When I read Vicky Abad's article, "Reaching the Socially Isolated Person With Alzheimer's Disease Through Group Music Therapy Work" (Vol 2, #3, 11/02).I realized the similarity it had to what I experienced when I was nine and had a traumatic brain injury. Like a person with dementia, I often couldn't remember the date, what I had for breakfast, or anybody's name. My strengths came in my long-term memory, which held many pointless tidbits of information that I could randomly recall. I understand that people with dementia may have had a significant amount of personality change, and therefore may not be able to interact as a healthy person would. It is easy to become bitter and mad at the world because more often than not, an elderly person doesn't have family and friends with which to share the wonders of life. Like a person with Alzheimer's disease, I could not interact with my friends because none of them liked me. My personality was substantially different and no one wanted anything to do with me because I was not the person they remembered.
The negative effects of the issue of social isolation and other dilemmas may be effectively addressed through group music therapy work. Although it is a struggle to simply maintain the will to get up in the morning, music groups may provide motivation where there has been none and ultimately, address interpersonal problems using music as a medium. A music therapist may implement a song writing activity in which the patient expresses him/herself through lyrics, or through an interacting improvisation. A person may write a song about a holiday that is nearing, or write a song to express their like or dislike with a facet of his/her life, lack of friends, or complex medical procedures. I remember how scared I was when I had to go into the x-ray room for repeated CAT scans. I cried and held my mother's hand as they put my head in the scary bright tunnel. It was terrifying for me as a child to go through so many alien medical procedures and I can only imagine it being equally as terrifying for a person with dementia. The frustration of having all of these medical personnel around doing strange procedures is a likely catalyst for creating a stressful and unpleasant environment for the patient. Personally, I think it would have been beneficial for me to have musical enjoyment while dealing with the frightening experiences I endured while hospitalized. After being returned to my room, I would always listen to several of my favorite songs, over and over. This, I feel, ultimately helped me to retain my language capabilities and relax after a long, confusing day.
When I started school two months late in the fall, I would often become angry when the teachers would give me extra leeway in doing my assignments. I was convinced that I was still exactly like all of the other students. In reality, this was far from the truth. I think a music therapy group would have been highly beneficial in helping me learn how to interact with my peers. There could have been many cognitive and academic benefits as well. However, this was not a time or place where music therapy was used and I was expected just to re-enter regular class and have an easy time adjusting. I tried so hard to be 'cool' and to do the things I used to love to do with my friends; only I couldn't remember too well what these things were or how I acted before my accident. I would often become disoriented and experience visual hallucinations, such as bugs on my bedroom ceiling, that would cause a high level of stress and anxiety for me. On a daily basis, after I was tucked into bed, when my mom turned off the lights and closed the door, I would holler for her to come back and protect me. To my dismay, as soon as the lights were turned back on, the bugs disappeared and everything was fine. People who experience dementia of any type may have similar experiences that need to be talked about and worked through.
I can only imagine the fear and anxiety that those persons with various diseases feel every time they wake up. Being able to voice those fears aurally or through playing instruments can help the socially isolated work through some of the inner turmoil that he/she experiences. In 'John's' instance in the article, his frustrations became too extreme for any of the personnel to deal with. It was in working through this frustration and agitated states through musical expression and processing of his feelings that 'John' was able to become a happier, well-adjusted individual. This is only one example of how useful music therapy can be for patients with dementia. There are many problems that the elderly need to address and through music therapy it is possible for the individual to come closer to what was once known as a normal life.
Abad’s article about group music therapy for a person with Alzheimer’s disease (AD) is very touching and encouraging for those who may have friends or loved ones with the disease. Although I do not have any immediate friends or family members with AD, I am currently doing my practicum work at a nursing home where I work with an individual with late-stage AD. She has reached the point where she can no longer verbally communicate with others and some of the people around her may think that she has been completely lost to the disease. She used to have a friend or family member visit, but she has not been seen in months and there have been no additions to her room, such as flowers or cards, or gifts of any sort. Even though others may think this I have seen music therapy work with this individual. She responds to the music. She may not be able to sing a long, but she is able to relax and her anxiety is decreased. When we first enter the room you can see how visibly distressed this client is, but then the music starts and she hears her familiar songs. She responds to the music with her signature laugh and immediately becomes more relaxed and at ease.
