Application of Music Therapy Curriculum and Techniques Utilized by Music Therapists - Mary Catherine Wolverton

THE FLORIDA STATE UNIVERSITY
COLLEGE OF MUSIC
APPLICATION OF MUSIC THERAPY CURRICULUM AND TECHNIQUES UTILIZED BY

MUSIC THERAPISTS: A SURVEY OF HOSPICE MUSIC THERAPISTS
By
MARY CATHERINE WOLVERTON
A Thesis submitted to the

College of Music
in partial fulfillment of the
requirements for the degree of
Master in Music Therapy
Degree Awarded:
Spring, 2012
UMI Number: 1515795
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Mary Catherine Wolverton defended this thesis on November 21, 2011
The members of the supervisory committee were:
Jayne Standley
Professor Directing Thesis
Clifford Madsen
Committee Member
Dianne Gregory
Committee Member
Alice-Ann Darrow
Committee Member
The Graduate School has verified and approved the above-named committee members, and
certifies that the thesis has been approved in accordance with university requirements.
ii
ACKNOWLEDGEMENTS
I would like to thank Dr. Jayne Standley, for all of her guidance, patience, and inspiration
throughout this project. Her passionate attitude towards music therapy has motivated me to
always strive for personal and professional growth everyday.
I would also like to thank Dr. Clifford Madsen, Dr. Alice-Ann Darrow, and Dianne
Gregory, for being members of my committee and being profound influences during my time at
Florida State University. You each have provided me with a wealth of knowledge in your classes
that will resound with me throughout my career.
Lastly, I would like to thank all my friends and family, especially my parents, who have
supported and encouraged me throughout my life.
iii
TABLE OF CONTENTS
List of Tables ...................................................................................................................................v

Abstract .......................................................................................................................................... vi
1. INTRODUCTION .......................................................................................................................1
Review of Literature ............................................................................................................1
Defining Hospice Music Therapy.............................................................................1
Function of Music Therapy in the Hospice Field .....................................................3
Educational Practices for Hospice and Palliative
Care Relating to Music Therapy ...............................................................................6
Purpose......................................................................................................................9
2. METHOD .................................................................................................................................10
Participants.........................................................................................................................10
Survey Instrument..............................................................................................................10
Procedure ...........................................................................................................................11
3. RESULTS ..................................................................................................................................12
4. DISCUSSION ............................................................................................................................23
Conclusion .........................................................................................................................26
APPENDICES ...............................................................................................................................27
Appendix A: Survey ..........................................................................................................27
Appendix B: Letter to Executive Director of AMTA........................................................33
Appendix C: AMTA Letter of Approval ...........................................................................35
Appendix D: Florida State University Institutional Review Board
Letter of Approval........................................................................................36
Appendix E: Informed Consent Letter...............................................................................38
REFERENCES ..............................................................................................................................40
BIOGRAPHICAL SKETCH .........................................................................................................43
iv
LIST OF TABLES
TABLE 1........................................................................................................................................12
TABLE 2........................................................................................................................................13
TABLE 3........................................................................................................................................13
TABLE 4........................................................................................................................................13
TABLE 5........................................................................................................................................13
TABLE 6........................................................................................................................................15
TABLE 7........................................................................................................................................16
TABLE 8........................................................................................................................................17
TABLE 9........................................................................................................................................18
TABLE 10......................................................................................................................................19
TABLE 11......................................................................................................................................21
TABLE 12......................................................................................................................................22
v
ABSTRACT
Current research shows the numerous benefits of music therapy techniques within
hospice settings. However, there is little research to show us how often these techniques are
differentiated or employed within hospice settings. The purpose of this study is to examine how
music therapists working in the hospice field apply music therapy techniques and how their
education has prepared them to do so. A web-based survey was sent out via email to the 82
hospice music therapists who were members of the American Music Therapy Association
(AMTA). Only 39 of these music therapists completed the survey, a return rate of 49%.
Respondents reported the most commonly employed music therapy technique to be validation.
They also indicated that they felt most prepared to use patient instrument play based on
education emphasis in their college coursework. Musical repertoire building was shown to be the
most helpful aspect of the music therapy curriculum that applied to clinical hospice practice.
Survey results indicated a high demand for more curricular emphasis on the techniques of
bereavement and grief counseling.
vi
INTRODUCTION
Music therapy techniques utilized in hospice cover a range of interventions that can help
the patient and family attain different goals depending on their needs. From these techniques, a
variety of outcomes emerge. Music therapy creates unique opportunities in palliative care. The
hospice setting requires the music therapist to be well versed in not only music therapy
techniques, but aspects of counseling and medical practices as well. Since individuals are
multidimensional and unique, the music therapist must adapt to changing situations quickly and
effortlessly. Armed with the knowledge gained in college coursework, a music therapist is faced
with a variety of situations that vary in magnitude. Research pertaining to educational practices
used to prepare music therapists for work in hospice is minimal. Examining the use of clinical
hospice music therapy techniques being commonly used, with comparison to the current
educational practices, is crucial to developments of the growing hospice music therapy field.
REVIEW OF LITERATURE
Defining Hospice Music Therapy

Music used in the healing process is not a new concept for the human race. Davis,
Gfeller, and Thaut (1999) suggest that music in the form of healing dates back as far as ancient
civilization where music was believed to be an essential component for mental, emotional, and
physical well being. In biblical literature, perhaps the most well known example would be that of
anxiety ridden King Saul being calmed and lulled to sleep by the sounds of David’s harp (Starr,
1999). Within the United States, music in the medical field shows up in literature as early as the
American Civil War by providing soldiers and doctors with motivation, boosted moral, and
distraction, and quickened healing (Sullivan, 2007). Since then, the medical field accumulated a
wealth of knowledge on music and it’s effects on people. However, given the ambiguous nature
of the human brain and its wide range of responses to music, there is still much to be discovered.
Clearly defining hospice music therapy is an important aspect in order to establish a
unified idea. The American Music Therapy Association (AMTA) (2011a) defines music therapy
as being “the clinical and evidence-based use of music interventions to accomplish
individualized goals within a therapeutic relationship by a credentialed professional who has
1
completed an approved music therapy program”. The Hospice Foundation of America (2011)
defines hospice as “a special concept of care designed to provide comfort and support to patients
and their families when a life-limiting illness no longer responds to cure-oriented treatments.”
Merriam-Webster dictionary defines hospice defined as “a facility or program designed to
provide a caring environment for meeting the physical and emotional needs of the terminally ill.”
From these definitions, an idea of hospice music therapy can be formed as: the use of musical
interventions to meet the physical and emotional needs of patients who have been diagnosed with
a terminal illness, and their families, within a therapeutic relationship by a credentialed
professional who has completed an approved music therapy program.
In order to practice music therapy, one must complete an undergraduate or equivalency
degree from an AMTA approved college or university, a clinical supervised internship of no less
that 1040 hours, and receive a passing score on the national exam provided by the Certification
Board for Music Therapists (CBMT). With these credentials, music therapists who practice in
the hospice field apply techniques to address a number of physical and psychosocial needs in
patients and their loved ones who have made the choice to be admitted into hospice. Within the
hospice and palliative care context, needs addressed by music therapists include physical (e.g.
pain, agitation, shortness of breath) social (e.g. loneliness, isolation, communication,
interpersonal relationships), emotional (e.g. depression, frustration, exasperation, fear,
nervousness), cognitive (e.g. confusion, neurological impairments), and spiritual (e.g. desire for
spiritual connection) (Hilliard, 2005b). As these needs are addressed, it allows the patient and
family to express their feelings and thoughts, and in turn continue to have meaningful
communication and interactions during this difficult time.
Hospice is different than other medical settings can seem impersonal and somewhat
distance themselves from the patient (Frampton, 1986, pg 1593). Dr. Elizabeth Kübler-Ross
(1997) stresses the importance of the wishes and opinions of the patient who has been diagnosed
with a life-limiting illness. The patient and families are vital components in forming a plan of
care. Music therapists are just one member of an interdisciplinary team that cares for and
supports the patient and loved ones. This team includes physicians, nurses, social workers,
chaplains, aides, and other additional therapies, which could include music therapists, art
therapists, or massage therapists. While all members of the team may not visit the patient at one
time, they are all in communication about the patient’s needs, wishes, and physical and
2
emotional states. As an integral part of this team, the music therapist can determine cognitive
functioning, emotional stability, physical limitations, communication skills, mental health, and
social functioning based on the patient’s responses to the music.
Function of Music Therapy in the Hospice Field

