Ep. 027 | Music Therapy in the NICU

Today, we chat with guest, Evelyn Stagnaro, a board-certified music therapist,  as she shares about what music therapy looks like with infants in the NICU.

RESOURCES

Music Therapy for Premature Infants: Research and Developmental Interventions by Dr. Jayne Standley | Book

Using Your Voice with Newborns in the Hospital by Dr. Helen Shoemark | YouTube

Advanced Training in NICU-MT by Dr. Jayne Standley | Website

Time Together Program by Dr. Helen Shoemark | Website

TRANSCRIPT

Erica: Welcome, friends! You’re listening to The Feeling is Musical — as presented by the Snohomish County Music Project. My name is Erica Lee, and today, we are talking about music therapy in the NICU, with board-certified music therapist, Evelyn Stagnaro.

Evelyn is a Seattle-based music therapist with advanced training in NICU music therapy and neurologic music therapy. She is the founder of Life on Music, a private music therapy practice engaging kids with disabilities in the Seattle area. She also works at Seattle Children’s Hospital, where she specializes in music interventions for infants. Evelyn is passionate about increasing access to music therapy for Washington residents, and advocates for insurance reimbursements and state recognition through her role as co-chair of the Washington Music Therapy State Taskforce.

[Podcast intro music plays]

Erica: Welcome to the podcast, Evelyn. Thanks for being here.

Evelyn: Thanks for having me!

Erica: So, to get us started and just kinda give background as to who you are, can you tell us how did you originally decide to become a music therapist. And how do you describe your therapeutic philosophy?

Evelyn: So, I started in music. So, my first degree is actually in percussion performance - and I was just very much in the classical music/classical percussion world. There was one time I had um memorized this 20 minute marimba concerto - I like worked to get all the details like super perfect - and afterwards, the only feedback I heard was, how did you play with 4 sticks at a time? And so that just kinda got me thinking, you know, I - I kinda find myself, you know, laughing at myself a little bit. Like, oh, go figure like, classical, concert style percussion doesn’t like ree - reach the audience. You know, music in the brain and how all these things play together. And I found sort of music therapy through that curiosity, I suppose. And it’s just been the absolute perfect fit ever since.

So, going into your next question - my therapeutic philosophy. I went to Florida State, and they teach a cognitive behavioral approach to music therapy, and so I’m pretty heavily biased in that way - and, like add neurologic music therapy to that as well. I’ve just found it really works - especially in my work with kids. I think music is inherently reinforcing, and it’s really fun and really natural to use music to positively reinforce the behaviors I’m looking for. All that being said, I do think it’s important to have a baseline knowledge of, you know, some other big approaches as well, like the analytical approach/the Nordoff-Robbins approach. I’m not an expert in these in any means, but they’ve absolutely come in handy with my work at the hospital, I think especially.

It’s not uncommon for a session to go kind of behavioral - like neurologic - like rehab type interventions, to more expressive and more improvisational even - sometimes - sometimes even in the same minute, you know what I’m saying?

A NICU example would be like if I’m working with an infant and they’re working on increasing their tolerance to stimulation. So, I’m singing - I’m playing guitar to accompany myself, and helping this infant sort of regulate their state. And suddenly, a parent whose sort of in the background might become sort of appropriately emotional - just processing the labor/processing the delivery/processing what brought them hear to the hospital, and the things they’ve experienced since then. So, just in a matter of moments, you know, the focus of my intervention can shift. And I think, describing how music therapy can facilitate each of those outcomes, you know, and sometimes they’re happening in the same minute of each other becomes really difficult - but I do think defining it has to be a priority for music therapists, because that’s one thing that’s unique about music therapy compared to a lot of other jobs.

Erica: Great. So, you’re my expert in NICU music therapy. So can you tell me more about when a family is in the NICU, what can they expect in music therapy? What does a session look like?

