1

Senescence :
The existential stage

Translation : Pauline GAUDEUL

N° ISBN : 978-2-9567724-1-5
Concerti de vie : Life concerti
N’être par la musicothérapie : Being through music therapy
(french phonetic: ‘to be born’ through music therapy)
 Senescence: the
Senescence: the existential
existential stage
stage

Or
Or

Music therapy: non-medicated healing with a therapeutic purpose, in the service of Elders with
Music therapy: non-medicated healing with a therapeutic purpose, in the service of Elders
severe neurocognitive disorders (residents at the EHPAD1 de la Bourgonnière)
with severe neurocognitive disorders (residents at the EHPAD2 de la Bourgonnière)

2
EHPAD : Etablissement d’Hébergement pour les personnes âgées dépendantes / Hosting
structure/establishment for dependant older people)

2
“Slow snail
Climb, climb up
Mount Fuji”
Issa’s haïku (1763-1828)

3
 To “Mrs. Thursday”, my mother.

4
Prequel: the genesis of the report.

1. Anamnesis.

Since I was 11 years old, I chose to gravitate towards the anawims3 of modern times. For the past 15
years I have been working as a state certified special-needs educator in the ‘various disabilities’ sector.
I decided to study further in order to have a more therapeutic approach. This report is the result of
over 1600 hours of professional placement as a Music therapist (I have since received my degree from
the Faculty of Medicine.) I wrote this report in the mushotoku approach. This approach is inherent to
the zen4 attitude (which I have been practicing for the past 30 years). The translation of which could
be: “with no intention or search for profit”. However, I wrote this full of gratefulness: as an homage to
the residents and professionals of the EHPAD who welcomed me, to the residents who agreed to be
music therapy patients.

2. Starting point.

This was the watching of the video from the round table: “from music therapy to fundamental
research”. Intervention by Misters Hervé Platel and Olivier Bonnod, were of particular interest to me.
I will come back to this later.

3. The choice of words.

I will often justify the use of certain key words, in particular in several areas: History; Anthropology;
Ethnography; Etymology; Epistemology; Neuroscience progress; DSM5 IV and V; linguistic Heuristics;
Music.

3
Anawim: Hebrew word, in the Torah, describes those who have lost everything. Here, in modern times, I use it
to refer to those who lost everything, until their social life, their dignity, their faith, their health, their hope, …
4
Zen: Buddhism integrated into the Japanese Religion. It is the most abrupt, yet quickest path of Buddhism. Zen
resides in the practice of “za-zen”: a seated posture (where position points, breathing method and attitudes to
reflection have been passed on for 2500 years), totally immobile, yet very invigorating. My practice is however
separated from practice of the Shinto religion.
5
Diagnostic and Statistical Manual of Mental Disorders.

5
Key words and expressions:

End of life care; transitional area; therapeutic alliance;

appropriation of sonic medias; apprenticeship;
psycho-musical evaluation; psychic changes; setting;
non-verbal communication; creativity; non-violent
communication; discontinuity of the setting; caring
empathy; clinical improvisation; instrumentarium
unknown to the patients; present instant; integration
(Erikson); nychthemeral rhythm inversion; Montessori
method; death; active or receptive music therapy;
neurogenesis; neurosciences; neurotransmitters;
opportunity of saying “no”; degenerative pathologies
in older people; inversed pyramidal paradigm;
cerebral plasticity; sundowning syndrome; external
supervision; time; severe neurocognitive disorders;
Validation (Naomi Feil); verbalization; Zen.

6
Welcome to summary !

I. Introduction. ………………………………………………………………………………………………………………………………..11

II. Specificity of the EHPAD “La Bourgonnière”. .............................................................................. 14

A. Living environment. .................................................................................................................. 14

B. Presentation of the residents. .................................................................................................. 16

1. Elders, dependent older people, crones? ............................................................................ 16

2. Senescence. ........................................................................................................................... 19

3. Reversed pyramidal paradigm. ............................................................................................ 19

4. Residents in “La Bourgonnière”. .......................................................................................... 21

5. Residents with specific neurocognitive disorders. .............................................................. 23

C. In service of the residents: a benevolent hydra. ..................................................................... 29

1. Preface: linguistic choices..................................................................................................... 29

2. Inventory of the care-giving staff (internal and external)................................................... 29

3. Common approach for the caregivers: the humane-attitude. ............................................ 30

4. Continuous training for the caregiving staff. ....................................................................... 32

5. Non-drug treatments. ........................................................................................................... 32

6. Defense mechanism. ............................................................................................................ 34

7. Mini-conclusion. ................................................................................................................... 34

III. Immersion, observations, problematics. ................................................................................. 38

A. General personal positioning in the EHPAD. ........................................................................... 38

B. Immersion. ................................................................................................................................ 39

1. Identification......................................................................................................................... 39

2. Approach and contacts. ........................................................................................................ 40

C. Observations. ............................................................................................................................ 40

1. Methodology......................................................................................................................... 40

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 2. The notion of time. ............................................................................................................... 41

3. X-sports and very old people. .............................................................................................. 42

4. Other observations. .............................................................................................................. 43

5. The Team............................................................................................................................... 43

D. Problematics. ............................................................................................................................ 44

1. Main objective. ..................................................................................................................... 44

2. Related therapeutic goals..................................................................................................... 44

IV. Theoretical construction. ......................................................................................................... 46

A. Foundations. ............................................................................................................................. 46

1. Introduction. ......................................................................................................................... 46

2. Montessori method. ............................................................................................................. 47

3. Validation according to Naomi Feil. ..................................................................................... 48

4. Carl Ransom Rogers. ............................................................................................................. 50

5. Therapeutic empathy. .......................................................................................................... 51

6. Thierry Tournebise................................................................................................................ 52

7. Jean Maisondieu. .................................................................................................................. 53

8. Individuation process, the Self. ............................................................................................ 54

9. Views on the psyche. ............................................................................................................ 55

B. Underground of my theoretical construction. ......................................................................... 59

1. External supervision. ............................................................................................................ 59

2. Instrumentarium (finally) being used. ................................................................................. 60

C. Ground-floor. ............................................................................................................................ 66

1. Contribution of neurosciences (Part 2). ............................................................................... 66

2. Therapeutic alliance. ............................................................................................................ 68

3. Following Winnicott. ............................................................................................................ 69

1. The frame. ............................................................................................................................. 70

2. The “No”................................................................................................................................ 71

3. Points on music therapy. ...................................................................................................... 72

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 4. Benezon’s Sound Identity. .................................................................................................... 76

5. Mini-conclusion..................................................................................................................... 77

V. The Clinic. ...................................................................................................................................... 79

A. Preface. ..................................................................................................................................... 79

1. Reminder of different therapeutic aims. ............................................................................. 79

2. Presentation of the patients ................................................................................................ 79

B. Giving the opportunity to say something to oneself............................................................... 84

1. Means. ................................................................................................................................... 84

2. Opening up to emotions. ...................................................................................................... 85

3. Use of the psycho-musical evaluation. ................................................................................ 87

4. Use of Wigram’s clinical improvisation................................................................................ 89

5. Therapeutic pathways. ......................................................................................................... 90

C. Giving the possibility to communicate with one another ....................................................... 96

1. Means. ................................................................................................................................... 96

2. Specific theoretical tools. ..................................................................................................... 98

3. Therapeutic pathways. ....................................................................................................... 100

4. Consequences on the life of the group. ............................................................................. 101

D. Contributing to easing symptoms. ......................................................................................... 102

1. Means. ................................................................................................................................. 102

2. Syndromes. ......................................................................................................................... 102

3. Contribution of neurosciences (Part 3). ............................................................................. 102

4. Therapeutic pathways. ....................................................................................................... 103

E. Accompanying the person at the end of their life. ................................................................ 106

1. Preface. ............................................................................................................................... 106

2. Fairy-tales, testimony, beliefs. ........................................................................................... 106

3. Means. ................................................................................................................................. 107

4. Therapeutic pathways. ....................................................................................................... 108

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 F. Mini-conclusion. ..................................................................................................................... 112

VI. End of the work in music therapy. ......................................................................................... 113

A. Last sessions of individual music therapy. ............................................................................. 113

1. Preface. ............................................................................................................................... 113

2. Mr Moï. ............................................................................................................................... 113

3. Mrs Néü. .............................................................................................................................. 113

4. Mrs Mui. .............................................................................................................................. 113

6. Mrs Dui. ............................................................................................................................... 114

7. Mrs Gaï. ............................................................................................................................... 114

8. Mr Poé. ................................................................................................................................ 114

B. Mini-conclusion. ..................................................................................................................... 115

VII. General conclusion. ................................................................................................................ 115

Bibliography. ....................................................................................................................................... 119

Appendices.......................................................................................................................................... 125

Appendix 1: list of needs and feelings in non-violent communication. ....................................... 126

Appendix 2: Post work-placement period. .................................................................................... 134

Appendix 3: Study of a background music, for the group, based on the resident(s). .................. 138

Post scriptum. ..................................................................................................................................... 153

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 I. Introduction

At 11 years of age, after two years of arid solfeggio, I was allowed to choose an instrument. The one I
had the most affinity with was the transverse flute. It was with this instrument that I finished my
studies at the Conservatory during my adolescence. The flute is my acoustic medium. It has allowed
me and still allows me to say how I feel, where words can no longer express, even to express the
droplets of the ineffable. Furthermore, during this period of adolescence, I received a pair of
earthenware Moroccan tablas (of the largest size), I studied singing and became strongly interested in
native music (such as the Ocora Radio France collection, for example). The foundation was laid. This is
how I experienced the medium of sound during my adolescent period.

The period of the birth and development of the child are described by William Fritz Piaget (1886-1980),
Swiss biologist, psychologist and epistemologist. Another facet is unveiled by Lev Vygostski (1896-
1934), Belarus psychologist, who introduces social constructivism into child development. Françoise
Dolto (1908-1988), French pediatrician and psychoanalyst, opens us up to the psychoanalysis of the
infant where “everything is language”.

Then comes adolescence which is an important part of life, where our image changes and our intra-
and inter- psychic relationships change. The same (though we speak about it less like an existential
crisis) is senescence, which we find principally amongst elderly people. The psychoanalyst and
psychologist Erik Erikson (1902-1964) approaches this by describing the psychosocial development of
the human being during his whole lifespan. At this moment, the human being also passes through a
radical change of image. But we add to this with the social pressure of ‘Youthism6’ and all the possible
ways to conserve it despite the irretrievable flow of time, as well as the collective fear of death.

It is therefore past time we start reconsidering this period of life.

By personal choice and in order to better scrutinize my research, I focused my attention on the Elders,
those residing at the EHPAD, who present with severe neurocognitive disorders.

In its history Western medicine is rather organicist. That is to say that all illness finds its origins in a
lesion or a dysfunction of one or more organs. It brings the organs as the source of life. It follows that,
to heal or relieve the patient, one must treat the offending organ(s).

6
Youthism is to be understood as the praise of youth above all else.

11
According to WHO, in 2015, elderly people showing severe neurocognitive disorder, recently named
senile dementia, would constitute a group of 47.5 million people in which 60 to 70% are suffering from
Alzheimer’s disease. If nothing is done, the number of people affected by this illness could increase by
60% before 2040.
We now find ourselves in a strictly organicist point of view. Research on Alzheimer’s disease
emphasizes the aggravating factors such as arterial hypertension, high levels of cholesterol, smoking…
but the principal risk factor is advanced age! Old age is, at best, considered as a symptom of the illness,
not a cause of said illness.

Gerontopsychiatrists Jean Maisondieu, Louis Ploton et Pierre Chazerac, without rejecting clinical
symptoms, raise the debate a little. According to Jean Maisondieu: “Old age is a crime punished by
exclusion” and: “our culture practices the apartheid of age”. Their point of view, which I will develop
later on, is that dementia would actually be a neurological disconnection caused subconsciously by the
person who, in order not to go so far as to commit suicide, disconnects so as not to endure their own
perception and the vision society has of old age, thus also trying to escape the anguish of death.

In fact, they do not ask to be healed from their dementia, but to be listened to, understood, recognized,
validated and relieved. It is here that active and receptive music therapy workshops come in, such as
non-medicated healing with therapeutic aims.

The collective fear of death in our societies (survival instinct), we reject the idea of it by ‘doing’. But,
when the nearing of death becomes inescapable (surrounding us completely), a terror can emerge
whichever our beliefs may be.

At this advanced age, for people suffering from severe cognitive disorders, there is very little room
left for ‘doing’. Then, a space for the fulfilment of the ‘being’ may become necessary. It was in hiding
and was used by the ‘doing’ for all these years. This is the time of senescence.

Can music therapy workshops prepare the way for a successful senescence? In the same way, at the
end of one’s life, intense and unique life experience, can music therapy help a person to depart whilst
being at peace with oneself?

12
This is what I propose to discover along the course of this report. It is constructed in the style of Russian
nesting dolls, each part drawing from its roots in the mold of the previous one:

Patient within their

own therapeutic path

Surroundings and specific

culture of the EHPAD

Observations and
problematics
Theoretical construction
in adequacy

Music therapy workshops with the

addition of specific theories

13
 II. Specificity of the EHPAD “La Bourgonnière”.

A. Living environment.

a. Distribution of the various accommodations.

There are 3 distinct living units:

▪ The ‘Village’ unit, comprising 49 apartments, two of which are for temporary stays (for
less than three months), and 4 ‘couples’ apartments.
▪ The ‘Hermitage’ unit, comprising 14 individual apartments.
▪ The ’Pierre Mara’ unit, also comprising 14 individual apartments.

These last two units are specialized for people presenting cognitive disorders and/or people in a state
of significant dependency. It is to be noted that for these two units the limitations are swinging fire
doors but without coded door locks (at the behest of the director).

People presenting with cognitive disorders have an apartment in a verdant and relaxing setting
(therapeutic garden).

These units are places to live that do not have rectilinear corridors, with some small lounges promoting
sociability, some libraries, ambient music and numerous armchairs and sofas.

The central area is made up of a patio, the dining room and the reception area. It is the style of a village
with areas for a hairdresser’s, beautician, shop and mail desk amongst others.

The lounge is designed to host parents and friends. The maintenance of the social areas is one of the
priorities. Visits (in respect of the care and of the other residents), information and consultations with
families and the establishment are strongly encouraged.

14
In addition:

- Lots of plants can be found inside (watered by one of the female residents) and outside.
- There is a concerted effort to encourage natural lighting thus avoiding the phenomena
surrounding acoustic resonance.
- Some pets reside at the establishment: two small doves near the patio area. In the ‘Pierre
Mara’ unit there is a beautiful fighting fish in his bowl as well as a cat who belongs to everyone
and no one.

b. Individual apartments:

Each is made up of a surface area of 27 square meters, a terrace, a balcony, quality equipment
adapted to the person’s dependency, and a certain intimacy (each resident possesses their own
key and letter box outside their door). The majority of the residents bring objects and/or furniture
from their former dwelling, before they arrived at the EHPAD care home. Personalization is
strongly encouraged.

c. Other area:

There are numerous care rooms, a pharmacy, offices for the caregivers, Snoezelen7 room, a
bathroom, with adapted bathtub (with solid waterproof canvas and numerous directional massage
jets). Lifting harnesses are also at one’s disposal.

d. Entry lock:

This is a place guaranteeing safety. It is indeed the only available place with a digital lock using a
code, that’s changed periodically. The personnel, but especially those in charge of the secretarial
services and the reception observe and alert other staff if a resident with cognitive disorder exits
the building, thus placing themselves in danger. The entry lock is engaged during mealtimes and
at night.

7
A description of the Snoezelen Room is given forwards.

15
 B. Presentation of the residents.

1. Elders, dependent older people, crones?

a. Elders.

In the Antiquity, same as today in many societies of oral traditions in the world, the group of Elders is
respected, first because they are few but also thanks to the part the play as a repository and
transmitter of the tradition and practical knowledge of their people. They are a reference in civil affairs
(marriage, births, …), in the ruling of legal dispute or delicts and are a link between Heaven and Earth.

Some examples:

• In “The Republic” (-300), Plato quotes Socrates in his talk with Cephalus, a rich merchant from
Piraeus: “I enjoy speaking with Elders, for what they have lived before, we will probably have
to live too and I am of the opinion that we should learn from them what, on this path, is bitter
and harsh or what is easy.”
• Apostle Peter, in his first letter [5,1-4], in the 5th decade, when Roman Emperor Nero was trying
to eradicate Christians during the time of bloody martyrdoms: “[You, Elders] be the shepherds
of this flock (…) who was entrusted to you, (…), not by as masters of those you are responsible
for, but by becoming role models for the flock…”

• In Native American culture, in the book of John G. Neihardt8: “Black Elk speaks : being the life
story of a holy man of the Oglala Sioux” (Lincoln : University of Nebraska Press, c1979), the
role of Elders is crucial: for instance, as an instigator, an advisor, the one who shows the way,
or in their role as a transmitter of holly history…

• In Japan, when an Elders reaches the peak of their art, they enter the category of living national
treasures.
• Finally, in Africa, the Pulaar writer and tale-teller, Amadou Hampâté Bâ, said, at the UNESCO
in 1960: “[In Africa], when an Elder die, it is a library that burns” Although this quote reflects
reality, it is said with a sly sense of humor.

8
This testimony, edited for the first time by John Neihardt in 1932, was then studied by Carl Jung and his team.

16
 b. The dependent elderly person.

That is the definition of a person in the acronym, EHPAD, which by now became an inexplicable word
for outsiders. The English language, usually more pragmatic and precise than French, speaks of: ‘old
people’, ‘old old people’ and ‘very old people’.

c. Old people and crones.

The culture of books, and nowadays of Internet, deprives the Elder of his role of transmission.

Moreover, the decay of religion in France, and of religious beliefs or religions in the world (as showed
by the following documents), also deprives them of the role of initiation and link between Heaven and
Earth:

Catholic

Protestant

Other religions

Non
The chart religious the situation in France is should be compared to the following one, in which
representing
the global beliefs tendencies are represented:

17
 Christians Muslims Hindus Chinese Buddhism
30 20.5 13.5 Religions 6.2 5.8

*: Sikhs, Jews, Jains, Bahá’ís, Confucianists, Shinto, Taoists, …

Animists Other * New Religions Atheists Non-religious

4 4 (cults) 4 4 (Agnostics) 4

The Elder has, at this point, lost his/her social function. They become, in a politically and grammatically
correct manner, an elderly at best or an old person (or even more pejorative crone), that is to say
someone obsolete, useless (in the French language).

In sociology, until the end of the ‘30 Glorious Years’ (post-World War II economic expansion in West
Europe), the major social integrator was the value of work. This is what the ‘old folks’ of today have
known. Being intimately linked to this core value, and still today, each one uses this heuristic linguistics:
“What do you do for a living?”, “I am a factory worker, a teacher, a mason, a female nurse, a
housewife…”, that is to say we have gotten into the habit of mixing ‘doing’ and ‘being’. The
consequence of this is that old people consider themselves as, and I quote: “having lost all value”.
Today, however, the significant social integrator is the status of consumer. Old people are growing in
number, as such they have become a prime target for marketing (for better or for worse), and they are
generating more and more jobs. In our societies, where money remain one of the founding values,
older people are called: “grey gold”. Yet this corresponds to today’s values, which are foreign to old,
old people.

18
 d. Personal choice.

In order to bring the elderly person, dependent or not, back to their rightful place, I will favor the use
the label ‘Elder’ (hence the title of this report). Yet, for pragmatic reasons, I will have to use the classic
label from the professionals of ‘elderly dependent persons’ or ‘residents’.

2. Senescence.

Often misinterpreted, senescence (which does not have anything to do with senility) is a major step in
human beings’ life. In this perspective, I quote geronto-psychiatrist Louis Ploton: “aging, is to grieve
one’s image to assume another, it is enduring an identity crisis”.

3. Reversed pyramidal paradigm.

The law issued 2 January 2002 stipulates that the resident must, as much as possible, be at the center
of his personalized support project. Thus, the law highlights:

“The respect of privacy, intimacy.

The right to maintain family connections.
The personalization of the follow up.
The free choice of treatment.
The systematic search for the consent of the user, or in pertinent cases, their legal guardian.
Access to all document relating to the person’s care.”

This law applies to every health and/or social structure. Moreover, in an EHPAD, there is the
unavoidable importance of confidentiality, the healthcare mission related to the everyday care and
the basic support that is the Charta of right and freedoms of elderly persons presenting with a handicap
or as dependent.

19
It is usual to present the dispositive in this manner:

Outside Participants

Partnership network

Intradisciplinary Professionals
from the EHPAD

Resident

Funding Organisms

Families
Health network

During an interview with a service chief, we looked further into this point of view, making it evolve to
a reversed pyramidal paradigm. The user is not only at the center of the dispositive, but also its
foundation.

Care system

Resident

Care system

View from above View with perspective

This point of view originates form the Sophonia archimandrite9, writing about the life of Silouane
(1866-1938), an orthodox monk from mount Athos, at the Cerf editions (2010). It takes its source in
the book of Mathew verse 21,42: “the stone the builders rejected became the angle stone.” The
multidimensional phrase here, is professionally applied in this manner: everything is done for the

9
Archimandrite: superior abbot in an orthodox monastery.

20
resident, with him, as an actor in every way possible and without him, the whole system would lose its
purpose.

This principal finds its continuation in the first philosophy book, autobiographic, by Alexandre Jollien
“L’éloge de la faiblesse”10 staging a dialogue between the author, a cerebral-motor disabled person,
and Socrates. He writes: “The question ‘how are you?’ was vital to us (…) [this way] we would enter in
the existence of the other (…) communicating our friendship.”

4. Residents in ‘La Bourgonnière’.

a. Current global picture.

- Today, there are 85 residents and 2 loggings for temporary stays.

- Average age is 88,74 years old.
- Average duration of stay before death is 3 years and 72 days.
- One must note the progression in the average age: the oldest is 102 years old and the youngest
71 years old. In 2010 the average age was of 86 years old.
- 14 residents passed away in 2014 and 17 in 2015
- 15% of residents are originally from Nantes, 35% from neighboring towns (specially Indre) and
45% from Saint-Herblain.

b. GMP11: measurement of dependency.

