Brief structured Cognitive Behaviorial Therapy (Akkerman)

Principal Investigator: Rhonda L. Akkerman, Ph.D.

Contact information: email Rhonda.Akkerman@MemorialHermann.org

I. Summary and Description:

The nine-week CBT intervention designed for anxious family caregivers of persons diagnosed with AD reduced anxiety as measured by self-report and clinician-administered psychological assessment scales. Moreover, these reductions in anxiety were maintained through a six-week follow-up period suggesting that CBT may offer caregivers assistance in modulating anxiety across time.

The nine-week CBT intervention assisted Alzheimer’s disease (AD) caregivers in reducing anxiety and the risk for mental health compromise by altering appraisals and coping behaviors to enhance resistance to environmental demands and reduce vulnerability. The CBT intervention featured a tri-component model to address the physiological, cognitive, and behavioral components associated with anxiety through two-hour weekly meetings.

Each week one new skill designed to assist caregivers in reducing anxiety was examined. Using methodology similar to Greene & Monahan (1989), each group meeting was subdivided into social, educational and relaxation segments. Each session started with a brief social period to encourage cathartic expression and instill a supportive atmosphere. AD caregivers were encouraged to discuss environmental demands and anxiety-provoking situations experienced over the past week. Caregivers discussed challenges or benefits experienced by completing homework assignments. Through these discussions, interventionists encouraged the receipt and enactment of new skills. The middle third of the session focused on skill acquisition. AD caregivers received weekly handouts of the material to be discussed from the treatment manual. Each session concluded with the practice of a relaxation exercise. Brief homework assignments (requiring a daily maximum of 20 minutes) were given to caregivers at the conclusion of the session. These assignments were designed to examine whether the AD caregiver demonstrated receipt and enactment of the weekly skill. Homework was collected and entered into the database system as completed and returned at the next meeting. AD caregivers were required to attend two sessions of each component. Caregivers failing to complete a sufficient number of sessions were dropped from the analyses. One make-up session was offered following the completion of the fifth week. Caregivers missing any sessions prior to this time point were provided with an opportunity to revisit the material discussed.

Managing the physiological component of anxiety was reviewed in the first three sessions. Caregivers were taught to identify the presence of physiological anxiety (e.g., clenching teeth, muscle tension) and ways of reducing and managing its impact. Participants learned diaphragmatic breathing techniques, Progressive Muscle Relaxation (Bernstein & Borkovec, 1973) and visualization. Caregivers also were introduced to a new concept encouraging present moment focus, namely mindfulness. Participants were asked to practice daily relaxation skills and the focused awareness techniques to reduce anxiety associated with caregiving demands. Sessions four through six focused on the cognitive component of anxiety and assisted caregivers in recognizing erroneous thought processes and situational appraisals that increased their anxiety. Universal caregiver concerns, worries, and beliefs were the focus of these groups. Participants gained an understanding of how irrational and unrealistic cognitive schemata impact mental health (Beck, 1967). The goal of these sessions was for individuals to gain a meta-cognitive understanding of their thought processes to increase realistic appraisals. Group members were instructed to use cognitive skills to lessen anxiety through problem-focused appraisals, self-statements, and thought stopping techniques. The final three sessions addressed ways of managing anxiety through coping behaviors. Caregivers were taught to identify maladaptive behavioral responses to anxiety, namely avoidance, escape and procrastination. Participants practiced more adaptive responses to reduce anxiety including exercise, regular sleep, time-management strategies, and effective communication with family members. Participants were asked to monitor their caregiving coping behaviors and assess their impact in decreasing anxiety.

Key search terms: Skills training, cognitive-behavioral intervention for anxiety, dementia caregiver support

II. Intervention Materials

Description of materials used in the intervention:

The intervention provided weekly handouts to the participants as well as written homework assignments to be completed after each session. The homework assignments were returned to the participants after review. The materials are obtainable by contacting the PI via email. The PI conducted the CBT intervention and would be available for consultation regarding training sessions.

III. Implementing the Intervention:

Training qualifications and guidelines for those delivering the intervention:

A specific training program does not exist for the intervention. It is based on commonly used Cognitive-Behavioral therapy techniques. A Ph.D. level psychologist would be capable of implementing the treatment provided the individual received training in Cognitive-Behavioral interventions. The PI is available for consultation for additional training.

Estimated costs of implementing the intervention:

The intervention is relatively inexpensive in regards to written materials. The AD caregivers were provided with 3-ring notebooks to use throughout the duration of the intervention (cost $3/notebook). Copies of the training materials as well as homework assignments are roughly ($5/person). The remaining costs would be associated with providing the implementation, reviewing homework assignments, and being available for calls during the week (approximately 4 hours per week for 9 weeks) for the individual conducting the intervention.

Caveats/ limitations on the implementation of this intervention

The data were collected from a relatively small sample. Current data need to be expanded to a larger sample and follow-up data collected beyond a six-week period. Also, it may be useful to include a sub-sample of individuals being treated simultaneously with psychotropic medications to determine the efficacy of a biopsychosocial approach.

Other useful implementation information:

Screening of AD caregivers needs to be conducted carefully – particularly for spousal caregivers. Older generation AD caregivers often mistake the symptoms of anxiety for somatic issues. Furthermore, many are confused about whether they are experiencing primarily depression or anxiety. Screening needs to be thorough and it is recommended that data be reviewed by more than one research team member prior to enrollment in the intervention

References:

Akkerman, R. L. & Ostwald, S. K. (2004). Reducing Anxiety in Alzheimer’s Disease Family Caregivers: The Effectiveness of Nine-Week Cognitive-Behavioral Intervention. American Journal of Alzheimer’s Disease and Other Dementias, Mar-Apr; 19(2):117-23.