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Electronic Theses, Treatises and Dissertations The Graduate School

2011 Hospice Music Therapy Song Repertoire and Music Therapy Techniques Janelle A. Pierce

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COLLEGE OF MUSIC

HOSPICE MUSIC THERAPY SONG REPERTOIRE AND MUSIC THERAPY TECHNIQUES

By

JANELLE PIERCE

A Thesis submitted to the College of Music in partial fulfillment of the requirements for the degree of Master of Music Therapy

Degree Awarded: Summer Semester, 2011 The members of the committee approve the Thesis of Janelle Pierce defended on May 18, 2011.

______Kimberly VanWeelden Professor Directing Thesis

______Jayne Standley Committee Member

______Dianne Gregory Committee Member

The Graduate School has verified and approved the above-named committee members. ii I would like to dedicate this to my loving parents who have supported me throughout graduate school. They helped me realize that anything is possible if I set my mind to it. They believed in me and always encouraged me throughout my life.

iii ACKNOWLEDGEMENTS

I want to thank Dr. Kimberly VanWeelden for all of her guidance throughout this research project. Thank you for being so patient with me and taking time out of your busy schedule to help me. You made it possible for me to reach this far. I would also like to thank Dr. Standley and Prof. Gregory for being members of my committee and for also giving me so much knowledge on hospice care. The both of you inspired me to pursue a career in hospice. Lastly, I would like to thank all of my friends and family who supported me throughout this process.

iv TABLE OF CONTENTS

List of Tables ...... v

Abstract ...... vi 1. INTRODUCTION...... 1 History of Hospice ...... 1 Interdisciplinary Team ...... 3 Music Therapy Services……………………………………………………………….3 2. REVIEW OF LITERATURE...... 5 Interdisciplinary Team……………………………………………………………...…5 The Role of Music Therapy………………………………………………………….. 7 Repertoire ……………………………………………………………………………10 Need for the Study………………………………………………………….………..11 Purpose ………………………………………………………………………………11 Research Questions ……………………………………………………………….…11 Operational Definitions ……………………………………………………………..12 3. METHOD ………………………………………………………………………………..15 Participant Description ……………………………………………………………..15 Dependent Variable...... 15 Procedure ...... 16 4. RESULTS …………………………………………………………………………………….19 Data Analysis for Research Question 1…………………………………………….19 Data Analysis for Research Question 2…………………………………………….25 Data Analysis for Research Question 3…………………………………………….26 Data Analysis for Research Question 4…………………………………………….30 Data Analysis for Research Question 5…………………………………………….31 Data Analysis for Research Question 6…………………………………………….36 Data Analysis for Research Question 7…………………………………………….37 Data Analysis for Research Question 8…………………………………………….40

v Data Analysis for Research Question 9………………………….…………………41 Data Analysis for Research Question 10…………………………………………...47 Data Analysis for Research Question 11………….………………………………..48 Data Analysis for Research Question 12…………………………………………...50

5. DISCUSSION…………………………………………….……………………………..…….55

Overview of All Recommended Repertoire……………………………….…….………55 Recommended Repertoire for the Genre of Oldies (popular music prior to 1950)……..56 Recommended Repertoire for the Genre of Religious/Spirituals…………………….....57 Recommended Repertoire for the Genre of Country/Western……………………….…58 Recommended Repertoire for the Genre of Musicals…………………………………..59 Recommended Repertoire for the Genre of Popular (popular music from 1950 to the present)………………………………………………………………………………….59 An Overlap in Music Therapy Repertoire………………………………………………60 Music Therapy Techniques Used By Hospice Music Therapists……………………….61 Conclusion………………………………………………………………………...…….62

APPENDICES…………………………….……………………………………………………..64

A Survey…………………………………………………………………………………………64

B Institutional Review Board Approval Letter………………….………………………...……..69

C Introductory Email………………...…………………………………………………………..72

D Informed Letter of Consent……………………………………………………………………74

REFERENCES…………………………………………………………………………………..77

BIOLOGICAL SKETCH………………………………………………………………………...80

vi LIST OF TABLES

Table 1: Oldies (Popular music prior to 1950) Used By Hospice Music Therapists ...... 19

Table 2: Mislabeled Songs Within the Oldies Genre ...... 24

Table 3: Top Ten Oldies (Popular music prior to 1950) Used Frequently By Hospice Music

Therapists ...... 26

Table 4: Religious/Spiritual Songs Used By Hospice Music Therapists ...... 27

Table 5: Top Ten Oldies Religious/Spiritual Songs Used Frequently By Hospice Music

Therapists ...... 31

Table 6: Country/Western Songs Used By Hospice Music Therapists ...... 32

Table 7: Mislabeled Songs Within the Country/Western Genre ...... 35

Table 8: Top Ten Country/Western Songs Used Frequently By Hospice Music

Therapists ...... 36

Table 9: Songs From Musicals Used By Hospice Music Therapists ...... 37

Table 10: Mislabeled Songs Within the Musical Genre ...... 40

Table 11: Top Ten Songs From Musicals Used Frequently By Hospice Music

Therapists ...... 40

Table 12: Popular Songs (Popular music from 1950 to the present) Used By Hospice Music

Therapists ...... 41

Table 13: Mislabeled Songs Within the Popular Genre ...... 46

Table 14: Top Ten Popular Songs (Popular music from 1950 to the present) Used Frequently By

Hospice Music Therapists ...... 47

Table 15: The Sum and the Percentage of use of the Music Therapy Techniques with Clients .... 48

vii ABSTRACT

The purpose of this study was to investigate the repertoire and therapeutic techniques utilized by hospice music therapists. An electronic survey consisting of two sections was sent to 134 hospice music therapists through email. Of these, only 40 music therapists completed the survey, creating a return rate of 30%. The first section of the survey pertained to the songs music therapists use the most frequently in the following five genres: Oldies (popular music prior to 1950); Religious/ Spirituals; Country/Western; Musicals; and Popular (popular music from 1950 to the present). The second section of the survey compiled a list of 20 therapeutic techniques and the music therapists were asked to rate how frequently they use each technique. The results for this study revealed a total of 577 song recommendations for all five genres. The genres which received the most song recommendations were Popular (n = 146) and Oldies (n = 139). Additionally, results found all listed techniques, with the exception of one, were used by at least one music therapist to some degree within the hospice setting. Further results are discussed in the paper.

viii CHAPTER 1

Introduction

Hospice is not a place to die. On the contrary, the mission of all hospice services is to restore dignity to the patients, as well as provide the patients with a sense of fulfillment and closure. Hospice is an establishment dedicated to helping those who have a life-limiting illness, meaning that instead of receiving aggressive treatment, the patient will receive care that will increase their quality of life. According to the National Hospice and Palliative Care Organization (2010), the Hospice patient's interdisciplinary team treat the patient's physical pain, as well as their emotional and spiritual pain. Although the hospice movement began in England during the early 1960s, the concept of hospice can be dated back to the 7th century in ancient Greece.

History of Hospice

In Ancient Greece, wandering strangers could seek refuge in the homes of kind strangers and receive food and shelter (Forman, Kitzes, Anderson, & Sheehan, 2003). This tradition of housing wandering strangers continued in the Roman empire. Forman et al. (2003) state that private hospitality was legally defined and arrangements between the host and traveler were confirmed by shaking hands and a written contract, tabula hospitalis. This practice of housing travelers developed into Roman state officials appointing citizens in a foreign state to house and protect Roman citizens (Forman et al., 2003). Hospice developed from the word hospitium, meaning entertainment, lodging, hospitality, or inn (Forman et al., 2003). In the Middle Ages the term hospice meant “travelers were given hospitality on their journey” (Sendor & O'Connor, 1997; Hilliard, 2005; Walworth, 2007). During the Middle Ages, a hospice became a perennial residence for the poor, people with mental or physical disabilities, and for those with an incurable disease. During the Renaissance, European cities began to flourish and the need to care for the elderly and those with medical illness became prominent. Soon hospices became shelters for these populations (Forman et al., 2003).

1 In the 1960s, Dame Cicely Saunders became one of the founders of hospice care in England. Saunders worked as a nurse and volunteered at St. Luke’s Hospital. Forman et al. (2003) state that, “Saunders came to fully understand the need for home care, family support, research, and that pain and symptom management was crucial” (p. 4). Saunders also came to the conclusion that patients have needs that can be met by an interdisciplinary team. She formulated the following principles for hospice care: 1. Death must be accepted. 2. Patient’s total care must be managed by a skilled interdisciplinary team whose members communicate regularly with one another. 3. The common symptoms of terminal disease need to be effectively controlled. 4. Patient and family as a single unit of care must be recognized. 5. An active home-care plan should be implemented. 6. An active program of bereavement care for the family after the death of their loved one should be implemented. 7. Research and education should be ongoing (Forman et al., 2003, p. 5) Around this same time period, Dr. Elisabeth Kubler-Ross wrote a book discussing the five stages of death (denial, anger, bargaining, depression, and acceptance) based on her interviews with 500 dying patients. Based on her observations, death appeared to be a dire topic that should be avoided at all costs (Kubler-Ross, 1975). In a hospital setting, dedicated to curing ailments, death can be viewed as a failure. It was Dr. Kubler-Ross that made the suggestion to treat terminally ill patients in their own homes rather than in a hospital setting (Hilliard, 2005). In 1963, Saunders was invited to present a lecture at Yale University Medical School where she met Florence Wald, the dean of the graduate school of nursing (Forman et al., 2003). and was invited back to Yale to present a workshop on hospice in 1966. These lectures inspired Wald to open the New Haven hospice home care and opened inpatient services in 1979 (Forman et al., 2003). It was these hospice openings that researchers demonstrated that Americans were comfortable with home care services. Balfour Mount, another hospice pioneer, opened a hospice in the Royal Victoria Hospice of McGill University in Montreal. Forman et al. (2003) state “this model demonstrated the

2 importance of the presence of a hospital-based palliative care service, especially in terms of research and education on pain control” (p. 6). It was in this setting that the term palliative care was used for the first time (Forman et al., 2003). Interdisciplinary Team

A hospice interdisciplinary team is assigned to each patient and must consist of a doctor of medicine, a registered nurse, a social worker, and a chaplain (Hilliard, 2005; Forman et. al. 2003). The interdisciplinary team meets on a weekly basis to discuss the patient’s plan of care. After the first six months in which the patient has been admitted, the patient's status is reviewed by the interdisciplinary team. If the patient is still appropriate for hospice care, the patient is re- certified into the program and their status will be reviewed within three months. If the patient is no longer appropriate for hospice care, they are discharged from hospice. The patient can always be re-admitted into hospice if they begin to decline in health. Additionally, the patient can always revoke Hospice services in order to pursue aggressive treatment (Hilliard, 2005; National Hospice and Palliative Care Organization (NHPCO), 2010). Volunteers are also considered members of the interdisciplinary team and are assigned to patients as needed. Volunteers also provide administrative support through clerical work (Forman et. al 2003). In addition to the interdisciplinary team, hospices offer other services as well. These services include massage therapy, music therapy, art therapy, pet therapy, financial counseling, therapeutic touch, reiki, harp music, aromatherapy, guided imagery, and reflexology (Demmer & Sauer, 2002). Music Therapy Services

Music therapy is one of the complimentary therapies afford by certain hospices. Common Hospice patient symptoms for which music therapy receives referrals are for anxiety, depression, and isolation (Groen, 2007). Music therapy has been known to help increase the quality of life for patients. For example, research has found when patients diagnosed with cancer in the Hospice program were asked to rate their quality of life after receiving music therapy they rated increases over time (Hilliard, 2003). The same study also found those cancer patients who did not receive music therapy rated their quality of life as decreasing over time.

3 According to the American Music Therapy Association (AMTA) (2010), "Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program" (p. 6). Music therapy began after World War II when musicians visited Veterans hospitals and played for veterans who were suffering from the trauma of war. Health professionals could see the medical and emotional benefits of music, but still believed that the musicians needed proper training before entering the hospital and that is how the music therapy curriculum came to be (AMTA, 2010). Music therapists can assess and evaluate the emotional well-being, physical condition, social functioning, communication, and cognitive levels of the patients through musical responses. Music therapists also create therapeutic sessions based on the individuals needs using an array of interventions including musical improvisation, music listening, song writing, lyric analysis, music and imagery, and music performance (AMTA, 2010). Through music therapy, patients have the opportunity to express themselves and communicate with their loved ones. Hospice music therapists also take on the same philosophy as the hospice organization, in which they treat the patient in a holistic manner and improve the patient's quality of life. Music therapy has been shown to have an effect in increasing the patient’s quality of life, which is one of the main goals in hospice care (Choi, 2010). A few hospice music therapy interventions may include providing a basis for reminiscence and life review, using music to provide a means for relating with loved ones, using music to distract patient from physical pain and discomfort, using music to provide emotional comfort and relief form anxiety, using music for enjoyment purposes, and music that provides release in the last hours of life (Krout, 2000, p. 327).

4 CHAPTER 2

Review of Literature

Hospice is an establishment dedicated to helping those who have life-limiting illnesses. Instead of receiving aggressive treatment, hospice patients receive care that will palliate their pain and increase their quality of life. According to the National Hospice and Palliative Care Organization (2010), the hospice patient's interdisciplinary team treat the patient's physical pain, as well as their emotional and spiritual pain. The interdisciplinary team consists of a primary physician, nurse, social worker, chaplain, volunteers, and may include complimentary therapies such as music therapy. Hospice music therapists use music as a tool to provide emotional comfort for the patient, as well as reduce their level of pain. There are many music therapy techniques and repertoire that can be used to help music therapists achieve their treatment goals for their patients. Studies have been conducted to determine which techniques and repertoire are appropriate for specific situations. Interdisciplinary Team Doctors working for any hospice organization are trained to treat the whole patient, not just their illness. Research has found that hospice patients would like the opportunity to discuss their spirituality with their doctors because spirituality determines whether or not a patient would like to receive a certain intervention. Hospice patients also appreciate when doctors treat them as a person, rather than doctors focusing solely on their illness (Hart et al., 2003). It is the doctor’s role, as well as the other interdisciplinary team members, to relieve the patient of all discomfort. Spiritual distress can cause the patient some discomfort. Pronk (2005) suggests that doctors must be able to identify the type of spiritual distress the patient is exhibiting. Understanding the patient’s spiritual beliefs can help doctors determine the type of care that best suits the patient (Pronk, 2005). It can also guide the doctor in how to approach the topic of advance directives with the patient and patient’s family (Bernal, 2007). Hospice nurses play a vital role in direct patient care. Hospice nurses manage the patient’s pain and administer medicine to the patient. Additionally, they inform the patient’s primary caregiver of any changes they see in the patient and describe the final stages of death. Nurses are the only ones who can announce the time of the patient’s death.

