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							  Using Artistic Advanced Accurate
Empathy to Assist a Client to Deal with
          Death and Dying



   Wilfred Gallant. Ed.D., M.S.W. I. C. A. D. C.
         Michael Holosko, Ph.D., M.S.W.
    Melanie Gallant, Ph. D., B.A. , B. Sc. , M. A
      I   Purpose of Presentation

 To Report on The Use of
   Artistic Accurate Empathy
   Artistic Advanced Accurate Empathy

 Using Client Identified Themes to
  Develop a Stage Specific Model of Music
  Intervention with Clients Confronted
  with Death and Dying
      I   Purpose of Presentation

 To Demonstrate the Practical Utility of the
  Music Impact Inventory Scale (MIIS) to
  Measure

   Artistic Accurate Empathy
   Artistic Advanced Accurate Empathy

 As a Tool of Professional Accountabity
     I   Purpose of Presentation


 To Demonstrate the Use of Music-
  Based Intervention

 With a Client Who Has a Life-
  Threatening, Inoperable Brain Tumor
      I   Purpose of Presentation

 Involves a single system design
 Uses anecdotal data to:
   Describe how music therapists may
    use artistic interventions
     e.g. prose, songs, poems, movies,
      videos, reflective journals etc.
 To reach the spiritual souls of
  clients at higher levels of empathy.
     I   Purpose of Presentation

 Our experiences with such clients
  have revealed that:
   Actualizing deeper levels of
    empathy are the keys to unlocking
    specific stages that typically house
    very complex, difficult and
    troublesome issues that such clients
    face.
    II   Method (Sample)

 A middle age woman, Elena, 55

 Diagnosed four years ago with a
  life threatening brain tumour.
      II   Method (Sample)

 Following surgery, I made regular
  bi-weekly visits with Elena and her
  husband over a three year period as
  surgeons were only able to remove
  80% of the malignant growth.
        II   Method   (Sample)

 Stage 1 work consisted of
  helping her:

   Come to peace with her
    predicament
   Find an inner strength within
    herself, and
          II   Method   (Sample)

 In   Stage 1 also
  – Aiding her husband with his denial of
    the seriousness of her condition and
  – Elena‟s discernment over her
    impeding loss of life
  – (Therapeutic Artistic Entry Point)
    with the song: “Don‟t Give Up” I
    Hear You Crying.
         II   Method     (Sample)

   “In Stage 3 helping Elena to:

    – Accept affirmation and support from
      others through the (Therapeutic
      Artistic Entry Point) open her to her
      higher power with the song: “For
      This I Pray.”
  Using the Stages of Death and Dying to
      Demonstrate AAE and AAAE
Three client themes:

   1. Facing death and dying in the
      “here and now”

   2. Spiritual self-discovery

   3. Saying: “good-bye”
Using the Stages of Death and Dying to
    Demonstrate AAE and AAAE

 Three stages:

 1.     Seeking an Inner Peace
        Within the Self
Using the Stages of Death and Dying to
    Demonstrate AAE and AAAE



 2.     Acknowledging the Need of
        Others Outside Oneself

 3.     Accepting Affirmation and
        Support From Others
Stage 1 Therapeutic Artistic Entry Points


Dealing with Blind Spots, Denial and
Discerning One‟s Loss

Worker Composed Song
“Don‟t Give Up” I Hear You Crying

Client Composed Poem
“Tears Amidst Laughter”
Stage 2 Therapeutic Artistic Entry Points


Renewing An Interest in Others and
Becoming “Part Of”

Worker Composed Song
“Music Maker”

Client Composed Poem
“Whisper Softly Whisper”
Stage 3 Therapeutic Artistic Entry Points


  Reminiscing About Friendships and
  Relationships and Opening to Communion
  With a Power Greater Than Oneself

  Worker Composed Song “For This I Pray”
  Client Composed Poem “Ode To This I
  Pray”
               Empathy
 Definition
  – Unconditional acceptance or
   agape
     Involves active engagement in the
      inner self of another in order to
      affirm the person's humanness.
                       Tillich (1962)
                             Accurate

                             Empathy


Accurate empathy entails “being there” for a
client in a reflective and facilitative way and
capturing the substance of the client‟s verbal
and non-verbal communication.
   Artistic Accurate Empathy

