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Nordic Journal of Music Therapy

ISSN: 0809-8131 (Print) 1944-8260 (Online) Journal homepage: http://www.tandfonline.com/loi/rnjm20

Atmosphere - an aesthetic concept in music


therapy with dementia

Jan Sonntag

To cite this article: Jan Sonntag (2015): Atmosphere - an aesthetic concept in music therapy
with dementia, Nordic Journal of Music Therapy, DOI: 10.1080/08098131.2015.1056216

To link to this article: http://dx.doi.org/10.1080/08098131.2015.1056216

Published online: 04 Sep 2015.

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Download by: [Orta Dogu Teknik Universitesi] Date: 23 December 2015, At: 13:59
Nordic Journal of Music Therapy, 2015
http://dx.doi.org/10.1080/08098131.2015.1056216

Atmosphere - an aesthetic concept in music therapy with


dementia
Jan Sonntag*

MSH Medical School Hamburg, Praxis Alte Wache, Eichenstraße 37a, 20255 Hamburg
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Germany
(Received 14 August 2014; accepted 7 April 2015)

This paper introduces readers to a conception of music therapy based on


atmosphere. Its practical application has been developed over many years of
work in the field of dementia and its basis in theory has also been described.
At its centre is an aesthetic understanding of therapy whose aim is to create
Therapeutic Atmospheres. The practical context is described and a brief
account is given of the research methodology used in developing the con-
ception. Theoretical relationships are highlighted and insight is offered into
their content and structure. Brief case descriptions help to present the world
of experience within which music therapy operates when carried out as part
of the residential care of people with dementia.
Keywords: dementia; atmosphere; music therapy; aesthetics; Therapeutic
Atmospheres; qualitative research; therapeutic conception

The world of music therapy is becoming increasingly aware of elderly people


in general and of those with dementia in particular. As the numbers of people
affected by dementia increase, the need for help and support becomes ever
greater. Work in this field is therefore undergoing considerable theoretical
and practical development. The first monograph on the subject was published
by Bright in Australia in 1984 and many international authors contributed
studies from the 1990s onwards to yield what is now a remarkable body of
research. Aldridge (2003), Smeijsters (1997), Vink, Birks, Bruinsma, and
Scholten (2004) and Gerdner (2005) deserve recognition for their reviews
of many of the early works. Sutter (2010) presented an evaluative study of
the literature and Wosch (2011, 24ff) summarised outstanding international
studies demonstrating the effects of music on memory, behaviour and
psychology.
Two of these studies fulfilled the evidence requirements specified for level 1b
of the Cochrane classification (Guetin et al., 2009; Raglio et al., 2008). Their
findings led to the inclusion of music therapy in guidelines on working with
dementia published in 2009 by the German organisations for psychiatry,

*Email: jansonntag@gmx.de

© 2015 GAMUT – The Grieg Academy Music Therapy Research Centre


2 J. Sonntag
psychotherapy and neurology. Standardised examinations demonstrating signifi-
cant effects are an important aid when arguing for music therapy to be recognised
in the health care field. However, as McDermott, Crellin, Ridder, and Orrell
(2013) have shown, they should be accompanied by studies demonstrating how
music therapy can improve the well-being of people suffering from dementia and
how it can be understood theoretically. For example, Ridder (2003, 2005)
profoundly examined and defined singing as a way to communicate and gave
an overview of the wide range of music therapeutic methods. In Germany,
several comprehensive conceptual studies (Dehm-Gauwerky, 2006; Muthesius,
Sonntag, Warme, & Falk, 2010; Tüpker, 2001) have considered both practical
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and theoretical issues and thus complement the studies of efficacy.


Recommendations from this work were considered in the research presented
in the current paper and linked to an extensive body of practical experience. On
this basis, a theoretical model was developed around the philosophical and
aesthetic concept of atmosphere. The result is a broadly based understanding
of music therapy in the dementia field1 which is introduced below.

