Music therapy at the end of life

Cheryl Dileo and Mariagrazia Baroni (eds.) (2024). Music Therapy at the End of Life. 2nd edition. Jeffrey Books, 767 pages

Alongside the many solid and comprehensive handbooks in music therapy that have appeared in recent years—those extensive “handbooks” intended to cover all areas of practice and theory within the field—anthologies are also being published that offer in-depth overviews of what is happening within specific arenas of music therapy. This time, Cheryl Dileo and Mariagrazia Baroni serve as editors of contributions on music therapy in palliative care and hospice. The result is no fewer than 78 chapters, spanning 767 pages on my iPad—enough to intimidate anyone contemplating reading it from cover to cover.

I long postponed engaging with this anthology, even though I ideally should have incorporated much of this knowledge into my new textbook on music therapy, in which I managed to limit myself to 465 pages to cover the entire field. This is a textbook, the editors write, and they provide many compelling reasons why such scope is necessary. Not least, the chapters document that this is an important area of work for music therapists—perhaps a field of practice where the value is self-evident and where one might assume that extensive research would not be required to demonstrate effects. Yet it turns out that this field is exceptionally well supported by both research and clinical experience.

The anthology limits itself to music therapy with patients who have a terminal diagnosis, grounded in the hospice philosophy. At the same time, we understand that music therapy also takes place with patients with life-threatening and incurable illnesses in many contexts, not only in hospitals and units specifically designated as hospices. The articles have been selected with cultural and international relevance in mind, featuring contributions from music therapists from sixteen different countries. Before I begin reading, I note that the editors promise that all 78 chapters will be short and focused…

Music Therapy at Its Best

This will be a long review—and of all the chapters—so before you read any further, I will offer a conclusion here. This is an immensely rich work, an extraordinarily comprehensive description of a highly specialized field of practice. An enormous amount of work lies behind this anthology, not least in establishing such a large international network of music therapists. The chapters are equipped with web links that provide access to audio and video via the publisher’s website. We are offered a wealth of ideas and practical advice, as well as case descriptions that are both illustrative and deeply moving. This is demanding work that requires a high level of competence—personal, clinical, and musical. We encounter a group of authors who also demonstrate great wisdom in their judgments, phronesis, as Aristotle called this form of knowledge. Great credit is due to the editors for the tremendous effort they have invested—and to the many authors who have created this multifaceted anthology. Read on to gain deeper insight into what this work is about. There is much to learn here about music therapy in general and about the possibilities music offers to support and help people in vulnerable life situations.

Basic Information

The book consists of four main parts. The first provides foundational information about hospice philosophy, terminology, and an overview of research. There is a substantial body of research and documentation in this field. One reference that stood out to me involved 1,500 patients who responded to questions about symptoms such as pain, anxiety, depression, shortness of breath, and mood before and after music therapy sessions. Significant improvements were found in these symptoms, along with changes in facial expression and vocalization. As many as 96% responded positively to participation in music therapy—regardless of age, gender, or diagnosis.

There are also other reasons to involve music therapists in this work. They foster strong connections to and between other professions; they help patients articulate a life narrative; they can provide crucial support in processing spiritual or existential challenges; and they offer help and support to family members. All these aspects—the physiological effects of music on the body, the psychological effects on emotions and moods, and the cultural references that are evoked—fall within the domain of music therapists.

A Review of the Literature

Clare O’Callaghan provides a comprehensive review of the literature in the field, particularly research on palliative care and hospice. This is a credible and valuable synthesis based on a systematic review with transparent inclusion and exclusion criteria. In addition to describing aims and various research designs, the chapter presents findings from pediatrics and from studies of adult patients, encompassing quantitative, qualitative, and mixed-methods research. The studies are briefly described, making it possible to see more clearly what they address. Various limitations are discussed, opening avenues and opportunities for future research in the field.

A Diverse Practice

Part Two of this extensive volume contains the majority of the chapters. Cheryl Dileo offers an excellent introduction to the forthcoming articles in the chapter “Moments of Grace: The Uniqueness of End-of-Life Music Therapy.” This chapter should become required reading for all music therapy students and a guide for everyone practicing in this field. Dileo reminds us that “hospice” is not merely a place or an institution, but a philosophy. It is about safeguarding the patient’s dignity through a holistic approach that encompasses physical, psychological, social, and spiritual needs. The family—both biological and chosen—must also be cared for by an interdisciplinary team, within which the music therapist may assume a particularly important role by contributing insights from a person-centered approach.

Dileo further reminds us of several key contextual factors inherent in this work: we will all die, but as therapists we are at a different point in this journey, which creates particular challenges and calls for reflexivity, processing of countertransference that may arise, and the need for supervision. There is a sense of urgency—something is at stake—in these sessions; the first session may be the last, as it is stated in one place.

Another factor is the complexity of the medical conditions patients bring with them, compounded by the intertwined psychological, communicative, familial, social, and cognitive challenges that characterize this final stage of life. Patients are vulnerable and do not always have the energy required to participate in all forms of music therapy. Families need support, which is also addressed in a dedicated chapter in the anthology. This reality is reflected in the choice of methods and therapy roles discussed across the chapters, with particular emphasis on supporting and conveying the patient’s life narrative.

The music therapy process will necessarily go deep, touching on existential and spiritual themes and opening up experiences of resonance in an interpersonal encounter that will leave its mark on both patient and therapist. This is one of the challenges of this practice and requires therapists to process the emotions that arise within themselves (countertransference), creating a strong need for self-care and collegial supervision. At the same time, this aspect of the therapist’s role can also imbue the work with profound meaning.

A final issue addressed concerns how boundaries between patient, family, and therapist may differ from those in other therapeutic contexts. Touch, a warm embrace for patients and family members, flexible time frames, and the sharing of personal information take on particular significance in this work.

