The Couples Life Story Approach: A Dyadic Intervention for Dementia

Abstract

This article describes an approach for working with individuals who have dementia, along with their spouses or partners. The 5-week intervention focuses on helping couples communicate, reminisce about the story of their relationship, find photographs and mementoes from their past, and develop a book that incorporates these mementoes. This clinical approach highlights the strengths and the resilience of couples and adds to the limited repertoire of dyadic interventions for dementia care which are currently available. Preliminary findings from 24 couples are presented, including the intervention's feasibility and acceptability.

LITERATURE REVIEW

As people grow older, noticeable changes in cognitive functioning can have a dramatic impact on the individuals who are experiencing the changes, as well as on their spouses or partners. Although the prevalence of dementia is almost 14% for people over age 70, the rate increases dramatically with each decade (Plassman et al., 2007). The loss of personal memory and the consequent changes in relationships from Alzheimer's disease or other forms of dementia can have devastating outcomes for both care recipients with dementia and their caregivers (Kuhn, 1999; Mittelman, Epstein, & Pierzchala, 2003). When people with dementia lose their personal memories, both members of the caregiving dyad may experience communication problems and feelings of estrangement. Those with dementia can feel misunderstood and decrease their efforts to talk; and their caregivers can feel lonely, frustrated, and emotionally burdened (Gentry & Fisher, 2007). When the caregiver is a spouse or partner, these negative consequences may be more salient due to the loss of communication and shared meaning within a previously intimate relationship (Rankin, Haunt, & Keefover, 2001). These negative consequences may, in turn, make caregiving even more difficult and burdensome, ultimately resulting in costly residential placement.

To date, most efforts to intervene with individuals who have dementia and their caregivers have focused on the caregiver. Such interventions have attempted to teach caregivers how to assist care recipients with their activities of daily living, how to manage their problem behaviors, how to resolve family conflicts, and how to decrease their own sense of burden (Belle et al., 2006; Coon, Thompson, Steffen, Sorocco, & Gallagher-Thompson, 2003; Hepburn, Tornatore, Center, & Ostwald, 2001). However, these earlier interventions did not actively involve the care recipient in the intervention (Whitlatch, Judge, Zarit, & Femia, 2006).

A small but growing body of literature suggests that simultaneously engaging both caregivers and care recipients in interventions may be especially promising. For example, efforts to involve caregivers and care recipients in group interventions (Zarit, Femia, Watson, Rice-Oeschger, & Kakos, 2004) and in-home interventions (Whitlatch et al., 2006) have resulted in highly satisfied responses from both members of the dyad. In addition, there is evidence (Burgio, Schmid, & Johnson, 2008) that care recipients with dementia can provide valid and reliable self-reports with scores as low as 15 on a Mini-Mental Status Evaluation (MMSE), thus making it possible to include their evaluations of interventions as well as their caregivers. Based on this body of literature, a 2008 report from the Institute of Medicine concluded that actively engaging both the care recipient and the caregiver is a fundamental characteristic of successful interventions.

Our intervention, the Couples Life Story Approach, contributes to this effort to develop new methods that simultaneously intervene with care recipients who have dementia and their caregivers. Rather than focusing on the deficits of the care recipient, we use a strengths perspective that highlights the couple's relatedness, adaptability, and resilience over the years (McGovern, 2011). In so doing, we attempt to address several issues salient to dementia care, including the need for meaningful engagement, shared communication, and pleasurable activities. The focus of this article is on describing the intervention and providing preliminary findings concerning the intervention's feasibility and acceptability.

The language we use when working with individuals with dementia and their family members is important. During recruitment and intervention, we use the term memory loss rather than dementia, because this term is more understandable and more palatable to families affected by this condition. Also, because this approach attempts to give equal voice both to persons with memory loss and their partners, we try to avoid the terms caregiver and care recipient during the intervention. However, in this article, we use these terms because they are generally used in the literature on dementia care.

