Creative songwriting in therapy at the end of life and in bereavement

Abstract This article explores creative songwriting in therapy at the end of life and in bereavement by focussing on the experience of the authors, whose work as music therapists in hospice settings includes writing songs with clients. It draws upon their work as practitioners, teachers and researchers, and is also informed by the published literature and work of other music therapists who have specialised in this field. A brief introduction to music therapy is followed by the contextualisation of creative songwriting within the authors' experience of the therapeutic relationship. Using case study vignettes the article provides an insight into the clinical practice of the authors and into the world of their clients at what can be an extraordinary time in their lives. The songs that emerge in therapy are often emotional, challenging and deeply thought provoking, and can provide a valuable contribution to our understanding of the experience of terminal illness, death and loss.


Introduction
Songs are powerful ways to express our thoughts and feelings and to communicate important stories and messages. They can provide us with an opportunity to celebrate our lives, mourn our losses and to preserve our history (Wigram & Baker, 2005, p. 11). People facing death or bereavement may find themselves seeking new ways to express and understand the many feelings that may arise. The authors' experience as music therapists working in hospices is that creative songwriting in therapy can provide an opportunity to express these complex feelings within a cultural form that is both ancient yet wholly contemporary. The songs that clients create express a vulnerability that can seem profoundly intimate and yet deeply familiar.
In the UK, music therapy is a relatively young and small profession emerging in the 1950s and achieving professional registration in 1999. Today there are almost 700 music therapists practising in the UK with a diverse group of clients in a wide range of clinical settings (see www.bamt.org). These include mental health, special education, adult learning disability, forensic and dementia care. Although few therapists are working in adult palliative care settings (approximately 30), evidence suggests that these numbers are increasing (O'Kelly & Koffman, 2007, p. 235).
While an in-depth discussion of music therapy is beyond the scope of this paper, at its heart is the establishment of a relationship which aims to support and encourage physical, mental, social, emotional and spiritual well-being (Bunt & Hoskyns, 2002, p. 11). Although music therapists may employ a wide range of techniques and approaches, the use of improvisation has been central to the training and development of UK music therapy practice. Improvisation will usually involve the therapist and client creating music together using instruments that are accessible and where the client needs no prior musical experience or particular skill in order to participate. It is as a result of these musical dialogues that the therapeutic relationship begins to be formed.
It is only comparatively recently that songwriting has begun to receive recognition as a therapeutic technique (Baker, Wigram, Stott, & McFerran, 2008, p. 105). Indeed the first book detailing songwriting methods and techniques for clinicians and students was published as recently as 2005 . This publication has helped to establish the importance of songwriting as a therapeutic approach alongside improvisation (Wigram, 2004) and receptive techniques (Grö cke & Wigram, 2006). Over the last seven years the authors of this article have actively promoted the use of songwriting in music therapy, creating and delivering courses for trainee and qualified music therapists both in the UK and overseas. Their approach has also attracted interest from other therapeutic disciplines and caring contexts.

Songwriting in clinical practice
As a clinical approach in music therapy, creative songwriting leans on a tradition that is ancient and yet flourishes as an overtly contemporary art form in the world today. Baker and Wigram define songwriting as 'the process of creating, notating and/or recording the lyrics and music within a therapeutic relationship to address psychosocial, emotional, cognitive and communication needs of the client' (Baker & Wigram, 2005, p. 16). They stress that the role of the therapist is to ensure that the song: 'can be felt as owned by the client and expressive of his or her personal needs, feelings and thoughts' (p. 14). This involves maintaining a delicate sense of agency and balance to ensure that the client's own creative sense of self is maintained at the heart of the work. The combination of aesthetic and clinical skills together with the receptivity that musical relationships in therapy often afford has been well-documented (Ansdell, 1995;Bunt, 1994;Nordoff & Robbins, 2004: Robarts, 2009Rogers, 2003;Wigram, 2004).
The ubiquitous nature of song would suggest that songwriting should form a natural part of the music therapist's tool kit. However, until quite recently there was only a little relevant literature to refer to and the approach did not form part of most British music therapy training. As a result, clinical approaches to the work have been understandably unsystematic and spontaneous, using methods that draw on the therapist's own personal background and experience (Baker & Wigram, 2005, p. 17). Indeed Heath's research 'An exploration of collaborative songwriting in contemporary music therapy practice' confirmed the idiosyncratic nature of the approach taken by music therapists in the UK (Heath, 2009).

