Family Bereavement Program (FBP) Approach to Promoting Resilience Following the Death of a Parent

Abstract

This paper describes a research-based program designed to promote resilience of parentally-bereaved children and their bereaved surviving parent. A contextual resilience model is described as the conceptual foundation of the program. The program is designed to enhance specific parenting and coping skills and to help caregivers and children accomplish goals they set for themselves at the outset of the program. The content of the twelve-sessions and the approach to teaching and supporting parents work on their program and personal goals are described. Evaluation of the program using a randomized experimental design indicates that the program is effective in promoting resilient outcomes of children and of the bereaved parent six-years following their participation in the program.

The Family Bereavement Program is based on a contextual resilience conceptual framework (Sandler, Wolchik, & Ayers, 2008) of family adaptation following the death of a parent. The adaptation process enables bereaved parents and children to satisfy their basic needs and to accomplish developmentally appropriate life tasks in the newly restructured family. Basic needs include the need for safety and biological integrity, positive evaluation of self, a sense of control, and meaningful and supportive social relationships (Sandler, 2001). The death of a parent threatens the family’s ability to meet these needs by disrupting bonds to the surviving parent and raising doubts about what is controllable and by leading to other negative stressors that threaten the stability of the child’s world. Developmentally appropriate life tasks differ across infancy, childhood and adolescents, but across these developmental periods the family plays a critical role in supporting successful task accomplishment (Sandler, 2001). For the surviving parent the death of their spouse is a massive disruption of their world, challenging them to reconstruct a life in which their own needs for relationship, control, and well-being can be met.

For both children and their parent, successfully meeting their basic needs and accomplishing their developmental life tasks lead to more resilient outcomes. Resilient outcomes are defined broadly to include lower levels of problems (e.g. mental health problems, substance abuse and physical illness) and higher levels of life satisfaction and well-being (e.g., developmentally appropriate role performance in school, work and relationships, positive subjective sense of well-being, efficacy and self-worth). Resilient outcomes following bereavement also include lower levels of intrusive and distressing grief over time and higher levels of positive outcomes, such as development of personal strengths (Wolchik, Coxe, Tein, Sandler & Ayers, 2009). The Family Bereavement Program (FBP) was designed to help the children and caregivers to acquire and practice skills that promote resilient outcomes for children. The FBP also supports the surviving parent in their pursuit of personal goals that enable them to meet their individually defined needs.

The contextual resilience framework of the FBP is distinct from other approaches to child bereavement in several ways. Although it includes a focus on grief as the normal experience of children and parents in the group, it does not focus on pathological grief experiences as the central focus of the program. Rather, it is concerned more broadly with promoting successful adaptation with the goal of decreasing a broad range of negative outcomes and increasing a broad range of positive outcomes. Second, although it sees a supportive environment for bereaved children and parents as a necessary component of the helping process, it does not see support as sufficient to helping bereaved children and parents. Rather, it identifies specific skills as necessary for creating a family environment and individual coping processes that lead to resilient outcomes.

Family Bereavement Program: Promoting skills and achieving child and caregiver goals

The skills that are targeted by the FBP have been discussed in some detail in prior publications (Ayers et al., 2008; Sandler, Wolchik, Ayers, Tein, Coxe & Chow, 2008), and will be only briefly reviewed here. Separate intervention components were designed to teach caregivers and children/adolescents skills to influence risk and protective factors that have been identified in prior empirical literature as being related to resilient outcomes for bereaved children (see Ayers et al., 2008 for a discussion of specific studies that support the relation between each of these risk and protective factors and child outcomes). We use the term ‘caregivers’ throughout the paper because all those in a caregiving role were included in the program, including grandparents, relatives or friends who played such a role, in addition to biological parents. We refer to the targeted risk and protective factors as mediators of the program effects on children because theoretically changing them will lead to improvements in child outcomes. Consistent with the theme of this special issue on family issues in bereavement this paper will focus mainly on the caregiver component of the FBP. As shown in Table 1, the skills taught in the caregiver component of the FBP are designed to strengthen caregiver-child relationship quality and caregiver use of effective discipline, to decrease caregiver demoralization and to decrease youth exposure to stressful events that follow the death.