5 Nurses also play a role in advance directives. Advance directives are legal documents that allow the patient to make decisions about their end of life care. It provides a way for the patient to state their wishes to their family members and health care professionals (National Institutes of Health, 2011). Black (2006) states that hospice nurses educate both the patient and the family members of their options in advance directives. One study describes the hospice nurse as an educator. The hospice nurse describes to the patient and family members the disease process, what to expect from a particular diagnosis, prognosis, and the final stages of life (Black, 2006). Hospice social workers are not only counselors for the patient but they also serve as counselors of the patient’s family. Haskins, Dobbins, Clanton, Bliss, & Dugan (2009) report that social workers aid the patient with resolving any financial and personal issues. If a patient is worried about leaving their pet behind after they die, the social worker aids in finding the pet a new home. Another role of a social worker is to explain advance directives to the patient and patient’s family. This helps both the patient and family avoid confusion later on when the patient is unresponsive. Additionally, they help the patient and family members with funeral arrangements and assist the patient and patient’s family through their anticipatory grief (Black, 2006). Hospice chaplains are non-denominational based and provide services to all religions and spirituality. Chaplains respect all patient’s denomination and provide spiritual support based on the patient’s beliefs. Chaplains also integrate family members into their sessions. Through their sessions, chaplains can facilitate interactions between the patient and the family members. Similar to social workers, chaplains also aid the patient and family members with funeral arrangements (Haskins et al., 2009). Hospice searches for specific personality traits when interviewing volunteers. People who are good listeners, compassionate, respectful, and empathic tend to be suitable for volunteers (Claxton-Oldfield et al., 2010). Research has revealed that female volunteers scored high on three out of the “Big Five” personality traits, which were agreeableness, extroversion, and openness (Claxton-Oldfield & Banzen, 2010). These personality traits are crucial for becoming a suitable volunteer at any hospice organization.

6 The role of volunteer includes running errands for the patient and patient’s primary caregiver, driving the patient to any appointment, and providing emotional support. One of the most important roles a volunteer can provide is respite care, which allows the primary caregiver time to rest (Claxton-Oldfield et al., 2010). Additionally, researchers found that, “having the volunteer offer them emotional support, provide them with information (e.g., on what to expect with their loved one’s condition), and spend some time with them was also highly valued by family members” (p. 194). Although it is not required, some hospice organizations offer complimentary therapies such as pet therapy, art therapy, and music therapy. Hospice patients may experience social isolation due to their illness and it may lead to loneliness. Also, patients and their family members might experience stress during end of life care. Research has found that pet therapy used in a hospice setting can improve patient relationships and provide companionship (Geisler, 2004). Art therapy and music therapy are beneficial in hospice situations. Art therapy is the use of creating art to improve the well-being of patients (American Art Therapy Association, 2011). Through the use of art therapy in a hospice setting, patients have reported experiencing physical and spiritual benefits. In regards to music therapy, music plays a major part in a person’s life and people link music to these memories. Music therapy can provide positive socialization between the patient and family members, therefore increasing the patient’s quality of life (Magill, 2009). The Role of Music Therapy Music therapy has been shown to have an effect in increasing quality of life. Choi (2010) found that music therapy had a positive effect in reducing the anxiety levels of family caregivers of Hospice patients. Music therapy interventions can also aid in decreasing fatigue and increasing quality of life of Hospice caregivers. Also music paired with progressive muscle relaxation has shown benefits of increasing caregiver's quality of life (Choi, 2010). Patients admitted into the Hospice program do not die immediately after being admitted. In fact, Hospice patients can live well beyond their original prognosis under certain circumstances. Terminally ill hospice patients living in nursing homes receiving music therapy lived longer than those patients not receiving music therapy. Music therapy appeared to increase

7 patient's quality of life, allowing them to live longer than projected (Hilliard, 2004). The same results were found for cancer patients receiving hospice care. The cancer patients receiving music therapy had a longer length of life and experienced an increase in their quality of life (Hilliard, 2003). Hospice patients can experiencing grieving while still living and may withdraw within themselves (Buglass, 2010). Music therapy can help patients cope and work through their grieving and increase their quality of life. In regards to physical and chronic pain, music has been shown to be effective in reducing pain (Standley, 2000). Music can help reduce patient's perception of pain and anxiety both during and after a medical procedure (Madson & Silverman, 2010). One technique used to help alleviate pain is the ISO-principle; ISO meaning same. In the ISO-principle, the music therapists plays a patient-preferred song that matches the patient's state of being, meaning if the patient is breathing rapidly, then the music therapist would play a song that matches the rhythm of the patient's breathing. The music therapist would then gradually bring the patient down to a steady and relaxed level. As patients go on their journey towards the end of life, they may question their life. Life review is a time for one to reflect on their life and decide how they want to be remembered. They also may wonder how they will be remembered by others. Music and poetry help facilitate life review. A music therapist may give a patient song choices to choose from. After the song has been played a sung together by the music therapist and patient, the music therapist may begin lyric analysis and help the patient engage in reminiscence (Wlodarczyk, 2009). through life review they are able to have closure with themselves and with their family. The patient may also decide that they want to leave something behind for their family members and loved ones. Music therapy can help patients achieve this by doing a Living Legacy project with the patient. During the process of creating a Living Legacy project, patients may choose to made a video of themselves telling their life story for their family members. Another option may be recording several music therapy sessions in which the patient reminiscences about their life. Music can aid in sparking past memories. The music therapist can also help the patient write a song for the patient’s family members, leaving them a final message. It could be a parody of a song or an original song. Additionally, patients may choose to have the song given to the

8 family members after the patient has passed away. Lastly, patients could choose to leave a cd of specially selected pre-existing songs, each containing a message for the family members. One study investigated the effect of a music therapist's nonverbal behavior on the participation level and affect of Alzheimer's patients. Cevasco (2010) found that music therapist's nonverbal behaviors do have an effect on Alzheimer's patients affect and participation level. When the music therapist was at a close proximity to the patients and utilizing facial affect, the patient would also respond nonverbally and participate with the music therapist in instrument playing (Cevasco, 2010). Music can be used as a tool to enhance social skills and communication, therefore improving the patient's quality of life. One case study investigated the effect of instrument playing on a Hospice patient diagnosed with debility. Pierce (2010) found that instrument playing had a positive effect on the patient's mood and emotions. In music therapy sessions that did not involve the use of instrument playing, the music therapy intern found that the patient would sleep throughout the music therapy session. In music therapy sessions that involved the patient playing a small egg-shaped shaker, the patient would remain awake and make eye contact with the music therapy intern. The patient smiled and even sang with the music therapist while playing the shaker. The patient would shake the shaker with more energy whenever the music therapy intern gave the patient positive feedback (Pierce, 2010). "Music as a stimulus is unique in its ability to simultaneously affect both emotion and neurophysiology" (Krout, 2000, p. 327). Music therapists can use improvisation to help patients cope with their terminal illness, as well as provide a way for the patient to express their emotions (Krout, 2000). A patient may no longer be able to verbally communicate with their loved ones or with those who care for them, but music can provide a way for the patient to express their feelings. Improvisation on an instrument can help the patient express their emotions. Music listening can also help the patient express their emotions. Having knowledge of the patient's preferred music is essential. Asking the patient to choose songs can help them express what they cannot say (Krout, 2000). Songwriting provides an emotional outlet for the patient (Krout, 2000). Sometimes the patient has difficulty speaking or may not feel comfortable with speaking about their feelings,

9 but writing a song gives them the freedom express themselves. Singing and songwriting also can have an effect on the spirituality of patients (Krout, 2000). Patients may feel the need to praise their God, but may not be able to attend a church due to their illness. Music therapy can provide an opportunity for the patient to worship through singing or music listening. The patient may also feel compelled to write a song that speaks of their love for their God. The music therapist can either help the patient create an original song of worship or help the patient write a parody of a pre-existing song. Repertoire In order for music therapists to be effective in their job, they need to have a wide variety of songs in their repertoire. However, in certain populations, some songs may be more effective than others. What repertoire would be appropriate in a hospice setting? Hospice music therapists often determine what songs a patient may enjoy by choosing popular songs from when the patient was between 18-25. Previous research has found that music therapy students had difficulty in identifying the decades in which songs were composed and correctly naming the titles of songs (VanWeelden, Juchniewicz, & Cevasco, 2008). According to VanWeelden et al. (2008), "Selecting songs from correct decades is extremely valuable when working with clients in acute rehabilitation settings or individuals with Alzheimer's disease, who might not be able to communicate preferences" (p. 455). Although selecting music from the patient’s young adult years may determine appropriate repertoire, empirical data has indicated this may not be the only factor when choosing music for older adults (VanWeelden & Cevasco, 2010). The study, consisting of undergraduate and graduate music therapy majors and geriatric clients, were asked if they recognized and name songs from a list of songs used for geriatric patients. The songs that the geriatric patients recognized were from 1910 or earlier, 1920s, 1930s, and 1940s. "[T]his research indicated the young adult years hypothesis did not exist for these participants; geriatric clients did not identify music that was most familiar to them from their young adult years" (VanWeelden & Cevasco, 2010, p. 86). There have been compilations of songs used for the geriatric population. A previous research study investigated the type of music that was popular among older adults and compiled

10 a list of recommended repertoire for geriatric clients (VanWeelden and Cevasco, 2007). In addition, Russell Hilliard also compiled a list of songs used in the Hospice music therapy setting from the genres of Americana (popular prior to 1950), Country and Western, Popular (1950+), Musicals, and Religious/Spiritual (Standley & Jones, 2007). These are currently the only up-to- date repertoire list for the geriatric population. Need for the Study Although there have been studies conducted on music therapy techniques, only a few of them focus solely on techniques used in a hospice setting. In 2000, Krout compiled a list of 20 techniques that can be used by music therapists in a hospice setting. Choi (2010) also conducted a study which focuses specifically on hospice music therapy techniques. Are the techniques in these studies currently being used by hospice music therapists? Additionally, there have been few studies on the repertoire being used in hospice settings. Both professional music therapists and music therapy students need to be aware of the repertoire currently being used in hospice situations. Purpose The purpose of this study was to determine the specific genre-related repertoire used by professional hospice music therapists. Additionally, this study sought to investigate what specific music therapy techniques were being used in a hospice setting, as well as the frequency these techniques were being used. The following are the specific research questions addressed in this study: Research Questions 1) What songs are most frequently used by professional hospice music therapists in the genre of Oldies (popular music prior to 1950)? 2) What songs are most frequently used by professional hospice music therapists in the genre of Religious/Spiritual? 3) What songs are most frequently used by professional hospice music therapists in the genre of Country/Western? 4) What songs are most frequently used by professional hospice music therapists in the genre of Musicals?

11 5) What songs are most frequently used by professional hospice music therapists in the genre of Popular music (popular music from 1950 to the present)? 6) What are the top ten songs frequently used by hospice music therapists in the genre of Oldies (popular music prior 1950)? 7) What are the top ten songs frequently used by hospice music therapists in the genre of Religious/Spiritual? 8) What are the top ten songs frequently used by hospice music therapists in the genre of Country/Western? 9) What are the top ten songs frequently used by hospice music therapists in the genre of Musicals? 10) What are the top ten songs frequently used by hospice music therapists in the genre of Popular (popular music from 1950 to the present)? 11) Is it possible for the recommended song repertoire to be categorized into music for emotional expression or music for enjoyment? 12) How often were specific music therapy techniques used with clients? 13) Were there differences between the amounts of client use for each music therapy technique?

Operational Definitions

Oldies Popular music between the years 1900-1950. Religious/Spirituals Traditional Christian hymns and gospel music. Country/Western Traditional and popular music originating from the southern region of the United States. Musicals Music derived from musical theatre productions. Popular Popular music from the year 1950 to the present.

12 Music Listening Listening to live or recorded music. Improvisation Creating music in response to one’s feelings or a prompt. Singing Client vocally singing alone or with music therapist. Songwriting Creating lyrics and melody for an original song or re-writing lyrics to an already existing song. Music Playing Client participating by playing an instrument. Song Choice Music therapist providing two or three song choices and asking the client to choose one song. Music listening and imagery for relaxation Music therapist providing instrumental music while verbally creating a relaxing scene for the client. Lyric Analysis Music therapist asking the client questions pertaining to the lyrics of a song. Guided Imagery and Music (Bonny Method) Specifically selected Classical music designed to stimulate images in the mind of the client. Musical Life Review The use of music to engage the client in communicating and reminiscing about their life. Creative Art Therapies The use of art therapy, dance/movement therapy, drama therapy, music therapy, poetry therapy, and psychodrama. Music and Drawing/Painting

13 The use of live or recorded music to aid the client in creating art that reflects their feelings. Music Therapy and Verbal Social Work Techniques Incorporating social work techniques in a music therapy session. Hypnosis Inducing the client in a state of unconsciousness in order to access the subconscious mind. Meditation Training the mind and body to enter a state of consciousness and awareness. Multi-modal Stimulation Engaging the client by use of tactile, auditory, and visual stimulation. Music Therapy Combined with OT and Speech Therapy Incorporating music therapy techniques to help achieve goals in OT and speech therapy. Pediatric Group Therapy Group music therapy sessions with pediatric clients. Stimulation Protocol Gradually adding new stimuli to help confused or agitated patients adapt to their environment. Toning The use of vocal techniques to correct imbalances in the client’s body.

14 CHAPTER 3

Method

The purpose of this study was to determine the specific repertoire used by professional hospice music therapists in the following genres: Oldies, Religious/Spirituals, Country/Western, Musicals, and Popular. Furthermore, based on the participant’s responses, a list containing the ten most frequently used songs for those genres would be compiled. Additionally, this study also investigated how often specific music therapy techniques were used by music therapists in a hospice setting. Differences between the amounts of use for the music therapy techniques will also be investigated.