Practical background
The context for the development of this understanding was the City of
Hamburg’s special residential dementia care service (Besondere Stationäre
Dementenbetreuung) which started life in the 1990s as a model project. Its
purpose was to provide care for mobile people with moderate to severe
dementia living in residential homes, a group presenting particular challenges
(see BSFGV 2009). The project was subsequently incorporated into local
service provision. It exerted a major influence on care in Germany and helped
to create a new care culture. Other states around the country also have now
adopted the basic features of Hamburg’s programme which was strongly
influenced by Kitwood’s concept of person-centred care (Kitwood, 1997). In
most facilities, day-to-day practice incorporates Dementia Care Mapping
(a method of evaluating and improving care practice developed by Kitwood
and the Bradford Dementia Group) in order to continually improve the care
culture. In person-centred care, dementia is regarded not only as a medical
problem but also as a holistic bio-psycho-social phenomenon that has to be
dealt with in a thoughtful and caring way.
One of the special features of the Hamburg dementia programme is its
inclusion of music therapy in multi-professional care. During the development
of the programme, up to 12 music therapists were employed in the 12 homes run
by the organisation “pflegen und wohnen”. Over the years, the members of this
1
This dissertation was accepted by the Music Therapy Institute of the Hamburg School of
Music and Theatre in April 2013 and has been published in full (Sonntag, 2013). An
Introduction to this comprehensive work was published in the Musiktherapeutische
Umschau (Sonntag, 2014) and forms the basis of the present paper.
Nordic Journal of Music Therapy 3
music therapy team discussed their practical experience and considered the limits
and the opportunities of music therapy with regard to the special features of
dementia in the context of residential care. The results of these discussions
provided the basis for further research taking in other information sources and
ultimately for the concept as a whole.
A particular property of music therapy in this institutional context is that
the work takes place in an open setting and forms part of life for people with
dementia. This aspect was mentioned in the foundation study cited above
(Muthesius et al., 2010) and is further addressed here in relation to atmosphere.
It is related to concepts such as Community Music Therapy (Pavlicevic &
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Ansdell, 2004; Stige, 2003) or Ecological Music Therapy (Bruscia, 2014,


242ff) addressing goals like well-being and social understanding, and extends
the conventional therapeutic settings into non-therapeutic spaces. Music therapy
is hence rooted in everyday life. It allows for the complexity, the dependencies
and intricate interconnections that normal life involves. This fact also highlights
the egalitarian standpoint of the concept, which aims to foster participation and
inclusion, and reflects the subjective reality of people with dementia who often
feel themselves to be young, dynamic and very much alive. Here is an
example:

I am sitting in a room in a residential home for people with moderate to severe


dementia. The room is accessible to the residents. I am sitting over a pile of
paperwork when Mr. G. comes in. He appears not to notice me. He seems irritated
and begins energetically to rearrange and stack the tables and chairs. He mutters to
himself as he works. The language is not comprehensible but it is clear that he is
angry. I have heard from his daughter that he used to be a master carpenter. I
imagine that he thinks he has gone into his workshop and found it very untidy.
Maybe the apprentices have failed to clear up again. Maybe he’s thinking “Do I
have to do everything myself?”
At first I see no need to get involved. Mr. G. seems to be re-enacting a perfectly
normal part of his life and playing a very familiar role. But he seems to become
increasingly involved in this situation and begins to look desperate. No matter how
hard he tries, things refuse to be orderly! At this point I would like to offer my
support and help him regulate his affect but I know he would not understand me if I
were to address him in words. So instead of speaking to him I sit down at the piano
and incorporate his expressions of affect into a musical improvisation. He pauses,
considers and then continues his vocalisations to my piano playing. Gradually we
match each other in terms of dynamics, pitch and phrasing and we carry on into a
dialogue of sense and affect during which Mr G.’s mood improves greatly. The
improvisation goes on for at least 15 minutes and wanders through various different
moods until Mr G. eventually leaves the room through the open door and goes his
way, noticeably calmer and almost cheerful.

