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By Sandra E. Shilling, MSW

“I’m an alcoholic. I drank away the years I could have spent with my kids, drove away those who loved me, and have been generally unsuccessful in every respect. If you ask me now what I think I’ve done with my life, I think I’d say not a damn thing.”

These words peppered the first conversation I had with Ms. V. and foreshadowed the great struggle she would have in her process of dying. I was green—new to social work and without any idea of how to respond—so I listened. Though it was a painful process, we spent the next few months examining her past. The evolution of her spirit was palpable. What was once an embittered shell of a woman became a proud resident of earth for the last few days she spent on it. In identifying who she had been, we determined who she desired to be and what she could do to make that happen.

Ms. V.’s feelings are not uncommon. Many older adults struggle with feelings of inadequacy as they reflect on their lives and, much like Ms. V., may experience depression if those feelings remain unresolved.

Depression in Older Adults
Depression is a common psychiatric condition in older adults that is often misdiagnosed and undertreated. Late-life depression can be attributed to extensive losses, including physical decline, bereavement, retirement, and social isolation. The consequences of untreated late-life depression are devastating and can include suicide, diminished quality of life, lower life expectancy, and physical illness.

Ms. V.’s case exemplified the results of depression in this population. Her life was a series of storm clouds with no silver linings. Her impending death robbed her of a future in which she could rectify her past mistakes. She was left feeling hopeless and her ability to see anything positive was distorted by the negative lens through which she viewed herself and the world. She had long ago spiraled into a depression that was now complicated by her recognition of the finality of life. Psychotropic medication provided only mild and temporary relief.

Structured life review and reminiscence therapy offer an alternative intervention for treating depression in older adults. Several studies show that within the elder population, reminiscence therapy produces results comparable to cognitive behavioral therapy and antidepressant medications (Peng, Huang, Chen, & Lu, 2009; Adamek & Slater, 2008). While this research shows promising results, existing studies have several limitations. Interventions are not standardized or clearly defined, and various measurement tools were used, which makes comparison among studies difficult. Many studies fail to differentiate between structured life review and reminiscence therapy, although the interventions and treatment goals vary. In addition, few studies examine the long-term effects of these interventions.

Theoretical Basis for Life Review
Erikson’s Theory of Psychosocial Development, combined with Butler’s definition of reminiscence, formed the blueprint for structured life review. In 1963, psychiatrist and aging expert Robert Butler, MD, explained that reminiscence is a universal and naturally occurring mental process in which experiences from the past, particularly unresolved conflicts, are returned to consciousness and can be reintegrated into life. Reminiscing allows older adults to identify past accomplishments and maintain a balanced perspective that integrates the full spectrum of life experience. The process facilitates successful completion of Erikson’s last psychosocial stage.

Therapeutic results from life review include reduced depression, increased life satisfaction, self-acceptance, bonding, catharsis, and reconnecting with family and friends (Haight & Haight, 2007). Although it was difficult, Ms. V.’s participation in the life review process permitted her to openly discuss events from her past that were sources of shame and embarrassment without fear of judgment or condemnation. Through the use of affirmation, unconditional positive regard, and validation, Ms. V. eventually arrived at a point of self-acceptance. While she was unable to reconcile estranged relationships with family, her life satisfaction increased after reframing negative events from the past. She experienced a revelation as she recalled with tear-filled eyes abuse experienced as a child. The abuse sent her on what felt like an endless journey—a search for love and an antidote to the emptiness and humiliation that consumed her. Although these horrible events would never completely justify her behavior, she recognized them as key contributors to her alcoholism and the succession of unhealthy relationships that she developed in adulthood. Through this process, she was able to forgive herself and her perpetrators.

Overview of Assessment Process and Interventions
Unlike other forms of reminiscence therapy, structured life review is performed on an individual basis and involves only the reviewer and the therapeutic listener. The therapeutic listener asks probing questions in an attempt to elicit the reviewer’s experiences, deepest thoughts, and secrets. Participants reflect on both the positive and negative aspects of their lives, evaluating the significance of these events and working through unresolved conflicts. During the assessment process, information about the reviewer is collected and a suitable environment is selected. Through observation and direct questioning, the therapeutic listener assesses the reviewer’s physical, psychological, and cognitive functioning. A meeting location that ensures privacy is selected; also important is adequate lighting and minimal noise interference to accommodate individuals with visual and hearing impairments (Haight & Haight, 2007).

