The framing of music therapy in research articles involving dementia

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The University of Bergen, Norway

The framing of music therapy in research articles involving dementia

Oleksandr Kapranov

PhD, post-doctoral researcher

The present article involves a qualitative study aimed at establishing how music therapy in dementia is framed in scientific texts published by the peer-reviewed journal Alzheimer's and Dementia within the period of time from 2015 until the end of 2016. Dementia is referred to in scientific literature as a range of neurodegenerative illnesses of which Alzheimer's disease is the most well-known and prevalent variant (Van Gorp & Vercruysse, 2012: 1274). According to the definition of dementia by Alzheimer's Association, dementia is classified as aneurocognitive disorder, characterised by a significant cognitive decline, `a decline in memory, language, problem-solving and other cognitive skills that affects a person's ability to perform everyday activities. This decline occurs because nerve cells (neurons) in parts of the brain involved in cognitive function have been damaged and no longer function normally.' (Alzheimer's Association, 2015: 333).

Dementia involves a range of behavioral and psychological symptoms, which are treated pharmacologically (e.g., sedatives, neuroleptics and antidepressants) and non-pharmacologically. Music therapy is deemed to be a promising nonpharmacological approach for treating clients with dementia. Music therapy is based on the systematicuse of musical instruments to improve communication between music therapist and clients (Raglio et al., 2008). In this respect, there is `the growing demand for music therapy services with people affected by dementia. ' (Pavlicevic et al., 2015: 659).

Music therapy is defined as `a three-dimensional therapeutic interaction between a trained music therapist, the music, and a patient who meet to reach defined goals and objectives.' (Ray et al., 2016: 428). According to American Music Therapy Association, music therapy is `the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.' (American Music Therapy Association, 2015). In clinical settings, music therapy involves individual therapy and group therapy (Chang et al., 2015). Whilst in individual music therapy the music content and activities are provided according to the client's background and preferences, the focus of group music therapy is on the interactions among the clients, as well as on the experience sharing (Chang et al., 2015: 3426). A further distinction of the definition of music therapy is often made between receptive approaches, for instance listening to music, and active or participatory approaches (Pavlicevic et al., 2015: 660).

Music therapy is considered to involve `a cooperation between client and therapist to support the client's physiological, mental and social resources by using music experience in a goal-directed, knowledge - and evidence based, and participatory approach.' (Wosch, 2011: 23). Evidence for the benefits of music therapy in dementia involves short-term reductions in behavioural disturbance and improved mood (McDermott et al., 2013: 781). In particular, music therapy is now used with increasing frequency, especially for the treatment of agitation and aggressiveness (Raglio et al., 2008: 158).

Whilst there is a burgeoning body of literature associated with music therapy in dementia, there is still insufficient research involving the framing of music therapy in scientific texts. The novelty of the present research rests with a qualitative approach employed to explore how the use of music therapy in dementia is framed in scientific articles published by Alzheimer's and Dementia. The present article is structured as follows: First, previous studies involving music therapy in dementia will be outlined. Second, the notion of framing in medical discourse will be discussed. Third, a qualitative study of framing associated with music therapy in dementia will be introduced. Previous Studies Involving Music Therapy in Dementia.

In previous research literature, music therapy is regarded as one of non-pharmacological treatment options in dementia (Svansdottir & Snaedal, 2006: 614). Previous research findings suggest that the use of music therapy to treat clients with dementia has facilitative effects on memory, arousal, attention, learning, and anxiety (Keough et al., 2016: 1). Werner et al. (2015) suggest that music therapy reduces depressive symptoms, concentration difficulties, lassitude, inability to feel, pessimistic thoughts and inner tension. Cabrera et al. (2015: 148) observe that a live-music intervention has positive effects on behavioral symptoms by decreasing agitation and anxiety. It is reported that a group music-listening intervention has showed a statistically significant decrease in agitated behavior scores (ibid.).

The positive effects of music therapy in dementia have been reported in a variety of health care settings. In this regard, Ray et al. (2016: 429) posit that Alzheimer's disease and other types of dementia are among the disorders most commonly treated with music therapy. Music therapy for individuals with dementia focuses on improved communication, memory, behavioral management, and facilitating interactive relationships with therapists and carers. Music is seen as a tool to achieve those goals, and the outcomes of music sessions are measured either quantitatively or qualitatively.

