Singing Dialogue : Music therapy with persons

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Ridder, Hanne Mette Ochsner
Publication date:
2003
Document Version
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Ridder, H. M. O. (2003). Singing Dialogue : Music therapy with persons in advanced stages of dementia.: A case
study research design. Aalborg Universitet: Institut for Musik og Musikterapi, Aalborg Universitet.
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Hanne Mette Ochsner Ridder
Singing dialogue
Music therapy with persons in
advanced stages of dementia
A case study research design
PhD-thesis, 2003
Institut for Musik og Musikterapi
Aalborg Universitet
Revised edition 2005
Copyright ⃝c 2003 Hanne Mette Ochsner Ridder
2 Ridder: Singing Dialogue
Abstract
Persons suffering from primary degenerative dementia at later stages of the disease experience
problems in perceiving environmental information and in expressing themselves in verbal lan-
guage. This leads to difficulties in entering and maintaining dialogue. Failing possibilities of
entering dialogue, psychosocial needs are not easily fulfilled, which leads to serious secondary
symptoms of dementia. In this research the use of familiar songs in music therapy is suggested
as a way of entering dialogue, where the communication is adjusted to the individual person.
A flexible mixed-method research design is carried out based on video observations, heart
rate data, and observations from staff, external assessors, and the music therapist. One part
of the research consists of 6 case studies where physiological data are used to validate obser-
vational data. Next part is a hermeneutic analysis of observations done by external assessors,
leading to a catalogue of gestural responses and a coding and categorization of the qualities
of these responses. In a third part examples from the case studies are analysed, using the
categories that evolved in the previous part and describing various levels of communication.
The results show that; 1) Singing has a positive influence on the 6 participants, defined
by degree of compliance, by changes in heart rate levels, and by various ways of taking part
in the music therapy; 2) The six participants communicate responsively, and this commu-
nication can be recognised by a system of communicative signs, representing different levels
of communication: emotional valence, receptive participation, sociality, active participation,
communicative musicality, and dialogue. There exists a relationship between a balanced
arousal level and communication at more intensive levels for all six participants; 3) In 5 of 6
concrete cases music therapy shows an influence on aspects in residential daily life, defined in
a statistical significant decrease in heart rate levels pre/post therapy, for persons with severe
dementia showing agitated behaviour.
The participants clearly profit from the music therapy sessions, and most important: these
persons suffering from severe dementia are communicating and are able to be brought into
a state where a communicative dialogue takes place. The songs offer a structure, which
functions in focussing attention by mediating stability, as well as social and contextual cues.
Additionally the songs are used in regulating the arousal level of the participant towards
environmental attention and a state most optimal for entering dialogue.
Danish abstract
Personer med en primær degenerativ demens vil p˚a senere stadier af sygdommen have vanske-
ligheder med at omsætte sanseindtryk og med at udtrykke sig verbalt. Det kan føre til prob-
lemer med at indg˚a i dialog med andre. Psykosociale behov kan vanskeligt opfyldes uden
muligheder for at være i dialog, hvilket igen fører til sekundære symptomer p˚a selve de-
menssygdommen. I dette forskningsprojekt tages der udgangspunkt i brugen af velkendte
sange i musikterapi som en m˚ade at indg˚a i dialog hvor kommunikationen er tilpasset den
enkelte person.
Forskningsdesignet er et fleksibelt design baseret p˚a en integration af definerede metoder
og med data best˚aende af video observationer, pulsm˚alinger samt observationer udført af
personale, eksterne observatører og af musikterapeuten. Den første del af forskningen best˚ar
af 6 casestudier hvor fysiologiske data indg˚ar i analysen sammen med de øvrige observa-
tioner. Næste del er en hermeneutisk analyse af observationer, som er udført af eksterne
observatører. Dette munder ud i en systematisk opstilling af gestisk respons samt en kodning
og kategorisering af de kvalitative aspekter af denne. I en tredje del samles de to indfaldsvin-
kler, og udvalgte eksempler fra casestudierne analyseres med udgangspunkt i de kategorier,
3
der førhen er opstillet, og som beskriver forskellige grader af kommunikation.
