Describing a Music Therapy Based Socialization Program for an Integrated Stroke Unit

Briana Gregoris^* and Anna M Sewell

Mackenzie Health Organization, Vaughan, Ontario

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Abstract

A music therapy program was started at a large multicultural community hospital North of Toronto in September 2023. Situated on the integrated stroke unit, this program has become a cornerstone in after-stroke recovery. The program focuses on lived experiences during and after a stroke and is intended to assist patients with healing and coping. This paper is not a research article. This article describes a novel music therapy program and the core elements. The article will also share satisfaction feedback from both patients and staff involved in the unit. The article also outlines future goals for further integration of music therapy into other aspects of care and treatment on the integrated stroke unit. Currently, the stroke network consisting of 5 district stroke hospitals and many community hospitals, of which this program is situated do not offer any other music therapy programs. There is research happening at a comparably sized hospital within the network with a focus on music and post-stroke depression. Patient feedback about this current program describes the session as catalyst for inspiration, a place to connect, mood-lifting, motivational and reminiscent. Patients also introduce the cultural considerations of the program. Staff feedback echoed the positive experiences of the patients. Staff felt that the patients were eager to participate in and noted a marked difference in behavior/mood after attending. The staff members felt it helped their patients' overall recovery.

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Introduction

"Music gives a soul to the universe, wings to the mind, flight to the imagination, and life to everything¹."

— Plato

The uniqueness of this music therapy program is that it is organized and delivered by a trained music therapist accredited with additional training in psychotherapy and Neurological Music Therapy^TM. Started in Summer 2023, the program has been running consistently for three years. Patients gather in a common space weekly, accommodating about 20 people to attend a one-hour structured session. Music therapy takes place in a large multicultural/faith community hospital on a 32-bed integrated stroke unit. It is delivered with the help of stroke nurses, volunteer services, students, rehabilitation therapists with unit manager and department director support. This program is in addition to individual bedside consultation with patients and families. Sessions are designed to include elements of peer support and music therapy to aid in stroke recovery. A sign was posted in the common gathering area, and the session information was available on the screen saver of patients’ bedside iPads. The sessions are interactive and well attended with an average of eight patients weekly - excluding staff and family.

The Canadian Association of Music Therapy² defines music therapy as “a discipline in which Music Therapist Accredited (MTAs) use music purposefully within therapeutic relationships to support development, health, and well-being”. Music therapy utilizes interventions of songwriting, instrumental improvisation, singing and vocal toning, re-creating familiar music, and mindfulness with music.

Literature Review

An article search was performed looking for articles into the past 5 years using the key words search terms: music therapy, music and group, music and peer support, music and multiculturalism, music and recovery, music and rehabilitation, music therapy research in stroke population. A total of 15 research articles were retrieved, and 2 were excluded because of the generality, population size and not relatable to the music therapy program.

Music therapy has emerged as a promising intervention in stroke rehabilitation. A literature review about music therapy among stroke patients revealed that music therapy can improve a patient's gait and speech function³. Noteworthy, listening to vocal music was demonstrated to enhance verbal memory recovery⁴. Research on peer support among the stroke population, particularly the person receiving peer support, reported having increased sense of social connections, personal growth, enjoyment, and the belief their actions had a positive impact on others⁵. According to Särkämö⁶, listening to music can enhance mood, increase arousal, and temporarily improve cognitive performance or memory tasks in patients with neglect, while also supporting the use of music-based interventions outside of music therapy sessions.

The majority of interventionalists using music with the stroke population are not trained music therapists, in fact, they are comprised of other healthcare workers such as nurses and researchers7. There is still much to comprehend about music therapy in the stroke population. According to Brancatisano⁸, the use of music and mechanisms of action needs further attention. There is a need for clear definitions and links between the interventions and the outcomes being studied. The lack of protocols, standards, and methods described make it harder for organizations to adopt.

Drawing from the existing research, it is noted that baseline data in the studies is often not described resulting in a gap of pre and post data ⁹. There is a clear need for large high quality random control trials to build solid clinical knowledge ¹⁰. Lastly, clinicians need a change in thinking to design programs that place music at the center of rehabilitation rather than be the backdrop to treatment ¹¹.

The literature underscores the clinical value of music therapy in stroke rehabilitation.

Although there is still much to learn about the role music can play in stroke rehabilitation, both the patients and the staff have a positive, almost inherent, affinity to participating. This article will share details of a novel program and the implementation of a music therapy session in a group setting led by a trained music therapist. It shares both practical and qualitative insights into the benefits of music therapy based on feedback surveys.

This article highlights the potential of group music therapy sessions in promoting holistic recovery, building connections within hospital, and enhancing emotional well-being. The feedback received about the program is encouraging and efforts are being made to integrate music therapy in other aspects of treatment and care.

