Group music therapy methods in cross-cultural aged care practice in Australia.

Ip-Winfield, Vannie ; Grocke, Denise

Introduction

Elderly Australians in the twenty-first century represent an ever-increasing diversity of ethnic, cultural and religious backgrounds; the same is true of both music therapists and music therapy students. The changing demographics of both client and therapist provide unique challenges in music therapy training, preparation and practice.

For example, the principle author of this study is of Hong Kong Chinese background. Since her migration to Australia, she went through various cultural adjustments that impacted the way she relates to people around her. Her work as a music therapist working with older adults in a multicultural aged care facility has made her even more aware of linguistic and cultural barriers in music therapy practice. Due to these experiences, she concluded that her training did not adequately address the important issues of cross-cultural practice. The author constantly seeks to adjust her methods with the aim of fostering socio-cultural integration amongst her CALD clients and she believes that other music therapists, with different clients, training, personal style or theoretical orientation will also develop their own blend of cross-cultural music therapy methods. With this understanding, the author became interested in surveying methods used in cross-cultural music therapy.

Research addressing cross-cultural music therapy is limited. Some music therapists have written about their personal experiences in this area (Amir, 1998; Dos Santos, 2005; Forrest, 2000; Ikuno, 2005; Yehuda, 2002); about cross-cultural training and supervision (Estrella, 2001; Forinash, 2001; Kim, 2008; Toppozada, 1995); about cross-cultural repertoire (Baker & Grocke, 2009) and about ethical considerations in cross-cultural practice (Baker & Grocke, 2009; Bradt 1997, Bright, 1993; Dileo, 2000; Estrella, 2001; Kenny & Stige, 2002; Ruud, 1998). Despite this, little is known about the practical details - most particularly, the methods used.

It is the purpose of this study, therefore, to provide a survey of methods used by Australian music therapists in cross-cultural music therapy, with particular focus on group therapy involving CALD participants, as well as assessing how education and experience inform practice.

Literature Review

Following the Second World War, migration to Australia from Western and Southern Europe increased dramatically. People came from such places as Italy, Poland, Germany, Greece and the Netherlands and these people make up much of the aged CALD population today. Cultural diversification nonetheless continues, as immigration from Asia has proliferated since the 1980s. It is expected that Chinese, Indian and Vietnamese immigrants will begin to overtake older migrant streams within the aged community in the very near future (Gibson, Braun & Braun, 2001) (See table 1).

For the purposes of this study it is important to remember that 'culture' is a term of great complexity that goes beyond broad national definitions. 'Culture,' as Dileo and Starr (2005) remind us, 'includes a constellation of factors, each of which interacts with the others. These factors include: age, religion/spiritual orientation, ethnicity, socio-economic status, sexual orientation, indigenous heritage, national origin and genders' (p.85). There is, therefore, a growing emphasis on the complexity of this issue in music therapy research. Authors have stressed the importance of cultural empathy and self-awareness and to show respect for the client's values and beliefs without passing judgment (Bradt, 1997; Brown, 2001; Chase, 2003; Dileo, 2000; Dileo & Starr, 2005; Valentino, 2006). There is also a growing recognition that music therapy models--based upon Western psychology--are not impartial but subject to their own cultural limitations (Dos Santos, 2005; Pavlicevic, 2001) and an understanding that therapists must constantly reflect on their practice and question the suitability of their methods, rather than transplanting Western models to non-Western contexts (Brown, 2001; Pavlicevic, 2001). This study aims to build on this understanding and expand music therapy's cross-cultural methodological library.

'Cross-cultural music therapy' is defined in this study as 'music therapy practice in which important cultural differences exist between the therapist and client/s and/or among the clients themselves.' Music therapy methods discussed in multicultural literature include receptive music therapy methods: 'listening to music that the therapist plays/sings' (Forrest, 2000, Orth and Verburgt, 1998) and active music therapy methods: 'singing with reminiscence' (Amir, 1998; Forrest, 2000; Orth & Verburgt, 1998), 'song writing,' 'instrumental playing along to music' (Orth and Verburgt, 1998), 'instrumental improvisation' (Amir, 1998, Elwafi, 2005, Moreno, 1988), 'vocal improvisation' (Orth, 2005) and 'music and movement/ folk dance' (Aluede & Lyeh, 2008). These definitions will be used in this study.

