bs_bs_banner

Bioethics ISSN 0269-9702 (print); 1467-8519 (online)

doi:10.1111/bioe.12148

DEMENTIA AND THE POWER OF MUSIC THERAPY STEVE MATTHEWS

Keywords dementia, social agency, narrative, well-being, music therapy

ABSTRACT Dementia is now a leading cause of both mortality and morbidity, particularly in western nations, and current projections for rates of dementia suggest this will worsen. More than ever, cost effective and creative nonpharmacological therapies are needed to ensure we have an adequate system of care and supervision. Music therapy is one such measure, yet to date statements of what music therapy is supposed to bring about in ethical terms have been limited to fairly vague and under-developed claims about an improvement in well-being. This article identifies the relevant sense of wellbeing at stake in the question of dementia therapies of this type. In broad terms the idea is that this kind of therapy has a restorative effect on social agency. To the extent that music arouses a person through its rhythms and memory-inducing effects, particularly in communal settings, it may give rise to the recovery of one’s narrative agency, and in turn allow for both carer and patient to participate in a more meaningful and mutually engaging social connection.

1. INTRODUCTION As you walk down the street, or make your way to the living room, or enter the garden shed you abruptly realize that you’ve forgotten what it is that you thought you were doing. It’s both a familiar and uncanny, sometimes unnerving feeling, and it brings agency to a halt. What we try to do in these situations is to trace back and reconstruct our purpose in an effort to make sense of what we are doing, for our behaviour now is almost always a segment of some larger narrative agency. The forgetful agent is endeavouring to situate her current behaviour within a larger story that best explains it. Now what if, for some agent, forgetting like this gradually became pervasive, and the disorientation described above obtained as a near-global feature of daily life? Its effect would be impairing, not just of efficaciousness, but presumably of our sense of our own agency as such. I want to suggest that a fruitful way of understanding one central aspect of the losses for dementia sufferers is to see that condition as depriving them of their narrative

agency, particularly in its social losses.1 For it is a feature of quite severe dementia that, for a sufferer, you have quite literally ‘lost your story’, as Oliver Sacks has put it.2 The argument that follows from this is that, aside from all the practical difficulties of inconvenience, many of these losses have concomitant moral losses – to wellbeing and

1

The phenomenon of wandering is related to the disorientation described above. Some 60% of those with Alzheimer’s dementia will exhibit wandering which is caused by the combined effects of memory loss, poor judgement and losses to abstract thinking. Becoming lost is then compounded if the person has also forgotten who they are. See MA Rowe. People with dementia who become lost. Am J Nurs 2003; 103: 32–39. Also, these losses in the capacity for memory overlap two of the cognitive domains for the Neuro-cognitive Disorders in DSM-5 – executive function, and learning and memory. For a detailed account of the links between failures of memory (and more broadly mental time travel) and losses to planning and control, see J Kennett, S Matthews. Mental Time Travel, Agency and Responsibility. In: M Broome, L Bortolotti, editors. Psychiatry as Cognitive Neuroscience: Philosophical Perspectives. Oxford: Oxford University Press; 2009. p. 327–351. 2 Quoted in R De Lauro. Music and Memory – Elders with Dementia Find Hope in a Song. Social Work Today 2013; 13: 18–21.

Address for correspondence: Dr Steve Matthews, Plunkett Centre for Ethics, St Vincent’s Hospital, Victoria Street, Darlinghurst NSW 2010. Telephone: + 61 2 8382 2871 Fax: + 61 2 9361 0975. Email: [email protected] Conflict of interest statement: No conflicts declared © 2015 John Wiley & Sons Ltd

