A Symphony of Life: Creating and

Preserving Legacy through Innovative

Medical Music Therapy Interventions

Brian Schreck, MA, MT-BC

Title of Program: Family Medicine Grand Rounds Title of Talk: A Symphony of Life: Creating and Preserving Legacy through Innovative Medical Music Therapy Interventions Speaker/Moderator: Brian Schreck, MA, MT-BC Planning Committee Members: John King, MD, MPH, Melisa Gibson, MD, Anne Morris, MD, Whitney Calkins, MD Date: November 17 , 2014 Workshop #:15-101-12 Learning Objectives 1. Synthesize current evidence based practices of the role of creative arts therapies in palliative and hospice care.

2. Identify the importance of medical music therapy in palliative and hospice.

3. Share/apply innovative medical music therapy interventions with multidisciplinary psychosocial teams

DISCLOSURE: Is there anything to disclose? Yes or No Please list the Potential Conflict of Interest (if applicable): ______________________________________________________________ All Potential Conflicts of Interest have been resolved prior to the start of this program. Yes or No (If no, credit will not be awarded for this activity.) COMMERCIAL SUPPORT ORGANIZATIONS (if applicable):

______________________________________________________________ The University of Vermont College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Vermont designates this live activity for a maximum of 1 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Overview

• “creative arts therapies involve the implementation of an arts intervention by a trained, credentialed creative arts therapist; the presence of a systematic psychotherapeutic process; the use of individualized treatment interventions”

- JAMA vol 173 (no.11) June, 2013

Creative Arts Therapies

An Overview

• Specialties include art therapy, music

therapy, dance/movement therapy, drama

therapy, and poetry therapy.

• Can significantly reduce anxiety, depression,

pain, and improve quality of life

• Music therapy for cancer patients can reduce

anxiety, pain and improve mood

• Dance therapies can improve QOL

Individual CAT

Art- uses art media images and creative process to create projects of as reflections of development, abilities, personality, interest concerns and conflict.

A therapeutic means to resolve emotional conflicts, fostering self awareness and reduce anxiety. ( American Music Therapy Association)

Drama therapy is the systemic and intentional us of drama/theatre to achieve therapeutic goals of symptom relief, emotional and physical integration, and personal growth. It is an active approach that helps to tell the patients story, to solve problems, achieve catharsis, extend the breath and depth of the inner experience, understand the meaning of images, strengthen the ability to observe personal roles (National Drama Therapy Association)

Dance/movement therapy is based on the assumption that body and mind are interrelated and is defined as the psychotherapeutic use of movement as a process that furthers the emotional, cognitive and physical integration of the individual. (National Coalition of Creative Arts Therapies Associations)

Biblio/poetry therapy- the intentional use of poetry and other literature for personal growth and healing (National Coalition of Creative Arts Therapy Associations)

Definitions Music Therapy is the clinical and evidence-based use of music

interventions to accomplish individualized goals within a therapeutic

relationship by a credentialed professional who has completed an

approved music therapy program. It is an established health profession in

which music is used within a therapeutic relationship to address physical,

emotional, cognitive, and social needs of individuals (AMTA, 2011).

Active Music Therapy: Administered by a board-certified music therapist

and requires physical action by the medical patient and/or patient’s family.

Passive Music Therapy: Administered by a board-certified music

therapist and requires no or limited physical action by the medical patient

and/or patient’s family.

Music Medicine: Passive listening to pre-recorded music offered by

medical personnel (Dileo 1999).

Well-Being: Individual’s perceived health and quality of life based on

satisfaction with emotional, social, and physical life experiences.

Overview of MT Methods

• Receptive Music Therapy: Live music listening,

recorded music listening, song analysis, music guided-imagery

for relaxation.

• Improvisational Music Therapy: Instrumental, vocal,

storytelling and symbolic play.

