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. Author manuscript; available in PMC: 2017 Jun 1.
Published in final edited form as: Omega (Westport). 2015 Mar 9;73(2):107–125. doi: 10.1177/0030222815575895

“One Size Doesn’t Fit All” – Partners in Hospice Care, an Individualized Approach to Bereavement Intervention

Michael S Caserta 1, Dale A Lund 2, Rebecca L Utz 3, Jennifer Lyn Tabler 4
PMCID: PMC4851167  NIHMSID: NIHMS635211  PMID: 27141124

Abstract

We concluded in a recent study that a “one size fits all” approach typical of group interventions often does not adequately accommodate the range of situations, life experiences, and current needs of participants. We describe how this limitation informed the design and implementation of an individually-delivered intervention format more specifically tailored to the unique needs of each bereaved person. The intervention comprises one of three interrelated studies within Partners in Hospice Care (PHC), which examines the trajectory from end-of-life care through bereavement among cancer caregivers using hospice. The PHC intervention employs an initial needs assessment in order to tailor the session content, delivery, and sequencing to the most pressing, yet highly diverse needs of the bereaved spouses/partners. Although an individually-delivered format has its own challenges, these can be effectively addressed through standardized interventionist training, regular communication among staff, as well as a flexible approach toward participants’ preferences and circumstances.

Substantial attention in bereavement research, including studies regarding the loss of a spouse or partner, has focused on theoretically based intervention approaches (Stroebe, Hansson, Schut, & Stroebe, 2008), particularly those in a group-delivered format (Currier, Neimeyer, & Berman, 2008; Levy & Derby, 1992). In this paper, we discuss the design, implementation, and testing of a group-based intervention (known as the Living After Loss [LAL] study) that has now led us to develop an individually-based approach. Both the group and individual approaches were guided by Stroebe & Schut’s (1999, 2010) dual process model (DPM) of coping with bereavement, a theoretical model that has gained prominence since the late 1990s. We begin by describing the findings and limitations of the group-based LAL intervention and then explain why and how they informed the design and implementation of an individually-delivered format more specifically tailored to the unique needs of each bereaved person. Our current individual-based approach guides one of three interrelated studies within the overall Partners in Hospice Care research program that follows hospice caregivers (to spouses/partners with end-stage cancer) from end-of-life care through the first year and a half of bereavement.

Living After Loss [LAL]: A Group-Based Intervention

The DPM (Stroebe & Schut, 1999, 2010) posits that as individuals adapt to loss, they benefit by oscillating between two coping processes: Loss-orientation (LO) involves coping with the effects of loss itself, which typically encompasses engaging in grief work, cognitive processes and ruminations in attempts to make sense of the loss, and reconfiguring the nature of the bonds one has with the deceased. Restoration-orientation (RO), on the other hand, is the form of coping used to address those stressors related to the life changes consequential to the loss. In the context of spousal bereavement, these issues relate to taking on new responsibilities, mastering new skills to manage various tasks of daily living, initiating or re-engaging in important self-care activities, and adjusting to a new role or identity as a newly bereaved spouse or partner. Another key feature of the model is the need to occasionally (but not chronically) take time away from grief to engage in momentary types of diversion or to attend to daily matters needing immediate attention – and vice versa, to consciously attend to the loss-oriented grief work rather than only focusing on the daily-life restoration-oriented adjustments. Throughout the course of bereavement, individuals will need to move back and forth between the two forms of coping, sometimes on a moment-to-moment basis. While there tends to be a greater emphasis on LO soon after the loss with an increasing emphasis on RO later, oscillation typically occurs as needed throughout the bereavement trajectory to achieve more effective adaptation. This concept of oscillation between LO and RO coping is a feature of the DPM that especially distinguishes it from other models.