Whilst positive effects of music therapy have been reported, it should be noted that the body of previous research studies involving music therapy in dementia is based on a limited number of participants (Svansdottir & Snaedal, 2006: 614). Consequently, case studies associated with music therapy in dementia are characterised by a great degree of variability (ibid.). The limitations of the case studies have led the research community to believe that a fundamental evaluation of music therapy benefits in the treatment of dementia cannot yet be made (Grassel et al., 2003).

Grassel et al.'s (2003) observation is corroborated by the research findings reported by Thornley and the colleagues (2016). The results of the study by Thornley et al. (2016: 870) seem to contradictcurrent evidence showing the benefits of music therapy for clients with dementia in nursing home settings. The lack of benefit of music therapy in the study is reportedly evident from the clients' with dementia inability to meaningfully engage in the intervention (Thornley et al., 2016).

The above-mentioned findings are echoed in Koger et al. (1999: 9) who indicate that it is problematic to determine the relative efficacy of different methodological protocols within the existing literature pertaining to the effectiveness of music therapy intervention when dealing with clients with dementia. Interestingly, whilst Koger et al. (1999: 11) point to the inconclusiveness of the positive outcomes of music therapy, the authors, nevertheless, emphasise that 'all humans, regardless of dysfunction or lack thereof are responsive to interactions involving music'.

The Notion of Framing in Medical Discourse

There is a substantial body of cross-disciplinary literature on medical discourse, characterized by significant differences among the interests, theories, and methodologies (Ainsworth-Vaughn, 2003). One of the approaches to the analysis of medical discourse involves the so-called `framing analysis'. This analysis is based upon the notion of a frame.

According to Entman (1993), the concept of framing is applicable to the description of a communicative text. Framing illuminates `the precise way in which influence over a human consciousness is exerted by the transfer (or communication) of information fromone location-such as a speech, utterance, news report, or novel-to that consciousness' (Entman, 1993: 51-52). Frames involve schemas, or mental constructs representing expectations about what the world is like in general. It is posited that these expectations are organized as chunks of information (Tannen & Wallat, 1987).

Since frames involve expectations about particular interactions via information chunking, they are deemed to be associated with macro-structures, which account for the global meaning of discourse (Van Dijk, 1977). Consequently, frames can be regarded as the schemas of interpretation, which organise experiences, guide actions, and provide coherence to a set of idea elements (Fiss & Hirsch, 2005: 30). Frames have been explored as shared cultural tools for the creation and interpretation of meaning in a variety of contexts, e.g. political news, science, technology, and medicine (Koteyko et al., 2008: 226). In the latter context, frames have been applied to elucidate avian flue (Koteyko et al., 2008), the issues of hygiene (Crawford et al., 2008), diabetes (Hunt & Koteyko, 2015), etc.

The framing in medical discourse is associated with public health issues. The framing involves the definition of a health problem, and the establishment of its causes and possible solutions (Lawrence, 2004). Frames are constituted by the participants' interactive behaviorin medical settings. Specifically, Lawrence (2004) indicates that the doctor-patient encountersare framed as a part of the medical institution, whereby the participants are constituted as doctors, patients (clients), nurses, and caregivers.

The notion of a frame has been applied to a number of previous studies involving dementia discourse (Kapranov, forthcoming). In particular, the qualitative framing analysis in Kapranov (forthcoming) has yielded a set of frames associated with dementia in the research articles published in `Alzheimer's and Dementia' in 2016. These frames construe dementia as a range of issues, which are associated with gender, age, medical costs, caregivers and care-recipients, disability and death, health policy, medical conditions, and ethnicity.

The study involving the framing analysis of dementia discourse by Kapranov (forthcoming) has revealed that the framing of dementia as an age-related issue in `Alzheimer's and Dementia' serves as a background for other foregrounded construals, for instance, gender, ethnicity, spatial orientation, etc. It is concluded in Kapranov (forthcoming) that the `age' frame provides a broad background against which more specific framing takes place. However, the findings in Kapranov (forthcoming) suggest that the framing of dementia associated with medical condition tends to be an isolated frame, where the construal of dementia is foregrounded without explicit reference to other frames.

