Robert N. Butler, MD

Visionary of Healthy Aging

W. Andrew Achenbaum

• Publisher: Columbia University Press
• Year: 2013
• ISBN:
  9780231535328
• Topic: Ciencias sociales
• Subtopic: Gerontología

Robert Neil Butler (1927–2010) was a scholar, psychiatrist, and Pulitzer Prize–winning author who revolutionized the way the world thinks about aging and the elderly. One of the first psychiatrists to engage with older men and women outside of institutional settings, Butler coined the term "ageism" to draw attention to discrimination against older adults and spent a lifetime working to improve their status, medical treatment, and care.

Early in his career, Butler seized on the positive features of late-life development—aspects he documented in his pathbreaking research on "healthy aging" at the National Institutes of Health and in private practice. He set the nation's age-based health care agenda and research priorities as founding director of the National Institute on Aging and by creating the first interprofessional, interdisciplinary department of geriatrics at New York City's Mount Sinai Hospital. In the final two decades of his career, Butler created a global alliance of scientists, educators, practitioners, politicians, journalists, and advocates through the International Longevity Center.

A scholar who knew Butler personally and professionally, W. Andrew Achenbaum follows this pioneer's significant contributions to the concept of healthy aging and the notion that aging is not synonymous with physical and mental decline. Emphasizing the progressive aspects of Butler's approach and insight, Achenbaum affirms the ongoing relevance of his work to gerontology, geriatrics, medicine, social work, and related fields.

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LIFE REVIEW

“Life review” has become a standard method of working with older people in clinical settings and adult learning centers. Life review gives older people an opportunity to arrange the threads of their biographies. They can review afresh both the primary and dystonic motifs that become manifest in the process. Ideally, life review—rarely a one-time exercise—prepares subjects to face finitude with equanimity, possibly to tie up loose ends in representations of self and relationships with others.

I start with life review because Butler, at age thirty-six, stressed its value for treating the aged—even those abandoned in nursing homes. His ideas and methods quickly gained wide usage for younger persons as well. He himself engaged in life reviews of his own at several junctures, including the very end of his life. Life review thus affords us a synoptic aperçu into Butler and his ideas as he aged.

Early in his scientific career Butler fired gerontological imaginations with a path-breaking article, “The Life Review: An Interpretation of Reminiscence in the Aged” (1963b). This article questioned whether late life was invariably a period of deterioration and loss. Psychiatrists and other health-care professionals, according to Butler, too often presumed that mental, physical, and socioeconomic decline determined experiences and meanings associated with advancing years. “It is fair to say that the major portion of gerontological literature throughout the country is concerned almost enthusiastically with measuring decline in various cognitive, perceptual, and psychomotor functions” (Neugarten, 1968). Butler thought otherwise, based on his talking with elders residing both independently and institutionally. Convinced that his research into late-life mental health corroborated his clinical experiences, two related areas in which few other scientists did work, he set out to overturn conventional wisdom by interpreting late-life reminiscences as a normal, integral activity. Doing life review made Butler certain that there was far more to aging than declining.

The publication and dissemination of “The Life Review” greatly affected many mental-health workers after 1963. “I was then a very junior social worker on the staff of a home for the aged,” recalled gerontologist Rose Dobrof. “The Butler paper came out and was read and talked about and our world changed.” Dobrof added, “In a profound sense, Butler’s writings liberated both the old and the nurses, doctors and social workers; the old were free to remember, to regret, to look reflectively at the past and try to understand it. And we were free to listen and treat rememberers and remembrances with the respect they deserved, instead of trivializing them by diversion to a bingo game” (1984:xvii–xviii).

People in the field increasingly embraced Butler’s presentation of what late-life remembrances signified. Accepting Butler’s argument meant that reminiscing would no longer be viewed as “pathology—regression to the dependency of the child, denial of the passage of time, and the reality of the present, or evidence of organic impairment of the intellect” (Dobrof, 1984:xviii). Changing entrenched professional views of reminiscences was going to take time, however.