• Re-creative Music therapy: Song singing

• Compositional Music therapy: Songwriting

-Lindenfelser, 2013

MT Goals

Pt/family will exhibit increased

• Comfort/relaxation

• Increased coping ability, esteem, well-being

• Decreased anxiety

• Decreased shortness of breath

• Report decreased pain/discomfort

• Express loss and grief

• Verbalize spiritual or cultural needs

• Plan music for memorial/funeral

-Lindenfelser, 2013

MT Interventions

• Provide music for relaxation/comfort

• Provide music for decreased pain/agitation/anxiety

/discomfort

• Encourage emotional expression and response

• Provide music and guided imagery

• Assist Pt/family in songwriting or song analysis

• Encourage Pt/family participation in improvisation

play

• Provide music to validate and support Pt/family

spiritual beliefs

• Provide music to validate Pt/Family’s cultural heritage

-Lindenfelser, 2013

Why is the music meaningful

• It takes on deeper significance during times

of loss and grief

• An art form that is universally valued

• Has cultural and spiritual significance

• Personal significance to specific events,

rituals and traditions (Magill, 2009)

-AMJHPM vol 26 2009

The significance of the music for as

perceived by surviving caregivers Strategies used:

• Precomposed songs- reminiscence, life review, lyrics can guide thoughts

• Song composition – use of familiar melodies, life stories, enhances sense of personal value, attributes about the self, messages to significant others, opportunity for resolution

• Imagery in music for symptom relief, use of peaceful images

• Music listening-live music in sessions with caregivers, familiar music, connection to transformative events in life (Magill, 2009)

Clinical Aims

Reengage children with their environment using

CAT to create three elements of contextual

support:

• Structure: To provide Pt’s with opportunities for successful

mastery over their environment.

• Autonomy Support: To afford Pt’s opportunities to

make choices and direct activities

• Involvement: To express unconditional acceptance of Pt’s

and reinforce their efforts and actions. (Robb, 2003)

-Bradt, 2013

1. Listening to live, therapist-composed,

improvised music

• I invite you to imagine you are sitting in a

hospital room with a loved one. You are

holding their hand and it is very quiet.

Everyone present is thinking of the right

things to say, but no one is saying anything.

Gentle music is offered…

2. Performing on an Instrument

Functional (Re)Creation!

3. Improvising

Re-Creative &

Compositional MT

• Song: Singing/playing familiar songs

to normalize the experiece and to

validate patient’s interests and identity.

• Songwriting: Can help facilitate

communication of the patient’s

experiences and feelings –often a

treasured and tangible part for the

family (Lindenfelser, 2013)

E.

• E. is a 13-year-old with spinal cord astrocytoma,

secondary quadriplegia

• At approximately 5:30 3/9/10 respirations stopped and

HR slowly decreased. Time of Death 5:48 AM.

• Legacy theme/intervention: Preserving E.’s voice by

utilizing and celebrating her physical expression/Live

music for comfort care post-mortem

E.

Continue living in the midst of letting go

E. was

an artist

and wanted to

be a fashion

designer

These sketches

were designed

before E. lost

the use of her

arms

These images were

used to label the Cd’s

of our recordings

created for her family

Tell Me A Story

Family-Centered Synergy • "On the day it became evident that Critter would lose his

battle, Brian stayed with him and his family in the ICU,

playing the songs that Critter loved, singing with the family

and providing them with CD copies of the recordings. As we

walked Critter back to A5 South in his bed, still on the

ventilator, Brian was there, playing the music that meant so

much to Critter. "When the family gathered around Critter's

bedside to say a final goodbye, his father requested that

Brian come and be close to the family. He was an essential

part of Critter's care team, and his presence and music at

the end of the journey provided such a comfort to the family.

Critter's mother asked Brian to provide the music at his

funeral, and Brian did a fantastic job.”

• She added, "Critter's best friend is a current patient, and at

the funeral, he wanted to sing a song he had written. Brian

assisted him in playing, and I believe that in the difficult

months ahead for this child, Brian will also bring comfort

through the love of music that all three share."

The Battlefield “The Battlefield”

My Cancer’s like a battlefield

That I just keep on rockin’ through

Every day and night I fight

And I just keep on rockin’ through

Fartin’ and makin’ it right

Hoagies, fries and sprite

I just keep rockin’ through

My Cancer Is A Battlefield

Cancer is a battlefield

IV pumps and hospital beds

That I just keep on rockin’ through

Doctors and nurses all around

That I just keep on rockin’ through

Pepsi, steak, & corn

That I just keep on rockin’ through

Battlefield, battlefield

My cancer is a battlefield!”

