Music’s dynamic potential to stimulate interaction, self-expression and community-building can encourage well-being in residents challenged with cognitive impairment, memory loss and dementia in long-term care settings. Consider the following illustrations:
—A woman whose short-term memory is so impaired, she cannot recall singing a song immediately upon finishing it, is nonetheless steadily improving in confidence and ability as a singer and public performer in facility cabarets.
—A man with a strong church background and deep spiritual conviction would escalate into hyper-religious, inconsolable agitation after singing or even hearing gospel music but is now able to enjoy singing hymns, investing them with a powerful yet controlled emotion.
–A socially withdrawn and verbally unresponsive man with a history of physical aggression and disoriented wandering becomes socially related, friendly, humorous, active and engaged while singing a wide range of songs and sometimes dancing with peers and caregivers.
—A middle-aged man who sustained a traumatic brain injury at a young age is often socially disruptive and loud with minimal ability to interact. In music, he becomes capable, oriented, joyful and expressive.
—A group of residents collaborate in the composition of a heart-warming song, then rehearse and film a spirited performance, making a music video and generating positive feelings and pride for themselves, their peers and professional staff.
What do all these examples have in common? In music, these individuals are not simply receivers of services whose current lives are defined primarily by their medical needs and diminished capacity. They are active members of a community, engaged in a process of growth, contribution, sharing and feeling worthwhile. For those with failing health and cognitive loss, so much of their former sense of identity (professional, spouse, parent, provider, etc.) has fallen away.
Who are they now? Music therapist, David Aldridge1 referred to identity as achievable only through active feedback and dialogue with others. We are performed beings, Aldridge says; that is, we realize ourselves in the world—mentally, physically and socially—as performances. Music is a performance art whether it is played in a room, on a concert stage, while recording a CD or filming a video. While residents may not be able to “perform” their previous roles, they may discover something new about themselves, or something old remembered, through musical expression and interaction.
That individuals with cognitive impairments, unable to engage in a functional conversation, can still sing entire songs is a common phenomenon in music therapy. Why is this so? Possibly because, as music researcher Daniel Levitan2 relates, music listening, performance and composition engage nearly every area of the brain that has so far been identified and involves nearly every neural subsystem.
No other activity is known to do this. Music has also been shown to increase dopamine levels related to positive affect and well-being and dopamine pathways are dispersed throughout the brain. Music’s “whole brain” phenomenon allows for parallel processing and learning in many structures all at the same time, generating neurological connections not typical of cognitive awareness.
This “upliftment factor” intrinsic to musical engagement was noted by Dr. Charles Limb of Johns Hopkins University School of Medicine, who stated, “It is almost as if the brain ramps up its sensimotor processing in order to be in a musical state.”3 This is extremely important for long-term care residents with cognitive loss since the idea of “brain exercise” has become well-known as an intervention to reduce or slow decline.
Studies have shown that the positive results of musical activity, including elevated mood, increased socialization and appetite, reduction in agitation, last long after the completion of the session. These benefits are attributed to the “cognitive workout” the brain receives during participation in music. Residents can become more optimistic about their health and quality of life in spite of their health problems and disabilities.
Emerging models of psychosocial well-being have raised the awareness of nursing home cultures to reflect lifelong living. Failure to meet well-being needs may lead to a resident becoming increasingly dependent and depressed with poorer quality of life and outcomes. Studies vary, with clinically significant depression of nursing home residents ranging from 25%-50% and it has been reported that nurses commonly observe even more symptoms of depression than is diagnosed and treated.4
Although, in general, the field of psychology has devoted more attention to understanding human suffering than to the factors that influence well-being, some psychologists, including such notables as Jung, Rogers and Maslow, have extended theories aimed at defining positive psychological functioning. Their ideas have led to current fields such as “Positive Psychology”5 along with popular articles and books about the “Science of Happiness.” Although terminology and definitions vary, the following list indicates the “Essential Elements of Well-Being.”
