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Life Review Therapy Using Autobiographical Retrieval Practice for Older Adults With Depressive Symptomatology.

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Abstract

The aim of this study was to examine the efficacy of life review based on autobiographical retrieval practice for treating depressed older adults. Forty-three adults aged 65-93 with clinically significant depressive symptomatology and no dementia were randomly assigned to treatment or to no treatment. The results indicated significant differences between experimental and control groups after 4 weeks of autobiographical retrieval practice. At posttest, those in the treatment condition showed fewer depressive symptoms, less hopelessness, improved life. satisfaction, and retrieval of more specific events. The findings suggest that practice in autobiographical memory for specific events may be among the components of life review that account for its effectiveness and could be a useful tool in psychotherapy with older adults.
Life Review Therapy Using Autobiographical Retrieval Practice
for Older Adults With Depressive Symptomatology
Juan Pedro Serrano and Jose Miguel Latorre
Universidad de Castilla–La Mancha Margaret Gatz
University of Southern California
Juan Montanes
Universidad de Castilla–La Mancha
The aim of this study was to examine the efficacy of life review based on autobiographical retrieval
practice for treating depressed older adults. Forty-three adults aged 65–93 with clinically significant
depressive symptomatology and no dementia were randomly assigned to treatment or to no treatment.
The results indicated significant differences between experimental and control groups after 4 weeks of
autobiographical retrieval practice. At posttest, those in the treatment condition showed fewer depressive
symptoms, less hopelessness, improved life satisfaction, and retrieval of more specific events. The
findings suggest that practice in autobiographical memory for specific events may be among the
components of life review that account for its effectiveness and could be a useful tool in psychotherapy
with older adults.
Drawing from theory and research about the effects of depres-
sion on autobiographical memory, we developed a life review
therapy and tested whether this therapy led to changes in depres-
sive symptomatology in older adults. Life review is often pro-
moted as a therapy for depression in older adults. Originally, life
review took its rationale from Erikson’s (1959) theory of life
stages, in which life review facilitated resolution of Erikson’s
eighth stage, that is, achieving ego integrity. Diverse activities
have been proposed that aim to augment life review processes. One
of the first proponents of life review was Butler (1963, 1974), who
suggested use of different stimuli, for example, old photographs, to
foster memories, audiotaping one’s autobiography, attending re-
unions, and constructing a genealogy. Haight and Dias (1992)
concluded that the most therapeutic aspects of life review included
participation in individual one-on-one reminiscence, reflection on
one’s personal evaluation of events, and coverage of the entire
lifespan. A book by Haight and Webster (1995) provides system-
atic guidance on conducting life review groups and includes rec-
ommended topics for discussion. Birren and Birren (1996) con-
ducted classes in guided autobiography where members wrote and
shared their autobiographies. They developed various sensitizing
questions to structure participants’ writing.
Life review has most often been used with older adults who are
not selected for clinical depression but are potentially at high risk
for depression, such as those who are homebound or residents of
nursing homes (e.g., Haight, Michel, & Hendrix, 1998). Our focus
was older adults with clinically significant depressive symptom-
atology. A few controlled studies of life review have been con-
ducted with older adults who are depressed. Fry (1983) found that
both individually administered structured life review and unstruc-
tured reminiscence interventions reduced depressive symptoms
significantly when compared with an attention placebo group, and
that life review was superior to unstructured reminiscence. In
nondemented nursing home residents with mild to moderate de-
pression, Dhooper, Green, Huff, and Austin-Murphy (1993) ob-
served significantly reduced depression in those who received a
combined structured life review and problem-solving intervention
compared with a no-treatment control group. In a community
sample of older adults who were diagnosed with major depression,
Arean et al. (1993) compared group-administered life review with
problem-solving group therapy and a waiting list control condition.
Life review was significantly better than the waiting list control in
reducing depression but less effective than problem-solving ther-
apy. Even across these studies, notably, there was considerable
variability in what was regarded as life review.
