Article

The ‘ripple effect’: Towards researching improvisational music therapy in dementia care homes

Dementia 2015, Vol. 14(5) 659–679 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1471301213514419 dem.sagepub.com

Merce´de`s Pavlicevic and Giorgos Tsiris Nordoff Robbins Music Therapy, UK

Stuart Wood Barchester Nordoff Robbins Initiative, UK

Harriet Powell Nordoff Robbins Music Therapy, UK

Janet Graham and Richard Sanderson Barchester Nordoff Robbins Initiative, UK

Rachel Millman Nordoff Robbins Music Therapy, UK

Jane Gibson Barchester Nordoff Robbins Initiative, UK

Abstract Increased interest in, and demand for, music therapy provision for persons with dementia prompted this study’s exploration of music therapists’ strategies for creating musical communities in dementia care settings, considering the needs and resources of people affected by dementia. Focus group discussions and detailed iterative study of improvisational music therapy work by six experienced practitioners clarify the contextual immediacy and socio-musical complexities of music therapy in dementia care homes. Music therapy’s ‘ripple effect’, with resonances from micro (person-to-person musicking), to meso (musicking beyond ‘session time’) and macro level (within the care home and beyond), implies that all who are part of the dementia care ecology need opportunities for flourishing, shared participation, and for expanded self-identities; beyond ‘staff’, ‘residents’, or ‘being in distress’. On such basis, managers and funders might consider an extended brief for music therapists’ roles, to include generating and maintaining musical wellbeing throughout residential care settings. Corresponding author: Giorgos Tsiris, Nordoff Robbins Music Therapy, 2 Lissenden Gardens, London NW5 1PQ, UK. Email: [email protected]

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Keywords dementia care homes, music therapy, practice-led methodology, ripple effect, wellbeing

Truly to sing, that is a different breath. Rainer Maria Rilke

Background The growing demographic bulge of older people in many parts of the world, together with the corresponding growth in the number of people with dementia-related conditions is well documented (Alzheimer’s Disease International, 2012; Alzheimer’s Society, 2012). Dementia care is focused on managing the condition by enhancing quality of life, through addressing the physical, social, emotional and spiritual needs of persons living with dementia (Alzheimer’s Society, 2008; DoH, 2009). Correspondingly, an increased interest in a range of musical activities with older people is reflected in the growing demand for music therapy services with people affected by dementia. A collaboration between Nordoff Robbins Music Therapy, the largest music therapy charity in the UK, and Barchester Healthcare, the ‘Barchester Nordoff Robbins Initiative’ (BNRI), signals a response to this situation. Therapeutic practices using music can be broadly clustered under music in therapy (where music facilitates therapeutic work through another modality such as psychotherapy or physiotherapy), and music as therapy (with music as the primary therapeutic medium). As a profession registered with the UK’s Health and Care Professions Council (HCPC), the latter is defined by music therapy scholar Kenneth Bruscia: Music therapy is a systematic process of intervention wherein the therapist helps the client to promote health, using musical experiences and the relationships that develop through them as dynamic forces of change (Bruscia, 1998, p. 20).

A further distinction is often made between receptive approaches (e.g., listening to music) (Grocke & Wigram, 2006) and active or participatory approaches, which focus on therapeutic musicking.1 In the UK, improvisational music therapy is the prevailing participatory approach. Nordoff–Robbins music therapy (Nordoff & Robbins, 1977) is further characterised as music-centred (Aigen, 2005): privileging the role of shared improvisatory musical-therapeutic experiences, with a corresponding music-wellness narrative that offers relief from an unrelenting ‘illness’ and ‘care’ identity and narrative (Ansdell & Meehan, 2010), or – as in this instance – narratives of ‘dementia’ and ‘dementia care’. A relatively recent professional development, signalled by Community Music Therapy (Pavlicevic & Ansdell, 2004; Stige & Aarø, 2012; Stige, Ansdell, Elefant, & Pavlicevic, 2010), offers expanded possibilities for situating therapeutic musicking as part of, and engaging with, the entire socio-musical ecology of the workplace and people’s everyday experiences. The ‘ripple effect’ as a metaphor conveys the temporal, social and physical contagiousness of therapeutic musicking. The ripple effect contrasts with more traditional music therapy practices that limit their focus to ‘the therapist working with the resident’ (see Bunt & Hoskyns, 2002; DarnleySmith & Patey, 2003; Meadows, 2011) as emblematised by the Bruscia quote above.

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This study emerged from Nordoff Robbins practitioners’ desire to explore the role of music-centred, improvisational music therapy within dementia care settings, and to also consider the contextual immediacy and the music-centred focus of their practices. Six music therapy practitioners2 with substantial experience within the dementia care sector were invited to form a practitioner-research group: the ‘Nordoff Robbins Music Therapy and Dementia Practitioner-Research Forum’ (NRDF), led by Merce´de`s Pavlicevic (first author) and assisted by Giorgos Tsiris (second author). This paper is structured in five sections. Following a brief review of studies regarding music’s and music therapy’s role in dementia care, the study’s methodological framework and emerging aims are presented. A description of the data collection and analysis methods, precedes the clustering of findings according to three levels: person-to-person musicking (micro level), musicking beyond ‘session time’ (meso level) and within the care home and beyond (macro level). Lastly, the findings are discussed in relation to their implications not only for music therapy practitioners, but also for managers, funders and policy-makers in the dementia care sector.

