Abstract
For those of us who had the honor of spending some time with Robert N. “Bob” Butler, reading this book will be a bit like sitting down across from a treasured friend. If you never met Bob, then Andy Achenbaum’s book, a historically grounded explanation of Butler’s intellectual, professional, and lived experiences, will likely make you wish your paths had crossed with him. Butler, who passed away in 2010, spent most of his life shaping and answering a seminal question in geriatrics: How do we (individually and as a society) age healthfully?
The book seeks to answer this question by opening with a detailed exploration of one of Butler’s best known contributions, the “life review.” Achenbaum spends much of the first chapter drawing links between Butler’s development of this key theory in aging and its evolving role in his clinical practice. Butler’s views of reminiscence in later life were dynamic and he argued that reminiscing were normal processes that emerged from a desire to enjoy, grow, cope, or change. Recognizing the universal appeal and significance of reminiscence, Butler encouraged more formal life reviews that systematically elicited memories for educational and therapeutic purposes. Increasingly over the four decades since Butler (1963) published his seminal article, practitioners in the community have translated the desire to reminisce among older adults into a more formal life review practice. The book closes with an appendix titled, “Prologue or Introduction to Life Review” written by Butler primarily for his children and completed a week prior to his death. These are literally Butler’s “last words” on this theoretically and clinically important concept, and Achenbaum demonstrates Butler’s passion for continual refinement of ideas by bringing Chapter 1 and appendix together.
Having this robust introduction to Butler—the clinician and theorist—Achenbaum grounds his analysis of Butler—the man—using Elder’s (1974) life course approach. The historical context of the Great Depression is significant for both Butler and in Elder. Butler was a child during the Depression, raised from infancy by grandparents, and Achenbaum details the influence of Butler’s early childhood, where his intelligence and character helped move him from a child of poverty into a student at an elite university and then on to a brilliant career. While some might question the inclusion of so many early life details, Achenbaum makes the case for how and why these details shaped Butler’s life narrative. For example, the core curriculum at Columbia College, where Butler did his undergraduate degree and his work editing the college newspaper, gave him the intellectual breadth and the real-world skills enabling him to win the Pulitzer Prize for his 1975 book, Why Survive? Being Old in America. He chose to continue his medical education at Columbia where he became interested in geriatrics only during his internship and then took a residency with the relatively new and largely unorthodox Langley Porter Neuropsychiatric Institute on the west coast. Achenbaum’s detailed description of Butler’s “apprenticeship” there helps the reader understand the significance of his move into psychopharmacy in an institute that was itself pioneering new approaches to clinical care and research on aging. As Achenbaum carefully documents, Butler viewed his 8 years of interdisciplinary research on healthy aging as the most stimulating and significant phase of his career. The move from conceptualizing aging as pathology to healthy aging became a foundation for all of Butler’s subsequent clinical and theoretical work.
The remaining chapters carry Butler through his leadership as the first director of the National Institute on Aging (NIA; 1976-1982), his decision for giving high priority to Alzheimer’s disease, and his limited success in promoting clinical geriatrics and enhancing Alzheimer’s disease research in American medical schools. While working at NIA, he engaged in numerous professional and organization-building activities that resulted in the ideas and the concepts for what he is cited. Over the next 6 years, Dr. Butler set an agenda for bio-medical and psycho-social investigations into processes of aging, invested in research on Alzheimer’s, and built partnerships within the National Institutes of Health and among U.S. researchers to advance geriatrics and gerontology scientifically and pedagogically. He generated demographic and epidemiological evidence to justify national legislation to end age discrimination in employment and to shore up Social Security financing.
Butler championed geriatric education and training at the NIA. Butler had greater, if transient, success at New York’s Mount Sinai Medical Center where he accepted the challenge of creating the first U.S. Department of Geriatric Medicine. Thanks to skills at developing interdisciplinary teams, many social workers, nurses, occupational therapists, dentists and epidemiologists have acquired training in geriatrics and now play a role in preventing disease and promoting productive aging. The field grows, although far more slowly than Dr. Butler anticipated, particularly with regard to the supply of geriatricians. The numbers of health care professionals with necessary expertise to address the needs and desires of baby boomers as they become eligible for Medicare is woefully lacking, but thanks to Butler and his collaborators, we have a good sense of priorities and best practices in geriatrics and palliative care.
Butler then turned to other projects including playing a critical role in creating the concept of “productive aging,” considered a step beyond “healthy aging.” He used his leadership and persuasive skills to attract colleagues in Europe, Japan, and Latin America to share his vision to establish a U.S. Branch of the International Longevity Center at the Mount Sinai Medical Center and then extend their support to assist in creating International Longevity Centers in other countries. Part of Butler’s success at institution building was his ability to connect people with access to money with strategies to implement compelling ideas. Funded largely with corporate donations, these centers together made up a new institution focused on “productive aging” devoted to examining the socioeconomic, health, and quality of life impact of population aging. It is here that Achenbaum once again shows his strength as a historian and biographer, providing considerable detail of the changing historical circumstances in which Butler struggled, and in large measure succeeded, in terms of giving birth to big ideas and lasting institutions.
One of the major strengths of this book is that it is a historically grounded biography. Achenbaum provides extensive historical information about the social institutions and the political context that shaped the environment in which Butler lived and worked. These institutions shaped Butler’s life story and, in turn, influenced his own ability to shape events. Achenbaum does more than just restate the question “does history make great people or do great people make history” through his detailed unpacking of salient individual and global perspectives. For example, Achenbaum provides a persuasive account of why Butler’s first book, Why Survive, was more successful than his last, The Longevity Revolution (2008). To be truthful, the analysis benefits from Achenbaum’s lengthy relationship with Butler, who generously provided him interviews and access to his personal files.
Achenbaum also does a superb job of communicating Butler’s compassion and warmth. It is connecting with Butler’s underlying humanity which should remind readers, both seasoned gerontologists and younger cohorts, that creating and sustaining institutions is hard work. Those who strive to understand aging and improve the lives of older people should understand that their task is hard and never ending. Achenbaum portrays Butler as a good role model for researchers, clinicians, and finally for something that will touch upon the lives of most readers—growing older. While remaining humble throughout his life about the contributions of his theories, including the life review concept, Butler strongly criticized deterministic age categories and theories that were prominent over much of his career. With that bias in mind, I suggest that readers review the concluding appendix on life review again, this time to glean Butler’s own advice as to how to live and age in a meaningful way and with a sense of purpose through the later years. Always the teacher and mentor, and for many a good friend, Bob leaves us with a roadmap well worth following.