Age, Death, and Life Review
Robert N. Butler
Fifty years ago people thought that reminiscing was a sign of senility-what we now call Alzheimer's disease. In that era, many geriatrics researchers confined themselves to the study of people who were long-term residents in chronic disease hospitals and nursing homes. The results of these studies only served to reinforce the stereotypes of old people as confused, decrepit, and leading meaningless lives. Their reminiscences confirmed that they were living in the past.
In 1955 I had the great privilege of joining the National Institutes of Health's Laboratory of Clinical Science, where we studied in detail healthy older people, age 65 and above. Somewhat similar studies were conducted at Duke University. Both groups of investigators initiated the first long-term studies of healthy older persons. Healthy old people who lived in the community were found to be mentally alert and active. An interpretive summary of the multidisciplinary studies was published by the American Journal of Psychiatry (Butler, 1963). Some researchers suggested we were studying an elite group of "super-healthy" people who were not representative of the true population of old people. Later studies confirmed our work.
Thus, during my years at the National Institutes of Health I spent a great deal of time with a group of vibrant older people. I slowly became aware that they seemed to be going through a profound internal process that focused on reviewing their life and trying to come to terms with everything that had happened to them in the past. I wrote a preliminary article based on these observations and this phenomenon, which I labeled the life review among older persons, entitled "Recall and Retrospection" (Butler, 1963), and a later comprehensive paper entitled "The Life Review: An Interpretation of Reminiscence in the Aged" (Butler, 1963).
For several more years I worked with patients in both individual and group therapy. I concluded that the life review is a normal function of the later years and not a pathological condition. Over time, my patients taught me that memories, reminiscence, and nostalgia all play a part in the process. Far from living in the past or exhibiting "wandering of the mind", as was commonly thought, older people were engaged in the important psychological task of making sense of the life they had lived.
WHAT IS LIFE REVIEW?
Life review is a personal process by which a person evaluates his or her life as it nears its end. This spontaneous psychological event is seen especially when one is confronted by death or a major crisis, although some individuals may not be fully aware of it and may even deny that it is happening at all. The intensity and emphasis placed on putting one's life in order is most striking in old age.
ASPECTS OF LIFE REVIEW
People may recall unresolved conflicts that happened many years before. By reexamining what has happened, they may be able to come to terms with their conflicts. This may involve reconciling with a long-estranged relative or friend, or it may simply mean forgiving oneself or the other person and letting go of the negative feelings associated with the memory. Through these efforts, such reminiscence can give new significance and meaning to life and prepare the person for death by lessening anger, fear and anxiety.
In late life, people have a particularly vivid imagination and memory of the past. Often, they can recall with sudden and remarkable clarity early life events. They may experience a renewed ability to free-associate and to bring up material from the unconscious. The life review can occur in a relatively tranquil form, through nostalgia, mild regret, reminiscing, storytelling, and the like. Sometimes, the life story is told to anyone who will listen. At other times it is conducted in private, as a monologue not meant for others to hear. Life reviews are extremely complex, often contradictory, and frequently filled with irony, comedy, and tragedy.
In many ways life review is similar to the psychotherapeutic process. In both instances, a person reviews the past in order to understand the present. In recent years life review has come to be respected as an entity in itself, and a variety of psychotherapeutic techniques have been developed. They include life review therapy (Lewis & Butler, 1974), guided autobiography, described by Birren and Deutchman (1991), and structured life review therapy, (Haight and Webster, 1995).
A variety of life review and family history training manuals have been developed to guide older people on their journey. The Hospice Foundation of America published A Guide for Recalling and Telling Your Life Story (2001). In Great Britain, Age Concern has developed Reminiscence and Recall: A Guide to Good Practice (Gibson, 1998) and the Reminiscence Trainer's Pack (Gibson, 2000), both of which are available through Age Concern's website: http://www.ace.org.uk. Finally, Handbook for Mortals offers practical guidance for people facing serious illness, which includes life review (Lynn & Harrold, 1999).
THE PURPOSE OF LIFE REVIEW
The goals of life review include the resolution of past conflicts and issues, atonement for past acts or inaction, and reconciliation with family members and friends. People often reunite with family and friends after years of separation or estrangement, and return to their birthplace for a final visit. Overall, the life review is a necessary and healthy process and should be recognized in daily life as well as used in the mental health care of older people. The strength of life review lies in its ability to help promote life satisfaction, psychological well-being, and self-esteem.