Table 1.

Skills taught in the caregiver program and their targeted risk and protective factors

Program Skills	Targeted Risk and Protective Factors
Listening skills Family Time One-on-One time Catch-em-Being Good Guided Problem Solving	Positive and Caregiver-Child Relationship
Clear expectations and rules Effective and contingent consequences Consistent use of consequences	Effective Discipline
Positive reframing Encourage support seeking Support for achieving bereavement–related personal goals	Caregiver Distress, Depression and Grief
Reduce occurrence of negative events that impact children Shield children from negative events Support effective child coping	Stressful events

It is important to be aware that the caregiver component is complemented by a child/adolescent component. The child/adolescent component targeted skills that could potentially increase positive caregiver-child relationships, increase positive coping (active coping, coping efficacy), strengthen adaptive control beliefs (e.g., understanding the cause of events and making appropriate distinctions between controllable and uncontrollable events), reduce appraisals of stressful events which threatened child/youth well-being or self-esteem, and promote adaptive emotional expression (see Ayers et al., 2008 for a more complete description of the activities included in the child/adolescent component of the FBP).

More concretely: The Family Bereavement Program is a 12-session group program for parentally bereaved children and adolescents and their caregivers. There are separate groups for children (ages 8–12), adolescents (age 12–16) and caregivers. The program is fully described in program manuals that leaders follow to present each of the activities. Each session follows a common structure. The first activity of each session is a group review of the caregivers’ experience in using program skills with their families (referred to as “home practice”) and of caregivers’ progress on their personal goals. The members describe how they used the program skills in the past week and the leaders provide support, encouragement and assistance in problem solving how to use the skills most effectively. The next set of activities introduce a new skill or skills and explain why these skills are important. The skills are presented in a way that enables the participants to see how they are relevant to caregivers’ life experiences and goals. Role-play by the group leaders is used to model effective use of the skill. This is followed by an exercise in which the participants role-play use of the skill and receive feedback from the group leaders and the other group members. Finally, participants are presented with their weekly home practice assignments to use their program skills to strengthen their families and to make progress towards achieving their individual personal goals.

Learning structures promote active involvement and make the program relevant to each caregiver’s unique goals

Although the program teaches a common set of skills, the learning structures are designed to fully engage the caregivers to contribute their own experiences to the group learning process through an active learning approach derived from the adult learning literature (Merriam, Caffarella & Baumgartner, 2007). We conceptualize four principles as underlying an active learning approach. 1. People learn best when they understand and buy into the importance of what is being taught. For example, as described below, the first session of the caregiver program focuses on providing a framework for how the learning of the program skills is designed to help caregivers develop positive rather than negative family interactions. This exercise provides the conceptual framework for caregivers to understand why their use of these skills will impact the well-being of their children and will reduce their own distress. 2. People learn best when they can relate the material to their own life experiences and goals. For example, both caregivers and children identify personal goals that they want to accomplish in the program and discuss ways that use of the skills they are learning will help them accomplish their own goals. 3. People learn best when they are actively involved and self-directed in the learning process. Specific learning strategies were employed to maximize the time that the participants are actively processing the material and bringing their own experiences into the discussion of the program skills. For example, participants might be asked to share experiences that illustrate a given skill with another member of the group and then these dyads report back to the full group for a discussion of their experience and of the skill. 4. People learn best when there is a positive, supportive group environment. The leaders provide unconditional support and encouragement for group members, normalize experiences, provide specific positive feedback for successful use of skills and convey a message of participant efficacy. Similarly, they encourage a group environment of sharing similar experiences and positive feedback and support between group members.

