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#75 The Healing Power of Music

Dr. SarahRose Black, Music Therapist at Princess Margaret Cancer Centre and Kensington Health

February 26, 2020

Music, we listen to it when waking up, while in transit, at work, and with friends. It is a form of entertainment, but also has the potential to provide so much more. Music is a universal language with the ability to connect and reach people on social, intellectual, emotional, and spiritual levels. It can bring us joy and motivate us, accompany us through difficult times, evoke nostalgia, and alleviate our worries. These qualities allow music to be applied to improving physical, emotional, and mental well-being. In this episode, we invite you to join us as we explore the science of music therapy. We hear from five music therapists working in various aspects of the field: Dr. Michael Thaut, Canada Research Chair in Music and Health Sciences; Dr. SarahRose Black, Music Therapist at Princess Margaret Cancer Centre and Kensington Health; Priya Shah, Music Therapist at Journey Home Hospice, Fudger House, and the Music Therapy Centre; Dr. Corene Hurt-Thaut, Assistant Professor of Music and Health Sciences at the Faculty of Music at the University of Toronto, and Program Director of the Academy of Neurological Music Therapy; and Bernice Chu, Neurologic Music Therapy Fellow in the United Kingdom at the Royal Hospital for Neuro-disability. In addition to our guests' insights, they also shared musical snippets of their work with their clients, which may tug at your heart strings and inspire. You'll want to stay tuned to the very end! We hope this episode opens your ears and heart to the role of music in health and wellbeing, and inspires you to listen and explore the power of music. Until next time, keep it raw!

Written by: Stephanie Nishi

Music Therapy Association of Ontario (MTAO)
The Academy of Neurologic Music Therapy
UHN Music Therapy Inpatient Resource
Certification Board for Music Therapists
Canadian Association of Music Therapists
Music Heals

Priya Shah [0:00] Calling, I am calling. Listen to my call. I am calling, I am calling. Can you hear my call? We can hear you, we can hear you, we hear you when you call. We are with you, we are with you, we are with you when you call.

Eryn Tong [0:40] The song we just heard is called "Many Voices." This beautiful piece was written by a patient near the end of life, together with her music therapist Priya Shah, who we'll introduce further and hear from in just a bit. It was written as a call and response song. A call to her family and loved ones for support and response and return from them. In the clip, the song was performed around her bedside one afternoon at a hospice by her health care team and loved ones. Priya expressed how powerful this moment was, to witness her patients words and phrases come to life. This legacy creation in the form of music is about one aspect of music therapy. the theme of today's episode. We'll continue to unpack and explore many other approaches and forms of music therapy throughout the episode. We have more surprises in store for you right until the very end, so keep your ears out, literally, until then. We spoke with five music therapists, each sharing their unique perspectives working in different patient populations and healthcare settings, to hopefully paint a fuller picture of the diverse creative value of music therapy. This is Eryn,

Stephanie Nishi [1:39] Steph,

Jilian Macklin [1:40] and Gillian

Eryn Tong [1:41] and welcome to Episode 75 of Raw Talk.

Stephanie Nishi [1:57] Here's Dr. Michael Thaut, Professor in the Department of Music at the University of Toronto with cross appointments in Rehabilitation Science and Neuroscience. He is the Director at the Music and Health Science Research Collaboratory and the Music and Health Sciences graduate programs. He is also the Canada Research Chair in music and Health Sciences. Michael tells us how this field came to be.

Dr. Michael Thaut [2:19] Music Therapy is really an umbrella term for a lot of different schools of thought philosophies, approaches, that can range from more psychodynamic to more behavioral-oriented. It's been around in the US, organized since 1950. Canada, not sure but it's a relatively new profession now in the world. Although the idea of music as therapy has been ancient, I mean, the idea that music has some kind of medical or therapeutic value, it's been probably around for thousands of years. If you look at sort of the artifacts, it was obviously not very scientific. And still, some of the popular concepts about music and housing therapy are still not very scientific, although they become more and more popular. But the first country, to my knowledge that actually organized a profession of music therapy was the US in 1950. It came out of the music educators organization, they had a music psychology section, and the music psychology section, it created the society, National Society for music therapy. And it actually started practicing during World War Two, when musicians were invited to go into hospitals, and play for the patients. And so some of the results they saw were, obviously beyond the entertainment idea. And so this idea of 'Is there a therapeutic core?' that cashed out, it's sort of in the VA system in the United States in the 40s triggered really by what can we do for our wounded soldiers

Jilian Macklin [4:11] Who have experienced a lot of trauma. Right.

Dr. Michael Thaut [4:24] Well, we actually have writings in the Baroque in a 17th century where people write in great detail. The vibrations of music can sort of shake loose the poisonous humors in the body and in some very interesting ideas. We have documentation of Egypt in those writings. Somebody sits there with a harp and supposed to be sort of a priest, musician. David plays the harp for us all in the Bible to lift his depression. So it's really sort of scattered all over the place. But yeah, that the idea that music has is more than an art form, that's been around for a long time actually. Music was considered a science for 2000 years before it became in our modern worlds, mostly art form.