Resultaterne viser at 1) Sang her en positiv indflydelse p˚a de 6 personer med svær demens.
Denne indflydelse kan defineres ud fra graden af kompliance, ændringer i pulsfrekvens og ud
fra forskellige m˚ader at deltage i musikterapien p˚a. 2) De seks deltagere form˚ar at kommu-
nikere med musikterapeuten, og denne kommunikation kan karakteriseres ud fra et system
af kommunikative signaler der afspejler forskellige grader af kommunikation: grundstemning,
receptiv deltagelse, socialitet, aktiv deltagelse, kommunikativ musikalitet samt dialog. Der
ses en sammenhæng mellem et afbalanceret arousalniveau og mere intensive grader af kom-
munikation. 3) I 5 ud af 6 konkrete tilfælde viser musikterapien en indflydelse p˚a aspekter
i dagliglivet udover musikterapien, defineret i et statistisk signifikant fald i pulsfrekvens i en
periode før og efter terapien for personer med svær demens som udviser agiteret adfærd.
Deltagerne viser tydeligt at de har gavn af musikterapiforløbet, og vigtigst: disse 6 svært
demensramte kommunikerer, og de lader sig lede til en tilstand hvor dialog kan opst˚a. Sangene
er udtryk for en struktur som kan fungere som opmærksomhedsstimulering ved at formidle
stabilitet samt sociale og kontekstuelle cues. Sangene har ydermere den funktion at de kan
bruges til regulering af arousal, s˚aledes at deltageren kan ledes til en tilstand hvor vedkom-
mende er mest opmærksom overfor sansestimuli. Dette giver de bedste betingelser for at
indg˚a i dialog med et andet menneske.
Acknowledgements
This work has only been possible because a large number of people have given me support.
Support in very different ways, ranging from inspiration, challenge, information, trust, en-
courage and time.
I want to thank David Aldridge in his position as my supervisor. A supervisor is literally
a person who is able to view matters from a broader sight. In German a supervisor is a
Doktorvater (doctor father). Even though Germans traditionally would say ”Sie” to their
Doktorvater, there is familiarity and confidence connected with the naming. In Danish a
supervisor is a Vejleder (way-leader), a guide and instructor. It is a person who knows the
way and the direction to go, and is able to show which direction to go. To carry out research
and writing a thesis is a privilege when one person, who manages being your supervisor as well
as your Doktorvater and Vejleder, is at your side! Although there is a great distance between
Witten-Herdecke (Germany) and Aalborg (Denmark), David Aldridge has been present in
cyberspace, and always promptly answered my mails. The supervisions fully answered my
questions, gave me lots of inspiration, information, encouragement, and new questions – and
helped me in keeping my focus.
Thanks to Tony Wigram who arranged very giving, inspiring, and instructive courses
for the PhD-students enrolled in the doctoral programme at Aalborg University. He invited
leading authorities in the music therapy field to present at the courses, and made the ba-
sis for exciting and educational discussions at a very high level. Additionally, Tony Wigram
organized presentations done by the PhD-students in the peer group in a professional and con-
fident atmosphere, and the very constructive and challenging feedback – from Tony Wigram,
the guest researchers, and the rest of the peer group – on our works in progress meant a lot to
the quality of these respective works. He has made the PhD-courses a highlight in the study
period and after each course I was loaded with new ideas, information, and perspectives.
Six persons, Mr A, Mr B, Mrs C, Mrs D, Mrs E, and Mrs F, spend 20 music therapy
sessions with me and in this way contributed considerably to the clinical part of this research.
I still often think of these six, forceful personalities and I am grateful about what the gave to
4 Ridder: Singing Dialogue
me without themselves being aware of it. I want to thank their relatives for the very positive
attitude towards the research project and by letting the anonymized stories of their loved
ones be part of this work.
