“OUR SONG”
MUSIC THERAPY WITH COUPLES
WHEN ONE PARTNER IS MEDICALLY HOSPITALIZED
Thesis
Presented to
the Faculty of the College of Nursing & Health Professions
Drexel University
In Partial Fulfillment
of the Requirements for the Degree
Masters of Arts
by
Meghan L. Hinman
Creative Arts in Therapy Program
April 2005
ii
Acknowledgements
To Ted Jordan, Cheryl Litzke, and Paul Nolan,
my thesis committee, for their invaluable assistance, encouragement,
feedback, and time in preparing this paper.
To Joanne Loewy and Kristen Stewart,
for the hours of caring and supportive supervision and training
that helped me to approach my clinical work
in the best way that I could.
To my co-interns,
Daniela DeFronzo, Courtney Parker, Adam Staub, and Amy Pace
for their moral support and solidarity,
and to my friend and classmate Nikki Larkham,
who was always only a computer screen away.
To my family,
Mom, Dad, and Jamie,
for introducing me to the importance of songs between loved ones.
What a wonderful foundation for my work
and for my life.
To Chris Cafiero,
who held my hand through times of darkness in the past two years
and helped me to see the light at the end of the tunnel.
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Table of Contents
Abstract ……………………………………………………………………………… iv
Introduction ……………………………………….…………………………………. 1
Review of Literature……………….………………………………………………… 4
Psychological Issues of Hospitalized Medical Patients……………………… 4
Effect of Hospitalization for the Intimate Partner Unit……………………… 7
Existing Couples Treatment Approaches……………………………………..12
Music Therapy in a Medical Setting…………………………………………. 16
Music Therapy with Families………………………………………………… 20
Methodology………………………………………………………………………….. 24
Results………………………………………………………………………………… 28
Discussion ……………………………………………………………………………. 44
Conclusions…………………………………………………………………………… 54
Bibliography…………………………………………………………………………... 56
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Abstract
Our Song: Music Therapy With Couples When One Partner is Medically Hospitalized
Meghan L. Hinman
Paul Nolan
This study explores music therapy with couples when one partner is medically
hospitalized. Multiple sources have documented the deleterious effects that illness and
the hospital experience can have on intimate relationships. Music therapy may be able to
provide positive experiences, promoting intimacy and emotional openness, that can be
diminished through the stress of illness and in-patient treatment. Through the analysis of
literature and clinical case material, this study begins to explore the development of a
method for music therapy with couples in an in-patient medical setting.
1
The purpose of this descriptive study is to explore the ways that music therapy—
through the use of songs and other music therapy interventions—can affect the
relationship between intimate partners when one partner is medically hospitalized. The
paper will review literature about the ways in which couples are affected by
hospitalization of one partner. Clinical vignettes will provide a context in which to
explore the development of a music therapy method for working with couples in a
hospital setting.
Couples may function in crisis mode while one is hospitalized. Issues about the
relationship which may be problematic can escalate, however, neither partner may want
to raise the issue verbally due to the compromised health of the other or potential feelings
of guilt in the non-hospitalized party. Literature outside the field of music therapy
(Langer, Abrams, & Syrjala, 2003; McDaniel & Cole-Kelly, 2003) has documented the
difficulties faced by couples who are dealing with the hospital experience. Music therapy
experience is known to include empathy and experiences of intimacy, and has been used
to promote empathy in families (Hibben, 1992). Music therapy has been found to
facilitate effective communication (Miller, 1994) and reduce anxiety (McDonnell, 1984)
in family sessions. Still, music therapy literature regarding work with families is limited,
and the intimate partner or husband/wife dynamic has not been specifically studied.
Examining relationship struggles as defined in the non-music therapy literature and
applying music therapy interventions will help to make clear the issues of this population
and the role that music therapy can play in finding solutions.
When one member of a marital couple/intimate partnership is hospitalized and the
relationship becomes stressed, the integrity of that relationship may become threatened
2
over the course of time, as with chronic illness. McDaniel and Cole-Kelly (2003)
documented the relationship between illness of one member of a couple and poor marital
functioning. Langer, Abrams, and Syrjala (2003) studied the effects of one partner’s
hospitalization on the marital satisfaction of both members of the couple. These studies
and others have indicated that interventions may be necessary to protect intimate
relationships from the negative implications of the hospital experience.
Music therapy literature illustrates that music therapists work with couples in
practice (deKoning, 1995). Bailey (1984) reported on a method for using songs when
working with cancer patients and their families, making mention of the power of songs to
elicit memories of enjoyable times between a couple from the time before one partner
became ill. In contrast, the present study will focus more specifically on the medical
patient and his partner in a general hospital setting, and how a music therapy intervention
can effectively facilitate communication and support between the couple.
Clair (1997) studied the effect of music therapy interventions on improving
interpersonal interactions between dementia patients and their caregiver spouses. In this
study, couples participated in group music-making activities. The study found that
caregiver spouses did not report improved quality of life after experiencing the music
therapy intervention. The present study will instead describe individual sessions with
couples during in-patient medical treatment for a variety of medical treatment reasons.
The objective of this descriptive study is to begin to explore the development of a
method for treating intimate couples when one partner is hospitalized. Qualitative data
utilized for this study will include relevant literature, clinical vignettes from the author’s
experience working with couples, and considerations of the role of the therapist.
3
Although the method of this study may be reproduced elsewhere, its clinical
applications will be limited to the patient population at a large general hospital in the
Northeast. Furthermore, this study does not address couples therapy in a music therapy
context. Case vignette examples will be limited to the needs of the couples that are
available and will only include work during their in-patient medical hospitalization. This
study will not follow couples through a full process of learning to cope with medical
issues over time.
There are several possible applications of music therapy with couples in a medical
setting. As an intervention that can promote intimacy and communication, music therapy
can be valuable with couples who have already identified the strain of hospitalization. In
addition, however, music therapy may be used as a preventative approach. Hospital
patients and their partners often have complex issues and stressors to manage in regards
to handling the admission and its related complications such as job absences, home
responsibilities, health insurance coverage, financial burdens, etc. Particularly with so
many worries to consider, couples are likely unaware of possible risks to their
relationship and troubles that may be ahead. Music therapy could be applied in these
cases as well, to keep a link of intimacy so that both partners are better emotionally
centered or in tune with the core of their relationship before interpersonal difficulties are
manifested.
The results of this study could provide a starting point for an on-going exploration
of how music therapists can meet the needs of couples who are dealing with a chronic
illness. Music therapists may begin to consider the needs of intimate partners and the
couple as a whole while working with patients in hospital settings.
4
Review of Literature
Psychological Issues of Hospitalized Medical Patients
Chronic illness is a growing medical issue in today’s world. Fewer patients are
treated for one-time illnesses or infections in hospitals, and more and more patients are
seen for symptoms of chronic diseases—illnesses which often have a slow onset and
symptoms that last for an indefinite period of time (Burish & Bradley, 1983). Many
people who suffer from chronic illness will remain ill for extended periods, and
sometimes for the rest of their lives. The implications of having a chronic disorder may
include strict medication regimens, lifestyle changes such as diet and exercise
restrictions, difficult or painful treatments such as chemotherapy, and regular, if not
frequent, doctor visits and hospitalizations (Burish & Bradley, 1983; Burish & Lyles,
1983; Kleinman, 1988; McDaniel, 1992).
Hospitalization in itself is a stressful undertaking. As Falck (1987) describes:
Entering a hospital is akin to moving to a new neighbourhood, however
temporary it may be, without the advantages healthy people enjoy in
making the major adaptations to new people and different relationships.
Hospitalization makes patients vulnerable and dependent strangers, fearful
of what may lie ahead (714).
When a patient is in and out of in-patient treatment as symptoms change and are managed
in different ways, these stressors take on a different meaning. Patients are often expected
to bounce with ease between being independent and managing their own care,
medication, etc. when they are outpatients, and submissively and gratefully accepting
care and being a receiver as an inpatient (Kleinman, 1988).
5
Strain (1977) outlined specific categories of psychological stressors that are often
relevant for hospitalized medical patients. These include a general threat to self,
including fear of death; fear of strangers; separation anxiety; fear of the loss of love and
approval; fear of the loss of control of bodily functions; fear of loss of or injury to body
parts and fear of pain; and reactivation of feelings of guilt and shame for experiences
prior to the hospitalization. Kleinman (1988) emphasizes that the fear of death is
common among chronic illness patients and their families, even though most patients will
not die from symptoms of their illness. At the same time, behavior and psychological
symptoms displayed by patients in treatment are not often considered equivalent to the
same behaviors and symptoms in physically healthy individuals (Burish & Bradley,
1983). Sufferers of chronic pain, for instance, often meet the diagnostic criteria for major
depressive disorder just in their symptom-related distress (Kleinman, 1988). For other
patients with medical problems, denial is sometimes considered an adaptive and healthy
coping mechanism (Burish & Bradley, 1983; Falck, 1987; McDaniel, 1992).
