Interview Video 1: What is music therapy?

Interview Video 2: What it meant for one family

Interview Video 3: Challenges for the field

Key Points

Interview Video 1: What is music therapy?

Listen in to our discussion with Bryanna Tobin, a Licensed Music Therapist who explains the unique role and service offered through a music therapy program. This introductory video explains how and when music therapists contribute to the multidisciplinary team.

• Music therapy: a trained clinician engages patients/families through music to reach a clinical goal.
  • Example goals: increased relaxation, building connection
  • Example modalities: writing autobiographical songs, reflecting on experiences with loved ones
• Reasons to consult music therapy:
  • A patient expresses interest in music
  • A patient’s behavior changes with music

Interview Video 2: What is meant for one family

Listen as Bryanna Tobin, LMT, recounts how engagement in music therapy profoundly impacted the family of a dying patient. This powerful story demonstrates both how music as a medium can connect with patients once other means have failed and how music therapists use this to help families heal.

Interview Video 3: Challenges in the field

Bryanna Tobin, a Licensed Music Therapist shares about why implementation of music therapy is challenging and opportunities for improvement in the field.

• Starting a music therapy program can be difficult because it is not typically reimbursed through insurance.
• Formal research is limited in this area.
• This lack of research and formal education about music therapy creates an opportunity for learning, Ask questions and stay curious!

Transcripts

Interview Video 1: What is music therapy?

Harry Han: So Brianna, I would love to get an introduction of what is your role on the interdisciplinary team and how do you support our patients at the end of life

Bryanna Tobin: So basically my role on the team is to work with families as a family unit in a lot of cases to use music as the medium to achieve a goal, a clinical goal of some kind. So often when I’m working with our hospice patients and their families or their advocates and their care teams, it looks any number of ways, and it’s really hard to make a blanket statement, but some examples of a goal that we may be working to achieve are increased opportunities for relaxation increased quality of life and meaningful connection between family members, legacy projects. Sometimes we work with individuals to write songs about their lives, to do autobiographical work or to do any number of things that can be emotionally processing can be emotionally expressive. So really we come in as music therapists, as a psychosocial support for the patient, for the families and oftentimes too, for any number of people in the family unit. Not always is it the unit completely together, but sometimes it’s a sibling or sometimes it’s a child. Sometimes it’s the parent if we’re working on a case in which maybe it’s a pediatric hospice case. So music actually has this beautiful neurological, power right to hold, space to hold things that are really hard for us to process. One of those things being what exactly it’s like when somebody that you care about is on hospice care and when they’re approaching the end of their life. So I work on the interdisciplinary team directly with families, and I also collaborate with the members of the interdisciplinary team, so nurses and social workers and chaplains any type of spiritual care member, child life specialists. And I really start to become supports not only for them, but for our hospice patients and the unit as a total. 

Harry Han: That’s such a wonderful summary and I’m curious, how does the interdisciplinary team recognize when you’re needed, when you’re not needed?

Bryanna Tobin: Absolutely. It can be. So the kind of way I even show up right is so different depending on the situation. Sometimes it’s an assessment by the social worker during admission and sometimes it’s very clear that this family could benefit or this patient could benefit from music therapy services. Maybe the patient expresses, “oh, I have experience as a musician earlier in my life and I still find an abundance of meaning. In being in a musical situation” whether that be seeing live music, listening to music whether that be feeling just emotionally tied to music at this point in their life, sometimes too caregivers can notice their loved ones being connected to music if the patient even isn’t able to express that. An example of what that may look like is if somebody is very agitated and maybe they have dementia, or they have a diagnosis in which it maybe feels that there could be like pharmacological intervention and this and that, but they start to notice, oh, when I put on this certain type of music, or when they’re watching this certain musical, or when there’s, they’re engaging in music in some way, that agitation seems to go down a little bit. A lot of times people are not a hundred percent sure and they’re like, music, I like music’s great. Sure, let’s try it. And then it’s my job to come in and to say, okay, so here’s an example of what music therapy is. I show up with my guitar on my back and I, with it’s really a funny scene and I have my mask on and my guitar on my back and I have a bag full of instruments and I’m like, what’s up? How are you? And a lot of times people are like, what in the world are you going to ask me to do? So the initial referral comes from social work typically. It can also come directly from family members. It can come directly from any number of people on the interdisciplinary team. But I’d say 99% of the time it comes from social work. Once I get that referral, I then make the determination of okay, what are we going to focus on? What really are our goals of care? Because what I’m looking for is not just to sit and sing songs and have fun, that can be really beneficial in its own right. But music therapy is the clinically evidenced practice of using music to really achieve those goals. And then on my end, after I do an assessment, after I work with a patient, after I work with a family, I come back to the IDT and I say, Hey, I see your assessment, social work. I see your assessment, nursing. I see your assessment, spiritual care. This is my assessment. Now, let’s like strengthen all of our understandings of this person, of this family unit as an entirety. So I’m not just looking at, things that are very specifically minute, right? I’m not looking at oxygenation levels or blood pressures. That’s a really important thing that nursing takes a peek at. It’s not really my specialty, but what I can notice is, okay, we sat and we engaged in an intervention that was specifically designed for this patient and we were singing together and we sang Elvis Presley’s Can’t Help Falling In Love with You. And that person has their late partner in a photo next to their chair. And during that song, they stopped singing during a certain lyric, but they looked over at that picture during that certain lyric. And moments later, they were able to come back and be reoriented into the song. And afterwards we could have a conversation about that, where they could take this space, they could reminisce, they could tell me a story about that person that was so important to them. And that’s what we’re looking for. We’re looking for these moments where somebody can really have an opportunity to express themselves in some capacity. And that’s really essential for the IDT team to know, because this is not just a number and it’s not just a person, it’s this is a person who has lived a complex life just as complex as yours or mine.