2

Steve Matthews

meaningfulness of life, particularly as this is affected by lost relationships – and if that is the case, we then have an ethical reason for a particular approach to therapy: one that aims to restore, even if temporarily, the kind of social agency that the dementia sufferer once had. It turns out that music therapy is one such highly potent form that leads to this temporary restoration. I discuss music therapy for two main reasons. It is the most common of the art therapies (and there is a growing body of evidence for its effectiveness), and it is eminently practicable – its costs are low, and it may be introduced with relative ease.3 This last rather utilitarian point is important in a world where rates of dementia are growing rapidly – for example, it is now the third highest impost on the national health budget in Australia, after cardiovascular disease and cancer. I use music therapy illustratively in order to make the ethical points, for music therapy is a means to an end, and there are other means of a similar type, for example, reminiscence therapy.4 The empirical nature of the question of what is most effective therapeutically would be helped along by investigating both the neuropsychological bases of music therapy and the social aspects of its delivery. Importantly, playing old songs triggers those parts of long-term memory still unaffected by the disease.5 However, the improvements in patients may also be a function of the relationships to carers who engage in the therapy.6 Studying the topic is complex, however, given the highly variable nature of the phenomena.

2. DEMENTIA AND SOCIAL AGENCY I just claimed that dementia undermines human relationships because of the way it emasculates the capacity for narrative social agency.7 It is worth considering the sense 3

For a review and description that situates music therapy in the wider scheme, see RL Beard. Art Therapies and Dementia Care: A Systematic Review. Dementia 2011; September: 1–24. DOI: 10.1177/ 1471301211421090. On cost, see WD DeLoach. Procedural-support music therapy in the healthcare setting: a cost effectiveness analysis. J Pediatr Nurs 2005; 20: 276–284. 4 On reminiscence therapy see B Woods, AE Spector, CA Jones, M Orrell & SP Davies. Reminiscence Therapy for Dementia. Cochrane Database of Systematic Reviews 2005; 2, No. CD001120. DOI: 1002/ 14651858.CD0020.pub2. 5 L Braben. A Song for Mrs Smith. Nursing Times 1992; 88(54). 6 Sixsmith and Gibson remark that music provides for the opportunity to be ‘. . . involved in activities that support and reinforce positive emotions towards relatives, carers or activities’ (p 133). See A Sixsmith, G Gibson. Music and the Wellbeing of people with Dementia. Ageing and Society 2006; 27: 127–145. 7 I distinguish between a narrative account of the self and a narrative account of agency. I take agency to be part of what makes us selves, but not the only part. See S Matthews. Blaming Agents and Excusing Persons: the case of DID. Philosophy, Psychiat & Psychol 2003; 10: 169–174. As narrators we are trying to make sense of what we are doing,

in which this is supposed to happen and to do so we may reflect on one recent influential account of close relationships by Cocking and Kennett (1998).8 In an analysis of the concept of friendship, they argue that its value derives from the intimacy generated by the interpenetration of selves. What does this mean? First, with close others we respond positively to their invitations to engage in activities, and we often find ourselves willing to participate, not necessarily for the sake of the activity, but simply because we wish to spend time with the friend. These activities bring us together and our agency comes to then figure jointly in pursuit of a common end. Memories of a shared meal, a game of bridge, a night out bowling, or a dancing date with friends are co-biographical, since the event recalled makes sense only as a story featuring the kinds of human interaction and motivation that would explain its narrative aspects. Cocking and Kennett call this aspect of friendship, direction. Second, in responding to a close other’s view of the world, including her view of you within the social world you both inhabit, you come to take on her interpretation of both of these aspects by seeing the world and yourself through her eyes; and as a mutual relationship she will come to take on your interpretation of her. I notice my friend is always a little too quick to criticize those around him; when I gently mention this to him, he is receptive to this take on his behaviour precisely because it comes from me, his close friend. In a dynamic way these ongoing interpretations constitute the writing of the story which characterizes the relationship. Close relationships such as friendships, then, are ongoing co-authored works, and it is worth adding that these elements – direction and interpretation – may be present to some extent in close relationships that fall short of the friendship model. Indeed the interpenetration of agential narratives occurs to some extent almost any time we engage with another human being. Close relationships to family and friends are typically a central source of value to those within them. The claim and even if our narrative-making does not feed directly into action, it helps us make sense of our pasts in remembering, and remembering is a kind of action. Many authors have gone for the broader view of narrative selfhood. These include: A MacIntyre. After Virtue: A Study in Moral Theory. Notre Dame, Indiana: University of Notre Dame Press; 1984; C Taylor. Sources of the Self. Cambridge: Cambridge University Press; 1989; Ricoeur P. Time and Narrative. Chicago: University of Chicago Press; 1987; M Schechtman. The Constitution of Selves. New York: Cornell University Press; 1996. David Velleman has given an account of the narrative self with a focus on agency. See D Velleman. The Self as Narrator. In: J Anderson, J Christman, editors. Autonomy and the Challenges to Liberalism: new essays. Cambridge: CUP; 2005. 8 D See Cocking, J Kennett. Friendship and the Self. Ethics 1998; 108: 502–527. For my own purposes I couch the explanation of their view partly in narrative terms; they did not use the language of narrativity to explain the ways in which agents are shaped in response to the features of what they called direction and interpretation that characterize intimacy.

