Experimental Evaluation of the Effectiveness of Group ...

Copyright 1987 by The Cerontological Society of America

Family caregivers of elderly community-dwelling dementia patients who were randomly assigned 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 caregivers rated the groups as quite helpful, group participation did not lead to improvements on objective measures of depression, life satisfaction, social support, or coping variables. Discussed are methodological issues in assessing the efficacy of caregiver groups, as well as clinical implications. Key Words: Family caregivers, Support groups

Experimental Evaluation of the Effectiveness of Group Intervention for Dementia Caregivers1

Family caregivers of elderly patients with Alzheimer's disease and related dementias clearly experience high levels of stress (Mace & Rabins, 1981; Zarit et al., 1985), which often leads to such negative caregiver outcomes as depression, interference with social activities, and health difficulties (Haley et al., in press; Pagel et al., 1985; Zarit et al., 1980). Because of these stresses, psychosocial interventions for caregivers, emphasizing information, problem-solving, and emotional support, have been described by a number of clinicians (Aronson et al., 1984; Barnes et al., 1981; Schmidt & Keyes, 1985; Zarit & Zarit, 1982) and widely implemented. Unfortunately, there has been little systematic research on the effectiveness of psychosocial intervention for caregivers. Most published reports have been clinical descriptions of group intervention, which reported clinicians' observations of positive effects of groups without controlled assessment of outcome. Most of the published studies which have attempted to more systematically evaluate the effectiveness of caregiver groups have had methodological problems such as sole reliance on participants' reports of satisfaction, or failure to randomly assign participants to treatment and control conditions (Glosser & Wexler, 1985; Kahan et al., 1985), which limited accurate assessment of the effectiveness of these groups. These studies have, however, been important first steps in evaluating outcome in

caregiver groups and have tended to support clinical observations that these groups are effective. The current project was aimed at systematically evaluating the effectiveness of group intervention for caregivers of elderly dementia patients. Two formats were compared, a supportive group and a group with both supportive and stress-management components. A waiting list control group was also used. Also included in the study were several important methodological features, such as random assignment of caregivers to conditions and confidential assessment of outcome measures by research assistants who were blind to whether caregivers were in treatment versus waiting list conditions. A comprehensive series of outcome measures was used which in prior research (Haley et al., in press) has been found to be affected by the stress of caregiving, including depression, life satisfaction, and social activity variables. In addition, effects of the groups were assessed on a number of exploratory variables, such as coping style. Finally, measures of participant satisfaction were included with the groups as a whole and major components of the groups as a way of identifying particular aspects of group participation seen as most helpful by participants. The hypothesis was that participation in the groups would lead to decreased depression, increased life satisfaction, and increased social activity. Method

Supported by a grant from the AARP Andrus Foundation. Appreciation is expressed to Jack Berry, Bonanza Hale, Jackie Logue, Glenn Hughes, Bets Murray, and Al Bartolucci for their assistance with the project. Assistant Professor, Department of Psychology, Associate Scholar, Center for Aging, and Staff Psychologist, Birmingham Veterans Administration Medical Center, University of Alabama at Birmingham, Birmingham, AL 35294. 3 Doctoral Candidate, Medical Psychology Program, Department of Psychology, University of Alabama at Birmingham, Birmingham, AL 35294. 4 Doctoral Candidate, Medical Psychology Program, Department of Psychology, University of Alabama at Birmingham, Birmingham, AL 35294.

Recruitment of Participants Participants were recruited through a local Alzheimer's Disease Society as part of a larger project to assess the stress-related consequences of caring for an elderly relative with dementia (Haley et al., in press). To maximize the likelihood that participants had not already received the full benefit of support

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

Characterization of the Groups All group sessions were co-led by the first author, a male clinical psychologist with experience in psychosocial intervention with caregivers, and the second author, a female graduate student in clinical psychology. A treatment manual describing the groups' specific goals and structure was developed and utilized in order to reliably administer the interventions. Croups were closed and time-limited and averaged about 5 participants each. Because of their size and structure, groups were characterized by rather quick development of trust between group members and a norm of mutual concern and helping. For each group, 7 weekly sessions were followed by a postgroup evaluation, then two sessions at 2-week intervals, and a final follow-up group after a 1 month delay. After this final meeting, participants comVol. 27, No. 3,1987

