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Clin Soc Work J. Author manuscript; available in PMC 2015 April 10. Published in final edited form as: Clin Soc Work J. 2014 March 1; 42(1): 99–100.

Constructing Couples’ Stories: Narrative Practice Insights from a Dyadic Dementia Intervention Kristin S. Scherrer, School of Social Work, Rutgers, The State University of New Jersey, 536 George St., New Brunswick, NJ 08901, USA

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Berit Ingersoll-Dayton, and School of Social Work, The University of Michigan, 1080 South University, Ann Arbor, MI 48109, USA [email protected] Beth Spencer Turner Geriatric Center, The University of Michigan, 4260 Plymouth Rd., Ann Arbor, MI 48109, USA [email protected]

Abstract

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Memory loss and dementia can be devastating for both caregivers and care recipients. Narrative therapeutic approaches offer promise, as well as challenges, for social interventions with couples where one partner has dementia. The Couples Life Story Approach is a recently-developed method by which practitioners work with such couples to help them narrate the story of their life together. This narrative approach is augmented by mementoes (e.g., photos, cards) that are collected by the couple during the intervention. Significant memories are elicited from both partners and developed into a Life Story Book. Drawing on data from this clinical research intervention with 20 older couples, we ask: What are some of the challenges of conducting narrative-based therapeutic interventions with older couples with memory loss? Clinical themes were identified utilizing a multiple case study approach during weekly team meetings. Six of the most prominent themes are presented here. Specifically, how to: (1) construct a narrative from disparate stories, (2) tell a mutual story, (3) tell the story of a couple that has been in a shorter relationship, (4) incorporate others in the story, (5) include difficult life moments, and, (6) end the story. Within each theme, we utilize case examples to illuminate relevant issues and describe strategies that were developed to resolve these clinical challenges. Implications for practitioners and clinical researchers who are engaged in dyadic interventions are discussed.

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Keywords Narrative therapy; Alzheimer's disease; Older couples; Memory loss

© Springer Science+Business Media New York 2013 [email protected].

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Introduction Although couples of all age groups face challenges in their intimate relationships, biopsychosocial aspects of the aging process contribute to unique issues for older couples. One particularly relevant and difficult issue for older couples is that of dementia or memory loss. Researchers estimate that almost 14 % of individuals over the age of 71 meet criteria for Mild Cognitive Impairment, Alzheimer's disease, or other forms of dementia, and that these conditions increase dramatically with age (Plassman et al. 2007). Although dementias are often contextualized as medical or biological issues, the psychological and social effects of memory loss can also be devastating. In this paper we examine clinical issues that may emerge when utilizing a narrative approach with older couples where one partner has memory loss and provide strategies for clinical social work practice.

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Couples’ Experiences with Memory Loss

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The slow deterioration of autobiographical memories is often emotionally devastating and people with dementia experience high rates of depression and anxiety (Kuhn 1999). This loss of autobiographical memories presents potential challenges to one's sense of self and identity (Basting 2003; Hinton and Levkoff 1999; MacRae 2010; Young 2010). For instance, people with dementia see themselves simultaneously as changing, yet still work to preserve important aspects of their identity (Beard 2004; Ryan et al. 2009). Indeed, clinicians who work with people who have memory loss often suggest addressing issues of self and identity as important aspects of clinical practice with this population (Ryan et al. 2009; Cohen-Mansfield et al. 2000). In this paper we use the terms “dementia” and “memory loss” interchangeably to indicate an inclusive group of memory disorders including Mild Cognitive Impairment, Alzheimer's disease, and Lewy Body Dementia, amongst others.

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Although some clinical research has focused on the person with memory loss, the majority of this research focuses on spouses, or caregivers, who are also greatly affected by the diagnosis. Spouses often take on a great deal of work as they may perform additional household chores, manage medical appointments, maintain connections with friends and family, or provide care for their partner's physical or emotional needs. This “care work” takes a toll and caregiving partners often experience “caregiver burden,” as their physical and mental health is compromised (England 2005; Kuhn 1999; Mittelman et al. 2003; Whitlatch et al. 2006). These issues may also be magnified by strained communication (Gentry and Fisher 2007; Rankin et al. 2001). Although less is known about how having a partner with memory loss informs one's identities, formative research suggests that the caregiving spouse also experiences dramatic changes in identity following a dementia diagnosis (Hasselkus and Murray 2007). For example, caregivers might adopt new household identities, such as financial manager or meal planner, as their partners’ cognitive faculties decline. While both the person with dementia and the spouse or partner of the person with dementia experience dramatic changes in their understandings of themselves and in their interactions with others, considerably less is known about how dementia affects the couple's identity as a couple. Formative research on this topic indicates that couples vary greatly as some are more Clin Soc Work J. Author manuscript; available in PMC 2015 April 10.

