Pastoral Music Therapy in the Nursing Home
C. Gourgey Ph.D.
“Very truly, I tell you, when you were younger, you used to fasten your own belt and to go wherever you wished. But when you grow old, you will stretch out your hands, and someone else will fasten a belt around you and take you where you do not wish to go.”John 21:18
In our language certain words are not spoken in polite company. These words are usually said to contain four letters. One four-letter word poses a particular challenge to health care. More on that later.
In the hospice where I used to work, I formed an alliance with the spiritual care team. I developed an approach to music therapy that overlapped with pastoral care. This happened in a number of different ways. I planned the memorial services held periodically at the hospice - both the Catholic Mass and the Interfaith Service - and provided the music for them. The chaplains and I would also jointly lead special ceremonies for families who wished to place a plaque on the wall in memory of their loved one. But my most fruitful collaborations with the spiritual care team came through the direct care of our patients.
Through music therapy I supported the chaplains’ work when appropriate. Often after the priest administered communion to a patient, I would provide a communion hymn. Music was especially helpful to patients who could not express themselves verbally. Many could still respond to music, and spiritual music often enhanced the prayers the chaplain would say at the bedside.
One particularly rewarding aspect of my work was the opportunity to use music to serve people of many different faiths - and even of no faith, for everyone has spiritual needs. Contrary to popular opinion, music is not a universal language. There are as many musical languages as verbal ones. If one learns to speak several musical languages, one can minister to many different kinds of people. And so through music I was able to help people of many different backgrounds, including Catholics, Protestants, Buddhists, and Jews, feel some contact with their spiritual home.
It is especially gratifying when family and friends become part of the experience, for then music can help heal the wounded spirits of patients and caregivers alike. In a hospital room music therapy can recreate the atmosphere of a Baptist church, or a Jewish home preparing for the Sabbath. Through this practice of music therapy I can cross boundaries that usually separate people, and for me this has been its greatest joy.
Sadly, our hospice fell victim to the economic crisis when the hospital that housed our hospice unit had to close. No similar job was available, so I became a nursing home volunteer. Most nursing homes offer recreational therapy and some (though not many) offer music therapy. No nursing home to my knowledge offers pastoral music therapy. As a volunteer I could pretty much write my own job description, so I saw this change as an opportunity to develop pastoral music therapy and bring it to a different setting.
Since I can’t think of a better name, I will call my new setting St. Eligius Nursing Home: since it was not a hospice, it was “elsewhere” for me. But soon I came to understand how the needs of nursing home residents differ from those of hospice patients, and to feel at home using pastoral music therapy to address those needs. I would now say the need for this work is greater in nursing homes than it is in hospice. Most hospices have better resources than most nursing homes, and most hospice patients have better support systems than do nursing home residents. In the nursing home one finds many people who live for years isolated and abandoned, people with dementia or other serious infirmities and whom nobody wants to be around - people whom Jesus liked to call “the least of these.”
St. Eligius is no worse than other nursing homes in the city. Like all nursing homes it could use more resources and staffing, but most of the people who work there do care and they do a good job. My intention is not to criticize, but rather to illustrate how our system of eldercare puts pressure on residents and workers alike, forcing residents to struggle for their dignity and creating deep spiritual needs that pastoral care, both traditional and musical, must address.
Encounters with Individual Residents
On two different occasions I have had residents say to me, for the same reason, “God bless you, God bless you, God bless you!” What was the reason? I brought them a glass of water when nobody else could or would. Why wouldn’t they? I don’t know. Perhaps no one else was available. We don’t invest enough in our nursing homes to maintain acceptable staff/resident ratios. Or perhaps no one was paying attention. That too is common. Serving water is an act of spiritual care. That glass of water - such a simple thing - says “I see you, and you matter.” As I was soon to learn, the spiritual need involved is as great as the body’s need for the water itself.
This will become clearer as I briefly discuss the stories of several residents (all of whose names have been changed). Gary, in his nineties, is known as “the Deacon” because that’s who he was in his church. He would often become depressed, and many times when I entered his room I found him quiet and subdued. Then I would sing a gospel song for him, and watch his mood change completely. He would smile and sing with me, even making prayer motions with his hands. For a short while he was back in his church, reconnected to God.
Gary’s health soon started to decline. He developed kidney stones, which kept him in constant pain. Unfortunately, given Gary’s age, there was no treatment he could tolerate. While he never complained about his pain, he kept his roommate up at night with his constant groaning. The chaplain told me of this change in Gary’s condition, and I went to see him immediately. I brought his favorite hymn, “Near the Cross,” which I hadn’t known but found in my Baptist hymnal. We started singing together:
Jesus, keep me near the cross,
there a precious fountain
free to all, a healing stream,
flows from Calvary’s mountain.