First encounters
The following case vignettes detail the authors' own first encounters using songwriting in music therapy and begin to illustrate the above points. I began to work with a man in his fifties (Carl) 1 soon after I arrived in post as the music therapist in a hospice. Carl had been diagnosed with a rare form of cancer and had been given a prognosis of weeks. He began to attend the local hospice's day provision on a weekly basis, which is where we met. As a result of his prognosis, he had some difficulties in investing in anything, either financially or emotionally, for his life might end at any time. Having attended group music therapy sessions for a year we began to work together on a one to one basis. This largely involved us in improvising, Carl on the keyboard and myself on the flute. He avoided verbal engagement, reminding me that, in his own words, 'we're here for the music'. Despite the fact that his music flitted from one idea to the next, he often expressed the desire to compose a finished piece of music that could be written down. I had a hunch that a clear musical structure, such as a song, might help this process. I recalled a paper I had read about songwriting in palliative care (O'Callaghan, 1995, p. 35) and began to follow the 'brainstorming' technique described to generate lyrics, transcribing his words verbatim. This immediately seemed to unlock a process where for the first time Carl allowed himself to talk about his feelings, as well as play music. Gradually the shape of a verse and chorus emerged: Looking back on a life that's changed The rough and smooth, the mixed emotions The way to understand my life till now The shattered moments of despair The times when joy then filled the air While developing a melodic and harmonic structure on the keyboard, Carl continued to create lyrics and completed a song which he entitled 'Looking Back'. He subsequently went on to write a further three songs, including a song to celebrate his granddaughter's first birthday, an anniversary he never expected to witness. His final song, when he was aware of progressing disease, said goodbye to his family. He described the songwriting process as being 'all to do with feelings and stuff . . . if you look at it purely from the therapy side, that's good because it gets it all out, it's better to talk about things than not (to), . . . and to put music alongside is fantastic, but . . . it does open you up a great deal'.
Carl described having a framed copy of the notated music on his wall at home and, before his death, was also able to hear his first song performed in front of 800 people at a hospice event.
I had begun to work with a young woman (Jenny) who had been diagnosed with borderline personality disorder and had a history of self-harming including several failed suicide attempts. Jenny had begun to bring recordings of her favourite songs to our sessions, which she would ask me to listen to. Most of this material was from the genre described as 'Death Metal'. The lyrics contained graphic references to violence and death and the overall presentation could be described as apocalyptic. Jenny felt that these songs represented many of her own feelings, particularly about the future, and there was little doubt that she invested great importance in them. Having acknowledged the power of the material and their importance I asked Jenny to consider writing her own song suggesting that this might provide a true reflection of her feelings at the time. Despite her initial reluctance -'I could never write a good song myself' -Jenny eventually agreed and we began the process by improvising on drums and guitar, with me writing her thoughts and feelings on a white board as they emerged in the session. Over three sessions she completed her first song, which she addressed to her father and brother, both of whom had been involved in her abusive adolescence. The song contained many references to her past, the rage she was experiencing and some of her feelings of helplessness. Her words also contained a great deal of her own thoughts on death and dying. However, the song also began to reveal her own desire to keep on living and an, albeit small, sense of hope. Her key lyrical line was 'Can I Come Away Sane?' and this eventually became the chorus that was repeated throughout the piece. Each verse posed a new question; 'Can you see into my soul?, . . . Can I ever forgive you?' and this provided us with the opportunity to review and negotiate our way through issues that in previous sessions had been forbidden territory. The final verse reflects the distance that Jenny had moved during the creation of this song as she asks us: Can you reason these feelings And through all your dealings Help me change my thoughts And come away sane.
Jenny displayed real pride in her song and went on to compose several more. She began to learn to play the guitar and talked positively of using songwriting as a strategy to support herself when she was, hopefully, able to return home.
What emerged from these early encounters was a sense of the potential for therapeutic songwriting to be an extremely efficacious intervention. However, we were both aware that the approach also called for new skills and a deeper understanding of the processes involved. Ruud confirms this need for new skills, suggesting that songwriting as a therapeutic intervention can '. . . transcend the many theoretical traditions that feed the work of music therapists' (Ruud, 2005, p. 9). Our subsequent experience suggests that the collaborative nature of the approach can involve both client and therapist working at a profoundly deep level, leading to therapeutic relationships that can be extremely revealing for both parties (Mearns & Cooper, 2005, p. xii;Mearns & Thorne, 2007, p. 2).