The Therapeutic Relationship

In a well-written chapter, Nadine E. Cadesky addresses a crucial and overarching theme at the core of work with dying individuals: the therapist’s way of being—the demanding relational dimension and the many roles this therapeutic practice entails. Music therapy may be one of the few opportunities patients have to encounter a healthcare professional who is simply present, without the imperative to treat. This requires a presence—being with—characterized by acceptance, without control or an agenda for change. Music therapists must remain open and receptive to the profound grief and suffering that are inherent to the dying process, while also being clear and centered enough to contain and address the needs that arise.

Cadesky refers to a model developed by Dileo and Dneaster that outlines three levels of practice. At the first level, the focus is on supportive care, offering music therapy to palliate physical, psychological, and cognitive symptoms common at the end of life. Music therapy should provide comfort and serve as a means of offering joy and positive experiences. At the second level, the work involves communicative or expressive music therapy, giving patients opportunities to become aware of and express emotions. The third level entails a transformative practice, in which music therapy facilitates insight and growth during this final phase of life. This may involve resolving conflicts, forgiveness, addressing spiritual and existential themes, or exploring what lies beyond death and finding peace.

Music therapists may assume many roles in this work. Cadesky describes these as “welcomer,” “comforter,” “supporter,” “companion,” “witness and survivor,” “mirror and reflector,” “container,” “facilitator,” and “advocate and representative.” In a concluding case description, she illustrates how these roles may be enacted throughout a therapeutic process. What also stands out to me across these chapters is the crucial role music therapists play as caregivers.

Assessment and Integrative Thinking

Several chapters address general aspects of working with dying individuals. Joanne Loewy offers insightful reflections on observation, assessment, and the use of all available information from patients, family members, other professionals, and research findings in relational work with patients. By attending to personal, experiential, musical, ethical, and integrative forms of knowledge and approaches, therapists are equipped to meet patient groups and their families across the lifespan—from newborns and pediatric populations to adolescents, adults, and older individuals in this transitional phase between life and death.

Michael Zanders continues with an introduction to Kenneth Bruscia’s method for assessing improvisations in music therapy, known as the Improvisational Assessment Profiles (IAP). Bruscia’s model of Integral Thinking in Music Therapy (ITMT) is further elaborated by Lauren DiMaio. I note here that most therapeutic orientations and music therapy approaches are represented within hospice philosophy. Through Bruscia’s integral approach, this diversity is distilled into perspectives that encompass outcomes, context, and experience. At times, music therapy may target specific symptoms, such as pain. At other times, understanding context is essential, while dialogue about the patient’s experiences becomes a key element of the approach.

Three Levels

Cheryl Dileo provides an in-depth yet concise overview of the three levels of music therapy practice: supportive, communicative, and transformative. This framework underpins the organization of the subsequent chapters. In short, supportive practice includes everything from regulating breathing and reducing pain, building trust, increasing tolerance for stimuli, enhancing motivation, adapting to changes in body image, and preparing for what lies ahead. Communicative and expressive needs are addressed through conversation, identifying and validating difficult emotions, maintaining identity, accepting loss and limitations, and preserving connections with close relationships. At the transformative level, the work involves addressing issues related to dying, helping to create a life narrative, completing relationships, finding meaning in life, cultivating hope, reducing hopelessness, and experiencing inner peace, among other outcomes.

In addition to direct patient work, music therapists may also support other caregivers, including family members, by helping to reduce stress, cope with loss, enhance self-care, and receive support during the grieving process.

A Good Death

Are there good ways to die? Kirsten O’Grady and Yelena Zatulovsky pose this question from a developmental psychology perspective—what they refer to as “developmentally driven end-of-life care.” The task for those who are dying is both to die and to live well during the remaining time. We remain capable of learning, developing, and having new experiences right up until the end. We can share a song, find a new perspective on our life narrative, relinquish traditions, and create new ones, the authors write.

Needs will differ across the lifespan. In this work, music therapists encounter infants, children and adolescents, adults, and older people—all with different needs and relational contexts. Common to all situations are the three primary tasks of the music therapist: helping patients achieve a good death, supporting patients in their relationships, and assisting them in meeting specific developmental needs.

Here, a distinction is made between developmental tasks—what patients feel driven to accomplish—and developmental needs—what individuals require to feel safe and cared for. This is where age- and development-related differences become evident and where care must be adapted accordingly. The chapter provides numerous examples of how to address specific developmental needs or desires to complete projects and find meaningful closure at the end of life.

Pain

Reducing the experience of pain at the end of life is a universal concern in palliative care and hospice philosophy, supported by references to human rights. Nevertheless, this right is not universally realized, due to unequal access to pain medication and healthcare worldwide. Once again, Kirsten O’Grady and Yelena Zatulovsky take responsibility for a comprehensive chapter on pain and symptom management, rich in essential medical knowledge for music therapists navigating this challenging landscape.

First and foremost, pain is shown not to be merely a physical or somatic phenomenon, but one that must be understood multidimensionally. The chapter also provides a strong account of psychological and emotional pain, spiritual and existential pain, and social pain related to interpersonal experiences. Illustrated through numerous powerful and well-crafted case descriptions, the chapter offers valuable insight into what music therapists can contribute in resolving dilemmas and conflicts that may arise as dying individuals take stock of their lives in this final phase—issues that profoundly influence experiences of and decisions about pain management. While I would have liked to explore the authors’ reflections and situations in greater detail here, I instead encourage readers to consult the text itself to grasp these important nuances.

Pain also arises in connection with various medical procedures and disease states, including respiratory challenges, withdrawal of ventilatory support, intake of food and nutrition, continence-related difficulties, neurological changes, and more. The challenges associated with these conditions are linked to potential music therapy interventions. The same applies to psychological states related to anxiety. The presentation is exemplary in its attention to developmental aspects, ensuring that specific challenges encountered by children or adults are addressed in a tailored manner.