Health-care professionals in postwar America mainly concentrated on deficits accumulated with advancing age, Butler contended. Most of his peers underestimated—indeed, missed altogether—older people’s ongoing capacity to learn and to grow. His contemporaries generally were not interested in identifying, measuring, and evaluating positive attributes of growing older; they did not look for assets and advantages that accrued over time because they reckoned that there was little to find. Deeply held biases against age, according to Butler, caused scientists and clinicians to misinterpret elders’ reminiscences. For instance, Dr. Theodore Lidz, an expert on schizophrenia at Yale, classified reminiscences as “memory impairments”:

Elderly people, as is well known, spend an increasing amount of time talking and thinking about the past. … When the future holds little, and thinking about it arouses thoughts of death, interest will turn regressively to earlier years. Still, in most persons who become very old, the defect is more profound. … This type of memory failure depends on senile changes in the brain and is perhaps the most characteristic feature of senility.

(LIDZ, 1968:487)

It was such characterizations of reminiscences, expressed in scientific terms with clinical detachment, that Butler sought to overturn. To him, memory work with older patients was worth doing: through the life review a therapist might hope to sustain or restore in clients those attitudes and behaviors conducive to healthy aging. Some elderly people who uttered meaningless, garrulous sentiments reverted to childlike behavior, he recognized. In such instances reminiscences probably were manifestations of depression or some other late-life malady. Yet “hidden themes of great vintage may emerge,” Butler felt, in memories shared and discussed between patients and therapists (Neugarten, 1968:496).

Embellishing this motif—with the therapeutic aim of recovering or (better yet) uncovering potentials of old age so that individuals could enjoy a ripe maturity in a manner beneficial to society—became one of the major priorities of Butler’s long and distinguished career as a physician, research scientist, medical educator, policy analyst, and public intellectual in the United States and abroad. It sustained an even bolder aim. For nearly six decades he formulated positive images of age as he attacked stereotypic ones. In this context the asset-based approach to aging in “The Life Review,” now widely accepted among practitioners working with elders, can be seen at its outset as a harbinger of things to come.

Butler initially described “The Life Review” as an interpretation, not a scientific theory. The concept’s scope and usefulness would evolve, he reckoned, as life review’s value as an integrative psychological process was debated and modified. The apposition of “life review” to “reminiscence” in the paper’s full title, however, did not mean that he considered these key words to be equivalents (Woodward, 1997). Life reviews might stimulate personal insights that elders preferred to keep private, whereas reminiscences generally are shared. Life reviews analyze an individual’s entire life, whereas reminiscences usually evoke moods surrounding particular moments. Here is Butler’s definition of life review in 1963:

I conceive of the life review as a naturally occurring, universal mental process characterized by the progressive return to consciousness of past experiences, and, particularly, the resurgence of unresolved conflicts; simultaneously, and normally, these revived experiences and conflicts can be surveyed and reintegrated. Presumably this process is prompted by the realization of approaching dissolution and death, and the inability to maintain one’s sense of personal invulnerability. It is further shaped by contemporaneous experiences and by the life-long unfolding of character.

(NEUGARTEN, 1968:487)

To Butler, life review entailed critical analyses that stimulated ubiquitous, natural, and normal mental processes in assessing the quality of life. The imaginations and memories of older people brought to surface materials from their unconscious. Free association, recall, and assessment, he argued, ideally would illuminate “progressive” steps for older persons to take as they tackled two ultimate challenges: (1) addressing issues unresolved from earlier in their life histories and (2) preparing for death.

Acknowledging vulnerability and coming to terms with dying and death surely were life events likely to trigger life reviews. The unfolding process could take many turns, ranging from redemptive to self-defeating. Particularly in late life, mourning could induce guilt or inspire gratitude for life’s gifts; grieving losses might prompt restitutions or kindle a desire to leave a legacy (Kaminsky, 1984:12–13). A wide array of metaphors of self emerged from life review.

