Addressing Issues of Ethnicity and Identity in Palliative Care Through Music Therapy Practice
By Lucy C. Forrest
[The article presented here is republished from The Australien Journal of Music Therapy Vol 11, 2000 with the kind permission from the publisher and the author.]Abstract
In preparing for their death, patients with terminal illnesses may express a need to explore and confirm their identity in terms of their familial, social, cultural and ethnic heritage. This paper examines the mechanisms which underlie the construction of individual and basic group identity, the latter of which is also referred to as ethnicity. The maintenance and evolution of identity over time and across different places is explored, and the use of music as a means to construct, express and sustain identity discussed. Finally, the role of music therapy, and specifically the use of music-facilitated life-review in addressing issues of ethnicity and identity in palliative care is explored through the case study of 'Gretel', an Australian woman of Russian descent who was diagnosed with a terminal illness.
This article is based on a paper written in partial fulfilment of the Masters of Music Degree in Ethnomusicology at Goldsmiths College, University of London, 1999.
Each of us seeks to define and maintain our sense of identity in terms of the familial, social, cultural, ethnic and historical heritage of which we are, or would like to be a part. The identity of patients with terminal illnesses may in many ways be challenged and controlled, defined and at times consumed by illness, and the loss and grief associated with this illness. For patients who have emigrated from the country of their birth, the issue of identity may be affected by factors such as their physical separation from the land and people of their ethnic and cultural birthright, their degree of assimilation into the culture of the society that they have entered, and the extent to which their cultural customs, beliefs and traditions are maintained (Bright, 1996).
Towards the end of their lifetime, patients who have a terminal illness may express a need to return to, explore, re-establish and confirm their identity as a member of their family, social circle and wider cultural and ethnic heritage. This may be evident through a process of reminiscence and/or life review, and enable conflict resolution and preparation for death. Music may play an integral role in this process (Munro and Mount, 1978), triggering memories of other times, places and people (Stokes, 1994a), and providing a creative means of communication and expression (O'Callaghan, 1989a). Through their musical experiences, patients who have a terminal illness can potentially explore and resolve the issues and conflicts they are facing, and reaffirm their identity in preparation for death.
Ethnicity, Identity and Music
The concept of identity has been examined by psychologists, social scientists and anthropologists alike (Erikson, 1959; Freud, 1922/1959; Isaacs, 1974). Researchers have discussed the traits and characteristics that contribute to, shape and influence individual and basic group identity, the latter of which Isaacs (1974) describes as "the identity derived from belonging to...an 'ethnic group'" (p.15). From the time of birth, individual identity is inextricably linked with basic group identity (Isaacs, 1974; Peterson, Novak & Gleason, 1980).
Basic group identity is acquired at birth (Isaacs, 1974), and recognises each individual as "speaking from a particular place, out of a particular history, out of a particular experience, a particular culture, without being contained by that position" (Peake & Trotz, 1999, p.4). Basic group identity may be determined internally by members of a group - through the presence or absence of specific characteristics - or externally by someone outside of a group (Isajiw, 1974). This phenomenon can be observed in relation to the indigenous peoples of Australia. Internally, these people may be divided into different groups that are defined by specific relationships, customs, beliefs, languages and other identifying characteristics, whilst externally, they may be referred to collectively in relation to non-indigenous Australians (Magowan, 1994).
The characteristics which construct and define basic group identity, and hence individual identity include shared national, regional or tribal origin and ancestral descent, historical context, culture and customs, religion, physical characteristics, language, values and beliefs (Isaacs, 1974; Isajiw, 1974). Importantly, Isaacs (1974) suggests that basic group identity is shaped not only in terms of descent from an inherited past, but also by the circumstances of the present, such as the relative political, social and economic status of one group to the next.
Culture is a "primary defining characteristic" of basic group identity (Keyes, 1976, p. 203), articulating "a particular people's values, value systems, beliefs and ideologies which give meaning, logic, worth, and significance to their existence and experience, within a particular context" (Kanitsaki, 1991, p. 68). However, Keyes (1976) suggests that culture may undergo considerable change through the course of time and with movement from one place to another. Similarly, the boundaries of basic group identity are not necessarily static through time and changing circumstances, but may be impacted upon and evolve in response to factors such as migration and assimilation of or conflict between individuals and communities (De Vos, 1995, p. 16).
