Some Ideas About Music Therapy for the Elderly
By Kimmo Lehtonen
Music therapy is a target-oriented and purposeful activity where the therapist and the individual or group taking part in the treatment use musical expression and especially memories, feelings and sensations that it arouses. In this article, a theory of "musical thinking", is presented, in order to give a theoretically justified explanation of musical effectiveness. The purpose of the article is to create a theoretical basis for old people's music therapy and thus give grounds for initiating different experiments.
In Finland the use of music therapy for the elderly has been limited to a few separate experiments and individual therapists' activity. It may well be that old people are not comparable challenges as objects of psychotherapy with younger people suffering from psychic disturbances. There is also a lack of research and experimental activity in the area, and therefore the workers may hesitate to connect the use of music with the treatment of old people. In spite of this it is becoming more and more widely used and accepted in Finland.
In Salminen's research project (1990) "the formation of musical tastes" it is stated that people in old age are very interested in music, although many of them have weakened hearing or other old-age problems. On the other hand pensioners have plenty of time for their hobbies as long as they are healthy enough. McCullough (1981) has also got similar results when examining over 65-year-old people living in the United States (276 persons). Of the old people examined, 31 % considered music "important to some extent", 11 % "important" and 29 % "extremely important". Through music it was possible to reach vividly pleasure-giving memories and meaningful experiences connected with earlier phases of life, which could otherwise remain out of reach. This kind of experiences became all the more important, as the old person's earlier social relations decreased as his/her close circle got smaller. In McCullough's research (1981) half of the subjects reported that the meaning of music had increased with age and only one fifth reported that it had not increased. The examined persons said that music gave them new energy. Especially listening experiences were considered therapeutic. They also promoted common group discussions, which gave listeners feelings of unity in sharing experiences anchored in music.
Music Promotes Memories
In our own research (Lehtonen, Suhonen & Grönholm 1999) we noticed that music formed a vital landscape of memories, which helped old people to work through their wartime memories. In our research project we kept therapeutic discussion groups for war veterans. Each group consisted of 12 Second World War veterans who were 76-85 years old. We ran the groups during three years. The purpose of these groups was therapeutic but they were not true music therapy groups because we combined different kinds of cultural activities. During the project I worked together with two social workers and we used a lot of music in order to activate their memories, social relationships and expression. We noticed that there were certain key songs, which easily opened their mental locks and helped also painful memories also to get their verbal expression. Such Finnish wartime popular songs as Little blossoming mounds and Life in the trenches had a great significance as the memory anchors of the whole generation. For instance the song Little blossoming mounds was very important because it greatly helped people to work through their sadness and longing for their killed fellow soldiers during the Second World War. These songs still have their meaning and they remind old people directly of their dead relatives, friends and neighbors. These songs represent Kleinian "healing sorrow" which enables feelings to break through without too much pain and suffering. There were also special songs that told the story of the individual. Once we were listening to a piece called Red rowan berries which has following language pictures:
I see red rowanberries
They are so red that I can see blood on them
Old ships had left this lonely harbor
My sister will be wind and night
Which are singing their songs
And rain with its ice-cold drops is drumming
My dark window
I see many wandering strangers just passing through
The one I was longing for
Will never come back...
After singing this particular song in the group an old lady started crying and she told us that the song was a symbol of her killed husband. She heard the song before she was told that her husband died in the front. She told that since then she has been unable to tell anybody about her deep sorrow and she had tried to bury it and fought against it. In the group this particular song suddenly opened the defense mechanisms and she was able to tell her story, which also changed her behavior to a much more social and open. How is this possible? The answer lays in the symbolic deep structure of music.
The Symbolic Distance Created by Music as a Promoter of Psychic Working
As a form of art, music functions "in the borderland of the internal and external" as Lehtonen (1986a) has indicated in his doctoral thesis. With the help of music it is possible for the individual to handle internal as external and external as internal. The forms of music function like a "mirror" (Lacan 1971) where the listener sees himself or herself and his or her inner feelings and experiences. In music therapy, music seems to create a symbolic distance between the individual and his/her traumatic experiences. Music seems to push traumatic and distressing meaningful experiences aroused by it to such a symbolic distance that their examination, analysis and therapeutic treatment is possible without excessive psychic anguish.(Bullough 1977, Casebier 1977, Lehtonen 1989). The American composer, Aaron Copland (1952), described the symbolic distance linked with abstract forms of music in his comment concerning his own aesthetics:
"I don't think that music can move us more than other arts. I have often been moved to tears in the theater but never has it happened in connection with musical performances. There is something in music that keeps it as if at a distance even at the moment when taking us into its embrace. It is simultaneously absent outside us and yet it is an inner part of ourselves. Even though it shakes us profoundly it is all the time under our control. It leads us forward but for some reason we never lose control." (Copland 1952, 78).