When the first hospice was founded in the United States in the 1970s, music therapy was
already a significant part of the structure. Musical influence in a person’s life is too profound not
to recognize—milestones, celebrations, and hardships can all be acknowledged through music.
Given the exceptional influence music can have, it can be an advantageous tool to address a
number of symptoms and issues for patients at many stages of their life-threatening illness and
impending death. Munro (1985) conveys that the aim music therapy within hospice and palliative
care is to diminish “the impact of crises around terminal illness and death, not resolve them” (p.
79). Given the complex nature of each individual’s experience and personality, it must not be
assumed that one patient in hospice is the same as the next. Hilliard (2005a) emphasizes the idea
in stating “as births and lives are all unique, deaths are also individual experiences” (p.19).
Several studies confirm that music therapy used in a holistic manner within hospice and
palliative care increases the patient’s quality of life by addressing physical and psychosocial
needs. As the patient’s terminal illness progresses, there will be in inevitable loss of abilities.
Depending on the nature of the illness, these declines may progress quickly or slowly. It is at this
critical time that the patient have other activities to invest in. Dr. Frampton of St. Joseph’s
Hospice in London writes that certain types of therapies in hospice can “help patients not to
deteriorate faster than their disease dictates and to help them gain prematurely lost function,
particularly in the realm of mental and creative stimulation, which are very important when
physical ability is waning” (Frampton, 1985, pg 1829). In addition to losing the ability to
participate in activities they used to enjoy, patients can feel overwhelmed with changes that are
happening to their body and surroundings. Music therapy can provide productive and creative
opportunities for patients through music interventions such as song writing, instrument playing,
life review, lyric analysis, creating a legacy project or song choice. These creative opportunities
provide the patient with a sense of control, distraction, emotional support, decreased feelings of
isolation and loneliness, increased feelings of self-value and self-esteem, and in turn, increased
quality of life.
3
Music therapy has also been proven to be successful in reducing pain perception and
promoting relaxation in terminally ill patients. One study determined that terminally ill patients
self reported higher scores of feelings of contentment when listening to patient preferred music,
than with the control of background noises in the hospital (Curtis, 1986). Even though feelings of
pain are subjective to each individual person, the music can serve as a distraction from the pain
and promote relaxation. Groen’s (2007) study surveyed for hospice music therapists about pain
assessment and management techniques and found the following:
Music listening was the single most frequently reported technique used to treat pain my
music therapists (93%) followed by music for distraction/attention refocus (76%) and
deep breathing (65%). Music listening was reported to be most often used for chronic
pain symptoms where as distraction was most commonly utilized for acute symptoms. (p.
102)
Depending on the level of pain the patient is feeling, music can aid in altering the perception of
pain so that the patient may gain some sense of relief. Research yields numerous theories and
principles on the connection between pain and the mind. Perhaps one of the most compelling
theories on using music for pain control is Melzack and Wall’s gate control theory (1965). This
theory suggests that gates along the nerve pathways to and from the brain open and close. When
open, pain signals can travel through these gates to the afferent and efferent pathways leading to
the brain, and back to the peripheral nerves, generating pain. When closed, pain is blocked from
entering the nerve pathways all together, leading to no feelings of pain. The process of closing
the gate is achieved by influencing the efferent nerve pathways and, in turn, changing the way
the mind perceives pain. McCaffrey, Frock, and Garguilo (2003) state that these efferent nerve
pathways and impulses are impacted by numerous psychological factors. Such factors include
attitudes and emotions, present surroundings, past experiences, conceptions about the unknown,
among many others. The gate control theory “integrates the physiological, psychological,
cognitive, and emotional components that regulate the perception of pain (McCaffrey et al, 2003,
p. 283). Since music holds a unique component that can captivate the mind in ways not fully
understood, it poses as a meaningful technique to abate the perception and sensation of pain by
flooding the brain with a pleasant sensation.
Symptoms of anxiety, depression, and agitation are other issues are can also be addressed
within hospice music therapy sessions. These issues can be exacerbated by a variety of factors
4
and influences that the patient comes in contact with (e.g. family attitudes, physical
surroundings, symptoms of the illness, acknowledgement of impending death). Nakayama,
Kikuta, and Takeda (2009) conducted a study that revealed that stress levels of hospice patients
after a group music therapy session were significantly lower than at the beginning of the session.
Meaningful interactions and relationships can have a powerful effect on a patient’s demeanor.
Engagement in music therapy has also been shown to increase levels of excitement and
refreshment, while decreasing levels of anxiety and depression (Nakayama, et al, 2009).
Agitation can be an increasing problem as a patient approaches their final hours. Music can be
used in ways to relax the patient similarly to how music is used to decrease pain and promote
calmness. Seeing the patient agitated can be distressing for the family members. Music can also
serve as a medium to calm the families as well (Krout, 2003). Providing options for song choices
can give the patient and families opportunities for control when situations can seem completely
out of anyone’s control. This type intervention not only leads to improvement of quality of life,
but also provides outlets for communication and expression of feelings.
Hospice patients cannot only reap the benefits of music therapy directly through
mentioned techniques and interventions, but indirectly as well. Caregivers of hospice patients
can undergo an enormous amount of pressure and stress. As patients decline in hospice, their
level of care can become increasingly involved and complex. When a caregiver feels the burden
of caring for their loved one is taking a toll on them, it can sometimes feel like a struggle of the
need for self-care and the guilt of not being about to provide for the patient. Choi (2010) found
that music therapy reduced anxiety levels of family and hospice caregivers, especially when
paired with progressive muscle relaxation. When levels of anxiety are reduced, the level of
quality of life increases. With caregivers feeling increased quality of life, they are able to provide
a higher quality of care to the patients.
When a patient in hospice dies, it does not indicate that the work of a music therapist is
over. After the death of a loved one, the process of coping with grief begins for the family.
Feelings of “denial and isolation, anger, bargaining, and depression” can seem difficult to cope
with (Kubler-Ross, 1993, as cited in Hilliard, 2001, Abstract section). Music therapy as an
intervention in bereavement counseling can offer the family a chance to communicate and re-
identify with their personal identity (Smeijsters & van den Hurk, 1999). Incorporating music to
facilitate communication, validate feelings, offer support, and promote wellness, the bereaved
5
can look to music for comfort and opportunities for remembrance. Acknowledging the stages of
grief and creating coping strategies allows the family to move back towards a sense of normalcy
and remain active. However, cultural considerations should be taken into account in order to not
interfere with mourning rituals and traditions that are commonly seen in various cultures (Bulkin
& Lukashok, 1991). Also, as different cultures grieve death differently, children process grief
differently than adults. “Children may regress developmentally, experience physiological and
social changes, display care giving behaviors, and change eating and sleeping patterns. They may
have explosive emotions, disorganization and panic, fear, guilt, self-blame, regret, emptiness,
and sadness” (Hilliard, 2001, Abstract section, para 2.) While adults may experience similar
emotions, children’s display of these emotions is likely to be escalated. Music therapy groups
proved to be successful in reducing grief symptoms and reducing behavioral problems as home
(Hilliard, 2001, Discussion section, para 1.) Providing an outlet that is constructive, enjoyable,
and promotes creativity can allow family members to work through grief and bereavement at
their own pace.
A powerful force such as music can lead to significant changes with mental, emotional,
and physical realms. Bruscia (1998) explains:
“Songs are ways that human beings explore emotions. They express who we are and how
we feel, they bring us closer to others, they keep us company when we are alone. They
articulate our beliefs and values. As the years pass, songs bear witness to our lives. They
allow us to relive the past, examine the present, and voice our dreams of the future. Songs
weave tales of our joys and sorrows, they reveal our innermost secrets, and they express
our hopes and disappointments, our fears and triumphs. They are our musical diaries, our
life stories. They are the sounds of our personal development" (p. Song section, para 1).
Within hospice, these songs and music play an integral part of allowing the patient and family to
reflect and work towards a sense of peace. Music therapy encompasses a value of meeting the
patient where they are in all psychosocial aspects. Music provides a unique and effective
medium to accomplish theses goals.
Educational Practices for Hospice and Palliative Care Relating to Music Therapy
Given the advancements in life-sustaining abilities available in the medical field and the
increasing amount of input that patients and their families have over their healthcare, medical
6
professionals should be knowledgeable and cognizant of end-of-life care (Plumb & Segraves,
1992). As previously mentioned, death is unique to every individual, which leads to little
concrete information about its process. Also, the unpredictability of death offers little long-term
research within the field. Ogle, Mavis, and Wyatt’s (2007) survey of physicians’ understanding
of hospice care indicated that a physicians were not incorrect, but unclear on a significant areas
pertaining to hospice. Nonetheless, medical professionals should maintain an adequate amount of
knowledge in order to assist patients and families, within their discipline’s scope of practice,
when death inevitably approaches.
Education acquired in coursework and curriculum related to death and dying within the
medical field is lacking. Billings and Block (1997) closely examined articles pertaining to end-
of-life care education within undergraduate medical curriculum and concluded “current training
is inadequate, most strikingly in the clinical years” (Data Synthesis section). Research has shown
that instruction on end-of-life care has increased within the curriculum of the medical fields
through developments of palliative care programs. However, these courses were shown to be not
well integrated within the curriculum and falls short in information regarding hospice, assisted
living facilities or nursing homes, and home care (Billings & Block, 1997). In some cases,
opportunities for learning aspects of end-of-life care are available, but not fully taken advantage
of. Plumb et al. (1992) found that only 17% (n=595) of national postgraduate medical training
programs use hospice rotation as a form of training, “despite the presence of a hospice program
in the area of a majority of the training programs” (p. 34). Clinical experience can be an
extremely valuable source of information for medical professionals by exposing them to multiple