A notable quality of chronic diseases is that its etiology is often related to a
person’s lifestyle choices, such as exercise, substance use, and diet. In this way, patients
often are forced to assume some level of responsibility for their illness. Burish and
Bradley (1983) have even described chronic illness as a behavioral problem. Guilt is a
common feeling for these patients (Burish & Lyles, 1983; McDaniel, 1992; Strain, 1977).
For some patients, the illness is also accompanied by a stigma, which assigns the patient
to an outcast role in society. Patients suffering from AIDS, leprosy, skin and body
deformations, or traumatic brain injury often feel shame as a result of the cultural
meaning of their particular illness, or because of the reactions of their family members.
6
Shame may also lead to behavior shaped by this negative self-perception (Kleinman,
1988).
Many individuals suffering from chronic illness most also find methods of pain
management, although chronic benign pain (pain that persists for 6 or more months and is
not the result of a malignant disease process) is often considered to be an independent
disorder rather than a symptom (Bradley, 1983). Chronic diseases are often
unpredictable and may cause anxiety that produces increased perceptions of pain.
Sufferers of any form of chronic pain frequently must deal with the validity of their claim
of pain being questioned, by either family members or medical practitioners or both
(Kleinman, 1988). This can lead to antagonism and hostility within the patient’s
treatment experience. Family members may also react to the patient’s claims of pain
with resentment and hostility (Kleinman, 1988).
Many types of cancer are viewed as chronic illnesses, and patients with cancer
face shock, fear, and uncertainty as they learn to adapt to the disease. Common
psychological responses include emotional numbness, depression and anxiety, concerns
related to the possibility of abandonment or death, practical fears concerning finances,
concerns about the loss of personal control, and fears of cancer recurrences (Halford,
Scott, & Smythe, 2000; Lichtman & Taylor, 1986). Although most individuals return to
normal functioning after recovery, an estimated 10%-15% of cancer patients meet criteria
for Post-Traumatic Stress Disorder up to ten years after diagnosis. Burish and Lyles
(1983) specifically studied the difficulties inherent in cancer treatment, which often leads
to financial and personal demands on patients and their families and causes painful and
aversive side effects. Surgery may lead to disfigurement, often leaving patients with
7
impaired self-image and impaired sexual functioning. Chemotherapy can produce the
direct pharmacological effect of anxiety and depression for patients who must undergo
this particular treatment, and conditioned side effects such as nausea and vomiting can be
similarly difficult. In particular, treatment for cancer often brings up the issue of personal
control, as cancer patients are often instructed to be passive in their treatment, and have
little to no responsibility within their medical care.
Effect of Hospitalization for the Intimate Partnership Unit
In studying the psychological effects of illness and hospitalization, it is difficult to
research the patient’s needs and issues without also reading about the effect of the illness
on the family. Except in the case of children’s families, the spouse or intimate partner of
the patient is often the focus.
Connell and Connell (1995), in their study focusing on a systemic philosophy of
medical treatment, state that illness is not an experience limited to the sphere of the
patient; that everyone involved with the patient, including family members, experiences
the uncertainty and lack of control inherent in a hospitalization experience. A family’s
identity and resources are challenged during this time. In turn, family members who
respond to the illness with depression, anxiety, or argumentative stances may complicate
the patient’s adjustment and communication with the healthcare team.
McDaniel, Hepworth, and Doherty (1992) give conscious attention to the
interpersonal life of the family. A diagnosis of chronic illness is a crisis and a loss for the
family as well as the patient. The authors note that a family seems to halt its
development when one member is sick—the members resist change as they focus on the
sick person. This shift, where the needs of the hospitalized individual are made top
8
priority and other family members’ needs are pushed aside, can create frustration,
resentment, and poor communication within the family unit. Families may become
exhausted from caring for their relative, and isolated in that process. Serious illness, in
other words, threatens to take over the family identity and interfere with the development
and adaptive responses of the family.
Kleinman (1988) discusses each family’s meaning of illness and how this can
affect the patient and the family’s attitude toward illness and recovery. According to
Kleinman, “illness influences relationships as strongly as it influences individuals” (185).
One member’s sickness has profound consequences for the rest of the family.
Burish and Bradley (1983) also comment on the role of the family in illness. The
family member who is ill may feel the effect of the suffering imposed on loved ones
through their illness and treatment. Family members may respond to illness and
treatment by being overly protective, overly indulgent, by socially excluding the patient
or by withdrawing from intimate interactions. The sick member’s dependency also can
result in role confusion within the family system and increased demands on caretaking
members.
Role confusion and conflict over roles is a common issue within couples,
according to McDaniel and Cole-Kelly (2003), who note that the spouse or intimate
partner is most often the person who helps the sick partner to identify symptoms and seek
treatment. When treatment begins, expectations that the couple abide by traditional
gender roles when one partner is ill may come into play even for couples who choose
non-traditional family. Difficulties may be amplified in heterosexual relationships where
the female partner is ill, as caretaking behaviors are often contrary to male socialization.
9
Shifts in sexual behaviors, attitudes, confidence, and identity may occur at various stages
of chronic illness for both partners. These authors also note that communication may be
an area of difficulty.
Some authors have also noted the effect that a satisfactory or unsatisfactory
marital/intimate relationship may have on the health or recovery of a patient (Connell &
Connell, 1995; Groth, Fehm-Wolsdorf, & Hahlweg, 2000; McDaniel & Cole-Kelly,
2003). Groth et. al. (2000) documented several studies that noted the psychobiology of
intimate relationships, particularly noting the connection between negative interactions
and physical or immunological health. This feature, while not a focus of this study, is an
interesting component illustrating the connections between intimate partnerships and
health.
Schmaling and Afari (2000) studied couples in which one partner has a chronic
respiratory condition. Their investigations found, on one hand, that a healthy relationship
with a spouse or intimate partner increases the probability of surviving lung cancer and
complying with medications and treatments for asthma. Conversely, couples with
respiratory disorders such as Chronic Obstructive Pulmonary Disorder (COPD) display
decreased marital satisfaction, particularly in the partners of patients. Increased stress
and work, decreased sexual and marital satisfaction all seem to be associated with this
serious chronic respiratory condition.
Multiple sources have studied the effect of chronic pain on familial relationships,
particularly relationships between spouses or intimate partners. Schwartz and Ehde
(2000) note that chronic pain often negatively affects both the relationship and the partner
of the patient. Dissatisfaction with both the relationship and sexual relationship are
10
common. The partner is often emotionally strained with caretaking responsibilities, major
life changes such as returning to the work force, and increased financial demands.
Couples dealing with chronic pain in one member may be prone to an approach-
avoidance conflict, in which the well partner reaches out to and then is pushed away by
their spouse/partner. This leads to avoidance of future interactions, which may result in
guilt, decreased control, and helplessness.
Watson, Bell, and Wright (1992), in a single case design, studied the effect of a
couple’s bitterness over the husband’s medical condition on their overall relationship
satisfaction. They noted that each partner’s beliefs about the etiology of the illness had a
more profound effect on the relationship than the illness itself. This case emphasized the
demoralizing and deteriorative nature of the chronic pain experience for the couple.
In their literature review, Payne and Norfleet (1986) discovered that studies
linking chronic pain and marital adjustment have unanimously found that chronic pain
patients and their spouses always scored lower in marital adjustment than control groups.
They discussed and determined that there is some evidence for the controversial theory
that pain can decrease conflict between partners due to a dysfunctional homeostasis
created around the sick role of one partner. They also noted findings of high scores in
depression ratings for partners of chronic pain patients, spousal avoidance of marital
closeness, and high rates of marital maladjustment, even in relationships that were stable
over time.
The effects of cancer on the intimate partner unit have been examined in several
sources, including Langer et. al. (2003), who studied caregiver and patient marital
satisfaction following hematopoietic stem cell transplantation, a treatment for some
11
leukemias and lymphomas. Their study cited other literature that suggested that spousal
caregivers experience more distress and care burdens than other caregivers, and
investigated these dyads with a longitudinal, prospective study. Their results indicated
that patient and caregiver perceptions of the relationship grew mismatched over time,
with caregivers expressing less satisfaction than their patient partners. A “happy
relationship” did not seem to indicate that strain would not occur later in the marriage.
Female caregivers displayed greater dissatisfaction, which the authors attributed to
gender norms—where a female spousal caretaker was expected to provide care, a male
spousal caretaker often received more support and assistance in caretaking from the
patient’s mother. In this study and others it seems clear that the affects of chronic illness
and hospitalization on couples is directly affected by outside factors in addition to
relationship factors.
Burish and Lyles (1983) studied the adverse effects of cancer treatment and found
that patients often feel that their relationships suffer after the ordeal of treatment for
cancer, particularly gynecological, urinary, and colorectal cancers. These cancers are
associated with shame for the patient and, at times, sexual rejection from partners. The
authors also noted studies documenting impairment in marital functioning.
