As I celebrate another birthday, my head is full of tales. Birthdays provide an annual impetus to reflect on the past while simultaneously setting goals for the future. Gene D. Cohen, a pioneer in geriatric mental health and aging research, would say I’m entering the “summing up phase” of my life. According to Cohen, in this phase (which can span decades) people are reexamining and assessing their lives and reviewing not only events but also lessons learned; we seniors become “keepers of the culture” in shared lessons, storytelling, community activism and other forms of giving back.
Stories acquire heightened significance as we continue to age and acknowledge our proximity to death. Harvey Chochinov, a psychiatrist at the University of Manitoba and the creator of Dignity Therapy, observes, “When you are standing at death’s door and you have a chance to say something to someone, I absolutely think that the proximity to death is going to influence the words that come out of your mouth.” With such stories, we have the opportunity to emphasize what has mattered most and how we wish to be remembered. There’s also the opportunity to affirm love, to make amends, and to reframe the past to align its lessons with a current, more mature perspective.
John O’Donohue penned a poetic and related thought when he wrote, “I believe that there is a place where our vanished days secretly gather. The name of that place is memory.” In Dignity Therapy, these memories are sorted, prioritized, transcribed, and preserved as one’s preferred legacy. I’ll elaborate on this brief, yet often powerful, therapy below.
Unlike life review, which is an historical recounting of events, Dignity Therapy is a review of thoughts, ideas and events that have special meaning to an individual. Folks have an opportunity to share the moments that shaped their lives. The ultimate goal of Dignity Therapy is to help bolster the self-worth of patients with advanced, life-limiting illnesses. It’s a brief form of individual psychotherapy that guides patients to reflect on important life experiences. The interview also considers how these patients wish to be remembered. Patients edit the transcripts and then decide who should receive a copy.
Dignity Therapy differs from life review in other ways as well. The intervention utilizes 10 core questions that guide an interview, including: “What are your most important accomplishments, and what do you feel most proud of? What are your hopes and dreams for your loved ones? What have you learned about life that you would want to pass on to others?”
Standardized training for interviewers (usually professionals from a broad range of disciplines including psychologists, social workers, chaplains, and physicians) is important to assure that each patient receives the same standard of care. Sessions are audio-recorded, transcribed, edited, and given back to patients to distribute as they desire.
Ideally, an interviewer will be close enough to a patient to engender comfort and trust but have enough distance to maintain composure during sessions. Because of the value of standardized training and the importance of an impartial perspective, family members and close friends may not be preferred interviewers. Training manuals describe steps in detail to promote intervention fidelity. Above all, the sessions should be structured and considerate in both timing and scope. The therapy should follow the respondent’s cues–always prioritizing the patient’s (rather than the therapist’s) agenda
Dignity Therapy is not for everyone. There are candidates for these interviews who refuse, stating they have “no more to say.” Sometimes the therapy is considered, but the patients are too sick or too medicated to participate meaningfully. Late stage dementia patients may be too advanced in their cognitive decline to provide coherent narratives..
Patients who receive Dignity Therapy usually report benefit and high satisfaction for themselves and their families. A sense of role completion is an element of the satisfaction for many participants. The spiritual benefit of this therapy—including its impact on death acceptance and existential angst—continues to be assessed.
The narratives generated in Dignity Therapy might serve to reinterpret, to warn, or perhaps, even repent. Musing on regret, David Whyte writes, “Except for brief senses of having missed a tide, having hurt another, having taken what is not ours, youth is not yet ready for the rich current of abiding regret that runs through and emboldens a mature human life.” It is not uncommon for regrets and lessons learned to be expressed in these sessions. Recounting one’s life as a prolonged conclusion can be a telling exercise in perspective and provide a meaningful legacy for loved ones in the process.
So on the occasion of another birthday, I am reflecting on life’s journey and taking stock. Though I’m anticipating a few more decades of life, I am intensely aware of the importance of my story and with whom I want to share it. Another of Gene Cohen’s quotes is especially sweet to me in this regard: “The older brain is more resilient, adaptable, and capable than we thought.” He wrote that adults in the second half of life tend to utilize and integrate both sides of the brain more effectively than younger folks. He further asserts that because autobiography engages both the right and left hemispheres, it’s like “chocolate for the brain.”
My 91-year-old Mom (whose picture accompanies this article) has occasional short term memory lapses these days, but her storytelling has never been better! On a recent visit, she recounted a long tale to me and my daughter-in-law, Kristin, about a visit to her pediatrician several months after my older brother (her first child), Bill, was born.
She had complained about Bill’s colicky, fussy nature. Dr. McKenzie commanded, “Frances, hand me that baby and hand me a bottle.” In short order, my brother proceeded to down 5 ½ small bottles of formula, then burped and fell fast asleep. Mom’s efforts to breast feed as Bill’s sole means of nutrition just weren’t cutting it! Unwittingly, she had been starving him. She learned a lesson; Bill’s “colic” ended, and the recounting of the tale gave all of us hearty chuckles.
I encourage you to assess and document your life stories periodically. And consider Dignity Therapy for yourselves and your loved ones when the timing is appropriate.
Dignity Therapy allows a person who senses death is near to reflect on their complex life-mosaic of emotions, remembrances and lessons learned, and then to gift a document created from this reflection as a lasting legacy. The value to both narrator and recipients just might be priceless.
Stephen L Hines, MD
1. Dignity in Care. http://www.dignityincare.ca/en/
2. Fitchett G, Emanuel L, Handzo G, et al: Care of the human spirit and the role of dignity therapy: A systematic review of dignity therapy research. BMC Palliative Care. 2015 May 14(8):1-12.
3. McNees P: The Beneficial Effects of Life Story and Legacy Activities. J Geriatr Care Manag. Spring 2009:15-19.