The Academy Award-winning animated film "Coco" is all about the power of music to bring people "back into the world" including the elderly and (seemingly) infirm. Watching the film, it's hard to not to be moved almost to tears by the power of music and its effect on familial relationships. And while not all people respond to music emotionally, most of us do.
For many, music from certain eras can bring back memories of better times. For others, music soothes anxiety or gets them pumped up for a workout. When it comes to people living with dementia, music can help in all of those ways, but it can also help cognition.
Hospice organizations are keenly aware of the soothing power of music. Sometimes the music may be used casually, by the facility or the family, knowing that this is a type of music that the person who is in the dying process had always enjoyed. Increasingly, though, employing trained music therapists has been favored. This type of therapy seems especially helpful with those who are dying from Alzheimer’s or other forms of dementia. Perhaps this is because in the final stage of dementia, people have usually moved beyond the point where conversation is possible.
Karen Sholander, a life-long musician, is a board certified music therapist (MT-BC) in Dallas, Texas. She works with hospice patients and their families, helping them navigate through any terminal diagnosis to closure at the end of life. Many of her patients have dementia.
HealthCentral asked Karen to answer some questions via email about the nuts and bolts of music therapy. Our conversation, edited for length, is below:
HealthCentral: Karen, music has been shown in studies to increase quality of life for people living with dementia and, in some cases, it seems to improve their cognitive functioning. Music for hospice patients is also about quality of life. Do you work with both communities or just with hospice?
Karen Sholander: I currently work only with hospice patients and their families, many of whom have dementia. I visit patients in their homes, group homes, or larger facilities, and the majority of sessions are one-on-one. Some patients live in a small residential care home, so I may implement a group music therapy session with all of the residents, but only if this still meets the goal for the individual patient. When family members are present, I always invite them to participate in the sessions as terminal illness affects the whole family unit. Family members often become the voice of their loved one, and that voice needs to be heard.
HC: What drew you to this work?
KS: I have been a musician my whole life and have always felt called to use my gifts to enhance the quality of life for seniors living in care facilities. When I began volunteering to play the piano several years ago in a nearby memory care facility, I was just amazed at the responses to the music. I was told by the care staff that their patients experienced improved mood and congeniality as I played, and this effect lasted after I left. I had people sit beside me on the piano bench who couldn't tell me their own names, yet they could sing every word to an old familiar song. I started exploring the effects of music on the brain, found that music therapy was a field of study based on research and evidence, and knew I needed to go back to school to learn how to use this musical gift of mine to best meet the needs of individuals.
HC: Do you need special qualifications in order to provide music in a hospice setting?
KS: To be credentialed as a music therapist, you must first earn a bachelor's degree, bachelor equivalency, or master's degree in music therapy. Students take music courses, music therapy for various populations, and psychology courses as well as basic college courses. They must pass proficiency tests in piano, voice and guitar. Part of this degree plan is completing over 200 hours as a practicum student and a six-month, 1,000-hour internship with a board-certified music therapist.
Following the internship, candidates then take a board certification exam to earn the title of MT-BC (Music Therapist-Board Certified). Music therapists are re-certified every five years by completing continuing education courses. MT-BC's are bound by a Scope of Practice and Code of Ethics, and many belong to the professional organization, the American Music Therapy Association (AMTA). Although some people may claim to "do" music therapy, only professionals with the MT-BC credential have been educated, trained and certified as such. Several states have moved towards a state licensure to protect the professional standards and title. And just a note: it is music therapy, not musical therapy, and never musical therapist!
HC: What instrument or instruments do you use and why?
KS: The main instruments I use in therapy sessions are the guitar and singing. I find that the guitar is an intimate instrument that allows me to be close enough to my patient to provide therapeutic touch if needed. I also use piano (keyboard) for people who prefer this instrument. I have used clarinet, dulcimer, and Indian flute. The instruments and music I choose are always based on the patient's preferences and needs. Many times, the patient will also play an instrument, generally a small hand percussion instrument such as a drum or shaker.
HC: Is there an extra charge for the hospice families or is this service covered in the same manner as other hospice services and then paid for by insurance?
KS: When music therapy is offered through a hospice company, there is no extra charge. If a family hires a music therapist outside of their hospice company, then most likely the family will need to pay that therapist directly. However, some music therapists are able to bill through insurance companies.
HC: Please explain music therapy versus just playing music.
KS: Music therapy is therapy at its core, and the modality is music. It is based on a therapeutic relationship between the client and the therapist. After an initial assessment, we target individualized goals related to end of life, such as the need to have positive connections with loved ones, the need for self-expression, relief from pain, improving quality of life, creating legacies to leave behind, and processing life changes. Every session looks different. The amount and type of music is always guided by the patient's preference which they or their loved one has told me. A passerby may peer into a room and think that the therapist is just playing music to the patient, but this is rarely the case. I am always manipulating the musical elements to respond, reflect, and engage with the client. This may be hard for most people to see.
HC: I know that you have a lot of stories that warm the heart. Could you please share one?
KS: One of my favorite stories is about a woman in her early 90s who I will call Mary. Mary had late stage Alzheimer's disease so had very limited ability to speak and sing. In the course of our time together, I met both of her adult children who helped me get to know Mary better. They shared stories of her life, the songs she sang to them when they were little, and told about her faith. During individual sessions with Mary, I used music that Mary responded to - sometimes with just a smile, other times she was able to sing a few repeated words. She often waved her hand as if conducting when she really was enjoying herself. It was a good session when Mary's face would brighten up with the music.
Mary's hospice nurse called me one day and told me that Mary probably had only a few days left. Her children were on their way from out of town. When I visited later that day, Mary was resting with her eyes closed, and appeared peaceful. I sat next to her and began to play the music that had been important to her as I recounted the related stories that her children had told me. As I spoke, played music, and sang, Mary stirred and with great effort, she opened her eyes to see me, just for a moment. Under the blanket, I could see her hand moving, as if conducting. She smiled and closed her eyes again. It was wonderful! She knew I was present with her.
Mary passed away peacefully just a few hours later. Although her children were not able to be with her, they later told me how grateful they were that I was able to provide a musical closure to her life. It was a great privilege for me to do so.
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