pleted the follow-up assessments. This format was developed to maximize participants' initial benefit from the group and to fade, rather than abruptly terminate, therapist contact. Conditions Waiting list. — Caregivers assigned to the waiting list group were re-assessed on two occasions, when the caregivers in the two active groups received their post-group and follow-up assessments. They were later given the opportunity to participate in groups identical to those offered to caregivers who were randomized to immediate treatment. Support group. — Participants in this group were given 10 sessions, of Vh hours apiece, of structured intervention. Groups were designed utilizing the conceptual model described byZaritandZarit (1982), including emphasis on information about dementia, emotional support, and assistance in problem-solving. The initial six sessions had clearly structured formats designed to systematically address the problems faced by caregivers. Specifically, the first session included introductions and a lecture and discussion about the causes of cognitive impairment, stages of dementia, and common behavioral, intellectual, and self-care problems encountered in different stages of dementia. Caregivers were given copies of Mace and Rabins' (1981) book, The 36 Hour Day, and several brochures about Alzheimer's disease and other causes of cognitive impairment. During the second session, didactic presentations about the effects of Alzheimer's disease on the brain, including some basic neuropsychological information about how damage to different areas of the brain affects patients' behavior, was presented. Information and discussion was included about problems in communicating with the dementia patient and management of behavioral problems encountered by caregivers, using group problem-solving efforts and advice from group leaders. Included in the third session was a presentation by the consulting nurse, an experienced RN who was Director of Nursing at a local home health agency, who discussed home nursing care of dementia patients. The session included discussion of specific problems either being encountered, or anticipated, by group participants. The fourth session was focused on the necessity of the caregiver utilizing outside resources, such as the help of family and friends, community agencies, or paid help. Caregivers were also encouraged to structure time away from their caregiving responsibilities to give themselves a break and to maximize their ability to continue caregiving as best as they could and discussed were barriers to seeking help and support. Included in the fifth session was a presentation by the consulting social worker, an MSW who was the Director of Social Services at a local home health agency. The social worker developed a comprehensive resource guide for caregivers, including information about Medicare, Medicaid, in-home services, 377


group intervention, potential participants were excluded from the study if they had participated in six or more sessions of the local monthly Alzheimer's support group. Other participants were solicited through local radio and newspapers, social service and home health agencies, and physician referral. Potential participants went through a 2-stage screening to assure that they were family caregivers of elderly patients with dementia. First, a telephone screening of each potential participant was completed to assure that they had at least weekly direct caregiving responsibility for a community-dwelling family member, over age 60, with at least 6 months of disability and cognitive impairment suggestive of dementia. Caregivers were also interviewed concerning medical evaluations received by their patients and were included only if their patient had received a diagnosis consistent with dementia. For families who passed this telephone screening, an additional session was arranged in which the relative identified as impaired was administered the Mini-Mental State (MMS) (Folstein et al., 1975), a widely used measure of cognitive impairment, to ascertain whether the relative had significant cognitive impairment. Families whose relative scored over 24 on the MMS were excluded from the study. The resultant 54 potential caregiver participants were then further assessed and entered into the treatment outcome study. Caregivers were solicited in two stages through a year-long period. During the first wave of recruitment, 34 families were recruited and randomly assigned to 1 of the 2 types of treatment groups or a waiting list control group. During the second wave of recruitment, 20 families were recruited and randomly assigned to 1 of the 2 types of groups. Randomization took place after the caregivers had been given all initial assessment measures. All assessments were completed by 1 of 2 research assistants who were blind to whether caregivers were in treatment or in waiting list conditions. Most assessments, including initial assessments, postgroup assessments, and follow-up assessments, were conducted in caregivers' homes to maximize compliance with the repeated assessments.

