Copyright 1987 byThe Cerontological Society of America

Family caregivers of elderly community-dwelling dementia patients who were randomlyassigned to 1 of 2 types of support groups completed pregroup, postgroup, and followup

assessments. A waiting list condition was also used. Results indicated that although caregiversrated the groups as quite helpful, group participation did not lead to improvements onobjective measures of depression, life satisfaction, social support, or coping variables.

Discussed are methodological issues in assessing the efficacy of caregiver groups, as well asclinical implications.

Key Words: Family caregivers, Support groups

Experimental Evaluation of the Effectivenessof Group Intervention for DementiaCaregivers1

William E. Haley, PhD,2 S. Lane Brown, MA,3 and Ellen G. Levine, MA4

Family caregivers of elderly patients with Alzhei-mer's disease and related dementias clearly experi-ence high levels of stress (Mace & Rabins, 1981; Zaritet al., 1985), which often leads to such negativecaregiver outcomes as depression, interference withsocial activities, and health difficulties (Haley et al.,in press; Pagel et al., 1985; Zarit et al., 1980). Becauseof these stresses, psychosocial interventions forcaregivers, emphasizing information, problem-solv-ing, and emotional support, have been described bya number of clinicians (Aronson et al., 1984; Barneset al., 1981; Schmidt & Keyes, 1985; Zarit & Zarit,1982) and widely implemented.

Unfortunately, there has been little systematic re-search on the effectiveness of psychosocial interven-tion for caregivers. Most published reports havebeen clinical descriptions of group intervention,which reported clinicians' observations of positiveeffects of groups without controlled assessment ofoutcome. Most of the published studies which haveattempted to more systematically evaluate the effec-tiveness of caregiver groups have had methodologi-cal problems such as sole reliance on participants'reports of satisfaction, or failure to randomly assignparticipants to treatment and control conditions(Glosser & Wexler, 1985; Kahan et al., 1985), whichlimited accurate assessment of the effectiveness ofthese groups. These studies have, however, beenimportant first steps in evaluating outcome in

Supported by a grant from the AARP Andrus Foundation. Appreciation isexpressed to Jack Berry, Bonanza Hale, Jackie Logue, Glenn Hughes, BetsMurray, and Al Bartolucci for their assistance with the project.

Assistant Professor, Department of Psychology, Associate Scholar, Cen-ter for Aging, and Staff Psychologist, Birmingham Veterans AdministrationMedical Center, University of Alabama at Birmingham, Birmingham, AL35294.

3Doctoral Candidate, Medical Psychology Program, Department of Psy-chology, University of Alabama at Birmingham, Birmingham, AL 35294.

4Doctoral Candidate, Medical Psychology Program, Department of Psy-chology, University of Alabama at Birmingham, Birmingham, AL 35294.

caregiver groups and have tended to support clinicalobservations that these groups are effective.

The current project was aimed at systematicallyevaluating the effectiveness of group interventionfor caregivers of elderly dementia patients. Two for-mats were compared, a supportive group and agroup with both supportive and stress-managementcomponents. A waiting list control group was alsoused. Also included in the study were several impor-tant methodological features, such as random as-signment of caregivers to conditions and confiden-tial assessment of outcome measures by researchassistants who were blind to whether caregiverswere in treatment versus waiting list conditions. Acomprehensive series of outcome measures wasused which in prior research (Haley et al., in press)has been found to be affected by the stress of care-giving, including depression, life satisfaction, andsocial activity variables. In addition, effects of thegroups were assessed on a number of exploratoryvariables, such as coping style. Finally, measures ofparticipant satisfaction were included with thegroups as a whole and major components of thegroups as a way of identifying particular aspects ofgroup participation seen as most helpful by partici-pants. The hypothesis was that participation in thegroups would lead to decreased depression, in-creased life satisfaction, and increased social activity.

