Episodes of Relationship Completion Through Song In
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EPISODES OF RELATIONSHIP COMPLETION THROUGH SONG IN PALLIATIVE CARE by Amy Aileen Clements-Cortés A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy in Music Education Graduate Department of Music University of Toronto © Copyright by Amy Aileen Clements-Cortés 2009 EPISODES OF RELATIONSHIP COMPLETION THROUGH SONG IN PALLIATIVE CARE by Amy Clements-Cortés Doctor of Philosophy in Music Education Graduate Department of Music University of Toronto 2009 ABSTRACT This study utilized a combination of intrinsic and instrumental case studies to describe the experience of four dying persons and their significant relations, as they engaged in music therapy sessions designed with the goal of facilitating relationship completion. The four primary participants were inpatients of the Baycrest palliative care program who were diagnosed with a terminal illness and a life expectancy of less than six months. Two spouses who were involved in music therapy sessions were co-participants. I developed four case studies to represent each of the rich and detailed stories. Through the use of narrative research methods I was able to describe, interpret, and understand the complexity held within the multiple data sources that informed each case study. Data sources included: music created, utilized, recorded, and/or discussed in music therapy sessions; discussions during music therapy sessions; the researcher’s field notes; formal notes placed in the participant’s medical charts; the formal written assessment; transcriptions of audio-taped music therapy sessions; interviews; interview transcriptions; artistic pieces crafted by myself that emerged from the experiences of the participants as reflected in their interviews, and weekly participation in sessions which were verified by the participants; and other artistic material. ii The rich knowledge that emerged from the individual case studies informed a cross-case analysis where global themes were identified from a thematic analysis of participants’ experiences; and process motifs arising from the progression of participant engagement in music therapy are described. Global themes included: love; loss; gratitude; growth/transformation; courage/strength; and goodbye. The five process motifs that emerged were: (1) music therapy helps and was valued as a means of sharing the participants’ perceptions of their situation. (2) music therapy provides a safe place to become aware of, explore, and express feelings. (3) music enhances communication. (4) music therapy techniques provide creative avenues for self-expression. (5) music therapy provided a vehicle for revisiting and reminiscing. The thesis concludes with a summary of the knowledge revealed and a discussion of implications for music therapists and health care professionals, as well as a presentation of final thoughts and reflections on my role as researcher in this study. iii DEDICATION To my research participants: This thesis is a celebration of your stories! I dedicate this writing and the CD to you and your families. Thank you for inviting me into your lives to share beautiful moments with you. iv ACKNOWLEDGEMENTS Thank you to: The Hy and Bertha Shore and Harry and Sara Gorman Families, who provided funding for the production of the accompanying CD. Thank you for supporting professional development and creative projects in the health care field. Sincere Tung, who provided the instrumental accompaniments for the original composed songs, and for several of the pre-composed songs. Your dedication to the creation of the CD was outstanding and your accompaniments inspired me. My research participants who worked with me in their last days of life and who taught me many lessons, while sharing their personal experiences, and feelings with me. Thank you for trusting and welcoming me into your lives in your last days and weeks. My outstanding doctoral committee, Dr. Lori Dolloff, and Dr. Lucanne Magill who provided insightful and guiding direction in seeing this thesis develop. Your continual support and encouragement were much appreciated. To Dr. Pat Shand and Dr. Cheryl Dileo thank you for being part of the thesis defense as the additional thesis reviewers. Your contributions to my development as a researcher and music therapist are greatly valued. My academic advisor and doctoral committee chair, Dr. Lee Bartel, who engaged me in a process of probing inquiry of my ideas and practice to develop this thesis and my growth as a music therapist. Your commitment to me and my process was outstanding. I am blessed to have you as a mentor who inspires and encourages me in my work. My outstanding, loving, supportive, caring, and nurturing family, especially: Kathleen, Zia Rina, Father Edwin, Father Eugene, and Jorge. Your daily expressions of love and support were unwavering. My mother, Bruna Clements, the most inspirational and loving role model a daughter could have. Thank you for fostering the love of music in me as a child. Thank you for supporting, and encouraging me on a daily basis, and for all your expressions of love and gratitude. Thank you for being my biggest fan. I only hope to become more like you as I continue to live my life; a person who is loved by so many, and who gives love unconditionally. v TABLE OF CONTENTS ABSTRACT ii DEDICATION iv ACKNOWLEDGEMENTS v CHAPTER ONE: INRODUCTION 1 Background and Context 1 How Can End-of-life Be Improved? 