Program Details

The music therapy program is highly interactive and sometimes co-facilitated by patients who have musical talents or great story telling skills. These dynamic sessions often include elements of fine and gross motor movements, utilizing drums, tambourines, maracas, and egg shakers to enhance mind-body connection and awareness of space and timing.

All aspects of the music therapy sessions are purposeful and internationally planned, including interventions and instrument use. The music therapist chooses safe interventions and music while considering patients' cultural background, past trauma, medical diagnosis, and emotional needs.

Toronto’s rich cultural mosaic presents both a challenge and the opportunity for music therapists seeking to foster inclusive and meaningful therapeutic experiences. In such a diverse environment, cultural sensitivity is a foundational necessity. Music therapy must reflect the varied identities, languages and spiritual traditions of the community moving beyond a Western- centric repertoire and embrace a global musical experience.

Incorporating music from diverse cultural backgrounds into the group music therapy sessions offers a powerful avenue for emotional expression, interpersonal connection and cultural education. Musical instruments from non-western traditions can often evoke an emotional response that differs from Western music. Encouraging patients to share music from their own cultural background within a group context fosters a sense of agency and belonging. Patients are invited to explain the personal or cultural significance of the music they present. It deepens their own therapeutic engagement and facilitates cross-cultural learning among the group and therapist.

The use of technology may be helpful in circumstances of language barriers to allow for accessible communication and open dialogue.

Music therapists should not assume music preference based on a person's age, gender, culture, or religion. Music therapist and practitioners involved must also check their own conscious and unconscious bias when observing music from cultures apart from their own. An important mindset is to be open to discovering music preferences and not to make any prejudgments.

Recognizing cultural celebrations, asides from the celebrations in the Liturgical Year, are important in providing a culturally diverse and inviting space for patients. Celebrating all holidays adds to the inclusive environment and provides an opportunity to share cultural traditions.

Interventions completed in group music therapy to promote socialization include songwriting, drumming, mindfulness, for reminiscence, music and movement, playlist creation and singing familiar songs. The goals of the group are to assist patients with socialization soon after stroke, allowing space for emotional support, increasing self-confidence, and creating opportunities for the group through movement and vocalization to help in rehabilitation. This is accomplished through a shared music experience creating a safe space for recovery.

Interventions utilized within the group include:

Songwriting: The music therapist's role in songwriting is to provide the framework and organize participants' ideas in a cohesive way that incorporates patients' feelings and emotions. Songwriting promotes self-expression and enhances the group dynamic by creating a group coping strategy. When looking at songwriting as interventions, the dialogue can be centered around the weekly topic and their correlations with the music or finding commonalities and differences within the music preference of the participants.

Mindfulness: With the appropriate music chosen by the music therapist, the patients are guided through breathing exercises and asked reflective questions to reorient them to their present circumstances. This intervention may prove challenging when patients have difficulty being present with their thoughts and may feel uncomfortable.

Drumming and instrument play: Dependent on the intervention, participants are offered small percussion instruments, such as djembes, tambourines, maracas, and egg shakers, to assist in motor movements.

Music for reminiscence: Patients often describe linking music to family members or meaningful moments in their life. Music for reminiscence provides opportunity for dialogue about key moments in their life. Interventions are meant to engage participants in a sense of community and socialization, while also supporting their mental health and assisting in coping skills through their post-stroke recovery.

Patients are identified by the interdisciplinary team based on cognitive function, emotional needs, mood, social support, and coping challenges. Patients congregate in a shared space designated for visitors. Wheelchairs and chairs are arranged in a circular fashion. There is a large screen television mounted to the wall connected to an iPad to share presentations, music, YouTube, and lyrics.

Patients are invited to attend and provide consent to attend music therapy groups.

Facilitated by the music therapist, patients discuss weekly rotational topics of hope, spirituality, emotions, nutritional lifestyle modifications after stroke, community support, and relationships. This rotation helps to ensure that the topics are not repetitive to new attendees.

Documentation is important because it provides insight to the interdisciplinary team on how the patient responded to group members and how patients responded to the music therapy interventions. Documentation reviews consent, information about active or passive participation in the group, the interventions completed, and topics discussed within the support group.

Documentation can also include the music therapist's subjective observations or the objective interactions by patients within the session. There is no standardized music therapy documentation in Canada. Music therapists are required to document based on the organizational needs and regulations as per college competencies. The documentation standards would be the responsibility from the association, however in absence of standardized documentation, as a clinician, the S.O.A.P notes (Subjective, Objective, Assessment, Plan)¹² could be used as a template to summarize necessary information that would be valuable to the rest of the team.