The worker‟s ability to clearly
denote and convey through the use
of prose, poetry, drama or music
the quality, texture and varied
nuances of the client‟s expression
and the manner in which such
individuals experience their world
at the cognitive, affective,
behavioural and experiential level.
  Artistic Accurate Empathy (AAE)
Reflects the worker‟s awareness of the
content, feeling, meaning, behaviour
and experience of the client‟s life
situation. AAE or acceptance of self and
of others is closely paralleled to love or
„agape‟ which enters the dark, repulsive
ravishes of the human condition in order
to elevate it to a place of dignity, value
and respect               (Tillich, 1962).
      Artistic Accurate Empathy (AAE)


   An “act of loving imagination”

   Enables clients, by means of the worker
    internalizing their message

   To feel a sense of competence, efficacy, and
    responsibility in achieving their own goals

             (Miley, O‟Melia, & DuBois, 2001)
Comparison of Empathic Communication Scale and the Music
                 Impact Inventory Scale


         Empathic Communication Scale

          Level 1   Low Level
          Level 2   Moderately Low Level
          Level 3   Interchangeable Or Reciprocal
          Level 4   Moderately High Level
          Level 5   High Level
Measuring Therapeutic AAE and AAAE
Using The Music Impact Inventory Scale

 The Music Impact Inventory Scale (Part II)

              (Facilitative)        (Worker)

   Level 1    Not At All                (Detracts Significantly
   Level 2    A Little                  (Subtracts Noticeably)
   Level 3    Somewhat     (AAE)        (Interchangeable)
   Level 4    Moderately      (AAE)    (Adds Noticeably)
   Level 5    Considerably (AAAE)       (Adds Significantly)
   Level 6    Very Much       (AAAE)    (Captures Full Expression)
      Scoring MIIS   (Likert Scale)

1. Level 1 - 2       Score = 1    - 29

2. Level 3 - 5       Score = 20 - 59

3. Level 5 - 6       Score = 60 - 90
Artistic Empathic Assumptions

that a spiritual framework for
wellness-directed music –based
intervention provides counsellors
with an effective venue to assist
clients in putting a sense of
meaning and closure to their
experience
       Generalizability of the Model

 Although, our work was primarily
 developed and „field-tested‟ with
 addictive clients in recovery

 We  have generalized the approach
 successfully to clients challenged with
 a life threatening illness who are not
 addicted
Facing Death and Dying in the „Here and
        Now‟: A Case Example

 Elena‟sbrain tumour was tenaciously
 lodged behind her eye and in her jaw
 bones. She was warned of the
 seriousness of a life-threatening
 operation.
Facing Death and Dying in the „Here and
        Now‟: A Case Example


  She recorded a tape for each of her
  children sharing her love for them should
  she not survive the surgery and she
  assured them that she was not afraid to
  die and that at the time of her surgery her
  faith was sustaining her.
         Facing Death and Dying
in the „Here and Now‟: A Case Example

  Theaftermath of the surgery has left
  Elena at times in excruciating pain
  with severe muscle spasms, sharp
  piercing headaches and with
  agonizing nerve tremors which
  shake through her whole body.
     The Husband in the Picture


 Ricardo, a very caring husband,
 unwittingly, has attempted at times
 to minimize her actual anguish and
 distress by endeavouring to
 persuade her to ‘cheer up’ and ‘look
 and the brighter side of things’.
            Elena‟s Needs
 Elena(wife) is troubled and feels that the
 seriousness of her condition is being
 undermined and somewhat diminished

 Sheis pleading for him to be with her
 should these be her last moments of life
 and to not deny the immanent possibility
 of her impending demise
Elena‟s Needs

   Client is Feeling Helpless And Needs
    Someone to Feel the Depth of Her Pain

   Client Is Willing To Submit to “God‟s
    Will”

   Client Is Confidant That Both of Them
    Can Weather the Storm Through Prayer
    and Faith in God
 Issues With Caring Husband

 Husbandin Denial about the
 impending death

 Husbandin the “Doing” Phase as
 Opposed to the “Being” Phase
 Issues With Caring Husband


 Husband Is Attempting to Inspire
 His Wife, Giving Her Hope in the
 Midst of Discouragement
 Issues With Caring Husband
 Husband Further Aggravates His
 Wife‟s Condition By Ineffectively
 Trying To Boost Her Morale.

 Husband  Tormented With the Fear
 of Losing His Wife.