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“we” identified and some are more “I” or individually identified (Kaplan 2001). Other research indicates that couples do a great deal of “identity work” to maintain their relationship and identity as a couple following the diagnosis of dementia (Molyneaux et al. 2011). Taken together, this research indicates that memory loss and dementia are increasingly prevalent issues that affect older adults and their spouses thus highlighting a need to better understand how social work clinicians can best intervene with couples with dementia. Previous Clinical Interventions

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A number of clinical interventions have been developed to ameliorate the negative intra-and inter-personal consequences of dementia. On the one hand, interventions with the spouses or caregivers of people with memory loss aim to prepare caregivers for issues such as managing problem behaviors, resolving family conflict, and reducing feelings of burden (Hepburn et al. 2001; Mittelman et al. 1995; Whitlatch et al. 2006). On the other hand, clinical interventions with the person who has memory loss aim to address issues such as improving coping strategies or coping with loss (Kasl-Godley and Gatz 2000; Lewis and Trzinski 2006). Interventions with the person with memory loss often focus explicitly on issues of identity, aiming to help people with memory loss affirm their personhood, share their stories with others and explore their changing identity (Beard 2004; Caldwell 2005; Ryan et al. 2009; Young 2010). This research has offered important clinical insights such as the importance of attending to themes in the stories of older adults with memory loss rather than on chronological coherence (Young 2010). However little is known about what types of clinical issues may emerge and how social work practitioners may effectively address these issues.

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Research indicates that dyadic interventions have a positive impact on couples’ overall wellbeing (Allen 2009; Allen et al. 2008), yet such interventions for couples dealing with dementia are rare (Whitlatch et al. 2006). Given the centrality of the couple's relationship to issues such as caregiver burden or depressive symptoms, dyadic approaches are likely useful for clinical work with couples with memory loss. As such, the Institute of Medicine (2008) has called for developing interventions that actively engage both members of the couple as a fundamental characteristic of successful interventions for reducing problems associated with dementia.

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Previous interventions with couples with memory loss range greatly in format and content. For example, some focused on group support and education (Zarit et al. 2004), while others conducted separate life reviews with both members of the dyad (Haight et al. 2003). Still others consisted of marriage counseling (Epstein et al. 2006), or combined elements of evidence-based protocols, such as caregiver skills training and cognitive rehabilitation (Judge et al. 2012). Evaluations of these interventions indicate that dyadic approaches are associated with positive outcomes such as identifying and building the couple's strengths (Judge et al. 2009), improved communication between the caregiver and care receiver (Judge et al. 2009; Whitlatch et al. 2006), and improvements in caregiver well-being (Judge et al. 2012).

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Although previous research demonstrates the promise of dyadic approaches, it also illuminates some of the challenges associated with dyadic interventions with this population. For example, couples where one partner has memory loss often experience communication challenges, drift apart emotionally, and struggle to maintain shared involvement in decision making and “we-ness” (McGovern 2011). Other research finds that some issues “such as feelings of personal loss” (Judge et al. 2012, p. 11) may be particularly challenging to address in a dyadic format. As couples focus increasingly on the deficits associated with memory loss, another challenge they experience is the missed opportunities to share in mutually enjoyable activities. These opportunities to share in mutually significant activities have been conceptualized as “meaningful engagement” (Allen 2009). Although addressed centrally in dyadic interventions with other populations (Allen 2009), an explicit focus on meaningful engagement has not been a central component of previous work with older couples with memory loss, and represents a gap in clinical interventions with older couples with memory loss. Thus, although dyadic interventions are promising, they are not without clinical practice challenges. This paper illuminates these challenges while also offering suggestions for how to effectively address them. Theoretical Framework: Narrative Strategies

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Given the centrality of identity and selfhood for individuals who are experiencing memory loss, narrative therapeutic approaches have been proposed as a particularly effective theoretical framework for working with this population (McGovern 2011; Ryan et al. 2009; Young 2010). It is not uncommon for people with memory loss to gradually be left out of conversations and storytelling. As memory falters the person often becomes increasingly reliant on their spouse to be the spokesperson for the couple. Narrative approaches may be particularly useful for highlighting couples’ strengths and bolstering their sense of togetherness (McGovern 2011). To date, little is known about the clinical challenges associated with utilizing narrative approaches with older couples with memory loss.