Flow of the sessions: Cumulative building of skills to develop a family that promotes child and caregiver resilience

The flow of the sessions for the caregiver program is designed to cumulatively develop skills to promote effective parenting (positive caregiver-child relationships, stability and effective discipline), decrease children’s exposure to stressful events and decrease caregivers’ sense of distress, depressive affect and demoralization. The first two sessions are designed to develop a group environment of support and cohesion and to begin to develop a common understanding of the program objectives and how they relate to the caregiver’s situation. Caregivers share their stories of the death of their spouse or loved one with the group, what has been the most difficult part for them and what they found to be helpful. They are then asked to share what gains they would like to achieve from participating in the program for themselves, their families and their children. A group exercise called the “Bereavement Equation” is used, in which the caregivers share the changes that have occurred in their children’s lives and their own lives following the death, the emotions that result from these changes and how these changes and feelings lead to strained relationships between caregivers and children. At the conclusion of this activity the leader describes the purpose of the program as helping caregivers develop stronger families by using skills and activities that are taught in the program.

The second session builds upon the common understanding of the program in two ways. One way is through a description of negative and positive family cycles that often occur within bereaved families. The cycles describe ways in which caregivers and children can get into a downward spiral of negative interactions. The skills and activities caregivers will be practicing in the FBP are designed to help them create positive interactions in the family which break the negative cycle and lead to a more supportive family environment. Caregivers also identify changes they would like both for themselves and their families during the program, which are called bereavement-related personal goals and family goals respectively. Many of the skills taught within the program are to address what caregivers might identify as family goals, for example, improved relationships with their children, help their children deal with their grief and cope with other problems they experience in their everyday lives. Bereavement-related personal goals refer to things caregivers would like to accomplish in the program concerning furthering their own adjustment following the death of their spouse. Some examples of these types of goals can be found within Table 2. Time is allocated during the home practice reviews for group members to discuss and receive support for working on their personal and family goals. The second session also presents the first targeted program skill, Family Time, which is designed to promote more positive caregiver-child interactions. Family Time is a regularly scheduled time during which the family as a whole does an activity together with the goal of having a good time. The routine nature of this positive activity is described as being important to create a stable family structure.

Table 2.

Examples of caregiver bereavement-related personal goals.

Examples of Caregiver Bereavement Related Personal Goals
Take care of financial issues of the deceased Go through dresser and closet of the deceased Make trip to disperse ashes of deceased at a special location Plan and carry out a special way of remembering the deceased Begin to date once again Work on improving in-law, extended family relationships Take up regular exercise regime to lose weight and get in shape

Sessions three to six of the caregiver program teach new skills to promote positive family interactions including “catch-em-being good”, “one-on-one” time and listening skills. Catch-em-being good, which is taught in session three, involves providing positive feedback to children when they do something or say something positive. Caregivers are encouraged to recognize small things, and to reinforce them as often as possible. One-on-one time, which is taught in session four, is a brief period of time spent by the caregiver with each child individually, where they do an activity that the child enjoys, and during which the caregiver gives the child their undivided positive attention. One-on-one time also occurs on a routine schedule, with caregivers encouraged to do this once a week for each child in the family.

Session three provides a rationale for the importance of using effective listening skills and presents an overview of the three components of effective listening (i.e. listen, think, and respond). Leaders help caregivers see the link between good listening and the likelihood that children will share bereavement-related concerns as well as their other experiences with their caregiver. In session three caregivers are taught the first step in listening, use of good non-verbal behaviors, open-ended questions and conversational “continuers”. These skills are presented as the “four talk to me’s”; a) having “big ears”: tuning into what their children are saying, b) good body language (such as eye contact and facing the child), c) “good openers” (open versus closed questions), and d) good continuers, such as “tell me mores.”

In session four, caregivers are taught the second step in listening, to stop and think about what the child said and to provide a summary response to feed back to the child what they heard and to check out that they got it right. The next two sessions focus on teaching caregivers to “think” and “respond”, which involves thinking carefully about what the child was trying to express and then using both “summary” or “feeling” responses that reflect and check out what the child is saying or feeling respectively.

