A Hybrid eHealth Mindfulness-Based Music Therapy Intervention for Adults Receiving an Allogeneic Hematopoietic Stem Cell Transplant

Abstract

Allogeneic hematopoietic stem cell transplantation (allo-SCT) serves as a potentially life-saving treatment option for various hematological malignancies. Although survival rates for allo-SCT recipients have improved over the last decades, survivors often experience persistent adverse physical and psychological symptoms, including nausea, fatigue, depression, and anxiety throughout their treatment and recovery. Additionally, the pharmacological interventions used to support the allo-SCT process (e.g., immunosuppressants, anti-infectives) come with limitations and adverse effects that may have a negative impact on allo-SCT recipients’ well-being. Both mindfulness and music therapy have been found to improve symptoms in cancer patients when used separately, although less is known about their combinatorial effects in a hybrid e-Health delivery format in the context of allo-SCT. The current paper introduces a novel integrative intervention, hybrid eHealth Mindfulness-Based Music Therapy (eMBMT), designed to address the physical and psychosocial symptom distress in adults undergoing allo-SCT. We describe the content of the eMBMT program, which is currently being delivered in a pilot research phase to patients with allo-SCT as part of a larger randomized controlled trial. Drawing on evidence-based music therapy and mindfulness practices, the program delivers eight one-hour individual eMBMT sessions, including audio and text materials guided by a board-certified music therapist, all tailored to adults receiving an allo-SCT.

Allogeneic Stem Cell Transplant

An allogeneic hematopoietic stem cell transplant (allo-SCT) is a potentially curative treatment for various hematologic cancers including multiple myeloma, lymphomas, and leukemias (American Cancer Society [ACS], 2024; Bazinet & Popradi, 2019; National Cancer Institute, 2023). During an allo-SCT, intensive conditioning chemotherapy and/or radiotherapy are administered before healthy stem cells from a donor are infused into the bloodstream (Chu et al.; 2020; Karadurmas et al., 2017; Sadanandan et al., 2021). Although relapse and survival rates for allo-SCT have improved over the past decades (Penack et al., 2020), the stem cell transplantation process remains arduous, and transplant complications may persist well beyond active treatment, including many physical and psychosocial side effects (Penack et al., 2020; Rueda-Lara & Lopez-Patton, 2014).

Short-term physical symptom burden during the allo-SCT process can include fatigue, pain, sleep disruption, nausea, diarrhea, mucositis, and increased susceptibility to infections (Bazinet & Popradi, 2019). Allo-SCT patients face an additional risk of graft-vs-host disease (GVHD), a post-transplant syndrome in which the immune cells of the transplant attack the recipient’s host cells (ACS, 2024; Flinn & Gennery, 2023). Psychological distress before and during the allo-SCT process can include anxiety, depression, and adjustment disorders, all of which can be exacerbated by extended hospital stays, loss of independence, and long periods of isolation (Janicsák et al., 2021; McQuellen et al., 2019; Rueda-Lara et al., 2014). Further, abundant pharmacological treatments (e.g., patients often take over 20 pills daily for the first 3–6 months) utilized to support the allo-SCT process (e.g., immunosuppressives, antibiotics, antivirals) can have limitations and unintended side effects. They can include tremors, confusion, hypertension, susceptibility to infections, kidney and liver toxicity that may further compromise patient well-being. Thus, there is a pressing need for integrative therapeutic interventions that can address negative physical and psychological symptoms without additional pharmacological burden, enhancing overall quality of life and potentially improving treatment outcomes.

Previous studies indicate that interventions aimed at reducing psychological distress may contribute to better patient health outcomes (e.g., better sleep, increased energy levels, mood improvements, and fewer cognitive impairments) and long-term health-related quality of life (HRQOL) in SCT survivors (Amonoo et al., 2019; Brice et al., 2017; Chen et al., 2022). Among these interventions, music therapy and mindfulness practices have shown promising results. For example, listening to music in a therapeutic context may promote positive mood, reduce feelings of anxiety, and alleviate fatigue among SCT patients (Dóro et al., 2017; Geyik et al., 2021; Jafari et al., 2017; Ratcliff et al., 2015). Additional studies suggest that music therapy may reduce pain, discomfort, and nausea in this population (Bates et al., 2017; Tuinmann et al., 2017). Similarly, mindfulness, has shown promise in reducing symptom distress in SCT patients (Carlson, 2016; 2023; Cillessen et al., 2019; Zhang et al., 2019).