For my colleagues, staff members on unit II, Plejehjemmet Caritas, the research project
caused them extra work when filling out questionnaires and putting on equipment for heart
rate measurements on the participants. I am thankful about our good collaboration, our talks,
and the daily information about the participants. The knowledgecenter for ˚Arhus county at
Caritas supplied me with important information. Inga I. Petersen supervised ethical issues
concerning the participants, and principal, Birgit Mikkelsen, backed up the project from the
very beginning.
My five music therapy colleagues: Bent Jensen, Niels Hannibal, Morten Højgaard, Sanne
Storm and my teacher and Vejleder Inge Nygaard Pedersen spend many hours doing valuable
analyses on the video clips, and contributed with important data to this work.
Christian Gold, the peer group expert in statistics, willingly discussed t-tests and sta-
tistical calculation with me. Tom and Gitte Duus, and Irene and Carsten Bro Brinkmeyer
offered Bed & Breakfast when I needed to stay in Aalborg, and supported me with giving
talks and very useful social research literature. Ulla Holck, whom I first time met when I
started studying music therapy in 1985 and who finished her PhD in 2002, supported and
encouraged me with comments on the text, talks and mails, and Lise Overgaard supported
in a very special manner by pulling me out into the fresh air for long joggings.
When I write these lines, that are my last lines before this material goes to the printers,
Christoph, my husband, is sitting at his computer working with layout details, while Christa
Ridder, my mother-in-law is with the children. Together with Karen Ochsner, my mother,
who spend hour after hour proofreading and trying to teach me a proper English, they have
been the most supportive team to have around. Christoph’s IT-support and layout knowledge
has been indispensable, and not least our dialogues.
5
Introduction
By mere chance I saw a small advertisement in the local paper offering a job as music therapist.
I was attracted to the outer aspects of the job; it was close to my home, it was a part time
job, and the conditions of appointments were all right. But! . . . the job was with old people.
Having worked with children and adolescents I had no experience in working as a music
therapist with old people, and felt I had to start from scratch. Giving it a try I applied, and
plunged headlong into the job. What I first saw were old patients with various deficits. Some
had spent long periods of their lives on psychiatric wards, and were now offered a home here.
Others had led a “normal” life, but were struck by dementia and could no longer take care
of themselves.
There were only 24 residents at the unit, and soon this group of patients or strangers
became familiar to me. Not only did I learn their names, hear about their lives, and meet
their relatives, but my perspective seemed to change, and I saw a person behind the deficits
and saw the resources that were still there. I realised that my job as a music therapist was very
privileged. The music often worked as a key that gave assess to pleasure, achievement, and
expression within the person. I saw Mrs S close her eyes, smile, and sigh with contentment
when she heard Placido Domingo sing, and Mr R accurately tapping the beat with his hand,
when I played old songs from revues, and the tears in Mr G’s eyes when he joined in singing
the song he had asked me to sing. Pleasure, achievement, and expression is described by
the music therapist Trygve Aasgaard (2002, p. 219) as connected to Homo Ludens, a being
who plays, Homo Faber, a being who creates/produces, and Homo Communicans, a being
who communicates. – Aspects that again are connected to environmental characteristics in
a culture of leisure, a culture of creativity, and in a culture of dialogues. Seeing these old
people having fun, enjoying themselves, being creative and giving, expressing themselves and
entering dialogue was seeing the person behind the deficits.
It was a privilege too when 5 years later I had the possibility to carry out research in this
field. It was clear to me that my focus would be on the use of familiar, pre-composed songs in
individual music therapy, although in my clinical job I worked in various ways with music. I
see the songs as a key to the person, and a key to enter dialogue with persons who might have
lost the ability to use words in spoken language and the ability to play on music instruments.
Actively playing with instruments and improvising seems to be the most described form of
music therapy.
This work deals with a group of “clients” or “patients” with severe symptoms of dementia,
and the participants described in the study suffer from dementia in advanced stages and are
living in a special gerontopsychiatric care unit. When I refer to texts I might repeat the
authors’ way of naming this group of people as patients, clients, or subjects, but otherwise I
name them as persons with dementia or as the participants.