A note on the literature and emerging aims Skingley and Vella-Burrows’ (2010) review of existing studies suggests that there is an increasing evidence base to support the therapeutic effects of music and singing for older people. Many research studies consider music’s impact on people with dementia. Music can help increase confidence and alertness (Bannan & Montgomery-Smith, 2008), improve behavioural and psychological symptoms (Choi, Lee, Cheong, & Lee, 2009; Gue´tin et al., 2009) and cognitive abilities (Lipe, 1995). Music can also decrease aggressive behaviours (Clark, Lipe, & Bilbrey, 1998) as well as anxiety and agitation (Ragneskog, Asplund, Kihlgren, & Norberg, 2001), and has a positive impact on the mood and mental state of elderly patients with Alzheimer’s (Lord & Garner, 1993). In a study by Cooke, Moyle, Shum, Harrison and Murfield (2010), although no significant impact on agitation and anxiety in older people with dementia was found, participation in an eight-week group music programme (including singing and music listening) gave participants a ‘voice’ and increased their verbalisation behaviour. Sung, Chang and Lee (2010) show that preferred music listening has a positive impact by reducing the anxiety level in older adults with dementia, while Chan (2011) reports that music listening can impact on the sleep quality of older people. Some research addresses music’s impact on caregivers (e.g., Choi, et al., 2009). A number of studies suggest that music (including both music-making and listening) can help nurses as part of their holistic caring for older people (Chan, 2011; Skingley & Vella-Burrows, 2010). Due to its effect on the alertness of people with dementia (Clair, 1996, 2000), singing, in particular, is reported as an effective intervention to accompany daily routines and activities (Brown, Go¨tell, & Ekman, 2001). One study reports on music therapy’s integration within multidisciplinary programmes for the management of dementia and explores nurses’ contribution to appropriate music interventions and referrals (Gue´tin et al., 2009). Go¨tell, Brown and Ekman (2009), for example, suggest that the presence of background music and caregiver singing enhance positive emotions and intimacy, and improve the mutuality of the communication between caregiver and patient, creating a joint sense of vitality. Various studies (e.g., Engstro¨m, Hammar, Williams, & Go¨tell, 2011; Go¨tell, et al., 2009; Ragneskog, et al., 2001) further support the value of caregiver singing as a method to

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improve the quality of dementia care and reduction of secondary symptoms (e.g., anxiety, shouting, irritability). Similar benefits (to music studies) are reported in the music therapy literature – and this covers a broad sweep of musical-therapeutic activities. Music therapy is reported as an effective intervention for maintaining and improving active involvement, social, emotional and cognitive skills, and for decreasing behavioural problems of people with dementia (Koger, Chapin, & Brotons, 1999). In particular, music therapy can help with memory as well as verbal and non-verbal communication (Koger & Brotons, 2000; Ridder, 2003); it is reported to be effective in managing agitated behaviour (Raglio et al., 2008; Vink, 2000), improving mood and reducing behavioural disturbance (McDermott, Crellin, Ridder, & Orrell, 2012). Music therapy is also reported to enhance interactive relationships, including relationships between carers and people with dementia (Clair, 2000, 2002; Powell & O’Keeffe, 2010; Simpson, 2000; Wood, 2007). Music therapist Harriet Powell’s (2006) evaluation study is closer to the ethos of this study, reporting on the social aspects of improvisational music therapy practice in residential care homes. Powell describes the various dimensions of service-users’ experiences including psychological/emotional (e.g., respect/support, choice/autonomy), social (e.g., intimacy, reminiscence), as well as mental/physical (e.g., stimulation, distraction from pain). In addition, she describes music therapy’s impact on staff members and the residential carehome. Staff members report on their experiences which include seeing good approach to care, experiencing different aspects of service-users, encouraging contact between people on different floors, and making music-making a part of the institution; offering possibilities for creating musical communities. Three impulses triggered this research. The first is that while there are encouraging findings on the effects of music and music therapy on persons with dementia, music therapy encompasses a range of approaches (such as behavioural, psychodynamic, medical, music-centred). Their varied theoretical underpinnings, techniques and applications render statements about ‘music therapy’ as though it were a homogeneous praxis somewhat misleading. This study therefore, focuses specifically on Nordoff–Robbins music therapy, an improvisational, music-centred approach. The second impulse is that, despite some description of music therapists’ strategies in the improvisational music therapy canon (Nordoff & Robbins, 1977; Pavlicevic, 2003; Wigram, 2004), there is an absence of strategies specific to everyday dementia care situations. The third is the recent awareness of and interest in music therapy’s role in forming part of the broader socio-cultural ecology of everyday life of people and organisations, as signalled by the emergence of Community Music Therapy (Pavlicevic & Ansdell, 2004; Stige & Aarø, 2012; Stige et al., 2010). This, together with the emergence of the Music and Health movement (Bonde, 2011; MacDonald, Kreutz, & Mitchell, 2012) has to date spawned a small range of studies (e.g., Hara, 2011; Stige et al., 2010). This study seeks to add to this small canon, which appears to be more representative of contemporary music therapy practice. Two aims emerged from preliminary discussions by the NRDF music therapists: (1) To explore the needs of people affected by dementia, their social-musical resources and music therapists’ strategies for optimising the possibilities for creating musical communities in dementia care settings. (2) To explore the fit between music therapy and the UK’s New National Dementia Strategy (DoH, 2009).

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The second aim is addressed and reported in a separate study (Spiro, Farrant, Tsiris, & Pavlicevic, 2012).

