A most important statement on the power of music was written under duress by a musician facing possible death: "It is hardly possible to imagine the quality of the orchestra which scarcely existed for a year; in any case, one thing was revealed to me, that the power of music is so great that it draws every human being possessing a heart and an open mind into its realm, enabling him to bear the hardest hours of his life."1
Music is therapeutic for any age group. Recently, however, music therapy uses in geriatric care are becoming known and articles have appeared on this subject in the literature. An overview of some basic concepts appropriate for music therapy in geriatric care could be useful to those working with the elderly. While music therapy groups are geared and modified according to patient level of care, some general concepts may be formulated.
The first assumption to make in music therapy is the interrelationship between music and medicine. The twin relationship is directly evident in the biblical account of David alleviating King Saul's melancholy by playing the harp. (ISam. 16:23).
In long-term-care facilities for the elderly, the emotional responses of patients to their illnesses are long-term also. That is why there is usually an overlay of depression in the chronically ill.
Several factors influence an individual's response to the stress (anxiety) in chronic illness. These are 1) the nature and degree of the current stress; 2) the psychological responses (adaptive and defensive) available to the patient; and 3) resources available to the patient in his present environment, such as supportive human relationships.2
One modality currently being used to alleviate the psychological stresses of patients in long-term-care facilities is music tiierapy. It is a synthesis to utilizing specific music skills plus the conscious use of self in establishing warm relationships with the patients. In this way music therapy is a type of spiritual balm for the elderly in nursing homes.
The second assumption is the acknowledgment of life tasks. Freud said that in order to reach maturity, one must learn two tasks, the ability to love and to work. Mental health also includes the ability to play. Restoration, in a modified way, of these life tasks can be utilized for the institutionalized aged through contacts with children, participation in sheltered workshops, and by leisure time activities. Many gerontological patients learned to play only to a limited degree during their lifetime. Leisure time activities in long-term care can compensate for this lack of background.
Listening to nostalgic music, whether as an active or passive participant still affords the aged patient pleasurable moments when they can relax and enjoy themselves in a carefree, pressure-free environment. This sets up a therapeutic milieu for play coupled with the music leader's conscious use of self in creating the atmosphere and music programming. There is intrinsic therapeutic value in leisure-time activities and play, especially so in the day-to-day living of the institutionalized aged.
The professional who has skills in the area of music and empathy without over-involvement is the ideal music therapist. It is the meaningful, caring interaction with die aged patients that has impact on their emotional comfort. To define the prerequisite of empathy, "This is someone who has tfie ability to place himself in another's position and feel what the patient feels with appreciative perception and understanding. Empathy, by definition, also includes the capacity to maintain objectivity at the same time. (This differs from sympathy which involves a subjective experience.)"3 With empathy, the music therapy is moved to play a musical instrument with feeling and expression, and also relate to the elderly with feeling and caring. Music is an art and so are human relationships.
One way in which supportive human relationships are maintained is through music group work with the elderly. The music group leader performs a wide range of roles that can fluctuate and overlap at any one time: 1) the dutiful son or daughter-filial attitude, 2) the parental figure, whether rejecting or benevolent; 3) the teacher, providing information, 4) the friend/ally; and, 5) the advocate protector.4 These roles lead to a positive transference mechanism of group members and pleasurable music programs when specific nostalgic songs are played. The keys to success in these roles, however, are the basic ingrethents of empathy and kindness. Also needed is the integration of basic principles of music group work with the elderly.
As everyone knows, music has universal appeal and is an interwoven, complimentary part of our lives. Knowing the power of music's appeal to everyone, it seemed an inevitable conclusion that it could be used as a growth tool medium with nursing home patients as well.6 This concept of growth is closely aligned with Erikson's life-cycle theme. The last stage of the life cycle, according to Erikson is ego integrity versus despair. It seems that a task of the aged is a summative or recapitulation of themes integral to their identities, e.g. a growth process. The way in which this concept could be implemented is through nostalgic music content of the group meetings.
