Music Engagement and Therapeutic Music
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This chapter outlines the role of music in well-being for people near the end of life. Written for the care professional or member of a multidisciplinary team, this chapter assumes that music engagement and a therapeutic approach to music in palliative care is relevant and accessible for all healthcare professionals, not only specialists or music therapy experts. The information provided here looks at the potential impact of music on pain, agitation, and diversion and for supporting emotional and spiritual life quality. Music is especially useful as a relational tool supporting whole-person care and a good end-of-life experience for the patient and their family and friends. This knowledge can be utilized to provide music, to facilitate therapeutic musicians interacting with a patient, and to increase awareness among staff and patients, and patients’ families regarding the benefits of music in care, in particular, supporting emotional, psychosocial, spiritual, and physical needs not otherwise supported by medical care. Therapeutic music is presented from a historic, scientific, and holistic perspective, including considerations that will assist in cultural sensitivity.
Knowledge of the potential application of therapeutic music in palliative care is relevant for the care professional. Firstly, whole-person care is everyone’s concern. An appreciation for the evidence-based benefits of music and well-being will help care professionals balance the emotional and psychosocial aspects of well-being that cannot be nourished by medical care, as well as physical symptoms such as pain, loss of appetite, and sleeplessness that can also be improved with appropriate music intervention.
Some of the practical information in this chapter will equip care professionals, irrespective of musical or technological experience, in using or suggesting music as part of palliative care services. In addition, the care professional may need to represent the needs of the patient and advocate for the family when liaising with music therapists, thanatologists (bedside musicians providing a quality end-of-life service), therapeutic musicians, and volunteers involved in music services. In a diverse society, sensitivity to the cultural or spiritual needs of patients and families is core to cultural competency.
It may surprise some people that emotionally impactful music surpasses merely providing joy and relaxation but may also reduce pain and agitation and support appetite, diversion, relational care, and spiritual care.
David Aldridge notes that, “within the past decade music therapists have developed their work with people who have life-threatening illnesses and with those who are dying” (Aldridge 1999). This chapter serves to ensure that medical and care professionals are aware of the advances and scientific corroboration of ideas so that this information reaches patients and their families. Palliative care is also a specialization in which quality of life and meaningful experience supersede the approaches found in other areas of therapy, such as curative, targeted, and physician-directed goal-oriented programs, in favor of patient-initiated choice and focus on inner psychosocial and spiritual wellness, more than physical goals. Aldridge describes this situation as working collaboratively and creatively: enhancing “the quality of living can help patients make sense of dying … [integrating] the physical, psychological, social and spiritual dimensions of their being” (Aldridge 1999).
The contemporary disciplines of music therapy and therapeutic music emerged from a confluence of occupational therapy, general psychology, psychotherapy, special education, music education, anthropology, and medicine, with a variety of goals ranging from artistic, scientific, psychosocial, behavioral, psychotherapeutic to rehabilitative (Wigram et al. 2002, p. 30). To this list may be added the work of pastoral carers and social workers who use music for awareness, insight, spiritual and emotional expression or exploration, facilitation, and “auxiliary” ways (Bruscia 1998). Supportive interventions include intentional distraction and provision of coping skills, and comprehensive resonance therapy includes entrainment and guided imagery with the objective of resolving pain (Wigram et al. 2002, p. 33).
The language of “constructionism” (participant engagement and meaning-making) has found its way into the therapeutic activity of creating “meaningful experiences.” These ineffable and ephemeral experiences constructed with music are nonetheless important, especially for friends and family members of the dying person, who will cherish and remember experiences shared and enjoyed together long after the event. In music, there is always the interplay between composer, listener, symbolic language-like rules, and the ambiguous, metaphorical, inexpressible, and spiritual aspects of subjective imagination and active listening.
2 Differentiating Between Music Therapy and Therapeutic Music
The distinction between music therapy and therapeutic or healing music is relevant here. Music therapists have expertise and qualifications in “music therapy.” They use goal-oriented therapeutic approaches to music in a variety of settings including aged care, rehabilitation and restorative care, and many related fields. In practice, “music therapy is the use of music as a tool in interactive therapy, while therapeutic music uses music and music only as the therapy itself” (Riley 2010, p. 108). Professional music therapists often combine music and other disciplines, such as exercise, art, and so on.
In the USA, the National Standards Board for Therapeutic Music (NSBTM) and the American Music Therapy Association (AMTA) distinguish between music therapy and therapeutic music (which includes the work of Certified Clinical Musicians, Certified Harp Therapists, Certified Healing Musicians, and Certified Bedside Harpists). In Australia and the UK, music therapy requires different training and qualifications from either music performance or therapeutic musicianship.
While music at the bedside of a patient is “prescriptive,” it is a service (not a performance) – a “compassionate action without agenda” (Riley 2010, p. 109). The appropriate music cannot be anticipated, and the musician usually cannot ask the patient directly about their medical condition and treatment. Instead, the therapeutic musician responds to observed cues, body language, vital signs, monitors, and breathing. The patient is the sole attention of focus, in the moment.
This chapter focuses on therapeutic music in palliative care settings, in which music responds to the patient rather than aims to cure or rehabilitate. The “healing” that occurs concerns wholeness and well-being of mind and soul, as much as of body. If live instrumental playing is utilized, the musician intuitively and spontaneously responds to the patient’s status. If recorded music is utilized, it is selected specifically for a patient (e.g., by a friend, relative, or the patient themselves). Music may be used therapeutically by a non-musician to enhance the quality of care, which is undertaken by any member of a multidisciplinary team or combined with pastoral care or relaxation approaches.
Musicians and volunteers (who are not formally trained in music therapy or who are not Certified Clinical Musicians) often adopt a responsive, therapeutic approach, too. Yet others may volunteer to perform music as entertainment: community groups and children’s choirs may visit and sing or perform music in nursing homes, hospices, hospitals, etc. The latter is valuable for its distraction and levity; however it is geared toward entertainment rather than intentional healing intervention and tends to occur in group settings and social spaces.
3 The Link Between Music and Well-Being from Antiquity
Historically, efforts to relate structures in music and the universe and the human body hark back to theories of vibrations, and parallel forms found in the micro- and macrocosmos were already well-established in the antiquarian world of Pythagoras (c. 500 BC). The corresponding connections in periodicity have been associated with revolutions of celestial bodies and planets, the bodily fluids or “humors,” somatic disturbances, and consciousness. Before instruments were developed for accurately measuring frequency, theories of relationship could still be calculated by using the ratios of vibration that produce the natural overtone series that echo forms in nature such as resonating cylinders, reeds, strings, etc. (Wigram et al. 2002, pp. 22–23).
From these ideas we retain the concepts of “attunement,” “resonance,” “sympathy,” and “harmonizing” that have both metaphysical and physiological applications. “Attunement” is used not only in contemporary developmental psychology (Stern) but also in Løgstrup’s theory of music education.
Therapeutic and healing qualities of music are present in many traditional and ancient indigenous cultures. This includes medicine men, shamans, chanting and meditation traditions, vibrational healing, spiritual and existential music, and pre-Renaissance healing visionaries such as Hildegard von Bingen (musician, visionary, nun, and physician). At the height of Western scientism developed in the Age of Reason, which really harks back to the influence of Classical Epicureanism, we frequently observe a false dichotomy depicted between arts and sciences. It is not surprising that in our reductionist and positivist society of the West, healing with music and the power of “an art” to affect physiological and mental changes is met with skepticism in some circles. Nonetheless, in African, Australian Aboriginal, and various Asian cultures, to name a few, there are millennia of appreciation for the subtle links between inner and outer well-being and arguably a greater appreciation of whole-person wellness that does not depend on a modern clinical model.