Continuum Of Care/Legacy Work

The Battle Field

Movement 4: The Voice of home

• “Music From An 8 X 8 Room” Inspiration from Diego Stocco’s “Music From A Tree”:

http://www.youtube.com/watch?v=fY-ZoVMwGKM

5. Music combined with other modalities

(i.e., movement, imagery, art)

Search Strategy

• Keywords: music therapy, medical music therapy,

pediatric music therapy, music therapy and: quality of

life, pediatrics, hospitalized children, pain, inpatients

• Databases: MEDLINE/PubMed, CINAHL,

PsychInfo, Cochrane Library, Alt Healthwatch,

OhioLink, GoogleScholar, &

• National Association of Children’s Hospitals and

Related Institutions (NACRHI) electronic mailing list

The Evidence Summary • Peutz- meta-analysis CATs effect on psychological

symptoms and QOL in patients with cancer during and

after treatment, 27 RCTs

• During treatment, CAT significantly reduced anxiety

(Δ = 0.28 [95% CI, 0.11-0.44]), depression (Δ = 0.23

[0.05-0.40]), and pain (Δ = 0.54 [0.33-0.75]) and

increased QOL (Δ = 0.50 [0.25-0.74]). Pain was

significantly reduced during follow-up (Δ = 0.59 [95%

CI, 0.42-0.77]).

• Exposure to CAT can improve anxiety, depression,

and pain symptoms and QOL among cancer

patients -Peutz, et al (2013)

Evidence Synthesis

Effect MT may have on Well-Being in Pediatric Patients

Emotional:

• Reduces trauma

• Lowers maternal anxiety

• Less crying in neonates

• Reduces distress before/during/after blood tests

• Increases positive affect

• Active MT reduces anxiety

• Music medicine reduces pain/fear for pediatrics

undergoing lumbar punctures.

Evidence Synthesis continued

Social:

• Facilitates coping strategies

• Reduces maladaptive behaviors

Evidence Synthesis continued

Physical:

• Influences physiology

• Reduces migraine frequency

• Decreases pain during burn debridement

• Reduces the amount of pharmacological

interventions in neonates: Increases feeding rates,

increases quiet sleep states, reduces heart rate

Evidence Synthesis Continued Other Findings • May enhance cognitive abilities

• Facilitate non-verbal/verbal communication

• State of science is underdeveloped

• Consistent outcome measures

• Consensus on research priorities

Other palliative care outcomes/functions

• Preloss grief

• Postloss grief

• Means for expression for decision-making and goals

• Dignity and identity

• Expression of emotions

Encouraging decision-making

No one is quite like you

Or can be all you are

So loving, so caring

And always by my side

When I see your face

It makes me happy

You make me strong

You give me faith

With every song we sing

You are in my heart

You are my family

We’ll never be apart

“No One is Quite Like

You” Written for Mom

I’ll always be with you

I’ll always be your friend

I’ll always love you

And be your baby girl

Focus on Family-Centered-Care

Case: 30 yr male w NF-1

Severe neuropathic pain unresponsive to :

Opioids

Anticonvulsants

Benzodiazepine

Tricyclic antidepressants

Topical Local Anesthetic patches

TENS

Culinary Arts: Finding Control

Leaving a legacy

• http://www.shutterfly.com/custompath/viewEdi

t.sfly?fid=55b8e05dd84b633626cd1d30d33b

21f1

“If I don’t make fun of it, then who’s

gonna?”

• My goal is to approach living

with cancer with humor,

optimism, and yes indeed

sarcasm (that is a part of who I

am.) I look forward to many,

many more years of accidental

distaste, but I hope to fail

miserably in that department

and continue to teach

optimism, patience, how to

laugh in despair, and to never

give up.

Eight weeks have gone and passed;

I wasn't sure if I would last.

But the time has come to raise the mast,

Sail along and continue this blast

Of a ride my life has been.

I believe that news will be great, .

But a few months I have to wait,

And during that time I appreciate

The value of patience and an optimistic state

Of mind.