With a few exceptions (e. g., Caserta, Lund, & Obray, 2004; Caserta, Lund, & Rice, 1999; McKibbin, Guarnaccia, Hayslip, & Murdock, 1997; Tudiver, Hilditch, Permaul, & McKendree, 1992; Wilcox & King, 2004), most bereavement interventions prior to the LAL, especially those that were group-based were largely LO-focused, providing mostly grief support to participants. The LAL study was therefore designed to incorporate both LO and RO features of the DPM. The DPM intervention consisted of 14 weekly sessions led by trained facilitators. There were 7 LO and 7 RO sessions scheduled in alternating fashion to facilitate oscillation between the two forms of stressors described in the model (Stroebe & Schut, 1999, 2010). The LO-focused sessions concentrated on grief-related feelings and emotions, loneliness, dealing with watershed events such as birthdays, holidays, anniversaries, and how it was important for the bereaved to be realistic in what to expect from themselves and others as they progressed through the grief experience. The RO-focused sessions were intended to help the bereaved address ways to meet new responsibilities and the challenges associated with learning new tasks of daily living, such as those that may have been the responsibility of their deceased spouse or partner. These also included ways to effectively engage in self-care (e.g., nutrition for one) and how to become or remain socially connected to others. RO topics were typically delivered by guest presenters who had expertise in a specific RO-focused skill or activity. Within the RO sessions, the participants were guided through goal-setting strategies to help them take small doable steps toward engaging in these new behaviors and making life changes related to their new status as a bereaved spouse or partner (See Caserta, Utz, Lund, Swenson, & de Vries, 2014; Lund, Caserta, de Vries, & Wright, 2004; and Lund, Caserta, Utz, & De Vries, 2010 for more detail about intervention design and content).

Recently bereaved spouses or partners, age 50+ were randomly assigned between the DPM intervention and a traditional bereavement support comparison group that also consisted of 14 weekly sessions but all sessions were exclusively LO-focused. Participants in both groups were assessed over 4 data points covering an approximate 12-month period: The baseline measure occurred 2-6 months post-loss, followed by a post-test after the 14-week intervention ended, and 3- and 9-month follow-up data points (Caserta et al., 2014; Utz, Caserta, & Lund, 2013a, 2013b). Midway between the last two follow-up data points, each participant received a booster phone call from his or her group facilitator. The main purpose of the call was to discuss how the participant had coped or was presently coping with the one-year anniversary of the death; but also to review with them how well they addressed any challenges they encountered since the weekly sessions ended – acknowledging successes and discussing how remaining challenges could be met. Primary outcomes measured included grief, depression, loneliness, stress-related growth, and perceived self-care and daily living competencies (See Utz et al., 2013a). Also assessed was the extent to which the participants were engaging in LO and RO coping processes as well as the amount of oscillation between them (Caserta & Lund, 2007; Caserta et al., 2014).

How Effective Was the Group Intervention in the LAL Study?

We hypothesized that those in the DPM treatment group would fare better over time compared to those in the traditional support comparison group – both in terms of engaging in oscillation between LO and RO coping processes (Stroebe & Schut, 1999, 2010) and bereavement outcomes. Consistent with the DPM, there was oscillation between the two processes throughout the course of the study with a greater emphasis on RO over time, especially for those who were more LO-focused at baseline. This effect, however was independent of study condition – participants in the DPM treatment group and the comparison group both showed increased emphasis on RO coping in equal fashion (Caserta et al., 2014). Furthermore, there were no treatment effects pertaining to the bereavement-related outcomes we measured, with the exception of improved skills among those in the DPM intervention (vs. the comparison group) related to attending to one’s own health care needs, which the participants reported were highly applicable to their daily lives. We speculated that these health care issues were largely ignored or forgotten by the bereaved given their preoccupation with more immediate grief-related matters until the session on this topic served as a reminder “…to refocus on their own health and self-care again” (Utz et al., 2013a, p. 35). We found that greater group cohesiveness and bonding “chemistry” were more influential than differences in content between the two study conditions (Utz et al., 2013b).