elements of medical practice.
Within the music therapy realm of education, clinical practice gained during a required
internship is often focused to one particular population. Hands-on experience with other
populations is gained from practicum opportunities during the completion of coursework.
Practicum sites provide the student with an opportunity to integrate themselves with a variety of
populations while being supervised by a professional music therapist. McClain surveyed music
therapy majors about practicum experiences and found that students wanted more variety of
practicum settings, increased guidance on choosing practicum sites, more information on the
practicum setting and population before beginning, and earlier implementation of practicum
opportunities (as cited in Hadsell, 1998, p. 71). Gaining exposure to music therapy settings and
7
techniques while under direct supervision as a student allows the student to focus on choosing an
internship that provides them with the best opportunities for growth and professional
development. Practicum opportunities within hospice settings allow the student to procure a
better understanding of hospice music therapy. Should the student choose to continue pursuing
hospice music therapy, an internship in hospice allows the student to be fully immersed in the
field. Internships yield valuable insight from a hospice music therapy standpoint, but from other
hospice medical professionals as well.
While practicum and internship provide clinical exposure for a music therapy student, the
crucial elements of application, technique, counseling, research, and philosophy applied to music
therapy are taught in the classroom. As a medical based profession, it is imperative that music
therapists be proficient in medical knowledge about their field. Lectures and textbooks provide
accredited information that is valuable to personal and professional growth. However, in terms of
end-of-life care, little attention is paid to information on hospice and death and dying. An
investigation of medical texts on topics of terminal illnesses, only one fourth of the textbooks
included information about end-of-life issues (Krout, 2000). In order to provide the best service
to patients, one must know the patients. Within college coursework, students listen and absorb
the messages put forth by our educators—it is the students’ responsibility to take the knowledge
and apply it meaningfully.
The knowledge and aptitude gained through educational approaches may or may not
directly influence performance as a music therapist. Madsen and Kaiser (1999) examined the
fears of pre-intern music therapy students and noted how “the classification of ‘inability to apply
knowledge’…received little attention from the therapy majors, yet a related expressed fear of
‘being prepared/not having knowledge’ was perceived high by the therapy majors” (Discussion
section, para 4). The initial fear of moving into something unknown could be considered a
natural reaction to change. Similar to the concept of death, some hospice patients may portray
emotions, thoughts, or fears in several ways. As a music therapist aiming to meet the
psychosocial and physical needs of the patient, a sense of unfamiliarity could be projected.
Personal experiences of the music therapist with death can also affect the level of comfort
surrounding the topics of death and dying. Utilizing end-of-life-specific communication
resources and clinical observation would lead to a better understanding of issues surrounding
terminal illness and increased levels of comfort in conversing with patients and families (Ury,
8
Berkman, Weber, Pignotti, Leipzig, 2003). Becoming proactive with opportunities to expand
knowledge and understanding of end-of-life care, not only in the medical field, but also within
society, can lead to an increased recognition of quality care as death approaches.
Purpose
The purpose of this study is to examine how board certified music therapists practicing in the
hospice field apply music therapy techniques and how their education has prepared them to do
so. The following research questions will be addressed:
• What is the most commonly used music therapy technique used by MT-BCs in daily
hospice music therapy sessions?
• What kind of educational techniques are used to prepare future music therapists
specifically for the hospice field?
• Which of these educational techniques offer the best preparation for music therapy
practice in the hospice field?
• What focus should the music therapy curriculum provide for hospice and end-of-life
care?
The results of this study can contribute useful information to the literature and educational
institutions in which a college degree for music therapy is offered. Existing research that pertains
to education in music therapy predominantly focuses on the field as a whole—there is little
research that specifically emphasizes education on hospice within the music therapy field.
Information yielded in this study can also inform development of qualifications for board
certified music therapists. Finally, information obtained from board certified music therapists in
the hospice field could provide expert guidance for those currently practicing and for those
contemplating a career as a hospice music therapist.
9
METHOD
Participants
Participants were members of the American Music Therapy Association (AMTA) who
identified themselves as working in the hospice field within the 2011 AMTA database. There
were 82 hospice music therapists who were included in this list. A web-based survey was
designed by the researcher and sent to the participants via email, along with a brief description of
the study, the purpose and research questions being pursued in the study, instructions and
conditions for completing the survey. The Florida State University’s Human Subjects Committee
approved the study. Email addresses for participants registered in the hospice field were gathered
from the AMTA executive director, ensuring that only music therapists working in the hospice
field with a valid email address would be included in the study.
Survey Instrument
A survey (see Appendix A) was created by the researcher using the website
surveygizmo.com (Surveygizmo, 2011). The survey consisted of questions about demographic
information, educational background, clinical experience, commonly used hospice music therapy
techniques (19 techniques), and educational topics and procedures used to teach hospice music
therapy within university curricula (12 topics and procedures). Information to form questions
addressing commonly used hospice music therapy techniques were taken from Hospice and
palliative music therapy: a continuum of creative caring (Krout, 2000) and Introduction to
Approaches in Music Therapy (Darrow, 2004). Information to form the questions addressing
educational topics and procedures used to address hospice music therapy within music therapy
curriculum where drawn from the AMTA Standards for Education and Clinical Training
(2011b), Hospice and palliative music therapy: a continuum of creative caring (Krout, 2000) and
Music therapy for older people: research comes of age across two decades (Prickett, 2000).
Participants were asked to rate the hospice music therapy techniques on Likert-type scales
that measured how often each technique was employed during their personal daily hospice music
therapy sessions, and how prepared they felt using each technique based on their education and
experiences during their college coursework. A Likert-type scale was also employed when the
participants were asked to rate the helpfulness of each topic and procedure commonly included
10
in music therapy curriculum. Two multiple choice style questions were included to see which
hospice music therapy technique and educational topic taught in the curriculum the participant
felt should have been more thoroughly addressed during college coursework.
Procedure
A cover letter detailing the purpose of the study was emailed to the executive director of
AMTA requesting the contact emails of all music therapists who identified themselves as
working in the hospice field (see Appendix B). Approval to provide email addresses for the
purpose of the study was granted by the executive director of AMTA (see Appendix C).
Approval for research involving human subjects was acquired through Florida State University’s
Institutional Review Board (see Appendix D.) A cover letter (see Appendix E) was emailed to all
participants (N=82). The cover letter included a brief description of the study, the instructions
and conditions for completing the survey, contact information for the principal investigator,
faculty advisor, and Florida State University’s Human Subjects Committee, and a hyperlink
directly to the survey. The email advised that participation was completely voluntary, there
would be no compensation for participation, and there would be no penalty for not participating.
It was stated that consent was implied upon completion of the survey. In order to maintain
complete anonymity and gain the maximum response rate, all 82 participants received cover
letter and hyperlink a total of four times, spanning over a course of four weeks.
11
RESULTS
Of the 82 hospice music therapists who were listed to receive the survey, two were
excluded from the study. One withdrew due to no recent clinical experience and the other was
listed as an “associate” member of the AMTA, and therefore did not meet the inclusion
requirements. From the remaining 80 hospice music therapists, a total of 40 (50%) surveys were
received. Only one of the 40 surveys was found to be incomplete and was not included in the
data analysis. The remaining 39 surveys were found to meet the requirements for inclusion in the
study, yielding a 49% return rate. Data analyzed describes the population responding and
included hospice music therapists’ gender, years of experience in the field, geographic location,
and the age of the patients they most often worked with.
Tables 1-4 represent the sample demographic characteristics by gender, geographic
location, years worked in hospice, and level of education completed. Of the 39 respondents, the
great majority was female. A majority of the respondents (51%) identified their geographic
location as being in a state within the Midwestern region of the United States. Other regions
included Southeastern, Northeastern, Western, and Southwestern. Almost 85% of the
respondents have worked in hospice for five years or less, leaving a small percentage that have
worked 6-11 years. Results indicated that 43.6% of the respondents had completed a Bachelor’s
degree, and 56.4% had completed a Master’s degree. None indicated completing a PhD.
Respondents were asked to indicate what age group they most often conducted hospice
music therapy sessions with on a daily basis. The geriatric age group was revealed to be the most
common, followed by older adults, adults, children, and adolescents (see Table 5). None of the
respondents indicated that they often conducted music therapy sessions with adolescents or
young adults in hospice settings.
TABLE 1
Demographic Distribution by Gender
Gender Frequency (%) of Respondents
Male 5 (12.8%)
Female 34 (87.2%)
Total 39 (100%)
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TABLE 2
Demographic Distribution by Geographic Location
Region Frequency (%) of Respondents
Northeastern 6 (15%)
Southeastern 8 (21%)
Midwestern 20 (51%)
Southwestern 1 (3%)
Western 4 (10%)
Total 39 (100%)
TABLE 3
Demographic Distribution by Years Worked in Hospice
Number of Years Frequency (%) of Respondents
Less than 1 year 7 (17.9%)
1-2 years 10 (25.6%)
3-5 years 16 (41%)
6-8 years 2 (5.1%)
9-11 years 4 (10.3%)
12 + years 0 (0%)
Total 39 (100%)
TABLE 4
Demographic Distribution by Level of Education Completed
Level of Education Frequency (%) of Respondents
Bachelor’s Degree 17 (43.6%)
Master’s Degree 22 (56.4%)
PhD 0 (0%)
Total 39 (100%)
TABLE 5
Demographic Distribution by Age Group Most Often Worked Within a Hospice Setting
Age Group Frequency (%) of Respondents
Children (ages 0-12) 2 (5.1%)
Adolescents (ages 13-19) 0 (0%)
Young Adults (ages 20-25) 0 (0%)
Adults (ages 26-65) 1 (2.6%)
Older Adults (ages 66-80) 12 (30.8%)
Geriatrics (81-100+) 24 (61.5%)
Total 39 (100%)
A series of questions pertaining to hospice music therapy techniques were presented.