Mindfulness and Allo-SCT

Mindfulness involves the practice of being fully present in the current moment, without judgment or distraction (Bishop et al., 2004; Brotto, 2013; Kabat-Zinn, 2013). This practice includes objective, non-evaluative awareness of both external events, such as challenging situations, and internal reactions, such as thoughts or feelings. Kabat-Zinn (2013) describes seven attitudes of mindfulness (non-judging, patience, beginner’s mind, trust, non-striving, acceptance, and letting go) and exercises for practicing them in the pursuit of mindful behavior.

While it is beyond the scope of this paper to include a complete and thorough description of mindfulness practices in Western and Eastern medicine, a brief description of the roots of mindfulness and of the origins of Mindfulness-Based Stress Reduction, Jon Kabat-Zinn’s model on which our Mindfulness-Based Music Therapy program is based, may be useful. The term “mindfulness” can be traced back to Buddhist and pre-Buddhist Pali terms for “clear comprehension” (sampajañña) and “lucid awareness” (sati) (Bodhi, 2011; Shapiro et al., 2024). Kabat-Zinn, a physician and student of Eastern mind-body techniques, developed Mindfulness-Based Stress Reduction (MBSR) in 1979 as a technique for helping chronically ill patients cope with pain (Kabat-Zinn, 2013; Williams and Kabat-Zinn, 2011). MBSR is an 8-week, systematic training course that emphasizes one component of mindful behavior (i.e., one “attitude”) each week. While weekly exercises draw from Zen Buddhist and Hindu philosophy, Hatha Yoga and Vipassana meditation, MBSR is an entirely secular practice and is meant to introduce individuals to the mental and physical benefits of objective, present-moment awareness one step at a time (Kabat-Zinn, 2013; Nilsson and Kazemi, 2016). The MBMT program described in this paper is based on the seven attitudes of MBSR, which will be discussed individually.

Mindful behavior can prevent rumination over past events and anxiety about possible future events (Carlson & Speca, 2010; Kabat-Zinn, 2013; Williams et al., 2007). Thus, mindfulness training may improve the ability to respond skillfully and consciously to the mental processes that can contribute to emotional distress or maladaptive coping strategies (Bishop, 2004). Recent research indicates that mindfulness practice may improve attention and working memory, concentration, mood, sleep, and self-regulation in oncology patients (Baer, 2003; Carlson et al., 2013; Chiesa et al., 2010; Jha et al., 2007). Studies including SCT recipients indicate that mindfulness practice, especially present moment awareness and nonjudgment, may have positive effects on both physical and psychological symptoms both during treatment and in recovery (Compernolle, 2019; Corman et al., 2022; Duong et al., 2017; Larson et al., 2019; Stonnington et al., 2016).

While mindfulness practice typically concentrates one’s attention to their breathing, other stimuli, including auditory stimuli, can serve as a source of contemplation (Graham, 2010; Loo et al., 2020; Taraban et al., 2017). Mindful listening trains the ability to recognize mind-wandering and strengthens attentional control by providing a specific aural target for guidance (Sinha et al., 2013).

Mindfulness-based Music Therapy

Mindfulness-based music therapy (MBMT) is defined as the practice of music therapy (i.e., use of music-based interventions by a board-certified music therapist) in the context of mindfulness practice. All the MT-BCs who facilitate interventions in our eMBMT pilot study have had systematic mindfulness training (e.g., MBSR training, mind-body wellness training, mindfulness workshops). While not all MT-BC’s are trained in mindfulness, the training is an important practice of MT-BCs who deliver MBMT to patients. The systematic and sustained training in formal and informal mindfulness practices is foundational for therapeutic outcomes in all mindfulness-based approaches (Crane, 2016).