Stephanie Nishi [5:13] Music and its therapeutic value had been around for a long time. But what does it look like today? We spoke with music therapists working in various fields of healthcare, one of which was Dr. SarahRose Black. SarahRose, who just defended her PhD a few weeks ago, began working at the Princess Margaret Cancer Center during her internship in 2012. She continues to work as the only music therapist in the hospital now. She has since grown the program into an incredible trifold Clinical Research and Education Program. She also works at Kensington hospice, a 10 bed residential hospice close by. She tells us about her experience working in supportive cancer care.

Dr. SarahRose Black [5:14] As a creative arts therapist, I find I am invited into patients' experiences of health and of disease and of coping through the medium of the arts. So that in and of itself is unique. When people see me in the elevator with a keyboard, or a violin or a guitar, it's often striking because it's not what you would typically expect in health care facility. However, I'm a firm believer that human beings are inherently musical by virtue of the fact that our bodies are quite rhythmic. We have a drum - our heart inside us, and we move through the world in a rhythmic, melodic way. So there is definitely a unique aspect of being a music therapist and that I am bringing live music to the bedside and doing various things with it through psychotherapy. However, once people start to connect their emotions to music, they find it's a very natural extension of processing what it means to be dealing with an illness or to be coping with cancer in general. A typical music therapy session generally involves some component of live music, as well as some component of talk therapy. It depends on where the patient's at and what their symptom levels are like. I've been in patient rooms where they are so fatigued, they don't want to talk, they're sort of talked out. So I may come in, and I may play live music for 20 to 30 minutes, sometimes as few as five minutes, sometimes as many as 60 minutes. I will be at the bedside with my keyboard. And I will do something called breath in treatment, where I will match the person's breathing patterns. They may be lying in bed or in a chair. And I will play music that matches the speed at which they are breathing. And what happens in that process is subconsciously the patient's breathing will match up with the speed of the music I'm playing. And effectively if I slow the music down, their breathing will slow down, calming their nervous system, relaxing their body. I draw on familiar music if patients have very specific songs or artists or genres that they love. But I also do a lot of improvisation. I may use my voice, I may use only the piano, I may use a different instrument completely. So that could be a typical kind of receptive music therapy session. A more active session might involve something like songwriting, where I go in and do a fair bit of verbal psychotherapy, where I'm exploring patients' thoughts, feelings, emotions, and I invite them to put those into words. And then we put the words to music. That can happen in a period of 20 minutes, that can happen over a period of a month if a patient wants to spend more time. But often patients don't necessarily have a lot of time depending on how long they are hospitalized, or if they are physically declining and find it exhausting to engage verbally. So I always take my lead from the patients and go with what their needs are as well as what the clinical focuses from the team.

Stephanie Nishi [8:43] SarahRose works in cancer and end of life care. But there are many different forms and approaches in music therapy, which we will continue to explore. We heard the beautiful singing voice of music therapist Priya Shah in the opening of this episode. After completing a Bachelor of Music with a minor in psychology and Women's Studies at Carleton University, she went on to complete her Master's in Music Therapy at Wilfrid Laurier University in 2018 with an internship at Princess Margaret Cancer Centre in Toronto. She works in diverse settings throughout the week, including a Music Therapy Center, a long term care home, and a hospice for the vulnerably housed in homeless called Journey Home Hospice, which you might remember from Episode 69 - Forgotten Voices: Exploring Homelessness and Health. In addition to seeing clients in private practice, Priya also leads groups at Sheena's Place to support people with eating disorders, Gilda's Club to support people living with or impacted by cancer, and Covenant House, a youth shelter. We asked her to walk us through a group music therapy session. She began by describing the instruments she brings, including a keyboard, guitars, small percussion instruments such as shakers or a tambourine, hand drums, a bass, occasionally the accordion, and a singing bowl.