First, the respondents were asked to rate how often each technique was employed in daily
13
hospice music therapy sessions using a 5-point Likert-type scale, with 1 representing “never” and
5 representing “always.” Descriptive statistics of the responses are portrayed in Table 6.
From mean data, it can be determined that the most commonly used hospice music
therapy technique among hospice music therapists is validation, followed by supportive
presence, ISO principle, and life review. Low standard deviation scores indicate high levels of
agreement on nearly every technique. Improvisation and legacy projects are the only two
techniques that show a standard deviation higher than .98. This larger range of discrepancy could
be credited to the respondent’s personal interpretation of the technique.
Guided imagery was revealed to be the least commonly used technique by hospice music
therapists with a mean rank of 2.1. However, a higher SD (0.89) shows more disagreement
among the respondents’ answers. It is noted that as the mean score decreases, the SD increases.
This indicates that while some respondents indicate rare use of the techniques, others may
employ them more frequently.
An “other” option was provided to allow the respondent to insert a technique that was not
mentioned, and commonly used within their daily hospice music therapy sessions. Other
suggested techniques by respondents included music sensory orientation, music
listening/discussion (for non-reproducible live music, such as opera), and musical autobiography.
Respondents were also asked to rate how prepared they felt using each technique based
on the instruction and education gained during their college coursework. A 5-point Likert-type
scale was employed with 1 representing “not at all prepared” and 5 representing “very prepared.”
Table 7 illustrates descriptive data from the responses. Unlike Table 6, where a lower trend of
SD scores was noted, a higher focus of SD scores in Table 7 reveal a higher rate of disagreement
among respondents’ answers. This implies a wide sense of diversity among the hospice music
therapy curriculums being used in the universities and the sense of focus they may have. Mean
value data shows that hospice music therapists felt most prepared to employ the technique of
patient instrument play, followed closely by lyric analysis. The highest range of agreement is
seen in these top two techniques. The techniques that respondents felt least prepared to employ
were bereavement and grief counseling.
14
TABLE 6
Frequency of Hospice Music Therapy Techniques in Hospice Music Therapy Sessions
N Mean SD
Validation 39 4.6 0.59
Supportive Presence 39 4.5 0.59
ISO Principle 39 4.2 0.71
Life Review 39 4.2 0.66
Music Based Relaxation Techniques 39 3.8 0.77
Emotional Guidance 39 3.7 0.67
Sensory Stimulation 39 3.6 0.95
Spiritual Discussion 39 3.5 0.59
Improvisation 39 3.3 1.13
Lyric Analysis 39 3.3 0.94
Intergenerational Family Sessions 39 3.3 0.72
Patient Instrument Play 39 3.2 0.86
Grief Counseling 38 2.9 0.81
Songwriting 39 2.9 0.74
Legacy Project 38 2.8 1.11
Bereavement 39 2.8 0.74
Procedural Support 38 2.4 0.98
Progressive Muscle Relaxation 39 2.2 0.65
Guided Imagery 39 2.1 0.89
Having completed education and gaining field experience, respondents were