Modern psychologists, however, acknowledge the interaction between mind and medicine, seen and unseen, physical and psychological, experiential and conceptual: the phenomenological experience of humanness. Philosophy, too, has largely rejected the Cartesian divide between cognitive and somatic experience. Grand connections, such as music of the spheres, harmony in the universe, and relationships between aesthetics, beauty, nature and art, perfection, and mathematics, date back to the Classical writings of Plato and Aristotle, persisting through the golden ages of fine art in work by multidisciplinarians such as Leonardo da Vinci, Michelangelo, Albrecht Dürer, Johann Sebastian Bach, Palladio, etc. A contemporary medical model clearly emphasizes pharmacology and physiological symptom management over the importance of spiritual and emotional wellness in a patient’s overall diagnosis, thus needing adequately integrating whole-person healing in the treatment approach.
Medieval theorists, such as Robert Fludd in his 1617 ‘Divine Monochord’ (James 1995, p.130) and Agrippa von Nettesheim’s theory of 1510 (Wigram et al. 2002, p. 25), correlated mind-body-spirit in terms of the physical world, human body, and vibrations in music; language, human mind, and notes and intervals or “grammar” in music; and the cosmos, human spirit, and divine proportions.
Western philosophers ranging from Plato, Aristotle, Augustine, Schopenhauer to Nietzsche consider the theoretical and practical role of music for the individual and health. Arabic (Muslim) physicians were among the first in the world to have used music medicinally as an integrated element of whole-person health as early as the eleventh and twelfth centuries. Paradoxically, these seemingly antiquated ideas have been revived through quantum physics, in terms of particle energy, rather than merely vibrational waves and the paradoxical relationship of concurrent wave and particle characteristics.
3.1 The Healing Harp in Antiquity
The harp, lyre, and psaltery were interchangeable terms in ancient times – i.e., a plucked chordophone. A 15,000 BC cave painting of a hunting bow shows the possible origin of plucked strings. Early Chinese healers attributed health to the C’hin zither-like instrument. In ancient Egypt, harps were part of the court consort and used in storytelling, songs, and tributes to deities. Harp and lyre were believed to mobilize fertility and usher in births. Sarasvati, the Hindu goddess (wife of Brahma), used “harp” to guide people and gave humans the arts. She is often depicted playing the “vina” arched harp. Ancient Greeks believed the gods communicated with people through harp or lyre music. In the Middle East, lyres had seven strings associated with Pleiades, the constellation, and represented a microcosm of universal order and harmony.
In Scandinavia and Europe, harps were also associated with magic and enchantment in mythology. Symbolic of peace and connection to the “other” world, harps were linked to sleep, to release of tears, and in Ireland 2000 BC, to the Danen people or faeryfolk. Again harp was linked with fertility, agriculture, nature, faery folklore, and the heart of the Gaelic culture. Celtic nobles and Druids held the harp in high esteem – teachers, judges, shaman priests, and holistic healers who used subtle energies, herbs, and bards and musicians/poets were the keepers of knowledge of ancient lore.
The biblical King David soothed King Saul (who was speculated to be depressed) in approximately 1100 BC with music of the kinore, an early lyre. Pythagoras of Samos developed the harmonic series overtone scales and Western modes and associated different emotions with different tunings. In 324 BC Alexander the Great’s sanity was restored by music of the lyre – recognized for healing and calming. Harp was considered to be a link between worlds and used as a guide through death process. In Mesopotamia in Ur, early lyre instruments have been found. Harpies were harbingers of death, who sometimes heralded fearful times, and the harp ushered the soul to heaven in the Judeo-Christian tradition.
4 A Brief Overview of Music for End-of-Life Care and Dying Well
Thanatology is the scientific study of dying. Music thanatology is live music (often harp or vocal music) at the bedside of dying patients to relieve suffering from physical, emotional, and spiritual pain. It is generally responsive (sometimes called “prescriptive”), the musician interacting with the patient’s biomarkers, such as heart rate, breathing rate, mood, anxiety, etc.
Since the 1950s, music therapy was recognized as a vocation. The (USA) National Association for Music Therapy and American Association for Music Therapy converged in 1998 to form the current American Music Therapy Association (AMTA). Music therapy according to their definition uses “clinical and evidence-based music interventions to achieve individualised goals” (Riley 2014, p. 8). The goal of music therapy is to “address a range of physical, emotional, cognitive and social needs of individuals” across a range of settings and needs including hospitals, psychiatric care, community mental health, rehabilitation and day care centers, residential nursing homes, in schools and in private clinics. Music therapy has been effectively utilized in assisting people with physical and cognitive impairments and learning disabilities.
The word Thanatos comes from the Greek, and refers to the mythological figure who is the twin brother of Sleep (Hypnos) and the son of Nyx or Night. There are many kinds of thanatologists today – medical, academic, theological, psychological … In its sole focus on the physical and spiritual care of the dying with prescriptive music, it is also a pastoral art which takes the words of the [Christian] Gospel seriously, and turns toward the face of suffering without reserve. (The Chalice of Repose 2016)
Key figures in the development of therapeutic music include Dr. Ron Price (founder of Healing Harps – who found neurological benefits of playing harp with palsies and dystrophies and other neurological challenges), Therese Schroeder-Sheker (who established The Chalice of Repose music thanatology project to pastorally support peaceful and dignified death), and Sarajane Williams (who established therapeutic harp to help people with psychological conditions including chronic pain, stress, and depression and vibroacoustic harp therapy using the resonance and vibrations of an acoustic instrument to palpably affect the client) (Riley 2014, p. 8). A number of educational programs emerged offering this bedside approach to healing music: the International Harp Therapy Program, International Healing Musician Program, Clinical Musician Certification Program, and the Music for Healing and Transition Program. Thanatology and music vigil are terms specifically used for individually attentive end-of-life settings. “Healing” has the broader meaning of restoration, making peace, improving overall well-being including satiation of emotions and soul, rather than the more specific implication of “cure” that generally pertains to eradicating symptoms of disease.
The use of clear melody or more atmospheric textural sound depends on the situation and the patient. Music composed mostly of chord progressions and non-melodic structures suits those needing deep relaxation and sleep, as well as people in the final moments of life, because melodic lines and metered rhythm in a gentle tempo can help engage the body and “encourage stability of vital signs” (Riley 2014, pp. 22–23). Riley posits that major keys are suited to hospital environments and minor keys may be suited to hospice or palliative care setting, though modal improvisation allows the musician to oscillate from one to the other with ease. As a generalization, a faster tempo should be reserved for situations when the alert patient requests it, and for most situations a slow or moderate tempo is more conducive to calm and relaxation. Other research in the area of dementia care suggests that moderate to slow music evokes a calmer dopamine-induced response, and very fast energetic music is associated with the cortisol (stress hormone) “fight or flight” reaction. The effect on the body should be observed.
4.1 Instruments for Therapeutic Music
The guiding principle is to use instruments that are not loud and intrusive or disruptive; therefore, many acoustic instruments and well-selected keyboard sounds work well. Patient preference should be taken into account. Plucked strings, such as guitar or harp (with nylon or gut strings), are more appropriate than metal-stringed instruments. Bowed instruments can be muted, and wind instruments played gently. Amplified instruments are usually too loud to be relaxing and may affect other patients and staff. While drums are sometimes used in music therapy participatory groups, they are seldom used in therapeutic music at the bedside.