FROM PALLIATIVE CARE TO DEMENTIA CARE

Our intervention adapted an empirically-based model developed for a palliative-care population to a dementia-care population. The original model, Legacy Therapy, is a dyadic approach for individuals receiving palliative care and their family caregivers (Allen, 2009; Allen, Hilgeman, Ege, Shuster, & Burgio, 2008). In this model, care recipients and caregivers work together with a mental health practitioner on a mutually agreed upon project to evoke positive memories and to provide a pleasurable activity for the dyad. The dyad chooses from a variety of different pleasurable activities (e.g., talking about a specific time in the past, discussing favorite recipes) and subsequently creates a legacy object based on that activity (e.g., a tape recording of reminiscences, a cookbook). Allen and her colleagues (2008) found that this model was beneficial for care recipients who needed palliative care (e.g., increased talkativeness, less depression and pain), as well as for their caregivers (e.g., less depression and caregiver burden).

Retrieving recent memories is often a problem for adults with dementia (Budson & Solomon, 2011). Thus, one way in which we adapted Legacy Therapy was to focus on a single pleasurable activity, the sharing of earlier memories that were more likely to remain intact (Welsh-Bohmer & Warren, 2006). Using a structured life review approach (Haight & Haight, 2007), we asked couples to recall significant events from the past. Asking individuals to recall past events in this way has been associated with increased ability to identify specific autobiographical memories (Serrano, Latorre, Gatz, & Montanes, 2004), the ability to find meaning (Haight & Haight, 2007), and reduced depression (Scogin, Welsh, Hanson, Stump, & Coates, 2005). Further, evidence from clinical research (Haight, Bachman, Hendris, Wagner, Meeks, & Johnson, 2003) shows that a structured life review approach may have benefits for both care recipients with dementia (i.e., enhanced mood) and their caregivers (i.e., decreased burden).

Because dementia care can extend over a period of many years, we also adapted the Legacy Therapy approach in a second way. That is, we worked with the dyad to develop a legacy object (i.e., a couple's Life Story Book) that included memories from the past but also included space for future stories and mementoes. Thus, the Life Story Book has several blank pages to which the couple can add new mementoes and stories. In so doing, this legacy object can be augmented over time.

Finally, dementia can affect older adults’ ability to communicate (Gentry & Fisher, 2007). Thus, a third adaptation of Legacy Therapy was to include a skills training component that focused on facilitating dyadic communication. We drew from the clinical research literature on skills needed to enhance communication with individuals who have dementia (Bourgeois, 1992; Gentry & Fischer, 2007). Based upon this literature, we taught caregivers and care recipients skills for asking questions, listening, and talking more effectively with each other as they created a joint Life Story Book (with labeled pictures and personal stories), and used this book to facilitate talking about positive memories.

The resulting intervention, the Couples Life Story Approach, integrates three key components. The first pertains to asking couples structured reminiscence questions about their life. The second involves the creation of a Life Story Book based on the dyad's selection of, and discussion about, mementoes that highlight significant memories from their shared past and includes space for adding future significant events. Mementoes include objects such as pictures, postcards, newspaper clippings, and wedding vows. The third teaches couples communication skills to compensate for memory loss and to facilitate positive engagement with each other.

Through a pilot-testing process, we have tailored each of these intervention components to our target population (i.e., couples in which one person has memory loss) based upon methods used in translational research (Burgio, 2010; Burgio et al., 2009). We began this tailoring process by working with six couples from our target population to identify preliminary modifications. These early efforts helped us develop reminiscence questions that evoked memories for both members of the dyad. We also identified ways of helping such couples select their most important mementoes for the Life Story Book. In addition, during these piloting efforts, we developed specific communication tips intended to help each member of the couple to listen and to share stories with the other. The next step in our tailoring process involved obtaining feedback from our target population. To do this, we described the intervention to four couples who were potential participants. They provided suggestions about possible adaptations of the materials. Next, we presented our preliminary protocol to four experts in reminiscence and legacy interventions and/or dementia care. These experts provided additional suggestions about how to phrase reminiscence questions, how to integrate these reminiscence questions and communication skills, and how to involve the couple in the development of their storybook. The final step in this pilot-testing process focused on implementing the intervention with 24 couples while examining its feasibility and acceptability.