Methodological concerns For this practice-based research, the practitioners sought to ensure that the research methods were in alignment with their everyday work in residential dementia care homes. They considered it important to develop a study methodology that would ‘fit’ with, rather than compromise or reduce, everyday realities; and to also ensure that methods resonated closely with the theoretical and disciplinary framework of improvisational, music-centred music therapy (Aigen, 2005; Ansdell & Pavlicevic, 2010; Nordoff & Robbins, 1977, 2007). This stance was a response to research whose methods ignore practice-based knowledge and experiences, and risk compromising the integrity and complexity of practices, relying instead on ‘imported’ methodologies, often from bio-medical sciences. Such studies often prioritise ‘proving efficacy’ using, for example, outcome measures not linked to musical activities or values, or not originally developed for researching music therapy practice (Raw et al., 2012; Rogers, Maidman, & House, 2011). Music therapists have been aware for some time of the consequences of such protocols, which conceptualise music therapy as an ‘intervention’ or ‘treatment’ to be ‘applied’, and that can replicated at a specific time and place without acknowledging context-specific complexities. Consequences include ‘good’ practices being considered un-rigorous, on the basis of methodological flaws, and conversely, ‘weak’ practices being considered efficacious, on the basis of so-called methodological robustness (Ansdell, 2006; DeNora, 2006; Pavlicevic et al., 2009; Raw et al., 2012; Wigram, 2006). This study’s reflexive practitioner-research stance suggested instead that the practice would guide the sourcing of data, and the nature of the data would, in turn, guide the ‘right level’ of analysis. Data would be sourced from everyday experiences, and would include therapeutic reflections and documenting of practitioners’ work (through audio and film recordings, and session notes and reports). Iterative data analysis cycles would include focus group discussions and study of targeted music therapy extracts by the NRDF.

Data collection and analysis The NRDF members met four times over an 18-month period. The data corpus included materials from practitioners’ everyday documentations (i.e., recordings and written narratives) in addition to focus group discussions and research journals. Ethical approval was granted by Nordoff Robbins, Barchester and Social Care Research Ethics Committees, on the bases of appropriate levels for informed consent of use of material, safe data storage and anonymity and privacy of all participants. The data work comprised two main cycles: cycle A (meetings 1 and 2) and cycle B (meetings 3 and 4). For cycle A, practitioners provided video or audio recordings showing different music therapy situations with accompanying narratives, originating from their own work in care homes. In addition to pragmatic selection criteria (i.e. good quality recordings and consents), practitioners were asked to bring recordings that were as representative as possible of music therapy that ‘worked’ and ‘didn’t work’. This helped to address potential bias from practitioners who might wish for ‘highlights’ to be the focus of data analysis. The length of the video/audio recordings ranged from 1 to 7 min (Table 1).

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These recordings and narratives formed the basis of the first focus group: practitioners analysed the recordings collectively using Nordoff–Robbins music therapy indexing techniques (Nordoff & Robbins, 2007). Indexing allows for close analysis of music therapy recordings on the basis of a real time base. Flexible enough to accommodate micro-descriptions and musical transcriptions, indexing forms the basis for practitioners’ reports and session notes, providing a consistent documenting of work over time. In addition to analysing the recordings, the practitioners discussed the relationship between different people’s needs, social-musical configurations and music therapy strategies as portrayed in each recording. Analysis of focus group transcripts formed the basis of data cycle B, where the initial findings were explored further through three focus subgroup discussions and one plenary (meeting 3). Finally, in the fourth meeting, a follow-up plenary focus group helped to cross-check and complement previous findings. During cycles A and B, each NRDF member also completed individual research journals which included guiding questions and space for spontaneous reflections during the focus groups. All focus group transcripts and practitioners’ research journals were coded and analysed thematically, using interpretative phenomenological analysis (Smith & Osborn, 2003). Table 1. Data corpus assembled from video (v) and audio (a) recordings

Recording

Characteristics of recorded music therapy data examples Format

Recording 1 (v)

one to one (resident and music therapist)

Recording 2 (v)

Drop-in group (residents, staff, volunteers, families, visitors, and music therapist)

Locality Corridor

Lounge

Recording 3 (v)

Use of music I mprovisation

I mprovised use of songs I m p rov i s a ti on

Recording 4 (a) Music therapy room

Recording 5 (a) Recording 6 (a)

Improvisation

one to one (resident and music therapist)

Recording 7 (v) Balcony Recording 8 (v)

I m p rov i s ed u s e of songs I m p rov i s a ti on

Recording 9 (v)

Ad-hoc group (residents, staff, and music therapist)

Recording 10 (v)

Tea-time music and dance (residents, staff, volunteers, and music therapist)

Corridor

I mprovised use of songs

Lounge

Pre-co mposed songs

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Findings In alignment with the first aim of the study, a broad range of needs of people affected by dementia, social-musical resources and the strategies used by music therapists are identified and organised in three levels: micro (person-to-person musicking), meso (musicking beyond ‘session time’) and macro (within the care home and beyond). Findings are illustrated with direct quotes by focus group discussions.3 Some quotes refer to analysis of recordings (Table 1) and practitioners’ written narratives accompanying recordings. Some verbal quotes have been edited grammatically to ensure coherence of information. The summary findings in Tables 2–4 do not assume a linear, causal or hierarchical relationship between columns and rows.

Micro level: Person-to-person musicking In response to listening to recordings of music therapy sessions, NRDF practitioners comment on the qualities of residents’ spontaneous, and at times erratic, movements and vocalisations in music therapy sessions. They discuss these qualities as a reflection of the agitation, disorientation, and disruption to sense of self that characterise people living with dementia. They report that such movements and vocalisations, however fragmented, provide a vocabulary of gestures and sound, from which a music therapist can begin to build musical relationships with residents. Drawing from such gestural vocabulary, and through discerning hints of musical snippets from residents’ brief vocalisations, the practitioners in the extracts aim to create sustained musical narratives, continuously inviting the residents’ contributions, however fleeting.