Repertoire choice is significant in terms of music therapy with older adults. Various studies have shown that older adults respond most positively to repertoire that was popular during their early 20s-30s (Baker & Grocke, 2009; Bright, 1991; Moore, Staum & Brotons, 1992; Vanweelden & Cevasco, 2009). The Ulverscroft Large Print Song Books (Baker, 1981; Donald & Lehmann, 1987), widely used by Australian music therapists since their publication, are out-dated now for anyone younger than 80 years old (Baker & Grocke, 2009). Moreover, songs with cross-cultural appeal and culturally specific songs are very under represented in these books (0.06%), making them even less relevant for CALD clients.

Interestingly, a comparison of two recent studies investigating repertoire selection for older adults in Australia and the US (Baker & Grocke, 2009; Vanweelden & Cevasco, 2007) show that time of composition is not always the most helpful factor for repertoire selection (see table 2). Nearly half (47%) of the most popular song recommendations by Australian music therapists were composed after 1940s, but all of the US most popular selections were pre--1940s. While it appears that the Australian participants are more likely to utilise newer and more diverse repertoire than their American counterparts, studies by Vanweelden and Cevasco (2007, 2009) indicated that a number of pre--1925 songs such as 'Let Me Call You Sweetheart ' (1910) have stood the test of time and are still enjoyed by American older adults. Hence, cultural context and individual preference are as important as the time of composition in determining suitable repertoire.

With these issues in mind, the following research questions were posed: In cross cultural music therapy in aged care in Australia,

1. Which music therapy methods are used a) the most and b) the least, by RMTs?

2. Which music therapy methods are perceived by RMTs as a) effective, b) difficult to implement, or c) culturally insensitive/ inappropriate?

3. What musical styles are used by RMTs?

4. What culturally specific music idioms are used by RMTs, if at all?

5. What are the concerns or challenges experienced by RMTs in conducting cross-cultural practice?

Method

Survey design

The questionnaire contained four sections: 21 closed questions that included rating scales and multiple choice, and 6 open-ended questions. The sections of the questionnaire were:

1. Demographic data (questions 1-9)

2. Methods used in cross-cultural music therapy practice (questions 10-18)

3. Incorporation of culturally specific idioms (questions 19-20)

4. Challenges experienced by RMTs (questions 21-26).

The survey was piloted with seven RMTs to ascertain clarity. As a result, several questions were reworded. It was established that the survey would take approximately 10-15 minutes to complete.

In previous research on repertoire, validity was affected by unclear definition of styles resulting in overlapping in selections. Hence, the following text box was displayed prior to question 15 to provide clear explanations and examples (See Box 1).

Recruitment of participants

A small and specific sample population was selected to reflect the aims of this study. Inclusion criteria were as follows:

* Professional practicing member of Australia Music Therapy Association (AMTA).

* Employed in aged care as an RMT during September - December 2008.

* Has conducted group music therapy involving CALD elderly clients. (More than three clients in a group qualified as a group situation.)

Following ethics approval (project number: 0829905.1) from the Music Human Ethics Advisory Group at the University of Melbourne, the AMTA was contacted to assist in sending invitation emails to all practicing RMTs (n = 281) listed in their directory. The survey was available online for three months with a reminder email at the end of the second month to increase response rate. According to the 2008 AMTA membership directory, 88 RMTs (not including the principle author) were identified as practicing in 'aged care/old age care/dementia/ community aged care/aged psychiatry.' Thirty RMTs responded, hence a 34% (n = 30) response rate was achieved for this study, although only 26 respondents (29%) had completed data sets suitable for data-analysis.

Text Box 1

Explanation of repertoire styles

In question 15, I am interested to know about the types of songs
that you use in music therapy groups involving multiple CALD clients.

As songs often span over more than one musical style, please refer to
the following examples while you make your selections:

* Songs with cross-cultural appeal (known by more than one cultural
group, excluding anthems) e.g. Home sweet home, Roll out the barrel/
Rosamunda, La vie en rose, Tulips from Amsterdam, Muss ich den/
Wooden heart (German), Pote tin kyriaki / Never on Sunday (Greek).

* Popular songs (e.g. You are my sunshine), songs from musicals (e.g.
Edelweiss) and folk songs in English (e.g. Home on the range).

* Cultural specific songs (sung in LOTE, known by one specific culture
only): e.g. Jasmine Flower (Chinese), Hava Nagila (Yiddish), De
Zilverloot (Dutch), Sakura (Japanese).

