Music therapist Deborah Salmon on the power of music, connecting with dying patients, and the richness of the palliative care experience
鈥淭he work of music therapy really touches quite deeply and helps people express what is deep in their hearts鈥�
By Devon Phillips. When Deborah Salmon was asked by Balfour Mount to commit to two years in her new job as a music therapist, she had no idea it would turn into a gig of nearly 35 years. Deborah鈥檚 exceptional contribution includes mentorship and training of 30 or more music therapy students, multiple publications to support the visibility and advancement of music therapy, and most importantly, her work on the palliative care unit in using music as a way to support and connect with dying patients and their loved ones. I spoke with Deborah at the 麻豆AV Hospital Centre in (MUHC ) Montr茅al, Qu茅bec.
Q: The name Deborah Salmon is synonymous with music therapy. What was the path that led you to the palliative care unit at the MUHC?
A: I graduated from New York University with an MA in Music Therapy in 1982, and worked in New York City for a couple of years when I learned about this job. Eugene Bereza, who held the position at the time, had decided to pursue medical studies. I had heard Susan Munro, the music therapist who started with Bal Mount at the Royal Victoria Hospital, speak at a conference, and was inspired by her, so I applied. I wasn鈥檛 certain that I wanted to return to Montreal, the place of my childhood, but I got the job and here I am! Bal insisted that I commit to two years so I did, and here I am 34 plus years later!
Q: 34 years is a huge period of time. What stands out for you in your career?
A: Ah, so many things. Now is a big time of reflection as I am getting ready to leave, just as our patients look back on their lives as they prepare to die. There have been so many wonderful people, and so many great ideas that I grew with 鈥� whole person care, Michael Kearney's聽surface to deep, Sheldon Soloman鈥檚 inspiring work on mortality salience, Eric Cassel and personhood鈥� A lot of my thinking developed in palliative care. I鈥檝e been privileged to work with so many fabulous people, and of course the work of music therapy in palliative care is so rich.
Q: What is music therapy? How does music help people at the end of life?
A: In music therapy, music is like a co-therapist. The music, carefully chosen or created, often with the patient, will stimulate memories, thoughts and/or feelings that are then expressed. So the work of music therapy can really be quite profound, and help people express what is deep in their hearts. I find that such a privilege and so wonderful. Other times, the music may be used more for pleasure or relaxation. For example, a patient may engage in imagery and go to the beach with the sounds of the ocean drum; they escape the hospital for a short time and reconnect with memories and sensations of their healthier selves. Music is such a broad and flexible tool, we really try to follow the patient鈥檚 wishes and needs when offering music therapy.
Q: All your work is with people at the end of life. How do you manage working with people in a compressed time period?
A: Palliative care is different from working with other populations, as there are few long-term goals. We hold each session as a complete session because you never know; the next day the person may be unresponsive or gone. So every session has to stand on its own.
Q: How do you know what a patient might need?
A: I am part of the team so I go to the rounds and I read the charts and I have a sense of what the physical, psychosocial and spiritual needs are for a patient. I always tell my students to go in with a metaphorical knapsack on your back that鈥檚 filled with tools and ideas and interventions, but your mind and heart should be open. I also work collaboratively with the patient and family. I talk with the patient and ask about how they are feeling that day, what their relationship and history is with music, if there is particular music that they鈥檇 like to hear, etc. Sometimes we go in a completely different direction than I鈥檇 anticipated, or there might be information that has not come out in rounds yet, like the person is very religious, and perhaps a hymn is the best intervention at that moment. I was just in a room where the patient was unresponsive, but 10 days ago he sang along to a favourite hymn. Now all we have to work responsively with is his breathing. I offered to his wife that I play some of those hymns that he loves in time with his breathing, as a way of connecting with him. This can be very powerful.
Q: That鈥檚 a lot of being with people and being there for them as well.
A: Yes, with and for. Another thing that stands out is the awareness that we all die. I have been exposed to all kinds of people from every corner of the world, rich and poor, with great family support and coping mechanisms to really dysfunctional families with terrible coping strategies. I have had this amazing window on a huge slice of life through palliative care and I am super grateful.
Q: Is it ever overwhelming?
A: It has been most overwhelming when I over-identify with the person. So when I had small children, the women dying with small children made me crazy. The thought of me dying and leaving my small children was unbearable, so sometimes it鈥檚 hard to keep a healthy boundary. Or at times when I have been very vulnerable, like when my father died, I found the work too difficult and took some time off.
Q: You are in a highly interpersonal space. I cannot imagine it being more intimate.
A: It is often very intimate.
Q: I understand that you regularly have music therapy students. Is this part of your legacy?
A: It is. They are a bit like my music therapy children who are out in the world. I think I鈥檝e had about 30 or so interns over the years. They have been wonderful, they give of themselves and I learn so much from them. Having students has really kept me honest, it鈥檚 been very enriching.
I think one of the things I have had to offer students, which is maybe a little different from most internships, is my training in psychotherapy. So I have brought a lot of the psychotherapeutic teaching into the music therapy. Music can bring up deep stuff. I believe that the work that we do as therapists can only be as deep as the understanding and openness we鈥檝e developed in ourselves I think every music therapist should have some psychotherapeutic training.
Q: What is the value of psychotherapeutic training for music therapists?
A: In music therapy we want to be open to what鈥檚 going on for patients and families, so we need to listen for themes on multiple levels. If a patient chooses a song about love and loss, for example, we might wonder about the meaning of that particular song with the patient, to open inner exploration and expression. Psychotherapeutic training also promotes awareness of transference and countertransference, and teaches how to work with intra and interpersonal dynamics.
Q: What are some of the most important pieces of music in your life?
A: I am classically trained so I do veer towards classical music. I love Bach. When I am feeling discombobulated I go to Bach because everything comes together in a miraculous beautiful way. I love jazz as well. I play in classical trio for my own pleasure. We met through palliative care and have now been playing together for over 30 years. Our pianist is a palliative care nurse, the cellist was a neighbor of another palliative care nurse, and I play the flute. We play purely for pleasure, usually in our living rooms, but we have played at a few weddings and many house parties.
Q: How do you envision life after palliative care?
A: I want to give myself time to feel what it鈥檚 like to have more spaciousness in my life, and will have to resist getting busy too quickly. I would love to be able to hear more live music though, and may play more piano and flute, or take an art course. I鈥檒l also maintain my psychotherapy practice with individuals and couples, so it鈥檚 really more like semi-retirement than retirement.
Q: Any last comments or messages?
A: I鈥檝e been reflecting on the many losses and changes in palliative care. We are having to do more with less. For example, we have lost our designated head nurse, assistant head nurse and unit coordinator, as well as many other experienced personnel. We鈥檝e stopped offering a staff support group and have reduced regular team meetings where we gather to exchange. On the other hand, patients that come to the palliative care unit still often feel safe with the excellent care they receive. So I remain grateful for the vision that manages to survive despite all the changes: the importance of volunteers, a vital and diverse multidisciplinary team, compassionate doctors that really know how to treat whole people, and an incredible core of superb nurses. Enough of what is essential to palliative care has remained, and that gives me hope.
Q: Congrats for all the commitment and contribution you have brought as a music therapist to palliative care.
A: Thank you! I鈥檝e been very lucky, I鈥檝e had a very satisfying career, and in many ways I will be sad to leave. To be with people and with music at such an intimate time, and to work with such superb colleagues, has been a huge privilege.