What touched me the most about Abad’s article was her statement about personhood. Kitwood (1992; 1993) as stated by Abad (2002) that “we need to see the person with dementia as a whole and develop a sense of personhood. He stated that dementia is the result of a complex interaction between the person’s personality, their physical health, life history, social psychology, and their neurological impairments. These factors combine to make a person who they are, hence the concept of personhood.” Goldsmith (1996) as stated by Abad (2002) says “to concentrate on one of these only without proper regard to the others is to treat the person as less than a whole person.”
This is a very strong statement and something that needs to be remembered when working with people with dementia. John was deemed hopeless by the nursing staff, but the music therapist saw through what others said and found the person that was lost and alone. John became more involved with music therapy than any other program even as his disease progressed. He participated in group discussions, answered trivia questions and helped others figure out the answers. He also requested his favorite songs every week and complained that music ended too soon when the goodbye song was sung.
Justin Schrum, a music therapy student at Lesley University, responded to this article with an interesting quote about a new model of treatment called habilitation. According to Justin (2007) the goal of this model was to “maximize their functional independence and morale” not to restore the individual to how they used to be. I could not agree more with this approach. Alzheimer’s disease is described by Rybash, Roodin, and Santrock (1991) as stated by Abad (2002) as a “progressive, degenerative disease that attacks the brain and results in impaired memory, thinking, and behavior.” Individuals with this disease are not going to be able to return to who they once were, but it is our job to “maximize their independence and morale.” John was socially isolated and angry individual but music therapy improved his quality of life.
Abads final statement provides a good summary of why music therapy is needed with this population. “As dementia becomes more prevalent in our society, there will be a greater necessity to provide specialist care which encompass the person's holistic needs, hence the introduction of treatments that focus on the needs of people with dementia, such as music therapy, must be more readily accepted. We must see the person behind the disease (Kitwood, 1993) and provide individualized services that are flexible, specialized and person centred (Goldsmith,1996, p.35). These people deserve the best that we can offer as a society, the best we can provide that is specific to meeting their unique needs as people, people who have dementia.”
This article interested me because I am currently interning at a nursing home with residents who have dementia and Alzheimer’s disease. As I read Vicky Abad’s article I found myself bringing one specific resident to mind. This resident reminds me of John because he is a socially isolated man who has agitated, aggressive, and inappropriate behaviors. This man does not go to any of the activities held at the facility and constantly argues and complains to staff. He is in a single room, but his yelling and swearing carries out into the hall way where other residents can hear him. When I first began interning at my site I walked by his room and heard the yelling and swearing for myself. I was shocked because I had not heard any of the other residents express their frustrations this way. During my next supervision hour my supervisor explained this mans situation to me and said that the staff are frustrated by him and have deemed him difficult and behavioral. Much like John from Abad’s article was deemed “difficult to manage” (Abad 2002). My supervisor advised me to look past his aggression and see the man behind the disease. Abad finishes her article with the same sentiment. The disease is not the person, the disease is camouflaging the person, and if we are able to see past the camouflage we can find the person inside. My question is how can we see past such an aggressive and unpleasant camouflage?
Music therapy is unique in that it can find the person inside because it is individualized and person centered (Abad 2002). Music therapy addresses the social and emotional needs of individuals with Alzheimer’s and dementia (Abad 2002). The music therapist who worked with John went against the facilities advise of not to bother with him because there was basically no point. After their first meeting the music therapist found that John had enjoyed music in the past (Abad 2002). With this knowledge the music therapist was able to tailor group music therapy sessions to Johns needs. I wonder what my initial meeting would uncover about the resident at my facility. I also wonder how music therapy could help this resident.
Since music therapy is an individualized treatment it can be tailored to fit individual needs. In the case of an individual with dementia and/or Alzheimer’s disease, music therapy can improve the quality of life of these individuals by addressing social and emotional needs (Abad 2002). In the case of John, the music therapist found out that he enjoyed listening to music when he was younger and had favorite songs that he loved to sing (Abad). In order to tailor music therapy to an individual we must find what music is preferable to them. Using preferable music in music therapy sessions motivates the individual to participate (Clair and Memmott 2008). With the integration of preferred and desired music comes the integration of emotions, memories and association that the individual experienced in the past from the music (Clair and Memmott 2008). This in turn addresses social and emotional needs of the individual.