Halford et. al. (2000) addressed couples coping with cancer of one partner and
focused on the positive effect that healthful marital relationships can have on the outcome
of a cancer diagnosis. Similarly, Lichtman and Taylor (1986) specifically studied women
with cancer and found that in some studies, marriages improved following recovery from
cancer due to increased closeness between partners. However, in other cases, marriages
tended to deteriorate during or after cancer treatment, often due to problems with
12
communication. Couples who had unstable relationships prior to the cancer diagnosis
seemed to be most adversely affected. In such cases, the well spouse may show physical
symptoms of nervousness and fatigue. The researchers also postulated that when the wife
is a cancer patient, her husband does not discuss with her his worries about her condition.
Since wives are often the key emotional support for their spouses, a husband may
experience added difficulties in dealing with worries about his wife’s condition. The
female patients in this study, on the other hand, often wished for more communication
with their husbands, and the breakdown in this key area had the potential to lead to role
confusion and other marital difficulties. The marital relationship was found to do well
overall for couples who participated in this study, but communication seemed to be the
key issue when problems did arise.
Existing Couples Treatment Approaches
Medical Family Therapy, developed by McDaniel et. al. (1992) and mentioned
previously, combines biopsychosocial and family systems perspectives and works with
patients and families coping with medical illness, their health care professionals, and
community groups and agencies together. The goals of Medical Family Therapy are to
develop agency, a commitment and active involvement in one’s own care, and
communion, a sense of being cared for, with a focus on creating and maintaining
emotional bonds, in the patient, family, and medical professionals working on the case.
Some techniques used by medical family therapists include creating a genogram to gain
perspective on a family’s attitudes toward illness, normalizing negative feelings,
externalizing the illness to help the patient see himself as a person aside from his illness,
13
and facilitating communication between families and health professionals. The medical
family therapist respects the defenses of their patients, as defenses are often needed to
deal with the stress of coping with illness. The therapist focuses instead on removing
blame and accepting unacceptable feelings, to be an empathic presence for the patient and
family. Couples in particular may need assistance with achieving greater role flexibility
in order to balance agency and communion (McDaniel & Cole-Kelly, 2003).
Kleinman (1988) suggested that physicians themselves can practice a kind of
“medical psychotherapy,” in which the chronic illness patient’s emotional needs (and
those of the family) are attended to in an authentic, caring way. A mini-ethnography can
be taken to gather information about the family’s experience with illness and the way
those experiences affect current illness and treatment. Treatment choices should be
negotiated with the family. Clinicians should also respect the existence of uncertainty in
the treatment of chronic illness, knowing that they cannot answer every question, and
strive for a reduction of disablement rather than a miracle cure.
Schmaling and Afari (2000) describe their interventions for working with couples
with one partner who has a respiratory disorder. Their psycho-educational approach
focuses on enhancing acceptance as a means to bring about increased awareness of self
control and use of problem solving and coping strategies. They educate partners on the
disorder and treatment and encourage the partner to provide support toward their partner
in helping to remember medications or other health regimens. They also teach both
partners to work with limiting their emotional arousal (a trigger for many respiratory
disorders) and recognizing the roles of stability and stress. Their interventions aim to
address both emotional and physical health of participants.
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The psycho-educational approach seems common for working with couples
dealing with varied medical diagnoses. Bradley (1983) found that the literature he
surveyed often trained patients with chronic pain and their families in self-management
skills and coping mechanisms as a psychological intervention. Schwartz and Ehde
(2000) concur on the use of psycho-education, particularly for partners. They also note
that although many pain clinics will not complete pain assessments of patients without
their spouse or significant other present and the importance of the partner in the pain and
its treatment is widely established, little research on couple intervention exists. However,
they suggest several interventions, including a cognitive-behavioral model of therapy that
focuses on changing patterns of interaction between the couple that may reinforce pain
behaviors. Sex therapy and integrative behavioral couples therapy (an intervention that
includes both behavioral and acceptance strategies) are also suggested.
Watson et. al. (1992) addressed chronic pain from a systemic view in their single-
case design intervention. Over a period of 17 months, therapists met with one couple that
was experiencing bitterness and low marital satisfaction in conjunction with the
husband’s chronic pain. Approximately half of the sessions took place with only the
patient’s wife in this case; however, the result of self-report instruments indicated that the
couple perceived an increase in connectedness and a decrease in stress.
In the area of cancer patients and their spouses, Halford et. al. (2000) describe
“CanCOPE,” their six-session cognitive-behavioral couples-based intervention program,
which they offer to women diagnosed with breast or gynecological cancers and their
partners. Each session is given in the couple’s home. Key content of these sessions
includes encouraging supportive communication and helpful behaviors, coping, activities
15
management (gradual return to activities that may have been suspended because of
medical treatment), addressing sexual problems, and goal-setting. Their controlled trial,
compared to standard care and work with patients alone, produced significantly greater
improvements in mood and reductions in long-term psychological morbidity.
In addition to physicians and psychologists/therapists, social workers and nurses
address the needs of the family in a hospitalization setting. Hansen, Cornish, and Kayser
(1998) describe their method of supporting family relationships by including family
members in decision-making conferences with physicians and other hospital staff. The
researchers describe the complexities of supporting, educating, and encouraging the
family in these stressful situations. The viewpoint of the nurse, who often has the most
contact with the patient and family, is documented by Santopietro (1975), who describes
her work with hemodialysis patients and their spouses. This patient contact focused on
providing support and active listening.
It seems that interventions for couples coping with chronic illness in a hospital are
diverse and may come from multiple sources. It seems noteworthy that some hospital
professionals mentioned above, such as doctors, nurses, and social workers, must deal
with primary tasks of their position, such as monitoring medications and treatments for
physical health or case management duties, and may not have the resources to provide a
high level of support to couples. By nature of their job description, psychotherapists and
psychiatrists may be more available for family interventions, however, as seen in the
literature, programs for couples are often long-term and must expand into outpatient
treatment. Additionally, couples may decline therapeutic assistance from mental health
16
workers within the hospital because of the stigma that sometimes exists in seeking family
therapy.
Music therapy, on the other hand, cuts quickly to the feelings of connection
between the couple. Music focuses on and brings to the forefront what is well within the
patient (Turry & Turry, 1999) and the couple dyad. This mode of treatment may be more
conducive to the short-term nature of psychosocial intervention that often will be used in
a general hospital setting due to the quick turnover rate of an acute treatment setting.
Within a short period of treatment, reconnecting the patient to their existing health
through music may allow a sense of normalcy between patient and partner to be restored,
and perhaps prevent a clinical problem from developing. In addition, many of the
existing programs that work with couples in this setting are focused on psycho-education
and behavior modification, while music therapy in a medical setting may provide for
contrasting needs such as acceptance and expression of feelings.
Music Therapy in a Medical Setting
The presence and scope of music therapy in the medical setting is expanding, and
more and more clinical and research information is becoming available (Dileo, 1999).
Dileo notes that music psychotherapy may be used to address psychological and
emotional needs in a medical setting, but that physical health (as well as social and
spiritual health) may be influenced as well. Music therapy has been used as treatment in
multiple medical specialty areas, including general medicine, surgery, intensive care,
cardiology, physical rehabilitation, pain management, obstetrics, oncology, pediatrics,
neonatology, and others.
17
Yeager (2003) and McDonnell (1984) describe the use of music therapy when
working with families of children who are hospitalized. Yeager’s supportive family
music therapy model focuses on the role changes, control issues, and anxiety that often
exist in parents and affect the family unit when a child is hospitalized with chronic
illness. Her study found that supportive family music therapy was effective for treating
those issues for the study participants. McDonnell’s study focused on music therapy as
an intervention with pediatric trauma patients and their families. With this population,
music therapy is used to help families cope with the stress of hospitalization, restoring
pleasurable interactions between family members and aiding the child’s adaptation to his
injury.
Aldridge and Aldridge (1999) propose that musical improvisation can provide a
metaphor for developing and understanding each individual’s response to life-threatening
illness and the meaning that they find within their illness. One of the benefits of music
therapy for these types of patients is its focus on potential and expressive creativity rather
than pathology. Music therapy can also offer hope in situations that have seemed
hopeless. The authors note, in their experience with breast cancer patients, that musical
improvisation enables patients to become more aware of their own feelings and promotes
interpersonal communication. Playing without expectations and judgment may allow for
the development of a new sense of identity, and improvement of mood and quality of life.
In terms of introducing and using music therapy in a medical setting, Aldridge
and Aldridge suggest starting soon after diagnosis, using music improvisation as a
diagnostic tool, and including caregivers or partner in therapy plan.
18
Scheiby (1999) describes the use of Analytical Music Therapy with medical
patients. This specific music therapy intervention developed by Priestley focuses on the
symbolic use of improvised or composed music. Scheiby has found, through the use of
this method in a medical setting, that common themes include lack of control, isolation,
denial, anger, frustration, hopelessness, and loss. In a session, the therapist identifies a
patient’s primary issue at that time and then helps either to translate that issue into a title
of an improvisation or to find a song that relates to it. After the music has been created,
the therapist and patient verbally integrate what has been expressed in the music. This
kind of music therapy treatment in medical settings may occur individually or in groups.