The basic group identity of migrant groups which come into contact or conflict with one another is shaped by the populations which they leave and enter, both in terms of each population as a separate and discrete entity, and through contact between different populations (Keyes, 1976; Petersen et al, 1980). Contact between peoples of different cultures may result in the maintenance of certain aspects of culture, a degree of assimilation and/or syncretism between cultures, the potential emergence of new identities shaped in terms of both the old and the new culture (Isajiw, 1974; Keyes, 1976; Petersen et al. 1980), or the disintegration and rejection of previously accepted group identities "imposed by stronger on weaker groups" (Isaacs, 1974, p.30). As such, it is possible for individuals - in this case migrants and their descendants - to be members of more than one group, constructing different identities through a process of acceptance, rejection and/or assimilation in relation to each group. Elements that constitute an ethnic culture may also be shared or not shared across different sub-groups of people of that culture. For example, two groups of people of the same ethnic culture may practise the same religion but speak different languages (Isajiw, 1974; Petersen et al. 1980). Importantly, "ethnic groups, unlike races, are not mutually exclusive, but are structured in segmentary hierarchies with each more inclusive segment subsuming ethnic groups which were contrastive at another level" (Keyes, 1974, p. 208).
The elements that shape and define individual and basic group identity are contained in and communicated through the history, mythology, folklore, art, music, literature, religious beliefs and practices of ethnic culture (Isaacs, 1974). This article explores the role of music in creating and maintaining identity.
Like other arts, music may be used to maintain identity at three distinct and yet inter-related levels. First, at a social level, music may define and articulate social identities and boundaries, communicating information about the world as it is understood by people at a particular time, in a particular place and within a particular cultural and social context (Stokes, 1994a; Waterman, 1955). Music, song and dance may be used to teach aspects of culture and social organisation, or to transmit a group's view and experience of the world from one generation, community or society to the next (Magowan, 1994; Waterman, 1955). Interestingly, Stokes (1994a) suggests that music may be both a symbol of social unity and cohesion - bringing people together in celebration and communion - and a symbol of social difference, disunity, even violence or oppression - highlighting the strength, power and aggression of one group of people towards another.
Second, music may be used to develop or perpetuate individual identity (Stokes, 1994a). Music may not only reflect society and social boundaries, but also enable individuals to assert, negotiate and transcend the boundaries and hierarchies of their accepted or inherited identity, and place in the world (Baily, 1994; Stokes, 1994a). Further, individuals may develop multiple personal identities, each of which is embedded in a specific set of social and musical boundaries (ibid.)
Third, music may define identity historically, reminding the listener or performer of a specific time and place, and triggering thoughts and memries associated with that time (Stokes, 1994a). For individuals and groups living in multi-ethnic societies, music may maintain "a sense of shared ethnic and historical identity" (Allen, 1988, p.20; Allen & Groce, 1988; Baily, 1994). Music may also provide "a ritual of stability in an unstable world" (Small, 1987, p.19), passing through time and changing circumstances, and from one generation to the next, to be performed in circumstances which are perhaps very different from those in which it was conceived (Baily, 1994; Blacking, 1977). Importantly though, music may not only reflect society, social experiences and historical traditions, but also become a means by which these structures undergo transformation (Stokes, 1994a, 1994b).
One of the most distinct consequences of globalisation and modernisation is world-wide movement of people, resulting in places becoming "thoroughly penetrated by and shaped in terms of social influences quite distant from them" (Giddens, 1990, p.18) Whilst contact - direct or indirect - between different peoples may result in the fusion and syncretism of different musical styles, social forms and cultural identities, it may also potentially create a sense of confusion and dislocation for individuals seeking to define their identity in terms of a particular community or society within a specific time and place. Contact between different communities, and the exchange, retention or abolition of cultural, social, musical and other elements alter the fabric of the community or society in which individuals seek to define themselves, in turn impacting on identity formation. The process of establishing and defining identity may require that individuals dislocate themselves from one place, and then relocate in another place (Stokes, 1994a). Music can be a useful tool in this process. Musical events may trigger memories and experiences of other times and places, and also define the boundaries of the present, so that individual identity may be created in response to the circumstances of both the past and the present (ibid.).
