Editorial
Editorial John Habron Performing Arts Coventry University, UK
Dementia 12(1) 3–6 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1471301212469220 dem.sagepub.com
‘A conversation without words’ – reflections on music therapy and dementia This is the last day of music therapy for the group. Angela makes the most of it, as does David her son, who is the first to fetch an instrument. Within seconds they are taking turns on a pair of bongos, communicating musically. A no-nonsense start. They smile and laugh, looking into each other’s eyes. Not only do their rhythms overlap and intertwine, but Angela’s fingers also move around the surface of the drum in an intricate dance. David reflects these movements in his playing. The rest of the group holds this duet by providing a supporting groove. ‘It’s like having a conversation without words’, says Angela.1
Angela has dementia, but that is not the focus of this session. It is not even mentioned. Instead, we witness and partake in a flow of spontaneous action and creativity. Right now, it would seem, loss and deterioration have no place, although Angela’s comment may show an unconscious awareness of something yet to come. . . In this vignette we see Angela realising her whole self: cognitively (turn-taking, playing in time), physically (patterning her movements), socially (communicating, interacting) and emotionally (enjoying). She has learnt, through the facilitation of the music therapist, through the developing group dynamic and through mobilising her own energy in new ways, how to make the most of the opportunity to improve her quality of life through music. Together, the music therapy group has risen to the pressing challenge: ‘to escape the medical confines of disease and to assemble a new humanity in the loss’ (Shenk 2003: 93). This is just one example of music therapy for people with dementia and their carers (see also Aldridge 2000). Here, as with other populations, music therapy aims to enable and to foster positive change. Music therapists work with people’s abilities as well as their existing cultural and musical resources (Rolvsjord 2004) in order to help them to ‘perform’ their health (Aldridge 2005). Music therapy, as practiced in the UK, tends most often to be improvisational (using voices and instruments freely to create unique musical interactions), although work with dementia patients often includes song (Clair 1996, 2000). Only practitioners registered with the Health Professions Council may facilitate music therapy.2 As well as being allied health professionals, music therapists are specialists, trained to listen carefully and to use music to ‘assemble a new humanity’.
Corresponding author: John Habron, Performing Arts Coventry University, Ellen Terry Building, Jordan Well, Coventry CV1 5FB, UK Email: [email protected]
Downloaded from dem.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 9, 2015
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Dementia 12(1)
They can also help patients and families to help themselves; music therapy and its benefits need not remain in the music therapy room (Pavlicevic and Ansdell 2004). Let us now consider Sven, whose cognitive, language and motor skills are more impaired than Angela’s. His movements, for example tapping his fingertips on his thighs, nevertheless show awareness, a sense of rhythm and a willingness to participate with others. In so doing he brings himself into interactional synchrony with the group (Sawyer 2005), whose musical responses in turn validate Sven’s movements by, for example, adapting to his changing tempo. It is such moments of synchrony and flow that help to form our very selves in early infancy (Stern 2010) and, in music therapy, we can use such synchrony to promote communication (Malloch and Trevarthen 2009; Miell, MacDonald and Hargreaves 2005).3 The examples above are taken from Music in Mind, a project led by Manchester Camerata, a chamber orchestra.4 This partnership-funded project, highlighted as a case study in Dementia 2012: A national challenge (Alzheimer’s Society 2012), offered group music therapy to people with dementia and their carers. It brought together people living in the community, rather than residential care, and offered them 10 free sessions of music therapy. Orchestral musicians worked as music therapy assistants, moving the therapy away from a more traditional model. The research evaluation of Music in Mind has begun and we hope to publish our findings in 2013. The need to share findings and to theorize around them is a constant in the world of music therapy, which sits within a wide field of practice and research in music, health and wellbeing (Edwards 2007; MacDonald 2012). One driver behind this is evidence-based practice (EBP) and the evidence to date5 has already had an impact. The NICE guidelines on dementia recommend that providers consider music therapy as an intervention for noncognitive symptoms and challenging behaviour. They also emphasize that such interventions should be: ‘tailored to the person’s preferences, skills and abilities’ (NICE 2006: 34), something that is second nature to music therapists. Service providers