The Songwriting Works Model: Enhancing Brain Health and Fitness through Collaborative Musical Composition and Performance
JUDITH-KATE FRIEDMAN, founder and director,Songwriting Works™ Educational Foundation
(Excerpts from Stein and LaRue, eds. Enhancing Cognitive Fitness in Adults: A Guide to Use and Development of Community-Based Programs, Springer 2011).
- INTRODUCTION – The Music of Being Human
It is a spring day at an Alzheimer’s day center. Twelve elders are gathered for a songwriting session, seated in a circle opposite a large easel. The facilitator is in the middle, colored markers in hand, guitar at the ready, leading discussion. A man begins to reminisce about holidays. Soon the group is alive with memories: family vacations, honeymoons, adventures. Conversation turns to Hawai’i, a place where many have traveled. “Ah,” a woman says, her face lighting up. She has been quiet and apparently disoriented for most of the hour and now speaks for the first time. She describes the beauty of that place; how much she loves it. The facilitator sings her words back to her. The woman grins, widely: “I don’t know who said that” she says, “—but I sure do feel that way!” The group sings together, weaving a chorus, threading each other’s stories into song. (Friedman, 2004)
Music is a full-bodied experience and a whole-nervous system activity; it involves nearly every part of the brain (Parsons, 2009). As such, it belongs in any “use it or lose it” cognitive fitness and health program. Music aids in cognition. It sparks memories and new ideas, and helps sustain brain function as it builds social and neurological relationships. Humans are built to engage musically. The importance of developing musical intelligence in young minds (Rauscher 2001, Gruhn and Rauscher 2002, Weinberger, 1998) continues to the very end of life, even for those whose ability to think and communicate is limited by brain illness or injury (Sacks 2007, Allison, 2010). Older adults who regularly participate in step-by-step learning with music professionals, in a community of peers, experience significant increases in their physical, mental, emotional, and social health (Cohen, et al 2006). Family caregivers and their loved ones with dementia report greater satisfaction and communication when they are making music together (Clair and Ebberts, 1996).
2. SONGWRITING WORKS™—Enhancing Brain Health through Song
“I’ve never sung before in my life and now I’m singing.” —E.N., age 90 (participant, 2001)
Medical doctor and ethnomusicologist Theresa Allison concluded in her nine-month study of Songwriting Works: “Songwriting in the nursing home is not a mere activity—it is an opportunity for intellectual, artistic, relational and spiritual growth. As such, it fosters a real sense of neighborhood and transcends the artificiality of the institutional life.” (Allison, 2008).
ACCESS TO MUSICALITY
“Those who didn’t know they could, collaborate with energy they didn’t know they had.”
—Marcia Perlstein M.S.W. L.M.F.T.
. To date, more than 3,200 have composed 320 songs. Songwriting Works Educational Foundation now operates as a non-profit organization based in Port Townsend, WA, and offers workshops, trainings, and concerts internationally. In 2009, with support from the National Endowment for the Arts, Songwriting Works launched a facilitator certification training program for professional songwriters and a pilot program in which caregivers and their loved ones wrote songs together (see Case Study 3). In 2010-11, in conjunction with the Washington Health Foundation, Songwriting Works is developing music-for-wellness tools to give homebound elders, families and music lovers of all ages increased access to making original music.
“I’ve always been a ‘listener’ — I found out that I can be a singer, too.”
—L.W., age 88
INCLUSION is KEY
To date, participants average age 87; Ninety percent have some level of physical disability; Seventy to eighty-five percent have some degree of memory loss or cognitive impairment due to neurodegenerative disease including early through later stage Alzheimer’s and other dementias, post-stroke aphasia, apraxia, Parkinson’s, Multiple Sclerosis, brain injury, and depression.
“The woodpecker knocks at the door of our dullness and awakens us into life through our ears.”
–Robert Rice (2008)
3. AT ANY AGE, IN ANY RHYTHM — The Songwriting Works™ Experience
In cognitive terms, this experience stimulates neurogenesis, dendritic sprouting and gleal cell formation through multi-region brain function, free associations, memory retrieval, and meaningful social interaction (Cohen 2005).
Songs take shape in the course of conversation.