Another concept incorporated in music therapy with the aged is Hennessey's statement. "Music apparently affords (the patients) active relief to get away from feelings he experiences when alone and isolated from others."4 (Being alone, may, at times, be desired. The feeling of loneliness, however, is an altogether different matter.) "Also, what could be more challenging than to appeal to their auditory sense to reengage the geriatric patient and provide a socializing experience?"5 Music programs are an activity where patients can enjoy themselves and recapture past identities through nostalgic music that highlighted their life-cycle events.
The milieu of the group is a happy, cheerful environment which provides auditory stimulation and some socialization among group members. Through the music activity, the patients relive their former roles and identities, triggered by the specific nostalgic music selection. The object is not remotivation of clients, but bringing meaningfulness, relevance, reverie, review, and enjoyment into their lives in an accepting, nonjudgmental environment.6
Aged patients remember the past better than the present, for a number of reasons. In order to trigger the life review process through active or passive participation in reminiscence, two types of music programming can be used: old, nostalgic American songs, and ethnic music, to enhance the patients' cultural and religious heritage. A prerequisite for programming groups called Musical Memories is familiarity with these songs. The popular musical instruments from the turn of the century were the piano and violin.
In music programs prepared and performed by the author, we found the use of the piano particularly effective.
The use of old popular requests more so than focusing exclusively on classical music is due to the fact that popular music was more commonly known. The music therapist, in utilizing popular requests (music of the people) should remember that art should bring pleasure and happiness to the world, and especially to those who are denied some of the usual sources of happiness.7
A study of the general cultural context of nostalgic songs helps to induce patient reveries as well as commenting musically on patient reveries. Cues are picked up from patients' verbal and nonverbal responses as well. It is a twoway street whereby music "cues" and patient "cues" are synthesized each time Music Memory programs are given. There is an overall format, but flexibility and spontaneity in programming is also a prerequisite in order to match the patient moods with appropriate musical commentary.
The prime prerequisite, however, is the intimate knowledge of American nostalgic and ethnic music and their place in the cultural history of patients. Use of ethnic music for specific target populations is most effective for recapturing their basic identities, die most valued part of themselves. Emnic music also represents a shared group commonality with intrinsic religious values and meaning. Music, then, while affecting the individual, also expresses collective emotions and aspirations. This includes not only music of an emnic nature, but also national anthems, marches and folk songs belonging to particular occupations or group activity.
Music programming is also a tool that has current meaning to the patients . Current events and news of the day are discussed with patient groups and then followed with nostalgic music commentary appropriate to me context of the reality orientation. For example: One day it was pouring rain, a fact which dampened the spirits of the patients. In discussing the weather with me patients, we played relevant piano music to cheer them up. Songs like "Let a Smile Be Your Umbrella," "Singing In The Rain," "April Showers," "You Are My Sunshine," and me "new" song, "Raindrops Keep Falling On My Head" were played. By the end ofthat specific music programming, the institutionalized patients were lifted from their depressed states and were clapping, singing, smiling, and dancing together.
Another useful concept seems to be that "beneficial effects can be induced by using music of a specific character (soothing, stimulating, cheerful) in order to arouse the corresponding emotions and conditions which appear to be lacking in, and are needed by, the patient."8 Selective use of rhythm, whether three-quarter time or two beat in music selections helps to convey die specific emotions mandated by the spur of the moment. Use of rhythm, the fundamental element of music, dates back to primitive people whose music consisted solely of rhythm. Of course, the inclusion of melody, harmony, and tone color today makes our music selections pleasing to the ear. In fact, it is to the auditory sense of tiie aged to which music is appealing. A music-specific character, aided by its rhythmic character, has direct impact for Music Memory programming. For example, "many peaceful and solemn adagios, many soothing lullabies and barcarolles induce with their soft charm a beneficial relaxation in a more natural and healthy way than any chemical sedative.8
"Songs are the world's diary and its barometer, describing history's events and ideas and measuring the emotional climate of the brief period we speak of as generations."9 The elderly share with the therapist their treasured reminiscences, prompted by the music played. There is a wonderful saying that captures this thought: "To learn from die young is to eat unripe fruit and drink new wine; to learn from the old is to eat ripe fruit and drink old wine."10 Music tiierapy, then, is not only meaningful to the aged patients, but to the provider as well.