The listening skills caregivers are taught in sessions three, four and five are complementary to the communication skills children and adolescents are taught in their groups, which encourage them to express their feelings and to ask parents for help in problem solving how to cope with difficult situations. In a conjoint activity in session six children and parents meet for an exercise in which children first share a personal memento of their deceased parent and caregivers use their listening skills to help clarify why the child selected that particular memento. In session six parents are also taught another skill that is complementary to a skill children are taught, namely, guided problem solving. Guided problem solving is designed to help parents facilitate children’s use of the four step problem solving model that children are taught in their groups.

Session seven focuses on the management of parents’ own grief-related distress, and negative, depressive affect. The session uses several strategies, including acceptance and normalization of distress, cognitive reframing of experiences associated with depressive affect, and increased engagement in positive activities. Normalization of distress is promoted by a caregiver sharing times when they have felt overwhelmed by intense sadness or anger or feelings of longing for the deceased. Leaders help caregivers see these experiences as a normal part of the grieving process for many individuals and reassure the caregiver that the intensity and frequency of these experiences typically decrease over time. Leaders also help caregivers identify ways of combating the feelings of being overwhelmed and discouraged by such intense grief experiences.

Cognitive-behavioral techniques are used to decrease negative and increase positive self-talk and pleasurable experiences. Challenging negative thinking is an important way for caregivers to regain a sense of control and increase hope. “Thinking traps” such as overgeneralization and catastrophizing are described as leading to feeling hopeless and helpless. Caregivers are taught to recognize such thinking traps (e.g., This is impossible for me to handle); and to replace the negative thought with a more hopeful thought (e.g., This is hard but I can handle it).

Sessions eight, nine and ten focus on strengthening caregivers’ use of effective discipline skills. Effective discipline is taught as involving “The three C’s: Be Clear, Be Calm, Be Consistent”. Being clear involves having specific and realistic expectations of their children and clearly communicating those expectations. Caregivers are taught to positively attend to and reinforce their children when they meet expectations. When children do not meet “realistic” expectations, being calm involves a composed rather than angry level of affect when deciding on consequences. Caregivers are encouraged to select consequences that are fair, that can be consistently applied, that help children learn about the effects of their behavior and that are the least harsh consequences that will be effective. Being consistent involves sticking to delivering the consequences despite their own feelings of guilt or fatigue or the protestations of the child.

Caregivers practice their discipline skills by developing a “change plan” to address a specific misbehavior of each of their children. They first count the misbehavior for a week, and following that they develop a change plan that includes appropriate consequences for its occurrence and a clear, calm communication of the consequences to the child. After using the change plan, leaders and caregivers evaluate its effectiveness and discuss how to change it to make it work most effectively. Caregivers also learn about how parents and children can get into coercive negative cycles around discipline issues in which they each do things to hurt the other through yelling, saying hurtful things, nagging or whining. Parents are taught skills, such as anger management to prevent and de-escalate such coercive cycles.

Session eleven focuses on things the caregivers can do to support children’s effective coping with the stressors in their lives and to reduce children’s exposure to negative events. Child stressors include those that are the consequence of changes following the parental death and the normative stressors of childhood and adolescence. The coping skills that are taught in the child program are reviewed, including dealing with bereavement-related feelings, challenging negative thoughts, learning to distinguish things they can control from those they cannot, problem solving, and communicating their feelings and their need for help in dealing with stressors in their lives. Caregivers also discuss things they can do to help their children with the stressors that often occur in bereaved families (e.g., seeing their parent being depressed), such as using their good listening skills, modeling good coping and providing reassurance to help children positively reframe the situation (e.g., as one that will not last forever and as one that they can cope with effectively). The home practice is to use the strategies discussed in this session to support children’s coping with problems they may be experiencing.