Research background
The research process leading to the atmosphere-related conception created a
break in the process of continuous change described as reflected therapeutic
4 J. Sonntag
practice. I use this name to indicate the process of realisation and theory
development that is always a part of the therapist’s work. Supervision, writing
about experiences and other methods of reflection feed into this process,
which itself is not initially bound into any scientific framework, so that the
therapist’s work oscillates continually between action and reconstructive
understanding. To a certain extent, therefore, research is already a part of
the therapeutic act (see Freud’s postulated combination of research and heal-
ing, Freud, 1927, 293) and can be continued and refined with the support of
scientific methodology.
A wealth of data in the form of case sketches, supervision notes and
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therapy diaries have accumulated over the course of many years of reflected
therapeutic practice. This heterogeneous corpus of accumulated text, which
has settled out like sediment into a collection of analogue and digital files,
was the raw material of the present study. It then had to be concentrated by
selecting, processing and sorting it to arrive at concepts rooted in experience
which were united in the central category of atmosphere. In the style of
grounded theory (Barney, Anselm & Strauss 1967), this process was not a
linear series of steps. Rather, it was a spiral process that drew in material and
theory and also returned repeatedly to therapeutic practice, thus involving
constant alternation between induction and deduction. In this way, patterns
and connections gradually appeared, ideas became clearer and terms became
more precise.
A particular property of the research method, which has its roots in the nature
of artistic therapy as applied to dementia, is that non-rational intuitive moments
were reflected. These moments were incorporated into the research and had a
major influence on the structuring of the data. As well as being subjected to
rational analysis the material was also subjected to daydream-like “treatment” in
a process comparable to musical improvisation. Artistic and scientific methods
were seen as alternative ways to access knowledge and as possessing equal
value.

Introduction to atmospheres
What our world is like for us, what relationship we have to it at any one moment
and how we feel in it is not a matter of concrete fact but a matter of atmosphere.
(Hauskeller, 1995, p. 101)

Atmosphere is a central category that has come increasingly to the fore in the
research process and acquired sharper contours. It serves both as a means of
understanding and as a concept capable of directing activities and has now
become a hallmark for a particular form of therapeutic access – the atmo-
sphere-oriented approach. Atmosphere has been developed theoretically as a
philosophical term in more recent phenomenological writing, such as that of
Hermann Schmitz, and particularly in the work of the philosopher Gernot
Nordic Journal of Music Therapy 5
Böhme. He identified atmosphere as a key concept in radical aesthetics (Böhme,
1995) based on sensual experience.2 A feature of his theory is its easy accessi-
bility for those whose work involves awareness and creation of atmospheres,
such as architects, designers and artists. Böhme described these activities as
“aesthetic work” (Böhme, 1995, 24ff), a term that was then adopted for atmo-
sphere-related music therapy because of its reference to sensual-affective action
and experience. But what are atmospheres in the present context? Experience of
music therapy with people with dementia suggests that they should be under-
stood as an in-between phenomenon, an interpretation according with Böhme’s
theory. Atmospheres in this interpretation are linked to “the association between
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environment qualities and human state. The atmospheres are the and joining the
two – the bond linking environment qualities and human state together” (Böhme,
1995, 22f). Atmospheres dictate how we feel wherever we are. They relate the
physical and social environment to our internal experience. If this means pri-
marily a subjective quality of the experience, there can be a gain in intersubjec-
tivity because atmosphere is transmitted socially and by the external
environment. Atmospheres are perceived as a pre-reflective overall feeling in
which input from all the senses is combined. They are created by the presence of
things, people and environments. Spatial, but without edges (see Schmitz, 2009),
atmospheres exert a strong but amorphous influence on feelings. They act subtly
on everyone but have a particularly strong influence when reflective capacity is
reduced or absent (as is the case, for example, in babies, people with dementia
and people under the influence of alcohol).
Relaxed, supportive atmospheres are seen here as essential if people with
dementia are to benefit from the psychosocial help on offer. Music can make a
major contribution to creating such atmospheres because it possesses atmo-
spheric qualities like no other medium.

Atmosphere as a means of understanding


The atmosphere approach offers one potential means of accessing the central
phenomena dementia, music and therapy and makes it possible to relate them to
each other. Practical experience with music therapy supports this.