Traditional Russian Folk Music
Originating in pagan times, the tradition of Russian folk music has been carried through the centuries, to tell the story of Russia's turbulent history, and the day-to-day lives and loves of the Russian people (Yurchenco, 1989). The songs are based on poetic texts of both beauty and drama, and express by turn the joy and sorrow of the Russian people. They also reflect "the varied folk ways of both city and country" and the characteristically "bold and dramatic imagery" of Russia - her mountains and valleys, her steppes and fields (Yurchenco, 1989, p.5). As such, the folk songs are integrally tied in with and expressive of Russian identity.
Until the early twentieth century, folk songs and music accompanied many activities of daily life in rural and urban Russia (Warner and Kustovskii, 1990; Yurchenco, 1989). Music, song and dance heralded the different stages and phases of the religious and agricultural calendars, the seasons, and related rituals and ceremonies; described the experiences, and especially the hardships, of work and war; and fulfilled an important role in the celebrations, and daily life and routine of the family (Warner, 1990; Yurchenco, 1989). From wedding songs and funeral chants, through historical and lyrical songs to industrial folklore, music and song have, through the centuries, defined, structured and been expressive of the life and soul of the people of Russia (ibid.).
The traditional Russian folk song repertoire is sung by men, women and children, although different types of songs within the various activities of daily life are divided into male/female categories, and sung by different age groups within the community (Warner, 1990; Yurchenco, 1989.) The tradition of singing byliny - historical songs describing the feats of Russia's heroes, and important national events - is passed from father to son, whilst each year, women and children welcome the arrival of Spring with song, and young girls herald the return of the lark with singing and dancing (Yurchenco, 1989). The funeral laments are sung almost exclusively by the older women of the community, whilst it is the young girls of the village who assist the bride in the singing of her wedding lament prior to her marriage ceremony (Warner, 1990). Non-ritual laments and some other forms of songs - such as the celebratory songs and dances, and the lyric songs - may be sung by men or women, young or old, and by people from all walks of life (Warner, 1990; Yurchenco, 1989). Specific songs may be used to identify individual singers with particular events or circumstances in their lives, to attribute them with a specific role, or to unite them with others of the same standing or situation (ibid.).
This division and structuring of songs between men and women, and young and old undoubtedly has a direct bearing on the identity individuals assume as they move through the various phases of life as a member of a particular community. Music, song and dance identify different sub-groups within the community, defining each in terms of specific roles and attributes, whilst also uniting the entire community through the shared experiences and responses brought about by the music and the activities of which it forms an integral part.
Ethnicity, Identity and Music Therapy in Palliative Care
Palliative care offers physical, social-emotional, psychological and spiritual care to patients who have a terminal illness and their families (Aldridge, 1996; Munro and Mount, 1978; Webster, 1992), and may be offered to patients in their own home or through specialist palliative care units and hospices (Munro and Mount, 1978; O'Callaghan, 1996), or, increasingly, through general hospitals (Webster, 1992). Working within an holistic framework, the primary principles of palliative care include the prevention or reduction of symptoms (Munro, 1984; Webster, 1992), and the maintenance or enhancement of the quality of life of the patient (Webster, 1992).
Music therapy is increasingly being found to be an effective intervention in addressing the principles of palliative care, and there is a growing body of literature exploring the use of music therapy to address the diverse and evolving needs of patients who have a terminal illness. 1 However, the literature exploring issues of ethnicity and identity in palliative care and/or music therapy practice is, in contrast, quite limited. Whilst it is acknowledged that issues of identity (Munro and Mount, 1978), and ethnicity and culture (Kanitsaki, 1989; Webster, 1992) should be taken into consideration when caring for and treating patients in palliative care, there appears to be only limited discussion about these issues. The concept of personal identity is explored by Aldridge (1995, 1996) in relation to issues such as spirituality, health and illness, and creative musical improvisation, whilst Munro and Mount (1978) suggest that music can be an effective medium through which to reinforce the personal identity and self-concept of the patient with a terminal illness. Aspects of ethnicity and culture are explored by Bright (1995, 1996) in relation to 1) issues of loss and grief for migrants and refugees, and 2) music cognition and response of clients receiving music therapy in grief counselling.