As we sang Gary smiled and moved his hands in prayer. He did not groan once. This became our pattern for subsequent visits: music of faith seemed to take away Gary’s pain, if only for a few precious moments.
Soon Gary was placed on hospice care, and he now has an aide assigned to him during the day. When I first met her she was sitting by one side of the bed, with Gary on the other side sitting in his wheelchair. Both were completely silent, doing nothing. I began singing Gary’s hymn for him, and as we reached the chorus a third voice joined ours: “In the cross, in the cross, be my glory ever....”
It was Gary’s aide, singing with us, raising her voice to God. She too was a Baptist, and knew all the hymns Gary knew. I encouraged her to sing more for Gary, and asked her to watch how Gary’s face changed completely as she did so. The easing of his discomfort, his smile, his happiness - she had made it happen, and she deserved to know it. Once she began singing, she did not want to stop. Now Gary had a companion in faith even on days I could not visit. This is an important part of my job: helping caregivers and family members minister to their own loved ones.
One floor above I found another resident whose faith helps her deal with her condition. Naomi is a Jewish woman, only 58, yet has been living in the home since she was 40. After surviving a car accident, she became unable to walk. She has many other problems, including a brain aneurysm and a blood disease that eventually will turn fatal. After her accident, her husband left her.
Since coming to the home she has turned to Judaism for support. She didn’t know much about her religion before her accident, but now she studies with a tutor twice a week, learning Hebrew and Jewish tradition.
I helped Naomi put music to some of the prayers she was learning, teaching her some of the liturgy. Friday afternoons, just before the arrival of the Sabbath, became a good time to chant some Sabbath prayers. One in particular that seemed to comfort her speaks of two guardian angels who accompany us on Sabbath Eve. We would chant it together in Hebrew:
Peace be with you, ministering angels, angels of the Most High,
From the Supreme King of Kings, the Holy and Blessed One.
Naomi liked it when I told her about the angels.
Naomi’s command of Hebrew is very elementary, but she could follow along as I sang for her songs of the Sabbath and other special occasions. She has made a spiritual home for herself in the institution. Her night table is piled high with prayer books and other devotional material. I could sense God’s presence not only in how she transformed her room but in other ways. I once saw Naomi in the corridor holding the hand of another resident and comforting her, an anxious woman with severe dementia whom no one else wanted to be with and who was known for screaming hysterically at unpredictable moments.
From my hospice work I know that there is no greater resource one can possibly have than faith. If a resident has faith or is searching for faith, I use music to support that faith. But what about those residents who do not profess a particular faith?
Everyone who lives in an institution, be it a hospital, hospice, or nursing home, has spiritual needs. These needs are aggravated by institutional life, yet are often overlooked in our concern about caring for the body. These spiritual needs do not always find expression in traditional faith; still, we need to recognize them and address them. I have seen music transform several residents from a quiescent, catatonic-like state to one of aliveness and excitement and reconnection to their former selves.
Max, 58, was born with severe mental retardation. He also has an obsessive love of the music of Elvis Presley. His sister tells me he owned every record Elvis ever made, and would listen to them all the time. On his wall are pasted photographs of Elvis, but without the music they just seem to stare into nothing. In the nursing home, with very little stimulation, Max just sits quietly most of the time. But whenever I play an Elvis song he becomes animated and sings along. He always wants another, asking me which ones I know.
Max is not always easy. He is very sensitive, and if I smile too much he thinks I am laughing at him. His mood can change without warning, from seeming happy to becoming tense and irritable and occasionally even yelling and screaming. But even then, an Elvis song always draws his participation and restores his equanimity. He gave me a sense of my function when one day he asked me, “Are you a clown?” I didn’t deny it.
Music fills a similar need for Ruben, a young black man (46) who also has strong retardation as well as multiple sclerosis. Typically I find him lying on his back in bed, in the dark, eyes closed and looking lifeless.
Ruben tells me that he likes soul music. It’s not a type of music people asked for much in hospice - in fact, I can’t remember a single hospice patient asking me for it - so I had a lot of homework to do. I learned songs by the Temptations, the Four Tops, the Supremes. Nothing puts Ruben into ecstasy like a Supremes song, or a song by the Godfather of Soul himself, James Brown. The change in Ruben is sudden and dramatic. He ceases to look like the living dead and raises his head, looks right up at me and smiles with wide open eyes. When he knows the words, he sings along - and he always knows the words. He grips my hand like a vise and tells me happily, “That’s all right, brother!” “You got it going on!” “No doubt!” Now he looks more than alive. He is joyful.