Instrumental register also impacts the effect. “Pleasing” tones of lower and mellow instruments often sound more appropriate than high-pitched potentially annoying sounds or shrill tone. Children can tolerate higher pitch ranges.
4.2 Tailoring Musical Elements to the Patient
Improvisation gives the therapeutic musician the elasticity to adapt to the situation more easily than prepared learned music. Learned music may also be adjusted in register and tempo to suit a certain context.
Rhythmic music, even slowly lilting music, invites involvement and entrainment (synchronizing listening, breathing, and movement to match the beat). This can help a person to breathe at a steady slow rate, for instance, which is linked to relaxation, as understood in meditation. Regular slow rhythm is antithetic to panic and stress.
Nonrhythmic music, more atmospheric and nebulous in character, can be appropriate to the atmosphere of impending death as vital signs are fading, conducive to a peaceful death. Peaceful, nonrhythmic music promotes tranquility and relaxation. Sometimes the musician plays on after the death to hold the meaningful atmosphere with family and friends. Nonrhythmic music can also be fitting for “relieving pain and stress” (Riley 2014, p. 27). Riley suggests that familiarity from early in a person’s life is valuable for elderly patients and people with dementia. This requires familiarity with music of, say, the 1920s–1950s, as well as culturally specific knowledge.
4.3 The Chalice of Repose Project
The Chalice of Repose Project is one of the founding therapeutic music organizations (established in 1973 now spanning the USA), calling itself the “voice of music-thanatology” – providing “beauty, intimacy, reverence in end of life palliative and pastoral care” (The Chalice of Repose 2016). Music thanatology derives profound spiritual inspiration and meaning from the Benedictine Cluniac tradition of monastic medicine. The Chalice of Repose Project contemplative curriculum “re-unites medicine, spirituality and music,” working “towards the relief of physiological pain and spiritual suffering that may be eclipsing the quality of life at the end of life” (The Chalice of Repose 2016).
Deathbed vigils aim to bring peace, tranquility of silence, and a shift to acceptance. Music thanatology involves intimate concentrated person-to-person connection, entrainment of sound, and breathing. The musician’s goal is to support peace-filled, blessed, or conscious dying.
Silence moves (usually) toward synchronization and entrainment, often leading to pain relief, decreased heart rate and pulse, stabilized breathing patterns, change in body temperature, deep restorative sleep; emotional, mental, or spiritual release; and profound relaxation. Sometimes, patients decrease requests for pharmaceuticals.
5 The Relational Facilitation of Music in Care
If progress of disease leads to increasing isolation, the music-therapeutic relationship may provide important interpersonal contact (Aldridge 1999, p. 22). Tenderness is an important quality in loving relationships. Listening to music together, playing music together, or even the instrumentalist and patient bond can legitimize simple holding of hands. That two people are listening to music and exposing their emotions and vulnerability together creates a kind of unspoken intimacy and sensitivity within an acceptable manner of feeling closeness.
The choice of musical engagement, e.g., active creativity such as art therapy or making music in a group, a metaphor for new growth, creativity, and materiality may not suit someone aware of their deteriorating corporeal condition, for whom it may highlight weakness or incapacity, whereas listening in or singing along more calmly might be entirely appropriate. Providing “enabling” experiences or “empowering” experiences that someone can execute gives them freedom and accomplishment. This independence is especially important for a person with high care needs, to maintain their dignity and agency. Usually providing this opportunity through music-making or participation has no clinical disadvantage yet restores some control, decision-making, and expression.
Aldridge says that what patients and friends and families want “is to be fully alive even in the face of impending death” (Aldridge 1999, p. 24) in the presence of relationships, including opportunities for expression and sharing experiences, which may be valuable to ameliorating suffering. Music emphasizes the lived body as sensed, not only as spoken words, i.e., a felt and emotive response to a palpable and somatic sensory experience that may be difficult to articulate in words.
Music is human contact, even when someone is in a coma. Singing “goodbye” (Aldridge 1999, p. 102) is important so that someone is not alone when dying and dies at peace.
Difficulty expressing thoughts, feelings, needs, and desires
Difficulty exploring spiritual and existential issues
Distressing physical symptoms (complex pain problems, persistent nausea, anxiety and fear, restlessness, insomnia, dyspnea, disorientation and confusion, and dysphasia
Cultural language barriers (Aldridge 1999, p. 69)
6 The Neuroscience of Listening to Music
We respond to music physiologically or “viscerally,” to the material properties of sound. Medicine refers to this effect as musical “stimulus.” The syntactical or organizational level of music imbues it with therapeutic aspects of imprecise description and interpretation. The “semantic” or “message” level of music conveys emotional expression and metaphorical meaning. The “pragmatic” level of music as a social, interactive phenomenon also has a therapeutic purpose in facilitating interaction, connection, communication, and social experience (Wigram et al. 2002, p. 40). Therapeutic musicians work alongside neuropsychologists and psychologists to understand the brain’s nonverbal functioning, in areas such as history, identity, and the effects of auditory perception and musical memory; auditory imagery (equivalent to visual imagination), brain processing of musical input, effects of musical abilities, idea formation, and the implications of performance; and participation or active creativity (composition).
Psychoacoustics describes the effect of hearing, such as the physiological characteristics of the ear, on sound perception. Attributes such as the shape of the pinna (external shell-like ear structure), interaural distance (distance between the ears that contributes to spatial understanding of sound in three dimensions around the body, source location, and proximity), loudness, and frequency acuity filter our experience of sound. The phasing and delay of binaural sounds can have interesting psychoacoustic effects on the body that manifest as physical sensations.
Many parts of the brain are involved in the appreciation (and performance) of music. While this means that certain aspects of musical experience will be affected by localized lesions or brain damage, the generalized neurological stimulation that occurs listening music also works to the patient’s advantage in that musical appreciation usually outlasts dementia, traumatic brain injury, other cognitive impairment or partial deterioration of senses including hearing. For example, people who have experienced stroke affecting one hemisphere of the brain can often sing better than they can speak with a therapist. More complex musical tasks such as the creative activities of composition or performance involve the cerebral cortex, subcortical motor and sensory nuclei, and the limbic system, combining left-brain dominant structuring and mathematical and organizing functions with right-brain dominated creative, emotional, and “spiritual” elements in a singular activity. Recent brain plasticity research, however, suggests that the hemispheric localization can also change adaptively, and there is currently some controversy about hemispheric localization in music. Despite an abnormally high incidence of blind musicians or blind people pursuing music ably, generally “the auditory system, visual system, somatic motor and sensory systems and memory all play an important role in the appreciation and performance of music” (Wigram et al. 2002). In addition, culture, conditioning, and training affect musical memory.
“Why do songs from your past evoke such vivid memories? Listening to music engages large scale neural networks across the entire brain” (Bergland 2013), ranging from timbral activations in cognitive areas of the cerebellum, sensory area, and gray matter of cerebral hemispheres to musical pulse and tonality that recruit the cortical and subcortical cognitive, motor, and emotion-related circuits, supporting the idea that music and movement are intertwined. Limbic areas of the brain, associated with emotions, are also involved with rhythm and tonality processing, while the default mode network engaged in timbral interpretation is assumed to be also associated with creativity and imagination. Aimee Baird and Séverine Samson found that: “Music was more efficient at evoking autobiographical memories than verbal prompts of the Autobiographical Memory Interview (AMI) across each life period” (Bergland 2013).