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Narrative therapeutic approaches posit that individuals organize and make sense of their life experiences through stories about themselves and their world (Clark 2001; White and Epson 1990). These stories, or narratives, offer individuals, “a framework for understanding a purpose of life, connecting past events, and planning future actions” (Clark 2001, p. 275). In narrative therapy, there is no one way to make sense of people's complex lived experiences, and thus, “there is always room to alter stories” (Lawson and Prevatt 1999, p. 288). As such, helping clients re-author or re-story more constructive narratives about who they are and what they are capable of is a central goal for narrative clinical practice. Narrative therapy is often utilized with individuals; however, recent scholarship illuminates its potential with other clients systems, such as couples (Molyneaux et al. 2011). To achieve the goal of helping clients re-author more constructive stories about themselves, narrative therapists rely on a number of strategies (Carr 1998; White and Epson 1990). One such therapeutic strategy is to focus broadly, not on the problem itself, but on the person's overall story. As such, when working with a person with dementia, clinicians would focus not on their cognitive gaps, but on the strengths embedded in their shared history, everyday life and relationships. Secondly, narrative practitioners also invite clients to make meaning

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of, and at times, reinterpret previous events. As applied to dementia care, practitioners may encourage the caregiving partner to reexamine the meanings and significance of events that are particularly memorable for the person with memory loss. A third common strategy used by narrative therapists is to utilize artifacts or other symbolic objects, such as photos or written words, to visually illustrate the new narrative. For instance, Caldwell (2005) suggests that artifacts such as journals, life maps, memory books or time capsules are potentially helpful ways for older adults with dementia to express themselves and construct stories of resilience.

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Given the malleability of clients’ self narratives, narrative therapy scholars have noted the therapist's multiple roles such as assisting the client to narrate their story, expanding clients’ notions of the possibilities for change, and co-authoring more constructive stories (Clark 2001; Kenyon and Randall 1999). The challenges of this task are considerable as a clinical social worker must take care to ensure that the client is “in charge of the change process” (Clark 2001, p. 279). As such, social workers are expected to reflectively analyze their role in co-constructing clients’ stories.

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In this paper, we address several of the gaps in the literature, as we contribute to knowledge about narrative clinical practice with older couples with memory loss, as well as narrative work with couples more generally. Specifically, we describe an intervention, the Couples Life Story Approach, that was developed for older couples in which one person is experiencing memory loss. First, we provide an overview of this intervention and summarize the benefits associated with this approach. Second, we describe the methodology and sample (20 older couples where one person has dementia or memory loss). Then, we identify some of the clinical challenges that may arise in conducting narrative-based therapeutic interventions. Lastly, we provide best practice strategies for working with this clinical population.

Method Description of the Couples Life Story Approach

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The Couples Life Story Project is a 5 week structured dyadic intervention for individuals with dementia or memory loss and their spouses or partners. The goals of this intervention were multiple: (1) to provide couples an opportunity for meaningful engagement, (2) to highlight couples’ strengths, (3) to improve communication between partners and, (4) to enable couples to reflectively examine their shared life. In weekly sessions, a social worker visits the couple about once a week, usually in their home. The social worker facilitates a structured review of the couples’ life together, utilizing pictures and other mementos. The intervention also includes a communication skills building component to help the couple better communicate given their changing relationship dynamics. The project culminates in the creation of a Life Story Book that utilizes couple's mementos (e.g., photographs, cards, news items) to document the story of their life together. This Life Story Book is created through a collaborative process whereby the couple identifies mementos and discusses significant life events. The social worker uses these stories and artifacts to compile the Life Story Book, as early focus group data from the development

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stage of this intervention, indicated that couples preferred to have the social worker compile the Life Story Book. Each week, the Life Story Book is brought back to the couple for their review and revisions. At the end of the project, couples receive a final copy of their Life Story Book to review together and share with family; blank pages are included so they can continue documenting their story.

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Our preliminary work with this approach suggests that it provides couples with a meaningful way in which to engage with one another. For example, one caregiver wrote at the end of the intervention, “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.” During team meetings, social workers noted the ways in which couples demonstrated increasing intimacy as they reminisced about their past and reviewed their Life Story Book together, as couples often moved closer together, held hands, or put their arms around each other. In addition, as participants described themselves, they were more likely to refer to each other as “partners” during the course of the intervention. It seems that talking about their shared past gave couples an opportunity to meaningfully engage and focus on their identity as a couple. This shared focus, in turn, was associated with greater intimacy and closeness, qualities that are particularly important as couples cope with the challenges of progressive dementia (Davies 2011).

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We found a number of benefits for both partners involved in the Couples Life Story Approach. For example, at the end of the intervention, many of the participants reported that they enjoyed reminiscing about their life together and reliving memories from earlier times. In the words of one care recipient, “We remembered what a full life we have had and found so many good memories of half-forgotten times that we realized our life wouldn't fit into one book.” Participants also told us that they particularly enjoyed the process of putting the Life Story Book together. Some talked about how they found that the Couples Life Story Approach helped to jog their memories. One of the participants with memory loss noted that the intervention, “helps organize some things–organize memories of things; makes you think about things; (it's a) good way of organizing things.” Participants told us that, following the intervention, they looked forward to reviewing their book with each other as well as sharing it with family members and friends. Most of the caregivers and some of their partners with memory loss observed that the communication tips were also very helpful. For example, one caregiver noted, “I have learned different ways to help him remember things so he doesn't feel like he is having a problem.” In sum, the Couples Life Story Approach helps couples focus on each other's remaining assets and addresses the need for more strengths-based models when working with dyads who are dealing with dementia (McGovern 2011). A more comprehensive account of the goals, methods and successes of this intervention are provided elsewhere (Ingersoll-Dayton et al., in press).