The overall benefit of a life review is that it can engender hard-won serenity, a philosophical acceptance of what has occurred in the past, and wisdom. When people resolve their life conflicts, they have a lively capacity to live in the present. They become able to enjoy basic pleasures such as nature, children, forms, colors, warmth, love, and humor. Creative work may result, such as memoirs, art, and music, and there is a comfortable acceptance of the life cycle, the universe, and the generations.
MEMOIR AS LIFE REVIEW
Sometimes, life review can take the form of memoir or autobiography. Public personalities write memoirs and autobiographies because they value their lives and feel that they have important ideas or information to convey to others. They also write to set the record straight or get back at an adversary. Robert McNamara's memoir, The Tragedies and Lessons of Viet Nam (1996), was an explanation that included an apology to the American people for his role in events that had occurred nearly 25 years before.
Like life review, a memoir does not necessarily represent the unvarnished truth. Truth and Poetry was how 19th century writer and philosopher, Johann Wolfgang von Goethe, entitled his own autobiography. He recognized that he was rewriting his life by tinkering with reality and explaining misdeeds, perhaps to lessen his guilt and soften the judgment of others.
As life nears its end, life review-whether written as a memoir, spoken to a trusted health care worker, family member or friend, or whispered in private to the walls-is the last chance to edit a life story and make it come out "right". It is the last effort to explain, integrate and reconcile everything that has happened in the course of a lifetime.
MEMORY AND LIFE REVIEW
What ignites a memory? A fleeting smell or sound can bring people back to an event that happened when they were children. For that moment, time and space are suspended. Reminiscing about a happy event and savoring the memory of a special moment in time can be a rare and heartfelt joy. Unfortunately, over the course of a lifetime, people also live through experiences that are so grief laden that they are pushed from conscious memory. They remain forgotten until a traumatic event forces them back into consciousness. The recent terrorist attacks on New York and Washington provided one such example. Many older New Yorkers who lived through traumatic wartime trauma were confronted with sights and sounds that rekindled terrible memories. Although many older people who lived near the site exhibited resilience and an impressive resourcefulness, there was a minority for whom the experience brought to consciousness unbearable memories. Workers who came to their aid reported that in addition to physical assistance, they needed to be able to speak to someone who would listen to them and help them integrate what they had experienced in the past with the more recent experiences.
HELPING THE PATIENT
A health care professional who approaches the patient with an open mind and a compassionate, listening ear can greatly facilitate the life review process. People who embark on a life review are making a perilous passage, and they need support that is caring and nonjudgmental. Some people revise their stories until the end, altering and embellishing in an attempt to make things better. Pointing out the inconsistencies serves no useful purpose and, indeed, may cut off the life review process.
It is especially important that those who work with the dying not impose their own values on those of a dying person and to understand that each person has his or her own special forms of meaning that must be respected.
While it is important to be receptive and nonjudgmental, the health care professional must also keep in mind that it is often hard to tap into the life review of someone who wishes to be silent or is psychologically isolated. In addition, not all outcomes are favorable, and life review sometimes results in a major depression or a depressive trend. The individual who conducts his or her life review alone is at much greater risk of depression than those who allow another person to share in the process.
Life review therapy is sometimes conducted in a family setting. This has the therapeutic advantage of facilitating consensus and clarification of specific family issues. Visual images such as family albums, scrapbooks, and cherished possessions can be used to evoke crucial memories. In lieu of direct contact with family members, some people write letters to their children or other important persons in their lives. Others might leave an ethical will, as either a letter or tape recording that shares their values, hopes, insights, beliefs, and wisdom.
Life review is selective, and not all past experiences are remembered or shared. For most people, it is a combination of hard objective truths and the softer lens with which they remember their less noble acts. Some memories are recalled with clarity and focus, while others are indistinct and blurry. Sometimes, people entirely forget significant events that are too painful to remember. On the other hand, they may judge themselves harshly for minor hurts they inflicted by word or deed many years before. Individuals may experience a sense of regret that becomes more painful the more they examine their lives. In severe forms, this process can lead to anxiety, guilt, despair, and depression. In extreme cases, if a person is unable to resolve problems or accept them, terror, panic, and suicide can result. The most tragic life review is one in which a person decides that his or her life was a total waste.