When structured life review is initiated, the reviewer is provided with a list of potential questions and informed about the process. The intervention typically consists of six to eight 1-hour sessions. The conversation begins with the individual’s earliest memory and progresses to the present. Generally, the first two hours are devoted to childhood, family, and home. The second two hours are devoted to adulthood. The final two hours focus on summarizing and evaluating the reviewer’s life in its entirety (Haight & Haight, 2007). These two hours provide a unique opportunity for the therapeutic listener to gain insight into what the process has meant for the reviewer. While structuring the intervention is essential to the process and all parts of the lifespan should be discussed, reviewers often move back and forth between developmental stages.

Several tools and techniques are available to enable the therapeutic listener to facilitate discussion. The Life Review and Experiencing Form is used as a guideline for structured life review and provides probing questions that are organized by session (Haight, 2007). If these questions do not effectively elicit memories, the therapeutic listener can ask the reviewer to recall what he or she was doing on the day of a significant historical event. Narrowing the focus of questions in this manner may prove to be less threatening because the perception of right or wrong answers is alleviated. Reviewers can be encouraged to complete a genogram or timeline and include family members in the process. Additionally, props such as music, aromas, pictures, and antiques can be used as tools during life review.

A lack of standardized interventions complicates the evaluation of life review’s therapeutic utility and makes replication difficult. The best attempt to evaluate the intervention is the use of a pretest/posttest design. Baseline emotional well-being and physical functioning should be established prior to the intervention and should be reevaluated after. The results can be used to establish a correlation between life review and a decrease in depression. Measuring outcomes in this manner is often difficult within the context of daily social work practice

Relevance for Diverse Populations
The benefit of life review for diverse populations is extensive. Reviewers can be healthy, frail, chronically ill, or terminally ill. Literature shows benefits for nuns, individuals with HIV/AIDS, substance abusers, older adults living in the community or long-term care settings, preoperative surgical patients, sexual abuse survivors, and a variety of ethnic groups (Haight, 2007). Life review can even be used with patients with dementia because remote memory is generally not affected in the early stages of the disease. Questions can be modified and adjusted to accommodate the reviewer’s cognitive and intellectual abilities and cultural background. While structured life review has shown positive results with many groups, it is not recommended for everyone. Individuals who refuse to recall the past or have a psychotic diagnosis may require additional mental health services appropriate to their illness.

For Ms. V., the greatest deterrent to acceptance was that she believed she was leaving the world without making a positive impact. This theme emerged repeatedly as she recounted myriad failures and follies that she believed characterized her life. The process of life review brought to the forefront a secret desire to atone for those failures through selfless service to humanity. Though not appropriate for some, Ms. V.’s rare form of cancer and financial hardship made her an ideal candidate for body donation. When I broached the topic, the woman who felt so ineffectual in life lit up with enthusiasm as she entertained the idea that maybe her life wasn’t wasted after all.

Our subsequent conversations were pleasant. I felt a different presence in the room. Though Ms. V. was unable to change who or what she was in the past, she was able to accept it. By doing so, she was able to live positively in the present and died peacefully knowing she had made an impact.

— Sandra E. Shilling, MSW, is a medical social worker at a hospice agency.

References
Adamek, M. E., & Slater, G. Y. (2008). Evidence-based interventions for cognitive and mental health issues. Journal of Gerontological Social Work, 50(3), 151-189.

Haight, B. K. (2007). Transformational reminiscence: Life story work. New York, NY: Springer Publishing Co.

Haight, B. K., & Haight, B. S. (2007). The handbook of structured life review. Baltimore, MD: Health Professions Press.

Peng, X., Huang, C., Chen, L., & Lu, Z. (2009). Cognitive behavioural therapy and reminiscence techniques for the treatment of depression in the elderly: A systematic review. The Journal of International Medical Research, 37(4), 975-982.