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Sample The 20 couples (40 individuals) who have participated in the Couples Life Story Project were recruited through several organizations: 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

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with materials for potential couples and distributed flyers around the community (e.g., libraries, grocery stores). There were several inclusion criteria for this study. The first was that caregiver-care receiver dyads were spouses or partners in which the care recipients’ memory problems were confirmed by the caregiver. Further, these memory problems were demonstrated through the care recipient scoring between 15 and 27 on the MMSE (Mini Mental Status Examination, see Folstein et al. 1975), a score that indicates mild to moderate cognitive impairment. Last, neither the caregiver nor the care recipient reported suicidal thoughts or behaviors and neither the caregiver nor the care recipient had problems with vision that would inhibit seeing photographs or reading large text.

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Care recipients’ were, on average, 74 years old and well-educated (65 % had at least a college education). On average, their caregiving partners were 72 years old and also welleducated (55 % had at least a college education). Couples were racially homogenous (100 % white or Caucasian identified) and mostly heterosexual (95 %), except for one same-sex couple. Most couples did not report financial hardship (70 %). The intervention was typically conducted in the couples’ homes with the exception of two couples with whom we met in the home of a family member and a Continuing Care Retirement Community. Data Collection and Analysis

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We utilized a case study approach in collecting and analyzing data for this paper. Case study approaches “draw on multiple perspectives and data sources to produce contextually rich and meaningful interpretation” (Padgett 2008, p. 33) of data. Case studies are particularly valuable for illuminating the applied or clinical applications of a given topic, such as memory loss with older couples (Padgett 2008). Analytic procedures are somewhat less specific when utilizing multiple cases, leaving some discretion to the researcher as to how to privilege “holism over disaggregation” (Padgett 2008, p. 34) in analysis of qualitative data (Stake 2006).

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Data for this paper are drawn primarily from weekly team debriefing meetings that occurred over a 2 year period. Weekly team meetings were co-facilitated by the two project leaders (the second and third authors), a clinical researcher and a dementia care specialist, respectively. Both project leaders are licensed clinical social workers. Meetings involved social work interventionists (including the first author) and research assistants. These meetings provided an opportunity to discuss ongoing cases and emerging clinical issues, as well as providing a formal structure for clinical supervision of the social work interventionists. During team meetings, social workers described the positive changes that they observed in their weekly meetings with couples, as well as the challenges they encountered. These challenges were discussed as the project leaders and other members of the project team considered strategies to address them. The first step in our case study approach was to carefully document the clinical issues that arose during the intervention and were discussed during team meetings. All members of the team took notes about the clinical issues that emerged, as well as practice strategies that were suggested and used. The first author kept detailed notes during initial, and subsequent, conversations on this topic and facilitated an ongoing dialogue with the team to identify the common clinical challenges and strategies that best addressed the challenges. Issues were Clin Soc Work J. Author manuscript; available in PMC 2015 April 10.

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described as common clinical challenges when they emerged with at least two couples. The first author compiled an initial list of clinical challenges, which was reviewed and discussed with the research team over several months. Specifically we utilized cross case analysis (Creswell 2007; Stake 2006) to examine similarities and differences across clinical cases, with the goal of illuminating clinical practice insights that emerged in multiple cases. After several weeks of focused discussion, some themes were combined into a broader thematic category (e.g., experiences of death and experiences of illness combined into one theme of difficult life moments). The six themes presented here are the result of this iterative effort. To illuminate these themes, we utilize case examples from our clinical work. Cases are composite examples to preserve participants’ anonymity. Further, we have changed other identifying information, including clients’ names, to protect confidentiality.

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In facilitating structured multi-week sessions with 20 older couples where one of the partners had memory loss, we had many opportunities to actively listen to couples’ narratives about their lives together and re-construct these narratives in the Life Story Book artifact. However crafting this narrative was not a straightforward process and we encountered many clinically relevant challenges in co-constructing these narratives. These challenges were resolved through multiple strategies that originated both from the clinicians and from the clients and have implications for social work practice. How to Tell a Mutual Story

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A first challenge emerged as social workers attempted to elicit mutual stories from couples. The unique goal of this project was to help couples, not individuals, narrate the story of their life together. The goal of creating a mutual story was sometimes challenging for social workers as we sought to continually highlight the stories and strengths of the couple. Often this challenge emerged as the person without memory loss focused on highlighting his/her partner's strengths. Caregiving partners were often deeply invested in helping their partners with memory loss reminisce and remember their accomplishments, thus complicating their ability to narrate mutual stories. In these instances, only one partner's stories and accomplishments were highlighted, while the other person's story was omitted. Rather, our aim was to affirm their strengths as a couple and enhance the couple's identity.