Idiom, whimsy, melody, and meaning arise spontaneously through storytelling, improvisation and life review. Participants direct all artistic decisions. They may determine musical genres in advance (“Let’s write a Polka!” “My favorite is Country & Western”) or one person’s spoken cadence (rhythmic phrase) may suggest a tradition such as gospel for “you can serve your God under your own fig tree” or klezmer for a Chanukah song. Facilitators stay true to participants’ musical inflections, including those expressed through tapping feet or moving hands. Catchy, funny or poignant lines and illuminating side comments are gathered verbatim and scribed for all to see. Words are recapped, sung, rhymed, and repeated. Pitch (note and key) changes—even in spoken speech (see Case Study 2, 3)—are recorded and re-sung. Rhythmic entrainment further increases neural connectivity and availability of expression, spirit, and thought.
“What have I learned? Can you put a count on a sunset?”” —J.D., age 87
The songs tell stories, true and imagined (“Dancing with the Daughter of a Flower Rancher”, “Don’t Forget Me”). They may collect reminisces (“Summer”, “The Jazz Age”) or offer new views on love, peace, work, faith, and family. Time of year or day may inspire tributes to seasons, holidays, new grandchildren, or community events (“A Special Day for Moms,” “the Butterfly Song” to celebrate a new garden). Consensus on editing and polishing can be tested by vote but is more often revealed in bursts of laughter and excitement, nonplussed silence or agitated boredom. Pleasing punch lines, melodic grooves or “hooks” send ripples of mutual agreement through a group. A communal ‘yes’ or ‘aha!’ follows a good story. Spontaneous unsolicited repetitions “stick,” or parts are shed or adjusted when a majority unconsciously skip phrases or avoids less singable stumbling spots. An experienced elder may simply say “Enough! That’s it! We’re done!” Cultural preferences are always honored (Bartlett, Kaufman and Smeltekop 1993). Song styles have included folk, country, gospel, nueva cancion, rock, jazz, swing, and a choral cantata about WWII Homecoming (Case Study 3). The social context further boosts self-esteem, cognitive engagement, positive affect, and immune system response (Rodin 1989, Lachman and Weaver 1998, Glass and Mendes deLeon, et al, 1999, Cohen et al 2006).
4. RESEARCH—Toward an Evidence-Based Model
Dr. Allison observed that participants with short-term memory deficits due to dementia retained words and music to the original songs that they and/or their community had collectively composed; their songs entered the repertoire of the institution. Even those with advanced cognitive decline were able to generate fresh, creative, memorable lyrics, melodies, images and word choices, and sing lines to the choruses of songs they helped compose without prompting (Allison 2008 and 2010). Repeated participation had a demonstrated cumulative and lasting impact on cognition and socialization. Through songwriting, elders were able to break through isolation and forge new relationships. Their singing of original Psalms for the dedication of a new synagogue transformed institutional spaces (the synagogue, the Home) and their relationship to them.
To quote one of the songwriters:
‘It’s life-long learning all the time.’ (Allison 2008)
5. SINGING INTO THE FIELD—Other Research Supporting the Songwriting Works Model
“Creativity is our species’ natural response to the challenges of human experience.”
—Adriana Diaz (Diaz, Miller 2010)
We’re learning to treat diseases because we’re learning to listen. Not only to our patients but to single cells in the brain. If we listen carefully, they tell us a story… How fast they’re talking, the pattern of how they talk …Each of us has many different subplots going on within our brain. Sometimes those subplots are not unfolding in such a way that they result in beneficial symptoms. We call that disease. .…We’ve learned that if we can disrupt this chatter and normalize it—we can improve disease. —Michael Okun (in Cavanaugh and Drewry 2008)
It is an exciting time to be working at the crossroads of musical creativity and brain health. Research in diverse arenas of study and practice are converging as publications of findings proliferate and filter into popular consciousness. Studies confirm the challenge of pinpointing complex levels of brain activity involved in vocal singing and musical improvisation; while functional MRIs, EEG, MEG, and PET scans make closer investigation possible. Knowledge has exploded over the last twenty—and even five—years, supplying answers and opening unforeseen, fascinating paths of inquiry. Case Study 1, summarizing the composition of “Out On the Water,” is interwoven here with findings from other research that support the Songwriting Works’ model.