Evelyn: Yes. So, of course it’s going to look a little bit different for each family. If a family finds themselves in the NICU and they are curious about music therapy, they can always ask their nurse or their medical team to put in a referral for music therapy. So our team - our music therapy team at the hospital doesn’t automatically meet every patient - we need a referral from somebody to get kind of our foot in the door. So that will cue us in that you’re there - that you’re open to a conversation about music therapy - and we’ll kind of go from there. So once I see that referral, I’ll call the nurse and schedule a time to pop by the room, and really just start a conversation with the family about their relationship with music, about why they’re here at the hospital, and about some of the ways music can help their baby.

So, most of the time, it starts - so, of course, when - a lot of the kids who come into the NICU are born prematurely or have something medically complex about them, which is why they’re in the hospital - and one of the problems with premature babies is um that they’re very easily overstimulated by their environment. And of course, if you are very easily overstimulated, the hospital is probably, you know, the least pleasant place you could be - bright lights, there’s people walking in and out of your room at all hours of the night - you knw, sometimes there’s needle pokes and things like this. And so, what - one of the things that music therapy can do is help increase that baby’s tolerance to stimulation in a more positive way, ‘cause music is actually - you know, babies don’t have a lot of skills - you know, music is something that they can engage in, and it’s age appropriate.

So, typically I start with very slow, very quiet guitar finger picking. Uh, I always have to warn parents, you know, this is not for you - you know, this song is gonna be unrecognizable - it’s gonna be so slow [chuckles] and so quiet. So just very slow and very quiet. And this is, of course, because babies are sensitive, and their reactions can be really delayed - their reaction to stimulus - so even, you know, as much as 11 seconds delayed to a stimulus. So we’re going super slow just to make sure they tolerate the sound of the guitar. If the baby looks like they’re tolerating the guitar, I’ll add humming on top of that. If the baby looks like they’re tolerating the guitar with the humming, I’ll add singing. The final layer - if the baby is tolerating all those things is some tactile stimulation - so some gentle touching or rocking to accompany that. And this process - so it usually - when I meet a newborn, I hardly ever spend more than 15-20 minutes actually delivering the music intervention, which is about all a newborn - especially a premature newborn can tolerate.

So, that’s sort of the first intervention that I’ll assess for is, you know, how is this baby tolerating the environment around them, and can we use music to systematically increase their tolerance to the world around them. If they’re a little bit older - if they’re a little bit more stable, we can do some music to promote these emerging developmental milestones. And so I might use songs that might prompt a little bit more eye contact from the infant. I might present them with a little maraca or a shaker, and have them - and prompt them to kind of visually track it - left to right and up and down - just get a little bit more engaging. Depending on the age, I will facilitate an intervention to help the reach and grasp a maraca - and hold the maraca and bring it to their mouth. And the fun thing, of course, about music therapy is it all feels like play. So, you know, they’re all working on reaching and grasping and bringing their hands to midline, but it’s all, you know, under the guise of playtime.

We can fold parents and caregivers in as much as they want to be involved. We always encourage parents and caregivers to be involved in music therapy, um and facilitating that caregiver-child bond is something music therapy can do too. So, pairing it with kangaroo care or skin to skin, or a time when parents or caregivers can hold their kid is always super special. And then, of course, coaching parents to use music outside of music therapy time, ‘cause the benefits go, you know, beyond the time that I’m in the room.

Erica: Yeah. When you’re working with a new family - or a new family’s asked for a referral - what sort of questions are common from them? What - what are they generally looking for? Or what kind of information do you usually get when you come into a room?

Evelyn: The responses can be varied. Sometimes parents come into the NICU asking for music therapy - and they usually have kind of a sense of what they’re looking for. Like, I just met a family last week who’d heard of music therapy, and they were concerned for their child’s early development, so they said right off the bat, we would like music to make sure our child is - you know, has the best opportunity A lot of times, parents are kind of surprised when I walk in the door. One of the comments I get - or - a lot - or, I use to get more often than I do now is, you know it’s a baby, right [chuckles]? Like, yes, I am aware, thank you very much. Then just kinda providing more education - um, like this is what it’s gonna look like - this is what I want to do based on the information I got from your medical team - does that sound good to you - is, you know, sort of my approach.