Due to these unexpected and disappointing results, we attempted to uncover potential reasons for the absence of treatment effects. One is that 14 weekly sessions, equally divided between LO and RO issues might not have provided sufficient dosage, especially taking into account that only 7 of them were RO sessions – the primary design feature that distinguished the DPM intervention from the comparison group (Caserta et al., 2014). Posttest questionnaire data revealed that some in the treatment group reported that the alternating nature of the LO and RO sessions disrupted the continuity from one session to another. In this instance, there was a desire to continue grief-related issues from the previous week, but because new RO content was scheduled it did not allow for adequate time for such attention (Lund et al., 2010). Third, observational notes from the group sessions and reports from the facilitators disclosed that a significant number of comparison group participants engaged in RO-focused coping activities on their own even though it was not deliberately encouraged by the facilitators. It is likely that they learned new skills from others in their network or even witnessed fellow group members remark about an RO-focused activity they had undertaken (e.g., getting involved in the community to meet and become connected with other people) and then decided to attempt it themselves (Caserta et al., 2014; Lund et al., 2010). Finally and perhaps most importantly, bereaved individuals’ needs as well as preexisting skills and life experience, especially those pertaining to issues typically considered restoration-oriented, vary so much that RO-focused content is difficult to provide in a group-delivered format (Caserta et al., 2014; Lund et al., 2010). Even though the content we addressed in the LAL study was informed by our own previous research (Caserta et al., 2004; Lund, Caserta, Dimond, & Shaffer, 1989; Utz, Carr, Nesse, & Wortman, 2002; Utz, Reidy, Carr, Nesse, & Wortman, 2004) and that of others (e.g., Carr, 2004; Johnson, 2002; Williams, 2004), the group-based delivery could not adequately target the specific RO-related needs, skill levels and concerns of each individual.

Partners in Hospice Care (PHC): The Emergence of an Individualized Approach

In response to these perceived limitations, we surmised that in order for a bereavement intervention based on the DPM to be most effective an individualized approach is needed. Although a group format can take advantage of mutual support among its members, a “one size fits all” design common to group interventions is less likely to be effective, especially for those stressors that are restoration-oriented.

As the LAL study concluded, we encountered an opportunity to collaborate with colleagues on a National Cancer Institute-funded program project grant, which we named Partners in Hospice Care (PHC) that integrates three studies examining the trajectory from end-of-life care through bereavement among cancer caregivers who are recruited at the time a terminally ill family member is enrolled into hospice. A distinguishing feature of PHC is that it provides caregiver outcome data across the entire trajectory (end-of-life caregiving through bereavement) and available to investigators in all three studies (for more detail regarding the overall PHC design see Mooney et al., 2013). Two of the three studies focus primarily on the pre-death phase of the trajectory. One study examines the effectiveness of an automated telephone-delivered symptom management system on the well-being of the caregiver, while the second is an observational study examining communication patterns between caregivers and hospice staff during the in-home visits. The third study, the one we report on in this paper, tests a bereavement intervention individually tailored to the needs of the bereaved person and assesses their outcomes over a 12-month period. Because the PHC study is still ongoing, we do not report outcome data here but rather describe how the design of the bereavement intervention (study 3) was informed by the lessons we learned from the limitations of the group approach used in LAL. We also report on the flexibility of the intervention delivery to meet individual needs and provide some examples of both LO issues discussed and RO activities that participants addressed during the intervention.

Cancer-related bereavement is particularly distressing (Holtslander & Duggleby, 2010; Holtslander & McMillan, 2011; Kramer, Kavanaugh, Trentham-Dietz, Walsh, & Yonker, 2010) and has been shown to be more difficult than that from many other causes of death (Caserta, Utz, & Lund, 2013). Cancer caregivers could be adversely impacted by witnessing their partner’s deterioration and/or suffering (Carr, 2003; Kim & Schulz, 2008), as well as experience declines in their own physical health from providing virtually constant care to their ill family member (Holtslander, Bally, & Steeves, 2011; Lee & Carr, 2007). Some caregivers also neglect their own self-care (Cain, MacLean, & Sellick, 2004) or become socially isolated (Carr, House, Wortman, Nesse, & Kessler, 2001; Clark, Brethwaite, & Gnesdiloff, 2011) as a result of being preoccupied with the intensity and multitude of caregiving tasks or responsibilities.

