Journal of Geriatric Mental Health

REVIEW ARTICLE
Year
: 2019  |  Volume : 6  |  Issue : 1  |  Page : 7--13

Reminiscence therapy in geriatric mental health care: A clinical review


Pragya Lodha1, Avinash De Sousa2,  
1 Clinical Psychologist and Research Assistant, Desousa Foundation, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
2 Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Avinash De Sousa
Carmel, 18, St. Francis Road, Off S. V. Road, Santacruz (West), Mumbai - 400 054, Maharashtra
India

Abstract

Reminiscence therapy (RT) has been used over the past two decades extensively in the management of patients with dementia and geriatric depression. The following review study looks at the current role of RT in geriatric patients from a clinical perspective. The review elucidates the concept of reminiscence and looks at the historical aspects of RT. It also looks at the taxonomy and classification of the various types of reminiscences and RT techniques. The difference between reminiscence and life review is discussed. There are sections that look at the clinical role of RT in the management of patients with dementia and geriatric depression. The role of art therapy as a form of RT is discussed and elaborated. The existing literature on RT is reviewed, and certain recommendations for RT are made. There is also a slight deliberation on the need for RT in Indian settings. The role of RT as positive geriatric mental health intervention is also discussed.



How to cite this article:
Lodha P, De Sousa A. Reminiscence therapy in geriatric mental health care: A clinical review.J Geriatr Ment Health 2019;6:7-13


How to cite this URL:
Lodha P, De Sousa A. Reminiscence therapy in geriatric mental health care: A clinical review. J Geriatr Ment Health [serial online] 2019 [cited 2019 Sep 16 ];6:7-13
Available from: http://www.jgmh.org/text.asp?2019/6/1/7/264498


Full Text



 Introduction



“Reminiscence” means to recall and remember the past experiences, i.e., what one did, how one was, what kind of relationships one had, what were some pertinent life epochs, and everything that makes one's life complete till date.[1] A reminiscence is a memory, or the act of recovering it, that we all engage in and probably at a diurnal level.[2] There does not exist a scientifically robust definition of reminiscence; however, the most inclusive one till date has been proposed by Bluck and Levine[3] where there are some essential elements to the definition that hints reminiscence to be a naturally occurring process, namely “Reminiscence is the volitional or nonvolitional act or process of recollecting memories of one's self in the past. It may involve the recall of particular or generic episodes that may or may not have been previously forgotten, and that are accompanied by the sense that the remembered episodes are veridical accounts of the original experiences. This recollection from autobiographical memory may be private or shared with others.“[3]

 Method of Conducting this Review



For identifying articles that focused on RT in geriatric patients, the terms “reminiscence therapy,” “reminiscence,” “life review,” and “reminiscing” were used. For identifying articles that focused on specific disorders, terms such as “old age,” “geriatric depression,” “dementia,” “geriatric mental health,” “elderly,” “older adults,” and other terms were used. These two search strategy results were combined with an “and” statement in the following databases with the time frame being specified from 1988 through 2018. The databases used were PubMed, Google Scholar, and the Cochrane Database of Systematic Reviews. In total, 239 articles were identified which included reviews, mini reviews, case studies, case series, and randomized controlled trials in the elderly for RT. The randomized controlled trials reviewed were centered on those addressing RT as a treatment for geriatric depression and dementia.

We only included trials and quantitative studies with sample sizes of >25 participants and reported either mean scores or percentages with appropriate statistical analysis and ratings. Both the authors reviewed all of the articles, and the most relevant ones were chosen for this review. The papers reviewed in this article include review articles, trials, and research papers on RT. This is supplemented with the personal clinical experience of both authors who work regularly with geriatric patients that have mental health problems. The experience is a mix of their work at a government tertiary hospital and their private practice.