The Framing of Music Therapy in Research Articles Involving Dementia

Whilst there is a burgeoning bulk of literature on framing in medical discourse (see Salager-Meyer et al. (2003) for an exhaustive meta-analysis), there are not so many studies involving the framing of music therapy in dementia. The present qualitative investigation seeks to address the gap by analyzinghow music therapy is framed in one of the most prestigious peer-reviewed journals, Alzheimer's and Dementia. The Hypothesis of this investigation is based upon the following assumption: Given that previous literature is inconclusive in regard of the positive effects of music therapy interventions in dementia, it is hypothesised that music therapy will be operationalised by a variety of competing frames. The exact nature of the variety of frames will be established by means of the qualitative analysis. Hence, the specific research aim of the present qualitative investigation is to elucidate how music therapy is framed in scientific articles published by Alzheimer's and Dementia.

Materials

The corpus of this qualitative study involves scientific articles published in Alzheimer's and Dementia in 2015-2016. The articles have been collected via an electronic search on the web site scholar. google.com with the active filters involving the publication date (from 1.01.2015 till 1.11.2016), and the key words`Alzheimer's', `dementia', and `music therapy'. The electronic search has been manually checked for the presence of the key words in each respective article. In total, 15 articles with an explicit reference to music therapy in dementia have been selected for the present analysis.

Methods

The methodology employed in the present article replicates a previous study by Kapranov (forthcoming), which elucidates the framing of dementia in Alzheimer's and Dementia. In particular, Kapranov's (forthcoming) methodology follows the guidelines described by van Gorp & Vercruysse (2012), whose research focus is on how dementia is framed in media texts. The qualitative component of van Gorp & Vercruysse's (2012) methodology has been applied to the present corpus of scientific articles involving dementia, published in `Alzheimer's and Dementia' in 2015-2016.

Results and Discussion

The results of the qualitative framing analysis have been summarised in Table 1 below.

Table 1. The Framing of Music Therapy in Alzheimer's and Dementia in 2015-2016

As evident from the data, the framing of music therapy in dementia discourse published by Alzheimer's and Dementia in 20152016 is construed by several frames, such as `Nonpharmacological Intervention', `Caregiver', `Apathy', `Agitation', `Behavioural Symptoms', and `Memory and Cognitive Function'.

The frame 'Nonpharmacological Intervention'

The framing of music therapy as a non-pharmacologic therapy has been identified in Alzheimer's Association (2015; 2016), Beynon et al. (2016), Kim et al. (2015), Lanctot et al. (2016), Li et al. (2016), Ogunlade & Ray (2016), Ray & Maier (2016), Schall et al. (2015), Shahinfard et al. (2016), Sullivan et al. (2015), and in Yang et al. (2015). In the majority of these studies, the framing of music therapy via `Nonpharmacological Intervention' is embedded into other frames, e.g. in Beynon et al. (2016), Lanctot et al. (2016), Li et al. (2016), Ray & Maier (2016), and Sullivan et al. (2015). Arguably, the frame `Nonpharmacological Intervention' serves as a background for other frames to be fore grounded.

Judging from the framing analysis, the narrative of music therapy as a nonpharmacological therapy by Alzheimer's Association (2015; 2016)is characterised by a neutral and cautious discursive tonality, seen from the following excerpts:

As with current pharmacologic therapies, non- pharmacologic therapies havenot been shown to alter the course of Alzheimer's disease. ...Additional research onnon-pharmacologic therapies is needed to better evaluate their effectiveness. (Alzheimer's Association, 2015: 338) ...nonpharmacologic therapies have not been shown to alter the course of Alzheimer's disease. However, compared with pharmacologic treatments, relatively few non-pharmacologic therapies have been tested in multiple large randomized controlled studies and shown consistent results. Additional research on nonpharmacologic therapies is needed to better evaluate their effectiveness (Alzheimer's Association, 2016: 466).

The framing of music therapy as `Nonpharmacological Intervention' by Lanctot et al. (2016) is construed along similar lines identified in Alzheimer's disease facts and figures by Alzheimer's Association (2015; 2016). Lanctot et al. (2016) note that many studies involving music therapy are small and qualitative, which report benefits that can not besupported quantitatively. Whilst acknowledging the evidence for efficacy of music therapy interventions, Lanctot et al. (2016) indicate that the standard of the current state-of-the-art research involving music therapy is generally low.