Priya Shah [9:56] When the group starts, I like to start with playing the singing bowl to bring everyone into the space and to kind of bring them into inner awareness. So I like to kind of say, "Take a moment to turn inwards and do a scan." So a body scan, and notice if there's any tension anywhere, and then if there's tension somewhere, maybe breathe it to that tension, as the singing bowl continues to play. Sometimes I vocalize with the singing bowl, sometimes not. After that, I usually do around of a check-in. So each person can kind of share how they're doing today, or how they've been doing this feeling this week, and just be able to share that with the group, and it's received by the group members supportively. Or it could be a musical check-in so taking an instrument, and playing something and then talking about what that represents, what feeling it may represent. And then I like to go into a musical experience, such as sound layering. So that would be where each person creates a little sound bite on their instrument, and it could be really simple, just hitting the drum, doing a steady beat on the drum, for example. And something that's simple enough, they can continue to repeat. And then after they start that, each person will consecutively add their sound bite so that by the end, everybody's playing. Then it becomes this really interesting sound of all these instruments and the patterns that they're doing. And I sometimes tell people, if you start something, and after a few moments, you don't like it anymore, feel free to change it. It ends organically by when you're done, you just drop out, and eventually one person's left playing, and then it ends. And we talk about, you know, what that might have felt like. Were you listening to others? Were you pretty absorbed in what you were playing? Did you make any changes? Yes, no, maybe, why? So that's one kind of example of a structured improvisation. And then we might go into more referential or more open improvisations, where, for example, we come up with a theme. So the theme could be an emotion, the theme could be anything that the group is feeling right now is important to explore through music. So if it was an emotion, for example, we might start with an overall feeling that people are having, feeling tired or sad or frustrated. Anything. And then we maybe explore that emotion through music, and add in the option to shift to another emotion. And so we'll bring down the music discuss it, what came on. And then sometimes, if there's a theme for the day, I like to use that as a prompt to do some creative writing. And then we might turn that creative writing into a song afterwards. So let's say the prompt was: today we're exploring the inner child. And the creative writing project might be: what is something you want to say to your inner child? And then there's opportunity for each person to share, if they want. And then we'll brainstorm, taking some of those words, putting them on paper, and then turning it into a song somehow. So the song doesn't have to be, you know, a traditional verse, chorus, verse. Sometimes it is, but sometimes it could be just an instrument playing in the background. So maybe I'm playing the keyboard or the piano or something. And each person's going around and seeing a line that really resonates with them, so singing or speaking that line. And so it turns into more of a spoken word piece. So it really depends. But sometimes it is like a full, some verse, chorus verse, and everybody's in the room is singing, and it's playing percussion while they're doing that. So that's one example. Other times I incorporate art as well. With art as a prompt for improvisation or as a prompt to do some storytelling, about people's experiences related to the theme that we're exploring. So it really varies. I often like to close with singing, because I find that as the singing bowl grounds us and brings us into the space, sometimes singing also has the same function to bring everybody together again, before we all disperse, and to have us feeling unified, especially if what was brought up in the group was challenging. It's a good way to kind of bring everyone back together again. And then we do a checkout where we sing sometimes the chorus of "Let It Be", and then each person has a chance to kind of share something for their closing checkout as the music's playing in the background. So it kind of provides like an accompaniment for their checkout.

Eryn Tong [14:19] Priya has learned a lot about music therapy in practice. And she says she continues to learn each and every day, in every client and patient encounter. We asked her about her key takeaways when describing the important elements of music therapy.

Priya Shah [14:32] There are three elements to music therapy: the therapeutic relationship (so the relationship between client and therapist), music, and clinical goals. And I think the latter is super important, because in every relationship I have, whether it's with an individual client or with a group, I always have goals, and I'm reassessing constantly after each session, how these goals are being met. And so for example, let's say I'm looking at one of the groups that I run. One of the goals is for emotional expression. So I'm looking at how is music able to help clients identify and express their emotions? Another one could be building self awareness and gaining insight. So how could the music we make compared to or relate to their experiences outside of music therapy? And can connections be made between what we're learning through the process of making music and discussing a discussion afterwards? Can links be made that relate to how they're doing in recovery or how they are on their journey? In music, oftentimes, there can be chaos, especially an improvised music, but there can also be moments of harmony and unity, and cohesion. And so how does that relate to outside? Well, life itself is nonlinear. And there's ups and downs, constantly. So music or improvisation especially allows for challenging motions to arise, but also to stay with those emotions, because that's sometimes the hardest part - to stay with those challenging emotions and to ride through those waves as they come up. And so being in that together in a supportive environment can really allow people to develop the tools to cope with those emotions as they come up and to relate it to what's happening for them outside of the room.

Stephanie Nishi [16:22] Music therapy often lies at the intersection of many different fields in healthcare. And so music therapists often work alongside interdisciplinary team members and caring for their patients.

Dr. SarahRose Black [16:33] I'm very fortunate to work as a member of an interdisciplinary team. And I'm actually part of several teams - so part of the Department of Supportive Care, which encompasses fields like psychiatry, psychology, and social work. But I also work closely with nursing, with physicians, Allied Health, such as physiotherapists, and occupational therapists, as well as spiritual care. And within all of these different teams that I am a part of, I get formal referrals from any number of clinicians. So a nurse might refer a patient to me because the patient is having trouble sleeping or trouble managing their pain, or is very, very anxious. A physician might refer their patient to me because they are looking for alternative or complementary methods of symptom control. For example, nausea. Music can act as a distraction from symptoms, but also a way to integrate what they are feeling into a form of self expression, and it can be a really unique opportunity to say what they're feeling and thinking in a different way. I may have a referral from a spiritual care professional who notices that the patient is really interested in music and finds music very comforting, particularly with dealing with themes of existential distress, fear, loneliness, music can often be a great comfort. And sometimes I will have patients self refer or family members see me in the hall and say, "can you come see my loved one? They would really find great comfort in music at this time."

Stephanie Nishi [18:03] For some therapists, working in multidisciplinary settings actually led them to pursue music therapy. Our next guest, Dr. Corene Hurt-Thaut is an Assistant Professor at the Faculty of Music and Research Associate at the Music and Health Research Collaboratory at the University of Toronto.