 Historical Aspects



The essence of reminiscence in therapy is that the act of integrating memories of one's life at the last stage of life can be therapeutic. The idea that reminiscing could be therapeutic was first proposed in the 1960s.[4] Reminiscence therapy (RT) is a treatment that is offered to people in their later years. With the help of prompts such as photographs, music, familiar items/objects from the past, and other remembrances, the therapist encourages the patient to talk about memories from earlier in life.[5] The idea that reminiscing could be therapeutic was first proposed by Richard Butler,[6] a gerontologist and psychiatrist, who has been credited with coining the term “life-review” which he explains as an integrated view of one's past life, including positive memories and achievements alongside the reconciliation and acceptance of failures and disappointments, and results ideally in wisdom, the experience of meaning in life, and the acceptance of one's own death.[7] Butler argued that life review has a positive function in helping a person come to terms with unresolved conflicts from the past and with his or her approaching vulnerability and death.[8] The same was also explained by Erik Erikson in his stages of life development. He explained the eight stages of development as integration versus despair and further deliberates that for the greater part of adulthood, we are challenged to find creative, meaningful, generative work so as to avoid stagnating. Consequently, or otherwise, we are likely to review where we have been and what we have accomplished to feel integrated, in the later life.[9] RT was developed with the fundamental layout of theoretical underpinnings of both Butler and Erickson's concepts of life review and (eighth) social developmental stage, respectively. Thus, RT would serve a functional purpose of engaging older adults in mental health well-being practices, and it is a mental activity to adaptive functioning and well-being, in particular in the later phase of life.[10]

The present understanding on remembering and RT connotes the simple recall of instances from long-term memory as well as memories that are reconstructed in relation to existing schemas about the self and vice versa.[11],[12] Research in 1980s and 1990s shows that this treatment has a small but significant positive effect on mood, self-care, ability to communicate, and well-being. In some cases, this therapy improves intellectual functioning in the elderly as well.[13],[14],[15]

 The Taxonomy of Reminiscence and Reminiscence Therapy



Consideration of context and contents of reminiscence may advance the functional approach to the adaptive value of reminiscence. Researchers have further developed a taxonomy for classifying types of reminisces, and different researchers have come up with distinct explanations of types of reminiscence. Wong and Watt[16] made the first substantial attempt to develop an empirically grounded taxonomy of reminiscence on the basis of previous research and using content analysis. They came up with an exhaustive list of six forms, i.e., integrative, instrumental, transmissive, narrative, escapist, and obsessive. Webster[17] used factor analysis to distinguish different uses of reminiscence, developing the Reminiscence Functions Scale, and proposed eight factors such as identity, death preparation, problem solving, teach/inform, conversation, boredom reduction, bitterness revival, and intimacy maintenance. Some authors have compared the functions of reminiscence to three functions of autobiographical memory: self, directive, and social.[18] Research on different types of reminiscence led to a comprehensive conclusion on understanding reminiscence as a construct. The summarized understanding on reminiscence emerges as follows, namely reminiscence can be used to discover meaning and continuity, to draw on the past experiences to solve present problems and to cope, to provide an instructive story, to provide a descriptive story, to dwell on the “good old days” and escape from the present, to ruminate about unresolved disturbing events in the past, to prepare for death, and to maintain memories of significant others.[19],[20],[21],[22],[23]

Fry[24],[25] further suggested that different types of reminiscence are associated with different personality factors and psychosocial variables. However, it is essential to have knowledge on the antecedent conditions of reminiscence to better understand the adaptive value of the different kinds of reminiscence. In another dimension of understanding, RT is a practice close to existential therapy where one recalls memories from earlier life and integrates them to derive meaning of the same. It is the making of memories of one's life that is attached with the contentment and positive mood and emotions experienced.[25]

 Reminiscence and Mental Health



It is crucial to note the relationship between reminiscence and mental health. Researchers also delineate the fact that different types of reminiscence may affect whether reminiscence has a positive or negative relationship with happiness; for instance, bitterness revival, boredom reduction, identity construction, and problem-solving were found to be negatively related to happiness, whereas conversation and teaching/informing were found to be positively related to feelings of happiness.[26] Reminiscence is not always adaptive in old age. With relation to mental health, reminiscence seems to have a bidirectional relationship. It is difficult to draw a causality relationship between reminiscence and mental health since both appear to influence each other conversely; particular uses of reminiscence might result in better mental health, but better mental health might also lead to particular uses of reminiscence.[16]

