Cross-cultural music therapy in community aged-care: a case vignette of a CALD elderly woman.

Chan, Grace

Ethnic Community Care Links Inc. (ECCLI) is a culturally inclusive public benevolent institution funded by the Australian Government through the Department of Social Services. ECCLI has been servicing the frail aged and people with disabilities from culturally and linguistically diverse (CALD) backgrounds in North Queensland since 1991(see Figure 1). ECCLI is currently supporting over 400 clients and their families whose cultural or language barriers present significant difficulty in accessing mainstream services to continue living at home in Townsville-Thuringowa, Burdekin and Hinchinbrook regions. Since 2010, the Functional Independence Model (FIM) has been implemented in ECCLI to maximize clients' capacities to be independent and to promote their well-being, including physical, intellectual, mental, emotional, social and spiritual well-being. In conjunction with the FIM, one-on-one music therapy is implemented for CALD older people in the community who are socially isolated or have difficulty in travelling to attend other music therapy programs.

CALD community in North Queensland

There are large proportions of people from CALD backgrounds living in North Queensland (see Table 1). The majority of older people from CALD backgrounds are from Italy, Germany, Greece and the Philippines (Australian Bureau of Statistics, 2011).

German migration began in the 19th century, with the post World War II period (1952-1961) being the peak of German migration. The German-born people in Australia are generally well-educated, have skilled occupations and well-established social networks. In the 19th century, large numbers of Italian migrants worked in the cane fields and market gardens in Queensland. Their numbers increased dramatically after World War II, and many of them are now resettled in Burdekin and Hinchinbrook for their retirement (Department of Immigration and Border Protection, 2013). Another major group of migrants is from Greece, with migration beginning during the gold rush in the 18th century. The 2011 census indicated that the median age of people born in Greece was 67 years (Australian Bureau of Statistics, 2011). The Filipino population was another fast growing CALD population in Australia since the declaration of a new martial law in Philippines in 1972. Many migrants married Australian residents and subsequently sponsored their family members to join them in Australia (Department of Immigration and Border Protection, 2013).

Development of a cross-cultural program in community aged care

The population of older people from CALD backgrounds in North Queensland continues to grow (Australian Bureau of Statistics, 2011). Many CALD older people need assistance and support to allow them to continue living independently within the community. However, cultural or language barriers present significant difficulties for them in living in the community. They become isolated and feel vulnerable due to deteriorating health, declining social networks or the death of a spouse. Some have difficulties in articulating their needs and accessing services due to poor English language skills (Australian Institute of Health and Welfare, 2007). The loss of acquired language ability may be a result of ageing or dementia (Rowland, 1999). As the intergenerational culture changes, some older people also have feelings of the loss of homeland, family, and peers (Department of Health and Ageing, 2012).

The motivating factor in developing cross-cultural music therapy was to address the needs of older people with CALD backgrounds in the community. Music was chosen because it transcends ability, age, gender and cultural backgrounds whilst being accessible to all (Brown, 2002; Chase, 2003). Funds were awarded to ECCLI by the Queensland Government Regional Arts Development Fund (RADF) to develop the "Rainbow Choir" for CALD clients in June 2010. A music movement group and one-on-one sessions were also developed at the same time. The purpose of cross-cultural music therapy was to strengthen the clients' self-identity, optimising their cognition, physical ability, self-expression, socialisation and communication. Participating in regular social activities enables CALD clients to experience an enhanced sense of belonging in the community and reduce their feelings of isolation (Amir, 2004).

One-On-One Music Therapy Program

The rationale for the one-on-one music therapy program was to create a platform for CALD clients to share and strengthen their ethnic and historical identity, as well as to optimise their capabilities and improve self-esteem. The program is conducted in clients' homes, and is of benefit to those who are socially isolated or have difficulty in travelling to attend other music therapy programs.

