[Original Voices: Perspectives on Practice]
By Patrice Dennis & Daphne Joan Rickson
This case story was undertaken as part of a research project investigating music therapy to aid relationships between people with dementia and their family members. Involving family members in the music therapy process was found to be valuable in fostering a sense of community between residents, family members, and care staff (Dennis, 2012). However, a sense of community was also fostered by the interactions of the residents themselves as they participated in music therapy over a ten month period. Music making became a natural part of the environment, an important medium for individual expression, shared communication, enhancing social events, and demonstrating mutual care and love. We demonstrate this through our case story of Jack whose music making permeated the dementia ward to invite the active participation of others, and led to the development of caring relationships.
Jack was an 82 year old gentleman who had a diagnosis of Alzheimer’s disease and resided in a secure facility that provides specialist care for people who have dementia. Alzheimer’s disease is a progressive disease of the brain which involves multiple symptoms including disturbances in memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement (American Psychiatric Association, 2000). People with Alzheimer’s disease are confused and can become irritable, aggressive, and experience mood swings, and withdraw from family and friends. They find it progressively more difficult to engage with activities of daily living such as dressing and eating. It is eventually fatal (American Psychiatric Association, 2000).
There were fifteen other people residing at the facility with Jack ranging in age from 65 years and onward. The physical environment was spacious with one large lounge, and several smaller sitting areas that provided a more private and contained environment where music therapy sessions might be held. The onsite multi-disciplinary team included doctors, registered nurses, a diversional therapist and caregivers.
The philosophy of the facility was one of person-centred care which encourages and nurtures residents’ individuality, dignity and self-worth. The New Zealand Ministry of Health (New Zealand Ministry of Health, 2002) highlights the need for service providers in dementia care to adopt person-centred approaches which focus on patient quality of life. They have suggested that interventions such as music and arts therapies can address the social and emotional needs of people who have dementia and are critical components of care programmes. There was no music therapist at Jack’s facility so the music therapy student, who is the first author of this paper, worked closely with and was supported by the diversional therapist. Music therapy programmes were offered to patients over a ten month period as a means of maintaining creativity, of reminiscing, facilitating social activity, communication, movement and helping to deal with the multiple losses that people with dementia and their family members face.
Haesler, Bauer, & Nay (2007) proposed that taking a holistic approach which seeks to understand the greater social system within which an individual functions, and which involves direct work with family members, is the best guarantee of wellbeing. The New Zealand Ministry of Health (2002) also acknowledges the importance of working with family members and carers of people who have dementia by encouraging providers to engage them in the care process in an on-going way. Music therapy which aims to engage patients in purposeful interaction with family caregivers can enhance the quality of life for both parties (Clair & Ebberts, 1997); is effective in facilitating expression and communication (Brotons & Marti, 2003); and can restore relationship reciprocity between people with dementia and their family members (Clair, 2002). Music can provide a way for family members to share, connect and process issues that are important to them (McIntyre, 2009). Dennis (2012) found that involving families gave her access to residents’ unique life histories, strengthened her relationships with residents, and facilitated shared meaningful moments between residents and families. Music has also been used to improve communication and the quality of social interactions and to promote positive relationships between staff caregivers and residents (Brown, Götell, & Ekman, 2001; Davidson & Fedele, 2011; Hammar, Emami, Engström, & Götell, 2011).
Various people have unique yet valid understandings and beliefs of what constitutes family. Each person is part of a greater social system, and the functioning within these systems allows people the possibility and capacity to belong, to care and to share (Drurie, 1998). The New Zealand Ministry of Health (New Zealand Ministry of Health, 2000, p. vii) suggests that a family is a set of relationships that is defined as family by the tangata whaiora. Family is therefore not limited to relationships based on blood ties, but can include a mixture of relatives, friends and others in a support network. A small community of people, who live together on a locked dementia ward, will share many features of what constitutes "family."