Session twelve focuses on three issues. The first is to review the skills they have learned and to troubleshoot problems in use of the skills. The second is to discuss strategies to maintain use of the skills following the program. Maintenance strategies include setting priorities to make time to do the things that are most important for their children; to anticipate setbacks and to counteract becoming discouraged during those times by recognizing their own accomplishments; and to use the setback as a cue to use the program skills they have learned. Caregivers then practice maintenance skills by anticipating a problem that may occur in the future and generating approaches they may use to handle those problems. The final activity is to recognize and celebrate the positive changes the caregivers have made as well as the changes they have seen in their children and to recognize and reward themselves.

Practice of skills at home is a central feature of the FBP

Theoretically the FBP promotes resilience of children and caregivers through their use of skills that promote more positive family interactions and more effective coping with stress and that help caregivers achieve the goals they set for themselves and their families. Use of program skills with their children at home is seen as the mechanism that leads to change. Each session presents a new skill or set of skills, and provides role play practice in use of the skill(s) in order to prepare caregivers to utilize the skill(s) with their family. Each week caregivers set goals to apply program skills with their children and to take steps to move closer to accomplishing their own personal goals. The first activity of each session is to review the caregivers’ use of program skills at home, to problem solve difficulties and to provide encouragement and positive feedback for successful skill use and for accomplishing personal goals. Feedback reinforces caregivers’ growing sense of efficacy and highlights how positive changes in the family are due to caregivers’ own behavior in use of the skills.

The home practice skills for each session are presented in Table 3. As can be seen, the new skill that is taught in a session is practiced at home each week, along with the skills that have been learned in previous weeks. The use of each skill begins with the week when it is first introduced and continues for all following weeks they attend the program. For example, Family Time is first used following session two, and then is continued throughout the program. The program strategically focuses on skills to increase positive caregiver-child interactions very early in the program, so that they would be used repeatedly and become routine. The positive caregiver-child relationships which result from use of these skills facilitate more effective use of other program skills such as listening, problem solving and supporting children’s coping. Use of program skills is cumulative, so that caregivers start with a single skill of goal setting and by the end of the program are using many different skills.

Table 3.

Cumulative Practice of Program Skills Across FBP Sessions

Home Practice Skills	Session
	1	2	3	4	5	6	7	8	9	10	11
Personal and Family Goals	*	*	*	*	*	*	*	*	*	*	*
Family Time		*	*	*	*	*	*	*	*	*	*
Catch-em-Being Good Listening skills: Four Talk-to-Me’s			*	*	*	*	*	*	*	*	*
One-On-One Time Listening skills: Summary Response				*	*	*	*	*	*	*	*
Listening skills: Feeling Response					*	*	*	*	*	*	*
Listening skills: Guided problem solving						*	*	*	*	*	*
Challenge Thinking Traps							*	*	*	*	*
Discipline: Clear and realistic expectations, counting misbehaviors								*	*	*	*
Discipline: Communicate and implement change plan									*	*	*
Discipline Continue and refine change plan; Use anger management										*	*
Support child coping with stress											*

Evaluation of the Effects of the FBP to Promote Family and Parent Resilience

The question addressed in the evaluation of the FBP is whether a relatively brief, twelve session program can bring about lasting change in family processes and in the well-being of bereaved children and caregivers. The findings from the evaluation have been reported in numerous prior publications (Hagan et al., 2012; Luecken et al., 2010; Sandler et al., 2003; Sandler et al., 2010a, b; Schmiege, Khoo, Sandler, Ayers & Wochik, 2006; Tein, Sandler, Ayers & Wochik, 2006). We will first describe the research design used in evaluating the program. We will then briefly review the program’s short-term and long-term impact on children. Then, in keeping with the family-oriented theme of this special issue, we will review findings regarding the impact of the program on factors targeted in the caregiver component of the program. We will then discuss findings concerning how the program’s impact on factors targeted in the caregiver component account for program effects on child resilience outcomes. Finally, we will review findings that identify aspects of the caregivers’ experience in the program that predict change in their own parenting and depressive symptoms.