DESCRIPTION OF THE INTERVENTION

The Couples Life Story Approach involves five 1-hr sessions, usually conducted weekly with the person with memory loss and his/her spouse or partner. To facilitate the couple's ability to participate, the social worker meets at the couple's house, care facility, or the home of a family member. During each session, the social worker introduces and discusses with the couple a different communication skill. The sessions are designed to help the couple to review their life together. A first step in this process is to assist the dyad in defining their time as a couple in relation to three chapters of their life: their early years, their middle years, and their recent years. Questions are distributed during the sessions to facilitate the couple's reminiscence about each of these life chapters. Reminiscing about these different time periods occurs both during the session and between sessions. During the session, the social worker insures that both members of the dyad have time to share their reflections and also models ways of giving persons with memory loss opportunities to be involved in reminiscence without being put on the spot about topics they do not remember. The social worker takes notes on the couple's stories and reflections.

At the end of each session, the social worker gives the couple home practice (we use this term because homework had negative connotations for some of the couples during pilot testing), which includes discussing a list of reminiscence questions from the next chapter of their life, finding up to 10 significant photographs or mementoes that elicit memories from that period of time, and practicing communication skills while discussing their memories with each other. Between sessions, the social worker incorporates the mementoes into a Life Story Book. Each memento is given a caption or is accompanied by a story that has been provided by the couple. The book is shared with the couple each week and they are asked to suggest additions or modifications as needed.

Session One

This first session provides a general introduction to the Couples Life Story Approach. At the beginning of the session, the social worker shows an illustrative Life Story Book. (To maintain confidentiality, this book is based upon the marriage of one of the social workers involved in the intervention.) In addition, the first communication tip is distributed and discussed with the couple. This tip focuses on the importance of long-term memory and life stories. Couples are encouraged to let each other tell stories without correcting factual information because frequent corrections can be demoralizing to the person with memory loss. The social worker then provides the couple with a list of questions about their early years together. Two of these questions are discussed in detail (i.e., How did the two of you meet each other? What attracted you to each other?) and the other questions and prompts are given to the couple to discuss during their home practice (e.g., What are your most important memories from your early years together? Where did you live early in your life together? If you have children, talk about their births and early years.).

Session Two

The social worker begins by inquiring about the couple's home practice and providing a second communication tip (i.e., listening and showing understanding by asking clarifying questions and rephrasing) which is discussed with the couple. The social worker then shows the couple the beginning of their Life Story Book, which includes their responses to the questions about how they met and what attracted them to each other. The couple has the opportunity to review and edit these stories; a pattern that is continued in the following sessions when the couple's narratives are interspersed with captioned photographs and other mementoes. The remainder of the session is devoted to looking at the mementoes that the couple identified during their home practice about their early years together and hearing their stories about this time period. For their home practice, the social worker provides the couple with questions about their middle years (e.g., What are your most important memories about your middle age years together? What kind of work did you do during your middle years? How did you balance work and family? What did the two of you do for fun and relaxation?).

Session Three

After inquiring about their home practice, the social worker distributes and discusses with the couple the third communication tip (i.e., pointing out each other's strengths from the past and into the present). The social worker then shows the couple the new additions to their story book, which now integrates mementoes and stories from the previous session. The remainder of the time is devoted to discussing mementoes and stories from their middle years together. At the end of the session, the social worker distributes for home practice a new set of questions that focuses on the couple's recent years together (e.g., What are your most important memories from your recent years? If you are retired, what has that experience been like for you? What activities do you do together and what do you do separately?). Included in this set of questions are two that address the future (i.e., What are your wishes and hopes for the days ahead? What would you like people to remember about you and your relationship?).

