Learning to Feel Better (Hebert)


PRINCIPAL INVESTIGATOR(S):

Réjean Hébert, MD, MPhil
Research Centre on Aging, Sherbrooke Geriatric University Institute
1036 Belvédère Sud, Sherbrooke
Québec, Canada J1H 4C4
Email: rejean.hebert@usherbrooke.ca

Louise Lévesque, Ph.D. Centre de recherche
Centre de recherche, Institut universitaire de gériatrie de Montréal (IUGM)
Université de Montréal
4545, chemin Queen-Mary
Montréal QC H3W 1W4
Office : M-7818
(514) 340-3540 ext. 4771
Fax: (514) 340-3530
Email : louise.levesque@umontreal.ca

OVERALL SNAPSHOT OF CAREGIVER INTERVENTION/PROGRAM: This group caregiver program for caregivers is based on the work of Folkman et al. (1991) who developed a stress management intervention model based on the stress and coping theory of Lazarus & Folkman (1984). This program consists of fifteen 2-hour weekly meetings offered to a small group of caregivers (6 to 8 per group). The primary objective is to train caregivers to cope more effectively with daily sources of stress. A participatory approach is used (discussions, written exercises, role playing) and a great deal of importance is placed on each participant’s own perception of the caregiver experience. Assignments that caregivers do alone at home are the means through which coping strategies are learned and practiced. The first four sessions covers the key elements of the program (Folkman et al., 1991) to identify stressful situations with precision, to distinguish between the changeable and unchangeable aspects of a specific stressful situation and to ensure a tight match between the choice of coping strategy to use and the changeable and unchangeable aspects of a specific stressful situation (problem-focused coping to deal with changeable aspects and emotion-focused strategy for unchangeable aspects). The other eleven sessions are devoted to three coping strategies: problem solving (problem-focused strategy), reframing (emotion-focused strategy) and seeking social support (problem- and emotion-focused strategy).

Evidence supporting this intervention has been demonstrated in the literature. In a randomized clinical trial (RCT), the program has been shown to present a 14% decrease at 8-month follow-up (post-intervention) in their reactions to the behavioral problems of the care-recipient as opposed to a 5% decrease in the control group. The frequency of behavior problems also decreased significantly as did the cross-product frequency/reaction. A qualitative process evaluation was undertaken to identify the primary processes of the program in order to better understand intervention outcomes. Participants learned coping strategies, with reframing playing a more important role than problem-solving or seeking social support (see Lavoie et al., 2005). The results support recommending this new program for health organizations. This program can also be applied in individualized intervention during home visit or counseling.

BRIEF BACKGROUND RELATED TO THE DEVELOPMENT OF THE INTERVENTION:
The investigators developed this intervention in response to the lack of available psychoeducational treatments with a theoretical basis to guide the intervention process, limited sample sizes and moderate effect sizes documented in the literature. According to the intervention developers, previous interventions focused on practical advice and encouraging the expression of feelings. In contrast, the developers developed this intervention with a theoretical framework in mind to address the long-term and ongoing needs of caregivers of older adults with dementia. The intervention is based on a paradigm of stress and coping, the transactional theory proposed by Lazarus and Folkman (1984). According to this theory, stress results when transaction between an individual and their environment is appraised by the individual as exceeding his or her resources and endangering his or her well-being. The investigators argue that what relates to well-being is not the mere objective presence of stressful demands in the environment but rather the individual’s cognitive appraisal of these demands and of his/her resources, as well as his/her repertoire of coping strategies. Essentially, these are defined as cognitive or behavioural efforts to manage the stressful demands. The transactional theory of stress and coping as translated into a specific intervention framework by Folkman et al. (1991) to improve stress management abilities.

The current version of the intervention originally consisted of 8, 2-hour sessions (see Hébert et al., 1994). Modifications with regards to the intensity as well as the content coverage and theoretical framework were made following the original investigation. In the original investigation (Hébert et al., 1994), the results showed that only modifications in knowledge about the disease increased among those in the intervention group compared to those in the control group.