wish to ensure high-quality evidence-based clinical work. However, the most recent Cochrane Collaboration review on dementia and music therapy, which looked exclusively at randomized controlled trials (RCTs), is equivocal about its effectiveness (Vink, Bruinsma & Scholten 2011). In response, the debate about EBP shows no signs of abating (Wigram and Gold 2012) and fundamental questions remain: what constitutes relevant evidence, what evidence most eloquently captures the experience of service-users and caregivers, should we accept the assumption that the best evidence is only to be derived from RCTs? The prevailing supremacy of the systematic review – itself open to bias – and the difficulty in securing significant research funding mean that music therapy has an uphill struggle, but one which it is facing with increasing energy and focus. Irrespective of research, the time seems to have come for ‘dementia and music’. Authors such as the neurologist Oliver Sacks (2007) have helped to implant the association in the public imagination, as have a number of successful schemes such as Singing for the Brain.6 Earlier this year a YouTube clip of a man called Henry ‘went viral’ (around 7 million plays to date).7 The impact of listening to recorded music on Henry is clear; after being slumped in chair, seemingly inert, he becomes animated by the music and sings expressively. However, lest we think that iPods are a quick fix, it is worth noting that it is during the human interaction after the music that ‘positive person work’ is done (Kitwood 1996). Here a carer acknowledges and celebrates Henry’s musical past and engages him in conversation. Nothing can substitute for the social element in this story and it is specialized listening and human relationships that remain at the root of music therapy interventions. But, we might
Downloaded from dem.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 9, 2015
Editorial
5
ask: has the time yet come for ‘dementia and music therapy’? There are some high-profile success stories such as MindSong8 and newer ventures such as Music in Mind. There is a wealth of published evidence and plenty of longstanding excellent practice. And yet, music therapists often struggle to find work in the rapidly expanding field of dementia care. As a profession, and as a wider community of healthcare providers, practitioners and researchers, we need to engage in a discussion that asks ‘why?’ – especially when people like Angela, David and Sven tell us how much it improves their quality of life.
Notes 1. Participants gave informed consent for the sharing of their views and experiences. Identities have been altered. 2. www.hpc-uk.org. See also the British Association for Music Therapy (BAMT), the professional body for music therapy in the UK: www.bamt.org 3. An emphasis on loss, especially language deficit, will not reveal these musically communicative potentials and there is consequently a persuasive argument for music therapy’s place in dementia assessment (Aldridge, G. 2000). 4. www.manchestercamerata.co.uk/news/music-in-mind 5. For a selection of recent research, go to the Evidence Bank at: www.nordoff-robbins.org.uk 6. www.alzheimers.org.uk 7. www.youtube.com/watch?v¼NKDXuCE7LeQ&feature¼related 8. www.mindsong.org.uk
References Aldridge, D. (Ed.) (2000). Music Therapy in Dementia Care. London: Jessica Kingsley. Aldridge, D. (Ed.) (2005). Music Therapy and Neurological Rehabilitation: Performing Health. London: Jessica Kingsley. Aldridge, G. (2000). ‘Improvisation as an Assessment of Potential in Early Alzheimer’s Disease’. In D. Aldridge (Ed.), Music Therapy in Dementia Care (pp. 139–165). London: Jessica Kingsley. Alzheimer’s Society. (2012). Dementia 2012: A national challenge. London: Alzheimer’s Society. Clair, A. A. (1996). ‘The effect of singing on alert responses in persons with late stage dementia’. Journal of Music Therapy, 33/4, 234–47. Clair, A. A. (2000). ‘The Importance of Singing with Elderly Patients’. In D. Aldridge (Ed.), Music Therapy in Dementia Care (pp. 81–101). London: Jessica Kingsley. Edwards, J. (Ed.) (2007). Music: Promoting Health and Creating Community in Healthcare Contexts. Newcastle: Cambridge Scholars. Kitwood, T. (1996). ‘A dialectical framework for dementia’. In R. T. Woods (Ed.), Handbook of the Clinical Psychology of Ageing. London: John Wiley & Sons. Malloch, S., & Trevarthen, C. (2009). Communicative Musicality: Exploring the basis of human companionship. Oxford: Oxford University Press. MacDonald, R., Kreutz, G., & Mitchell, L. (Eds.) (2012). Music, Health and Wellbeing. Oxford: Oxford University Press. Miell, D., MacDonald, R., & Hargreaves, D. J. (Eds.) (2005). Musical Communication. Oxford: Oxford University Press. NICE. (2011). NICE clinical guideline 42 (amended March 2011) Dementia: supporting people with dementia and their carers in health and social care. London: NICE. Pavlicevic, M., & Ansdell, G. (Eds.) (2004). Community Music Therapy. London: Jessica Kingsley. Rolvsjord, R. (2004). ‘Therapy as Empowerment’. Nordic Journal of Music Therapy, 13/2, 99–111. Sacks, O. (2007). Musicophilia: Tales of Music and the Brain. London: Picador.