The previously mentioned benefits of music therapy for oncology patients are further enhanced by incorporating mindfulness practices. For example, repetitive patterns in music may enhance mindfulness practice by creating expectancies that keep the neural default mode network engaged and facilitate a state of absorption (Koelsch et al., 2018; Reybrouck et al., 2018; Vroegh, 2019). Listening to preferred music also activates the mesolimbic reward pathways, increasing the strength of the engagement (Ferreri et al., 2019; Gebauer et al., 2012; Lesiuk, 2010). Active music interventions, such as instrument playing or singing, can enhance mindfulness practice by cultivating objective awareness in the present moment, fostering self-trust, and promoting creative flexibility (Lesiuk, 2015). Engaging in rewarding music experiences releases dopamine which creates a feeling of pleasure, deactivates negative affect, and motivates one to repeat the behavior in the future (Blood & Zatorre, 2001).

Previous Work on Mindfulness-Based Music Therapy in Cancer Care

Drawing on both music therapy and mindful practices, mindfulness-based music therapy (MBMT), shows potential as a beneficial approach for reducing anxiety, depression, and fatigue and increasing attention in individuals undergoing allo-SCT. Founded on mindfulness-attitudes championed by the mindfulness-based stress reduction program (Kabat-Zinn, 2013), MBMT was first developed to enhance attention from cancer-related cognitive impairment and to aid in decreasing symptom distress in women with breast cancer (Lesiuk, 2015, 2016). In a single-arm pilot study, fifteen women receiving adjuvant chemotherapy for breast cancer attended individual MBMT sessions once weekly over four weeks. Music was the central stimulus for the practice of attention in the present moment, along with the practice of four mindfulness attitudes intended to increase distress tolerance (Lesiuk, 2016). Patient homework and journaling were also part of the program. Findings from this study showed that anxiety, depression, and fatigue were significantly decreased, and attention was significantly improved in women receiving adjuvant chemotherapy for breast cancer (Lesiuk, 2015, 2016).

The aim of this paper is to present a hybrid ehealth-supported mindfulness-based music therapy program (eMBMT) for allo-SCT patients. The development of a novel eMBMT was driven by the critical need for effective, non-pharmacological interventions to manage both psychosocial and physical symptoms in adults undergoing an allo-SCT.

We begin with an overview of mindfulness and mindfulness-based music therapy in cancer care. Then, we delve into the specifics of the eMBMT program, currently undergoing evaluation in a pilot randomized controlled trial to determine its feasibility, acceptability, and preliminary effects on health-related quality of life and symptom burden (Fleszar-Pavlovic et al., 2024, 2025).

Hybrid eHealth Delivery Platform

Our intervention aligns with a hybrid eHealth model, which integrates both in-person and remote sessions to provide a seamless transition from hospital to home. We use the term “eHealth” to denote that our program leverages a digital platform accessible on tablets, smartphones, or computers to deliver consistent therapeutic content. This hybrid approach is an emerging model within eHealth, bridging the in-hospital and post-discharge periods and supporting continuity of care. We acknowledge that eHealth encompasses a spectrum of delivery models, including fully remote telehealth services, synchronous virtual sessions, and hybrid interventions like ours, which combine in-person and virtual modalities.

The eMBMT program includes a web-based component, named SmartManage, for two main reasons: (a) to increase patient engagement outside of therapist-facilitated sessions, and (b) to reduce face-to-face interpersonal interactions after discharge from the hospital. Research studies and reviews indicate that a web-based component to in-person education may enhance reductions in symptom distress during cancer treatment by increasing accessibility to content delivery and adherence to program protocol (Benzo et al., 2022; Matis et al., 2020; Penedo et al., 2020). Literature specific to music therapy indicates that virtual music therapy sessions can be as effective as those conducted in person (Cephas et al., 2022; Knott & Block, 2020). Because of increased infection risk, those recovering from an allo-SCT should limit their interpersonal activities as much as possible after discharge from the hospital. Creating a virtual component for the post-discharge sessions of the eMBMT program enables the facilitators to target areas of symptom distress specific to stages of stem cell transplant survivorship, and participants who are unable to travel to an outpatient clinic can complete the program.

Patients in racial and ethnic minority groups, particularly those in lower social-economic status brackets, tend to experience more physical and psychological distress during transplant and have poorer health outcomes post-transplant (Ashok et al., 2024; Sawalha et al, 2021). Behavioral interventions such as mindfulness-based music therapy present as a set of interventions that provide coping tools that are available at no cost or inconvenience, especially when delivered virtually.