2
The concept of atmosphere extends beyond music therapy standards. Because of its basis
in philosophy, it has good compatibility with other disciplines and can be understood by
those in related areas such as medicine and nursing. Rooted in phenomenological concepts
such as Merleau-Ponty’s theory of perception (1964), it can directly influence our under-
standing of, and dealings with, dementia (Fuchs, 2010; Weidert, 2007). Atmosphere
theory was discussed in relation to music therapy in a special issue of the journal
Musiktherapeutische Umschau (ed. DMtG 2005). Certain aspects had already appeared
in my own earlier publications (Sonntag, 2003, 2005; Sonntag, Brixel, & Trikojat-Klein,
2008, 2011) and are related to the work of Kittay (2008) and Woodward (2004).
6 J. Sonntag
Atmospheres in the life and experience of people with dementia
Dementia is a way of ageing in which affected people become increasingly
receptive to atmospheres as their cognitive abilities dwindle. This is because
their capacity to shape their environment lessens and, equally, because they
become less able to use cognitive strategies to distance themselves from the
effects of atmosphere. If a person with dementia experiences a temporary cool-
ness of the atmosphere, he/she is not able to think “It’ll be warm again soon”. If
dementia causes situations to be experienced afresh every few minutes, the
atmosphere will be experienced repeatedly too. This means that people with
dementia are particularly vulnerable to damaging, malign atmospheres but, at the
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same time, are receptive to benign atmospheres. Here is an example:

Mrs S. is lying across the water bed with her feet hanging down. The water bed is
in a relaxation room adjoining the day room and is always accessible for all
residents. Mrs B. is sitting on the edge of the bed and talking about something in
incomprehensible words. I am leaning on the bed frame and doodling on the guitar.
Mr B. comes in and lies down on the bed on his side, facing tenderly towards Mrs
S. Mrs S. sings along whenever she thinks she recognises a song in my guitar-
playing. She folds her hands in front of her and yawns. “Oh well, back to real life
again tomorrow. I have to go back to work.”

People with dementia perceive primarily their own embodied being within their
surroundings. This means they are dependent on the caring attention of the
people around them but are also able to rediscover elemental ways of living
and experiencing. This interpretation changes the perspective. If we start from
the life and experience of the person with dementia in a given context, we create
a different image of that person’s being. That image is oriented towards the
person’s own resources and sensual experience. From an atmospheric point of
view the altered language of many people with dementia, for instance, is not seen
in pathological terms (as aphasia, apraxia, etc.) but viewed aesthetically and
answered in a corresponding way. The yardstick is not the functioning of speech
but rather the state of the person. Here is an example:

Mr M. is not responsive. When I greet the group he does not respond, remaining
buttoned-up and stiff. I greet the other people present and start the music therapy
session. Taking in and reflecting the moods in the room I play music and sing
songs. At some point during the session I notice how Mr M. straightens up in his
chair and directs his gaze towards me. Suddenly he calls out the word
“Sonnenstrasse” (literally meaning “sun street”). I turn towards him and try to
find out what surrounds the word by asking questions like “Isn’t it sunny today?”,
“Did you know that my name’s Sonntag?” and “Is that where you live?” but
without success. He calls out the word “Sonnenstrasse” a few more times and
seems happy, radiant, as he does so. Repeating it I take up the key and the affective
state, looking at him at the same time. Mr M. appears inspired so we then repeat
this single word in different ways, celebrating it like a festival, and infect other
residents with our happiness.
Nordic Journal of Music Therapy 7
This scene shows how the influence of music was able to get this resident
moving again. Freeing him from his motionless, unreactive state it allowed
him quite suddenly to begin taking part in the events around him. The personal
meaning of the word “Sonnenstrasse” remains hidden. Our images of people
would be very deficient if the value of these people were measured only
according to their ability to express themselves through language. Many of the
companions of people with dementia are, indeed, helpless and out of their depth
when their attempts at verbal interaction fail. The fact that a single word as an
affective-sensual entity can be taken up, used and altered suggests a process led
by atmosphere. In this process, connections of meaning can occur at an aesthetic
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level without something lost being experienced as a loss.

Music as atmosphere
Music is a part of being human that focuses on hearing and action as such. It can
be seen as prototypically atmospheric because of its lack of location as a
phenomenon and the way in which it envelopes the hearer. Certain musical
forms and concepts (including Ligeti’s “Atmospheres” and other New Music
and Sound Art pieces) focus particularly strongly on atmospheres. However, the
parallels between music and atmosphere are not bound to particular rules of
composition or practical rituals of performance. In the experiencing of sound, a
form of perception beyond cognitive analysis, every noise can have an atmo-
spheric effect. It is important here to recognise, as Böhme (2005, 310 and
elsewhere) has pointed out, that music as an art form is not time-related but
space-related. Music makes it possible to experience the surrounding space and
one’s own state within it in a sensual-affective way. Furthermore, music is able to
modulate the way in which people perceive themselves in space (Böhme, 2005,
311). Anyone who listens atmospherically

lets himself out into the open and can therefore be affected by acoustic events.
Mellifluous styles may seduce him, thunderclaps may strike him down, buzzing
noises may threaten him, a cutting tone may hurt him. Hearing is being outside
oneself. For just this reason, it can lead to the positive experience of feeling that one
is in the world at all. (Böhme, 2006, 82)

When understood in this way, music can serve to create atmospheres that are
therapeutic.