Mahathi Komaragiri: Wow. I’m blown away and I’m now thinking why all these opportunities for music and especially for people who feel constrained by their physical condition, their illness, their, they’re looking at a certain narrowed horizon. But there is, there’s freedom in in the space of music. You can escape, you can identify with a different story. You can make your, another story. You can, fall into prayer, fall into re remembrance. You can do fall into all these things of legacy as you said. This is a really s powerful meaning making practice as much as any other kind of written form and patients may feel more apt to do it this way with a known song or with a song that they’ve had a history with. Do you find that  I’ve seen people like musicians who are not board of certified music therapists who donate their time to a hospice house, to an inpatient hospice facility. And is there a large group of just musicians that are getting themselves involved in this work?

Bryanna Tobin: Yeah, I’ve definitely I’ve definitely come into contact with a ton of folks who are performers who do wanna volunteer their time. And I think that is, such a beautiful medium. The trick though is then making sure this is where we get into the muddied water and the great area between what is music performance and environmental music and volunteer services. And then what is music therapy practice? The really important distinction is that music therapists do have a specific level of training, a specific university level bachelor’s degree in music therapy, which is its own designation  And if folks are looking to get music through the doors, if they’re looking to have environmental music for people, if they’re looking to have performers that is absolutely an available thing. I think people really do find a ton of meaning when they’re able to be in spaces sharing music together. And then creating a music therapy, a therapeutic, a delivery is its own different thing. And I think both have a seat at the table. It’s really important that we validate both of those things as being really important because at the end of the day when we zoom out and we say. What is the goal of a service delivery? It’s to increase the quality of life of an individual. So even if a music performer if a volunteer who’s a performer comes in and they are in music with somebody, that, that’s not to say it’s not a therapeutic medium, that’s to say it has its own therapeutic benefits. And then when a music therapist comes in, we’re able to dive a little deeper with a little bit more training and be able to unpack what exactly it is that we’re experiencing in the music. And then what can that person take away from the experience.

Interview Video 2: What is meant for one family

Mahathi Komaragiri: I would love to hear more of these stories about times from patients have. Made connections, made a powerful moment. Had a powerful moment with you, with the music, with making music anything like that.