In contrast to the afore-mentioned approaches, the framing of music therapy as a nonpharmacological intervention is also characterised by a positive (Shahinfard et al., 2016; Yang et al., 2015) and neutral discursive tonality (Ogundale & Ray, 2016). To illustrate, Ogundale and Ray (2016) frame music therapy as a neutral and standard means of the non-pharmacological treatment for dementia, which `may become recognized as a standard treatment option for dementia in Lagos, Nigeria'.

Yang et al. (2016) posit that music therapy is an effective treatment in dementia. Yang and the colleagues (2015) have measured the effectiveness of music therapy by means of examining the neural basis in fMRI. Yang et al. (2016) frame their positive narrative of music therapy as a nonpharmacological treatment by showing that the clients with Alzheimer's dementia have significantly greater activation with familiar music in the superior and middle temporal gyrus, pars triangularis, right insula, right inferior frontal gyrus, and left supplementary motor area. These findings have led Yang et al. (2016) to suggest that clients with Alzheimer's dementia pay more attention to familiar music, which can be successfully applied to facilitate dementia management in clients with Alzheimer's.

The framing of music therapy as a nonpharmacological intervention by Shahinfard et al. (2016) is analogous to that by Yang et al. (2016). Specifically, Shahinfard and the colleagues (2016: 1030) suggest that ...music therapy has been proposed as a safe and effective treatment for patients with Alzheimer Disease (AD). We hypothesized that a 4-week, twice weekly, 45-minute MT intervention would improve behavioural and clinical outcomes in patients with mild to moderate AD, and the clinical improvements will be correlated with changes in brain activation measured by fMRI during passive listening to music.

Shahinfard and the colleagues (2016) report the increase in fMRI activation patterns during passive listening to familiar and unfamiliar music in clients with Alzheimer's. Shahinfard et al. (2016) have confirmed that the activation pattern of the brainduring the processing of familiar and unfamiliar music isdifferent after music therapy interventions.

The frame 'Caregiver'

The frame `Caregiver' has been identified in research articles by Beynon et al. (2016) and Yu-Ying (2016). The framing of music therapy by Beynon et al. (2016) involves a collaborative choral programme comprised of clients with Alzheimer's disease and their caregivers. Music therapy in a choir provides respite, reunion, and learning opportunities for caregivers and clients with Alzheimer's disease (ibid.). It is evident from Beynon et al. (2016) that the framing of music therapy as `Caregiver' involves discursive themes associated with learning about singing, about personhood and identity, client - caregiver relationships, as well as affective and aesthetic engagement.

Similar interactive music therapy activities are proposed by Yu-Ying (2016). These activities involve an interactive course «Love microphone», designed for dementia caregivers. The interactive nature of the caregiver involvement in the song course is evident from excerpt (4) below:

Each family prepared a song, after singing to encourage other partners' applause from the scene. When finished, go back to caregiver support groups, sharing the moment with each other feelings, through personal involvement, observation and discussion, release emotions and perceptions. (Yu-Ying, 2016).

The frame 'Apathy'

The frame `Apathy' has been identified in the review article by Lanctot and her colleagues (2016). With the main focus of the article being on apathy, the authors mention music therapy as one of many other nonpharmacological means of the management of apathy. These means are referred to by Lanctot et al. (2016) as cooking, exercise, pet therapy, and multisensory stimulation, etc. Lanctot et al. (2016: 11) posit that `Improvements in apathy have been reported with interventions that are creative, for example, music and art, employ reminiscence therapy, use skills training, problem solving, and cognitive behavioural techniques... '. However, the authors conclude that future studies should examine and quantify the combinations of drug treatments with nonpharmacological treatments.

The frame 'Agitation'

The framing of music therapy as a means of managing agitationis present in Ray and Maier (2016), and in Sullivan et al. (2015). Ray and Maier (2016) emphasise that music has the effect of lessening agitation in people who are diagnosed with Alzheimer's disease. This narrative of music therapy in Ray and Maier (2016) seems to be basedupon two frames, `Agitation' and `Caregiver', respectively. The frame `Agitation' is used as a background, against which the framing of music therapy via the frame `Caregiver' takes place. The `Caregiver' frame is associated with certified nursing assistants (CNAs) who assist with music-based activities aimed at facilitating agitation and other symptoms in clients with Alzheimer's.