The treatment of pain and suffering through music entrainment is addressed by
Dileo and Bradt (1999). In the process of entrainment, which requires advanced training,
the music therapist matches a musical improvisation with the patient’s description of their
pain. Entrainment is based in part on the iso-principle, which states that “after having
matched music to the existing mood of a person, the mood can be altered through gradual
changes in the music.” The improvisation is played by the therapist and tape recorded so
the patient may listen to it in the moment and later. It musically represents the onset of
pain, a peak of pain intensity, and then a gradual diminishing of pain music into healing
sounds. Through this process, the patient can confront his pain by externalizing it and
creating it in the music. It may also help the patient towards realistic awareness of the
pain and provide validation. The tape may later be used by the patient in other situations
to provide pain relief.
The use of improvised songs, with both adults and children with cancer, is
explored by Turry and Turry (1999). Improvised songs can increase awareness of
19
feelings and allow the patient to express these in a non-threatening way, as improvisation
in general can help illuminate painful feelings. The attentiveness and musical
collaboration from the therapist can lead to a feeling of equality and inter-responsiveness
that provides an important contradiction to the loss of control and weakness often felt by
patients suffering from cancer. Singing can be used as a way to access the self, and the
song form in particular can be a “familiar musical bridge that allows the client and
therapist to live in the creative moment together” (p. 173). The repetition and flow in
song forms helps to keep order and reinforce meaning in improvisations. Music in
general “can help to underscore that a patient is more than the illness. Through music,
persons with cancer can simultaneously mourn their condition, while celebrating their
existing vitality as they tap into their inner life, their imagination, and their potential” (p.
176).
Other sources have documented the specific use of songs in music therapy with a
medical population. Dileo (1999) discussed the use of songs with oncology patients, and
gives rationale for the use of songs within a bio-psycho-social-spiritual model. Her
fifteen-point rationale includes the ways in which songs are associated with various
aspects of life, the ways in which songs promote interpersonal communication, and the
ability of songs to enhance feelings of hope. In assessment, song choice may help the
music therapist to assess a patient’s attitudes and feelings about his illness and health.
Song discussion provides further insight. The therapist can focus on the elements of
music in addition to the lyrics in discussion, drawing meaning from the patient’s
reactions to rhythm, dynamics, melody, and harmony. Improvised songs are also a
20
valuable tool in therapy, to promote communication and self-expression and sometimes
provide a starting point for the patient’s spiritual journey.
Bailey (1984) studied songs as a music therapy intervention when working with
cancer patients and their families. She identifies major themes in song choices for cancer
patients and their families, which most significantly include reminiscence and
relationships. Reminiscing allows families to reconnect over music that brings up
significant memories, or to discover unresolved issues that then may be addressed with
the help of the music therapist. The song theme that focuses on relationships may allow
patients and family members to process unresolved feelings about their various
relationships. The use of songs in music therapy also allows patients and families to
experience increased connectedness.
Music Therapy with Families
In an investigation of music and family therapists, de Koning (1995) found that
music therapists who work with families often work with the couple or parental dyad in
therapy. One of the most common reasons that families are referred to music therapy,
according to this study, is communication problems, which includes marital problems.
Despite this indication, music therapy literature involving work with couples is minimal,
although treatment designed for the needs of the intimate couple unit is often included in
case examples described in some literature.
Much of the documented music therapy work with families seems to take place
within the medical population, which is one of few settings where music therapists have
contact with families. This may also provide some explanation for why documented
music therapy work with families and couples is limited, since a very small percentage of
21
music therapists work in medical settings. As mentioned previously, Yeager (2003) and
McDonnell (1984) focus on the effects of the hospitalization of a child on the family and
parental unit, in addition to the child himself. Bailey’s work with cancer patients gave
specific consideration to the needs of the family during hospitalization. Bailey’s goals
for patients and families in this setting include promoting comfort, developing
meaningful communication, and resolving issues.
Decuir (1991) reviewed music and family therapy literature and found that the
most common use of music in family treatment is the facilitation of communication
among family members. Through the use of multiple music therapy interventions, the
non-threatening, nonverbal nature of musical interaction seemed to allow, according to
Decuir’s findings, for families to interact in a more relaxed and functional manner.
Alicia Clair (1997) studied the effect of group music therapy on late-stage
dementia patients and their familial care-givers, mostly spouses. Clair considered the
deleterious effects of dementia on the relationship between the patient and care-giver, and
provided music therapy programming as an opportunity to restore meaningful
interactions between the couple. Music therapy interventions in this study included
group singing and rhythmic activities using drums, and the study found that caregivers
identified a positive shift in the quality of interactions with their care receivers.
Allison (1996) documented her work with one couple in assisting childbirth with
music therapy. Based on meetings and interviews with the couple, the therapist created
cassette recordings of music to be used for listening in the weeks before the birth as well
as during the natural labor and childbirth. Allison concluded that Music Therapy-
Assisted Labor was a technique that held promise for couples seeking a natural birthing
22
process, as in the documented case it proved to be an effective technique for managing
pain and decreasing anxiety for the couple.
In addition to sources involving work with young children mentioned above,
Hibben (1992) found that music therapy is an effective tool for treating families with
young children that are often considered too young for family treatment. Her article
describes work in outpatient family therapy. In the cases she describes, the nonverbal,
play-oriented, and symbolic aspects of music-making allow for inter-generational
communication during treatment.
Music therapy has also been used to treat family relationships between adult
children and their dying parents. Susek (2004) created a model of Relational Integrity
(based in part on Erikson’s psychosocial stages of development) in music therapy at end
of life, wherein family members, facilitated by music, could come to accept and integrate
aspects of their relationship and acknowledge or increase intimacy. Susek found
songwriting to be an effective intervention when working with family members facing
this change, who were able to share their feelings and connect in the music.
Miller (1994) described possible connections between theories of family therapy
and applicable music therapy treatment. He suggested that a family’s music-making style
may reveal the family processes of interaction and family structure without having to
include specific content, a focus of structural family therapy. The family’s response to
rhythm may be indicative of each family member’s response to structure, and positive
interactions and learning through music may advance the pace of treatment.
The documented uses of music therapy to treat families and medical patients
seems to suggest that more work with families and couples is indicated Common goals
23
and uses of music therapy in family sessions and in medical settings seems ideal for
meeting the needs of couples as documented in the literature. Goals and principles of
music therapy treatment also seem to fill gaps in the treatment opportunities available to
couples.
24
Methodology
Design
This is a descriptive study in the qualitative research tradition. Themes and
concepts from the literature will be applied to four case vignettes of this researcher’s
work with intimate couples in a medical setting.
Subjects
There were no human subjects used for this study. Case material is based on
previous music therapy sessions conducted by the researcher.
Procedures
Data for this study is drawn from the researcher’s clinical experiences with
couples in a medical hospital setting. In this setting, music therapy services are initiated
by written or verbal referral from doctors, nurses, social workers, and patient care
associates. Patients and their partners may be referred for reasons related to coping with
the illness, anxiety, depression, to work with the patient’s pain, or for preventative
reasons in regards to maintaining the health of the relationship despite the stress of illness
and/or hospitalization. The music therapist approaches the patient and his partner in the
hospital room and explains that a referral has been made and asks the couple if they are
interested. If the couple declines, the therapist may ask if it is acceptable for them to
have the therapist return to “check in” with them on another day. The therapist is
generally persistent about following up with couples who have declined, but always
respects their wishes to refrain from participating in music therapy.
25
Once a music therapy session has been arranged with a couple, the session
generally occurs in the patient’s hospital room. The music therapist makes contact with
the couple and begins the session with a warm-up in the form of music—an improvised
song or guitar music without singing—or, in some cases, introductory conversation. A
musical warm-up would most likely be deferred when the patient and spouse are
particularly conversational or eager to choose favorite songs and an additional, musical
warm-up seems unnecessary or redundant. The music therapist may introduce
instruments that are available for use during the session and invite the couple to choose
instruments to play during the session if they wish. The music therapist also inquires
about favorite music genres or songs, and initiates playing and singing these songs
together, or playing for the couple to listen to.
Sessions with couples frequently include verbal processing of the music created.
Often certain songs will trigger memories for the couple about earlier times in their
relationship or other associations with music and family. The music seems to provide a
safe holding environment that allows the couple to communicate their feelings about the
hospitalization, to each other and to the therapist. The music therapist may initiate
discussion about themes in the songs chosen by the couple or topics initiated by the
couple, about the significance of certain music to the couple, or about each partner’s
reaction to the music created together. The choice of the therapist to elicit further
discussion of any particular theme might be based on high symbolic content in lyrics,
visible emotional reactions of the intimate partners, or the occurrence of interaction
between the couple that seems important to the interpersonal dynamic between them.
26
This interpersonal dynamic between the intimate partners is a main focus for the
therapist’s attention in choosing verbal interventions.