Music at the End of Life

While the introductory chapters have provided a great deal of necessary general and specific background knowledge for working in palliative care and hospice-based practice, a series of shorter chapters follows that illustrates more concrete approaches to this work. Cheryl Dileo and Heather Wagner’s chapter on music therapy as a means of creating a good ending to life serves as a transition into these chapters. Four expressions are central to the process of saying farewell to life for those involved: “I love you,” “Thank you for everything,” “Forgive me,” “I forgive you,” and “Goodbye.” These emotionally charged statements may form the basis for song selection and musical approaches when the music therapist enters these decisive hours and moments.

Dileo and Wagner illustrate these situations through short narratives—powerful and moving—that vividly demonstrate the meaningful caregiving role the music therapist assumes in such circumstances. Not least, they show how this work belongs among the most meaningful and challenging practices music therapy has to offer, as the authors point out. This is something I fully agree with after reading these accounts, which strongly underscore the humanistic value base on which music therapy rests. As the authors state (p. 180): “Working with the dying also challenges us to learn to truly love, for indeed love is at the heart of what we do. There is no more powerful opportunity to witness the human condition and to experience solidarity with the humanity we share with our patients.”

At the same time, it cannot be denied that this work comes at a cost, as therapists must carry the suffering and perceived injustice that can weigh heavily on empathic music therapists and requires both supervision and self-care. Yet we also come to understand that the human encounters that arise in these marginal situations can be life-changing—not only for the dying person and their loved ones, but also for the therapists.

Grief

Music therapists encounter patients and family members facing an imminent death, often in states of anxiety, pain, and depression. It is important to have a strategy when approaching the family’s anticipated grief, so that one can also provide support throughout the grieving process, writes Guacimara Molina Sosa. We are taken into a case in which the music therapist creates space for a meaningful ending to life for a young husband and his family. In this story, we see the importance of living a meaningful life for as long as possible and not dying in sheer suffering. Music sessions can become places where people connect with one another, revisit cherished memories, and create new shared experiences.

Life Narratives and Memory Work

It is also in this final phase of life that the music therapist can make a valuable contribution to shaping a life story—a narrative that supports a good ending to life. Natalie McLune and SarahRose Black provide valuable insight into how music becomes a powerful trigger in reminiscence work, and how musical memories can be woven together into a life story, a “life review” that places individual memories and experiences within a broader perspective.

The formulation of a musical autobiography—something I became well acquainted with in the 1990s when I used it as a method to explore connections between music and identity—is a particularly potent tool for working through unresolved conflicts as well as positive experiences, as illustrated through case descriptions. At the same time, the authors provide helpful guidance on questions that can be asked to facilitate the creation of a musical autobiography. Attention is also drawn to contraindications—not all individuals in a terminal phase of life have the resources to reflect on their history, life choices, and values.

Song Selection and Lyric Analysis

Four chapters devoted to song selection and lyric analysis in work with children and adults are written by Louise Miles and Guacimara Molina Sosa. Allowing children to choose which songs are sung is of great importance, particularly because making one’s own choices is crucial for children in such difficult situations. Songs also play a significant role in communication. Singing offers a safe space that is separate from treatment and illness; it has a calming and reassuring function in an otherwise frightening situation for the child, writes Miles. When young people’s preferences are respected, situations may arise in which song choices challenge or even provoke the adults around them. One example is an adolescent who chose “Stairway to Heaven” and was met with reactions from caregivers.

Song selection is also important for fostering connection between the child and family, and the chosen music may take on strong symbolic meaning for those left behind after the child’s death. For adult patients as well, songs help give form to what individuals wish to express. Songs open creative channels for describing moments, situations, and memories—ways of describing oneself, writes Molina Sosa. She also provides guidance on how song selection can occur, either through associations or through more deliberate choices.

Using song lyrics as the starting point for therapy creates opportunities to stimulate memories, thoughts, and emotions, foster understanding, and establish new forms of connection. For adolescents and older adults, song lyrics may provide an opportunity to reflect on their situation and what is unfolding. Once again, we are given practice-based narratives that illustrate the importance of using song lyrics as a foundation for therapeutic processes, along with practical advice and thoughtful reflections on the therapist’s role in these processes.

Songwriting

Another widely used method in music therapy is songwriting, which takes on particular significance in work with children, adolescents, and adults in the terminal phase of life. Amanda Maestro-Scherer writes about the role of songwriting with children and families, while Charla Burton and Meredith Ferrel focus on this work with adult patients. For children, songwriting can help them articulate their situation, cope with it, and share messages with their families. Writing songs can also help children—and sometimes their siblings—process the difficult thoughts and emotions associated with leaving life behind. Maestro-Scherer notes that it is often not the emotions themselves that frighten children, but rather the feeling of being alone with those emotions. Songwriting can help break this sense of isolation.

Similar benefits may apply to adult patients. In addition, processing anxiety and depression through songs, or simply engaging memories and cognitive abilities by creating lyrics, can help improve quality of life. We are also offered suggestions for different song forms that may be effective. For example, blues is well suited because it is a familiar form that allows repetition of simple statements and opens space for dialogue with the therapist. Narrative songwriting based on personal life experiences, or the use of “song parodies,” where new lyrics are written to familiar melodies, may also be appropriate.

Robert E. Krout provides an insightful introduction to how he composes songs for people at the end of life. He writes about songs that the music therapist composes and performs directly for the patient. These may be tailored to the individual patient’s situation or be more generic—what he calls “original therapist-composed” songs—addressing themes common to people in such circumstances. He guides us through the songwriting process, describes the use of musical elements, and offers a list of themes likely to be relevant in most situations. Lyrics are crafted to validate patients’ feelings, help identify and normalize emotions, and provide opportunities to express difficult experiences.

Improvisation

Several additional short chapters focus on various methods and approaches familiar from music therapy, here adapted specifically to hospice philosophy. Nadine E. Cadesky contributes two chapters on the use of vocal improvisation and spontaneous song improvisation, from both the therapist’s and the patient’s perspectives. We are introduced to the many ways therapists can employ spontaneous, non-referential vocal improvisation—using sounds and music without specific textual reference—as well as referential improvisation, where something is created spontaneously around a particular theme.