Downloaded from dem.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 9, 2015
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Dementia 12(1)
Sawyer, R. K. (2005). ‘Music and Conversation’. In D. Miell, R. MacDonald, & D. J. Hargreaves (Eds.), Musical Communication (pp. 45–60). Oxford: Oxford University Press. Shenk, D. (2003). The Forgetting – Understanding Alzheimer’s: A Biography of a Disease. London: Flamingo. Stern, D. (2010). Forms of Vitality: Exploring Dynamic Experience in Psychology, the Arts, Psychotherapy, and Development. Oxford: Oxford University Press. Vink, A.C., Bruinsma, M.S. & Scholten, R.J.P.M. (2011) Music therapy for people with dementia (review), Cochrane Database of Systematic Reviews, Issue 3. The Cochrane Collaboration: John Wiley & Sons. Wigram, T., & Gold, C. (2012). ‘The Religion of Evidence-Based Practice: Helpful or Harmful to Health and Wellbeing?’ In R. MacDonald, G. Kreutz, & L. Mitchell (Eds.), Music, Health and Wellbeing (pp. 164–182). Oxford: Oxford University Press.
John Habron is Senior Lecturer in Music at Coventry University, where he researches into music composition, education and therapy. He is a Fellow of the Higher Education Academy and External Examiner in music composition for the University of Huddersfield. John holds an MA in Music Therapy from the University of the West of England and he currently focuses on group work for people with dementia and their carers. John has run workshops, education projects and outreach activities for numerous organisations including the BBC Symphony Orchestra and Manchester Camerata. During 2007-08 he was composer-in-residence at Handel House Museum, London.
Downloaded from dem.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 9, 2015
Editorial John Habron Performing Arts Coventry University, UK
Dementia 12(1) 3–6 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1471301212469220 dem.sagepub.com
‘A conversation without words’ – reflections on music therapy and dementia This is the last day of music therapy for the group. Angela makes the most of it, as does David her son, who is the first to fetch an instrument. Within seconds they are taking turns on a pair of bongos, communicating musically. A no-nonsense start. They smile and laugh, looking into each other’s eyes. Not only do their rhythms overlap and intertwine, but Angela’s fingers also move around the surface of the drum in an intricate dance. David reflects these movements in his playing. The rest of the group holds this duet by providing a supporting groove. ‘It’s like having a conversation without words’, says Angela.1
Angela has dementia, but that is not the focus of this session. It is not even mentioned. Instead, we witness and partake in a flow of spontaneous action and creativity. Right now, it would seem, loss and deterioration have no place, although Angela’s comment may show an unconscious awareness of something yet to come. . . In this vignette we see Angela realising her whole self: cognitively (turn-taking, playing in time), physically (patterning her movements), socially (communicating, interacting) and emotionally (enjoying). She has learnt, through the facilitation of the music therapist, through the developing group dynamic and through mobilising her own energy in new ways, how to make the most of the opportunity to improve her quality of life through music. Together, the music therapy group has risen to the pressing challenge: ‘to escape the medical confines of disease and to assemble a new humanity in the loss’ (Shenk 2003: 93). This is just one example of music therapy for people with dementia and their carers (see also Aldridge 2000). Here, as with other populations, music therapy aims to enable and to foster positive change. Music therapists work with people’s abilities as well as their existing cultural and musical resources (Rolvsjord 2004) in order to help them to ‘perform’ their health (Aldridge 2005). Music therapy, as practiced in the UK, tends most often to be improvisational (using voices and instruments freely to create unique musical interactions), although work with dementia patients often includes song (Clair 1996, 2000). Only practitioners registered with the Health Professions Council may facilitate music therapy.2 As well as being allied health professionals, music therapists are specialists, trained to listen carefully and to use music to ‘assemble a new humanity’.