2 Importance of Relationships 4 Relationships and Serious Illness 5 Problem 6 Need for the Study 6 Central Purpose of the Research 7 Central Question 8 Further Questions that Guided the Inquiry 9 Implications 9 Significance 9 The Research Gap 9 Who has Informed the Care of the Dying to Date? 10 Music Therapy 11 Personal Motivation for this Investigation 12 My Position as a Musician, Music Therapist, Music Teacher, and Researcher 12 Intentionality and Researcher Presence 14 Physical Pain 14 Psychological Pain 15 Emotional Expression 15 Relationship Completion 17 Audience and Knowledge Advancement 19 Structural Outline of the Thesis Document 19 CHAPTER TWO: CONCEPTUAL FRAMEWORK 21 Overview 21 Constructs and Definitions 21 What is Experience? 22 The Concept of Experience as it Relates to Narrative Inquiry? 22 A Definition of Experience for This Study 23 What is Phenomenology? 24 Phenomenological Music Therapy Studies in the Care of the Terminally Ill 26 How Will A Phenomenological Outlook be Implemented in This Study? 26 Relationships 28 Types of Relationships for This Study 29 Intrapersonal Relationships 29 vi A Definition of Intrapersonal Relationships for This Study 30 Interpersonal Relationships 31 A Definition of Interpersonal Relationships for This Study 33 Transpersonal Relationships 33 A Definition of Transpersonal Relationships for This Study 34 Relationship Completion 34 A Definition of Relationship Completion for This Study 35 Music Therapy 35 Music Therapy and Humanistic Psychology 36 A Definition of Humanistic Music Therapy for This Study 38 Music Therapy Techniques 38 History of the Development of Music Therapy Techniques in Palliative Care 38 A Delineation of Music Therapy Techniques for This Study 41 Levels of Practice in Palliative Care Music Therapy 44 Music Therapy Model for Sessions in This Study 44 Music Therapy Research and Descriptive Articles on Relationship Completion 45 Research on Music Therapy to Facilitate Relationship Completion at the Supportive Level 46 Facilitating Intrapersonal Relationship Completion at the Supportive Level 46 Facilitating Interpersonal Relationship Completion at the Supportive Level 47 Facilitating Transpersonal Relationship Completion at the Supportive Level 48 Facilitating Combined Relationship Completion at the Supportive Level 49 Research on Music Therapy to Facilitate Relationship Completion at the Communicative/Expressive Level 50 Facilitating Intrapersonal Relationship Completion at the Communicative/Expressive Level 51 Facilitating Interpersonal Relationship Completion at the Communicative/Expressive Level 52 Facilitating Transpersonal Relationship Completion at the Communicative/Expressive Level 54 Facilitating Combined Relationship Completion at the Communicative/Expressive Level 54 Research on Music Therapy to Facilitate Relationship Completion at the Transformative Level 55 Facilitating Intrapersonal Relationship Completion at the Transformative Level 55 Facilitating Interpersonal Relationship Completion at the Transformative Level 56 Facilitating Transpersonal Relationship Completion at the Transformative Level 58 vii Facilitating Combined Relationship Completion at the Transformative Level 58 Summary 59 CHAPTER THREE: METHODOLOGY 60 Overview 60 Music Therapy Research Design in Palliative Care 60 Case Study 62 What is a Case Study? 62 How Does the Writing of a Case Study in Clinical Practice Differ From the Writing of a Case Study in Research? 62 What Are the Characteristics of Case Study Research? 63 Purposes and Types of Case Studies 64 How Was Case Study Methodology Applied in This Study? 65 Why Was Writing in the First Person Important for Writing the Case Studies in This Investigation? 66 Narrative as a Framework for Writing Case Studies 67 Narrative Methodology 68 What is Narrative Inquiry? 68 How Was Narrative Used in This Study? 69 Artistic Pieces 72 I Am Still Alive 72 What is an Artistic Piece in This Study? 73 Design and Procedures 74 Participants 74 Data Sources 75 Music 76 Semi-Structured Interviews 76 Researcher’s Field Notes 78 Additional Artistic Material 78 Data Analysis 79 Transcription