Furthermore, although death due to cancer may be anticipated, the surviving spouse/partner may be so involved in caring for the dying person and consumed by the emotional distress that accompanies it, there is little time or energy to plan for unfamiliar daily demands, some of which are unforeseen prior to the loss (Chentsova-Dutton et al., 2000; Clark et al., 2011). This gap between abilities and demands, which can vary among individuals given their unique situations and contexts, justifies tailored intervention strategies that improve skills such as mastering tasks of daily living, engaging in self-care behaviors, and functioning socially as a single or uncoupled person in society (Caserta et al., 2004; Stahl & Schulz, 2014; Utz, 2006). Thus, an individually-delivered intervention is particularly relevant for those whose spouse/partner died after a terminal illness like cancer because they may be better helped by an approach that is tailored to their specific needs (Bergman & Haley, 2009; Burton, Zdaniuk, Schulz, Jackson, & Hirsch, 2003; Caserta et al., 2013; Patterson & Dorfman, 2002; Penson, Green, Chabner, & Lynch, 2002).

Caregivers are randomly assigned to receive upon their spouse’s’ or partner’s death an individually-tailored, individually-delivered bereavement intervention or treatment-as-usual, which is defined as the usual bereavement follow-up care provided by the hospice. The quantity and quality of bereavement care varies across hospices, but usually consists of an initial risk assessment (e.g., for complicated grief) followed by periodic phone calls or mailings beginning as early as one month after the death and throughout the first year following the loss. Typically, information about local community resources, including what the hospice offers, is also provided. Medicare reimbursement requires hospices to conduct the risk assessment, provide at least one follow-up contact with the family, and make bereavement counseling available to their clients within the first year (USDHHS, 2014).

The PHC intervention was designed to be similar to the original LAL study in its focus on the dual processes of coping (LO & RO), but was modified to avoid the limitations previously noted that were associated with the group-delivery format of the LAL intervention. Similar to the LAL design, the PHC intervention consists of a 14-week contact period, as well as a booster session timed near the one-year anniversary of the death. Also like the LAL, the PHC is delivered by trained facilitators (e.g., social workers, gerontologists, or counselors) who have experience working with older bereaved populations and who underwent a standard training procedure specifically related to the DPM of bereavement (LAL and PHC training manuals available, by request). Unlike the LAL intervention which forced the oscillation of LO and RO focused sessions on a standardized schedule, the participants in the PHC intervention can modify the frequency and sequencing of their LO and RO related sessions throughout the 14-week intervention period. For example, if a participant prefers to address loss-related issues more immediately within the intervention period, the intervention delivery is adjusted accordingly. In some cases, this could allow for a greater emphasis on either one of the coping processes (but not at the exclusion of the other) over the course of the intervention. We have also found it important to build in time during each session for the interventionist to review with the participant what was covered in the prior session and how it might have affected what transpired during that week. These features are designed to foster better continuity between sessions, avoid disruptions as new content is covered each succeeding week, as well as ensure that adequate attention is given to those issues that are most pressing for the bereaved individual.

Also, in keeping with the goal to deliver bereavement support tailored to the unique needs, preferences, and resources of the participant, the PHC intervention begins with an initial needs assessment where the bereaved participant, with the help of the interventionist, will identify specific daily-life challenges that are causing distress and may need more immediate attention. The general topics include, but are not limited to, managing household finances, home safety, household and auto maintenance, nutrition and preparing meals, addressing health care needs, dealing with insurance (private and Medicare) and legal matters, consumer issues (avoiding scams and fraud), accessing services, and how to remain socially connected. Also included are issues related to learning how to assume new roles and responsibilities, making role transitions, living as a single person, recognizing the importance of having appropriate time away from grief and learning how to be aware of and control their oscillation between LO and RO processes as needed or desired. The needs assessment is intended to help the participant prioritize 2-5 specific problem areas that could be addressed over the course of the 14-week intervention, with the assumption that some issues may require more than a single session to address or master. We also allow for the possibility that any of the areas initially identified can change as participants are potentially confronted with new unanticipated challenges; if this happens, the content of the intervention is adjusted to accommodate these changes.