Support/skills group. —This group was conducted in a manner similar to the support group, but with the addition of specific material on the use of stressmanagement skills. Caregivers received training in progressive relaxation and were taught cognitive skills for managing negative cognitions which might be a factor in depression, anxiety, excessive anger, and guilt. These cognitive interventions were modeled after the techniques developed by Beck et al. (1979). When appropriate, participants also rehearsed specific problem situations encountered (e.g., asking a reluctant relative for help) and utilized behavioral assignments for attaining treatment goals. Measures Descriptive measures. — Demographic information on the age, race, sex, marital status, and income of participants was gathered. Age and sex of participants' impaired patients and caregivers' report of the duration of patient memory loss were also assessed. For descriptive purposes caregivers also completed interview assessments of their impaired relatives' degree of disability, including the number of impairments on the 6-item Activities of Daily Living (ADL) (Katz et al., 1963) and 8-item Instrumental Activities of Daily Living (IADL) (Lawton & Brody, 1969) scales. A modified version of the Memory and Behavior Problems Checklist (MBPC) (Zarit & Zarit, 1982) was also used, in which the occurrence of 17 behavioral problems in the impaired patient over the past month was assessed. Objective outcome measures. —The Beck Depression Inventory (BDI) (Beck et al., 1961) was used as a measure of severity of depression. The BDI is a 21item measure which assesses mood, vegetative, and 378

Exploratory measure. — To explore the mechanisms of any changes found in caregiver functioning, several measures of caregiver coping responses were also assessed. In particular, individual differences in coping responses were assessed using scales from the HDLF (Moos et al., 1984). Information on psychometric properties of the scales, which have been used in many studies of stress and coping, and their validity, are summarized elsewhere (Billings & Moos, 1984; Moos et al., 1984). Participants rated the degree to which they used each coping response on the The Gerontologist


cognitive aspects of depression and which has been successfully validated and used as a treatment outcome measure with both young and elderly patients (e.g., Gallagher et al., 1983; Gallagher et al., 1982; Lewinsohn & Teri, 1982; Steuer et al., 1984). Participants also completed the Life Satisfaction Index - Z (LSIZ) (Wood et al., 1969), a 13-item scale concerning perceived life satisfaction. The LSIZ has good psychometric qualities and has been found to reflect positive and negative change in overt life circumstances over time and in treatment outcome studies (Thompson et al., 1983; Wood et al., 1969; Wylie, 1970). Negative impact on elderly-caregiver family relationship (ECR) (Poulshock & Deimling, 1984), an 11item, factor-derived scale, assesses family members' negative affect toward a relative, including feelings of anger and resentment. In past research (Poulshock & Deimling, 1984), the scale was found to be related to disruptive behavior of the impaired elderly patient and the patient's impairment in activities of daily living. These items were adopted for use in a questionnaire format by asking participants to rate each item on a 0 (not at all) to 3 (extremely) scale. Caregivers completed the scale with reference to their impaired elderly relative. Several measures of social activity were also included. From the Health and Daily Living Form (HDLF) (Moos et al., 1984), which has been widely used in research on stress and coping, scales were used for activities with friends and for activities with family members. For each scale, caregivers noted how many of 11 activities, such as taking a walk, they had engaged in over the past month, separately for family members and for friends. A measure of social network satisfaction was attained by summing caregivers' ratings of satisfaction with five aspects of their social networks from the HDLF Scales (number of friends, close friends, people who would help, clubs, and church attendance) on a scale of 0 (not at all satisfied) to 3 (extremely satisfied). Besides the prior published data on the objective outcome measures, all of these measures had been found to differ significantly between caregivers and a matched control sample (Haley et al., in press), with caregivers showing higher levels of depression and negative affect and lower levels of life satisfaction, social activity, and network satisfaction. In addition, correlation analyses showed that the social network and activity variables were significantly correlated with caregiver depression and life satisfaction.

day care centers, resources for medication and psychiatric consultation, sitter services, legal consultation relevant to problems of dementia patients, respite services, nursing homes, and domiciliaries and boarding homes. Caregivers were given copies of the resource guide and reviewed their particular situations and likely resources which might be helpful to them. The sixth session was focused specifically on caregivers' psychological reactions to being caregivers and ways to manage the stress of their role. Emotions of depression, guilt, anxiety, anger, and resentment, among other reactions, were included. The seventh to tenth sessions did not have specific structured content, but caregivers were encouraged to discuss issues of concern to them. In addition, problems which had been discussed in earlier sessions were followed up on. Common topics of discussion, besides those covered during the earlier sessions, included feelings about the death of patients, conflicts with other family members, and problems in carrying out plans discussed during earlier groups. Included in the final session was a review of each participant's experience during the groups and of future plans.

