[Original Voices: Perspective on Practice]
By Cornelia Hessenberg, Wolfgang Schmid
In this article an intergenerational music therapy group including persons with dementia and children and adolescents in psychiatric care will be introduced. The special feature of this group is that people with dementia and children and adolescents in psychiatric care come together to make music. Young and old participants share important life issues such as the experience of a stigmatizing illness, or not being able to live in their familiar environment any more. The promotion of social skills and resources, as well as the support of emotional expressivity, and reminiscence work are particularly important in the intergenerational group. The article presents the project with its contents and discusses it with respect to theoretical perspectives from music therapy, sociology and gerontology.
Keywords: Persons with dementia, children and adolescent psychiatry, intergenerational music therapy, inclusion
In the intergenerational music therapy group persons with dementia and children and adolescents from a psychotherapeutic educational center (HPZ) come together to make music with each other. The HPZ is an integrated institution for children and adolescents providing both the specialized treatment of a psychiatric hospital, and curative therapeutic youth services. The persons with dementia live in a home for the elderly situated in the same area as the HPZ. Both institutions are located nearby Wuppertal in Germany and driven by the Bergische Diakonie Wülfrath. The close neighborhood of the two institutions and a music therapist working in both fields are two basic prerequisites for the implementation of the project.
The project has been carried out since 1994 (Hessenberg 1994; 2006). After initially sporadic intergenerational group activities during school holidays, the music therapist and a visiting external colleague initiated the idea of more regular, weekly music therapy group sessions. Since 2006, the sessions have taken place once a week and are normally led by two music therapists, or a music therapist and a social worker. Usually up to six children and adolescents aged between 7 and 14 years, and 8-10 persons with dementia participate in the group. The sessions take place in the reception room of the home for the elderly, and the children travel there from their resident groups.
In music therapy literature work with children and adolescents in psychiatric care, and with individuals living with dementia is well documented. Music plays an important, role in the individual lives of young and old people (DeNora, 2000). Music therapy can support children and adolescents with psychological problems emotionally, improve their social skills and abilities, and promote their autonomy (Frohne-Hagemann & Pleß-Adamczyk, 2005). Gold, Voracek, & Wigram (2004) found in their meta-analysis on effects of music therapy for children and adolescents with psychopathology that in particular clients with behavioral or developmental problems might benefit from this therapeutic approach. In the field of health care for persons with dementia music therapy is an established therapeutic possibility (Aldridge, 2000; Brotons, 2000; Muthesius, Sonntag, Warme, & Falk, 2010; Ridder & Aldridge, 2005; Wosch, 2011). Music therapy has been found to lead to positive changes in the areas of agitation, anxiety and depression (Hicks-Moore & Robinson, 2008; Choi, Lee, Cheong, & Lee, 2009), and in the reduction of irritability and nighttime disturbances (Raglio et al., 2008).
Literature on intergenerational projects including music can predominantly be found in the field of music education and intergenerational education (Werner, 2010; Bowers, 1998). These publications focus on the encounter of children from schools or music schools and older people living in nursing homes. The authors of the present article did not find published conceptual works concerning intergenerational music therapy projects with persons with dementia and children and adolescents with emotional and social challenges.
The encounter of persons with dementia and children and adolescents in psychiatric care in a music therapy group provides constellations and dynamics similar to an extended family including the grandparent- and grandchildren generations.
The older participants of the group are located in different stages of dementia and are variously, and increasingly, dependent on professional care services. Therefore they often have to give up their autonomous lives in their own apartment or house, and move into a nursing home. The children and adolescents live in their resident groups due to problematic relationships within their families. In the HPZ they receive specialized psychiatric treatment combined with curative therapeutic youth services. During their stay they live apart from their families and their familiar environments including school and friends. All participants engage voluntarily in this project.