Music can play a helpful role in anesthesia. Spintge’s studies especially have found that music (anxioalgolytic music as distinct from merely relaxing music) significantly reduces distress, anxiety, and pain suffered particularly in operations where the patient is conscious and under spinal anesthesia and improved presurgical compliance, thereby reducing the amount of subsequent medication needed for procedures using other than general anesthetic (Spintge 1982). This reduction in anxiety could be translated to intravenous cannulation and other potentially uncomfortable processes in palliative care.
7 Effects of Music on the Mind and Emotions
It would be fair to say that we don’t fully understand the emotional effect of music; however, generally music that is more meaningful (and therefore familiar) for a person has greater emotional impact than music that is not meaningful. This is the motivation for attempting to understand the music of relevance and importance to patients in the palliative care setting – i.e., music with associations, memories, and past experiences (good or bad). The human relation to music is a lifelong development, not only linked to the psychology of early development in childhood, for instance. Humanistic psychology related to existential and transactional therapeutic theories have been especially influential in the development of music therapy. While traditional music therapy may look to the supportive, explorative, or regenerative characteristics of a piece of music, the more open approach of therapeutic music in death and dying looks beyond psychotherapeutic potential to experiential, existential, and aesthetic qualities that resonate for the individual. Nonetheless, the steady somewhat predictable, rhythmic, recognizable gestures that lend reassurance reinforce psychotherapeutic principles, such as Pachelbel’s Canon – a series of melodic variations over a cycling ground bass.
According to Riley, “Studies in mind-body sciences have indicated that memories, experiences and emotions are stored not only in the brain but in the cells of the body as well. There is no boundary between mind and body … Emotions that arise may be perceived as positive or negative, but catharsis is almost always healing” (Riley 2010, pp. 34–35). Music can draw out unexpressed emotions and help us feel, explore, and express them, including anger, sorrow, and grief. Bill Moyers in Healing and the Mind, and Candace Pert in The Molecules of Emotion, supports this view that repressed negative emotions are toxic and that appropriate expression has a positive effect on the body (Riley 2010; Pert 1999).
The Guided Imagery and Music method – The Bonny Model – is practiced on North and South America, Oceania, and approximately ten European countries. Its pretext is music-centered investigation of consciousness, where imagery is evoked during music listening – leading to an unfolding of inner experiences “holistic, humanistic, transpersonal and allowing for the emergence of all aspects of human experience: psychological, emotional, physical, social, spiritual and the collective conscience” (Wigram et al. 2002; Bonny 1990).
Various other established music therapy methods, such as the Nordoff-Robins method, or even free improvization therapy, are relatively formulaic and therapist-led in contrast with the paradigm advocated in therapeutic musician certification which focuses on the musician responding to the patient, rather than leading or facilitating the interaction. The latter is often well suited to the context of palliative care when patients may be quite frail, inert, or somewhat cognitively “hazy” due to medication. The horizon for therapeutic music in palliative care is more focused on comfort, relaxation, pain relief, distraction from the medical environment, spiritual and existential reassurance, companionship, and expression of emotions.
Unpredictable changes in tempo
- Unpredictable or sudden changes in:
Timbre (tone color)
Harmony (e.g., unexpected dissonance or change of key/modality)
Wide variety in texture
Lack of perceptible structure
Overall, these characteristics are united by surprise, unpredictability, dramatic changes, dramatic variety, and inconsistency (Wigram et al. 2002, p. 138).
Stable tempo (speed)
- Stable or only gradual changes in:
Timbre (tone color)
Conventional harmonic modulation
Cadences, or phrase-endings
Predictable melodic lines
Identifiable or inherent structure and form
Gentle timbre (sonorities)
Few accents, especially of an irregular nature
Thus, overall, these characteristics involve consistency; reliability; predictability (related to familiarity of music or stylistic tendencies); stability; minimal variation, without surprising/jarring shocking or dramatic changes; and change only through incremental steps (Wigram et al. 2002, pp. 138–139).
These generalizations can be used to transcend genres or styles. It is obvious why it has led to some people generalizing that Baroque music fits well; however that does not take into account the stylistic tastes of the individual that can usually also be met by choosing appropriate music within the kinds of music that is favored, e.g., smooth jazz or lyrical calm popular music, slow sonorous movements of Romantic music, etc. Genres of music whose characteristics tend outside of these guidelines will be the most difficult to satisfy, e.g., finding relaxing rap music, because it is almost always fast tempo with a reliance on syncopation. These characteristics can also guide improvisation by the therapeutic musician, e.g., Stella Benson advocates gently lilting consistent rhythmic music within particular modes for playing harp at the bedside for a person in palliative care or choices of recorded music for the patient. Predictable music offers safety and stability that can meet needs of certain patients.
Auditory pattern recognition is called “active listening.” Long periods of overstimulation create fatigue, dizziness, and nausea. “Television addiction” in humans watching fast-cut video is a genuine phenomenon that numbs this response. Auditory overload leads to confusion and fatigue which may, in turn, manifest in frustration, agitation or emotional upset, and problematic behaviors – for animals or humans and especially for people who cannot express themselves verbally (aphasia) – and eventually auditory cognitive overload leads to anxiety. This effect is exaggerated in people with dementia who may have difficulty locating sounds in space and associating a sound source with its purpose or meaning. Attention consumed in active listening is not available for other tasks. Chronic overstimulation invokes the mind-body syndrome of perpetual fight or flight sympathetic overdrive. For this reason, careful attention should be given to the intensity and duration of music used therapeutically, especially anyone with dementia or other cognitive impairment that affects sensory overload.
8 Effects of Music on the Body
Vibroacoustic music is a receptive form of therapy in which the patient directly experiences the vibrations of the music through contact with a resonating surface. This can range from a large resonant instrument such as the harp to a developing range of vibrotactile instruments invented in Japan and the USA using extremely low frequencies, for example, pulsed and sinusoidal (sine wave) tones of very low frequency (between 30 and 70 Hz). Vibroacoustic therapy is reportedly effective for pain disorders such as bowel problems, fibromyalgia, migraine, menstrual pain, neck and back pain, and rheumatism. Therapists will adjust the frequencies used according to the pathology (Chesky and Michel 1991).
Riley states that “states of mind do not dictate the body’s status, but they do affect the body, sometimes profoundly” (Riley 2010, p. 89). Correlates include heart rate, nausea, perspiration and stress, “fear” responses, and physiological responses to the stress hormones, cortisol, and adrenaline. Negative states of mind can also inhibit endorphin production, and reduced serotonin levels may be associated with depression and suppress immune responses. Stressors can be worry, grief, or too much responsibility, for example. Thus, a holistic approach to treatment includes body, mind, and spirit and awareness of this mind and body interaction (Riley 2010, p. 88).
A relaxed state in which pain relief is induced by listening to music is called “audioanalgesia.” A related phenomenon is “psychoneuroimmunology” that examines immunologic neuropeptide activity and the body’s own capacity to heal when in a relaxed state (Drohan 1999). One of the earliest documentations of the effects of music on humans is Helmholtz’s text, On the Sensation of Tone, written in 1862 (Helmholtz 2003; Benson 2003).
Anecdotal reports from palliative care are substantiated by empirical evidence including studies by Bailey (1983), Curtis (1986), and Whittall (1989). Bailey found that cancer patients were less tense and anxious and experienced a more positivity and vigor listening to live music than the corresponding recorded music. In her review of 465 cancer patients receiving music therapy, Bailey reported a reduction in pain, mood improvement, and improved communication. Curtis and Whittall’s studies corroborate the promotion of pain relief and relaxation, as well as contentment. A decrease in heart rate and respiration rates was measured among a small number of people during intervention of music with guided imagery, deep breathing, and progressive relaxation exercises that suggested a reduction in anxiety (Whittall 1989).