© 2015 John Wiley & Sons Ltd

Dementia and the Power of Music Therapy here is that when dementia sufferers begin to ‘lose their story’ they thereby lose the capacity for closeness with others. Their responsiveness to friends once known, even very close family members, as intimates, with recollections of a shared history, and with the capacity to engage in further writing of the story, is diminished, and sometimes seems to be almost wholly lost. However, this conclusion may be too hasty. What if a therapy was available which re-activated, even to some small extent, a person’s capacity to respond to others and to appreciate objects like music? I later go on to connect the point concerning the conditions of valuable human relationships with a point about the ways in which the attitudes of carers are informed by the kind of relationship they conceive themselves to be in with a dementia sufferer. Is it one in which they react to the sufferer as a participant in social life (with at least some degree of direction and interpretation), or is it one in which they predominantly adopt a more objective managerial attitude? The account I offer here is that therapeutic approaches in dementia do best when they are oriented towards enabling a sufferer to be more visible as a person-participant, someone apt to form a relationship, and so someone to react to as a person. As I explain, music therapy represents one highly successful means for achieving such an orientation. It has the effect of bringing those who engage in it back into the social space, back to where they once were as recognizable, and recognized, social agents, fit for the development of relationships with carers, and reprisal of relationships with loved ones. This is the source of the moral value of such therapies. Typically in dementia the features pertaining to social interaction and recognition gradually cease to operate the way they once did. Depending on the type of pathology, this period – the early to middle stages – can extend for many years.9 I do not claim that in the late stages of dementia music therapy might enable a sufferer to develop new friendships in which the features of direction and interpretation are fully active. The claim is more modest. It is simply that the ability to engage another socially may be rekindled. Music therapy enables those with dementia to re-enter their social world, to be responsive to others, to participate, to converse, even to engage in some minimal kinds of interpretation as described above; in short, it provides the means to restore their status as socially recognizable actors. In addition, and as I explain more fully in Section 5, not only does it enhance the wellbeing of dementia sufferers in the sense outlined here, music therapy also provides its practitioners with an

9

In Alzheimer’s dementia, average life expectancy is around 8 to 10 years, though cases of up to 20 years have been recorded. The severe late stage lasts from between 1 to 3+ years.

© 2015 John Wiley & Sons Ltd

3

effective tool for providing meaningful care, and so provides those carers with a more meaningful participation in professional life.

3. HENRY, MUSIC THERAPY AND SOCIAL AGENCY To bring this alive consider the case of Henry, an elderly man with severe dementia.10 Most of the time he sits slumped in a chair, barely responsive, and unable even to recognize his own daughter. He is in a state of severe ill-being in which self-esteem, agency, social confidence and hope seem to have gone.11 But this apathetic condition is not insuperable: when Henry’s carers expose him to his favourite music he is ignited, sitting up, he begins to move to the music, his eyes wide, his demeanour transformed. After the music has stopped, remarkably, Henry retains for a period his animation and cognitive awakening, able to respond to questions and to converse a little with his carers. In the video clip he is asked about his music. ‘I’m crazy about music . . . Cab Calloway was my number one band – guy I liked.’ When asked about the effect of music on him he responds thoughtfully ‘It gives me the feeling of love, romance . . . The Lord came to me and he made me a holy man, so he gave me these sounds.’ It appears that Henry’s case is spectacular, though it is not isolated. In a recent interview neurologist Oliver Sacks remarks that: Where I work at the hospital, and all of these old age homes . . . a lot of people there have Alzheimer’s or dementias of one sort and another. Some of them are confused, some are agitated, some are lethargic. Some have almost lost language. But all of them, without exception, respond to music, especially to old songs, and songs they’ve once known, and these seem to touch springs of memory and emotion which may be completely inaccessible to them. And it is most amazing to see people who are out of it and dour . . . suddenly respond to a music therapist and to a familiar song. First they will smile and then perhaps start to keep time and they will join in and sort of regain that part, or that time of their lives and that identity they had when they first heard the song. So it’s almost an amazing thing to see and of course to experience and that sort of lucidity and pleasure can last for hours afterwards . . .12 As remarkable as Henry’s case is, the suggestion is not that music therapy restores him to his former self, able to 10 Footage of Henry has been posted online, available at http:// www.youtube.com/watch?v=fyZQf0p73QM. [cited 2014 Oct 28]. 11 See T Kitwood, K Bredin. Towards a theory of dementia care: personhood and well-being. Ageing Soc 1992; 12: 269–287. 12 Interview transcription available at http://www.youtube.com/ watch?v=MdYplKQ4JBc. [cited 2014 Oct 15].