Palliative care
Music therapists who work in end of life care encounter a wide range of people with illnesses including cancer (Hanser, 2005;Hilliard, 2003Hilliard, , 2005Magill, 2001), congestive heart failure (Dileo & McGill, 2005) and neurodegenerative disorders (Lings, 2010;Scheiby, 2005). Songwriting as a therapeutic intervention will have a cognitive as well as emotional, physical and spiritual dimension (O'Callaghan, O'Brien, Magill, & Ballinger, 2009, p. 1151. It can facilitate selfexpression, enhance self-esteem, promote the exploration of meaning and hope, and address existential and spiritual needs during the process of dying (Baker, Wigram, Stott, & McFerran, 2009, p. 33;Ruud, 2005, p. 10). Clients facing death will often find the process revealing and transformational. For example, Lings (2009) details how Harry, a man with a deteriorating neurological disease, used songwriting as a way of uncovering and expressing his own feelings about his illness. A sample of the titles alone -'Daily Victories', 'I Can Do it By Myself', 'Don't Give Up', 'Bright Side' -reveal some of his coping strategies. Harry himself referred to these songs as 'the milestones on my journey'. The explicit value of songs as containers for emotional expression is described by Rolvsjord: 'Emotional involvement is inevitably part of any musical interaction, but in the process of songwriting this is explicated within the song product' (Rolvsjord, 2005, p. 98).

Approaches to songwriting in therapy
In the following case vignettes we describe a range of different songwriting techniques and approaches that we have employed in our work, and reflect on how the therapy has been beneficial.

Beginnings
Many clients coming to music therapy for the first time do so with little or no musical experience or skills and often with a certain sense of trepidation. Approaches such as improvisation will often begin the process of opening up and will afford the therapist the opportunity to begin to form their initial assessment. It is as a result of these improvisations, and the reflective dialogue that often follows, that the idea of songwriting may emerge. The following vignette is one illustration of how this process unfolds: Hannah is sitting with her eyes closed gently tapping out notes on the metallophone (an instrument similar to the xylophone, with metal bars) while I provide harmonic support on the acoustic guitar. She had come into the session having just received the results of her latest scan, which confirmed that her prognosis was extremely poor. Playing the simple melody on the metallophone appears to have helped to reduce her distress and she begins to describe a visualisation: a place of peace and tranquillity. I write down her words as she speaks: The sun is shining and I'm alive I close my eyes and I'm sitting on a hill The grass is full of daisies and the butterflies are drifting on a warm breeze I'm not looking for trouble Just a place where I belong I'm not looking for trouble So I ain't gonna bring it on.
Using the melody that we'd been improvising I begin to sing the words as they appear on the page and a song soon begins to emerge. Inspired, Hannah continues experimenting with the images: It's a picnic Like jelly and ice-cream Laid out on the grass making daisy chains With the sound of people laughing, like you'd just put the record on Playing everyone's favourite summer song I've had my share of trouble So I ain't gonna bring it on.
Within an hour the complete song is created and recorded onto a CD. Hannah is delighted with her work and decides to take a copy of the song so that she can share it with her family at home. She subsequently went on to write many songs and heard some of these performed before she died.
In our experience, this form of creative visualisation in music is more likely to produce introductory themes rather than complete song lyrics. Helping clients to identify these themes will often be a useful way of facilitating the development of their thinking and insight.