LIFE REVIEW AS ORAL HISTORY
Recollecting historic events and the era in which they occurred are valuable eyewitness accounts of part of a nation's heritage and are one kind of life review. For example, in Britain, Age Exchange has a Reminiscence Theatre company, through which Londoners have shared their memories of living through the blitz in World War II.
In America, obviously only a few hundred of the 200,000 orphaned and poor children who were sent west between 1854 and 1929 are still alive. They meet annually to share remembrances, and their stories are important historical accounts of a little known social experiment.
In the summer of 1976, under the auspices of the Smithsonian Institution Margaret Mead, Wilton Dillon, and I arranged to obtain the stories of visitors to the Mall in Washington, D.C. In 1993, Sarah L. Delany and A. Elizabeth Delany provided a firsthand account of what it was like to live as African-Americans in the United States in the 20th century, when they wrote their life stories, Having Our Say: The Delany Sisters' First 100 Years. These life reviews are an important record our nation's heritage from the point of view of the people whose lives were shaped by historic events.
Some consider life review a Western phenomenon because of its focus on the individual, however, a number of research studies have been conducted around the world. Major programs of reminiscence and life reviews are carried out under the auspices of both national organizations and individuals in Japan and Singapore as well as in the United States and the United Kingdom. In 1995, an International Society for Reminiscence and Life Review was established.
The life review, as sometimes manifested by nostalgia and reminiscence, is a natural healing process. It represents one of the underlying human capacities on which all psychotherapy depends. Some of the positive results of a life review can be the righting of old wrongs, making up with estranged family members or friends, coming to accept one's mortality, gaining a sense of serenity, pride in accomplishment, and a feeling of having done one's best.
Yet, notwithstanding the importance of the life review and its acceptance today as a normal developmental process, health care professionals who care for older persons depend far too much on drugs to quiet psychic pain. It is hard to believe that a pill has the power to help an old person get to the bottom of genuine guilt, or the capacity to satisfy the need to share memories with an empathic listener. Along with pain, anger, guilt, and grief, health care professionals at all levels need to listen to their older patients. We must facilitate the opportunity for a person to achieve resolution and celebration, affirmation and hope, reconciliation and personal growth in the final years.
Butler: Chapter 1
Birren, J.E., & Deutchman, D.E. (1991). Guiding autobiography. Baltimore: Johns Hopkins Press.
Butler, R.N. (1963). The life review: An interpretation of reminiscence in the aged. Psychiatry, 26, 65-70.
Butler, R.N. (1963). Recall and retrospection. Journal of the American Geriatrics Society, 11, 523-529. Abstracted in Biological Abstract.
Butler, R.N. (1963). The façade of chronological age: An interpretative summary of the multidisciplinary studies of the aged conducted at the National Institute of Mental Health. American Journal of Psychiatry, 119, 721-728.
Delany, S.L., & Delany, A.E. (1993). Having our say: The Delany sisters' first 100 years. New York: Kodansha.
Gibson, F. (1998). Reminiscence and Recall: Second Edition. United Kingdom: Age Concern.
Gibson, F. (2000). Reminiscence Trainer's Pack. United Kingdom: Age Concern.
A guide for recalling and telling your life story. (2001). Washington, D.C.: Hospice Foundation of America.
Haight, B.K., & Webster, J.D. (Eds.). (1995). The art and science of reminiscing: Theory, research, methods and applications. Washington, DC: Taylor & Francis.
Lewis, M.I., & Butler, R.N. (1974). Life review therapy: Putting memories to work in individual and group psychotherapy. Geriatrics, 29, 165-69, 172-73.
Lynn, J., & Harrold, J. (1999).Handbook for mortals: Guidance for people facing serious illness. New York: Oxford University Press.
McNamara, R. (1996). In retrospect: The tragedies and lessons of Viet Nam. New York: Random House.
This article originally appeared in Living With Grief: Loss in Later Life, Kenneth J. Doka, Editor, © Hospice Foundation of America, 2002.