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Objectivist and Constructivist Music Therapy Research in Oncology and Palliative CareAn Overview and Reflection1 Peter MacCallum Cancer Centre and St. Vincent’s Health, Victoria, and the Department of Medicine and Faculty of Music, The University of Melbourne, Australia Correspondence: Clare O’Callaghan, Social Work Department, Peter MacCallum Cancer Centre, Locked Bag 1, A’Beckett Street, Victoria, Australia, 8006; e-mail: clare.ocallaghan{at}petermac.org
Objectivist and constructivist music therapy research in oncology and palliative care since 1983 is detailed, and the meaningfulness of evidence gathered is considered. Objectivist approaches are informed by positivism and commonly use experimental, hypothetically driven methodologies incorporating researcher-designed measures. Constructivist approaches are informed by varied theoretical frameworks (e.g., postmodernism, phenomenology) and commonly aim to understand participants' subjective experiences. Methodologies include grounded theory, ethnography, and discourse analysis. Both research approaches have uncovered varied and evolutionary understandings about how music therapy can help people deal with loss and maintain life quality when affected by life-threatening and end-stage illnesses. Furthermore, constructivism and palliative care are compatible in that both focus on understanding individualized and multiple interpretations of experience. It is contended that objectivist and constructivist research will never be able to capture an absolute "truth" about music therapy’s effectiveness; however, findings from both approaches can be conceptually generalized to comparable clinical contexts.
Key Words: music medicine • music psychotherapy • music therapy • oncology • palliative care
First described in palliative care over three decades ago (Munro & Mount, 1978), music therapy has since become a widely accepted discipline that can promote resilience, control, comfort, and peace among people affected by life-threatening illnesses, including patients and their families, friends, and staff caregivers (Dileo & Loewy, 2005; Hilliard, 2005; Lee, 1995; Magill Bailey, 1984; Martin, 1989; Munro, 1984; O’Callaghan, 2006a; Rykov & Salmon, 2001). Music therapy in oncology and palliative care can be described as the professionally informed and creative use of music within a therapeutic relationship with people who have been identified as needing psychosocial, physical, or spiritual help or who desire further self-awareness, enabling increased life quality (O’Callaghan, in press). Palliative care, also described as hospice care, is defined as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual (World Health Organization, 2008).While traditionally palliative care was associated with those dying from malignant disease, its principles are now considered relevant throughout the trajectory of any degenerative and life-threatening condition (Doyle, Hanks, Cherny, & Calman, 2004) and for the bereaved (Kissane, 2004). Hence, music therapy in palliative care now encompasses oncology. To develop evidence-based practice, music therapists have embraced the challenge of researching their own, as well as music’s, role in the field. Traditional medical research designs (objectivist), such as controlled trials (Magill Bailey, 1983), and qualitative (constructivist) methods (Forinash, 1990) have been used. In this article, historical precursors to the objectivist and constructivist research "divide" are described, and major differences between the two approaches are clarified. Following this, 61 objectivist and constructivist research studies (Kuper, Reeves, & Levinson, 2008), conducted by music therapists in palliative care since 1983, are delineated, and the meaningfulness of the research findings are discussed. Reflections about using alternate research approaches in palliative care are also offered, including my belief that palliative care aims are compatible with constructive research approaches: Both focus on clients' individualized interpretations of their experiences. The favoring of objectivist research in evidenced-based medicine, which includes standardized treatment protocols, can be problematic for palliative care music therapists who tailor techniques to address clients' idiosyncratic (Edwards, 2004) and holistic needs within a multidisciplinary team approach (Aoun & Kristjanson, 2005). It is important to examine and discuss existing objectivist and constructivist research contributions in palliative care music therapy to help readers understand different paradigms informing this research and the kinds of knowledge they produce. Historically, a distinction was made between "music in medicine" and "music therapy in medicine." In the former, music is the primary therapeutic agent, whereas in the latter, the therapist–client relationship and the music experience are the primary therapeutic agents (Bruscia, 1989). Music therapy research, in this article, however, depicts research involving music therapists as researchers and/or service providers because their knowledge and skills have informed the studies' questions, designs, and/or conduction. Music research in cancer and palliative care without music therapist involvement also importantly exists (e.g., Beck, 1991; Sabo & Rush Michael, 1996; Zimmerman, Pozehl, Duncan, & Schmitz, 1989) but is beyond this article’s scope. The term palliative in this article encompasses only people receiving care from cancer and palliative inpatient and home-based services. It is hoped, however, that readers can transfer understandings about research approaches outlined here to any population where a human relationship therapy is directed at improving life quality.