I cannot fall behind

I remind

Myself to find

All the beauty in this seemingly cruel world

Into which we've all been hurled.

Like a flag coming unfurled,

My heart becomes twirled

With thankfulness and gratitude

That I have a positive attitude

And that I'll travel to any latitude

To keep on being that dude.

This radiation treatment is coming to an end,

It made my body contort and bend.

A painful round each day would send,

But I was greeted each day with a smile from a

friend.

The people I met who have taken care of me,

Who have always seemed to want to be

There doing their best to make us tumor free ...

I will leave here optimistically.

optimistic

02.02.11

Legacy

• “Brian, there are no words to express what

the time you spent with Q meant to him and

to me. We received this email (of the

recording) from you before we even got home

and the cd immediately thereafter. I am so

grateful to you and to whomever summoned

you to our room.”

TAB

StoryCorps

Our Principles StoryCorps is built on an uncompromising

commitment to excellence across all aspects of the

project, from collecting, sharing, and preserving

people’s stories; to organizational management; to

maintaining an extraordinary work environment

where respect and dignity are paramount.

The interview session is at the heart of StoryCorps.

We treat participants with the utmost respect, care,

and dignity.

• Metastatic desmoplastic round cell

tumor, diagnosed in 2/07. DOD: 1/3/09

• 27 years of age, two children at home

• Lullabies for two children

• Legacy theme/intervention: Creating

consistent night rituals for coping &

comfort

M.

M.

HEARTBEAT MUSIC THERAPY

Re-Creative &

Compositional MT

• Song: Singing/playing familiar songs

to normalize the experiece and to

validate patient’s interests and identity.

• Songwriting: Can help facilitate

communication of the patient’s

experiences and feelings –often a

treasured and tangible part for the

family (Lindenfelse 2012, Bradt 2013)

doppler

infant

toddler

Infant

Rock

School

aged Pt.

12 mo +

parents

Rock with

Sibling

Hip

hop

Infant +

parents

First

Birthday

http://cincinnatichildrensblog.org/patient-family-

experience/and-the-beat-goes-on/

http://abcnews.go.com/blogs/health/2014/05/26/therapist-

turns-heartbeats-of-dying-patients-into-music/

http://www.huffingtonpost.com/2014/07/02/recorded-

heartbeats-brian-schreck_n_5552019.html

http://wvxu.org/post/using-dying-heartbeats-make-music

Future Challenges

• Can a deceased person’s legacy intensify

loss associated with a complicated

relationship?

• How to assess the potential impact of a

legacy work on the recipient? Will they be

comforted?

• How to assess the emotional consequences

of the work in progress?

“This is the voice of home.”

-Clive Robbins

“One of the last things that Paul Nordoff said to a

colleague when he was dying in hospital was, ‘You

know, the greatest mystery of all is that we’re made

of music.’”

Ansdell, G. (1995). Music For Life. P.8 ISBN 1-85302-299-3

Let’s Dance

References

• Ansdell, G. (2000). Music For Life: Aspects of Creative Music Therapy with Adult Clients (p.8). 325 Chestnut Street, Philadelphia, PA 19106: Jessica Kingsley Publishers Ltd.

• Armstrong, L. (N.D.). Quotation #27042 from Laura Moncur’s Motivational Quotations.Retrieved April 27th, 2006 from http://www.quotations.com

• Cincinnati Children’s StarShine Program: http://www.cincinnatichildrens.org/service/s/starshine/default/

• Cincinnati Children’s Hospital Medical Center (2010): “Tell Me A Story” http://www.youtube.com/watch?v=JEXxVG550bs

• Dorak, M.T. Retrieved December 5th, 2005, from http://dorakmt.tripod.com/music/symphony.html

• Keys, A. (2004). “If I Ain’t Got You” from her album The Diary of Alicia Keys.

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• Stocco, D. (2009). Music From A Tree: http://www.youtube.com/watch?v=fY-

• ZoVMwGKM

References

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MT in the Seacrest Studio

• http://cincinnatichildrensblog.org/rare-and-

complex-conditions/heart-

conditions/seacrest-studios-performance-

was-my-victory-lap/#.Uqn5ERZyHww

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