Cadesky offers valuable reflections on required preparations, therapeutic prerequisites, the importance of familiarity with one’s own voice, procedures, and specific considerations to keep in mind. She presents numerous ways of using improvisation and spontaneous song, emphasizing how this form of singing enables therapists to be fully and completely present with the patient. As in other chapters, narratives provide compelling illustrations of how these approaches can support children, adolescents, and older adults in this phase of life.

Several chapters also address the use of instruments in improvisation. Elizabeth Harman writes about improvisation with pediatric patients at the end of life, offering guidance on preparation and procedures, such as adapting to situations in which parents are often present during sessions. Mariagrazia Baroni presents several case narratives involving improvisation that effectively illustrate how music serves multiple goals, particularly emotional release, which in this final phase of life can contribute to a meaningful ending.

Teresa Miquel Sellés gives special attention to instrument selection for this work. She finds the transverse flute particularly suitable, along with the guitalele (a small, compact six-string hybrid of ukulele and guitar) as an accompaniment instrument. Many other instruments may also be used in combination with the voice.

Music Therapy and Legacy Work

“Legacy work” refers to how music therapy can help honor or preserve defining elements of a patient’s identity, support caregivers in coping with grief, or give patients opportunities to reflect on their lives and the impact they have had on others, write Amy Love and Lydia Westle in their chapter on pediatric practice.

This work may be process- or product-oriented, or a combination of both. It may involve shared experiences of creating songs, audio recordings, or videos that survivors can carry with them. Music therapy interventions may include composing music, creating personalized lullabies, recording heartbeats (see below), or other projects involving audio and video, often with participation from family members. For older children and adolescents, personalized playlists representing key relationships and life experiences may be created.

These chapters provide concrete guidance on necessary preparations, communication strategies, appropriate questions, procedures for audio and video recording, songwriting, and possible contraindications.

Lucanne Magill writes about legacy work with adults and older people. We learn how it becomes natural to look back on life and reflect on memories, accomplishments, and values. Music’s capacity to evoke and recreate memories can be used to foster meaningful relational and communal moments. Through such a life review, what Magill calls “legacy themes” emerge—central narratives highlighting contributions made throughout life and how one wishes to be remembered. Numerous examples from music therapy practice illustrate these processes.

We also encounter music therapist Brian Schreck, who describes his pioneering work with heartbeat recordings, known technically as “amplified cardiopulmonary recording” (ACPR). This involves recording the heartbeats of infants and pediatric patients using, for example, a stethoscope microphone, and editing the recordings in software such as GarageBand. From school age onward, Schreck recommends the Thinklabs “One” digital stethoscope, which allows volume amplification before processing the sound in a digital audio workstation (DAW).

Heartbeat recordings may be used as background tracks in compositions written for patients or as rhythmic foundations beneath beloved songs associated with them. As in other chapters, many examples and instructional videos are provided, accessible via web links in the chapters through the publisher’s website using a password. This is an impressive editorial achievement that adds another dimension to this comprehensive anthology.

Music Therapy in Grief Work, Rituals, and Funerals

Several chapters address how music therapists can support families during the difficult time when children or adults die—both as death approaches and in the period following, up to and including the funeral. Lydia Westle describes how music therapy can provide strength and a supportive environment for both families and healthcare staff by fostering connection, comfort, and meaningful closure in the moments immediately following a death. Once again, I am struck by the courage, care, and empathy music therapists demonstrate in these situations, which must be among the most demanding they encounter.

SarahRose Black discusses this work with adult patients, emphasizing the importance of thorough preparation, psychological readiness, and sensitivity to how overwhelming such situations may be for families. Empathy, situational awareness, and the ability to read complex dynamics are essential. In grief work with both children and adults, it is of great value if the therapist has accompanied the patient throughout the final phase, becoming familiar with musical preferences and repertoire, establishing relationships with family members, and clarifying expectations regarding the therapist’s role.

When it comes to planning and potentially participating in children’s funerals, family members often wish for assistance in selecting music and creating rituals that preserve and honor the memories formed through music, writes Amanda Maestro-Scherer. In this way, the funeral can become a continuation of the therapeutic process leading up to this final ritual. The music therapist may be asked to sing and play, as well as help present music videos and other creative expressions left behind by the child.

Charla Burton and Meredith Ferrel elaborate on these themes in the context of adult patients nearing death, where patients themselves may participate in planning their funerals and selecting music. Here, the music therapist may play a crucial mediating role, particularly when patients’ wishes differ from those of family members. These chapters are rich in practical advice, reflections, procedures, and illustrative case descriptions that highlight the great competence, wisdom, and empathy characterizing these music therapists.

We also learn how music therapists actively participate in the development and implementation of special rituals within institutions, aimed at providing a dignified conclusion to a course of care. These rituals allow healthcare staff and family members to take part in symbolic ceremonies. Katie Lindensfelser writes about such rituals developed at Crescent Grove, a pediatric hospice near Minneapolis, Minnesota. These rituals often take place in “sacred spaces” adorned with flowers, artwork, and colored fabrics, filled with music. Every opportunity is taken to celebrate children with limited life expectancy—birthdays, transitions from preschool to school, entry into adolescence, and more. Everyday rituals are created with care, recognizing the immense value of such moments. When a child dies, so-called “honor walks” are organized, in which the entire care team prepares a ceremony together with the family. These rituals also serve an important function in supporting staff as they process their own grief after losing a patient.

Similar “farewell rituals” have been developed for adult patients, as described by Mariagrazia Baroni and Francesca Bonancini in their work at Hospice Casa Madonna dell’Uliveto in Reggio Emilia, Italy. Often, patients themselves have participated in planning and expressed specific wishes regarding the ritual and the music to be played. Music therapists naturally play a central role. Three types of rituals have been developed: a religious ritual, a secular ritual, and one based on nature, incorporating symbols such as an olive branch, a rose, and a sachet of lavender—all gathered from their own garden.