Participant Description Participants for this study consisted of professional music therapists (N=40) working in a hospice setting. This study was limited to professionals because music therapy students would not be able to effectively complete the survey. The American Music Therapy Association Sourcebook (2010) lists music therapists by population and work setting. Only music therapists that included an email address were considered for this study. Music therapists listed under the “Hospice/Bereavement Services” work setting (pp. 196-197) were matched with their corresponding email addresses provided in the “General Membership Listing” (pp. 43-142). The music therapists classified as working in a hospice setting had to also be classified as a professional music therapist in the “General Membership Listing.” Music therapists were not included in this study if they were listed as a student, retiree, or honorary member. A list was compiled which contained the email addresses of all professional music therapists arranged under the “Hospice/Bereavement Services” work setting. The music therapists who met the criteria were sent an email asking them to participate. This introductory email included a link to the survey.

Dependent Variable

15 The dependent variable was a survey created by the researcher on the SurveyMonkey website. In the first section of the survey participants were asked to list up to 10 song titles they use most frequently in their music therapy sessions within five individual genres,. The five genres included Oldies (popular music prior to 1950), Religious/Spirituals, Country and Western, Musicals, and Popular (popular music from 1950 to the present). The second section of the survey asked the participants to rate the frequency in which they use specified music therapy techniques with their clients in a hospice situation. The music therapy techniques include: music listening, improvisation, singing, songwriting, music playing, song choice, music listening and imagery for relaxation, lyric analysis, guided imagery and music (Bonny method), musical life review, creative art therapies, music and drawing/painting, music therapy and verbal social work techniques, hypnosis, meditation, multi-modal stimulation, music therapy combined with OT and speech therapy, pediatric group music therapy, stimulation protocol, and toning. The rating scale consisted of: 1 - never with a client, 2 - with certain clients, 3 - with more than half of the clients, and 4 - with all clients. A copy of the complete survey is included in Appendix A. Procedure First, approval for research involving human subjects was obtained from Florida State University’s Institutional Review Board. A copy of the approval letter is included in Appendix B. After receiving approval, certain criteria was developed to determine the type of participants for this study. Music therapists who were of professional standing and worked in a hospice setting met the criteria for being a participant in this study. Email addresses of all professional hospice music therapists were collected through the AMTA Sourcebook. The email addresses were arranged and organized onto an electronic spreadsheet. Next, an email was sent to all professional hospice music therapists. The email briefly introduced the study and invited the music therapists to participate in the study. The email stated the length of the study, the approximated time it would take to complete the study, as well as a link to the electronic survey. A copy of the introductory email letter is included in Appendix C. After clicking the link to the survey, participants were directed to the first page of the electronic survey. This page contained an informed consent form. Participants were informed

16 that this study was voluntary and they may withdraw from the survey at any time. A copy of the informed consent form is included in Appendix D. A response was required for the informed consent form. If the participant click the “Yes” button, they were directed to the survey. If “No” was clicked, the participant would be directed to the end of survey which contained a message thanking them for their time. Lastly, in regards to the other survey questions, a response was not required in order to progress through the survey. After progressing through all survey questions, a message appeared thanking the participants for their time. All responses to the survey questions were collected anonymously through SurveyMonkey. The researcher compiled and arranged all responses onto a spreadsheet. All data was tallied, arranged alphabetically, then organized into tables based on this study’s research questions. After organizing the song repertoire, the ten songs recommended frequently by music therapists were compiled into a list.

17 CHAPTER 4

Results

A total of 157 music therapists were listed as working in a hospice setting; however, several from this list were excluded a priori to participate in this study. Reasons for excluding some individuals included: (1) no email address was provided, (2) were music therapy students and not professionals, (3) were retired from the profession, and (4) were listed as an “honorary” member. Therefore, a total of 142 professional music therapists who worked in a hospice setting were contacted by email and given a link to complete the survey. Of the 142 email addresses, eight email addresses no longer were operational creating a list of 134 music therapists available to complete the study. Of these 134 music therapists 40 survey responses were received creating a 30% return rate. A combined total of songs (N = 577) were recommended within the five categories. When the music style categories were separated, oldies (n = 139) comprised 24%, religious/ spirituals (n = 108) comprised 19%, country/western (n = 106) comprised 18%, musicals (n = 78) comprised 13%, and popular (n = 146) comprised 25%. However, since music therapists were free to choose the style category for each composition, several songs were placed within more than one song category. To determine if song titles were recommended under more than one category, creating overlaps, each category’s list of song was investigated. Results found 75 songs (or 19%) were identified within multiple genres by music therapists. The overlaps occurred between Oldies and Musicals (n = 9), Oldies and Country/Western (n = 14), Oldies and Religious (n = 7), Oldies and Popular (n = 16), Religious and Country/Western (n = 1), Religious and Popular (n = 3), Country/Western and Musicals (n = 1), Country/Western and Popular (n = 11), and Musicals and Popular (n = 8). Therefore, the true number of individual songs that were recommended was 465. To determine if the recommended songs were within the correct category, each song was investigated to establish the year it was composed and the style category it is labeled within the music industry. Songbooks that contained this repertoire, the Internet, and historical reference materials were used to gather the data. Results found 40 songs were mislabeled in the genre of oldies, 13 songs were mislabeled in the genre of country/western, 5 songs were mislabeled in the 18 genre of musicals, and 23 songs were mislabeled in the genre of popular music. Additionally, through this investigation several songs, and the resulting genres, results found several songs from different style categories that weren’t specifically listed in the study. These included: Christmas Carols (n = 3), Folk Song (n = 4), and Patriotic (n = 5). Therefore, when the music style categories were separated by correctly categorized songs oldies (n = 99) comprised 21%, religious/spirituals (n = 108) comprised 19%, country/western (n = 93) comprised 18%, musicals (n = 73) comprised 15%, and popular (n = 119) comprised 25%.

1) What songs are used by professional hospice music therapists in the genre of Oldies (popular music prior to 1950)? Music therapists listed 139 popular songs they use with clients in a hospice setting. From this list 99 were popular songs composed before 1950. Based on the participant’s responses, the songs Let Me Call You Sweetheart and You Are My Sunshine were both listed by the greatest number of professional hospice music therapists (n = 27 or 27%). There were also five other popular songs that were listed by 10 or more music therapists: Always; Daisy Bell; Five Foot Two, Eyes of Blue; Sentimental Journey; and Side By Side. Conversely, there were also a large number of songs (n = 71 or 71%) that were only recommended by a single music therapist. Full results are listed in Table 1.

Table 1

Oldies (Popular music prior to 1950) Used By Hospice Music Therapists

Decade Song Titles ∑ Composed Style

After the Ball 1 1890s Oldies Ain't She Sweet 5 1920s Oldies Ain’t Misbehavin’ 1 1920s Oldies Alexander’s Ragtime Band 2 1910s Oldies All I Have to Do is Dream 1 1950s Oldies

19 Table 1 (continued)

Song Titles ∑ Decade Style Composed

All of Me 2 1930s Oldies All Through the Night 2 1930s Musical Always 15 1920s Oldies Amazing Grace 3 1770s Religious/Spiritual America the Beautiful 3 1890s Patriotic April Showers 1 1920s Musical As Time Goes By 6 1930s Musical At Last 1 1940s Musical Baby Face 3 1920s Oldies Be Sure It’s True When You Say I Love 1 1930s Oldies You Beautiful Dreamer 3 1860s Oldies Beautiful Ohio 1 1910s Oldies Besame Mucho 1 1940s Oldies Beyond the Sea 1 1940s Oldies Blue Moon 1 1930s Oldies Blue Skirt Waltz 1 1940s Country/Western Blues Skies 4 1920s Oldies Brahms’ Lullaby 1 1860s Oldies Button Up Your Overcoat 1 1920s Oldies By the Light of the Silvery Moon 1 1900s Oldies Carolina Moon 1 1920s Oldies Chattanooga Choo Choo 3 1940s Oldies Cielito Lindo 1 1880s Oldies Clementine 1 1860s Oldies Count Your Blessings Instead of Sheep 1 1950s Oldies Daisy Bell (A Bicycle Build For Two) 13 1890s Oldies Danny Boy 6 1910s Oldies Darktown Strutter’s Ball 1 1910s Oldies Don't Sit Under the Apple Tree 6 1940s Oldies Don’t Get Around Much Anymore 1 1940s Oldies Dona Nobis Pacem 1 1930s Oldies Down by the Old Mill Stream 2 1910s Oldies

20 Table 1 (continued)

Song Titles ∑ Decade Style Composed

Down in the Valley 1 1920s Oldies/Folk Dream a Little Dream of Me 1 1930s Oldies Edelweiss 2 1960s Musical Embraceable You 1 1920s Oldies Five Foot Two, Eyes of Blue 13 1920s Oldies Fly Me To The Moon 4 1950s Popular For Me and My Gal 1 1910s Oldies Glory of Love 1 1930s Oldies God Bless America 3 1930s Patriotic Goodnight, Irene 1 1930s Oldies He’s Got the Whole World in His Hands 3 1920s Religious/Spiritual Hey Good Lookin’ 2 1950s Country/Western Home on the Range 8 1910s Oldies How Much is that Doggy in the Window? 1 1950s Popular I Don’t Know Why (I Love You Like I 1 1930s Oldies Do) I Got Rhythm 1 1930s Oldies I Love You Truly 3 1900s Oldies I Wonder Who’s Kissing Her Now 1 1900s Oldies I'm Forever Blowing Bubbles 1 1910s Oldies I’ll Be Seeing You 4 1930s Oldies I’m Looking Over a Four Leaf Clover 4 1940s Oldies I’ve Been Working on the Railroad 5 1890s Oldies In the Garden 1 1910s Religious/Spiritual In the Good Old Summertime 3 1900s Oldies In the Mood 2 1930s Oldies In The Shade of the Old Apple Tree 3 1900s Oldies It Had to Be You 4 1920s Oldies Ja Da Ja Da 1 1910s Oldies Just Because 1 1920s Oldies K-K-K-Katy 1 1910s Oldies La Bamba 1 1950s Popular Let Me Call You Sweetheart 27 1910s Oldies

21 Table 1 (continued)

Song Titles ∑ Decade Style Composed

Let the Rest of the World Go By 1 1910s Oldies Look For the Silver Lining 1 1920s Oldies Love Letters in the Sand 1 1930s Oldies Love Me Tender 1 1950s Popular Love’s Old Sweet Song 2 1890s Oldies Ma, He’s Makin’ Eyes at Me 1 1960s Popular May the Good Lord Bless You and Keep 1 1950s Popular You Meet Me in St. Louis, Louis 1 1900s Oldies Memories 2 1900s Oldies Michael Row the Boat Ashore 1 1860s Religious/Spiritual Moon Glow 1 1930s Oldies Moon River 2 1960s Popular Moonlight Bay 2 1910s Oldies Moonlight in Vermont 1 1940s Oldies My Blue Heaven 2 1920s Oldies My Bonnie Lies Over the Ocean 3 1920s Oldies My Buddy 3 1920s Oldies My Country ‘Tis of Thee 2 1830s Patriotic My Old Kentucky Home (regional) 2 1850s Oldies My Wild Irish Rose 3 1890s Musical Night and Day 2 1930s Musical Now the Day is Over 1 1860s Religious/Spiritual Oh Susanna 2 1840s Oldies Oh What a Beautiful Morning 1 1940s Musical Oh You Beautiful Doll 2 1910s Oldies Ol’ Man River 1 1920s Musical Old Folks at Home 1 1890s Oldies On the Sunny Side of the Street 4 1930s Musical Pennies from Heaven 2 1930s Oldies Polly Wolly Doodle 1 1880s Oldies Que Sera Sera 1 1950s Popular Red River Valley 3 1920s Country/Western

22 Table 1 (continued)

Song Titles ∑ Decade Style Composed

Red Roses for a Blue Lady 1 1940s Oldies Red Sails in the Sunset 2 1930s Oldies Redwing 1 1900s Oldies Sentimental Journey 16 1940s Oldies She’ll Be Coming Around the Mountain 1 1920s Oldies Shenandoah 3 1800s Popular Shine on Harvest Moon 3 1900s Popular Show Me the Way to Go Home 2 1920s Oldies Side By Side 10 1920s Oldies Simple Gifts 1 1840s Oldies Singing in the Rain 2 1920s Musical Somewhere Over the Rainbow 9 1930s Oldies Stand By Me 1 1960s Popular Star Spangled Banner 1 1810s Patriotic Stardust 3 1920s Oldies Swing Low, Sweet Chariot 1 1920s Religious/Spiritual Take Me Out to the Ball Game 4 1900s Oldies Tennessee Waltz 2 1940s Country/Western That’s Amore 1 1950s Popular The Ash Grove 1 1800s Oldies The Beer Barrel Polka 2 1920s Oldies The Way You Look Tonight 1 1930s Oldies This Land is Your Land 1 1940s Patriotic Till We Meet Again 3 1910s Oldies True Love 1 1950s Popular What a Wonderful World 2 1960s Popular When I Fall In Love 2 1950s Popular When Irish Eyes are Smiling 5 1910s Musical When It’s Springtime in the Rockies 4 1930s Country/Western When the Red, Red Robin Comes 2 1920s Oldies Bobbin’ Along When the Saints Go Marching In 2 1890s Religious/Spiritual When You’re Smiling 1 1930s Oldies

23 Table 1 (continued)

Song Titles ∑ Decade Style Composed

Whispering Hope 1 1860s Oldies White Cliffs of Dover 1 1940s Oldies Yankee Doodle Boy 1 1900s Musical You Are My Sunshine 27 1940s Country/Western You Made Me Love You 1 1910s Oldies

When examining the recommended songs, several inconsistencies were noted when compared with the style category. For example, of the 139 songs, 15 were songs composed after 1950. Additionally, several songs were not popular songs at all (n = 25). Table 2 contains the songs that were mislabeled within the Oldies style category.