Method

Recruitment of Participants

Participants were recruited through a local Alzhei-mer's Disease Society as part of a larger project toassess the stress-related consequences of caring foran elderly relative with dementia (Haley et al., inpress). To maximize the likelihood that participantshad not already received the full benefit of support

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group intervention, potential participants were ex-cluded from the study if they had participated in sixor more sessions of the local monthly Alzheimer'ssupport group. Other participants were solicitedthrough local radio and newspapers, social serviceand home health agencies, and physician referral.Potential participants went through a 2-stage screen-ing to assure that they were family caregivers ofelderly patients with dementia. First, a telephonescreening of each potential participant was com-pleted to assure that they had at least weekly directcaregiving responsibility for a community-dwellingfamily member, over age 60, with at least 6 months ofdisability and cognitive impairment suggestive of de-mentia. Caregivers were also interviewed concern-ing medical evaluations received by their patientsand were included only if their patient had received adiagnosis consistent with dementia. For families whopassed this telephone screening, an additional ses-sion was arranged in which the relative identified asimpaired was administered the Mini-Mental State(MMS) (Folstein et al., 1975), a widely used measureof cognitive impairment, to ascertain whether therelative had significant cognitive impairment. Fami-lies whose relative scored over 24 on the MMS wereexcluded from the study. The resultant 54 potentialcaregiver participants were then further assessedand entered into the treatment outcome study.

Caregivers were solicited in two stages through ayear-long period. During the first wave of recruit-ment, 34 families were recruited and randomly as-signed to 1 of the 2 types of treatment groups or awaiting list control group. During the second wave ofrecruitment, 20 families were recruited and ran-domly assigned to 1 of the 2 types of groups. Ran-domization took place after the caregivers had beengiven all initial assessment measures.

All assessments were completed by 1 of 2 researchassistants who were blind to whether caregiverswere in treatment or in waiting list conditions. Mostassessments, including initial assessments, post-group assessments, and follow-up assessments,were conducted in caregivers' homes to maximizecompliance with the repeated assessments.

Characterization of the Groups

All group sessions were co-led by the first author, amale clinical psychologist with experience in psycho-social intervention with caregivers, and the secondauthor, a female graduate student in clinical psychol-ogy. A treatment manual describing the groups' spe-cific goals and structure was developed and utilizedin order to reliably administer the interventions.Croups were closed and time-limited and averagedabout 5 participants each. Because of their size andstructure, groups were characterized by rather quickdevelopment of trust between group members and anorm of mutual concern and helping. For eachgroup, 7 weekly sessions were followed by a post-group evaluation, then two sessions at 2-week inter-vals, and a final follow-up group after a 1 monthdelay. After this final meeting, participants com-

pleted the follow-up assessments. This format wasdeveloped to maximize participants' initial benefitfrom the group and to fade, rather than abruptlyterminate, therapist contact.

Conditions

Waiting list. — Caregivers assigned to the waitinglist group were re-assessed on two occasions, whenthe caregivers in the two active groups received theirpost-group and follow-up assessments. They werelater given the opportunity to participate in groupsidentical to those offered to caregivers who wererandomized to immediate treatment.

Support group. — Participants in this group weregiven 10 sessions, of Vh hours apiece, of structuredintervention. Groups were designed utilizing theconceptual model described byZaritandZarit (1982),including emphasis on information about dementia,emotional support, and assistance in problem-solv-ing. The initial six sessions had clearly structuredformats designed to systematically address the prob-lems faced by caregivers. Specifically, the first ses-sion included introductions and a lecture and discus-sion about the causes of cognitive impairment,stages of dementia, and common behavioral, intel-lectual, and self-care problems encountered in dif-ferent stages of dementia. Caregivers were givencopies of Mace and Rabins' (1981) book, The 36 HourDay, and several brochures about Alzheimer's dis-ease and other causes of cognitive impairment. Dur-ing the second session, didactic presentations aboutthe effects of Alzheimer's disease on the brain, in-cluding some basic neuropsychological informationabout how damage to different areas of the brainaffects patients' behavior, was presented. Informa-tion and discussion was included about problems incommunicating with the dementia patient and man-agement of behavioral problems encountered bycaregivers, using group problem-solving efforts andadvice from group leaders.

Included in the third session was a presentation bythe consulting nurse, an experienced RN who wasDirector of Nursing at a local home health agency,who discussed home nursing care of dementia pa-tients. The session included discussion of specificproblems either being encountered, or anticipated,by group participants. The fourth session was fo-cused on the necessity of the caregiver utilizing out-side resources, such as the help of family andfriends, community agencies, or paid help. Care-givers were also encouraged to structure time awayfrom their caregiving responsibilities to give them-selves a break and to maximize their ability to con-tinue caregiving as best as they could and discussedwere barriers to seeking help and support.

Included in the fifth session was a presentation bythe consulting social worker, an MSW who was theDirector of Social Services at a local home healthagency. The social worker developed a comprehen-sive resource guide for caregivers, including infor-mation about Medicare, Medicaid, in-home services,

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day care centers, resources for medication and psy-chiatric consultation, sitter services, legal consulta-tion relevant to problems of dementia patients, res-pite services, nursing homes, and domiciliaries andboarding homes. Caregivers were given copies ofthe resource guide and reviewed their particularsituations and likely resources which might be help-ful to them.

