Top 10 Rules to Break in Hospice Music Therapy
… or maybe I should say “rules”… I’ve been a board-certified music therapist for a little more than seven years now. Hospice work now makes up a bigger portion of what I do on a day-to-day basis than it has for a while, which has made me more aware of how I’ve grown as a clinician in the last few years. For me, gaining experience has meant gaining clinical flexibility. These days I feel comfortable enough with the “rules” for hospice music therapy to know when to bend or break the rules I thought were steadfast as a beginning therapist. (If you’re reading this from the perspective of a caregiver rather than a music therapist, take these as deviations from what you might expect from a music therapist.) Here are my top ten rules to break in hospice music therapy: 1. Visits must be one hour long. I made this my standard visit length for purposes of budgeting and billing, but sometimes hour-long visits just do not make sense, like when someone is too tired to try staying awake for an hour or when a visit starts late for some reason and the person is ready for a longer visit. Fortunately, the hospice philosophy is all about meeting the client’s needs in-the-moment, and that means shorter or longer visits, depending on the day. I LOVE that this is the standard in hospice care. (P.S. It’s helpful that billing per visit rather than per hour has been the norm for the hospices I serve.) 2. Sessions must be private, for the client only. I have always involved family members in hospice music therapy sessions, since the hospice philosophy includes caregivers in the overall care plan, but more recently I have expanded my own idea of who to include in music therapy sessions. For example, I currently have a client who lives in a care facility. His family is not close, but the facility staff and some of the other residents at the facility are close. They are his support system at this time of life, and it seems appropriate to include them in music therapy sessions. More to the point, he enjoys sharing this gift of music with his friends. Taking him to his room for a private session just would not be as effective. 3. Always play music. I’ve had sessions when it seems that me singing a song or two would just be intrusive. Sometimes people just want to talk, so my presence and a listening ear is enough. Sometimes getting a hold of the hospice nurse or an aide to address an immediate physical need is exactly what I should be doing. Sometimes even just adjusting the lighting in the room, turning off the TV, and holding someone’s hand is an effective therapeutic intervention. 4. Always talk about the music. I used to think that a song wasn’t really therapeutically effective unless we had a discussion about it afterwards. I still like to encourage song discussion, but sometimes just providing the music is a powerful intervention, and forcing a conversation would detract from that. 5. Avoid songs about death (or saying goodbye) unless you’re planning on a song discussion. I used to avoid songs like “Red River Valley,” “Clementine” and the last verse of “Because He Lives” because they talked about death and going away. Now I realize that I was avoiding them because I felt weird singing them with a hospice patient, not because they wouldn’t have been appropriate clinically. Sometimes a musical mention of death is appropriate, and sometimes I’m probably just over-thinking the matter in the first place. 6. Always play the client’s preferred music. Another common method I’ve used is to ask a hospice patient about her favorite kind of music, then to play one of her favorite songs. This is a great method, but sometimes patients can’t communicate their preferences clearly, and sometimes preferences are difficult to predict. What’s more, very meaningful interactions can come from experiences with less-familiar music or even improvised music. (For more on the difficulties of determining music preferences, read this.) 7. Keep your primary focus on pain management. At some point, I learned to start every session by asking patients to rate their pain level on a 1-10 scale. This isn’t a bad thing to do by any means; after all, hospice is about making people comfortable. Sometimes, though, physical pain is not the biggest concern for a patient and should not be my main focus. In fact, recently I started a session with an elderly woman with the usual 1-10 pain rating question. She looked at me kind of funny, said, “I don’t know. Why does everyone ask me that?” and turned away. I paused for a minute, said, “you’re right. That’s a strange question to ask,” then shifted the conversation over to the music we could have together. The “Pain Question” doesn’t always need to be front and center. 8. Always follow the treatment plan. All hospice professionals write care plans for their patients, and these care plans are discussed and revised in interdisciplinary team meetings every two weeks. Part of the beauty of hospice care, though, lies in its flexibility and adaptation to the patient’s in-the-moment needs. Sometimes I’ll go into a session with a plan for songwriting to facilitate life review or music-assisted relaxation training for pain management, and a patient will be too tired to talk or will have a family member visiting. These are the times when adjusting the plan is the right thing to do. 9. Keep an emotional distance. I used to be extremely careful about sharing anything about my personal life or interacting with clients and their families on anything other than a formal, professional basis. The term we often use for this is “boundaries,” and mine were rigid (probably because I was coming from a mental healthcare background.) Learning how to establish and maintain appropriate boundaries with clients takes time, and it is a HUGE area where supervision and consultation with colleagues is necessary. It’s probably better to err on the side of protecting your clients and yourself, but keeping boundaries that are too rigid can detract from the therapeutic process as well. For example, you might tear up when providing music during a patient’s final moments. (I know I do that sometimes!) Allowing the client’s loved ones to see those tears helps them to know that you genuinely care for the patient and that it is okay to have emotional reactions at such a sensitive time. It can help you to cope with the losses of patients to find an appropriate way to work through your feelings, too, rather than trying to keep yourself somehow aloof from the pain of losing people you care for. (Read more of my thoughts on self-disclosure here.) 10. Be serious, because dying is serious business, right? My default approach in hospice music therapy (and music therapy in general) used to be very serious – I was there to provide music to meet a specific therapeutic need, not to entertain. Now I understand, though, that a big part of my role as the music therapist in hospice is to bring joy, to encourage smiles, and to inspire laughter. This isn’t true for every session, of course, and there certainly are serious moments, but joy can be part of it, too. These are my top ten rules to break in hospice music therapy. What are yours? Which of these resonate with you, and which would you add? Please leave your comments below!]]>
Hi Rachelle. I especially agree with your number 10. I have met some very special clients/residents who seem to truly enjoy humor. In fact, one of the goals I have when I meet a client/resident is to try to understand his or her sense of humor. Though I am very careful not to cloak any matters in false laughter or forced jokes, etc., I do find importance in humor and laughter. And your number 9 is also very relevant. In fact, your whole list is great. Thank you; I appreciate your thoughtfulness.
