… or maybe I should say “rules”…
I’ve been a board-certified music therapist for a little more than seven years now. Hospice work now makes up a bigger portion of what I do on a day-to-day basis than it has for a while, which has made me more aware of how I’ve grown as a clinician in the last few years. For me, gaining experience has meant gaining clinical flexibility. These days I feel comfortable enough with the “rules” for hospice music therapy to know when to bend or break the rules I thought were steadfast as a beginning therapist.
(If you’re reading this from the perspective of a caregiver rather than a music therapist, take these as deviations from what you might expect from a music therapist.)
Here are my top ten rules to break in hospice music therapy:
1. Visits must be one hour long. I made this my standard visit length for purposes of budgeting and billing, but sometimes hour-long visits just do not make sense, like when someone is too tired to try staying awake for an hour or when a visit starts late for some reason and the person is ready for a longer visit. Fortunately, the hospice philosophy is all about meeting the client’s needs in-the-moment, and that means shorter or longer visits, depending on the day. I LOVE that this is the standard in hospice care. (P.S. It’s helpful that billing per visit rather than per hour has been the norm for the hospices I serve.)
2. Sessions must be private, for the client only. I have always involved family members in hospice music therapy sessions, since the hospice philosophy includes caregivers in the overall care plan, but more recently I have expanded my own idea of who to include in music therapy sessions. For example, I currently have a client who lives in a care facility. His family is not close, but the facility staff and some of the other residents at the facility are close. They are his support system at this time of life, and it seems appropriate to include them in music therapy sessions. More to the point, he enjoys sharing this gift of music with his friends. Taking him to his room for a private session just would not be as effective.
3. Always play music. I’ve had sessions when it seems that me singing a song or two would just be intrusive. Sometimes people just want to talk, so my presence and a listening ear is enough. Sometimes getting a hold of the hospice nurse or an aide to address an immediate physical need is exactly what I should be doing. Sometimes even just adjusting the lighting in the room, turning off the TV, and holding someone’s hand is an effective therapeutic intervention.
4. Always talk about the music. I used to think that a song wasn’t really therapeutically effective unless we had a discussion about it afterwards. I still like to encourage song discussion, but sometimes just providing the music is a powerful intervention, and forcing a conversation would detract from that.
5. Avoid songs about death (or saying goodbye) unless you’re planning on a song discussion. I used to avoid songs like “Red River Valley,” “Clementine” and the last verse of “Because He Lives” because they talked about death and going away. Now I realize that I was avoiding them because I felt weird singing them with a hospice patient, not because they wouldn’t have been appropriate clinically. Sometimes a musical mention of death is appropriate, and sometimes I’m probably just over-thinking the matter in the first place.
6. Always play the client’s preferred music. Another common method I’ve used is to ask a hospice patient about her favorite kind of music, then to play one of her favorite songs. This is a great method, but sometimes patients can’t communicate their preferences clearly, and sometimes preferences are difficult to predict. What’s more, very meaningful interactions can come from experiences with less-familiar music or even improvised music. (For more on the difficulties of determining music preferences, read this.)
7. Keep your primary focus on pain management. At some point, I learned to start every session by asking patients to rate their pain level on a 1-10 scale. This isn’t a bad thing to do by any means; after all, hospice is about making people comfortable. Sometimes, though, physical pain is not the biggest concern for a patient and should not be my main focus. In fact, recently I started a session with an elderly woman with the usual 1-10 pain rating question. She looked at me kind of funny, said, “I don’t know. Why does everyone ask me that?” and turned away. I paused for a minute, said, “you’re right. That’s a strange question to ask,” then shifted the conversation over to the music we could have together. The “Pain Question” doesn’t always need to be front and center.
8. Always follow the treatment plan. All hospice professionals write care plans for their patients, and these care plans are discussed and revised in interdisciplinary team meetings every two weeks. Part of the beauty of hospice care, though, lies in its flexibility and adaptation to the patient’s in-the-moment needs. Sometimes I’ll go into a session with a plan for songwriting to facilitate life review or music-assisted relaxation training for pain management, and a patient will be too tired to talk or will have a family member visiting. These are the times when adjusting the plan is the right thing to do.
9. Keep an emotional distance. I used to be extremely careful about sharing anything about my personal life or interacting with clients and their families on anything other than a formal, professional basis. The term we often use for this is “boundaries,” and mine were rigid (probably because I was coming from a mental healthcare background.) Learning how to establish and maintain appropriate boundaries with clients takes time, and it is a HUGE area where supervision and consultation with colleagues is necessary. It’s probably better to err on the side of protecting your clients and yourself, but keeping boundaries that are too rigid can detract from the therapeutic process as well. For example, you might tear up when providing music during a patient’s final moments. (I know I do that sometimes!) Allowing the client’s loved ones to see those tears helps them to know that you genuinely care for the patient and that it is okay to have emotional reactions at such a sensitive time. It can help you to cope with the losses of patients to find an appropriate way to work through your feelings, too, rather than trying to keep yourself somehow aloof from the pain of losing people you care for. (Read more of my thoughts on self-disclosure here.)
10. Be serious, because dying is serious business, right? My default approach in hospice music therapy (and music therapy in general) used to be very serious – I was there to provide music to meet a specific therapeutic need, not to entertain. Now I understand, though, that a big part of my role as the music therapist in hospice is to bring joy, to encourage smiles, and to inspire laughter. This isn’t true for every session, of course, and there certainly are serious moments, but joy can be part of it, too.
These are my top ten rules to break in hospice music therapy. What are yours? Which of these resonate with you, and which would you add? Please leave your comments below!