4

Steve Matthews

hold his own in social life, form new relationships and so on. It is important to be clear about the limits of the therapeutic outcomes associated with music. Neurocognitively three separate theses might be proffered. First: music therapy repairs and regenerates those brain areas in which music processing takes place. Second: music therapy is neuro-protective – repeated use of brain areas associated with music processing either delays neuro-degeneration or slows the progression of the disease. Third: the therapeutic action resuscitates dormant but functionally intact systems. (These three possibilities, particularly the last two, are not incompatible.) I have found only one reference supporting the first possibility, the regeneration claim.13 The neuroprotection claim is hard to test with absolute rigor because ideally only a randomized controlled twin study would demonstrate the connection between music therapy and delay of onset of dementia or slowed progress of the disease. No such study has ever been done or, for both logistical and ethical reasons, is ever likely to be done. Instead the evidence for the claim of neuroprotection is less direct, coming from comparisons made between similar groups, who then diverge on that single variable.14 It is, however, the last possibility – music therapy exercises an area of the brain (relatively) untouched by the disease – that looks highly plausible.15 As mentioned, it may be the case also that in discovering that Henry’s latent ability to process music is preserved, the therapists simultaneously discover the key to slowing the progress of his dementia pathology. So, the second and third possibilities are causally bound up. The effect of the music on Henry is initially one of arousal, and it would appear that this has a cascading effect, since self evidently he is then able to converse with his carers and family in an intelligible way.16 We might say that music therapy is a tool of access – access to 13 See H Fukui, K Toyoshima. Music Facilitates the Neurogenesis, Regeneration and Repair of Neurons. Med Hypotheses 2008 Nov; 71(5): 765–769. 14 For a careful review of the relatively recent state of play on the question of music, the memory systems in play, and neuropsychological explanation, see A Baird, S Samson. Memory for Music in Alzheimer’s Disease: Unforgettable? Neuropsychol Rev 2009; 19: 85–101. 15 Some studies have focused on showing that brain areas, such as the basal ganglia and cerebellum, devoted to implicit memory (specifically involving the stimulation of procedural skills) are initially spared in alzheimer’s patients. See O Zanetti, G Zanieri, G DiGiovanni, L Pietre De Vreese, A Pezzini, T Metitieri & M Trabucchi. Effectiveness of Procedural Memory in mild Alzheimer’s disease patients: A Controlled Study. Neuropsychol Rehabil 2010; 11: 263–272. 16 The case of Henry has generated a lot of attention outside research circles, but the phenomenon of increasing social interaction during and after music therapy sessions has been known for some time. Sambandham & Schirm (1995:79) cite six studies going back to the late 1980s, each with similar results: continued responsiveness to the music, reduction in negative symptoms, improved participation, improved spatial and temporal orientation, less anxiety and lift in mood. (See