At times, such as in the case of serious or terminal illness, the couple may not be
ready to verbally acknowledge their fears and worries about the hospitalization. Familiar
songs may then become a projective tool through which the couple can express intense or
difficult feelings indirectly in a non-threatening way. The music therapist may then focus
more on simply being a supportive presence to the couple and engaging with them in the
music.
Operational Definitions of Terms
Countertransference- refers inclusively to the therapist’s transference projections onto the
patient, the therapist’s identification with the transferential material that the
patient has projected onto her, and the emotional or psychological empathy
responses of the therapist (from Priestley’s (1994) modification of Racker’s
(1968) definitions)
Hospitalized medical patients- refers to patients who are hospitalized for acute
medications or acute exacerbation of symptoms of a chronic medical condition
Intimate partner relationship- inclusively refers to marital couples, domestic partners,
cohabiting or non-cohabiting partners in a close monogamous relationship
Safe holding environment- based on Winnicott’s concept of the “good enough mother,”
in this study applied to the supportive, continuous presence of the therapist that
helps to create a contained space and facilitate a feeling of safety
27
Data Analysis
The linking of concepts and data for this study was based on data analysis and
coding concepts as described by Creswell (2003) and by Coffey and Atkinson (1996). To
analyze case material, this researcher first scrutinized clinical observations in the form of
session and chart notes from each case for observable indicators of the incidence of
negative effects of hospitalization on the couple as noted in the literature. This data was
analyzed for themes, and compared between cases and to the literature.
The researcher also examined the perceived effects of the music on the couple
within the session. This data included qualities of the music created by the couple
(degree of participation, emotional expression, collaboration with partner), observable
behaviors seen in the music, themes in their choices of music and content of verbal
processing, and how the music affected the relationship between them.
Another component of data from this study relevant to music therapists is the
consideration of the experience of the therapist in working with couples. This subjective
data will be presented in an effort to illustrate the broad array clinical and personal issues
that may emerge during a process of music therapy treatment with couples in an in-
patient medical setting.
28
Results
Major findings of this study are based on the content of four clinical vignettes
listed below. In regards to these four couples, music therapy services were generally
initially received as an opportunity for entertainment. This researcher often found, in
approaching couples in a hospital room, that the visiting partner would be open to music
therapy services, encouraging their hospitalized partner to accept, but being careful to
leave the final decision to the patient. Interestingly, patients who then accepted music
therapy services often indicated that they considered the music to be an intervention or
distraction aimed equally if not primarily towards their visiting partner. Couples who
declined music therapy would often leave the door open for future follow-up with
comments like, “It’s not a good time,” or “I’m not feeling well today.”
The couple’s initial reaction to the music therapy approach seemed to depend
upon the degree of sickness or trauma being experienced at the time of the session. A
couple accepting music therapy services in a time of distress might respond to the music
with more raw emotionality than a couple that is beyond the initial stages of their medical
treatment/recovery and anticipating a timely discharge. In the latter case, in this
researcher’s experience, the couple might tend to ask more questions about the reason
and purpose of the music therapy referral and the nature of the services before feeling
ready to participate or reveal personal information, whereas a couple in distress may be
more willing to unquestioningly accept a service that they perceive as potentially
soothing.
In working with these couples, the level of need of the visiting partner often
became abundantly clear. The level of participation and engagement of the partner,
29
although often masked as encouragement toward the identified patient, often seemed to
indicate a need to address their own reactions to the hospitalization, or a need to see their
partner doing so.
The sessions drawn upon for this study utilized familiar songs as the primary
intervention. In these sessions, one or both partners connected quickly and easily to
familiar songs that they requested and were sung and/or accompanied by the therapist. In
one case, the process of choosing familiar songs led to a song-writing experience. Some
couples sang together, others involved the visiting partner in joining the therapist to
create music for the patient to receive, and other couples listened or received the music
together. The idea of “receiving” the music was introduced by the therapist in these
cases; the choice of language was designed to reassure the couple that physically or
verbally active participation was not expected and to enhance a feeling of nurturance
from the music and the therapist. Two of the four cases highlighted below involved
patients on contact precautions, which limited the possibility of inviting the patient to
play instruments, and instruments were often declined in favor of using their voices or
receiving music from the therapist.
Patient and partner responses indicated that the music often took on a soothing or
relaxation function. In other cases, the music seemed to function primarily as a vehicle
within which to express feelings, or a holding environment where such expression
became safe. The music also seemed to have an observable effect very early on in music
therapy sessions. Within moments of the first notes of music, the patient and his partner
would be holding hands. Familiar songs led to reminiscing about the relationship or
processing of feelings about the hospitalization.
30
The following clinical vignettes illustrate some of this researcher’s music therapy
sessions with couples in a general hospital.
Stephen and Rose
Stephen, a patient on the oncology floor, is hospitalized due to bone cancer,
spinal cord compression, and a possible infection. His wife Rose, who works an
overnight shift, comes to visit him on her way home from work each day before he
leaves for his radiation treatment. Stephen and Rose, who are in their late 50’s,
were referred to music therapy for preventative reasons, and continue to be seen
by the researcher at this time.
Stephen and Rose identify themselves as having an “opposites attract”
relationship, and their disagreements and use of humor to diffuse tension are a
regular part of their interaction during music therapy sessions. Sessions with
Stephen and Rose seemed to involve a good deal of talking and reminiscing
around favorite songs, which are sung and played by the therapist and Rose.
Stephen generally chooses not to play or sing.
Stephen often speaks at length about how little the hospitalization and his illness
affect him, however, the music seems to provide a space where he feels
comfortable being more open. He once commented between songs that at night
he hears other patients crying out and that “you have to wonder if someday that
will be you.” Rose became tearful at this time, telling Stephen that she had never
heard him say anything like that before, how glad she was to hear him say it, and
31
how worried she is that he never talks about his feelings during this difficult time.
A brief dialogue ensued about their different coping styles.
Stephen and Rose have very different musical tastes and often tease each other
about their respective song choices, but at the same time certain songs seem to
bring them together. Rose asked for “Moon River” and sang it with the therapist
while playing the ocean drum, a disc-shaped hand drum with one clear head and
small metal balls inside that roll around inside the drum, creating a sound
reminiscent of water or ocean waves. Stephen sat reflectively during this time,
looking serious and almost tearful. After the song, each spoke about memories
the song elicited about trips they had taken together and began to reminisce about
the wonderful times they have had traveling the world. During this conversation,
Rose spontaneously began to touch her husband affectionately.
Stephen and Rose agree on what they identify as “soothing” and “relaxing”
qualities of music and are often eager to schedule the next music therapy session
for a time when Rose will be visiting.
For Stephen and Rose, the music provided a space wherein feelings could be
expressed and a soothing and relaxed state could be achieved. Stephen’s vehement denial
that his illness affects him in any way is accepted in the music therapy session and, at this
point in his hospitalization, seems to help him to cope with the stress to which he later
admitted. The music also provided a safe space where he was able to share some of his
distress, which in turn produced relief for his wife and allowed her to share her own
perspective about coping. His decreased denial may have led to reduction of barriers (to
32
closeness/intimacy and communication) in their relationship, and clearly provided relief
for his spouse. The safe holding environment created by the music may have also
contributed to this couple’s ability to express the tension between them and discharge it
through the music and their use of humor, which seems to be a usual and healthy mode of
interaction in their relationship.
The safety of the holding environment created by the music and the referential
qualities of the song choices Stephen and Rose made may have helped them to draw upon
the positive aspects of their relationship during a time of increased tension. Their
dialogue about favorite trips and different places they had traveled to allowed them to
share their appreciation for their marriage and the special things they had experienced
together. Stephen reported increased relaxation; the reduction of his anxiety then
positively affected Rose’s experience of anxiety. The musical safe holding environment
was particularly important in this case, since Stephen’s feelings of safety in the music
therapy session decreased his need for denial as a defense, which then provided relief for
Rose and elicited open communication between them.
Greg and Maggie
Greg was hospitalized for a ruptured gall bladder and was in the hospital for just
over a week. His nurse referred Greg and his wife Maggie, both in their early
50’s, for music therapy as a preventative measure.
The music therapist began the session with a greeting song and then engaged in
some conversation with Greg and Maggie about their histories with music and
33
their questions about music therapy. Greg spoke about his frustration about
being in the hospital for a week, but otherwise let his wife do most of the talking.
Maggie indicated that she was interested in singing, and began choosing songs,
which she sang with the therapist, including “Daisy, Daisy” and “The Man on
the Flying Trapeze.” Greg did not sing, but watched Maggie sing and smiled at
her, sometimes shaking a maraca along with the music.
Eventually Greg commented, “There should be a gall bladder song!” The
therapist suggested that they could write their own gall bladder song, and
initiated a blues song form. Greg indicated that he loved the blues, and then
began recounting the situation surrounding his and Maggie’s rush to the
emergency room and his resulting hospitalization. The therapist played a 16-bar
blues shuffle in the key of A under his speaking and sang his words back to him as
he told the story. Maggie expressed a desire to record the lyrics and the therapist
gave her a paper and pen after Greg expressed that his wife was “an expert in
shorthand.”