Session Four

The social worker asks about the couple's home practice, and then distributes and discusses the fourth communication tip (i.e., providing each other with time to remember stories and avoiding the testing of each other's memory). The couple has the opportunity to look at the most recent additions to their Life Story Book, which is then followed by examining the new mementoes and hearing stories about their recent years, as well as comments about their future.

Session Five

The beginning of this session is devoted to asking about home practice from the previous session and reviewing all the communication tips, including the final tip (i.e., listening for the meaning behind stories that are frequently repeated) to identify those that are most relevant to the couple. Next, the social worker presents the couple with their story book and encourages the dyad to go through the book together while the social worker is present. Following the couple's review of the book, the social worker highlights examples of engagement and positive communication that they demonstrated while looking at their storybook. The social worker encourages the couple to use the Life Story Book together over time by setting aside a regular memory time and sharing the book with others. She leaves the book with the couple and gives them a magnet with a summary of the communication tips.

DESCRIPTION OF THE STUDY

The research was conducted in the Midwest and approved by the university Institutional Review Board. The research team was led by two investigators, a clinical researcher and a dementia-care specialist. Social workers on the research team had a master's degree in social work or were graduate students in social work. Training focused on becoming familiar with dementia-related issues, as well as proficiency in how to conduct the Couples Life Story Approach. The training incorporated an experiential component (e.g., participating in a respite program for adults with dementia), as well as a cognitive component (e.g., discussing with the research investigators several assigned articles on dementia). Proficiency for conducting the Couples Life Story Approach was demonstrated by discussing several background articles relevant to this research project, role-playing, shadowing the trained social workers, and being observed as they worked with a couple. At the end of each session, the social worker completed a monitoring form that focused on the couple's ability to follow through with their home practice (i.e., finding mementoes, reminiscing, practicing communication tips) and the social worker's ability to follow through with each component of the session's intervention. In addition, the social work team met on a weekly basis to discuss cases and how to deal with emerging clinical issues.

Characteristics of the Study Sample

Couples for this study were recruited in a number of ways. We contacted the Alzheimer's Association, organizations involved in conducting Alzheimer's disease research, caregiver groups, churches, and geriatric clinics (e.g., doctors, nurses, and social workers). We provided these organizations with a letter of invitation to potential couples and brochures that described the approach. We also distributed flyers around the community (e.g., libraries, grocery stores). Recruitment materials emphasized that one person in the couple should have memory loss. Interested couples contacted us and were screened for eligibility. Inclusion criteria for this study were: (a) caregiver–care receiver dyads were spouses or partners, (b) the caregiver confirmed that the care recipient had memory problems, (c) the care recipient had an MMSE (Folstein, Folstein, & McHugh, 1975) score between 15 to 27, (d) neither the caregiver nor the care recipient had suicidal thoughts or behaviors, and (e) neither the caregiver nor the care recipient had severe visual problems that would inhibit seeing photographs or reading large text. We had no exclusion criteria concerning how long couples should be together. Couples who chose to be involved in this intervention were generally from long-lasting relationships; the shortest of which was 10 years. A few late life marriage partners chose not to participate because their marriages had been very brief prior to the onset of one partner's dementia.

The initial sample was comprised of 48 individuals (i.e., 24 couples). The intervention was conducted in the couples’ homes with the exception of two couples with whom we met in the home of a family member and two couples who lived in continuing care retirement communities. Of the 24 couples who began the study, 20 couples completed the intervention. The characteristics of those who began the study and those who completed the intervention are displayed in Table 1. Two of the couples dropped out at the beginning of the intervention because one member of the dyad was not interested in participating. In one case it was the person with memory loss and in the other case it was the caregiver who did not want to continue with the intervention. The other two couples dropped out due to the worsening health of the person with memory loss.