memory of music and access to a past social self. Henry’s agency, to be sure, is scaffolded by his external circumstances, the music and the carers who make it available. Yet in so far as Henry is sufficiently agentially restored, he finds himself re-admitted to the social world, as a conversant within it. His carers now view him as a respondent in social discourse, and for that brief period engage with him as such; their stance with respect to him switches from managing his care to being a minimal kind of participant, someone apt for at least a modicum of direction and interpretation. In the language of Strawson, his carers now move from the objective standpoint of managing Henry, much as one might guide a small child, to the adoption of a different stance: the participant stance.17 In social interaction, regarding another as a person – an individual with rights, responsibilities, language, and agency – requires that we hold a certain set of attitudes to one another, what Strawson called the participant reactive attitudes involving, inter alia, resentment, gratitude, esteem, indignation, forgiveness or reciprocal love. When Henry is brought back by the music, his carers and family briefly see the version of Henry as he was, and it is this individual who is the deserving subject of at least some recognizable core of the participant stance, a responsiveness that is interactive and respectful, at the very least to Henry’s understanding and opinions of his love of music. Certainly, Henry’s brief recovery does not warrant re-admission into social life in any full blown way. Nevertheless, enough of his former self is brought back for us to appreciate the deserved shift in response to him.

4. MUSIC THERAPY The case of Henry provides a representative profile for the way music therapy rekindles narrative social agency, and it demonstrates an effective and ethical approach to eldercare. Nevertheless it is just one case, and so in this section I describe music therapy in more general terms. First, what exactly is music therapy? Which groups receive music therapy and who delivers it? Does it require trained therapists? Second, Henry listens to his music through headphones, placed there by the nurse. What are the other ways in which the therapy is delivered? How, exactly, does music therapy work? Will any music do? Does it work for some and not for others? Let’s divide this set of questions in two. M Sambandham, V Schirm. Music as a nursing intervention for residents with alzheimer’s disease in long term care. Geriatric Nursing 1995; 16: 79–83.) 17 P Strawson. Freedom and Resentment. Proceedings of the British Academy 1962; 48: 1–25.

© 2015 John Wiley & Sons Ltd

Dementia and the Power of Music Therapy

What and who? The Australian Music Therapy Association defines music therapy as, ‘. . . a research-based practice and profession in which music is used to actively support people as they strive to improve their health, functioning and wellbeing’.18 The American Music Therapy Association defines it as the ‘[p]lanned and creative use of music to attain and maintain health and well being’.19 These very general, open-ended definitions remind us that music therapy is not limited to those with dementia, as it targets people of all ages, cultures, and levels of musical competence. It is used in a wide range of health contexts including (but not limited to) cardiac cases of anxiety, autism, children and adolescents with psychopathology, stressed cancer patients, those suffering postoperative pain, migraine sufferers, and the terminally ill. Stress is placed on the professional application of music for therapeutic ends; and so its function is explicitly not for education or entertainment. Music therapy higher degrees are now available in universities in the United States, Canada, Europe, UK, Australia, New Zealand, and South Africa. The World Federation of Music Therapy holds a World Congress every three years, and has done so since 1974. Indeed, music therapy has a lengthy history. The American Music Therapy Association notes that references to the healing powers of music go back at least to 1789, and that by the early 1800s there were reports of its application within institutional settings. By the early 1900s various associations had evolved including the National Therapeutics Society of New York, in 1903. In 1922 in Australia the International Society for Musical Therapeutics was founded, and in 1950 the Red Cross Music Therapy committee assembled. Suffice to say, and to say the very least, confidence in the healing powers of music cannot be dismissed as a fad. Its longevity as a practice, commitment to accreditation for practitioners, the various membership groups and funding initiatives by government all suggest a growing success in both its clinical and social effects.

What and how? Music therapy in dementia may be delivered actively (where patients play or sing) or passively (where they listen and observe). It may occur in the domestic home, in an aged care residence, as a one-on-one therapy, or in group sessions, and the type of therapy should depend on