* Religious songs or hymns (from any faith/ culture.)[] []

* National anthems (from any country.) [][]

* Songs from European Classical music: e.g. Schubert Ave Maria,
Brahms lullaby.

Method of analysis

Quantitative data was analysed using descriptive statistics. A thematic analysis was conducted on qualitative data collected from the open-ended questions. The researchers read through these responses many times until common themes emerged, and then codes were allocated. Similar comments were grouped together under the codes and subsequently these codes answered the questions.

Results and Discussion

Demographic information: The changing culture in the profession

Most of the RMTs surveyed were practising in Victoria (n = 14, 53.85%). None of the respondents were practising in the Northern Territory, Western Australia or Tasmania. A sizeable proportion of therapists belonged to younger age groups (39 years old and below). There were as many 20-29 years old (n = 8, 30.77%) as there were 30-39 years old (n = 8, 30.77%). They received training at a number of different institutions (one respondent was trained in Germany) and had diverse professional experience including nursing, welfare work, language teaching overseas and community music.

Linguistic skills

Respondents reported a total of thirteen languages other than English (LOTE) as their second language. Mainstream European languages (i.e. Italian, German and French) were most prevalent (34.6%); Serbian, Hindi, Russian, Croatian, Bosnian, Korean, Chinese, Urdu and Polish were also spoken. Interestingly, of all respondents who spoke a language other than Italian, German and French (n = 7, 26.85%), only one was over 39 years old. It is possible that younger RMTs are better equipped to communicate in Asian languages because of the recent introduction of languages from the region in schools as well as the high exposure to diverse cultures in today's society. Migration or CALD family heritage could also be factors: responses to the last question of the survey showed that at least two respondents were migrants and/or refugees to Australia and another two claimed to have German or Italian backgrounds.

A majority of RMTs (73.08%) knew a 'smattering' of Italian, possibly because Italians are a prominent group in aged care and will continue to be so for the next 15 years (Gibson, Braun, Benham & Mason, 2001). However, only two respondents possessed knowledge of Greek and Dutch respectively, despite the high proportion of Greek and Dutch clients at present and in the foreseeable future (Gibson et al., 2001).

Q1: Which music therapy methods are used a) the most and b) the least, by RMTs?

The survey found that almost all respondents (n = 24, 92.31%) used both receptive and active music therapy methods when working with aged CALD clients in group therapy, a result not dissimilar to that of Vink's (2000) survey of Dutch aged care music therapists (78.6%), although her study was not restricted to cross-cultural situations.

The most frequently used method (1) was 'singing with reminiscence' (n = 23 88.46%), followed by 'listening to recorded music or music that the therapist plays or sings' (88.46%, n = 19) and 'instrument playing along with music' (n = 17, 65.38%). The least used method (2) was 'folk dance (n = 20, 76.92%),' followed by 'song writing' (n = 16, 61.54%) (See Table 3).

Singing with Reminiscence

Overall, singing was the most popular method in this survey. Indeed, it has been integral to music therapy for older adults over many years (Bright, 1991; Clair, 2000).

Listening to Music

The popularity of 'listening to recorded music or music that the therapist plays or sings' might be due to its ease of use, or the fact that it provides a more authentic musical experience than the therapist's attempt to reproduce foreign language songs; the original vocalist might be preferred by the client (e.g., Vera Lynn, Frank Sinatra). It is important to point out that listening to music is not merely a passive method (Vink, 2000): During listening, the clients are actively involved in reminiscing, relaxing (through induction) or experiencing different emotions.

Improvisation

The results were equally distributed for both 'instrumental' and 'vocal improvisation' (See Table 3). This result may be because RMTs may have a varied understanding of improvisation, which is a very broad term. In future studies it would be important to identify the different styles of improvisation such as creative music therapy (Nordoff Robbins method), or simple music dialogue based on modeling of expected response, etc., in order to avoid an ambiguous result. It is important to note that improvisation techniques are featured in four multicultural case studies/journal articles because this is a method that is non-language dependent (Amir, 1998; Moreno, 1988; Orth, 2005; Orth & Verburgt, 1998).

Question 2a: Which MT methods are perceived by RMTs as a) effective, b) difficult to implement, or c) culturally insensitive/ inappropriate?