CASE STUDY 1: “Out on the Water” ~~LESSONS of PLACE and TIME
On a summer afternoon at an Olympic Peninsula care center seven women in their 70’s and 80’s gather to write a song for the first time. All have mid- to later-stage dementia. The facilitator has conducted hundreds of workshops in dementia care for more than fifteen years in urban and suburban settings. No single workshop for a group with a significant degree of cognitive impairment has gone longer than sixty minutes. Here, in a rural seaport town—with few available interactive music programs other than sing-alongs—the host agency has planned a two-hour session. After introducing herself and greeting each person by name, the facilitator asks about favorite music.
After a long silence the activity director, a man, jumps in: “Cowboy songs!”
“Opera!” a woman replies in turn. “Western.” “Elvis!” …“Jazz”
At the start of each workshop, Songwriting Works solicits musical preferences. Bartlett, Kaufman and Smeltekop’s research exploring positive immune systems outcomes for music listeners found that “preferred music types, in particular, tend to increase the likelihood of obtaining positive sensory experiences, and possibly for evoking chemical changes” (Bartlett, Kaufman and Smeltekop, 1993). In other words, on a biological as well as psycho-social level, opportunities to have one’s aesthetic preferences respected and brought to the fore of interactivity may be key in optimizing beneficial outcomes for individuals and programs.
The group warms up with a familiar cowboy song; most sing. However, two women sit quietly, staring past the facilitator, apparently quite disengaged. They remain this way for the next hour, while the session unfolds:
Facilitator: “What shall we write about today?”
After a long pause a woman smiles heartily: “Being out on the water.”
In this town surrounded on three sides by water the theme hits home. Others begin to add thoughts and images, slowly filling the easel with words:
“It’s nice to be on a boat on the water”
“A blue motorboat”
“Round about this time”
“It’s so peaceful”
The facilitator goes back and forth asking open questions, sometimes reframed from new angles:
“What’s it like in that boat?” “What do you do when you’re there?”
After each question she respectfully leaves time for responses. There are no wrong answers; rather, a welcoming space is made evident through facial expression, body language, pace, eye contact, well-articulated speech and genuine patience. Contributors’ words, images, ideas and phrases are scribed, repeated and recapped; each is acknowledged by name.
Respect is a pre-requisite when seeking authenticity and providing access to those with diverse needs. Dignity is of the utmost importance, especially for those who have been marginalized or isolated due to age, cultural or cognitive prejudice. For those with cognitive deficits who can no longer easily communicate, dignity seems to be “grasped” one could say, in “meta-awareness.”
“What’s being on the water like?” the facilitator asks again.
“Soothing” comes a thoughtful reply.
“I meditate” says another.
“Crying—sometimes” says a third.
Addressing this woman directly, the facilitator asks, gently: “Say more?….”
“You think about old times… think about sad times”
“Sing!” the woman who had the initial song idea says loudly.
Another adds in an even tone: “Think of all the good things that have happened to you.”
Music therapist and researcher Alicia Ann Clair, Ph.D, RMT-BC has extensively studied the impacts of making music with and for elders with late-stage dementia. One study measured responses to a series of specifically replicated two-minute music therapy interventions including unaccompanied singing, silence, and reading. Sessions took place over a series of days. Clair noted that given proper respect and support “persons who are in very late stage dementia are still capable of responding to stimuli in their environment. …Extremely long response latencies may require stimulation over time. …It is possible that these persons respond slowly over time and any attempts to determine their response patterns must be done in a series of sessions…” (Clair 1995 and 1996). These findings suggest that greater responsiveness is aided by relationship building.
The session is now at 50 minutes; staff and facilitator meet eyes acknowledging a subtle shift in the room. The women’s sentences are growing longer; there is more interactivity.
“Enjoying the quiet.”
“I’d have my radio going, lie down and just listen to it.”
“I sooner be on water than on land”
“I prefer a sailboat.”
“Not hearing so much noise as you do on land.”
“I’d rather be watching from the shore.”
The most outspoken women adds: “I like it when its rough; The boat goes up and down up and down.”