Music therapy also offers structure and consistency. In the case of John, the music therapist suggested that he attend two different groups, Music Therapy Stimulation Session that met four times a week and Music Appreciation Session that met ounce weekly (Abad 2002). John was attending music therapy sessions everyday and only complained when music ended (Abad 2002). This provided consistency because the session met at the same time everyday with about the same number of people in attendance (Abad 2002). This also provided structure because within the session John was experiencing similarity in music and content. Music provides predictability, order, and structure in a reality that can be unstructured (Clair and Memmott 2008). Music can also provide familiarity in an unfamiliar environment (Clair and Memmott 2008). This may be helpful when an individual is residentially placed in a nursing home because the unfamiliar setting can create anxiety. Music can provide some familiarity that may make the transition less stressful for the individual.
Music is engaging, motivating, and stimulating. Music provides structure, consistency, and familiarity. With this in mind I can see how music therapy would be beneficial for the individual at my internship site who is suffering from dementia which is causing his aggression and agitation. The case of John reminded me of this resident because they seem to have similar behavior and social needs that are not being met by any other treatment. Music therapy can break through the barriers established by the resident, the staff and other residents and allows the music therapist to work with the person behind the disease. Abad’s article put into context a man who I did not know how to help through music therapy. The case of John was very interesting and inspirational for me especially because I am interning at a dementia and Alzheimer’s nursing home.
References
Abad, V. (2002). Reaching the Socially Isolated Person with Alzheimer's Disease Through Group Music Therapy- A Case Report. Voices: A World Forum for Music Therapy. Retrieved November 23, 2009, from https://normt.uib.no/index.php/voices/article/view/101/78
Clair, A. A., & Memmott, J. (2008). Therapeutic Uses of Music with Older Adults (second ed. , pp. 79-113). Silver Spring, MD: American Music Therapy Association.
Since starting my internship, I have come to realize just how difficult it is to not only help those with Alzheimer's disease and dementia in music therapy sessions, but also to physically and emotionally care for them. I work as a music therapy intern in a day-treatment facility for those with the debilitating disease. I am amazed at the responsibilities the families and the staff share in caring for the residents, and I admire the fact that the facility has adopted a mission in the treatment of the residents that is a model of care known as "habilitation." Joanne Koenig-Coste and Dr. Paul Raia of the Massachusetts Chapter of the Alzheimer's Association have coined this distinct definition of care:
I found this viewpoint of care to be quite influential to not only the residents, but also the staff who see these individuals day in and day out. Abad (2002) mentions this aspect in her paper:
After a few weeks of observation, I became well-aware and completely understood their mission and I began comparing "habilitation" to the model of music therapy with which I align myself. Once beginning my training as a music therapist, I immediately identified myself as a humanistic person. Focusing on the reasons why I wanted to become a music therapist (growing interest and care in my relationships with others, my love of music and my distaste in performing), I immediately knew that the humanistic theory is how I wanted to work. My own viewpoints about humanism are ones that include no pressure on the client, and an environment that is supportive and strengthening. Forinash (2005) writes of humanistic theory as "the focus is on recognizing the client as a complex being who exists in a relation to the world, and helping the client achieve meaning and fulfillment in a variety of life circumstances."
The facility where I work bases their mission off of the humanistic view of psychologist Abraham Maslow. The humanistic theory of music therapy aligns well with this suggested care of Alzheimer's patients. "Habilitation starts with the premise that there is an innate drive in all people to maximize their potential, even as we would apply it, when the person is afflicted with a dementing illness (Koenig-Coste, Raia, 1996)."
Abad's report of John, an elderly man suffering from Alzheimer's disease, really emphasizes the meaning of humanistic treatment and person-centered therapy. Those living in these facilities receive the utmost of care and support from their caregivers. I began thinking about the places where those in music therapy live, and I wondered if there is a consistent model of care like humanistic and habilitation, especially between the staff and the therapists.
For John, his aggressive behaviors were beginning to push him away from the staff and eventually other people in the nursing home. "Interactions with other residents and staff almost invariably resulted in John becoming aggressive, raising his voice and striking out at others (Abad, 2002)." It was clear that John needed some support not only from the nursing home staff but also in group music therapy to help increase his exposure to others in a healthier environment. After observing the residents at the day treatment program where I intern, I began to see what Abad mentions about those with the disease being "socially isolated." Early in the morning, I greet the residents as they sip their coffee and eat their breakfast. I make an effort to get to know them and really see the world from their perspective. Most of them don't really talk to each other very much and they seem completely closed off. The disease has really restricted them in terms of their communication. They really come together when involved in the recreational activities and in group music therapy.