The sparse coverage of issues of ethnicity and identity in the music therapy and palliative care literature should be addressed for the following reasons. The issue of identity may be a prominent one for patients, as their lives are increasingly challenged, impacted on and ultimately overcome by illness. Isaacs (1974) suggests that the basic function of group identity is to provide a sense of belonging and to raise self-esteem. He suggests that group identity is most palpably observed through the body, shaping people's views of the world, and in turn shaping their perceptions of themselves. As patients become progressively less well, their changing physical health and appearance, abilities, role and status essentially equate to a loss of personal identity (Aldridge, 1996). Furthermore, the contact - or lack of contact - that patients have with their social, cultural and ethnic communities may impact on their feelings of isolation, anxiety and dislocation, in turn affecting their ability to 'relocate' (Stokes, 1994a, p.3) themselves in the ever-changing reality of their illness, and recreate or re-establish their identity within that reality.
Aldridge (1996) suggests that the loss of identity associated with a terminal illness may be compensated for to some degree through music and the creative arts, enabling patients "to explore and express their being in the world" through a creative medium that is not restricted or impeded by illness (Aldridge, 1996, p.216). As such, patients can use music to address the changes in their health, and potentially recreate their identity musically in response to these changes. The music that patients choose to hear, the songs they write, the instruments they play, and the modes, rhythms, tempi and dynamics they use in their playing are all expressive of their identity, whether proclaiming or whispering to the world "this is me and this is my reality".
Many western, industrialised societies - the people of which are currently most likely to be the recipients of palliative care and music therapy services - have become increasingly ethnically and culturally diverse, particularly during the latter half of the twentieth century, as large groups of people migrate trans-nationally (Bright, 1996). 2 The increasing ethnic diversity of society at large will undoubtedly impact to some degree on the ethnic diversity and cultural background of patients referred to palliative care and music therapy services in the future.
The implications of providing palliative care and music therapy services for peoples of varying ethnic backgrounds are profound, and require that service providers are aware of the ethnically and culturally specific "responses, customs and beliefs about death" of patients who are terminally ill (Bright, 1996, p.81; Munro, 1984; Webster, 1992). The ethnic and cultural identity of the clinician, perhaps shaped by circumstances quite different from those of the patient, may also impact on the provision of music therapy services (Aigen, 1996; Bright, 1996; Munro, 1984). Importantly, immigrants with terminal illnesses are dying in a land and culture that is often far-removed from that in which they were born, a situation which, in the context of palliative care, may trigger a range of issues relating to the patient's personal, ethnic and cultural identity. Music therapy can be effectively used with terminally ill patients to explore issues of ethnicity and identity in the context of their illness, as discussed below in the case study of Gretel.
Case Study - "Gretel"
Gretel was an 84-year-old Australian woman of Russian descent with terminal cancer, who was first seen for music therapy when she was admitted to hospital for respite, and ultimately terminal care. Her malignancy had been diagnosed just three months prior to her admission to hospital, and she had been receiving regular chemotherapy from the time of diagnosis.
Gretel's immediate family included her sister, her second daughter by her second husband and her granddaughter. Her second husband, whom she had met and married in Australia, had died several years previously.
Gretel had a diverse musical background, and clearly enjoyed music. She stated that she loved to sing and dance, and played the piano and the balalaika 3 . Her knowledge of Western classical music was extensive, as was her familiarity with many genres of Western popular and film music.
On admittance to hospital, Gretel's condition deteriorated rapidly. The Music Therapist visited Gretel daily, singing and playing western popular and classical music on the piano, as requested by Gretel, her sister, daughter and granddaughter, who were present at each of the sessions. She described the music as reassuring and comforting - reminding her of good times spent with her sister, her Australian husband and family, and her friends in Australia.