Singing with and without Reminiscence

The results showed that therapists preferred 'singing with reminiscence' (n = 23, 88.46%) (3) to 'singing without reminiscence' (n = 17, 65.38%). (4) These responses could mean that a number of CALD clients are proficient in English, or that therapists facilitate reminiscence in ways that are not language dependent. Either possibility does not safeguard the risk of evoking powerful emotions, which might be difficult to explore or resolve adequately. In multicultural case studies, singing has been a form of active music making (Amir, 1998) and has been used to engage with clients in palliative care (Forrest, 2000). However, the authors question the effectiveness and appropriateness of using 'singing with reminiscence' as a method for groups of CALD clients who are not proficient in English. As Dileo (2000) has recommended, therapists should focus on 'activity orientated experiences, rather than verbal therapy' in multicultural group work, especially for those clients 'who have low levels of acculturation' (p. 166). In the opinion of the authors, cultural and verbal based techniques such as reminiscence should only be used after careful consideration, particularly because cognitive impairment and language barriers are prevalent amongst aged CALD clients.

'Movement to Music' and 'Instrumental Playing along with Music'

Most RMTs (79.17%, n = 19) perceived 'music and movement' and 'instrumental playing along with music' as effective methods in engaging aged CALD clients. In a linguistically diverse group, non-verbal interactions elicited by instrumental playing and movement to music can compensate for the lack of common language.

Several comments pointed to the fact that 'physical disabilities,' 'lack of space' and 'the risk of fall' could inhibit the use of 'movement to music,' but many RMTs (79.17%, n = 19) considered it an effective method. A respondent provided 'music and sensory experiences with silk scarves, bubbles or a scent,' as examples of movement to music activities. There is no language required in these activities. The choice of music influences the level of participation, for example, up-tempo and rhythmic accompaniments help to motivate and enliven the mood.

Question 2 b: Methods that are 'difficult to implement'

Song Writing

Respondents clearly indicated that song writing was 'difficult to implement' (82.61%, n=19); this method was rarely used (61.54%, n = 16). (5) One respondent commented,

'Song writing does not tend to work well when working with clients who have dementia. They respond better to songs they relate to from their long term memory.'

With speech and memory impairment commonplace amongst aged clients, song writing is a difficult method for this group, even without language barriers or cultural difference. It is, however, an important and useful technique in facilitating self-expression and as a validation of feelings. It might be possible to simplify song writing for this population: for instance, lyrics substitution in the client's language, or English, rearranging an English song into a culturally specific style (i.e., playing 'Daisy' in Phrygian mode to create a Spanish/Arabic/Middle Eastern sound) or vice versa. This calls for creativity on the therapist's part.

Folk Dance

Folk dance was also 'difficult to implement,' according to most respondents (72.73%, n = 16), yet there were contrasting views on the use of folk dance in group music therapy. There were as many respondents who thought folk dance was 'culturally inappropriate' (13.64%, n = 3) as those who thought that it 'works well' (13.64%, n = 3). Reasons given by respondents who found it difficult to implement included:

1. Clients have impaired mobility and were considered 'high fall risk' n = 4).

2. Workplace environment/lack of space (n = 2).

3. Lack of confidence in attempting folk dance (n = 1).

The last comment regarding confidence implied a deficiency in music therapy training. Folk dance could certainly be utilised more in cross-cultural music therapy. Dance and music are deeply rooted within the traditions of some cultures. For example, in southern Italy, the tarantella dance and its music were associated with both romantic courtship and the frenzied remedy for the toxin of the tarantula spider bite (Britannica, 2010). In Turkey, Bakshi dance, which originated from shamanic healing rituals, has been used in music therapy practice in the areas of autism, geriatrics, oncology, immunology, neurology, cardiology, depression and anxiety (Guvenc, 2006). Nigerian music therapists Aluede and Lyeh also claimed that,' [in Nigeria] music and dance are closely knit. This is so because dance is rarely ever performed without music and music in very many instances calls for dance.' Dance and music in some cultures are therefore inextricably linked, which needs to be understood by the therapist in order to provide an authentic experience for the client.

Some respondents implied that cross-cultural music therapy is not dissimilar to working with non-CALD clients:

* 'Many clients I have worked with cannot communicate verbally anyway.'

* 'I approach them as if I would any other client.'

* 'Impaired verbal language is often an issue in my practice whether the client is from the CALD category or not.'