Our life review intervention was based on research about auto-
biographical memory. Studies on autobiographical memory show
that if depressed people are presented with a cue word, they
retrieve less specific and more general memories than a control
group of nondepressed persons (e.g., Kuyken & Dalgleish, 1995;
Moore, Watts, & Williams, 1988; Puffet, Jehin-Marchot, Timsit-
Berthier, & Timsit, 1991; Williams & Dristchel, 1988; Williams &
Scott, 1988). This problem of overgeneral recall has been repli-
cated in depressed and suicidal patients and is one of the most
reliable features of memory in depression (Kuyken & Brewin,
Juan Pedro Serrano and Jose Miguel Latorre, Department of Psychology
(Faculty of Medicine), Universidad de Castilla–La Mancha, Albacete,
Spain; Margaret Gatz, Department of Psychology, University of Southern
California; Juan Montanes, Department of Psychology (School of Teach-
ers), Universidad de Castilla–La Mancha.
Correspondence concerning this article should be addressed to Juan
Pedro Serrano, Departamento´ de Psicologı´a Facultad de Medicina, Edificio
Benjamin Palencia, Universidad de Castilla–La Mancha, Avda. Almansa
S/n, 02006 Albacete, Spain. E-mail: juanpedro.serrano@uclm.es
Psychology and Aging Copyright 2004 by the American Psychological Association
2004, Vol. 19, No. 2, 272–277 0882-7974/04/$12.00 DOI: 10.1037/0882-7974.19.2.272
272
1995; Williams, 1992; Williams & Broadbent, 1986). When peo-
ple try to retrieve autobiographical memories, they first access
general descriptions, using these as intermediate steps to point to
specific event descriptions (Reiser, Black, & Abelson, 1985; see
Rubin, 1996, for a review). Autobiographical memory can be
characterized as a hierarchy. General information is higher in the
hierarchy, and more detailed, specific information is lower in the
hierarchy. People normally can navigate through the hierarchy and
select the level of specificity that makes most sense in any given
situation.
Williams and Dristchel (1992) pointed out that although people
normally can control the specificity of their recollections, some
seem to find it too effortful. Studies of autobiographical memories
show that both depressed individuals (Williams & Scott, 1988) and
older adults (Winthorpe & Rabbitt, 1988) have difficulties being
specific in autobiographical memory. If an individual does not
produce a specific memory, then an overgeneral memory is
recalled.
Although overgeneral memory was originally described as a
stable characteristic (Brittlebank, Scott, Williams, & Ferrier,
1993), it may, in fact, be open to change. Compared with a group
of controls, Williams, Teasdale, Segal, and Soulsby (2000) found
that depressed patients who received 8 weeks of mindfulness-
based cognitive therapy showed a reduction in overgeneral mem-
ories. Watkins, Teasdale, and Williams (2000) found that Nolen-
Hoeksema and Morrows (1993) distraction induction led to
diminution of overgeneral memory in depressed and dysphoric
participants. However, overgeneral memory was maintained if
participants were given rumination induction, in which they were
essentially encouraged to continue engaging in dysfunctional types
of thinking that have been associated with depressive disorder.
On the basis of this literature, the approach that we took to life
review was to provide practice for participants in producing spe-
cific autobiographical memories. If participants produced specific
memories, we theorized, then the types of rumination that maintain
depression should be reduced. The aim of our study was to
examine the effects of autobiographical retrieval practice for spe-
cific events in older adults with depressive symptomatology. We
predicted that older adults who received practice would improve
their mood state, as reflected in decreased depressive symptoms,
decreased hopelessness, and increased life satisfaction.
Method
Participants
One hundred twenty older adult volunteers who were clients of Social
Services in Almansa (Albacete), Spain, were recruited. Participants in the
study were receiving 1 hr of social services per day, 5 days per week, from
the private corporation Service Assistant Almansas Home, which also
helped with recruitment.
After verbal consent was given, five assistants screened all volunteers.
Criteria for inclusion in the study were as follows: Individuals had to have
clinically significant symptoms of depression (as determined by a score of
16 or higher on the Center for Epidemiological StudiesDepression
[CESD; Radloff, 1977] scale); had to show no evidence of dementia (as
determined by a score of 28 or higher on the Mini-Mental State Exami-
nation [Mini Exa´men Cognoscitivo, MEC; Lobo, Ezquerra, Go´mez Bur-
gada, Sala, & Seva-Dı´az, 1979]); and could not be receiving pharmaco-
logical treatment for depression. Seventy-six individuals scored 16 or
higher on the CESD. Within this group, 12 scored below 28 on the MEC
and were excluded, and 14 decided not to participate (response rate
78%). The remaining sample of 50 participants was assigned to matched
pairs according to baseline CESD, gender, and age. Within each pair, one
participant was randomly assigned to the experimental group and the other
to the control group. The control group received social services as usual.