Several days after her admittance to hospital, Gretel's condition worsened considerably, and she appeared to be physically distressed: her breathing was becoming more laboured and irregular, and she was restless and highly agitated. Gretel also appeared somewhat confused, and poorly oriented to time and place, talking about her present reality and past memories alternately but as though they were one, in both English and Russian. She frequently commented that she was running out of time, and that she must "go back" and "find them", before it was too late. At times she confused her sister with her mother (who was deceased), and called her granddaughter 'Anja' (the name of her first daughter who died as an infant in Russia). Throughout she wept disconsolately, and seemed progressively less aware of the presence of her family around her as she became more preoccupied with her thoughts and memories. Gretel's sister, daughter and granddaughter were present during this time, and visibly distressed by Gretel's obvious distress and the fact that she did not appear to recognise them for much of the time that they were with her. They spoke to her in Russian, but Gretel's response was confused and unclear.
At this point in time, the atmosphere in Gretel's room was very tense. Gretel and her family members were all crying, and each seemed unable to support the others as they tried to come to terms with their own distress. The Music Therapist talked with, counselled and comforted the family, discussing Gretel's behaviour in relation to her illness and answering the family's questions regarding this. Gretel appeared to be trying to return to and resolve some part of her past and reconcile this with her present, as indicated by her comments of needing to "go back" and "find them", and her continuous movement between the present and her memories of the past.
Through discussion with Gretel's family, it was ascertained that Gretel and her sister had been forced through circumstance to leave their family and Gretel's husband and baby daughter, and flee Russia as young adults during the Second World War. They emigrated to England where they remained for the duration of the war, and where they had planned to wait for and rejoin the rest of their family. However, in 1946, they received the news that no member of their family had survived. Knowing that they could neither return to their homeland nor remain indefinitely in England, the two sisters decided to emigrate together to Australia.
Gretel's sister stated that she and Gretel had never talked about their flight from their homeland or the loss of their family from that time onward, although they spoke often of their childhood and growing up in a small rural village in Russia. She described Gretel's love of Western popular music as developing first in England, and later in Australia, but stated that they had both grown up surrounded by Russian folk music and classical music, although Gretel rarely sang the folk songs of her youth after emigrating to Australia. Gretel had not shown any discomfort or unease on hearing Western popular or classical music during her previous music therapy sessions, and the music had not appeared to trigger a significant emotional response in her or facilitate the exploration of any issues or conflicts. Hence it was assumed that the conflict that she appeared to be experiencing stemmed from an earlier period of her life, most probably from the time of her flight from her homeland.
The Music Therapist suggested that the singing of songs related to this time of Gretel's life may help in triggering memories for her, and assist her in addressing and resolving the issues related to these memories, which in turn would allow her to begin to reconcile these memories with her present reality. The Music Therapist then discussed Gretel's past with her family, including her childhood and adolescence, and the songs that Gretel had enjoyed as a young woman.
Presently the Music Therapist and Gretel's family seated themselves around Gretel's bed and sang several popular Russian folk-songs from Gretel's youth: soft, reflective ballads, lullabies, laments and love songs. These were sung in Russian, a cappella or accompanied by the music therapist on piano or guitar, and were interspersed with classical and Western popular songs that Gretel had chosen in previous music therapy sessions. Whilst the Music Therapist and Gretel's family were singing to her, Gretel gradually became very quiet, and her weeping eased. During the singing of a particularly sad ballad telling the story of a mother losing her child, Gretel began to sing softly with the Music Therapist. She then told of her flight from Russia during World War Two as a young wife and mother without either her husband or her baby, and her subsequent escape to England, and then emigration to Australia. She expressed her immense sadness, guilt and anxiety at having to leave her husband and sick baby daughter behind in Russia. Her parents, husband and brothers were to follow them to England later, when the baby was well enough to undertake the hazardous journey; however, all died in Europe, as prisoners of war. Gretel then began to sing softly again, unaccompanied, and more to herself and with her memories than to the other people in the room. Her singing continued for several minutes, becoming softer and softer until it gradually just faded away.
The Music Therapist picked up the tail of the melody, humming softly to Gretel, and then moving into a different folk song: a ballad that told the story of a young man leaving his homeland and family. At the end of the song, Gretel told of her arrival in Australia, and the difficulty she had in adapting to her new country and home, without her family, "just like the young man in the song". She talked about her sense of loss and confusion at realising that her heritage and traditions - her language, stories, music and memories - had no place in this new land; and her sense of betrayal and guilt at abandoning these and taking on the Australian culture and heritage as her own, in order to survive. Gretel also described feeling envious of her younger sister who seemed to adapt so easily to her new home and life, and stated that she had never felt able to talk with her about their escape from Russia, or the loss of their family, even though they had always been very close.