The lyrics began to take form as Greg revised his ideas and took suggestions from
Maggie about wording. He began to take over singing the lyrics that Maggie had
recorded while the therapist continued to play the guitar. The lyrics described the
evening activities that were taking place before he first felt the abdominal pain
that eventually brought him to the hospital. When Greg came to the point where
he wanted to describe the pain sensation, he struggled over picking the right
words. Maggie made several suggestions that he rejected, stating that words she
suggested didn’t begin to describe the feeling of this pain. Greg eventually
34
decided that he would need to consider this further and decide at another time
what the right word would be. He went on to describe the rest of the night, with
Maggie recording and helping him to fill in the details of everything that had
happened until he was finally admitted and treated.
For Greg and Maggie, music therapy became a way to facilitate communication
and understanding about a traumatic event. Although they had been together throughout
the evening leading up to Greg’s hospitalization, Greg had not disclosed to Maggie the
pain he was experiencing for several hours because he did not want to disturb their
evening with guests from out of town. Through the composition and performance of
“The Gall Bladder Blues,” Greg and Maggie were able to process the events of the
evening and communicate their different perspectives, using humor and music as a
container. Through the music, Greg had the opportunity to share with his wife the
magnitude of the pain experience for him, thus increasing her understanding of his
trauma.
Music therapy had several notable effects for Greg, all of which were structured
and driven by the presence of Maggie. The couple seemed to have developed an ability
for one to rely on the strength of the other, and this helped both of them through the
hospital experience. Greg was able to clearly communicate his pain experience, his fear
and stress about the moment when it occurred, and his need to be heard and validated.
Greg was also able to develop mastery over the threat to his health/existence that he
experienced—the emergency illness rendered him helpless and traumatized, but through
35
the music he was able to regain control over his own feelings and process the events
surrounding his trauma.
Anthony and Claudette
Anthony and Claudette are a couple in their seventies. During his in-patient
treatment for gastric cancer, Anthony was referred for music therapy due to
decreased appetite, insomnia, and pain. His wife stayed with him in the room
regularly. Anthony and Claudette declined music therapy several times before
participating in one session.
In this session, Anthony lay in his bed, in visible discomfort. Claudette sat in a
chair near his feet with a magazine on her lap. The therapist began the session
with soft music as a warm-up, and both Anthony and Claudette expressed their
appreciation for the music as it finished. They began to explain Anthony’s
treatment schedule and plan, talking over each other at times and finishing
sentences for each other at other times. The therapist responded with active
listening and reflecting.
Anthony began to speak about dying. He told the therapist that he was “okay”
with his forthcoming death because he was in good conscience about what he had
done with the world thus far. He began to cry as he added that the only reason he
was not ready to leave this world was the thought of leaving his wife behind. As
the emotion seemed to overwhelm him he whispered, “Play something.”
The music therapist hummed and finger-picked the guitar, integrating parts of the
song “Stand By Me.” Anthony closed his eyes and listened, and at other times
36
watched the therapist intently. Claudette sat in her chair stiffly with a non-
expressive smile on her face, sometimes making eye contact with the therapist and
sometimes turning the pages of her magazine.
When the therapist stopped playing, Anthony expressed gratitude for the music
and then asked for “something spiritual.” The therapist began to play several
spiritual songs in a medley, including “Amazing Grace,” “How Great Thou Art,”
and “Angels Watching Over Me.” As the music began, Anthony murmured, “yes,
just like that,” and then reached his arm towards his wife and called for her to
hold his hand. Claudette stood beside the bed and held his hand through the
music, still smiling. Anthony lay with his eyes closed and cried at times.
After this session, Claudette often met the therapist at the door and would decline
music therapy before the therapist could make any contact with Anthony.
Music therapy for Anthony and Claudette seemed to create a level of intimacy
and a safe space for emotionality that was welcomed and needed by Anthony but
threatening to Claudette, as seen in her vehement declines of follow-up music therapy
sessions. Her way of coping seemed to manifest in a kind of distancing by smiling and
examining her magazine during the session, a sharp contrast to the strong emotional
content of her husband’s contributions. At the same time, it seemed that both partners
needed a space to reflect about the hospitalization, so much so that they eagerly talked
over each other when asked about their reaction to the hospital stay.
Future sessions with Anthony and Claudette were planned although they never
took place. Inviting Claudette to play the ocean drum while the therapist sang may have
37
been one way to engage Claudette in a non-threatening way. The soothing sound of the
ocean drum would contribute to the soothing quality of the music, which Anthony has
indicated is desired and effective for him. Playing the ocean drum can engage the
player’s full concentration if desired. This would allow Claudette to nurture her husband
with music without requiring her to become fully focused upon his raw emotionality.
With her increased security in the music therapy session, both partners and their
relationship as a whole could possibly have been able to benefit more from the
intervention.
Rob and Heather
Rob was initially referred for music therapy services by the case manager on his
unit, to address his feelings of isolation and depression. Rob suffered from AIDS
and, at the time of referral, had been hospitalized for one month with tuberculosis
due to rare drug allergies that had prevented his recovery. His wife, Heather,
who was not infected, had stopped working in order to be with him at the hospital
almost every day. Rob and Heather received music therapy services once or
twice a week for approximately two months. For all but the last week of this time,
Rob was on medical isolation due to the respiratory contagion of his illness and
anyone who entered his room wore a face mask. Rob was sometimes seen alone
but mostly seen in joint sessions with his wife.
Music therapy interventions with Rob and Heather mostly consisted of choosing
and singing familiar songs, with the therapist playing guitar or keyboard. A
typical session would consist of opening conversations with an update about any
38
changes in Rob’s condition, followed by singing familiar songs with conversation
and some processing interspersed between.
The couple’s song choices tended to reflect themes of Rob’s isolation and
resignation to his illness as well as he and Heather’s love for each other. In their
first music therapy session together, Rob and Heather asked for “Fire and Rain”
by James Taylor and explained that it was the last song that a friend of theirs had
sung before he died. Another song that was requested frequently throughout
treatment was “Rhymes and Reasons” by John Denver, and it was sometimes
paired with a request for “Teach Your Children” by Crosby, Stills & Nash.
Other songs included “Desperado” and “Both Sides Now.” Songs acclaiming
their relationship included “In My Life” by the Beatles, “Lean On Me,” and, as
Rob’s condition worsened, Jim Croce’s “Time in a Bottle.” Sometimes the love
songs requested would spontaneously elicit memories about different times in
their relationship, but often the next song would be requested as the last words of
the previous song were being finished, and the couple would resist the therapist’s
attempts at verbal processing.
Rob and Heather presented as very musical people, and both of them sang
beautifully, with a lot of feeling in their voices and often using harmony. When
the session began, they would move to sit closer to each other and usually held
hands during the music. In some sessions Rob and Heather would be too upset to
sing, and on these occasions the therapist would invite them to “receive” the
music—they would then hold hands and close their eyes as they listened to
39
familiar songs that the therapist chose. Often during these sessions they would
cry together.
Rob and Heather chose to explore the musical instruments made available by the
therapist (shakers, small drum, and small metallophone) in only one session. On
this day, each partner clearly portrayed a very different energy, which was
apparent in the way each approached the instruments and created music. As they
played and sang during this session, the incongruence between them was clear.
At times they would roll their eyes at each other, although most of the tension
between them was expressed in the music, and their language toward each other
remained loving and respectful.
Shortly before Rob’s discharge Heather was forced to return to work and 4 out of
15 music therapy sessions took place with Rob alone.
Music therapy sessions gave Rob and Heather an opportunity to celebrate the
intimacy between them in the hospital room together—an environment where the ability
to achieve and maintain intimacy could have been severely impeded by, among other
things, the mask that Heather (in addition to any other staff member or visitor) had to
wear permanently while in the room until the final week of the hospitalization. While in
other cases the music seemed to help to activate that which was just under the surface,
with Rob and Heather the intimate bond between them was strong. The music allowed a
space where the intimacy between them could flourish. The music created by Rob,
Heather, and the music therapist in these sessions highlighted, through song choices, the
couple’s mutual support and closeness despite their stressful situation. Often in music
40
therapy sessions Rob and Heather spoke freely about their appreciation for one another.
At other times, the music allowed Rob and Heather to express the natural tension
between them in a contained, healthy way.
The music also served as a projective tool with which Rob and Heather could
process the existential issues, such as death and isolation, that arose as his condition
worsened through the course of the hospitalization. Towards the end of the
hospitalization, Rob and Heather began to verbalize their feelings about Rob’s terminal
prognosis, but before they were ready to do that, songs like “Fire and Rain” and “Time in
a Bottle” helped them to address the topic from a distance. The theme of children (which
Rob and Heather did not have although Rob spoke about his love for children during his
individual sessions prior to discharge) came up in “Teach Your Children” and “Rhymes
and Reasons.” Their feelings of isolation tempered by their love and support for each
other found voice in “Lean On Me,” “Bridge Over Troubled Water,” and “Moon River,”
among others.