TABLE 1.

Demographic Characteristics of Eligible Participants and Those Who Completed the Intervention

	Eligible Participants (n = 24 Couples)			Completed Participants (n = 20 Couples)
	Caregiver	Care Recipient	Couple	Caregiver	Care Recipient	Couple
Average age	73.3	75.7		72.2	74.0
Gender
Men	7 (29.2%)	18 (75.0%)		7 (35.0%)	14 (70.0%)
Women	17 (70.8%)	6 (25.0%)		13 (65.0%)	6 (30.0%)
Gender orientation
Heterosexual couples			23 (95.8%)			19 (95.0%)
Same-sex couple			1 (4.2%)			1 (5.0%)
Race
White/Caucasian	23 (95.8%)	23 (95.8%)		20 (100.0%)	20 (100.0%)
Black/African American	1 (4.2%)	1 (4.2%)
Education
College and above	13 (54.2%)	15 (62.5%)		11 (55.0%)	13 (65.0%)
Less than college	11 (45.8%)	9 (37.5%)		9 (45.0%)	7 (35.0%)
Financial hardship
Yes			7 (29.2%)			6 (30.0%)
No			17 (70.8%)			14 (70.0%)
Average Mini-Mental Status Evaluation		23.0 (16-27)			23.5 (16-27)

Intervention Feasibility

Because the Couples Life Story Approach represents a new dyadic approach to dementia care, it is important to determine whether the intervention can be implemented successfully. Our study used three indicators of feasibility: (a) attendance (number of sessions and length of sessions); (b) social workers’ ability to deliver this new approach; and (c) participants’ ability to follow through with home practice assignments. With regard to attendance, the 20 completing couples all finished during five sessions with the exception of two couples who needed one extra session. These two couples had a large number of mementoes and particularly lengthy stories. We expected that the sessions would take approximately 60 min. We found that sessions averaged 76 min, but they ranged widely from 40 min to 120 min.

To assess their ability to deliver the Couples Life Story Approach, social workers completed at the end of each session a checklist of the intervention components they had addressed. An analysis of these checklists indicated that there was 100% follow-through with respect to most of the components of the intervention: inquiring about home practice sessions, discussing mementoes and relevant stories, reviewing communication tips, discussing reminiscence questions, highlighting examples of positive communication demonstrated by couples during the session, and discussing a plan for continued use of their Life Story Book. There were two components of the intervention that were exceptions to complete follow-through. One exception was showing the couple an illustrative Life Story Book at the beginning of the intervention (90% follow-through). The lack of follow-through occurred because the book was either unavailable when social workers went to the first session or they forgot to take the book. The second exception was showing the couple their own Life Story Book during session 2 (95% follow-through) and session 3 (85% follow-through). This lack of follow-through occurred when social workers did not have sufficient time to put together the book materials between sessions (i.e., there was a large number of materials to organize in the book and/or the time between sessions was too short).

We also assessed the extent to which dyads engaged in the weekly home practice assignments. Couples were asked to participate in three activities as part of their home practice (i.e., reviewing reminisce questions, finding mementoes for the Life Story Book, and practicing communication skills.) We provided the couples with a chart to keep track of whether or not they participated in these activities between sessions. In addition, at the beginning of each session, we asked couples whether they had completed these activities. As is evidenced by Table 2, most of the couples were able to participate in these three between-session activities. Specifically, finding mementoes to include in the Life Story Book was the activity that occurred with the most frequency while reviewing the reminiscence questions and practicing the communication tips occurred with somewhat less frequency.

TABLE 2.