9 Different Formats of Therapeutic Music
There is great diversity to the range of techniques that music therapists and therapeutic musicians use in palliative care to “enhance quality of life … and ease suffering: musically supported individual counselling (Munro 1984); improvisation (Delmonte 1993; Salmon 1993); music to facilitate communication between the patients and their significant others (Munro 1984; Salmon 1993); life-review including music (Beggs 1991); music-facilitated pain control and relaxation (Munro 1984); guided imagery and music (Bruscia 1991; Salmon 1993); and group work” (Aldridge 1999, p. 44).
Common themes that emerge in creative musical reflections include self-reflections; compliments; memories; reflections on significant others (including pets); expression of adversity; imagery; prayers; care experiences and experiences of love; gratitude to family members, staff, and God; continuing to remember close people who are deceased; nature imagery and scenes; and the fight with cancer or degenerative disease (Aldridge 1999, p. 55). Staff can assist people by facilitating them choosing their own music for passage and transitioning out of life.
9.1 Different Methods in Music Therapy
Guided imagery and music – the Bonny model
Analytically oriented music therapy – the Priestly model
Creative music therapy – the Nordoff-Robins model
Free improvization therapy – the Alvin model
Behavioral music therapy
The extent to which patients elect participatory, active, or passive music approaches will depend on how well they are. People in the early course of palliative care may find participatory methods useful for diversion from pain and procedures, whereas weakness and medication may diminish the ability to be creative as the palliative care trajectory advances.
To sound healing may be added techniques including toning, healing with gongs/overtones, body and voice work, drumming, and sound environments or vibrotactile apparatus. Crowe and Scovel (1996) suggest that music therapy and sound healing are different poles on a spectrum. Pragmatism and an open mind are probably useful in the context of palliative care where the objective is maximizing quality of life rather than pursuing a cure.
Hanne Mette Ochsner Ridder (2013) highlights the diversity and non-homogeneity of older adults. Older adults constitute the majority of people in palliative care settings even though it is important to be able to address the needs of people of all ages and experiences (e.g., in 2016, around 90% of HammondCare Greenwich Hospital’s palliative care inpatients (in Australia) were senior or elderly, and approximately 91% had cancer). Elderly people may be especially affected by changing relationships to new people, new surroundings, new routines, the disturbing behaviors of other patients, staff who invade their personal space in care situations, and time-poor staff (Wigram et al. 2002, p. 188). Continuity and familiarity of relevant music can be beneficial in this situation to distract from change and disruption, as well as to provide some stability and reassurance. Music in the room or via headphones and a personalized music device can be used as an interactional tool and to ease the institutional setting of a hospital.
9.2 Biomagnetic Fields and Frequency Intervention
Therapeutic musicians can make use of beneficial resonant frequencies and repetition of specific notes that patients can physically feel reverberating through their bodies. Different organs and body structures are associated with different frequencies, though a frequency-related approach should not be formulaic. Riley uses the expression frequency not only to refer to pitch/frequency, measured in Hertz, but also to refer to periodicity of a repeating event. For example, a practitioner may play in a tempo mimicking the heartbeat, to encourage entrainment to that beat.
Adult heart rate averages around 60–80 beats per min.
Healthy adult respiration averages 12–16 breaths per min.
The gastric cycle that controls the stomach contracts on average once per 3 min.
The intestinal cycle contracts in waves approximately once per min.
Delta (deepest sleep) = 1–3 cps (cycles per second)
Theta (sleep) = 4–8 cps
Alpha (light slumber) = 9–16 cps
Beta (awake) = 17–22 cps (Riley 2010)
Mathematician Barbara Hero and sound healers – Jonathon Goldman and Kay Gardner – have written about the resonant frequencies for each organ and function in the body, with the caveat that bodies are individual and this is not an exact science. Furthermore, some frequencies are multiplied by octave factors in order to be musically presented in the audible range. Some vibrational therapists, such as Bruce Tainio and Gary Young, believe that changes from normal frequency range produce illness.
“Cymatics” is the term given to visible effects of frequency on matter drawing from the work of Ernst Chladni (1756–1827) and, subsequently, Hans Jenny (1904–1972), e.g., the waves, ripples, and formations in different densities of liquids in response to particular frequencies and intervals: visible waveforms, dissonance, and geometric patterns (Jenny 2016). Cymatics uses audible sound frequencies for specific healing stimulation. This approach can be traced back to ancient wisdom traditions (Cymatics Source 2016).
9.3 Toning and Chant
Chant such as repetitive use of words, phrases, or sounds that cause overtones to resonate in the body has long been part of meditation, faith traditions, and ancient wisdom, for example, Medieval Christian chant, Indian Sanskrit mantra, Vedic or Upanishad scripture (Riley 2010, pp. 92–93), Tibetan Buddhist Tantric overtone singing, and in Africa. Such chanting often combines both a rhythmic effect and certain modes or intervals that elicit harmonic overtones. For instance, a close interval will create “difference tones” or a beating sensation relating to the size of the interval, or high overtone harmonics may be heard above extremely low register tones. Certain vocal and throat techniques bring harmonic overtones into audible range. Due to the phenomenological experience of integrated mind state and physiological vibration, chant can be understood as holistic in both the medical and philosophical sense. Generally, this type of chant is more related to meditation than “music” per se. Its psychological effect is of greater importance than melodic features. When a person is actively involved in chanting, not only the palpable sensation of the vibrations and voice but also the long rhythmic periodicity of breath cycles and slowed respiration affects the body. Toning (i.e., chant without the use of words or syllables) has been linked to melatonin production according to Dr. Ranjie Singh and Marc Micozzi, musician Fabien Maman, and several ancient belief systems including Qigong, Taoism, Egyptians, and Zoroastrian rituals and yogic traditions (Riley 2010, p. 91).
9.4 Allopathic (Complementary) Modalities
Many alternate or complementary modalities of therapeutic music and sound have grown up alongside conventional medicine since the 1970s.
Music therapy (interactive/participatory)
Chanting and toning
Vibroacoustic harp therapy
Intention – always for the good of the patient, whatever that may be, putting aside personal satisfaction
Taking neither credit nor blame for the effect of genuinely delivered music
Playing simple rather than complex music for healing, not performance; relief and blessing, not entertainment
Healing not curing – restitution to wholeness of mind and spirit, not eradication of physical illness or injury – e.g., reducing perception of pain, promoting better sleep, and facilitating relaxation
9.5 Harp Thanatology
Why the propensity to use harp in bedside vigils of people nearing death?
The rationale is not related to heavenly imagery. While monadic or melodic instruments play one note at a time, the harp is able to capture chords, harmony, and resonance – i.e., multiple notes simultaneously. A “travel” or Celtic harp is also relatively portable, allowing the instrument to come to the bedside in a range of settings. The volume of harp allows it to be played softly and calmly in a confined space. The pitch range of the instrument also permits the musician to harness mellow resonant low-frequency notes in prescriptive music empathetic with relief of pain and suffering. Finally, the timbre (tone color) of a well-plucked harp is widely considered to be pleasing and soothing. The anatomy of the harp with its large soundboard and open holes in the back emits the tone with vibroacoustic properties that some believe are healing and certainly viscerally palpable. Some people will sit so that they can rest their back on the harp and literally feel the vibrations permeating their physical body. The polyphonic nature of the harp makes it suitable for encapsulating relevant harmonic modes. Stella Benson’s book on Healing Modes ascribes different elevating and calming moods and healing purposes to different harmonic modes.