Spirituality and Existential Questions

Roughly halfway through this extensive anthology, we encounter chapters that address the spiritual needs that may arise at the end of life. Lucanne Magill offers a thorough exploration of this theme by concretizing the values and personal concerns that are at stake. These include themes such as love, meaning and purpose in life, relationships and attachment, identity, reconciliation, belonging, faith and hope, as well as peace. Music therapy opens pathways to such themes, particularly where music listening can bring people into altered states of consciousness, create peak experiences, and offer transpersonal experiences—something that BMGIM in particular can facilitate. Magill emphasizes the crucial role of the music therapist in offering presence to patients and their families by being attentive, supportive, validating, and affirming. The chapter also provides examples of relevant clinical approaches using voice and instruments.

Cheryl Dileo elaborates on these existential concerns in her chapter by drawing on theory and research related to aging and the final phase of life. She refers to the psychologist Erik Erikson, who described how different life stages involve distinct developmental tasks. Erikson termed this final stage “Ego Integrity vs. Despair.” Dileo further outlines psychotherapeutic approaches that focus on how we create meaning in life.

A key point of departure is found in humanistic–existential therapies, which seem particularly relevant in this context. We are introduced in more detail to what is known as Meaning-Centered Psychotherapy (MCP), which is grounded in Viktor Frankl’s understanding of meaning. Here, the music therapist seeks to explore and activate four central sources of meaning: historical sources, connected to what we have created and what we leave behind; attitudinal sources, referring to the attitudes that have helped us through difficult and challenging life circumstances; creative sources, encompassing all creative contributions that have given life meaning, such as work, artistic expression, and good deeds; and finally experiential sources, which involve becoming aware of experiences related to meaningful relationships, encounters with beauty in nature and art, and similar experiences. The chapter provides examples of how music therapy can help activate such experiences of meaning, offering a compelling illustration of the fruitful relationship between music therapy and humanistic–existential therapy and theory.

Receptive and Expressive Approaches

This is followed by several chapters that introduce central approaches and methods in music therapy work with children and adults in the final phase of life. These include GIM, improvisation and analytic music therapy, a Nordoff-Robbins–based approach, as well as the use of vocal techniques with hospice patients.

M. Louise Cadrin provides a concise and general introduction to the receptive listening method (BM)GIM, which is useful for those unfamiliar with the approach. At the same time, she points to necessary adaptations when using the method with patients in palliative care. These involve modifications related to patients’ energy levels and emotional states, suggesting shorter music journeys and the use of less challenging music. She also offers helpful references to GIM therapists with experience working in palliative contexts.

Filippo Giordano shares his experiences using a modified form of GIM with children and adolescents who have life-limiting illnesses. He refers to this adaptation as M-BMGIM, which involves modifications within the traditional GIM structure. Since parents are often present when younger children receive this intervention, special considerations are required. In general, the preparation phase focuses on safety, and music selection is adapted to the tastes of children and adolescents, including genre preferences. Adolescents may be engaged by mobilizing energy, and programs from the classical GIM repertoire—such as The Hero’s Journey and Childhood Experiences—may be chosen. The chapter is rich in useful reflections, and Giordano offers important insights for anyone wishing to use this listening method with children and young people.

South Korean music therapists Seung-A Kim Jung and Soyoung Park provide a solid introduction to analytic music therapy as originally developed by Mary Priestley, with later modifications and adaptations for work in palliative care. This involves so-called referential improvisation, where the themes for improvisation are drawn from the patient’s current life situation and are informed by principles from traditional (psycho)analytic theory. The work aims to help patients process difficult emotions and conflicts experienced during this phase of life.

The music-centered approach developed by Nordoff and Robbins is also the subject of a dedicated chapter. Fraser Simpson offers an overview of key themes in this method, drawing on his experiences working at Mountbatten Hospice on the Isle of Wight. A historical line is traced from Nordoff and Robbins’ work with improvisation for children with special educational needs, through David Aldridge’s work on music therapy and palliative care in the 1990s, with contributions from music therapists such as Colin Lee, Nigel Hartley, Mercedes Pavlicevic, and Gary Ansdell. Kenneth Aigen developed a strong theoretical foundation for anchoring music therapy in musical goals. Ansdell further advanced improvisational therapy toward contemporary community music therapy, opening up for more group work, choirs, listening groups, performances, and other hospice-related projects.

Simpson also presents the background and philosophy of Mountbatten Hospice, whose goals align closely with the values conveyed by this music-centered therapy. Creating a shared world and mutual recognition through improvisation is about fostering shared humanity. Simpson has also written a separate chapter on leading a choir at the hospice, where a community is formed among patients, caregivers, relatives, and members of the local community who wish to participate. “Why should every hospice have a choir?” he asks, offering convincing arguments and documentation for the value of such a community music therapy–oriented initiative.

That such music therapy work requires a particular form of sensitivity becomes especially clear when the voice is the primary musical medium. This is conveyed by Carrie Rupnow-Kidd, Brooke Carroll Lemchak, and Karen Dennery Melita in a rich article on the use of advanced vocal techniques with hospice patients.

The voice is the most intimate of all instruments and requires heightened sensitivity and awareness when offered as the primary means of expression. The authors remind us of Kenneth Bruscia’s four Modes of Consciousness—sensing, feeling, thinking, and intuiting—as prerequisites for developing the attention and presence required in this work. These are further linked to countertransference reactions that therapists must remain aware of, both to notice subtle patient responses and to avoid crossing boundaries. The chapter introduces three central vocal techniques previously proposed by Cheryl Dileo: the “synchronizing voice,” the “nurturing voice,” and the “emotionally expressive voice.” Each of these vocal qualities is described through technical guidance and illustrated with case examples.