The two sisters then sang many of the songs from their childhood and homeland, together with Gretel's daughter and granddaughter, sharing memories of their life together in Russia, and of their family, and talking for the first time of their flight from Russia, crying and laughing with each other, reminiscing, and sharing their anguish and pain. At times Gretel seemed to withdraw temporarily into her memories, as though completely unaware of and removed from her present reality. On returning to the present, she would frequently share some of these memories with her family or ask for another song related to her memories. Sometimes all four women sang together - Russian folk songs, Western popular songs and religious songs. At other times one or other sang alone, or the Music Therapist sang to them. At the end of the session, Gretel said she felt that her 'Russian family' - her parents, her husband and baby, and her brothers - were all very nearby, waiting for her, and stated that she felt "ready to go" because "everything was in order".
Although no longer restless or agitated, Gretel's breathing remained laboured, and later that night she slipped into unconsciousness. The following morning her family requested a music therapy session be held by her bedside, and a variety of Western and Russian songs were sung for Gretel and her family. The songs allowed the family to explore and express their feelings of loss and grief at Gretel's imminent death, and encouraged them to reminisce at length about both their 'Russian' memories and their 'Australian' memories, sharing and discussing the past in relation to their present reality.
Several hours later, Gretel ceased to breathe. There followed a period of music and prayer, during which time the family reminisced and shared their thoughts and memories of Gretel, whilst mourning her passing.
On speaking with Gretel's family later in the day, Gretel's sister, who was only 18 when she had emigrated to Australia, described the last few days of Gretel's life as being very important and special for her. She stated that she had felt 'lost' and 'incomplete' for so long, trying to forget and ignore what had happened to her and her family during the War. However, being able to share their musical memories, talk about their past together, and express the immense sense of loss and grief that she had been carrying since her youth was highly affirming and releasing. She described feeling 'frozen', 'lost' and 'completely terrified' when she arrived in Australia, uncertain, afraid and desperately yearning for her family and home. However, she also described feeling unable to talk with Gretel or anybody else of her feelings or fears, as though by refusing to voice her pain and fear, she could deny the circumstances that gave rise to these feelings and hence obliterate the harsh reality that meant that she had survived but her family had not. Denying and ignoring her past had kept an unbearably frightening reality at bay, enabling her to survive.
Gretel's daughter also described the last few days with her mother as being very special for her, and stated that although she had always known vaguely about her mother and aunt's flight from Russia, it was something that noone in the family ever discussed openly. She described feeling as though she never knew completely who she was, as though a piece of her life had been left blank. Despite frequent contact with her father's large extended family in Australia, she had no contact with anyone from her mother's extended family other than Gretel's sister and stated that she had always felt curious and sad that she knew relatively little about her mother's people and her Russian heritage. Similarly, Gretel's granddaughter expressed her regret at never having been able to talk with her grandmother about her life and memories from Russia, and stated that as a third-generation Russian-Australian she still associated herself very strongly with her mother's and grandmother's Russian heritage and identity, but at times felt torn between her Russian 'roots' and her Australian heritage. Both mother and daughter expressed a strong intent to visit Russia and explore their Russian roots together.
Reflections and Conclusion
In addressing issues of identity and ethnicity for Gretel and her family, the process of music therapy acted on a number of levels. First, it allowed Gretel to explore her present situation in relation to her memories, experiences and important life events. The music from her past, so long denied, triggered memories of long-forgotten or denied times, places and situations, allowing the expression of feelings of pain, loss and grief and the sharing of memories. Through the exploration of these memories and the resolution of issues or conflicts associated with them, Gretel was able to begin re-establishing and affirming her personal identity in the context of her family, society, ethnic community and wider cultural heritage.