Ecological (Bronfenbrenner, 1989) and family systems (Piercy, 2010) theories both propose that individuals influence and are influenced by the environments they interact with, and underline the relevance of interpersonal relationships to foster individual and family/community wellbeing. Bright (2006) suggests music therapists need to work from a basis of cultural competence, which involves developing a deep sensitivity to, and understanding of the “social structure, customs, and spiritual context of the macro- and micro-cultures from which (patients) come” (p. 70). The requirement for music therapists to consider the interrelationships between social and cultural factors, and health and wellbeing has been well documented with the relatively recent emergence, or resurgence, of community music therapy theory (Ansdell, 2005a; Pavlicevic & Ansdell, 2004; Stige, 2004; Stige, Ansdell, Elefant & Pavlicevic, 2010; Stige & Aarø, 2012). Community music therapists have a primary focus to increase participants’ opportunities for participation in, and empowerment through, music (Ansdell, 2005b; Pavlicevic, 2005; Pavlicevic & Ansdell, 2004; Procter, 2004; Ruud, 2004a, 2004b; Stige, 2004, 2005, 2006). That is, they aim to help people to access a variety of musical situations and to develop sustainable musical relationships with other community members, by working in and with participants’ communities rather than in private spaces dedicated to therapeutic activity.
Ansdell (2002) suggests community music therapy involves “accompanying patients as they move between therapy and the wider contexts of musicking.” It involves helping people negotiate whether their actions might be private or public, and whether they might involve just the client, other residents or staff, or the client and the community (Ansdell, 2002). Performance can be considered to be one possibility in the community music therapy process, richly connected to other possibilities and sometimes and in some places it can be key (Ansdell, 2002). Performances create and sustain networks of relationships between and amongst people, institutions and communities (Ansdell, 2002) and reinforce and validate internal changes within patients as they experience being heard by others (Baker, 2013). In many ways Jack and his fellow residents, staff, and family members were disconnected by dementia, so creating and maintaining connections with others was a primary therapeutic aim. The student music therapist was therefore open to the possibility of performance emerging naturally as part of the process.
For clients whose circumstances have silenced them, performance can restore them to a sense of their voice (Baker, 2013). Baker notes that public performances may enable members of the community to discover a new appreciation and understanding of people who might otherwise usually be avoided because of their disability or illness. They can allow the community to see individuals as creative people who have an important and valid story to tell (Baker, 2013). Audience perception of performers can be transformed as they become connected during performances, and performers can thus receive support and validation from the audience (Baker, 2013). O’Brien (2006) found opera therapy, which has many parallels with community music therapy and results in a final product for performance, is able to unify multiple community partnerships.
On the other hand, Ansdell warns that performance is not a ubiquitous good for all. While it is a potential “resource” that can promote powerful experiences for individuals and groups and places, it can also be loaded with pressure, expectations and judgement. It is therefore not without risk for vulnerable people. Some therapists working in psychodynamic contexts have considered the idea of performance in music therapy to be “dubious” and problematic (McFerran, 2010, p.241). Ansdell (2005a) went so far as to say that some might even consider that performance for ill, vulnerable people, troubled people can be counterproductive, coercive, ethically dubious, professionally confusing and possibly dangerous. Music therapy is about process not product, and the therapist strives to be fully attuned to patients throughout the process. When there is a focus on performance as part of a therapy process, there is risk that the client’s issues or needs will be missed or ignored by the therapist (Turry, 2005). The use of performance in music therapy therefore requires active reflection on the part of clinicians who need to be mindful of their reasons for moving toward performance with people. It is important for example to consider whether clients can be fully informed about what a performance might involve, and who might benefit from it (Turry, 2005, O’Grady & McFerran, 2012). Therapists need to be aware of their own issues around performance.
While there is clear evidence that family members are often involved in the therapy process with people who have dementia, the literature contains little or no specific reference to community music therapy with this population. This case story is an example of how community music therapy approaches can be employed within residential care settings. The case begins with an introduction to Jack and a description of his individual response to music therapy including an account of the way in which music groups naturally formed, eventually to become fundamental to life on the ward bringing richness and joy to the community of patients. This is followed by an account of Jack’s final days with his hospital family. We celebrate in the knowledge that his music lives on through them. The music therapy process is told by the music therapy student who is the primary author of this paper and examples have been taken from her clinical reflections. The account is therefore written in first person prose.