Music therapy had a distinct effect on Rob individually as well. The feelings of
depression that initially instigated his referral were rarely apparent during the music-
making. Rob enthusiastically chose songs and spoke about his tastes in music, as well as
the role that music had played in his relationship with Heather. In individual sessions
Rob shared the difficulty that he felt in watching his wife’s distress over his condition,
and in music therapy sessions he would often encourage Heather to sing with the
therapist while he listened or brainstormed for the next song that would be sung. It was
important to Rob to see his wife engaging in an activity other than worrying about him,
41
and music therapy sessions were one of his only opportunities to experience his wife in
this way during his three months on medical isolation.
The cases described above illustrate the effect of music therapy on these couples,
as well as the negative impact of the hospital experience and medical trauma on the
intimate partner unit. These negative effects are highlighted in the chart below. As noted
in the literature (Kleinman, 1988; McDaniel et. al., 1992), these negative effects related
to one partner’s illness were prevalent for both the patient and the spouse.
Table 1: Effects of Illness on Intimate Partner Relationship
Stephen and Rose Increased tension, confronting possibility of death, isolation
Greg and Maggie Frustration, trauma, feelings of the unknown
Anthony and Claudette Confronting death, pain, anxiety
Rob and Heather Frustration, isolation, confronting death
Varied and similar responses to the hospital experience and the music therapy
sessions are apparent in each of these four cases. The way that each couple in this study
utilized music in music therapy sessions is summarized in the chart below.
Table 2: Primary Use of Music In Session
Stephen and Rose Choosing familiar songs for Rose and therapist to
play/sing, reminiscing about relationship
Greg and Maggie Greg composed “Gall Bladder Blues” to process feelings
about trauma leading to hospitalization
Anthony and Claudette Listening to spiritual music played by therapist and having
space for emotional reactions
Rob and Heather Choosing and singing familiar songs to help process
feelings about forthcoming death and love for each other
The use of songs, familiar or composed, was an important element of music
therapy work within all of the cases utilized for this study. Songs provided a space where
emotional reactions were safe and a vehicle to process difficult topics or to reminisce
about the relationship. This is a clear pattern in the four cases.
42
Further data from each case is displayed in the following two charts.
Table 3: Verbal and Non-Verbal Indications of Intimacy within Music Therapy
Couples Non-Verbal Indications Verbal Indications
Stephen and Rose
Relaxed body posture
Spontaneous, affectionate
touching
Stephen receiving music
from Rose
Discharge of tension through
playing instruments
Reported feeling relaxed
“We really love each other”
Discharging tension by
teasing each other about
musical choices
Elicitation of memories, led to
appreciative comments about
the relationship
Reflection about status of
relationship during
hospitalization
Greg and Maggie
Sitting in close proximity
Listening attentively and
smiling at one another
Supporting each other: Greg
watching Maggie and
smiling, Maggie recording
Greg’s lyrics
Increased number of verbal
responses
Increased personal content in
responses in music
Increased communication and
increased understanding of
trauma
Maggie connected to familiar
songs and Greg wanted to
write his own
Anthony and Claudette
Hand-holding
Actively receiving music by
holding hands
Anthony’s emotional
responses to music
“I feel so much better”
Spontaneous emotional
response (tears)
Space provided for expression
of feelings
Rob and Heather
Hand-holding
Moving to sit in close
proximity
Increased range of affect
expressed in music
Playfulness at times (teasing,
joking)
“It’s not so lonely when you
come.”
Reminiscing about
relationship
Provided a vehicle to assist in
coping
Increased acceptance of
illness over time
43
Table 4: Assessments of Effects of Music on Intimacy
Couples Effects on Patient Effects on couple
Stephen and Rose
Increased relaxation
Space to express feelings
Increased communication
Discharge of tension
Celebration of relationship
Greg and Maggie Mastery over trauma
Space to express feelings
Increased communication
Increased understanding/intimacy
Anthony and Claudette Soothing
Space to express feelings
Provided a space to experience
intimacy in the hospital
Rob and Heather Space to process feelings and
come to acceptance of
prognosis
Soothing
Celebration of relationship
Increased intimacy
Decreased feelings of isolation
44
Discussion
Overview and Interpretation of Results
This study examined music therapy treatment with four couples in an in-patient
medical setting. The case vignettes described indicated some variations and similarities
in the couples’ use of the music in sessions, experienced negative effects of
hospitalization, qualities of the music, and affects of the music on the patient and on the
relationship.
The negative implications of hospitalization that each of the four couples seemed
to experience is relevant to the literature, with some recurring themes. All four patients
and their wives were confronting the possibility and/or fear of death in some way. Death
was a more conscious issue for Rob and Heather, who dealt with numerous changes in
Rob’s condition during his hospitalization, but the fear of death had a presence in each of
the four sessions. This is consistent with Kleinman (1988), who has noted that
hospitalized patients often fear death even when it is not an approaching probability. The
diagnoses of three of the four patients used for this study were terminal illnesses, so the
occurrence of feelings about death are warranted and expected.
Isolation was another theme that occurred in two of the four cases—Stephen and
Rob were both on different contact precautions that limited their connection with other
people, including their wives. Tension/frustration/anxiety also emerged as an issue being
faced, in one form or another, by each of the couples. These themes are noted to have
been observed and communicated by patients to music therapists in the music therapy
literature by Yeager (2003) and Scheiby (1999). The loss of control inherent in
hospitalization (cited by Connell and Connell, 1995), although not specifically mentioned
45
in the verbal responses of any of the couples, may have been one source of the feelings of
frustration or anxiety.
The results of this study seem to indicate that music therapy can most
significantly contribute to increased communication and intimacy between partners. As
reported earlier, Lichtman and Taylor (1986) indicated that communication is a key issue
and problem area between partners when one spouse is hospitalized, and in all four
vignettes presented in this study, music therapy was able to facilitate communication in
some form. This is consistent with Aldridge and Aldridge (1999), who pointed out the
tendency of music to promote communication, and Dileo’s (1999) assertion that songs
promote interpersonal communication. In the first vignette, Rose indicated that the
comments Stephen shared about his worries over being hospitalized were the first that
she had heard him communicate his feelings, a disclosure that she indicated was
important to her. Greg used a new composition to share with Maggie not only his
experience of and fears about the event, but also his need for her empathy and support.
In the music, Anthony expressed his love for Claudette and his fear of leaving her. Rob
and Heather reminisced and shared their fears and support for each other through their
musical selections.
The communication and experiences of intimacy elicited by the music therapy
session may have contributed to an improvement in each partner’s ability to support the
other. Increased understanding of each other’s experiences with the hospitalization and
reminders of their supportive relationship found in the music may have helped both
partners to be aware of the other’s perspective and needs. The soothing effects of the
music may have allowed each partner to regain some energy and peace of mind. The
46
increased awareness of each other’s needs, combined with reminders of intimacy and
appreciation for the relationship (as seen in the reminiscing) and energy renewal may
have improved each partner’s ability to be supportive of the other. It is notable that,
particularly in the cases of Greg and Maggie and Stephen and Rose, the strength of the
well partner was drawn upon by the hospitalized partner to aid in safe expression of
feelings about the hospitalization. This safe space can be co-created by each couple—
Stephen and Rose were able to create it for themselves by speaking about their
experiences traveling the world. This expression certainly illustrates the Susan McDaniel
(1992) definition of agency (“a commitment and active involvement in one’s own care”).
The observable responses to the music provided a particularly poignant
illustration of the powerful positive effect that music therapy can have on couples in this
setting. Hand-holding and spontaneous touching, moving to sit close to each other, and
spontaneous disclosure and expression of emotions (for example, crying), all
demonstrated the clear effects of the music that transcended the treatment goals.
Implications and Clinical Applications
The negative effect of hospitalization on intimate partners has been documented
by numerous sources, and visible in the vignettes used for this study. Tension, isolation,
and fear of death were all issues to varying degrees with each of the couples. The
stressors of ongoing medical treatment, forthcoming death, the trauma of admission, and
separation from each other are real and difficult obstacles that the couples in this study
had to confront. The communication and experiences of intimacy that happened within
47
the music therapy session may have helped these couples to cope with their stressors and
therefore protect the integrity of the relationship.
It is possible that the positive interactions that occurred during and as a result of
music therapy sessions may have further effect on the recovery of the patient and the
overall health of both partners. As noted earlier, Groth et. al. (2000) documented the
connections between familial interactions and physical or immunological health.
Creating a space for positive interactions between intimate partners in a music therapy
session may have positive implications for the patient’s medical recovery as well as the
health of the relationship. In this way, music therapy with couples in a medical setting
also contributes to treatment goals of the medical teams treating patients in the hospital.