Dr. Corene Hurt-Thaut [18:19] I actually asked my first boss, and she was an occupational therapist. So she also had this very functional mindset. And I said, "could I just try to use music differently in this population and see what happens?" And so she gave me a month to kind of show what my ideas were and really change the program that I was running. And she was so excited about the things that she saw, that instead of going in and doing sing alongs with the patients, I was actually going in and having them playing instruments and working on rehabilitation of arm function after a stroke, or working on attention after a traumatic brain injury. And so it was actually very relatable for her because as an occupational therapist, that's how she imagined also that music could be used. It wasn't until I did my Master's degree and met Michael Thaut, that we started looking further at how can music really be used in a consistent way. What is actually happening when the brain engages in music? And obviously, advances in neuroscience and technology have allowed us to learn and understand a lot more about the brain and answer that question.

Eryn Tong [19:35] Corene started out as a musician-turned-music therapist, and was inspired to explore how music could impact functional rehabilitation, rather than the psychosocial focus that had been the emphasis of music therapy. She ended up developing a career in neurologic music therapy. Corene works with Michael, who gave us a brief history lesson on music therapy earlier. They're both internationally recognized in the field of Neurologic Music Therapy, or NMT for short, which is an evidence based system of clinical strategies for speech and language, cognitive, and sensory motor training, with 20 developed clinical techniques.

Dr. Michael Thaut [20:09] Well, music therapy started and stayed. And then based on music neuroscience research, the clinical part of that research, most in the 90s. We got to the point where medical personnel, neurologists, other therapists, looked at the data, and they were very impressed with the data and the videos and everything that demonstrated such a huge effect on just walking, for instance, in stroke patients with Parkinson's patients - the walking pattern changes 100%. And so the question was, who can do that? Because the traditional music therapist does not do that. They work from a different model, more of a social science model. And so we actually had to get to the point where there was a Academy of Neurologic Music Therapy formed, and whose purpose is to continue education all over the world. So that's been going on for 20 years, currently about 3000, maybe three or 4000, certified neurologic music therapists or people from other professions that hold an NMT certificate in about 30, a little over 30 countries in the world.

Jilian Macklin [21:21] Wow. So it's grown quite a bit.

Dr. Michael Thaut [21:23] It's grown quite a bit. And it's continues to grow. The Academy teaches about seven to eight courses all over the world, two here in Toronto. So there's a huge demand for this kind of work, because it works. The evidence was first there, the research was there first. And then, based on the research data, the treatment interventions were developed.

Stephanie Nishi [21:54] Corene is the Program Director at the Academy of Neurologic Music Therapy that Michael mentioned. She and her students worked with many different populations, as NMT is a functional therapy, relevant to a broad spectrum of context. She explains why.

Dr. Corene Hurt-Thaut [22:11] So neurologic music therapy is really not population-based, but it's function based. And so, if you have a brain, and you have attention, or executive function, or motor skills, then those can be impaired and anyone not just somebody who had a stroke. And so the word "neurologic music therapy" does not really refer to neurologic conditios, it refers to if you have a brain. Understanding how when the brain engages in music, it's changed. And how can we use that knowledge to actually change brains, depending on what the need area is?

Stephanie Nishi [22:54] We asked Corene to walk us through one of the 20 clinical techniques of NMT: melodic intonation therapy. This technique is used in speech and language training, specifically,

Dr. Corene Hurt-Thaut [23:05] Melodic intonation therapy is actually a technique developed by neuroscientists in the 70s. And it was looking at this idea of how they could create a structured process to use music to help people with aphasia. So helping somebody who had expressive aphasia who could no longer speak and tapping into that ability that they often have to still sing, and utilizing that to teach them not to just sing familiar songs, but to actually sing functional phrases that they may need to be able to say in their everyday lives. It's one of 20 techniques. But MIT was originally developed by speech therapy. And so it was often used by them in clinical practice. However, over the years, that has really changed in how we use it just based on how long people are actually in hospitals, and what kinds of other aspects of health care and our increased knowledge. So we include it in the neurologic music therapy taxonomy because it is such an effective treatment. But I want to make sure that the credit goes to the speech therapist, who really originally designed to the technique. I'll tell you about the six steps. What we want to do first is create sentences that we know that this person would want to be able to say, and so we can talk to the patient. And obviously, if they're having difficulty speaking, the family becomes a really good resource for what would you like your loved one to be able to say in their everyday life? What would help make things easier or less frustrating? So from there, we create a list of sentences. And we think about what the melody of that sentence would be. So when we speak, it has to be called prosody. So it has this prosody melodic component to it. And so we put the speech to a melodic melody and or the sentence to a melodic melody. And we tap the client's hand as we sing them out or as we hum the melody. So we help them kind of prime and internalize that melody. And as we tap their hand, we're trying to stimulate the motor strip, which is close to the Broca's area, or the speech area that we're trying to activate. So as we're tapping the client's hand, we'll hum and just help them learn the melody we're going to use. And then we would add the words to that melody while they're listening. So at this point in time, in the process, the client usually knows that they can sing. And it's quite exciting when you are having difficulty speaking, but you realize that you can sync. So they'll often try to sing anything, even before they know what the words to the melody are going to be. So they start out, they listen first, and then they start joining in and singing along with you to rehearse the sentence and really internalize it and learn it. Because the idea is eventually for them to reproduce it. So as you're practicing it, as the therapist, I would start to fade out my voice and my cues to see if they've learned it and if they can initiate it on their own independently. From there, there's a little bit of a call and response between the client and the therapist. So I would sing the sentence, and then I would ask the client to sing it back to me to see if they're able to independently do that. And then the final step is to really just see if they can use that in a functional context. So it's very exciting when the client is able to sing a sentence. But can they say the sentence? And if a real situation happens when they need to use the sentence, can they actually initiate it? So that's probably the most important step of the six is that transfer? If I ask you a question, can you initiate that sentence we've been practicing?