What is so especially healing about the harp?
Sympathetic vibrations are resonances perceived in the body vibrating with string and overtones (harmonics), crossing between the spiritual and physical realm. Others have suggested that the beautiful aesthetics of sound and shape of the harp echo the golden sequence (or Fibonacci series of ratios with “universal” appeal). The ADSR (attack, decay, sustain, and release) of a soundwave determines its timbre (or tone color). The harp has an especially long decay envelope or resonance and energy exchange. Dr. Abraham Kocheril has written about the organizing and calming effects of harp music on chaotic electrophysiology (cardiac arrhythmia), believing that the characteristics of the instrument influence physical symptoms.
10 Music and Pain
“Pain occurs in the physical, emotional, and spiritual realm” (Benson 2003, p. 19). Perception of pain is shaped by many aspects, such as gender, culture, how pain affects the patient’s life, stress or anxiety, previous experience with pain, outlook, and other psychological factors. Hence, different individuals will have a different “pain threshold.” “Music is known to reduce the sensation of pain, fear, anxiety, need for excess anaesthetic agents … recovery rates, mortality rates, hospital stays …” and requests for medication. People who are experiencing post-traumatic stress disorder (PTSD), financial or other life instability and stress, or depression, for example, may perceive a greater impact of pain from injury or disease.
Physical pain affects several measurable characteristics, e.g., blood pressure, immunoglobulin levels, and skin temperature (Benson 2003). Other indicators of pain can include moaning, quick or intermittent inhalation/exhalation, holding breath, muscle tension, tight jaw, facial grimaces, fisted hands, knees to chest, moodiness and restlessness, and sensitivity to light.
Music can be used as a noninvasive analgesic. For musicians playing live, Benson suggests slowing down tempo and simplifying melody and harmony, shifting from moving harmony toward a drone, correlating with increased pain. In other words, more spacious, calm music is advocated for people with a high level of pain and more rhythmical, elaborate music for people with a lower level of pain.
Linda Bloom (2016) suggests that pain should be considered as the “fifth vital sign.” Bloom criticizes overprescription, especially of addictive narcotics and patient-managed expectations of pain relief in the USA. She believes that “patients are led to expect that they will have ‘little or no pain’” and that powerful and addictive pain medicines are automatically provided in response to patient-assessed pain scales, whereas according to Bloom, 73 RCTs on the role of music conducted by Dr. Catherine Meads at Brunel University found that music reduces pain before, during, and after surgery. Meads states that: “This level of relief is comparable to that achieved by a dose of pain-relieving drugs.”
According to the International Association for the Study of Pain, pain is an “unpleasant sensory and emotional experience associated with actual or potential tissue damage … Pain is both a sensory process felt in the body, and a subjective phenomenon, influenced by the psychological and emotional processes of each given brain” (Bicknell 2011). The brain and nervous system sense and process vibrations. “The spinal cord is composed of nerve bundles carrying different kinds of sensation; heat and cold; pain, pressure, and vibration” (Thompson 2010). The processing of pain involves both the peripheral and the central nervous system. During musical vibrations, the nerve tracts for vibrational sensing are “preoccupied or “overloaded,” effectively disrupting pain sensation. As a pain control feature, musical sound is good and vibratory sound may be even better. Furthermore, the emotional and spiritual effects of music impinge on physiological and psychological responses. The brain has endogenous opioids, and other neuropeptides, such as oxytocin, that may be stimulated and released by hearing music.
With regard to relaxation, the effect of music has been measured on the autonomic nervous system, manifests in a reduction in sympathetic arousal, and increases in parasympathetic activity (Warth et al. 2016).
11 Music and Agitation
Agitation is common among people with dementia, people in the terminal stage of end of life, and as a result of some medications. The so-called agitation is often the expression of an unmet need, especially when someone is unable to communicate verbally. “High levels of agitation are … associated with low levels of quality of life” (Samus et al. 2005), and the “use of psychotropic medication is associated with reduced quality of life” (Ballard et al. 2000). Agitation can be linked to stressful triggers or activities such as visitors, grooming, bathing, or mealtimes (Beilharz 2017) and medication “breakthroughs.” Music can be a helpful diversion from social triggers, especially if introduced before the trigger activity. Music can be helpful getting to sleep or distracting from tense procedures and situations.
“Cognitive impairment lowers the stress threshold so that external stimuli are more likely to cause agitation” (Gerdner 2012). Individualized music intervention “overrides the stressful environmental stimuli that the cognitively impaired person cannot synthesise, and instead evokes remote memory with pleasant associations, decreasing agitation” (Gill and Englert 2013). It has been shown that brain activation in response to a painful heat stimulus is significantly reduced when a person focuses attention on a musical or auditory stimulus instead of focusing on the heat stimulus. Thus distraction is a genuinely effective counter-pain measure (Bushnell et al. 2000).
12 Spiritual Support
What makes a person feel whole? Anthony Storr (1992) refers to the phenomenon of music as “mental furniture,” i.e., the music that plays in our head un-summoned. It could be argued that if someone is accustomed to having one’s “mental furniture” present and stoked from time to time, then to remove its stimulus is also to lose something stable, familiar, and comforting. For many philosophers, including Schopenhauer, Kant, Hegel, Nietzsche, Freud, and Jung, among others, the metaphysical quality of music permeating inner life (inhabiting spiritual vitality, as it were) also imbues it with power to create meaning and passion. Nietzsche went so far as to say that music made life worth living.
12.1 What Is Spirituality?
There are many different definitions of spirituality; however there is consensus that aging, dying, and enduring disease involves a spiritual dimension. It is often a time of life when various changes occur including physical, relationships, dependency and support needs, looking backward and forward through life, assimilating experiences and information differently, emotional needs and feelings, wondering about end of life and legacy, diminishing importance of material riches, and growing emphasis on experiences and relationships.
“The spiritual dimension focuses on meaning of life, hope and purpose, explored through relationships with others, with the natural worlds and with the transcendent” (Mowat and O’Neill 2013). Evidence suggests “genuine and intentional accompaniment of people on their ageing journey; giving time, presence and listening are the core of good spiritual practice.”
Tools in the practice of listening and presence include reminiscence, life-story keeping, creative activities, and meaningful rituals (signifying practices) that help with processing change. Many people receiving palliative care have complex conditions, including pain management and cognitive or psychological issues, which also require spiritual support.
Spirituality often involves the search for meaning in a spectrum from centrality of divine presence at one end and the secular concept of inner life, personal belief, and focus on self at the other end.
To think about the supporting role of music in spirituality, it is helpful to consider various manifestations of spirituality. In secular society, there is a distinction between the terms “spirituality” and “religion,” which has become particularly enunciated because many contemporary forms of spirituality do not involve a faith or religion. This clarification has emerged as participation in organized religion has declined and interest in spirituality has ascended, a move from creaturely worship to autonomous subjectivity, a movement from faith in God to faith in self, especially the postmodern sense of self-sufficiency (Swinton and Pattison 2010).
12.2 Music as an Alternative to “Hyper-cognition”
Hyper-cognition refers to the overemphasis on cognitive ability to the detriment of other capacities. Due to its deep emotional connection, arguably transcendent qualities, and relative portability, music provides a way to bring ritual and liturgies (and reminder of community involvement) into the home, hospital, or hospice palliative care.
Music can carry associated feelings of belonging; reassurance; acceptance; hope; forgiveness; acquiescence; compassion; peace; resolution in relationships; purpose, meaning, and context in the vast cosmos; and plane of time.