Conclusively, reminiscence has been found to have an adaptive function in the elderly with a positive correlation to successful adaptation to old age through maintaining their self-esteem, reaffirming their sense of identity, and mastering their personal losses experienced in later life.[27]

 Method of Conduction Of Reminiscence Therapy



RT could be conducted formally or informally (structured or unstructured) with individuals, families, or groups. Frequent themes addressed in therapy are that of family and friendships, love and losses, achievements and disappointments, and adjustments to life's changes. RT requires 4–12 sessions on an average range depending on the nature of challenges. On a typical basis, every session extends from 30 to 60 min on a weekly basis. Sometimes, if the need arises, there may even be several sessions in a week. Depending on the training of the clinician, the patient's needs, and the setting, the goal can be multifarious, ranging from – to improve communication, to foster a person's sense of self, to improve mood, or simply to provide an enjoyable social activity.[28]

Therapists using reminiscence believe that reminiscence is either an unstructured or structured process that either occurs alone, with another person, or in a group, and “can be done for the process alone or can lead to conclusions about a person's life, life's meaning, and significance.”[29]

 Reminiscence Versus Life Review



Life review and reminiscence are very often interchangeably used when spoken of in terms of modalities for elder care. However, the therapeutic implementation of the two reveals a nuanced understanding between the two concepts. Reminiscence, in brevity and straightforward understanding, is remembering and recollecting the past memories to enhance present affective and cognitive functioning (in the elderly). Reminiscence with its severally factor analyzed taxonomical definitions, is most times unstructured or semistructured. However, life review is generally structured around some themes. These themes relate to the life of an individual, most often family themes – ranging from one's childhood, the experience of being a parent, the experience of being a grandparent and work themes – from first job to retirement. As compared to reminiscence, a life review is more likely to be an evaluative process, in that participants examine how their memories contribute to the meaning of their life, and they may work at coming to terms with more difficult memories.[30]

Sometimes, the terms reminiscence and RT are used synonymous to life review. In such scenarios, the terms do not merely refer to the simple and spontaneous recall of memories but a structured and systematic process deliberately implemented with willing participants.[31]

 Role of Reminiscence Therapy Patients Suffering from Dementia



In the 1950s and 1960s, mental health professionals regarded reminiscence as a sign of pathology and senile dementia.[32] Richard Butler,[6] however, pointed out that reminiscence is a natural occurring process of aging, diverting the understanding of reminiscence from pathological to normative. Life reviews and RT are one of the most used psychosocial tools in the nonpharmacological interventions for dementia with a promising hope with extensive use. RT as an intervention for dementia care has seen rising attention and clinical contribution for >25 years.[33]

Reminiscence is a naturally occurring universal and spontaneous mental process in which past experiences, especially unresolved conflicts, are progressively returned to consciousness.[2] Anecdotally, reminiscence is a common practice among the elderly. It has been seen in an Indian setting, where the elderly spends time with each other to recollect moments of their life and recelebrate them. Reminiscence is also the essence of an Indian joint family where the cultural traditions are ascended as a transgenerational practice. Reminiscence as an experience or therapy has continued to be a positive experience for older adults with or without dementia.[34]

Professionals leading RT for older persons with dementia are specially trained. They carry out a wide variety of activities: group and individual activity, structured themed groups, the development of life story books and posters, and the use of visual prompts such as photographs, videos, and clothing to support communication and discussion. RT is about remembering good and bad experiences, integrating them at a stage of life into an album of memories.[35]