Corresponding author: John Habron, Performing Arts Coventry University, Ellen Terry Building, Jordan Well, Coventry CV1 5FB, UK Email: [email protected]
Downloaded from dem.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 9, 2015
4
Dementia 12(1)
They can also help patients and families to help themselves; music therapy and its benefits need not remain in the music therapy room (Pavlicevic and Ansdell 2004). Let us now consider Sven, whose cognitive, language and motor skills are more impaired than Angela’s. His movements, for example tapping his fingertips on his thighs, nevertheless show awareness, a sense of rhythm and a willingness to participate with others. In so doing he brings himself into interactional synchrony with the group (Sawyer 2005), whose musical responses in turn validate Sven’s movements by, for example, adapting to his changing tempo. It is such moments of synchrony and flow that help to form our very selves in early infancy (Stern 2010) and, in music therapy, we can use such synchrony to promote communication (Malloch and Trevarthen 2009; Miell, MacDonald and Hargreaves 2005).3 The examples above are taken from Music in Mind, a project led by Manchester Camerata, a chamber orchestra.4 This partnership-funded project, highlighted as a case study in Dementia 2012: A national challenge (Alzheimer’s Society 2012), offered group music therapy to people with dementia and their carers. It brought together people living in the community, rather than residential care, and offered them 10 free sessions of music therapy. Orchestral musicians worked as music therapy assistants, moving the therapy away from a more traditional model. The research evaluation of Music in Mind has begun and we hope to publish our findings in 2013. The need to share findings and to theorize around them is a constant in the world of music therapy, which sits within a wide field of practice and research in music, health and wellbeing (Edwards 2007; MacDonald 2012). One driver behind this is evidence-based practice (EBP) and the evidence to date5 has already had an impact. The NICE guidelines on dementia recommend that providers consider music therapy as an intervention for noncognitive symptoms and challenging behaviour. They also emphasize that such interventions should be: ‘tailored to the person’s preferences, skills and abilities’ (NICE 2006: 34), something that is second nature to music therapists. Service providers wish to ensure high-quality evidence-based clinical work. However, the most recent Cochrane Collaboration review on dementia and music therapy, which looked exclusively at randomized controlled trials (RCTs), is equivocal about its effectiveness (Vink, Bruinsma & Scholten 2011). In response, the debate about EBP shows no signs of abating (Wigram and Gold 2012) and fundamental questions remain: what constitutes relevant evidence, what evidence most eloquently captures the experience of service-users and caregivers, should we accept the assumption that the best evidence is only to be derived from RCTs? The prevailing supremacy of the systematic review – itself open to bias – and the difficulty in securing significant research funding mean that music therapy has an uphill struggle, but one which it is facing with increasing energy and focus. Irrespective of research, the time seems to have come for ‘dementia and music’. Authors such as the neurologist Oliver Sacks (2007) have helped to implant the association in the public imagination, as have a number of successful schemes such as Singing for the Brain.6 Earlier this year a YouTube clip of a man called Henry ‘went viral’ (around 7 million plays to date).7 The impact of listening to recorded music on Henry is clear; after being slumped in chair, seemingly inert, he becomes animated by the music and sings expressively. However, lest we think that iPods are a quick fix, it is worth noting that it is during the human interaction after the music that ‘positive person work’ is done (Kitwood 1996). Here a carer acknowledges and celebrates Henry’s musical past and engages him in conversation. Nothing can substitute for the social element in this story and it is specialized listening and human relationships that remain at the root of music therapy interventions. But, we might
Downloaded from dem.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 9, 2015
Editorial
5
ask: has the time yet come for ‘dementia and music therapy’? There are some high-profile success stories such as MindSong8 and newer ventures such as Music in Mind. There is a wealth of published evidence and plenty of longstanding excellent practice. And yet, music therapists often struggle to find work in the rapidly expanding field of dementia care. As a profession, and as a wider community of healthcare providers, practitioners and researchers, we need to engage in a discussion that asks ‘why?’ – especially when people like Angela, David and Sven tell us how much it improves their quality of life.