Across the hall on the same floor lives Phil, 65, one side of his body paralyzed from a stroke. Phil’s condition forced him to give up his passion, playing the guitar professionally in a pop music band. Phil’s knowledge of popular music is encyclopedic, and I’ve been learning a lot from him. Because Phil had been a pro and knew so much more than I did I felt hesitant to play and sing for him, but he is always so gracious and appreciative that I soon got over it.
As weeks passed I got to know Phil pretty well. He told me that he craved intellectual stimulation, that he loved to talk about politics and religion but that he has no one who can join him. For a time he felt so depressed he was placed on suicide watch. When I visit him now, aside from the music I also talk about current events, asking his opinion about Obama’s latest speech or the situation with health care. But Phil is at his best when speaking of his greatest love, popular music.
Recently I’ve started enlisting Phil’s help in finding songs for Ruben. Phil knows Ruben, and he also knows just about every soul song ever written. So Phil has been an inexhaustible supply of ideas - and more important, his ability to help in this way supports his identity and confirms who he is. It is also good for a resident to feel he can give as well as receive.
Especially if one’s mind still functions clearly, one feels one’s constant dependency as a persistent humiliation. One day I saw this with Phil. He could not concentrate on our conversation because he urgently needed to make a bowel movement. He needed a nurse’s aide to help him to the bathroom. I went to find his CNA, and after a couple of tries I spotted her. She told me she couldn’t come right away. I insisted, as gently as I could, that the need was urgent. I offered to help, but rules do not permit volunteers to perform such tasks. When she finally arrived she was clearly unhappy, complaining loudly that “This job is not a rewarding one.” Phil was sitting right there and heard every word of it.
Experiences in Groups
One way to minister to large numbers of people is through a group. I have one group I meet with semi-regularly. Keeping people together can be a challenge. Sonia, who is very confused but loves music, will spontaneously break into her own song regardless of what everyone else is doing. I will accompany her with my guitar, then invite the group to sing along with us. Rosie has very limited speech and movement but an endearing smile, and with an awkward roll of her head she indicates how happy she is to be there. Marta speaks only Spanish. She enjoys all the music, but really comes to life when I sing a Spanish song she can sing with me. Henry cannot speak but makes only grunting noises. Yet from the rhythm of those noises I can tell it is his way of singing too.
If I used a keyboard in the group I would feel like an entertainer. The guitar, on the other hand, is such a great instrument because it permits me to walk around the room. And so I do, making sure each member of the group receives my attention and feels recognized.
Once again it is moving to see how the residents look out for each other. Eve, a kind lady who likes quiet music, drew my attention to Nancy and told me to sing for her. Nancy is 42 but looks half her age. She has been living in the home since she was 25. She has severe mental retardation and appears autistic, totally immobile in her wheelchair, her head slumped over, staring blankly out into nowhere. At the time I did not know her real age and sang her a children’s song, “Puff the Magic Dragon.” She turned her head towards me and her eyes met mine.
All of the group’s members have their own way of communicating, and over time one learns their different languages. Music fills a big space in their lives. But more than just the music is the recognition. Whenever I notice Rosie in the hallway, even if just quickly passing by, I always make it a point to greet her and say how happy I am to see her. She will smile and clumsily rotate her head all the way around her shoulders, which tells me she is grateful to be visible to someone.
Discussion: Recognizing Spiritual Needs
Before coming to St. Eligius I worked in other nursing homes, but my most recent job was in hospice. One would think there is no greater need for spiritual care than in a hospice. I did have the chance to minister to the needs of many patients and families. Like chaplaincy, pastoral music therapy in a hospice can address common needs such as anxiety and the fear of dying, loss and grief, and the affirmation of faith. Similar needs do arise in the nursing home, yet now that I’ve returned to nursing home work after my years in hospice, I can see more clearly that nursing home residents have special needs unique to their situation. These needs desperately require spiritual care, and they are not getting nearly the attention they deserve.
Most hospice patients receive very good care. The staff/patient ratios in a hospice inpatient unit are typically far better than in a hospital or nursing home. Hospice patients are also likely to have families who visit them regularly, and who care for them at home to whatever extent they can. The hospice inpatient unit is not a long-term-care facility but rather a safety valve for times when a patient temporarily requires more care than can be given at home. When the patients are ready, they are discharged from the inpatient unit and return to their homes. Most nursing home residents never return to their homes. Indeed, most no longer have homes to return to.
