When It’s Not About the Music: Dialogues in Clinical Practice in the Paediatric Hospital Setting

There was a period in my music therapy practice where I strongly believed that in order to demonstrate the effectiveness of music therapy, I just needed to ‘let the music speak for itself’. People will ‘get’ music therapy, I reasoned, if I could just capture those significant moments through video recordings, therapeutic projects, or live demonstration of music therapy to others.

While this belief still somewhat holds true, I also realized that truly effective advocacy does not rely solely on the music. Rather, advocacy in music therapy requires the therapist to promote, protect and defend their work, in all aspects of their practice.

This facet of practice has been an area of growth for me in the past two years, working independently in an acute paediatric hospital setting. My previous experience in long-term residential care for adults with severe and profound neurological needs did not prepare me for this transition. In hospital, all my preconceived notions of music therapy were disrupted. How exactly does one prepare a therapeutic space when predictability, familiarity, safety, and protected time are inherently unavailable?

Music therapists are adept at being flexible in the moment, guided by the patient’s needs and preferences as they arise. However, many variables that can impact the therapeutic process are simply beyond our control. The weight of these external factors can make any music therapist feel stuck, helpless, disappointed, frustrated, overwhelmed, or stressed.

I think to my first interaction with Jesse[1], a young person with a new diagnosis of aggressive bone cancer. The family, still overwhelmed with a revolving door of multiple introductions and meetings, politely declined. I recall the session where Coen, an Aboriginal[2] boy with chronic illness, has just opened up about some very big feelings about his cultural and racial identity, recent death of a relative, and feelings of neglect from his family. While we sat with these big feelings together, the Patient Services Assistant came in to clean the last room on the ward before the end of their shift. This led to some long pauses and an uncomfortable ending. I also remember the session where I was working with Maisy, a baby on the surgical ward. During our improvised musical experience, the physiotherapist steps into the room with a student for their review and ask if they can stay to observe the remainder of the session. I note my immediate feelings of frustration at the interrupted musical exchange, and there is an unspoken sense pressure to bring the session to a close.

In paediatric music therapy, there are multiple entry points along a patient’s hospital journey where we may provide support. A fast-paced, high-pressured environment like the acute hospital setting means that sometimes we often only have a small window of opportunity to provide support. This can lead to questions about the value of our work and whether we have done a good enough job within this space.

Remember that our work exists within a larger organizational workflow. We are only responsible for our portion. Music therapists care for the whole child but are not responsible for their entire medical journey. We are a piece of a larger puzzle. Though it may seem like a small piece, every piece matters. We know we can positively impact the patient and their family’s hospital trajectory.

I think it is important to acknowledge that, in this work, therapeutic encounters can often feel unfinished. It is not a perfect cadence we experience, but an unresolved, interrupted interval. It can leave us hanging and ruminating on all the ways that the interaction could have ended not like THAT. However, these encounters can have a profound impact, no matter how it may have felt.

Jesse, whose family initially declined music therapy, was later re-referred by a doctor to support her brother, Samuel. The doctor had noted my previous interaction with the family documented in case notes. It turns out that music was a huge connecting piece between the siblings. Through a short-term music therapy intervention, Samuel and I recorded a series of instrumental pieces for his sister. After Jesse died, the family chose to play one of the recorded pieces at her funeral.

After my session with Coen, I approached the nurse unit manager to debrief and shared the themes explored in our session. Our conversation led to multiple referrals being made to Psychological Medicine and the Aboriginal Liaison teams for further support. The Spiritual Care team also contacted Coen’s family for support.

In Maisy’s case, I invited the physiotherapist and student to step closer to the cotand observe our interactions. I maintained my focus on Maisy and, in the pauses, described how I used vocalizations to match her arousal levels and observed responses. This allowed for further conversations about potential co-treating opportunities in the future.

Part of advocacy is engaging in conversations with others about our role as music therapists. We speak for the field when we initiate dialogues, ask questions, seek clarification, share observations, and provide feedback. This can sometimes feel one-sided and perhaps a little awkward. Take the risk and embrace the awkward!

Sharing music therapy with our colleagues is just as important as our interactions with patients. I am still learning how to be the best advocate but have become more accustomed to stepping into these conversations. Once I started doing this, I found myself feeling less weighed down by the limitations of being the only music therapist in a workplace with endless demands. Rather, doing more, with less, has resulted in greater workflow output.

In Coen’s case, it was taking the time to be intentional and seek out a dialogue with the nurse manager instead of documenting the session and rushing off to see the next patient. With Maisy, it was reframing an interrupted session as an unexpected opportunity for education and resource sharing. I was able to build relationships instead of protecting the space by asking the physiotherapist to leave the room[3]. The encounter with Jesse reminded me how important documentation could be. What I believed was a one-off (and unsuccessful) visit allowed a greater need to unfold. We should not discount those periods of unseen, behind-the-scenes work. It is integral to our practice.

When we begin to regard this process as a crucial component of the therapeutic encounter, we are able to speak more confidently to the non-musical aspects of clinical care involved in music therapy practice. This kind of advocacy promotes music therapy, protects the ethical principles that guide our work, and defends the boundaries of our clinical process from other forms of music-based programs facilitated by non-music therapists.

Our dialogues with colleagues can shape the experiences of a patient’s medical journey, deepen someone’s understanding of our work, and shine a light on additional opportunities for moments of meaningful change. When we initiate these conversations, we invite our colleagues to consider our piece in the larger puzzle. Amidst a fluctuating, uncertain environment, this is how music therapists, in the non-musical moments, can add value to a patient and their family’s encounter with paediatric hospital care.

[1] All case illustrations have been de-identified. [2] Aboriginal and Torres Strait Islander peoples are the recognized First People nation of Australia. Since Australia’s colonization, Aboriginal and Torres Strait Island people have experienced extreme racism and exclusion as a result of mainstream government policies. Most notably, these practices resulted in the forcible removal of Indigenous children from their families between 1910 and the 1970s; these children are remembered as the Stolen Generations. Aboriginal people continue to experience social, political, health and economic burdens compared with the non-Aboriginal population. It is every Australian’s responsibility to remember the past and pay respect to Aboriginal people as the Traditional Custodians of the land, and acknowledge their continuing connections to land, sea and community. [3] In some cases it may be more appropriate to protect the therapy space and have a dialogue with the clinician outside the room after the session. We should exercise sensitivity and clinical judgement in these situations.