The sixth session was focused specifically on care-givers' psychological reactions to being caregiversand ways to manage the stress of their role. Emotionsof depression, guilt, anxiety, anger, and resentment,among other reactions, were included.

The seventh to tenth sessions did not have specificstructured content, but caregivers were encouragedto discuss issues of concern to them. In addition,problems which had been discussed in earlier ses-sions were followed up on. Common topics of dis-cussion, besides those covered during the earliersessions, included feelings about the death of pa-tients, conflicts with other family members, andproblems in carrying out plans discussed during ear-lier groups. Included in the final session was a reviewof each participant's experience during the groupsand of future plans.

Support/skills group. —This group was conductedin a manner similar to the support group, but withthe addition of specific material on the use of stress-management skills. Caregivers received training inprogressive relaxation and were taught cognitiveskills for managing negative cognitions which mightbe a factor in depression, anxiety, excessive anger,and guilt. These cognitive interventions were mod-eled after the techniques developed by Beck et al.(1979). When appropriate, participants also re-hearsed specific problem situations encountered(e.g., asking a reluctant relative for help) and utilizedbehavioral assignments for attaining treatment goals.

Measures

Descriptive measures. — Demographic informa-tion on the age, race, sex, marital status, and incomeof participants was gathered. Age and sex of partici-pants' impaired patients and caregivers' report of theduration of patient memory loss were also assessed.For descriptive purposes caregivers also completedinterview assessments of their impaired relatives'degree of disability, including the number of impair-ments on the 6-item Activities of Daily Living (ADL)(Katz et al., 1963) and 8-item Instrumental Activitiesof Daily Living (IADL) (Lawton & Brody, 1969) scales.A modified version of the Memory and BehaviorProblems Checklist (MBPC) (Zarit & Zarit, 1982) wasalso used, in which the occurrence of 17 behavioralproblems in the impaired patient over the pastmonth was assessed.

Objective outcome measures. —The Beck Depres-sion Inventory (BDI) (Beck et al., 1961) was used as ameasure of severity of depression. The BDI is a 21-item measure which assesses mood, vegetative, and

cognitive aspects of depression and which has beensuccessfully validated and used as a treatment out-come measure with both young and elderly patients(e.g., Gallagher et al., 1983; Gallagher et al., 1982;Lewinsohn & Teri, 1982; Steuer et al., 1984). Partici-pants also completed the Life Satisfaction Index - Z(LSIZ) (Wood et al., 1969), a 13-item scale concerningperceived life satisfaction. The LSIZ has good psycho-metric qualities and has been found to reflect posi-tive and negative change in overt life circumstancesover time and in treatment outcome studies (Thomp-son et al., 1983; Wood et al., 1969; Wylie, 1970).

Negative impact on elderly-caregiver family rela-tionship (ECR) (Poulshock & Deimling, 1984), an 11-item, factor-derived scale, assesses family members'negative affect toward a relative, including feelingsof anger and resentment. In past research (Poul-shock & Deimling, 1984), the scale was found to berelated to disruptive behavior of the impaired elderlypatient and the patient's impairment in activities ofdaily living. These items were adopted for use in aquestionnaire format by asking participants to rateeach item on a 0 (not at all) to 3 (extremely) scale.Caregivers completed the scale with reference totheir impaired elderly relative.

Several measures of social activity were also in-cluded. From the Health and Daily Living Form(HDLF) (Moos et al., 1984), which has been widelyused in research on stress and coping, scales wereused for activities with friends and for activities withfamily members. For each scale, caregivers notedhow many of 11 activities, such as taking a walk, theyhad engaged in over the past month, separately forfamily members and for friends.

A measure of social network satisfaction was at-tained by summing caregivers' ratings of satisfactionwith five aspects of their social networks from theHDLF Scales (number of friends, close friends, peo-ple who would help, clubs, and church attendance)on a scale of 0 (not at all satisfied) to 3 (extremelysatisfied).

Besides the prior published data on the objectiveoutcome measures, all of these measures had beenfound to differ significantly between caregivers and amatched control sample (Haley et al., in press), withcaregivers showing higher levels of depression andnegative affect and lower levels of life satisfaction,social activity, and network satisfaction. In addition,correlation analyses showed that the social networkand activity variables were significantly correlatedwith caregiver depression and life satisfaction.