Another says (possibly in response, though this cannot be ascertained): “You should never go on in life having no idea what so ever.”
Later as lyric and music take shape, the facilitator offers a format of couplets which can accommodate diverse viewpoints:
“Out on the water, cool clear water—In my sailboat, with the radio on.
Out on the water, cool clear water—Peaceful, soothing, we enjoy the quiet….”
(Composing Together Works and Friedman 2007)
As noted, facilitators are trained to model cooperation and respectful exchange across cultural and other differences, countering gossip and stereotyping and accommodating cognitive variances within the group. Their genuine interest helps dissolve social barriers. Likewise, the physical setting is arranged to maximize eye contact and rapport.
Following a snack break, the facilitator asks for a melody to match the words “cool clear water,” steering clear of the first melodies offered which resemble the cowboy classic “Cool Water” by the Sons of the Pioneers. Originality is elicited by sharing the composition: sung pitches are gathered from one for “on the water,” and another for “cool clear water.” The group’s enthusiasm confirms the melody for the song’s refrain.
“On the water, water, cool clear water…’”
As the session reaches seventy, then eighty, minutes the two women who have been seemingly unengaged throughout the workshop begin to contribute.
“Happy as a bird”
“I see seagulls”
“Take cover!” the raconteur banters in response, “I’ll rush for shore”
Another who has become more and more active throughout says: “Take it any way it comes”
Another: “It makes me anxious to watch it.”
Time constraints—quite rigid in most healthcare delivery systems, classrooms, and workplaces—also fall away as “progress” in songwriting is not something to be expedited. While facilitators are aware of time, songs evolve organically from a group’s expression; time “flies by” for those deeply engaged. The principles of “timelessness” and openness foster spontaneity. In their pioneering work on the Eden Alternative and Green House projects Dr. William and Jude Thomas’ name spontaneity as a key to turning institutional living environments into humane habitats. (Thomas 1996, NCPAD Monograph, 2010)
The session closes with singing the group’s song “Out On the Water” and thank yous all around. Afterward, the activity director comments that he thinks it may have taken the two women seventy or more minutes to orient to the process and find their place in it. (Friedman, 2007)
The two-hour time frame has proved successful and is now Songwriting Works’ standard practice.
MUSIC and the BRAIN: SPEECH, SONG, RHYTHM and MEMORY
“Music making is thought by some researchers to be the most extensive exercise for brain cells and for strengthening synapses. Brain scans of musicians reveal that nearly all of the cerebral cortex is active during performance. It would be difficult to find another activity that engages so many of the brain’s systems.”
—Norman Weinberger (1998)
COGNITIVE BENEFITS OF MUSICAL IMPROVISATION
“The process of improvisation is involved in many aspects of human behavior beyond those of a musical nature, including adaptation to changing environments, problem solving and perhaps most importantly, the use of natural language, all of which are unscripted behaviors that capitalize on the generative capacity of the brain.”
—Charles J. Limb and Allen R. Braun (2008)
Limb and Braun’s 2008 study of improvising professional jazz musicians suggests that instrumental music improvisation—including that with a biographical and/or emotional component such as the reminiscence-based spontaneous melodic expression that occurs in the Songwriting Works process—has been found to increase the level of complexity in brain activity. Improvising was found to simultaneously activate and de-activate different brain regions. This suggests that the relationship between activation and deactivation may be a key to understanding how creativity blossoms when conscious control is relaxed.
LEAPING INTO AGING
To illustrate cognitive fitness and the brain’s capacity for neural growth and engagement even amidst significant decline, Dr. Gene Cohen used the image of squirrels leaping between trees:
In a brain with fewer dendrites the leaps between synapses would be like leaps between bare-branched trees. The spaces on bare-branched trees would be wider to navigate, the leaps more difficult to make. In contrast, in a brain [with] many branches and connections—a great number of dendrites—a person’s thoughts and responses, like our leaping squirrel, could move with more facility between ideas and associations. The more bridges or branches there are, the more connectivity and communication. (Cohen 2005)
Cohen‘s groundbreaking “Creativity and Aging” study demonstrated significant health impacts for community dwelling older adults, average age 80, who attended weekly professionally-conducted arts programs (choral ensemble, theater group, painting class) in three U.S. cities. (Cohen et al 2006) At the end of three years, participants had experienced significantly fewer falls, fewer doctor’s visits, reduced need for medication, improved scores on loneliness and depression scales, and increased social engagement beyond the time of the study, compared to those in a control group who did not participate in similar programs. Cohen had hypothesized that master teaching artists—those adept at breaking down complex learning activities into accessible increments for their students—might create conditions for health by engendering in learners a greater sense of mastery (Rodin 1989, Lachman and Weaver 1998) while positively engaged in a social context (Glass et al1999).