Clarifying feelings
The 'existential crisis' that may accompany dying is often played out against the background of invasive treatment regimes, changes in body image and the many restrictions imposed by fatigue and lack of mobility. These dilemmas will almost always be accompanied by the impact of the illness upon family members and loved ones. Understandably, for many clients the very act of thinking about their imminent death and its implications can be frightening and at times feel overwhelming. Creative songwriting is one very effective way that clients can explore and hopefully clarify these confusing and at times contradictory feelings. The following is an example of this experience of unlocking and revelation: Mary had been given a very short prognosis; however she was still alive and was trying to make sense of this. Questions such as 'Why am I here? What is it that I'm meant to be doing?' began to emerge in our first music therapy session. Although she struggled to express herself using some of the musical instruments, she responded warmly to the idea of songwriting. During the session she had already begun to form a melody on the metallophone and soon started to sing about a recent dream: The reaper came for tea this morning Very polite very sweet He asked me if I'm ready Not quite I've something to complete Creative songwriting in therapy 111

Don't know what it is Don't know who it's for Something's keeping me
This side of the door. In the final verse she sang: I would love you by my side Right now right now To journey through it all together Cos when you're in love You can smile Through any kind of weather.
Mary went on to write many songs and became fascinated by the revelatory nature of her work. She recalls wrestling with the questions 'Why am I here? What is it that I'm meant to be doing?' and reflects that: 'Suddenly the lyrics of the song just threw all that aside and said it was to do with love. And I knew immediately it was absolutely right, the song lyrics felt real whereas what I'd been exploring consciously didn't feel real . . . So that was kind of the beginning of a process of unlocking; it was profoundly healing actually'.
These important early encounters with songwriting may lead clients into discovering that through this creative medium they can begin to express themselves in new and surprising ways. It is not uncommon for clients to go on to write several songs, some of which may confront the complex issues and fears around dying that had in the past been too difficult to talk about. As the creative therapeutic relationship develops, music therapists can employ a variety of techniques. The following vignette illustrates the use of a creative writing tool to help generate lyrical ideas: Anne and I had been working together for about three months. During this time, Anne's illness had progressed to the point where she was experiencing chronic fatigue. Despite describing herself as ready to die, we had both become aware that there was still a sense of unfinished business. I suggested that we might explore what this could be about by engaging in some life-review work. Anne had not dismissed this idea but had also stated that quite frankly she wouldn't know where to begin. Utilising a simple creative writing tool often called acrostic, I invited her to write the name of the town of her birth vertically on an empty page and, using the letters as the starting point of a word, phrase or sentence, to write freely whatever came into her mind. While she did this I played a guitar piece based on the music that had emerged in our earlier improvisation. Anne wrote: Arriving back home where everything is warm This is where I want to be, this is where I want to be.
When you said 'lets do this And see what we can find' The simplest things mattered And what we saw was home to me. I must go home I must go back, home Home to ******* a refuge in my mind.
We placed the words on the music stand and began to sing them to the melody that had accompanied the improvisation. Shortly into this process Anne became startled and asked me to stop. 'My God' she said, 'I've just realised how important ******* has been in my life'. She went on to describe her early experiences of growing up with rather absent parents but very loving grandparents, the simplicity of the place and the people that live there, and noticing how throughout her whole life she'd strived to replicate this. We talked at great length about this and its impact on her life and her family and at the end of the session we recorded the song. Despite her frail condition, Anne recognised the need to go back and visit ******* and with the help of her family managed to do this before she died. The song became a central focal point at her own funeral service, something that her husband described as profoundly comforting and beautiful.