The experimental group received the life review intervention while con-
tinuing with social services.
During the intervention, 7 participants dropped out of the study (reten-
tion rate 86%). Of these, 3 moved to another city, 1 was hospitalized due
to illness, 1 died, and 2 were not motivated to continue. Of the latter 2, one
was in the experimental, and the other, the control group. Dropouts were
not significantly different from those who continued on their baseline
CESD, Beck Hopelessness Scale (BHS), Life Satisfaction Index, or
number of specific events recalled. If anything, they were somewhat less
depressed and more hopeful, although not significantly so.
The final sample, shown in Table 1, included 43 older adults ranging in
age from 65 to 93 years (M77.19 years; SD 7.68); 33 were women
and 10 were men. The educational levels were able to read and write
(7.0%), completed elementary school (67.4%), completed secondary
school (23.3%), and attended university (2.3%). There were no differences
between experimental and control groups in age, gender, or education.
Experimental and control groups did not differ significantly at pretest on
CESD, BHS, Life Satisfaction Index, or number of specific memories,
either including or excluding the dropouts.
A short form of the Composite International Diagnostic Interview
(Kessler, Andrews, Mroczek, Ustun, & Wittchen, 1998) was used to
evaluate whether participants met criteria for major depressive disorder.
The pretest interview asked about symptoms during the past 2 years; at
posttest, participants were asked about the past 2 weeks. At pretest,
experimental and control groups did not differ significantly in proportion
with major depression (50% of the experimental group vs. 30% of the
control group).
Mood Measures
Depression. Depression was measured by the CESD (Radloff, 1977;
translated into Spanish by Latorre Postigo & Montan˜e´s Rodrı´guez, 1997).
The CESD is a 20-item self-report scale developed to screen for depres-
sive symptomology in the general population, with each item scored on a
4-point scale from 0 (little or no experience of the symptom over the past
week)to3(nearly constant experience of the symptom). Total scores range
from 0 to 60, with higher scores indicating more depressive symptoms. In
the present sample, Cronbachs alpha was .63.
Table 1
Background Data for Participants in the Study
Variable
Experimental
group
(n20)
Control
group
(n23) Statistical test
Age, M(SD) 75.8 (8.1) 78.4 (7.3) t(41) 1.11
Education (frequency)
2
(3, N43) 5.08
Able to read and write 0.0% 15.0%
Completed elementary
school 73.9% 60.0%
Completed secondary
school 26.1% 20.0%
Attended university 0.0% 5.0%
Gender
2
(1, N43) 0.95
Male 17.4% 30.0%
Female 82.6% 70.0%
Note. None of the differences are statistically significant.
273
AUTOBIOGRAPHICAL MEMORY AND DEPRESSION
Life satisfaction. Life satisfaction was measured with the Life Satis-
faction Index A (LSIA; Adams, 1969). The original Life Satisfaction Index
(Neugarten, Havighurst, & Tobin, 1961) consisted of 20 agreeor dis-
agreeattitude items. Adams (1969) reduced the scale to 18 questions,
using Woods scoring method (Wood, Wylie, & Sheafor, 1969). This
method assigns 2 points for positive answers, 0 for negative answers, and
1 for dont knowanswers, providing a range of 0 to 36, with the highest
scores indicating the greatest satisfaction. The scale was translated into
Spanish by Stock, Okun, and Go´mez (1994). In the present sample,
Cronbachs alpha was .66.
Hopelessness. The hopelessness instrument (BHS; Beck, Weissman,
Lester, & Trexler, 1974) reflects an individuals negative expectancies of
the probability of attaining important goals. Twenty items representing the
types of pessimistic statements made by psychiatric patients are answered
true or false, and the scale is scored for pessimism, with a score of 20
reflecting the highest degree of pessimism. The authors of this article
translated the BHS into Spanish. In the present sample, Cronbachs alpha
was .74.