Many Conditions and Client Groups

Music therapists encounter patients with a wide range of conditions that have led them to hospice and holistic palliative care. Several chapters address work with people living with dementia, perinatal hospice care and premature infants, soldiers at the end of life, incarcerated individuals, and trauma-informed care. These contexts may involve conditions that require specific knowledge, sensitivity, or specialized practices. Inclusive practice is always preferable, particularly where family members can be involved in music therapy—a point illustrated by John Mondanaro through an extended case example of a family-centered approach.

Similarly, Laurel Young writes about providing music therapy to patients with advanced dementia, even where many might assume the intervention would not reach them. Young is committed to offering all patients a dignified end of life and has witnessed numerous instances in which music reached individuals who had shown no signs of presence for extended periods. Her reflections, grounded in examples from her own practice, will be valuable to others working in similar settings.

Lauren Fagan-Antonelli contributes a chapter on music therapy in hospice settings for perinatal conditions—situations in which a mother carries a child with an expected shortened lifespan or who is stillborn. Music therapy addresses such painful losses and anticipated grief processes by helping to create memories of the child that can support parents both around the time of birth and afterward. This work draws on procedures developed within the “First Sounds: Rhythm, Breath, Lullaby (RBL)” method and the “HeartSong” intervention, previously introduced by its developer Brian Schreck.

These two approaches are also central to the chapter on “HeartSong” for premature infants and their parents, written by Lauren Fagan-Antonelli and Joanne Loewy. The authors also introduce other approaches, such as combining RBL with heart songs that represent so-called “songs of kin”—songs rooted in family music preferences, memories, and traditions. The chapter highlights the importance for parents of preserving meaningful memories through these musical recordings of a child who never grew up.

Another group of hospice patients with particular needs includes individuals with a background as veterans. These individuals may carry especially vivid memories of wartime experiences and may be traumatized, burdened by disappointment and loss, physical injuries, substance abuse, or other complex conditions that can be intensified by a life-threatening diagnosis. What is crucial here is knowledge of military values and the individual’s life history—insights clearly conveyed in the chapter written by Lucanne Magill.

Another chapter focuses on incarcerated individuals. Many people end their lives in prison and require palliative care, yet access to humane care can be limited due to lack of services, ideological barriers related to differing views on the purpose of incarceration, and the challenging personal histories common among many offenders. Heather Wagner draws on her experience in an institution designed to receive high-security inmates in need of palliative care, offering an insightful discussion of this complex set of challenges.

Mitsi Akoyunoglou, Elizabeth Kaczynski, and Elide Scarlata address challenges related to palliative care for individuals affected by natural disasters, war, famine, racism, persecution, and forced displacement. These contexts involve challenges on many levels, including language barriers, cultural differences, severe health conditions, and the state of healthcare systems in different countries. Hospice and palliative care are generally underdeveloped in many countries that receive refugees.

In work with traumatized older adults, knowledge of trauma-informed care is essential. Heather Wagner provides a comprehensive overview of what a trauma-informed approach entails—an orientation that is, in fact, necessary in all settings. This includes creating safety, trust, and transparency around procedures, ensuring support from people close to the patient, fostering collaboration and mutuality, promoting empowerment, and demonstrating cultural humility. Musical stimuli can often evoke memories, sometimes of unwanted or painful experiences. The risk of retraumatization is always present, even long after a trauma has occurred. Wagner deserves particular recognition for including a case narrative that went badly wrong and offering thoughtful reflections on it afterward. Given that most chapters present positive practice examples, it is especially important to illustrate situations in which one might have acted differently.

Death Education

There is a need for initiatives that can help children and other groups gain knowledge and experience related to death. Giorgos Tsiris writes about the project “GRESCO Agape,” a collaborative online initiative involving Greek (GRE) and Scottish (SCO) hospice patients and schoolchildren, with a focus on songwriting. This innovative project, conducted during the COVID-19 pandemic, included a training program for teachers and an online process in which all participants met and shared experiences. The participants then collaborated on songwriting with community musicians, music therapists, and other healthcare professionals.

A radical and activist project is described by Australian artist Ania Tait, who, together with three other artists, formed The Death Quartet (DQ). This interdisciplinary art group seeks to engage local communities through artistic projects aimed at raising awareness about death. Tait describes a project in which participants were invited to engage in various artistic expressions while responding to questions about their own relationship to death. This important, radical, and innovative project should inspire similar initiatives.

Religious, Spiritual, and Cultural Contexts

Molly G. Hicks has written an extensive chapter on the necessity of addressing spiritual and religious needs that arise at the end of life. Perhaps it is precisely at this stage that such needs become particularly pressing, as individuals seek to clarify their relationship to their own lives, higher powers, or to take stock of their values. Music is connected to religious practice in many ways; it may be part of rituals and thus evoke memories of religious and spiritual experiences from one’s lived life.

However, music serves different functions across religions. Hicks contributes essential continuing education in this area by describing the role of music at the end of life in Christianity, Judaism, Islam, Hinduism, Buddhism, Sikhism—and not least among those who do not belong to any organized religion. Religion can be a vital resource for many in enduring pain and confronting existential challenges at the end of life. At the same time, it is important not to impose religious rituals or prayer on those who are non-religious. This work requires knowledge, great sensitivity, humility, and a measure of self-reflection on the part of the music therapist. Hicks’s comprehensive chapter is an excellent place to begin.

This is followed by a series of chapters addressing hospice perspectives within several major cultural and linguistic contexts. Rather than going into detail, I will simply reference the authors and regions to illustrate the diversity represented in this extensive anthology.

Marianela Corboda Saborio reflects on hospice care for Latin American clients—a vast and diverse topic encompassing many countries and languages, regional differences, individual needs, family traditions, and a wide range of national and regional musical genres. As in what follows, it is crucial not to be guided by prejudice or stereotypes—not all Latin Americans like “Bésame Mucho.”