Participant satisfaction. — To assess caregivers' overall satisfaction with the groups and impressions of helpful components of the groups, participants completed an additional questionnaire after the follow-up evaluation. The Impressions of the Caregiver Group form was modeled after a questionnaire specifically developed for the evaluation of caregiver groups (Woods, 1984). The questionnaire listed 40 aspects of the potentially beneficial aspects of the group and caregivers were asked to mark items which they felt were helpful to them. In addition, they rated their overall satisfaction with the groups on a 1 (not at all satisfied) to 5 (extremely satisfied) scale. Comparability of Groups Preliminary analyses were conducted on all demographic, descriptive, and dependent variables to ensure that pre-treatment dependent variables were equivalent between the 2 treatment groups and the waiting list control group. Categorical variables were analyzed with chi-squared analyses. All analyses of variance (ANOVA) were performed using the SAS Institute, Inc. (1982) General Linear Model procedure to adjust for discrepant cell sizes. When oneway ANOVAs were computed on the pre-treatment continuous descriptive, demographic, and dependent variables, no significant differences were found between groups on any of these measures. The dementia patients in the sample were primarily female Caucasians, with an average age of 78.3 years. The patient sample can be considered to be in the moderate to severe range of impairment, averaging 5 years of caregiver-reported cognitive impairment, 9.7 items correct on the MMS, 2.9 deficits on the ADL, 7.5 disabilities on the IADL, and 7.5 current problems on the MBPC. Family caregivers were primarily spouses and daughters and their average age was 56. Caregivers reported an average family income of $24,000 and an average of 13.7 years of educational attainment. Vol.27, No. 3,1987

A number of participants did not complete the additional assessments after randomization, most for reasons beyond their control. Two of the waiting list caregivers did not complete the two follow-up assessments, one because of the death of his patient and one because of her own illness and hospitalization. Of the 43 caregivers assigned to the two treatment groups, 12 either did not attend our minimum criterion number of 6 out of 10 sessions, or were unable to complete 1 or more assessments and were thus classified as dropouts and removed from the subsequent treatment outcome data. Most attended either 0 or 1 sessions, usually because of patient death, inability to find a sitter, or personal illness. Seven dropouts were in the support group and 5 were in the support/skills group, leaving 9 caregivers in the waiting list group, 14 in the support group, and 17 in the support/skills group. Pre-treatment data of dropouts from the waiting list and treatment groups were statistically compared with completers on all dependent and demographic measures. Dropouts had lower incomes and their impaired relatives had lower scores on the MMS than completers, but did not differ significantly on any pretreatment outcome measures. Finally, the 2 groups of treatment completers were compared with the waiting list group on all pretreatment dependent measures with a one-way ANOVA. No significant between-group differences were found. Although there was a substantial dropout among those who enrolled in the groups, the groups remained comparable on pre-treatment demographic and dependent measures. Results

The subsequent treatment outcome analyses were performed on caregivers who completed the groups and measures, as well as on waiting list caregivers. When data were analyzed by a repeated measures ANOVA with 3 groups and 3 times of measurement, and significant effects were assessed by using the least-squares means procedure, there were no significant effects for time of measurement, or the interaction of group x time of measurement, for any of the dependent variables. Significant main effects were found, however, for groups on several measures. On the use of the coping style of emotional discharge a significant main effect was found (p < .05) and it was revealed by subsequent analyses that waiting list subjects used higher levels of emotional discharge than the 2 treatment groups. Significant main effects for group were also found on the use of the coping style of affective regulation (p < .05), with members of the support group having lower scores compared with the support/skills and waiting list groups. Repeated measures ANOVAs on the descriptive measures also indicated no significant changes in patient impairment over the course of the study for treatment or waiting list groups. The absence of any significant effects for the interaction of time and group suggested that group participants did not show significantly greater improve-

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questionnaire on a scale of 0 (not at all) to 3 (extremely often). The five subscales included: 1. Logical analysis, a 4-item scale, including such items as, "Went over the situation in my mind to try to understand it." 2. Information seeking, a 7-item scale, including items such as, "Tried to find out more about the situation." 3. Problem solving, a 5-item scale, included, "Made a plan of action and followed it." 4. Affective regulation, a 6-item scale, had items such as, "Got busy with other things to keep my mind off the problem." 5. Emotional discharge, a 6-item scale, included such items as, "Let my feelings out somehow." Because no a priori predictions were made about what types of changes in coping responses would represent improved outcomes, these measures were included on an exploratory basis and were given only at pretreatment and follow-up assessments.