Erica: What are some - I - the thing about the baby makes me think of this question is —

Evelyn: Mmhmm —

Erica: What misconceptions do you hear about music therapy - in the NICU particularly, but also just generally in a medical setting?

Evelyn: Absolutely. Yeah, so the - the it’s a baby yeah is um [chuckles] is probably one of the most fun ones.

[Erica chuckles]

Evelyn: Yeah, and that has come from parents and caregivers, but - and it comes from the medical staff too - and so, you know, I’m just the type of person to see it as an opportunity to provide some education and to say like, yes! And most of the time it makes sense to people - kinda like I pointed out earlier, you know, babies can’t do a whole lot just yet, but listening to music is one of the things that they can do. And so providing some context about the types of things I might assess for when I’m in the room and the types of outcomes I’m looking for. Another one that is really common, especially from the medical staff - and that, you know, shout out to them because they’re top nautch, these nurses and doctors are fierce advocates for these babies that they care for. And a concern that comes up quite a bit is music therapy’s going to overstimulate this baby, you know, and then they’re just gonna be kind of like a mess the rest of the day. And it’s actually a good question - and it’s actually not wrong. You know, like, music can be overstimulating to babies. Um, and so, again, just, you know, providing some education, like, I actually have special training to do music in the NICU, and that includes recognizing signs of overstimulation - and I take that very very seriously, and that’s absolutely not the outcome I’m looking for. And if I notice that a baby’s overstimulated, I’m going to stop right away and take a step back and see where we need to go from there.

The last one is probably the trickiest of all. I hear people say um, like well, our nurses can provide music at the bedside. You know, they can push play on a YouTube channel or a CD player. What’s the difference? What kinda gives? And, you know, I absolutely see that side, and there’s certainly benefits to listening to music at the bedside, and I - I definitely see the sustainability argument - you now, it’s definitely a little bit easier to push play on an iPad than to, you know, get a music therapist on staff. But, of course, having a person in the room - getting that live interaction - getting that opportunity to have some social interaction and promote those emerging social skills - and being able to respond to the baby’s cues in the moment, for sure. You know, you can push play on an iPad, but talk about music being overstimulating - you know, if that baby does happen to become overstimulated and you’re not in the room to turn it off or make an adjustment, you know, could cause some harm. And so, having a music therapist at the bedside can respond to those cues in the moment. And these could be positive and negative. A baby’s overstimulated, you could pull back. But if a baby is actually really engaged and really awake and alert, you can actually lean in a little bit and, you know, challenge that baby a little bit more.

Erica: You’ve mentioned folding in the caregivers, or the family - whoever’s present for the baby. How much of your work would you say is working with the infant themselves - maybe not versus, but like, and the family members? ‘Cause, if they’re present during. The session, which I’m assuming they’re some - most of the time, how much are you working with them? So you’re kind of doing like a family session quote unquote —

Evelyn: Mmhmm —

Erica: And so then you still have to utilize all of your skill and knowledge about how to work with adults - work with teens - work with different parts of the life span.

Evelyn: Absolutely. Yeah, you’re spot on there. I would say it’s probably about 50/50 - now I’m kind of curious exactly where the numbers lie. But there are a  lot of infants where their families or caregivers can’t be at the bedside, and those kids at our hospital are always more - the highest priority, because they’re getting less social interaction, less calm awake playtime than the babies that do have family and caregivers present. Of course, it’s so much more beneficial to do music therapy wen you can wrap in that family, and it is, like you pointed out, just an opportunity to work on explaining what I’m doing in a way where, hopefully, that family feels comfortable replicating some of those things when I’m not in the room.