Planning for Additional Therapy
The use of music in long-term care is therapeutic, and so mere is a need to explore new modalities for reaching the homebound elderly in the community. As Meals-on- Wheels was created for physical nourishment, a Music-on-Wheels could be created for musical nourishment. The music would include a variety of American and ethnic records. The personnel involved in this contact would be trained in helping skills. If families are present in the home, they would require attention also. Funding could come from the United Appeal, the local symphony, or private philanthropy.
We need to tap our resources for creative ways to reach out to the elderly. The burgeoning field of music therapy with the aged is one such method.
While concepts in music therapy with the aged are useful and provide an outer structure, an internalization of the helping process results in a philosophy of care. Whether one knows of imminence or not, the aura is, practically speaking, one of the end of the life cycle. What comes to mind, above and beyond principles and purposes of music group work in the field of gerontology, is the feeling of playing "Swan Songs." Weekly music programs of selected nostalgic songs that have the most meaning to the patients provide a basis for helping the aged maintain ego integrity through a variety of swan songs. It is also a final form of creative energy through the medium of music that triggers these responses and feelings.
Basic to a philosophy of care of the aged is the need to accept one's own mortality. There is a poignant story written to that effect by Leo Tolstoy (1828-1910) called the "Death of Ivan Ilyich." When Ivan Ilyich was terminally ill, his family and friends abandoned him. Only a peasant servant cared for him and was his companion. Ivan asked the peasant why he bothered to care for him. The peasant replied that it was no bother because someday he would be in Ivan's shoes. While helping professionals in geriatrics work in a milieu of endings, not beginnings, they are planting seeds of empathetic love of others based on the worth of all human life.
There is an interrelationship between music and medicine. Music alleviates psychological stresses of patients and is a tool in establishing ego integrity. Specific nostalgic American music and ethnic songs help in triggering memories which serve as a life review process of high points in the lives of the elderly. Supportive, caring relationships given by the music group leader plus music and group work skills are essential elements of music therapy. A relaxed, informal ambiance sets up an atmosphere of self-expression of patients where they can enjoy themselves. Spontaneity, flexibility, and creativity in music programming helps to match patient moods and current events of the day with appropriate musical commentary. Skills and knowledge of music plus its context in reflecting cultural history is useful for music therapy with the aged. It is true what the artist of Terezin said: "The power of music is so great that it draws every human being possessing a heart and an open mind into its realm, enabling him to bear the hardest hours of his life."1
The use of music therapy with the aged is not only meaningful to these patients, but to the provider as well . The life of the music therapist is enriched by these associations.
- 1. Green G: The Artists of Terezin. New York: Hawthorn Books, Inc. 1969, p. 78.
- 2. Schnaper N: Management of the chronically ill patient, in Balis, G.V., Wurmser, L., McDaniel, E. and Grennel, R.G. (eds), The Psychiatric Foundations of Medicine, Vol. 6. Boston: Butterworth Publishers, Inc. 1978, p. 277.
- 3. Kartman LL: Inopie helping people: Burnout. Activities, Adaption, and Aging Journal. 1983; 3(4):52.
- 4. Hennessey MJ: Music and group work with the aged. IN Irene Mortenson Burnside (ed.)Nursing and the Aged. New York: McGrawHill, 1976.
- 5 . Kartman LL: The use of music as a program tool with regressed geriatric patients. J Gerontolog Nurs. 1977; 3(4):39.
- 6. Kartman LL: The power of music with patients in a nursing home. Activities, Adaption, and Aging Journal. 1980; 1(1):9.
- 7. Ainley GW: The place of music in military hospitals. IN Schullian, Dorothy and Schoen, Max (eds). Music and Medicine. New York: Henry Schuman, Inc., 1948, p. 329.
- 8. Assagioli R: Psychosynthesis. New York: The Vlking Press, 1965, p. 254.
- 9. Meyer H: The gold in Tin Pan Alley. New York: The J. W. Lippincott Co. , 1958, p. 11.
- 10. Rosten L: Treasury of Jewish Quotations. New York: Bantam Books, 1977, p. 338.
- The author wishes to express appreciation to Dr. Nathan Schnaper for his encouragement and assistance.