stage of dementia and the person involved. For instance, song choices are important.20 The therapy’s success is associated with four different aspects of the music and the context of its application: the communal nature of its delivery, the rhythmic quality of composition, the entrancing effect of music’s mood, and the physiological arousal accompanying listening. These are not put forward as necessary conditions, but rather those typically present in the music and its delivery when its effects are most noticeable.21 When these features obtain, and especially in combination, the results can be spectacular, as the case of Henry reveals. Included among these are its mood-shifting effects; enhancement of cognitive function; reduction in agitation, anxiety, or wandering; the improvement in response to family and staff; and improvement in coordination and motor function. This last point is worth stressing. Sacks, for example, has emphasized the importance of using rhythmic music or familiar songs.22 A person with early to mid stage dementia is likely to retain memories of songs they knew when younger. The importance of rhythmic music turns on the fact that a rhythmic response can occur in absence of the need for sophisticated levels of neuro-cognitive processing. The capacity for such cortical processing may be severely diminished but since the motor centre of the brain is functionally intact, and so far relatively untouched by neuro-degeneration, music’s pulsing elements can be picked up leading to arousal.23

5. MUSIC THERAPY, NARRATIVE SOCIAL AGENCY, AND WELL-BEING In this section I make the links between music therapy, narrative social agency and well-being more explicitly. I begin with some description of a model of music therapy, and apply it to the case of Henry. I then go on to explain that such therapy is very much at home with what Kitwood and Bredin (1992) label the socialpsychological model of dementia care. This model is contrasted with a purely medical model in which patients receive as primary, psycho-pharmacological treatment. In the social-psychological model the disability of dementia is distinguished from the (medical) impairment resulting from the neuro-degenerative pathology. The disability can then be seen as partly a function of aetiological trajectories stemming from the 20

18

Australian Music Therapy Association. 2014. What is music therapy? Available at: http://www.austmta.org.au/content/what-music-therapy [cited 2014 Oct 5]. 19 American Music Therapy Association. 2014. What is music therapy? Available at: http://www.musictherapy.org/about/musictherapy/ [cited 2014 Oct 10].

© 2015 John Wiley & Sons Ltd

5

RS Moore. Music Preferences of the Elderly: Repertoire, Vocal Ranges, Tempos, and Accompaniments for Singing. J Music Ther 1992; 29: 236–252. 21 Oliver Sacks comments on each of these. See his excellent The Power of Music. Brain 2006; 129: 2528–2532. 22 Ibid: 2528. 23 Zanetti et al., op cit. note 15, p. 264.

6

Steve Matthews

socially imposed environment. Thus, it becomes clear under this construal that music therapy introduces a condition that takes account of the highly contingent and potentially disabling aspects of the place of residence for the person with dementia. These disabling aspects of the residential environment are easily adjusted through a simple change in policy. The ethical question is to consider what the ends of such a policy are, and how to be most effective in achieving them. The claim here is that music therapy is currently one of the most effective – indeed, cost effective – ways of achieving respectful recognition of the agency of the dementia sufferer while at the same time enabling social life for both sufferers and their carers to be improved. On one model of music therapy cited by Lucanne Bailey, a three-stage process of contact, awareness and resolution is put in place. At the contact stage, a trusting relationship is established between the therapist and patient, followed by an awareness stage in which the patient and/or her family focus on music choices that address their therapeutic needs, with the last stage of the process seen as resolving the tensions that motivated it from the start.24 It is against this backdrop that appropriate music choices are made. In Henry’s case the choice of Cab Calloway is important in what later takes place when he responds to questions pertaining to the music. His relative lucidity is facilitated by the capacity to connect with his past. His sociality, his responsiveness to questions from his carers, depends on his having a story to tell that makes sense of his agency now. His recognition of the music associates with his recognition of himself as he was when he first heard it, and that’s the story he tells to those around him. There are significant gaps in Henry’s autobiographical memory system, but what matters is that he can connect to a past that is his own, and so he gets back a part of his narrative selfhood that is central to his selfunderstanding. We might put this by saying that the music is a key that unlocks the door on his narrative social agency. Kitwood and Bredin observed, with some optimism, that an opportunity lay open for re-working the social environment of dementia care. Their optimism was based on the observation that the state of cognition of a resident-in-care is strongly a function of how they relate to the conditions of that care. They wrote that this hope was based on the fact that many individuals: 24 See LM Bailey. The use of songs in music therapy with cancer patients and their families. J Music Ther 1984; 4–17. Bailey applies the model to cancer patients but the stages for song choice apply equally well in the palliative domain. For a person with moderate or even severe dementia, the intercession of family members to choose the music assumes more importance.