National grid AGGIR12 is a tool designed to evaluate the degree of autonomy loss or of physical or
psychological dependency of applicants for the personalized autonomy allocation, for the individual
support of everyday actions at home.

The evaluation of dependency is also done in specialized establishments using the AGGIR grid, and it
gives the calculation for the GMP, which allows to obtain the dependency dotation including for the
recruitment of care personnel and material or technical aides.

10
The praise of weakness.
11
GMP: GIR Moyen Pondéré / ISO Ressources Group weighted average.
12
AGGIR: Autonomie Gérontologie Groupe ISO Ressources / Autonomy Gerontology ISO Ressources Group.

21
The GIR ratings give quotations (high level of dependency: high quotation):

GIR 1: 1000 points; GIR 2: 840 points; GIR 3: 660 points; GIR 4: 420 points; GIR 5: 250 points;
GIR 6: 70 points.

GMP is the calculation resulting of the establishment’s number of points / host person’s number.

Variables allow to measure what the person actually does. GIR only takes into account the coherence,
orientation, personal hygiene, dressing, alimentation, transfers (getting up, lying down, sitting) and
indoors movements capabilities.

The ‘Village’ unit has a GMP of 476.

The ‘Pierre Mara’ unit has a GMP of 840.
The ‘Hermitage’ unit has a GMP of 895.

For a couple of years, GMPs have been in constant evolution. However, as referent nurse in the EHPAD,
Michel Bauer says: “the notion dependency is very relative, it can be a consequence of the build-up of
various disorders, yet it is defined as: the incapacity to accomplish at least three of everyday life
actions”

c. Trial to encompass the world from a resident’s perspective.

Figaro newspaper from 21/01/2014 relates the results of a study from the National End of Life Office
collected in an EHPAD residents survey: acknowledgment of desperation: “40% of dependent elderly
persons living in EHPAD would be suffering from depression. The feeling of being useless: the first
death of older people is their exclusion from ‘real life’, that of moving, living, working people. (…) For
three quarter of the residents, there is also the lack of want to enter in an institution. They stayed as
long as possible at home, with at home help and health care, but at some point, the aides become too
expensive or when dependency becomes too strong (with or without an advanced pathology). This
often represents for them a denied danger and they end up placed with the feeling of being dumped.
EHPADs receive an average of 42% patients suffering from an Alzheimer’s type disease, this ‘mirror of
dementia’ and ‘those screams’ terrify people who are most afraid of ‘losing their head’. The arrival of
death scares a lot less than the prospect of a slow and painful death with futile medical care.”

I will come back to the anguish of death for persons suffering from severe neurocognitive disorders in
the foundation of my theoretical construction.

22
I suggest we go back to the EHPAD ‘La Bourgonnière’, even though the above mentioned remains true,
a pleasant atmosphere rules there amongst the residents. Either coming from affinities, common
geographical origins, the merry atmosphere brought by numerous animations or the relationships with
the staff. Many people chose to come there and stay. In the ‘Pierre Mara’ unit, during breaks at certain
times, 50’s songs blossom spontaneously in some groups for the other residents to listen and enjoy.

5. Residents with specific neurocognitive disorders.

a. Preface: linguistic choices.

a1. DSM IV and V:

DSM V appeared in 2003, in France it led to an outcry from doctors. Except for severe neurocognitive
disorders which regroup, amongst other, Alzheimer’s type diseases and associated disorders, vascular
dementias, combined dementias and others (these pathologies I was confronted with).

EHPAD designates these pathologies under the notion ‘DSM V’.

I will however use ‘DSM IV’ for diseases’ nosology.

a2. Senile dementia: etymology and historical background:

➢ Etymology: dementia comes from Latin ‘de’, which means ‘out of’, and ‘mens’, which means
‘mind’. Senile also comes from Latin ‘senex’ which means ‘old man’.

This is a very pejorative diagnosis for a patient and his family, it can have a traumatic effect.
For some time, it affected the medical community and started the use of a Therapeutic
nihilism. It was considered that nothing could be done for the patient, except somehow
accommodating his basic needs and relieving his physical pain as best as possible. This is what
Maria Montessori (1952-1970) denounces and after her, Cameron Camp.

23
 ➢ Historical background of senile dementia (in the words of Philippe Albou, psychiatrist, general
secretary of the International Society for the History of Medicine):

- From the Antiquity to 16th century:

l will simply quote these two quite eloquent passages:

o Euripides (-480, -406) The Phoenician Women: “We, elders, are only a flock, an
appearance, we roam like the images of dreams, we don’t have common sense
anymore, as smart as we could be thought to be.”
o Montaigne (1533 – 1592), Les Essais [1,57]: « Tantôt c’est le corps qui se rend
le premier à la vieillesse, parfois aussi c’est l’âme (…) ; et d’autant que c’est un
mal peu sensible à qui le souffre et d’une obscure montre, d’autant est-il plus
dangereux ».13

- 18th to 19th century, evolution of the word ‘dementia’:

This word is seen by everyone as a madness, dangerous folly even. In 1810, in the
French penal code, article 64: “There is neither crime, nor delict, when the defendant
is in a state of dementia during the course of the act.”

At the beginning of the 19th century, doctors Pinel (1745-1826) and Esquirol (1722-
1840), his student, defined dementia in a more clinical manner. They created the first
asylums (the word ‘asylum’ come from the Roman Antiquity and mean ‘inviolable place
in which a person in danger can find refuge’) in which all the alienated will be tend to.
(from the Latin word ‘alien’: something or someone other).

- End of the 19th to the beginning of the 20th century, isolation of late onset mental disorders:

Starting around 1840, dementia is not considered as a state of being but the process
developing through time. In France it was, for example, studied by Charcot (1825-
1905), founder of modern neurology.

13
“Sometimes it is the body that first surrenders to old age, sometimes it is the soul (...); and all the more so
since it is an evil not very sensitive to whom it suffers and of an obscure watch, making it all the more dangerous.”
(the quote is in 16th century French).

24
 - 20th century, neuro-anatomy of dementia:

Following the work of neurologists Paul Broca (1824-1880) and Carl Wernicke (1848-
1905), psychiatrists keep studying their studies on neuro-anatomy and the symptoms
of dementia, especially Aloïs Alzheimer (1864-1915).

In the theories and nosologies I will use, I will write as their authors, whom for the most part, use the
DSM IV.

a3. Precisions on the notion ‘Alzheimer’s disease’:

The diagnosis of Alzheimer’s disease is made post-mortem, at the autopsy, during which a
recrudescence of senile plates and neurofibrillary degeneration appears. Yet as mentioned by Christian
Derouesné, honorary professor in Paris University V and old head of neurology service in La Pitié
Salpetrière hospital (20 years dedicated to research on Alzheimer’s disease and age-related disorders):
“neither senile plates, not neurofibrillary degenerations are specific to the disease: they are relatively
common in subjects free of cognitive disorders (…), in 19% of the subjects, the intensity of the lesions
is akin to that of subjects suffering from dementia.” I will therefore speak of Alzheimer’s type disease
and associated disorders.

b. Description of the encountered pathologies.

b1. Definition of severe neurocognitive disorder:

Here are severely touched “the psychic processors such as perception, spatial visual analysis, memory,
language, thinking, attention, reasoning, … all these functions allow to acquire knowledge, that is the
means and mechanisms of information acquisition”.

b2. Alzheimer’s type disease and associated disorders (the most frequent of
neurodegenerative disorders):

This disease presents with a progressive loss of autonomy which translates into mnemonic type
cognitive disorders and associated infringements in one or more other areas. It is also associated with
psycho-behavioral disorders. In order for an Alzheimer’s type disease to be diagnosed, the patient

25
must present with these symptoms for at least six months and be free of another pathology (for
example a tumor).

First, explicit memory (verbalized) is impacted, then implicit memory (non-verbalized, the ‘doing’). The
first area of the brain touched is the area responsible for the memorization of recent information, it’s
located in the hippocampus, in the center of the cerebral cortex. It is the episodic memory. Old
memories remain intact, hence the shelter sought by the person in the past. Then the semantic
memory is touched: The knowledge one has of the world gets empty (along with the discourse), leaving
only “portmanteau words”. Then, procedural memory is affected, the ‘doing’. Here are some
examples:

- Apraxia: difficulty to perform certain movements, use certain objects, get dressed.
- Aphasia: difficulty to express oneself, going up to incoherence of language and muteness.
- Temporary and/or spatial disorientation.
- Trouble focusing, for example: great distress to make decision.

Finally, sensory, perceptive, emotional memory (as does the taste of a madeleine in memory of the
narrator of "À la recherche du temps perdu" in "Du côté de chez Swann", the first volume of Marcel
Proust's novel.). It is this memory that is preserved the longest, it is located in the cerebellar tonsils, of
the reptilian brain. This pathology is evolutionary and trip.

• Effect on memory:
Onset stage: omission, repetition.
Mild stage: disorientation, omission of friends.
Terminal stage: information doesn’t settle anymore, incoherence, brain damage
(deglutition, breathing, …), death.
• Time variable:
In function of the pathology.
In function of the patient.
• Evolution of the cognitive profile and of behavioral disorders in the progress of the disease:

26
 b3. Neurodegenerative disease of Parkinson (second most frequent after the former):

This disease affects older people (over 65 years old). It is characterized by the deterioration of
dopamine neurons. It is a chronic disease, with slow and progressive evolution, its beginning is
insidious. The patients stay asymptomatic until at least 50 to 70% of the dopamine neurons are
destroyed and the brain is no longer able to compensate thanks to cerebral plasticity.

The following symptoms then appear:

• Three symptoms related to motor skills (they are not necessarily present at the same time and
can be of changing intensity. They can long remain asymmetrical):
o Akinesia: slowness in the doing and coordinating of movements
o Hypertonia: excessive muscle rigor
o Trembling: happen during rest period, affects especially the hands and arms. They are
intermittent and asymmetrical. While conscious, the affected person has to make a
great effort in focus so as not to let them show in public, which can lead, once alone,
to crises of more or less importance.

• Non-motor skill related symptoms:

As repercussion of the disease on the brain, the person can present with troubles to
sleep, a loss of smell (anosmia), cognitive disorders, balance-loss, pain, troubles
eliminating, depression like symptoms more or less important.

b4. Vascular cerebral dementia (non-degenerative and second cause of dementia

after Alzheimer’s type disease):

They are due to an anomaly of blood circulation which results in a lack of oxygenation of certain brain
areas. The tissue-loss is irreparable and leads to deterioration of cognitive capacities and memory.

The type of dementia I have encountered is due to multiple heart attacks resulting from the repetition
of mini cerebral vascular accidents or a single cardiac incident followed by a stroke.

b5. Mixed dementia:

This disease associates with lesions of degenerative origins (in this case Alzheimer) and vascular
dementia.

27
 b6. Severe neurocognitive disorders exposed by Naomi Feil (born 1932):

Her theory exposes that the specific behavior of very old people who fight to solve their problems
during the remaining of their lives before their deaths. It is what she calls Resolve.

This behavior can be organized in four categories:

• Wrong orientation: expression of passed conflicts in a disguised manner.

• Confusion: the person does not lean on reality anymore, she lives in her own internal world.
• Repetitive motion: these movements replace words and are used to express non-resolved
conflicts.
• Vegetative state: the person escapes interiorly, escaping completely from the world and trying
to resolve their life.

These people are usually wrongly diagnosed as having an Alzheimer’s type dementia.

The ones I met could present with associated disorders, such as: behavioral disorders, Broca aphasia
or even profound depressive disorders, bordering melancholia, with suicide attempt.

b7. Severe neurocognitive disorders due to old age:

Without specific pathology, the natural aging of the brain (I am talking about people approaching 100
years old) leads to a diminution in the number of neurons and neuro-mediators.

The memory and cognitive disorders encompassed by the degenerative process of the brain and the
diminution of performance are variable from one subject to the other.

28
 C. In service of the residents: a benevolent hydra.

1. Preface: linguistic choices.

It is often referred to “care service”, “head of the service”… The term service has many senses. I like
this word, because, in the background, I hear one of its many definitions: “what one does for another
person”.

2. Inventory of the care-giving staff (internal and external).

There are 45 employees, to which one must add 3 cooks, who work in the establishment, which means
32.47 full time jobs.

More specifically:

o For the ‘Pierre Mara’ unit (14 residents)

1 orderly in the morning and the evening,
1 Medico-Psychologic Assistant and 1 Nurse in the morning,
1 Medico-Psychologic Assistant or 1 Nurse for the rest of the day, until 9pm.
o For the ‘Hermitage’ unit (14 residents)
1 Orderly in the morning and the evening,
3 Nurses in the morning,
1 Nurse for the rest of the day, until 9pm,
o For the whole structure, from 9pm to 6:30am
1 Nurse and 1 Medico-Psychologic Assistant.

As per decided by the Direction, the care-givers working in the ‘Pierre Mara’ and ‘Hermitage’ units, are
not arbitrarily appointed, but the freely choose to work in these services. Some only stay for a few
months, others (the majority) stay for dozens of years (or more). These care-givers follow adequate
professional training which I will detail later.

29
The resident (or his/her trust person if necessary) remains free to choose his doctors and specialists,
and also his multiple medical auxiliaries (physical therapist, pedicure, speech therapist, …). It results in
30 doctors, essentially working in Saint-Herblain, but also in Indre, Couëron, Nantes, take care of the
residents in the establishment. If they cannot come, or out of work hours, it is possible to contact SOS
Médecins or dial 1514 if necessary. There are also 7 physical therapists who work in the establishment
and give their feedback through health-care specialized software.

The EPHAD is part of a psychiatric sector 1 attached to Saint-Jacques Hospital in Nantes. A psychiatric
nurse for Beaumanoir Medico-Psychological Center can work with the residents. It is also possible to
call a psychiatrist. Following his intervention, a psychiatric nurse will come for the resident and/or his
health-care team to validate the follow up.

La Bourgonnière working in partnership with various institutions in order to offer quality service to
their residents. They collaborate with hospitals and medical care facilities, as well as with associations
specialized in the care of the elderly. They also work hand in hand with other nearby EHPADs and with
a strong citizen network.

3. Common approach for the caregivers: the humane-attitude.

a. Origins.

According to Albert Jacquard in his book “Cinq milliard d’hommes dans un vaisseau”15 (editions Seuil,
1987), the humane-attitude recovers: all gifts of evolution made from humans to one another across
generations, from the moment they became aware of being and the ones they can still make, in an
endless enrichment.

14
SOS Médecins & 15 are emergency medical services.
15
“5 billion people on a ship”.

30
 b. Practical application in the care.

Here are the four pillars of humane-attitude:

The look: must be exchanged face to face, eye to eye, at face’s height.
The speech: must announce every gesture beforehand.
The touch: it is about trying to transform ‘utilitarian touch’ into ‘tender touch’, thus while
respecting the person’s sphere of privacy.
The verticality: trying, as much as possible to accompany the standing person, while respecting
their limits and state at the moment.

Individualization of care: the care-giver tries, as much as possible, to adapt to each resident, to be
attentive to his/her wishes and needs, to get to know their story.

The limits: GMPs increase every year but the grants to hire new personnel don’t. Therefor the
increasing weight of patient care leads to less time with the resident

31
 3. Continuous training for the caregiving staff.

In order to better be in service of the resident, professionals follow specific and multiple trainings,
which then allows them to share this knowledge with those who couldn’t follow these trainings, even
if just by their doing. For instance:

10 professionals had the opportunity to follow the Montessori training, adapted to dependent
older people.
5 professionals followed the Snoezelen training
3 professionals followed the training for “assistant care-giver in gerontology
3 professionals benefited from an approach to the validation method of Naomi Feil

Moreover, the coordinating doctor is a strong fellow of Geronto-psychiatrist Jean Maisondieu and thus
knows how to diffuse and infuse this approach among the care-givers. I’ll add this professor’s point of
view in my theoretical construction.

4. Non-drug treatments.

a. Given by the care-givers.

Thanks to their training, the care-givers know how to care for people with non-drug treatments:

o Memory workshops.
o Confection of soup every night in the ‘Pierre Mara’ unit.
o Therapeutic meals, with the other residents.
o Care in the Snoezelen room (…).

b. Animations.

There is no scientific proof that animations are part of non-drug treatments but one must notice an
improvement in the resident who participate (voluntarily). There are many activities, and the animator
(who isn’t part of the care giving personnel) is helped by a strong team of pro-bono workers.

For instance:

32
 o Singing takes place in the common room, many people come from all three units. I would
like to point that singing songs dating from the time the residents were 20 or 30 years old,
is used in music therapy for people with memory problems of more or less importance:
through the emotion caused by the song (sang or listened to), a small flame lights in the
darkness of their memories and senses or feelings from the time can update.
o The annual vacation week in a house in Pornichet (a city by the sea).
o The lotto game.
o The field trips (movie theatre, market visits, theatre, …).
o Participation to the house’s interior decoration according to the time of the year.
o The “canine link”; dogs and their masters are invited for a friendly, judgement-free, time
of exchange with the residents.
o Celebration of mass every Thursday and Sunday morning.
o Monthly celebration of birthdays.
o Invitation of music animators.
o Reading animation.
o Invitation of children groups with a project.
o Mild gymnastics.
o Aesthetic care.
o “Dancing tea” events in common with retirement homes (…).

c. Empowerment of the residents.

Is it possible to speak of non-drug treatment in the empowerment of the residents? I think so.

In this matter I would like to underline:

o Active participation to the “Social life Committee”.

o Shop management.
o Watering the many plants.
o Creation of floral decoration (…).

33
 5. Defense mechanism.

a. Formal.

There are regular analyses of the way of practice. The care givers can also ask for private interviews.

b. Informal.

It is indeed not always easy to work with depending persons, physically and mentally messed up, to be
exposed to death. It can remind the staff of their own families or what they might one day become
and rekindle their anguish towards death.

Therefore it is important to have informal defense mechanisms such as common breaks (where shop
talk is forbidden), hallway chats about everything and anything, laughs, giggles, teasing, tenderness in
the mode of address between staff members, friendships… And also, background music, played in the
whole building, sometimes quite loud, often the radio RFM16, which impulses dynamism and helps to
take a step back (annex 3).

6. Mini-conclusion.

a. Studies and rating.

In 2013, France Radio published the results of a survey on retirement homes rating in France.
The survey was done in 10400 establishments, whether public, private or associative.
64 establishments were graded 10/10 and the county at the top of the rating was… Loire
Atlantique17
In 2014 and 2015 UFC Que Choisir18 anonymously visited 2404 EHPAD in France. The comments
and criteria of rating were based on: the resident’s room, the premises and the environment,
everyday lifestyle and the reception.

16
RFM is a French radio station with regular info flashes, modern music (pop-rock, international hits, rap, …).
17
Loire Atlantique is the county where the EHPAD La Bourgonnière is located, it’s in the West of France, close
to Brittany.
18
French association offering advice to customers.

34
 La Bourgonnière was part of the top rated EHPAD in Loire Atlantique and received the
maximum amount of points. It’s rated 4th of the region.

b. Improvements to be made.

b1: Snoezelen room:

Of Netherlandish origin, the word Snoezelen comes from the contraction of two verbs, ‘snuffelen’ (to
smell) and ‘doezelen’ (to doze off). It refers to the notion of exploration, relaxation, pleasure of sensory
stimulation.

In EHPAD La Bourgonnière, I believe this room needs to be improved in certain areas:

- The too little surfaces of fabric glued on the wall, to improve the sensation of touch.
- The music played, commercial music supposedly relaxing, but actually empty, when it
would be more appropriate if it were in sync with the acoustic identity of the person .
- The bed, hardly flexible, covered in plastic draw sheets (though practical, it is not very
cozy).
- The perfumes: use a natural essential oil diffuser after researching the desired effects.
- The temperature, rather low. As is it this room is sadly also used for the apartment
bikes, as part of the mild gymnastic. The latter is very useful but could be located
elsewhere, as for example in an unoccupied care room on the 1st floor of the “Village”
unit which was lent to me for the time of my internship. Correctly arranged, it could
host the bikes.

b2. The professional link:

The absence of formal transmission time (at least amongst referents) when a resident is transferred
from the ‘Village’ unit to the ‘Hermitage’ or ‘Pierre Mara’ units due to an evolution in their state.

b3. The background music:

It is generating stress and annoyance amongst the residents and shows the staff’s fear of silence; the
latter being assimilated to death.

35
 c. History and linguistic choice.

c1. Changing of the baseline:

Before the second half of the 20th century, Elders, except if they suffered from dangerous disorders,
were kept at home. Three generations lived together (children, parents, still living grand-parents). It
was for better and for worse. It is what the current residents of the EHPAD knew during their childhood
and youth. What a cultural turmoil!

c2. History of the names of establishments for older dependent people, sometimes
suffering of dementia:

o During the 17th, general hospitals were created. Etymology of the word hospital comes
from Latin ‘hospes’ which means host, it is the same root for the word hospitality.
On the contrary, the point of general hospital was to lock up every person judged as
undesirable by society, including indigent crones.
Progressively, the care specialized according to the type of persons accommodated.
o At the end of the 19th century, the name changed for “hospice”, which has the same
etymology as previously.
These places, with a housing capacity of hundreds of beds, which mix all sorts of old people
all in a great promiscuity.
o In 1962, after the Laroque report, retirement homes were created, with 3 requirements:
- Creation of establishments close to interest center in agglomeration to foster social
integration.
- Individualization and personalization of rooms.
- Architecture (for a maximum of 70 people) which will favor the layout of premises with
the objective of easing common life in small groups.

I invite you to have a closer look at this denomination:

The term ‘home’ is actually “gentle violence” (an oxymoron used by psychotherapist Thierry
Tournebise when he describes the care of dependent older people), because, though the EHPAD is a
place of life, residents are not fools (see survey by ONFV), and often, whether it is conscient or not,
they want to go home, their own house.

The term retirement is ambiguous. ’Retirement’ can be defined as ‘being withdrawn’. This word can
also mean that one is defeated and fleeing in front of the enemy (e. g. ‘retreat from Russia’). But on
another side, it can also mean a quiet place where you can recharge your batteries and take stock.