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Case Example—Matthew and Ellie, a couple in their mid-70s, had been married for almost 50 years. Matthew was diagnosed with Alzheimer's disease 2 years earlier. Although he had a difficult time retrieving memories, Matthew was generally able to reminisce when his memories were cued with help from Ellie. In reminiscing about their life together, Ellie made many efforts to highlight Matthew's strengths, including his years as a counselor for youth in crisis. Although Matthew spent most of his professional life working to help other people, he had difficulty retrieving memories about this part of his life. During one session, Ellie talked a great deal about Matthew's interactions with particular people from his work life to cue his memory of his many professional relationships and accomplishments. Indeed, it proved to be important to her to help him remember all of the good he did for others over his life.

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Ellie's focus on Matthew's accomplishments, coupled with Matthew's genuine excitement about rediscovering and reminiscing about his work experiences, monopolized much of this session. Ellie's investment in helping Matthew remember his many professional accomplishments was fitting with the goals of this project in many ways; however, it is notable that the majority of these memories did not centrally involve Ellie. So, while this reminiscing was a positive experience for both Matthew and Ellie, it limited their abilities to tell the stories of their accomplishments, challenges and joys as a couple.

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Strategies for Resolution—Ellie and Matthew were one of many couples who tended to favor the stories and experiences of one partner over the other, most frequently the person with memory loss. In these interactions, we utilized several strategies to address this tendency. For instance, we learned to carefully solicit memories and stories from both members of the couple. For example, one of the first questions we asked of couples was “What first attracted you to one another?” When asked this question, Ellie responded that they were drawn together based on their mutual investment in their church community and their love of the outdoors. However, because this question is framed in such a way that the thoughts and feelings of both members of the couple are required, we were able to draw Matthew into the discussion as well. When asked, Matthew said to Ellie: “You were a good looker... and you still are.” This affirming comment enabled Ellie to elaborate further about what it was about Matthew's personality that first appealed to her. This type of dyadic question included the person with memory loss and set a tone of inclusion and mutuality for subsequent reminiscing. By increasing the involvement of individuals with memory loss in the reminiscing process, their partners were able to perceive the continuing meaningful contributions of the person with memory loss.

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In addition, we also learned to ask unifying questions that drew attention to the partner that was missing in the story. In one story, Ellie said that after they were married, they went on a long trip together. While she told this story to illustrate Matthew's adventurous spirit, in the process of telling this narrative, we asked her to reflect on what this story meant about who they were as a couple. In responding to this unifying question, Ellie realized that this story also illuminated her own spirit of adventure as well as the ways that they nurtured one another's courage and willingness to take on new challenges. This example highlights how even stories that focus on one person's strengths, can still illuminate aspects of the couple. How to Construct One Story from Many

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One of the most common challenges emerged as we sought to help couples distill their lifetime of stories, often told piece by piece, into a coherent narrative that would fit in the Life Story Book. As narrative scholarship indicates, peoples’ stories are complex, messy and incoherent (Clark 2001; White and Epson 1990). Thus, part of the goal of narrative interventions such as this one is to help couples create coherency between, and within, their stories. This could be seen when couples told nonlinear stories, traveling backwards and forwards in time as they reminisced about what had come before and what would come after the memory at hand. Not only were stories complex and messy, but for many couples, there were more stories than could be captured easily in a handful of pages in a Life Story Book. Given our goal of using the Life Story Book to provide opportunities for reminiscing,

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included pictures or stories were not meant to convey the entirety of their experience together as a couple, but to inspire additional memories and prompt future opportunities for reminiscing. Thus the process of refining and distilling couples’ stories required paring down on the quantity of stories, as well as creating a coherent narrative from pieces of stories that emerged along the way.

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Case Example—Edith and Simon, a couple in their early 80s, had been married for more than 60 years when Simon started to develop symptoms of Alzheimer's disease. Since they had been together for such a long time, both Simon and Edith had many stories to tell of their life together. As such, they would sometimes talk over the top of one another, provide additional details to each other's stories, or tell stories that were tangentially related to the stories they intended to tell. For instance, while talking about their honeymoon during their early years together, Simon went on a tangent about their 50th anniversary as he described some of their friends and family that were able to be with them on their anniversary. This created challenges for the social worker as she sought to put captions on pictures about the story of their honeymoon experience. Strategies for Resolution—One of the strategies that proved most successful in helping couples create cohesive, coherent narratives from their memories was using a story telling framework that centered on talking about their early, middle, and recent years together during different intervention weeks. Early in the process, couples would define what the terms early, middle, and recent meant for their relationship and this framework was then revisited as a guide for helping couples stay focused on important life moments. Reminding Edith and Simon about this framework proved to be helpful for keeping them focused on the time period they were reminiscing about.