Couples' Implementation of Home Practice Activities

	Session 1	Session 2	Session 3	Session 4	Session 5
Reviewed reminiscence questions	–	18 (90%)	18 (90%)	18 (90%)	–
Found relevant mementoes	–	19 (95%)	19 (95%)	20 (100%)	–
Practiced communication tips	–	13 (65%)	17 (85%)	17 (85%)	15 (75%)

Intervention Acceptability

At the end of the intervention, the participants completed questionnaires that included several open-ended questions about their reactions to the Couples Life Story Approach. The social workers assisted the person with memory loss in answering these questions while their caregivers completed the questionnaires independently. The responses of the care recipients and their partners were analyzed by two of the authors, who identified the primary issues that emerged with respect to the positive and the problematic aspects of the intervention. They then independently coded the questionnaires for these different aspects of the intervention, discussed any discrepancies in their coding decisions, and arrived at a consensus. The results of their analysis appear in Tables 3 and 4.

TABLE 3.

Positive Aspects of Intervention

Aspects of Intervention	Representative Quotes
	Care Recipients	Caregivers
Enjoyed reliving story of life together	(n = 11) It gives you an opportunity to revisit your life and think about how things have gone and think about the good things and the not so good. (CR#65)	(n = 16) We remembered what a full life we have had and found as many good memories of half-forgotten times that we realized our life wouldn't fit into one book. (CG#32)
Communication tips were useful	(n = 6) Very helpful. We have used them off and on. Improved communication between us. More aware of how we communicate. (CR#8)	(n = 17) I have learned different ways to help him remember things so he doesn't feel like he is having a problem. (CG#22)
Enjoyed the Life Story Book	(n = 14) We had a good time doing it. We were on the same page, but my spouse remembers more detail. To have (the) privilege of looking back on our experiences—don't know many people who have had as many opportunities/privileges—great sense of gratitude. (CR#7)	(n = 19) I first thought it would be wonderful for our family to have an orderly record of our life, but we both realized as we progressed with it that our life has been quite wonderful and beyond the bounds of one “orderly record!” (CG#32)
Planned to share the Life Story Book with others	(n = 10) We will look at it often and share it with our family and friends. (CR#32)	(n = 8) We will read it [the book] together and expand on the items in the book. We will let our children and grandchildren read it, and we will answer their questions and expand on items in the book. (CG#34)
Meaningful engagement	(n = 4) We sit down and run through a lot of things that we haven't talked about in a long time and fit them into the pattern of our lives. (CR#65)	(n = 11) For just me it was good—I didn't think it would be, but it's the first time anyone focused on us as a couple-put us at the center. I was grateful for something I could actually do with my spouse. (CG#8)
Helped memory	(n = 4) Helps organize some things—organize memories of things. Makes you think about things. Good way of remembering things. (CR#8)	(n = 3) What one person remembers helps stimulate memories for the other. (CG#19)

TABLE 4.

Problematic Aspects of Intervention

Aspects of Intervention	Representative Quotes
	Care Recipients	Caregivers
Problems finding/distilling pictures	(n = 0)	(n = 3) Sometimes frustrating—50 years in 30 photos—yikes! (CG#7)
Identified memory gaps	(n = 0)	(n = 3) We discovered increasing memory gaps for my spouse and watching him discover the gaps was awful for me. (CG#7)
Identified losses	(n = 2) It makes me cry. (jokingly) My crying is a longing for past moments. It's bittersweet. (CR#36)	(n = 4) It was a trip down memory lane showing us so many of the good times we have had, but bittersweet because it also shows what we can no longer do. (CG#52)
Communication tips were difficult for care recipients to remember	(n = 5) I don't remember the tips. (CR#19)	(n = 2) We had no problem following them except for his lack of memory. (CG#1)
Intervention was too late	(n = 0)	(n = 2) Doing memory books earlier would be helpful. Gets you into a good routine of how to talk about things. And gives you a way to talk about memory. (CG#8)

Table 3 highlights the positive aspects of this intervention for both the care recipients and their caregivers. Most of the participants reported that they enjoyed reliving their story together and enjoyed both the making of and looking at their Life Story Book. Several planned to share this book with others. A few of the care recipients and caregivers indicated that their involvement in this intervention helped to jog the memory of the person with memory loss. As for the communication tips, most of the caregivers and a few of the care recipients indicated that they found them helpful. One explanation for this discrepancy between caregivers and care recipients with respect to the usefulness of communication tips is evidenced in Table 4, which indicates that, by the end of the intervention, care recipients had difficulty remembering the communication tips.