Table 2

Mislabeled Songs Within the Oldies Genre

Song Titles All I Have to Do Is Dream All Through the Night Amazing Grace America the Beautiful April Showers As Time Goes By At Last Blue Skirt Waltz Count Your Blessings Instead of Sheep Fly Me to the Moon God Bless America He’s Got the Whole World in His Hands

24 Table 2 (continued) Song Titles Hey Good Lookin’ How Much is that Doggie in the Window In the Garden La Bamba Love Me Tender Ma, He’s Makin’ Eyes at Me May the Good Lord Bless You and Keep You Michael Row the Boat Ashore Moon River My Country Tis of Thee My Wild Irish Rose Night and Day Now the Day is Over Ol’ Man River On the Sunny Side of the Street Que Sera Sera Red River Valley Singing in the Rain Stand By Me Star Spangled Banner Swing Low, Sweet Chariot Tennessee Waltz That’s Amore True Love What a Wonderful World When I Fall In Love When It’s Springtime in the Rockies Whispering Hope

2) What are the ten most frequently used songs by hospice music therapists in the genre of Oldies (popular music prior to 1950)? Many individual song titles were recommended by multiple music therapists, which allowed the creation of a list of most frequently used popular songs in a hospice setting. Table 3 lists the top ten frequently used songs by music therapists. Additionally, because many songs

25 were recommended the same number of times, which created a tied rank, Table 3 contains more than 10 songs.

Table 3

Top Ten Oldies (Popular music prior to 1950) Frequently Used By Hospice Music Therapists

Song Titles Sum Let Me Call You Sweetheart 27 You Are My Sunshine 27 Sentimental Journey 16 Always 15 Daisy Bell (A Bicycle Built For Two) 13 Five Foot Two, Eyes of Blue 13 Side By Side 10 Somewhere Over the Rainbow 9 Home on the Range 8 As Time Goes By 6 Danny Boy 6 Don’t Sit Under the Apple Tree 6

3)What songs are used by professional hospice music therapists in the genre of Religious/ Spiritual? Music therapists’ listed 108 religious/spiritual song titles they use frequently with clients. Based on the participant’s responses, the song Amazing Grace was listed by the largest number of professional music therapists (n = 39). The second most listed song was In the Garden (n = 30). Six other songs were also listed by 10 or more music therapists: How Great Thou Art; I’ll Fly Away; Just a Closer Walk With Thee; Swing Low, Sweet Chariot; The Old Rugged Cross; and What a Friend We Have in Jesus. There were also a large number of songs that were only recommended once by a single music therapist (n = 69 or 70%). Full results are listed in Table 4.

26 Table 4

Religious/Spiritual Songs Used By Hospice Music Therapists

Song Titles ∑ Decade Style Composed

Abide With Me 3 1840s Religious/Spiritual Amazing Grace 39 1770s Religious/Spiritual Alleluia 1 1970s Religious/Spiritual As the Deer 1 1980s Contemporary Christian At the Cross 1 No Date Found Religious/Spiritual Ave Maria 4 1820s Religious/Spiritual Ave Verum Corpus 1 14th century Religious/Spiritual Away in a Manger 1 1880s Christmas Carol Be Not Afraid 2 1910s Religious/Spiritual Because He Lives 2 1970s Religious/Spiritual Beulah Land 1 1880s Religious/Spiritual Beyond the Sunset 1 1930s Religious/Spiritual Blessed Assurance 9 1870s Religious/Spiritual Children of the Heavenly Father 1 1850s Religious/Spiritual Church in the Wildwood 1 1860s Religious/Spiritual Come Sing a Song With Me 1 1970s Religious/Spiritual Count Your Many Blessings 1 1890s Religious/Spiritual Crown Him With Many Crowns 1 1860s Religious/Spiritual Do Lord 2 1860s Religious/Spiritual Down By the Riverside 1 1920s Religious/Spiritual Fairest Lord Jesus 1 1840s Religious/Spiritual For the Beauty of the Earth 1 1830s Religious/Spiritual Go Tell it On the Mountain 1 1980s Religious/Spiritual God Be With You 'Till We Meet Again 2 1900s Religious/Spiritual God Will Take Care of You 2 1880s Religious/Spiritual Going Home 2 1890s Religious/Spiritual Grace Like Rain 1 2000s Contemporary Christian Great Is Thy Faithfulness 1 1920s Religious/Spiritual Hail Holy Queen 1 No Date Found Religious/Spiritual Hal'luya la olam 1 No Date Found Jewish

27 Table 4 (continued)

Song Titles ∑ Decade Style Composed

Hatikva 1 No Date Found Jewish Folk Song Hava Nagila 2 1910s Jewish Folk Song He Touched Me 1 1960s Religious/Spiritual He's Got the Whole World in His 5 1950s Religious/Spiritual Hands Hevenu Shalom Alechem 1 No Date Found Jewish Folk Song Hineh Ma Tov 2 No Date Found Jewish Folk Song His Eye Is on the Sparrow 6 1900s Religious/Spiritual Holy God We Praise Thy name 1 1770s Religious/Spiritual Holy, Holy, Holy 1 1860s Religious/Spiritual How Great Thou Art 25 1950s Religious/Spiritual I Believe 1 1950s Religious/Spiritual I Can Only Imagine 2 2000s Contemporary Christian I Feel Like Travelin' On 1 1950s Religious/Spiritual I Know Who Holds Tomorrow 1 1950s Religious/Spiritual I Let Go 1 No Date Found Unknown I Love to Tell the Story 2 1860s Religious/Spiritual I Need Thee Every Hour 1 1850s Religious/Spiritual I Release & I Let Go 1 No Date Found Unknown I Sing the Mighty Power of God 1 1710s Religious/Spiritual I Surrender All 1 1890s Religious/Spiritual I'll Fly Away 14 1920s Religious/Spiritual Immaculate Mary 1 1920s Religious/Spiritual In the Garden 30 1910s Religious/Spiritual In the Sweet By and By 5 1860s Religious/Spiritual It Is No Secret 1 1950s Religious/Spiritual It is Well With My Soul 6 1870s Religious/Spiritual Jerusalem of Gold 1 1960s Religious/Spiritual Jesus Loves Me 8 1860s Religious/Spiritual Joyful Joyful We Adore Thee 2 1900s Religious/Spiritual Just a Closer Walk With Thee 12 1940s Religious/Spiritual Just a Little Talk with Jesus 1 1860s Religious/Spiritual Just as I Am Without One Plea 1 1830s Religious/Spiritual

28 Table 4 (continued)

Song Titles ∑ Decade Style Composed

Leaning on the Everlasting Arms 2 1880s Religious/Spiritual Let There Be Peace On Earth 1 1980s Religious/Spiritual Make Me a Channel of Your Peace 1 1910s Religious/Spiritual Mansion Over the Hilltop 1 1940s Religious/Spiritual May the Good Lord Bless and Keep 1 1950s Religious/Spiritual You Michael Row the Boat Ashore 1 1860s Religious/Spiritual Morning Has Broken 1 1930s Religious/Spiritual My Faith Looks Up to Thee 1 1830s Religious/Spiritual Nearer My God to Thee 4 1850s Religious/Spiritual Oh Happy Day 1 1750s Religious/Spiritual Oh How He Loves You 1 2000s Contemporary Christian On Eagle's Wings 9 1970s Religious/Spiritual On the Wings of a Dove 1 1840s Religious/Spiritual One Bread, One Body 1 1970s Religious/Spiritual Ose Shalom 3 No Date Found Jewish Oyaheya 1 No Date Found Jewish Peace I Leave With You 1 No Date Found Unknown Peace in the Valley 2 1930s Religious/Spiritual Pour Yourself in Me 1 2000s Religious/Spiritual Precious Lord, Take My Hand 7 1930s Religious/Spiritual Precious Memories 1 1920s Religious/Spiritual Rock of Ages 2 1770s Religious/Spiritual Shall We Gather at the River 2 1860s Religious/Spiritual Shalom Chaverim 1 1980s Jewish Silent Night 1 1810s Christmas Carol Softly and Tenderly 2 1880s Religious/Spiritual Standing on the Promises 1 1880s Religious/Spiritual Sweet Hour of Prayer 1 1860s Religious/Spiritual Swing Low, Sweet Chariot 10 1980s Religious/Spiritual Tell Me the Old, Old Story 1 1870s Religious/Spiritual That Glad Reunion Day 1 1950s Religious/Spiritual The Lord's Prayer 3 1930s Religious/Spiritual

29 Table 4 (continued)

Song Titles ∑ Decade Style Composed

The Old Rugged Cross 17 1910s Religious/Spiritual The Plan 1 No Date Found Unknown This Little Light of Mine 2 1980s Religious/Spiritual Unclouded Day 1 1980s Religious/Spiritual Valleys of Green 1 No Date Found Unknown Victory In Jesus 1 1930s Religious/Spiritual What a Friend We Have in Jesus 16 1850s Religious/Spiritual When I Survey the Wondrous Cross 1 1820s Religious/Spiritual When We All Get to Heaven 1 1890s Religious/Spiritual Where Could I Go? 1 No Date Found Unknown Whispering Hope 3 1860s Oldies You Are the Face of God 1 No Date Found Unknown You Raise Me Up 1 2000s Religious/Spiritual

When examining the recommended songs, several songs were not standard hymns but were still religious songs. There are many sub-genres for the genre of religious music. For example, of the 108 songs, two songs were Christmas carols. Additionally, eight recommended songs were of the Jewish tradition and four songs were Contemporary Christian songs. 4) What are the ten most frequently used songs by hospice music therapists in the genre of Religious/Spiritual? Many religious/spiritual song titles were listed multiple times by hospice music therapists, which allowed the creation of a list of most frequently used religious/spiritual songs used in a hospice setting. Table 5 contains a list of the ten most frequently used religious/ spiritual songs by music therapists.

30 Table 5

Top Ten Religious/Spiritual Songs Frequently Used By Hospice Music Therapists

Song Titles Sum Amazing Grace 39 In the Garden 30 How Great Thou Art 25 The Old Rugged Cross 17 What a Friend We Have in Jesus 16 I’ll Fly Away 14 Just A Closer Walk With Thee 12 Swing Low, Sweet Chariot 10 Blessed Assurance 9 On Eagle’s Wings 9

5) What songs are used by professional hospice music therapists in the genre of Country/ Western? Music therapists listed a total of 106 country/western songs they use with client in a hospice setting. From this list, 93 songs were actual country/western songs. Based on the participant’s responses, the song I Walk the Line was listed by the greatest number of music therapists (n = 20). Seven other songs were recommended by 10 or more music therapists: Crazy; Hey Good Lookin’; Ring of Fire; Take Me Home, Country Roads; Tennessee Waltz; and Your Cheatin‘ Heart. A large number of songs were recommended only once by individual music therapists (n = 65 or 75%). Full results are listed in Table 6.

31 Table 6

Country/Western Songs Used By Hospice Music Therapists

Song Titles ∑ Decade Style Composed

Abilene 1 1960s Country/Western Always on My Mind 5 1970s Country/Western Back In The Saddle Again 8 1930s Country/Western Ballad of Jed Clampett 1 1960s Country/Western Best of Both Worlds 1 2006 Popular Big Rock Candy Mountains 1 1920s Country/Western Blue Eyes Crying in the Rain 2 1970s Country/Western Blue Moon of Kentucky (regional) 1 1940s Country/Western Blue Skirt Waltz 1 1940s Country/Western Breathe 1 1990s Country/Western Clementine 2 1860s Country/Western Coal Miner’s Daughter 2 1960s Country/Western Coat of Many Colors 3 1960s Country/Western Could I Have This Dance 2 1980s Country/Western Crazy 19 1960s Country/Western Daddy Sang Bass 3 1960s Country/Western Deep in the Heart of Texas 4 1940s Country/Western Desparado 1 1970s Popular Don't Fence Me In 8 1930s Country/Western Don’t It Make My Brown Eyes Blue 1 1970s Country/Western Down in the Valley 1 1920s Country/Western Five Hundred Miles 1 1960s Country/Western Folsom Prison Blues 4 1950s Country/Western Forever and Ever, Amen 1 1980s Country/Western Gentle on My Mind 1 1960s Country/Western Go Rest High 1 1990s Country/Western Goodnight Irene 1 1930s Oldies Green Green Grass of Home 2 1960s Country/Western Happy Trails 6 1950s Country/Western Have I Told You Lately That I Love 3 1940s Country/Western You 32 Table 6 (continued)

Song Titles ∑ Decade Style Composed

Hello Darling 1 1970s Country/Western Hey Good Lookin' 18 1950s Country/Western Home on the Range 8 1910s Country/Western Honey, I'm Home 1 1990s Country/Western I Can't Help it if I'm Still in Love With 1 1950s Country/Western You I Fall to Pieces 3 1960s Country/Western I Hope You Dance 2 2000s Country/Western I Saw the Light 1 1940s Country/Western I Walk The Line 20 1950s Country/Western In the Jailhouse Now 1 1920s Country/Western Islands in the Stream 1 1980s Country/Western Jambalaya 2 1950s Country/Western Just a Closer Walk With Thee 1 1940s Religious/Spiritual Kentucky Rain 1 1970s Country/Western King of the Road 7 1960s Country/Western Kiss an Angel Good Morning 1 1970s Country/Western Leaving on a Jet Plane 2 1960s Popular Let the Rest of the World Go By 1 1910s Oldies Live Like You’re Dying 1 2000s Country/Western Lonesome Dove 1 2000s Country/Western Love Me Tender 2 1950s Country/Western Make the World Go Away 2 1960s Country/Western Mamas, Don't Let Your Babies Grow 1 1970s Country/Western Up to be Cowboys Man! I Feel Like a Woman 1 1990s Country/Western Mockin’ Bird Hill 1 1950s Country/Western My Heart Will Go On 1 1990s Popular Oh Susanna 1 1840s Country/Western Old Smoky 1 1920s Country/Western On the Road Again 5 1960s Country/Western On the Wings of a Snow White Dove 1 1960s Country/Western Party in the USA 1 2000s Popular