ment over time as compared to waiting list controls on any of the dependent measures. Scores on the dependent measures were relatively stable over time, as indicated by the lack of any significant effects for time of measurement. The significant group differences which were found were probably due to the effects of differential dropout from the groups, with statistical significance attained on these analyses because of the increased power of the repeatedmeasures analysis to detect stable differences between groups. On the measure of participants' satisfaction with the treatment groups, the 2 treatment groups did not differ significantly on analysis of variance. The overall mean, including waiting list caregivers who later completed the group, was 4.57 on the 1 to 5 scale, with 76% of participants endorsing the highest level of satisfaction. Croup participants were clearly enthusiastic about the value of the groups. Caregivers' evaluations of the components of the group experience considered to be helpful to them were also analyzed. Few significant differences were

found between items endorsed by participants in the 2 types of groups, so for simplicity of presentation the percentage of group participants in the total sample endorsing each item was computed. As shown in Table 1, the highest-rated items included the value of belonging to a group with others with similar problems, learning about available community resources, learning about the effects of dementia on the brain and behavior, and receiving encouragement to experiment with new ways to manage problems. It was again suggested by the high percentages of group participants endorsing these items that participants were enthusiastic about the benefits of the groups. Discussion

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 mine. 2. Learning about available community resources and getting the resource guide from the social worker. 3. Finding out about the effects of dementia on the brain and how this affects my relative's behavior. 4. Getting encouragement to experiment with new ways of managing my problems. 5. Belonging; being an involved member of the group; feeling close to others. 6. Receiving encouragement to consider not only my relative's needs, but also my own life and my own happiness. 7. Seeing how others were coping and enduring was inspiring and uplifting to me. 8. Being able to express warm feelings to others in the group. 9. Seeing different ways of approaching the same problem. 10. Seeing how others were handling situations similar to mine. 11. Gaining insight into the causes and sources for the difficulties I have experienced. 12. Receiving advice or practical suggestions about how to deal with some of my problems. 13. Learning what medical science knows about senile dementia. 14. Expressing negative feelings, getting some things off my chest, being able to talk rather than hold it in. 15. Feeling supported and approved of by the others in group. 16. Learning about nursing management (such as hygiene, bowel and bladder) from the registered nurse. 17. Recognizing that the tasks of caring for an impaired relative were extremely difficult for everyone. 18. Getting honest feedback from others about what I was doing. 19. Finding that there were other people I could turn to for help; no longer feeling alone. 20. Coming to accept the true condition of the person I am caring for and what I can and cannot do for him/her. 21. Receiving encouragement to get away from my caregiving responsibilities occasionally (take a break). 22. Revealing some of my fears and anxieties. 23. Understanding better the person I am caring for. 24. Helping others who were facing a similar situation, giving part of myself to others. 25. Receiving encouragement to get outside help in caring for my relative. 26. Specific planning or practice during the group about how to handle problems. 27. Having the chance to get out of the house to come to the group. 28. Learning new ways to think about my problems to help me control my emotions. 29. Learning that I could count on my own judgment. 30. Recognizing that I must take responsibility for my own decisions and actions in this situation. 31. Understanding why I think and react the way I do. 32. Learning progressive muscle relaxation techniques. 33. Getting away from my problems for a while. 34. Seeing that I was just as well off as others. 35. Learning more about my own positive strengths. 36. Having the opportunity to receive a free home visit from the nurse for evaluation of my patient. 37. Getting a sense of hope. 38. Learning how I come across to others. 39. Recognizing that life is sometimes unjust and unfair. 40. Finding someone I could pattern myself after.

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a

92 89 89 89 86 84 84 84 84 81 81 81 81 81 81 78 78 78 78 76 76 73 73 68 65 62 59 59 57 54 52a 49 49 46 41 38 35 32 14

n = 21 caregivers given relaxation training.