During an initial assessment, a music therapy assessment tool is used to identify various areas, including cognition, communication, emotion, social interaction, motor skills, musical preference and musical training. The clients' current health status, diagnoses, behaviour and psychological conditions are obtained from other relevant assessment reports, such as Ongoing Needs Identification (ONI) (Queensland Government, 2013), Aged Care Assessment Team (ACAT) assessment (Department of Social Services, 2014) and/or Occupational Therapy functional assessment. The ensuing music therapy program plan is developed to meet individual needs and abilities, enabling clients to make progress at their own pace(Powell, 2004). The ongoing plan is evaluated by documenting clients' responses to the intervention techniques, and having regular discussion about goals and objectives with the client, related health care workers and/or family members.

In cross-cultural music therapy, the music plays an important role in developing individual and cultural identity (Forrest, 2000). It can also trigger memories which remind people of life experiences, specific events or past activities in their own culture (Stokes, 1994). As music from clients' own culture may have a strong influence on their life, reminiscence can help them to bring back memories from their homeland (Pinson, 2013). It enables older people to achieve a sense of self-identity and self-integrity by reminding them of past experiences and accomplishments (Baker & Grocke, 2009; Ip-Winfield & Grocke, 2011).

Clients are respected in relation to their values, beliefs, backgrounds, decision-making, musical preferences and pace of progression. Music is used not only to confirm individual cultural identities, but is also as integration because it can transcend cultural boundaries and hierarchies. Music can create a common space for CALD clients and the music therapist to share and to address issues concerning cultural differences. Therefore it is an integral element which can bring people from different cultural backgrounds together and minimise cultural and linguistic barriers (Forrest, 2000).

Case Vignette: Adalie

The following case vignette explores the ability of cross-cultural music therapy to address issues concerning social isolation and loss of capability in the life of a 92 year-old Austrian woman, who is named "Adelie" (pseudonym). Written informed consent was obtained from Adelie giving permission for this material to be published. Adalie was born in Austria and emigrated from her homeland to Canada with her husband during World War II. They owned a business in Canada and Adalie worked several jobs to support her family. After her husband died, Adalie lived on her own in Canada for another seven years before moving to Townsville in Australia with her son in 2000. Adalie stated that she had to work hard to adapt to a new environment in her 70s. In order to make connections with people in the community, she joined several social clubs which enabled her to develop social networks. Adalie's son moved overseas with his family after marriage, after which Adalie lived in a retirement village in Townsville on her own.

In 2010 Adalie joined the Rainbow Choir and music movement group in ECCLI. Adalie said that it was a time she looked forward to every week to get out of the house and meet friends. In the choir, Adalie was encouraged to share music and to take part in choir performances in the community. These performances further empowered Adalie, and she appeared to regain a sense of achievement and capacity in her life. Adalie revealed that she enjoyed sharing her achievements with her son and grandchildren overseas, as well as working together with the other group members to choose appropriate songs and make suggestions to improve the performance standard. She described that participating in the choir performances enhanced her sense of belonging in the community and reduced her feelings of isolation.

However in 2012, Adalie had a major fall and severely injured her hip and legs. She suffered a lot of pain and could hardly get out of the house. Adalie could not participate in any of her activities anymore, leaving her feeling lonely and isolated. Therefore the music therapist suggested implementing weekly one-on-one music therapy sessions at Adalie's home, which she was happy to accept. The specific goals were to promote positive self-identity, enhance coping ability, develop meaning in life, maintain connection with others, and maintain desire for hope.

The music therapist is of Chinese background and speaks Cantonese and Mandarin as well as English, and listens to traditional Chinese operas or Chinese folk songs. With this difference in cultural and linguistic backgrounds, the music therapist needed to explore Adalie's cultural background, the language that she spoke and the music she preferred. As Adalie lived in Canada for many years, she was competent in English, so there was no difficulty in in using English as the shared language for communicating. As the language that she had spoken in Austria was German, a lot of songs that Adalie preferred were in German. Owing to the music therapist's lack of knowledge of German repertoire, she worked together with Adalie in the first two sessions to find her preferred music. Adalie showed the music therapist the song books and the German music that she had, such as Lili Marlene, Wenn ich ein Voglein war, Es klappert die Muhle etc. In song discussions, Adalie shared her life experiences in Austria and Canada. For example, during World War II, she worked in the Air Force for three months to monitor the invasion of Russia. She also shared about her school days and family life in Austria, working in Canada, and different dialects that she used in her home country. The understanding of Adalie's cultural experience, language, beliefs and values enabled the music therapist to develop a cross-cultural relationship.