Containing and communicating feelings
For many dying people, the isolation they experience can be the result of being unable to talk honestly and openly with loved ones. For some relatives and friends, being faced with the finality of the death of a loved one can cause them to withdraw, perhaps becoming unrealistic or in some cases completely unable to engage with the truth and its consequences.
Having identified this as a problem, music therapists may wish to suggest the use of an original song to communicate the truth in a form that may be more accessible to the listener. The use of the song as a container in this way may also help the client to articulate their own feelings and needs in new and helpful ways: Angela was a patient at a local hospice, who had become quadriplegic and was in the end stage of her disease. During our first meeting at her bedside, she described her anger and frustration that was resulting from her emotional and physical needs not being understood or met appropriately. I suggested that, despite her profound physical difficulties, she could be involved in active music making by writing a song. Armed with a guitar and notebook, I met her again at her bedside for our first session. As we talked and I wrote down her words she used the phrase 'so simple' and I responded by saying: 'What a perfect line to begin your song with'. She agreed and we began to explore what kind of style and form the song could take with me singing the line in different ways with a range of harmonies to give her some examples. Angela was very clear about what she liked and we started to craft the song together, incorporating all of her ideas, which I had written down. The song began: It's simple just so simple Don't tell me what I feel -ask me Don't run off half way through -follow through Don't think you know how I feel -just ask 'Cos it's simple just so simple 'Cos you don't have to find a solution And you don't have to make it better And you don't have to solve the problem Just be with me Just be with me.
Having completed the song, I prepared a recording for Angela and played it to her. Apart from some reservations about the overall balance between the voice and the instruments that I altered, she was very pleased with the result. The song's meaning and message is reflected in its simple melody and open harmonic progressions, capturing the express wishes of a dying woman who had become entirely reliant upon her professional carers. Since her death the song has become a valued teaching tool, offering a personal insight into the lived experiences of a patient and her need to be heard and acknowledged.

Songs as legacies
Creating songs as legacies can also form an important part of the music therapist's work. Clients may find the anguish that accompanies thoughts of final separation from loved ones almost impossible to articulate, asking 'how can I possibly put this into words?' Creative tools such as memory boxes are often suggested by palliative care professionals and have become increasingly familiar to patients. A selfcomposed song containing the client's own words and music, often recorded using their own voice, provides a highly personalised and powerful legacy that is both profound and unique. Creative work like this can continue to live and breathe causing a ripple effect as the impact of the work continues to pass down the generations, becoming embedded within the family history: Caspar attended his first music therapy session when he was 33 years old, married with a 10-month-old daughter. Four months earlier he had been diagnosed with a brain tumour and, despite active treatment, had been given a prognosis of approximately 6 months. He was a pianist but the tumour had robbed him of many of his motor skills and he was finding it deeply frustrating attempting to express himself in music -something he had previously done on an almost daily basis. I suggested that he might write some songs as an alternative to playing the piano and he took to this new creative form immediately. As his illness progressed it became increasingly important for Casper to write a song for his daughter to, in his own words 'prove that I really did exist'. The song 'Liva's Lullaby' was written and recorded in one session and became the last recording that the family have of Casper's own voice. A simple lullaby by a father for his daughter, it contains his message of love, wisdom and hope: Liva's Lullaby When you are in bed but can't go to sleep Try closing your eyes and think what to keep Of all you have seen we will pick up the best Find a little thought that will give us some rest Should bad or evil dreams disturb you in the night I know it can be tough to keep them out of sight I hope that you feel that I am holding your hand Close your precious eyes sleep as long as you can But when you wake up and wonder what is true Put your hand on your heart to give you a clue Just trust how it feels though it does feel unreal Daddy was here -just ask the seal*.
(* The seal was his daughter's favourite soft toy) Four years later I had the opportunity to meet Liva during a visit to the hospice with her family. I was able to show her the instruments that her father had played when he wrote his songs and to play the original recordings that I had retained. Liva was able to add her own voice to one of these recordings, in effect singing with her father. Not only did Liva know the words to all of his songs, she was also able to play the melody of Liva's Lullaby on the metallophone and referred to it as 'my song from Daddy'.