Each session includes recurring rituals, as well as spontaneous musical activities related to the needs and ideas of the participants. Welcome and farewell songs, in which everyone is greeted by name, frame the one-hour sessions. Usually a child or adolescent takes over this part. The welcome and farewell songs appear to be as important rituals for the orientation of both the older and the younger people. Noticeably everybody enjoys to be greeted by name in front of the group and seems to feel welcome and important. The recurrence of the same songs in every session provides a safe frame for all participants wherein an initial mutual perception becomes possible, founding a basis for further encounters.
It has turned out to be useful that each child sits between two older participants, to be able to calm down, and fully engage in the situation. Beside this every child can assist his or her older neighbor from time to time, for example holding the songbook.
Both generations show a very natural and playful wish to make music with each other (Malloch & Trevarthen, 2009). Usually, a musical give and take arises very quickly between old and young, supported by a friendly, open atmosphere. Singing favorite songs and playing and improvising on instruments are the focus of the sessions. These musical activities are the unifying element and clearly support and animate the encounter of the two generations (Cross & Morley, 2009). Young and old people identify themselves with their music and introduce themselves to the group with their preferred songs. In the mutual mediation of age-specific songs the children and adolescents develop a tremendous willingness to learn the traditional folk songs and favorite Schlager of the older people. For the latter the ability to still to pass on and teach their favorite songs despite cognitive impairment can be seen as an underrated resource as Ridder (2011a) suggests. In return the children and adolescents present their Hip-Hop-, and Pop-songs, and try to teach the older participants the texts and melodies. This sometimes causes curiosity in the older people, but also joy and admiration for the children. Beyond that, the joint improvisation of a young and an old person on instruments is of particular significance when it comes to building relationships between the generations. In these creative moments the whole group becomes an attentive audience, listening to the premieres, and providing them with applause and appreciation.
Songs as well as improvisations can work as starting points for personal stories of an old or young person. They may result in discussion rounds referring to the subjects of the lyrics such as friendship, loss and childhood in past and present times, which are important and of interest for both generations.
In the following paragraphs, four aspects, which are specific to the therapeutic setting of the intergenerational music therapy group, will be focused on:
As mentioned earlier the intergenerational music therapy group provides elements of a conventional extended family. Most of the older participants know these constellations from the past, as they grew up in families with grandparent, parent as well as children and grandchildren generation. Recent research shows that persons with dementia express the wish to live at home in their familiar environment with their partners and families as long as possible (von Kutzleben, Schmid, Halek, Holle, & Bartholomeyczik, 2012). In contrast, the children and adolescents are not so much used to intra-familiar encounters with the older generation, but are more often accustomed to family-structures with a single parent, or with children from different parents. Given this, the intergenerational group setting requires initially a higher adaptive capacity from the children than from the elderly.
By making music with each other, and talking about common life issues such as leave, exclusion, or the joy of music, a bridge is built between the young and the old people. Thus, for example, the children talk about their problems at school or home, and the difficulties they experience. This is understood and relativized by the old people. In return, the children, especially their lives outside their familiar circles, question the life-situation of the elderly. In this context themes like the growing dependence of the elderly on nursing care and professional assistance are also discussed in the group. Making music together inspires the participants to also discuss these difficult and often taboo topics, and contributes to the fact that the individuals feel valued and belonging. Often, a consolidation and extension of social competencies such as the joy of self-efficacy, or the development and delivery of mutual recognition and appreciation can be recognized in the groups´ participants. Essential parts of these processes are an increasing awareness for the weaknesses and strengths of others, as well as a willingness to give assistance. Understanding and communication can arise from these encounters, and participants find ways from being cared for to become active and engaged on their own and to care for each other. They are motivated to get involved, and give each other mutual support. They share their abilities and get positive feedback. Often strong relationships develop between young and old people. These relationships are characterized by respect, friendship and care.