Also evidenced in Table 3 are a substantial number of caregivers and a smaller number of care recipients who noted that being involved in this Couples Life Story Approach provided them with an opportunity to engage more meaningfully with each other. This meaningful engagement was both emotional and physical. In their weekly notes and during team meetings, the social workers observed that couples often became more intimate as they discussed their mutual memories and as they reviewed their Life Story Book together. For example, as she conducted the intervention, a social worker noted that her couple “increased their physical contact with each other (e.g., sitting close, holding hands, her head on his shoulder).” With one couple, the husband with memory loss put a comforting arm around his wife as she talked about memories that made her sad. With another couple, the wife patted the arm of her husband who had memory loss and complimented his improved memory when he observed that the intervention had given him “confidence in my memory and the ability to remember important things.” In another instance, a husband with memory loss read aloud the letter to his wife in which he had proposed to her. Afterwards he stated, “That probably is one of the best things I wrote.” His wife emphatically responded, “You are right” and then kissed him.

Although many of the responses to the intervention were positive, there were also some negative reactions. Table 4 focuses on the problematic aspects of the intervention for both members of the dyad. In general, the caregivers tended to note more problems than did the care recipients. In particular, a few caregivers remarked that it was difficult to find the pictures and mementoes and to distill them into a manageable number for the Life Story Book. It is likely that the caregivers highlighted this difficulty more than the care recipients because the caregivers tended to assume more responsibility for locating and choosing the pictures for the book. A few caregivers and care recipients described the intervention as “bittersweet.” Although the proportions were low, more caregivers than care recipients noted that the intervention was a painful reminder of losses that had occurred in their lives and of the memory gaps in the person with dementia. Finally, a few of the caregivers observed that this intervention would have been more useful if it had occurred earlier in their care recipient's memory loss process.

DISCUSSION

The Couples Life Story Approach expands on the limited number of psycho-social interventions that focus on enhancing the well-being of both individuals with memory loss and their partners. Preliminary findings suggest that this approach is both feasible for social workers and participating couples, as well as acceptable to these dyads. Our findings show that couples clearly enjoyed both the process of collaboratively telling the story of their life together and reviewing the resulting Couples Life Story Book. We observed that couples became more intimate with one another. We also noted that dyads were more likely to use words such as we and partners toward the end of the intervention, suggesting that this approach may help to enhance their view of themselves as a couple. Some couples commented that reviewing their lives together helped them refocus on their partnership. This sense of being part of a dyad that works well together is likely to be important as couples cope with the difficult aspects of progressive dementia (Davies, 2011).

Particularly salient was the extent to which couples felt that this approach gave them an opportunity to be meaningfully engaged with one another. Practitioners who work in the area of dementia care often observe that, as caregivers necessarily take over more of the instrumental activities of daily living, the number of shared pleasant events decreases and the dyad's communication can become primarily task-focused. It appears that, by concentrating on their shared history, the Couples Life Story Approach may help couples to collaborate on an activity that is meaningful to both members of the dyad which may, in turn, help them to face together the problems that they are likely to encounter during the dementia process. This approach also attempts to help dyads focus on each other's strengths, as well as their past strengths as a couple. In so doing, the Couples Life Story Approach addresses McGovern's (2011) call to avoid deficit models when working with dyads who are dealing with dementia.