Jack had immigrated to New Zealand from Scotland in the 1960s. He was described by his daughter as a great lover of music and dancing. His favourite artists included Shirley Bassey, Ann Murray, and “anything Scottish.” He had lived for three years at the facility having been admitted from his home when his dementia progressed to the point where it was unsafe for him to continue living independently in the community. I perceived Jack to be a warm, friendly and gentle man, with a sharp sense of humour. He was always quick to tell a story and reminisce about family, and Scotland. Jack had previous contact with music therapy students and his talent for playing the spoons was already well known. I planned to engage him in individual sessions focusing initially on his interest in percussion instruments. He could not remember my name during initial sessions and would repeat the same story each time he met me. However the drum and beaters needed no explanation, and Jack required no direction or modelling of how to use them.
In early sessions Jack appeared to have no interest in my attempts to accompany his drumming. He started without me, continued to play after my music had stopped, and his rhythm seemed perseverative. I worked with this by first matching his rhythm and tempo then introducing small changes. Gradually he was more able to attend. He began to look up at me when songs finished, acknowledging the shared nature of our music making. He appeared to be more present and his musical responses became more sensitive. Jack understood when he saw me that I was there to make music with him, and that he would drum. He would say “Hello, are we ready to go then, where are my sticks?”, and begin tapping his knees with his hands while I set up the equipment.
I introduced a “percussion station” of floor tom, bongos on a table, a cymbal on a stand, spoons, and a maraca, and positioned them so Jack could reach the instruments easily from his seated position and make his own choice regarding what he would like to play. This was the beginning of our improvised music making. At first Jack would establish a strong and steady beat on the floor tom which might continue throughout a piece. I would provide a steady accompaniment with few variations in rhythm or dynamics until I thought he might be ready to finish. I would then slow down to indicate the possibility of a cadence and Jack would match me, slowing his rhythm and stopping with me. He would even add a drum roll at the very end of the last phrase. Gradually he became even more creative; alternating between the floor tom and bongo drums, and seizing the opportunities I created for him to solo. His solos would include drum rolls and a cadential crash of the cymbal, before returning to the initial rhythm. He began to play a maraca, sometimes shaking it and sometimes gently using it as a beater on the floor tom. He was able to create interesting syncopated rhythms by combining the sounds of the maraca and drums.
Jack was clearly benefitting from having the opportunity to express himself in and through the music, but there were indications that it would be helpful for him to share his music more widely. First, it seemed that music making would remind him of his sister. He was able to tell me that she had been very musical, a wonderful singer and dancer, and he wished she could be with him to join in the music. So he was clearly used to sharing music with others. Second, he would approach and sit down with me when I was working with other residents. And third, one day in response to staffs request, Jack volunteered to say grace before lunch. He pulled the spoons out of his pocket and proceeded to play a spoon solo for approximately one minute. When he finished, he looked up, put his spoons down, and began his lunch. He had begun to use his music to connect with his hospital family.
I arranged for Jack to join four others for a group music session. Jack chose to play the drums and demonstrated that in this context he was still able to respond astutely to musical cues, endings and dynamics, and to perform drum solos, finishing with a drum roll. He looked up to other group members when he stopped and they would sometimes break into applause. Jack would make a brief remark such as “I really enjoyed that”, and resume his playing position. One group member commented “We are just like a band.”
The majority of the groups I facilitated would be open. People were free to come and go as they wished. I would position chairs in a circle in one of the smaller lounges off the corridor and invite residents to attend if they wanted to. During one session Jack was joined by five others. A small table in the middle held various percussion instruments including bongos, and the floor tom and cymbal were also available. Jack naturally assumed his position next to the floor tom. He picked up the beaters and asked whether we were “ready to go?” Another group member chose to play the bongos with beaters after asking me to demonstrate some of the ways she might play. At one point she commented “who would have thought half an hour ago, that I would be a drummer?”
The energy of the group was quite lively so we played through a number of old rock and roll tunes. I stopped singing during a well-known rock and roll riff and invited others to sing, beginning by improvising lyrics to the song and including people’s names. When one of the group members began scatting Jack, along with someone else, applauded and encouraged her to continue. Jack and another group member had established a steady beat on their respective drums and I joined them by using the back of my guitar as a drum. Our percussion improvisation continued for approximately two minutes with the ‘scatting’ persistent over the beat. A group member clapped with the music, smiling broadly; while another had begun dancing around the edge of the group, playfully swinging her legs high, and using the handrail as if it were a dance partner. We generated such a lot of interaction, improvisation, and playful energy. I started to play the riff again, and the music came to a natural end.