There are several opportunities for the residents to attend groups and meet one-on-one with an expressive, art, or music therapist. The groups are not a mandatory requirement for these people, as some members get up in the middle of the group and leave. While hearing a myriad of complaints such as, "Tell me the quickest way out of here" or "What time is it? I gotta go home soon," I was amazed at the patience of the staff in dealing with the residents.
I was looking forward getting to know the residents both in music therapy groups and was interested in seeing their response to songs and drumming. Those who I had once thought were quiet and reserved now were open, singing and smiling. Seeing two residents wave to each other across the room and then hug each other brought a smile on my face. The singing and dancing had really brought them together. I felt the facility remained true to their mission and the residents' quality of life was improving by being socially active.
I was observing a drumming session one day when I began questioning this work. In a group of about 10 residents, a resident, who is a reverend, was a participant. The group was happily drumming along when, after the music stopped, the reverend suddenly spoke up. He asked the therapist, "What am I supposed to get out of this?" He then went on to say that he really was not getting anything out of the drumming and quite forcefully wanted the therapist to tell him the purpose of all this. The therapist told him that drumming helps improve your immune system and is a way to bring everyone together. The reverend didn't know how to respond. Most of the residents seemed really happy during the drumming session and I was in awe of what just happened. This led me to wonder about the reverend's role in the group. In the group before drumming, the chaplain leading the group always asks the reverend if he would like to lead them in a prayer and the reverend always does. I had mentioned the reverend's distaste with the drumming with my supervisor and professors. They had hypothesized that since the reverend was not a "leader" in the drumming group, he may have had to question the meaning of what he was doing in order to fulfill a need to "stand out". The staff questioned whether or not he should be in the group in the future.
A few weeks had passed and I was singing songs and leading a drumming session during our "Community Music" group. What struck me about this meeting was that the reverend didn't show any problems with the drumming or the singing. But what I had noticed was that he was sitting next to his primary caretaker the entire time. This little tidbit of information proved useful in the future. After the rearranging of some group members, my supervisor had decided to try the reverend in the drumming group again. Wondering if he was going to reject the process again, I was amazed when he questioned the purpose of the drumming and the same conversation ensued. When being escorted out of the room and to the next activity, the reverend said "put me by someone that I know." This brought me back to the idea of the socially-isolated resident. I witnessed the very important need for familiarity with this population. I compared this incident with Abad's successful story of John. John's love of music was an indicator that music therapy was the right thing for him. His involvement in the group allowed for his behaviors to subside and his social isolation to decrease.
In the case of the reverend, I was constantly asking myself the overwhelming question of "How do you know music therapy is right for a client?" Should you listen and respect what they have to say? Should the therapist meet with the resident one-on-one in an effort to understand the opposition? Reaching the Alzheimer's patient can be a great feat and the idea of a humanistic model of care is central in the support of an Alzheimer's patient. "For caregivers, the primary learning task becomes how to value what is still there, and not dwell on what the person has lost (Koenig-Coste, Raia, 1996)." I feel very privileged to be working at a site where the mission of "habilitation" really coincides with my future work as a music therapist. The support that is in humanistic music therapy and "habilitation" care is so helpful with this population and the use of group music therapy creates socialization that speaks vividly to the socially isolated Alzheimer's patient.
References
Abad, V. (2002). Reaching the Socially Isolated Person with Alzheimer's Disease Through Group Music Therapy- A Case Report. Voices: A World Forum for Music Therapy. Retrieved November 15, 2007, from https://normt.uib.no/index.php/voices/article/view/101/78
Forinash, M. (2005) Music Therapy. In C. Malchiodi (Ed.), Expressive Therapies (pp. 46-67). New York: The Guilford Press.
Koenig-Coste, J. & Raia, P. (1996). Habilitation Therapy: Realigning the Planets. Alzheimer's Association: Massachusetts Chapter, 14. Retrieved November 17, 2007, from http://www.alzmass.org/newsletters/prior2000/habilitation_therapy.htm