The first intervention session occurs about a week after the initial needs assessment. In its original conceptualization, LO sessions were going to be delivered one week over the phone (each call typically lasting about 30 minutes), while the RO sessions would be delivered the following week via home visits (lasting approximately 60-90 minutes) where the participant would work collaboratively with his/her interventionist on a specific topic. In reality, participants are allowed to choose whether they want to receive support via telephone or in-person meetings with their assigned interventionist. Telephone support has been used successfully in the past with bereaved populations; it is cost-effective, feasible, flexible and amenable to an individualized approach (Kaunonen, Tarkka, Laippala, & Paunonen-Ilmonen, 2000; Walsh & Schmidt, 2003). Thus, not surprisingly, the PHC staff have found much success in delivering support (including the LO and RO related topics) through the telephone. In limited circumstances, staff also employed text and email correspondence, as ways to deliver information, resources, or individualized follow-up required by this type of intervention. Some participants, such as those who are older and retired, prefer more personalized home visits, whereas others, such as those who are younger and still employed have requested to receive the intervention almost exclusively over the phone. The individualized approach of the PHC intervention allows for participants’ unique communication preferences to be accommodated. Given the many modes of communication available today, intervention protocols for a program such as this need to be flexible enough so that the primary content can be delivered in formats and mediums that participants may use and prefer.

Similarly, participants and staff often modify the dosage (i.e., frequency & timing) of the intervention. Not all participants need or want the prescribed weekly contacts during the 14-week intervention period. Some participants prefer to have regular weekly contacts or even more frequent contact with their intervention staff, whereas others have expressed a desire for less frequent support during the 14-week period. As well, individual intervention sessions are not always focused specifically on an LO-only or RO-only topic, as originally conceptualized when designing the intervention. Often times, both an LO- and RO-focused topic can be addressed during a single session. This is especially the case when RO-focused topics overlap with LO-focused topics. Other times, the staff have had to conduct a few introductory sessions with the participant, as a way to build rapport, before beginning the LO and RO sessions of the intervention. As a result and as shown below in Table 1, there is differential dosing of the intervention across individuals, which is in line with PHC’s goal to provide an individually-tailored and individually-administered intervention. Bereaved individuals do not all require the same level of support and it would be futile to provide more than what one needs or desires (Currier et al., 2008). Hence, an individually-tailored intervention requires well-trained staff who are allowed the autonomy and flexibility to adjust the delivery of their support based on individual needs and preferences.

Table 1. Examples of the Differential Dosing in the Partners in Hospice Care Bereavement Intervention.

Female. 77. 1 needs assessment, 7 LO, 6 RO 16 total contacts
Male. 68. 1 needs assessment, 7 LO, 5 RO 14 total contacts
Female. 62. 1 needs assessment, 9 LO, 7 RO 12 total contacts
Female. 80. 1 needs assessment, 8 LO, 4 RO 10 total contacts
Female, 65. 1 needs assessment, 7 LO, 2 RO 9 total contacts
Male, 68. 1 needs assessment, 3 LO, 3 RO 7 total contacts
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Each intervention session begins with a conversation of how things have gone for the participant since their last conversation. During every session, the participant is reminded of the importance of attending to both loss- and restoration-oriented issues. For example, if the interventionist had recently helped the participant address a specific RO-related need, he/she discusses with the participant if what they had learned was helpful to them in coping with his/her grief. This process is intended to encourage participants to become more aware and able to consciously control their oscillation between the required LO and RO coping tasks (Caserta & Lund, 2007). At the conclusion of the session, the interventionist reviews with each participant what was discussed and asks him or her to think about ways to focus attention on those issues that are of particular concern at that time.

The specific content of the LO-oriented sessions is very similar to what was provided in the group-delivered LAL study described earlier (Lund et al., 2004; Lund et al., 2010). Like the LAL and other types of common bereavement support programs, the PHC interventionists are trained to address the nine predetermined topics at some point during the intervention period: normalizing feelings and emotions, dealing with loneliness, reminiscing about the deceased, dealing with unfinished business and things that interfere with grieving, making needed changes in relationships with others, continuing bonds with the deceased, putting one’s own needs first, and rediscovering sources of joy. Unlike the LAL group-based delivery, the individualized approach of the PHC intervention allows the participant and interventionist to decide the order, sequencing, and time devoted to each of these topics, further emphasizing and recognizing the unique needs and preferences of each participant. Table 2 provides specific examples of issues representing each LO-related topic.