As we reflected on the music a group member again reiterated that she felt as if she was playing in a band and suggested we name our group the “Groovies”. With the agreement of the group the Groovies were born and with a few suggestions to get them started the group developed a ‘set list’ for the band. The interaction felt significant, particularly since group members were almost unaware of each other initially, and the group had begun to feel cohesive. Jack continued to express a wish that his sister could be with them, but during and following this session he began to talk of other things, including his experience of playing for years in a school band.
During the period of Jack’s music therapy we experienced a royal wedding. The team agreed it would be important to celebrate and that it might be fun to bring the occasion alive for residents by recreating a wedding atmosphere. The lounge was transformed into a church, residents were all invited and many family members attended the celebrations. Jack and another band member from the Groovies joined me to provide music throughout the morning. Others also joined us for short periods as they wished and were able. I discussed the music programme with Jack and the other band member and gave them both a set list. Jack played the drum, while his duo partner took vocals and accompanied us on the egg shaker. At the end of each song Jack would put his beaters down and look up, and she would rest her shaker on her knee. We interacted with each other throughout to find instrumental breaks and endings. Family members sang along. When Jack’s duo partner left us to join her husband Jack and I continued to play background music for the guests. His daughter, who had been unable to attend but had heard much about the event from staff and residents, wrote:
(I) can’t think of better therapy for him really. Thanks so much once again for opening up his horizons. ... He was so much of a star on the royal wedding day. (It’s a) shame his memory doesn’t let him recall it to me but as long as he enjoys the moment that makes it so worthwhile.
In subsequent sessions Jack continued to develop his skills with percussion instruments and his interaction with group members. He used instruments creatively, for example alternating between playing the bongos with the spoons, playing them with beaters, and playing the spoons by themselves. He did this in a very decisive manner, and established steady beats on each instruments. He appeared to be purposefully choosing different sounds for different songs. He would often look up at us and appeared to be looking for musical cues. Jack played sensitively and responded to changes in dynamics and tempo. His playing was less repetitive as he explored different sounds and rhythms. It seemed that he took his role as band musician seriously, and was determined to offer the group good quality rhythmic support. While our verbal dialogue during "practice" was often kept to a minimum, the dialogue we had in music felt rich; our communication in music was far more fluent than with words. I noticed though that Jack had begun to drift off to sleep before the end of group and this was unusual for him.
I returned from a two-week break to hear Jack had deteriorated rapidly and was receiving palliative care in his bed. This was a big shock to me because last time I saw him we had been playing music together and I had planned sessions which would further extend his drumming and music making skills. After a discussion with staff we decided it might be comforting for Jack if we held a small music group in the lounge outside his room so he could hear music from his bed. I invited his band to attend and we sat in a close circle, to sing familiar songs. I didn’t introduce any instruments, except my guitar, because I wanted the group dynamic to remain relaxed and gentle. Several patients were singing tender songs with me while one, who was a significant wanderer, moved around the group. I invited her to join us by singing directly to her and she came and sat, singing quietly, where she remained for the rest of the session.
Later I took the floor tom that Jack loved to play and placed it in corner of his room. It was bright blue and I put it where he might be able to see it if he opened his eyes. I spoke to him as he lay in his bed, eyes closed, his breathing laboured and moist, coughing frequently. He didn’t open his eyes, or show any sign of visible response. I felt comfortable being with him, and felt it was appropriate to be there, having shared so much music with him. I played through songs that I knew Jack enjoyed from previous sessions, including a few of the rock and roll tunes he used to drum along to, but softly and in a slower tempo. I noticed Jack’s breathing becoming less laboured and I tried to match the rhythm of my playing to his breathing. I stayed and played for forty-five minutes until he was sleeping peacefully. I returned in the afternoon to put a CD of Scottish songs on so that he might listen.
