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Life Review — Therapeutic Opportunity
By J. Scott Janssen, MSW, LCSW

For months Charley had avoided talking about her father, for whom she was acting as sole caregiver. As a hospice social worker, I'd engaged her in life review during which she'd told many stories about her mother, siblings, and friends. Whenever I'd asked about her father, though, her affect would flatten and she'd say things like, "He was always busy," or "He didn't have much time for me," before quickly changing the subject.

Now, her father had advanced dementia and spent his days in bed totally dependent on Charley for care. The nurse and nursing assistant had shared with me concerns that Charley was being rough with him when attending to his needs and that she was verbally abusive. When the nurse found bruises on his arms and lower back that she believed could not have been caused by his lying in bed or from routine care, I'd gone out to discuss the issue.

Despite her silence on their relationship, life review had allowed Charley to take in the vast sweep of her life and distill aspects that were meaningful, lessons learned, and accomplishments about which she was proud. She had reflected on the impact of her life, identified important values and strengths, and singled out challenges she had met. These are often the kind of things people think about when considering the benefits of life review in elders or those facing challenges associated with the end of life.

Creating Safe Spaces
Social workers in geriatric, palliative, and hospice settings are aware of the potential usefulness of creating safe opportunities to reflect on the significant events and relationships of one's life. There is often a natural impulse when nearing life's end to look back and take stock. Studies looking at the therapeutic value of life review have shown that it can improve mood, foster an enhanced sense of meaning and purpose, strengthen one's sense of connection with others, and fortify a sense of life having been worthwhile. But while many assume this process of looking back and sharing memories must be uniformly positive and enjoyable, it is often much more complex.

Listening to how a person tells the stories—which events and experiences they chose to focus on and which they leave out, how they see themselves and others—often reveals places of pain, self-doubt, or issues related to meaning, regret, grief, or shame. In Charley's case, it had raised suspicions that there may have been a history of some kind of trauma—verbal/emotional, physical, or attachment-related—when it came to her father.

I decided to start the visit made to assess for physical and verbal abuse by referring to our prior conversations. "Charley, I've noticed that whenever I ask about your relationship with your father, you seem uncomfortable and change the subject. Have you noticed that?"

Her eyes looked downward, her hands got fidgety, and her voice lowered (people's bodies also tell stories). "I don't like talking about it," she said softly.

"I'm not trying to pressure you. But, if you're willing, I'd like to understand a little better. Can I ask you some questions?"

"Why do you want to know?" She started making eye contact again; her expression appeared serious, almost grave. I told her that her father had bruises that we couldn't explain.

"You think I would beat my own father?"

"I don't know where the bruises came from, Charley, but when something like this happens we have to assess for things like that. It's nothing personal and no one's jumping to conclusions; that's why I came out to talk with you."

She looked up, tears in her eyes, one fist clenched. She glared at me, speaking with uncharacteristic anger and sarcasm: "Well, this is just perfect. I'm breaking my back to take care of him, sacrificing my job, my life, to take care of him!" She pointed angrily toward her father's room. "And you come out here wanting to know if I'm the one being abusive?"

It was evident that her nervous system was on high alert: breathing rapid and shallow, face red, and hands trembling. It was also clear that a button has been pushed. I leaned toward her, infusing my voice with warmth: "I didn't come out here to make accusations. I came because I care about you and your dad. I want to understand what's going on."

What followed was an intense conversation during which she told me about how her father had been a "heavy drinker" who wasted his paychecks on whiskey, leaving her mother to do odd jobs "just to scrape together enough to keep a little food in the pantry." Throughout her childhood he'd been physically violent, repeatedly beating Charley's mother and her two brothers. "He'd beat me too, sometimes with his hands, sometimes with a belt. There was never a reason. Now, all his doctors think he's a sweet old man. Well, he is not a sweet old man!"

A few times during the conversation Charley seemed in danger of becoming overwhelmed by anger and intense physical sensations (such as accelerated respirations). It's not uncommon for life review to turn up these kinds of posttraumatic wounds. It is important for anyone doing this kind of life review to be familiar with the dynamics of posttraumatic stress and ways to help clients stay grounded.

A couple of times, I asked Charley to pause and anchor herself in the present moment by feeling her feet on the ground and consciously slowing and deepening her breathing. I also taught her a mindfulness technique with which to recount memories, if she chose to do so, without being as easily swept up by the turbulent emotional and psychological pain with which they were coupled.

Just as importantly, I listened as deeply as I could, trying throughout to convey care, attunement, and empathy. This may seem self-evident—indeed, it is an elemental dimension of good social work care—but when hearing the kinds of detail Charley began to share ,it's not as simple as it sounds. To remain present and open when hearing about things like physical violence requires practice and an inner compass orienting toward solid ground. It's easy to get overwhelmed ourselves, even as social workers. If so, we may be tempted to gloss over horrific events or attempt to push clinical interventions too quickly. Attempting to use cognitive restructuring too soon, for example, in an effort to rapidly shift a person's feeling state or negative beliefs, may come across as anxious or out of touch. It may even convey the silent message that we are not prepared to listen to such troubling material.