Table 2. Examples Representing Loss-Oriented Topics Discussed During the Partners in Hospice Care Bereavement Intervention.

Topic Specific Examples
Reminiscence Participant gets travel brochures in the mail and this reminds him of his wife and the good trips they used to take. He enjoys reminiscing about his wife and the cruises they took.
Loneliness Hard for participant to only have self to care for. Fixing breakfast for one, making decisions based on her own preferences are difficult and are reminders that spouse is no longer with her.
Getting in Touch with Feelings Participant talked about how she has been experiencing low moments, not as many before, but they are more intense. She is very surprised by this but feels she is coping well through them.
Rediscovering Joy Participant stated that she is trying to feel joy again and stated that she has not cried since her husband passed away…Participant feels that the time she had with her husband is a blessing and now she needs to be on her own two feet. She stated that she needs to grow up and that death is a part of life.
Putting Self First Participant mentioned that she is reading a lot more now that she has more time to herself. She is also making time for organizing.
Continuing Bonds She has gotten together with friends and that has been very cathartic. Her biggest concern right now is that she decided to putout a picture of her husband to be able to… continue her relationship with him.
Interferences to Grieving One thing that really bothers participant is that wifewasn’t aware of what was going on at the end when she was on hospice. He is not upset at hospice but at himself because she wasn’t aware at the end. He didn’t get a chance to really say goodbye to her because she was non-responsive.
Changed Relationships She has had some good things happen, her son moving in with his family to her home has helped her not be so lonely and has helped financially.
Unfinished Business Thanksgiving was really hard when she was alone. Her kids went to her x-husband’s house for a few hours. She is realizing that she has a lot of grief that she didn’t deal with when her first husband cheated on her and then they got divorced.
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Like the LO sessions, the RO sessions are also tailored to the skills, knowledge, and needs of each participant. While the specific topics addressed are unique to each individual, as determined by the initial needs assessment, Table 3 outlines specific examples of RO-related topics that have been addressed during the PHC intervention. As illustrated by these examples, bereaved persons often identify a simple daily-life task that they would like to gain mastery such as cooking, cleaning, or going out with friends. Oftentimes however, a seemingly simple task is intermingled with other grief-related concerns – an individual might possess the needed skills to accomplish it, but the void resulting from the loss could render him or her unmotivated or too emotionally drained to pursue the task. Thus, it is important for the same intervention staff to be able to address both the LO- and RO-related needs together.

Table 3. Examples of Restoration-Oriented Issues Addressed During the Partners in Hospice Care Bereavement Intervention.

Topic Specific Examples
Getting Out, Staying Connected, Personal Leisure Before her husband passed away she was a very confident person but now she wants to be a home body and not go outside and socialize. She said “Home is safe, outside is not”. She said she is not sure what is triggering this emotion and why she feels this way. She thinks it’s that she doesn’t feel emotionally safe outside in the world with people so she prefers to stay home
Financial and Legal Issues Participant voiced concern over her unemployment benefits, being able to find another job, and health care
Health Needs Participant is concerned about the expense of her medications--she has lost her health care coverage after losing her job.
Household & Automobile Responsibility Participant said he is having trouble with getting motivated to do things such as the cleaning around the house and then the deep cleaning. He did mention that he thinks it’s still a good idea to do the time journal to see how he is spending his time.
Nutrition The participant would really like to be more motivated to cook for one. He said he knows how to cook and what he likes to eat, but that he is simply not motivated to cook. Thus, he has been eating out and gaining weight.
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In general, an RO-focused session aims to empower the participant to gain greater independence and competence in a specific daily-life activity. That is, the interventionist does not “do” the task for the participant, but guides the individual oftentimes through a series of steps to be able to complete the task on his/her own. Depending on the issue, a variety of learning strategies can be employed. For example, new skills might be first identified, then demonstrated by the interventionist, and finally practiced together with the participant. This approach emphasizes small do-able steps in order to enhance self-efficacy and build confidence. Alternatively, the participant might be given printed handouts with additional information, including websites, that can be visited on one’s own time. The participant could also be directed to resources within the community to learn more beyond what the home visit covered. At the conclusion of the visit, the interventionist reviews with each participant what was taught, encourages further practice if needed over the coming week, and mentions that he or she will be available for follow-up if additional questions arise. Each participant is encouraged to make a conscious effort to address the RO issue that was covered by applying what was learned and to observe if this new strategy helps them cope better with their situation. The intervention staff is encouraged to work individually with the participant to creatively address the need and to allow the participant to gain the competence and confidence to master the identified skill/task independently. Table 4 shows three case-examples summarizing how specific RO-focused needs were addressed during the course of the intervention.