I also organised for the group to play music outside Jack’s room again. I explained to group members that Jack was not well and unable to attend sessions. Some were able to acknowledge this and to agree that it was a good idea. One suggested we sing songs that Jack particularly liked. Another, who typically wandered, stayed seated throughout the entire session, smiling and whistling to certain songs. He appeared relaxed and a number of staff commented that it was unusual for him to remain so focussed. A further group member was initially agitated and restless but, as in a previous session, was drawn in when I sang directly to her. She sat calmly, listening, until a care worker asked her to leave the group to engage in tasks of daily living. Another sang heartily to certain songs and commented, “Lovely”, “Well done, this is lovely.” My attempts to engage the group in discussion between songs led to dialogue about church and to the singing of hymns.
During subsequent days Jack continued to deteriorate and was given regular doses of morphine. He would open his eyes when nurses were caring for him but his breathing was very slow and laboured. During one session I sat on a chair beside his bed, facing him, and began Swing Low Sweet Chariot (a historic American Negro Spiritual). I noted that Jack’s breathing was immediately less laboured. So I continued to play the chord progression for several minutes, humming quietly, matching my rhythm to his breathing. Caregivers entered the room to turn and change him. I suggested I might continue playing to ease the distress he sometimes signalled during cares, possibly due to pain with movement. I sat in the corner of the room looking away to maintain his privacy and dignity, and began to sing Amazing Grace. The caregivers both sang with me and for approximately four minutes there were three or four voices singing just for Jack. The caregivers explained to Jack what they were doing while they continued to sing and hum. They also talked to Jack about music. I stayed with him after they left. His breathing had become more laboured again and he shifted uncomfortably in his bed for several minutes. It was distressing for me to see him in obvious discomfort. I decided to sing “Scotland the Brave” and when I began Jack opened his eyes momentarily. He eventually appeared to relax and to drift off to sleep but I stayed for another thirty-five minutes to sing, hum, and sometimes just sit beside him in silence.
We had one more session after this. I spent an hour with Jack playing the guitar softly, singing familiar songs, humming, sometimes talking, and sometimes sitting in silence with him. At the end of my session I said goodbye to Jack, thanked him for sharing so much music with me, and told him it was an honour to have met him and to have spent the last few days with him. Although I felt really sad I was pleased that I had the opportunity to be with Jack and to facilitate his hospital family to musick with him when he was dying, and hopefully provide him with some comfort through music. I selected a few more CDs, and suggested to staff they might play them for some of the time but explained that silence would be equally as important. I also reminded staff of their positive experience of singing to Jack when performing cares. A few days later I received an email from Jack’s daughter.
Thank you so much for all the time spent with Jack and the others at (the hospital). I know Jack enjoyed his music and I was looking forward to being at one of the sessions but unfortunately he passed away today. We also played the music CD's to him during our visits over the past days and it did seem to calm him and us at the same time. I hope that you keep up the good work and once again can't say how much it has meant to us that he was so happy and that he had obviously built up a bit of a bond with you as well.
I attended Jack’s funeral with other staff at Kowhai. His love of music was mentioned a number of times during the service, and he was piped out of the chapel by a piper in full Scottish regalia. In his order of service the family had included the following verse which the diversional therapist had pinned on Jack’s wall.
Music touches feelings that words can not
It is melody of the heart, the voice of the Spirit.
It inspires some to think of the past, some to create, and some to cry.
Music makes me Love.
This case demonstrates how the music therapy process with patients who have dementia can evolve from focusing on an individual, to group and community music therapy. Music making not only brought Jack into the moment but it also enabled him to increase his participation with others in his hospital community. Pavlicevic and Ansdell (2004) introduce the metaphor of the “ripple effect” to describe music permeating environments and calling to others, connecting them and creating community. However, they expand on this notion by introducing the idea that the impact of music therapy can also move an isolated person towards the community, and bring the community toward the individual. Within the wider hospital setting of this case story, the music that residents made drew them to each other. Jack was moved to sit in on other residents’ sessions, and they were motivated to play with him in group settings. Moreover, both residents and staff developed musically based caring behaviours that were witnessed in their support of him in his final days.
Community music therapy practice "follows where music's natural tendencies lead: both inwards in terms of its unique effects on individuals, but also outwards towards participation and connection in communitas" (Ansdell, 2002). The possibilities for Jack to be able to use his skills as a percussionist to increase reciprocal interaction with and between other residents arose naturally. The students’ music, Jack’s music, and the provision of an appropriate physical space were crucial resources that were needed to increase possibilities for action, inspiring residents to set up the Groovies, a band which enjoyed lively musical interactions and social exchanges which extended beyond the band practice room. Jack and his band members would have gained important social capital (Procter, 2011), as they were able to create positive connections with each other, with the hospital residents and staff, and with the wider community members who attended their social function.