An explanation of the phenomenon described by Copland (1952) can probably be found in music's "ability" to act as a transitional phenomenon as presented by psychoanalyst Donald W. Winnicott where the person creating or receiving music can safely and without anguish work through his or her feelings (Winnicott 1982). Racker (1951) has described the qualities of music as a transitional phenomenon connecting it with the following qualities facilitating communication and self-communication:
Music gives protection to an individual in paranoid situations.
Music protects an individual against unhappiness, sadness, incoherence, loneliness and guilt and it is functioning like a pleasure giving transitional object.
Music protects an individual against unpleasant feelings and yet, at the same time, gives psychic strength to face and overcome them.
Music can also be used in frightening and unpleasant situations, for instance, against silence representing loneliness.
As another example I will tell you about my own 70 years old father, who in old age spontaneously processed meaningful experiences in his earlier life by means of music. It seemed that in order to keep his integrity he had to return over and over again to certain experiences in his youth. One of the most central worlds of experience was the wartime and especially his "lost" youth on the front. He processed his experiences as well through singing and listening to wartime music. Music seemed to lead his thoughts back to that time. We also discussed a lot about his experiences and the purpose of the whole activity seemed to be to work through and clarify the experiences and phenomena of that confused, traumatic and chaotic time period.
The music, which inspired his experiences, was mainly pre-war and wartime hit music in which he took an active interest. The music seemed to be clearly connected with the "lost time" (cf. Proust 1970) and searching of subjective experience world linked with it. In the process, music seemed both to activate memory and also give an opportunity to go through self-therapeutically distressing and guilt-producing experiences anchored in that time (his own serious wounds, dead and missed fellow soldiers). Correspondingly, some other tunes seemed to bring into his mind experiences of childhood connected with country life (experiences linked with being a herdsman and a farm-hand as well as looking for the first job in the local factory).
It seemed that this process was especially a question of searching for the lost time, in connection with which there was continuous self-reflective movement between the present, the past and the anticipated future. Musical flow brought to his mind different meaningful persons, interactions and episodes of the past as well as strong emotions connected to them.
Music as a Meaningful Experience
Music forms a certain kind of "meaningful space" (Musikraum) about which Wellek (1934) talks, emphasizing the spacial and temporal nature of the musical experience. He links experience of music together with human emotional layers of essential unity. The American researcher, Leonard B. Meyer (1967), states that music is connected with meanings originating both from the piece of work and the environment. In the meanings "originating from the piece of work" music refers either to itself or the some other music. Different themes and motifs associate themselves with one another and make us expect something new. In the meanings "originating from the environment" music in turn associates itself with abundant external music material, which originates from the world of emotions, images, ideas and physical objects.
Examining musical experience is, in this respect, interesting also from the viewpoint of the interpretative hints and "language pictures" produced by the musical structure and lyrics of certain meaningful songs. Compared to absolute instrumental music, vocal music containing direct verbal narration contains "language pictures" that give music quite unambiguous ready interpretation schemes, whose metaphors lead the imagination and associations. Listeners can easily change those "language pictures" to their own individual "mental pictures" which represent more or less directly their own memories and associations.
My father's favorite hits were, among others, The Waves of Donau, Warum, Life in the Trenches, Autumn Leaves, Greens leaves, and Scarborough Fair. Similar aspirations in my father's artistic interests were, on the other hand, likings directed towards pre-war and wartime literature. What was important for him was the opportunity to live through and tell about his experiences and in this way to get understanding and support.
The Symbolic Deep Structure of Music as a Constructor of Meanings
According to Stravinsky (1973) music is nothing but a series of tensions, which strive towards their resolution. Maybe this statement of Stravinsky, known as rather cynic, is a genius's indication of arrogance towards intellectual examination of music. On the other hand, the statement however contains a general and simple theory about musical influences. The tensions mentioned by Stravinsky also take on new interest when they are examined in relation to a newborn baby's archaic world of experience, which, according to modern cognitive research, consists of a cyclic variation of different tensions and their relief.