33 Table 6 (continued)

Song Titles ∑ Decade Style Composed

Ragtime of Cowboy Joe 1 1910s Country/Western Red River Valley 4 1920s Country/Western Red Sails in the Sunset 1 1930s Oldies Ring of Fire 13 1960s Country/Western Rocky Top 1 1960s Country/Western San Antonio Rose 1 1940s Country/Western Satisfied Mind 1 1950s Country/Western Sentimental Journey 1 1940s Oldies Shenandoah 1 1800s Country/Western Shenandoah Waltz 1 No Date Country/Western Found Sioux City Sue 1 1940s Country/Western Snowbird 1 1960s Country/Western Stand By Your Man 1 1960s Country/Western Streets of Laredo 1 1920s Country/Western Sunshine on My Shoulders 3 1970s Popular Sweet Georgia Brown 1 1920s Oldies Take Me Home, Country Roads 14 1970s Country/Western Tennessee Waltz 15 1940s Country/Western The Climb 1 2000s Popular The Gambler 3 1970s Country/Western The Ol’ Black Train 1 1930s Country/Western The River 4 1970s Country/Western The Water is Wide 1 1600s Country/Western This Land is Your Land 1 1950s Patriotic Through the Years 1 1980s Country/Western Tie a Yellow Ribbon 1 1970s Popular Up! 1 2000s Country/Western Vaya con Dios 1 1950s Country/Western Wabash Cannonball 5 1880s Country/Western Walk Through This World With Me 1 1960s Country/Western Walkin' After Midnight 7 1950s Country/Western Waltz Across Texas 1 1960s Country/Western

34 Table 6 (continued)

Song Titles ∑ Decade Style Composed

Wayward Wind 1 1950s Country/Western What a Wonderful World 1 1960s Popular When It’s Springtime in the Rockies 2 1930s Country/Western When There's Twilight on the Trail 1 1950s Country/Western When Will I Be Loved 1 1960s Country/Western When You Say Nothing at All 2 1980s Country/Western Who's Sorry Now 1 1920s Country/Western Wildwood Flower 2 1860s Country/Western Yellow Rose of Texas 2 1850s Country/Western You Are My Sunshine 6 1930s Oldies You Needed Me 1 1970s Country/Western You're Still the One 1 1990s Country/Western Your Cheatin' Heart 11 1950s Country/Western

When examining the recommended songs, several inconsistencies were noted when compared with the style category. For example, of the 106 songs, three songs were popular songs from 1950 to the present. Additionally, several songs were not country/western songs at all (n = 10). Table 7 contains the songs that were mislabeled within the country/western style category.

Table 7

Mislabeled Songs Within the Country/Western Genre

Song Titles Best of Both Worlds Goodnight, Irene Just a Closer Walk With Thee Let the Rest of the World Go By Party in the USA Red Sails in the Sunset Sentimental Journey

35 Table 7 (continued) Song Titles Sunshine on My Shoulders The Climb This Land is Your Land Tie a Yellow Ribbon What a Wonderful World You Are My Sunshine

6) What are the ten most frequently used songs by hospice music therapists in the genre of Country/Western? Many individual song titles were recommended multiple times by hospice music therapists, which allowed the creation of a list of most frequently used country/western songs used in a hospice setting. Table 8 contains a list of the ten most frequently used country/western songs by music therapists. A few songs were recommended the same number of times creating a tied rank within the list.

Table 8

Top Ten Country/Western Songs Frequently Used By Hospice Music Therapists

Song Titles Sum I Walk the Line 20 Crazy 19 Hey Good Lookin’ 18 Tennessee Waltz 15 Take Me Home, Country Roads 14 Ring of Fire 13 Your Cheatin’ Heart 11 Back in the Saddle Again 8 Don’t Fence Me In 8 Home on the Range 8

36 7) What songs are used by professional hospice music therapists in the genre of Musicals? Professional hospice music therapists listed 78 songs from musicals that they use with clients in a hospice setting. From this list, 73 were songs from musicals. The song Edelweiss was listed by the largest number of music therapists (n = 23). Four other songs from musicals were listed by 10 or more music therapists: My Favorite Things; Oh, What a Beautiful Morning; Somewhere Over the Rainbow; and You’ll Never Walk Alone. Conversely, there were also a large number of songs that were only recommended by one music therapist (n = 46 or 65%). Full results are listed in Table 9.

Table 9

Songs from Musicals Used By Hospice Music Therapists

Song Titles ∑ Decade Style Composed

76 Trombones 1 1950s Musical Alexander's Ragtime Band 1 1910s Oldies All I Ask of You 1 1980s Musical As Long as He Needs Me 1 1960s Musical Back In The Saddle 1 1930s Musical Bali Hai 3 1940s Musical Cabaret 2 1960s Musical Can't Help Lovin' Dat Man 1 1920s Musical Circle of Life 1 1990s Musical Climb Ev’ry Mountain 8 1950s Musical Day By Day 2 1970s Musical Do, Re, Mi 9 1950s Musical Don't Fence Me In 1 1930s Country/Western Edelweiss 23 1950s Musical Falling in Love with Love 1 1930s Musical For Good 1 2000s Musical Getting to Know You 6 1950s Musical Goodnight My Someone 2 1950s Musical Hello Dolly 6 1960s Musical

37 Table 9 (continued)

Song Titles ∑ Decade Style Composed

Hello Young Lovers 1 1950s Musical I Could Have Danced All Night 4 1950s Musical I Dreamed a Dream 1 1980s Musical I Whistle a Happy Tune 2 1950s Musical I’m Gonna Wash That Man Right Outta 1 1940s Musical My Hair If Ever I Would Leave You 1 1960s Musical If I Loved You 1 1940s Musical If I Were a Rich Man 1 1960s Musical Isn't It Romantic? 1 1930s Musical Les Mis 1 1980s Musical Love Makes the World Go Round 2 1960s Musical Lullaby of Broadway 1 1930s Musical Maria 1 1950s Musical Meet Me in St Louis, Louis 2 1900s Musical Memory 6 1980s Musical Moon River 3 1960s Musical My Favorite Things 19 1950s Musical New York, New York 1 1970s Popular Now or Never 1 2000s Musical Oh, What a Beautiful Morning 22 1940s Musical Oklahoma 2 1940s Musical Old Man River 2 1920s Musical On a Clear Day 1 1970s Musical On My Own 1 1980s Musical On the Street Where You Live 2 1950s Musical On the Sunny Side of the Street 1 1930s Musical One 1 1970s Musical People 2 1960s Musical People Will Say We're In Love 1 1940s Musical Raindrops Keep Falling 1 1960s Musical Right Here, Right Now 1 2000s Musical Send in the Clowns 1 1970s Musical

38 Table 9 (continued)

Song Titles ∑ Decade Style Composed

Shall We Dance? 3 1950s Musical Singing in the Rain 3 1920s Musical Sioux City Sue 1 1940s Country/Western Some Enchanted Evening 4 1940s Musical Someone to Watch Over Me 1 1920s Musical Somewhere (There's a Place for Us) 1 1950s Musical Somewhere Over the Rainbow 17 1930s Musical Sound of Music 9 1950s Musical Start of Something New 1 2000s Musical Stay Awake 1 1960s Musical Summertime 6 1930s Musical Sunrise, Sunset 5 1960s Musical Surrey with the Fringe on Top 1 1940s Musical Till There Was You 3 1950s Musical Time to Remember 1 No Date Found Unknown Tip Toe Through the Tulips 1 1920s Musical Tomorrow 3 1980s Musical Try to Remember 2 1960s Musical What a Wonderful World 1 1960s Popular What I did for Love 1 1970s Musical When You Wish Upon a Star 1 1940s Musical Where or When 1 1930s Musical White Christmas 1 1950s Musical Who Will Buy This Wonderful Morning 1 1960s Musical You Gotta Have Heart 1 1950s Musical You'll Never Walk Alone 12 1940s Musical Younger Than Springtime 1 1940s Musical

When examining the recommended songs, several inconsistencies were noted when compared with the style category. Of the 78 songs, several songs were not songs from musicals (n = 5). Table 10 contains the songs that were mislabeled within the musical style category.

39 Table 10

Mislabeled Songs Within the Musical Genre

Song Titles Alexander’s Ragtime Band Back in the Saddle Again New York, New York Sioux City Sue What a Wonderful World

8) What are the ten most frequently used songs by hospice music therapists in the genre of Musicals? Many individual song titles were recommended multiple times by hospice music therapists, which allowed the creation of a list of most frequently used songs from musicals used in a hospice setting. Table 11 contains a list of the ten most frequently used songs from musicals by music therapists. Since many songs were recommended the same number of times, which created a tied rank, Table 11 contains more than 10 songs.

Table 11

Top Ten Songs from Musicals Frequently Used By Hospice Music Therapists

Song Titles Sum Edelweiss 23 Oh, What a Beautiful Morning 22 My Favorite Things 19 Somewhere Over the Rainbow 17 You’ll Never Walk Alone 12 Do-Re-Mi 9 Sound of Music 9 Climb Ev’ry Mountain 8 Getting to Know You 6

40 Hello Dolly 6 Memory 6 Table 11 (continued) Song Titles Sum Summertime 6

9) What songs are used by professional hospice music therapists in the genre of Popular music (popular music from 1950 to the present)? Music therapists listed 146 popular songs they use with clients in a hospice setting. From this list, 123 songs were from1950 to the present. Compared to the other four genres, song titles were repeated by less than half of the participants. The song Let It Be was recommended by the highest number of music therapists (n = 17). Four other songs were recommended by 10 or more music therapists: Love Me Tender; What a Wonderful World; Wind Beneath My Wings; and You’ve Got a Friend. There were a large number of songs only recommended once by individual music therapists (94 or 80%). Full results are listed in Table 12.

Table 12

Popular Songs (Popular music from 1950 to the present) Used By Hospice Music Therapists

Song Titles ∑ Decade Style Composed

All I Have To Do Is Dream 4 1950s Popular All My Loving 1 1960s Popular American Pie 1 1970s Popular Angel 2 1980s Popular Annie's Song 3 1970s Popular Around the World 1 2000s Popular Baby (Justin Bieber) 1 2000s Popular Baby Beluga 1 1980s Popular Blowin’ In The Wind 6 1960s Popular 41 Blue Hawaii 1 1960s Popular Blue Moon 1 1950s Popular Table 12 (continued)

Song Titles ∑ Decade Style Composed

Blue Suede Shoes 5 1950s Popular Blueberry Hill 2 1950s Popular Both Sides Now 1 1960s Popular Bridge Over Troubled Water 7 1970s Popular Brown Eyed Girl 2 1960s Popular Bye, Bye Love 1 1970s Popular California Dreamin' 1 1960s Popular California Girls (Kate Perry) 1 2010s Popular Can You Feel The Love 1 1990s Popular Can’t Help Falling In love 1 1960s Popular Carolina in My Mind 1 1960s Popular Catch a Falling Star 2 1950s Popular Circle Game 1 1960s Popular Circle of Life 1 1990s Musical Coat of Many Colors 1 1960s Country/Western Could I Have This Dance? 1 1980s Country/Western Count on Me 1 2010s Popular Danny Boy 1 1910s Oldies Dear Heart 1 1960s Popular Dear Hearts and Gentle People 1 1940s Popular Do, Re, Mi 1 1950s Musical Dock of the Bay 3 1960s Popular Don’t Be Cruel 1 1950s Popular Don’t Sit Under the Apple Tree 1 1940s Oldies Dona Nobis Pacem 1 1930s Religious/Spirituals Down on the Corner 1 1960s Popular Dream 1 1940s Oldies Dust in the Wind 2 1970s Popular Edelweiss 3 1950s Musical El Condor Pasa 1 1970s Popular Fascination 1 1980s Popular

42 Feelin’ Groovy 1 1960s Popular Fields of Gold 1 1990s Popular Table 12 (continued)

Song Titles ∑ Decade Style Composed

Fly Me to the Moon 7 1950s Popular Forever Young 1 1980s Popular Getting to Know You 1 1950s Musical Happy Together 1 1960s Popular Happy Wanderer 1 1950s Popular Heart of Gold 1 1970s Popular Here Comes the Sun 5 1960s Popular Hey Jude 1 1970s Popular Hound Dog 2 1950s Popular House of the Rising Sun 1 1960s Popular How Much is That Doggie in the 2 1950s Popular Window? I Believe 1 1950s Inspirational I Believe I Can Fly 1 1990s Popular I Can Only Imagine 1 2000s Contemporary Christian I Can See Clearly Now 9 1970s Popular I Can’t Help Falling in Love With You 5 1960s Popular I Hope You Dance 1 2000s Country/Western I Will Remember You 1 1990s Popular I'll Be There 1 1970s Popular I'll Stand By You 1 1990s Popular Imagine 7 1970s Popular In My Life 5 1960s Popular It’s Not Easy Being Green 1 1970s Popular Itsy Bitsy Yellow Polka Dot Bikini 1 1960s Popular Kansas City 1 1970s Popular Kisses Sweeter than Wine 1 1950s Popular La Bamba 1 1950s Popular Lean on Me 7 1970s Popular Leaving on a Jet Plane 4 1960s Popular Lemon Tree 1 1990s Popular

43 Let It Be 17 1970s Popular Let the Way of the Heart 1 No Date Found Unknown Table 12 (continued)

Song Titles ∑ Decade Style Composed

Life is a Highway 1 1990s Popular Longer 1 1970s Popular Love Me Tender 16 1950s Popular Make the World Go Away 1 1960s Country/Western Melissa 1 1960s Popular Memories 1 1980s Musical Memories are Made of This 1 1950s Popular Moon River 5 1960s Popular Morning Has Broken 3 1970s Popular My Girl 4 1960s Popular My Guy 1 1960s Popular My Way 2 1960s Popular Never Say Never 1 2010s Popular New York, New York 1 1970s Popular Now or Never 1 2000s Musical Ob-La-Di, Ob-La-Da 1 1960s Popular Oh What a Beautiful Morning 2 1940s Musical Peaceful Easy Feeling 3 1970s Popular Put Your Head On My Shoulder 1 1950s Popular Que Sera Sera 5 1950s Popular Rainbow Connection 1 1970s Popular Raindrops Keep Falling on My Head 1 1960s Popular Right Here, Right Now 1 2000s Musical Rock Around The Clock 1 1950s Popular Route 66 1 1940s Popular Send in the Clowns 2 1970s Musical Sentimental Journey 1 1940s Oldies Somewhere My Love 3 1960s Popular Somewhere Over the Rainbow 2 1930s Musical Sound of Silence 2 1960s Popular Spinning Wheel 1 1960s Popular