Trauma-Informed Practice
Given the ways life review can uncover intense psychologically charged material, it is helpful for social workers facilitating this process know something about working with PTSD, complex grief, and relational conflict, as well as a wide range of clinical issues including depression and anxiety. Traumatic memory, in particular, is not like ordinary narrative memory. Simply inviting the sharing of such memories can easily escalate into difficult-to-manage emotions, feelings of being overwhelmed, even retraumatization.

Blending life review with focused psychotherapeutic interventions as material arises can be nuanced and complex. Life review done with this complexity in mind can be a powerful therapeutic resource not only for helping patients identify and integrate meaningful and affirmative life experiences but also for identifying places where there is suffering. Sometimes, as was the case with Charley, one begins to sense areas of suffering by observing events or relationships that are omitted from the life story. (I have often found this to be the case with combat veterans who avoid or minimize the impact of war.)

In other cases, inner pain may be signaled by the appearance of intense emotions or by an apparent lack of emotion (possibly suggestive of psychic numbing or dissociation). Clients may express negative beliefs about themselves (e.g., "My life has never amounted to anything"), others ("Most people I know don't really care about me"), or the world ("Ever since my mom died when I was a kid, I've felt unsafe").

Hidden suffering may be revealed by incongruities between a person's professed beliefs, emotions, or experience and what their body reveals. For example, I worked with a patient who told me with a cheerful smile that she had "just accepted it as God's will and trusted in him" when her infant daughter had died some 60 years earlier. Despite her smile, she had tears in the corners of her eyes and was nervously wringing her hands. When I asked if we could pause for a moment to explore the event more fully, her smile vanished, tears began to flow, and grief that had been hidden for decades emerged. In the course of processing this grief, we discovered pockets of guilt ("It should have been me who died"; "I worry that God was punishing me") and shame ("After Sadie died, I felt like I had no right to ever be happy again, felt like I'd failed as a mother").

Sometimes the suffering is on the surface and emerges quickly in the life review process as patients gravitate to events or internal stories that have worn grooves into memory, even into one's perceived identity. Listening for potentially troubling themes, phrases, or experiences that recur in conversation can be good places to give clients an opportunity to explore if they choose to do so. One patient liked to repeat the phrase, "There's always dirt behind the daydream," which I had found a bit cryptic. When I asked him to elaborate on what it meant to him, he spoke about growing up in a family that was well respected as a pillar of the community on the surface while behind the walls of their home he was constantly criticized by parents who were emotionally aloof and demanding. When I asked why he thought this phrase came up so frequently in his conversation, he said that throughout his life he had always felt judged and alone, even by those with whom he was closest.

Of course, life review can be done with an emphasis on identifying, affirming, and reinforcing positive aspects of one's life and identity. When facilitated as a shared experience within a family, such an approach can create moments of profound sharing and love. But for geriatric and hospice social workers trained in psychotherapeutic processing and intervention, life review can also be a nonthreatening and engaging strategy for identifying opportunities for therapeutic exploration.

As issues are identified and places of suffering revealed, these can be woven into the larger context of a person's life journey. An enhanced perspective on that journey may serve as a potential source of insight, even healing. Taking an interest in another's life tends to build trust and can lay the groundwork for difficult conversations as the need arises. Learning about our clients' lives deepens empathy and understanding, activating compassion and mitigating any tendencies we might have to judge or label.

This was certainly the case with Charley. It turned out that, in her stress, frustration, and anger, she had beaten her father with a plastic shampoo bottle. Knowing her story in no way justified such action, but it provided a context for understanding it, dissolving any impulse I might have had to blame or condemn (it's usually hurt people who hurt people). This allowed Charley to speak openly about what had happened and to work with the hospice team to come up with a plan for her safety and that of her father. It also allowed me to explain why her behavior had to be reported to Adult Protective Services in a way that underscored the possibilities that might be helpful, rather than as something punitive or accusatory.

Life review is a multifaceted process that can be used in many settings and situations. It can be used individually, with couples, or in larger systems to enhance meaning, build confidence, and affirm one's life passage and legacy. It can be a fruitful source of insight into how patients see themselves, the world, and others. As such, it can be used to identify areas in which a patient has been struggling. The end of life, or any time during which there is profound change and uncertainty, can be a time of reflection as well as intense, frightening challenges. Life review has the capacity to be a useful avenue as we help patients and families navigate their way forward.

— J. Scott Janssen, MSW, LCSW, is a social worker with the Hospice and Palliative Care Center of Alamance-Caswell, Burlington, NC.