The vicissitudes of life, observed Butler, provoked diverse responses. Life review hopefully helped elders to revive memories that, when integrated with how they assessed their vulnerability, engendered “candor, serenity, and wisdom.” Engaging in the process did not always yield positive results, however. Struggling to work through long-standing, unresolved conflicts was risky business. So was piecing together seemingly irreconcilable facets of one’s life, especially if the client were unaccustomed to “intrepid exploring” (Lee, 2010:18). Some elders became threatened by discoveries that undercut changes in equanimity, or they became distracted when focusing on past events.

An important, lasting message in Butler’s original formulation of “The Life Review” is his unequivocal affirmation that the process he had created often had negative outcomes. Attempts to make sense of the past, he wrote, could spark feelings of regret, anxiety, despair, and depression, or aggravate neuroses. Life review might reinforce false illusions of self. “Although a favorable, constructive, and positive end result may be enhanced by favorable environmental circumstances, such as comparative freedom from crises and losses, it is more likely that successful reorganization is a function of personality—in particular, such vaguely defined features of the personality as flexibility, resilience, and self-awareness” (Neugarten, 1968:490).

Butler never claimed to have invented the concept of life review. In fact his 1963 paper included three historical references to late-life reminiscing: one ambiguous, one flattering, and one dismaying, each drawn from different historical periods. He first invoked lines from Aristotle’s Rhetoric: “[Elders] live by memory rather than hope, for what is left to them of life is but little compared to the long past. This, again, is the cause of their loquacity. They are constantly talking of the past, because they enjoy remembering.” The passage was ambiguous. Did elders in ancient Greece, like us, try to deny death by looking backwards? Or, did talking about the past help them savor whatever time remained to them? The second allusion, from the eighteenth-century English poet and hymn composer William Cowper, in contrast, was more upbeat: he praised “mem’ry’s pointing wand, that calls the past to our exact review.” Finally, in quoting Somerset Maugham (1874–1965), Butler presaged the dark shadow of life review: Maugham at age eighty-five declared that “what makes old age hard to bear is not a failing of one’s faculties, mental and physical, but the burden of one’s memories” (Neugarten, 1968:486).

Literary and historical references rarely are found in scientific papers, but “Butler elevates literature to the status of truth in the scientific sense” (Woodward, 1986:146). The humanities and arts were not ornamental; to him, they served to ground clinical findings. Elsewhere, in linking the life-review process to thoughts about death, Butler referred to the matador’s “moment of truth” during the faena; he then punctuated his notion of the life review as a Janus-like process by mentioning Lot and Orpheus. Furthermore, he praised Ingmar Bergman’s Wild Strawberries (1957) as “a beautiful example of the constructive aspects of the life review” (Neugarten, 1968:488, 490).

That said, the 1963 interpretation rested on his earlier work as well as the best available psychological theories of aging and prototypes of life review that emerged as part of intensive psychotherapeutic relationships. To document deleterious reactions to life review associated with isolation, loneliness, and death, Butler cited studies by Walter Cannon, Frieda Fromm-Reichmann, Curt Richter, and Otto Will, among others, whose work was respected by gerontologists. He then moved to actual case studies of “manifestations of the life review.” He concluded his 1963 article by citing Erik Erikson’s epigenetic model, which mapped out successive stages of identity over the course of human development. Butler asserted that “the entire life cycle cannot be comprehended without inclusion of the psychology of the aged” (Neugarten, 1968:488, 496).

After disclosing his wide-ranging sources of inspiration, Butler took credit for some clinical observations about the positive value of reminiscences; he also acknowledged his role in developing techniques to prompt elders to recapture meaning in their lives. Life review, he noted, was not orderly: “Although the process is active, not static, the content of one’s life usually unfolds slowly; the process may not be completed prior to death” (Neugarten, 1968:488). It requires time, he realized, for individuals to synthesize random musings about their life histories into a cogent narrative. Far from discounting reminiscences as signs of “psychological dysfunction,” Butler wanted to help elders make stories out of their lives’ messiness by letting the past inform current challenges and contingencies.