Narrative (Recording 4) – Musicking restless memories Mrs D is in her late seventies and has taken a long time to settle in the unit. She spends much of her time rattling the (locked) main door and asking anyone who comes near how she can get out to catch a bus back to her village. She thinks her husband is still at home and that he’ll be worrying about where she is. Mrs D is anxious to move away from the door and it takes about four months before she agrees to come into the music therapy room with me. She often begins very tentatively, saying that she has to go and find her husband and that she isn’t any good at music anyway. Once she begins playing, however, she becomes more confident and it soon becomes apparent that she is able to respond and interact well (despite severe hearing loss) and that the music evokes memories. She tells me that, as a child during the Second World War, she was evacuated from her home in a ship-building town on the coast to her grandparents’ house. Her grandmother had taught local girls the piano, and had attempted to teach Mrs D. However, she had met with little success as Mrs D had been more interested in helping her grandfather pick fruit in his orchard. The recording comes from about two months into Mrs D’s music therapy. Before the session she appears very agitated, walking up and down the corridors and saying she needs to go and see her (long deceased) father and her husband (who, unknown to me, was also dead by this time; Mrs D’s family had not told her of his death and so she had not had the opportunity to attend his funeral). Mrs D is crying at the beginning of the session, but soon begins to play the drum. This extract comes from a few minutes into the session. She is playing the metallophone and I am at the piano. The music is in three-four time. She sometimes moves between black and white notes and I try to incorporate this into the music with some chromatic harmonies in the treble while at the same time keeping a ‘safe’ harmonic framework in the bass. The music is not as fast as some of Mrs D’s usual playing, suggesting that it has more expressive significance than that of merely a distracting activity. Her playing is purposeful and she seems to concentrate well.

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One strategy that emerges from the discussions is that of musical matching, where the music therapist’s playing and vocalising refers directly to the tempo, intensity, pitch and/or phrasing of residents’ voice/playing, and to their movement. Matching is described as offering possibilities for following the resident’s lead, framing their movements and sounds as cues. Reflecting on the music therapist’s actions in one of the video recordings, NRDF members comment: It’s tuning into what she [the resident] is doing . . . going at her pace, not letting her feel that in anyway she’s doing something wrong. The music therapist doesn’t alter the resident’s tempo or make any attempt to change anything that she’s doing. The music therapist is just there with her (FG3; 1; 7–20).

Music therapists also describe the need to be constantly alert to possibilities for embryonic musical structures and genres, however brief, through short musical offerings that invite the residents to become part of shaping the music together. The music therapist started off with very short structures, and I think people with dementia do have a need of working towards a structure because they feel secure with it (FG3; 1; 56–68).

NRDF practitioners describe the intentional and flexible use of musical elements (such as pulse, harmonic structure, metre, melody, speed, phrasing) in order to build connections with residents. This shared evolving musical framework (which may or may not be a known song or familiar musical genre) is described as helping to provide repetition and consistency, develop musical familiarity through recognition. Emerging shared recognition enables practitioners and residents to work with repeated musical patterns, and these are reported to help residents shift from habitual vocalisations and actions (such as crying), to being intentionally communicative. Such developing and even fleetingly reciprocal musical relationships are described as providing a musical conduit for emotional expression. . . . it was her habitual vocal sounds the music therapist was working with . . . Making it into an expressive singing voice . . . the music therapist powerfully inserted her musical presence alongside this woman’s [and] turned it into something, and it was the intensity of the voices being matched . . . when she [the music therapist] brought in the guitar, then that showed the intervention of music because then you’ve got pulse, harmonic structure, metre, melody, speed, phrasing, and all of those things, which are so comforting because they involve repetition and recognition . . . It introduces a deeper level of structure into which this woman was able to put her quite distressed sounds at that moment (FG2; 1; 26–32).

Just as with one-to-one music therapy work, in group sessions, music therapists describe remaining alert to possibilities for developing shared musical patterns or phrases through moment-by-moment attending to residents’ musical offerings – however fragmented – and responding within a musical idiom or song familiar to the resident. It’s two people making music together in a style that they both understand, in a structure that they can both join in . . . the music therapist as accompanist is very flexible because he can adapt to her sounds and draw them in, but she’s not doing anything that isn’t related completely in terms of phrasing, pulse, metre (FG2; 13; 9–25).

While also addressing individual musical actions, practitioners describe their intention as enabling the group participants jointly to settle into shared predictable musical structures and become more alert to one another.

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What she [the music therapist] did was build something up that people [in the group] would recognise as a structure of music [. . .] building it out and then emptying out so that each person’s contribution is really noticed. There’s quite a lot of looking around when [the music therapist] drops out, [the residents are] very aware of each other (FG1; 1–2; 62–2).

The therapist’s ‘dropping out’ here refers to an intentional strategy; practitioners describe ‘holding back’ from playing and singing, and using silence as a strategy to raise residents’ levels of alertness and to refocus them onto the music therapist and on shared musicmaking. We sense when to hold back, when to support more, when to support with silence (FG4; 9; 51– 52) [. . .] when to bring a musical device or a theme back, knowing when to use it, knowing when to stop using it, knowing when to take a risk and when not to take a risk, and knowing when to leave space as well (FG4; 10; 1–4). [T]he music therapist introduced some rests into the music – there was some space and . . . this lady in the red – it refocused her onto [the music therapist]. She seemed to look and re-engage. Certainly with her eyes she was looking across to [the music therapist] where the music was coming from (FG1; 1; 40–45).