In a nursing home people in very vulnerable states are thrown together with total strangers for periods possibly lasting several years, in an environment that is strange and frightening. Some are fortunate enough to have family visit every day. Most do not, and many get no visitors at all. They have left behind formerly active lives in which their roles were clearly defined, and have come to a place where they have no role other than dependent. They suffer losses of many things most of us take for granted: the loss of their physical abilities, the loss of familiar surroundings, the loss of regular contact with loved ones and friends, the loss of their freedom, the loss of their privacy, and the loss of others’ respect. All these individual losses contribute to one big one: the loss of their identity.
As a result, depression is common. I have often observed the beginnings of depression in a new arrival, which gradually deepens until the person’s spirit dies. At that stage dementia, for those who suffer from it, may be a blessing. But who really knows what they feel? Many residents with dementia seem to exhibit tremendous anxiety, and some may scream constantly about things we can only guess.
As I mentioned before, St. Eligius is a good home. If I had to pick a nursing home for my loved one, I might pick St. Eligius. But for all the reasons just mentioned, even a good nursing home is a difficult place in which to survive. I don’t mean survive physically. Caring for the body is not difficult, in spite of the fact that in many nursing homes it’s often not done properly. I mean survive as a whole person, with one’s spirit intact.
Try to put yourself in Phil’s wheelchair for a moment. You urgently need to go to the bathroom. You wait anxiously for the CNA. She finally enters, a stranger of the opposite sex upon whom you are dependent and who is about to have very intimate contact with you. She is upset and complains that her job is not rewarding. How does that make you feel? How would it make you feel to experience similar encounters nearly every day?
I do not know this CNA and cannot say what pressures she may be struggling with. I do know that staffing levels in most nursing homes are not ideal, and that workers often feel they have more than they can handle. They too need attention and support. Perhaps things should not be this way, but they are because we as a society permit it. I sometimes wonder how many CNAs could be paid for by a single bonus given to a single top executive of a Wall Street firm that taxpayers had to bail out. Perhaps it’s because we simply don’t want to think about the lives our frail elderly must lead, but we place more value on corporations that helped ruin our economy than we do on nursing homes that care for the people we love.
Because we as a society do not pay attention to this problem, it has become a crisis. I have worked in places much worse than St. Eligius. The abuse is not always physical; even simple indifference becomes a subtle form of cruelty as hurtful as a physical blow, and lasting much longer. I have seen residents routinely yelled at and humiliated. I have seen family members afraid to open their mouths to ask a simple question of a surly staff member. I have seen staff members refuse to take a desperate resident to the toilet because they are on break or because “She’s not my patient.”
Even when things are working properly, life in a nursing home is hard enough. I mentioned two residents who blessed me just for bringing them a glass of water. One of them told me that hardly anyone pays attention to her, so she was grateful to me simply for that. I remember the day I met the other one.
Virgilio was born in South America and speaks only Spanish. One day I found him in his wheelchair in the busy hallway. He was in a state of panic. I spoke to him in his native language and he told me he felt cold and wanted to go back to his room and to bed. The aide on duty told me she kept him in the hallway so she could keep an eye on him. Apparently her eye didn’t register his distress. I took Virgilio to his room, and once there he started to cry and said he wished he could go home to his country. He told me he has five daughters who don’t visit. It comforted him to find someone who speaks his language, and who relates to him as a friend. I think the hallways must look much longer and the walls much higher to someone who has lost the ability to move freely from one place to another.
Nursing homes have limitations that make problems like these almost inevitable. There are not enough resources; there is never enough staff. To leave it at that, however, leads to a misplaced fatalism. No matter how much we lack, we can still make things better.
The One Great Need and Its Remedy
The first thing we can do is recognize the hidden need. We have mentioned it: aside from the care of basic physical needs, the one great need nursing residents have is to be protected against the erasure of their identity. Unlike a bedsore this type of wound is not readily visible, unless one takes care to notice. Even residents whose bodily needs receive adequate attention may suffer spiritual damage that goes ignored and untreated.
This is when we have to speak the often unutterable four-letter word. I am not referring to those swear words that come to mind when we feel frustrated by the demands of the job. There is another four-letter word that we also try not to mention in professional circles. It’s time for that to change, because the word I am thinking of is “Love.”
We have to love the people we care for, because if we don’t, their spiritual wounds will bleed and fester. We have to not be afraid to love them and we have to not be ashamed to say that we love them. Nevertheless, you generally don’t hear professionals speaking this way. You are more likely to hear talk of “setting boundaries” and “professional distance.” “Love” in the context of health care, especially mental health and spiritual care, is looked upon with suspicion. It is called “countertransference” and considered a clinical error.