In dementia care, reminiscence work has been noted as the most popular psychosocial intervention for over two decades now. RT is fusion of cognitive and emotion-focused approaches. The outcomes of reminiscence work generally have a potential implication on autobiographical memory and well-being. Important to consider is that as opposed to reminiscence practiced with elderly, rigorous evidence on the effectiveness of reminiscence work for people with dementia is relatively less.[36] The key feature of RT done with persons with dementia is that in contrast to reminiscence work done with elderly, which has a narrative and informative function, reminiscence work done with dementia patients has a focus on the individual making sense of their own life story, which is described as having an integrative function.[37] There are different approaches to reminiscence used for dementia care. In “life story book approach” also referred to as “life review” approach, the intervention is focused on the production of a life story book based on one-to-one life review sessions using Haight's Life Review Experiencing Form. The approach is described as “specific reminiscence,” in that the triggers were personalized according to the person's life history, as far as possible. There is “general individual reminiscence approach” which involves focusing on a particular life phase in each session and introducing objects for discussion that are relevant to that period of life. This focuses on six phases of life that include childhood, schooldays, domestic life, weddings, family life, and holidays.[38]

Reminiscence work, even for dementia care, can be done on an individual basis or on a group level. There may be differences in the approach between that of individual and group reminiscence work, and thus, it is important to consider them separately and to take account of the interaction between treatment modality. It also accounts for the type of reminiscence that may be effective on an individual or group level.[39] Integrative reminiscence (requires memory triggers specific to the person) is almost always individual, whereas narrative and informative functions (requires more general memory triggers, such as broad range of stories and memories) are well suited for one-to-one settings as well as in a group. Integrative reminiscence is to achieve a sense of self-worth, coherence, and reconciliation with regard to one's past with a primary function of being intrapersonal even though it may be carried out in an interpersonal context with one or more others.[40] Simple or general reminiscence work involves discussing past events based on a number of selected topics or themes. Prompts may be generic, such as common experiences of school relevant broadly to the person's age cohort, or specific, relating specifically to the person's own experiences.[38]

Research has shown that group RT, like one-to-one reminiscence work, can and does lead to positive effects in the elderly with dementia and depressive symptoms in dementia.[41],[42],[43] The positive changes were affirmed by different markers of psychosocial intervention such as increased scores on the Mini–Mental Status Examination, decreased scores on the Geriatric Depression Scale, markers of quality of life, positive mood, and communication along with other biomarkers of electroencephalography readings. However, these findings do come with limitations.[42] Several randomized control trials have been performed to evaluate the effectiveness of RT in older persons with dementia and the conclusions for the same are a mix of individual and group therapy sessions would benefit more than anyone approach alone. We need further work and compartmentalized results on individual and group therapy to have greater evidence-based results on the effectiveness of the either.[44]

In our clinical experience, a loophole in the present model of RT in dementia care is lack of addressing of caregivers and family members. It is a known fact that the burden of care is edged toward the family members and care providers in dementia care. It would be interesting to expand reminiscence work for family members and care providers along with dementia care. It would be an interesting model to see an integrated therapy session with dementia patients and their family and care providers together in reminiscence work (personal clinical experience).

Apart from the traditional RT, art therapy in the form of RT has also been found to be effective for individuals with dementia. One of the activities and forms under art therapy is that of collage making. The collage process served as an opportunity to reminisce, which is an essential component of the life review process. Art therapy's potential for slowing the progress of dementia with respect to a person's artistic impulse and activity is promising; however, several challenges exist with this population.[45] Research has shown that art production as a self-reflexive means to confront, heal, and provide closure to developmental and previous life issues. Her research also showed an outcome that art making allowed her clients to address Erikson's stage of integrity versus despair.[46] It has also been found that a visual life review is effective in art therapy with older patients who had short-term memory loss.[47] The collage is an effective vehicle for the process of reminiscence.[48]