6. Methodology—EIGHT PRINCIPLES THAT SUPPORT HEALTHY CREATIVE ENGAGEMENT
“Everybody felt they were a part of the program for the day. It was very good for us.
Better than pills!“
—C.G., age 80
Restoration occurs at several levels: Participants and communities (re)engage in the physiological and cognitive experience of music-making and vocal (sung, recited) expression. Honor is restored as individuals’ precise creative input is incorporated and repeatedly validated. Recognition later extends in public celebration. Feedback from surveys and interviews suggests that the experience affirms elders’ and caregivers’ sense of usefulness, belonging, value and overall well-being (see Case Study 3).
Cognitive psychologist Barbara Rogoff describes a “social matrix of purposes and values” that is created as humans define, discover, solve and learn from problems they encounter; they collectively respond, in part, by developing more resources (social structures, strategies, technology, tools). This social contextualization further catalyzes engagement and cognitive development (Rogoff 1990 and 1998). In both song composition and performance, the Songwriting Works’ model helps create this type of “social matrix” for growth.
“When they see—it makes me cry and I can’t talk.
I’m going to take this (songbook) home and show it to my children
so they can take it to my grandchildren.”—B.C., age 86
MUSIC as a KEY TO COGNITIVE INTELLIGENCE
“If you can walk you can dance, if you can talk you can sing.”
“It is reasonable to suppose that musical skills played a major role early in the evolution of human intellect, because they made possible formation of human societies as a prerequisite for the transmission of acquired knowledge across generations. —Walter Freeman (2000)
Songwriting Works’ mission is to restore health and community through re-integrating musical practice and original sung expression into daily life. Through their songs and performances elders’ and others’ presence—their voices and value—are re-introduced into the culture aiding in “transmission of acquired knowledge across generations.” It is well documented that musical memory is one of the last aspects of memory to deteriorate in elders with debilitating late-stage dementia. Extensive study of the singing of popular songs with such elders has demonstrated that vocal musical engagement is an effective aid in increasing communication, cognition and well-being (Claire 1996, Götell 2003 and 2009). Songs entering the “musical memory bank” early in life appear to be the last memories depleted.
Could it be that a similar phenomenon operates for humans as a species? Might the earliest input of vocal musical function—which some theorize preceded plain speech in human evolution—have set neurological architecture in place for retention of music in the brain as an overall foundational component? Might vocal music, if considered an elemental ‘blueprint’ or template in neurological structure, underlay or foundationally interact with additional neural networks or areas in ways that serve as keys to function within, or communication between, any number of neural locations?
“It doesn’t surprise me that people with dementia compose songs,
but it does surprise me that they remember them.”
—Jewish Home Geriatrician (Allison 2008)
As a direct result of the Songwriting Works program our residents have a better quality of life. Residents that were not verbal prior to this program continue to have a voice in our community. Caregivers learned new ways of listening and accepting resident input and most importantly, families are able to share laughter and joy again.”
—Kathy Burrer, administrator, Dungeness Courte
PASTORAL CARE—ADDING A SPIRITUAL DIMENSION TO THE MODEL
“I just never thought this was possible for me in my lifetime” —participant, age 88
describing her experience of performing original songs for the dedication of her synagogue (Allison 2008)
In 2003, the author and Rabbi Sheldon Marder co-founded Psalms, Songs & Stories™, a program that blends the Songwriting Works experience with intensive text study and reflection upon the Psalms. The program, as noted in Dr. Allison’s research, seeks to awaken personal and communal intelligence through spiritual study, self-inquiry, collective collaboration, and musical exploration. Workshops engage groups with mixed cognitive ability; sixty percent or more have some level of dementia. Their average age is eighty-eight. The replicable Psalms, Songs & Stories model deserves mention in a cognitive fitness context, particularly since the construction and intention of Psalms can be profoundly re-orienting for participants (Marder 2005). Re-orientation appears to occur irrespective of individuals’ prior religious background or familiarity with the text. Though this has yet to be formally studied, observers have noted that participants in this program tend to break into spontaneous singing and melody “finding” through improvisation more frequently than in the original Songwriting Works model. The founders speculate that this may be due in part to an increased sense of spiritual mission or permission.