Patient and Staff Satisfaction Feedback

During a one-month evaluation period, a subset of patients (n=5; 16%) voluntarily participated in a feedback survey regarding their experiences in the music therapy sessions. The survey was administered across multiple therapy sessions. Each categorized by distinct dynamic and thematic content, thereby introducing variability in the patient experiences. Participation in the survey was optional, and all respondents spoke English. The administration of surveys was supported by nursing students. Due to the restraints of clinical placement schedules and limited resources the survey collection was brief. However, the team still feels it is valuable to share the information collected. Although the feedback survey is not validated, the team considers the insights gathered valuable in understanding patient perspectives. Questions were created by the music therapy team interested in meaningfulness, personal experience, peer interaction and connection to the music.

Questions asked include:

1. Was the music therapy session meaningful to you? Why or why not?
2. What part of the music therapy did you enjoy the most? Which part did you enjoy the least, and why?

1. a) Did the music bring back any memories from your past?
2. b) How did it make you think about your current situation?
3. c) Is there anything else you would like to share about your experience with music therapy?
4. d) How do you feel when you share with others during music therapy? Describe its impact on your recovery?

Patient feedback showed psychosocial benefits associated with participation in the music therapy program. One patient described the experience as an opportunity to “bond over something mutual is cool, and you meet different people”, underscoring the role of shared musical engagement in facilitating interpersonal connections. Within group settings patients frequently demonstrate empathetic behavior including consoling peers during episodes of emotional distress. Other evidence of social bonding was observed through patients’ seating preference and efforts to maintain proximity to peers, implying the formation of friendships and a sense of community. Patient interactions during music therapy sessions revealed a strong sense of comfort and openness, particularly when individuals shared personal songs that held cultural or emotional significance. These moments of self-expression were often met with encouragement from peers who responded by cheering them on verbally. These exchanges contribute to a positive group dynamic and reinforces the therapeutic value of peer engagement “Give some time to let your peers talk and not just focus so much on music therapy.” This feedback supports the place of group therapy sessions and building a sense of community while in hospital. Some patients have gone on to maintain those relationships post discharge.

This feedback from an aphasic patient offers a reflection on the emotional landscape of stroke recovery. “I like to see everybody, even though they feel hopeless, but not to give up because it is so beautiful”. Although the sentence structure was non-fluent due to the language impairment, the underlying theme of resilience and peer encouragement is clearly conveyed. This feedback touches on “hope”, which plays on the themes often discussed in group sessions. Patients often share motivational advice with one another regarding how to move forward with their recovery.

One patient shared that “I less enjoy the music in a foreign language, it feels more like an escape from my –– current situation,” and another shared that “I liked learning music from other cultures.” The team has observed on occasion, if patients are unable to connect with the music, they leave the session early. On other occasions, patients are curious, and they like to hear music from cultures apart from their own. At times, it is difficult to orchestrate the “right” integration of different music to provide benefit to everyone. Some patients benefit more from a 1:1 session at the bedside, based on the music therapist's clinical judgement.

“Music does bring life to people,” “A device to slow down and think,” and “it motivates me to get back to where I was,” were noted when discussing the uplifting and self-regulating qualities of the music program. Patients often arrive at the program appearing tense, but once they have interacted and taken part in the interventions, they are noted to be less anxious. Some patients are provided with individual follow-ups to process unresolved emotions.

To assess the perceived therapeutic value of music therapy from a clinical perspective, feedback was solicited from members of the interdisciplinary care team. A total of 17 surveys were completed representing 43% of the targeted staff. Surveys were collected both in-person and via QR codes. A staff feedback survey was created with 7 closed-ended questions, without the inclusion of a “not applicable” option. A comment section was also added to the survey allowing respondents to elaborate on their answer. The format was intended to encourage definite responses and facilitate clear interpretation of staff attitudes. Staff working on-site during regular clinical hours were asked if they agree or disagree with the following statements:

1. Patients are eager to attend the music therapy Patients benefit from socializing in the group music therapy.
2. Have you noticed a difference in mood or behavior of patients once they attended music therapy? If you have noticed changes in mood or behavior, what changes have you noted?
3. Do you think music therapy is beneficial to your patients? why or why not?
4. Have you attended a music therapy session?
5. What feedback have you heard from patients and families who participated in music therapy on the unit?

Most staff respondents agreed with the statement that patients were eager to attend the music therapy session, while only one selected to disagree with the response. The consensus suggests a generally positive sense of patient engagement; the absence of a follow-up question limits the insight into the reason behind the lone disagreement. Notably, the same staff member disagreed with the benefits of socialization in the music therapy group. In the open-ended question concerning benefits of socialization, staff noted that patients appear to form a sense of community. The music therapy team observed familiarity amongst group members, as they would call each other by their name, and looked forward to meeting weekly. One staff member reported that patients began to engage with each other outside of the therapy session. The stroke team reported that patients and their families expressed excitement for the programming.