Secondly, the music therapy process facilitated exploration of issues of ethnicity and identity for Gretel's family members, provoking discussion and examination of the differences between their experiences as first- and second-generation migrants in Australia, and Gretel and her sister's experiences as new migrants who had lived in two distinct and separate cultures. The musical experiences and preferences of each, as discussed during the music therapy sessions, also raised a number of questions regarding the maintenance of cultural heritage and ethnic identity within a multi-cultural, multi-ethnic society. Gretel's daughter and granddaughter described musical and life experiences that differed markedly from those described by Gretel and her sister, and yet the traditional music of their Russian heritage was able to transcend both the differences each felt at a generational level, and differences of time and place, uniting them immediately as members of the same family and cultural heritage. The connection each felt with their ethnic and cultural heritage appeared to be very strong for Gretel's descendants. This is despite the fact that their identity as first- or second-generation Australians had been shaped and defined largely in terms of a culture far removed in time, place and essence from that in which Gretel and her sister spent much of their youth.
Thirdly, the music therapy process impacted on and challenged the author to explore her understanding of the concept of identity, and how it is constructed and conveyed across different times, places and spaces, and within the context of palliative care. As a clinician of anglo-saxon background, the author found herself exploring the issues of death and bereavement and how these confronted her with her own mortality and impacted on her sense of personal identity as understood and shaped by 1) her ethnic and cultural background, 2) her present circumstances, and 3) her experiences of working with people who are terminally ill. The author also considered how, in turn, her ethnic background, cultural beliefs and sense of personal identity could potentially impact on the way in which she approached her work with patients who are dying, and patients whose ethnic and cultural background is different from her own.
There is little research exploring issues of ethnicity and identity in palliative care and the potential of music therapy in addressing these issues. Given that patients who are diagnosed with a terminal illness may express a need to engage in a process of life review and conflict resolution in preparation for death, it would seem that culturally specific music could be an effective medium to use in addressing the needs of patients of diverse ethnic and cultural backgrounds. Music that is culturally significant or meaningful to the patient may trigger memories of other times, people and places, potentially allowing patients to explore and resolve past conflicts, and to reconfirm their identity as a member of their family, social circle, and wider cultural and ethnic heritage in preparation for death.
The existing literature concerning the use of music to create and sustain identity points to the potential for using music in therapy to address the culturally specific needs of patients and clients, not only in the field of palliative care, but also in other areas of music therapy practice such as aged care. There is a need for further research to examine the different mechanisms that underlie the concepts of ethnicity and identity, including the effects of migration on identity formation, and generational and cultural differences of experience. The role that music may play in creating and sustaining identity, and the role that music therapy may potentially play in addressing issues of ethnicity and identity in fields such as palliative and aged care should also be further explored. This paper offers a preliminary discussion of the role of music therapy in addressing issues of ethnicity and identity in palliative care.
Notes
1) Aldridge, 1995, 1996; Bailey, 1983, 1984, 1986; Beggs, 1991; Curtis, 1986; Fagen, 1982; Hogan, 1998, 1999; Martin, 1991; Munro, 1984; Munro and Mount, 1978; O'Callaghan, 1989a, 1989b, 1996; Robertson-Gillam, 1995; Salmon, 1995; Whittall, 1991.
2) In Australia alone, the number of people born overseas has risen from 10% in 1947, to 23% in 1998 (ABS, 2000a). A further 27% of Australia's total population in 1998 had at least one parent who was born overseas (ibid.). Importantly, there has been a marked diversification in the country of birth of people entering Australia. In 1947, 81% of overseas-born Australians were born in the main English-speaking countries (Britain, Ireland, New Zealand, South Africa, Canada and the USA.), whilst in 1998, this figure had dropped to 39% (ibid). The 1996 Census reports that people born overseas originate from more than 200 countries, with 282 major languages being spoken within Australia, including 170 indigenous Australian languages (ABS, 2000b). Further, 92 religious denominations were classified by the 1996 Census (ibid), and 16% of the total population spoke a language other than English at home (ABS, 2000c).
3) The balalaika is a three-stringed instrument with a triangular body. One string is made of steel and is the melodic string, usually tuned to a, whilst the other two strings are usually made of gut or nylon, tuned a fourth lower, and played as accompaniment drones. The balalaika can be traced to the eighteenth century, at which time it had a pear-shaped body similar to the long lutes of that period (Baines, 1983).
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