It’s clear that [Frederico Garcia] Lorca is often leaping from one brain to another.… Lorca pulls an image out of the memory bank of the mammal brain: “The creatures of the moon sniff and prowl about their cabins,” and then immediately follows with an image from the memory bank of the reptile brain, “The living iguanas will come to bite the men who do not dream”, and then an image from the memory bank of the new brain comes in: “The man who rushes out with his spirit broken…” He doesn’t do it deliberately—that’s simply how the brain works when it is confident and excited.
—Robert Bly (1990)
Songwriting Works excites parts of the brain and makes connections where verbal, musical, rhythmic, gestural, and imaginal processes take place. It does this while offering participants and practitioners alike new avenues of mastery and confidence on the health-enhancing path of creativity. Multivalent stimulation offered in the act of collective songwriting increases neural activity and growth. Research on the specific impacts of the Songwriting Works experience and brain function, especially for those elders with dementia and other neurodegenerative illness, has yet to take place. Nevertheless, what is known, without doubt, is that intentional cultivation of group musical resonance consistently builds community, promotes self-esteem, and creates conditions for improved cognition as well as physical, mental and spiritual well being.
With age, and even with deterioration and illness, the human body, mind and spirit remain attuned to our inherent human proclivities: to learn, to participate, to express, and to give. When these processes are activated, health and wellness significantly improve for the individual and the collective (Cohen et al 2006). Communal musical interactions which contain depth of meaning for elders have profound positive impacts on their physical and social well-being and can transform the culture in which they live. (Allison 2008 and 2010).
“When I grew up we didn’t have TV. We didn’t sit around. People played music and they sang.
Just because you may not get to Carnegie Hall doesn’t mean you can’t have the experience of playing music…. The music is the medicine.” –Andy Mackie, Andy Mackie Music Foundation
As music composers and group facilitators it is our job to maximize engagement, to welcome elders onto a playground of possibility—drawing out story, word, gesture, idiom, emotion, image, sound, and musical shapes. In this way different parts of the brain, including storage zones of reminiscence, springboards of imagination and the mysterious “breeding ground” of curiosity can be engaged. Through doing this work we heal the culture; we restore dignity to people of all ages and abilities, and awaken and welcome the dormant and marginalized musical intelligence in individuals and communities.
Humankind is neuro-biologically “wired” for making music (Wallin, Merker and Brown et al. 2000). Music is, as all art-making, a natural expression of the human process of making sense of, and relating with, and to our surroundings (Dissanayake 2000, Hodges 2000). We appreciate music, dance to its rhythms, identify with symbols, shapes and sound colors, create and attune to language, tonality, and pitch. It moves us and we join in. Hence, any cognitive fitness and health program should include active musical engagement.
If we have lost a sense of empowerment or feel we’re “out of practice” the good news is: we already know how to do it. Throughout the life cycle, at any point on the continuum of aging and of physical, emotional, spiritual and cognitive health, musical experiences and support for our remembering are readily available. All that is needed is opportunity, patience, and a context of practice to be restored.
“We all hunger for stories, both the telling and the hearing. They are how we come to make sense of the world. When stories are told and songs sung, the generational differences disappear. Now, late in the game, these elders’ gifts to us are their stories. Our gift to them is to listen, with respect and care, and to midwife those stories into birth as songs.”
–Paula Lalish (apprentice facilitator, 2010)
The author thanks Nancy Horowitz Moilanen, Dr. Theresa Allison, and Daniel Deardorff for conversations about music and medicine, and Paul Kleyman and Daniel Deardorff for their help in editing this chapter. Dedicated to the work and memory of Robert Rice.