Consider two of our sister professions:

For performing musicians, the music is the point of their professional work. They may use speech as banter, as a bolster to the entertainment value of their show, but it’s probably considered to be ancillary to the music itself. This is especially clear in a classical concert, where you’ll hear very little speech. The conductor comes out, the orchestra plays, the conductor bows and everyone leaves. No jokes, no history lessons – just music.

"What are they talking about?"

“What are they talking about?”

On the flip side, for therapists who primarily work verbally – psychotherapists, social workers, counselors, and others – the verbal discussion is the point. They may use music as an added element in their sessions, but it is likely that the intention is to have that music start a meaningful discussion. Communicating through the music itself is not the intention.

For music therapists, though, music and verbal interaction are both integral parts of the therapeutic process. In fact, one of the major strengths of our medium of therapeutic interaction is that we can move back and forth between non-verbal (musical) communication and verbal communication as appropriate. And, as usual, these decisions are based on the needs and goals of the clients.

How do music therapists do verbal interaction differently?

Imagine a hospice music therapy session. The music therapist, Karen, is talking with Pat, a woman in her 80s who loves the gospel music of her rural Baptist church. In one session at Pat’s bedside, singing “How Great Thou Art” leads to a conversation about Pat singing in the church choir, which leads to her and Karen singing “Just A Closer Walk With Thee” and “Precious Lord, Take My Hand.” The session flows easily from music to conversation and back.

On another day, though, Pat is not chatty at all. Karen offers to sing “Precious Lord, Take My Hand,” and Pat agrees, but she doesn’t sing along, and her eyes glisten. At the end of the song, Karen pauses, waiting for Pat. After a few moments, Karen prompts Pat gently, saying, “what’s on your mind?” Pat responds that she’s just feeling tired today, that she’s “ready to be with Jesus.” Then, Pat closes her eyes and turns her head away.

What is Karen thinking about during these sessions?

1. Deciding When To Talk

Of course, the first decisions are whether to communicate verbally or musically, and whether to talk or to listen. In Karen’s first session with Pat, the conversation and music were feeding into each other easily. Here, the goals may have been assessment, establishing rapport, or facilitating reminiscence. Karen was likely mindful of gathering information about Pat that could be important in future sessions – her musical background and preferences, her spiritual background – as well as communicating an unconditional positive regard while engaging in music together.

Deciding whether to talk would have been trickier in the second session, when Pat was quieter and the session had more frequent silent moments. At the end of “Precious Lord, Take My Hand,” should Karen have started in on another song? What comes next – music? Silence? Talking? The end of the session? All of these are questions that the music therapist would have to consider in the moment, while thinking about the client’s needs and goals at that time.

2. Choosing What To Say

Beyond deciding whether to talk or not, the music therapist must consider the content of what she says carefully. For instance, after that silent moment with Pat, Karen could have said a number of things. She could have made a cheerful comment about how pretty the song was. She could have chided Pat for not singing that day. She could have suggested another gospel song, to get back into singing as quickly as possible. Or, as she did, she could have given Pat an opening for verbal interaction on another level.

The same choices applied after Pat made her statement about being ready to go to Jesus. Karen could have encouraged more verbal interaction. She could have let the silence stand longer. She could have chosen a song that validated Pat’s statements, to communicate empathy and acknowledge Pat’s spiritual beliefs, like “Peace in the Valley.” Or she might have jumped back into singing something to shift the mood, maybe something more upbeat.

What would have been the “correct” decision? It’s impossible to say, without being in that session at that time. In any case, Karen would decide what to say based on Pat’s needs in that moment.

3. Refining How We Say It

Deciding on verbal interaction vs. music vs. silence, then deciding what words to say – that’s tricky enough. But another level of nuance comes with how we say what we say. Doing music therapy can never be as simple as following a decision tree or a strict protocol, saying, “if Client says x, then MT sings y. Then MT says z with great empathy while patting Client’s left hand.” Rather, all of the music therapist’s experience and training and intuition come into play as he/she decides what to say or sing or do, and how to sing/say/do it.