Eryn Tong [26:58] We wanted to hear her in action. Here's Corene with a patient.

Dr. Michael Thaut [28:40] My personal journey is actually a journey as a researcher. And so I became interested in clinical applications. And that's still part of it. 70% of my research is translational. There's also about one third, which is we're looking at still basic music perception processing in the brain. But the clinical angle sort of started maybe 25 years ago. And because when we tested people with music, we looked at memory function of dementia persons, we looked at walking movement, ability of stroke, and Parkinson, and we used music to cue them, or to help them remember things. We saw tremendous effects. And we documented that very carefully for many, many years in research, in papers that we presented. And then the question was not anymore, "are these data correct?" Because people had replicated that they found the same thing. They've developed other angles that were great. The question was, "who can do it?" And so this is when neurologic music therapy as a sort of certificate, clinical branch practice that people practice was established in around 2000. And so this has been around for 20 years. My role is to do research. So we don't really do clinical stuff in here in my research center at all. And the graduate programs we have, you have a Master's and a PhD in Music and Health Science. We don't teach therapy. We teach research skills, usually mostly clinical research skills, and obviously with focus on auditory neuroscience and also on music. So my role, I think, in all of this is to help discover and push the research agenda forward so that we have evidence-based ways to help people.

Stephanie Nishi [30:43] Michael explains the basis of his research and gives us a sneak peek at what some of his work examines.

Dr. Michael Thaut [30:49] Music is a very pervasive stimulus. It's a very complex auditory stimulus, probably the most complex auditory language the brain has developed. So when we listen to music, or do any kind of musical task in the brain, the hallmark of what we see in the images is that there is a very large array of networks that are activated cortically subcortically, even from the priming aspect, you know, spinal cord, motor neurons can be triggered. So there is not a music area in the brain, rather that music stimulates a large, large network of multiple regions in the brain. And that's, of course, helpful when we look at injured brains because we are pretty sure that somehow some area that is in need of plasticity and work, so to speak, will also be impacted by music. So we have auditory areas, you have cognitive prefrontal areas, we have motor areas, parietal areas, pattern perception - the whole brain is really, really very, very active. And we do have musical tasks. My original hypothesis really came out of musicianship. I was interested in studying why musicians can plan and execute an enormous amount of rapid movements very, very fast. If you would take the musical context out of that and just say, okay, move your fingers 3000 times for one minute. In some kind of pattern, people would probably look and say, that's certainly a crazy idea. But that's exactly what a pianist does. So that was actually my original hypothesis. Then people were interested in talking to me about music therapy. The way this I see it, currently, it may not be very science-based. Let's try a different approach. Let's look at the music itself. So we started looking at the effect of rhythm, musical rhythm, auditory rhythm. Does that change how people entrain and move, and the first experiments we did were quite dramatic, and the effect is still dramatic. So a stroke patient walks with much more symmetry and much more stability. A partisan patient can walk much faster, with less freezing. So the auditory system, and that was part of the things that we saw to help discover, the auditory system is very closely linked to the motor system and to the cognitive system, and speech Language system. And so it is a very central network role in shaping an impact in other areas. And so this is how we discovered, step-by-step, these multiple translational effects of music on non-musical functions. We are doing a big study right now with St. Michael's Hospital looking at the neural basis, the brain basis why people with mild cognitive dysfunction, Alzheimer's disease, why do they remember music so much longer and autobiographical memories associated with music? So we just completed a brain imaging study that gives us some very good ideas of why these music memory networks that were built over 20, 30 years, 40 years sometimes have much more preservation and resilience built in. And so we can actually probably say that some focused neurologic music therapy interventions, to stimulating and boosting these kinds of memory networks that are embedded in general cognitive networks can give Alzheimer patients, and we tested that neuro psychologically about a year ago, can give him at least a boost. I mean, we cannot reverse obviously, the progression of the disease, but we can hopefully create a slowing down, ramping down of the progression.

Eryn Tong [34:45] In addition to the study that was just described in Alzheimers disease, Michael is overseeing 17 other research projects in NMT now, spanning many other populations and applications. These include a mechanism research study at CAMH, which uses near imaging techniques to understand why music helps Parkinson's patients walk better. His team is also working with Holland Bloorview Kids Rehab Hospital to look at how brain waves between children and their caregivers synchronize during neurologic music therapy sessions. His team is also exploring a new line of research, using a robotic kinematics system to look at optimal motor performance learning in musicians. And they're hoping to eventually translate this work to movement disorders.