Charla Burton and Maya Johnson follow with reflections related to the African American population, which has a distinct history and rich musical traditions. This population also often approaches the healthcare system with a degree of mistrust, due to years of discrimination and reduced access to quality care compared to white Americans. A rich religious musical tradition serves as an important resource for resilience and coping with suffering—spirituals, hymns, and gospel singing—genres that have inspired musicians worldwide, from blues, ragtime, and jazz to rhythm and blues, rock and roll, rap, and hip-hop.

Fu-Nien Hsieh writes about Taiwanese culture, reminding us that in some cultures it can be taboo to speak about death. Instead, one may speak of rebirth rather than dying. We also learn that in this culture, the pronunciation of the number four closely resembles the word “death,” which is why one does not find a fourth floor, hospital bed, room, or elevator labeled with this number. Many prefer to die at home, fearing that the soul may not find its way back home if one dies in a hospital.

Ayumu Kitawaki and Rieko Eguchi write about the situation in Japan, where we encounter another contextual factor related to communication. A more restrained form of emotional expression is valued, with an emphasis on attentiveness to others’ thoughts and feelings. Silence is highly valued, and many Japanese consider death a taboo topic and avoid discussing it.

Turning to the vast and diverse context of India, we encounter a multitude of religions and customs, as described by Sumathy Sundar. We are introduced to central features of Indian philosophy and worldviews, as well as the significance of sound (OM) and the development of Vedic chant traditions. Since religious music and various scales or ragas are culturally associated with specific emotions through ritual practice, it becomes important for the music therapist to know which scales, for example, are suitable for improvisation.

We also find a chapter on the situation in the Middle East—more specifically, the Gulf states—written by Kristal Foster. Here it may be important to allow patients themselves to define who they consider family and whom they wish to involve in the care situation. Many of the same practices and considerations discussed earlier in relation to Muslim patients apply here. For example, music-making should be avoided during the call to prayer (Adhan), and many prefer to avoid music in the period immediately following a death.

Gabi Frank writes about palliative music therapy for children in Israel, working with both Jewish and Palestinian children treated in Israeli hospitals. In this context, difficult political issues inevitably arise for music therapists. Language barriers, roadblocks, and religious traditions—such as those among Orthodox Jews—require deep reflection on the part of the therapist.

Among the final groups addressed are individuals with diverse gender expressions (LGBTQ+). While not a homogeneous group in terms of religion or musical taste, they share common experiences of discrimination, particularly within healthcare systems. Carrying one’s gender identity into the final phase of life can be difficult due to fear of rejection. Here, the music therapist has a crucial role in offering acceptance and care, as Alexa Economos writes.

Indigenous peoples are the final group discussed in this section of the book. Tinaya Entz focuses on Canada’s First Peoples, describing communities that have often been colonized and that maintain their own cosmologies and holistic, relational worldviews closely connected to nature. Family is often understood in an expanded sense, with extended kinship networks gathering to say farewell to the deceased. Many individuals live within two cultures—integrated into mainstream society while also belonging to Indigenous traditions. For the music therapist, this calls for what is known as “Two-Eyed Seeing,” the capacity to honor and hold both ways of life simultaneously.

Ethics

In light of what has been described so far, it becomes clear that ethical issues are central to this field of work. One of the anthology’s editors, Cheryl Dileo—who has previously authored a seminal work on music therapy and ethics—elaborates in this chapter on ethical dilemmas related to working with people at the end of life. The ethical challenges associated with this work are unique and complex and may indirectly involve the music therapist in difficult medical decisions, for example when physicians, patients, and family members are making decisions related to the withdrawal of life-sustaining treatment. In addition, Dileo addresses themes already touched upon earlier, such as boundary-setting, cultural considerations, religious and spiritual concerns, value conflicts, interdisciplinary teamwork, and rights-related issues concerning audiovisual recordings. There is an ethical obligation to know oneself and one’s own reactions. Here, understanding the feelings and attitudes generated through transference and countertransference becomes important, as analyzed within psychodynamic theory. The chapter concludes by outlining an analytic–reflective, seven-step problem-solving method.

Resilience, Grief Reactions, and Supervision

Heather Wagner writes about the emotional cost therapists may experience in their work with dying patients. Music therapists are continually exposed to death and loss, which makes them particularly vulnerable to compassion fatigue, burnout, traumatic stress, and related conditions. Wagner asks how we can build resilience—that is, the capacity to withstand negative experiences and sources of stress. One factor she highlights is what she calls vicarious resilience, which refers to the reciprocal influence between client and therapist and can lead to growth and transformation that arise from witnessing clients’ processes of healing and adaptation.

There are many sources of strain and barriers to developing resilience. Beyond the inherent challenges of the work itself, these include difficulties in maintaining a balance between work and personal life, challenges related to boundary-setting and accepting one’s own limitations, as well as systemic stressors linked to the workplace—such as organizational structures, collaboration, documentation requirements, and lack of support from colleagues and supervisors.

To strengthen resilience, Wagner suggests approaching the work with as positive a mindset and as many positive emotions as possible, in order to counteract the negative feelings that may arise. She emphasizes the value of feeling competent, having confidence in one’s professional abilities, and grounding that confidence in the professional identity that the field of music therapy has developed. Wagner reminds us of a survey of American music therapists in which 94 percent reported that their work is appreciated by service users. Connecting with a network of other music therapists is important, as is finding meaning in this work through self-reflection and self-awareness.

Lauren DiMaio writes about the grief that therapists may experience in connection with their professional role—referred to as professional grief. This grief can be as profound as the “personal” grief experienced in a therapist’s private life. However, such professional grief is not always equally recognized by the surrounding environment. It may be anticipatory, chronic, or disenfranchised, and can easily lead to burnout. DiMaio offers guidance on how therapists can use music therapy methods and other strategies for themselves to process grief reactions.