36
 o In 2002, following the 2002-2 law, EHPAD were created, they reinforce users’ rights and
many more elements that are very beneficial to them (see above). But for the residents:
they find themselves facing an acronym turned into a word, for which only professionals
understand the beginning and end.

In order to be more just, clearer and less discriminating, I suggest a new name, such as:

‘Place of life in service of Elders’

37
 III. Immersion, observations, problematics.

A. General personal positioning in the EHPAD.

When I watch, in accelerated version, the film of a tree growing up towards the sky, releasing his fruits,
which in turn take roots and grow, it’s breath taking. I take as metaphor the red mangrove tree, main
specie constituting the mangrove swamps.

I compare this to our life as human beings, as families (cf. Genealogical tree), as part of a given society,
as part of humanity.
The cycle is comparable. Young buds will become bearing roots… Thus, Elders and Ancestors make my
roots and their life story is also my history.

38
That is how I did this work, with the continuous feeling of being privileged as well as feeling the joy of
potential encounters. I have long appreciated listening to the Elders’ stories.
For instance, a resident telling me about his job, which at the time was the latest, when he was an
engineer working on radio transmitters, putting radios within everyone’s reach. Or in a similar sector,
when a resident told me about the time she was a technical worker on the first televisions.
I am passionate about all the adventures and turmoil of the 20th century and enjoy hearing about it
directly through first hand witnesses.

I arrived on November 1st, 2014 at the EHPAD. Coincidence? Because that day, in our culture, is when
we traditionally honor our ancestors. The cemeteries are flooded with flowers, star of which,
chrysanthemum19.

B. Immersion.

1. Identification.

It was important that I had on me exterior signs describing my functions (I was not wearing a uniform),
other than my music instruments (which is unreliable, as they usually are in one of my bags). This is
how I differentiated and identified myself:

The directorate also untrusted me with a master-key, opening almost every door.

19
In China, Chrysanthemum is one of the 4 national flowers. It symbolises peace, peaceful life, consistency and
long life…

39
 2. Approach and contacts.

In my core project, I mostly headed towards the ‘Pierre Mara’ and ‘Hermitage’ units. Warned form my
professional intention, the care-givers allowed me to participated in certain care activities. These were
also directed towards residents of the ‘Village’ unit.

Especially during the first week, and later less and less in order to focus my time on the music therapy
sessions:

I accompanied residents (one at a time) for strolls outside of the establishment, on the
adapted sidewalk along the Bourgonnière lane or in the nearby public park;

I participated to therapeutic meals at ‘Pierre Mara’ unit: which means, eating with them,
at their table. (I was eating with 3 future patients);

I participated in the snack distribution (to future patients too) in the ‘Hermitage’ unit. I
would remind: the residents in that unit are very dependent, and need, for the most part,
to have an exterior person help them with food and drink, as to also avoid food going down
the wrong pipe. (ex: jellified water).

C. Observations.

1. Methodology.

Through my current job as a specialized educator and through the practice of Non-Violent
Communication, I have tried to observe professionally, in the most objective way possible, without
judgment, without a priori, without fear, discerning, as far as possible, my counter-transfers.

40
Professor of Non-violent Communication (NVC) and psychotherapist, Thomas d' Ansembourg quotes
the Indian philosopher Jiddu Krishnamurti (1895-1986) for whom: "to distinguish the observation of a
fact from its interpretation is one of the highest stages of human intelligence".

Following the practice of the NVC, I clarified my feelings and needs, without any personal affect (see
Annex 1).

In order to be observant, I have also put into practice the metaphor of the wheel that turns, in the Zen
tradition: the individual, especially if he is carrying a suffering, remains placed on the surface of the
tire of the wheel of events, which turns quickly, and sees almost nothing, if not the asphalt that passes
by. The practice of Zen consists in choosing a radius and gradually descending towards the center of
the hub. The individual then goes slower (the radius being smaller) and sees more and more clearly
what is happening around him. Arrived at the center of the wheel, it is completely motionless and sees
the whole, awakened.

2. The notion of time.

This is my first observation. There are several notions of time in the institution. Roughly speaking, there
are the ‘hares’, the staff, and the ‘turtles’, the residents. Some because of their professional mission,
others because of their age and dependency.

This can be seen in another way, that of the stages of development, or ways of living: a continuous
construction of the "I" (cf.: Freud), through narcissisation, or even the effort made to preserve it, and
the affirmation of the Self (cf.: Jung) which is the culmination of the senescence. I will come back to
this in the foundations of my theoretical construction.

Because of my position, I'm lucky enough to have time.

Well above Agadez, in Niger, a Tuareg friend had taken a handful of sand in his hand, fingers tightened,
and then opened his fingers and joining words to the gesture, he told me: "You see, if you don't take
the time, you lose it".

People with major cognitive disorders, especially those suffering from memory degeneration, live their
present moment in accord with the unanimous representation of time or with a time that belongs only

41
to them. Working with them, I saw the koan20 of Zen master Kodo Sawaki (1880-1965) germinate in
me: "The present moment is a trap for eternity".

A koan cannot, by definition, be explained, but the philosopher and musicologist Vladimir Jankelevich
(1903-1985) can help. I quote: "The opportunity is an adventure, and it always happens for the first
time, never before and never again", "To the irreversibility of time, it is necessary to bring its
unpredictability: time is not a pure continuation of being, but perpetual innovation, unpredictability
and irreversibility are moreover like the front and back of the same temporality: if the new event is
always new, it is because older events do not suffer any repetition ".

3. X-sports and very old people.

The X sports, or extreme sports, for some years now, have been very popular, mediatic and increasingly
spectacular. These sportsmen and women develop their performances in an increasingly daring way,
pushing their own limits through sheer work. They are "death-daring", receiving high natural doses of
adrenaline and dopamine. Spectators experience the thrill, beauty and respect. As a forerunner, we
can recall James Dean and Nathalie Wood in "Rebel Without a Cause" (1955).

What is far less spectacular and not at all recognized are the tremendous efforts a very old person can
make in his or her movements, among other things, in order to preserve a bit of dignity. Indeed, the
advanced age leads, at least on the physical level, to progressive loss of capacity (e. g. the melting of
muscles, joints trapped in continuous relapses of osteoarthritis, dysfunctions of the organs, etc.). Thus,
to put on one's socks alone, to be able to ensure one's hygiene, to make a little walk every day, and
many other actions, that seem so simple to us, are actually carried out with a lot of will, perseverance,
effort through pain and almost permanent risk of seriously injuring oneself. Not in high speed but in a
vigilant slowness, very old people practice extreme sports on a daily basis.

20
Koan: short absurd or even enigmatic sentence used in Zen schools as an object of meditation, putting into
action a totally unusual logic, confusing the mind.

42
 4. Other observations.

There are several different underlying attitudes in the interaction with the very elderly person,
suffering from severe neurocognitive disorders.

They are not necessarily all well adapted, and I can see a certain amount of disarray on the part of the
caregivers, despite their kindness, professionalism and humaneness.

➢ Use of Validation (according to Naomi Feil), whom I quote:

The intervener never discusses or confronts the person.
He's not trying to get them to explain his own behavior.
He doesn't try to direct them to a time and place, if they don't want to.
He doesn't use positive or negative reinforcement techniques to change the behavior
of his interlocutor."

This method is, in my opinion, the most appropriate one (I will pick it up again in the foundations of
my theoretical construction).

➢ Use of Orientation towards reality (developed by psychiatrist James Folsam in 1964):

This attitude works for dependent elderly people, but it can cause pain in cases that concern me,
because people with severe neurocognitive disorders intentionally distort the realities of the present
day, either to recreate situations that they have not resolved in the past, or as a mean of surviving
losses caused by their age.

➢ Use of Diversion (usually works):

It is used to modify negative behaviors by providing a pleasant distraction. However, this action can
only be short time, because the distraction offered is not the answer to the profound need that
triggered the behavior.

5. The Team.

I was able to observe a healthy professional team, i.e., one in synergy {differentiation - confrontation
- complementarity}. In addition, thanks to their defense system, among other things, caregivers are
available and patient with the residents.

43
If I had made a sociogram of Moreno (sociologist and psychotherapist (1889-1974)), aiming to
determine the socio-emotional organization, the arrows connecting people would have been mainly
in both directions, with no singleton. Of course, it appears, but without separation, groups of belonging
for each unit, each pole.

D. Problematics.

1. Main objective.

To help the person suffering from severe neurocognitive disorders, through music therapy, to solve as
well as possible the objective of the stage of senescence.

2. Related therapeutic goals.

In order to reach the main objective, different therapeutic means and workshops will be set up (a same
person can be found in several workshops, depending on the evolution of his or her condition). Here
they are:

a. Through the practice of music therapy, and the simulation of neuro-mediators, try to
contribute to the alleviation of chemical treatments whose active substances have side effects
often harmful for the elderly.

b. By using an Instrumentarium unknown to people, stimulate brain plasticity and neurogenesis

following Hervé Platel.

44
c. To give the person, in active listening, the opportunity to express himself/herself in his/her
emotions, feelings and needs through the implementation of individual active music therapy
sessions (see Annex 1).

d. Through small group sessions of active music therapy, help people in the same unit
communicate with one another, trying to free them from their preconceptions or roles.

e. Through live individual receptive music therapy, participate in the accompaniment at bedtime,
to work on the person's aggressiveness, the sundowning syndrome and the inversion of the
nycthemeral rhythm.

f. Through receptive music therapy (live) and verbalization, help the person in accompanying
him/her towards the end of his/her life (what is "dying in peace"?).

g. Empower caregivers, with a music therapy perspective, to create an ambient soundtrack based
on the resident (see Appendix 3).

45
 IV. Theoretical construction.

A. Foundations.

1. Introduction.

a. Culture of the EHPAD of La Bourgonnière.

Each EHPAD has its own culture. So that my work in music therapy can fit in with that of La
Bourgonnière, I choose to graft it on a work already in progress. I will therefore rely on the Validation
of Naomi Feil, the Montessori method adapted to dependent elderly people and the angle of view of
geronto-psychiatrist Jean Maisondieu.

b. A story of punctuation.

I refer to Hamlet, in William Shakespeare's play of the same name (1564-1616). In Act 3, Scene 1, in
the middle of all the drama, Hamlet is immersed in his meditations before the arrival of his mistress,
orchestrated by the adviser of the murderous king, in order to expose him. It is at this moment, when
alone in an apartment of the castle, that he says this famous phrase, beginning of a monologue "To be
or not to be, that is the question? ».

From the very beginning of translation, however, there is confusion in punctuation, which changes the
meaning and the original emphasizes the genius of the author. The original text is "To be or not? To
be, that's the question " i. e.: To be or not? the question is about being.

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 2. Montessori method.

a. Presentation.

This method, inspired by the work of Dr. Maria Montessori (1870-1952), was adapted by Professor
Cameron Camp, an American neurologist and researcher, in 1999.

b. Back to therapeutic nihilism.

It is the idea that an elderly person with dementia is incapable of learning or expressing anything and
is simply declining in many areas. This idea is insidious, because it destroys hope and condemns to
accept that there is nothing to do. The psychologist and psycho-gerontologist Tom Kitwood (1937-
1998) was one of the first to question this idea. The use of a psycho-social model gradually replaces
the medical model in care and dementia. I will soon show it using Jean Maisondieu's point of view.

c. Activities and care.

The proposed activities aim to optimize the persistent capacities (procedural memory and emotional
memory). They must interest people and have meaning for them. The caregiver should also give them
a role to play (sense of belonging, security and self-esteem).

Conduct of an activity (individual or group):

Start the activity with an invitation.

Demonstrate before asking the person to do it on their own. This allows him/her to
focus on the procedure and not on verbal directives, which can be confusing.
Break down the activity into successive tasks.
Close the activity by asking the person if they would like to repeat it another time.

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 3. Validation according to Naomi Feil.

a. Introduction.

I started talking about this method before. Validating is recognizing a person's emotions and feelings.
Validation uses therapeutic empathy to match the inner reality of the disoriented elderly person.

b. Correspondence with the theory of psychologist Erik Erikson (1902-1994).

Erik Erikson developed a theory on stages of development through life, with their respective tasks,
based on interactions between biological, mental and social abilities, needs and impulses. Growing up,
the fulfillment of a task depends on how the tasks of the previous steps have been accomplished. The
"great disoriented old men", in what Naomi Feil calls the Resolution (never total), will try to regain
Integrity, trying to reconcile themselves, to re-appropriate the stages of their life that went badly or
very badly.

I quote the following explicit table, according to Naomi Feil with some additions (in italics):

Behaviors observed in disorientated

Step Psychosocial Crisis
elderly person
Trust Vs Defiance Make reproaches, feel hopeless and
abandoned, worthless.
Early Childhood
Fruit: Hope Anything new scares them. They
"swallow" their emotions.
Autonomy Vs Shame, Doubt Good boys and good girls never say "no".
They fear taking risks, lack self-
Childhood
Fruit: Willingness confidence, fear of losing control. They
accumulate reserves.
Initiative Vs Guilt Don't try anything new. Depression, guilt,
constant crying, victim position.
Playing Age
Fruit: Exploration

Willingness Vs Feeling Make reproach, "I'm worthless";

School Age depression.
Fruit: Competence

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 Identity Vs Feeling Acting out of a sexual nature. Resignation.
Loss of identity, confusion of proper
Adolescence
Fruit: Fidelity names.

Intimacy Vs isolation Withdrawal, avoidance of others.

Dependence.
Young adult
Fruit: Love

Creativity Vs Stagnation Hang on to the past, old social roles or

work. Tell others what and how to do it.
Adult Age
Fruit: The taking care Work all the time, want to "be useful".
Denial of age-related losses.
Integrity Vs Despair, Disgust Depression, disgust of the world. Blame
others for their failings. "I'm worthless."
Advanced Age
Fruit: Wisdom

c. Techniques and Validations allowing to communicate with elderly people suffering

from Severe Neurocognitive Disorders.

According to Naomi Feil, this concerns old people disoriented at the 3rd stage "repetitive movements"
and the 4th stage "vegetative life".

c1. Focus: It is up to the validation practitioner to try to enter the world of the
person. To be opened to their emotions, it must be freed from its own, it must
be centered (cf.: the Zen metaphor of the spinning wheel).

c2. Work and accept ambiguity as a means of responding to a person who is

unable to express himself or herself sensibly. Indeed, at these stages of
Resolution, patients tend to invent their own vocabulary.

c3. Link behavior to needs: There are three persistent basic needs: to be loved,
to be useful and to express one's feelings (but there are all the needs detailed
by the N.V.C. in appendix 1).

c4. Use physical contact.

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 c5. Reflect their image back to them by copying the movements of their body,
their way of breathing, or even dance to their rhythm.

c6. Use the voice, touch, close eyes in a sincere way to bring a reaction.

c7. Use the music (sic).

c. Attitudes of the validation practitioner in all cases.

Be centered.
Observe people's physical characteristics, their non-verbal language.
Listen to them carefully.
Do not discuss the truth of the facts.
Do not make judgments.
Be attentive to each individual's private space, both physical and psychological.

4. Carl Ransom Rogers.

a. Presentation.

Carl R. Rogers (1902-1987) had a PhD in psychology and professor at the University of Chicago. I will
note in his conception of humanistic or existential psychology, the points which will contribute to my
base of therapy.

b. Congruence.

When the psychotherapist is congruent, it is because he is authentic in his relationship with his patient,
without mask or facade. The more the therapist knows how to listen to and accept what is happening
in him, his own feelings and needs, the more he will then be able to express them at the opportune
moment and the psychological change in the patient will be facilitated.

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 c. Empathy (therapeutic) in the helping relationship.

I will return to this point in more detail, but Carl Rogers' empathy seems to me to be the only
therapeutic part of the helping relationship. That is to say:

Let everything that the patient is experiencing resonate within himself, in congruence
and without judgment (while remaining centered), at this precise moment.
Reformulate in order to see if you have understood well, so show the patient that he
or she has been heard; perhaps suggest a few leads, in empathy.
Allow the patient to progress, supported (less and less) by the therapist, so that he/she
can find within himself/herself the resources to solve his/her problem, through
psychological transformations.

d. Continuum.

Echoing Vladimir Jankelevich, Carl Rogers understands that "individuals do not evolve from a fixed
point and homeostasis to a new fixed point. On the contrary, the most significant continuum develops
from a fixed point towards change (...), from a state of stability towards an evolutionary process ". And
this happens all life long, just like for every living being.

5. Therapeutic empathy.

Empathy is not limited to putting oneself in the place of the other (this is an illusion) and thus directing
it towards solutions that would suit us very well, if we were to find ourselves in the same situation.
This is not healing. Psychotherapist Thierry Tournebise defines empathy as "relational narcissism".

Caregiver (or therapeutic) empathy is clearly defined by Carl Rogers: to allow the patient's informative
(representation), emotional and psycho-affective states to resonate in themselves, without judgment,
while remaining objective and centered.

I pick up the Zen metaphor of the wheel again, but this time with two: the patient's wheel rolls at its
own speed, the patient being on the surface of the tire, and this wheel, by therapeutic alliance (I will
return to it), as if by a transmission belt, is linked to the therapist's wheel, which is centered, immobile,
on the axis of its hub. By listening actively to the therapist, he will find his own ray to focus.

51
It is important, says Thierry Tournebise, that the therapist is neither carried away in the affects, nor
put himself in the distance (use of the patient up to the opposite: absence of relation), but must be
distinct, therefore differentiated (cf.: Winnicott).

6. Thierry Tournebise.

a. Presentation.

Thierry Tournebise (born in 1951) is a psychosomatician, psychotherapist and trainer for health care
staff. He is the founder of the "Maïeusthesia", composed of the Greek maieutke, art of giving birth to
someone, and the word of Indo-European origin aisthanesthai, to feel, to perceive.

b. Gathering scattered parts of oneself, Isis's love.

In Egyptian mythology, Isis was Osiris' wife. Osiris had a brother Seth, jealous and envious, who set a
trap for him (...) In order to put an end to it for good, he cut Osiris into fourteen pieces and scattered
them over the land of Egypt.

Isis, with the help of her sister, set out to find him and then gather the pieces of her husband. Osiris
was gathered together with so much love that not only did he return to life, but he also became fit for
procreation. Together they conceived Horus.

For Tournebise, therapy is a “path of love between who you are and all you have been”. The pieces, in
the objective of my problematic, were not scattered in space (Egypt) but in time (every personal story).
Once the process of rebirth is over, however, we still have to learn to live. But in the birth process,
although the solution is always to welcome, it is necessary to respect the resistances, not to force,
because what resists “is part of the assembly instructions of the kit [distributed pieces]”.

c. Guide on the wire.

The reflex of trying to forget what hurt us, properly protects us from immediate pain. It's the “survival
drive”. In order not to lose this precious moment of our life from which we have personally amputated

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ourselves, we attach it to a thread, the other end of which we preciously keep close to us. We will deal
with it later, when we have matured, this is the work of the “impulse of life”.

For Tournebise, being a therapist, “is knowing how to recognize the Ariane's thread that the patient
proposes to us and helping him to borrow it to gain better access to himself. It’s respecting his pain
and resistance (…) If the patient is a tightrope walker, the therapist must be his pendulum, helping him
not to lose balance on his line.”

7. Jean Maisondieu.

a. Presentation.

Doctor Maisondieu is a geronto-psychiatrist in hospitals and proposes a psycho-dynamic approach to

dementia, at the crossroads of medicine, sociology and psychology.

b. Alzheimer's disease: a large and practical drawer?

The purely biological approach of this disease has the disadvantage, according to Jean Maisondieu, of
dispensing from seeking to understand the individual, whose neurons deteriorate. Cognitive
impairment in old age has increasingly been called Alzheimer's disease. The displayed objectivity that
the lesional model allows thus slipped towards belief. What raises questions, is the implicit
condemnation of incurability. I quote: "The paradoxical message is: “Treat dements, they are sick, but
don't cure them, they are incurable”, and he adds after many pages: “even if dementia is not incurable,
it is difficult to cure”.

c. Anxiety of death, the concept of thanatosis.

According to the author, dementia develops in response to the unbearable aspect of aging as much as
to the anguish of the proximity of death21, and the taboo it entails.

21
In 2014, 28% of people over 65 years of age commit suicide with a peak of 40.3% for those aged 85-94. France
has the highest rate in Western Europe. This 'silent epidemic' among the elderly is increasing in countries with a
high standard of living. To come back to the symptoms of poor health in French society, I would like to remind

53
While sexuality was the taboo of yesterday, nowadays it is omnipresent; it is death that we tend to
conceal. Jean Maisondieu thus describes dementia as a psychosocial defensive response to a triple
destructive approach: individual, family and social, it is the concept of thanatosis. I quote: “Excluding
without rejecting and rejecting without excluding, excluding oneself without killing oneself and killing
oneself socially so as not to die are half-measures that are carried out (...) by those who are incapable
of admitting complete defeat in the face of death”, and also “refusing to give meaning to symptoms
forces patients to increase them unconsciously in order to make themselves understood”.

The first battle to be waged is a fight against our collective anguish of death.

8. Individuation process, the Self.

a. Presentation.

It is psychoanalyst Carl Gustav Jung (1875-1961) who defines individualization as follows:

“I use the expression ‘individualization’ to designate the process by which a being becomes a
psychological individual, i.e. an autonomous and indivisible unit, a whole”.

b. Process.

It consists of the successive integration of different archetypes in order to liberate the Self.
The Self being both the center of these archetypes and the archetype that organizes them.

Here are some archetypes:

o The “persona” or social avatar.
o The “shadow”, which contains everything the person considers reprehensible.
o The “anima” (for the men) and the “animus” (for the women), which represents respectively
feminine and masculine values.
o The Self.

you of these figures: France ranks first of the world for the consumption of drugs with a record on the use of
neuroleptics; and is the third highest for the number of alcoholic patients.

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 c. The Self.

For Jung, “the Self is not only the center but also the complete circumference that embraces both
conscious and unconscious.”

(It’s through this symbol of Tao, that Carl Jung represents the Self)

9. Views on the psyche.

a. Presentation.