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Another strategy that was successful for distilling couples’ stories was searching for central themes. For instance, after some questions from the social worker, it was discovered that many of Edith and Simon's memorable events (e.g., their honeymoon, camping with their young children, their 50th anniversary party), occurred on a nearby lake. The importance of the lake was a central theme for Edith and Simon and the social worker was able to use this theme as an organizing framework within their Life Story Book. For other couples, central themes emerged around their love of travel, their dedication to promoting intergenerational family relationships, or their faith community.

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We discovered several strategies to address couples’ desire to include all their stories. For example, with most couples we reminded them that the purpose of the Life Story Book was not to tell every possible story, but merely to tell some of their important stories and provide a starting point that they could use to reminisce with one another in the future. Another strategy utilized was of finding an image or story that could represent a broader cluster of memories. For example, with one couple that traveled frequently, we included a picture of several of their travel scrapbooks to stand in for some of their travel stories. For another couple, we included a map of the world, with stars and captions that indicated places the couple had visited.

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How to Tell the Story of a Couple that Been in a Shorter Relationship

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Although many of the couples that participated in this intervention had been married for much of their adult lives, some of the couples had not been together for as long. For instance, a few couples met after their first spouse had passed away. As such, events that occurred before their relationship started, such as the birth of a child with a previous spouse, proved to be important for the couple even though the event did not occur during their relationship. For some couples, the person with memory loss occasionally confused the role of their current spouse in earlier memories, likely because of the memory distortions that can occur with some forms of dementia (Budson and Solomon 2011).

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Case Example—Daniel and Jason, a same-sex couple in their early 60s, had been in a relationship for about 10 years when Daniel was diagnosed with Mild Cognitive Impairment (MCI). For both Daniel and Jason, important events had occurred before their life together. For example, long before they met, Daniel wrote a series of fiction books and both Daniel and Jason wanted this accomplishment to be included in their Life Story Book. Given our clinical goals of helping couples to reminisce about their life together, this focus on events that occurred before their relationship was incongruent with our goals. An additional challenge emerged as Daniel occasionally reminisced about events that occurred in his previous relationship, sometimes even mistakenly calling Jason by the name of his previous partner. Although Jason was generally gracious and patient with Daniel, there were several times when Jason was clearly frustrated by the confusion of his role in Daniel's memories.

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Strategies for Resolution—As Daniel and Jason's experiences illustrate, participating in a dyadic intervention such as this one, can be a particular challenge for couples who had not been together as long. The issues surrounding Daniel's confusion between Jason and his previous partner are complex. To address these complex issues, one of the strategies we employed was educating couples about how memory works as we talked about communication skills. Both Jason and Daniel appreciated the chance to learn more about Daniel's changing memory and why earlier events and relationships were more likely to intrude into later memories. Education about these issues was a primary goal of this intervention within the context of improving communication skills and served to normalize this aspect of Daniel's memory loss. We also prompted Jason and Daniel to talk with one another about how to best handle moments like this, saying, “Confusing important people in your life is something that often happens for people with memory loss. So, it's important to talk openly and honestly about how you would both like to handle this when it happens in the future.” Encouraging couples to plan ahead about how to best address this issue both normalized this aspect of the memory loss, as well as provided space to dialogue about how best to handle situations like this in the future. When couples were particularly invested in including a story that did not involve both members of the couple, as was the case with Daniel's writing career, we learned to purposefully involve the non-participating member into the story. For instance, when discussing Daniel's writing, the social worker solicited Jason's opinion about Daniel's writing, by asking where he fit into this story. Jason said that Daniel's writing was one of the things that really impressed him about Daniel when they first met. In hearing about Daniel's

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writing from Jason's perspective, we learned more about some of the factors that attracted them to one another in the first place as well as reconstructed this individual story as a mutual story. How to Incorporate Other Important People in the Story Another challenge we encountered was in assessing how to portray other people in the story, particularly family members. Many couples discussed sharing their Life Story Book with friends and family, making the representations of others an important component in the narrative process. For some couples, this issue emerged as they talked negatively about prominent people in their lives, while for others, important family members were simply absent from their photographs and stories.

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Case Example—Clara and Michael were in their late sixties and had been married for over 30 years. In talking about their life together, Clara and Michael frequently discussed their daughter and her children, often presenting an idealized image of her. In contrast, they rarely mentioned their son, who lived with them and helped them, and did not provide pictures of him. When their son did emerge in stories, he was described as disappointing and as the “black sheep” of the family, yet during the sessions it was clear that he provided a great deal of assistance to his parents.