There is a close link between anxiety or stress and pain. People with post-traumatic stress or depression, for example, may be more sensitized to pain, meaning it is worse for them than it would be otherwise. Conventional chronic and severe pain management, unfortunately, often serves people living with cognitive impairment very poorly. It is estimated that a large group of palliative care patients have cognitive impairment due to confusing medication, metastases in the brain, primary tumors, other disease conditions, or aging and dementia.
A number of alternative methods used for pain management are principally cognitive, such as relaxation and meditation techniques and cognitive behavior therapy (a process of analyzing, abstracting, and objectifying feelings that accentuate anxiety and pain). It is helpful to offer less cognitive and more intuitive ways to relax, appease anxiety, and access meditative or reflective calm for spiritual reasons, because conventional meditation techniques, even breathing exercises or concentration meditation, are not suited to a person with cognitive impairment or pharmacologically impaired concentration.
Music has an important place in spirituality, especially in palliative care. People with cognitive impairment need to be released from the responsibility or expectation of reciting liturgy or prayers, naming requests for forgiveness or meditation. They should be given alternative methods of belonging to their community and finding communion, reconciliation, hope, peace, comfort, and reassurance.
Many older people in palliative care also have dementia. Oliver Sacks in Musicophilia (2008), and Cohen and Eisdorfer in The Loss of Self (2002), writes about the benefits of music in the context of identity because dementia is most tragically often associated with a disintegration of identity. Music can foster a sense of self and identity that is not contingent on memory but rather on character expressed through musical taste, an embodied response and feelings, stimulation of memories of significant events and associations, and a sense of familiarity and “homeliness.”
12.3 Using Music to Support Spiritual Well-Being in the Hospice
Supporting the spiritual well-being of people involves appreciation of these intricacies and looking for opportunities when alternative approaches to spirituality, such as music engagement, can be of value without compromising cultural identity. Ideas should be adapted to the individual’s experience and background.
David Vance writes: “Many spiritual and religious activities rely on more resilient cognitive features such as procedural memory and limbic system aspects of attachment and motivation” (Vance 2004). By “resilient” Vance means enduring through all stages of cognitive impairment, medication, or dementia. Russell Hilliard reviewed the empirical evidence for music therapy in hospice and palliative care. While he focuses on visits by expert music therapists (as distinct from music engagement more broadly as part of everyday care), the results corroborate the impact of music in supporting comfort and reduced stress toward the end of life. “The primary goal of palliative care is to promote patients’ quality of life by alleviating physiological, psychological, social and spiritual distress, and improving comfort … There are several forms of complementary therapy (e.g., massage, art therapy, aromatherapy, reflexology, therapeutic touch) … [and] the emergence of an evidenced-based approach to music therapy in end-of-life care” (Hilliard 2005). There is a rich array of qualitative studies that report music’s ability to support end-of-life care and address patient and family needs.
The social (e.g., isolation, loneliness, boredom)
Emotional (e.g., depression, anxiety, anger, fear, frustration)
Cognitive (e.g., neurological impairments, disorientation, confusion)
Physical (e.g., pain, shortness of breath)
A considerable concurrence of depression, anxiety, and loneliness may be experienced by people in palliative care due to their social isolation, uncertainty, and feelings of helplessness. In hospice and palliative care, therapeutic musicians treat the many needs of patients and families receiving care.
Wlodarczyk investigated the effect of music therapy on the spirituality of people in an inpatient hospice unit. Statistical analyses indicated a significant increase in well-being (using a spiritual well-being scale). His study supports the use of music therapy to increase spiritual well-being for the terminally ill (Wlodarczyk 2003). “The expression and discussion of feelings of loss and grief can be very difficult for terminally ill patients. Expressing their emotions can help… experience a more relaxed and comfortable state” (Clements-Cortes 2004). For people who have very little or no speech, the only realistic way for them to express their responses is through emotional expression, and music is one way to feel together, to sing or make music, to harness music that encapsulates a poignant sentiment, or to stimulate volubility so that people can utter and release strong emotions.
12.4 Cultural Sensitivity
Spirituality is an aspect of cultural competency. “Cultural competence” refers to: “The process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diverse factors in a manner that recognises, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each” (Jutlla 2016). At least a minimal understanding and of varying attitudes to acceptable music in different faiths (e.g., karma and reincarnation, afterlife, necessary rituals, stigmas, and taboos) is necessary to support the end of life and illness with sensitivity, dignity, and respect using music tailored to the cultural situation.
Christians believe in eternal life after death. Music can be used to reinforce “hope,” restoration of the perfect relationship with God, satiety that does not depend on earthly or material possessions, health, or physical wellness. Music, especially familiar church music, can reinforce a person’s sense of belonging and community, fellowship, and sense of being part of a larger entity, the Church. Christians believe that human creatures have intrinsic worth as God’s creations, made in His image. This value is not undermined by frailty, illness, or disability. Songs that evoke God’s limitless love and grace may provide reassurance and comfort to the believer. Music can be used to mark seasons of life and for faithful contemplation. Apostle Paul suggests that singing and music-making is a collective worship experience: a harmonizing act of inclusion, oneness, community, and communion in the Holy Spirit, embodying the unity of the Church, a corporate act of thanksgiving and praise, and an edifying, unifying imperative (Ephesians 5:18–21).
Hindu religious observance can include prayer, meditation, bathing and cleanliness, dietary needs, and astrological beliefs. The needs of the individual are contextualized in the greater unit of the family, culture, and environment (Coward et al. 2000). Hinduism encourages family members to take a role in care of family members, and selecting and listening to music together can provide a tangible way to be involved in caring. Hindus believe that all living beings possess a soul that passes through successive cycles of birth and rebirth (reincarnation). The great sitar performer, Ravi Shankar, said: “We view music as a kind of spiritual discipline that raises one’s inner being to divine peacefulness and bliss … Thus, through music, one can reach God” (Hindu Music 2016). The Indian poet and Nobel Prize winner, Rabindranath Tagore, wrote: “For us Hindus, music always has a transcendent meaning, even when its intentions are by no means mystical or religious, but epic and amorous. Above all, music tries to touch the great hidden reasons for happiness in this world” (Hindu Music 2016).
Like Hinduism, Buddhism has the concept of karma (consequences of past actions – in this life or previous incarnations) and reincarnation. The latter means that the way of dying, dying well, and peace and non-agitation at end of life are important for a good reincarnation. Buddhism often uses music as part of spiritual practice, especially in temple practice and many forms of Buddhism practice meditation (by laity as well as monks and nuns). Buddhism takes on local cultural hues wherever it is, such that different manifestations have quite distinctive practices and cultural inflections. Aspects of food, dress, music, humility, and so on adapt within the local environment, from Nepal, India, and Tibet to China, Korea, Japan, India, Thailand, Sri Lana, Cambodia, and Myanmar. Despite this immense variety, most forms of Buddhism have meditation as part of their practice, and in various cultures this is assisted by “music,” where music is not “entertainment” but chant, drones, liturgical recitation, and sound vibration as part of the spiritual experience. Music that we might otherwise call soothing or calming is an aid to concentration, immersion, mindfulness, or even working to achieve a “no mind” state of detachment from active thoughts running around in the head. Pain and anxiety can bear all the traits of repetitive, persistent, or obsessive thoughts that detract from quality of life.