. . . show considerable reversal or ‘rementia’ when their conditions of life, and especially their social relationships, are changed. The positive changes that are most notable are in the areas of social skill . . . As social being is recovered, so ‘mind’ (in some of its aspects) is restored. (Kitwood and Bredin p 278) They go on to add two other lines of evidence grounding reasons for hope that the medicalized understanding of dementia under-describes the situation. One is that intensive nursing care involving a programme of activities, in contrast to traditional care, significantly halts deterioration due to the disease.25 A second was a kind of ‘rat park’ version of a study in dementia care, where a group of geriatric rats were placed in an ‘impoverished and solitary’ environment, following which some of these rats were then moved to an environment where there were activities and plenty of company with other rats.26 ‘Putting it crudely’, they said (p279), and noting the limits of rat-to-human inferences, ‘these experiments show that the brain of a declining geriatric rat can be revived solely through a change in environmental conditions’. The claim, then, is that music therapy may provide a significant contribution to ‘rementia’. It does so by arousing its participants out of a state of malaise, anxiety, confusion or depression, and into a state where they connect. They connect with the music, possibly with the past (and possibly their own past), and with those around them. In virtue of doing so, they become social participants again. It is in virtue of the removal of the anhedonic tendencies and the re-admission to social life that the ethical grounding of music therapy for dementia is proffered. It is interesting, then, to compare what Kitwood and Bredin say are the underlying features of well-being for those with dementia. They list these as personal worth, a sense of agency, social confidence, and hope. Each of these is directly supported by music therapy. First, personal worth refers to the losses of selfesteem accompanying diminishing cognitive loss, and the treatment that follows. This connects to the Strawson point: to lose the ability to participate and to gradually sense that one is becoming a patient to be managed, must be a particularly effacing experience. Second, I have already discussed the link between nar25

See B Rovner, J Lucas-Blanstein, MF Folstein & SW Smith. Stability over one year in Patients admitted to a Nursing Home Dementia Unit. Int J Geriatr Psychiatry 1990; 5: 77–82. 26 The expression ‘rat park’ arises in connection with a study in the addictions field that might be seen to parallel the current one. See B Alexander, BL Beyerstein, PF Hadaway & RB Coams. Effect of early and later colony housing on oral ingestion of morphine in rats. Pharmacol, Biochem and Behav 1981; 15: 571–576. The geriatric rat study is from M Diamond. 1985. The Potential of the Ageing Brain for structural regeneration. In: T Arie, editor. Rec Adv in Psychogeriatr.

© 2015 John Wiley & Sons Ltd

Dementia and the Power of Music Therapy rative social agency and the meaning and value of personal relationships, but, to briefly reprise, the simple point is just that if I can communicate my story I can form and maintain a valued relationship, and music has a special tendency in dementia sufferers to bring back acquaintance with a part of their story. Third, in terms of social confidence, regular music sessions for many allow them to feel more at ease with others, to belong to something, and to have a place and a purpose in the social group to which one is contributing. Finally, although a little more tenuous, the regularity of a musical encounter, something which structures one’s day and gives a sense of peace (or at least reduced agitation), may well provide for a sensed future that contains something good to which one looks forward. Narrative agency is of value because it provides for a meaningful existence, and in so far as this is the case, it reduces anxiety and stress, and contributes to an atmosphere more conducive to happiness and comfort and a feeling of security, as many of the studies have noted. By meaningful existence, I mean quite literally an existence in which an agent is able to make sense of what they are doing, and to communicate it. It becomes meaningful when it is communicated both to the person himself, and to those around him. Telling your story – to oneself and to others – is part of what meaningful agency consists in. When I tell myself I am listening to my favourite music, or playing my chosen instrument, this feeds into that very process itself; when I tell others about what I do – I am a music lover, or an artist, or a writer – this becomes constitutive of the interpretation spoken of earlier that undergirds the closeness of relationships. This article has focused on the ethical considerations that relate to the well-being of dementia sufferers. Yet, the therapeutic strategy described here does not exclude a consideration of the well-being of those caring for dementia sufferers. Carer well-being matters greatly both in itself and relationally, given that within this context staff morale is strongly implicated in staff effectiveness. The anecdotal evidence shows that those engaged in the delivery of music therapy experience relatively high levels of worker satisfaction. To bolster this, a 2005 quantitative study into the attitudes, stress and satisfaction of dementia care workers concluded that staff training and worker satisfaction in person-centred care, something at home with music therapy, most saliently impacted worker attitude.27 27