The practice of re-enacting the royal wedding with people who have difficulty holding on to reality may be considered controversial. However, in this case the multidisciplinary team considered the event would stimulate discussion and enhance resident’s cognitive functioning. Moreover, it was anticipated that they would enjoy the event. It is important to note however that each resident was considered individually, and each of their abilities, interests, preferences and needs were taken into account in planning the day. In line with the person-centred philosophy adopted by the facility, staff members were available at all times to support them to be involved or withdraw as they needed to.
When people are living with dementia, familiar ways of communicating are often no longer accessible to them. Creating positive connections is often fraught with difficulties. Performance can turn the focus away from problems and difficulties, bring strengths to the fore (O’Grady & McFerran, 2012) and transform audience perception of illness or disability as they become connected to the performer (Baker, 2013. p. 21). Baker (2013) suggests that performance can restore a sense of voice allowing the community to see previously silenced people as creative individuals who have an important and valid story to tell. When the Groovies performed, band members had the opportunity to play an important role in a community event and to receive support and validation from audience and community members. It was very clear when observing Jack that he was relishing the chance to perform at that particular time. He became, in the moment, an entertainer, a drummer in a band, a musician, and a performer. He was making a positive contribution to the event, for which he received warm, genuine and positive feedback. The constraints, difficulties and losses associated with his dementia were unapparent for a time.
On the other hand, entering the performance space with sick or vulnerable people has associated risks (Ansdell, 2005a; Baker, 2013; O’Grady & McFerran, 2012; Turry, 2005). Some therapists have even considered the use of performance in music therapy as “ethically dubious and problematic” (Ansdell, 2005a). Arguing that it is our responsibility as therapists to reflect on any pros and cons of the therapeutic approach we choose to use, O’Grady & McFerran (2012) developed some key questions therapists must consider before embarking on the performance journey with clients. They suggest it is important to actively reflect on how willing the clients are to perform, who is to benefit, what the underlying rationale is for performance, and how the client’s capacities are being appraised.
In this case, it was difficult to know how much of the performance process Jack and his fellow residents would understand. And so it was with careful consideration, reflection and assessment that the student music therapist proceeded with the performance on the day. She did not begin music therapy sessions with the intention of developing a band, or including a performance as part of her music therapy work with the residents. It was an organic process that through musicking felt like a natural progression for all involved. The idea of forming a band, the naming of the "Groovies", the decision to perform, and the choice of set list came from the residents themselves. The band members were free to come and go at any time and in the event Jack was left very happily performing solo with the support of the music therapist. He had found his voice, was connecting with others, and was making a valuable contribution to a community event. Staff, fellow residents and wider family members were able to see him in a different light. Further, the musicians who choose not to play on the day still identify positively as band members. To this day, a group member who does not remember the (now qualified) music therapist’s name still recalls the experience with pride. When they make music he will often say “Oh remember the Groovies? We were a fun band!”
One of the tasks of a community music therapist is to help build a community feeling (Stige, 2004). People who have dementia and live on locked wards all have a need to feel content and to relate to others (Simpson & Mitchell, 2005). Hospitals are places that frequently feel clinical, even cold, and in a ward where people have dementia the lack of natural interpersonal interaction is often startling. It can be far from what we might describe as a feeling of community. People are linked within communities of interest by some shared need or interest which cannot necessarily be defined by an outside observer (Stige, 2004). It was clear that the residents of this hospital community were linked by relatively obvious needs associated with dementia, but it was not so clear until musical relationships were developed that they were also linked by their shared interest in rock and roll music.