Supervision becomes especially important in this work, DiMaio continues in a subsequent chapter. She draws on a model developed by Kenneth Bruscia, which is based on the needs of the supervisee. Supervision may be action-oriented, meaning that the supervisor offers clear advice on what to do. It may also be learning-oriented, when the supervisee needs more knowledge, insight, or skills. Client-centered supervision refers to gaining a better understanding of the client, while experiential or process-oriented supervision aims to help the supervisee better understand their own reactions and experiences. Bruscia also describes countertransference-oriented supervision, which focuses on becoming aware of how interactions with patients may evoke reactions that replicate earlier relationships in the life of the therapist or the patient. This chapter likewise provides a range of guidelines on how supervision can be conducted and which topics may arise, including musical and clinical skills, culture, self-care, relational development, grief, and ethics.

Education, Specialization, and Interdisciplinary Collaboration

After reading about the breadth and diversity of this work, it becomes evident that this field requires extensive and multifaceted competence. A general music therapy education, even at the master’s level, can hardly cover all aspects of hospice work. Further training is therefore necessary, and the chapter on advanced, specialized education in hospice music therapy is written by Cheryl Dileo. She has extensive experience in this area and has developed curricula and guidelines for what such advanced training should include.

Dileo identifies a set of required competencies. In total, twelve areas are proposed as a starting point for discussion and possible modification where healthcare systems and cultures require it. These competencies include: theoretical knowledge; cultural knowledge and skills; clinical skills; assessment and evaluation; verbal communication skills; clinical and medical knowledge; musical skills; research skills; skills related to interdisciplinary teamwork; professional ethics; personal competence; and self-care. It goes without saying that each of these areas encompasses numerous subcomponents. Dileo also presents a curriculum she has used in her teaching at Temple University and in workshops in many countries around the world, including Norway.

The other anthology editor, Mariagrazia Baroni, together with Elisa Rabitti, has written a chapter on interdisciplinary collaboration. The necessity of such collaboration becomes clear, as does what music therapists risk missing if they are not included as part of a team. Given the number of different professional groups involved in this work on a daily basis, effective communication and an understanding of each team member’s role are essential. There may also be a need for music therapists to present their work, offer training sessions, or invite other professionals to observe their practice in order to enhance understanding of what music therapy can offer patients in this phase of life. A group of Spanish music therapists (Guacimara Molina Sosa, Laura Bosa Quevedo, María Luisa Munguía Suárez, and Meritxell Yanes Hernández) also share their experiences of forming teams and regularly exchanging insights from hospice music therapy practice.

The Music Therapist as Administrator and Advocate

Toward the end of the anthology, several chapters feature music therapists who describe their transition from clinical practice to leadership positions within hospice organizations. Katie Lindenfelser begins by describing her impressive entrepreneurial work in establishing a children’s hospice from the ground up. This chapter offers a powerful insight into what such an endeavor requires in terms of networking, legal knowledge, financial management, fundraising, and professional expertise. Tracy Leonard-Warner follows with her account of the path from practicing music therapist to administrator, and how she has drawn on her experiences, values, and knowledge from the field of music therapy to create holistic, person-centered care.

Russell Hilliard continues with a compelling narrative of how an encounter with a dying HIV/AIDS patient in the early 1990s shaped him for life. As a young music therapy student at Florida State University (twenty years after I myself began my music therapy studies at FSU), he chose to work with those affected by what was then a fatal disease. This marked the beginning of a career that eventually led him to a senior administrative position within American hospice care.

Music therapist Nigel Hartley has also assumed a central leadership role as Chief Executive Officer of the large Mountbatten Hospice Group on the Isle of Wight and in Hampshire, UK. He has a background as a pianist, is trained as a music therapist at Nordoff-Robbins, and has many years of experience as a practicing music therapist in institutions for people at the end of life in England, including St. Christopher’s Hospice in London. There, he became acquainted with Cicely Saunders, a pioneer of the hospice movement, who developed the concept of “total pain.” This concept emphasizes that pain is not only physical and bodily, but—as discussed earlier—also encompasses social and existential dimensions. Those in need of hospice care are often marked by loneliness and isolation and have a need to tell their life stories before they die. Increasingly, people die socially long before they die physically, and many have family-related and psychological challenges that can be addressed through hospice care, Hartley writes.

Hartley notes that there are around 220 hospices in the United Kingdom and approximately 120 countries worldwide with similar initiatives. The crucial question he raises is what it means for a hospice when a music therapist assumes leadership. In his own experience, he has worked under leaders from various healthcare professions and observed that different professional backgrounds may emphasize different aspects of music therapy. Hartley highlights the values inherent in music itself and in music-therapeutic care as a strong foundation for shaping organizational values. He also emphasizes how music therapists possess strong personal qualities suited to leadership roles, not least through the discipline developed through countless hours of musical practice.

Finally, the anthology concludes with two articles addressing the importance of promoting music therapy within hospice care. Jennifer Borgwardt, Melissa Srolovitz, and Majesta Wong all stress the necessity of advocacy at multiple levels—within hospital settings, among other professional groups, in local communities, with administrators of such services, and at a broader political level. These chapters outline the challenges associated with such advocacy and offer a range of strategies for effectively communicating the value of this work.

A Forward-Looking Concluding Perspective

The two anthology editors conclude by highlighting key characteristics of this field and how it may be further developed to create the best possible conditions for people at the end of life. They point to many of the themes that have emerged across the chapters, including the need to strengthen cultural sensitivity and to work toward social justice by ensuring that as many people as possible have equal access to palliative care at the end of life.

Assessment practices can be strengthened, new methods and approaches can be developed, and resources can be used more effectively by improving prioritization of those who may benefit from music therapy. Music therapists’ self-care must be given high priority, and greater emphasis should be placed on supporting therapists’ capacity for self-awareness and reflective practice. Music therapists can also do more to educate society about the processes and needs associated with the final phase of life, as part of promoting music therapy as a central component of hospice care.

Translated from Norwegian by ChatGPT and edited by the author