I will try to synthetically clarify the four elements of the psyche: The Id, the Ego, the Super-ego and the
Self, as well as to distinguish between the objectal and the existential.

b. The Id and the libido.

Taken from the second topical of the psychoanalyst Sigmund Freud (1856-1939), the Id indicates an
inner source that escapes our will and exerts pressure. The libido is a flow of energy for which the Id is
the source. The behavior of this flow varies according to whether it will be free, thwarted, repressed,
channeled...

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 c. The ego and narcissism.

Taken from Sigmund Freud's second topical, following a narcissistic precondition, where the libidinal
flow flows towards itself, this one will be directed outward, towards the “external objects”. The ego is
therefore going to be this psychic door through which the individual will try to invest the outside world
with his libidinal flow, in an attempt to profit, to feed on the other, it is the ego.

d. The Super-ego.

Still taken from Sigmund Freud's second topical, the Super-ego is the regulating element of the Ego.

The foundation of the Super-ego is the Ideal of the Ego, where the individual, in front of his
environment, constructs an Ideal to reach to optimize the performances of the flow of energy.

The Super-ego will thus take the place of a prosthesis replacing the missing consciousness and will have
the task of avoiding the impulsive overflows of the Id. The individual will rely on “ready-made” models
to ensure an acceptable life.

e. The Self.

Pulled from Carl Jung's archetypes, I referred to them in the previous paragraph. If Id is considered to
be a libidinal source, the Self is considered to be an existential source, it goes, not towards what
surrounds it to use it, but towards the beings to meet them. While the Super-ego was a consciousness
prosthesis, the Self seems to be a consciousness in its own right.

f. Balance between the two flows.

The psychic structure will therefore have to satisfy two types of flow flows: the flow of energy (libidinal)
and the flow of life (existential). It is useful to point out that energy is DOING and life is BEING.

g. Objectal and Existential.

The libido always turns to an “object”, isn't it said “the object of desire” or even an “object love”? The
world of objects concerns the relational (the relationship being different from communication).

The world of subjects:

56
The existential flow turns towards the Self in an individuation process. The project is to re-establish
existential circulation, this world is that of communication, where beings count more than words.

There is thus coexistence between the libidinal flow towards the ego, which gives narcissism and the
existential flow towards the Self, which gives the situation.

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These diagrams come from Thierry Tournebise. That is why the main title of this report is “Senescence:
The existential stage”.

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Note, starting from these diagrams22, on the care of residents in EHPAD:

In good professional faith, caregivers of the elderly, in a non-care-giving empathy, tend to treat the
raising of self-esteem with a continuity of narcissisation (as much as possible). Indeed, it is a projection
of what they think, they bring better, according to their own current life path.

As I indicated in Part III, and reading these diagrams, a harmonious and constructive growth for people,
aiming to build their Ego (libidinal flow), requires a process of narcissisation; what cannot be projected
on people aiming at the process of the situation of their Self (existential flow).

Care for a successful senescence requires this essential awareness: the means of construction of
residents and staff are very different, even antagonistic.

Unintentionally or unknowingly, this can help accompany the elderly person to senility!

B. Underground of my theoretical construction.

1. External supervision.

From the very beginning of my internship, and seeing it last, I felt it was important to be followed in
supervision, with, as a starting questioning: discern my counter-transfers and strip away my empathy
so that it could be a caregiver.

Halfway through my internship, I was able to find a competent person. Every two weeks, we worked
for an hour. I'm unveiling a few leads:

- Work on the motto inscribed in Delphi's frontispiece, which Socrates takes up: “Know thyself”:
[Knowledge is immanent to man, and not external, wisdom consists in remembering it. This
can only be done thanks to maieutic] says Socrates in substance.

22
At the intersection of the two flows, in the "mid-life", many people resume studying, make in-depth
assessments of motivations and skills, change their state of life.... This is so that their “doing” becomes at last at
the service of their “being”. This crisis is so important that in France, for example, the suicide rate in 2014 among
45-54 year olds is 26.4%.

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 - Work on the observation of my way of being, without any judgment, going to work on my
fixed-term contract in the manner described by Jiddu Krishnamurti. This, in order to discern
my filters.
- Work on a psychosocial definition of the relationship proposed, among others, by Serge
Moscovici (1925-2014): “the relationship is based on an exchange of interests”. What are my
interests in my relationship with EHPAD patients in music therapy and vice versa?
- Work on my personal story: elements of answers to the 1600 hours of internship.
- Work on the unexpected resonance of my work with patients: my own integration and my own
process of active individuation.

I suggest that each person involved in a helping relationship could do this substantive work. Formal
oversight bodies (internal or external) would then be set up for this purpose.

2. Instrumentarium (finally) being used.

a. Presentation.

Approved by Hervé Platel (professor in neuropsychology), my instrumentarium, unknown to patients,

is an important element in my objectives. In “les allegros d'Alzheimer”, he says that patients with
severe neurocognitive disorders show the ability to retain melodies, unknown songs.

This is my instrumentarium:

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Sanzula:

Bells:

Pentatonic balafon:

Wind chime:

Cabasa:

Maracas and shekere:

2-tone resonant guiro tube:

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Darbouka and djembe: Japanese Gong:

Bodhran and tambourine:

Tibetan bowls :

Mallets and sticks:

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 Baroque tenor flute and transverse flute
"Silver head" :

The two flutes are for my personal use.

The voice, rhythmic, melodic, needs to be added too. The improvised singing in relation to the history
of the person on a background of sanzula (like a griot), the improvisation on the free singing of vowels,
without conscious reference to the ‘yoga of vowels’, actually stemming from ancient Egypt.

According to the psychoanalyst Guy Corneau, who uses the yoga of vowels: “the wave produced by
the sound [of vowels] facilitates the expansion and opening of the being”.

In fact, these simple and rewarding instruments of good craftsmanship are instruments (including the
voice) of music that I call original or native.

The voice, flutes, scrapers and percussions are the very first musical instruments of our human
heritage.

In a previous internship, working with patients suffering from similar disorders, the following
observations had emerged, which were, at first sight, the healing elements of such an
instrumentarium:

o by the touch, kinesthetic sensation, sought after by the person;

o by the memories generated by the making of instruments (aid to semantic memory);
o by the sound of the instruments, new auditory sensation, which may unintentionally cause
emotions to reappear;
o by the history, the origin of the instrument (invitation to travel, concretization of television
coverage);
o by a new group dynamic in the creation of a sound history;

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 o the awakening of curiosity;
o by the pleasure of producing, in a free choice (aid to the difficulty of making choices in already
known things);
o through sound and non-verbal communication (help with language difficulties, aphasia);
o by manipulation (help with apraxia), hence the importance of mallets to compensate for
fatigue;
o the pleasure of finding instruments that have already been invested before (aid for episodic
memory, agnosia);
o by relaunching and stimulating with the instrument I play, in an appropriate way (help with
concentration disorders);
o through the creation of new sound related emotions (aids to psycho-behavioral disorders);
o through the effect of surprise, breaking a deadly daily life;
o by capture (helping to calm down).

In the clinic part, I will show you the apropos of these observations and how to broaden and deepen
them.

b. The contribution of neuroscience (part 1).

Thanks to this particular instrumentarium, two observations on the human brain can be developed.

b1. Cerebral plasticity:

Simply put, brain plasticity is due to the ability of neurons to make and break their synaptic
connections. The brain is called plastic, because the synaptic connections are reinforced or not, by the
environment, by practice. Music provokes a “neuronal symphony” (cf.: Hervé Platel), i.e. it activates
zones throughout the brain, which helps with plasticity.

In her doctoral thesis in 2012, Aline Moussard shows that "the sensory-motor activity of musical
practice leads to a reorganization of the brain". Music, through cerebral plasticity, causes “transfer
effects to non-musical skills”, such as language and motor skills. Which is highly appreciated by people
suffering from severe neurocognitive disorders.

b2. Adult Neurogenesis:

Here too, in a simplified way, the adult brain continues to produce neurons. The division of
endogenous neural stem cells gives rise to cells capable of differentiating into (new) neurons that
integrate into existing brain circuits (limited in adults).

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Music may well accelerate neurogenesis: experiments conducted on mice and rats subjected to
musical stimuli show that the production of neurons is increased in their hippocampus. “But we don't
always know exactly what produces this neurostimulant effect,” points Hervé Platel.

This would tend to confirm the Japanese proverb “We start aging when we stop learning” and I dare
add: whatever one’s civil age may be.

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 C. Ground-floor.

1. Contribution of neurosciences (Part 2).

a. The lower way.

Despite the hope of neurogenesis in the hippocampal area, glued at its lower end to the cerebellar
tonsil, people with severe neurocognitive disorders often have a damaged or destroyed hippocampus.

In my approach as a music therapist, I will mainly follow the patient's path from below, “addressing”
directly to his cerebellar tonsils.

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 b. Exponential stimulation of neuro-mediators.

Canadian neuroscientist Daniel Lévitin (born in 1957) demonstrates that, in music therapy among
others, the fact of practicing music and/or singing together exponentially stimulates the following
neuro-mediators (exponentially: that is, 3 people practicing music together, for example, do not
generate 3 times more stimulation but much more). Here they are:

▪ Endorphin.
▪ Dopamine.
▪ Oxytocin.
▪ Natural cortisone.
▪ Natural morphine (see endorphin).
▪ The drop of cortisol levels.

I suggest getting to know them a little better, as well as showing how they can help, or even replace,
so-called “agonist” drugs (action comparable to these neurotransmitters), without their side effects:

b1. Definition of neuro-mediator:

A neuro-mediator is a chemical substance (also called a neurotransmitter), manufactured by the body

and allowing neurons to transmit a nervous flow (the message) between themselves, or between a
neuron and another variety of body cells (muscles, glands).

b2. Endorphin:

It is a neurotransmitter involved in pain relief. It acts on the same receptors as morphine. It is

interesting to note that this “natural brain morphine” is 10 times greater than the synthetic morphine
given to relieve a suffering person.

b3. Dopamine:

It is a neurotransmitter synthesized by certain neurons (whose degeneration characterizes Parkinson's

disease) that intervenes in motor control. The phenomenon of shivering due to a strong pleasure is
related to dopamine (called “reward hormone”). It is also the precursor of adrenaline and
norepinephrine, thus increasing the pleasure aroused by risky behavior.

Within the framework of music therapy, I will remain on the predominant help of dopamine in motor
skills and pleasure.

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 b4. Oxytocin:

It is a peptic hormone produced by neurons in the brain. It is active in the bond between two individuals
in a loving relationship, and more broadly, in the social bond that unites us to our loved ones.

b5. Natural Cortisone:

It is a hormone produced by the adrenal cortex glands (above the kidneys). It has an essential role in
sugar metabolism, immune defenses, action on inflammation... in short, on the proper functioning of
the body.
b6. Cortisol:
Cortisone being an inactive precursor of cortisol, it is commonly called “stress hormone”. It is also the
awakening hormone, it controls the energy level, but it is also stimulated by physical and psychological
stress.

It’s this effect that I will retain in my music therapy practice: the decrease in cortisol therefore brings
consequently a greater resistance to stress.

2. Therapeutic alliance.

a. Preamble.

History and etymology of the word therapist: in 1877, this word meant “doctor who treats” borrowed
from the Greek “who takes care”.

This same definition still applies today. I find it interesting that earlier, in 1732, this word meant “a
Jewish ascetic living in community not far from Alexandria” and in 1704, this word meant “who serves
God”.

b. Therapeutic alliance.

When the medical team introduces me to a resident so that he can become a music therapy patient,
the first condition is to establish a therapeutic alliance with him.

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“This begins as soon as the person experiences, in the relationship, a listening different from that to
which he is accustomed to, a listening that helps him identify the true nature of his request,” says
psychology doctor Monique Brillon. She relies on the therapist's relational capacities (openness,
authenticity, ability to listen and welcome, personal assurance) which, of course, remains focused and
distinct. Thus, the patient's trust in the therapist (and vice versa?) can be established.

3. Following Winnicott.

From the therapeutic alliance, the music therapist will become “a good enough environment”, as
Winnicott says. He will establish a safe and ritually containing framework and co-construct with the
patient a transitional play area.

Good enough
environment

Transitional Area

For the patient, Winnicott tells us, the transitional area fulfils its function “Quand le jeu devient ‘je’ ”23.

In this area, acting out events can occur. By the controlled discontinuity of the framework, the
therapeutic relationship opens up to zones of risk, zones of uncertainty, highly interesting for
creativity.

All this brings hope for new points of view (of the music therapist and of the patient) and, if possible,
for psychological changes in the patient.

23
when the game becomes ‘I’ (in French “jeu” – game – sounds the same as “je” – I –).

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 4. The frame24.

The frame is, in itself, essential in a music therapy workshop, because it allows the implementation of
a therapeutic relationship.

It is defined by its location, frequency, duration and equipment. It is also distinguished by the position
of the people; the frame according to D. W. Winnicott and confidentiality. It represents a role of
countenance (delimitation between the inside and the outside).

R. Benenzon, when he refers to Winnicott's setting, compares it to the surgeon's operating room. At
the moment when the place is determined, he affirms that “only in this room can the real links in music
therapy occur”.

The choice of the place thus favors the recognition of the mediator (used only for this therapeutic
activity). It is reassuring because of its holding capacity, both physically (in the functional sense) and
psychically (it affirms the differentiation of roles and positioning of everyone in the interactions
between patient(s)/therapist and patient/patient).

The periodicity of the sessions is reassuring. For elderly people with severe cognitive problems, their
relationship to space and time may be more or less uncertain and it is therefore particularly necessary
that the frame be determined according to the rhythm of the institutionalized person. If a meeting
must be cancelled or postponed, it is necessary to inform them.

It is through this secure frame that the workshop can function and will allow the patient, or group, to
interact, being protected from what may come from the outside.

By my regular presence, my function as music therapist represents one of the elements of the frame.
Indeed, the music therapist is the guarantor of the shoring function (in reference to the notions of
carrying and maintenance that Winnicott names respectively holding and handling). It is indeed this
capacity to contain, and not simply carry, that allows residents to access this intermediate area of
experience and to express their internal experiences (acting out).

The frame is delimited by rituals, one at the entrance and the other at the exit. The coming and going
to the workshop room are part of it, just like the known pieces (the same at each session), that I play
at the beginning and at the end of the session.

24
The word “frame” is used here to remind us of a painting’s frame which acts as a limit for the picture and
here a countenance for the session.

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 5. The “No”.

a. Contributions of Jacques Salomé.

In his book “T'es toi quand tu parles”25, the psychologist Jacques Salomé brings milestones for a “new
relational grammar”.

By daring to re-appropriate one's word (verbal or not), by finding one's personal signifiers, by taking
the risk of defining oneself in front of others with one's own references, everyone gives himself/herself
more means to exist. And also, by taking responsibility for accepting to be open to a possible learning
process.

This is how he makes four basic principles emerge:

Dare to ask: move from the confinement of demands to a relationship of proposal and
stimulation.
Dare to give: move from an imposition relationship to altruism.
Dare to receive: move from the dynamics of taking to those of welcoming.
Dare to refuse: move from opposition to affirmation.

The music therapist that I am today will therefore try to work with these four axes and to make these
same four axes emerge in dependent elderly people.

b. The “no”, in older dependent people suffering from severe neurocognitive

disorders.

b1. Knowing how to interpret the “no”:

The person uses “no” for two major reasons: the first is to avoid choosing and having to justify his
choice (it is a “no” that can say “yes”), the second to clearly express disapproval. Non-verbal
communication helps to distinguish between the two (as well as the usual caregivers).

b2. Daring to say no:

I think that it is essential for a dependent, or even very dependent, person to be able to refuse a
treatment (here, by music therapy, a non-drug treatment). This is a rare (and conflict-free) opportunity
to assert yourself.

25
“Be yourself when you speak”. In French it sounds the same as “tais-toi quand tu parles”, which means “shut
up when you speak”.

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 6. Points on music therapy.

a. History (in our culture).

I find interesting to superimpose this brief history on those already mentioned (history of senile
dementia and history of institutional names).

a1. For the Hebrew (around -1000):

In the situation between King Saul (who has depressive outbursts) and David (his future successor),
David is considered the first music therapist, who calms Saul down with the play of his zither and his
singing. Here is the account given by the Bible in the Old Testament in first book of Samuel [16:14-23]:

“The spirit of Yahweh had withdrawn from Saul, and an evil spirit coming from Yahweh was terrorizing
him. Then Saul's servants said to him, “Behold, an evil spirit of God is terrorizing you. Let our lord give
the order and the servants who assist you will seek a man who knows how to play the zither: when an
evil spirit of God assaults you, he will play it and you will feel better.” Saul said to his servants, “Find
me a man who plays well and bring him to me.” One of the servants answered and said, “I have seen
a son of Jesse, the Bethlehemite: he can play, and he is a mighty man, a man of war, he speaks well,
he is beautiful, and Yahweh is with him.” So, Saul sent messengers to Jesse, saying, “Send me your son
David (who is with the flock).” Jesse took five loaves of bread, and a
bottle of wine, and a kid, and had all these things carried to Saul by his
son David. And David came to Saul and served him. Saul took great
affection for him and David became his squire. Saul sent to Jesse,
saying, “Let David remain in my service, for he has earned my
benevolence.” So, whenever the spirit of God assaulted Saul, David took
the zither and played it; then Saul calmed down, he got better and the
evil spirit moved away from him.”

(The penultimate page of this brief quotes a psalm by David).

a2. In Europe:

o In the 13th century: for Barthélémy L'Anglais26, a French Franciscan brother

and one of the first encyclopedists (who died in 1272), music was used to
treat madmen. He writes in his “Book of Properties of Things”: “...music to
delight them and to remove their fear and sadness.”

26
Bartholomew the Englishman

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o In the 15th century: Marsile Ficin (1433-1499), an Italian humanist, poet,
philosopher and priest, wrote in his book “De triplici vita”: “The musical
sound, by the movement of the air purifies, excites the air spiritus, which
constitutes the link between the body and the soul, by means of emotion,
it acts on the senses at the same time on the soul”.
o In the 17th century: Robert Burton (1576-1640), theologian at Oxford
University, wrote in his book “Anatomy of Melancholy”: “Music is the
expression of the evil of living and its remedy”.
o In the 19th century: Jean Etienne Esquirol (1772-1840), an alienist doctor,
brought the mentally ill (experiment on 80 convalescent women) to listen

73
 to private concerts at La Salpetrière hospital27, in a room separate from
the musicians.
François Leuret (1797-1851), French alienist anatomist, student of
Esquirol, chief physician of the hospital of Bicêtre, organizes, with the
insane and confirmed musicians, choirs, internally in the hospital. But it
was Octave Du Mesnil (1832-1898), a doctor at the Vincennes asylum, who
generalised orchestras of alienated people.
o In the 20th century:
Between the two world wars, there was a widespread abandonment of
music, it was “hospital silence!”. But music therapy is “in gestation”, taking
a secondary place in occupational therapies to help the patient socialize.
o Years 1970 and following:
In 1969, Jacques Jost (sound engineer and music therapist) and Edith
Lecourt (psychologist, psychiatrist and music therapist) created the Centre
Français de Musicothérapie28.
Jacques Jost studies the psycho-affective power of music. Edith Lecourt
reintroduces the report to the patient, putting him at the center of music
therapy.
In 1986, Jacques Jost and Rolando Omar Benenzon (who since 1977, has
been training music therapist in Buenos Aires according to his discovery of
the principle of Sound Identity), created the World Federation of Music
therapy.
o In 1996, the first International Congress of Music therapy was held.

b. Example of care, with the help of music, in other cultures.

b1. The trance (according the ethnomusicologist Gilbert Rouget (born in 1961):

In all continents, music plays an essential role in the rise into a trance. It takes place in a set of
representations:

• Either identification, as in possession.

27
La Salpetrière hospital, Bicêtre Hospital and Vincennes asylum are all in Paris
28
French center for music therapy

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 • Either the incarnation, as in shamanism.
• Either emotional phenomenon, as in the communal trance.

Differentiation:

The possessed, hearing the ritual music played by professional musicians, enters into induced
trance: it is the arrival of the spirit world that he incorporates into his body.
The shaman, playing the ritual music himself, goes into a trance conducted. He is master of
the trance and travels in the spirit world.
In the communicative trance, the subject keeps his personality and the spirit coexists, speaks,
acts with him, as in the semâ mevlevi found in Sufism.

The phases:

The modification takes place according to a series of phases: preparation, triggering, fullness,
resolution.
There is initiation trance (with slow songs, notion of luminous purity) and possession trance
(with songs, drums and bells, played for the initiated).

Music:

Its hypnotic action on the nervous system and its psychological action linked to cultural
representations are underlined.
The role of music is to serve the group. It allows the trance to socialize and flourish. It triggers
it just as it can soothe it.

b2. In India:

Nada Yoga divides music into two categories:

• The inner music, which corresponds to the unique and personal vibration of the sound
"om". This sound represents the first vibration that generated all manifestations in the
universe.
• External music, which produces electrochemical changes in the brain. Melody and
intonation are the keys to Indian music.

75
The raga is the basis of the melody. The ragas system dates back to before the Indus Valley civilization
(2000 before J.C.).

In the therapeutic field, there are special ragas for targeted care, whether physical, emotional or
spiritual. The therapist is the musician who knows how to adjust the raga, discerning the subtle alliance
of the inner sound unique to the person and the outer sound necessary to relieve it.

The raga acts on both the musician and the patient.

7. Benezon’s Sound Identity.

a. Presentation of the author.

Argentina's Rolando Omar Benenzon (born 1939), psychiatrist and psychoanalyst, musician and
composer, is one of the world's great pioneers of music therapy. He founded the first music therapy
faculty in Buenos Aires in 1966. He is also the discoverer, in 1981, of the principle of the ISO (Sound
Identity).

b. Definition of ISO.

Each ISO defines each human being in a unique way. The experiences of an individual are, according
to Benenzon, "the condensation of energies that belong to [Universal ISO + Gestalt ISO + Cultural ISO]".