This is frustratingly difficult to describe. So, here is where I find it especially helpful to think of music therapy sessions as being MUSICAL from start to finish, regardless of the level of silence or verbal interaction involved. As any musician knows, beautiful music is made of more than playing the correct notes and rhythms or singing the correct words. So it goes for music therapy sessions – the value of the whole music therapy session is more than the sum of the words we say and the songs we sing.

Verbal interaction is one important piece of the entire picture of the therapeutic relationship in music therapy.

That’s how music therapists do verbal interaction differently.

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Song Spotlight: “Yes, My Darling Daughter”

  • Mood: Nervous excitement
  • Themes: Parenting, Moms and Daughters, Dating
  • Tempo: Upbeat
  • Genre/style: Big Band era

I’ve been trying to think of a good song to highlight for Father’s Day, but the one that keeps coming back is a favorite from my Mother’s Day playlist. There’s a fatherly twist, though, so we’ll go with it.

Yes, My Darling Daughter” is a 1941 song written by Jack Lawrence and made famous by Dinah Shore. The melody Jack Lawrence used as the basis for this song has an interesting backstory. The music is based on the Ukrainian folk song “Oj ne khody Hrytsju,” which is thought to have been written by Catterino Cavos in 1812. This same folk song was published in translation in 1816, and its English version did gain some popularity in the United States. Interestingly, the final phrase of the melody, to the words, “yes, my darling daughter” follows the Hyrts sequence, a melody common in Ukrainian songs and one that was used by several classical composers, including Haydn, Mozart, Boccherini, and Liszt. Musical motifs really do travel across time and distance, don’t they?

Daddy, may I go out dancing? Yes, my darling daughter!

Anyway, let’s get back to Jack Lawrence’s lyrics. In this song, we hear the conversation between a nervous young woman on her way to the dance, and her beloved mother. Here are a few lines from the beginning of the song: Continue reading

A Musical Response for When a Senior Says, “I Just Want to Die”

I just read an article on how a caregiver can respond to a senior who is saying, “I just want to die.” I appreciate the advice given by Margaret Sherlock, M.A., Clinical Director of the Behavioral Health Program & Assessment Program Services at the Visiting Nurse Service of New York, which includes not ignoring the statements and being realistic about a senior’s need to talk about death and dying, while still setting limits on such heavy discussions and monitoring for signs of clinical depression in both the senior and in yourself. You can read all of her advice here.

This is sound advice, but I do think there is one important piece missing: you must think about how to deal with all of the emotions you and your loved one are both feeling. In fact, this kind of conversation can be so emotional for both the senior and the caregiver that it can be difficult to tell who is feeling what. You might think, is this person feeling depressed? Or is he just ready to die? Or is this person saying she wants to die because she wants to make me upset or get more attention from me? Or am I interpreting all of this wrong because I am the one who is feeling sad, or tired, or frustrated? Or maybe it’s a mixture of all of the above feelings, and I’m not really sure how to put words to it?

Even just trying to identify these feelings is difficult. No wonder these emotional conversations can wear you out! As Ms. Sherlock advised, though, you can’t just sweep the difficult feelings under the rug: they’ll just build up and create bigger problems for you and the senior later on. That’s why I’m usually not a fan of just changing the topic or putting on happy music to avoid the conversation.

When someone says, “I just want to die,” you need to acknowledge their emotional expression and honor your own. Continue reading

Song Spotlight: “Hound Dog”

Our newest family member - Duke the Basset Hound

  • Mood: Upbeat, full of attitude
  • Theme: Dogs and/or freeloading gigolos
  • Tempo: Moderate
  • Genre/style: Rhythm and blues/Rock and roll

We have a new family member in our house! This one gets around on four legs and has very long, droopy ears. His name is Duke, and he’s the adorable basset hound pictured above. I alluded to the inevitable canine addition to our household in this previous song spotlight post, but I thought his arrival was worth another song spotlight. Fortunately, that means I get to feature one of my go-to songs for elders both in group music therapy and in one-to-one interactions: “Hound Dog.”