asked to indicate which hospice music therapy techniques they believe should have received
more emphasis in their college coursework. Respondents were permitted to submit multiple
answers. Based on the frequency data, over 74% of respondents indicated that both bereavement
and grief counseling should receive more emphasis and instruction within coursework (see Table
8). This is consistent with data from Table 7 that shows respondents perceived lack of
preparation in these two techniques specifically. None of the techniques were indicated to need
15
less emphasis. However, techniques with the lowest frequency were life review, lyric analysis,
and patient instrument play.
TABLE 7
Self-perceived Level of Preparedness to Utilize Hospice Music Therapy Techniques Based on
Instruction Received from College Coursework
N Mean SD
Patient Instrument Play 39 4.3 0.81
Lyric Analysis 39 4.2 0.81
Supportive Presence 39 4.1 1.09
Validation 39 4.1 0.98
Sensory Stimulation 39 3.9 1.14
Music Based Relaxation Techniques 39 3.9 1.06
ISO Principle 39 3.9 1
Songwriting 39 3.7 1.16
Improvisation 39 3.6 0.93
Progressive Muscle Relaxation 39 3.5 1.13
Life Review 39 3.4 1.13
Emotional Guidance 39 3.2 1.2
Intergenerational Family Sessions 39 3.1 1.24
Guided Imagery 39 3 1.15
Spiritual Discussion 39 3 1.49
Legacy Project 38 2.8 1.42
Procedural Support 35 2.4 1.41
Grief Counseling 38 2.3 1.18
Bereavement 39 2.3 1.07
16
TABLE 8
Frequency of Hospice Music Therapy Technique that Should Receive More Emphasis in College
Coursework
Hospice Music Therapy Technique Frequency (%) of Respondents
Bereavement 29 (74.4%)
Grief Counseling 29 (74.4%)
Spiritual Discussion 15 (38.5%)
Emotional Guidance 14 (35.9%)
Legacy Project 13 (33.3)
Procedural Support 12 (30.8%)
Improvisation 11 (28.2%)
Music Based Relaxation Techniques 10 (25.6%)
Intergenerational Family Sessions 10 (25.6%)
Sensory Stimulation 6 (15.4%)
ISO Principle 5 (12.8%)
Supportive Presence 5 (12.8%)
Validation 5 (12.8%)
Progressive Muscle Relaxation 5 (12.8%)
Guided Imagery 4 (10.3%)
Songwriting 4 (10.3)
Life Review 1 (2.6%)
Lyric Analysis 1 (2.6%)
Patient Instrument Play 1 (2.6%)
Total 39 (100%)
Specific educational topics and procedures, commonly used within music therapy
curriculum, were rated on the helpfulness in preparing students for a hospice music therapist
session. A total of 12 educational topics and procedures were rated on a 5-point Likert-type
scale, with 1 representing “not at all helpful” and 5 representing “very helpful.” High mean
rating for musical repertoire building, internship, and education on end-of-life care indicates a
high helpfulness of these educational topics (see Table 9). Minimal difference between the mean
17
ratings of the rest of the topics should be noted. Although simulation is shown to have the lowest
mean rating of 3.5, it is still in the higher satisfaction range of perceived helpfulness.
TABLE 9
Self-perceived helpfulness of Educational Topics and Procedures Applied in Hospice Music
Therapy Curriculum
N SD
Musical Repertoire Building 38 0.92
Internship 38 0.88
Education on End-of-Life Care 39 0.56
Education on Death and Dying 39 0.77
Practicum 38 0.96
Guest Speakers from the Field 37 1.18
Musical Training 38 0.94
Education on Bereavement Counseling 39 0.80
Lectures 38 1
Reviewing Research Articles 39 0.71
Role-Playing 38 1.02
Simulation 37 1.24
Lastly, the respondents were asked which educational topics and procedures applied in
hospice music therapy curriculum should be more thoroughly addressed within the educational
setting. Table 10 depicts the topics and procedures ranked from highest need for emphasis to
lowest based on the frequency of responses. It should be noted that respondents were permitted
to submit multiple answers. Almost 77% of respondents expressed the need for more emphasis in
education on end-of-life care, followed by close rankings of education on bereavement
counseling (71.8%) and education on death and dying (69.2%). None of the topics and
procedures indicated need for less emphasis. Lectures were rated as needing the least amount of
additional emphasis within hospice music therapy curriculum.
18
TABLE 10
Educational Topics and Procedures Applied in Hospice Music Therapy Curriculum that Should
Receive More Emphasis in College Coursework
Educational Topic or Procedure Frequency (%) of Respondents
Education on End-of-Life Care 30 (76.9%)
Education on Bereavement Counseling 28 (71.8%)
Education on Death and Dying 27 (69.2%)
Musical Repertoire Building 21 (53.8%)
Guest Speakers from the Field 17 (43.6%)
Musical Training 14 (35.9%)
Role-Playing 14 (35.9%)
Practicum 9 (23.1%)
Internship 7 (17.9%)
Reviewing Research Articles 6 (15.4%)
Simulation 6 (15.4%)
Lectures 4 (10.3%)
Total 39 (100%)
A series of Mann Whitney U tests were calculated to determine if there was a statistical
difference in the responses according to level of education, years of experience, and geographic
location. First, the most commonly used technique among Bachelor and Master’s degree holders
was analyzed. With n1=17 and n2=22, and an alpha level set at <.05, critical value for this two-
tailed test was 117. The obtained value (U) was 179, greater that the critical value. There was no
significant difference between the level of degree held and technique most commonly employed.
An analysis by Mann Whitney U was also preformed to see if there was a statistical
difference in the perceived feeling of preparedness to employ techniques based on training
gained in college coursework and the level of degree held by the respondent. The two groups,
n1=17 and n2=22, and an alpha level set at <.05, yielded a critical value for this test of 117, with
obtained value of U=188. There was no significant difference between respondents’ degree level
and perceived feeling of preparedness when utilizing techniques.
No significant difference was found between the respondents’ degree level and the
perceived helpfulness of educational topics and procedures applied in college curriculum. The
19
critical value was 117 (n1=17, n2=22, α= .05). Obtained value of U was 172.5, which is greater
than the critical value.
Next, the Mann Whitney U analysis was applied to determine a statistical difference
between years of experience and the most commonly used technique. Years of experience was
split into two groups of 0-2 years (n1=17) and 3 + (n2=22) years of experience. Critical value
remained at 117 (n1=17, n2=22, α= .05) and the obtained value of U was calculated at 178. There
was no significant difference in responses based of years of experience.
Also, no significant difference was determined between years of experience and
perceived feeling of preparedness to employ techniques. The critical value remained at 117.
Obtained value of U was found to be 158.5, greater than the critical value.
In terms of years of experience and perceived helpfulness of educational topics and
procedures applied in college curriculum, no significant difference was found. Obtained value of
U was calculated to be 151.5, again, being greater than the critical value of 117.
Geographic location was also analyzed. Responses from all the regions (n1=19) were
compared against the responses from the Midwestern region (n2=20). No significant difference
was found regarding the geographic location of the respondent and the most commonly
employed technique (n1=19, n2=20, α= .05, critical value=119 < U=204), as well as, the
geographic location and rating helpfulness of educational topics and procedures (n1=19, n2=20,
α= .05, critical value=119 < U=136.5).
However, a significant difference was found between geographic location and perceived
feeling of preparedness to employ techniques (n1=19, n2=20, α= .05, critical value=119 >
U=112). Those in other regions besides the Midwest, reported significantly higher feelings of
preparedness to employ music therapy techniques in hospice, based on the training received from
their college curriculum. Table 11 shows the different rankings of each technique by respondents
from the Midwest, as compared to all other regions. It can be seen that techniques rated by the
respondents in other regions maintained a higher mean score on all of the techniques, as opposed
to the respondents in the Midwest. This indicates higher feelings of preparedness to employ these
techniques by the respondents in other regions.
20
TABLE 11
Midwestern Region Compared to All Other Regions in Self-perceived Level of Preparedness to
Utilize Hospice Music Therapy Techniques Based on Instruction Received from College
Coursework
Midwestern Region All Other Regions
N Mean SD N Mean SD
Patient Instrument 20 4.2 0.73 Patient Instrument 19 4.4 0.87
Play Play
Lyric Analysis 20 4.1 0.74 Lyric Analysis 19 4.3 0.86
Validation 20 4 0.89 Supportive Presence 19 4.3 1.08