Adult bereavement
Songs have always been one of mankind's most popular mediums for expressing feelings of loss. Psychologist Peter Hamel reminds us that Pythagoras himself used songs to cure bodily pains and to soothe the pangs of bereavement (Hamel, 1978, p. 165). Eric Clapton and Will Jenning's song 'Tears in Heaven', written after the death of Clapton's four-year-old son, is a powerful contemporary example of songwriting being used in exactly this way. Indeed a closer inspection of much contemporary songwriting will reveal many references to the loss of loved ones and the sometimes bewildering emotions that follow. Perhaps the song, as a container, enables the grieving person to express their profound feelings of loss and sadness without feeling completely overwhelmed by the common fear that, should they begin to cry, the tears may never stop falling. The recorded song can have the additional benefit of providing an opportunity to acknowledge and review these feelings from what can feel like a safer place. In her book 'Songs for Sharon', Jane Coutanche details her own journey using songwriting as therapy with Bob Heath, following the death of her daughter (Coutanche, 2010). Despite her initial scepticism, she described the very idea that songwriting could be helpful as strange and unlikely, she went on to write over 40 songs. She describes that in the beginning the pain she experienced was 'terrible', but through songwriting she was able to transform it into something that she could share with others, to say 'this is how I feel', in essence turning her sadness into something beautiful: When Sharon died nothing made any sense anymore. There was no meaning in anything. The songs were the only thing that did make sense; I think they were my way of finding meaning in the world again. (Coutanche, 2010, p. 12)

Child bereavement
Supporting children who have experienced the death of a parent or grandparent is an important part of the work of many hospices. Group work enables children to come together and, through sharing, can normalise their experiences and build resilience. Songwriting can be a powerful tool in helping to facilitate this (Ryan, 1994, p. 43). A frequently used and successful format, where time is short, involves children completing phrases rather than generating an entire lyric. This can be placed within an easy-to-use musical format such as a 12 bar blues beginning with the words: 'woke up this morning . . .'. However, even without such pro-formas, the recording of their words exactly and the incorporation of their suggestions for musical style and melody can help these young people to create a song validating their feelings in a product that they feel proud of. Often, devastatingly sad words are sung to up-beat music, which illustrates very well the nature of children's grief -at one moment tears and the next able to go off and play football seemingly without a care. These behaviours have been described as 'muddles, puddles and sunshine' (Crossley, 2010). The finished recording of these songs can provide the opportunity to share important information and feelings with other family members, often for the first time. This can be extremely helpful in situations where individual grieving has created an increased sense of isolation amongst members of the same family (O'Callaghan et al., 2009, p. 321).

Reflection and summary
Death and bereavement can be accompanied by a myriad of emotions and experiences and many are drawn to creativity, often for the first time, in an effort to express some of these feelings. The relationship between death and creativity is intrinsically linked in the human psyche, whether there is a desire to heal an old wound, leave behind an important message, or simply put down a marker that says 'I really was here'. It is therefore not surprising that individuals will often engage wholeheartedly in the songwriting process and find it both therapeutic and healing.
Songs are cross-cultural and trans-generational. One would struggle to find an event in history or in our own lives that has not been marked in some way by music and song. Songs are a way that civilisations preserve their traditions, their history and their truths (Curtis, 1968, p. 24). Popular songs have become a backdrop to almost every social activity that we undertake, persistent, relentless and on occasions invasive. This culture of song being a disposable commodity can lead us to stop listening. However, the art of songwriting to communicate important messages and to share important insights and feelings is not dead. Placed within a meaningful context, songwriting continues to flourish as a powerful form of storytelling and self-expression.
The use of creative songwriting, as described in this article, places our understanding of its unique role within the human experience into the context of the therapeutic relationship. Music therapists using this medium do so in the full knowledge that the process has the power to influence thinking and feeling states and can help facilitate communication, understanding, insight and change, not only for the songwriter but also for those to whom the song may be addressed. By describing case vignettes, the writers have attempted to demonstrate the use of creative songwriting during dying and bereavement. The vignettes included in this article are just a small sample from a body of work containing more than 500 songs, involving almost 200 clients. These clients and the songs they leave behind talk to us of people experiencing themselves in new ways, making new and surprising discoveries, seeking and at times finding reconciliation and peace.

Note
[1] Appropriate changes have been made to names and content to protect confidentiality. Consent has been obtained in all cases.