“Hound Dog” is a 12-bar blues written by Jerry Lieber and Mike Stoller in the mid-1950s. Elvis Presley’s 1956 version is by far the best known, but the song was first recorded by Big Mama Thornton in 1952. To me, her recording has a more improvisational, blues-y feeling, with Thornton’s vocal interplay with the instruments and all of the musicians barking and howling like hound dogs at the end of the song. Big Mama Thornton’s version drew a lot of attention and was followed by no fewer than six cover versions by country musicians in 1953. You can hear one by Billy Starr here. Continue reading

What Happened in One Group Music Therapy Session

Music therapy with seniors is incredibly valuable, but it can be difficult to understand and to explain. How is what a music therapist offers different than what any musician could offer as an entertainer?

Let me describe the session I just had today as one example.

Today’s music-making session was with a group of seniors who meet in a church basement once or twice a week for a day program that offers a range of activities, including exercise, craft projects, games, music, and a meal.  These folks live in their own homes but have some long-term health concerns, incuding the cognitive difficulties that accompany the early stages of dementia.  Group members generally need some extra social support, especially the opportunity to share their lives with other people.

I come to this group twice a month for music-making sessions. Today was the group’s Valentine’s Day party, so the room was already decked out in red and white. We started our session as we usually do, with “He’s Got the Whole World in His Hands” as our welcoming song. I then told the group that we were going to have LOVE songs for Valentine’s Day, an announcement met with smiles and perhaps a few eye rolls. Continue reading

Song Spotlight: “How Ya Gonna Keep ’em Down on the Farm?”

  • Mood: Lighthearted, Goofy
  • Themes: Country life vs. City life, Returning from War
  • Tempo: Upbeat
  • Genre/style: 1920s popular song

Something you find out about songs is that if you ponder them long enough and share them with enough people, multiple layers of meaning begin to emerge. Those layers may be deliberate on the part of the songwriter, or they may come from the personal experiences of the individual hearing the song or the context in which they hear it. Today’s song spotlight is on the 1919 song “How Ya Gonna Keep ‘Em Down On The Farm,” and it works in two ways, one that is more on the surface level, and one that is more profound. I’ll start with the easy one.

If you take this song at face value, with 21st century eyes, it’s just a goofy song about returning to farm life after spending time in the big city. Here’s the chorus:

How ya gonna keep ’em down on the farm after they’ve seen Paree?

How ya gonna keep ’em away from Broadway, jazzin’ around and painting the town?

How ya gonna keep ’em away from harm? That’s a mystery.

They’ll never wanna see a rake or plow

And who the deuce can “parley-voo” a cow?

How ya gonna keep ’em down on the farm after they’ve seen Paree?

Hearing this song, you can picture someone traveling to the big city for the first time, seeing all of the bright lights and beautiful people, taking in the sights at the Eiffel Tower and the palace of Versailles, then coming back home to be somewhat let down by the chickens scratching in the yard and the cows waiting to be milked.

I like to include this song in a session with older adults on the theme of living in the country versus living in the city. Most of my clients have been city-dwellers for a while, but a good number of them also lived in the country as kids. That means they have stories to share on both counts, perhaps including the culture shock involved in moving from world to the next. We also talk about taking vacations to places like Paris and Hawaii and maybe even Egypt or Russia then returning to the Midwest, and what that feels like. Some folks can also relate to what their children might experience by living in more exotic locales then coming home to visit their folks in Olathe, Kansas or Independence, Missouri. Overall, the song helps the discussion to stay lighthearted and not too negative about the country or the city.

Simple enough, right? It turns out that this particular song gets more interesting after you learn about its history. You see, this song came out in the last days of the first World War and was wildly popular in the years following the war.