Design of the randomized experimental trial

The FBP was evaluated using an experimental trial in which 156 families (involving 244 children and adolescents ages eight through sixteen) were randomly assigned to the FBP or a self-study comparison condition. Caregivers and children/adolescents were assessed at four time points; prior to being randomly assigned to either the FBP or a self-study condition, immediately after the program ended, eleven months after the post-test (14 months after the pre-test), and six years after the end of the intervention. The assessments included measures of child and caregiver mental health, grief and positive adaptation, children’s coping and parenting. At the six-year follow-up a measure of children’s biological stress response (evening cortisol in a challenge task) was added. Implementation of the program was assessed using records of attendance, homework reports, group leader ratings and independent, objective coding of session videotapes to rate the fidelity of group leaders’ implementation of the manual. Attendance at the program and fidelity of program implementation were outstanding, indicating that the program successfully engaged caregivers and could be delivered as described in the manual. Caregivers attended 86% of program sessions and children attended 88% of sessions. According to the independent, objective coding of videotapes of the sessions, group facilitators completed 89% of the actions described in the caregiver program manual and 84% of the actions described in the child manual.

Effects of the FBP on child outcomes

At post-test children in the FBP as compared with the controls had an increase in positive coping (a composite of coping using measures of problem solving, positive reframing, and coping efficacy), a decrease in their inhibition of expression of emotion and lower rates of problematic grief (Sandler et al., 2010a, b). However, they did not show a decrease in mental health problems. At 11-month follow-up for children who had higher levels of internalizing problems when they entered the program, those in the FBP improved more than those in the self-study condition on parent report of child internalizing problems. In addition, compared to girls in the self-study condition, girls who were in the FBP had lower externalizing and internalizing problems at the 11-month follow-up, as reported by both caregivers and youth. Analyses using growth curve modeling further clarified the nature of the gender by program interaction effect on mental health problems (Schmiege et al., 2006). Girls in the self-study condition showed little reduction in internalizing or externalizing problems over time following parental death, whereas girls in the FBP showed reduced levels of both internalizing and externalizing problems over time. In contrast, boys in both the FBP and self-study condition showed a decrease in internalizing and externalizing problems over time, with no significant difference of the change overtime between the two program conditions.

At the six-year follow-up (when youth were between 14 and 22 years of age), youth in the FBP as compared with those in the control condition had significantly lower levels of externalizing problems as reported by the youth, their caregiver and their teachers, as well as lower levels of internalizing problems as reported by teachers and lower levels of distressing grief responses (Luecken et al., 2010; Sandler et al., 2010a, b). Marginally fewer youth in the FBP met diagnostic criteria for an externalizing disorder (15.45%) as compared with the control group (27.37%, OR =1.57). Youth in the FBP also reported significantly higher self-esteem than those in the self-study group (Sandler et al., 2010b). In addition, youth assigned to the FBP demonstrated higher cortisol across a parent-child conflict discussion task as compared to control participants. Further, higher cortisol was associated with lower externalizing symptoms, suggesting that higher cortisol is representative of better neuroendocrine regulation in this sample (Luecken, et al., 2010).

Effects of the FBP on parents and parent-child relationships

Evaluation of the FBP effects on caregivers focused on the biological parents rather than the broader group of caregivers because of our interest in assessing program effects to reduce problem outcomes of the bereaved parent. At the immediate post-test significant effects were found for the FBP to reduce parent mental health problems, to increase positive parenting as rated by a composite of parent and child ratings, to reduce the number of stressful events experienced by children and to increase positive affective tone of the interaction between parents and children as rated by independent, objective raters (Sandler et al., 2003). At the six year follow-up parents in the FBP as compared to those in the control condition had higher levels of positive parenting (Hagan et al., 2012) and lower levels of depression, general mental health problems (Sandler et al., 2010b), distressing grief experiences and lower rates of alcohol abuse (Sandler et al., 2011). Fewer parents in the FBP than in the control group were above the cut point for moderate or higher levels of depression (21.31% vs. 34.62%, OR = 1.69).