Bryanna Tobin: Yeah, absolutely. I can tell you one that’s really very vivid because it just happened, I think on Monday or Tuesday. So I had received a referral for a patient who was in an assisted living facility and I attempted to contact the family before going to visit and wasn’t able to get in touch with them. But I knew based on some of the clinical notes that were given to me and the referral that this person was in, what we call a period of transition. When we’re thinking of somebody’s transition, we’re thinking of a series of signs and symptoms that tell someone, tell a practitioner that this person is approaching the active end of their life. So you may notice that somebody’s responses are really minimal. You may notice for some people, a rattling in their chest or in their esophagus. Things that, although to the outside eye may seem really uncomfortable, are actually not very uncomfortable to the person. Especially when their pain is mitigated and when they are appropriately medicated. So I had an idea of what to expect walking into the room knowing that this patient was in the transition or active dying process, and that if we were thinking of a timetable, it was really important for me to get out there sooner rather than later. So I arrive and I walk in the door and I knock on the door, and immediately I see the patient who’s sitting up in bed very much in the active dying process. I’m noticing a changing of color on the patient’s feet. I’m seeing them sitting with their mouth slightly opened, their eyes closed, looking very comfortable. But I’m really happy that I got there at that moment. And I walk in and I introduce myself to their healthcare aide. I introduce myself to the patient and I notice sitting next to him is his wife. And I don’t know anything about his wife in this moment. I have not spoken to her. I don’t know anything about her. And I quickly learn after asking her some questions and introducing myself that it seems that she may also have a slight dementia diagnosis. And through my experience and through working with other individuals as well as looking at some clinical notes, then I was able to notice, okay, I really need to assess what the need is in this situation because I can sit here and I can play music and pretend everything is fine, but clearly things are not fine right now. And so I’m gonna need to really adjust what my focus was. And in that moment I said, okay, I need to engage with his wife. This is not for him anymore. This is for his wife’s ability to process what is happening. Even when she may be confused when she’s feeling an abundance of intense emotion as anybody would with the loss of a partner, I then learned that they were together for 35 years and she told me all about their first date. And okay, great. This is good information for me to have. And so I immediately start thinking to myself as she’s talking, I’m processing, I’m going through my, I call my inner jukebox of okay, what music do I have on the on hand right now that I can pull together? And she says, , my husband, during our first date, we were on a ski trip in college and he stood up in front of everybody and grabbed his guitar and sang a folk song from the sixties and seventies. And I said, oh my gosh. That’s amazing. Do you remember what song it was? And she says, no. And I say the good news is you and I have the same taste in music. ’cause I also love the sixties and seventies, so let’s pick something. And so I start playing leaving on a jet plane, which has been done multiple times. It, I think it was originally John Denver and then Peter, Paul and Mary. There’s a couple renditions and I wanna really call attention to the choice of that song because leaving on a jet plane is essentially the theme of the song is that the person is leaving on a jet plane, right? They’re going on a trip and they’re hoping that they may be able to come back, but they know that they will not be able to come back. And in my mind, that’s my job, right? I think about, okay, if I’m gonna bring a song into this space, what is it going to hold meaning for in not just that person’s personal experience, but in the actual intricacies of the music. And so we start singing it. I invite her to sing with me. She absolutely does. And she’s holding her husband’s hand. Now. Her husband has not demonstrated any clear outward signs of physical movement. No squeezing of the hand, no moving of the feet. And what we do know is that the last sense to leave our bodies in the dying process is the sense of sound, right? We can hear so much longer than people typically even realize. It’s the first sense to develop. It’s the last sense to go. And so she’s singing. I’m singing, she’s holding her husband’s hand, and she jolts for a second and she looks down at his hand and she goes, he squeezed my hand with just two of his fingers. I said, yeah, that’s because he can hear you and he heard everything that you said about your first date, and I bet that he remembers that exact moment of standing up in front of all of your friends and singing that song to you. And she looks back at me and she says, that song is one of the songs he would sing to me all the time. And now that’s information I didn’t know. I’m not a superhuman, I don’t read minds or anything. And it wasn’t really about whether that was a relevant song or not. We knew it would be relevant because of the theme of the music. And so when we zoom out a little bit and we say, okay, it’s beautiful qualitative information that we have, of course, but what are we really looking at when we synthesize what happened in that moment? What really was it? And the goals that I was trying to achieve in that space were a, I. Emotional processing for his wife, being able to have a space for her to really reminisce about what their life was like together in a small way, but in a very meaningful way. And to be able to have a container that could hold something that felt so big. And when we think about grief and we think about loss, and we think about the processing of the death of somebody that we care about, it is incredibly overwhelming. And what the music can do when done well and when done clinically, is hold the space to make it a little bit lighter. I always say it’s like you add a blanket in the room, you can just sit back for a second and feel what you need to feel. And then on the other side of that, what we can do afterwards is look at the health outcomes for his wife, right? In the immediate bereavement period following that patient’s death. What is the impact of those moments and when there are multiple moments where somebody can feel interconnected to the person that they care about, when there are moments that they can feel that they have processed an emotion that has come up for them, both positive, negative, neutral, happy, sad, all in the same hand, and then how does that affect their bereavement status too? What does it really look like to provide opportunities for that person? And that was just a moment that I totally will never forget.