Daniel Stern (1985) has described the experience world of a small infant in his excellent book The Interpersonal World of the Infant. There, Stern states that the baby is already at a very early developmental stage able to identify structures connected with the similarity of different sensations and to form some kind of non-verbal abstractions, which also abound in musical language. More than traditional categorical affects (sorrow, fear, shame, hatred) the baby's experience world is dominated by so-called vital affects (silent, accelerating, exploding, soft etc.), which are just like the presentation notes of music. Vital affects, which are the most human and stable basic forms of experiencing identity, do not reflect so much their own being and quality but are experiences in trading functions of existence, which also music can arouse. (Stern 1985).
Both musical creativity and musical experience seem to have a clear connection to musical thinking which has its origin into archaic elementary forms, from which it extends up to the most developed and structured forms of thinking. Next there is a good reason to deal with human thinking and its temporal hierarchy a little more closely. Rechardt (1984, 1988) has examined musical connections with human archaic meaning schemes (placed in early developmental stages). According to Rechardt (1984) the opportunities for all understanding and comprehension are sought in archaic meaning schemes of physical understanding. The above-mentioned physical meaning schemes and the primary process-thinking connected with them are the essential features in difficult psychic disturbances, psychoses, mental retardation or dementia.
One example of the process happened in the individual music therapy process, where the therapist was working with an old man who was severely demented and could not remember almost anything. The therapist sang familiar Finnish songs to the old man, who often responded by singing his own songs. It was unbelievable that this man could sing old Italian romances with his broken voice. These songs were not easy to sing and he used Italian language, which seemed just to appear automatically in his mind. After singing those songs he also could tell something about those songs to the therapist. It is obvious that this kind of musical communication seemed to find some of his meaningful memories, which were verbally out of reach. I told about this old man to my colleague, a professor of neurology who just said: "I see there was such a pocket in his brain". Music could be very useful in searching those pockets, which contain meaningful memories about earlier life of demented old people.
The physical level of musical experience, the grounds of which are in archaic thinking, is from the viewpoint of musical effectiveness the most significant and human because of its extensive anthropological depth. What is common to researches concerning archaic thinking is unanimity about the fact that different early stages of human thinking can be reached and activated by creative process also at an older age. They do not disappear in the course of development but are constantly in human use. (Lehtonen 1986a, 1986b, Rechardt 1984, 1988). Correspondingly, in different disturbances of brain function, an individual can descent into forms of archaic thinking (primary process, chaotic thinking etc.).
The person creating or receiving music can place his or her psychic material, such as unconscious fragments of thoughts, unconscious images and associations, emotional experiences, sense impressions, physical reactions and, of course, logical thoughts into the "open" musical scheme, void of meaning". Adapting Lacan (1948, 1971), we can state that music is like a mirror where the observing individual can see his or her incoherent self integrated.
The Opportunities of Music Therapy in the Treatment of Old People
There is ample evidence that due to its abstract symbolic nature, music can have sensible meanings also in the case of such individuals, whose internal world of experience and thinking is strongly fragmentary, distorted and crowded. It is difficult to approach or understand these kinds of persons in psychotherapy based on the meanings of spoken language. Music can function, for instance, as an interpreter of the demented patient's world picture without the communication problem essentially connected with verbal interaction alienating the patient from other people's logical world of meanings.
Music can, through its meaningful experiences, construct and formulate the treated person's psychic world, which has not been constructed because of various disturbances.
What is essential in music therapy is the therapist's personality and his ability to use music according to the treatment objectives. As far as I can see, musical movements have their counterparts in mental movements. Flowing music is a means of making the mind move and activates the imagination and memory processes of the individual. It is the therapist's task to create favorable preconditions for the treatment in the form of his own personality, the music chosen by him and the open atmosphere with a minimum of anguish created by him. This allows the psychotherapeutic treatment of experiences and memories to be aroused in the patient by music. Music can shed light to meaningful persons, moments and episodes of the life span of the individual.