Table 4. Three Case-Examples to Illustrate How Different Restoration Oriented Needs Were Addressed During the Course of the Partners in Hospice Care Bereavement Intervention.

Female, Age 54 unemployed
 This bereaved woman needed some help with financial and automobile responsibilities. She knew that, financially, she should sell her deceased husband’s truck. However, she had difficulty committing because of its connection to memories. Intervention staff provided emotional support, mostly listening to the caregiver explain why the truck was important to her. Eventually she successfully sold the truck, but decided to sell it to her son, rather than a stranger so that the memory of her husband could remain in the family. She then used the funds to buy herself a new van.
Male, Age 69 retired
 This bereaved man expressed high levels of stress and anxiety after spouse’s death. He indicated an interest in learning self-help techniques. To help this man improve his self-care and meet his mental health needs, the intervention staff provided relaxation techniques. The participant found this to be helpful, and the intervention staff, at the end of the study, indicated that he had high coping skills.
Male, Age 68 retired
 This bereaved man expressed that his spouse was the one who took care of finances, and that he is not good at managing money or budgeting. He discussed his stress over preparing and submitting taxes and not overspending each month. Intervention staff set goals with participant regarding his tax preparation, setting up an appointment with an accountant, and getting in contact with his friend who is a financial planner to learn how to budget. By the end of the intervention, the staff felt like the man’s moderate financial planning needs were addressed.
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Challenges Associated with an Individualized Approach and Potential Solutions

While an individually-tailored and individually-delivered intervention has the potential to more appropriately account for the unique experiences, needs, and challenges as well as already existing skills and resources among bereaved spouses or partners, such an approach is not achieved without its own challenges or limitations. We have found thus far that the PHC-DPM is no exception. Virtually all the challenges tend to be unique to the one-on-one modality not typically encountered in group-based interventions.

The first limitation we have found is related to missed appointments by the participants and unanswered phone calls for scheduled sessions. While individuals who participate in group interventions also might not attend scheduled meetings, in most cases the session still takes place with those who are present. This obviously is not possible when all aspects of an intervention are delivered in a one-on-one format. The primary strategy available to interventionists when participants in an individually-delivered modality do not keep scheduled appointments is to make regular and persistent attempts to follow up in order to determine a reason for the missed appointment and to reschedule. Additionally, it is important to develop a commitment with each participant at the outset that encourages full participation in order to have maximum effectiveness. Most importantly, it is often imperative to modify the frequency of contacts and/or modality of delivery to accommodate the participants’ needs, schedule, and preferences. We have found that the reluctant and hard-to-reach participants are much more willing to participate if they were given the option to decide how often and through what types of communication (i.e., in-person or telephone) the support would be delivered.

At times, we found some participants were unable to identify specific grief-related issues he or she wanted to discuss or were reluctant to talk about such personal issues with their individual interventionist. If this occurs in a group setting, one or more of the other group members can bring up an issue that may serve as a catalyst for further discussion or consideration by the entire group. Similarly, some participants have difficulty during the initial needs assessment identifying 2-5 RO-related issues to address over the intervention sessions. If nothing comes to mind for the participant initially, the interventionist will begin to review a predetermined list of categories and subcategories listed in the standard training manual and forms/workbooks associated with the initial needs assessment in order to help the participant more easily identify an issue, no matter how simple, to address for the first time.

