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Dr. Magill is assistant professor and coordinator of the music therapy program at the School of Music, University of Windsor, Ontario, Canada (e-mail: lucannem@uwin dsor.ca). Dr. Levin is assistant professor with Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York City, and Weill Cornell Medical College, New York City. Ms. Spodek is with the Ferkauf Graduate School of Psychology, Yeshiva University, New York City.
A common challenge of psychotherapy with critically ill patients is that they are often too sick to engage in conventional cognitive-behavioral therapy (CBT), with regular 45-minute sessions and behavioral activation.We piloted a 20-minute, one-session intervention conducted jointly by a music therapist and a cognitive therapist that combines music therapy with CBT to improve coping for distressed, critically ill cancer patients.
Music therapy offers a supportive framework that can facilitate communication, enhance comfort via familiar music and lyrics, improve mood, inspire reflection, and strengthen faith. Singing with others enhances perceived support, diminishes isolation, and increases social integration. Music therapy postulates that singing and music connect to early sources of parental nurturance.
CBT has proven efficacy for depression and anxiety. Its central hypothesis is that reframing distorted perceptions can improve associated emotions. Unlike dynamic therapies, the tone of CBT is realistically upbeat rather than neutral and is therefore well suited to the life-and-death context of oncology.
The one-session intervention for individual patients and their families used a structured, patient-centered format. Distressed patients, identified by medical staff, were approached individually. The two therapists introduced themselves and invited the patient to participate. The patient was socialized to the model with an explanation of its rationale—listening to music and talking about the lyrics to improve emotional well-being. Family and staff were also invited to participate.
The agenda was set collaboratively with the patient, who was invited to choose two songs from an eclectic songbook or elsewhere. The music therapist played the guitar and sang, inviting others to join and adjusting rhythm, tempo, and volume to suit the patient's medical status and preferences. If the patient was too weak or shy to sing, he or she was invited to hum or listen. After the song, warm-hearted cheering and applause erupted—an important part of behavioral activation in the context of a cancer ward.
After the applause, feedback was elicited with an open-ended question such as, "How did that feel?" Either therapist then gently explored the meaning of the lyrics and emotions that arose with questions such as "What does this song say to you or remind you of?"
Cognitive distortions were reframed, and messages of hope and coping statements were generated. A second song was chosen, and the process was repeated. The session ended with a folk song ("He's Got the Whole World in His Hands") that was modified to include the names of the patient, family, friends, and all present.
As a maintenance technique, patients were presented with the song lyrics and a coping message either formulated by the therapists or adapted from the lyrics (for example, "Faith is important in `Times of Trouble'"). To bolster social support and reduce isolation, patients were encouraged to share these with their family. This was especially helpful if the song had a shared meaning for significant others.
The program was piloted with 39 critically ill cancer patients. Pretherapy and posttherapy scores were obtained with the Distress Thermometer, a well-validated 10-point Likert scale for measuring cancer distress. The mean distress score before the intervention was 4.6. After intervention it dropped to a mean±SD of 2.5±1.5, representing a 46% improvement. This was statistically significant (95% confidence interval of 1.6—2.9, p=.001). A qualitative thematic analysis encompassed the following topics: faith, hope, family, meaning in life, creativity, hopelessness, abandonment, and fear of death.
This feasibility study suggests a unique approach to behavioral activation for critically ill cancer patients by using combined music therapy and CBT. In addition to the therapeutic value of music, lyrics are used to generate coping statements, which are often based on memories that can be used to sustain the patient through his or her current adversity. The limitations of this pilot study include a small sample size, recruitment bias, and lack of a control group. Nevertheless, it demonstrates that offering this combined therapy is feasible with critically ill cancer patients and may help reduce their distress regardless of their stage of illness.
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