Notes 1. Participants gave informed consent for the sharing of their views and experiences. Identities have been altered. 2. www.hpc-uk.org. See also the British Association for Music Therapy (BAMT), the professional body for music therapy in the UK: www.bamt.org 3. An emphasis on loss, especially language deficit, will not reveal these musically communicative potentials and there is consequently a persuasive argument for music therapy’s place in dementia assessment (Aldridge, G. 2000). 4. www.manchestercamerata.co.uk/news/music-in-mind 5. For a selection of recent research, go to the Evidence Bank at: www.nordoff-robbins.org.uk 6. www.alzheimers.org.uk 7. www.youtube.com/watch?v¼NKDXuCE7LeQ&feature¼related 8. www.mindsong.org.uk
References Aldridge, D. (Ed.) (2000). Music Therapy in Dementia Care. London: Jessica Kingsley. Aldridge, D. (Ed.) (2005). Music Therapy and Neurological Rehabilitation: Performing Health. London: Jessica Kingsley. Aldridge, G. (2000). ‘Improvisation as an Assessment of Potential in Early Alzheimer’s Disease’. In D. Aldridge (Ed.), Music Therapy in Dementia Care (pp. 139–165). London: Jessica Kingsley. Alzheimer’s Society. (2012). Dementia 2012: A national challenge. London: Alzheimer’s Society. Clair, A. A. (1996). ‘The effect of singing on alert responses in persons with late stage dementia’. Journal of Music Therapy, 33/4, 234–47. Clair, A. A. (2000). ‘The Importance of Singing with Elderly Patients’. In D. Aldridge (Ed.), Music Therapy in Dementia Care (pp. 81–101). London: Jessica Kingsley. Edwards, J. (Ed.) (2007). Music: Promoting Health and Creating Community in Healthcare Contexts. Newcastle: Cambridge Scholars. Kitwood, T. (1996). ‘A dialectical framework for dementia’. In R. T. Woods (Ed.), Handbook of the Clinical Psychology of Ageing. London: John Wiley & Sons. Malloch, S., & Trevarthen, C. (2009). Communicative Musicality: Exploring the basis of human companionship. Oxford: Oxford University Press. MacDonald, R., Kreutz, G., & Mitchell, L. (Eds.) (2012). Music, Health and Wellbeing. Oxford: Oxford University Press. Miell, D., MacDonald, R., & Hargreaves, D. J. (Eds.) (2005). Musical Communication. Oxford: Oxford University Press. NICE. (2011). NICE clinical guideline 42 (amended March 2011) Dementia: supporting people with dementia and their carers in health and social care. London: NICE. Pavlicevic, M., & Ansdell, G. (Eds.) (2004). Community Music Therapy. London: Jessica Kingsley. Rolvsjord, R. (2004). ‘Therapy as Empowerment’. Nordic Journal of Music Therapy, 13/2, 99–111. Sacks, O. (2007). Musicophilia: Tales of Music and the Brain. London: Picador.
Downloaded from dem.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 9, 2015
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Dementia 12(1)
Sawyer, R. K. (2005). ‘Music and Conversation’. In D. Miell, R. MacDonald, & D. J. Hargreaves (Eds.), Musical Communication (pp. 45–60). Oxford: Oxford University Press. Shenk, D. (2003). The Forgetting – Understanding Alzheimer’s: A Biography of a Disease. London: Flamingo. Stern, D. (2010). Forms of Vitality: Exploring Dynamic Experience in Psychology, the Arts, Psychotherapy, and Development. Oxford: Oxford University Press. Vink, A.C., Bruinsma, M.S. & Scholten, R.J.P.M. (2011) Music therapy for people with dementia (review), Cochrane Database of Systematic Reviews, Issue 3. The Cochrane Collaboration: John Wiley & Sons. Wigram, T., & Gold, C. (2012). ‘The Religion of Evidence-Based Practice: Helpful or Harmful to Health and Wellbeing?’ In R. MacDonald, G. Kreutz, & L. Mitchell (Eds.), Music, Health and Wellbeing (pp. 164–182). Oxford: Oxford University Press.
John Habron is Senior Lecturer in Music at Coventry University, where he researches into music composition, education and therapy. He is a Fellow of the Higher Education Academy and External Examiner in music composition for the University of Huddersfield. John holds an MA in Music Therapy from the University of the West of England and he currently focuses on group work for people with dementia and their carers. John has run workshops, education projects and outreach activities for numerous organisations including the BBC Symphony Orchestra and Manchester Camerata. During 2007-08 he was composer-in-residence at Handel House Museum, London.
Downloaded from dem.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 9, 2015