44 Stand By Me 8 1960s Popular Start of Something New 1 2000s Popular Table 12 (continued)

Song Titles ∑ Decade Style Composed

Sunshine on My Shoulders 5 1970s Popular Sweet Caroline 1 1960s Popular Take Me Home, Country Roads 5 1970s Popular Teach Your Children 1 1970s Popular Tennessee Waltz 2 1940s Country/Western That’s Amore 1 1950s Popular The Rose 7 1980s Popular The Sharing Song 1 1970s Popular The Way You Do the Things You Do 1 1960s Popular There You'll Be 1 2000s Popular There's a Kind of Hush 1 1970s Popular This Land is Your Land 1 1940s Patriotic Those Were the Days 1 1960s Popular Three Coins in a Fountain 1 1950s Popular Three Little Birds 3 1970s Popular Tie a Yellow Ribbon 1 1950s Popular Tiny Bubbles 1 1960s Popular Today 2 1990s Popular True Love 1 1950s Popular Try to Remember 2 1960s Popular Turn, Turn, Turn 2 1960s Popular Unchained Melody 1 1950s Popular Unforgettable 2 1950s Popular Up on the Roof 1 1960s Popular What a Wonderful World 11 1960s Popular When You're 64 1 1960s Popular Wind Beneath My Wings 11 1980s Popular With a Little Help from My Friends 4 1960s Popular Yellow Submarine 1 1960s Popular Yesterday 9 1960s Popular You Are the Sunshine of My Life 1 1970s Popular

45 You Raise Me Up 3 2000s Religious/Spirituals You Send Me 1 1950s Popular Table 12 (continued)

Song Titles ∑ Decade Style Composed

You've Got a Friend 16 1970s Popular You’ll Never Walk Alone 2 1940s Musical Young at Heart 1 1950s Popular

When examining the recommended songs, several inconsistencies were noted when compared with the style category. For example, of the 146 songs, four were songs composed prior to 1950. Additionally, several songs were not popular songs (n = 19). Table 13 contains the songs that were mislabeled within the popular style category.

Table 13

Mislabeled Song Within the Popular Genre

Song Titles Circle of Life Coat of Many Colors Could I Have This Dance Danny Boy Do, Re, Mi Don’t Sit Under the Apple Tree Dona Nobis Pacem Edelweiss Getting to Know You I Believe I Hope You Dance Let There Be Peace On Earth Make the World Go Away Now or Never Oh, What a Beautiful Morning

46 Right Here, Right Now Route 66 Table 13 (continued) Song Titles Send in the Clowns Sentimental Journey Somewhere Over the Rain Try to Remember You Raise Me Up You’ll Never Walk Alone

10) What are the ten most frequently used songs by hospice music therapists in the genre of Popular music (popular music from 1950 to the present)? Many individual song titles were recommended multiple times by hospice music therapists, which allowed the creation of a list of most frequently used popular songs used in a hospice setting. Table 14 contains a list of the ten most frequently used popular songs by music therapists. Since many songs were recommended the same number of times, which created a tied rank, Table 14 contains more than 10 songs.

Table 14

Top Ten Popular Songs (Popular music prior to 1950) Used By Hospice Music Therapists

Song Titles Sum Let It Be 17 Love Me Tender 16 You’ve Got a Friend 16 What a Wonderful World 11 Wind Beneath My Wings 11 I Can See Clearly Now 9 Yesterday 9 Stand By Me 8 Bridge Over Troubled Water 7 Fly Me to the Moon 7 Imagine 7

47 Song Titles Sum Lean on Me 7 The Rose 7

11) How often were specific music therapy techniques used with clients? ! A total of 20 music therapy techniques were listed on the survey (see Table 11). For each technique, music therapists were asked to rate the amount of time they used them in a hospice setting. The usage rating options, which were converted into a four-point Likert-type scale, included: (1) Never with a Client, (2) With Certain Clients, (3) With More Than Half of the Clients, and (4) With All Clients. This provided sums and percentage of use for each technique. Results found all techniques, with the exception of hypnosis, were used by at least one music therapist to some degree within the hospice setting. Additionally, when comparing the sums and percentages of the amount of use for each technique, results found the greatest percentage of music therapists never used nine of the techniques: Guided Imagery and Music (Bonny Method); Creative Art Therapy with Music Therapy; Music and Drawing/Painting; Hypnosis; Meditation; Music Therapy Combined with OT and Speech Therapy; Pediatric Group Music Therapy; Stimulation Protocol; and Toning. For the remaining techniques, eight were listed as being used with certain clients: Music Listening; Improvisation; Songwriting; Music Playing; Music Listening and Imagery for Relaxation; Lyric Analysis; Music Therapy and Verbal Social Work Techniques; and Multi-Modal Stimulation. Two were listed as being used with more than half the clients: Singing and Musical Life Review; and one was listed as being used with all clients, Song Choice, by the greatest percentage of music therapists. Full results are listed in Table 15.

Table 15

The Sum and Percentage of Use of the Music Therapy Techniques with Clients

48 Music Therapy Never with a With Certain With More than Half With All Clients Techniques Client Clients of the Clients Sum Percentage Sum Percentage Sum Percentage Sum Percentage Music Listening 1 2.5% 16 40% 9 22.5% 14 35% Table 15 (continued) Music Therapy Never with a With Certain With More than Half With All Clients Techniques Client Clients of the Clients Sum Percentage Sum Percentage Sum Percentage Sum Percentage Improvisation 3 7.5% 29 72.5% 7 17.5% 1 2.5% Singing 0 0.0% 4 10% 19 47.5% 17 42.5% Songwriting 3 7.5% 36 90% 1 2.5% 0 0% Music Playing 2 5.1% 21 53.8% 13 33.3% 3 7.7% Song Choice 0 0.0% 4 10.3% 17 43.6% 18 46.2% Music Listening and 2 5% 29 72.5% 9 22.5% 0 0% Imagery for Relaxation Lyric Analysis 5 12.5% 26 65% 9 22.5% 0 0% Guided Imagery and 30 76.9% 9 23.1% 0 0% 0 0% Music (Bonny Method) Musical Life 1 2.5% 1 32.5% 21 52.5% 5 12.5% Review Creative Art 25 62.5% 14 35 0 0% 1 2.5% Therapy with Music Therapy Music and Drawing/ 28 70% 11 27.5% 1 2.5% 0 0% Painting Music Therapy and 8 20.5% 14 35.9% 11 28.2% 6 15.4% Verbal Social Work Techniques Hypnosis 40 100% 0 0% 0 0% 0 0% Meditation 20 51.3% 19 48.7% 0 0% 0 0% Multi-Modal 13 32.5% 20 50% 6 15% 1 2.5% Stimulation Musical Therapy 32 80% 8 20% 0 0% 0 0% Combined with OT and Speech Therapy

Pediatric Group 32 80% 7 17.5% 1 2.5% 0 0% Music Therapy

49 Stimulation Protocol 30 76.9% 9 23.1% 0 0% 0 0%

Toning 29 72.5% 10 25% 1 2.5% 0 0%

!

12) Were there differences between the amounts of client use for each music therapy technique? Results found significant differences for 19 out of the 20 music therapy techniques: music listening; improvisation; singing; songwriting; music playing; song choice; music listening and imagery for relaxation; lyric analysis; Guided Imagery and Music (Bonny Method); musical life review; creative art therapy with music therapy; music and drawing/painting; hypnosis; meditation; multi-modal stimulation; music therapy combined with OT and speech therapy; pediatric group music therapy; stimulation protocol; and toning. Furthermore, within the categories which had the largest number of music therapist use, 9 out of the 20 techniques were significantly different from the other three usage categories: Guided Imagery and Music (Bonny Method); creative art therapy with music therapy; music and drawing/painting; hypnosis; meditation; music therapy combined with OT and speech therapy; pediatric group music therapy; stimulation protocol; and toning. From those techniques, all participants rated hypnosis as a technique they never use with clients. ! Results found a significant difference in the amount of use for the music therapy technique of music listening, χ2 = 13.4, p > .05. To determine where specific differences may have occurred scores for each technique by amount of use were converted to z scores. Results found significant differences between the use category of “never with a client” and the other three categories; certain clients ( z = .0006), more than half the clients ( z = .0046), and all clients ( z = .82). No other significant differences were found for the other use categories. Results found a significant difference for the amount of use in the music therapy technique of improvisation, χ2 = 50, p > .05. After the amount of use was converted into z scores, results found significant differences between the use category of “never with a client” and one other use category; certain clients ( z = .00006). Significant differences were also found between the use category of “certain clients” and the two other categories; more than half the clients

50 ( z = .0022) and all clients ( z = .00006). No other significant differences were found for the other use categories. There was a significant difference in the amount of use for the music therapy technique of singing, χ2 = 26.6, p > .05. Results show a significant difference between the use category of “never with a client” and two other categories; more than half the clients ( z = .00006) and all clients ( z = .00010). There was also a significant difference between the use category of “certain clients” and two other categories; more than half the clients ( z = .034) and all clients ( z = .0088). No other significant differences were found for the other use categories. A significant difference in the amount of use was found for the music therapy of songwriting, χ2 = 90.6, p > .05. The only significant differences were between the use category of “certain clients” and the two other categories; more than half the clients ( z = .00006) and all clients ( z = .00006). No other significant differences were found for the other categories. Results found a significant difference in the amount of use for the music therapy technique of music playing, χ2 = 25, p > .05. There was a significant difference between the use category of “never with a client” and one other use category; more than half the clients ( z = .0098). There was also a significant difference found between the use category of “certain clients” and one use category; all clients ( z = .00004). No other significant differences were found between the other use categories. There was a significant difference in the amount of use for the music therapy technique of song choice, χ2 = 25.51, p > .05. Results found a significant difference between the category of “never with a client” and two other use categories; more than half the clients ( z = .00010) and all clients ( z = .00006). There was also a significant difference between the category “certain clients” and the two other use categories; more than half the clients ( z = .0088) and all clients ( z = .0056). No other significant differences were found between the remaining use categories. Results found a significant difference in the amount of use for the music therapy technique of music listening, χ2 = 62.5, p > .05. There was a significant difference between the category of “never with a client” and one other use category; certain clients ( z = .00006). There was also a significant differences in the category of “certain clients” and the two other

51 categories; more than half the clients ( z = .00006) and all clients ( z = .00006). No other significant differences were found among the other use categories. A significant difference was found in the amount of use for the music therapy of lyric analysis, χ2 = 38.2, p > .05. There was a significant differences between the use category of “never with a client” and two other categories; certain clients ( z = .0004) and all clients ( z = .0076). There was also a significant difference between the use category “certain clients” and two the other use categories; more than half the clients ( z = .007) and all clients ( z = .00006). There was a significant difference between “more than half the clients” and one other category; all clients ( z = .0076). No other significant difference was found among the remaining use categories. There was a significant difference found in the amount of use for the music therapy technique Guided Imagery and Music (Bonny Method), χ2 = 61.62, p > .05. Results found a significant difference between the category “never with a client” and the three other categories; certain clients ( z = .0014), more than half the clients ( z = .00006), all clients ( z = .00006). There was also a significant difference found in the use category “certain clients” and the two other use categories; more than half the clients ( z = .0078) and all clients ( z = .0078). No other significant differences were found in the remaining use categories. Results found a significant difference in the amount of use for the music therapy technique musical life review, χ2 = 23.6, p > .05. There was a significant difference between the category of “never with a client” and two other categories; certain clients ( z = .0032) and more than half the clients ( z = .00006). Results also found a significant difference between “more than half the clients” and one other category; all clients ( z = .0032). No other significant differences were found among the remaining use categories. There was a significant difference found in the amount of use for the music therapy technique creative art therapy and music therapy, χ2 = 42.2, p > .05. Results found a significant difference in the category “never with a client” and two other use categories; more than half the ( z = .00006) and all clients (z = .00006). Results also found a significant difference between the use category of “certain clients” and the two other use categories; more than half the clients

52 ( z = .0004) and all clients ( z = .0004). No significant difference was found between the remaining use categories. Results found a significant difference in the amount of use for the music therapy technique of music and drawing/painting, χ2 = 50.6, p > .05. There was a significant difference between the use category “never with a client” and two other use categories; more than half the ( z = .00006) and all clients ( z = .00006). There was also a significant difference found between the category “certain clients” and one other use category; all clients ( z = .0026). No other significant difference were found among the other use categories. Results found no significant difference in the amount of use for the music therapy technique of music therapy and verbal social work techniques, χ2 = 3.64, p > .05. There was also no significant difference found among any of the use categories. This is the only music therapy technique that had no significant difference. A significant difference was found in the amount of use for the music therapy technique of hypnosis, χ2 = 120, p > .05. Results found a significant difference between the category “never with a client” and the three other use categories; certain clients ( z = .00006), more than half the ( z = .00006), and all clients ( z = .00006). No other significant differences were found between the other use categories. Results found a significant difference in the amount of use for the music therapy technique of meditation, χ2 = 39.04, p > .05. There was a significant difference found between “never with a client” and two other use categories; more than half the clients ( z = .00006) and all clients ( z = .00006). Results also found a significant difference between the category “certain clients” and two other use categories; more than half the clients ( z = .00010) and all clients ( z = .00010). No other significant differences were found among the remaining use categories. There was a significant difference in amount of use for the music therapy technique multi-modal stimulation, χ2 = 20.6, p > .05. A significant difference was found between the category “never with a client” and one other use category; more than half the clients ( z = .0004). There was also a significant difference between the category “certain clients” and one other use category, all clients ( z = .0002). No other significant differences were found between the other use categories.