Interview Video 3: Challenges in the field

Mahathi Komaragiri: I don’t imagine that even every hospice IDT has music therapy involved in it or every hospital uses music therapy. And you’ve mentioned a lot of these powerful experiences, but just in your own voice, how do you describe again, what it is you bring to an IDT 

Bryanna Tobin: The tricky part is getting there and getting music therapists in the door. It’s particularly challenging to build out music therapy programs sometimes because it is a non-billable service. Specifically when it is only a practitioner who is a board certified music therapist. Now, there are ways around that we could get into and talk for hours about how you bill for insurance when you have additional designations like a mental health counselor when you have additional certifications and credentials and licensure that allow you to bill for insurance. Yes, of course you’re then able to bill for your mental health practice if you’re using music therapy techniques within that practice. But if we’re thinking of just board certified music therapists. In the state of Massachusetts, we don’t have a licensure specifically, we just have a board certification. And therefore we can’t bill through insurance. It is a non-billable service through Medicare and insurance. And so really unfortunately, something that we do have to consider is the bottom line for organizations, especially organizations who have a break even model where they are a not-for-profit or they don’t necessarily have the same number of resources that other organizations may have. And I think in a very real, true logistical way, that does have to be something we talk about and has to be a consideration that comes up because we can’t have the service if we can’t pay for the service and pay fair wages to clinicians. I think the other thing too is just advocacy, right? We, as music therapists, we do so much advocacy to really try and make sure that there’s really high quality research being done about music therapy techniques in the medical setting. And specifically in hospice too. And once again it’s really hard to find the spaces, right? When you have a full caseload of people, you’re worried about your client delivery and you’re worried about the service delivery to those people and really making sure you’re delivering high quality work and maybe not as worried about research in a lot of places. So research is important. Advocacy is important. Spaces like what you’re creating here today and that we’re talking about, this is incredibly important for forwarding the use of music therapy, especially in end of life, because it does have so many benefits, but sometimes the barrier to entry can be a little. Un unwieldy for an administrator who’s trying to increase the quality of services, but is I don’t actually know how to even start. And my advice always is to just start small.

Mahathi Komaragiri: I just wonder if you have any particular kinds of words that you’d want listeners who don’t have music therapy exposure to hear.

Bryanna Tobin: Yeah. Oh my gosh. There’s so much to say, right? It’s I think one of the things that I, I always I. Encourage people think about, and this is something that I say to my students and to the various fellows that we have join us from different universities. And what I like to say is when in the world, like you are exposed to something like that or you you are maybe around a music therapist and let’s say you’re observing a music therapist in practice or you pop your head into a hospital room and you see a music therapist singing a song with somebody to think deeper about it because on the surface it can really come off as just this fun, here’s the music person. Here they are, singing here somewhere over the rainbow. And so often. It’s really not just that. It can be just that sometimes, because sometimes that’s what you need. But to think deeper and to think deeper about the way in which each of us uses music in our lives. Because I think the key to really understanding what makes music therapy effective is actually to understand first the introspection that one can have about their own use of music. We use music in our everyday lives. The majority of people, I’d say use music in their everyday lives to like unconsciously. You get in the car, you turn on your phone, you hook it up to your Apple play, or you plug it into your, your ox jack and or you play a YouTube video off of your phone or this or that. But how often do we really sit down and say. I really want to listen to this album. Right now. I’m just being like, I feel like I need to listen to this album right now, or I really wanna listen to this song. Or I’m using music for studying as a study tool to play in the background. So I really would love for more people to take a look at the way that they use music in their everyday lives, and to do it without judgment, but to just really look and say, okay, like I am being intentional about the way that I’m using my music, even though I didn’t think I was. Or if you’re someone who doesn’t listen to music, how can you explore music? How can you explore recorded music? How can you explore? Making music. You don’t need to be a musician to make music. You don’t need to identify as a musician, you don’t need to play an instrument. I think when people dive into their understanding of their own habits, they then can start to understand that medium holds so much and has the potential to hold so much. And once we understand that music can be a container for experience that can be neurologically or cognitively overwhelming, we can understand that the science of music actually creates space for our brains to make sense of things, right? We think of patterns, we think of rhythm, we think of melodies, we think of predictability. There’s a functional use of it. And so my biggest thing is I don’t want people to write off the use of music in their everyday lives and then in the lives of other people because it is so beautiful. And then to ask questions like if this is the first time somebody’s hearing about music therapy, amazing. Ask questions, ask so many questions, ask why it works. Let’s look at the brain. Let’s look at neuropathways. Let’s look at the visceral response to grief. Let’s dive deeper about it. And that could be its own, conversation over 10 hours about the brain’s response to musical stimuli. But I think to ask questions and to really look at one’s own relationship to music.

• Guest discussant: Bryanna Tobin, LMT
• Original Interview by Dr. Harry Han and Dr. Mahathi Komaragiri
• Video by Dr. Holden Caplan and Dr. Alice Kennedy