The recent interest in research has increasingly focused on applying reminiscence work/therapy using multimedia computer systems for people with dementia and their caregivers. Computer Interactive Reminiscence and Conversation Aid is the technology product that aids to project reminiscence materials on a touch-screen interface to stimulate conversation among participants. It was found to improve quality of life in dementia care.[49] Research literature tells us that technology makes available a wide pool of information which can be used as material for reminiscence work. Technology in use for therapy allows for positive results in terms of increased interaction and facilitated communication and offering the person with dementia more control over the types of materials used.[50] Technology also allows for adequate control over social communication for people with dementia and reduces barriers due to motor deficits during interactions.[51] The use of the internet-based video sharing web site, “YouTube” is also a potential source of dynamic database of rich and engaging materials.[52]

 The Role of Reminiscence Therapy In Geriatric Depression



RT is a specialized therapeutic model designed, especially for the care of the elderly (although it is used with younger population, especially children, as well). It is one of the specifically molded therapeutic ideals for senile depression (mild to moderate).[53] Researchers have investigated the (varying) effect of RT on various cognitive, psychological, social, behavioral, and health outcome measures. These include depression, self-esteem, self-concept, self-assessment, self-acceptance, self-change ego integrity, ego strength, mood, anxiety, coping self-efficacy, social problem-solving ability, integration of life events, life satisfaction, physical activities, social behavior, cognitive status, health status, and well-being. Although guiding procedures and technicalities may have differed, the core principles were found to be similar across all the reminiscence approaches.[54],[55],[56] One of the superimposed aims of RT is to prevent or reduce depression, increase life satisfaction, improve self-care, improve self-esteem, and help older adults cope with life transitions.[57]

There are several research findings that can be elaborated on to discuss the findings of RT on reducing depression symptoms in the elderly. One of the pioneering works was performed by Wong and Watt[16] using the interventions based on one of the taxonomies of reminiscence, with an underlying belief that reminiscence is not a unitary construct. They investigated the differential relationships of instrumental and integrative reminiscence with adaptation and well-being among older adults. The finding that integrative and instrumental types of reminiscence were associated with successful aging provided the impetus for further examination of the specific cognitive and affective processes invoked by the use of these two types of reminiscence in the treatment of depression. The results of the 6-week intervention trial showed that both groups, exposed to instrumental reminiscence and integrative reminiscence, were equally effective in reducing symptoms of depression.[58] In these therapies (integrative and instrumental reminiscence), restoring positive memories and dulling negative memories increase self-esteem and self-confidence.[59] Findings have also shown that memorizing itself and without a therapeutic approach is associated with less pain and fewer depression symptoms while integrative reminiscence improves physical activity, increases optimism, reduces pain and depression symptoms.[60] Importantly, we must conclude that specific types of reminiscence can be useful in symptom reduction of depression in the geriatric population. This finding gains further weight in contrast to those studies that allowed participants to freely reminisce, which led to variable results of effective depressive symptom reduction in the elderly.[61] By promoting a specific approach to the review of memories, which targets psychological processes that have been linked with the onset and maintenance of depression, reminiscing was shown to act as powerful therapeutic intervention.[62]

Studies have also concluded significant differences in the rate of symptom reduction of depression among the elderly who were treated with reminiscence work versus those who received routine care.[63],[64]

A review showed that elderly people exposed to RT experience more happiness and less depression as compared to those elderly who were not exposed to reminiscence work. The clinical superiority of this therapy, however, did not extend to enhancing life satisfaction and self-esteem of the older adults which can plausibly explained given the difference in the nature of constructs.[65] RT results in positive recall and provides a pleasurable and relaxing atmosphere to the participants, unlike life review, during which the participants critically evaluate their life and work through both painful and pleasurable memories to achieve integrity.[66]

Some authors have suggested five categories of criteria that would help determine the effectiveness of RT with elderly people with symptoms of depression – type of persons, type of outcome measure, type of study design, type of control, and type of exposure. Results showed that the effects of RT on depression did not seem related to the intervention protocol, type of modalities, number of participants per group, or whether or not evocative material was used to aid in recall.[67]