In many inpatient health care settings, patients and their families are provided
with emotionally supportive services from social workers, nurses, psychiatric staff, and
other healthcare specialists. However, multiple qualities of music help to make music
therapy a unique intervention for meeting the needs of couples. The emotional and yet
structured aspect of music allow for intense emotional expression in a safe container. A
music therapy session may be the only time when that safety can be created. The
aesthetic experience of the music can be both moving and relaxing. Music-making is an
interpersonal process that engages individuals in a non-threatening way and brings them
together. Finally, and in particular with intimate couples, music often has multiple
referential meanings that remind listeners and participants of specific events or emotions
that they have experienced through the course of their relationship. Connections and
feelings are illuminated in a way that may not be possible or as expedient with traditional
talk-therapy interventions.
48
This study notably included four case vignettes where the husband was the patient
and the visiting partner was his wife. As reported earlier, McDaniel and Cole-Kelly
(2003) indicate that couples in which the identified patient is the husband may have less
difficulty with role confusion than couples in which the wife is the hospitalized patient
because, in contrast to men, women often can easily transition to a care-taking role
because of support and reinforcement from the society. Lichtman and Taylor (1986) also
addressed the difficulties that may be more prevalent when the female partner is the
identified patient, taking into consideration the tendency for wives, rather than husbands,
to initiate attention to emotional issues such as those that might arise during illness and
hospitalization. On the other hand, Langer et. al. (2003) found that wives who act as
primary caretaker for a sick husband more often report decreased marital satisfaction than
male spousal caretakers, perhaps due to the outside support (the patient’s mother or
friends) that may more often be offered to husbands of patients than to wives because of
societal caretaking norms. In regards to this study, then, music therapy may have
provided an intervention that gave each patient’s spouse an opportunity to experience
some relief or even self-care during a time of increased demands and stress.
In some cases, couples work may be contra-indicated, or most useful when
individual sessions are also possible with the hospitalized partner alone. In the case of
Anthony and Claudette, there may have been more opportunities for Anthony to process
his feelings about his illness and express himself openly if his wife had not so
vehemently refused a second session. With Rob and Heather, the music therapist had the
opportunity to conduct several individual music therapy sessions with Rob. In these
sessions, Rob explained that it was often hard to express himself with his wife at his side
49
because he found it so difficult to see her emotional suffering in response to his
hospitalization and physical illness. With this knowledge, the therapist could approach
future work with the couple with a different awareness. The individual sessions with Rob
provided important information for the therapist as well as giving Rob a space to achieve
individual insight that he may not have allowed himself to consider when he was
preoccupied with concerns for Heather.
Limitations of the Study
This study examines music therapy with four married couples in which the
husband was being treated in an in-patient medical setting. While the study begins to
explore and describe music therapy with couples in this setting, the results are not
necessarily generalizable to every couple experiencing one partner’s hospitalization. The
vignettes described in this study consist of one long-term music therapy treatment process
and three short-term cases, two of which consisted of only one session. Different or more
extensive results may have been obtained if more sessions were conducted with each
case, or if the same number of sessions were conducted for each case.
Incidentally, the four couples described above represent three different racial
groups, and two of the four couples emigrated from two different foreign countries.
Racial and cultural differences were not considered as part of this study but may have had
an effect on the outcomes. Additionally, all four of the vignettes presented couples in
which the husband was the hospitalized partner with a visiting wife, and it is unclear how
music therapy processes may have differed in a case where the visiting partner was a
50
husband and the patient his wife, if the partners were unmarried and/or not cohabiting, or
if the couple were homosexual rather than heterosexual.
Experience of the Self in the Therapist
Virginia Satir (1987) states, “Common sense dictates that the therapist and the
patient must inevitably impact on one another as human beings.” An important clinical
issue that emerged through the course of this study was the role of the therapist. The
reactions the therapist observed in herself have become important data in this study.
Strong counter-transference reactions became apparent through work with the
couples described in this study, particularly when patients and their spouses struggled
with issues of life and death. Music therapy sessions seemed to bring up strong
emotional responses from the couples in the study. Tender moments of hand-holding and
other physical contact, as well as poignant comments about the relationship, were
touching and emotive for the therapist.
Work with patients in a hospital room includes boundaries that are often very
different from therapeutic work in other arenas. Working around the schedules of test
results or other treatments may necessitate a very flexible schedule for therapy sessions.
Patients are often clothed only in hospital gowns or pajamas. The presence of physical
illness or pain further contributes to the vulnerability of patients. These boundary
considerations may have played a role in the transference and counter-transference
reactions that occurred in music therapy sessions.
In the cases described above, the experience of a female therapist working with
four couples in which the husband was the hospitalized patient became notable. In some
51
ways, the therapist served as a model for affective engagement with the husband. At
other times the role of the therapist seemed to be to reinforce a maternal connection to a
male patient. At one point during an individual music therapy session when Heather’s
work schedule conflicted with her ability to visit the hospital, Rob commented to the
therapist, “When you come it’s like a substitute for when my wife can’t be here.”
It seems that the situation of a female therapist approaching a couple and
providing nurturance or affective engagement to the husband, particularly in this setting
of lowered boundaries, may in some cases lead to some amount of discomfort on the part
of the patient’s wife. This consideration certainly came into play in some of the cases
described, particularly in the case of Anthony and Claudette, after Claudette vehemently
refused future music therapy sessions, and in the case of Rob and Heather, where Rob’s
transference reaction was apparent. However, the interpersonal qualities of music and its
role in the lives of these couples accentuated the relationship between the spouses. The
therapist facilitated the musical interactions, but the music produced in each session with
these couples was about them, their story, and their experiences.
This therapist’s personal reactions became most apparent in the long-term work
with Rob and Heather. As the couple grappled with the reality of Rob’s illness and
prognosis, the therapist felt a strong empathetic reaction to Rob’s suffering and grief as
well as to Heather’s suffering and grief. Developing a strong relationship with both
partners seemed to result in a more intense counter-transference reaction, perhaps due to
trying to provide safe holding for the intense feelings of two individuals at the same time.
Termination with this couple was particularly difficult, although one benefit to working
52
with the couple together was that when the therapeutic relationship ended, the couple
moved on together, carrying memories and benefits of the therapeutic work with them.
The therapist’s self-care became an important consideration in this work.
Supervision was utilized as much as possible and personal reactions needed to be
addressed on the therapist’s own time. One method of coping involved allowing time to
sing and react emotionally to some of the songs that acquired particular meaning during
music therapy sessions with these couples. Kate Richards Gellar (2002) worked with
singing “as a release, and as a means of self-soothing” in her work as part of the Caring
for the Caregiver program. For self-care in regards to personal reactions to this work
with couples, singing was utilized for these purposes, and to aid in processing feelings
that occurred both during and after emotionally evocative sessions. Journaling was
another method utilized by the therapist to increase awareness of and process personal
reactions. With greater awareness and mastery of these personal reactionary responses,
the therapist was most able to approach future sessions by being fully present.
Suggestions for Further Research
Music therapy research involving couples is very limited, and this researcher
found no literature relating to treating couples in an in-patient medical setting, despite the
regular opportunities for such work in most hospitals. A more standardized protocol for
working with couples or the inclusion of more case material may yield more definitive
results about the use of music therapy with this population. It may be useful to learn
more about the experience of the couples themselves in music therapy, and the perceived
effects of the music therapy on the relationship during the hospitalization. Another
53
avenue for further research could involve following up with couples after discharge to
determine whether any benefits of music therapy extend into the long-term.
54
Conclusions
This study has begun to explore the development of a method for working with
intimate couples when one partner is medically hospitalized. The needs of couples in this
setting and resources available through music therapy were addressed: Literature
presented in this study gave an overview of issues, stressors, and difficulties faced by
couples who experience the illness and/or hospitalization of one partner, and evidence of
the capabilities of music therapy to meet the needs of families and patients in medical
settings was also offered.
The development of a music therapy method for working with couples in general
hospitals for this study was based on clinical experiences of the researcher. Music
therapy sessions with four of these couples followed a similar outline of events, with the
use of familiar songs as the primary intervention in each case. A greeting song was used
to establish contact with the couples and musical instruments were available for active
music-making.
In presenting the results of this study, a clinical vignette was presented of each
case utilized for the study. All subjects were heterosexual couples, with diagnoses of the
identified patient including cancer, AIDS, and gall bladder rupture. Each couple used the
music in varying ways, but most often the music seemed to be used to create a space for
the safe expression of emotions.
In this research, music therapy seemed to result in increased communication,
increased relaxation, and increased experience of intimacy for these four couples. The
music seemed to have a profound effect in regards to bringing the couples together,
physically (in terms of hand-holding and spontaneous touching) and emotionally.
55
Considering the stressors faced by these couples, the relationship issues they were
at risk for, and the effects of music therapy in this study, it seems clear that music therapy
has the capacity to provide an important service for couples in this setting. Many
interventions already available for couples dealing with medical illness/hospitalization
are available only when the couple’s reactions reach a clinical level. This music therapy
method may provide significant clinical efficacy in preventing any such escalation,
through providing support to intimate couples during the difficult process of medical
hospitalization.
56
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