The origin of the quantitative and qualitative research divide emerged at the end of the 1800s, when German philosophers claimed there should be a distinction between Naturwissenschaften, that is, scientific ideas focused on the natural, physical world, and Geisteswissenschaften, that is, human sciences focused on the meaning of human action and spirit. By the early 1900s, anthropology was focused on studying "alien cultures" through fieldwork. In the 1920s, Chicago sociologists demonstrated how the same techniques could be used to study city life (D. Clark, 1997), and by the 1960s, comparable research methods emerged in health care (Glaser & Strauss, 1967). Barney Glaser and Anselm Strauss were the first qualitative researchers in palliative care. Their study on the awareness of dying in a Californian hospital’s oncology and geriatric wards led to the development of a "dying awareness" grounded theory characterized by how dying patients and their carers interacted with each other in a closed or open manner, or through suspicion, or through sharing a mutual pretense. Varied research approaches, informed by the natural and social sciences, have since evolved in palliative and broader health care. In articles published by the British Medical Journal in 2008, a distinction was made between objectivist approaches, which are aligned with positivism, and constructivist approaches, which are aligned with the qualitative and interpretivist stances, including phenomenology, interactionism, hermeneutics, critical theory, feminism, and postmodernism (Hodges, Kuper, & Reeves, 2008; Kuper, Lingard, & Levinson, 2008; Kuper, Reeves, et al., 2008; Lingard, Albert, & Levinson, 2008; Reeves, Albert, Kuper, & Hodges, 2008; Reeves, Kuper, & Hodges, 2008). Objectivist approaches reflect an assumption that an absolute truth can be discovered that is replicable and predictable. Constructivist approaches, however, reflect a belief that a person’s perceived reality is constructed by his or her individual, social, and historical context. Constructivists acknowledge that truth is multifaceted: Different people can have varying perspectives about a specific research phenomenon, and these perspectives can all be acceptable (Crotty, 1998; Edwards, 1999; Guba & Lincoln, 1994; Kuper, Reeves, et al., 2008). Until the late 1980s, music therapy in palliative care research was based on objectivism. Michelle Forinash (1990) then introduced constructivist research through a phenomenological examination of music therapy for 10 dying adult patients. Data included one taped music therapy session with each patient; the sessions were then transcribed and reflected on. Analysis included a three-stage reflection process. First, "meaning units" were distilled from the transcripts and process notes. Second, three categories emerged: relationship, music, and process. Finally, the essences were integrated and synthesized into a description of music therapy with the terminally ill, including that the therapist "always focuses on serving as a companion on the patient’s journey....The therapist sometimes reflects, sometimes questions, sometimes directs and sometimes listens as the patient travels on his or her journey" (pp. 105-106).
Features distinguishing objectivist and constructivist research approaches will be clarified and are also summarized in Table 1. Objectivist and constructivist theoretical frameworks and orientations have already been mentioned. These in turn reflect the research questions and the methodology used to answer those questions (Kuper, Reeves, et al., 2008). Objectivist researchers ask specific questions, such as, "Does music therapy improve quality of life?" To address that question in one music therapy study, for example, a researcher-developed quality-of-life questionnaire was used. Research participants were invited to indicate numerically whether music therapy improved factors that a researcher perceived to be important for their life quality (Hilliard, 2003). Objectivist methodologies also tend to be experimental (or closed-ended surveys). Constructivist researchers, however, do not assume that music therapy affects life quality. Constructivists are interested in what life quality means to research participants and whether music therapy affects what they describe as being important in their lives. Constructivist research tools, therefore, do not include researcher-validated questionnaires and inventories. Constructivists are more likely to invite participants to tell their stories through interviews and focus groups (Crotty, 1998): to explain their experiences of music therapy. A broad research question may instigate the commencement of a constructive study, for example, "What is the relevance of music therapy in a cancer hospital?" (O’Callaghan & McDermott, 2004). Constructivist methodologies encompass more open-ended investigations. Sampling tends to be purposive: Research participants (and data) are selected to represent a range of experiences and beliefs that the researcher thinks will be relevant to the question (Kuper, Reeves, et al., 2008). As constructivists analyze the data (which often occurs as it is collected), more specific questions may then emerge, which are then focused on through ongoing and purposive sampling and data collection (Corbin & Strauss, 2008; Kuper, Reeves, et al., 2008).