The intergenerational music therapy group provides a resource-oriented perspective for the participants. Each group member brings in his or her natural musical abilities and talents. The latter serve as starting point for common musical activities. In this way the resources and potentials of all participants are stimulated through an equal collaboration between clients and therapist (Rolvsjord, 2010). From this perspective the group members as well as the therapists can learn from each other, can plan and run the sessions together. All participants actively contribute to the content and course of the therapy, bringing their competence in using music in their own lives. Old and young people very naturally engage in a playful activity, explore possibilities and often surprise themselves and others with the way they sing a song, or improvise on an instrument for the very first time. With this explorative activity they access and experience their creative resources, and can experience self-determination, self-efficacy and a strengthening of their self-esteem (Schmid, 2005).
Especially in the joint improvisations of a young and an older group member, the activation of individual resources becomes audible. In these improvisations the creativity and spontaneity, as well as the fragility and vulnerability of the persons involved become audible. For the children and adolescents improvisation is a challenge and a release, as it “is fun and it is also a chance to be both free and in control, (which is) an important dichotomy for the adolescent” (McFerran, 2010, p. 144). For the elderly to improvise is mostly unfamiliar. But nevertheless most of them are brave enough to start with playing spontaneously, creating new, unfamiliar music, experiencing joy and accessing their hidden or unknown creative resources.
Singing, playing and improvising on instruments in the group facilitates emotional expression, vitality and shared experiences on a non-verbal level. Music is a structuring and regulating medium for emotions, providing room for a variety of emotional states the children and the elderly want to express. At the beginning, the children and adolescents often only have a small active repertoire of songs at their disposal. They enjoy singing together with the elderly, and often realize in the course of the sessions, that for the older people familiar songs are important as a means of guidance and emotional support. Even in people severely affected by dementia these resources are in place. For many teenagers playing or listening to music is a way of expressing their emotions, and therefore “an important facet of self-knowledge” (McFerran, 2010, p. 66). In the song repertoire of both generations the whole range of human emotionality can be found and expressed. A shared experience of joy, but also of sadness and grief becomes possible. This happens for example when children are released from the clinic, or when old people die; the group celebrates a farewell ceremony and sings a favorite song of the departing person. In this way “music is not communicative in the sense of sharing information. Instead, it is concerned with sharing feelings and experiences and the regulation of social behavior” (Trehub, 2003, p. 672).
Young and old people are emotionally more balanced, less anxious and overstretched after the therapy sessions. During the sessions the children and adolescents often calm down and can focus their attention to the joint music making for longer periods of time. The elderly become more attentive and lively by the presence of the children.
As mentioned earlier musical structures in the form of familiar songs, as well as greeting- and farewell rituals in the sessions, facilitate orientation in both generations. In addition music is a medium that encourages and supports individual remembrance and identification (McFerran, 2010; Ridder, 2011b; Tomaino, 2000). Both aspects are particularly important for children and adults, as they are facing fundamental changes in their lives and have to find strategies to adapt to several losses and challenges (Baltes & Lang, 1997). Young and old people identify themselves with certain songs or styles of music. The presence of the children reminds the old people of their own childhood, which significantly affects their presence and vitality during and after the music therapy sessions.
The preferred music of each person is directly connected with his or her individual biography, and music-associated events in life, as well as with the peer group (Pavlicevic, 2003). For both generations individual music preferences have a communicative function, expressing values, attitudes and belonging (Frith, 1981). Probably at no other time in life does music hold such a central role for representing identity, status and belonging, as it does in adolescence (McFerran, 2010). Gerdner (2007) found that individualization of music in music therapy is a key element in the effectiveness of this therapeutic approach with the elderly. Via the singing, playing and storytelling a bridge is built between individual biographies, and identity is (re-) constructed and updated (Engelhardt, 1997; Lauterbach, 2004). Music is utilized for both the expression of whom we are, and also of whom we want to be (Ruud, 1997). In this sense music provides a fundamental basis and context for the definition, maintenance, but also for the adaptation of identity.
Beside these four specific aspects the public relations and in particular regular feedback to the teams of the home for the elderly and the child and adolescent psychiatric service are essential components of the present project. Therefore a continuous documentation of the sessions is conducted. The observations and impressions are regularly incorporated into the team meetings of the nursing home. In the HPZ they are an integral part of the individual treatment plan for each child or adolescent.