Sullivan et al. (2015) posit that nonpharmacological approaches are necessary for people with dementia, who often experience agitation and anxiety. Analogous to Ray and Maier (2016), Sullivan and the colleagues (2015) co-frame music therapy by evoking two concurrent frames, `Agitation' and `Caregiver'. Caregivers may be included in these forms of treatment. Sullivan et al. (2015) suggest thatmusic and other nonpharmacological interventions with patients with Alzheimer'sand caregivers are effective in decreasing caregiver burden and patient agitation and anxiety. In the context of the clients' agitated behavior, music therapy is suggested as a safe and effective means for its treatment.

The frame 'Behavioural Symptoms'

The frame `Behavioural Symptoms' has been identified in the research papers by Beynon et al. (2016), Hsiung et al., (2015), Kim et al (2015), and Schall et al. (2015). Beynon et al. (2016), Kim et al. (2015), and Schall et al. (2015) frame music therapy as effective in improving cognition, behavioral and psychological symptoms, and quality of life of clients with dementia. These authors frame their narrative about music therapy as one of many other forms of nonpharmacological interventions, e.g. art:

Creative therapeutic approaches such as art or music therapy enable communicative resources to be supported and alternative access paths to the world of experience to be developed among people suffering from dementia. Empirical evidence demonstrating the efficacy of music therapy in dementia, particularly with regard to the enhancement of emotional well-being and special aspects of communication behavior, is available (Schall et al., 2015: 737).

Hsiung and the colleagues (2015) frame music therapy as beneficial in improving the clients' behavioural symptoms. Hsiunget al. (2015) suggest that music therapy has beneficial effects on managing behavioural symptoms in clients with Alzheimer's and decreasing stress as measured by morning cortisol levels. Hsiung et al. (2015: 749) posit that music therapy can be offered as a safe alternative to pharmacological treatment in managing the clients' behavioural symptoms.

The Frame 'Memory and Cognitive Function'

The framing of music therapy in dementia via `Memory and Cognitive Function' is present in research articles by Innes et al. (2016) and Li et al. (2016). Innes et al. (2016) indicate that music therapy in conjunction with other interventions, such as meditation, lead to marked improvements in both memoryand cognitive performance. Innes et al. (2016) suggest that music therapy and other forms of mind-body interventions may be effective in enhancing memory and cognitive function in adults, with improvements sustained atsix months. Whilst Innes et al. (2016) are positive in their framing, Li et al.'s (2016: 617-618)narrative of music therapy in dementia is more cautious: `No apparently additional benefits of this MT were noted in the globally cognitive assessments for 3 months'.

The present article involves a qualitative investigation of the framing of music therapy in dementia discourse published by Alzheimer's and Dementia in 2015-2016. The results of the framing analysis indicate that music therapy in Alzheimer's and Dementia is construed by several frames, such as `Nonpharmacological Intervention', `Caregiver', `Apathy', `Agitation', `Behavioural Symptoms', and `Memory and Cognitive Function'. The framing analysis has revealed that the frame `Nonpharmacological Intervention' appears to be embedded into the series of other frames and serves as their neutral background. The present findings can be taken to indicate that an overarching idea of the music therapy narrative published by Alzheimer's and Dementia in 2015-2016 involves a polyphonic discursive space. This space seems to be primarily structured by the frame `Nonpharmacological Intervention'. However, the polyphony of this discursive space is construed by a range of stand-alone (`Memory and Cognitive Function') and interrelated frames (`Apathy', `Agitation', `Behavioural Symptoms'). It can be concluded that the polyphonic discursive space associated with the music therapy narratives published by Alzheimer's and Dementia in 2015-2016 is characterised by `inconsistent effects on disruptive behaviours, anxiety levels, depressive moods and cognitive functioning in people with dementia'. (Chang et al., 2015: 3425).

Acknowledgements

The author wishes to acknowledge post-doctoral research fundingfrom the Norwegian Research Council and the University of Bergen (Norway), which enabled the author to write this article.

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