In the sessions, the music therapist played the music that Adalie had chosen. Adalie sang, discussed the lyrics and explained the meaning of the songs. She taught the music therapist some simple conversation in German, such as "Good Morning," "How are you?" "Nice to meet you," "Goodbye," etc. A greeting song and goodbye song were created in German. Adalie appeared to redevelop her singing skills and reported with pleasure that a neighbour told her she enjoyed her singing. Adalie expressed to the music therapist that she appreciated the time of sharing music as music had played an important role in her life and in her culture. The well-known musical "The Sound of Music," was produced in Austria and made Adalie proud of her country. She still remembered clearly the musical production backgrounds, the scenery and the songs sung by each character. Adalie was responsive in sharing the music, for instance explaining the source and characteristic of the "Edelweiss" flower. She also showed the music therapist some pictures which were taken in Austria some years ago. As Adalie indicated that she was still interested in the choir and music movement group, the music therapist provided her with up-to-date news in order to maintain her connection with other social events.

Adalie revealed that it was very difficult for her to accept that she had lost mobility and independence. She commented that opportunities to express feelings such as pain, frustration, disappointment, confusion etc. in the music therapy session gave her confidence to continue dealing with difficulties and challenges in life. She said that although physical pain interfered with many of her daily activities, she still tried to do as much housework as she could and regular exercise to maintain mobility. Adalie revealed that it was difficult to deal with all the challenges by herself, however the joy of music maintained her motivation and desire for hope in life. She expressed hope that a hip operation would help her regain independence so that she could rejoin the choir and other social activities in the near future.

Cross-cultural music therapy approaches and challenges

It is essential to establish a therapeutic alliance in any client-therapist relationship, with the therapist incorporating trust, active listening, respect, empathy, genuineness etc. (Cole & McLean, 2003; McCabe & Priebe, 2004). Empathy enables the therapist to perceive the client's world-view or feelings accurately and completely (Ridley & Udipi, 2002). However, in cross-cultural therapy, client and therapist are from different cultural backgrounds, and lack of awareness of the client's unique cultural background may create barriers to empathic understanding, and can further impact the appropriateness of therapeutic interventions (Valentino, 2006). Therefore cultural empathy is an essential element when working with CALD clients. It requires the therapist to acknowledge his/ her own cultural identity and cultural biases, as well as obtain knowledge to recognize and understand the client's unique cultural background and personal cultural experiences(Brown, 2002; Darrow & Molloy, 1998).

In working with Adalie, the Chinese music therapist lacked knowledge of Austria, so actively collected a lot of information regarding the culture, values, beliefs and language from the client. Further, understanding music as part of Adalie's own cultural experience was a major factor in developing a cross-cultural relationship. In discussion with the music therapist, Adalie indicated that music was important in her country, with German traditional folk songs expressing their culture. The German songs were a new linguistic challenge to the music therapist, but it was important to use them because empathy and relevant interventions are developed through understanding the unique cultural background of the client appropriately (Valentino, 2006; Williams & Abad, 2005). More importantly, using culturally specific music enabled Adalie to connect to her homeland and regain a sense of self-identity (Shapiro, 2005).