53 A significant difference was found for the music therapy technique of music therapy combined with OT and speech therapy, χ2 = 68.8, p > .05. A significant difference was found between the category “never with a client” and the three other use categories; certain clients ( z = .008), more than half the clients ( z = .00006), and all clients ( z = .00006). There was also a significant difference between the category “certain clients” and two other use categories; more than half the clients ( z = .0132) and all clients ( z = .0132). No other significant differences were found between the other use categories. Results found a significant difference in the amount of use for the music therapy technique of pediatric group music therapy, χ2 = 67.4, p > .05. A significant difference was found between the use category “never with a client” and the three other use categories; certain clients ( z = .0002), more than half the clients ( z = .00006), and all clients ( z = .00006). No other significant differences were found among the other use categories. There was a significant difference in amount of use for the music therapy technique of stimulation protocol, χ2 = 62.12, p > .05. Significant differences were found between the category of “never with a client” and two other use categories; certain clients ( z = .0014) and more than half the clients ( z = .00006). Significant differences were also found between the category of “certain clients” and the two other use categories; more than half the clients ( z = .0076) and all clients ( z = .0076). No other significant differences were found between the other use categories. Results for a significant difference in the amount of use for the music therapy technique of toning, χ2 = 54.2, p > .05. There was a significant difference between the category of “never with a client” and the three other use categories; certain clients ( z = .0040), more than half the clients ( z = .00006), and all clients ( z = .00006). A significant difference was also found between the category of “certain clients” and one other use category; all clients ( z = .0046). No other significant difference was found between the remaining use categories.

54 CHAPTER 5

Discussion

The purpose of this study was to examine the repertoire used by professional music therapists in a hospice setting. This study also investigated how often specific music therapy techniques were used in hospice settings. The participants for this study completed an online survey that addressed repertoire used frequently in the following five genres: Oldies (popular music prior to 1950); Religious/Spiritual; Country/Western; Musicals; and Popular (popular music from 1950 to the present). The music therapists also answered questions regarding the frequency in which they use the specified music therapy techniques. A list of all the recommended songs was created based on the participant’s responses. From that list, the ten most frequently recommended songs for each genre was organized into a table. Also, a table was created that compared the usage frequency of all 20 music therapy techniques. Overview of All Recommended Repertoire The music therapists recommended a total of 465 individual songs they use in a hospice setting. The songs that were recommended by the highest percentage of music therapists in the five style categories were: Let Me Call You Sweetheart and You Are My Sunshine (Oldies); Amazing Grace (Religious/Spiritual); I Walk the Line (Country/Western); Edelweiss (Musicals); and Let It Be (Popular). However, within each style category the majority of songs were recommended by a single music therapist: Oldies (n = 71 or 71%), Religious/Spiritual (n = 69 or 70%), Country/Western (n = 65 or 75%), Musicals (n = 46 or 65%), and Popular (94 or 80%). These results seem to indicate that music therapists who work in a hospice setting tailor music selections to reflect the client’s preferences rather than having a set list of songs they use with all. Music therapists are trained to play client-preferred music and these results demonstrate the importance of using repertoire that the client enjoys. Using client-preferred music can aid the 55 client in reminiscing about their life, give the client an opportunity to sing during music therapy sessions, and enhance their quality of life. Each hospice client will have a difference response to music selections, therefore it is important for music therapists to use repertoire that fits the client’s needs. Each song was investigated to establish the year it was composed and the style category it is labeled within the music industry to determine if the recommended songs were within the correct category. Results found 101 songs were mislabeled overall. Specifically, mislabeled songs were found within all the style categories listed on the survey with the exception of Religious/Spiritual. Results also revealed that of the total number of songs 75 were recommended in more than one style category, which created overlaps. Overlaps were found between Oldies and Musicals (n = 10), Oldies and Country/Western (n = 14), Oldies and Religious (n = 7), Oldies and Popular (n = 17), Religious and Country/Western (n = 1), Religious and Popular (n = 3), Country/Western and Musicals (n = 2), Country/Western and Popular (n = 11), and Musicals and Popular (n = 10). Reasons for this number of mislabeled and/or overlapped songs may lie within the style categories chosen for this study. Of the five categories, four could be considered sub-categories of “popular” music (i.e., Oldies, Country/ Western, Musicals, and Popular). Additionally, one could argue that certain songs within the Religious/Spiritual category could also be classified as “popular” (e.g., the Contemporary Christian songs). Therefore, it may not be surprising that mislabeling and/or overlaps existed between the style categories. Moreover, what constitutes “popular” music to an individual is very specific. For some it is country music while to others it could be Contemporary Christian. Since it is evident that music therapists choose client-preferred music, perhaps the style of music those clients’ consider popular is more encompassing. Further research into client perceptions is needed to determine what clients consider to be “popular” music or “oldies.”

Recommended Repertoire for the Genre of Oldies (popular music prior to 1950) The two highest recommended songs for this genre were Let Me Call You Sweetheart and You Are My Sunshine (n = 27). A possible reason these two songs are used by a large number of music therapists in a hospice setting could be due to the lyrics creating an emotional response in

56 their clients. Both songs mention strong feelings towards a loved one. Towards the end of life, clients might reflect on their loved ones and these two songs could possibly help clients reminisce. Conversely, songs such as Danny Boy, As Time Goes By, and Don’t Sit Under the Apple Tree were recommended by fewer music therapists (n = 6). These songs perhaps do not create as much of an emotional response within the majority of clients, unless the clients’ have a specific memory attached to the songs, and, therefore, are not used unless specifically requested or needed to accommodate a certain aged client. The large number of songs recommended only once was not surprising. There is a plethora of songs to choose from within this style category. And, as previously stated, popular- style music is very individual. That is, one person may prefer one song or group of songs while another person prefers a totally new song or group of songs. While both songs, or groups of songs, can be classified as popular oldies, the preferences of the client dictate which song(s) are used. Therefore, because there is such a large number of oldies to choose from, it is not surprising that many individual songs were chosen. When examining the top ten songs within this category it was found that all but two were recommended by less than 50% of the music therapists who completed the study. Again, it seems like within this category music therapists’ choose client-specific songs rather than relying on a set list of “oldies”. This is encouraging because it demonstrates that music therapists choose their repertoire based on each individual client’s needs.

Recommended Repertoire for the Genre of Religious/Spirituals

From the 40 participants of this survey, 39 music therapists recommended the song Amazing Grace and 30 recommended The Old Rugged Cross. It appears these songs might be highly recommended because they are such well-known hymns in all Christian denominations. Sixty-nine individual songs were recommended once by a single music therapist. In this particular genre there are many different faith-based practices which use specific songs. For example, the songs Hal'luya la olam, Hatikva, Hava Nagila, Hevenu Shalom Alechem, Hineh Ma Tov, Ose Shalom, and Oyaheya are considered Jewish songs and were recommended by three or

57 less music therapists. Songs such as Ave Maria, Hail Holy Queen, and Holy, Holy, Holy are used in the Catholic and Protestant faith backgrounds. Songs from the contemporary Christian background such as As the Deer and Grace Like Rain were recommended by two or fewer music therapists. This demonstrates that type of songs used from this genre all depends on the client’s faith and beliefs. Conversely, songs such as His Eye is on the Sparrow and It is Well With My Soul were recommended by fewer music therapists (n = 6). Again, this demonstrates that song selection depends on the client’s religious background. Again, the large number of songs recommended only once was not surprising. The many different religious backgrounds use a variety of music. Certain individuals may enjoy Christian hymns while others prefer contemporary Christian songs. The client’s own religious background also plays a role in determining the appropriate repertoire. Therefore, because there is such a large number of religious music to choose from, it is not surprising that an abundance of individual songs were chosen. When investigating the top ten songs within this category it was found that all but three songs were recommended by less than 50% of the music therapists who completed this study. Once again, it seems like within this category music therapists’ choose client-specific songs rather than relying on a set list of religious songs. The three songs recommended by more than half of the music therapists are songs that are well-known in many religious backgrounds.

Recommended Repertoire for the Genre of Country/Western The three highest recommended songs for this genre was I Walk the Line (n = 20), Crazy (n = 19), and Hey Good Lookin’ (n = 18). One possible reason are used by a large number of music therapists in a hospice setting could be due to their popularity in the Country/Western genre. Conversely, songs such as Coat of Many Colors; Have I Told You Lately That I Love You; and I Fall to Pieces were recommended once by fewer music therapists (n = 3). A possible reason for this may be that certain clients have a deep connection to these specific songs and, therefore, are not used unless specifically requested.

58 There was a large number of songs recommended once in this genre. There are many sub- genres in the Country/Western music such as Bluegrass and Country Gospel. Clients may prefer older Country songs from the early 1900s or from the late 20th century. There are many options to choose from in this genre. The preferences of the client dictate which songs are used in sessions. When examining the top ten songs within this category it was found that all but one were recommended by less than 50% of the music therapists who completed the study. The music therapists did not rely on a set list of Country/Western songs. It appears that the music therapists tailor their song selections based on the client’s preferences. Recommended Repertoire for the Genre of Musicals The two highest recommended songs for this genre were Edelweiss (n = 23) and Oh, What a Beautiful Morning (n = 22). A possible reason that these songs were frequently recommended could be due to the popularity of these musicals. Another reason these songs are highly recommended could be that they are both uplifting and positive songs. Conversely, songs such as Getting to Know You and Hello Dolly were recommended by fewer music therapists (n = 6). A possible explanation could be that songs from other musicals are more frequently requested than these two songs. This genre had a large number of songs recommended once by music therapists who completed this study. There are many musicals that date from the early 1900s to the present. This wide variety in music selection allows the client to choose songs for emotional expression or for enjoyment. Therefore, because there is such a large number of musicals to choose from, it is understandable that many individual songs were chosen. When examining the top ten songs within this genre it was discovered that all but two songs were recommended by less than 50% of the music therapists who completed this survey. Again, the client has many options to choose from in this genre. This demonstrates that music therapists select songs based on their client’s preferences.

Recommended Repertoire for the Genre of Popular (popular music from 1950 to the present)

59 The three songs that received the highest recommendation for this genre were Let It Be (n = 17); Love Me Tender and You’ve Got a Friend (n = 16). A possible reason these three songs are used by a large number of music therapists in a hospice setting could be due to the lyrics creating a strong emotional response in their clients. These songs deal with accepting one’s fate, love, and relationships respectively. As clients reach their final stages of life, acceptance, love, and relationships become very important. Conversely, songs such as Blue Suede Shoes; Here Comes the Sun; and I Can’t Help Falling In Love With You were recommended by fewer music therapists (n = 5). A possible explanation for this could be that these songs are not as emotionally involved as the other top recommended songs. This genre had an abundance of songs that were recommended once by music therapists. Again, the style of popular music has different meanings to people. Clients might prefer songs written in the 1950s while other client prefer songs written in the 1980s. Since there is a large amount of songs to choose from in this genre, it is not surprising that there were many individual songs recommended by music therapists. When examining the top ten songs within this genre it was discovered that all songs were recommended by less than 50% of the music therapists. Once again, this genre has many songs to choose from, therefore it is understandable why not one song was recommended by more than 50% of the music therapists. The music therapists seem to select specific songs to suit their client’s needs.

An Overlap in Music Therapy Repertoire Taking the overlap of song repertoire and misclassification into consideration, a total of 465 songs were recommended by music therapists for this survey. A possibility for the plethora of songs overlapping could be that the participants did not fully understand the definition of each genre. For example, the songs All I Have to Do is Dream; All Through the Night Amazing Grace; America the Beautiful; and April Showers were identified as oldies. Although All I Have to Do is Dream is an older song, it does not quite fit the description of oldies; popular songs prior to 1950. All Through the Night; Amazing Grace; America the Beautiful; and April Showers were all

60 written prior to 1950 but these songs are not popular songs because they can be classified in other genres such as religious/spiritual, patriotic, and musical. Christian hymns and gospel tunes are generally associated with the genre of religious/ spirituals. However, there were 17 recommended songs that are not hymns but are still considered religious songs. The songs Away in the Manger; and Silent Night are religious songs and they can be classified as Christmas carols. The songs As the Deer; Grace Like Rain; and I Can Only Imagine are all contemporary Christian songs. There were eight songs of the Jewish tradition recommended in this genre. There were 19 recommended songs that were misclassified as country/western. The song Goodnight, Irene has been performed by many country artists but the song was originally a popular song from the 1930s. Let the Rest of the World Go By is another song that was made popular by country artists but it also was written in the style of popular in the 1910s. Lastly, Sentimental Journey is another song that crossed the genres of country/western and popular music from 1950 to present. This well-known song belongs in the genre of oldies because it was written in the style of popular music in the 1940s. Although these songs can crossover to the genre of country, they do not belong in this genre. It appeared that songs used in non-musical films were listed under the genre of musical. For instance, the song Sioux City Sue was used in a film with the same title but it the film was not a musical. Also, many songs from musicals become so well-known that they cross over to the genre of popular music from 1950 to the present. For example, songs from the musical The Sound of Music and Oklahoma are well-known to the public and that may be a reason why music therapists suggested songs from these musical under the genre of popular music. Lastly, 26 songs were misclassified as popular music from 1950 to the present. The two songs I Believe and You Raise Me Up are categorized under the genre of inspirational music, although both songs could easily cross over to the genre of popular music. The song Circle of Life from the film and musical The Lion King was recommended in this genre. It is another song that gained much popularity and could possibly crossover to the genre of popular music. The songs Now or Never and Right Here, Right Now are from the musical High School Musical. Both

61 were recommended by one music therapist in the genre of popular music. These two songs could cross over to the genre of popular music for children and/or young adults. The genres and date composed of the following recommended songs could not be identified in songbooks or the internet: I Let Go; I Release and Let Go; Shenandoah Waltz; The Plan; and Where Could I Go. Perhaps these are not the correct song titles. The participants who listed these songs might have used lyrics from the song rather than the song title. Music Therapy Techniques Used By Hospice Music Therapists A total of 20 music therapy techniques were listed on the survey. The usage rating options, which were converted into a four-point Likert-type scale, included: (1) Never with a Client, (2) With Certain Clients, (3) With More Than Half of the Clients, and (4) With All Clients. Based on the responses, at least 50% of the music therapists rated never using the following techniques with clients: Guided Imagery and Music (Bonny Method); Creative Art Therapy with Music Therapy; Music and Drawing/Painting; Hypnosis; Meditation; Musical Therapy Combined with OT and Speech Therapy; Pediatric Group Music Therapy; Stimulation Protocol; and Toning. 9 out of 20 techniques (45%) are not being used with clients. A possibility for this could be that these techniques are not appropriate for the clients of these particular music therapists. Additionally, these techniques may not improve the quality of life for the clients in a hospice setting or of these specific music therapists. At least 50% or more of the participants used the following techniques with certain clients: Improvisation; Songwriting; Music Playing; Music Listening and Imagery for Relaxation; Lyric Analysis; and Multi-Modal Stimulation. This result might demonstrate that not all techniques are beneficial for every hospice client. All clients have different goals and objectives and it is up to the music therapist to determine what technique is best for the client. This appears to demonstrate that the techniques used are designed to serve the client’s needs. The only technique rated as being used with more than half the clients by 50% or more of the music therapists was Musical Life Review. One possible explanation is that clients feel the need to reflect on their life as they approach the end of their life. Musical Life Review is a technique that helps the client in reminiscing and reflecting on their life. There was no music therapy technique rated as being used with all clients by more than 50% of the music therapists.