 Husband   Not Prepared To “Let Her
 Go.”
AAE Revisited

By sensitively caring to the
needs of the client and
attentively listening to the
insights provided, the worker
AAE Revisited
 the
    thoughts, feelings, behaviours
 and experiences through
 “Accurate Artistic Empathy” by
 means of the following
 composition:

      Give Up, I Hear You
 Don‟t
 Crying
             REFRAIN
 “Don‟t give up”, I hear you crying. “Don‟t
 give up”, I hear you say. Well intentioned
 are such promptings, when you can‟t feel all
 this pain. Can you listen to my story. As I
 wipe tears from my eyes? Like a brave yet
 wounded soldier, my soul is stretched on
 bended knee. My soul is stretched, blessed
 lord so stretched, on bended knee.
     “Don‟t Give Up,” I Hear You Crying

I have so much to live for though I‟m
 not afraid to die. But if god in whisper
 calls me, can you be here by my side?
 In a journey rough and ragged with
 questions, doubts and fears, we can
 make it faith is calling, as we join our
 hands in prayer, as we join our hands
 in prayer. (R)
 “Don‟t Give Up,” I Hear You Crying

 Oh  God what dreadful challenge, often
 times a crippling cross to simply grasp
 this suffering mystery, its valleys low
 and mountains high. You are bread of
 life that nurtures, the cup of peace and
 grace. Fill my soul and bring me
 comfort. Let your will on earth be done.
 Let your will on earth be done. (R)
               (MIIS) [Short Form]

MIIS assesses the degree of“artistic accurate
empathy” and of “artistic advanced accurate
empathy”

Part I a written response by the client of impact of the
music

Part II is composed of 15 questions that evokes client
response at the cognitive, affective, behavioural and
experiential level, measured on a 6 point Likert type Scale
           The MIIS [Short Form]

PART I                              Date:10/12/01
Client: Elena\Ricardo
   Please indicate your immediate responses to
   the song:

     1. ________________________________________
     2. ________________________________________
     3. ________________________________________
     4. ________________________________________
Wife‟s Written Response


   This song is truly beautiful. I know with the
   hassles involved in the slow recovery from my
   surgery that I am not always “a happy
   camper”. Ricardo, as good as he is, and as hard
   as he tries to be here for me, is often the butt of
   my anger and frustration. I can see from here
   the tears in his eyes and this is honestly the first
   time that I have seen him cry since my
   surgery.
The words to this song and its music
has really made us both aware of how
much we do mean to each other and
what hope there is for us if we work at
this process with your continued
support and encouragement. I know
it is not going to be easy but I am
prepared to make the effort to make it
happen and to get us through this
ordeal.
     Husband‟s Written Response

Yes indeed, the whole composition has
brought tears to my eyes. We have been
married for 35 years and we have been
through thick and thin. Elena means more to
me than anything in the world and I know
that even though I may have my
shortcomings I am always willing and to be
there for her.
     Husband‟s Written Response
She is my love and my life. This song moves
me to renew my commitment of love, for
better or worse, for richer or poorer, in
sickness or in health, until death. I too am
prepared to work on those things which will
strengthen our relationship one step at a time,
one day at a time.
Part II
The following statements describe a
variety of possible reactions by people.
Some of the statements may represent
your own experience in listening to the
selected musical pieces, while others
may not. For each of the items there
are six possible choices.
Part II
Please mark with the number 1, 2, or
3, 4, 5, or 6 in the appropriate ( )
space below the choice which most
accurately describes your experience
in listening to the following musical
selection: Name of Song (“Don‟t
Give Up,” I Hear You Crying)
Part II
There are no "right" or "wrong" answers;
your personal response is what is
important. In order to ensure the
anonymity of all responses, please do not
put your name anywhere on the form.
After you have completed all the items,
please submit to the research associate.
Thank you.
MIIS (Part II ) Husband & Wife Scores
SONG TITLE:    “Don‟t Give Up,” I Hear
                           You Crying

    1. Not At All     (Detracts Significantly)
    2. A Little       (Subtracts Noticeably)
    3. Somewhat       (Interchangeable)
    4. Moderately     (Adds Noticeably)
    5. Considerably   (Adds Significantly)
    6. Very Much      (Captures Full Expression)

    Their response to this song was…
   MIIS (Part II) Husband & Wife Scores (Continued)

1. (T-F-E) It made me consider certain       (W) (H)
           thoughts, feelings and experiences
           in my own life                     (6 ) ( 6)

2. (B)     It made me examine my personal
           behaviour                           (6 ) (6 )

3. (B)     It made me want to change my
           present behaviour                   ( 5) (3 )

4. (F-B)   It made me become more relaxed (6 ) (6 )
5. (T-E)   It caused me to think about some
           things which are troubling in my life (4 ) (6 )
   MIIS (Part II) Husband & Wife Scores (Continued)