The use of music in the treatment of healthy old people often takes place in the form of different music groups (singing- and listening groups). In our research music groups we concentrated on the music originating from the best and most vital years of old people. By concentrating on group members' emotional experiences and memories connected with music we activate memory and emotional life. Music can also be used together with old photos or pictures (taken from old postcards or famous paintings or picture books), by looking at the old family pictures or making musical paintings or drawings. In our own research therapy group we used old songs together with slide show, which was composed of the old photos taken from our own hometown. This experiment with music and photos brought lots of memories about meaningful places and music as well. The normally quiet group was discussing vividly and telling stories about their experiences connected to those photos and music.
We also used old songs by famous local composers. Two of these songs told about our hometown. They were Telephone wires are singing and A little footpath through the forest. After listening to them the group started immediately to discuss their memories. Some of them told even where this foot path and telephone wires were - they were in the island where young people used to spend their time 50 years ago. An old man told us: "If you go to that place you can still hear those wires whisper in the wind". One of the members told us also that he has often been walking on this footpath with his bride.
In this case, the objective was to reach the level of the image essentially connected with the music. On the other hand, music can easily be linked with poems, literature and spontaneous recollection and narration, for instance, on the basis of a program "this is the poem or a piece of music I'd like to hear." Music groups can, in time, give opportunities to express emotions and experiences. It could be helpful to collect a list of songs and compositions which members experience as most important and meaningful. It is also possible to match the groups according to the background and musical tastes of the members. One group can concentrate on classical music and the other on entertainment music and so on.
Recollection by Means of Music Therapy
The creative inspiration created by music is linked with the psychic movement aroused by it, which in a unique way activates our imagination and memory. In this sense, the therapeutic use of music means profound consideration of the listener's own, unique micro historical "existence". Music can express personal experiences that can not be found in history books or which can not be told verbally, it can bring forth for us to examine unconscious experiences we thought were forgotten a long time ago. Music can revive suppressed sides of life, of which we were not aware of earlier. Finnish music therapist Kaisu Kärki, who is working in the health center of Kajaani, has also gotten positive results from the use of music in recollection therapy (Kärki 1990). With the demented old people she used the music of the 1940's. In the experiment it became evident that the music representing by-gone times brought to mind in the listening group both strong emotional memories and repressions in emotional life, disappointments and negative events, which the staff of the department, stressed by basic treatment, had not had time to listen to. Memories connected with music concerning by-gone times contained abundantly material linked with earlier phases of life, joy, sorrow and recollection of friendships, as well as memories about a mother and being a child.
It is obvious that the use of music and interest in music function in different stages of human life as a significant provider of meaningfulness, which can also "carry" and facilitate daily life of old people. The music used in old people's music therapy does not have to be temporally limited, but can be freely chosen according to the old people's likings. Sometimes also various stereotyped ideas of musical taste are connected with the use of music in old people's treatment. It is obvious that my grandfather who was treated in an old people's home was repeatedly cursing the fact that the ´classical or religious music based programs of the Finnish National Broadcasting Corporation were always played on in the master receiver although he would have liked to listen to light music, particularly hit melodies.
In the individual music therapy of old people we can also naturally proceed to a more intensive work and try to reach the old person's "musical self". The music used in therapeutic interaction also promotes analysis of the old person's musical ego, for instance, by arousing experiences about the control and reidentification of the musical world. Experiences connected with music function as the basis of psychotherapeutic groundwork, where difficult and traumatic phases of life can also be treated verbally together with the therapist.
One of my colleagues was conducting a music therapy group of demented old people. There were some members already catered in the therapy room when an angry old lady came and started shouting and blaming the therapist with hard words about the fact that the members of the staff have forced her to participate in the group. The therapist told her that she does not have to take part in the group if she does not want to, but after that he said that he likes to sing a song just for her. He took his guitar and sang a song called A girl like you which told a story about a female rebel who in spite of her nasty behavior had a golden heard. After the episode the lady stayed in the group and expressed a great collaboration and confidence in the other members and in the therapist as well.
I have discussed some theoretical and practical starting points of music therapy with the elderly. The purpose of the article is to encourage people to work with the elderly, to experiment with different applications and approaches. The use of music brings variety to established treatment routines. Musical interaction is rewarding to parties, the patients and therapists and also nurses. I have stated that the patients, in the end, teach their therapists how to implement music therapy together with them.
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