And so, one of the things I like to explain to parents is that infants - I mean, and very very premature infants also - will recognize their parents’ voices before they recognize anyone else’s. And they actually give their attention to their parents’ voice before anyone else. And so, one of the best things a parent could do for their kid is just talk to them or sing to them and use their voice. And so, if a family is comfortable, I will actually not be the one singing - I can sometimes do a little bit of guitar accompaniment, and I will invite a parent or caregiver to do the singing portion. It’s really interesting, because singing - there’s some emerging research showing that singing helps promote language development even down the road, and so I always communicate this to parents and say, this is something you’re working on just by talking to your kid - and your voice is a special voice that’s even special-er than mine. So keep going - just keep talking - your kid’s not paying attention if you’re singing on tune, you know, they just love your voice. So just go for it.

Erica: Absolutely. I love that so much. So, in thinking about the work you’re doing in a - in a systemic way, how do you practice trauma-informed care? Because just being in a hospital - having a child in the NICU for the child themselves being in the hospital, that can be, and often times is, a traumatic experience.

Evelyn: You’re exactly right. I think - I mean, regardless of a person’s background and their experience up to this point, the fact is, if I meet them in the hospital, I can already assume, you know, some level of trauma I think. So I definitely start by recognizing that everyone has a relationship with music. And using music for therapy can actually be a bit of a shift in thinking for these families. So, music can be grounding, and music can fortify families against these sort of waves of trauma that can occur in the hospital.

One of the domains that our music therapy team operates under is resilience, and so, recognizing the fact that music can actually promote resilience for these families during this time terrible time - and it’s a tool for them to connect to each other. It’s something to take this terrible moment and say, actually, you guys like, as a family can lean into this and have something that feels normal - that feels comfortable within the framework of this insane hospitalization.

But - absolutely have to make some unique accommodations to consider a family’s background with music - their medical status - their prognosis - what they are hoping to achieve with music. And, the most important thing, I think, is to meet each family where they’re at. And so it’s going to look different for every family, and I just work not to have a set of assumptions.

Erica: Do you collaborate with the other creative arts therapists that work at the hospital also?

Evelyn: A lot of times, yeah. So, we work really closely with the art therapy team - and that is a super fun opportunity to collaborate at times. But we also - we work really closely with the social work team, the child life team, and sometimes the rehab team. And, a lot of time, these teams meet families before music therapy will —

Erica: Mmhmm —

Evelyn: And so it is nice to stay in really close touch with them, and get a handoff from them, so we’re not, you know, walking into a situation and accidentally use something that might be - that might be triggering to a family, so —

Erica: Absolutely - absolutely —

Evelyn: Lots of collaboration.

Erica: Yeah. In your practice, how do you practice social justice/anti-racist specifically music therapy?

Evelyn: I love this question, and I love that we’re starting to ask each other these questions, because I think they’re so important. I feel thankful, because at my program at Florida State, this conversation was started for me actually. And I feel really thankful for that. We had some class discussions about bias in therapy, and especially in classrooms - there’s a lot of great research on bias in the classroom. So just being really really aware that um, as much as it sucks, you know, I’m not above bias - you know, like, these are things that I want to very deliberately filter for when I’m in a group setting - when I’m in a one on one setting. I am thankful ‘cause one of the hospital’s core values is equity, and we are constantly challenged to make sure we’re providing equitable services for everybody who walks in the hospital. And I do this by monitoring, you know, the number of sessions i deliver to a family, how long I’m spending with that family - and just making sure I’m providing an equitable amount of care for everybody.

I very much - and this is just like something about me - I very much have a growth mindset. And one thing that I do with myself is if I ever feel sort of an icky feeling, instead of being like, oh it’s probably nothing - I just always know that’s a cue to lean in to it and ask myself, you know, I definitely need to see what’s here - even if I just feel a little bit icky, I should look closer. And this is true for the NICU as well. So just making sure we’re providing the same level of care. And it’s ongoing, right - I think that’s one of the fun things we’re learning about this is it’s not like a, oh, I checked the box on this in grad school. You know, it’s week after week, month after month, am I providing equitable care.