6. (T-B)     It reminded me about something I need (W) (H)
            to work on                              (6) (6 )

7. (T-B)    It made me aware of ways I can change
            my present day life situation           (4 ) (6 )

8. (T-B)    It made me aware of ways I can change
            my life in the future                   (5 ) (6 )

9. (B-E)    It invited me to reflect upon
            instances/experiences which are
            important to me                         ( 6) (6 )

10. (T-B)   It reminded me of negative things
            (behaviour/s) I have done to myself and
            to others.                               (6 ) (6 )
   MIIS (Part II) Husband & Wife Scores (Continued)


11. (F)    It alerted me to my satisfaction with (W) (H)
           my life today                            ( 6) (4 )

12. (F-B) It gave me hope in my ability to change
            things in my life                        (6 ) (6 )

13. (T-B-E) It reminded me with remnants of my
            own story and my own experiences         ( 6) (6 )

14. (T-B-E) It reminded me of stuck points in my
            life today                               (5 ) (6 )

15. (F-B) It provided me with hope for changing
            my present circumstances                 (6 ) (6 )
                 MIIS (Part II)

Elena and Ricardo scored 82 and 85 respectively
out of 90 with a corresponding mean score of 5..5
and 5.7 out of 6.


Their scores indicate a very high rating (Level 5 &
6 of MIIS )where the worker has been able to add
significantly to their communication and captured
the fullness of their cognitive, affective,
behavioural and experiential domain.
Dealing With Close Family Bonds
      By The Use of AAA
  During my continued visits with Elena
  and Ricardo, I was discovering that the
  greater the love has been between a
  couple, the more heartbreaking it is
  to part and the more difficult it is to
  sever the ties which have bound two
  human souls together.
Having loved God through a bond
and fidelity to another person, it is
extremely discomforting to “let go”
and to give the other “permission” to
go to their rest.
This is especially true when the dying
person wants permission to part and
pleads: “Please do not interfere with
my dying.”
There‟s an unquestionable silence
which needs to be listened to in the
hidden centre of their hearts and a
hushed stillness that needs to be heard
which speaks of memories and
recollections, goals and
achievements as well as prospects
and expectations perhaps still
unrealized which require an avenue of
expression.
 To paraphrase Teresa Whalen Lux
 (Novalis, 2001) death can be compared
 to cleaning out one‟s garage. We
 often clutter the garage so badly with
 left over items that it becomes
 impossible to put the car in it, the
 actual objects which belongs in the
 garage. Death is an opportunity to get
 rid of the clutter in our lives so that we
 can make room once again for what is
 really most important: God.
        Elena (Wife) Asks Herself

As I approach the likelihood of my own
death, how can any meaning be achieved
that will enhance my final days of living?
Can I afford to ignore what can still go into
the quality of life before I say? “Good-
bye.”
    The Use of AAE in Song

The following song “For This I
Pray” was written to capture some
basic dimensions of Elena‟s present
situation.
Though sorrow fills my heart fills
my heart with woe, when the flame
of life growws dim, why waste my
breath on the grim and murky side
of things? I may not grasp the
fullness of this suffering or this pain
while through God I seek true
comfort, how much longer must I
wait? I pray!
    I‟ll use my strengthened courage to
    live my life god‟s way and gather
    blossoms from the vine to grace my
    side each day. I need not die in sorrow
    like those who have no hope but turn to
    god for solace where there is so much
    to gain. So much more. (R.)
Refrain:
For this I pray each morning
when the noon sun shines with
grace and when the shades of life
draw closed, oh God, do not
forsake me as I weave through
stormy seas. I trust your hand to
guide me safely home.
    You did not spare your only son
    through the gnawing pains of
    death, nor in the spring time to a
    mom, the throbbing strains of
    birth. When roses bloom in
    summer, they are not without the
    thorns for in each soul a cross is
    placed in a life oft‟n crowned
    with jewels, I pray.
I can‟t run toward the mountain,
 I can‟t rush toward the sea, my
 soul, an empty desert, seeks
 peace and harmony. When my
 heart is deeply troubled, in
 soreness, grief and woe, dear god
 do not abandon me but soothe
 me from my foes. Soothe me
 lord! (R.)
Client‟s immediate response to the song:

I   want this song played at my funeral

 It gives me strength to go on and be
  strong

 Your song shows me how much you
  understand the real me
I   wish other people could ponder on the
    words to this song and feel the hardship I
    am experiencing

    Your constant help and support has
    lessened my pain in ways that the medical
    profession has not been able to.