Whilst they were almost unaware of each other initially, the Groovies were connected by their shared love of old rock and roll tunes and during a well-known riff they began drumming, clapping, scatting, and dancing together. Drawing on memories evoked by the music to engage in mutual participation they developed a cohesive performance. Some of the Groovies’ memories, such as Jack’s experience of playing for years in a school band, would have been deeply personal but others such as the “way we dance to this” would have been shared. They showed their appreciation by smiling, applauding and encouraging each other. By developing a set list for the band they indicated their intention to continue and the potential for anticipation and hope for the future. As Ansdell (2005a) suggests, they learnt to “perform themselves differently in ensemble with others.” Performances enable performers to reflect on the real through the unreal. Ansdell goes on to suggest they can be personal, yet public. They can be shared, yet different for everyone. And they can allow people not only to be themselves, but to perform beyond themselves (Ansdell, 2005a). That is, as Vygotsky (1978) theorised, people are able to do more together than what they are able to do alone. Individuals who joined Jack’s band were able to become someone else, i.e. a member of the Groovies.
Only two of the group members took their performance into the public domain, to perform before family and friends during the royal wedding celebrations however. The music therapy student was careful to consider and support people’s choices about when and where they chose to perform. Some would have been anxious about performing publically and might have been less successful in that setting. Nevertheless they could still participate in musicking with Jack and his duo partner, supported by the student music therapist, as listeners, singers, dancers, and groupies. Their identity as band members might not be lessened as they listened or sang with the audience of family and friends. Stige (2006) reminds us that participation is a complex process of doing, thinking, feeling, communicating, and belonging, and thus involves our whole persons, including bodies, minds, emotions, and social relations. Drawing on Lave and Wenger (1991) he reminds us that peripheral participation is legitimate and can lead to increases in engagement and complexity over time.
Stige (2004) notes that community music therapists should not neglect the process of assessment as doing so could lead to worthless or even harmful work without noticing. It seemed important to come to know some of the individuals within the hospital community intimately as well as coming to understand the rituals and routines of life on the ward. Working with Jack individually gave the music therapy student the opportunity to understand his needs in the context of his environment. Jack gained the resources he needed during his individual sessions to actively develop his love of playing percussion instruments and, despite experiencing progressive dementia, to improve his relational and musical skills. Just as the expertise of the music therapy student was crucial in this process, so too were Jack’s expertise in Scottish music, spoon playing, and drumming. On the other hand, community music therapy focuses on creating healthy environments, social support, and caring networks, instead of just focusing upon the function of each individual. Health can be viewed as a process rather than a condition, changing as people establish a balance of psychological, physical, emotional, socio-cultural, and spiritual dimensions within and between themselves and their environment. One might argue that as Jack and his fellow residents developed mutual care and support for each other, they were becoming healthier even as they deteriorated physically.
Residents’ needs change when they are acutely unwell or in crisis and so too do the needs of those around them. In the final days of Jack’s life he needed individual time. His hospital family needed to be able to say goodbye to him and to grieve his passing. It is not possible to know what Jack heard of their music. Neither can we know how much his friends could understand the process from a cognitive perspective. Nevertheless there were clear indications that the process was meaningful for everyone. Pavlicevic and Ansdell (2004) wrote "there is often a time to be private, and a time to be public in music therapy; a time for the nurturing of intimate communication; and the time for the performance of the fruits of achieved communication, skill and confidence" (p. 23). As Jack lay dying in his room, he was afforded his privacy yet he received intimate communications from his friends who musicked outside his bedroom door, from the student as she turned away from him and played softly in the corner of the room, and from the staff as they sang while attending to his needs.
Jack’s case demonstrates how the music therapy process enabled an individual to defy his progressive dementia to increase his participation in music. He was drawn to actively participate in the music that was occurring around him and eventually drew others into his. The mutual influence of individual and community enabled members to develop a strong sense of connectedness.
"Community music therapy is … about changing the world, if only a bit" (Stige, 2004, p. 108).
 The qualitative study used secondary analysis of clinical data (also known as clinical data mining) to explore and describe a student music therapist’s experience of involving family members of people with dementia in a music therapy process at a residential care facility. The study has the approval of the Massey University Human Ethics Committee (HEC: Southern A – 11/41).
 Not his real name.
 Diversional Therapists organise, design, coordinate and implement client centred leisure based activity programs. See http://www.diversionaltherapy.net.nz/what-is-diversional-therapy/.
 Tangata whaiora is translated from Maori as “people seeking wellness”.
 The term musicking was introduced by musicologist Christopher Small (1998) to describe the actions and relationships that come into being when people create and perform music.
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