It is a fair and positive attitude to treat all clients equally regardless of their ethnicity, yet therapists should be careful not to assume a one-size-fits-all approach in their practice. To do this is to disregard the diversity and the richness of cross-cultural relationships. Rather, a competent therapist should be creative and resourceful in his or her practices (Kenny & Stige, 2002), and have their methods refined over time.

Q3: What musical styles (repertoire) are used by RMTs?

The most frequently used repertoire styles were 'songs with cross-cultural appeal,' followed by 'popular songs' in English, and 'culturally specific songs.' At present, there is only one study that examines repertoire for the global aged and CALD population (Baker & Grocke, 2009). While that study examined music selection, the present survey looked at the frequency of use for each particular music style. In both studies, respondents chose a number of songs with cross-cultural appeal. On reviewing the foreign music selection from Baker and Grocke's study, at least 28 out of the 109 (25.7%) suggestions were known by more than one culture (See Box 2).

Text Box 2

Selection of songs with cross-cultural appeal based on Baker & Grocke
(2009)

Que Sera Sera (English, Italian, Spanish, French)
Lilli Marlene, Happy Wanderer, Edelweiss (English, German, Dutch)
Stille Nacht, O Tannenbaum, Muss Ich Den/Wooden Heart/Farewell song,
Auf Wiedersehen (German, English)
O Sole Mio, Over The Waves/Loveliest Night of the Year, Santa Lucia,
Reginella Campagnola/Woodpecker song, Senza Catene/Unchained melody
(Italian, English)
La Vie En Rose, Allouette (French, English)
Pote Tin Kyriaki/Never on a Sunday (Greek, English)
Spanish Eyes (Spanish, English)
Tulips from Amsterdam, Grootvader klok/Grandfather clock (Dutch, English) La Paloma, La Spagnola (Italian, Spanish, Classical composer)
Brahms Lullaby, Blue Danube Waltz (Classical composer, German, English)
Marseillaise (French national anthem)

Source: Baker & Grocke (2009)

For a song to achieve pan-cultural status, it is often very popular in its country of origin before its reproduction and reinterpretation in other settings. An example of this is Muss Ich Den - a German folk song (English version 'Farewell song') that was reinterpreted in the 1960s and made famous by Elvis Presley. The 1960's version of Muss Ich Den became 'Wooden Heart,' which incorporated some German words, and was popular in the UK and US. Therefore, the same song, when played in a multicultural group, can conjure up different images, feelings and associations for the clients, depending on the way it is understood and experienced by the listener.

Popular songs

In the current study, the categories of folk songs (e.g. 'Home on the Range') and songs from musicals (e.g. 'Edelweiss') were rated as the most frequently used repertoire style (n = 24, 92.31%). Due to changing cultural environments and individual level of acculturation, it is likely that popular songs in English may appeal to some CALD clients and should not be overlooked.

Culturally specific songs

Culturally specific songs were selected most frequently (87.5%, n = 21) for use in cross-cultural group therapy. Findings from Baker and Grocke's (2009) survey also revealed a relatively large repertoire of foreign languages (20% of all music selections were in LOTE), compared to a similar US study (Vanweelden & Cevasco, 2007), which had only 2%. Unfortunately, Baker and Grocke's (2009) study also found that repertoire from some important cultural groups were limited. These groups were Chinese, Russian, Vietnamese, Yugoslavian and Indian. There was no repertoire suggested for Aboriginal, Eastern European nations, African or Middle Eastern cultures--as one respondent commented, 'the paucity of resources makes this a challenging area.' As almost half (n = 13, 46.15%) of the respondents in the current study were fluent in a second language and a large LOTE repertoire was known amongst RMTs (Baker & Grocke, 2009), it would be advantageous for these therapists to be provided with a space (e.g. Internet web site) to share their repertoire.

Religious songs and songs from European Classical music

This music shares common roots; classical music written in the Baroque and Classical period is associated with churches and Christianity (e.g., Bach's Jesu Joy of Man's Desiring). Most RMTs reported that both religious songs (n = 17, 65.38%) and songs from European Classical music (n = 18, 69.23%) were used only occasionally. Singing or listening to religious songs is not always appropriate in certain cultures (Yehuda, 2002): for example, Yehuda (2002) describes an occasion where the parents of her child client 'wanted to safeguard their daughter and to act according to the codes of the culture with which they wished to be affiliated: a culture of the ultra orthodox Jewish people that forbids its members to listen to this type of music [music of Bach]' ('Introduction,' para 5). Individual research by the therapist is therefore warranted prior to the use of religious songs. With the growing cultural diversity in the aged care sector, the singing of Christian songs (or hymns) may not be appropriate in a multicultural group situation (Baker & Grocke, 2009).