I    also hope that this song will help others
    like myself who have no one to feel their
    pain.
Elena scored 84 out of possible total
score of 90. Her mean score was 5.6 out
of 6.

She gave a score of 6 to Questions 1, 3, 4,
4, 5, 6, 7, 8, 10,12 and 15.

She assigned Questions 2, 9, 13 & 14 a
score of 5 while she gave Question 11 a
score of 4.
                      MIIS (Part III)

      Part III includes the first 15 Questions From Part
      II of the MIIS and the The Remaining 3 Questions
      Below

16.     If you were to examine your life five years down
        the road, what do you think it would look like?

17.     What things would you be doing differently?

18.     Are there any general comments you would like
        to make?
 Elena provides the following key points to the
 song related to Questions 1 –18:

 The song inspires me on my “journey of
 hope,” invites me to try harder and
 reinforces my commitment to walk with God.
    I always felt a need to be “perfect”,
    being there for everyone else and
    ignoring my own needs.

   My illness now calls me “to be” instead
    of rushing in the “doing.”
    I often hide my pain from my husband
    as he is more preoccupied with the
    “doing” and can‟t seem to be still enough
    to just “be.”

   I hope I have enough time to prepare my
    husband for my death.
I feel if we worked on this goal together,
 that he will be better able to cope when I
 am gone.
    Since I am so helpless to do anything, I
    feel that just being present to each other
    would do so much to strengthen and
    enhance our relationship
    This is the only way in which we can be
    there for each other otherwise, it will
    take him longer to work though the
    grieving process.

   Doctor‟s have told me: “There is nothing
    more we can do for you.”
      I am not hiding my head in the sand
    about my the closeness of my demise.

      I am not afraid to die but fear more
    the fact that I may have to experience
    more unbearable pain and suffering.
      I pray for a peaceful death and your
    song is balm for my body and calm for
    my soul.

      As your song says: “I‟ve mirrored
    love to others, a prism of God‟s grace”
    and now I am prepared to say: “Good-
    Bye.”
    The Client‟s Perception of the Worker:

   You lift me up out of the doldrums
   You help share my inner most thoughts, fears
    and aspirations

   You allow me the space to be myself and you
    believe in me more than most people do

   Through the Guided Imagery and Focusing, I
    have been able to look at negative issues in a
    more positive light.
Contract For Future Work:

 When  prone to depression, I need to
 learn how to develop a more optimistic
 attitude.

I need help in maintaining my integrity
 through all this ordeal.
Contract For Future Work:

      I want to work on keeping good
    relations with my relatives and friends
    and to stay open to the possibility of
    reconciliation with those who have
    abandoned me.
          Case Study Findings:
 This article has shown the effective use of
    AAE at Level 3 and 4 of MIIS

    The client responded positively to the two
    carefully selected songs and the music had an
    noticeable impact on the client‟s life situation
    at particular stage at which she found herself.
         Case Study Findings:
    The client was not afraid to reveal her
    most secret thoughts, fears or
    reservations which helped her to make
    sense of her predicament as she worked
    through each stage with the therapist.
        Case Study Findings:

 The MIIS provided a concrete tool of
 accountability by which the client could
 gauge her progress though the various
 sessions.
         Case Study Findings:
 This article has shown that the AAAE
 component of Levels 5 and 6 of the
 MIIS are powerful reinforcements for
 facilitating the dimensions of client self
 disclosure, self-exploration and
 concreteness thus eliciting relevant
 information from the client and act as
 powerful tools of intervention for
 therapists working with clients with a
 life-threatening illness.
  Concluding Remarks:
Implications For Therapists
This paper has shown the
effectiveness of AAE, AAAE and
MIIS in bringing clients to deeper
levels of awareness

Demonstrated the relevance of client
identified themes, therapeutic entry
points
  Concluding Remarks:
Implications For Therapists

This paper has shown the
relevance of client self-
assessment and goal setting to
deal forthrightly with central
key issues
  Concluding Remarks:
Implications For Therapists

It Underscores the importance
of using songs with therapeutic
themes to develop client
awareness
  Concluding Remarks:
Implications For Therapists

This work purposefully engages
the client in facing issues
related to death and dying
  Concluding Remarks:
Implications For Therapists


Shows the significance of using the
MIIS as a built in tool of
accountability and as a
collaborative undertaking with the
client
  Concluding Remarks:
Implications For Therapists

MIIS provides the client with a basic
degree of latitude in terms of:
        Self-discovery
        Problem identification
        Goal setting       and
        Task accomplishment