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The data yielded mixed and paradoxical results. On measures of caregivers' satisfaction with the groups and caregivers' ratings of the important components of group membership, the groups were consistently rated as helpful and as addressing the

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Butler & Lewis, 1982; Reifler & Eisdorfer, 1980). Certainly, however, it was indicated by the data that caregivers value the education and feelings of support which they gained from group participation. Such time-limited group intervention may have a beneficial, but limited, impact. Caregivers' responses to the participant checklist provided important information about caregivers' perceptions of the important components of successful group intervention. Supported by these results was the suggestion by Zarit and Zarit (1982) that information, problem-solving, and emotional support are essential components of such intervention. In particular, caregivers valued specific information about community resources and dementia and its effects on the brain and behavior. The importance of emotional support was most apparent in caregivers' ratings of the importance of identifying with other group members, belonging to a cohesive group, learning from others in the group, and support for increasing attention to their own needs. Assistance with problem-solving appeared to be important to caregivers, as indicated on several items having to do with encouragement to experiment with new approaches, direct advice, and modeling from other group participants. These ratings revealed that caregivers valued a number of outcomes not assessed in this project, including increases in knowledge about dementia and about coping skills which might help them to face the progression of dementia expected. Clinically, many caregivers also seemed more concerned with the goal of improving their effectiveness as caregivers than with decreasing their current levels of distress. Objectively assessing changes in these kinds of long-term outcomes to more fully understand the benefits and limitations of psychosocial intervention will be a major challenge for future clinical research with caregiving families. References Aronson, M. K., Levin, C , & Lipkowitz, R. (1984). A community-based family/patient group program for Alzheimer's disease. The Cerontologist, 24, 339-342. Barnes, R. F., Raskind, M. A., Scott, M., & Murphy, C. (1981). Problems of families caring for Alzheimer patients: Use of a support group. Journal of the American Geriatrics Society, 29(2), 80-85. Beck, A. T., Rush, J., Shaw, B., & Emery, C. (1979). Cognitive therapy of depression. New York: Guilford. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E., & Erbaugh, J. K. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Billings, A. C , & Moos, R. H. (1984). Coping, stress, and social resources among adults with unipolar depression. Journal of Personality and Social Psychology, 46, 877-891. Butler, R. N., & Lewis, M. I. (1982). Aging and mental health: Positive psychosocial and biomedical approaches. St. Louis: The C. V. Mosby Company. Folstein, M. F., Folstein, S., & McHugh, P. R. (1975). "Mini-mental state": A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. Gallagher, D., Breckenridge, J., Steinmetz, J., & Thompson, L. (1983). The Beck Depression Inventory and Research Diagnostic Criteria: Congruence in an older population. Journal of Consulting and Clinical Psychology, 51, 945-946. Gallagher, D., Nies, G., & Thompson, L. (1982). Reliability of the Beck Depression Inventory with older adults. Journal of Consulting and Clinical Psychology, 50, 152-153. Glosser, G., & Wexler, D. (1985). Participants' evaluation of educational/ support groups for families of patients with Alzheimer's disease and other dementias. The Gerontologist, 25, 232-236.

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concerns of caregivers. On more objective measures of caregiver psychological and social functioning, however, group participants did not show significant change after participation as compared with waiting list control caregivers. In a recent study, Zarit et al. (in press) have reported similar results, in which caregivers receiving family counseling or support group intervention showed no greater improvement after treatment than an untreated waiting list control group. Several methodological factors may have made it difficult to detect changes in caregiver psychological and social functioning after group participation. Caregivers were quite heterogeneous in their pretreatment levels of distress, with some showing minimal problems of depression and other measures of distress. This heterogeneity made it difficult for group means to show significant improvement. For example, pre-treatment mean scores on the BDI are higher than those found among non-caregiving controls (Haley et al., in press), but are in the range of scores found after treatment by researchers investigating the effectiveness of group treatment of depression (e.g., Steuer et al., 1984). Future researchers would be more likely to detect treatment effects if caregivers were pre-selected for high levels of pretreatment distress. Major random life events, such as changes in the severity of patients' impairment or caregivers' health status, also made it difficult to detect changes related to treatment. It appeared from clinical observation that these events, which occurred independently of treatment, often led to increases or decreases in caregiver distress. Such events also led to substantial attrition in the sample. It was also apparent that the 4month period of follow-up was a relatively short period, given the long-term nature of the caregiving role and stresses. Although impossible given the constraints of the current study, in a project focused on outcomes over a longer period of time, beginning with caregivers who have less severely impaired patients, there might be more likelihood of detecting any beneficial effects of caregiver groups on psychosocial variables. Albeit caregivers were subjectively satisfied with the groups, group intervention did not lead to significant, measurable changes on objective measures of caregiver functioning and quality of life. It was suggested by the data that even professionally-led, comprehensive, and seemingly successful caregiver groups may not be a sufficiently potent intervention to effect such measures, given the enormity of problems faced by dementia caregivers. It was often apparent during group sessions that caregivers needed concrete assistance, such as in-home chore services, sitters, and home health care, which they could not afford and which they were not eligible for on any reduced charge or free basis. Effective management of dementia patients and their families may require much more comprehensive, intensive, and expensive services than could be provided in a time-limited group setting, involving the coordination of psychosocial, medical, and home health services (e.g.,