Dr. Corene Hurt-Thaut [35:27] Research is obviously always the engine behind learning more about music and about how it influences the brain, so that we can be directly applying that to real people. And I feel like it's really amazing to be in a setting where I have things coming hot off the press in the research, and I can that same day, in a clinical setting with the students, be teaching them and showing them how to actually implement it.

Stephanie Nishi [35:57] This complimentary nature of research and practice is a theme we've always explored here at Raw Talk. In the field of music therapy is no exception. SarahRose chronicles her journey of how her research interests came to be, which was informed by what she was observing in her own clinical practice, providing music therapy in the context of medical assistance in dying, or MAID for short.

Dr. SarahRose Black [36:18] I found several years ago, when MAID became legal, that patients were actually asking for music as a part of their MAID process. Not that this surprised me, but it intrigued me and I developed a curiosity around what that experience was like. So for my PhD, I did a phenomenological study on the experience of music therapy within the context of assisted dying, working with and interviewing 10 patients over the course of seven months, also interviewing their primary caregiver, so a family member, usually several months after the patient's death. I also did my own reflections on what it was like to be a music therapist as part of an assisted dying process. And themes such as life reflection, immediacy of therapeutic relationship, trusting therapeutic process, and symptom management and control came up in the research. And it was really exciting, but also validating to see this as a trend in the data, so informing, hopefully, music therapy as a standard of practice within assisted dying, in the future. We currently have guidelines written about how music therapists can practice within assisted dying. And now with this new data, we're hoping to update those guidelines and encourage music therapists to make it part of their practice as they feel comfortable.

Eryn Tong [37:38] We asked SarahRose to tell us a bit more about why the use of qualitative methodology was necessary to address her research questions and exploration of music therapy in the context of medical assistance in dying.

Dr. SarahRose Black [37:49] I do believe that qualitative and quantitative research are two sides of the same coin and that they really don't exist as binaries - I think there is a huge spectrum on which we as researchers place ourselves. But at the end of the day, my deep curiosity is in patient experience. And that's something that cannot be quantitatively measured. We can try but we're never going to get quite as close as we would like to to a patient's experience, even with qualitative methodology. But the nuance the gray area, the complexity of exploring what someone feels, thinks, and sees as they are going through something that's life changing, or life ending. It's not something I wanted to measure. It's something I wanted to explore. And so phenomenological methodology, hermeneutics, interviews at taping lived experience and reflecting back on it, I felt I was able to sit in the gray area with this methodology, and not try and find answers, but just come up with more questions. And that really drove the research forward. I do feel when we try and express our voice or patients' voices or caregivers voices, there's always going to be layers, because human beings are layered. And when it comes to music, we have such complex associations that have such deep layers to them and deep roots that we don't always even have access to. So I think acknowledging that there's complexity just feels authentic for me.

Stephanie Nishi [39:18] Although music therapy is incredibly valuable in people's experiences of health, many misunderstandings about the field remain, including what music therapy is or what music therapists can bring to the table. We certainly held some of our own prior to working on this episode. We asked our guests to share some of those misunderstandings with us.

Dr. Corene Hurt-Thaut [39:40] I think one of the most challenging things about this field is that music tends to have a very mystical connotation. I mean, we all know music is powerful, but it's not just the powerful, you know, ability of music driving the change, but it's really having an understanding of what elements of the music or when should music be used in a specific certain situation.

Dr. SarahRose Black [40:06] It's definitely challenging to navigate people's assumptions and expectations of what it means to be a music therapist in a hospital. Folks often think that I am purely entertainment. There is an entertainment element to having live music that is important. But in fact, the most important thing is that psychotherapeutic relationship that I have with patients. So at the end of the day, it does not become performative, or entertainment. It's all about the therapeutic relationship and the goals we set out such as anxiety management, mood management, processing emotions. The music is often not necessarily beautiful, especially if patients want to express something very raw, very real. It's not about music for entertainment sake, it's about music for self expression. But trying to convey that in a healthcare facility where people assume that if you have a musical instrument, you're providing entertainment, that can be a little bit tricky. The fact that music therapy is a psychotherapy. And certainly in my work, not all music therapist practices psychotherapists, but many of us do, and we're part of the College of Psychotherapists of Ontario. That's often a surprise to other health care professionals. I find that once professionals refer me to their patients, and they see what happens in a music therapy session, or they hear about it from patients, they tend to have a broader understanding of the role of music, and that goes beyond performative, entertaining, or purely aesthetic. Sometimes the most challenging part of my job is getting in the door with a patient. Because just like clinicians have assumptions, patients also have assumptions, not only about me, but about themselves. Patients are often told they are not musical early in life. And so undoing some of those assumptions that people hold about themselves, can in and of itself be therapeutic, I may get a referral from a physician, but if the patient isn't quite ready to go there, it's very challenging to get anywhere psychotherapeutically. But it's hugely rewarding when we can develop a trust. And sometimes that can happen even faster through music than words alone. And it's hugely rewarding when patients invite me in and offer a glimpse of their life story through the lens of music. It's rich, it's intriguing, it's beautiful. It's messy. It's all of these things that I feel privileged to witness. And I always tell patients they never have to, they can of course, not use music because music can be too painful and too sensitive and too intense for patients to access. But knowing I have this as an option feels really rich and really exciting.