Classical pieces like 'The Blue Danube Waltz' are known around the globe, yet therapists should nonetheless ask themselves whether their selection of classical music or their belief in its aesthetic beauty is culturally driven or informed by their own personal preferences and bias.

New Age Music and Nature Sounds

No therapist chose 'New Age' music while four (15.38%) respondents included 'Nature sounds' in their repertoire. In contrast, Vink's survey showed that many more Dutch respondents selected 'New Age' music (46.4%) and 'Nature sounds' (53.6%) for their aged clients, although this was not restricted to the CALD population. Although these two music styles might be unfamiliar to older adults, they represent a relatively context-free option for CALD clients. Nonetheless, research on the effect of New Age and nature sounds on the aged population is recommended.

Three respondents gave examples of times when the choice of music was inappropriate for the group or the individual:

* 'when playing songs that were appropriate for one individual in the group but not appropriate for others (e.g. Russian v. Hungarian)'

* 'I presented "I love to go a-wandering' which an Austrian client associated with his concentration camp experience, as a work song. He said he hated this song, and I apologized for 1) playing the song 2) that he'd had the concentration [camp] experience.'

* A culturally sensitive song. E.g., Chinese song for a Taiwanese patient brought back many bad memories for this patient.'

It is important then, not to rush into a music therapy interventions before consultation with the client and their family and to try and understand the context of various kinds of music. This should be an essential part of culturally sensitive practice.

Q4: What culturally specific music idioms are used by RMTs, if at all?

Culturally specific music idioms used by RMTs included:

* 'Varied rhythm' (n = 17, 80.95%)

* 'Varied vocal timbre' (n = 14, 66.67%)

* 'Using specific mode or scale' (n = 9, 42.86%)

* 'Cultural specific dance' (n = 9, 42.86%)

The results suggested that RMTs are interested in playing diverse styles of music. Three respondents commented that their love of multicultural music and fascination with world cultures influenced their music therapy practice. Conversely, others indicated that they relied on the knowledge gained from music education such as 'Classical singing.'

Modern composers since the turn of the 20th century (e.g., Stravinsky, Bartok) experimented with ways of incorporating folk idioms into their compositions. With the movement away from the diatonic scale and the widespread use of modes in popular music (e.g., mixolydian in jazz), people of all ages are now accustomed to more colourful tonality and more complicated rhythms. It is beneficial and appropriate for music therapists to incorporate more culturally specific idioms in their music.

This study did not fully investigate the incorporation of culturally specific idioms. For future research, it would be interesting to examine how exactly RMTs utilise these idioms. Further training in the area of culturally specific idioms is recommended in equipping students for cross-cultural work.

Q5: What are the concerns or challenges experienced by RMTs in conducting cross-cultural practice?

The results suggested that respondents were generally confident in conducting cross-cultural practice; 92% of respondents rated their knowledge about different cultures, their values and beliefs as 'very good' or 'average.' In contrast to the findings from Stolk's study (2002) on Victorian mental health professionals, 84% of respondents rated their skills in assessing the mood of their CALD clients (as opposed to non-CALD) as 'equally well,' compared with more than half of Stolk's respondents who rated their skills as poor. Most RMTs (n = 17, 65.38%) likewise indicated that they were able to provide 'equal amount' and 'more' music therapy services for their CALD clients. It should be pointed out that these are RMTs' self-reflections only. However, RMTs are skilled in utilising music as a means of communication, whereas other mental health practitioners may have to rely on mainly verbal communication. The following responses seem to support this.

* 'often music creates immediacy.'

* 'music assists in therapeutic process.'

* 'music helps to connect to their emotive state.'

* 'they each seem to enjoy joining the group and listening/ playing music even if they don't understand the conversation.'

* 'music is a great expression and connects RMT with resident.'

* 'music is so varied you can always find lines of communication.'

* 'music is a universal language.'

Hence, language barriers were not considered a problem by some RMTs, particularly when group work was concerned:

* 'They tend to be very comfortable expressing their music in the form of singing and dancing.'