20 4 1.07 Music Based 19 4.2 0.83
Supportive Presence Relaxation
Techniques
ISO Principle 20 3.8 0.98 Validation 19 4.2 1.06
Sensory Stimulation 20 3.8 1.08 ISO Principle 19 4.1 1

Music Based 20 3.6 1.16 19 3.9 1.19
Relaxation Sensory Stimulation
Techniques
Songwriting 20 3.5 1.07 Songwriting 19 3.9 1.21
Improvisation 20 3.4 0.73 Improvisation 19 3.8 1.06

Progressive Muscle 20 3.4 0.92 19 3.7 1.13
Life Review
Relaxation
Life Review 20 3.2 1.08 Spiritual Discussion 19 3.7 1.29
20 2.9 1.18 Progressive Muscle 19 3.7 1.30
Emotional Guidance
Relaxation
Intergenerational 20 2.8 1.12 19 3.5 1.14
Emotional Guidance
Family Sessions
Legacy Project 20 2.7 1.31 Guided Imagery 19 3.4 1.04
20 2.6 1.11 Intergenerational 19 3.4 1.27
Guided Imagery
Family Sessions
Spiritual Discussion 20 2.3 1.30 Legacy Project 19 2.9 1.50
Procedural Support 20 2.2 1.29 Grief Counseling 19 2.8 1.14
Bereavement 20 2 0.92 Bereavement 19 2.7 1.07
Grief Counseling 20 1.8 0.94 Procedural Support 19 2.7 1.49
Open-ended responses were read and analyzed for trends. Six main points could be
derived from the comments (see Table 12). A prominent trend of the need for self-care and self-
21
awareness education, followed by hands-on experience, indicate strong areas of focus for future
music therapists. To a lesser extent, respondents mention multicultural awareness issues,
knowledge of advanced counseling techniques, population specificity, and increased knowledge
of the medical involvement.
TABLE 12
Analysis of Open-ended Responses
Focus of Comments Frequency (%) noted within
Responses (n=18)
Self Care/awareness education (e.g. personal growth, 9 (50%)
emotional impact, personal boundaries)
Hands-on experience (e.g. more practicum opportunities, 6 (33%)
two internships, generating true experiences, shadowing
all hospice professionals when possible)
Multicultural awareness issues (e.g. cultural/religion 5 (27%)
differences in end-of-life care)
Increased knowledge for counseling techniques (e.g. 4 (22%)
advanced psychotherapy, group dynamics, advanced
training)
Population focus within hospice (e.g. emphasis on 4 (22%)
hospice care with different age groups)
Increased need for medical terminology/knowledge of 3 (16%)
commonly used medications in hospice
22
DISCUSSION
Of the surveyed hospice music therapy techniques, validation was reported as the most
commonly employed technique within daily hospice music therapy sessions. This is congruent
with the rating of the perceived high level of confidence or preparedness in using validation, felt
by hospice music therapists based on the education and training received in coursework. Also, it
was concluded that validation ranked the lowest among the techniques that should receive more
emphasis during coursework. From this, conclusions could be drawn that music therapists are
currently receiving a substantial amount of education on this during college coursework.
In terms of the technique used the least, results point to the technique of guided imagery.
However, in terms of level of preparedness, guided imagery is ranked in a mid-satisfactory
range. Also, it was indicated that hospice music therapists did not feel strongly about increasing
the amount of emphasis placed on guided imagery in the curriculum. This could be due to the
uncertainty and individuality among hospice patients, and the utilization of other techniques that
are more applicable to their situation. A variety of factors can affect the music therapist’s course
of action within a session and which techniques they employ. Further research should be done to
specify the amount of opportunities for each technique within hospice music therapy sessions.
From the data, similarities can be seen in techniques of bereavement and grief
counseling. Not only did both techniques rank below the average mean value (3.3) in the
frequency chart, but also each averaged a mean score of 2.3 in perceived preparedness (closest to
“a little prepared”). This is further supported by almost 75% of all respondents requesting more
emphasis on bereavement and grief counseling within the music therapy curriculum. Also,
education on bereavement counseling was indicated to be a topic in hospice music therapy
curriculum that was thought to need more emphasis by over 70% of respondents. Both
bereavement and grief counseling techniques are noted to require more counseling skills than
other music therapy techniques. Throughout the open-ended responses, increased knowledge of
counseling techniques is mentioned a total of 4 times. It is also noteworthy that among the eight
techniques that fell below the average mean value (3.3) in perceived level of preparedness, seven
involve more in depth counseling skills than the other techniques listed above average
(emotional guidance, intergenerational family sessions, guided imagery, spiritual discussion,
legacy project, grief counseling, and bereavement). Of these seven techniques, five of them are
23
ranked highest on need for more emphasis within college curriculum.
Among the educational topics and procedures, musical repertoire building, internship,
and education on end-of-life care were ranked to be the most helpful. It can be noted that since
patient preferred music is the most effective in any music therapy situation, hospice music
therapy requires a large and diverse repertoire to accommodate its diverse populations. It is
especially important when the patient in hospice has specific requests that are significant within
his or her life that facilitate to other counseling objectives. As supported by the open-ended
responses, hands-on experience exposes the music therapist to the true dynamic of hospice care.
The importance of clinical exposure is also synonymous with existing research (Billings &
Block, 1997; Hadsell 1998; Plumb et al., 1992). Education on end-of-life care is a key
component to hospice care. Being a part of the interdisciplinary team requires a music therapist
to recognize and be knowledgeable about the roles of each team member. Also, the more
educated a hospice professional can be, the more likely the patient and family will be able to
place trust in and feel comfortable with the decision of hospice. Providing concrete information
and education or referring the question to the correct party, can provide more stability in the
patient and families’ lives.
Mann Whitney U analysis reveals significant difference between the respondents from
the Midwest and those from all other regions when asked to rate the perceived feeling of
preparedness in utilizing techniques based on the training gained in college coursework. The
higher standard deviations among the groups indicate high levels of disagreement on many of the
techniques. This shows a wide range of preparedness among the respondents that was gained
from the different and diverse curriculums. Feelings of preparedness could be affected by a
variety of factors other than college curriculum, including personal feelings of confidence and
amount of exposure or practice.
Graduate studies should lead to greater knowledge and provide more in depth focus on
the field of music therapy. Often times, a field of specialization can be focused on, allowing the
student to cultivate and refine techniques and information that applies to the field. Among the
responses, it is noted that there was no significant difference in the responses of those who held a
Bachelor’s degree and those who held a Master’s degree. This suggests that the graduate degree
is not functioning as further specialization in the field. Perhaps AMTA might consider moving
toward such a goal.
24
Since the value of education in one’s field is essential to providing the best care possible,
it is no surprise that education on end-of-life care is indicated to need more emphasis by over
75% of respondents. Types of education on end-of-life care could include a variety of aspects
(e.g. end-of-life care and religion, culture, gender, age, setting, etc). Education on death and
dying, in which 70% of respondents indicated a need for more emphasis in education, could also
be applied to these topics. High demands of increased emphasis within these topics correspond
with research within the medical and hospice fields (Billings & Block, 1997; Bulkin &
Lukashok, 1991; Krout, 2000; Plumb et al., 1992; Ury et al., 2003). Since these topics are so
broad, further research should focus on determining what area(s) of death and dying and end-of-
life care are lacking in hospice music therapy education curriculum.
As for the educational procedures ranking lower on the scale of helpfulness, the lowest
technique of simulation, still upholds a high satisfactory rating of 3.5 (between “moderately
helpful” and “helpful”). This indicates that none of the educational topics and procedures were
counterproductive and provided substantial education to the music therapists. In reference to the
educational topics and procedures that received lower votes for more emphasis (lectures,
simulations, and reviewing research articles), it cannot be determined if the respondents felt they
were receiving enough information from these techniques as is, or some of the higher ranking
techniques should be incorporated into them. From one of the main focuses of the comments was
that hands-on experience was one of the most valuable techniques for future hospice music
therapists. High frequency of the need for education about self-care was also seen among the
comments. Within a field that is enveloped by potentially burdening situations and issues, the
proper education on professional and personal separation seems vital. It could be interesting to
conduct a study to find what aspects and/or techniques a hospice music therapist learns in college
coursework, as opposed to what the therapist acquires in the clinical field.
Data and results may be applied to a variety of aspects within music therapy. Music
therapy educators can apply more information about mentioned topics and procedures to their
lectures pertaining to hospice. Focuses on strengths and weaknesses in utilizing music therapy
techniques can be addressed sooner in the classroom. Specific counseling techniques could be
identified, examined, and practiced on a more in depth level within the classroom. Music
therapists currently working in hospice can identify a sense of growth within their professional
field. Opportunities for self-exploration, professional improvement, and contemplations for
25
higher education can be evaluated. Music therapy students can gain a better understanding of
hospice music therapy techniques, values, and standards in today’s field. Data referencing the
preparedness to employ techniques and helpfulness of educational topics can be taken into
consideration when examining their own abilities. Information pertaining to educational
practices provides opportunities for students to initiate independent research, or organize
additional opportunities for exposure to the hospice field through his or her professor.
Conclusion
This area is still in need of further research. Topics addressed in this study should be
expanded to music therapists who may not be currently working in hospice, but have had
experience within the field. Further research should also be done in regards to the fields of
specialization that are seen among music therapists who have completed graduate school and
how many are practicing in their specialized field. Cautions should be taken in interpreting data.
The respondents’ subjective definition of the techniques, topics, and procedures may have
influenced answer choices. Clearly defining the techniques, topics, and procedures for
respondents before completion of the survey would reduce subjective interpretations.
Research involving hospice music therapy techniques and education is an important
outlet to pursue. This researcher suggests focusing on a specific topic within techniques or
education. The study presents a board spectrum of hospice music therapy techniques and
education that should be explored within detailed parameters. Results may be useful for music
therapy educators, music therapists currently working in the hospice field, students working
towards or considering a career in music therapy, other hospice and medical professionals, and
for further research.
26
APPENDIX A
Survey
(page one)
Hospice Music Therapy Techniques and Education
Page One
1) What is your gender?*
( ) Male
( ) Female
2) How many years have you worked in a hospice?*

( ) Less than 1 year
( ) 1-2 years
( ) 3-5 years
( ) 6-8 years
( ) 9-11 years
( ) 12+ years
3) In which state do you work?*