Here’s the scene: after the first World War ended in 1919, a generation of young American men came back home to the U.S. to return to the farms and jobs and families they had before the war. Of course, the same thing happened again after World War II, and it has happened again (in different ways) after every war since then: young men and women have come back home after life-changing experiences overseas. For all of these military members, they come home with a disconnect between the experiences of life in a war zone and life back home. While in a combat zone, decisions had to do with life and death; back home, it’s about what to cook for dinner and what clothes to put on the kids. While overseas, they had to be on alert at all times for possible threats to their physical safety; now they have to be able to handle the noisiness of modern American life without paranoia. While at war, they were surrounded by people who also had direct experiences of being at war; now, people at home are sympathetic but rather clueless, and they wouldn’t want to share the horrific details of what they saw anyway.

So, really, even in its humorous way, this song asks a serious question: how can soldiers return to life as usual after going through the life-changing experiences of being at war? For veterans of the first and second world wars, it certainly wasn’t an accepted practice to continue thinking and talking about the horrors of war after returning home, and post-traumatic stress wasn’t really a topic of discussion. (It was called shell shock back then.) Today’s returning veterans have more resources available for dealing with the transition back to life in the U.S., but it will always be a difficult transition to make. What’s more, the pain that comes from experiencing war can last for a lifetime – I’ve had more than one elderly client tear up remembering his service in World War II.

There are many ways to cope with the trauma of war and the transition back to civilian life, and certainly music is one tool to use. I bet that some of this song’s popularity came from its very quiet acknowledgment of the difficulty of returning home from war in the package of a cheesy, goofy, funny song (complete with cartoonish sound effects in this version.) Perhaps allowing that song to express and contain some of the pain of transition helped, at least a little.

What are your thoughts on this song? Which other songs do you know that work on multiple levels of meaning? What other songs do you know that have been particularly helpful to veterans and their families? Please leave your comments below.

This post is part of an occasional series on special songs to share with your loved ones. For more song spotlights, click here.

Top 10 Rules to Break in Hospice Music Therapy

… or maybe I should say “rules”…

I’ve been a board-certified music therapist for a little more than seven years now. Hospice work now makes up a bigger portion of what I do on a day-to-day basis than it has for a while, which has made me more aware of how I’ve grown as a clinician in the last few years. For me, gaining experience has meant gaining clinical flexibility. These days I feel comfortable enough with the “rules” for hospice music therapy to know when to bend or break the rules I thought were steadfast as a beginning therapist.

(If you’re reading this from the perspective of a caregiver rather than a music therapist, take these as deviations from what you might expect from a music therapist.)

Here are my top ten rules to break in hospice music therapy:

1. Visits must be one hour long. I made this my standard visit length for purposes of budgeting and billing, but sometimes hour-long visits just do not make sense, like when someone is too tired to try staying awake for an hour or when a visit starts late for some reason and the person is ready for a longer visit. Fortunately, the hospice philosophy is all about meeting the client’s needs in-the-moment, and that means shorter or longer visits, depending on the day. I LOVE that this is the standard in hospice care. (P.S. It’s helpful that billing per visit rather than per hour has been the norm for the hospices I serve.)

2. Sessions must be private, for the client only. I have always involved family members in hospice music therapy sessions, since the hospice philosophy includes caregivers in the overall care plan, but more recently I have expanded my own idea of who to include in music therapy sessions. For example, I currently have a client who lives in a care facility. His family is not close, but the facility staff and some of the other residents at the facility are close. They are his support system at this time of life, and it seems appropriate to include them in music therapy sessions. More to the point, he enjoys sharing this gift of music with his friends. Taking him to his room for a private session just would not be as effective.

3. Always play music. I’ve had sessions when it seems that me singing a song or two would just be intrusive. Sometimes people just want to talk, so my presence and a listening ear is enough. Sometimes getting a hold of the hospice nurse or an aide to address an immediate physical need is exactly what I should be doing. Sometimes even just adjusting the lighting in the room, turning off the TV, and holding someone’s hand is an effective therapeutic intervention.

4. Always talk about the music. I used to think that a song wasn’t really therapeutically effective unless we had a discussion about it afterwards. I still like to encourage song discussion, but sometimes just providing the music is a powerful intervention, and forcing a conversation would detract from that.