* 'They can reminisce with each other, whereas I am unable to understand most of their verbal communication.'

* 'The language barrier I may have is often forgiven as the clients (usually with dementia) fill in the gaps and engage more with one another ...'

One therapist even suggested that the language barrier could help to achieve therapeutic goals:

'When residents need to explain to me something in English their academic thought processes are triggered.'

The communicative aspects of music are useful in compensating for language barriers, but this is not a substitute for cultural empathy. (6) This is a concept that deserves greater attention and awareness: only one respondent mentioned empathy:

'General empathy with the plight of immigrants.'

Brown (2002) and Valentino (2006) argue that music therapists working cross-culturally need to work toward cultural empathy with the aim of reducing misunderstanding and misinterpretation of the client's world-view. For example, therapists must pay attention to how empathy is expressed in a client's culture: when working with clients who come from cultures where group interdependence is valued, the strength and support given by family members could be an important part of intervention. Collaborating with the client's family may help to ensure that therapeutic interventions are in line with the client's values (Brown, 2002). It is not enough to simply trust in the universalism of music: therapists must be willing to learn about - and from - clients' cultures.

Training

Despite their confidence in conducting cross-cultural work, all respondents rated their university training in cross-cultural practice only as 'average' or 'poor.' Many authors have indicated the need for more comprehensive training in preparing students to provide culturally sensitive practice (Brown, 2001; Dileo, 2000; Toppozada, 1995). Cultural issues should be an integral and central part of the curriculum training program, examining how factors such as illness, disability, health and therapy may be understood in relation to a person's cultural context, rather than cultural studies being offered as separate subject.

A skilled cross-cultural music therapist must observe the guiding principles for generic music therapy practice, such as positive regard for clients, and the notion that it is the therapist who finds ways of adapting music to the individuals (or groups) not vice-versa. A skilled cross-cultural therapist:

1. Recognises that music and musical activities are context-dependent (Stige, 2002).

2. Is musically flexible, and familiar with world music idioms (Moreno, 1988).

3. Has knowledge of different cultural values and beliefs (Dileo, 2000; Estrella, 2001; Valentino, 2006).

4. Actively and openly explores differences, similarity, expectations and biases with clients (Dileo, 2000).

5. Has self-insights--is aware of own world-view and how it influences their behaviours (Dileo, 2000).

6. Is flexible but directive and structured in their approach, rather than being ambiguous. A verbal based approach may not be appropriate when a language barrier exists (Dileo, 2000).

7. Is creative in adapting and inventing music therapy methods to engage and suit the needs of CALD clients.

8. Actively seeks and expands music repertoire that is meaningful and familiar to the clients (Baker & Grocke, 2009).

9. Participates in regular professional cultural exchanges, through reading, conferences, etc. Dokter (1998) speaks of arts therapists going abroad to facilitate workshops or training in situ.

10. Seeks out and receives supervision that addresses cross-cultural concerns.

This study is limited as the participants numbered only thirty. Statistics and themes that emerged from a small sample should be viewed with caution.

Conclusion

The RMTs surveyed reported that cross-cultural music therapy in aged care was influenced by various factors, including personal experience, professional training and background, as well as clients' abilities, level of acculturation and musical preference. This study also found that most respondents were confident in providing music therapy to CALD clients and perceived that they provide the same amount of attention and service as their non-CALD clients. Additionally, the respondents were generally comfortable with utilising culturally specific musical idioms, including ethnic instruments, dances and various musical aspects (i.e. rhythm, scales, modes, vocal timbre.) However, a number of respondents expressed reservations about their level of preparedness for cross-cultural work provided by university training, preferring to emphasise the importance of personal experience and interests.

Despite the results of this study, the authors conclude that a systematic professional approach to fostering cross-cultural awareness and methods is imperative. Music therapists and the music therapy profession will benefit from diversifying their methods and actively acquiring musical resources with an appropriate understanding of cultural context. More generally, the Australian music therapy profession and its association should strive to offer more multicultural training and support for practising therapists, as well as emphasising cross-cultural methods and self-insights for students.

A serious and comprehensive approach to cross-cultural training will necessarily reflect the intricacy of the individual cultural background of each CALD client and music therapist. The ever-growing complexity of human experience demands no less.