Erin Hade, MT-BC
Thanks, Erin!
I love your list! As I have recently gotten started in hospice music therapy in the past few months, I am finding each day that there is no set of rules that can be applied to every situation…because each patient and experience is so unique. Thanks for sharing!
Hi, Jenny! Thanks for your comment. You’re right – there are no hard-and-fast rules. That’s where the clinical training and expertise comes in.
Hi Rachelle! I love this post for a few reasons. Not only did you address some seriously great points about the role of music therapy in hospice, but it also helped to validate my own “rule-breaking” tendencies when working with hospice patients. I was even talking with a MT hospice intern the other day on this exact subject… This will be a great post for her to read! Thanks!
Great! I’m glad you found it to be helpful, Emily.
Rachelle, I give you a big bravo for recognizing that you have “rules” in your mind and questioning them. A few years ago my friend, Judy Belland, and I did a presentation at the Mid-Atlantic music therapy conference on the myth of the perfect music therapist. I plan to address the issue in the CMTE I’m doing at the conference, and I hope it’s okay that I make reference to your list here. Thanks so much for having the courage to question the absolutes and the music therapy “ideals”.
Thank you, Roia! Yes, please feel free to reference this post in your presentation. It’s helpful to know that others ponder what the “rules” are and when it’s appropriate to do something different. I get some of that courage to question the absolutes from reading your blog. 🙂
Aww. Thanks! Now I just have to get half a minute to write the (at least) two blog posts-in-waiting! Will you be at the Atlanta conference? Will I get to meet you live and in person?
No, I can’t make the conference in Atlanta. It just wasn’t in the budget this year. I hope you have a fabulous time, though!
Hi Rachelle!
This is really a great article! I think your list will be very valuable to new therapists especially. Thank you for sharing your experience! All of your posts I have read have been very insightful.
Happy Thanksgiving!
-Daniel
Oh, thank you very much, Daniel! I really appreciate your feedback. I keep an eye on your blog, too – I love being able to share resources and insight this way. Happy Thanksgiving to you, too!
Hi Rachelle,
I know this was almost a year ago, but I still think this is great! I’m currently an intern with a hospice organization and, well, I only have two weeks left, however, I want to continue to persue hospice music therapy.
Although I know I have a lot to learn, and know I have much growing to do, I have seen myself start at the rigidity of the “rules,” especially around counter-transferrence, and the tx plan. I now feel the flexibility that comes with each session, and I love it! It’s still sometimes scary to go in and have a pt. be at a completely place than you expected, but it has resulted in some of my best sessions.
I’ll have to start reading your blog more!
Thanks,
Megan
Hi Megan,
I’m so glad you found this post! It’s still one of my favorites. Yes, part of the internship experience is learning how to be flexible within the “rules,” and hospice demands more flexibility than some other settings, even. Thanks for the feedback, and congratulations on (almost) finishing your internship!
Great post! I’ve struggled with all of these rules the past few years that I have worked in hospice. Another area that I have struggled with is goals and data collection. The goals we work on sometimes get put on the back burner when a new situation arises. And I still don’t know about data collection. My data tends to be more of a narrative: what we were addressing, what intervention I used and what was the outcome. Any thoughts?
Hi Emily,
The beauty of the hospice philosophy is that we are supposed to address new needs as they arise and focus on comfort and quality of life. I agree with you that data collection is atypical in hospice. I use a narrative format for documentation, too. What’s more important in this setting is to document functional decline: last week, Betty sang 100% of 10 songs; this week she fell asleep after two songs. Or, last week, George spoke in complete sentences (“Play me another one.”); this week his words were unintelligible and he only spoke one time. Does that help?
Phew! Glad to know I am not the only one “breaking these rules”. I think I realized everything mentioned on the list very early on. I still, however, get chills when I accidentally use “Red River Valley” when a client is actively dying surrounded by family. I scream in my head “Brandon, you’re not thinking!” Great list though – kudos!
Thanks for your comment, Brandon! Incidentally, I think that “Red River Valley” can be absolutely perfect when it’s the right time with a patient who is dying imminently.
I enjoyed reading your article. I’m a hospice music therapist, too. Hope our path will cross sometime in the future. Best wishes to you!
Thanks, Yumi!
I love how you listed!! I am gonna share this! I really agree with what you wrote in misc therapy! 🙂
Thank you, Rachelle (your last name?). Though this very helpful list is 11 years past, I resonated with each of the 10 items! I provide some end-of-life music therapy in the assisted living and memory care community where I work. It is a balance of objectivity, connection, trust, humor, and reading each individual and social framework in the here and now. I love sprinkling in some humor! In appreciation, Suzan (suZON)
I’m glad this was helpful to you!