Changes in parenting and stressful events mediate effects of the FBP on child outcomes

An important part of evaluating the effects of the FBP is to use mediation modeling to test the pathways by which the program is having its effect. The theory underlying the program is that the program will lead to changes in targeted risk and protective factors and that these changes in turn will lead to resilient outcomes for children. A three-wave prospective mediation model was tested in which the program was predicted to impact each of the theoretical mediators targeted by the child and caregiver components of the FBP, each of which in turn were predicted to reduce child mental health problems eleven months subsequently. Significant effects were found for three mediators of child mental health problems for girls at eleven months following the program; positive parenting, stressful events and children’s active inhibition of emotional expression (Tein et al.,, 2006). Each of these mediators was significant in a model in which they were all entered together, indicating that they each contributed a unique effect to improving children’s mental health.

Luecken, Hagan, Sandler, Tein, Ayers and Wolchik (2012) tested whether changes brought about by the program at the post-test and eleven-month follow-up mediated program effects at the six year follow-up. Two outcomes were assessed at the six-year follow-up, namely, externalizing problems and cortisol dysregulation. Support was found for a multiple-linkage mediation chain in which program induced improvements in parenting and reductions in stressful events at post-test led to more positive parenting and lower stressful events eleven months later, which in turn led to reduced externalizing problems six years later. Decreased externalizing problems at six years was in turn significantly related to cortisol dysregulation. The test of this model provides empirical support for the theoretical model that proximal program effects on parenting and the experience of stressful events lead to positive long-term effects on child externalizing problems and physiological stress response outcomes.

Caregivers’ responsiveness during the program predicts program outcomes

Another important question concerns what aspects of the caregivers’ program experience are predictive of outcomes achieved following the program. Schoenfelder et al. (2012) found that three dimensions provided an adequate fit to assess caregivers’ program experience. One dimension was labeled “Skill Use” and consisted of measures of caregivers’ completion of home practice of the skills, their sense of efficacy in skill use, their fidelity of skill use and the frequency they reported in using program skills at home. A second dimension was labeled “Group Environment” and consisted of measures of caregivers’ subjective experiences while at the group, including group cohesion, expressiveness and leader supportiveness. A third dimension was labeled “Liking” and consisted of three measures that were seen as reflecting overall caregiver satisfaction with the group, including measures of attendance, program satisfaction and perceived helpfulness of skills taught in the program. These dimensions of group experience were then used to predict outcomes eleven months following the end of the group. Caregivers’ score on the Liking dimension did not predict any outcomes eleven months later, indicating that simply having a positive feeling about the group does not seem to be a critical component in bringing about change. However, the other two dimensions were predictive of different outcomes. Positive scores on the Group Environment dimension predicted decreased levels of depressive symptoms eleven months later. Higher scores on program Skill Use predicted improvement in positive parenting eleven-months later. These findings provide support for the emphasis the program places on creating a positive and supportive group environment in which caregivers acquire and use positive parenting skills.

Concluding Comments

The findings from the randomized trial of the Family Bereavement Program demonstrate that a brief, skill-focused intervention can be effective to promote healthy functioning of parentally-bereaved families, including increasing positive parenting and reducing children’s exposure to stressful events. Furthermore, the program was found to reduce mental health problems and distressing grief of children and of bereaved parents up to six years following program participation. The positive long-term effects of the FBP contrast with the discouraging findings concerning the effectiveness of bereavement interventions for children and adults as reported in two recent meta-analytic reviews (Currier, Holland & Neimeyer, 2007; Currier, Neimeyer & Berman, 2008). However, a major challenge remains to assess whether the FBP can be successfully implemented with fidelity and quality under naturalistic conditions of service delivery by community-based agencies working with bereaved families. Research is needed to test whether the positive outcomes found from this randomized experimental trial of the FBP can be achieved when the program is delivered as a community-based service.