Thus, a coordination and networking with other therapeutic and educational programs taking place in the institutions becomes possible, and the sustainability of the intergenerational music therapy project can be ensured. In addition, it has proven to be of great value to invite interested relatives, caregivers, and educators to the music therapy group from time to time. This allows the guests an immediate and extended glance on the strengths and resources of the group members, as well as on the special atmosphere.
Meanwhile the intergenerational music therapy project has become an integral part of the therapeutic offering, both in the home for the elderly and in the child and adolescent psychiatric service of the Bergische Diakonie Wülfrath. In the team meetings the observations and descriptions resulting from the music therapy group contribute a unique, resource-oriented perspective on the nursing home residents, as well as on the children and adolescents.
The intergenerational music therapy group includes young and old people who find themselves in a challenging life situation. Neither for the young, nor for the old people this group setting represents everyday life or normality. As mentioned earlier young and old group members share essential life themes, although being at different biographical life stages. This is a unique opportunity for most of the participants and provides important emotional experiences. "For young people in psychiatric care, these emotional experiences are so important, because due to their illness they have already undergone serious crises in their young lives. For the elderly with dementia this experience is so important, because they have to cope with numerous losses, and can find familiarity and security within the music therapy context” (Schäfer-Walkman, 2011, p. 3).
Due to the special composition of the group, the children can benefit from the life experience and the serenity of the old people, while the elderly may be inspired by the vitality and dynamism of the children. Basically the social roles and responsibilities are mediated implicitly in the intergenerational encounters. The elderly often represent natural authority persons for the children and adolescents. They encourage, support and regulate the children. Their mission is to pass on their experience and competence in the role of grandparents to the younger generation (Erikson, 1982). This allows the elderly to maintain a "dignified-generative function ... (which) is necessary in order to remain alive" (p. 81). These interpersonal dynamics are and seem to remain in place even in people with increasing cognitive impairments. Being accepted by others, by the adults and the peer group, is in turn an experience for the children and adolescents; they might not have very often. The social acceptance and inclusion is essential for building up their self-confidence and social competence. These capacities and properties become obvious in the group sessions when the children and adolescents show attitudes and positive behavior, not present in other contexts. According to McFerran (2010) the key elements of adolescents´ health and their connection to music are the four aspects of (1) identity formation, (2) resilience, (3) competence, and (4) connectedness to a cultural context (pp. 60). These positive factors unfold in the intergenerational group as well, and might not be applicable exclusively for the younger group participants.
Aging theories support this extended perspective when they point out that the subjective well-being or life satisfaction play key roles as indicators of successful aging. “The maintenance of activity, replacement of lost roles with new ones, and involvement in society and interpersonal relationships” (Lang & Baltes, 1997, p. 433) are seen as core factors for these processes. These key factors for human development can be extended to a life span perspective, defining factors for ongoing developmental processes our whole lives through.
Summarizing these aspects, two main themes are most evident in the encounters of persons with dementia and emotionally and socially challenged children and adolescents in the context of intergenerational music therapy. First, the encounters are nourished by the unifying gesture of music. Music involves people and builds sounding bridges, independent of age and state of health. Second, the encounter of the two generations explicitly and implicitly promotes very naturally common social roles and responsibilities. Each participant finds access to his or her musical but also social competencies and resources. This context promotes "social inclusion for people who are already extremely vulnerable or marginalized" (Schäfer-Walkmann, 2011, p.3). By emphasizing the aspect of social inclusion in this way, the present music therapy project provides an innovative psychosocial model for future intergenerational work as well as for the development of music therapy services.
 This intergenerational music therapy project received the Award to optimize the care for mentally ill elderly, FOPPAM 2011, in Berlin, 11.05.2011 by the DGGPP e.V. (Deutsche Gesellschaft für Geronotpsychiatrie und –psychotherapie), Wiehl/Germany.
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