( ) Alabama ( ) Kansas Islands
( ) Alaska ( ) Kentucky ( ) Ohio
( ) American ( ) Louisiana ( ) Oklahoma
Samoa ( ) Maine ( ) Oregon
( ) Arizona ( ) Marshall Islands ( ) Palau
( ) Arkansas ( ) Maryland ( ) Pennsylvania
( ) California ( ) Massachusetts ( ) Puerto Rico
( ) Colorado ( ) Michigan ( ) Rhode Island
( ) Connecticut ( ) Minnesota ( ) South Carolina
( ) Delaware ( ) Mississippi ( ) South Dakota
( ) District of Columbia ( ) Missouri ( ) Tennessee
( ) Federated States of ( ) Montana ( ) Texas
Micronesia ( ) Nebraska ( ) Utah
( ) Florida ( ) Nevada ( ) Vermont
( ) Georgia ( ) New Hampshire ( ) Virgin Islands
( ) Guam ( ) New Jersey ( ) Virginia
( ) Hawaii ( ) New Mexico ( ) Washington
( ) Idaho ( ) New York ( ) West Virginia
( ) Illinois ( ) North Carolina ( ) Wisconsin
( ) Indiana ( ) North Dakota ( ) Wyoming
( ) Iowa ( ) Northern Mariana
27
4) What is the highest level of education you have completed?*
( ) Bachelor's degree
( ) Master's degree
( ) PhD
5) What age group do you conduct hospice music therapy sessions with most often?*
( ) Children (ages 0-12)
( ) Adolescents (ages 13-19)
( ) Young adults (ages 20-25)
( ) Adults (ages 26-65)
( ) Older Adults (ages 66-80)
( ) Geriatrics (81-100+)
6) Some common hospice music therapy techniques are listed below. Check the appropriate
box to indicate how often the technique is employed in your daily hospice music therapy
sessions.*
Never Rarely Sometimes Often Always N/A
Bereavement () () () () () ()
Emotional () () () () () ()
Guidance
Grief Counseling () () () () () ()
Guided Imagery () () () () () ()
Improvisation () () () () () ()
Intergenerational () () () () () ()
Family Sessions
ISO Principle () () () () () ()
Legacy Project () () () () () ()
Life Review () () () () () ()
Lyric Analysis () () () () () ()
Music Based () () () () () ()
Relaxation
Techniques
Patient () () () () () ()
Instrument Play
Procedural () () () () () ()
Support
Progressive () () () () () ()
Muscle
Relaxation
Sensory () () () () () ()
Stimulation
28
Songwriting () () () () () ()
Spiritual () () () () () ()
Discussion
Supportive () () () () () ()
Presence
Validation () () () () () ()
Other (Please () () () () () ()
specify in the
text box in
question 7)
7) If you answered "other" to question 6, please specify below.
8) Some common hospice music therapy techniques are listed below. Check the appropriate
box to indicate how prepared you felt using each technique based on the instruction and
education gained in college coursework.*
Not at all A little Moderately Very
Prepared N/A
prepared prepared prepared prepared
Bereavement () () () () () ()
Emotional Guidance () () () () () ()
Grief Counseling () () () () () ()
Guided Imagery () () () () () ()
Improvisation () () () () () ()
Prepared N/A
Intergenerational () () () () () ()
Family Sessions
ISO Principle () () () () () ()
Legacy Project () () () () () ()
Life Review () () () () () ()
Prepared N/A
Lyric Analysis () () () () () ()
Music Based () () () () () ()
Relaxation Techniques
Patient Instrument () () () () () ()
Play
Procedural Support () () () () () ()
Progressive Muscle () () () () () ()
Relaxation
Not at all A little Moderately Prepared Very N/A
29
Sensory Stimulation () () () () () ()
Songwriting () () () () () ()
Spiritual Discussion () () () () () ()
Supportive Presence () () () () () ()
Validation () () () () () ()
Other (Please specify () () () () () ()
in the text box in
question 9)
10) In your opinion, which of the following music therapy techniques should have received
more emphasis in college coursework before your use of these techniques in a music
therapy hospice situation? *Participants could make more than one selection.
[ ] Bereavement [ ] Patient Instrument Play

[ ] Emotional Guidance [ ] Procedural Support
[ ] Grief Counseling [ ] Progressive Muscle Relaxation
[ ] Guided Imagery [ ] Sensory Stimulation
[ ] Improvisation [ ] Songwriting
[ ] Intergenerational Family Sessions [ ] Spiritual Discussion
[ ] ISO Principle [ ] Supportive Presence
[ ] Legacy Project [ ] Validation
[ ] Life Review [ ] Other
[ ] Lyric Analysis [ ] None of the above
[ ] Music Based Relaxation Techniques
11) Many of the topics and procedures below are commonly used in the music therapy
curriculum to prepare future music therapists for hospice sessions. Check the appropriate
box to indicate your opinion of the helpfulness for preparation in conducting a hospice
music therapy session.*
Of
Not at all Moderately Very
little Helpful N/A
helpful helpful helpful
help
Education on () () () () () ()
bereavement
counseling
Education on death () () () () () ()
and dying
Education on end- () () () () () ()
of-life care
30
Guest speakers from () () () () () ()
the field
Internship () () () () () ()
Lectures () () () () () ()
Musical training () () () () () ()
Musical repertoire () () () () () ()
building
Practicum () () () () () ()
Reviewing research () () () () () ()
articles
Role-playing () () () () () ()
Simulation () () () () () ()
Other (Please () () () () () ()
specify in the text
box in question 12)
13) Many of the topics below are commonly used in the music therapy curriculum to
prepare future music therapists for hospice sessions. Check which topics you feel should be
more thoroughly addressed in college coursework? *Participants could make more than one
selection.
[ ] Education on bereavement counseling

[ ] Education on death and dying
[ ] Education on end-of-life care
[ ] Guest speakers from the field
[ ] Internship
[ ] Lectures
[ ] Musical training
[ ] Musical repertoire building
[ ] Practicum
[ ] Reviewing research articles
[ ] Role-playing
[ ] Simulation
[ ] None of the above
[ ] Other
31
14) Please write any additional comments you may have.
(Page two)
Thank You!
Thank you for taking the survey! Your response is very important to this research study.
32
APPENDIX B
Letter to Executive Director of AMTA
Dear Ms. Farbman,
My name is Mary Catherine Wolverton. I am a board certified music therapist living in

Tallahassee, FL. I am also a current graduate student at Florida State University seeking a
Master's Degree in Music Therapy. I am writing to ask for your assistance in recruiting subjects
for a research study I am conducting for my thesis, under the advisement of Dr. Jayne Standley,
as partial requirement of my Master’s degree.
The purpose of my study is to examine how board certified music therapists working in the
so. This study will be a fourfold examination of which music therapy techniques are most
commonly used in hospice music therapy sessions, what kind of educational techniques are used
in music therapy curriculums to prepare future music therapists for the hospice field, which of
those educational techniques offer the best preparation for music therapy practice in the hospice
field, and what focus should the music therapy curriculum provide for hospice and end-of-life
care. Data gathered through the use of a brief, web-based survey completed by MT-BCs
currently working in the hospice field could contribute useful information to the literature and
educational institutions in which a college degree for music therapy is offered. Information
yielded in this study can also reinforce established qualifications for board certified music
therapists. Finally, information obtained from board certified music therapists in the hospice field
could provide expert guidance for stakeholders who are already working in the field and for
future stakeholders who are contemplating a career as a music therapist.
I would appreciate your cooperation in providing me with an email list of all MT-BCs registered
with AMTA under hospice. This email list will be kept private from any outside parties and will
be deleted after data has been collected and analyzed. Please find a link to the survey at the end
of this email for your review. Also, I have attached the letter that subjects will be receiving via
email from me, inviting them to participate in this study.
If you have any questions or concerns, please contact me, or my faculty advisor, Dr. Jayne
Standley, at any time.
Mary Catherine Wolverton, MT-BC, NICU-MT

Graduate Student and Principal Investigator
Dr. Jayne M. Standley, MT-BC, NICU-MT

Professor/Faculty Advisor
Music Therapy Department, Florida State University
33
Thank you for your assistance.
Sincerely,
Mary Catherine Wolverton
Survey Link: https://edu.surveygizmo.com/s3/610523/Hospice-Music-Therapy-Techniques-and-

Education
34
APPENDIX C
AMTA Letter of approval
Dear Mary,
Thank you for your request to use AMTA's members for your master's thesis.
It sounds like a very interesting study, one for which we would like to
see the results.
Please be advised that I have reviewed your materials and you have the
permission of AMTA to use our mailing list of hospice music therapists.
Please indicate on your survey that you are contacting respondents with
the permission of AMTA.
I have copied AMTA Director of Membership, Angie Elkins, who will provide
you with the email list you requested as specified below.
Thanks and best wishes for a successful study.