Therapeutic Atmospheres
Atmospheres do not have a therapeutic value per se. The origins of malign and
benign atmospheres are usually hidden among the subconsciously perceived
sensual influences conveyed by the environment, whose effect is subtle.
Atmospheres result from the totality of expressions of life in association with
8 J. Sonntag
the material environment. Therapy is therefore seen as one way of consciously
and skilfully shaping atmospheres and thus providing an environment for people
with severe cognitive impairments that is supportive and also stimulates senses
and affect. The Therapeutic Atmospheres concept enables us to identify the
qualities and functions that atmospheres must possess in order to be therapeuti-
cally effective. I define Therapeutic Atmospheres as a category of fundamental
wellbeing – a resonating space making it possible to be aware of oneself and to
experience well-being in the perceptible presence of others but without pressure
to act or emotional pressure. Important features of Therapeutic Atmospheres
(TA) are:
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TA are all-enveloping
TA include things that are not understood and things that are implied
TA are discreet
TA make it possible to be present together
TA are inviting
TA are connective
TA are friendly
TA create balance
TA relieve and do not exert pressure
(see Sonntag, 2013, Chapter 5.3.5)

The following example shows how the Atmospheres’ perspective is reflected in


the therapist’s viewpoint and behaviour and how the emergence of elemental
relations to the self and the world can be the result of a therapeutic process
characterised by seeking and groping.

I enter the day room and am overcome by a lifeless atmosphere without contact.
Two residents are sitting next to each other at the table, staring straight ahead.
Another has fallen asleep in her wheelchair. A fourth turns her head towards me
and looks at me with empty eyes. The other occupant, a woman, is sitting at a small
table in the corner and is quietly but continuously making a plaintive moaning
noise. My greeting, showing my guitar and explaining the musical session ahead, is
met with alienation, incomprehension and fearful expressions. I distance myself
inwardly from this mood, sit down at the table and play some arpeggios. They echo
in nothingness. I take my courage in both hands and sing a Contact Song “Wenn
alle Brünnlein fließen”. Some sing along out of habit, like machines. No affective
involvement. The song goes on and the mood changes gradually over the five
verses – a little. Eye contact, someone winks. Then the mood sinks back again
abruptly. Waiting, staring. There are no perceptible expectations, no wishes, no
drive. I suggest another song. “Lustig ist das Zigeunerleben”, the favourite song of
the potentially most communicative resident. In this situation the lively waltz
rhythm and jolly mood seem grotesque. They sing along and… the mood ebbs
away. I make a few references to people’s lives: “That’s your favourite song isn’t
it?..” Nourish the atmosphere more, invite contact. After the next song the mood
lasts a little and does not sink back so far. A memory emerges. “My parents have
got a flat in Hamburg…” “My father is with the factory security”. Bridges are built,
Nordic Journal of Music Therapy 9
small beginnings are strengthened. The group gradually begins to take shape.
Tentatively contact is made. A song is repeated, they like it. Each becomes more
aware of the others. The song “An der Saale hellem Strande” completes the
transition. I perform it, all the verses, singing lyrically about the landscape of castle
ruins (the subject of the song). In my imagination the ruins with the wind blowing
through them are an allegory for these battered minds, open to the winds of
dementia. “The knights have disappeared, (…) but tender, gentle figures still appear
to the wanderer in the old mossy stones”. For me, the residents become these
tender, gentle figures. I feel with them, sense affection. After the song most of the
people in the room are very moved. The level of feelings in the room has risen like
water. Now they are at a level that can be worked with, a level in which further
action is possible. The group has emerged.
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Atmosphere: a practical concept