Hence, unlike objectivist research, constructivist research may not have predetermined sample sizes. Sampling stops when one reaches a point of "saturation," which traditionally means that no new understandings emerge about the researched phenomenon as further data are collected (Fossey, Harvey, McDermott, & Davidson, 2002). Saturation actually means, however, that the phenomenon has been explored to a sufficient enough depth because "in reality a researcher could go on collecting data forever" (Corbin & Strauss, 2008, p. 148). Most constructivist music therapy studies do not reach saturation because the researcher runs out of time or funding, or the researcher may not regard saturation as important: Phenomenological researchers, for example, believe that deeper understanding of the subjective meaning of experiences for individual participants is enough (Forinash, 1995). Alternately, once data saturation is reached, grounded theories about the researched phenomenon can be developed (Corbin & Strauss, 2008), for example, the substantive grounded theory about music therapy’s effect on oncologic staff bystanders (O’Callaghan & Magill, in press). Within objectivism, researchers usually have predetermined hypotheses and therefore tend to analyze their data deductively (Kuper, Reeves, et al., 2008), to accept or reject their null hypotheses, or they might describe a phenomenon in a numerical way. Constructivists do not tend to have preconceived ideas about what is in, or not in, the data. Their analyses tend to be inductive, and the findings emerge (Edwards, 1999; Guba & Lincoln, 1994). While objectivist research produces numerical findings, constructivist research produces either only qualitative depictions, including textual, audio, and/or visual (Corbin & Strauss, 2008), or qualitative depictions and measurements of those inductively derived depictions (Kuper, Reeves, et al., 2008). Constructivists acknowledge that measurements can contribute to an expanded understanding of a subjective phenomenon, while not claiming it represents potential for making predictive generalizations (for examples, see Bunt & Marston-Wyld, 1995; O’Callaghan & McDermott, 2004). Research methodologies also inform measurement tools, assumptions about the findings' generalizability, the researcher’s stance, and factors that determine the quality of the research (Kitto, Chesters, & Grbich, 2008; Kuper, Reeves, et al., 2008; Popay, Rogers, & Williams, 1998), as are also described in Table 1.
Brief descriptions of oncology and palliative care research in music therapy encompassing the past 26 years are found in Tables 2, 3, and 4. Criteria for inclusion were that the research descriptions (a) were in English; (b) involved music therapists as researchers or service providers in contexts with cancer and palliative care affiliations; and (c) had been published in journals and textbook chapters known to me or found on the following databases: CINAHL EBSCO, PsycINFO, and MEDLINE. Three foci were examined in music therapy objectivist, constructivist, and combined "mixed methods" (Creswell & Plano Clark, 2007; Lingard et al., 2008) research outlined in the tables: (a) Does music therapy help patients, their significant others, and staff caregivers in cancer and palliative care contexts? (b) What are the session outcomes and would they indicate helpfulness? and (c) Questions related to practice issues pertinent for music therapists. Tables 2, 3, and 4 illustrate how the findings have emerged from (a) different music therapy methods; (b) different people’s perceptions of music therapy’s effects, including patients, therapists, family members, staff, and independent observers; (c) the use of different measurement tools; and (d) different control experiences (e.g., standard care or volunteer visits). Brief summaries of music therapy’s significant and positive effects, revealed by objectivist, constructivist, and mixed methods approaches, are now outlined. The 61 research projects were reported in 32 objectivist, 26 constructivist, and 10 mixed methods papers.
