bs_bs_banner

Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/bioe.12148

Volume 29 Number 8 2015 pp 573–579

DEMENTIA AND THE POWER OF MUSIC THERAPY

STEVE MATTHEWS

Keywords
dementia, ABSTRACT
social agency, Dementia is now a leading cause of both mortality and morbidity, particu-
narrative, larly in western nations, and current projections for rates of dementia
well-being, suggest this will worsen. More than ever, cost effective and creative non-
music therapy pharmacological 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 agency, particularly in its social losses.1 For it is a feature

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, some-
times 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 gradu-
ally 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
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: Stephen.Matthews@acu.edu.au
Conflict of interest statement: No conflicts declared

© 2015 John Wiley & Sons Ltd

 Dementia and the Power of Music Therapy
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 cardio-
vascular disease and cancer. I use music therapy illustra-
tively 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 unaf-
fected 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 relation-
ships 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,
© 2015 John Wiley & Sons Ltd
574
in which this is supposed to happen and to do so we may
reflect on one recent influential account of close relation-
ships 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 activi-
ties, 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 inter-
pretation – may be present to some extent in close rela-
tionships 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 narra-
tive 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.
575 Steve Matthews
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 recollec-
tions of a shared history, and with the capacity to engage
in further writing of the story, is diminished, and some-
times seems to be almost wholly lost. However, this con-
clusion 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 condi-
tions 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 achiev-
ing 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 rec-
ognizable actors. In addition, and as I explain more fully in
Section 5, not only does it enhance the wellbeing of demen-
tia sufferers in the sense outlined here, music therapy also
provides its practitioners with an effective tool for provid-
ing meaningful care, and so provides those carers with a
more meaningful participation in professional life.
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.
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 com-
pletely 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
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. Neuro-
cognitively three separate theses might be proffered.
First: music therapy repairs and regenerates those brain
areas in which music processing takes place. Second:
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: per-
sonhood 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].
© 2015 John Wiley & Sons Ltd
 Dementia and the Power of Music Therapy
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 incompat-
ible.) I have found only one reference supporting the first
possibility, the regeneration claim.13 The neuro-
protection 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 pro-
gress 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 neuro-
protection 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
memory of music and access to a past social self. Henry’s
agency, to be sure, is scaffolded by his external circum-
stances, the music and the carers who make it available.
Yet in so far as Henry is sufficiently agentially restored,
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 Con-
trolled 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
M Sambandham, V Schirm. Music as a nursing intervention for resi-
dents with alzheimer’s disease in long term care. Geriatric Nursing 1995;
16: 79–83.)
© 2015 John Wiley & Sons Ltd
576
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 stand-
point 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, responsi-
bilities, 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, forgive-
ness 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.
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 wellbe-
17
P Strawson. Freedom and Resentment. Proceedings of the British
Academy 1962; 48: 1–25.
577 Steve Matthews
ing’.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 suf-
ferers, and the terminally ill. Stress is placed on the pro-
fessional application of music for therapeutic ends; and so
its function is explicitly not for education or entertain-
ment. 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 associa-
tions 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 com-
mittee assembled. Suffice to say, and to say the very least,
confidence in the healing powers of music cannot be dis-
missed as a fad. Its longevity as a practice, commitment
to accreditation for practitioners, the various member-
ship 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
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].
20
RS Moore. Music Preferences of the Elderly: Repertoire, Vocal
Ranges, Tempos, and Accompaniments for Singing. J Music Ther 1992;
29: 236–252.
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 cog-
nitive function; reduction in agitation, anxiety, or wan-
dering; 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 demen-
tia 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 process-
ing. 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 ele-
ments 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 social-psychological
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 tra-
jectories stemming from the socially imposed environ-
ment. 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
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.
© 2015 John Wiley & Sons Ltd
 Dementia and the Power of Music Therapy
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 appro-
priate 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 capac-
ity to connect with his past. His sociality, his responsive-
ness 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 self-understanding. 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:
. . . show considerable reversal or ‘rementia’ when their
conditions of life, and especially their social relation-
ships, 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 inten-
sive nursing care involving a programme of activities, in
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.
© 2015 John Wiley & Sons Ltd
578
contrast to traditional care, significantly halts deteriora-
tion 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 soli-
tary’ 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 arous-
ing 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 partici-
pants 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 prof-
fered. 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 self-esteem
accompanying diminishing cognitive loss, and the treat-
ment 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 narrative social agency and the
meaning and value of personal relationships, but, to
briefly reprise, the simple point is just that if I can com-
municate my story I can form and maintain a valued
relationship, and music has a special tendency in demen-
tia 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 con-
tributing. Finally, although a little more tenuous, the
regularity of a musical encounter, something which struc-
tures one’s day and gives a sense of peace (or at least
25
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.
579 Steve Matthews
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 atmos-
phere 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 con-
stitutive 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 demen-
tia 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 satis-
faction. 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
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
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 indi-
vidual, 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 treat-
ing residents with dementia with dignity and respect.’
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.
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,
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.
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.
© 2015 John Wiley & Sons Ltd
Copyright of Bioethics is the property of Wiley-Blackwell and its content may not be copied
or emailed to multiple sites or posted to a listserv without the copyright holder's express
written permission. However, users may print, download, or email articles for individual use.