He defines them as follows:

The Universal ISO: it is the common sound prototype shared by all (heartbeat, breathing, water
sound, walking and moving rhythm, animal message, movements [dance] and sounds [music
and songs] ancestral, silence).
Gestalt ISO: this ISO is the heritage of the individual in particular that differentiates him from
others. It is structured from three sources which are "all the sounds that surround the mother
during pregnancy and reach the fetus through the amniotic fluid", sounds from inside the body
of the mother and those from "the unconscious of the mother to the unconscious of the fetus".
Cultural ISO: it is built by the sounds of the newborn's ecosystem.

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 c. ISO as a principle for music therapy.

I quote Benenzon: "To open channels of communication between a patient and a musico-
psychotherapist, it is necessary to recognize the patient's ISO and to balance them with the music-
psychotherapist's ISO", and thus, by reciprocity, to allow the patient to find, in the non-verbal, his
source. I will also use the ISO in interaction, i.e. the dynamics between the different ISO members of a
group.

8. Mini-conclusion

This theoretical construction (which does not represent a theoretical model, but a specific construction
wishing to treat the problem posed) was omnipresent in each music therapy workshop that I set up.
But, in addition, for each therapeutic aim, I have added specific music therapy theories and techniques.

It is like a theoretical metaphor of a process of individuation.

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78
 V. The Clinic.

A. Preface.

1. Reminder of different therapeutic aims.

The main goal is to help the person to live the senescence stage as well as possible. According to
Erikson, this corresponds to integrity and according to Jung to accompaniment of the Self.

To this end, I will be addressing patients with severe neurocognitive disorders by setting up various
workshops with complementary therapeutic aims.

• Individual active music therapy workshop.

• Active music therapy workshop in a small group.
• Individual music therapy workshop to work on specific syndromes during bedtime
accompaniment.
• Individual receptive music therapy workshop, with verbalization, to contribute to the
accompaniment of the end of their life.

2. Presentation of the patients

In order to respect their anonymity, and inspired by the singing of vowels, I will name them with an
initial consonant followed by two vowels. It reminds me of the particular singing of Polynesian and
Vietnamese languages. I present here their pathology, their age, their general behavior (which,
according to Naomi Feil can give leads as for the stages of life badly lived or "amputated"). Then, I will
not speak about it anymore, having in front of me Human Beings (in the Amerindian sense). I will,
however, talk about the consequences of music therapy on their behavior and their participation in
the workshops.

So here are the patients:

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❖ Mr. Moï:
He lives at the ‘Pierre Mara’ unit. He is 80 years old and has an Alzheimer's type
disease.
In the group, he is in an imposing role, with aggressive gestures. Other residents fear
him. He participated in:
10 sessions of individual active music therapy.
4 sessions of active music therapy in small groups.

❖ Mrs. Néü:
She lives at the ‘Pierre Mara’ unit. She is 90 years old and has psycho-behavioral
disorders related to an Alzheimer-type disease.
In the group, she is erased, in her bubble, fearing to disturb, in fear in general. She
participated in:
8 sessions of individual active music therapy.
5 sessions of active music therapy in small groups.

❖ Ms. Mui:
She lives at the ‘Pierre Mara’ unit. She is 95 years old and has mixed dementia, frontal,
with neurological degeneration (not diagnosed exactly).
In the group, she is independent, with a rhythm of activity followed by a deep sleep.
She participated in:
12 sessions of individual active music therapy.
5 sessions of active music therapy in small groups.

❖ Mr. Lao:
He lives at the ‘Pierre Mara’ unit. He died at the age of 92, he had an Alzheimer's type
disease.
In the group, he presented himself as a gentle and quiet person. He participated in:
5 sessions of individual active music therapy.
3 sessions of receptive music therapy during the accompaniment of the end
of his life.

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❖ Mrs. Baé:
She lived in the ‘Village’ unit then in the ‘Pierre Mara’ unit. She died at 91. She had
mixed dementia. Friendly, she would shout "Mom" continuously at times.
In the group, she could be sociable but also isolated in her bubble. She was involved
in:
5 sessions of individual active music therapy.
1 session of music therapy during the accompaniment of the end of her life.

❖ Mrs. Laü:
She lives at the ‘Pierre Mara’ unit. She is 87 years old and has an Alzheimer's type
disease.
Sociable in the group, she often sings and sings, leading others. She suffers from
nychthemeral rhythm inversion. She participated in:
14 sessions of receptive music therapy at bedtime.

❖ Mrs. Mai:
She remains at the ‘Pierre Mara’ unit. She is 91 years old and has an Alzheimer's type
disease.
In the band, she's in her bubble. She suffers from sundowning syndrome. She
participated in:
14 sessions of receptive music therapy at bedtime.

❖ Mrs. Bia:
She lived at the ‘Hermitage’ unit. She died at 75. She suffered from a form of
melancholy as well as sundowning syndrome.
In the band, she was in her bubble. She participated in:
5 sessions of receptive music therapy at bedtime, followed by 2 sessions of
receptive music therapy at the Clinique du Parc (Nantes) with the doctor's
approval.
3 sessions of individual active music therapy.

❖ Mrs. Dui:
She lives at the ‘Hermitage’’ unit. She is 92 years old and has Alzheimer's disease.
She's friendly and can't say no. She participated in:

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 7 sessions of individual active music therapy.

❖ Mr. Poé:
He lives at the ‘Hermitage’ unit. He is 82 years old and has mixed dementia with stroke.
He sleeps a lot and is inventive. He participated in:
7 sessions of active music therapy, then receptive, individual.

❖ Mrs. Gai:
She lives at the ‘Hermitage’ unit. She is 81 years old and has an Alzheimer's type
disease.
She is pleasant (if she is in confidence). She participated in:
7 sessions of individual active music therapy.

❖ Mrs. Gaâ:
She lives at the ‘Hermitage’ unit. She is 88 years old and has behavioral problems with
Broca's aphasia.
To me, she's a person of character. She participated in:
8 sessions of individual active music therapy.

❖ Mrs. Loè:
She lives at the ‘Hermitage’ unit. She is 95 years old and has Parkinson's disease at an
advanced stage.
She is modest about her tremors and shows great politeness. She participated in:
7 sessions of receptive music therapy, then active, individual.

❖ Mrs. Hoa:
She lived at the ‘Hermitage’ unit. Died at 102 years of age, she had problems related
to normal old age, still in bed. She participated in:
3 sessions of receptive music therapy during the accompaniment of the end
of his life.

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 ❖ Mrs. Buo:
She lived at the ‘Hermitage’ unit. She died at the age of 93 and suffered from vascular
dementia, the consequences of which are brain damage. She participated in:
10 sessions of receptive music therapy during the accompaniment of the end
of his life.

❖ Mr. Jao:
He lived at the ‘Village’ unit. Died at 88, he had Parkinson's disease with advanced
neurological disorders and periods of violence. He participated in:
5 sessions of individual receptive music therapy.

❖ Mrs. Giu:
She lived at the ‘Village’ unit. She died at the age of 86 with an Alzheimer's type
disease.
She was very courteous. She participated in:
2 sessions of receptive music therapy during the accompaniment of the end
of her life.

❖ Mrs. Puo:
She lived at the ‘Village’ unit. Died at 100 years of age, she had normal old age with
disorders. She showed an unpleasant mood towards the caregivers, towards the
institution. She participated in:
3 sessions of receptive music therapy during the accompaniment of the end
of his life.

In addition, entrusted by the psychologist of the EHPAD:

❖ Mr. Nay:
He lives at the ‘Pierre Mara’’ unit. He's 87 years old. He has Alzheimer's disease. I
intervened for 2 sessions of individual receptive music therapy, while he was in a
depressive period.

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 ❖ Mrs. Coü:
She lives at the ‘Village’ unit. She's 87, in normal old age with depressive disorders.
She was treated for a long time by Dr Alfred Tomatis (1920-2001) and for the three
years she has been living at the EHPAD, she has not dared to re-appropriate this
method.
She participated in:
4 sessions of music therapy receptive and active individual.

B. Giving the opportunity to say something to oneself.

1. Means.

The first step in developing the individual active music therapy workshops was to find a room, a frame.

The criteria were as follows: sound privacy, a place with window, a place ‘containing’ where the person
feels good. These criteria led me to use the large meeting room (see on the map), a place unknown to
the patients, which I could arrange according to the needs. I, of course, had to book it in advance.

Round trip to and from the room was an integral part of the workshop.

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 2. Opening up to emotions.

Etymologically, the word emotion comes from the Latin ex: to remove, to shake and movere: to set in
motion.

The six basic emotions are: pleasure, anger, anxiety, sadness, interest and disgust, with a myriad of
intermediaries and associations.

During my observations, I had noticed that the emotions expressed by people with severe
neurocognitive disorders were mainly limited to defensive attitudes: anger (via aggression) and refuge
in atony.

Having worked with people whose speech is well damaged, I have relied on non-verbal communication
to identify and best respond to their emotional reactions.

At least initially, I was inspired by the “observed emotions rating scale” of Mortimer Powell Lawton
(1923-2001), an American psychologist and gerontologist.

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I allowed myself to add disgust to it:

This then allows the person to access the expression of feelings (“lasting emotional states related to
certain emotions or representations”) and thus, based on non-violent communication, to whether or
not their needs are being met (see Appendix 1). This represents a therapeutic essential to help the
person in his senescence.

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 3. Use of the psycho-musical evaluation.

To begin, and to help me define my sessions, I proposed to each patient (after having read his/her life
history, often not very detailed), to pass an adapted psychomusical assessment, inspired by the one of
Jacqueline Verdeau-Pailles (1924-2010), neuropsychiatrist and French music therapist. This will be
more detailed in Annex 3. Here, it is important to start with this step, in order to first learn from the
patient whether music therapy sessions may be appropriate (measures of interactions), and, if so, what
style of sound medium is appropriate, how long a session may last, establish a contract of a number of
sessions with him, and, after a general evaluation, the possibility of establishing a new contract.

I invited them to discover and experiment six different instruments, both in terms of melodic
possibilities and volumes, timbres and pitch, one by one, isolated on the table, after having shown how
it could work (succinctly).

These six instruments are the balafon, the large Tibetan bowl, the bodhran, the gong, the small carillon
and a maracas. (On the advice of the caregivers, I changed the last instrument which was a harmonica,
indeed, what is usually brought to the mouth is food, and, no longer seeing the instrument, became a
source of anxiety).

Then equipped with my Lawton scale and the clinical parameters of the first part of the psychomusical
assessment of Verdeau-Pailles, I noted the reactions of possible future patients.

In a second time, I kept on the table the instruments that the patient had preferred and played on the
transverse flute four pieces corresponding to the clinical parameters of the second part of Verdeau-
Pailles' psychomusical assessment and noted the styles of interactions. Here are the measurement
tables:

FIRST PART CLINICAL PARAMETERS

87
 Body contact

Immersion

Acclimation

REPPORT Animism

Strength

Other

SECOND PART CLINICAL PARAMETERS

1st Extract 2nd Extract 3rd Extract 4th Extract

Very
Simple soft Structured, Out of the
rhythmic air
melodic air rhythmic and ordinary air
melodic
complete air

Description
(chronological) of the
REPORT TO
INSTRUMENTS

GESTURE

This allowed me to see the mediums adopted by the patients, their possible interactions and to target
a session duration.

For each session, then, I asked about the patient's condition, his rhythm during the day. The sessions
generally lasted 20 minutes or one hour.

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 4. Use of Wigram’s clinical improvisation.

Tony Wigram and Kenneth Bruscia have been professor emeritus of music therapy in the United States
since the 1990s. By developing a musical improvisation, in duo between the music therapist and the
patient, based on the natural sounds and rhythms coming from him, the music therapist makes him
rediscover his ISO.

I practiced sound improvisation rather in non-verbal, and I used, supported and encouraged, through
my sound play, the development of the person's sound expression without imposing a pre-established
structure.

After setting up a safe framework allowing the establishment of a transitional area, I pursued the
clinical goals that can be achieved through clinical improvisation, according to Bruscia:

Establish a non-verbal transmission channel, and a gateway to verbal transmission.

Develop the ability to explore one's interpersonal universe.
Develop socialization.
Develop creativity, freedom of expression.

The basic therapeutic techniques of clinical improvisation are used in relation to the patient, who is
the "conductor" and I, the music therapist, the "facilitator".
It is interesting to find again notions of active listening according to Carl Rogers. Here are these
techniques, used in accordance with the sound universe where the patient is at the very moment of
the session:

• Copying: I play what the patient plays on the same instrument together with him.
• Imitation: I repeat what the patient has just played.
• The reflection: in the affect, I replay what the patient wanted to make pass emotionally (I must
pay attention to my counter-transfers).
• The question/answer: we start a sound dialogue.
• The rhythmic base, like the ostinato, is a secure holding, supporting the patient's
improvisation.
• Dialogue: the patient and the music therapist communicate in their improvisation.
• The structured progressive accompaniment, in rhythm and melody, where the music therapist
supports the improvisation of the patient who has become richer.
• The surprise, which will act as discontinuity.
• Silence, which gives the patient his own time.

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This musicotherapeutic process was used for each patient, invited in this style of session.

It begins and ends with a well-known piece, which I play on the transverse flute. This, in order to
establish a reassuring and containing framework, limited by a receptive listening provoking a memory
echo in the patient, announcing the beginning and the end of the session.

The instruments available are from the family of those chosen by the patient during his psychomusical
assessment.

I now invite you to follow the therapeutic path of the patients in this workshop:

It should be noted that each patient has often diverted the usual use of his sound medium in order to
make it his own.

I remind you that each patient has his/her own rhythm and, theoretically, the moment when they are
most awake is fixed in time.

The sessions were repeated if the patient expressed the desire (at my request).

5. Therapeutic pathways.

a. Mr. Moï.

a1: Therapeutic alliance, beginning:

When I arrived at the “Pierre Mara” unit, I was the only man among the caregivers. In our first
meetings, this fact may have contained him, secured him. During my immersion I ate with him several
times as a therapeutic meal. Before his psychomusical assessment, invited in his room, I sang to him,
on the sanzula, his life, like a griot. This man, usually rigid, was all listening and his eyes misted with
tears of emotions (exceptional moment for him): there was born the therapeutic alliance, defined in
my theoretical construction.

a2: Throughout the sessions:

For 15 months, in cumulative time, we worked 100 hours.

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It is with a smile and joyful that he comes to the session. It lasts one hour and often I have to stop it
(frame it). In clinical improvisation, he reveals himself to be in fine interactions with a growing
creativity in his improvisation.

In the family of percussions and bells, it unfolded in rhythmic progressions, timbres, volume. On this
point, he played most often “piano” until almost silence.

a3: Significant change in behavior:

While remaining himself, he became more tolerant, going more towards others. He started talking
(softly) again, recognizing and talking with his children.

One evening, after an afternoon session, at the end of dinner, he performed a rhythmic ostinato
worked and soft with his cutlery. The group welcomed it as an “oblation”, in the sense used by Jacques
Salomé.

Another evening, he repeated this gift, in duet this time with the sweet, sung improvisation of a
resident of his table, patient of another music therapy workshop.

b. Mrs. Mui.

b1: Therapeutic alliance, beginning:

It started during the psychomusical assessment session. Indeed, she showed a great knowledge of the
pieces I played on the flute and had fun exploring the instruments.

b2: Throughout the sessions:

For 15 months, in cumulative time, we worked 120 hours.

She comes to the sessions with enthusiasm. She likes many instruments so we change them. The
session lasts approximately one hour, in joy. On her wheelchair (brakes on), she starts dancing to the
music. In moments of surprise, she is in the pleasure and adapts quickly. In support of improvisations,
we chant and sing, each in our own voices. It shows a lot of creativity. After the sessions, she is rested,
calm and joyful, while being awake.

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 c. Mrs. Néü.

c1: Therapeutic alliance, beginning:

Mrs. Néü is very afraid to leave the “Pierre Mara” unit. So, the first session took place in her room. She
quickly adopted the instruments and showed joy. I think the therapeutic alliance began when I used
“words and music” on original paper from the 1930s to the 1950s. She had a large collection, which
had disappeared during moves.

c2: Throughout the sessions:

For 15 months, in cumulative time, we worked 80 hours.

Little by little, she manages to come into the room, which has been prepped for the music therapy
workshop. The sessions last one hour, I often have to end them. The moments of surprise make her
laugh. She shows interaction very quickly and grows in the creativity of her improvisations. She also
cried with grief as she listened to Chaplin's “Little White Satin Slippers”.

c3: Significant change in behavior:

She is also opening up to other members of her unit. She leaves her “bubble” and expresses her
feelings.

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 d. Mr. Lao.

d1: Therapeutic alliance, beginning:

During a therapeutic meal taken with him, I tapped some rhythms on the table, gently. He then started
using my hand as a medium and played with me both ways.

d2: Throughout the sessions:

For 7 months, in cumulative time, we worked 10 hours.

Mr. Lao was gentle and at the same time very tense. He was mute and suffered from a continuous dry
mouth that made me remove any wand he had in his mouth. As we went along, there were more and
more interactions. Little by little he relaxed and sometimes danced on his armchair, he forgot his thirst.
The session lasted 20 minutes. A notorious fact: during a session, he spoke to me very clearly, in perfect
syntax, of a pleasant memory. This event occurred with other patients with various degenerative
aphasia. In my opinion, this is the result of several factors: cerebral plasticity, in connection with music,
being in a care according to the patient's time, being in a transitional area, being in an active listening
and Validation attitude.

He was also clear and polite in saying “no” to me once.

I continued to follow Mr. Lao in music therapy session in the accompaniment of the end of his life.

e. Mrs. Baé.

e1: Therapeutic alliance, beginning.

Welcomed in his room, I had noticed reproductions of impressionist paintings on his wall. I have some,
too, from the same source. I told her and she said, “I love what is beautiful,” hence the beginning with
receptive music therapy.

e2: Throughout the sessions:

For 10 months, in cumulative time, we worked 50 hours.

In his room, the sessions lasted about an hour. She played, after exploration, without inhibition.
Interactions were taking place. Little by little, at ease, she switched to improvisation more and more
worked, changing instruments at will. Yet she devalued herself on the music played together. She then

93
remained in the ‘Village’ unit. I found her at the unit ‘Pierre Mara’ in music therapy session in the
accompaniment of the end of her life.

f. Mrs. Loé.

For 15 months, in cumulative time, we worked 4 hours.

It was difficult for me at first to work with her. The hooks and attitudes I could try and the beginnings
of short workshops in her room were stopped after she confided in a known caregiver. I just came
back, finally knowing some causes, say goodbye.

Towards the end of my fixed-term professional contract, I was asked to work with her again. The active
music therapy sessions take place in her room, on two instruments she has chosen. These sessions can
last one hour. It is participatory, welcoming and peaceful, sometimes knowing how to say no, in peace.
She even agreed to be in session while being in pre-crisis tremors due to her illness.

g. Mrs. Dui.

For 15 months, in cumulative time, we worked 4 hours.

In her room, greeted by frank yeses, accompanied by smiles, the very first sessions are in receptive
music therapy where Mrs. Dui lets herself be rocked, while remaining awake.

During the sessions (from 20 minutes to one hour, depending on his condition), we work in individual
active music therapy. (In the ‘Hermitage’ unit, I need to find a system or positions for the patient to
play). Mrs. Dui invests the instruments in her own way, the interactions become more and more rich.
She has fun and improvises. She was able to say “no” to me, calmly, once.

h. Mr. Poé.

For 15 months, in cumulative time, we worked 4 hours.

During my immersion, I helped him take his snack. After having welcomed me in his room in order to
make a brief psychomusical assessment, Mr. Poé, for the following sessions of active music therapy,
comes to the room, which has been prepped for the music therapy workshop.

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He is inventive in using the instruments he has invested (just a few fingers of his right-hand work). The
interactions become more and more rich and joyful. His gaze sparkles and he invests himself in the
game and asserts himself (he appreciates loud sounds). Sessions last 30 minutes. Our code of
agreement or not is done by squeezing my finger.

Over time, his condition changes and he must remain in bed. With his agreement, I come for music
therapy sessions that become less and less active. He shows his desire to participate, to interact but
cannot.

I then went through a few sessions of receptive music therapy, explaining to him the instruments he
had invested. Then come smiles and sparkling looks, attentive listening.

i. Mrs. Gaâ.

For 15 months, in cumulative time, we worked 8 hours.

On the psychomotor side, she only has one hand left that works. This hand is rarely solicited because
the nursing staff must feed him to eat because of frequent false roads.

The therapeutic alliance began when I helped her take her snack. And then, it became stronger when
we found a subtler communication code than the two “yes” and “no” cards she had. This code is as
follows: according to her agreement or disagreement, with all the intermediate nuances, she pulled
my hand towards her or pushed it back.

I had to adapt the position of the instruments she had chosen and find very light sticks. The sessions
are done in her room or in room and last from 30 minutes to 50 minutes, depending on her condition.

Over the course of the sessions, Mrs. Gaâ increasingly appropriates the instruments she has chosen,
with pleasure. She asserts herself, she is in the interaction and in the initiative of long play areas. From
me, I add the singing, she seems to watch the singing come out of my mouth.

Her eyes are expressive and alert. During a session, she, so stoic, starts crying hot tears. Before my last
session, I meet her (as often) and greet her, she throws at me a guttural cry (with non-verbal language)
that I perceive as: “So, when do you come back with your music? I'm waiting for you!”.

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 j. Mrs. Gaï.

For 15 months, in cumulative time, we worked 4 hours.

Mrs. Gaï is of Spanish origin. Speaking to her with my meagre words and expressions in this language,
Mrs. Gaï opens her door to me. At the beginning of my immersion, I helped her take her snack.

First in the room, then in the bedroom, active music therapy sessions take place. The session lasts from
20mn to 40mn, depending on its state. She explores and plays the invested instruments in her own
way. We are in the first four interactions of clinical improvisation.

She shows open joy in being in session and knows how to be inventive.

C. Giving the possibility to communicate with one another

1. Means.

Having worked a lot in individual active music therapy with Mr. Moï, Mrs. Mui and Mrs. Néü from the
‘Pierre Mara’ unit, I proposed to the care givers and interested parties, the project of working in a small
group, together, in active music therapy, always in clinical improvisation.