Narrative (Recording 2) – Navigating diversity The music therapy group is a weekly event that I run at a care home for older people with dementia. Each week there are between 18 and 25 people who attend the group, mainly residents, but including care-staff, volunteers, family members or other visitors. Today there are eventually 20 people sitting in a circle, on sofas and chairs. They gather from the five residential units in the home. It is a very hot morning in June and most people have recently had breakfast. During the session a few fall asleep but most are engaged watching and listening, or directly involved in music-making vocally or instrumentally. At the beginning of this extract, which is 25 minutes into the 50-minute session, I am focussing on R, an Iranian woman, who has just accepted an offer to play the bongos with beaters. She starts singing quietly which is difficult to hear as F, her neighbour on her left, is talking. I am giving full attention to R and listening to her singing, and as R picks up on the harmonies and tonality of the accordion, F joins R’s probable Iranian tune with an English folk tune ‘‘Little Brown Jug’’. I choose an accompaniment style in a minor key which will hopefully encompass both singers and drum beat. F’s vocalising becomes more creative and interactive with the music. R then concentrates on playing the bongos. R is also watching E who is sitting at the end of the sofa near her, playing a tambourine. What seems to work in the first four minutes of this improvisation is the way the active participants really listen to each other and are aware of my music. There are exchanged looks and smiles. I am particularly listening and responding to the percussion instruments and F’s vocalising. At one point I begin to sing again to encourage F back into singing, and I quieten my accompaniment to highlight E on tambourine. Others in the group are listening or beating time. Aware that people on the other side of the circle are less actively involved and that the music might benefit from other percussion sounds, I begin to offer other instruments – a cymbal to V, castanets to the two care staff, a tambourine to others simultaneously. I just about manage to keep the music going.

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In group music therapy sessions, music therapists describe multi-tasking to invite and support diverse modes/types of musical participation, expanding the circle of participation from one person to the wider group. Helping the person to connect with themselves, to music and then, perhaps . . . to another person. Like we saw in the group: connecting with the therapist and then actually with a wider social context connecting to somebody else in the group (FG1; 7; 48–52). She [the music therapist] started off by creating the music from one person’s input and then other people joined in with it and then [the music therapist] would . . . focus on one lady singing and answer it while the same structures are going on and then she becomes like a cotherapist . . . enabling people and giving instruments around while she’s still continuing with the song. It’s a lot of layers to be working on at once (FG1; 2; 34–41).

Watching the recordings, the NRDF practitioners comment on the music therapist’s use of eye-contact and strategic body language that helps sustain engagement with different people. [The music therapist wants to] embody and to show that energy is happening [. . .] the music therapist is doing something with the right hand in relation to one person, something with the knees to someone else and indicating something else with their eyes, potentially, to someone else (FG4; 11; 38–42).

The NRDF practitioners comment on the therapist being highly mobile within the physical space. Practitioners report making informed choices about what impact the choice of certain musical instruments (for themselves as well as for residents) will have upon residents’ participation and the therapist’s own mobility. Being mobile enables music therapists to switch between engaging with individuals, with a subgroup or the whole group (as described in narrative from recording 2). NRDF members comment on recording 2: The fact that the music therapist is mobile with her accordion adds so much to it – it opens –if it were just a piano in the corner of the room it wouldn’t work. Whereas she’s this very visible Table 2. Summary findings. Micro level: Person-to-person musicking. Micro level Needs 

Communication



Sustained attention



Shared activities



Temporal and spatial coherence



Intimate personal interaction



Confidence



Predictability



Intentional activities



Connection with past life and identity



Sustained engagement

Social-musical resources

Music therapy strategies 

 Music therapists’ techniques and skills

 

 Residents’ past musical experiences and repertoire  Residents’ movements and vocalisations  Residents’, families’, and staff’s cultures and languages

     

‘Translating’ behaviours into music Remaining alert to musicking possibilities Musically matching, coordinating and reflecting Assembling shared musical framework, patterns and structure Using non- and familiar musical styles ‘Holding back’/silence Using body and space Multi-tasking Choosing musical instruments attentively

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presence – she moving all the time to make it visible [. . .] she can be a general music-making thing in the middle of the room one minute, then she can be a personal interactive one-to-one the next minute, [. . .] using her face, her eye contact, and her body to amplify the effect of the music (FG1; 4; 37–53).

While the micro level findings are predominantly musical and refer to timetabled music therapy sessions, the meso level findings are clustered under ‘people’, ‘timing’ and ‘physical spaces’; this clustering was an analytically expedient way of organising the range and volume of the data corpus.

Meso level: Musicking beyond ‘session time’ People. Residents’ family members and friends, visitors, carers and staff are described as contributing to the sessions’ musical repertoire and often participate in music therapy sessions together with residents. Connecting relatives with residents - that is quite regular I think. When relatives come, quite often they don’t have things to say . . . and then in the [music therapy] session they just take part together with their relative . . . it brings them together in a way they don’t really come together in everyday life (FG1; 10; 20–24).

Drawing from ongoing monitoring of residents’ and staff’s biographies and musical offerings, over months, practitioners assemble a musical portfolio with a range of musical styles, alert to the period song repertoire of older people (e.g., Music Hall, Second World War songs, regional folk songs and 20th Century rock/pop songs). Through bridging the personal with the social and public areas of a person’s living and dying (e.g., providing music in public social spaces like the tea room, providing music for people’s funerals and supporting bereaved family members), practitioners report aiming to provide a continuity of musicking right through the course of people’s care; seeking to accompany them, where and when appropriate, through to the final frail stages of life. Music therapists report remaining alert to how all the participants engage musically, and to the expanded opportunities for relating that shared musical participation offers them, e.g., staff participate as themselves beyond their professional roles. It’s possibly also triggering people to think more creatively and to see residents creatively, and see their work colleagues and the people they care for in that creative light (FG3.5; 9; 53–55).

Another reported strategy is the provision of training for residential care setting staff. In addition to formal training offered in staff training meetings, music therapists are alert to possibilities for informal learning during music therapy sessions. I try to talk about music, to talk about what I am doing: listening, observing, timing, all this kind of thing . . . and that’s really a sort of by-product of my work there, and then trying to encourage the staff to be musical as well . . . I really believe that in the staff training they can really learn so much from music therapy (FG1; 10; 58–64). When the staff can see the person and not the illness . . . when the staff are given confidence that there’s more possibilities for the resident, when the staff are given workshops, or training, or training videos which makes them think more about the resident and also think more about being more musical themselves [. . .] That’s about changing the dynamics between different people – families, staff and residents (FG4; 13; 4–13).