Furthermore, completing exercises online following the MBMT sessions may help solidify the eMBMT concepts and facilitate a regimen of MBMT training. An eMBMT manual for MT-BC will be disseminated once the NIH-National Cancer Institute trials are completed. The results of these trials and full manual accessibility will be published elsewhere.

Overview of the eMBMT Program for Patients Undergoing allo-SCT

The eMBMT program was created partially utilizing the attitudes espoused by Kabat-Zinn’s Mindfulness-based Stress Reduction (MBSR) Program (Kabat-Zinn, 2013; Niazi & Niazi, 2011). The full description and benefits of the MBSR program are beyond the scope of this paper. Readers are directed to Kabat-Zinn’s Center for Mindfulness as one possible resource (Center for Mindfulness—UMass Memorial Health (ummhealth.org)) and a helpful MBSR guide that addresses depression and anxiety (Williams et al., 2007).

The eMBMT program for patients with allo-SCT provides eight tailored sessions that span patients’ treatment and recovery journey. An orientation session given before medical treatments provides an overview of the program and aims of the hybrid eMBMT program. Seven sessions follow and each session is aligned to a component of the patients’ medical treatment trajectory. Each emphasizes a mindfulness attitude intended to be practiced as the allo-SCT treatments continue. The first attitude, called non-judging, emphasizes the mental practice of evaluating and/or absence of reacting in a habitual way to stimuli, whether the stimuli are initiated from internal dialogue or sensations, or external events. The second attitude, patience, is a helpful mental quality when a person feels irritated or worried; it is a practice of allowing events to unfold over time. The third attitude, letting go, is accepting things as they are and being open to change. Acceptance, the fourth attitude, is the mental practice of viewing one’s experience without fighting or striving to change one’s current state. The fifth attitude, called trust, emphasizes believing in one self’s thoughts and feelings as empowering one-self, as opposed to over-reliance on others’ thoughts. It also includes having trust in one’s medical team The sixth attitude, called beginner’s mind, is the practice of perceiving newness in one’s environment, even when the environment is very familiar. It is a positive attitude in which one is willing to practice a sense of wonder and leave old, practiced ways of perceiving, especially negative ones. The seventh and last attitude, called non-striving, while like the first attitude, emphasizes the willingness to try out new experiences and suspend one’s critical voice. This attitude can be easily practiced in the eMBMT program when patients are challenged to be open to trying new music experiences. All the attitudes are intended to enhance the practice of being in the moment—the core purpose of mindfulness.

Intervention Delivery, Setting, and Facilitation

The music therapist provides eight 1-hr eMBMT sessions to allo-SCT patient both in person at the oncology inpatient hospital room and remotely via videoconference. The first five sessions are held in person before the patient’s transplant engraftment. After the patient is discharged, the remaining three sessions are conducted online at the patient’s home. At the beginning of the eMBMT program, patients receive an iPad preloaded with the eMBMT program. The music therapist guides patients through the web-based session aims and materials. The eMBMT program begins with an orientation page that displays the mindfulness attitudes for each of the eight sessions. When a patient selects a session, they can access the session’s aims, objectives, and materials. Each session is supported by text, audio, and videos to reinforce the mindfulness attitudes.

Given our location in South Florida, we serve a large Hispanic population. Two music therapists are presently delivering the eMBMT program, and they both are able to communicate in English and Spanish. The role of music and the MT-BC’s are to support learning about and using mindfulness attitudes, which in turn support moment-to-moment experiences outside of the sessions. The sessions are timed to the patient’s treatment trajectory so that, for example, following engraftment, when the patient is feeling fatigued, the attitudes of acceptance and letting go are emphasized and are supported by music-assisted relaxation. Table 1 presents the eight sessions by treatment phase and the associated eMBMT intervention.

Each session begins with an opening exercise, followed by a music experience coupled with a new mindfulness attitude. At the closing of each session, patients are shown the ehealth platform session materials (see Figure 1). Patients are encouraged to review the materials introduced and experienced during the session and to access additional resources provided on the ehealth platform.