Objectivist Research As evident in Table 2, palliative care randomized controlled trials (RCTs) that achieved significant findings indicated that, among adult cancer and palliative care patients, music therapy improved mood (Cassileth, Vickers, & Magill, 2003; Magill Bailey, 1983), life quality (Hanser Bauer-Wu et al., 2006; Hilliard, 2003), relaxation, (M. Clark et al., 2006; Ferrer, 2007; Horne-Thompson & Grocke, 2008), comfort, happiness, (M. Clark et al., 2006; Horne-Thompson & Grocke, 2008), and diastolic blood pressure (Ferrer, 2007), and reduced distress (M. Clark et al., 2006), heart rate (Hanser et al., 2006), pain, depression (Horne-Thompson & Grocke, 2008), anxiety, (M. Clark et al., 2006; Ferrer, 2007; Horne-Thompson & Grocke, 2008), and fear (Ferrer, 2007). In a study where pediatric oncology patients were sequentially assigned to one of three conditions, it was also found that the children’s coping and initiation behaviors improved with active music engagement (Robb et al., 2008). In nonrandomized pre-post test studies, including questionnaires and visual analogue or affective face rating scales, findings indicated that, according to various perceptions, music therapy improved the mood of patients' family members (Gallagher, Lagman, Walsh, Davis, & LeGrand, 2006) and improved patients' comfort, relaxation (Krout, 2001), and mood (Waldon, 2001). Music therapy also reduced patients' anxiety, shortness of breath (Gallagher et al., 2006), pain (Gallagher et al., 2006; Krout, 2001; Sahler, Hunter, & Liesveld, 2003), and nausea (Sahler et al., 2003), and caused pediatric patients to display more engaging behaviors (Robb, 2000). Hospice staff also reported that both structured and unstructured music therapy support sessions significantly improved team building (Hilliard, 2006). Other quantitative studies indicated that music therapy reduced isolation (Bailey, 1985) and boredom (O’Brien, 1999) and improved spiritual well-being (Wlodarczyk, 2007), mood (Bailey, 1985; D. S. Burns, 2001), communication (Bailey, 1985), treatment tolerance (O’Brien, 1999), endurance, cooperation, participation (Boldt, 1996), interest, relaxation, satisfaction, symptom relief (Gallagher, Huston, Nelson, Walsh, & Steele, 2001), and life quality (D. S. Burns, 2001), and was satisfying (Weber, Nuessler, & Wilmanns, 1997). Relaxation exercises were also preferred (Boldt, 1996), as was classical music in a chemotherapy study (Weber et al., 1997). Another interesting feature of the objectivist research is that, of the 23 non-survey-type studies, 17 (74%) had significant findings. The 6 studies (26%) that had nonsignificant findings (Boldt, 1996; Curtis, 1986; Lane, 1989; Pfaff, Smith, & Gowan, 1989; Standley, 1992; Whittall, 1989) were all published before 1997, and their mean number of participants was 14 per trial. In the studies with significant results, all except 1 was published from 2000, and the mean number of participants was 51 per trial. This raises the possibilities of Type 2 error in the nonsignificant studies due to small sample sizes or the possibility of recent publication bias toward those studies with positive findings. Furthermore, a meta-analysis conducted by Dileo and Bradt (2005) identified 18 studies on music and people living with cancer, a terminal illness, or HIV (N = 641). They found a mean effect size measured by the Pearson correlation coefficient of .22 (95% confidence interval = .14–.30, p < .01), which was a moderate effect. Objectivist research examining practice issues also indicated that American hospice administrators wanted music therapists to include understandings about business benefits in their justification for music therapy and believed that student therapists needed more college training in end-of-life issues (Hilliard, 2004a). Almost all surveyed American music therapists (86%) reported that they assessed palliative care patients' pain, and most (93%) treated it with music listening (Mills Groen, 2007). Seventy percent of American music therapists also preferred to use live music interventions (Kruse, 2003). In another study, music therapists met broader patients' needs than other team members did, and patients who experienced music therapy were found to live longer (Hilliard, 2004b); however, increased longevity was not evident in other research (Hilliard, 2003). In some Australian hospices, nurses mostly referred patients to music therapy, and almost half of those referred had an Eastern Cooperative Oncology Group Performance Status of 3 (Horne-Thompson, Daveson, & Hogan, 2007). Many cancer patients are also interested in experiencing music therapy (D. S. Burns, Sledge, Fuller, Daggy, & Monahan, 2005).