5. Avoid songs about death (or saying goodbye) unless you’re planning on a song discussion. I used to avoid songs like “Red River Valley,” “Clementine” and the last verse of “Because He Lives” because they talked about death and going away. Now I realize that I was avoiding them because I felt weird singing them with a hospice patient, not because they wouldn’t have been appropriate clinically. Sometimes a musical mention of death is appropriate, and sometimes I’m probably just over-thinking the matter in the first place.

6. Always play the client’s preferred music. Another common method I’ve used is to ask a hospice patient about her favorite kind of music, then to play one of her favorite songs. This is a great method, but sometimes patients can’t communicate their preferences clearly, and sometimes preferences are difficult to predict. What’s more, very meaningful interactions can come from experiences with less-familiar music or even improvised music. (For more on the difficulties of determining music preferences, read this.)

7. Keep your primary focus on pain management. At some point, I learned to start every session by asking patients to rate their pain level on a 1-10 scale. This isn’t a bad thing to do by any means; after all, hospice is about making people comfortable. Sometimes, though, physical pain is not the biggest concern for a patient and should not be my main focus. In fact, recently I started a session with an elderly woman with the usual 1-10 pain rating question. She looked at me kind of funny, said, “I don’t know. Why does everyone ask me that?” and turned away. I paused for a minute, said, “you’re right. That’s a strange question to ask,” then shifted the conversation over to the music we could have together. The “Pain Question” doesn’t always need to be front and center.

8. Always follow the treatment plan. All hospice professionals write care plans for their patients, and these care plans are discussed and revised in interdisciplinary team meetings every two weeks. Part of the beauty of hospice care, though, lies in its flexibility and adaptation to the patient’s in-the-moment needs. Sometimes I’ll go into a session with a plan for songwriting to facilitate life review or music-assisted relaxation training for pain management, and a patient will be too tired to talk or will have a family member visiting. These are the times when adjusting the plan is the right thing to do.

9. Keep an emotional distance. I used to be extremely careful about sharing anything about my personal life or interacting with clients and their families on anything other than a formal, professional basis. The term we often use for this is “boundaries,” and mine were rigid (probably because I was coming from a mental healthcare background.) Learning how to establish and maintain appropriate boundaries with clients takes time, and it is a HUGE area where supervision and consultation with colleagues is necessary. It’s probably better to err on the side of protecting your clients and yourself, but keeping boundaries that are too rigid can detract from the therapeutic process as well. For example, you might tear up when providing music during a patient’s final moments. (I know I do that sometimes!) Allowing the client’s loved ones to see those tears helps them to know that you genuinely care for the patient and that it is okay to have emotional reactions at such a sensitive time. It can help you to cope with the losses of patients to find an appropriate way to work through your feelings, too, rather than trying to keep yourself somehow aloof from the pain of losing people you care for. (Read more of my thoughts on self-disclosure here.)

10. Be serious, because dying is serious business, right? My default approach in hospice music therapy (and music therapy in general) used to be very serious – I was there to provide music to meet a specific therapeutic need, not to entertain. Now I understand, though, that a big part of my role as the music therapist in hospice is to bring joy, to encourage smiles, and to inspire laughter. This isn’t true for every session, of course, and there certainly are serious moments, but joy can be part of it, too.

These are my top ten rules to break in hospice music therapy. What are yours? Which of these resonate with you, and which would you add? Please leave your comments below!

Song Spotlight: “Don’t Fence Me In”

  • Mood: Relaxed
  • Themes: Country life, Cowboys, Restrictions, Being “Fenced In”
  • Tempo: Moderate
  • Genre/style: Western/Cowboy

Being in the Midwest, I run into a lot of folks who love country and western music. “Don’t Fence Me In” is one of my very favorite songs to offer when western music is requested, for two reasons:

  1. It’s popular, so a lot of people can sing at least part of it along with me.
  2. It can open up a discussion about feeling restricted or “fenced in” by a client’s diagnosis, declining health, or placement in a facility.