Each session’s opening exercise focuses on the sound of a mid-register tone chime. Patents are asked to direct their attention to the sound of the tone chime and, when they no longer hear it, to raise their hand. The tone chime is then sounded out again. Attention is given to the dynamics and duration of the tone chime (e.g., “Now, listen again, and listen to whether the sound is shorter or longer than you just heard”). The tone chime is played again. Discussion about the experience follows focusing on questions such as What did you notice about your thoughts when you were listening? Was your mind focused on the sound of the tone chimes? Did your mind wander? Were you able to bring it back to the sound? The MT-BC explores with the patient how they are experiencing the present moment with the sound. Next, the MT-BC introduces the attitude of the session. Below is a description of how the music experiences reflect and provide experience and practice of the seven attitudes.

Session One: MBMT Orientation

Patients are provided a brief overview of the allo-SCT process and introduced to the eMBMT program, its aims (i.e., coping with allo-SCT using eMBMT), and its potential benefits. An experience with mindfulness to breathe and music follows.

Session Two: Non-Judging

The attitude of non-judging, which is in part becoming aware of habitual thought patterns that might lead to feeling stressed – is experienced by music listening and writing. We selected contrasting music elements and styles to heighten patients’ attention to listening with an awareness of their responses to the music. The choices contrasted in genre, instrumentation, tempo, and rhythmic complexity. For example, a classical orchestral piece, followed by rock selection with electric guitar, voice, and percussion, followed by a sustained classical soprano vocal piece provides differences in said musical elements. This variety of music helps support participants’ awareness of different music elements and their responses to the music (Reybrouck et al., 2018, 2021).

The participants identify their initial responses (good/bad), what they heard in the music (guitar, voice, dynamics), the emotion of the music, and then something they noticed in themselves (memory, image, body response, a judgment about self). The practice of awareness of the stimulus and self is then transferred to everyday situations considered pleasant or unpleasant. Keeping a journal is encouraged and shared at the beginning of the next session.

Session Three: Patience

This attitude is the practice of realizing that some processes cannot be hurried. Several music-listening exercises are given, and the patient stays focused on a particular instrument, melody, or other musical element as it unfolds. Questions are provided that encourage reflection on how the practice of patience was successful or challenging.

Session Four: Letting Go

This session is intended to support the patient at perhaps their lowest energy during treatment. Music-assisted relaxation is provided, and the patient is encouraged to release expectations and let things be as they are. Both this session and the next include scripted meditations with piano accompaniment. The scripts, “Sending Thoughts Away on Clouds” and “Body Scan,” align with the themes of “letting go” and “acceptance,” respectively. The protocol manual advises facilitators to play a simple pattern centered around the tonic and subdominant harmonies, using a smooth and connected technique in a tempo of 66 – 72 beats per minute. Research suggests that blood pressure, heart, and respiration rates, can be influenced by musical tempo (Darki et al., 2022; and Kulinski et al., 2022), thus facilitating a relaxation response. Furthermore, some studies show that consonant music may have a calming effect on neural and physiological systems ( Hernandez-Ruiz & Dvorak, 2020; Hernandez-Ruiz et al., 2020).

Session Five: Acceptance

The attitude of acceptance can be difficult, particularly when going through a medical challenge. While the patient begins to engraft, they may experience some physical distress that can seem discouraging. In this session, the patient and MT-BC can explore ways to acknowledge their present physical and mental state with patience and objective awareness instead of judgment. Music-assisted relaxation accompanying the imagery of the body scan encourages the patient to acknowledge their current state with compassion, giving their body time to heal.

Session Six: Trust

This session is the first one that patients attend virtually through Zoom. In a way, the new format symbolizes a new period of recovery—the participant has fully engrafted and has been discharged to recover at home. While patients look forward to the familiarity of their homes, continued care without their faithful team of physicians can seem daunting. The attitude of trust encourages participants to have confidence in their own abilities, exemplified by the music therapy intervention of vocal toning.

Session Seven: Beginner’s Mind

Briefly, this mental state is the attitude of bringing “awe” or openness to new and familiar experiences. Novel instruments (ocean drum, thumb piano) are explored and played by the patient, and the attitude of newness becomes evident. The attitude is then encouraged to be used with familiar songs, with the challenge of seeing something new that is long familiar (e.g., relationships, events).

