Table 3 Music Therapy mechanisms of change and facilitating context mapped to COS [6], PGD risk/protective factors [14]
Core outcome set for bereavement interventions | Risk and protective factors | Music therapy generated mechanisms of change | Facilitating context |
|---|---|---|---|
Ability to cope with grief | |||
Negative and overwhelming grief • Feelings of loneliness and emptiness • Feelings of blame, guilt, anger, bitterness, regret • Overwhelming thoughts and/or nightmares about loss • Preoccupation with thoughts of the deceased | • Bereavement depression and anxiety | • Social connectedness and support from the group created a sense of belonging and reduced perceptions of loneliness | Mode of delivery: group music therapy (optimal size of the group should be discussed and agreed with participants) Group characteristics: non-judgemental, supportive space to share feelings and receive social support Having a tangible output: e.g., recording to listen back on their song creation Facilitator/music therapist skills: foster a sense of self-efficacy among caregiver participants, especially when the music therapy intervention involves song writing, and provide leadership and support to foster participation and engagement Participant driven: flexible, tailored approach to suit carers’ needs Optimal dose: Discuss and agree optimal dose e.g., some prefer six weekly sessions whereas others prefer a longer-term ongoing intervention Collaborative/inclusive approach (e.g., participants choose the musical content/songs) |
Communication and connectedness • Ability to express feelings openly and honestly | • Musical catharsis: music therapy enabled carers to release repressed emotions | ||
• Feeling understood by and connected with other bereaved people | • Poor perceived social support | • Commonalities in experiences helped to foster solidarity, empathy, and the sense of enjoying a “safe space” to explore and share common feelings and needs. | |
Understanding, accepting and finding meaning in grief • Acceptance of grief experiences as normal | • Early non-acceptance of loss/denial • perceived preparedness for death | • Music therapy aided relationship completion – helped caregiver accept/prepare for loss via renewed intimacy with their loved one | |
• Understanding, acceptance, finding meaning in loss | • Higher spirituality | • Comfort, sense of meaning found in sharing/facilitating a music intervention that brought joy to their significant other/helped them reconnect and have hope in something more beyond bereavement | |
• Positive reminiscence and remembering of the deceased | • Family conflict at EoL • Difficulty accessing positive memories | • Music therapy as a shared activity which improved caregiver/patient relationships • Positive reminiscence | |
Finding balance between grief and life going forwards • Ability to find balance and channel grief • Ability to take control/ look ahead and start to move forward with life | • Music therapy provided an emotional channel for grief/increased preparedness for death of significant other • Motivated carers to re-engage/explore activities outside of the music therapy intervention going forward in their lives | ||
Accessing appropriate support • Accessing emotional support if needed • Accessing practical support if needed | • Poor perceived social support | • Group music therapy provided a safe, non-judgemental, supportive space to share feelings and receive social support | |
Quality of Life and Mental Wellbeing | |||
Participation in work and/or other regular activities • Ability to perform daily tasks • Ability to participate in work • Ability to participate in social activities | • Motivated carers to re-engage/explore activities outside of the music therapy intervention going forward in their lives | ||
Relationships and social functioning • Ability to function as part of a family • Relationships with friends and family | • Family conflict at EoL | • Improved relationships with significant others/renewed connection and sense of intimacy | |
Positive mental wellbeing • Sense of meaning and purpose in life • Optimism and hopefulness | • Higher spirituality | • Comfort, sense of meaning found in sharing/facilitating a music intervention that brought joy to their significant other/helped them reconnect and have purpose during pre-bereavement and hope in something more after bereavement | |
Negative mental and emotional state • Anxiety (feelings of tension, nervousness, panic and distress) | • Anxiety | • Carers experienced relaxation, calmness and inner peace | |
• Depression (a sense of hopelessness, pessimism, periods of crying) | • Bereavement depression | • Carers experienced improved mood, joy, happiness, a sense of achievement and contentment | |
• Suicidal thoughts | • Music therapy gave carers a renewed sense of hope and resilience through restoring a balance between grief and moving on with their lives. | ||