When working with participants who already feel quite competent or that they do not need any support (LO or RO), the interventionists have been trained to shift the focus of conversation to potential growth opportunities. In these instances, participants are guided on ways to explore new things that they might not have had the chance to pursue when they were caring for their ill spouse or partner. This exploratory and suggestive process can potentially facilitate the transition into a new role identity as an outcome of the loss. We have found thus far that many of the participants who initially had difficulty identifying areas of daily living to address eventually did so more easily over time in order to remain independent and/or to pursue further personal growth.

These challenges that are unique to working with individuals (rather than in groups) underscore the importance of the quality and comprehensiveness of the training provided to interventionists. The PHC interventionists are provided with a standardized training manual that includes useful prompts to help participants initiate a conversation related to specific topics. Regular ongoing communication among staff (conducted via virtual staff meetings using teleconferencing and email capabilities) also provides opportunities for staff to hone their skills in delivering bereavement support; the staff listserv often has conversations where staff would share their experiences working with particular types of participants or asking one another advice on how to best deal with certain circumstances. The initial staff training and on-going conversations amongst the intervention staff help to ensure that the established protocols that make the intervention somewhat standardized are followed, while also giving staff the autonomy and confidence to creatively modify the intervention to best address the unique needs and to accommodate the individual preferences of a given participant. Any intervention that uses an individually-tailored and individually-delivered approach should consider the initial and ongoing staff training among the highest priorities.

Conclusion

Although group formats (especially self-help or support groups) are common modes of delivering community-based bereavement interventions (Bergman & Haley, 2009; Currier et al., 2008; Levy & Derby, 1992), we learned from the experience provided by the Living After Loss study that a “one size fits all” approach typical of group interventions does not often adequately accommodate the range of situations, life experiences, and current needs of the participants. Within the scope of the DPM, this is especially problematic when attempting to address unique restoration-oriented needs.

It is important to acknowledge, however, that a group format can have its place among bereavement intervention options, especially when the desired focus is primarily on enhancing grief comfort and support. Support groups provide opportunities for its members to share common experiences, form bonds with each other based on shared life circumstances, and model effective coping (Levy & Derby, 1992; Richardson, 2006; Tedeschi & Calhoun, 1993; Utz et al., 2013b). Consequently, we have recently suggested that an effective design could integrate group-based bereavement support (primarily LO-focused) with an individually tailored treatment to address the much more diverse RO-focused issues among the bereaved participants (Caserta et al., 2014; Lund et al., 2010). The design and recruitment protocol of Partners in Hospice Care, however, does not allow for a group format because participants join the study as they are enrolled in hospice. Hence the timing of when they begin the DPM treatment of the bereavement study described here potentially would result in putting the participants on hold for an extended period of time until there was an adequate number to constitute and initiate a group. Future investigations examining the effectiveness of bereavement interventions should give serious consideration to such an integrated format, however, if the designs allow. Furthermore, because the LO and RO processes associated with the DPM could most likely be initiated before the death of the terminally ill person occurs (Carr, 2010), an intervention can be “upstreamed” and implemented even prior to hospice enrollment as a terminal diagnosis is made and palliative care commences. At the very least, interventions need to include mechanisms by which they are tailored to the specific needs of each individual (Bergman & Haley, 2009) because in such instances, “one size doesn’t fit all.”

Acknowledgments

Funding support was provided by grants from the National Cancer Institute (P01 CA138317) and the National Institute on Aging (R01 AG023090). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Contributor Information

Michael S. Caserta, Gerontology Interdisciplinary Program, 5175 College of Nursing, University of Utah, Salt Lake City, UT 84112, (801) 581-3572.

Dale A. Lund, Department of Sociology, California State University San Bernardino, 550 University Parkway, San Bernardino, CA 92407, (909) 537-3748, dlund@csusb.edu.

Rebecca L. Utz, Department of Sociology, 301 Behavioral Science Bldg. University of Utah, Salt Lake City, UT 84112, (801) 699-5685, rebecca.utz@soc.utah.edu.

Jennifer Lyn Tabler, Department of Sociology, 301 Behavioral Science Bldg, University of Utah, Salt Lake City, UT 84112, (801) 634-7913, jennifer.tabler@utah.edu.

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