There has been a review that looked at more than 100 published articles to conclude that reminiscence work does provide one or another form of therapeutic benefit to the elderly.[68] Empirically and clinically, it is crucial to appraise that the effects of reminiscence are not all positive. There are mixed evaluations of the effectiveness of reminiscence work with the elderly which considers various factors that may influence the results – the taxonomical implications of reminiscence, longevity of study, methodological alterations, statistical analysis, psychosociocultural factors, and many other variables that are inevitable to the conclusiveness of RT.[68] Several investigations which have empirically evaluated the effectiveness of reminiscence intervention on depression and psychological variables related to depression support the utility of reminiscence as a therapeutic intervention.[69] In contrast, many studies do not support the effectiveness of RT in the treatment of geriatric depression.[70],[71]

 The Role of Reminiscence Therapy as a Positive Geriatric Mental Health Intervention in Old Age



There is a shortage of studies on RT as a therapeutic intervention to enhance positive mental health in the geriatric age group. Our premise is that there is a need for RT to be implemented as a routine therapy in elderly patients as they may benefit from the essence and positivity that reminiscing brings. They need not suffer from depression or dementia to be a candidate for RT. Everybody above the age of 65 years wishes to integrate his/her life in a meaningful manner and hopes to feel no despair at the time of death. RT can help an individual in the geriatric age group achieve some happiness in this regard and prepare him/her for the acceptance of life and death as there is an existential framework for RT as well. This may be carried out for the elderly with assistance or support from family members that shall help him/her integrate his/her life and also enjoy the experience with him/her. There is also a need for family members to provide positive mental health support to the elderly in this face of their life.[72] This could serve as a useful means for elderly and their family members to reflect on their relationship and various facets of their life with their aged family member and may rekindle a whole new bond in the golden years of their life. There is a dearth of positive mental health interventions in geriatric patients, and RT could fit the bill as a useful intervention for the same.[73] Geriatric mental health in India has many challenges, and RT could be a useful solution for some challenges if implemented on a regular basis as a part of positive mental health promotion in the elderly.[74]

 Limitations and Critique



RT has therapeutic effects including elevated mood (reduced symptoms of depression), better interpersonal relationships with family members, reduced burden on the caregiver, higher self-esteem and higher self-worth, and improved cognition. It needs the patient and the therapist to be well engaged in the therapy to gain the best outcomes. However, it is critical to remember that RT is merely one of the therapies for improvising memory in old age, and there are a number of other therapies that may be a better fit. It requires a well-informed personal history of the patient to decide whether to adopt RT. RT may require someone to relive memories. Unpleasant memories may also come to the fore at times which may defeat the entire purpose of therapy. There is no formal training for RT in India to the best of our knowledge, and few therapists are inclined to work full time in geriatric mental health and dementia care. Another drawback of RT is that it may not take care of the developing and comorbid conditions that may exist alongside a disorder such as depression or dementia. Researchers have pointed out that there is a stage of dementia which most people reach when traditional reminiscence or life story work can no longer work and when it can even be counterproductive. This is the stage where people cannot remember many facts of their lives like which school they went to, what they liked as an adult, whom they got married to, and several others. At this time, using RT can make them feel disengaged and distressed. Thus, in the Indian setting and generally, RT does have some limitations.

 Conclusion



RT is an intervention that has been developed to provide alternatives to more traditional approaches to psychotherapy with older adults. It has been an effective psychosocial intervention for over three decades. There is a growing evidence base of literature that affirms RT as a growing positive psychotherapeutic intervention for geriatric care. It has been seen that the partial reconstructive nature of reminiscence and particular styles of reminiscence associate with specific mental health outcomes. Stimulating the positive functions of reminiscence has the scope to help improve mental health in the later years of life. The evaluation of the efficacy of reminiscence will continue to be inconclusive, and research niche demands a comprehensive theoretical framework of reminiscence to have more effective reminiscence interventions. Indian research on RT is conspicuous by its absence, and further steps for an Indianized approach to RT are warranted. Clinicians must try and make RT a part of their treatment approaches, and RT must make its way into treatment algorithms for geriatric mental health care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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