And so it came to pass that a lumbering, wordless young man, gripped by terror and drenched in urine and feces, without his parents and torn from the comforts of a home he’d known all his life, was strapped by the wrists and ankles to an ambulance gurney and delivered to the front door.

Estimates vary on the proportion of people with intellectual and developmental disabilities who experience co-occurring psychiatric disorders, but studies suggest it might be as many as a third (Quintero & Flick, 2010). In administration and funding, the mental health system has operated separately, historically, from the system of services for intellectual and developmental disabilities. On both sides of the institutional gap, agency staff feel ill equipped to provide adequate services for clients with multiple complex needs, as care protocols and treatment providers specialize, for the most part, in one set of issues or the other. Within each system of care, personnel tend to expect the other to provide services. Aaron exemplified, it seemed, the dually diagnosed patient who “falls between the cracks” – whose multifaceted needs seem to surpass the capacity of any single institution or agency to address them.

Records trickled in. A social worker invested overtime in myriad interagency emails and managed eventually to engage Aaron’s parents by phone. Years previously, we learned, he had graduated from a special school. He’d shown interest in puzzles and building blocks and was well liked by teachers and peers, though his spoken vocabulary, at its peak, had never included more than a few words. Later, as a young adult, he had attended a well-regarded day program, exercised in a gym, and even, for a time, held a paid job sorting containers in a training center. His condition had declined as his parents’ advancing debility turned into a cascade of personal disruptions, derailing long-standing life routines. We saw little evidence now of Aaron’s previous level of functioning. So we reached, at first, for familiar and available tools.

Aaron shoved aside the picture board which language-limited patients sometimes use as a communication aid to point to what they need (the picture of a bathroom, for example, or a bed, or a plate of food). He snubbed ball play, ring toss, and even simple puzzles arranged on a table, angrily scattering pieces to the floor. Pop music, a perennial favorite for most patients, sent him storming truculently down the hall, swiping at his ears as if waving away flies. He made no eye contact, acknowledged no greeting, said nothing, and he responded to no toileting or hygiene prompts. Several of the mental health techs sustained bruises within the first few days trying to change Aaron’s filthy clothing and wash him. His monitoring status was upgraded to the highest level so that he could be observed by multiple staff at the same time, as one of the psychologists initiated a strict behavioral regimen – praise and snacks for any move toward cooperation with basic care. Between the locked office doors, the hallway reeked. It was not hard to miss Aaron’s almost unfathomable isolation – an exile from fundamental structures of self-care and social exchange. By trial and error, however, some intrepid evening-shift staff found that if they occupied both his hands simultaneously with juice and cookies, Aaron could hold still for just long enough to accept oral medications and allow for his brow and cheeks to be wiped briefly with a washcloth. So began, inauspiciously, Aaron’s physical care. We tiptoed around him, guarded and vigilant.

Rhythm saturates social life, Henri Lefebvre, the French philosopher, has written (Lefebvre, 2004). It infuses our work and our play, our encounters with traffic and taxes and school calendars, our sleep cycles and eating schedules, our contact with nature and our contact with people. Rhythmic patterns are inscribed as a fundamental constituent of identity, reverberating in our oldest memories and fundamental sense of self. So when a rhythmic order is taken away, our bodies continue, distantly, to hear it, and we attempt, perhaps unwittingly, to reconstitute it.

The English romantic poet William Wordworth is considered the master of poetic rhythm, his huge body of work dense with a spare oscillating murmur, a determinacy that replicates, in sound, the rhythmicity of a walk in the countryside. It is said of Wordsworth that he wandered perhaps 180,000 miles in the course of his long life. His sister wrote in her diaries of the compulsiveness and single-mindedness with which he traversed, in thundering rain or in blistering heat, the small yard outside the cottage they shared (Gros, 2011).