Autobiographical Memory Test
This test measures respondentsability to retrieve a specific memory
under timed conditions in response to a cue word. The procedure is taken
from Williams and Broadbent (1986). We generated cue words for the
Spanish version of the test by presenting a list of 30 words to a focus group,
who identified which were more familiar positive, negative, and neutral
words. These words were presented orally to the respondent. In this
experiment, we used five positive (funny,lucky,passionate,happy,hope-
ful), five negative (unsuccessful,unhappy,sad,abandoned,gloomy), and
five neutral words (work,city,home,shoes,family). Words were presented
in a fixed, alternating order as above. To ensure that participants under-
stood the instructions, we provided examples of general memory (e.g.,
summers in the city) and specific memory (e.g., the day I got married).
In this procedure, participants were asked for a memory of which the cue
word reminded them, one that should have occurred at a particular time and
place and lasted no longer than a day. (The interviewers question for the
positive and negative words was Try to remember a day or situation in the
past when you felt [cue word]. Can you describe it?For neutral words the
question was Try to remember a special day about . . .). Participants were
given 30 s to produce a memory. If no memory was recalled in 30 s, this
was noted as an omission; the participant was not prompted. Each memory
was rated on whether it was general or specific. If the recalled event lasted
no longer than a day, it was coded as specific. If the memory happened on
a number of occasions, it was coded as general. Because the total number
of stimulus words was 15, the maximum score for either category was 15
and the sum of general plus specific memories could not exceed 15.
Additionally, each memory was rated for whether it was positive, negative,
or neutral. Two psychologists served as raters and independently scored the
responses of all participants; raters were blind to the hypotheses of the
study, to experimental or control group, and to pretest or posttest. Interrater
reliability for general versus specific was .89 at pretest and .91 at posttest.
At pretest, interrater reliability for positive was .78; for negative, .80; and
for neutral, .79. At posttest, the respective results were .77, .79, and .79.
Procedure
The intervention was individually administered on a weekly basis by
Juan Pedro Serrano. Participants were told that the study was investigating
effects of memory recall on mood and that the interviews were designed to
evoke memories. In the 1st week, participants gave consent, received an
explanation of the study, provided basic demographic data, and completed
the pretest mood measures. These measures were administered by two
assistants blind to the purpose of the study. In the 2nd week, participants
completed the autobiographical memory pretest.
During the 3rd to 6th weeks, the life review therapy was carried out with
the experimental group, and the control group was visited only for social
assistance. The life review consisted of autobiographical retrieval practice
that entailed focusing on a particular life period each weekchildhood,
adolescence, adulthood, and summary. For each period, 14 questions were
prepared (based on Haight & Webster, 1995) that were designed to prompt
specific memories. Examples of questions include, What is the most
pleasant situation that you remember from your childhood?;What did
your mother or father do one day when you were a child that astonished
you?;During adolescence, what moment do you remember as special
because it was the first kiss you received or because you shared something
special with someone with whom you were in love?;Tell me about a day
when you were an adolescent and you did something out of the ordinary;
Tell me a time that you remember experiencing the most pride at work;
Did someone close to you or someone you knew recuperate from a grave
illness?;If everything in your life were to happen exactly the same, what
moment would you like to re-live?; and What do you consider to be the
most important thing that you have done in your life?
1
Participants
reported memories were recorded, and each was coded as to whether it was
general or specific and whether it was positive, negative, neutral.
Autobiographical memory posttesting took place the 7th week, and the
8th and final week concluded with the CESD, BHS, and LSIA scales. The
self-report measures were again administered by two assistants blind to the
design of the study.
Intervention sessions were tape-recorded and were scored by a psychol-
ogist blind to the purpose of the study to ensure that the intervention was
presented according to the protocol. Each response to the prompting
questions was coded for whether the answer was positive, negative, or
neutral and whether it was specific or general. This coding determined that
each prompting question was administered to each participant and that the
participants performed the intervention. In addition, absence of unspecified
components such as encouragement or advice was confirmed.
Results
Our chief hypothesis was that individuals in the life review
therapy condition would show decreased depression and hopeless-
ness and increased life satisfaction. In addition, because the focus
of the intervention was increasing specificity of memories, it was
predicted that number of specific memories would increase from
pretest to posttest for those individuals who received life review.