I would also have liked to have set up this type of workshop with Mrs. Gaâ, Mrs. Gaï and Mrs. Dui from
the Hermitage Unit. But I would have needed caregivers from this unit, to hold the instruments
properly, so that everyone could play. Given their timed schedules, this proved impossible. I then
turned to the volunteers, who agreed, but for two reasons, this could not be done: it was a care and
the volunteers did not have sufficient connection with the people concerned.

So, I set up this project towards the end of my fixed-term contract with Mr. Moï, Mrs. Mui, Mrs. Néü.
The time had passed and it was necessary, for reasons of fatigability and increase of troubles, to find
a new room.

The criteria were the same as for the previous workshop, but the room had to be closer and in a more
locating, safer place. The joint office of the coordinating physician and the psychologist was adopted.

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Here is the layout of this office:

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The days, hours, durations are fixed and spoken with each person. Previously, in order to familiarize
them with this new place, I performed an individual music therapy session with each future participant,
so that the patient could restore his transitional area. It worked well, depending on each future patient
in this workshop.

2. Specific theoretical tools.

a. ISO interaction:

I quote Rolando Benenzon: "From birth a great space is also created between the individual and the
other or others. This space belongs to the non-verbal context. And it is here that the interacting ISO
condenses, which is the union of two spirals". The following diagram is from Rolando Benenzon:

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Benenzon continues: "The interacting ISO will also have a relationship with the complementary29 ISO
of individuals who are communicating. (...) The family ISO, the environmental ISO and all the non-
verbal codes that surround and invade the link space would also be added.

Indeed, in paragraph V.A.2, I briefly described the behavior in the ‘Pierre Mara’ unit of these three
patients.

b. The group and sound by Edith Lecourt:

I quote: “For the individual, the experience of the improvisation group constitutes a new invitation in
his adjustment to himself, to the group, to society”.

I propose you first of all to see how Edith Lecourt describes the phases of construction of a group in
sound communication, "his own Sound Identity":

First of all, the "rustling" begins: "it is the way in which the group, from the first moments of the
meeting, occupies the sound space". Then comes the "overall effect": "the moment when the group
perceives its production as a whole". Then appears "the music group": "the sound production is
designated by the group itself as "music", the group is then in isomorphic (negation of differences)".
Finally, the group moves on to the "musical form": "created by the group, taking into account the
differences, it is an elaborate manifestation, this time, of the group's identity".

During the 5 sessions scheduled, I observed the following steps described by Edith Lecourt, in a
progressive way:

o The rustle.
o Moments of overall effect.
o A certain construction of the sound identity of the group.
o Music group moments.
o Appearances of elaborate musical form.

29
The Supplementary ISO: "formed by a set of energies that appear and disappear according to the state of mind
of the individual and the relationships he establishes with others (...) it can be completely different from the
Gestalt ISO (...). These expressed energies will reveal a particular state of the individual that does not define his
true personality.

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 3. Therapeutic pathways.

a. Protocol.

The three patients are notified in advance of the session and prepared by the caregivers. I come to get
them, once the room is ready, and a caregiver helps me bring them. Mr. Moï refuses cane or armchair,
he walks at his own pace. Mrs. Néü, usually helping herself with a three-wheeled walker, comes in a
wheelchair, while keeping with her cane, a symbolic and reassuring object. Mrs. Mui comes in a
wheelchair.

Because of the fear of Mrs. Néü towards Mr. Moï, I placed her close to me, around a round table,
where the instruments are arranged. Mrs. Mui is at her side and Mr. Moï finishes the circle.

Each session begins with a fairly dynamic known piece (“Les amants de Saint Jean”), which I play on
the flute and ends with a softer piece that I play on the baroque flute (“Amazing grace”, slow).

Using the dabourka or the transverse flute, during the sessions, I continue the clinical improvisation,
being support and link between the patients, moving towards each one. That is, my game also serves
as a frame.

b. First session.

While individually, everyone showed in the improvisation, a creative joy, in group, during this session,
the games are more modest, intermittently, Mrs. Néü is the most enthusiastic despite her fear of Mr.
Moï.

This makes me think of a “round of observation”, with some games together, rather in listening and
waiting.

c. Second session.

The modesty of showing others one's own expressiveness fades. There are moments of overall effects.
I witness Mrs. Néü's astonishment to play with Mr. Moï. Mr. Moï and Mrs. Mui play lively.

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 d. Third session.

Mr Moï refuses to come. His place in the group is virtually present. Mrs. Néü doesn't recognize Mrs
Mui, but in the joy of the game together, with my support, several ensemble improvisation tracks
occur, in “music group”.

e. Fourth session:

The three patients are well present and participative. Mrs. Mui has a moment to fall asleep. By the
word, I reassure Mrs. Néü. Then soothed, surprised and happy to play with Mr. Moï, ensemble
improvisations emerge in several sound universes.

f. Fifth and last session:

The three patients may have been prepared a little earlier by the caregivers. They're waiting for me.
Mrs. Mui is angry (rare in her).

During the session, Mrs. Mui translates her emotion through a powerful sound medium from time to
time. At her side, Mrs. Néü, much more at ease than before, plays in interaction with Mr. Moï, in very
soft creative improvisation. In the end, everyone regained their calm.

4. Consequences on the life of the group.

According to the caregivers, they are not obvious but I hope that these three people have learned to
overcome their a priori, their roles, towards each other. Their non-verbal sound communication
consisted of new exchanges and allowed everyone to discover each other.

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 D. Contributing to easing symptoms.

1. Means.

In individual receptive music therapy sessions, usually listening alone, I work with patients at bedtime.
Sessions last on average 40 minutes in the patient's room. I choose to play music myself (my portable
instrumentarium consists of my two flutes, the sanzula and the large Tibetan bowl). This in order to be
more in phase with the psychic state of the moment of the patient (in volume, timbre and height).

2. Syndromes.

The syndromes that these sessions aim to alleviate are aggressiveness, sundowning syndrome and
nychthemeral rhythm inversion.

Sundowning syndrome or sunset syndrome is relatively common in people with severe neurocognitive
disorders. At sunset, identified with the coming of death, deep terror and anxiety appear in some
patients.

The inversion of the nychthemeral rhythm is also frequent. The person then lives at night and sleeps
during the day. Which adds to his confusion.

3. Contribution of neurosciences (Part 3).

Under the authority of Dr. Adarsh Kumar (1935-2016), in 1999, the Department of Psychiatry and
Behavioral Science of the University of Miami, published in the journal Altern Ther Health Med, his
work on increasing serum melatonin, through music therapy, in patients with Alzheimer's disease.

Serum melatonin (i.e. contained in serum or blood plasma) is a neurohormone, synthesized from
serotonin, in the pineal gland.

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Melatonin secretion decreases as early as adolescence and becomes rare in very old people.

In addition to regulating sleep, it has important effects on the immune system, agitation and anxiety.

4. Therapeutic pathways.

a. Mr. Jao.

For 7 months, in cumulative time, we worked 4 hours.

He was the first patient to take me in. We were mostly in validation-based therapy. For 45 minutes,
the sessions took place in the afternoon, in his room. According to his request, he responded to my
invitation for receptive music therapy. He would then let himself be rocked and soothed by attentive
listening, at the beginning of the sessions, in his armchair. Then her behavioral problems with physical
aggression towards caregivers increased. The therapeutic alliance between us once made him say,
“Don't come in today, I might hurt you”.

Responsive music therapy sessions continued, depending on his condition. I asked him to lie down,
and he would calm down and fall asleep while I played.

b. Mrs. Laü.

For 15 months, in cumulative time, we worked 10 hours.

She has severe memory problems and suffers from inversion of the nychthemeral rhythm. She always
welcomes me with joy (she once said “no”). She's my last patient of the evening. In her room, the
session lasts between 30 minutes and one hour, depending on her needs.

She enjoys known songs (she is a singer who keeps notebooks of song lyrics). I stay in instruments
without surprise (with flutes) and always start with known pieces. Then I intertwine slow and soft
pieces more and more unknown, inviting her to let herself be carried by the music.

I still play the same repertoire (“Le chant du guardian”, “Amazing grace”, two other Irish ballads, two
Breton hymns, a structured and soft music from Senegal [Keur Moussa], two melodies from Israel, a
Yiddish melody, two pieces from Llibre Vermeil by Montserrat). Her hippocampus doesn't remember

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any more but her cerebellar tonsil if, because gradually, she starts to sing pieces that I played at the
beginning of the sessions, which was completely unknown to her (cf. Hervé Platel).

She has a twisted and tense posture when she's in bed. After the sessions, the professionals noticed
that her posture had changed, completely relaxed.
The night lights tell me that after each session, she gets a full night's sleep.

c. Mrs. Maï.

For 15 months, in cumulative time, we worked 10 hours.

She suffers from sundowning syndrome and manifests it by shooting her fingers while counting, she
has great difficulties with verbal expression. Evening sessions last approximately 45 minutes.

She likes the sound of the sanzula.

At the beginning of the sessions, I started at her counting rhythm and improvised, copying, singing on
a sanzula background. Then I slowed down little by little while keeping the same structure. By the
effect, I think, of mirror neurons, it also made her slow down.

The therapeutic alliance became a reality when she agreed to take my hand and count my fingers too.
Physical contact has become more and more frequent.

She starts telling stories from her past that have troubled her, half in jargon. I repeat these stories
about the sanzula in improvised song. I also sing soft improvisations on vowels.

She is very interested in the sanzula and starts playing with me.

She clearly expressed sentences in French that could not be more correct, expressing deep wishes.

As the sessions progress, her behavior calms down.

After the last sessions, according to the caregivers, she no longer pulls her fingers counting, but hums
softly, quietly (hence the duet, one day with Mr Moï, after dinner).

d. Mrs. Bia.

For 10 months, in cumulative time, we worked 10 hours.

She suffers from the same syndrome as Mrs Mai, but can express herself clearly.

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She welcomed me with hope. The first session (45 minutes, in the evening): she had not been able to
sleep the night before, her lungs were so cluttered and she thought that her end was near, she was
terrified. She was very open and attentive to the different melodies whether it was the flutes, the
sanzula with improvisation singing, or the Tibetan bowl. The next day, during the transmission meeting,
the physiotherapist who came to give her respiratory physiotherapy came as a surprise: "It's amazing,
yesterday I couldn't get anywhere and this morning the work went very well". The state certified nurse
replied: "This is an effect of music therapy".

Many sessions followed, where she gradually calmed down.

Ms. Bia had two sessions of individual active music therapy in the room as well as the psychomusical
assessment:

The shared objective was the following: a work to put his anxieties into music as well as a work to emit
"her inner cry" by transferring it to the instruments. The sessions lasted 30 minutes.

While during the assessment, she said she preferred soft and muffled sounds and music, during her
two sessions, she used instruments with a powerful sound.

With joy, she was in interaction, "in the pleasure of playing", in dialogue, creativity and improvisation.

So, she used her mediums in a high volume. She says she is satisfied that she was able to put her fears
to music, that she was finally able to "scream". She was dizzy at the end of the sessions.

In July 2015, she was transferred to the psychiatric clinic of the Park in Nantes. In agreement with the
EHPAD caregivers and her psychiatrist at the clinic, I was able to continue my receptive music therapy
sessions. They were then carried out in a remote corner of the park on a bench.

Mrs. Bia was more and more peaceful, even happy. She died a few weeks later at Bellier Hospital in
Nantes.

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 E. Accompanying the person at the end of their life.

1. Preface.

Through receptive music therapy with verbalization, I am actually at the heart of my subject. It is an
additional privilege for me to accompany people during their last moments. For the person it is a strong
experience of life, with its feeling, and which particularly needs to be heard, recognized, met.

As Thierry Tournebise stresses: "The collapse of the "I" shows an unbearable emptiness (...) it is then
more appropriate to nourish the Self, by validation, leading to noble senescence".

To the question "what is dying in peace? "When someone goes on a long trip, he generally likes his
house to be clean and tidy, doors locked (so as not to be burgled), gas and electricity turned off (so
that there is no devastating accident). Likewise, at the approach of the end of his life, the person needs
to find himself whole, reconciled as possible with the "amputated" parts of himself, to be in
senescence, the existential stage, to be himself.

2. Fairy-tales, testimony, beliefs.

Here is a little story: the average age of a human being is about 90 years, the age of a fetus: 9 months.
Imagine that the fetuses, in their mother's womb, have mobile phones to communicate with each
other. There are so many things to tell each other (cf. Gestalt ISO) throughout their life as fetuses. But
there comes a time when one of the interlocutors feels pushed into a narrow tunnel, the phone doesn't
go through, and then the whole fetus community never hears from him again: he has disappeared.

In Brittany (for example), before the inventions of radio and television, people gathered for vigils, and
during the “black months”, i.e. October, November and December, stories were told about death.
Anatole Le Braz (1859-1926) collected them in his book “The Legend of Death”. There are the intersign
(between the world of the living and the world of the dead), the character of the Ankou...

There are many accounts of near-death experiences (NDEs). They are people declared clinically dead
who come back to life (not having been until the end of the experience all in all). The first book of
Doctor Raymond Moody (born in 1944), doctor in philosophy and psychology as well as doctor, is a

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collection of testimonies of people saying to have lived a NDE. He collected them during more than 20
years all over the planet. All the testimonies corroborate themselves on, for example, the fact of a de-
corporation, of being drawn into a dark tunnel towards a brilliant light...

His first book “Life After Life” was published in 1977. Since then, many people have testified to their
own NDE, such as the music therapist Martina Niernhaussen in her book “Du premier cri au dernier
souffle”. The few people who have made this NDE, whom I have met, have all changed their lives, in
order to put themselves, in their own way, at the service of others, so that their “doing” becomes at
the service of their “being” (and no longer the opposite).

I will mention only two beliefs:

Among the Amerindian people, Black Elk tells us, if the Spirit finds itself in the vast expanses of eternal
hunting, the Body, decomposing, joins, unites with the elements of Nature, we find it in the blade of
grass, the wind, the buffalo, the river... and by these vectors, becomes immortal; hence the sacred
importance of the Land of Ancestors.

In Tibet, the soul makes a long and perilous journey before reincarnating or better hope to be freed
from the wheel of successive incarnations. The Tibetan Book of the Dead, Bardo Thödol tells of this
journey. “Bardo” means interval, “Thö” means hearing, and “Dol” means liberation. The French
composer of electroacoustic music, Pierre Henry (born in 1927) put this book into music in his work
“Le Voyage” in 1962.

3. Means.

As a specific means, I use the person's first name, alone, singing on a sanzula background, or singing it
preceded by a “thank you” as the only word, with a vowel song. Indeed, the sound of the person's first
name has accompanied him intimately throughout his life, in good and bad days. This can help him, in
Ariadne's thread, to come together, to resolve his phase of integrity (cf.: Naomi Feil), to enter the
senescence by finding a unity of the Self (cf.: Tournebise).

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 4. Therapeutic pathways.

a. Mrs Hoa.

a1: Therapeutic alliance, beginning:

Mrs. Hoa was in bed. She is a person who spoke Breton for a long period of her life and, when she was
awake, she could speak half-Breton, half-French and.... half invented vocabulary. Knowing some words
and expressions in Breton, I came, at the beginning of January 2015, to wish her all the best in this
language30. It woke her up and she started talking to me.

a2: As the sessions progressed:

During 4 months, in cumulative time, we worked 1 hour.

There were three. I had asked the chapel master of Sainte Anne d'Auray, scores of hymns in Breton
usual in the 30’s. The sessions lasted 20 minutes. The greetings at the entrance and exit were in Breton.
I played to her, with her permission, Breton tunes with flutes (hymns, dances, complaints), she was
very attentive, sang with me certain tunes, smiled, calmed, her glance in mine.

b. Mrs Giu.

b1: Therapeutic alliance, beginning:

I think she started before the sessions, when she was alert. I often met her, and with happiness, we
took the time to share on relatively deep subjects, that is to say in the meeting, the sharing of ideas on
human relations, life, death, the beauty of what surrounds us and which passes unnoticed....

b2: As the sessions progressed:

During 15 days, in cumulative time, we worked 1 hour.

There were two 35-minute sessions. During the first one, I was alone with her. She showed me her
physical suffering. I played the sanzula to him with an improvisation of vowel singing, as well as soft
tunes on flutes. She beat the measure, gradually calmed down from her expression of pain, abandoned
herself.

30
Here is this phrase (I only learned Breton orally): “bléa mat a souhaitant dor, yaa, prospériti, é baradoz i feign
a gou bué”

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During my game, she looked into mine with intensity holding my hand strongly.

During the second, I found myself with family members. I asked if I could do my session. The
atmosphere was heavy at the beginning, then as I played, Mrs. Gia showed enthusiasm and applauded.
I proposed the sanzula to her daughter-in-law, who played it, tears in her eyes, she was also applauded
by all. When I left, the atmosphere in the room had become more serene, more peaceful.

c. Mrs. Puo.

c1: Therapeutic alliance, beginning:

Mrs. Puo, from the “Village” unit, sent the caregivers back dry and refused to eat. The alliance was
discovered when we recognized ourselves as being from the same town (50 years apart) and her
husband worked in the same place as my grandfather and father.

c2: As the sessions progressed:

During 2 months, in cumulative time, we worked 1 hour and a half.

We had three 30-minute sessions. I played songs softly on the flute of the time when she danced a lot
(pieces by Tino Rossi, Edith Piaf, Lucienne Delyle, Charles Trenet, Maurice Chevalier... following what
she wanted in my proposals). She was humming with me. We had many verbal exchanges about happy
memories, she was smiling, in peace and confided to me what tormented her (that I allowed myself to
transmit to the team). Having had her answer in the following sessions, she was at peace and enjoyed
the peace and laughter of her sessions.

d. Mr. Lao.

I already had him as an individual active music therapy patient. I followed him for three sessions of
receptive music therapy. The sessions lasted 30 minutes.

My sanzula playing resumed, by improvised song, the stages of his life, embroidering on the pleasant
memories he had entrusted to me. He smiled in those moments and his gaze was in mine. When his
breathing became painful, with complaints, I began to play on the sanzula, improvising a melody sung
on his first name, his breathing then calmed down. He was in a receptive listening mode. Moments of
silence, in non-verbal communication together, punctuated the sessions. He seemed to calm down.

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 e. Mrs. Baé.

She has also been a patient in individual active music therapy. It was at the “Pierre Mara” unit, in the
evening, that a caregiver invited me to see her because she had had a difficult day. Her communication
had been closed for several days. The session lasted 40 minutes.

She welcomed me, I began with an improvisation of song on the sanzula. We exchanged verbally. Then
I made the “song” of the Tibetan bowl resonate on her, she appreciated it. Then during the rest of the
session, she improvised in singing vowels with me, also singing, against a sanzula background. My
accompaniment has been structured, melodic and progressive, and she has invested herself more and
more in improvised singing. It lasted 30 minutes, her singing was more and more creative and
elaborate.

This is what I called “her swan song”, in reference to the eponymous sonata D 957, by Franz Schubert
(1797-1828). I left her well calmed and happy.

The next day, she spoke again with the caregivers in a state of wakefulness and calm, as well as the
evening before. Two days later she died.

f. Mrs. Buo.

If Mrs Baé's accompaniment had lasted one session, Mrs. Buo's was a series of ten sessions. After
fifteen days in bed, no longer communicating, hardly eating, her body and mind were sinking. So, the
medical team called for music therapy accompaniment.

f1: Therapeutic alliance, beginning:

It was quickly built, because to her surprise, I joined her in his mode where she was. That is, it was in
a severe form of aphasia, called verbal automatism, consisting in quickly and constantly repeating the
syllable “ma” in a large volume. She alternated with “please” continuously.

I copied, eyes in eyes, her verbal automatism, with the same volume, then little by little introduced
some light melodic nuances, thus opening her the possibility to leave her mode.

When she was in the “please” mode, her hand in mine, I would echo back to her “I'm here”, trying to
install a reassuring frame. This two-door entry protocol was repeated at the beginning of each session
and also during the sessions, then gradually faded, always within the time she deemed necessary.

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 f2: As the sessions progressed:

For 7 months, in cumulative time, we worked 8 hours.

The sessions started at 7:30 pm and lasted 45 minutes. After the communication protocol, words or
phrases were repeated. I was reformulating them. A time was also reserved for receptive music
therapy on Breton canticles, played on the wooden flute, which she listened attentively with obvious
pleasure and attention. She took my hand and stroked my face, touching the instruments I was playing.

Then I would repeat the words and phrases she had said in improvised singing on a sanzula background,
and this would lead to other words on her part.

At each session, these words and phrases constituted a particular moment in his story, which I thus
validated. At times, these stories agitated her at the beginning, then at the end of my validation, she
would fall asleep, in peace, to the sound of the Tibetan bowl fainting, or on a sanzula background, on
an improvised song on her first name alone or preceded by a “thank you”.

The penultimate session, she was very weak, but conscious, and at the end of the session, she turned
to me, and with her able eye offered me a look filled with recognition and gratitude.

The last session took place during what doctors call the rales of agony. It was in the presence of family
members. I asked her son to put on her hearing aid and did a regular session. The variations of his rails
and silences, listening to me, corresponded to the different periods of sessions that we had shared.
She died two days later, in great peace, according to her family.

g. The very last session of music therapy, accompaniment of the end of life, the
inhabited silence.

g1: The establishment’s procedures:

When a resident dies, the room is cleared of any care system. A small electric night light is lit on the
bedside table, with some of the person's favorite and symbolic objects. A thanatopractor, partner of
the EHPAD, comes to prepare the person with great care and dignity (one is far from the death mask).
Flowers are often present as well as chairs. The locked room has become a “burning chapel”. The
family, friends but also the caregivers of the unit come to mourn.

Then, the funeral directors arrive, also partners of the EHPAD, and remove the body, surrounded by a
silent hedge composed of the family, the care-givers and some residents. Most of the time, the

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ceremony takes place in the church of Saint-Herblain. Residents generally have this reaction “it's not
my turn yet, not this time”.

g2: The very last session:

This is my Instrumentarium of inhabited silence.

It is composed of two practices that I have been doing for a long time:

Zen, which specifies that, in the mind, the thoughts that arrive must neither be rejected nor held back.