Constructivist Research Music therapists perceived that a music therapist accompanies palliative care patients on a journey (Forinash, 1990), can help to expand a patient’s sense of identity (G. Aldridge, 1996; G. Aldridge & Aldridge, 2008), and can also help patients, hospital visitors, and staff to encounter alternate intra-awareness and community participation (O’Callaghan, 2005). Staff bystanders reported that they observed physical, psychosocial, spiritual, environmental (O’Callaghan & Magill, in press; O’Kelly & Koffman, 2007), and creative (O’Kelly & Koffman, 2007) benefits for patients experiencing music therapy. Interviewed staff also believed that music therapy provided children in hospice care, and their families, with opportunities to communicate and express their feelings, and hence it improves life quality (Amadoru & McFerran, 2007). Staff bystanders can also find witnessing oncologic music therapy’s effects personally helpful (O’Callaghan & Magill, in press). Caregivers who hear or participate in pre-loss music therapy have experienced meaning through transcendence, encompassing joy, connectedness, remembrance, and hope (Magill, 2009b). Caregivers have also been empowered through the music therapy that has helped them to offer their loved ones relief from distress, aesthetic beauty, and peace (Magill, in press). Caregivers also described the music in music therapy as a conduit (Magill, 2009a). In addition, oncology visitors have had positive emotional and awareness benefits through music therapy involvement (O’Callaghan & McDermott, 2004). Journal writing and analysis was helpful for a music therapy student’s practice development (Barry & O’Callaghan, 2008), and a music therapist’s reflections helped to uncover the "lullament" phenomenon, which signified the helpful moments when patients' and families' relationships with lullabies and laments were actualized in music therapy (O’Callaghan, 2008) and also understandings about how music therapy elicits hospital ward communities (O’Callaghan, 2005). Cancer patients reported that songwriting was a pleasurable, helpful, unique, calming, and easy experience that allowed them to express themselves and record significant life events (O’Brien, 2005). Lyric analyses of oncology patients' songs indicated that songwriting is a forum where parents can express important messages for their children’s future well-being, including love, memories, yearning, loss, their children’s meanings for them, hopes, compliments, existential beliefs, and suggestions about who the children can turn to in the future (O’Callaghan, O’Brien, Magill, & Ballinger, in press). General lyrics in palliative care patients' songs also often included messages, self-reflections, compliments, and memories (O’Callaghan, 1996). An examination of child and adolescent cancer patients’ songs’ "life histories" also revealed meaningful associations, including expression, achievement, and pleasure. Their lyrics reflected both the hospital and non-hospital worlds (Aasgaard, 2005). Constructivist research examining practice issues indicated that gender and the number of music therapy sessions experienced were scantly associated with how music therapy was described by research participants (O’Callaghan & Hiscock, 2007). Also, most patients chose to engage in music therapy when they had previously overheard it, had discussed their music preferences, were in moderate discomfort, and were offered live music (O’Callaghan & Colegrove, 1998). Music therapists can also find work life stressful in palliative care settings, mentioning, for example, concerns about others' not understanding their role, loss, and client identification (Clements-Cortes, 2006). Concerns related to incomplete legacies in music therapists' work, for example when a patient dies before finishing a song composition, were however relieved through reflexive group supervision research (O’Callaghan, Petering, Thomas, & Crappsley, in press). Finally, a discourse analysis provided alternate interpretations about positive oncologic music therapy research findings; for example, the propensity of cancer patient research respondents to provide socially desirable answers may have inappropriately affected the results (O’Callaghan & McDermott, 2007). Mixed methods research combines elements of both quantitative and qualitative paradigms to produce converging findings in the context of complex research questions. . . . Central to the effectiveness . . . is a clear and strategic relationship among the methods in order to ensure the data converge or triangulate to produce greater insight than a single method could. (Lingard et al., 2008, pp. 460-461)Robb and Ebberts (2003a, 2003b) researched six young cancer patients who were randomized into either a songwriting and DVD production condition or a standard care game condition. This was mixed methods research because a variety of tools were used to understand the children’s responses to these techniques. The young cancer patients' anxiety dropped in the three music conditions, while only one of the three young patients' anxiety dropped in the control condition. Also, an analysis of the three music participants' song lyrics revealed themes including coping, positive physical status, and family support. Barrera, Rykov, and Doyle’s (2002) mixed methods research also found that music therapy improved the emotions, play performances, and well-being of children with cancer. As also illustrated in Table 4, mixed methods research in adult oncology revealed that music therapy increased patients' well-being, faith, and hope (Magill, Levin, & Spodek, 2008); decreased their tension (S. J. Burns, Harbuz, Hucklebridge, & Bunt, 2001) and distress (Magill et al., 2008); and was associated with cancer survivors' empowerment and transcendence (Rykov, 2008). Cancer survivors also found that the Bonny Method of Guided Imagery and Music improved their life quality through an altered personal script (Bonde, 2005) and through their reduced anxiety and enhanced mood, coping, and dealings with death and spiritual issues (Bonde, 2007). Finally, practice issues examined with mixed research methods revealed that U.K. cancer care managers characterized music therapy as background, entertainment, enjoyment, communication, healing, and an exploratory and expressive release tool (Daykin, Bunt, & McClean, 2006). An international study on palliative care music therapists' work life also indicated that a dynamic tension was often experienced as therapists found palliative care meaningful and rewarding yet challenging and painful. Grief and death issues were stressors for many music therapist respondents (Salmon, 2003).