All respondents noted observable changes in mood and behaviors after patients attended the music therapy session. Validated by the team comment, “patients appeared to be happier and had an improved mood after attending the music therapy”. Staff reported music therapy helps people with hospital-acquired delirium, potentially by establishing a routine that supports orientation to time and place. The session appeared to help patients to be motivated, as therapy was often scheduled around the music therapy program and no fatigue or compliance issues were noted by the rehabilitation team.

Most staff agreed or strongly agreed with the statement that music therapy was beneficial to patients' recovery. One respondent shared, “It creates a safe space for them to explore their feelings”. Patients were observed sharing their emotions and private experiences about their stroke or memories the music conjures. The sessions fostered emotional support and peer validation. A staff member commented that patients, “share experiences of their recovery and feel a sense of belonging.” The following response elaborates this point further, “allows for social interaction, participation and mental health”. The staff shared their opinion on the influence of music-based socialization groups on patient recovery, “patients felt satisfied with the music therapy and most of them believed it helped them achieve their goals of recovery.” The team noted specific movement and speech aspects of the therapy group that assisted in attaining goals. To validate this connection to attaining rehab goals, further research is needed to isolate and measure functional outcomes.

Additionally, staff acknowledged the patient experience, stating the program “break up a long day”. This demonstrates the belief that patients benefit from more stimulus in their recovery. It is also a way to practice their regained skills of, “toe tapping, singing, humming and smiling.”

Approximately 71% of staff have attended at least one music therapy group program in the past.

Staff reported positive engagement from patients and families. One staff member summarized the group as a “conduit of support”, recognizing the potential for a mechanism by which patients can be offered emotional support and reinforcement of their rehabilitation goals.

There was a recommendation to increase the number of sessions, noting that when patients participate, family members feel their loved one is well cared for. Families that come to the hospital late will ask if their loved one attended the session, and some take photos and videos to share with other family members.

Considerations

Music therapy is sometimes viewed as a concert instead of patient therapy. Music therapy often requires increased advocacy and education to staff, patients, and families regarding the health benefits that music holds and its role in holistic care within recovery. The role of the music therapist may often be confused as volunteerism or recreationalist role. Unfamiliar observers may interpret the therapist's activities as entertainment without understanding the interventions and impact music can have on physical, cognitive, psychosocial, emotional, and spiritual wellness.

According to the Canadian Stroke Best Practices¹³, between 21-38% of stroke patients may experience aphasia. When working with patients with communication disorders, it may require extra time. Communicating effectively may include the use of pictures, written communication, simplified verbal communication, or contacting a patient's family to accurately receive consent. The involvement of families is particularly important when understanding a patient's needs.

Patients with communication disorders may also have difficulty communicating with group members or comprehending others in a group setting, and as a result, may avoid attending group sessions. Taking this into consideration, it is important to balance interventions appropriately to ensure all group members can contribute and participate within their abilities.

Consultation from Speech-Language Pathologists may be helpful in adapting the group to interventions and goals appropriately.

The Canadian Stroke Best Practices¹⁴, states that patients “may experience overwhelming tiredness, a lack of energy to perform daily activities, an abnormal need for naps or extended sleep, and tire more easily than pre-stroke". Patients who experience these symptoms may feel unable to attend and participate in group activities, specifically music therapy based support programs.

Experiencing a stroke can be a traumatic and life-altering event where patients lose aspects of their life that provided meaning. People are often hospitalized to undergo medical tests and engage in rehabilitation days to weeks depending on the severity of their stroke. Coping with these changes can be difficult, as there is minimal time to process the changes in body or speech once they have occurred. For some, being faced with a life-altering condition in isolation may feel easier than sitting in a room with other people experiencing a similar loss.

The content of this paper was written with limited amount of feedback from patients and staff members, and the findings may not provide a representation of global feedback for stroke patients and the interdisciplinary teams. This is a glimpse of patient and staff experiences related to this novel music therapy program in an attempt to understand the phenomena better.

Conclusion

This social-based music therapy group has evolved significantly over the past three years.

Flexibility has proven essential when launching such a program, as conditions shift with the cohort and unit culture, sometimes monthly or weekly. Success hinges not only on extensive resources, but on the presence of a trained music therapist to meet patients' stroke recovery needs.

A key next step for the team is to measure patient outcomes through research. Moving forward, the team intends to explore incorporating the use of music into rehabilitation settings, by utilizing Neurologic Music Therapy^TM into other physiotherapy and occupational therapy settings, such as the rehabilitation gym.

As music therapy is continuing to gain recognition within healthcare settings, there is a need to establish standardized protocols, develop implementation toolkits, and construct evidence-based patient-centered frameworks to ensure safe and effective integration to care.

Further research is needed on stroke specific rehabilitation and the impact on mental health in adults.

Conflict of Interest

The authors have no conflict of interest to report.

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