Exploratory measure. — To explore the mecha-nisms of any changes found in caregiver functioning,several measures of caregiver coping responses werealso assessed. In particular, individual differences incoping responses were assessed using scales fromthe HDLF (Moos et al., 1984). Information on psycho-metric properties of the scales, which have beenused in many studies of stress and coping, and theirvalidity, are summarized elsewhere (Billings & Moos,1984; Moos et al., 1984). Participants rated the degreeto which they used each coping response on the

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questionnaire on a scale of 0 (not at all) to 3 (ex-tremely often). The five subscales included:

1. Logical analysis, a 4-item scale, including suchitems as, "Went over the situation in my mind to tryto understand it."

2. Information seeking, a 7-item scale, includingitems such as, "Tried to find out more about thesituation."

3. Problem solving, a 5-item scale, included,"Made a plan of action and followed it."

4. Affective regulation, a 6-item scale, had itemssuch as, "Got busy with other things to keep mymind off the problem."

5. Emotional discharge, a 6-item scale, includedsuch items as, "Let my feelings out somehow."

Because no a priori predictions were made aboutwhat types of changes in coping responses wouldrepresent improved outcomes, these measures wereincluded on an exploratory basis and were given onlyat pretreatment and follow-up assessments.

Participant satisfaction. — To assess caregivers'overall satisfaction with the groups and impressionsof helpful components of the groups, participantscompleted an additional questionnaire after the fol-low-up evaluation. The Impressions of the CaregiverGroup form was modeled after a questionnaire spe-cifically developed for the evaluation of caregivergroups (Woods, 1984). The questionnaire listed 40aspects of the potentially beneficial aspects of thegroup and caregivers were asked to mark itemswhich they felt were helpful to them. In addition,they rated their overall satisfaction with the groupson a 1 (not at all satisfied) to 5 (extremely satisfied)scale.

Comparability of Groups

Preliminary analyses were conducted on all demo-graphic, descriptive, and dependent variables to en-sure that pre-treatment dependent variables wereequivalent between the 2 treatment groups and thewaiting list control group. Categorical variables wereanalyzed with chi-squared analyses. All analyses ofvariance (ANOVA) were performed using the SASInstitute, Inc. (1982) General Linear Model proce-dure to adjust for discrepant cell sizes. When one-way ANOVAs were computed on the pre-treatmentcontinuous descriptive, demographic, and depen-dent variables, no significant differences were foundbetween groups on any of these measures.

The dementia patients in the sample were primar-ily female Caucasians, with an average age of 78.3years. The patient sample can be considered to be inthe moderate to severe range of impairment, averag-ing 5 years of caregiver-reported cognitive impair-ment, 9.7 items correct on the MMS, 2.9 deficits onthe ADL, 7.5 disabilities on the IADL, and 7.5 currentproblems on the MBPC. Family caregivers were pri-marily spouses and daughters and their average agewas 56. Caregivers reported an average family in-come of $24,000 and an average of 13.7 years ofeducational attainment.

A number of participants did not complete theadditional assessments after randomization, most forreasons beyond their control. Two of the waiting listcaregivers did not complete the two follow-up as-sessments, one because of the death of his patientand one because of her own illness and hospitaliza-tion. Of the 43 caregivers assigned to the two treat-ment groups, 12 either did not attend our minimumcriterion number of 6 out of 10 sessions, or wereunable to complete 1 or more assessments and werethus classified as dropouts and removed from thesubsequent treatment outcome data. Most attendedeither 0 or 1 sessions, usually because of patientdeath, inability to find a sitter, or personal illness.Seven dropouts were in the support group and 5were in the support/skills group, leaving 9 caregiversin the waiting list group, 14 in the support group, and17 in the support/skills group.

Pre-treatment data of dropouts from the waitinglist and treatment groups were statistically comparedwith completers on all dependent and demographicmeasures. Dropouts had lower incomes and theirimpaired relatives had lower scores on the MMS thancompleters, but did not differ significantly on anypretreatment outcome measures.

Finally, the 2 groups of treatment completers werecompared with the waiting list group on all pre-treatment dependent measures with a one-wayANOVA. No significant between-group differenceswere found. Although there was a substantial drop-out among those who enrolled in the groups, thegroups remained comparable on pre-treatment de-mographic and dependent measures.