Means and standard deviations for experimental and control
groups at pretest and at posttest are included in Table 2. Experi-
mental and control groups were not significantly different at pre-
test on any of the four dependent variables, confirming that ran-
dom assignment was successful. Four analysis of variance
procedures (ANOVAs) were carried out, with treatment group
(experimental vs. control) as a between-subjects factor and time
(pretest vs. posttest) as a within-subject factor. The dependent
variables were CESD, BHS, LSIA, and specific recall scores. A
significant Group Time effect indicates that the experimental
group changed significantly more than the control group. For all
four ANOVAs, the main effects for time and the Group Time
interaction were statistically significant, as seen in Table 2. For
BHS, the main effect for group was also significant. Older adults
who received practice in autobiographical memory retrieved more
specific memories at posttest compared with the control group,
indicating that the intervention was successful in encouraging
older adults to generate more specific memories. In support of our
1
A copy of the treatment protocol is available from Juan Pedro Serrano.
274 SERRANO, LATORRE, GATZ, AND MONTANES
hypothesis, the experimental group, which received the practice in
autobiographical memories, improved in their levels of depressive
symptoms, hopelessness scores, and life satisfaction, when com-
pared with the control group.
Analyses were repeated with just individuals who met Compos-
ite International Diagnostic Interview criteria for major depressive
disorder at pretest. Those with a history of major depression had
significantly higher CESD scores at pretest than those without a
history of major depression, but amount of change on the CESD
was not significantly different for those with versus those without
a history of major depression. However, within the experimental
group, the proportion meeting criteria for major depression
dropped from 50.0% at pretest to 25.0% at posttest, whereas for the
control group, the proportion meeting these criteria was similar at
pretest and at posttest: 30.4% and 34.8%, respectively.
Additional analyses tested whether change on specific memories
was related to change on the outcome measures. A change score
was calculated by taking the difference between number of spe-
cific memories generated at posttest and number generated at
pretest. Three regressions were carried out, using all 43 partici-
pants, with posttest scores on CESD, BHS, and LSIA as the
outcomes and two predictors: pretest scores on the corresponding
measure and change on specific memories. For all three outcomes,
posttest scores were significantly predicted by pretest scores. In
addition, controlling for pretest scores, change on specific mem-
ories was a significant predictor for posttest hopelessness (
.29, p.01) and life satisfaction (
.24, p.03), and there
was a trend in the same direction for posttest CESD(
⫽⫺.25,
p.06). These results suggest that participants who increased the
most in production of specific memories were also those who
improved most on depressive symptoms, hopelessness, and life
satisfaction.
A test for mediation (Baron & Kenny, 1986) was also performed
on (a) the relationship between group (experimental vs. control)
and outcome; (b) the relationship between change in specific
memories and outcome; and (c) whether the relationship between
group and outcome was reduced when the measure of specific
memories was included in the equation. For hopelessness, there
was partial mediation, with the effect of group still significant
although slightly reduced, from
.53 to
.48. For life
satisfaction, the effect of group was reduced from
.45 to
.42; for CESD, it was reduced from
.60 to
.58.
A more detailed, descriptive examination of positive specific,
negative specific, and neutral specific responses is shown in Table
2. Repeated measures ANOVAs revealed significant Group
Time interactions for specific positive and specific neutral re-
sponses and significant main effects for time on all three measures.
The experimental group increased more than the control group in
production of both positive specific memories and neutral specific
memories.
Finally, number of specific memories produced during the in-
tervention was correlated with increase in specific memories be-
tween pretest and posttest. This relationship was most pronounced
for number of specific memories in response to neutral cue words,
where r.38, p.10, for the 20 participants in the intervention.
Discussion
The aim of this study was to examine the benefits of practice in
autobiographical memories in the context of life review therapy in
older people with depressive symptoms. We investigated whether
older adults who received autobiographical retrieval practice im-
proved their mood state and whether improvements would be
associated with changes in recall of specific memories. The life
review process involves emotional processing of events from the
individuals past. Autobiographical retrieval practice focused on
bringing up specific events that these older adults might not have
spontaneously reviewed. The results showed that older adults who
received autobiographical memory practice improved their mood
state, with decreased depressive symptoms and feelings of hope-
lessness, and improved their life satisfaction, compared with a
control group, who did not show changes in their mood state. The
results also provide further evidence that overgeneral memories in
depression are modifiable over short time periods; participants in
a life review therapy protocol in which they were trained on
autobiographical memory generated significantly more specific
memories at posttest than at pretest compared with those who did
not receive life review therapy.