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SAS Institute Inc. (1982). SAS user's guide: Statistics, 1982 Edition. Cary, NC: SAS Institute Inc. Schmidt, C. L., & Keyes, B. (1985). Croup psychotherapy with family caregivers of demented patients. The Gerontologist, 25, 347-350. Steuer, J. L., Mintz, J., Hammen, C. L., Hill, M. A., Jarvik, L. F., McCarley, T., Motoike, P., & Rosen, R. (1984). Cognitive-behavioral and psychodynamic group psychotherapy in treatment of geriatric depression. Journal of Consulting and Clinical Psychology, 52, 180-189. Thompson, L. W., Gallagher, D., Nies, G., & Epstein, D. (1983). Evaluation of the effectiveness of professionals and nonprofessionals as instructors of "coping with depression" classes for elderly. The Gerontologist, 23, 390-396. Wood, V., Wylie, M. L., & Sheafer, B. (1969). An analysis of a short selfreport measure of life satisfaction: Correlation with rater judgments. Journal of Gerontology, 24, 465-469. Woods, A. M. (1984, August). Support groups: Who joins them and do they deliver? Paper presented at the meetings of the American Psychological Association, Toronto, Ontario, Canada. Wylie, M. L. (1970). Life satisfaction as a program impact criterion. Journal of Gerontology, 25, 36-40. Zarit, S. H., Anthony, C. R., & Boutselis, M. (in press). Interventions with caregivers of dementia patients: A comparison of two approaches. Psychology and Aging. Zarit, S. H., Orr, N. K., & Zarit, J. M. (1985). The hidden victims of Alzheimer's disease: Families under stress. New York: New York University Press. Zarit, S. H., Reever, K. E., & Bach-Peterson, J. (1980). Relatives of the impaired elderly: Correlates of feelings of burden. The Gerontologist, 20, 649-655. Zarit, S. H., & Zarit, J. M. (1982). Families under stress: Interventions for caregivers of senile dementia patients. Psychotherapy: Theory, Research and Practice, 19, 461-471.

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Haley, W. E., Levine, E. C , Brown, S. L , Berry, J. W., & Hughes, C. H. (in press). Psychological, social, and health consequences of caring for a relative with senile dementia. Journal of the American Geriatrics Society. Kahan, J., Kemp, B., Staples, F. R., & Brummel-Smith, K. (1985). Decreasing the burden in families caring for a relative with a dementing illness: A controlled study. Journal of the American Geriatrics Society, 33, 664670. Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. W., & Jaffe, M. (1963). Studies of illness in the aged. The index of ADL, a standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185, 914-919. Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Selfmaintenance instrumental activities of daily living. The Gerontologist, 9, 179-186. Lewinsohn, P. M., & Teri, L. (1982). Selection of depressed and nondepressed subjects on the basis of self-report data. Journal of Consulting and Clinical Psychology, 50, 590-591. Mace, N. L , Rabins, P. V. (1981). The 36-hour day. Baltimore: Johns Hopkins. Moos, R. H., Cronkite, R. C , Billings, A. C , & Finney, J. W. (1984). Health and daily living form manual. (Available from Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Social Ecology Laboratory, Stanford, CA 94305.) Pagel, M. D., Becker, J. D., & Coppel, D. B. (1985). Loss of control, selfblame, and depression: An investigation of spouse caregivers of Alzheimer's disease patients. Journal of Abnormal Psychology, 94, 169-182. Poulshock, S. W., & Deimling, G. T. (1984). Families caring for elders in residence: Issues in the measurement of burden. Journal of Gerontology, 39, 230-239. Reifler, B. V., & Eisdorfer, C. (1980). A clinic for the impaired elderly and their families. American Journal of Psychiatry, 137, 1399-1403.