Islam provides Muslims with a code of behavior, ethics, and social values, which helps them in tolerating and developing adaptive coping strategies to deal with stressful life events (Sabry and Vohra 2013). There is considerable variety in the attitudes toward music, and so consideration is needed as to when and whether music engagement is an appropriate intervention in care for people of Islamic faith. Drawing from his thorough understanding of Shari’ah, rather than simply quoting the Qur’an or a Hadith, Imam Afroz Ali suggests that it is “important to note that music and singing are essentially two different things … The kinds of singing, which are unequivocally prohibited, are those which contain the celebration of the material world and includes sexual connotation and… inappropriate speaking … [that] remove a person away from the worship and appropriate presence with Allah” (Ali Imam 2016). The kinds of singing that are permitted are musical matters that glorify Allah and praise the Prophet. It is also permissible to sing in general terms about happiness (rather than about Allah specifically). Frivolous instrumental music, without singing, music purely for dance and sensual enjoyment (called malahi), is prohibited and abhorred. In a therapeutic or spiritually supportive capacity, great care should be taken to exclude lyrics and instruments that do not fit these criteria. Regarding the concept of whether music is allowed (halal) or forbidden (haram) in Islam, we can find different views from Islamic scholars; however, generally music is not considered forbidden in Islam as long as it is a therapeutic need. A millennium ago, Muslim physicians were considered leaders in medicine and innovative alternative therapies, now considered modern, including music therapy. In the past, Islamic researchers found that music has a great effect as a treatment of depression, insomnia, stress, schizophrenia, dementia, and childhood-related disorders like autism (Hanser and Thompson 1994).
Receptivity toward music in Judaism is similar to Christianity, and there is a rich use of music in Jewish culture, whether celebratory or serious.
13 Implementing Music in Palliative Care
Following are some approaches to implementation, ranging from bringing in expert performers, volunteer musicians, and trained therapists or providing recorded music on portable devices for listening with headphones that can be organized by staff or family and friends.
13.1 Engaging a Musician in Palliative Care
For the musician, a reexamination of values is important preparation for creating music for healing. This includes discarding investment in being right, exclusivity, attachment to past experiences, or expectation. Music for well-being is about an attitude of sharing and encouraging, and self-acceptance, rather than showing or performing. Therapeutic settings are frequently challenging. Concurrently, musicians need to deliver nothing less than their best, unselfishly, and with passionate commitment. The therapeutic musician must develop focus and relaxation, and relaxed posture and breathing that coheres with the musical expression, especially in a context when the musician is trying to help a patient relax, rest, or calm anxiety.
13.2 Considerations for Different Settings
The purpose of palliative care is patient comfort, especially pain control for people with medically incurable conditions, and enabling a peaceful and dignified death when appropriate. Not all patients in a palliative care ward or hospice are near to dying but may be there for symptom management. Music can extend to supporting the grieving process.
Acute hospitals typically have more monitoring equipment (O2 SATS, temp, BP, HR) that often displays vital signs obviously for the therapeutic musician.
It is important to understand the milieu and environment (Aasgaard 1999), e.g., tailoring therapeutic music to suit the different settings and expectations of the palliative care ward, general hospital, hospice, or residential care home in which someone receives palliative care or, increasingly, the individual’s home and community palliative care. Music ties in with meals, visitors, notions of privacy, and many situational and environmental factors and needs to be sympathetic with creating as relaxed and homelike environment as possible.
Sound in the environment of the home or ward for the person receiving palliative care influences tranquility, privacy, and ability to reflect. Reducing the noise from hospital equipment, alerts and announcements, clattering trolleys and foot traffic, visitors for other people, etc. will improve the experience for the patient and allow them to hear their own therapeutic music more clearly and immersively. Portable music devices and headphones are ideal in this setting rather than loudspeakers to help with occlusion and sound isolation.
13.3 Infection Control
A visiting or volunteering musician may be unfamiliar with requirements of infection control, both to protect the patient and themselves. The health professional may need to provide guidance. This includes sterile equipment, hand-washing protocols, quarantining, avoiding cross-contamination, and precautionary protection of patients and staff. Contagion is a higher risk for immune-compromised individuals who are unwell. Hospitals carry an inflated infection risk (nosocomial infection). Hand-washing and avoiding surface contact are the best strategies for reducing this risk.
13.4 Recorded Music for Individual Listening
Recorded music on portable devices has the several advantages. Firstly, the headphones allow a patient to use music to mask the operational noise of other people and equipment, an immersive environment that occludes or masks noise, chaos, and stress triggers. Secondly, it is not intrusive for others, as compared with small loudspeakers. Thirdly, a simple device, such as an Apple iPod or comparable MP3 player, for example, allows most patients to control the music themselves, thereby being proactively involved in their own music intervention and with the flexibility of being able to listen anywhere and at any time. The latter is very beneficial when music is deliberately used to aid going to sleep or to overcome pain and restlessness, i.e., at any time of the day. Individualized music can also be tailored with a list of music that is both calm and fits into the patient’s tastes and interests for the greatest emotional and spiritual impact.
Music can be organized by staff forming part of the whole-person service, or music may be provided by the family and friends as a way to be meaningfully involved in care. If a patient is not able to explain their own interests in music, friends and family are often able to provide this information.
14 Conclusion and Summary
This chapter has looked at the potential impact of therapeutic music in palliative care with special attention to its impact on diversion and minimization of pain perception and calming physiological and emotional effects that can assist in reduction of restlessness, agitation, and anxiety. Further areas of physiological and emotional impacted by music intervention include stimulation of appetite, aiding getting to sleep, reducing agitation, and behaviors triggered by specific events or activities, such as bathing, visitors, and medical procedures. This chapter has outlined the key distinctions between therapeutic music and music therapy: their respective applications and practitioners. The way in which music affects physiology, the brain and mind have been discussed along with a number of approaches in mainstream therapeutic music and some concepts of vibrational therapy from alternative medicine practices. A brief outline of music in relation to health from antiquity to the present, from historical and philosophical perspectives, has been provided for those who are interested in the origins and long cultural background of the healing role of music. A very brief introduction to cultural and faith-related sensitivities points to the importance of cultural competency and sensitivity in multicultural and diverse care delivery.
Most significantly, engagement with music can facilitate relational interaction with family, friends, and care staff and provide companionship, reminiscence, and reinforcement of identity in times of change or isolation. Music has been used therapeutically to help people express emotions and anxieties that are difficult to verbally articulate, and to vent repressed and abstract emotions, especially those associated with dying, resolution of relations, existential issues, and fears. Music engagement provides a complementary modality for supporting emotional, psychosocial, and spiritual needs to balance the physical and medical care that form part of whole-person understanding in palliative care.
Music has a valuable contribution at various stages of palliative care, dying and death, both for the individual in care and for their family and friends, in coming to terms with emotions and assisting with a calm, dignified environment. Throughout the palliative care trajectory, individualized music provides a flexible and proactive, potentially self-managed intervention that gives the patient some control over their environment, feelings, and pain management as appropriate in a situation where many aspects of their care are not in the patient’s own control. Music can be a gentle and subtle way to support spiritual, existential, and deep nonverbalized needs, especially for those who do not identify with a faith community but who, nonetheless, have spiritual and emotional needs that are not addressed by medical care. As a modality, music can often be used in partnership with other therapies to facilitate movement, creativity, creating a legacy, for meditation and reflection, and with pastoral care.
Given its inexpensive nature and lack of side effects, music can provide a very effective, meaningful therapeutic intervention and enhancement to life quality without risk. Music can manifest in a range of presentations ranging from live music at the bedside and vigils by specialist therapeutic musicians to the provision of recorded music on a portable device tailored to individual tastes and needs, supported by any member of the care staff or family and friends, without the need for musical or technological expertise.
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