Stephanie Nishi [42:47] We were curious to learn how each of our guests became interested and eventually pursued the field. And we found that each guest came from a very different path. Bernice Chu completed an honors Bachelor of Music Therapy at Wilfrid Laurier University and a Master's degree in Music Therapy at Anglia Ruskin University. She's currently a neurologic music therapy fellow at the Royal Hospital for Neurodisability in the United Kingdom. She shared her written story with us from across the pond.

Eryn Tong [43:13] I learned about music therapy at the end of high school when my piano teacher handed me a careers in music book. The first career listed was music therapy, and I instantly knew that that was what I wanted to do. Leading up to university, I knew I wanted to do something involving helping others and really could not see letting go of my hobby of making music. It was like a marriage of my greatest interests.

Dr. Corene Hurt-Thaut [43:34] I chose music therapy because I've always been a musician, and I've always seen how music can have a very powerful effect on people. I wanted to understand how I could actually use that to have an influence on people's lives, and because it was something that was so important to me in my life. As I started studying it, though, I realized there was so much more to it than I knew. There's so much we know about what happens in the brain when the brain interacts with music and how it can really change people's lives, particularly in different neurologic settings.

Dr. Michael Thaut [44:11] I started in Germany, and then I was was a professional musician in Germany in my 20s for about five or six years with LPs.

Jilian Macklin [44:21] What was your instrument?

Dr. Michael Thaut [44:22] Violin. And then I had a bit of a burnout of a very intense performance schedule as I had wanted to sort of take a timeout and had learned about this interdisciplinary PhD and Master's program at Michigan State that sort of combined music psychology, music therapy, music theory. I think I heard it's like many things. The best thing to do here is more like a by accident. I think I heard that from a friend of mine, my father, who was an American, and we had discussions about what I do with these. Maybe in the US actually you have those programs, those that did not exist in Europe at that time at all. And I was very, very surprised. And then I thought I'd check it out for a year or two. And then they offered me a research assistantship for my PhD, so that would pay for that. And so I guess you could leave and then now I have moved to Canada, which I think is fantastic. Sometimes I said, "now I'm halfway home." So it's a life here for me as a born European, it is a very easy adjustment. It's a very, very exciting country.

Dr. SarahRose Black [45:34] I started out as a music educator, I was a music education major at the University of Toronto in my undergraduate degree. I played the piano, and I taught for many years, but I found I was increasingly interested in my students' mental health more than I was in their technical abilities on the piano and felt that music was creating a platform for them to explore their emotions, and it really got me interested in the field of music therapy. From that point, I went on to study music therapy at Wilfrid Laurier, got my Master's degree and accreditation, and then began as an intern here at Princess Margaret in 2012.

Stephanie Nishi [46:09] If you're inspired or interested in pursuing music therapy as a career, you might be wondering what education is required to become a music therapist. Bernice explained that in Canada, accredited music therapists must complete a Bachelor or a graduate certificate in music therapy and 1000 hours of a supervised clinical internship. University coursework includes clinical placements in a variety of settings in academic studies and music therapy research, music and psychology. After completing an internship, graduates are eligible to take the certification board for music therapy exam. And after passing, can apply for the MTA certification. We'll have the website linked in our episode show notes. After qualification, music therapists must take part in continuing education and development as therapists and maintain their credentials every five years through the CAMT continuing education process. What advice did our other guests have to share for prospective music therapists?

Dr. Corene Hurt-Thaut [47:13] If this is an area that you're interested in, you would need to have a degree in an area that's connected. So we have a lot of Applied Health professionals, physical therapists, speech therapists, occupational therapists, that also do our trainings and are able to use the information within their scope of practice. So you don't have to be a music therapist necessarily. We also here at the University of Toronto have an applied music and health program where you can learn to become a neurologic music therapist. And then we also have our Master's of Music and Health Science, where you can really learn to understand more about what's going on in the brain. And underpinnings of why this works. So there are lots of opportunities. Everyone who practices as a neurologic music therapist goes through the official training through the Academy of neurologic music therapy. So students, professionals, all the training happens at the academy. And then there are several levels of advanced training as well that you can do.

Stephanie Nishi [48:18] Check out our show notes for links to upcoming workshops that are being offered through the University of Toronto.

Dr. SarahRose Black [48:23] For anyone who's wondering what it is, or whether it's for them, I was unsure for a really long time. And it felt like a huge leap to go back to school and study music therapy. What was hugely helpful was talking to a music therapist. I reached out to a few of the music therapists in Toronto who are now my mentors, and just said, "can I talk to you? Can I ask you questions? What do you do? Who do you work with? What does it feel like?" And that really gave me the inspiration and motivation to go for it. And also to know that the sky's the limit with music, as it is with music therapy. If you dream it, you can do it, if you want to work in a certain type of facility, amazing. If you want to do something totally unique and creative, you can. I have a really good friend who worked in the community in Vancouver's Downtown Eastside. And I have a really good friend who has worked in indigenous health and really wherever you can dream music therapy should go, I say go for it.