Erica: Absolutely. I love that you mentioned a growth mindset - it’s really important in our professional lives, in our personal lives - yeah.

Evelyn: Yeah, and I think our work as music therapists, you a little bit have to be this way. I mean, the work - new research is coming out all the time —

Erica: Mmhmm —

Evelyn: And, you know, fam - every family is so different. And I think it’s - it’s a challenging profession to be very rigid in your mindset I think [chuckle].

Erica: Absolutely - you have to be evolving. And yeah, as new research comes out, that’s one of the key components of what music therapists do, is using music in this intentional manner, and it has to align with the research.

Evelyn: Absolutely.

Erica: If you’re not up with the - the current researches —

Evelyn: Mmhmm —

Erica: Uh, I have some questions [chuckles] about your practice.

Evelyn: [Chuckles] Yeah. I think it’s really important that we’re starting to look a little bit closer on bias, and how it plays out in therapy - and specifically music therapy. And I think it is going to be important for music therapists to, yeah, reflect that on themselves and say, you know, that’s not - you know, that’s not the type of practice I want to have. And how do I deliberately filter —

Erica: Mmm —

Evelyn: For it.

Erica: Absolutely. So, in hospital settings, there can be really hard things that happen - and those look different, depending upon a bunch of different factors.

Evelyn: Mmhmm.

Erica: What motivates you or inspires you to keep going when hard things are happening?

Evelyn: Exactly. Yeah, working in a hospital there are a lot of high highs and there are a lot of low lows. You know, the - the emotional spectrum is a little bit broad I think compared to a lot of - a lot of jobs. And I think there are a lot of things that sort of ground me in that experience. And I think one of them is sort of just excepting the fact that this situation is happening to this family, and it’s, of course, you know, tragic - I mean, there’s no words to describe, you know, like an end of life situation for example - and it’s absolutely terrible, you know, for this family and, you know, the people going through it. But it’s happening whether I am there or not. And the fact that I’m there, and the fact that I was invited to be a part of that process, you know, whether it’s providing music during a compassionate extubation, whether it’s working with that family on accumulating some musical legacies - like a heartbeat recording, or a CD, or writing some original music - that it feels like an honor to be invited into that space, and to be taking a tragic situation and to be providing, you know -even if it’s just like a tiny tiny tiny, you know, little positive light, you know, during a really terrible experience. And that feels really good to me - and really sustaining, I’d say.

I also feel thankful - I mean, I have a team that I’m really close with, and they - you know, all of us just kinda get it. And so I can always turn to them for support when I need it. And I - part of it, I think is I’m just a little bit cut out for it. You know, I just recognize that my job is emotionally really draining, and it takes a lot of energy at times - and sometimes that means I cry at work [chuckles] and that’s not, you know, normal for a lot of other people, but for me it is. And I’m just okay with htat - I really am. Because I - it’s really a pleasure to be able to work with families at their absolute worst.

Erica: I - I so admire - well, first of all, there’s a lot of things I really admire about therapists —

[Evelyn chuckles]

Erica: But, I appreciate the fact that the level of vulnerability and self awareness that you have within yourself to say that like, it’s okay to cry at work for example —

Evelyn: Mmhmm —

Erica: Like, that’s a - a huge thing for a lot of people. I know some people in my life that work in quote unquote helping professions and still don’t allow themselves that opportunity —

Evelyn: Mmhmm —

Erica: To like have deep, real, uncomfortable emotion at work - as if, when you cry, it’s unprofessional?