Dr. Andi Farbman
Executive Director
35
APPENDIX D
Florida State University Institutional Review Board Letter of Approval
Office of the Vice President For Research

Human Subjects Committee
Tallahassee, Florida 32306-2742
(850) 644-8673, FAX (850) 644-4392
APPROVAL MEMORANDUM
Date: 10/4/2011
To: Mary Wolverton
Dept.: MUSIC SCHOOL
From: Thomas L. Jacobson, Chair
Re: Use of Human Subjects in Research

Application of music therapy curriculum and techniques utilized by music therapists: a survey of
hospice music therapy professionals
The application that you submitted to this office in regard to the use of human subjects in the
proposal referenced above have been reviewed by the Secretary, the Chair, and one member of
the Human Subjects Committee. Your project is determined to be Expedited per 45 CFR §
46.110(7) and has been approved by an expedited review process.
The Human Subjects Committee has not evaluated your proposal for scientific merit, except to
weigh the risk to the human participants and the aspects of the proposal related to potential risk
and benefit. This approval does not replace any departmental or other approvals, which may be
required.
If you submitted a proposed consent form with your application, the approved stamped consent
form is attached to this approval notice. Only the stamped version of the consent form may be
used in recruiting research subjects.
If the project has not been completed by 10/1/2012 you must request a renewal of approval for
continuation of the project. As a courtesy, a renewal notice will be sent to you prior to your
expiration date; however, it is your responsibility as the Principal Investigator to timely request
renewal of your approval from the Committee.
You are advised that any change in protocol for this project must be reviewed and approved by
36
the Committee prior to implementation of the proposed change in the protocol. A protocol
change/amendment form is required to be submitted for approval by the Committee. In addition,
federal regulations require that the Principal Investigator promptly report, in writing any
unanticipated problems or adverse events involving risks to research subjects or others.
By copy of this memorandum, the Chair of your department and/or your major professor is
reminded that he/she is responsible for being informed concerning research projects involving
human subjects in the department, and should review protocols as often as needed to insure that
the project is being conducted in compliance with our institution and with DHHS regulations.
This institution has an Assurance on file with the Office for Human Research Protection. The
Assurance Number is FWA00000168/IRB number IRB00000446.
Cc: Jayne Standley, Advisor

HSC No. 2011.6893
37
APPENDIX E
Informed Consent Letter
Dear Music Therapy Professional,
My name is Mary Catherine Wolverton. I am a board certified music therapist living in

Tallahassee, FL. I am also a current graduate student at Florida State University seeking a
Master's Degree in Music Therapy. I am emailing you to request your participation in a survey
study I am conducting for my thesis, under the advisement of Dr. Jayne Standley, as partial
requirement of my Master’s degree.
The purpose of my study is to examine how board certified music therapists working in the
so. I plan to answer the following research questions:
1. What are the most commonly used music therapy techniques used by MT-BCs in daily
hospice music therapy sessions?
2. What kind of educational techniques are used to prepare future music therapists
specifically for the hospice field?
3. Which of these educational techniques offer the best preparation for music therapy
practice in the hospice field?
4. What focus should the music therapy curriculum provide for hospice and end-of-life
care?
If you choose to participate in the study, it will take approximately 10-15 minutes to complete.
By clicking on the following link, you agree to participate in the study by electronically filling
out and submitting the completed survey. Questions in the survey will ask about demographic
information (gender, state currently working in, etc) and your ratings of music therapy
techniques and educational techniques pertaining to hospice music therapy sessions and music
therapy curriculum.
Your identity will be kept anonymous, maintaining ideal confidentiality standards. No one,
including me, will be able to identify your email address or identity with any data in the study.
You are free to withdraw from the study for any reason. If at any time after beginning the survey
you would like to withdraw from the study, simply exit out of the window and your answers will
not be submitted. The risks of participating in this study are minimal, but may bring up difficult
memories or emotions associated with past patients you may have encountered in your
fieldwork. There is no cost to participate in this study, nor will you be compensated in any way.
If you would like to receive the results of this study, even if you choose not to participate, please
notify me and I will email you the results after the research is completed.
If you understand and agree to the above conditions, please click on the link at the bottom of this
email to complete and submit the survey. You will have until November 1, 2011 to complete and
38
submit the survey. You will receive an email reminder once every week until the end of the
study. If you decide at any time you would not like to participate, notify me, and your email
address will be removed from the list.
If you have any questions, comments, or concerns, please feel free to contact my faculty advisor,
Dr. Jayne Standley, the Human Subjects Committee Board, or me at any time.
Human Subjects Committee, Office of Research

Florida State University
(850) 644-8673
Dr. Jayne M. Standley, MT-BC, NICU-MT

Professor/Faculty Advisor
Music Therapy Department, Florida State University
Mary Catherine Wolverton, MT-BC, NICU-MT

Graduate Student and Principal Investigator
Thank you for your assistance and participation!
Sincerely,
Mary Catherine Wolverton
Survey Link:
https://edu.surveygizmo.com/s3/610523/Hospice-Music-Therapy-Techniques-and-Education
39
REFERENCES
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http://www.musictherapy.org/about/quotes/
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therapy :Theory and practice, 2nd ed. The McGraw-Hill Companies, Inc.
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British Medical Journal, 208 (6484), 1829.
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Hilliard, R. E. (2001). The effects of music therapy-based bereavement groups on mood

and behavior of grieving children: A pilot study. Journal of Music Therapy, 38(4),
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Hospice. (2011). In Merriam-Webster Dictionary online. Retrieved from

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42
BIOGRAPHICAL SKETCH
Mary Catherine Wolverton is from Lakeland, FL. She graduated from Florida State
University with her undergraduate degree in Music Therapy. Mary Catherine passed her music
therapy board certification exam in 2011. This thesis is submitted as partial fulfillment of the
requirements for a Master of Music Therapy degree from Florida State University, to be awarded
in Fall 2011.
43

Application of Music Therapy Curriculum and Techniques Utilized by Music Therapists - Mary Catherine Wolverton

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THE FLORIDA STATE UNIVERSITY

APPLICATION OF MUSIC THERAPY CURRICULUM AND TECHNIQUES UTILIZED BY

MARY CATHERINE WOLVERTON

A Thesis submitted to the

All rights reserved

INFORMATION TO ALL USERS

The members of the supervisory committee were:

List of Tables ...................................................................................................................................v

Defining Hospice Music Therapy

Function of Music Therapy in the Hospice Field

A series of questions pertaining to hospice music therapy techniques were presented.

Having completed education and gaining field experience, respondents were

Musical Repertoire Building 38 0.92

Education on End-of-Life Care 39 0.56

Education on Death and Dying 39 0.77

Guest Speakers from the Field 37 1.18

Musical Training 38 0.94

Education on Bereavement Counseling 39 0.80

Reviewing Research Articles 39 0.71

Validation 20 4 0.89 Supportive Presence 19 4.3 1.08

Sensory Stimulation 20 3.8 1.08 ISO Principle 19 4.1 1

Improvisation 20 3.4 0.73 Improvisation 19 3.8 1.06

Procedural Support 20 2.2 1.29 Grief Counseling 19 2.8 1.14

Bereavement 20 2 0.92 Bereavement 19 2.7 1.07

Grief Counseling 20 1.8 0.94 Procedural Support 19 2.7 1.49

Hospice Music Therapy Techniques and Education

2) How many years have you worked in a hospice?*

3) In which state do you work?*

7) If you answered "other" to question 6, please specify below.

9) If you answered "other" to question 8, please specify below.

[ ] Bereavement [ ] Patient Instrument Play

12) If you answered "other" to question 11, please specify below.

[ ] Education on bereavement counseling

Letter to Executive Director of AMTA

Dear Ms. Farbman,

My name is Mary Catherine Wolverton. I am a board certified music therapist living in

Mary Catherine Wolverton, MT-BC, NICU-MT

Dr. Jayne M. Standley, MT-BC, NICU-MT

Survey Link: https://edu.surveygizmo.com/s3/610523/Hospice-Music-Therapy-Techniques-and-

AMTA Letter of approval

Thanks and best wishes for a successful study.

Florida State University Institutional Review Board Letter of Approval

Office of the Vice President For Research

To: Mary Wolverton

Dept.: MUSIC SCHOOL

From: Thomas L. Jacobson, Chair

Re: Use of Human Subjects in Research

Cc: Jayne Standley, Advisor

Informed Consent Letter

Dear Music Therapy Professional,

My name is Mary Catherine Wolverton. I am a board certified music therapist living in

Human Subjects Committee, Office of Research

Dr. Jayne M. Standley, MT-BC, NICU-MT

Mary Catherine Wolverton, MT-BC, NICU-MT

Thank you for your assistance and participation!

American Music Therapy Association (2011a). Retrieved from

American Music Therapy Association (2011b). Retrieved from

Bruscia, K. (1998). The dynamics of music psychotherapy. Gilsum, NH: Barcelona

Darrow, A. A. (2004). Introduction to approaches in music therapy. Silver Spring, MD:

Davis, W. B., Gfeller, K. E., & Thaut, M. H. (1999). An introduction to music

Frampton, D. R. (1985) Needs And Opportunities In Rehabilitation In Terminal Care.

Hadsell, N. A. (1998). Student evaluations of practicum training in music therapy by

Hilliard, R. E. (2001). The effects of music therapy-based bereavement groups on mood