The Alzheimer’s Society in the UK defines person-centred care as an approach that ‘. . . aims to see the person with dementia as an individual, rather than focusing on their illness or on abilities they may have lost. Instead of treating the person as a collection of symptoms and behaviours to be controlled, person-centred care considers the whole person, taking into account each individual’s unique qualities, abilities, interests, preferences and needs. Person-centred care also means treating residents with dementia with dignity and respect.’

© 2015 John Wiley & Sons Ltd

7

The authors write: To our knowledge, this study is the first to empirically assess correlates of person-centred care . . . The items reflective of this mode of care address the need to provide stimulating and enjoyable activities . . . to see residents as having abilities and reasons for their behaviour, and to enjoy being with residents . . . [my emphasis]28 In this section I have argued for a three-way link between music therapy, narrative social agency and wellbeing. It is a qualified case in several respects. First, the measures of narrative social agency and wellbeing are not intended as threshold-like categories; on the contrary these measures fluctuate on a continuum, and this observation provides an important incentive for those instituting therapeutic measures, perhaps captured nicely in the slogan that every little bit helps. Second, and to repeat, the case for music therapy shouldn’t obscure other therapies that might be based on similar bio-psycho-social mechanisms. An important empirical question remains open in relation to these mechanisms.29 The present work is concerned to identify the ethical dimension to the success of music therapy – that it boosts agency and well-being. Third, it is important to note there is no one-size-fits-all approach to music therapy. What works in one context may fail in another. The variables outlined above – stage of dementia, active versus passive, solo, group, geographical location and so on – are part of it. However, such aspects as personality style, cultural milieu, or known musical taste are said to be critical in tailoring therapy to particular needs. Henry, for example, might well have failed to respond in the way that he did had he been introduced to music to which he was indifferent.

6. CONCLUSION Given the increasing rates of dementia, particularly in western countries such as the USA, Canada, Europe, 28

S Zimmerman, CS Williams, PS Reed, M Boustani, JS Preisser, E Heck & PD Sloane. Attitudes, Stress, and Satisfaction of Staff who care for Residents with Dementia. The Gerontologist 2005; 45: 96–105. 29 A recent meta-study attempted to identify a mechanism for action that underlies the clinical success stories in music therapy. The authors surveyed 263 potential studies, ultimately analysing 18. By comparing and synthesizing the results of the studies the authors sought to identify a unifying theoretical basis for explaining what goes on in music therapy and why is works. The authors concluded, pessimistically, that more work needs to be done in order to establish such theoretical consistency. However, they did not dispute the overwhelming observational data that music therapy leads to improvements in well-being, particularly with vocalized music. See O McDermott, N Crellin, HM Ridder & M Orrell. Music therapy in dementia: a narrative synthesis systematic review. Int J Geriatr Psychiatry 2013; 28: 781–794.

8

Steve Matthews

the UK and Australasia, there are increasing pressures on both social infrastructure and health budgets to find low cost, and creative measures to deal effectively with the situation. Music therapy is one such creative approach to this difficulty, one that does not rely on a predominantly psycho-pharmacological approach to treating and managing a patient, but rather one in which a social activity alleviates problems arising towards the end of life when we’re not quite at our best,

and that allows old friends and family to catch glimpses of how we were before we started to lose the plot of our lives. Steve Matthews is Senior Research Fellow at the Plunkett Centre for Ethics (a joint centre of St Vincents & Mater Health and Australian Catholic University), and Conjoint Senior Lecturer, at the University of NSW, in Sydney Australia. His research interests are in the philosophy of mind and psychiatry, moral psychology and applied ethics.

© 2015 John Wiley & Sons Ltd

Dementia and the Power of Music Therapy.

Dementia is now a leading cause of both mortality and morbidity, particularly in western nations, and current projections for rates of dementia sugges...
98KB Sizes 0 Downloads 19 Views