Understanding the unique cultural factors of the CALD client with an open-minded attitude is an important process in establishing a sensitive therapeutic relationship. Consideration of their communication patterns, attitudes, behaviours, values and traditional beliefs is essential (Bolger, 2012; Chase, 2003; Valentino, 2006). Although the music therapist lacked knowledge of the client's culture, she explored German traditional folk music together with Adalie, who showed the therapist her German song books and explained the meanings of the cultural music. The music therapist learned some German lyrics from Adalie and created the greeting song and goodbye song in German together with her. During the therapeutic process, this not only enhanced interaction with the client and created a connection with her, but also provided opportunities to understand the client's unique cultural factors and as a result, minimise cultural and linguistic barriers. In addition, the well-known music from "The Sound of Music" created a common space for Adalie and the music therapist to share together. Adalie showed responsiveness in sharing and discussing the music, because it indicated that the client's culture was recognised and valued, and overall an effective therapeutic relationship was developed.

Another crucial factor in developing cultural empathy is to obtain cultural self-awareness. The therapist's own ethnicity, cultural values and beliefs may influence his or her interpretation of the client's behaviour or thoughts. Misunderstanding or misinterpreting may occur if the therapist is unaware of his or her own cultural bias or differences (Valentino, 2006; Ip-Winfield & Grocke, 2011). For instance, the interpretation of help-seeking and coping behaviours are different in various cultures. From the music therapist's point of view, it is a common and appropriate behaviour for older people to seek help. However, Adalie perceived this behaviour as losing dignity and self-reliance. She refused to accept any assistance until she was suffering a lot of pain. From the conversation, the therapist realised that Adalie's perception of being independent was influenced by her cultural experience as an Austrian immigrant and the difficult times she experienced during the war. With the understanding of cultural differences, the music therapist respected Adalie's perspective and decision-making, and made recommendations accordingly.

Conclusion

Cross-cultural music therapy has been playing an important role in North Queensland over the last two years for older people from CALD backgrounds. In conjunction with the FIM, one-on-one music therapy is implemented to maximise people's capacities to live independently and to promote their well-being, including physical, intellectual, mental, emotional, social and spiritual well-being. The case vignette about Adelie examined the importance of cross-cultural music therapy approaches and challenges. It demonstrated the capability of music therapy to promote a client's wellness and independence under the FIM. In the one-on-one sessions, Adalie stated that music therapy not only gave her joy and happiness, but also created meaning in her life. She indicated that she looked forward to the session every week as it gave her opportunities to share and express herself. Although Adalie suffered from physical pain and loss of mobility, she described music therapy gave her motivation to deal with challenges and maintained her desire for hope in life.

According to the Australian Bureau Statistics (2011), the number of older people from CALD backgrounds is projected to increase by 44% over the next 10-15 years. The rapid growth of a CALD older population indicates the need for increased supports and services to address cross-cultural issues as well as to allow them to live independently in the community. Cross-cultural music therapy is demonstrated as a successful tool in conjunction with the FIM to promote older people's well-being and maximize their capacities, enabling them to remain longer in their homes.

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Grace Chan BA MMusThy, RMT

Ethnic Community Care Links Inc., Townsville, Australia

Email: gchan@eccli.org.au

Table 1

Proportion of people from CALD backgrounds in North Queensland

Location       Total population   % Overseas born
(LGA)                             population

Townsville     174,462            19.9
Hinchinbrook   11,569             15.6
Burdekin       17,364             14.1

Location       % Language other than
(LGA)          English spoken at home

Townsville     6.0
Hinchinbrook   9.4
Burdekin       6.8

Note: LGA = Local Government Area. Source: (Australian Bureau
of Statistics, 2011)

Figure 1

ECCLI Clients cultural backgrounds

ECCLI CLIENTS CULTURAL BACKGROUNDS

Australian        10%

Chinese            4%

Czech              1%

El Salvadorean     1%

English            1%

Filipino           5%

Finnish            1%

German             2%

Greek              9%

Hungarian          1%

Italian           45%

Maltese            1%

Other              4%

Polish             1%

Slovenian          1%

Spanish            4%

Swiss              1%

Tokelauan          1%

Source: (Ethnic Community Care Links Inc., 2013)

Note: Table made from pie chart.