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Timing. NRDF practitioners report that they remain on ‘musical alert’ before, during and after sessions: noting any exchanges, singing, vocalising, requests and comments that could be woven into a session. The narrative (from recording 3) describes the music therapist setting up the room for a session – and listening to F, a person with dementia, who arrives with a greeting.

Narrative (Recording 3) – Musical alert As part of the gathering and settling of residents, a song emerges when I, following the melodic shape of a ‘hello’ from F, develop this into an unaccompanied welcoming song. This is fairly freely sung in terms of pulse, and incorporates greeting each person around the circle and their individual responses. Other people arrive during the song which I continue, now accompanying from the piano – a slightly jazzier and more rhythmic version. Care-staff come and go as they escort residents, there is some connecting across the circle and some people are waving at each other, clapping and tapping feet. There is laughter as F and others inject humorous, musical and melodic offerings into the song. As it finishes F says ‘it’s very nice’.

Practitioners report that their long-term presence in the care home, as well as regular (normally weekly) sessions, result in residents’ (as well as families’, carers’ and staff’s) anticipation of music therapy sessions. [. . .] there is some awareness or sense of anticipation that it is ‘that time again!’ The sense of the group happening each week at 13:10 means it’s lasting (J1).

One video recording (number 9) studied by the NRDF shows the music therapist walking around the care home with her piano accordion, outside session time. She spontaneously makes music with a small group of staff and residents who sit rather disconnected from one another on a bench in a corridor. Her music draws people together towards shared musicking, with spontaneous dancing between a resident and a staff member who happens to be walking by. The raised level of animation and engagement between this small spontaneous ensemble is palpable. Physical spaces. Practitioners remain alert to the care home architecture, and how any musicmaking might be heard beyond the music therapy room, influencing the general mood and atmosphere of the care setting. . . . sometimes you are in the corridor, sometimes you’re all over the place, and the music does spill into areas [. . .] It kind of just naturally leaks (FG3; 9; 13–29).

The social geography of the rooms, as well as their possibilities and limitations for musical ambience are also considered. In addition to addressing potential risks for residents (especially when physical arrangements may not be ideal for everyday social interaction), practitioners consider music’s potential to overcome limitations imposed by physical arrangements. When you see one of those care home rooms with 20-30 chairs in a huge circle – generally speaking, I feel that is the worst sort of setup for any socialising, any communication anything going on at all. But then this focus of the music, and what the music enables, changed that! (FG1; 4; 23–28)

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Table 3. Summary findings. Meso level: Musicking beyond ‘session time’.

Meso level Social-musical resources

Needs People

• Experience of self in relation to others • Shared experiences • Celebration of each other’s resources and skills • Awareness and recognition of each person’s musicality

Timing

• Orientation of time and space • Sense of togetherness (shared in time with other people) • Temporal coherence

• Residents’, staff’s and families’ life experiences • People’s relationships within and beyond the music therapy situation • In-service training opportunities

• People’s exchanges, singing, requests and comments before, during and after sessions • Anticipation of sessions

• Shared experiences • Change of mood and atmosphere of the care setting

• Ambience of the physical space (rooms)

• Purposeful physical engagement

• The architecture of the building

• Spatial orientation

• Physical and material equipment (e.g., chairs and musical instruments)

• Overcoming of physical space limitations • Safe mobility

• Assembling musical portfolio with range of genres (drawing on people’s preferences, backgrounds, etc.) • Remaining alert to people’s engagement / musical roles • Providing (informal and formal) training to staff • Provision of continuity of musicking / bridging personal and social / public areas of people’s lives • Remaining alert to musical exchanges, comments and requests beyond the planned session time • Continuum of musical presence; establishing a pattern and building anticipation for sessions • Drawing people together in shared experience in time and music

• Sense of continuity

Physical spaces

Music therapy strategies

• Alerting to the architecture of the care home building / rooms and their possibilities (and risks) for music-making • Being aware of the physical and social geography of the care setting • Considering the ambience of the physical space • Arranging the space to encourage and facilitate safe movement / dancing / bodily engagement in music

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Narrative (Recording 1) – Musicking the corridor F is in her late fifties, and has had early onset Alzheimer’s for approximately ten years. Her current stage in the disease is marked by an apparent aphasia, both receptive and expressive; and periodic and sudden mood changes. Her walking seems purposeful in the sense that she is quick, direct and occupied by her walking. She does not ‘wander’ with no aim; but cannot be diverted easily into sitting with staff or attending to objects. F lives on a locked unit in a care home. The unit has one long corridor, interrupted at the centre by a lift. At either end are small lounges, one with musical instruments and the other fitted to look like a nursery. Working in this space, I find it important to spend time ‘hanging out’ rather than organising only fixed sessions. The DVD extract begins when I encounter F in the corridor and see that she is about to start walking. I don’t want to insist on her staying in the lounge with me, so I decide to join her. My intention is therefore to communicate my presence, and through this to give F a sense of companionship, and shared enterprise. Also to elicit vocal response that relates to the physical world. We walk the first part of the corridor and I attune my walking to hers. I sing short tones with a consonant, timing the notes to both match the tempo of our footsteps and hopefully to reflect the forward-ness of her walking. I hear that this has meaning, from the quality of her vocal responses. At the lift, we find a teddy on the floor. She laughs and I laugh with her, pausing to let her comment, but I would like to see if I can use the musical connection to initiate further walking. I change tune, invite her with the melody, and she begins to walk again, offering more vocal responses that seem to indicate enjoyment and connection. I allow her to walk on ahead, yet keep the connection by maintaining the singing. The encounter is a typical example of how I spend time with people in restless states: and also of how I try to teach staff to be musical with their residents.