And the oration I've been practicing since I was seven. Practice where I always feel in the “beginners”.
In addition to the people who guided me along this path, I relied above all on two works: “The cloud
of unknowledge” written by an anonymous person in the 14th century, and John of the Cross (1542-
1591), reformer of the contemplative religious order of Carmel, with Therese of Avila. John of the
Cross, therefore, wrote a whole journey for the practice of prayer in three works: “The Rise of Carmel”,
“The Dark Night” and “The Bright Flame of Love” where, step by step, he shows how the soul gradually
detaches itself from “its affects (carnal and emotional)” then from “its will, its understanding and its
memory”, in order “to wait to fly away, in abandonment and confidence towards the encounter of the
Tout-Autre”.

Then, during the last session, in a time slot where I could be alone with the deceased person, I tuned
my thoughts on what we had lived together, in gratitude, in silence, centered.

F. Mini-conclusion.

So many wonders!

According to Carl Jung: “What man lacks is intensity.”

I think that the patients shared moments of intensity (through their speech, but especially through
their non-verbal expressions). All these therapeutic pathways, step by step, in their participation in
music therapy workshops, helped facilitate their personal senescence work. They opened themselves,
each in their own way, to the impulse of life, to the existential flow.

This was again demonstrated during the last sessions which will be described in the following section.

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 VI. End of the work in music therapy.

A. Last sessions of individual music therapy.

1. Preface.

It is important to put an end to therapeutic support. This is what I did when I went to their room to
propose a last session to the patients with whom we had worked in various workshops.

2. Mr. Moï.

In his room, I sing, in improvisation, a summary of the work done together with my thanks, with a
sanzula background. There are signs of non-verbal communication of emotions on his part. I ask him
to accompany me on his favorite instrument (a tambourine and his stick, belonging to the “animation”
department of the EHPAD), lying on his bed, he then gets up, takes the tambourine and the stick and
puts them away on his bedside table, behind his sailor photo.

I talk about it to his referent, who keeps it for him to try.

3. Mrs. Néü.

The session lasts one hour. She's happy, even a little euphoric. Her playing is fast, in listening, she
succeeds in reducing the cadence. There is a lot of interaction, laughter, closed mouth singing. Her
improvisation is rich. We leave by thanking each other.

4. Mrs. Mui.

According to the caregivers, she had no taste for anything during that day... She welcomes me warmly
and enthusiastically and quickly interacts in the instrumental playing. She changes instruments herself.
She is even more creative (in timbre, volume, innovation, rhythm, improvised singing of vowels...) She

113
is listening to my support game. The session lasts an hour and a half! (I had warned her at the beginning
that, for this session, she was master of time [all the same under my discreet control]).

She says that it has done her a lot of good, a lot of life, and expresses the desire that another music
therapist quickly replaces me.

5. Mrs. Gaâ.

The session lasts an hour and a half, with the same word from me as before. Her physical state has
deteriorated. We then find other instrument positions and other ways of playing. Her eyes are intense.
There are melodious, inventive and fair interactions on his part, time seems suspended. Then,
according to his desire, I switch to receptive music therapy. On an improvised song with a sanzula
background, she shows non-verbal signs of emotion.

6. Mrs. Dui.

The session lasts one hour and is divided, according to her desire in two parts: the first in active music
therapy where she shows creativity in a complicit game, the second in receptive music therapy, her
look is bright, she is full of smiles, letting escape “how beautiful it is”.

7. Mrs. Gaï.

The session lasts 45 minutes. After a very warm welcome, she asserts herself in the choice of
instruments and finds her own way to play on new mediums for her. Then begin the interactions in
our sound game. She shows non-verbal signs of joy, she dances on her armchair, looking awake, during
the receptive music therapy of the second part of the session.

8. Mr. Poé.

The session lasts 15 minutes. The disease has changed a lot. I offer him receptive music therapy on his
privileged instruments. Awake but eyes closed, hearing that this is the last session, he opens his eyes
wide and plunges into my gaze, fixed on the instruments I play with a sketch of a smile. I end with a
song recapitulating the work done on a sanzula background. His gaze is expressive.

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 B. Mini-conclusion.

On February 14, 2016, I returned my badge and pass. The time of my music therapy contract was over.

The link has been maintained in various ways. I invite you to discover them in Annex 2, called “fixed-
term post-contract”.

VII. General conclusion.

This conclusion develops in two complementary optics: a first, rather analog, shows the stakes of
senescence; a second, rather digital, shows the important points of the contribution of music therapy
to the Elders, suffering from severe cognitive disorders, in EHPAD, being in this stage of their life.

I come back to the fruits of Naomi Feil's painting, based on Erikson's work, about misdirected elderly
people. At each stage of his life, each human being fights intimately to reap the following fruits: Hope,
Will, Exploration, Competence, Fidelity, Love, Care, Wisdom.

With this in mind, I return to the organicism I mentioned in the introduction, but this time in two
different areas:

▪ In philosophy: according to Plato (-428; -348), reality can be better understood if it is

seen as an organic whole.
▪ In sociology: born in the 19th century, it consists of an approach to society which, by
analogy, is compared to a living organism for its organization and functioning, and of
which human beings are the cells.

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Each human being, in each stage of his/her growth, has thus worked specific moments, decisive stages.
Through this particular and unique work, in a society seen as a living organism, everyone can help
her/his fellow human beings, whatever the time of his/her growth they find themselves, by simply
sharing with them her/his own experience, hoping that they can benefit from it. Often, it will be better
if this experience is shown in the behavior rather than transmitted in the speech.

There is a trend that works very well today: it is the search for “well-being”. Wouldn't this lucrative
trend hide a deep “malaise”, or more simply a lack of “being”, with a headlong rush into “doing”?

With senescence, the existential flow of life has the possibility to liberate the unified Self, in order,
finally, to be. I think that the Elders, having the best possible success in their individuation process, can
thus find a determining role in the social bond, by sharing their experience.

Today, in our so-called modern societies, the majority of people are pushing back this step. They then
try to fill the void it creates if it is not assimilated, by all sorts of means, sometimes more or less
destructive.

Silence and being alone are, from this point of view, not terrible enemies, but allies.

I am used to comparing the evolution of humanity to a man's life. Certainly, at the moment we are in
crisis, but in my opinion, its visible and painful effects are the symptoms of a deeper crisis, the crisis of
adolescence of humanity.

If we don't destroy ourselves, we still have time until the senescence crisis!

Still in sociology, in our culture, we have gone from a holistic conception to modern individualism, to
the Renaissance. It is from this time that the artists signed their works by name. After a few hundred
years, we find ourselves trapped in individualism, in the ego, with its share of suffering.

Wouldn't it be time, not to return to a holistic conception, but to get the best out of it and move from
individualism to the individuation process?

Thus, in a unique and particular way, differentiated, we will be able to find the bond which unites each
human being and in a true and non-violent confrontation, to arrive at a complementarity.

Utopia? Maybe. Possible path? Probably.

From my experience, enriched by this fixed-term contract, I have noticed that the poorest people, in
whatever field, are precisely the cornerstones of this new social construction.

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In this program, music therapy shows all its effectiveness and its specificity. Indeed, making music
therapy a therapeutic choice in EHPAD means recognizing the person as a subject in his own right and
not just as a patient. It is also to introduce an alternative to medicalization that reinforces this idea of
pathology.

Moreover, using the mediating object that is music promotes and allows the emergence of pleasure.
The pleasure of feeling your body working, vibrating. The pleasure that breaks down the barriers of
anxiety allowing play and creation.

Similarly, offer old songs to initiate pleasure and let go. They directly affect the person's emotional
memory and inevitably bring back memories that allow the person to identify and find themselves.

Group care has helped to restore patients' self-esteem through mutual recognition and has given rise
to an activity and thus a social role that has hitherto disappeared. It is indeed the adaptation to the
rhythm of the other that allows them to register as a full member of the group. It is taking it into
account to take part. And it is by regaining a social place that we exist and thus regain our dignity.

The practice of music therapy mobilizes the faculties of listening, perceptive and cognitive, to express
themselves individually and collectively in the joy of creation and thus achieve a production in which
everyone recognizes himself.

Through their involvement in the various workshops, they have learned to be less defined by others to
reacquire free will. Together, they have gone from disorder to order, passing through the fundamental
stage of the right to error.

However, this work legitimizes the music therapy workshop in EHPAD because it once again allows
patients to project themselves, to express themselves and thus to reinvest their lives.

Finally, it leaves open questions that can serve as a basis for work. Wouldn't music help give
performances to people who might no longer have access to them?

This fixed-term contract allowed me to appreciate this therapeutic tool more and more and to begin
to find my own specificity as a music therapist. Through supervision, however, I clearly saw that I lacked
experience, by not bouncing directly and adequately on messages sent by the patient. I hope that time
will remedy that.

I end by leaving the floor to Khalil Gibran (1883-1931) Lebanese poet and painter, whose words have
for me the sound of the waves (which crossed many storms) vanishing on the sand:

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“Music is indeed the language of souls, and melodies are wild breezes that make the strings of the heart
vibrate. She is those subtle fingers that knock at the door of our senses and awaken the memory that
then exhume strong events from her past that the nights had buried.

She is these subtle melodies which, if they are sad, bring to mind memories of tragic moments, or, if
they are joyful, memories of moments of serenity and joy. (…)

Music is a body made of last breath, whose soul is made of breath and the mind is made of heart.”

“You'd like to unlock the secret of death. But how else will you find him if you search for him in the heart
of life? (…)

For life and death are one, just as the river and the ocean are one. (…)

Your fear in the face of death is nothing but the shepherd's trembling when the king does him the honor
of receiving him and putting his hand on his head.

But when he goes to receive the king's insignia, doesn't the shepherd know that a shiver of joy is already
awakening under his fear? (…)

Only when you have drunk at the river of silence, then you can truly sing. And when you reach the top
of the mountain, you will begin to climb. And when the earth claims your members, then you will finally
know how to dance.”

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 Bibliography.

- Albou Philippe: “Evolution of the concept of dementia”, The practician’s journal,

2005, vol.55, pp 1965-1969. french

- Anonymous from the 14th century: “The cloud of unknowing and the book of privy
counseling.”, Garden City, N.Y., Image Books, 1973.

- Badey-Rodriguez Claudine: “The elderly in institutions, life or survival”, Seli Arslam edition,
Paris, 1997. french

- Benenzon Rolando Omar: “Music Therapy Manual“; Springfield, Ill. : C.C. Thomas,1981.

- Camp Cameron: “The Montessori method adapted for people with dementia”, training
booklet, Hearthstone Alzheimer Care, 2009.

- D’Ansembourg Thomas: “Stop being nice be real”, l’Homme edition, 2001. french

- Deshimaru Taisen: “Zen pratice“, Albin Michel edition, Spiritualités vivantes collection, 1981.
french

- Deshimaru Taisen: “The bowl and the stick”, Albin Michel edition, Spiritualités vivantes
collection, 1986. french

- Dumont Jean Paul: “Ancient Philosophy“, Presse Universitaire de France edition, 1962. french

- Feil Naomi: “Validation : The Feil Method : How to help Disoriented Old-Old.” Cleveland : E.
Feil Productions, 1982.

- Feil Naomi: “The Validation Breakthrough : simple techniques for Communicating with People
with Alzheimer's And O.”, 3rd ed., Baltimore : Health Professions Press, 2012.

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- French National Association of Ergotherapists: “Activity and the elderly person”, Chronique
Sociale edition, 1982. french.

- Freud Sigmund, “The Basic Writings” , New York, The Modern library, 1938.

- Gibran Khalil: “The Prophet”, New York : Knopf, 1952.

- Jalmalv: “Accepting our differences”, magazine of the federation ‘Jusqu’à la Mort

Accompagner la Vie’ (Until death accompanying life), n°58, 1999. french

- Jankélévitch Vladimir: “Music and the Ineffable”, Oxford : Princeton University Press, 2003.

- John of the Cross: “Ascent of Mount Carmel”, London : Burns & Oates, 1983.

- John of the Cross: “Dark Night of the Soul”, 3rd rev. ed. Garden City, N.Y. : Image Books, 1959.
- John of the Cross: “Living Flame of Love”, London : Burns & Oates, 1977.

- Jollien Alexandre ; « Praise for weakness », Cerf edition, 1999. french

- Jung Carl Gustav: “Analytical Psychology”, rev. ed. Princeton : Princeton University Press, 2012.

- Krishnamurti Jiddu: “The First and Last Freedom” ; with a foreword by Aldous Huxley, New
York : Harper & Row, 1975.

- Lama Anagarinka Govinda: “Bardo-Thödol”, The Tibetan book of the dead, or, The after-death
experiences on the Bardo Plane, according to Lāma Kazi Dawa-Samdup's English rendering /
by W. Y. Evans-Wentz ; with a psychological commentary by C. G. Jung; 3d ed. London : Oxford
University Press, 1957.

- Le Braz Anatole: “The Celtic Legend of the Beyond” ; Llanerch, Wales : Llanerch Enterprises,
1986.

- Lecourt Edith: “Introduction to group analysis”, Erès edition, Transition collection, 2008. french

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- Leloup Jean-Yves: “Taking care of yourself, Philo and the therapists of Alexandria”, Albin
Michel edition, Spiritualités vivantes collection, 1993. french

- Lemarquis Pierre: “Serenade for a musician brain”, Odile Jacob edition, Pocket, 2009. french

- Levitin Daniel: “This is your Brain on Music : the Science of a Human Obsession”, New York,
N.Y. : Dutton, 2006.

- Maisondieu Jean: “The twilight of reason”, Bayard edition, 1989. french

- Moody Raymond: “Life after Life : the Investigation of a Phenomenon - Survival of Bodily
Death”, Harrisburg, Pa. : Stackpole Books, 1976.

- Mordillat Gérard: “The true Hamlet”, Grasset edition, 2016. french

- Niernhaussen Martina: “From the first cry to the last breath”, Archipel edition, 2011. french

- Psychologie Québec: “The therapeutic alliance“, magazine de l’ordre des Psychologues du

Québec, vol.28, n°02, pp. 20.39, mars 2011. french

- French Journal of Music therapy, “Alzheimer's dementia, communication and music therapy”,
magazine published by the French association of Music therapy, vol. XXXIII n°3, pp. 4-64,
octobre 2013. french

- Rivernal Colette: “Music, therapy, entertainment”, Chronique sociale edition, 1996. french

- Rogers Carl Ransom: “A Way of Being”, Boston : Houghton Mifflin, 1980.

- Rouget Gilbert: “Music and Trance : a Theory of the Relations between Music and Possession”,
Chicago : University of Chicago Press, 1985.

- Rosenberg Marshall: “Living Nonviolent Communication : Practical Tools To Connect And

Communicate Skillfully In Every Sit”, Boulder, CO : Sounds True, Inc., 2012.

- Salomé Jacques: “Be you when you speak”, Pocket edition, 2005. french

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 - Tournebise Thierry: “Therapeutic listening”, ESF edition, 2001. french

- Tournebise Thierry: “The psychotherapist's ledger”, Eyrolles edition, 2011. french

- Verdeau-Pailles Jacqueline: “The psychomusical assessment and personality”, Fuzeau edition,

2005. french

- Wigram Tony: “Improvisation, Méthods and Techniques for Music therapy Clinicians,
Educators and Students” Jessica Kingsley publishers, London and Philadelphia, 2004.

- Winicott Donald: “Playing and Reality”, London : Tavistock publications, 1971.

Websites:

How music meets science?

https://www.dailymotion.com/video/x1cfbbb

Michel Bernier: Respect for the dependent elderly person in an institution:

http://www.cairn.info/revue-vie-sociale-et-traitements-2005-2-page-116.htm

The despair of seniors in retirement homes:

http://www.lefigaro.fr/actualite-france/2014/01/21/01016-20140121ARTFIG00503-ladesesperance-
des-seniors-en-maisons-de-retraite.php

The admission of the resident to the EHPAD:

http://www.longuevieetautonomie.fr/sites/default/files/editor/files/stories/CAPACITE2011/ehp
ad/admissionehpadsr.pdf

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Collective accommodation for the elderly, Dominique Argoud, sociologue CLEIRPPA:
https://www.uclouvain.be/cps/ucl/doc/aisbl-
generations/documents/RevueGenerations10_11_12p19.pdf

The Montessori method adapted to dependent elderly people:

http://www.psppaca.fr/IMG/pdf/montessori_2015_domicile_uriopss_-_stagiaires.pdf

Alzheimer's allegros:
https://www.youtube.com/watch? v=s815lcfd5K8

The song of vowels:

http:// www.slog.fr/guycorneau/266/1/112

Moussard Aline, doctor thesis: « The use of music as a medium for new learning in normal aging and
Alzheimer's disease», 2012:
https://tel.archives-ouvertes.fr/tel-00795055/document

Nada Yoga: Indian Healing Technique:

https://voices.no/community/?q=country/monthindia_march2005b

Stéphane Guetin: Interest of music therapy on anxiety, depression in patients with Alzheimer's
disease:
www.encephale.com/content/download/86985/1520343/.../1/.../main.pdf.2008

More explanation on Benenzon’s theories:

https://www.benenzonacademy.com/philosophy

Music therapy increases serum melatonin, 1999:

http://www.ncbi.nlm.nih.gov.pubmed/10550905

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Trade sheet of the French Federation of Music therapy:
http://mediatheque.citedelamusique.fr/mediacomposite/cim/_Pdf/30_60_30_ReferentielMusicothe
rapeute .pdf

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Appendices

1. Non-violent communication.

2. Post work-placement period.

3. Study of a background music, for the group, based on the resident(s).

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 Appendix 1: list of needs and feelings in non-violent communication.

I. Foreword.

The Center for Nonviolent Communication (CNVC) is a non-profit organization founded in the United
States in 1966 by Marshall Rosenberg, PhD in Clinical Psychology, a student of Carl R. Rogers. Here is
the general principle:

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 II. List of needs.

SURVIVAL AUTONOMY

Shelter
Self-affirmation

Air
Self-empowerment

Water
Choice, to decide for oneself

Movements, exercises
Independence

Rest, continuity
Freedom

Security, protection
Solitude, quiet, peace, time / personal space

FOOD (large sense) INTEGRITY

Affection Authenticity, honesty

Heat Goal, direction, knowing where to go

Comfort Knowledge of oneself

Sweetness Determining values, dreams, visions

Relaxation, leisure, pleasure, hobbies Balance

Sensibility Self-respect

Care, attentions, presence Rhythm, integration time

Tenderness Sense of one’s value, one’s place

Touch

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 OF SOCIAL ORDER

Acceptance Expression

Friendship Honesty, transparency

Love, affection Independence

Belonging Privacy

Appreciation Sharing, exchange, cooperation

Communication Presence

Company Proximity

Consultation Receive

Confidence Recognition (resonance, echo, feedback)

Connection Respect, consideration

Contact Security (reliability, rely on, confidentiality, discretion,

stability, loyalty, permanence, continuity, structures,
Giving, serving, contributing
benchmarks...)

Listening, understanding, empathy

Support, assistance, help, comfort

Equity, justice
Tolerance, acceptance of difference, openness

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 SELF EXPRESSION MENTAL ORDER

Accomplishment, realization Clarity, understanding (through thinking,

discernment, experience)
Action
Coherence, adequation
Learning
Concision

Creativity Conscience

Exploration, discovering
Growth, evolution, actualization,
development, healing Information, knowledge

Precision
Creating, being cause for smth, participate

Simplicity
Control
Stimulation

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 OF SPIRITUAL ORDER CELEBRATION OF LIFE
(welcoming life in its stages and different aspects)

Love
Communion

Beauty, aesthetic sense

Grief, loss

Trust, let go
Fete, a desire to experience the intensity of life by
Hope oneself

To be Humor

Purpose Play

Harmony Birth

Inspiration Giving grace

Joy Ritualization

Order

Peace

Sacred

Serenity

Silence

Transcendence

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 III. List of feelings.

Feelings we have when our needs are met:

Absorbed Curious Harmony (in) Quiet

Adventurous Dazzled Hot Radiant
Affected Delighted Impatient Reassembled
Affection (full of) Detached In love Reassured
Aghast Disposed to help Over the moon Recognizing
Alert Dizzy Inflated to block Refreshed
Alive Drive (full of) Inspired Rejoiced
Amazed Ecstasy (in) Interested Rejoicing
Amused Effervescence (in) Intrigued Relaxed
Animated Electrified Involved Relieved
Appreciation (full of) Emotional Joy (overflowing) Revitalized
At ease Encouraged Life (full of) Satisfied
Attentive Energy (full of) Lighthearted Secure
Awakened Engaged Lightweight Self-satisfied
Beaming Enthusiasm Love (full of) Sensitive
Blissful Exalted Love (in) Sensitized
Boosted Expansion (in) Mad with joy Serene
Brightened Expansive Cheerful mood (in a) Shaded
Calm Expectative (in the) Mischievous mood (in a) Shocked
Captivated Exuberant Near Softened
Carefree Fascinated Nice to meet you. Sparkling
Centered Filled Nourished Stimulated
Charmed Filled with hope On the alert Stunned
Cheerful Flamed Optimistic Surprised
Cheering Free Overexcited Tenderness (full of)
Comfortable Friendly Packaged To the angels
Comforted Galvanized Panting Touched
Compassionate Gay Peace (in) Transported with joy
Concentrated Good mood (in a) Peaceful Well-rounded
Confident Gratitude (full of) Pleasure (experiencing)
Courage (full of) Happy Proud

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 Feelings we have when our needs are not met:

Affected Demoralized Ground Nervous Suspicious

Afflicted Depressed Guards (on his/her) Out of stock Taciturn
Afraid Deprived Hateful Overwhelmed Terrified
Aghast Disappointed Heavy Panicked Thirsty
Agitated Disassembled Hesitant Panting Tired
Alarmed Disconcerted Horrible Passionate Tormented
Alone Discouraged Horrified Perplexed Torn
Angry Disgusted Hungry Pessimist Troubled
Animosity (full of) Dissatisfied Impatient Pissed Unbelieving
Annoyed Dismayed Indifferent Resentment (full of) Uncomfortable
Anxious Distrustful Indolent Reserved Undecided
Apathetic Disturbed Inert Reticent Unhappy
Apprehension (full of) Down Insecure Saturated Unsettled
Aversion (against smth) Eagerness Insensitive Scared Unstable
Being tired of smth Embarrassing Interested Shaken Upset
Bitter Envious Intrigued Shaking Vexed
Blocked Exceeded Irritated Shocked Vulnerable
Broken Excess Jealous Skeptical Warm
Broken heart (having a) Excited Jitters Softened Weary
Chagrined Exhausted Lazy Sorrowful Wore out
Concerned Fearful Lethargic Sorry Wounded
Confused Fragile Low moral Stretched Wrathful
Curious Frustrated Melancholic Submerged
Dark Furious (mad) Morose Suffering
Dark Mood Gloomy Mortified Surprised

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Feelings including interpretations and judgments:

(The following words are often used as feelings when in reality they are judgments or interpretations
of what someone else is doing to us).