References

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Vannie Ip-Winfield

BMus, MMus, Grad Dip Mental Health Science (community), RMT

Denise Grocke PhD, RMT, RMT-BC, FAMI

The University of Melbourne

(1) The most frequently used methods were those voted 'almost always' or 'often.'

(2) The least frequently used methods were those voted 'almost never' or 'rarely.'

(3) Most respondents (88.46%) voted 'almost always,' or 'often' for singing with reminiscence.

(4) Most respondents (65.38%) voted 'often,' or 'occasionally' for singing without reminiscence.

(5) Most respondents (61.54%, n=16) voted 'rarely' or 'almost never' for song writing.

(6) Cultural empathy is defined by Brown (2002) 'the process of gaining an understanding of the client's personal cultural experiences with the aim of conveying this understanding (Brown, 2001, 'Cultural empathy,' para.2).'

Table 1

Top ten countries of birth for persons aged 65+ from
CALD backgrounds, ranked in order of size, in 1996 and projected
for 2011 and 2026

 1996 2011

1 Italy Italy
2 Poland Greece
3 Germany Germany
4 Greece Netherlands
5 Netherlands China
6 China Malta
7 India Croatia
8 Former Yugoslavia Former Yugoslavia
9 Hungary India
10 Malta Vietnam

 2026

1 Italy
2 Greece
3 Vietnam
4 China
5 Germany
6 No data
7 No data
8 No data
9 No data
10 No data

Source: (Gibson et al., 2001)

* Excludes English-speaking countries (e.g. the UK,
US and New Zealand.)

Table 2

Top five popular music selections recommended by music
therapists for older adults in Australia and USA #

Rank Australia (Baker and Grocke, 2009)

1. Que Sera Sera (1955)

2. Love Me Tender (1956)
 You Are My Sunshine (1940) *
3. It's a Long Way To Tipperary (1912)
 When Irish Eyes Are Smiling (1912)
 Edelweiss (1959)
4. Daisy (1892)
 Show Me The Way To Go Home (1959)
 Country Roads (1971)
5. Blue Moon (1934)
 Danny Boy (1913)
 I Did It My Way (1967)
 Pack Up Your Troubles (1915)
 What a Wonderful World (1935)
 Wish Me Luck (1939)

Rank USA (VanWeelden and Cevasco, 2007)

1. Let Me Call You Sweetheart (1910)

2. Five Foot Two, Eyes Of Blue (1925)

3. Take Me Out To The Ballgame (1908)

4. In The Good Old Summertime (1902)

5. Daisy (1892)
 You Are My Sunshine (1931)+

# Songs that were recommended the same number of times
result in a tied rank

* Date given in Baker and Grocke (2009).

([dagger]) Date given in Van Weelden and Cevasco (2007).

Table 3.

The frequency of use of various music therapy methods.

 Almost Often Occasionally
 always

Song writing 0 (0%) 2(7.69%) 8(30.77%)

Instrument
playing along 8 (30.77%) 9(34.62%) 5(19.23%)
with music

Vocal 1(3.85%) 5(19.23%) 6(23.08%)
improvisation

Singing with 12(46.15%) 11(42.31%) 1(3.85%)
reminiscence

Singing without 4(15.38%) 11(42.31%) 6(23.08%)
reminiscence

Instrumental 3(11.54%) 6(23.08%) 7(26.92%)
improvisation

Music and 3(11.54%) 12(46.15%) 7(26.92%)
movement

Folk dance
(culturally 0(0%) 2(7.69%) 4(15.38%)
specific dance)

Listening to
music that the
therapist 10(38.46%) 9(34.62%) 6(23.08%)
plays/sings, or
played on CD

 Rarely Almost Total
 never

Song writing 4(15.38%) 12(46.15%) 26

Instrument
playing along 1(3.85%) 3(11.54%) 26
with music

Vocal 6(23.08%) 8(30.77%) 26
improvisation

Singing with 1(3.85%) 1(3.85%) 26
reminiscence

Singing without 1(3.85%) 4(15.38%) 26
reminiscence

Instrumental 4(15.38%) 6(23.08%) 26
improvisation

Music and 3(11.54%) 1(3.85%) 26
movement

Folk dance
(culturally 7(26.92%) 13(50%) 26
specific dance)

Listening to
music that the
therapist 1(3.85%) 0(0%) 26
plays/sings, or
played on CD

Total respond to this question: 26 100%
Total who skipped this question: 0 0%
Total: 26 100%