Session Eight: Non-Striving

The attitude of non-striving reminds patients that sometimes events must unfold naturally. The healing process after a SCT is different for everyone, and, while certain lifestyle guidelines are helpful for recovery, sometimes complete health takes its own route. The use of music improvisation as a model for non-striving illustrates the concept of allowing things to unfold within a general framework. Additionally, music improvisation combines most of the previous interventions—nonjudgment, patience, beginner’s mind, letting go, and trust—to summarize the entire therapeutic protocol.

Clinical Implications

The development of the eMBMT protocol may provide music therapists with new insight into the needs of allo-SCT patients. Further, while this paper focuses on the development of the eMBMT program for patients with allo-SCT, music therapists may implement the interventions for use with other patient oncology diagnoses (e.g., Carlson, 2016; Lesiuk, 2015, 2016) and other patient illness-related needs in medical settings (Miller-Matero, 2019). The MBMT approach can also potentially be implemented by those working outside of medical settings, serving individuals or groups of clients who have psychological needs. For example, the mindful listening techniques have potential not only to reduce feelings of anxiety but also to increase selective attention in persons with ADHD (Cairncross & Miller, 2016). Additionally, the use of music as a framework for breathing and meditation techniques may be helpful for any individual struggling with rumination or excessive mind-wandering (Kabat-Zinn, 2013).

Of importance, while the multi-session, structured approach to learning mindfulness techniques through music is an attractive one, clients should be informed about the structure of the program. Focus groups conducted at the beginning of this study revealed that potential participants might prefer therapeutic music listening to a structured approach to using music as a tool to enhance mindfulness (Fleszar-Pavlovic et al., 2024). Feedback from these groups encouraged the study team to clearly explain the purpose of the interventions and the importance of adhering to the study protocol. Misunderstanding the nature of the study sessions could increase the risk of non-compliance and early withdrawal. To balance structure with personalization, patients are invited to use their preferred music for certain exercises (e.g., mindful listening in session 3, “patience”), allowing for individualized and culturally personalized choices. However, other practices involve engaging with our chosen music-assisted relaxation recordings and journaling about their experiences with the music. All exercises presented by the MT-BC are accessible on the eMBMT website via the provided iPad.

To ensure inclusivity, individuals of all races and genders are invited to participate in this study. Specifically, since South Florida has a large Hispanic population, a fully Spanish-speaking music therapist was included to deliver sessions to those whose prefer Spanish. Further, although modules such as non-judgment and patience use researcher-chosen music to illustrate the concepts, participants are encouraged to use the same techniques with familiar, preferred music. Adding familiarity not only increases engagement with the exercise but also validates various cultures and traditional preferences.

Although no references were found addressing contraindications of mindfulness for specific clinical populations (Binda et al., 2022), it is important to note that some individuals may not be able to face and process their feelings. Music therapists may not always be equipped to navigate such situations; therefore, careful consideration is essential when determining who is suitable for this insight-oriented program.

Future Recommendations

The eMBMT was developed specifically to meet allo-SCT patients physical and psychological needs (e.g., Rueda-Lara & Lopez-Patton, 2014), based on previous MBMT research (Lesiuk, 2015, 2016), patient focus groups (Fleszar-Pavlovic et al., 2024), and supportive eHealth cancer programs (e.g., Penedo et al., 2020). While the combination of music therapy and mindfulness practice supports allo-SCT patients through their treatment course, its proposed effectiveness is founded on timing the hybrid ehealth sessions to patients’ treatment trajectories and their coinciding psychological, emotional, social, and physical needs. The mindfulness expertise of board-certified music therapists is essential for successful implementation of mindfulness-based music therapy. MT-BCs interested in this field are encouraged to participate in mindfulness programs such as the mindfulness-based stress reduction program (Kabat-Zinn, 2013), which is widely available. Additionally, they should refresh their knowledge and training through local mindfulness workshops. It is our intention and hypothesis that the MT-BC is well equipped to meet the needs of the allo-SCT patient using a program as proposed here.

A future efficacy randomized controlled trial will determine the effects of the eMBMT on symptom burden and HRQOL among patients undergoing allo-SCT.

This study was supported by NCI 5R61CA263335-02 (Penedo, F. J. and Lesiuk, T: PIs).

References