Our sea: Music therapy in dementia and end-of-life care in the Mediterranean region
Authors: Tsiris Giorgos , Ceccato Enrico 
Published: April 2024

OPENING
Welcome to this special feature of Approaches, which was inspired by the 1st Mediterranean Music Therapy Meeting. Organised by the Giovanni Ferrari Music Therapy School of Padua, with the support of the Italian Association of Professional Music Therapists (AIM) and the Italian Confederation of Associations and Music Therapy Schools (CONFIAM), this event took place on 22nd September 2018 in Padua, Italy. Reflecting the theme of this meeting, Dialogue on Music Therapy Interventions for Dementia and End-of-Life Care: Voices from Beyond the Sea, this special feature aims to raise awareness and promote dialogue around music therapy in the Mediterranean region with a focus on dementia and end-of-life care settings.
The special feature contains brief country reports. Although reports vary in writing style and depth of information, each report has a two-fold overall focus: to outline briefly the current state of music therapy within each country and to describe particular applications of music therapy within dementia and end-of-life care contexts. Additionally, this special feature contains a Preface by Melissa Brotons, who was the keynote speaker at the 1st Mediterranean Music Therapy Meeting, as well as a conference report outlining key aspects of this meeting.
THE SEA AROUND US: A NOTE ON THE MEDITERRANEAN
The name of the Mediterranean Sea originates from the Latin mediterraneus, meaning “middle of the earth”. This name was first used by the Romans reflecting their perception of the sea as the middle or the centre of the earth. Interestingly, while perceived as a middle point, the Mediterranean was also experienced as something that surrounded people. Thus, both the Ancient Greeks and the Romans called the Mediterranean “our sea” or “the sea around us” (mare nostrum in Latin, orἡ θάλασσα ἡ καθ’ἡμᾶς [hē thálassa hē kath’hēmâs] in Greek).
The Mediterranean Sea is linked to the Atlantic Ocean. It is surrounded by the Mediterranean basin and enclosed by land: on the north by Southern Europe and Asia Minor, on the south by North Africa, and on the east by Western Asia. Since antiquity the Mediterranean has been a vital waterway for merchants and travellers, facilitating trade and cultural exchange between peoples of the region. The Mediterranean region has been the birthplace of influential civilizations on its shores, and the history of the region is crucial to understanding the origins and evolvement of the modern Western world. Throughout its history the region has been dramatically affected by conflict, war and occupation. The Roman Empire and the Arab Empire are past examples with lasting footprints in the region; while ongoing conflicts in Syria, Israel and the Occupied Palestinian Territories are contemporary examples, some of which have led to a refugee crisis in the region. As such, the history of the region has been accompanied by endeavours and struggles to define and redefine national identities, territories and borders. Interestingly, Cyprus is one of just two nations, and the first one in the world, to include its map on its flag (the second is Kosovo – a Balkan country close to the Mediterranean region).
The sea touches three continents, and today the Mediterranean region can be understood, framed and divided differently based on varying geopolitical and other perspectives (see, for example, the Eastern Mediterranean Region of the World Health Organization [WHO, 2020]). For the purposes of this special feature, we understand the Mediterranean region as including 12 countries in Europe, five in Asia and five in Africa. These countries, in clockwise order, are Spain, France, Monaco, Italy, Malta, Slovenia, Croatia, Bosnia and Herzegovina, Montenegro, Albania, Greece, Turkey, Cyprus, Syria, Lebanon, Israel, Occupied Palestinian Territories, Egypt, Libya, Tunisia, Algeria and Morocco.
Despite its relatively small geographical area, the Mediterranean region is characterised by the richness of cultures, religions and musical traditions. Likewise, there is a dramatic diversity in terms of political and socio-economic situations. This diversity is equally reflected in the development of dementia and end-of-life care in these countries. Regarding dementia care, in 2016, the Monegasque Association for Research on Alzheimer’s Disease, published the Alzheimer and the Mediterranean Report where is underlined that “[in] many Mediterranean countries, there is still little knowledge about the problems surrounding Alzheimer’s disease, which remains under-estimated and insufficiently documented” (AMPA, 2016, p.7). The report identified a concerning rise in the number of people with Alzheimer’s disease and related disorders in the Mediterranean area, but little biomedical, fundamental and clinical research, unequal and unspecialised access to home care services, and also a general lack of training among professionals and a lack of status recognition for family carers.