It is important to note that, although this approach engages both members of the dyad, their responses to different aspects of the approach may vary. For example, the communication tips were written for both members of the dyad but, predictably, caregivers found them more helpful and remembered them better. Weekly reviews of the tips provided a forum for talking about communication openly. Several times, caregivers turned to the social worker and asked whether it was right or wrong to try to help their partner when he or she was struggling to find words or memories. Such questions gave the social worker an opportunity to ask the care recipient how he or she wanted the situation addressed. In most cases, the care recipient was able to verbalize what was most helpful and what was irritating. In so doing, the communication tips opened the door for couples to discuss and evaluate their communication patterns.

Our findings, although preliminary, offer several suggestions for those who are interested in replicating this approach. One lesson learned is that, although most of the participants had a very positive reaction to talking about their past, a few were saddened by the losses that they experienced. For some, these losses were related to memories about loved ones who had died or to memories of pleasant activities in which they could no longer participate. For others, these losses were associated with a greater recognition of the care recipient's memory impairment. Our experience suggests that social workers should discuss these potential feelings of sadness with the dyad before the reminiscence intervention begins. Boss (2011; Boss & Couden, 2002) has used the term ambiguous loss to describe the experience of dealing with dementia. Boss (2011, p. 25) explained that dementia involves “having to accept the loss and acknowledge the need to grieve while someone is still alive.” Explaining the concept of ambiguous loss and providing a name for their experience can be helpful to caregivers and care receivers (Boss & Couden, 2002). When normalizing feelings of grief in this way, it is important to prepare participants for the variety of emotions that they may experience as they talk about their life together. During the sessions, social workers can help participants express their grief by talking about their feelings and finding meaningful ways by which to honor those who have died. For example, several of our couples decided to devote a portion of their Life Story Book to include mementoes (pictures, the Memorial Service Program) and stories about children and grandchildren who had died. The opportunity to memorialize significant losses was important for these participants. It may also be necessary to follow up with individuals whose grief does not subside. For example, when a caregiver became noticeably depressed toward the end of our intervention, the social worker followed up with him to insure that he received additional therapeutic support to deal with his grief.

A second lesson is related to the timing of the sessions. We found that sessions were most productive when they occurred on a weekly basis. When they occurred more frequently, couples had too little time to apply the communication tips, to discuss the reminiscence questions, and to find mementoes. Limited time between sessions also made it difficult for the social worker to prepare the Life Story Book for the next session. When the sessions occurred less frequently, couples forgot about their home practice activities and lost momentum. We also learned that sessions vary in length according to the needs of the couple. Therefore, it is helpful if social workers can be flexible in their scheduling but it is also important to find ways of containing the length of the sessions. For example, we attempted to reduce time spent during the session by asking dyads to decide between sessions on a limited number of mementoes (no more than 10 for inclusion each week) in the Couples Life Story Book. We also attempted to address the issue of time by helping participants keep organized. We gave each dyad a large folder in which to keep their mementoes, with subfolders for their early, middle, and recent years. In addition, we identified ways in which to enhance the social workers’ efficiency. For example, we provided social workers with an accordion file in which to keep all the necessary materials for each session (e.g., communication tips and reminiscence questions), as well as a step-by-step sheet for implementing the intervention each week.

This research also points to future directions for research on the Couples Life Story Approach. Because this research was limited by a fairly homogenous sample (i.e., predominantly White, heterosexual couples who lived in their homes), it is essential to examine the usefulness of this approach for a broader target population. Given that some of our participants noted that they would have preferred this intervention at an earlier stage of the dementia process, it would be helpful to include in future intervention studies those who have not yet been diagnosed with dementia but who have subjective memory complaints or mild cognitive impairment. The purpose of this study was to determine the feasibility and acceptability of this approach. Future efforts should focus on the outcomes associated with this intervention and should include measures that may be important, such as meaningful engagement and identity as a couple. As social workers and other mental health professionals seek to enhance their repertoire of dyadic approaches, we hope that they will consider using and adapting the Couples Life Story Approach to their practice settings.