Walking has long been associated with talking – the rhythms of steady step-wise motion bonded with the dance of voices summoning meaning in turns. Two and a half millennia ago, Aristotle founded a school of philosophy known to us as “the peripatetic” – named after the ancient Greek word peripatein, which means to walk and to converse, to engage in a dialogue while walking. We marveled, now, at Aaron’s ravenous, unending conversation of one foot in front of the other. Nightly, wobbling from exhaustion and heavily sedating medications, he collapsed into a mattress we’d placed on the floor for him. The staff covered him with blankets as he slept, tucking around the edges tenderly, pushing sweaty hair off his forehead and gazing in fearful wonder.

Pablo Casals, the Spanish cellist, was only 13 years old when he stumbled on a yellowed package of old sheet music in a tiny thrift shop in Barcelona. It turned out to be Johann Sebastian Bach’s cello suites, six short works originally written around 1720 but subsequently mostly neglected, as musicians of the 18th and early 19th centuries considered them dry and overly mathematical, something like practice exercises. Casals fell in love with them, and, in 1936, when he was 60 years old and already world-renowned, finally recorded them. Their popularity soared, and today they are considered among the most profoundly elegant and poignant works in the classical repertoire. (One of them was played at the opening of New York City’s World Trade Center memorial.) There are six of these suites, each organized symmetrically, with the harmonic precision and rigor for which Bach is famous, and each divided into six symmetrical smaller sections. Like other music of their time, they are polyphonic, which means a multiplicity of voice lines calls out in twining layers as the work progresses, evoking a sound image of depth and dialogic exchange.

Musically, the cello suites convey the idea of a voice in plaintive conversation with itself. Composer Tod Machover (2007) tells us that the cello, among all orchestral instruments, is the one which comes the closest in range to the human voice – its lowest notes at the bottom of the basso profundo, its top ranges capable of something like the trilling of the highest soprano. I had been listening in my car on the way to work. My mind called up suddenly a comment by one of the nursing aides: “Maybe he likes classical?” Aaron’s psychiatrist embraced the idea. What did we have to lose, after all, from introducing our patient to Bach?

Over the next few weeks, an interdisciplinary team played the cello suites intermittently, at least once but usually several times a day, each time introducing new activities or milieu elements to the backdrop of their musical accompaniment. Aaron allowed himself to stand at a table as the cello spoke around him. He permitted one staff member to escort him to the bathroom, another to wash him. His restless pacing began to diminish, as he paused more frequently, and, over a period of days, he began responding to simple directions (“go wash your hands,” “sit here for lunch”) which previously had greatly irritated him. Hoping to activate whatever reserve of words might resurface from Aaron’s mysterious silence, the floor-duty staff began narrating each increment of advance: “You changed your pants!” “You used the toilet!” “You are sitting in the chair!” Aaron began pointing – to a blanket, to the toilet, to the bed, to a paper towel – initiating goal-directed communications. He agreed to play a ball game. He worked a puzzle. Slowly, with the music shepherding his emergence from isolation, he accepted many of the activities which initially had been angrily refused. Three weeks in, we re-opened the hall doors so Aaron could enter the general patient area for brief forays around the nursing station. The cello suites attracted converts: more than a handful of staff members downloaded them for personal use.

As Aaron grew more comfortable, happier and more relaxed, engaging more readily in conventional therapeutic activities with the psychology and rehab departments, and so on, and allowing more of the clinical staff into his circle of contact, we turned off the music. A warm, good-natured, and likeable personality emerged over the course of the ensuing month, and Aaron was able, finally, to transition to a richer and far less restrictive community setting.

“Little as we know about the way in which we are affected by form, by colour, and light,” wrote Florence Nightingale in 1859, “we do know this, that they have an actual physical effect” (Nightingale, 1859). The gestural bridge here – in music form – speaks to this long-standing but underutilized nursing concept. We hoped that Aaron would find friends, safety, pleasure, and purpose in his new place of residence, and that music would continue to inspire and comfort him.