Essential elements of well-being
1. Affiliation – establishing positive relations and feeling connected with others
2. Self-Efficacy – feeling autonomous, competent and capable
3. Enjoyment – deriving pleasure and fulfillment from one’s experiences
4. Self-Expression – feeling that one’s unique personality, ideas and needs are being communicated and received
5. Engagement – being active, focused and immersed in one’s interests
In music, residents can experience all these aspects in varying degrees—warm relations with others, and the ability to sing, play and participate enthusiastically. They can feel creative, accepted and motivated to return. While it is true that a person with a cognitive impairment may not remember engaging in an activity minutes after having completed it, he or she seems to retain a feeling sense of the experience.
Activities Director Carol Nearing, who has worked with cognitively impaired adults in long-term care for more than 30 years, says, “It’s clear to me that even though a resident may not remember all the particulars of an encounter, they seem to have better recall for activities in which they had a positive experience, readily accepting ongoing invitations to participate. On the other hand, they tend to resist or refuse invitations to activities that have been previously unfulfilling, unpleasant or anxiety-provoking.”
It is natural for people to seek out situations that help them to feel good about themselves and withdraw from situations that threaten self-esteem, but the fundamental rehabilitative intent must aim beyond self-esteem and towards self-acceptance. Although the two concepts are often used interchangeably, self-esteem relates to one’s perception of success or failure in a given area within a given time and, as such, it can fluctuate.
Self-acceptance, on the other hand, implies a more stable sense of one’s worth regardless of shifting external circumstances or the opinions of others. If we utilize the “Essential Elements of Well-Being,” as a focus for the design of psychosocial care, residents can move towards a sense of self-acceptance. Life-span theories have emphasized self-acceptance as the single most important characteristic of personal development and well-being.
There is a part of us that is ageless. After a lifetime of experiences and all the “slings and arrows of outrageous fortune,” as Shakespeare put it, we are still very much the same inside as in the earliest days of childhood. We all know this to be true. Music helps us get in touch with that. One can have cognitive loss and still have a functional and personally fulfilling experience within the “creative now,” as music therapy pioneer Clive Robbins has termed it. As residents identify with their own creative power through singing, playing, writing songs, and performing, they realize they are still capable of connecting, feeling competent and whole, having fun, making a contribution.
Music gives us the permission and the language to express the full range of human experience. Are perennial sing-along’s such as “You Are My Sunshine,” “Goodnight Irene” and “Sitting on the Dock of the Bay” happy songs? Investigate the lyrics and you will find they are songs of loneliness and despair. Yet, singing them makes us feel happy. Paradoxical? In music we can mourn what we’ve lost even as we celebrate that which has not changed at all, embracing our lives with all their seeming imperfections and frailties.
Rick Soshensky, MA, MT-BC, NRMT, is the director of Creative Arts Therapies within the Northwoods Health System in the Albany, NY, area. Rick has been a practicing music therapist with children, adolescents and adults since 1992. He is the author of numerous professional publications and frequent speaker whose work has been featured nationally in print media, on the radio and on professional websites. Rick was selected by Therapy Times Magazine for its 2008-09 list of “Most Influential Therapists in the Field” and was awarded the New York State Health Facilities Association “Innovative Practice Award” in 2007.
1 Aldridge, D. (2006). Music Therapy and Neurological Rehabilitation: Performing Health. London, UK: Jessica Kingsley Publishers.
2 Levitin, D. (2006). This Is Your Brain On Music: The Science of a Human Obsession. NY, NY: Penguin Press.
3 Medical News Today. (2008). Large Portion of the Brain’s Prefontal Region ‘Takes 5′ to Let Creativity Flow in Jazz Improvisation. February 27. www.medicalnewstoday.com
4 Burrows, A.B. et al. (1995). Depression in a Long-Term Care Facility: Clinical Features and Discordance Between Nursing Assessment and Patient Interviews. Journal of American Geriatric Society. Oct; 43 (10) 1118 – 22.
5 Seligman, M. & Csikszentmihalyi, M. (2000). “Positive Psychology: An Introduction.” American Psychologist 55 (1): 5 – 14.