Results

The subsequent treatment outcome analyses wereperformed on caregivers who completed the groupsand measures, as well as on waiting list caregivers.When data were analyzed by a repeated measuresANOVA with 3 groups and 3 times of measurement,and significant effects were assessed by using theleast-squares means procedure, there were no sig-nificant effects for time of measurement, or the inter-action of group x time of measurement, for any ofthe dependent variables. Significant main effectswere found, however, for groups on several mea-sures. On the use of the coping style of emotionaldischarge a significant main effect was found (p <.05) and it was revealed by subsequent analyses thatwaiting list subjects used higher levels of emotionaldischarge than the 2 treatment groups. Significantmain effects for group were also found on the use ofthe coping style of affective regulation (p < .05), withmembers of the support group having lower scorescompared with the support/skills and waiting listgroups. Repeated measures ANOVAs on the descrip-tive measures also indicated no significant changesin patient impairment over the course of the studyfor treatment or waiting list groups.

The absence of any significant effects for the inter-action of time and group suggested that group partic-ipants did not show significantly greater improve-

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ment over time as compared to waiting list controlson any of the dependent measures. Scores on thedependent measures were relatively stable overtime, as indicated by the lack of any significant ef-fects for time of measurement. The significant groupdifferences which were found were probably due tothe effects of differential dropout from the groups,with statistical significance attained on these analy-ses because of the increased power of the repeated-measures analysis to detect stable differences be-tween groups.

On the measure of participants' satisfaction withthe treatment groups, the 2 treatment groups did notdiffer significantly on analysis of variance. The over-all mean, including waiting list caregivers who latercompleted the group, was 4.57 on the 1 to 5 scale,with 76% of participants endorsing the highest levelof satisfaction. Croup participants were clearly en-thusiastic about the value of the groups.

Caregivers' evaluations of the components of thegroup experience considered to be helpful to themwere also analyzed. Few significant differences were

found between items endorsed by participants in the2 types of groups, so for simplicity of presentationthe percentage of group participants in the totalsample endorsing each item was computed. Asshown in Table 1, the highest-rated items includedthe value of belonging to a group with others withsimilar problems, learning about available commu-nity resources, learning about the effects of demen-tia on the brain and behavior, and receiving encour-agement to experiment with new ways to manageproblems. It was again suggested by the high per-centages of group participants endorsing these itemsthat participants were enthusiastic about the benefitsof the groups.

Discussion

The data yielded mixed and paradoxical results.On measures of caregivers' satisfaction with thegroups and caregivers' ratings of the important com-ponents of group membership, the groups wereconsistently rated as helpful and as addressing the

Table 1. Items Described as Helpful by Group Participants Ordered by Their Endorsement (/? = 37)

Item % Endorsing

1. Learning that my problems were not unique; that others who face a similar situation also had experiences like 92mine.

2. Learning about available community resources and getting the resource guide from the social worker. 923. Finding out about the effects of dementia on the brain and how this affects my relative's behavior. 894. Getting encouragement to experiment with new ways of managing my problems. 895. Belonging; being an involved member of the group; feeling close to others. 896. Receiving encouragement to consider not only my relative's needs, but also my own life and my own happiness. 867. Seeing how others were coping and enduring was inspiring and uplifting to me. 848. Being able to express warm feelings to others in the group. 849. Seeing different ways of approaching the same problem. 84

10. Seeing how others were handling situations similar to mine. 8411. Gaining insight into the causes and sources for the difficulties I have experienced. 8112. Receiving advice or practical suggestions about how to deal with some of my problems. 8113. Learning what medical science knows about senile dementia. 8114. Expressing negative feelings, getting some things off my chest, being able to talk rather than hold it in. 8115. Feeling supported and approved of by the others in group. 8116. Learning about nursing management (such as hygiene, bowel and bladder) from the registered nurse. 8117. Recognizing that the tasks of caring for an impaired relative were extremely difficult for everyone. 7818. Getting honest feedback from others about what I was doing. 7819. Finding that there were other people I could turn to for help; no longer feeling alone. 7820. Coming to accept the true condition of the person I am caring for and what I can and cannot do for him/her. 7821. Receiving encouragement to get away from my caregiving responsibilities occasionally (take a break). 7622. Revealing some of my fears and anxieties. 7623. Understanding better the person I am caring for. 7324. Helping others who were facing a similar situation, giving part of myself to others. 7325. Receiving encouragement to get outside help in caring for my relative. 6826. Specific planning or practice during the group about how to handle problems. 6527. Having the chance to get out of the house to come to the group. 6228. Learning new ways to think about my problems to help me control my emotions. 5929. Learning that I could count on my own judgment. 5930. Recognizing that I must take responsibility for my own decisions and actions in this situation. 5731. Understanding why I think and react the way I do. 5432. Learning progressive muscle relaxation techniques. 52a

33. Getting away from my problems for a while. 4934. Seeing that I was just as well off as others. 4935. Learning more about my own positive strengths. 4636. Having the opportunity to receive a free home visit from the nurse for evaluation of my patient. 4137. Getting a sense of hope. 3838. Learning how I come across to others. 3539. Recognizing that life is sometimes unjust and unfair. 3240. Finding someone I could pattern myself after. 14

an = 21 caregivers given relaxation training.