Priya Shah [49:20] And I would say nurture your relationship with music is a huge aspect. Because if you're going to use yourself as a tool, in a clinical situation in a therapeutic relationship, you've got to really value your own relationship with music and to really trust yourself. So make music you don't improvise, keep on doing that. And then maybe also, if you've never had therapy yourself, I would encourage you to go try therapy or maybe even try a session with a music therapist. I would say both of those things: so nurturing your relationship with music and to go and try a therapy session.

Eryn Tong [49:57] As a relatively new music therapist, we ask permission also share with us what her experience has been like since beginning to work in the field.

Priya Shah [50:04] When I finished my Master's, it definitely wasn't realistic to expect to jump into a full time role as a music therapist. But I also knew talking to other peers and other music therapists in the field that there are many contracts available. So that's kind of what my life has become - a lot of contracts mixed together to create this full time kind of work. And so far, I'm really enjoying that because I love the diversity of my work and all the different people I get to talk to, and meet and work with. And it really continues to challenge me as well to get think of different ways to use music therapeutically. And I'm still learning every day about the potential of music therapy. And I learned through my clients, so they teach me so much. And so that gives me a lot of encouragement and drive to continue learning new ways, again, to use music. I also enjoy learning for my clients. I mean, even just songs, I think that I know so many songs, and so many artists, but I find out every day that there's another artist or another song that I never heard before. And so I'm constantly expanding my repertoire because of that, and that's beautiful. But I also think that a lot of people already use music therapeutically, and maybe don't realize. So my approach is very strengths-based and resource-oriented and music-centered. So I'm looking at how to enhance people's strengths that they already have. And then to use music as a resource in as many ways as possible in their lives. And to see, you know, everyday what can music teach us about ourselves?

Stephanie Nishi [51:45] So where is the field of music therapy headed? Well, to start, Bernice explains that music therapy is currently regulated in three provinces in Canada: Alberta, Ontario, and New Brunswick. The other provinces are now working towards regulation, aiming for change in the next few years. We asked our guests what other future directions they are hoping to see.

Priya Shah [52:08] I think that a lot of health institutions and even smaller settings and support centers are starting to realize like the value of music and music therapy as a very important part of treatment. So yeah, I do think that's changing. And I think the more that music therapists advocate for music therapy and raise awareness about it, and also the research in the field, which there's been more and more of, I think that will start to change in the bigger picture. And I think more healthcare settings will start to look for and want to implement music therapy as part of their treatment.

Dr. SarahRose Black [52:42] I would love to see more music therapists working in institutions and making it more of a standard of care. I keep thinking "standard of healthcare," that's the phrase that keeps running through my head, that it's not surprising to see a music therapist in a hospital, that clinicians aren't searching for music resources. If a patient does request something musical, that there is a music therapist on staff, and that training programs are more readily available. I do believe that's the direction we're going in. There's dozens of facilities and institutions in Toronto alone where music therapists are working, and it's only growing. So I'm hopeful that it becomes a standard of health care and that it's part of a standard assessment. I know here at Princess Margaret, we're very lucky, especially with social work that a lot of social workers make it part of their assessment when they first meet patients. "Do you want to meet the music therapist?" is one of their questions, which is exciting. I hope to see more of that.

Stephanie Nishi [53:34] I think that's an excellent place to wrap up today's content. We have one more surprise for you at the end. We'll leave you with SarahRose singing a beautiful and moving piece that she helped her mother write near the end of life as a love letter to her two young children.

Eryn Tong [53:47] But just briefly before we want to thank our team who put this episode together. Jillian stuff, Swapna and myself, Aaron, were the hosts and content developers. CJ was our photographer. Kat was our audio engineer, and Melissa was our executive producer.

Stephanie Nishi [54:01] We want to sincerely thank all of our guests and their clients for sharing their insightful thoughts, voices and creative work with us. Thank you, Bernice, Michael, Corene, Priya, and SarahRose, for opening our ears and minds to the value and importance of music therapy and people's journeys of health and well being. As SarahRose eloquently put it:

Dr. SarahRose Black [54:23] I would say human beings are musical, and everyone who's listening to this is musical. You start from that at baseline from the moment you're - actually before the moment you're born. As soon as you have a heartbeat, your body is music. And for that reason music can and should be and is becoming an integral part of what it means to be human, and what it means to be healthy, and what it means to live and cope with different aspects of health and well being.

Melissa Galati [56:30] Raw Talk Podcast is a student presentation of the Institute of Medical Science in the Faculty of Medicine at the University of Toronto. The opinions expressed on the show are not necessarily those of the IMS, the Faculty of Medicine, or the university. To learn more about the show, visit our website rawtalkpodcast.com and stay up to date by following us on Twitter, Instagram and Facebook. Support the show by using the affiliate link on our website when you shop on Amazon. Also, don't forget to subscribe on iTunes, Spotify, or wherever else you listen to podcasts and rate us five stars. Until next time, keep it raw.