The choice of [research] method is . . . influenced by the assumptions that the researcher makes about science, people and the social world. In turn, the method used will influence what the researcher will see. (Minichiello, Aroni, Timewell, & Alexander, 1995, p. 9)Objectivist and constructivist research uncovers multifaceted and evolutionary views of the varied phenomena characterizing music therapy and palliative care. Traditionally, objectivist research methods, specifically RCTs, are regarded as the gold standard in medical health research because they are derived from physical science research approaches and, it is assumed, enable predictive generalizations (Edwards, 2004) and eliminate bias (Aoun & Kristjanson, 2005). There is, however, increasing debate about what constitutes best evidence in public health, and re-examination of the taxonomy for grading literature in palliative care is recommended.1 Furthermore, it is suggested that the deliberate withholding of desired support services from a control group can be unethical (Keeley, 1999). It is therefore vital to not presume that objectivist research is superior when examining a human relationship therapy in palliative care. The inherent problems of RCTs in palliative care preclude predictive generalizations from their findings. Furthermore, objectivist methods do not foster respondents' individualized expression, which is important for patient-centered care. These points will be discussed in turn.
Inherent Problems With RCTs in Palliative Care While predictive generalizations are not possible in objectivist music therapy and palliative care research, generalizations from objectivist research can be conceptual, that is, can be made with qualification. This is comparable with how generalizations can be made from constructivist research (Kitto et al., 2008). Conceptual generalizations, for example, can be made from Hilliard’s (2003) RCT on music therapy’s quality-of-life effects on hospice home care patients (N = 80). The participants who experienced music therapy reported a significantly higher quality of life than those who did not on the psychophysiological subscale of the Hospice Quality of Life Index–Revised (HQLI-R). The participants' life quality also increased over the time of their two or three sessions, while those who had standard care experienced reduced life quality over time. Hilliard noted, however, that further multisite studies were needed to determine if comparable findings would be evident among participants with other characteristics than those in his study, including those who are non-Caucasian, who are from other geographic regions, and who have contrasting social norms and music preferences. Despite this, one can conceptually generalize that comparable palliative care participants who engage in similar kinds of music therapy contexts as those in Hilliard’s study are likely to experience increased life quality, as determined by the HQLI-R. Similarly, conceptual generalizations were made from O’Callaghan and Magill’s (in press) constructivist research, which examined 100 oncology staff members' perceptions about their experiences of music therapy in Australian and American cancer hospitals. A substantive grounded theory emerged revealing that in comparable oncology contexts, with comparable music therapy programs, staff witnessing music therapy can experience personally helpful emotions, moods, self-awareness, and teamwork, and can perceive improved patient care. Objectivist and constructivist music therapy studies in palliative care have comparable merit in being able to offer conceptually generalizable findings. Multisite studies with varied source populations and designs will further extend research findings' conceptual generalizability to varied clinical contexts, and should be encouraged.