62 A reason for this could be due to music therapists designing objectives for specific individual clients. If music therapists develop individualized objectives for clients, then it would be understandable for music therapists to not use the same techniques for all of their clients. Conclusion This area still needs further research. In order to determine if the same results can be found in future studies, researchers should investigate these topics with more than 40 music therapists across the country. A larger sample could give a better understanding of what songs Hospice music therapists are using in sessions. As baby boomers are approaching retirement and need for Hospice care, music from the early 1900s might not be relevant. Hospice music therapists need to stay current with the aging population. Compiling an up-to-date repertoire list of songs used by Hospice music therapists will aid in staying current with the next generation of older adults. Future studies should give participants clear definitions of all the genres and therapeutic techniques. Misclassification of songs will most likely be reduced by defining the genres. Another way to aid in the misclassification of songs, future research could have a list of correctly named song titles for the participants to choose from. This could lead to less confusion for both the researcher and the participants. Also, defining the therapeutic techniques could help music therapists determine whether or not they truly use a specific technique. This researcher suggests that Hospice music therapists should be asked how frequently they use the therapeutic techniques listed by Krout (2000). It is important for not only professionals, but students as well, to be current in music therapy techniques. Gaining knowledge of the techniques Hospice music therapists around the country are using will give perspective Hospice music therapists an idea of techniques they should focus on. Staying current with therapeutic techniques is also beneficial to the patient. Presenting frequently used techniques will give the patient more ways to express themselves. A current repertoire list and list of therapeutic techniques will allow the patient to experience an increase in their quality of life and it will be relevant to both professionals and students.

63 APPENDIX A

Survey

64 1. Please provide a list up to 10 song titles in the category below you use most frequently.

Oldies (Popular Music Prior to 1950)

1 2 3 4 5 6 7 8 9 10

2. Please provide a list up to 10 song titles in the category below you use most frequently.

Country and Western

1 2 3 4 5 6 7 8 9 10

65 3. Please provide a list up to 10 song titles in the category below you use most frequently.

Popular (Popular music from 1950 to Present)

1 2 3 4 5 6 7 8 9 10

4. Please provide a list up to 10 song titles in the category below you use most frequently.

Musicals

1 2 3 4 5 6 7 8 9 10

66 5. Please provide a list up to 10 song titles in the category below you use most frequently.

Religious/Spirituals

1 2 3 4 5 6 7 8 9 10

6. Please rate the frequency in which you use each of these techniques with your clients in a hospice situation. Never with a With certain With more than With all clients client clients half of the clients Music Listening Improvisation Singing Songwriting Music Playing Song Choice Music Listening and Imagery for Relaxation Lyric Analysis Guided Imagery and Music (Bonny Method) 67 Musical Life Review Creative Art Therapy with Music Therapy Music and Drawing/Painting Music Therapy and Verbal Social Work Techniques Hypnosis Meditation Multi-Modal Stimulation Music Therapy Combined with OT and Speech Therapy Pediatric Group Music Therapy Stimulation Protocol Toning

68 APPENDIX B

Institutional Review Board Approval Letter

69 Office of the Vice President For Research Human Subjects Committee Tallahassee, Florida 32306-2742 (850) 644-8673 · FAX (850) 644-4392

APPROVAL MEMORANDUM

Date: 4/22/2011

To: Janelle Pierce

Dept.: MUSIC SCHOOL

From: Thomas L. Jacobson, Chair

Re: Use of Human Subjects in Research Hospice Music Therapy Song Repertoire and Therapeutic Techniques

The application that you submitted to this office in regard to the use of human subjects in the proposal referenced above have been reviewed by the Secretary, the Chair, and one member of the Human Subjects Committee. Your project is determined to be Expedited per per 45 CFR § 46.110(7) and has been approved by an expedited review process.

The Human Subjects Committee has not evaluated your proposal for scientific merit, except to weigh the risk to the human participants and the aspects of the proposal related to potential risk and benefit. This approval does not replace any departmental or other approvals, which may be required.

If you submitted a proposed consent form with your application, the approved stamped consent form is attached to this approval notice. Only

70 the stamped version of the consent form may be used in recruiting research subjects.

If the project has not been completed by 4/17/2012 you must request a renewal of approval for continuation of the project. As a courtesy, a renewal notice will be sent to you prior to your expiration date; however, it is your responsibility as the Principal Investigator to timely request renewal of your approval from the Committee.

You are advised that any change in protocol for this project must be reviewed and approved by the Committee prior to implementation of the proposed change in the protocol. A protocol change/amendment form is required to be submitted for approval by the Committee. In addition, federal regulations require that the Principal Investigator promptly report, in writing any unanticipated problems or adverse events involving risks to research subjects or others.

By copy of this memorandum, the Chair of your department and/or your major professor is reminded that he/she is responsible for being informed concerning research projects involving human subjects in the department, and should review protocols as often as needed to insure that the project is being conducted in compliance with our institution and with DHHS regulations.

This institution has an Assurance on file with the Office for Human Research Protection. The Assurance Number is FWA00000168/IRB number IRB00000446.

Cc: Kimberly VanWeelden, Advisor HSC No. 2011.5763

71 APPENDIX C

Introductory Email

72 Dear Music Therapists,

My name is Janelle Pierce and I am a music therapy graduate student working on my thesis at Florida State University. I am conducting a survey about the repertoire and techniques used by music therapists in hospice situations.

If you are willing to participate in this study, please click on the link at the bottom of this message. Those who click on the link below will access the survey. Participation is voluntary and should take approximately 5 minutes. Thank you for your assistance.

Sincerely,

Janelle Pierce

73 APPENDIX D

Informed Letter of Consent

74 Letter of Consent for Adults

Dear Music Therapists,

I am a student at Florida State University and I am compiling a list of repertoire and music therapy techniques most frequently used by hospice music therapists. This list will be most beneficial to undergraduate music therapy students who want to learn more about hospice music therapy and the types of techniques they should become familiar with. This will also be a good resource for professionals.

In order to compile this list, I would like to ask you to provide up to 10 song titles that you use most frequently in the genres of religious/spiritual, oldies (prior to 1950), country/western, popular (1950 to present), and musicals. Additionally, the survey also contains 23 music therapy techniques and I would like you to rate the frequency in which you use these techniques in hospice.

This survey will be available online for 10 days. This survey should take approximately 5-10 minutes to complete.

For your convenience, I have made the survey available through the SurveyMonkey website. To participate, you will need to read the consent form on the SurveyMonkey website and click on the link at the bottom of the SurveyMonkey page to proceed to the survey.

Participation in this survey is voluntary. If you choose not to participate or withdraw from the study at any time, there will be no penalty. To withdraw at any time after beginning the survey, simply close your web browser. Your name or other identifying information will never be used in any written or oral presentation pertaining to this study. All data collected will only be used to the extent allowed by law and for the purpose of the study as it is described above.

There are no known risks or benefits to you for participating in this research study. If you have any questions concerning this research study, please email me. You may also contact my major professor, Dr. Kimberly VanWeelden at [email protected].

The completion of this survey will serve as your consent to participate in this study. Thank you for your time and cooperation.

Sincerely, Janelle Pierce

If you have any questions about your rights as a subject/participant in this research, or if you feel you have been placed at risk, you can contact the Chair of the Human Subjects Committee,

75 Institutional Review Board, through the Vice President for the Office of Research at (850)644‐ 8633, or by email at [email protected]

76 REFERENCES

American Art Therapy Association (2011). History of art therapy [Online]. Retrieved from http://www.arttherapy.org/

American Music Therapy Association. (2010). History of music therapy [Online]. Retrieved from www.musictherapy.org

Bernal, E. W., Marco, C. A., Parkins, S., Buderer, N., & Thum, S. (2007). End of life decisions: Family views on advance directives. American Journal of Hospice and Palliative Medicine, 24(4), 300-307.

Big Bend Hospice (2009). Hospice and palliative care: Music therapy 101. Tallahassee, FL: Haskins, J., Dobbins, S., Clanton, M., Bliss, J., & Dugan, S.

Black, K. (2006). Advance directive communication: Nurses’ and social workers perceptions of roles. American Journal of Hospice and Palliative Medicine, 23(3), 175-184.

Buglass, E. (2010). Grief and bereavement theories. Nursing Standard, 24, 44-47.

Cevasco, A.M. (2010). Effects of the therapist's nonverbal behavior on participation and affect of individuals with alzheimer's disease during group music therapy sessions. Journal of Music Therapy, 47(3), 282-299.

Choi, Y. K. (2010) The effect of music and progressive muscle relaxation on anxiety, fatigue, and quality of life in family caregivers of hospice patients. Journal of Music Therapy, 47 (1), 53-69.

Claxton-Oldfield, S. & Banzen, Y. (2010). Personality characteristics of hospice palliative care volunteers: the “Big Five” and empathy. American Journal of Hospice and Palliative Medicine, 27(6), 407-412.

Claxton-Oldfield, S., Gosselin, N., Schmidt-Chamberlain, K., & Claxton-Oldfield, J. (2010). American Journal of Hospice and Palliative Medicine, 27(3), 191-196.

Demmer, C., & Sauer, J. (2002). Assessing complementary therapy services in a hospice program. American Journal of Hospice and Palliative Care, 19(5), 306-314.

Forman, W. B., Kitzes, J. A., Anderson, R. P., & Sheehan, D. K. (2003). Hospice and palliative care: Concepts and practice. Sudbury, MA: Jones and Bartlett Publishers.

77 Geisler, A. M. (2004). Companion animals in palliative care: Stories from the bedside. American Journal of Hospice and Palliative Medicine, 21(4), 285-288.

Groen, K. M. (2007). Pain assessment and management in the end of life care: A survey of assessment and treatment practices of hospice music therapy and nursing professionals. Journal of Music Therapy, 44(2), 90-112.

Hart, A., Kohlwes, R. J., Deyo, R., Rhodes, L. A., & Bowen, D. J. (2003). Hospice patients’ attitudes regarding spiritual discussions with their doctors. American Journal of Hospice and Palliative Medicine, 20(2), 135-139.

Hilliard, R. E. (2003). The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer. Journal of Music Therapy, 40(2), 113-137.

Hillard, R. E. (2004). A post-hoc analysis of music therapy services for residents in nursing homes receiving hospice care. Journal of Music Therapy, 41(4), 266-281.

Hilliard, R. E. (2005). Hospice and palliative care music therapy: A guide to program development and clinical care. Jeffrey Books, Cherry Hill, NJ.

Krout, R. (2000). Hospice and palliative music therapy. Effectiveness of Music Therapy Procedures: Documentation of Research and Clinical Practice, 323-411. Silver Spring, MD: American Music Therapy Association.

Kubler-Ross, E. (1975). Death: The final stage of growth. New York, New York: Touchstone.

Madson, A. T., & Silverman, M.J. (2010). The effect of music therapy on relaxation, anxiety, pain perception, and nausea in adult solid organ transplant patients. Journal of Music Therapy, 47(3), 220-232.

Magill, L. (2009). The meaning of the music: The role of music in palliative care music therapy as perceived by bereaved caregivers of advanced cancer patients. American Journal of Hospice and Palliative Medicine, 26(1) 33-39.

National Hospice and Palliative Care Organization (2010). History of hospice care [Online]. Retrieved from www.nhpco.org.

National Institute of Health (2011). Advance directives. Retrieved from http://www.nlm.nih.gov/ medlineplus/advancedirectives.html

Pierce, J. A. (2010). The Effect of instrument playing on the emotions of hospice patients. (Unpublished research paper). Big Bend Hospice, Tallahassee, FL.

78 Pronk, K. (2005). Role of the doctor in relieving spiritual distress at the end of life. American Journal of Hospice and Palliative Medicine, 22(6), 419-425.

Sender, V. F., & O'connor, P. M. (1997). Hospice and palliative care: Questions and answers. Lanham, MD: Scarecrow Press.

Standley, J. (2000). Effectiveness of music therapy procedures: Documentation of research and clinical practice. Silver Spring, MD: American Music Therapy Association.

Standley, J., & Jones, J. (2007). Music techniques: In therapy, counseling, and Special education. American Music Therapy Association, Silver Spring, MD.

VanWeelden, K., & Cevasco, A.M. (2010). Recognition of geriatric popular song repertoire: A comparison of geriatric clients and music therapy students. Journal of Music Therapy, 47(1), 84-99.

VanWeelden, K., Juchniowicz, J., & Cevasco, A.M. (2008). Music therapy students' recognition of popular song repertoire for geriatric clients. Journal of Music Therapy, 45(4), 443-456.

Walworth, D. D. (2007). Hospice and palliative care music therapy. Journal of Music Therapy, 44(1), 85-88.

Wlodarczyk, N. (2009). The use of music and poetry in life review with hospice patients. Journal of Poetry Therapy, 22(3), 133-136.

79 BIOGRAPHICAL SKETCH

Janelle Pierce was born in West Palm Beach, FL in 1985. She graduated from Palm Beach Atlantic University in 2007 with a Bachelor’s degree in music and a minor in screenwriting. Janelle also passed her music therapy board certification exam in 2010. This thesis is submitted as partial fulfillment of the requirements for a Master of Music Therapy degree from Florida State University to be awarded in the Summer of 2011.

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