Butler deliberately included in his subject pool aged patients in hospitals and other institutional settings; he recognized life review’s efficacy among lonely, confined elders. Extrapolating from this idea, subsequent researchers attested that reminiscing might mitigate incipient dementia (Webster, Bohlmeijer, & Westerhof, 2010). Older people were better off, suggested Butler, if they learned to contemplate and prepare for what lay ahead. Life review offered elders a perspective on ways in which past experiences had brought them to their present situation. (Mental) health professionals, he lamented, generally overlooked their older clients’ need to look both backward and forward. “Younger therapists especially, working with the elderly, find great difficulties in listening,” Butler observed in 1963, because clinicians were not trained to heed what older people were saying (Neugarten, 1968:486). His approach to reminiscences in “The Life Review,” extending earlier work, presented clinicians with a counterintuitive way of interpreting how patients assess their accomplishments, deal with unfinished business, and plan legacies as they prepare to die (Butler, 1961).

MODIFICATIONS TO THE ORIGINAL FORMULATION OF LIFE REVIEW

Robert Butler periodically revisited his initial formulations concerning the purposes and value of life review. Interactions with patients (mostly healthy older adults in the Washington, D.C., area during the 1950s and 1960s) facilitated his evaluations. “Hearing them talk about their lives, I was so struck by the importance of it—the energy, the value, the effort to come to terms with their lives, to think about reconciling with others,” he recalled. “It was just a knock-out” (Wood, 2008). By 1974 he was asserting that life review fostered successful aging (Butler, 1974). Meanwhile, he devised a questionnaire to study creativity over the life course; among the notables interviewed in these unguided autobiographies was behaviorist B. F. Skinner (Kleyman, 2011). During the 1976 bicentennial celebrations, as part of the Smithsonian Institution’s oral history project, he collaborated with anthropologists Margaret Mead and Wilton Dillon to record for posterity the experiences and memories of ordinary people. Butler told me that visitors from all across the nation lined up to share their stories at tables that the trio set up on the Mall.

To underscore his contention that life review took many forms, Butler proposed “several methods of evoking memory in older persons that are useful and often enjoyable to them” (Lewis & Butler, 1974:166). He gave examples in an article entitled “Life-Review Therapy: Putting Memories to Work in Individual and Group Psychotherapy,” coauthored with social worker and psychotherapist Myrna I. Lewis, who shortly became his second wife and the love of his life. The pair recommended seven approaches: (1) embarking on written or taped autobiographies; (2) making pilgrimages to the locations of one’s birth, childhood, youth, or young adulthood; (3) attending family or school reunions; (4) taking an interest in genealogy; (5) preserving scrapbooks, photo albums, old letters, and other memorabilia; (6) summing up the meaning of one’s life work; and (7) preserving ethnic identity. Note the shift in the presentation of what prompts life review: Butler now was declaring that all sorts of memories (including ones not directly linked to the proximity of death) could trigger reminiscences useful in the task of coming to terms with the meanings of one’s life.

Other changes also occurred, even in psychotherapeutic settings where life reviews take place. Beginning in 1970 Lewis and Butler started to experiment with group psychotherapy. They conducted sessions with participants as young as age fifteen. The presence of youth altered the milieu in which older people focused on reminiscences. “The elderly often assume an active learning as well as a teaching role,” reported the co-therapists. “Groups are especially useful in decreasing the sense of isolation and uselessness felt by many elderly persons” (Lewis & Butler, 1974:173).

During this period Butler also developed a Life-Review Interview Manual with questions intended to bring to the forefront distinctive features of individuals’ life histories concerning child-rearing, marriage, and careers. Besides furnishing basic biographical details, older adults were asked to flesh out what made some of their friendships special. They were invited to talk about persons who were important in their lives. Additional questions sought to explore what people recalled about situations during the Great Depression and World War II that they had endured with others. Still other inquiries gauged how elders assessed their current circumstances (Butler, 2002b; Kleyman, 2011).

Like facets of a widening gyre, the items in Butler’s Life-Review Interview Manual were designed to stimulate people’s interest in narrating their lives. In the 1970s neither Butler nor Lewis was consistent in differentiating between retrieving memories and engaging in life review. This imprecision provoked criticism. According to William Randall and Elizabeth McKim, “the difference between r...