We certainly do need to set boundaries, but we can and must do so in love. If we don’t have a clear understanding of love in the health care setting, then we will set our boundaries out of fear: fear of getting too emotionally involved, fear of draining our energies, fear of feeling too much. When we set our boundaries from fear, those who receive our care will feel alienated. This is inevitable. Not setting boundaries is not the answer: that harms both our clients and ourselves. Only a practical understanding of love can solve this dilemma.
I have found the following definition of love (which is developed in detail in my book Judeochristianity: The Meaning and Discovery of Faith) very practical and helpful in working with others in clinical settings without violating their boundaries:
Love is the awareness of the other’s individuality.
A person’s individuality is the God-created essence that makes one completely unique. It includes one’s thoughts and feelings but also much more, the quality of each soul that makes it unlike any other and that cannot be conceptualized or summarized in words. The Talmud states (Mishnah Sanhedrin 4:5): “People make many coins from one mold and they are all exactly alike, whereas the King of Kings, the Holy and Blessed One, has made each individual through the pattern of the first human being, and not one of them is like another. Therefore each of us must say, ‘For my sake was the world created.’” Every one of us is infinitely important, and to perceive the quality that makes each not replaceable by any other is to see the individuality.
To be aware of another’s individuality means, among many other things, to see where one’s own self ends and the other begins. It means to see clearly enough not to project one’s own experiences onto the other. If our perception is distorted by countertransference, then we are not truly aware of the other as an individual and we are not practicing love.
This type of love, however, is far more than the awareness of boundaries. If we truly see the other’s individuality, then we will naturally experience a certain warmth toward the other and a desire for the other’s well-being. It cannot be otherwise. The individual is God’s creation, and God’s creation is good. The real proof of the concept, however, is in its practice. If we are not experiencing that warmth, then something is preventing us from seeing beyond the surface to the core of the other’s uniqueness. If we hold others in prayer, seeing them as they are, in their own right and not just in terms of how they relate to our own feelings and wishes, it is easier to behold the individuality that draws our desire for their good.
Because they are not a part of our personal lives, it is actually easier to see our clients in this way. There are no personal jealousies or professional rivalries to worry about; these are people whom we are here simply to serve. The best gift we can give them is our awareness of who they are. This form of love responds to a universal need. As spiritual caregivers we are blessed to be in a position to offer it.
Properly understood, love as a form of awareness not only protects us against the pitfalls of countertransference, it is not difficult to practice. It comes down to the willingness to see what is around us, and not to close ourselves off from the suffering of others. We must be aware enough of others to allow them to touch our hearts. Then we can express this awareness in ways that are simple but powerful: a smile alone can change the entire day for someone who takes being ignored for granted. Even the tone of our voice will change when this awareness is present and will affirm the humanity of those who come under our care.
One of the best things about offering this love to people is that it does not, or at least should not, depend upon economics. There can be as much love in a poor institution as in one that is lavishly endowed. In fact, an institution with greater challenges offers greater opportunities for love. Still, it is hard to give love to others when one does not feel loved oneself. All who work in caregiving, including the nurses, nurses’ aides, volunteers, and the people who clean the floors and the toilets, deserve to be respected and cherished for what they do, not just by the staff and administration but by society as a whole. We are willing to pay millions to athletes and entertainers. Let us at least give respect to those who care for our disabled loved ones.
It is easier to choose not to know how alienating and dehumanizing even the best institutions can be. But with the proportion of elderly and disabled steadily rising, fewer of us will be able to avoid finding out. It does not have to be this way. A revision of values and improved staff training can help make real the compassionate atmosphere that vulnerable people need for their humanity to survive. It starts at the top: while they must address financial realities, administrators need to have priorities beyond cost cutting and the bottom line. Supervisory personnel should be chosen who have this quality of compassion and who can impart it to others. Every worker in the health care hierarchy must know that he or she is valued and appreciated.
The existence of those who are poor, disabled, and isolated should challenge our faith. Faith must be more than a personal relationship with God. “Do you love me?” Jesus asks Peter. “Then feed my lambs” (John 21:15). Love is not meant only for family and friends; it must extend to the stranger. That is how we find God’s Kingdom on earth as it is in heaven. Instead of waiting for the Kingdom of Heaven, we should act as we would if it had already come - for that is the only way it will come.
I will close with a comment by Eve, a member of the group I mentioned earlier, which expresses in a single sentence the entire message of this article. When last I found her sitting in the dining room I greeted her and said, “Hi Eve, it’s good to see you.”
Without hesitation she responded: “It’s good to be seen.”
How ironic that the people whom our society most ignores and neglects are the ones best equipped to teach us what love really means.