Abandoned Discounted Loser Repeated

Abused Disregarded Manipulated Ridiculed
Accused Dumped Minorized Ripped off
Attacked Duped Mollycoddled Scammed
Beast Forgotten Neglected Shortchanged
Betrayed Guilty No value Smothered
Blame Harassed Not accepted Spread
Bluffed Hated Not heard Stolen
Caged Humiliated Not important Stupid
Cornered Ignored Not liked Threatened
Crushed Inappropriate Not raw Thrown
Deceived Incompetent Not wanted Trampled
Decreased Insulted Null Trapped
Defeated Intimidated Overworked Treaded underfoot
Denied Invisible Protected Ununderstood
Despised Isolated Put under pressure Unworthy
Devalued Judged Raped Used
Dirty Left behind Redone

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 Appendix 2: Post work-placement period.

I. Invitation for professionals.

For all of those who want to try out music

therapy:
(every participant of the smooth running of “La
Bourgonnière” is welcome)
See dates, hours, location, program and registration on
“Sandrine’s” bulletin board

- no need to “know” how to sing or “be a musician”, the instruments

offered are simple to use and easily rewarding
- for the employees of the EHPAD, this hour and a half will be
recuperated.

INVITATION
A MINI OF MUSIC THERAPY - SEMINAR FOR AN INTRODUCTION TO THE
PRACTICE
It is opened to every participant of the smooth running of “La Bourgonnière” who wishes
and has the time (this hour and a half will be recuperated).

WHEN?
Monday, 8th February or Thursday, 11th February from 14:00 to 15:30 (please
register in advance, in order to balance the groups)

WHERE?
Grande salle polyvalente

WHAT?
- Co-construction of a silence bubble
- Interactive games of sound communication, improvisation of seeing or body
percussion (the ‘4 by 4’);
- Short presentation of various instruments (27…);
- Choice by each participant of their favorite “medium”;
- Through games, experimentation of clinical improvisation techniques:
“imitation”, “reflexion”, “question/answer”, “ostinato rhythm accompaniment”,
“evolutionary structured accompaniment”;
- homage to the people I helped to accompany at the end of their lives (their
favorite tunes played on the flute);
- goodbye drinks, exchanges.

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Of the two sessions, 25 professionals came. Others would have liked to come, but their schedules did
not allow it. Others did not want to.

All functions (except for Nurses) were represented: full Board of Directors, Director, Executive
Secretaries, Logistics Manager, Health Executive, Coordinating Doctor, Psychologist, Medico-
Psychologic Assistant, Assistant Care-givers, Orderlies, Facilitator.

After a beginning where the hierarchy was slightly felt, everyone, to their measure, played the game,
more and more freely.

My instrumentarium had been enriched with instruments requiring less easy handling (water drum,
chickadee call, Indian tablas, rain stick, thunder tube, rattle, kalimba etc....)

The tools of clinical improvisation were experimented in a circle for imitation, reflection, question-
answer, where one person chose another to answer the worked mode.

In a circular arc for the rhythmic ostinato, which I played with Indian tablas. The same goes for the
evolutionary structured accompaniment, which I played on the flute, going to see each participant, one
by one, who continued to play. There were, for these two practices, phenomena of sound group, with
creativity and joy.

Then, after the moment of sharing, the participants spoke about this workshop to their absent
colleagues.

II. For the residents of the “Village” unit.

Friday, 16th February

Lunch time:
CONCERT MEAL
On the theme of travel
- through time
- visiting countries from the world

By Thierry, the music therapist intern, whom you have been seeing carrying his
bags and walking around with his coat rack…

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Having finished my work as a music therapist, I took on the role of facilitator during this peculiar time.

This concert took place at the residents' restaurant. Indeed, I had established special contacts with
them and they often wondered what my role was.

Sometimes, during gatherings in the "village square" before dinner, I played for them, improvised
songs, on the sanzula, for a short moment. Or, in front of some residents sitting by the elevator, seeing
me come and go again with my bags, I would open them and make some instruments chime. No more
than that.

This concert was mainly to thank them for their welcome. The kitchen had prepared a meal tailored to
my theme. For the soft pieces, I had a microphone and when I went up in the treble, I walked between
the tables (in order to spare their ears). I took the opportunity to repeat why I had been with them for
15 months, and even, after my thanks, told them that in difficult moments, they “gave me my life
back”.

The meal was ending, but not my program, so I asked them to choose. They wanted everything, and
extended their meal time, then at the end, some stayed to exchange.

During this “concert”, I covered a few pieces that I played to patients as receptive music therapy.

Here is the program:

- “Le chant du gardian”, Tino Rossi, 1942, France.

- “Valse galicienne”, a Spanish classic, linked to “Accordez, accordéon” by Juliette Greco in 1962.
“Bal doux suivi d‘une danse rapide”, 1350, Angleterre.
- “Chant à Marie” from “Llibre Vermeil de Montserrat”, 1480, Espagne.
- “Green Sleeves” Irish classic: Renaissance style (1500) followed by a traditional dancing style
with improvisations.
- Soundtrack of the movie “Mission”, which takes place in the Amazon in the 1760’s.
- “Danse de Guadeloupe” linked to an Irish classic
- “The foggy dew”, traditional Irish ballad.
- Another traditional Irish ballad
- “Amazing Grace”, traditional Irish anthem, followed by an improvisation on the theme.
- “Porgy and Bess” by Gershwin, USA, 1934, followed by an improvisation on the theme.
- “Cantiques Bretons”, 1930.
- Two melodies from Senegal
- Two traditional dances from Israel
- Traditional lent Yiddish.

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 - Indian Raga, inspired by traditional music.
- Traditional zen music, inspired by traditional music
- “Homage”. (a traditional gentle piece)
- “Les amants de Saint Jean”, by Lucienne Delyle, 1942, France.

In small groups, at the end, singing the vowels song on the sanzula.

III. Music show of June 4, 2016.

At the same time, in my current profession, I have been the choirmaster of a choir of 16 adults with
intellectual disabilities and various associated disabilities for 10 years. This choir is called “Les Poissons
Pilotes31”.

I applied psychomusical tools and the group changed its mode of expression. Now, we work and
present "sound journeys", leaving a large place to vocal and instrumental improvisation, framed.

Each June, we offer two performances, one in a so-called protected environment and the second in an
ordinary environment. This year, the trip is "On the trail of Marco Polo", for 45 minutes.

The first performance will take place in the multipurpose hall of the EHPAD of La Bourgonnière, where
anyone interested will be welcome.

31
Some large sharks, at the top of the food chain, masters of the oceans, are guided by insignificant small fish
yet without them, these sharks get lost and die. Symbolic of the ‘caring’ importance of people with various
disabilities to our sick society (verified by experience as educators).

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 Appendix 3: Study of a background music, for the group, based on the resident(s).

I. Presentation.

This study, intended for the whole EHPAD of the Bourgonnière, is first of all experimented and adjusted
for the ‘Pierre Mara’ unit.

It has two parts:

- A music therapy angle of view that I leave, in the form of a separate file, to the unit's caregivers.
- An angle of view of the coordinating doctor and the nursing staff who will have this tool.

The care framework seconded two members of the nursing staff from the ‘Pierre Mara’ unit to manage
this project. There is a Medico-Psychologic Assistant and an Assistant Care-giver, but all caregivers are
invited to get involved.

II. Suggestions for a Soundtrack for the ‘Pierre Mara’ Unit – from a Music therapy Angle.

The following, provides an overview of an internal file in the institution:

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SUGGESTIONS FOR A SOUNDTRACK

FOR THE ‘PIERRE MARA’ UNIT

MUSIC THERAPY POINT OF VIEW

MUSIC THERAPIST INTERN

2014/2015

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Summary

I. Findings and objectives.

II. Theoretical supports:

1. On the neurosciences side.
2. Sound Identity.
3. Focus on Caregiving Empathy.

III. Implementation:
1. Recollection.
2. Data processing: creating the soundtrack.
3. Evaluation.

Bibliography

Appendices:

- Lawton Emotion Rating Scale.

- Psychomusical assessment adapted from Madame Verdeau-Pailles.

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I. Findings and objectives.

1. Findings:

During my professional fixed-term contract as a music therapist, I noticed that the sound universe in
which residents are immersed is either radio, set on the RFM station, or television.

a. On the professionals’ side.

There is no doubt about the difficulty of this work. For two major reasons:

The constant proximity of damaged people at the end of their lives. The evolution of old age, with its
disorders. Relatively high mortality. All this echoes the caregiver's own existence. Silence is associated
with death.

The difficulty of the work itself, especially in relation to the increase in GMP.

I hypothesize that ambient music corresponds to caregivers, as a defense and stimulation mechanism.

For example, in consultation with the health framework, the ambient radio has been set to FIP, but it
always returns, often at high volume, to the RFM station, with its music of today, its lively, its
advertising and information spots (giving pride of place to disasters).

In the ‘Hermitage’ unit, the television is systematically put in the individual rooms and during the meal,
in order to keep them company (television nursing). This is done with a good intention, but, in my
opinion, it indicates a transferential fear of silence on the part of caregivers.

b. On the residents’ side.

At certain times, for example when the lift breaks down, the residents on the first floor of the ‘Village’
unit eat in the small living rooms. There's one across the street from the office that was loaned to me
during my fixed-term contract. I found myself there, going to meet the patients in music therapy, I
proposed them to play them some drops of music live. When I left, I offered to put the radio back on
and the residents said, "Oh, no, then! After hearing music, we won't make any more noise.

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In my sharing with the residents, I sometimes asked their opinion on the ambient music. Each time
they answered me: "It's annoying", "it irritates me"...

At the ‘Pierre Mara’ unit, in the rest and relaxation area, I heard, broadcast by the radio, good rap my
faith, in English. That seemed inappropriate and anachronistic.

At the ‘Hermitage’ unit, after each music therapy session, I proposed to put the television back on. The
answer was unanimously negative, preferring to remain in peaceful silence.

c. The ambient music for any person being in the EHPAD of the Bourgonnière.

Staff have hours of presence where they work in the service of residents. Then he goes home and
others replace him. The resident, on the other hand, is always present and sometimes shows a need
for silence, just to find himself.

It seems interesting to me to build an ambient soundtrack, starting from the resident. It could also
allow caregivers to be more in touch with the resident, in a concept of humane attitude.

2. Objectives:

It consists, starting from the resident, of building a soundtrack, in a way individualized, promoting
pleasure, interest and/or appeasement.

This soundtrack is a tool to be used at the discretion of professionals in the organization of the day.

a. Each resident will have contributed to it, from where, by listening, they will be able to have a sense
of belonging (to the space, to the place) and a sense of recognition (to the staff, to the group).

b. This sound universe will resonate in the emotional memory of the resident, I will come back to it
later.

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c. This may also lead to inter-psychic communication, knowing that a style of music chosen by one
person will be heard by all.

d. It will avoid the trap of empathy misunderstood as "what is good for me is good for that person if
I were that person".

II. Theoretical support:

[Refer to Part IV of the report dealing with the topics covered].

Here are two related examples that illustrate the two preceding paragraphs, [Sound Identity and
Caregiving Empathy]:

o The pregnant mother listens to Led Zeppelin and/or Ozzy Osbourne, and this gives her
pleasure, energy and escape from her troubles. His fetus feels it and it is imprinted in
him (Gestalt and Cultural ISO). When he reaches a mature or even advanced age, it
will be this music that will soothe him, give him pleasure and energy.
o An autistic person will be soothed by the sounds of pipes, the ear stuck to the pipes:
Gestalt ISO, the gurgle of the pregnant mother of him.

III. Implementation.

1. Recollection:

First, meet the person individually and explain the purpose of the approach, make him/her an actor in
this co-construction of the soundtrack.

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I then propose to use the first two stages of the psychomusical assessment established by the music
therapist Mrs. VERDEAU-PAILLES (see general structure in Appendix 2, to be adapted according to the
residents):

First of all, an interview with the person and/or his/her entourage on his/her past relationship with
music: what he/she listened to, what he/she appreciated, did he/she play or his/her relatives of an
instrument? Did he/she like going to the ball?

Then propose the listening of 10 short musical extracts. For people with hearing problems it is possible
to use an MP4 or headphones as long as the collector also hears what they hear. These pieces must be
without words and not generating words, (this aiming at another objective than what it occupies us),
without too particular connotation (like typically religious music - Gregorian for example - or political
– “international”).

These are 10 extracts of 3 minutes each in a precise order, i.e. (to be understood not literally but as
“targeted tracks”):

1) “Description”: you land without being pushed.

2) “Weighing and reflecting concern”.

3) “Affective and sentimental”.

4) “Intimate and warm”, promoting communication between beings.

5) “Unusual”: according to the previous and following extracts.

6) “Soothing”, transition 1.

7) “Usual aggressive noises”.

8) “Soothing”, transition 2.

9) “Oriental”.

10) “Balanced and grand”.

(This assessment is used to direct the person to music therapy sessions that correspond to him/her,
hence the interest of resistance, leaks (defense mechanism) that are signs of lead for therapeutic work.

For the purpose sought here, we will discern only what provokes pleasure, interest, appeasement, ...

The listener will react verbally and/or non-verbally. For non-verbal communication, I suggest using the
LAWTON table (Appendix 1).

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It is true that this enumeration of styles of musical extracts may seem abscond. Here is a list, for
example, that you can listen to and experiment on yourself (3 minutes clips):

1) Gershwin: “An American in Paris”.

2) Boulez: “Notation VII”.

3) Myers: “Cavatina”.

4) Miles Davis: “Blue in green”.

5) René Lussier: “Seeking error”.

6) Anouar Braham: “Leila au pays du carroussel”, album “Le pas du chat noir”.

7) Stockhausen: “Mikrophonie”.

8) Vivaldi: “Nisi dominus”.

9) Anouar Brahem: “Halfaouine”.

10) The Lord of the Rings: “The Two Towers” II.

It is useful (but not necessary) that the excerpts are appropriate for Pierre Mara's residents (who can
echo their musical culture). I propose, as examples, some music which could constitute the 10 extracts,
then feed the soundtrack:

- Classical music (with very different styles and periods, knowing that the beginning of
the 20th century attended the trio of composers Debussy, Ravel - avoid the Bolero -
Satie)
- Film music (Ragtime, pieces composed by Chaplin, film music by Marcel Carné, by
Grangier)
- Beginning of Jazz (New Orleans’, Amstrong, Duke Ellington, Gershwin...)
- Dance music, without induced words (Charleston, waltzes, tango - Cuarteto group
Cedron...)
- And others...

The preliminary interview with the person can also give leads. But let us remain the driving force
behind the proposals without putting ourselves in their place. For example, Ms. Y enjoys the TV game
“Don't forget the lyrics”, while the majority of the songs date from the 1980s to the present day. Here
it will be music from that time to, perhaps, introduce into the list (King Crimson, Pierre Henry, Pink

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Floyd, Keur Moussa “Kora Concertantes”, the baroque organs, the Scorff bears...) In any case, once the
list is made, it is given to listen in an identical way to each resident.
The collectors can be anyone in the nursing staff provided that the resident feels confident and that
the caregiver knows him enough to know how to decipher his non-verbal language in its subtleties.

2. Data processing: creating the soundtrack:

By meeting each resident individually, the collector puts a satisfaction coefficient on each extract. A
person may prefer a "winning third party" on the list. The coefficients will be 3 to 1, with one decimal
place. A person preferring only one piece will have a maximum coefficient of 3, with one decimal. The
musical past is also important and brings a multiplier coefficient (from 2 to 1 with one decimal) on the
answers of the person.

Then can begin the construction of the soundtrack, not with the extracts but with the styles of the
selected extracts.

I propose the following construction kit:

▪ Excerpts that have provoked emotions such as fear, sadness, disgust... in a single person at
least, are prohibitive and the corresponding music styles will not appear in the soundtrack.
▪ The frequency of appearance of specific styles will depend on the sum of the coefficients given
by each person.
▪ The pieces must have a beginning and an end.
▪ Between the pieces a time of silence must be respected, for emotional digestion, resting the
brain to keep it ready and eager to hear the next piece.
▪ The tape should be neither too long (people would get lost, as well as their feeling of
recognition and belonging), nor too brief (feeling of ritornello, possible annoyance). I propose
a tape composed of pieces of 4 to 5 minutes, for 1 to 2 hours.
▪ The audio tape will be played at the discretion of the staff for as long as they see fit. The restart
will take place where the previous use stopped.
▪ Since this is group specific, if one person leaves the unit and another enters, the coefficients
are likely to be changed (by the absence of the previous person and the responses of the
incoming person).

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 3. Evaluation:

The duration of the pieces, of the soundtrack is to be re-evaluated and readjusted according to the
observations made during the first days of their diffusion.

Bibliography.

[See the corresponding books and websites in the report]

Appendices:

- [Lawton's emotion rating scale is in the report].

- Here are, in structure, parts (as an indication) of Mrs. Verdeau-Pailles' psychomusical
assessment

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Mrs. Verdeau-Pailles' psychomusical assessment:

FIRST PART: PSYCHO-MUSICAL INTERVIEW

NAME: First name:

Date of birth: Place of birth:

Marital status:
Number of child(ren):
Profession:
Spouse's occupation:
Address:
Telephone number:

Attending physician:
Psychiatrist
Clinical diagnosis:
Psychiatric hospitalization:
Method of care:

RECEPTIVITY TO MUSIC

Do you think you are receptive to music in general?

(Do you like music? When you hear certain works, do you experience particular emotions? Do you
believe music can stimulate your imagination, help you to accomplish certain efforts? Can music calm
you, irritate you, anguish you?) Are you receptive to certain music or to all musical forms?
(Indicate the kind(s) of music you prefer, don't like to hear, don't care about)

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 ANTECEDENT SOUND ENVIRONMENT

Family history:

- father's country of origin:

of the mother:
of the grandparents:
people who played an important role in childhood:

- personal preferences and tastes in sound and music:

- parents’ acoustic world during pregnancy:

- parents’ particular reactions to sounds and noises:

- musical culture of the parents and their instrumental practice:

- highlights concerning the world of sound, the musical preferences of brothers and sisters:

Personal History:

- The sound world at birth and early stages of development

- Body Movement and Mother's Choice of Lullabies

- Sound atmosphere during childhood and adolescence

- Specific reactions to this sound environment

- Particularities concerning body noises (heart, breathing, chewing, intestinal noises...)

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 TODAY'S NOISE ENVIRONMENT

Noises during the day:

- instead of living:

- at the workplace:

- the sounds of the night:

- sounds in relation to the current family environment:

- special reactions to the world of sound:

MUSIC CULTURE

- Did you study music? Which ones? For how long? Do you play a musical instrument?

- Do you have records, cassettes? Which ones?

- How do you listen to music?

(records, radio, television, concert)
- Who are your favorite composers?

- Which composers do you not want to hear and why?

Do you like to associate music with other modes of expression? Why? Why?
- plastic arts (graphic and pictorial):
- dance and body expression:
- poetry and literature:

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 CONCLUSION AT THE END OF THE INTERVIEW:

SECOND PART: THE MUSICAL BAND (AUDITION OF WORKS) - N°

Date:

I- Descriptive work

II- Heavy and worrying work

III- Emotional and sentimental work

IV- Intense and warm work promoting communication between people

V- Unusual work (in comparison with the previous ones)

VI- Soothing work (transition n°1)

VII- Work using the usual aggressive noises

VIII- Soothing work (transition n°2)

IX- Oriental music

X- Balanced and grandiose work

………………………………………………………………………….

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III. Additional point of view by the care-giving staff.

Implementation work was started, based on the previous dossier, by the project pilots.

Submitted to the coordinating physician, the project raised the following questions:

• Short term and long-term interest.

• How long does the soundtrack last, 1 month? 6 months?
• Exhaustion criteria.
• Repeat a study in 6 months of the impact of this soundtrack.
• Impact on caregivers’ work.
• Interests for families.
• Scale of interest to create for caregivers.

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 Post scriptum.

Without them, this human adventure would not have been possible:

Thank you to the residents of the EHPAD de la Bourgonnière, for their welcome, their sharing,
their complicity, their authenticity.

Thank you to the residents who accepted to be patients in music therapy and, also to those
who refused.

Thank you to the director for his openness, his pragmatism and his desire for the best of the
residents.

Thanks to the health executive for finding the time to follow me.

Thank you to all those involved in the smooth running of the EHPAD, for their kind welcome.

Thanks to the support of my family, especially my father's (in a “nursing home”) and my sister’s
(a nurse specializing in palliative care).

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 Psalm 150, David (-907, -837)32

“Hallelou-Yah. Praise El in his sanctuary, praise him in the vault of his energy!

Praise him in his heroism, praise him for his immense greatness!

Praise him with the shophar, praise him with the harp, with the lyre!

Praise him with the drum, with the dance, praise him with the zithers, with the pipe!

Praise him with the loud sistres, praise him with the standing ovation of the sistres!

All breath praises Yah! Hallelou-Yah.”

Sophar:

32
English translation of André Chouraqui’s, 1985, literal translation of the Hebrew version.

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For readers on the internet:

Today, as a certified music therapist, this writing is a tribute, a testimony, a sharing.

I hope that some passages will add a little fresh water to your respective mills.

Your comments, criticisms, opinions and reactions are welcome at my following address:

concertidevie@free.fr

pace e bene.

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