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concerns of caregivers. On more objective measuresof caregiver psychological and social functioning,however, group participants did not show significantchange after participation as compared with waitinglist control caregivers. In a recent study, Zarit et al.(in press) have reported similar results, in whichcaregivers receiving family counseling or supportgroup intervention showed no greater improvementafter treatment than an untreated waiting list controlgroup.

Several methodological factors may have made itdifficult to detect changes in caregiver psychologicaland social functioning after group participation.Caregivers were quite heterogeneous in their pre-treatment levels of distress, with some showing mini-mal problems of depression and other measures ofdistress. This heterogeneity made it difficult forgroup means to show significant improvement. Forexample, pre-treatment mean scores on the BDI arehigher than those found among non-caregiving con-trols (Haley et al., in press), but are in the range ofscores found after treatment by researchers investi-gating the effectiveness of group treatment of de-pression (e.g., Steuer et al., 1984). Future research-ers would be more likely to detect treatment effects ifcaregivers were pre-selected for high levels of pre-treatment distress.

Major random life events, such as changes in theseverity of patients' impairment or caregivers' healthstatus, also made it difficult to detect changes relatedto treatment. It appeared from clinical observationthat these events, which occurred independently oftreatment, often led to increases or decreases incaregiver distress. Such events also led to substantialattrition in the sample. It was also apparent that the 4-month period of follow-up was a relatively shortperiod, given the long-term nature of the caregivingrole and stresses. Although impossible given theconstraints of the current study, in a project focusedon outcomes over a longer period of time, beginningwith caregivers who have less severely impaired pa-tients, there might be more likelihood of detectingany beneficial effects of caregiver groups on psycho-social variables.

Albeit caregivers were subjectively satisfied withthe groups, group intervention did not lead to signifi-cant, measurable changes on objective measures ofcaregiver functioning and quality of life. It was sug-gested by the data that even professionally-led, com-prehensive, and seemingly successful caregivergroups may not be a sufficiently potent interventionto effect such measures, given the enormity of prob-lems faced by dementia caregivers. It was often ap-parent during group sessions that caregivers neededconcrete assistance, such as in-home chore services,sitters, and home health care, which they could notafford and which they were not eligible for on anyreduced charge or free basis. Effective managementof dementia patients and their families may requiremuch more comprehensive, intensive, and expen-sive services than could be provided in a time-limitedgroup setting, involving the coordination of psycho-social, medical, and home health services (e.g.,

Butler & Lewis, 1982; Reifler & Eisdorfer, 1980). Cer-tainly, however, it was indicated by the data thatcaregivers value the education and feelings of sup-port which they gained from group participation.Such time-limited group intervention may have abeneficial, but limited, impact.

Caregivers' responses to the participant checklistprovided important information about caregivers'perceptions of the important components of suc-cessful group intervention. Supported by theseresults was the suggestion by Zarit and Zarit (1982)that information, problem-solving, and emotionalsupport are essential components of such interven-tion. In particular, caregivers valued specific infor-mation about community resources and dementiaand its effects on the brain and behavior. The impor-tance of emotional support was most apparent incaregivers' ratings of the importance of identifyingwith other group members, belonging to a cohesivegroup, learning from others in the group, and sup-port for increasing attention to their own needs.Assistance with problem-solving appeared to be im-portant to caregivers, as indicated on several itemshaving to do with encouragement to experimentwith new approaches, direct advice, and modelingfrom other group participants. These ratings re-vealed that caregivers valued a number of outcomesnot assessed in this project, including increases inknowledge about dementia and about coping skillswhich might help them to face the progression ofdementia expected. Clinically, many caregivers alsoseemed more concerned with the goal of improvingtheir effectiveness as caregivers than with decreasingtheir current levels of distress. Objectively assessingchanges in these kinds of long-term outcomes tomore fully understand the benefits and limitations ofpsychosocial intervention will be a major challengefor future clinical research with caregiving families.

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