We cannot claim that the improvements in mood were unam-
biguously due to the focused attention on specific recall during the
life review sessions. However, the results do suggest that increas-
ing the specificity of recall in autobiographical memory may be an
important mechanism in explaining how life review therapy might
achieve its effects. This conclusion is supported by both the fact
Table 2
Means (and Standard Deviations) for the Main Dependent Variables in the Study
Variable
Experimental group
(n20) Control group
(n23) F(1, 41)
Pretest Posttest Pretest Posttest Group Time Time Group
CESD 30.70 (6.76) 20.45 (7.25) 27.61 (6.29) 27.61 (7.48) 1.07 38.99**** 38.99****
Beck Hopelessness Scale 12.10 (3.04) 8.25 (3.54) 11.96 (4.08) 12.96 (4.38) 4.35* 11.62** 33.66****
Life Satisfaction Index 13.55 (4.73) 19.50 (6.48) 14.83 (6.29) 14.04 (7.77) 1.24 16.95*** 28.78****
Specific recall
Positive specific memories 1.60 (1.79) 3.25 (2.07) 1.95 (1.49) 2.17 (1.80) 0.64 8.87** 5.22*
Negative specific memories 1.45 (1.61) 2.50 (1.61) 1.17 (1.19) 1.78 (1.31) 1.99 10.36** 0.73
Neutral specific memories 0.10 (0.31) 0.60 (0.88) 0.30 (0.56) 0.22 (0.52) 0.44 2.79 5.63*
Total specific memories 3.15 (3.10) 6.35 (3.36) 3.42 (2.55) 4.17 (2.72) 1.63 15.34*** 5.99*
Note. CESDCenter for Epidemiologic Studies Depression Scale.
*p.05. ** p.01. *** p.001. **** p.0001.
275
AUTOBIOGRAPHICAL MEMORY AND DEPRESSION
that the intervention led to increases in specific memories and the
fact that those who increased more in specific memories also
improved more in mood. What cannot be resolved is whether
decreased depression led to less overgeneral memory, or whether
successful practice in specific memory did, in fact, lead to reduc-
tions in depressive symptoms.
We should note some limitations of the present findings. First,
there was no placebo control group in which participants received
the same amount of attention from the therapist but not the auto-
biographical retrieval practice. Total amount of contact was not
equated across conditions, as the control group received only
typical social services, in the form of visits from the social services
assistant. Therefore, we cannot definitively attribute the changes in
depression to the autobiographical memory practice. Second, the
prompting questions during the intervention primarily targeted
positive memories, although some questions were clearly neutral
and others referred to adversity, and the questions did stimulate
negative and neutral as well as positive responses. Therefore, it is
not possible to clearly separate elicitation of positive specific
memories from elicitation of specific memories as the mechanism
for improvement. Notably, the experimental group increased their
production of positive, negative, and neutral specific memories,
with the increase in positive and neutral memories greater for the
experimental than for the control condition. Third, there was no
follow-up to learn how long the changes maintained. Nevertheless,
the main intention of this study was to learn whether overgeneral
memory could be modified and whether this form of life review
was effective in improving mood among participants who had
symptoms of depression. Fourth, the sample size was rather small.
All the same, significant changes in mood were found in spite of
the size of the sample. Fifth, not all respondents had major de-
pressive disorder. Nonetheless, all did have significant depressive
symptoms.
These findings may help clarify what mechanisms underlie
effective life review therapy. Past research has led to equivocal
evidence regarding the impact of life review on depression (see
Karel & Hinrichsen, 2000). One reason for the inconsistency may
be the diversity of activities used by different life review therapies.
In the present study, we based the life review intervention on
current research about memory and depression. In conclusion, this
study provides further evidence that overgeneral memory in de-
pression can be modified by brief cognitive intervention and that
life review based on these principles can be useful in treating
symptoms of depression in older adults.
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Received March 19, 2003
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Accepted December 1, 2003
277
AUTOBIOGRAPHICAL MEMORY AND DEPRESSION
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