Research in Contexts Focused on Individualized Needs and Patient-Centered Care Meaning is not inherent in the data, it is influenced by the way in which the researcher interprets reality. . . . Once that interpretation bias is made clear, then we as readers are able to discern how that work resonates with our own premises of interpretation and, indeed, our own bias. (D. Aldridge, 1996, pp. 125-126) I am drawn to the constructivist approach in my palliative care research because I believe that there can be no absolute shared truth about human subjective experience. Constructivism also reflects my patient- and family-centered music therapy practice style: one of endeavoring to understand the clients' realities, and to be where they need and choose to be on their journeys. Constructivism helps me to appreciate that the reality experienced by a client is informed by the client’s life story, and as the client and I share our backgrounds in present moments, new individual realities and shared understandings can both emerge. I also support the objectivist approach because it helps my attempts to meaningfully describe palliative care music therapy to people aligned with objectivism. Furthermore, I believe that knowledge informed by objectivism can be located within the constructivist paradigm, as constructivists accept multiple realities: This includes accepting that some people adhere to the epistemology that objective truth can be discovered within human relationship therapies. Ultimately, I hope that the relationship between Hermes and Zeus is reflected in my connection, as a music therapy researcher (Hermes), with people interested in my work (Zeus): "When Hermes took the role of messenger to the gods, he promised Zeus not to lie. He did not promise to tell the whole truth. Zeus understood" (Crapanzano, 1986, p. 53). While I believe that one can never tell the whole truth about subjective human experience through health research, others may believe it is possible. Nonetheless, I hope that both objectivist and constructivist readers can resonate with the interesting and varied research investigations described in this article, which often substantiate music therapy’s rightful place in cancer and palliative care.
Outcome Measure (Inventories) Abbreviations CDI = Children’s Depression Inventory; CFS = Compassion Satisfaction/Fatigue Self-Test for Helpers ECOG = Eastern Cooperative Oncology Group Performance Status (e.g., 3 = limited "selfcare") EORTC QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire ESAS = Edmonton Symptom Assessment Scale FACES = Faces Pain Scale FACT-G = Functional Assessment of Cancer Therapy–General FACIT-F = Functional Assessment of Chronic Illness Therapy–Fatigue Scale FACIT-Sp = Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being HADS = Hospital Anxiety And Depression Scale HQOL-R = Quality of Life Index–Revised NRS = Numeric Rating Scale OSBD = Observational Scale of Behavioral Distress PANAS = Positive Affect and Negative Affect Schedule POMS = Profile of Mood State Inventory PlayPS = Play Performance Scale PhysPS = Physical Performance Scale QOL-CA = Quality of Life–Cancer SOC = Antonovsky’s Sense of Coherence Scale STAI = State-Trait Anxiety Inventory TBQ = Team Building Questionnaire UWIST = University of Wales Institute of Science and Technology Mood Adjective Checklist VAS = Visual Analogue Scale General Abbreviations cf. = compared to CO = cross-over method; participant sequentially exposed to all treatment modalities MI = music imagery ML = music listening MT = music therapy MV = variety of music therapy techniques PP = pre-post method; patient exposed to one treatment, with the outcome measured twice PPq = queried; possibly pre-post method or post-only analysis pt = patient RP = repeated-measures method; participant exposed to one treatment, with the outcome measured more than twice RMT = registered music therapist RCT = randomized controlled trial SC = standard care SW = songwriting
This article was enabled through the author’s National Health and Medical Research Council of Australia Post Doctoral Fellowship in Palliative Care (2008-2009).
Clare O’Callaghan, PhD, RMT, is a music therapist (on leave) at the Peter MacCallum Cancer Centre and St. Vincent’s Health and a clinical associate professor in the Department of Medicine and an Honorary Fellow in the Faculty of Music, at The University of Melbourne, Australia. She is currently a National Health and Medical Research Council of Australia Post Doctoral Fellow in Palliative Care (2008-2009). Declaration of Conflicting Interests The author has declared that there are no conflicts of interests in the authorship and publication of this contribution.
1 The evidence-based medicine framework reflects a series of evidence levels. The National Health and Medical Research Council of Australia’s (1999) criteria for rating levels of quantitative evidence include the following: Level 1, a systematic review of all relevant randomized controlled trials (RCTs); Level 2, at least one properly designed RCT; Level 3, other comparative studies; and Level 4, case series with either post- or pre-post testing.  Manuscript received January 26, 2009. Accepted for publication April 6, 2009.
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Music and Medicine, Vol. 1, No. 1,
41-60 (2009)
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Abstract
What Is Music Therapy...