Evelyn: Yeah, it’s definitely a little bit of a shift. You know, and I thank —

Erica: Yeah —

Evelyn: I’m thankful - you know, in - in the hospital and, you know the team I’m working with, you know, there is a safe space to feel authentically in that moment. I think there are ways to do it, you know, even with my job at the hospital that could be considered unprofessional - but, you know —

Erica: Sure —

Evelyn: The fact that I have, you know, once I step out of the session - like away from my role as a therapist for the family that I’m working with, there is absolutely space to say, you know —

Erica: Yeah —

Evelyn: This is just hard, you know —

Erica: Yeah —

Evelyn: And to be authentic with that feeling. Yeah, and, I think it is a bit unusual. But, you know, I am thankful for it. And yeah, I think it should be the new normal [chuckles].

Erica: It really should. Yeah.

Evelyn: Yeah. Like, sometimes hard thigns happen, and I think you should be allowed to feel them, you know - with the right supports.

Erica: Yeah. It’s your body’s natural reaction —

Evelyn: Absolutely,. Yeah —

Erica: Or response to a - a hard thing. We say that we bring all of who we are into therapy, and people bring all of who they are into their workplace –—

Evelyn: Absolutely —

Erica: And we work really hard to create safe space.

Evelyn: Exactly.

Erica: You can be your full authentic self, and if that means you’re having a hard day and you need to cry about it —

Evelyn: Mmhmm —

Erica: Find an appropriate moment —

Evelyn: Mmhmm —

Erica: And then have those emotions.

Evelyn: Exactly. Yeah - it’s so beautiful in a certain way, you know?

Erica: Mmhmm.

Evelyn: And everyone is different, and I just am thankful to have a team that supports, you know, the way that I process, and that there’s , you know, room to do that. It’s probably worth pointing out at the same time - you know, I have my own therapist that I work with, and I have a lot of, you know, tools - also row in my spare time and that’s sort of a release for me as well. So, yeah, it takes - I mean, there’s lots of supports here that - that kinda make it all sustainable.

Erica: Absolutely - absolutely. So, for listeners that are curious to learn more about the use of music in hospital settings, or in NICU settings specifically, what resources uh would you recommend so that they can investigate further?

Evelyn: Absolutely. Dr. Stanley has a book, Music Therapy for Premature Infants - and if you’re curious about ways that music therapists work in the NICU, I would definitely recommend grabbing a copy of it. Dr. Shoemark just made a lovely video about using your voice with newborns in the hospital - and so if you work in a hospital, or if you find yourself with an infant in a hospital setting, um there’s some really lovely tips about ways to use music and your voice with you. And if you just Google either of them - so Dr. Stanley and Dr. Shoemark are like, you know, are the experts in NICU music therapy - so just Google them - you’ll find a million articles and things to read. If you’re a music therapist or another service provider in the NICU, there’s a couple really cool trainings that I’d recommend. So Dr. Stanley has advanced training in NICU music therapy, so there’s like a course portion to it and a - like a  clinical portion - so some time supervised in an actual NICU. I definitely recommend you check that out. Um, and Dr. Shoemark as well has a program called Time Together more focused on um families, and families using their voice and using music in the hospital and beyond.

Erica: Well, Evelyn has already sent me these links and resources, so I will put them in the episode notes - they’ll also be on our website. And our website address is S as in Sam, C as in Cat, Music project dot org (scmusicproject.org). You can find all things podcast there. We do provide transcripts of the podcast, so if you’re d/Deaf, hard of hearing, or just prefer to have a written copy, you can find that there also. Please follow us on any social media that you use. You’ll get the latest and greatest about what we’re doing - we post every Monday about the podcast if you need a reminder to come back to it. But you can also just subscribe to the podcast, and then you’ll get a notification on your phone or whatever device you are using.

Thank you, Evelyn, again, for being here and chatting. And I appreciate you - and I appreciate the work that you’re doing with the taskforce - and everything that you contribute to the community.

Evelyn: Wow! Thank you, Erica - absolutely. Yeah, it was a pleasure to be here!

Erica: Well, thank you, listeners, for listening. And we’ll talk to you later.

Evelyn: Thanks so much, Erica.

[Podcast outro music plays]