When dialogue fails. Music therapy with elderly with neurological degenerative diseases

When dialogue fails. Music therapy with elderly with neurological degenerative diseases. In persons suffering from neurological degenerative diseases we often see the following symptoms: difficulties in remembering, concentrating, perceiving input, and controlling and timing movements. Normal every day conversation is building on abilities to remember facts or episodes, to sustain attention, to listen, and to time a response. Without these fundamental cognitive abilities it is difficult to communicate with others – unless the communication is adjusted to the person. Clients with a neurological degenerative disease like e.g. dementia are often socially isolated because of their failing abilities to communicate. Even if they live in a facility and are surrounded by care staff and peer residents, they might experience the environment as chaotic and the people as non-comprehensible. A missing meaningful interaction with others means that psychosocial needs are not met, and this leads to secondary symptoms of the neurological degeneration. Secondary symptoms might be expressed as repetitive behaviour, catastrophic reactions and situationally inappropriate behaviour. In a music therapeutical setting it is possible to adjust the communication in order to enter dialogue. The dialogue is the potential for sharing emotions and meeting psychosocial needs. The core of the music therapy is seen as the moments where interaction and dialogue occurs. But these moments are only “highlights” of the sessions, and before they can happen, the music therapist must build up a structure for the therapy that compensates for missing cognitive abilities of the client. This is illustrated by the following steps that integrate neuropsychological and psychodynamic theories: 1. Focus attention 2. Regulate arousal level 3. Dialogue 4. Conclusion 1. In order to compensate for missing short-term memory it is important to work deliberately with cuing. A specific song in the beginning of the music therapy session will e.g. signalise that the music therapy is to start. Using songs as cues activates cortical memory function, and work as memory traces in the brain. Using the same “hello-song” in the beginning of a session - session after session - gives stability. Stability is constancy and familiarity of cues over time (Roberts & Algase 1988), and even people with severe memory deficits are capable of creating new memory traces and of learning the meaning of new cues. The first step in music therapy is to focus attention, e.g. with stability and cues, and the next step is to regulate arousal level towards environmental attention. 2. Environmental attention depends on levels of arousal. There is a relation between medium arousal levels and the ability to understand ‘what is going on’. “You need to have just the right level of activation to perform optimally” (LeDoux 1998, p. 289). Stimulating and sedating effects of music or songs are obtained by musical parameters, such as tempo, rhythm, timbre, volume, pitch, phrasing, dynamic, and timing. By communicative parameters such as proximity, touch, movements, rhythmic rocking or “dancing”, the music therapist can apply his/her presence to stimulate or calm down the person. Altogether these techniques are inherent in our communicative musicality (Trevarthen 1999). 3. On some occasions the therapist needs many sessions in order to build up a structure and bring the person to a moderate arousal level, where the conditions for interacting and entering dialogue are at their optimum. When these conditions are created it is possible to meet psychosocial needs and decrease secondary symptoms of the degenerative disease. At this level the therapist might work with psychotherapeutic strategies such as validation, holding and facilitation (Kitwood 1997). 4. By marking and cuing the end of the session stability is established. A timeframe is given, and the client can trust that more sessions will follow in spite of the separation. Ending a music therapy session with a specific song might summarize and conclude what has been shared during the session. In the presentation theory and clinical practice will be illustrated with video clips. For background information, see: Ridder, H.M.O. (2003) Singing Dialogue. Music therapy with persons in advanced stages of dementia. A case study research design. PhD-thesis, Institute for Music and Music Therapy, Aalborg University.