In terms of end-of-life care, in 2017 the first systematic attempt to map and assess the development of palliative care in the WHO Eastern Mediterranean region was published (Osman et al., 2017). Results demonstrate that palliative care development in Eastern Mediterranean countries is scarce. Most countries are at the very initial stages of palliative care development, with only a small fraction of patients needing palliative care being able to access it. This situation also applies to the integration and provision of palliative care within care homes and nursing homes offering long-term care for older people (Froggatt et al., 2017). Recent reviews also demonstrate that palliative care is variable and inconsistent across the region, while various barriers exist to the development of palliative care delivery. Examples of such barriers include the lack of relevant national policies, limited palliative care training for professionals and volunteers, as well as weak public awareness around death and dying (Fadhil et al., 2017).
Similar barriers around legislation, training and public awareness are met in the development of music therapy in many Mediterranean countries. Music therapy, as a contemporary profession and discipline, and indeed its applications in dementia and end-of-life care, are equally limited and characterised by diversity across the region. As such, this special feature is a modest attempt to bring together perspectives and present initial information for areas of work which are not widely developed, explored or documented so far in most Mediterranean countries. Hopefully this publication will raise further awareness and inform the future development of music therapy with specific reference to its potential applications to dementia and end-of-life care in each country. This becomes even more relevant considering the increase of non-communicable diseases (NCDs), including cancer, in the region (Fadhil et al., 2017).
BEHIND THE SCENES
Inviting authors
Although the 1st Mediterranean Music Therapy Meeting included speakers only from a few Mediterranean countries, this special feature attempted to include authors from every single Mediterranean country. In addition to inviting the speakers from the meeting to contribute to this special feature, we invited authors from each of the other Mediterranean countries. After listing all the countries, we tried to identify music therapists in each of them. We drew on our own professional networks, as well as information available on the websites of the European Music Therapy Confederation (EMTC) and the World Federation for Music Therapy (WFMT), along with relevant publications in the open access journals Approaches: An Interdisciplinary Journal of Music Therapy and Voices: A World Forum of Music Therapy. In countries where we could not identify a music therapist (with or without direct experience of working in dementia and end-of-life care), we attempted to identify and invite other relevant professionals with an explicit interest in music therapy. When this second option was impossible, no authors were invited. There were also cases where potential authors who met the above criteria did not respond to the invitation. As such, this special feature does not include a report from every Mediterranean country. The absence of reports from some countries, however, does not necessarily reflect the lack of music therapy work in these countries.
Some of the contributing authors are members or representatives of professional associations and some are not. In either case, their contribution to this special feature aims to represent their views and experiences as individuals without claiming to represent national or other professional bodies. Depending on the position of each individual author, different aspects of music therapy may be explored, prioritised, silenced or challenged in each country report. We want to be clear: these reports are not about absolute ‘truths’ and do not provide comprehensive accounts of music therapy and of its applications in dementia and end-of-life care in each country. Instead of being a ‘full stop’, we see these reports as an opening; as invitations for dialogue, debate, critique and mutual growth. We encourage readers to engage with the contents of this special feature critically; being informed by their own experiences and practices, as well as by related literature and historical trajectories in the field (e.g. De Backer et al., 2013; Dileo-Maranto, 1993; Hesser & Heinemann, 2015; Ridder & Tsiris, 2015a; Schmid, 2014; Stegemann et al., 2016).