I was somewhat surprised to learn that this song was written by Cole Porter, who is better known for jazz standards like “Night and Day” and “I’ve Got You Under My Skin.” In fact, Cole Porter said this was his least favorite of his own songs. That didn’t stop famous performers like Kate Smith, Bing Crosby, the Andrews Sisters, and Ella Fitzgerald from recording the song, though. And, of course, this song was a signature piece for Roy Rogers, the famous singing cowboy of Hollywood.

Here are a few key lines of this song:

Oh, give me land, lots of land under starry skies above
Don’t fence me in
Let me ride through the wide open country that I love
Don’t fence me in
Let me be by myself in the evening breeze
And listen to the murmur of the cottonwood trees
Send me off forever but I ask you please

Don’t fence me in

Of course, this song is great just as a starting point for talking about country living, cowboy tales and Western movies. What I really love, though, is that the fence provides a great metaphor for talking about the restrictions that come with aging. Many of the clients I work with feel penned in somehow:

  • They’re stuck in a wheelchair or a bed and can’t move without help.
  • They can no longer drive their cars to go where they want when they want.
  • They have family or friends telling them what to do or making decisions without them.
  • They have memory slips or confusion that keep them from thinking on their feet.
  • The effects of a stroke have left them without the ability to say what they are thinking.
  • They find themselves behind a locked door and can’t seem to make it to the outside.

For clients who have the cognitive ability to hold a conversation about this song, I ask them what seems to be fencing them in. To make this concrete and visual, you could ask clients to write down or draw their “fences” on the picture of a fence before singing the song again. The tone of this discussion could be serious or more lighthearted, depending on the needs of the client or group of clients.

For clients who cannot hold a discussion on what is fencing them in, this song can simply serve as musical validation of the feelings a person seems to be experiencing. For example, if a person is trying to get through a locked door on the memory care floor of a nursing home, I might sing this song for them and reflect verbally that they must be feeling hemmed in. That way, the song can perhaps serve as a container for the frustration that person is feeling, so they can then come back to the music therapy group or regular activity programming.

Do you know people who love western music? Have you brought this song into the time you spend with your clients or loved ones? Please share your story below!

This post is part of an occasional series on special songs to share with your loved ones. For more song spotlights, click here.

 

Song Spotlight: “How Much is that Doggie in the Window?”

My husband wants one of these!

  • Mood: Silly
  • Themes: Pets, Relationships
  • Tempo: Relaxed
  • Genre/style: 1950s novelty song

My sweet husband has been lobbying hard over the last several months for our family to get a dog. I have never really been a dog person, but since one day soon we will probably be adding a pooch to our family, I have been paying extra attention to the variety of dogs around me, especially those that live with and are loved by my older adult clients. There are many beloved dogs around, and they are sure to draw attention from even some of the most quiet and passive people. Visits from these canine companions almost always call for one of my favorite songs for music therapy: “(How Much Is) That Doggie In The Window.” Here are the lyrics for the chorus:

How much is that doggie in the window?

The one with the waggly tail

How much is that doggie in the window?

I sure hope that doggie’s for sale

This song was written in 1952, with the iconic recording by Patti Page released in December of that year. The song was one of a string of successful novelty songs in the 1950s and 1960s, which also included one of our previously spotlighted songs, “Itsy Bitsy Teenie Weenie Yellow Polka Dot Bikini.” These songs are lighthearted and goofy, so they’re great for drawing out smiles, winks, and nods.

One of my favorite ways to adapt this song is to change the words slightly to match a description of the client’s pet. For example:

How much is that doggie in the window?

The one with the black and white fur?

How much is that doggie in the window?

I think that I will call him Buster.

Of course, you could change the words to be about any kind of pet. Here are a few good questions/prompts for getting the information to fill out the verses:

  • What kind of pet did you have? Tell me about it.
  • What was its name?
  • What color was it?
  • What did it like to do?
  • Did it do any tricks?

Creating a verse for each person’s special pet is an especially good way to get a discussion going in any size group. (P.S. Animals and pets are always great topics for discussion in intergenerational groups as well!)

What do you think? Could you use this song with seniors in your life? Let me know in the comments section!

This post is part of an occasional series on special songs to share with your loved ones. For more song spotlights, click here.