While the meso level findings consider the social, musical and physical needs, resources and possibilities beyond timetabled sessions (see narrative from recording 1), macro level findings situate music therapy within organisational and policy frameworks.

Macro level: Within the care home and beyond The practitioners report their roles as integral to organisational life. They foster close relationships with the care home as an organisation, and this enables them to respond to, and at times negotiate shifts and changes in practices and organisational ethos. Such roles are made possible by the collegial relationships developed through practitioners’ ongoing presence in care homes, at times over years. Practitioner 1: And it can be a slow process . . . music therapy isn’t something that you can just have for a few weeks [. . .] It’s a consistent relationship with the institution as well as our clients, particular clients. [. . .] It means you can build on things [. . .] It’s an evolving relationship, an evolving role in my experience. [. . .] [t]hat suits the institution rather than us imposing what we think should happen on the institution. [. . .] it’s a two-way process. Practitioner 2: And the institution is constantly changing and in flux, so it’s sort of, you know, with new people and with change (FG3; 9-10; 59–24).

Music therapy’s contribution to the organisation is described as a ‘musicalising’ process. [. . .] you can also think about staff training and all that sort of thing, the idea of musicalising the institution, bringing people’s awareness to the musicality of human beings (FG4; 5; 49–50).

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To ensure a sustained profile of music therapy’s presence, practitioners also emphasise the needs for maintaining efficient paperwork and communication channels. And also I think witnessing in terms of structural channels, like types of feedback, types of written word, types of mediums [. . .] and it’s because of good paperwork and good meetings. Yes, good formal communication (FG2; 12; 22–36).

Practitioners suggest that music therapy can play a key role in a process of ‘musicalising’ the entire care home ecology; music therapy could become a model for an optimally functioning system. And it’s generalised. It’s gone way out of just musical work, but its impact is focused on the musical work and it’s become the icon of types of good practice (FG2; 12; 31–33).

Practitioners describe their practice as part of the wider context of what ‘‘living well with dementia’’ (DoH, 2009) means. They see their work as offering possibilities for enhancing the atmosphere and mood in the entire care home, and enriching its ethos. Reflecting on music therapists’ strategies on organisational and public arenas, an NRDF member said: We are going there [dementia care setting] with a real purpose and will to work with the institution and their needs (FG4; 5; 42–44).

Music therapists talk of being alert to the continuities and links between their work and the wider dementia care sector and its policies. They describe such policies as providing a helpful framework for describing their work to non-music therapy audiences and to the public. Because of the way the care world is set up [. . .] and the care industry, and [. . .] the structures around it – dementia care is one of those things where there’s quite a strong framework outside care homes and outside the profession, like the dementia care strategies and things like that. [. . .] so I think part of your stance is relating what you’re doing inside that; your musical moments, and inside your persona in a building and all of that with some of other set of values outside, which at the moment in dementia care is quite strong. It’s quite alive . . . (FG2; 8; 9–12). Table 4. Summary findings. Macro level: Within the care home and beyond. Macro level Needs

Social-musical resources

Music therapy strategies 

 Ethos of care home Development of services  Policy documents that adhere to organisational ethos and policy guidelines  Organisational documents (e.g., notes and leaflets)  Person-centred care  Colleagues



 Partnerships/staff relationships

   



Aware of dementia care setting’s organisational frameworks Organisational and policy contexts Fostering an active relationship with the care home setting Being mindful of music therapy’s fit with national strategies Providing continuity of musicking throughout care and ‘musicalising’ the organisation Developing communication channels within and beyond the care home

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Discussion This practice-led study is a first attempt at systematising and characterising a distinctive music therapy approach, that of improvisational music-centred music therapy, in residential dementia care settings. The study aims and research questions, as well as the methodological stance, were developed by the NRDF, a group of experienced practitioners with a common approach and substantial experience of working in the field. Rather than isolating music therapy from its situated ecology and studying it as a ‘treatment intervention’, and rather than attempting to identify which aspect of practice might be its most potent ‘ingredient’, the NRDF elected instead to allow the practice – with all its multiplicities, unpredictability and idiosyncracies – to guide the research methodology and design. This stance resonates with the methodological attitude of ‘gentle empiricism’ espoused by two Nordoff Robbins scholars (Ansdell & Pavlicevic, 2010) who build on Nordoff and Robbins’ research heritage (influenced by Goethe) of sustained detailed observation of phenomena as part of their environments, rather than extrapolated or replicated for study in ‘the laboratory’. While the methodological risk was an abundance of ‘messy’ data, which indeed proved to be the case, the collective iterative analyses of journal narratives, session recordings and focus group transcripts, ensured methodological rigour, while also enabling the complexity of the data corpus to be retained and represented rather than hived off as an inconvenient fit. This is particularly relevant in considering that much of the data corpus was musical, with distinctive analytical complexities (Wosch & Wigram, 2007). The findings suggest music therapists strategically ensure that work drifts around the entire social and physical space, throughout the day, with music therapy engagements happening in, at times, surprising places. This intentional ‘drift’ contrasts with music therapy literature that portrays music therapy as confined to those who are referred to music therapy for particular reasons (usually linked to symptoms), and attending sessions at particular time for a certain duration and frequency (Aldridge, 2000; Meadows, 2011). This drift, together with practitioners’ sustained improvisational attitude, characterises Community Music Therapy’s ‘ripple effect’, in which music therapists become part of, and respond to, the immediacies of daily contexts. The ripple effect is congruent with music’s acoustic properties, which cannot be confined to particular spaces, and with its capacity to remain ‘in mind’ long after the music has ended (Pavlicevic & Ansdell, 2004). Such strategic work resonates with music sociologist Hara’s commentary on the contemporary emergence of a broader, ecologically attentive professional movement: The recent focus on community in music therapy (Pavlicevic & Ansdell, 2004; Stige et al., 2010) along with the Music and Health movement in the UK influenced local groups to start a number of music-related activities for older people both within local communities and in institutions in the UK (Bannan & Montogemery-Smith, 2008; Sing for Your Life, 2010; Music for Life, 2010). These music sessions may take place in the common areas of care homes or in community centres in order to support professional or local care initiatives. Unlike medical or traditional one-to-one music therapeutic interventions, these initiatives are situated in the everyday life of participants among other activities and also embedded in interactions between other residents/ participants, staff and families/carers (Hara, 2011: online).