The challenge of the review process
All reports were peer-reviewed. Although we strived to ensure a ‘blind’ review process, this was difficult to achieve in certain cases due to the nature of the reports and the small size of the music therapy communities in certain countries. We invited music therapists living and working in Mediterranean countries to serve as reviewers. We also invited some music therapists living in other parts of the world, given their experience and role within international music therapy bodies and initiatives. Reviewers were requested to evaluate not only the accuracy of the information provided in each report but also the reflexive stance of the authors. This comes with acknowledging that in some instances authors and reviewers came from diverse professional and disciplinary spheres, where music therapy can be understood and practised differently. This was particularly relevant to country reports where we could not identify reviewers with ‘inland’ knowledge of the music therapy field and of its relevance to local dementia and end-of-life care contexts.
Towards hospitality
Professionalisation issues – which seem to be a common denominator across the reports of this special feature – are often an area of controversy and conflict, where alliances and oppositions have emerged over the history of the music therapy profession within and beyond the Mediterranean region. Writing a country report, and indeed reviewing and editing a collection of such reports, can be a ‘hot potato’! Although it is impossible to remain apolitical, we argue (and we have actively tried to promote this through our editorial and reviewing work) that a constructive dialogue needs to be characterised by reflexivity. It needs to be underpinned by openness and transparency regarding our own values and assumptions, our pre-understanding, our standpoint, as well as our invested interests.
Professionalisation conflicts within some Mediterranean countries have led to the development of multiple and, at times, antagonistic associations and professional bodies. In Spain, for example, there are over 40 associations (Mercadal-Brotons et al., 2015), whereas in Italy there are four main associations (Scarlata, 2015). In other countries, such as Greece (Tsiris, 2011), there are communication challenges and conflicting situations between professional association, training programmes and governmental departments. Although such challenges tend to remain unarticulated and ‘hidden’ from the professional literature and discourse, they have real implications for the development of the profession within each context and for the morale of each music therapy community.
Overall, this special feature aims to promote a spirit of open dialogue and mutual respect. It is underpinned by a commitment to remain in ongoing dialogue while accepting that we can agree to disagree. As editors we tried to remain true to this commitment, and this became particularly evident in cases where reported practices and concepts were at odds with our own perspectives and understandings of music therapy and its development as a contemporary profession and discipline in Western countries. Indeed, the perspectives presented in some of the reports may sit on the edge or even outside the ‘professional canon’ of music therapy as developed in many contemporary Western countries. In line with the vision of Approaches, this special feature opens up a space where local-global tensions can be voiced (Ridder & Tsiris, 2015b), allowing multiple translations, transitions and borders to be explored. What becomes evident is that definitions of music therapy are inextricably linked to cultural, including spiritual and political, meanings and practices of music, health and illness.
Mediterranean people are known for their hospitality but also for their passionate temperament. We hope that this special feature creates a hospitable and welcoming environment for professional and intercultural exchange where passion can fuel creative action and collaboration instead of conflict. We invite the readers to engage with each report in this spirit of openness and reflexivity. This special feature will hopefully be only the start of future dialogue, debate and constructive critique. To this end, we also invite people to add their voices and perspectives regarding music therapy in the Mediterranean region in relation to dementia and end-of-life care. Music therapists, palliative care practitioners and other professionals are welcome to submit their own papers in the form of articles, reports or letters to the editor.
References
AMPA (2016). Alzheimer and the Mediterranean Report 2016: Overview – challenges – perspectives. Retrieved from https://ampa-monaco.com/files/MAA_Rapport_GB_web_sml.pdf
De Backer, J., Nöcker Ribaupierre, M., & Sutton, J. (2013). Music therapy in Europe: The identity and professionalisation of European music therapy, with an overview and history of the European Music Therapy Confederation. In J. De Backer & J. Sutton (Eds.), The music in music therapy: Psychodynamic music therapy in Europe: Clinical, theoretical and research approaches (pp. 24-36). London: Jessica Kingsley Publishers.
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Froggatt, K., Payne, S., Morbey, H., Edwards, M., Finne-Soveri, H., Gambassi, G., Pasman, H. R., Szczerbinska, K., & Van den Block, L. (2017). Palliative care development in European care homes and nursing homes: Application of a typology of implementation. Journal of the American Medical Directors Association, 18(6), 550.e7-550.e14.
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