Readers who have the courage to take a plunge into all these words are most likely profes-
sionals in the health care sector, interested in a non-pharmacological approach to dementia
care, therapists with an interest in the clinical application of music therapy with a client
group close to the one described here, and/or researchers with an interest in flexible research
design strategies.
The research is carried out in close collaboration with Care Unit II, the Nursing home
Caritas, the Knowledge Centre on dementia in ˚Arhus County, and Aalborg University, and
with approval from relatives, from the ethical committee in ˚Arhus County, and the Danish
register inspection.
6 Ridder: Singing Dialogue
Overview of the thesis
The first three chapters contain a theoretical introduction and presentation of terms and
understandings relevant to the research. Chapter 4 describes the research methodology, and
chapter 5 the clinical background. The next three chapters imply different research strategies
and give different perspectives on what I want to present as the essence of this kind of music
therapy work, approaching this essence with different means. Chapter 6 consists of 6 case
studies, chapter 7 of a hermeneutic analysis (using the computer software ATLAS.ti) of eight
short video clips with observations done by external assessors, and chapter 8 is a synthesis
of chapter 6 and 7, using the coding tool formulated in chapter 7 on examples from the case
studies in chapter 6. Chapter 9 is a conclusion of the work.
Each section or chapter is completed with a short summary. The index on the very last
pages facilitates the search for certain topics in the material, and at page 354 are listed the
abbreviations used in the text.
Contents
Contents 7
List of Tables 11
List of Figures 13
1 Music therapy and dementia 15
1.1 Deficits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.2 Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.3 Function and application of music . . . . . . . . . . . . . . . . . . . . . . . . 27
2 Singing as therapy 37
2.1 Singing and dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.2 General physiological influence of singing . . . . . . . . . . . . . . . . . . . . 39
2.3 Demands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.4 Contextual cues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.5 Reminiscence and identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.6 Communication/intrapsychic themes . . . . . . . . . . . . . . . . . . . . . . . 43
2.7 Intrinsic musicality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
3 Communication 49
3.1 Communication and dialogue . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
3.2 Arousal and dialogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
3.3 Regulating the arousal level . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.4 Arousal and attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.5 Attention and stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.6 Physiological parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4 Research methodology 67
4.1 Epistemology and paradigms . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
4.2 Methodological considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
4.3 Background issues for the research . . . . . . . . . . . . . . . . . . . . . . . . 76
4.4 Hypotheses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.5 Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
4.6 Analysis and use of data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
4.7 Ethical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
4.8 Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
7
8 Ridder: Singing Dialogue CONTENTS
5 Clinical context and approach 91
5.1 Description of the care unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
5.2 Description of the clinical setting . . . . . . . . . . . . . . . . . . . . . . . . . 93
5.3 Description of the songs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
5.4 Clinical music therapy method . . . . . . . . . . . . . . . . . . . . . . . . . . 102
6 6 case studies 107
6.1 Mr B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
6.2 Mr A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
6.3 Mrs C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
6.4 Mrs D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
6.5 Mrs E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
6.6 Mrs F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
7 Hermeneutic analysis of response 195
7.1 Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
7.2 Video data material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
7.3 Assessment procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
7.4 Processing the assessment data . . . . . . . . . . . . . . . . . . . . . . . . . . 203
7.5 The coding tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
7.6 Details of code families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
7.7 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
8 Analysis of case material based on chapter 7’s coding tool 239
8.1 Mr B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
8.2 Mr A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
8.3 Mrs C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
8.4 Mrs D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
8.5 Mrs E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
8.6 Mrs F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
8.7 Summary and discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
9 Discussion and conclusion 271
9.1 Discussion and review on hypotheses . . . . . . . . . . . . . . . . . . . . . . . 271
9.2 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
9.3 Clinical applicability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
9.4 Limitations of the study – and perspectives . . . . . . . . . . . . . . . . . . . 281
10 References 285
A Songs 303
B Songs sung with the participants 307
C Coding of response and quality of response 313
D Q- and R-Quotations 315
E Matrices - selected clips 321
F Matrices - selected examples 327
CONTENTS 9
G Tables 337
H English summary 343
I Dansk resum´e 349
Index 356