While many reported studies link music therapy with symptoms embedded within the condition of dementia (e.g., sleeplessness, anxiety, agitation), the practitioners’ micro to

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macro music-centred strategies offer possibilities for reframing the residential care home. This reframing extends such spaces towards being culturally and musically resourced places. Such spaces offer possibilities for eliciting people’s resilience, transforming them into empowered musicians, rather than restricting them to ‘persons affected by dementia’. Such a reframing resonates with notions of resilience and empowerment (Harris, 2008; Harris & Keady, 2008), and more specifically, resource-oriented music therapy, conceptualised by Norwegian music therapist Rolvsjord (2010). Based on empowerment philosophy, resource-oriented music therapy challenges the notion of residents being identified as only ‘receivers’ of ‘treatment’ or ‘help’, and considers the economic, political and cultural resources that help to construct ‘illness’ and ‘conditions’ as situated exclusively within the person living with (in this instance) dementia. Rolvsjord’s descriptions of the rich musical-cultural-social resources that music therapy clients contribute to sessions find resonances in the practitioners’ strategies identified in this study. These strategies ensure and enable musicking with and alongside persons, drawing from their personal and from the collective musical repertoire – in contrast to singing or playing to the person. While no claim is being made as to this study being a comprehensive mapping of improvisational, music-centred music therapy in dementia care homes, our hope is that this first attempt at identifying and classifying music therapy strategies in residential carehomes will contribute to substantiating and clarifying the temporal, spatial and social complexities of music-centred music therapy practice in situ, and also to a musical reframing of residential care homes. The micro level moment-by-moment shared musicking, as well as the meso- and macro- level engagements identified in this study suggest that care homes are sites well resourced with collective musical-social histories, whose resilience and flourishing can be animated with, and co-constructed by, all who visit, live, and work in, such contexts. Thus, all persons within the care home (whether cleaners, family members, managers or residents) can be invited and supported to participate in generating, sustaining and animating social-musical networks and pathways, through contributing to musical repertoire, participating in impromptu musical encounters in the corridor and so on. We propose that self-narratives and self-identities that restrict persons to their work status or lifelong condition can be reconfigured towards more complete narratives and identities through participative therapeutic musicking. This modest practice-led study signals that providing musical opportunities for flourishing, for shared participation, and for people experiencing themselves as more than being in a ‘staff’ role, having ‘disorders’, or being ‘in distress’ are at the core of music therapists’ strategies. On such basis, managers and funders of services might consider an extended brief for the music therapist’s role, to include using music to generate and maintain a sense of wellbeing throughout residential care settings. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Notes 1. Christopher Small (1998), uses the term musicking to discard the notion of music as ‘object’, and emphasise the activity of doing music among and between people, and the corresponding musicalsocial relationships and networks that musicking activates and animates. 2. The six practitioners are: Jane Gibson, Janet Graham, Rachel Millman, Harriet Powell, Richard Sanderson and Stuart Wood. 3. Direct quotes from transcripts and written narratives are identified as follows: ‘FG’ (focus group, e.g., ‘FG1; 1; 2–4’ would mean ‘focus group 1; page number 1; lines 2–4’), ‘N’ (accompanying narratives of videos), and ‘J’ (research journals).

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Author Biographies Merce´de`s Pavlicevic is Director of Research and of the PhD programme at Nordoff Robbins Music Therapy, and Research Associate at School of Oriental and African Studies (SOAS), University of London. Giorgos Tsiris is Research Assistant and a student on the Nordoff Robbins PhD programme. He is a music therapist at St Christopher’s hospice. Stuart Wood leads the Barchester Nordoff Robbins Initiative (BNRI) as Head music therapist, and is a student on the Nordoff Robbins PhD programme. Harriet Powell specialises in music therapy with older people, including those affected by dementia, and facilitates care-staff training. Harriet has delivered music therapy through partnerships between Nordoff Robbins and Camden Adult Social Care, Camden Training and Development Services. In 2011, she was awarded the Camden Unsung Heroes of Music Award. She is a musician and co-director of music/drama projects, including devised performance projects with older people and training of care-staff. Janet Graham was most recently Head Music Therapist for Nordoff Robbins North East, having previously worked as a music therapist in the rehabilitation, dementia and nursing home units and as a tutor on the Nordoff Robbins Masters in Music Therapy training programme in London. Richard Sanderson is a tutor on the Nordoff Robbins Masters in Music Therapy programme (Manchester base) and is a music therapist in a residential home for older people living with dementia in the North West. Rachel Millman was most recently Head Music Therapist of Nordoff Robbins South West, and has worked as a music therapist with people with dementia and neuro-disabilities. Jane Gibson has tutored on the Nordoff Robbins Masters in Music Therapy programme for many years, and has substantial clinical experience. Prior to her retirement in 2012, she delivered music therapy at a residential care home in the South West.

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