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Strategies for Resolution—Clara and Michael's experience saliently illustrates the negative ways that others can emerge in couples’ stories. This was one of the first cases where we dealt with this issue during the development of the intervention. During our team meeting, the social worker described feeling uncomfortable about how the caregiving son was portrayed by this couple, particularly as she knew that the resulting Life Story Book was often shared with others. The clinical supervisors suggested that one of the important facets of this intervention was for social workers to reflectively analyze their own interpretations of couples’ stories so that they could facilitate the couple's own story telling process. Our work with Clara and Michael, taught us that ongoing clinical consultation and supervision regarding the challenging aspects of cases provided an ideal opportunity for social workers to reflect on their own assumptions about couples’ stories. Indeed, weekly team meetings became an ideal site for social workers to examine their own expectations or interpretations about a couple's story, a dimension of narrative social work practice that is rarely discussed.

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Further, we also learned to discuss directly with the couple how significant others were portrayed in the Life Story Book. When she returned to Clara and Michael the following week, the social worker pointed out to them that many people share the completed book with their friends and family, and because they lived with their son, he was very likely to see it. By bringing this issue to their attention, we introduced their son's exclusion from their Life Story Book as a potential issue that they might wish to consider. In their subsequent discussion, Michael and Clara decided that including their son in the book was a good idea. As we became more experienced with this type of challenge, we became more skilled at helping couples reframe their experiences by acknowledging that certain relationships had challenges as well as strengths.

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Since there were relatively few positive accounts of their son, we had to be creative in finding stories that highlighted the positive aspects of their relationship with their son. For instance, when speaking about how their children participated in sports as children, Clara commented that, “Our kids are very good athletes”—a quote that was later incorporated into their final Life Story Book when referring to the son with whom they lived. Given that this was a time limited intervention, we could not address all underlying family or relationship dynamics. Rather this intervention utilized a strengths-based approach to reframe the couples’ relationship with their son and help them to view his contributions in a new light. Discussing the multiple potential audiences of the Life Story Book encouraged us to attend to the social context within which couples are embedded and examine, alongside the couple, who this story is for and what purposes it may serve in the future. How to Incorporate Difficult Life Events

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Many couples described experiencing difficult life events, such as the loss of a spouse or child. Revisiting these losses was often emotionally difficult for them, but the losses were also defining events in their life together. Given the intervention's focus on providing couples an opportunity for meaningful engagement and highlighting couples’ strengths, we were challenged to determine how to incorporate these difficult life moments.

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Case Example—Martin and Marie experienced their share of difficult periods during their 40 years of marriage. As Martin said at one point, “Life hasn't always been easy for us.” One of these challenges was Marie's Alzheimer's disease diagnosis the previous year. Another such difficult event was when Martin and Marie's youngest daughter died tragically in a car accident 5 years earlier. Although they both mourned their daughter's death, Marie's mourning was complicated by her memory loss. When Marie and Martin reminisced about their daughter's death, Marie would often experience this loss anew thus sobbing as she recalled her daughter's death.

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Strategies for Resolution—Martin and Marie's loss is illustrative of the myriad losses couples who participated in this project experienced. We learned not to make assumptions about how they would like their losses discussed in the book, but rather addressed this question directly with Martin and Marie by asking if they wished to have their daughter's death included in their Life Story Book. After looking at each other for a moment, Marie said, “Yes, because this is our story and this is who we are.” In reflecting on this in our weekly meetings, the social worker said that in compiling their Life Story Book she sought to both represent their daughter's death while also highlighting positive aspects of their relationship that this tragedy revealed. For Martin and Marie, their daughter's death prompted them to seek comfort with their religious community, a reconnection that they both treasured. In addressing these issues of loss, we also took a cue from Martin who took the lead in guiding their review of the Life Story Book. Based on timing and circumstance, Martin would decide if they would linger on the page that represented their daughter's death, which often prompted a long, emotional grieving process for Marie. At other times, Martin would prompt his wife to move past this page more quickly. In this way, Martin mediated Marie's

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reminiscence experience (as well as his own), by acknowledging their loss, even though he did not always choose to focus on it. This strategy of helping couples selectively discuss the aspects of their story that best facilitates meaningful engagement at a given time proved to be effective for helping couples reminisce about difficult life events. “Ending” the Story The final session provided an opportunity for couples to talk about their future as a couple as well as to conclude their professional relationship with their social worker. As in other clinical social work practice, terminating or concluding the professional relationship was a source of trepidation for some couples. However, termination is likely additionally complex for couples with memory loss as the inevitable decline of cognitive functioning left some couples feeling hopeless about their future.

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Case Example—Charlie and Renee had been married for over 30 years when Charlie was diagnosed with Alzheimer's disease. Sessions with Charlie and Renee were filled with largely pleasant reminiscing of their life together; however, during their last session the mood was more somber. When reviewing their Life Story Book together, Charlie flipped the last page closed and said, “I guess that's the end.” His comment prompted further conversation which revealed that he and his wife both had a hard time seeing positive aspects of their future together.