Atmosphere as a concept helps us to understand dementia, music and therapy at a
theoretical level. However, it also possesses a pragmatic side developed in
relation to people and the surroundings and, as such, can guide our actions. At
this point, the notion of Therapeutic Atmosphere in practical therapy divides into
different branches depending on the type of therapy concerned. This is not
limited to the description of therapeutic techniques or forms of intervention but
instead takes account of the fact that therapeutic methods are always dependent
on the setting and are used against a background of ethically based attitudes and
particular principles. A full explanation of all the facets of this model, including
supporting evidence in the form of case examples, is provided by Sonntag (2013)
in Chapter 6.1. Table 1 summarises the central points.
The diagram systematises the person-related dimension and also stands for a
process that aims to improve the environment of care home residents. In this case it is
not the people themselves but rather the environments in which they live and receive
care that are the targets of the intervention. Many residential establishments are not
yet in a position to care about atmospheres or their auditory aspects. Important
changes have still to be made with regard to psychosocial connections and also to the
milieu. Residents with dementia, and also those responsible for their care and
therapy, suffer from aesthetic neglect and often react with stress and health problems.
In this context, too, the Atmosphere approach offers a conceptual basis and defines
the factors which exert an influence on auditory milieus. These factors can be put to
practical use to promote liveability and maintain aesthetic value. The approach
includes pragmatic instructions on the quality and quantity of sounds and on
questions of acoustics. It also addresses acoustic aspects of staff behaviour and
considers the use of music (see Sonntag, 2013, Chapter 6.2). A final scene shows
how well-being can result from peace and the chance for relaxed encounters, in this
case with reference to the availability of acoustic niches. The final statement of this
female resident contains neologisms (quoted in their original form) that bring to
mind the word “sabbeln”, which means “to dribble”. Mrs S. is probably using them
to refer to the emotional challenges presented by social life in the big day room:
10 J. Sonntag
Table 1. Settings, attitudes, principles and methods in the
Atmospheres approach.

Methoden Methods

Einstimmen attune
Abwarten wait
Wahrnehmen take in
Ummanteln surround
Einmischen interfere
Aufgreifen pick up
Verstärken reinforce
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Unterhalten entertain
Prinzipien Principles
Beiläufigkeit casualness
Intermedialität intermediality
Situativität situativity
Begleitung companionship
Unabgeschlossenheit incompleteness
Passung matching
Inklusion inclusion
Langsamkeit slowness
Milieusensibilität sensitivity to milieu
Bedürfnisorientierung needs-based
Haltungen Attitudes
Gelassenheit Serenity
Rezeptivität receptiveness
Sorge Care
Setting Setting
Peripher peripheral
Passager Transitory
Mitgehend accompanying
Aufsuchend reaching out
Angelockt Attractive

In a secluded niche in the living area stands a small sofa. It is Mrs S.’s favourite
place. I sit down next to her and the following dialogue develops: Mrs S.: “I always
sit here, it’s lovely.” Me: “Not so many people come here.” Mrs S.: “it’s so quiet.”
Me: “You can hear what the others are doing but you’re left in peace.” Mrs S.:
“You always have to do ‘schlabbel’ and ‘dabbel’ over there.”

Conclusion
The atmosphere perspective leads to an interpretation of music therapy that is, at its
core, aesthetic. People with dementia are particularly sensitive to atmospheres and can
therefore benefit directly from this approach. The concept of atmospheres is presented
here and has been described in more detail elsewhere (Sonntag, 2013). It enables
practical music therapy consciously to draw in both material and social environments
Nordic Journal of Music Therapy 11
and to relate them to subjective states. Such an interpretation takes a lively, artistic
view of dementia as a way of being, accepting the individuals as they are and sharing
in their experience while at the same time promoting a creative attitude that
encourages them to respond. This approach is based on practical experience and
offers resource-oriented access to dementia, both for professional music therapists and
for members of other (caring, medical or therapeutic) professions. The atmosphere
perspective can be used to guide activities in professional practice.

Acknowledgement
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The author is most grateful to the Andreas-Tobias-Kind Foundation for sponsoring the
translation of this article.

Notes on contributor
Jan Sonntag, Prof. Dr. sc. mus., Dipl. Musiktherapeut FH/DMtG, Psychotherapie HPG, is
concerned primarily with dementia. Since 1999, he works as a therapist, researcher,
consultant, lecturer and author. He is professor for music therapy at the Medical School
Hamburg (University of Applied Sciences and Medical University) and journal-editor of
the Musiktherapeutische Umschau.

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