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Strategies for Resolution—The time limited nature of this intervention was, in many ways, a strength for the termination process, as each week the social worker alluded to the completion of the story book and therefore, the sessions. However, looking forward proved to be challenging. We learned not to avoid these feelings of trepidation and concern, but to ask about them directly alongside aspects of their future that the couple looks forward to. When asked about their future together, Charlie said, “I look forward to being together, taking care of each other, and enjoying our time together.” Renee added, “We have always worked as a team and we are still a team. I am anticipating establishing our new home and doing things with our grandkids, daughter and son-in-law. At the same time, it will be hard to leave behind our house and our friends.” These quotes indicate the bittersweet feelings of loss as well as hope that couples brought to their future outlook. In addressing their future directly, couples were able to identify positive aspects of their future together even in the face of anticipated cognitive losses. Additionally, despite the fact that the Life Story Book is completed in the context of the intervention, we sought to help clients see it as a living document that can be expanded on as they continue their lives together. As such, we asked couples to think about how they would expand the book following the end of the intervention, left couples with additional blank pages in their book to facilitate this process, and encouraged them to use the book regularly to serve as a trigger for their mutual reminiscing.

Conclusions Utilizing narrative therapeutic techniques, such as those employed by the Couples Life Story Approach, with couples in which one spouse is dealing with memory loss is a promising

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approach for clinical social work practice. Participants frequently commented that they found the reminiscing process pleasant. Further, initial evaluation results indicate that this intervention is promising for improving couples’ communication with one another and strengthening their identity as a couple. Further, this innovative approach illuminates some of the challenges that may emerge when utilizing a narrative approach in clinical social work practice with couples with dementia, as well as some practice strategies for addressing these issues. These insights may also benefit clinical social workers who primarily utilize other therapeutic modalities, particularly those working with older adults, couples, or people with dementia.

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In addition to the strategies outlined previously, other implications for clinical social work practice are evident from the Couples Life Story Approach. Co-constructing couples’ narratives was sometimes challenging for the clinical social workers in this project, as we sought to help couples tell their story. In this role we identified themes within couples’ stories, guided the conversation in particular directions, helped identify which stories would be included in the final Life Story Book, and used our narrative voice to summarize their accounts. We sought to address the issue of the power of the social worker/narrator by soliciting ongoing weekly feedback from couples about their Life Story Book, as well as by utilizing the weekly team meetings to reflect on our accounts of their stories. Nevertheless, these issues of power, authorship and critical reflection remain significant components of narrative clinical practice.

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These findings also reveal implications for future clinical research. Notably, this project represents one of the few models for clinical work with older couples with memory loss. As social workers seek to improve the quality of life of our quickly-growing aging population, future scholarship should expand our knowledge about effective practice modalities, clinical issues and therapeutic strategies. Our approach to this project also highlights the effectiveness of the case study method. By looking at multiple cases and systematically analyzing common clinical challenges and effective strategies, we were able to gain further insights about common challenges associated with a dyadic narrative approach when addressing dementia. This multiple case study approach holds promise for future scholarship as social work practitioners develop innovative practice strategies.

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Additionally, future research must also assess the applicability of an intervention such as the Couples Life Story Approach to a more diverse sample of couples, across characteristics such as race, socio-economic status, sexual orientation, and geography. We are currently working to assess the transferability of this approach amongst a more diverse group of couples within the United States, as well as internationally. We encourage others to adopt and adapt, as appropriate, this approach to clinical research and practice with other populations. Expanding beyond the issues of memory loss and dementia may be another fruitful path for clinical researchers, as this approach may translate well to older couples facing other challenging issues.

Acknowledgments The authors would like to express their appreciation to Becky Allen, Ruth Campbell, Barbara Haight and Yukiko Kurokowa for their assistance with intervention development, Louis Burgio and Joe Himle for their consultation on

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translational research methods, and to Minyoung Kwak and the other graduate students involved on the research team. We would also like to thank the Michigan Institute for Clinical and Health Research (UL1RR024986), NIA Training Grant AG0017, and the University of Michigan School of Social Work for their financial support. In addition, we appreciate the University of Michigan Alzheimer's Disease Center, the Alzheimer's Association (Great Lakes Michigan Chapter, Greater Michigan Chapter, and Northwest Ohio Chapter), and the University of Michigan Geriatrics Center Clinics for their assistance with recruitment.

Biography Kristin Scherrer, PhD, MSW is an Assistant Professor in the School of Social Work at Rutgers, the State University of New Jersey. Dr. Scherrer conducts research on aging and the lifecourse, families, and Gay, Lesbian, Bisexual, Transgender and Queer sexualities that informs clinical social work practice.

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Berit Ingersoll-Dayton, PhD, MSW is a Professor and Director of the Joint Doctoral Program in Social Work and Social Science at the University of Michigan. She conducts research on families in later life, including issues pertaining to cross-cultural variations and clinical practice. Beth Spencer, LMSW, MA is a clinical social worker who has specialized in dementia care for more than 30 years in a variety of settings, including a cognitive disorders clinic, an adult day program, residential care and private practice. She is the co-author of several practical manuals for family caregivers.

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