TARGETED CAREGIVER POPULATION (AGE, ETHNICITY, CONDITION/DISEASE):
The primary targeted population for this program is for caregivers of persons with dementia living at home. Of the studies to date, the majority of the caregivers were women with no mention as to ethnicity or race.

MANUAL OF PROCEDURES: A treatment manual for this program is available by contacting Dr. Hébert or Dr. Lévesque.

OUTCOME MEASURES: Various outcome measures have been used to evaluate the efficacy of the intervention in randomized control trials. However, to date there are no intervention-specific outcome measures for the intervention.   

WORKBOOK/WORKSHEETS
: Contact PI to determine availability.

OTHER INTERVENTION RESOURCES
: Contact PI to determine availability.

TOTAL LENGTH OF INTERVENTION/PROGRAM
: 15-weeks total (15-weekly 2-hour sessions)

DESCRIPTION OF SESSION CONTENT:
Overall Description of Program
This group-based psychoeducational program is delivered over 15-weeks. Each weekly session is approximately 2-hours. The content is comprised of two components, cognitive appraisals and coping strategies. For a full description of the process of the group intervention, interested readers are referred to read Levesque et al., 2002.

First Component-Cognitive Appraisals (4 sessions total):
The first component, cognitive appraisals, consists of 4 sessions. The primary objective consists of improving caregivers’ ability to shift from a global stressor to a specific stressor. Breaking down a global situation into specific elements not only helps caregivers clarify the problem at hand, but also increases their awareness that something can be done.

The second and third objectives of this component are to develop the caregivers’ ability to distinguish between the changeable and unchangeable aspects of a stressor, and their awareness of the importance of the match between the changeability of a stressor and the choice of coping strategies. These notions are discussed between the group leader (a health professional experienced in the care of persons with dementia and group facilitation) and the caregivers. The caregivers are also asked to complete a home assignment to practice their ability to select four specific stressors linked to their caregiving situation and to identify the changeable and unchangeable aspects, as well as their emotional reactions.

Second Component-Coping Strategies (11 sessions total):
The second component is referred to teaching coping strategies in three areas (problem-solving, reframing, and seeking social support) and consists of a total of 11 sessions. Problem-solving (problem-focused coping) is used to alter the changeable aspects of a stressor (4 sessions). It is most useful when the situation concerns of the person with dementia’s dysfunctional behaviors, with many of these behaviors amenable to change. Over the course of these four sessions, caregivers have the opportunity to learn to use well-documented steps to clarify a target problem that is changeable and to find an appropriate solution to the problem. The problem-solving strategies integrate elements of behavioral techniques in precisely defining the stressful situation, thereby making it possible to modify its frequency and intensity.

The second coping strategy consists of reframing the meaning of a stressor (emotion-focused coping). The objective is to find an alternative way of thinking about a situation so that it was easier to manage the painful emotion generated by the unchangeable aspects of a stressor (3 sessions). The content of reframing is based on the cognitive approach, according to which thoughts are often what generate emotions.

The third coping strategy consists of seeking social support (4 sessions). This strategy can be helpful whether focusing on either a problem or emotions. Social support is often viewed as a factor that has a protective effect on well-being, but caregivers have been found to be reluctant to seek support. In this program caregivers are invited to examine their reluctance to seek support and to identify the types of support needed and the persons in their informal network and community resources likely to provide the support. Possible disagreements or conflicts in the exchange of support are discussed. Next, the caregivers examine how to mobilize this support (e.g., how to present a specific request to the selected individual or resource), and how to maintain this support.

METHOD OF ADMINISTRATION/DELIVERY: Group setting

TRAINING:
Group facilitators are specialized health clinicians (e.g., nurses, psychologists, social workers) who have experience in group facilitation and knowledge of the issues regarding family caregivers and persons with dementia. Length of training is estimated at three days of coursework to learn this program.

COST AND TIME CONSIDERATIONS:
Staff time for training in intervention procedures and techniques (three days)
Time to implement program (15-weeks)
Considerations for conducting a group (e.g., refreshments/snacks, setting/space)

VIDEO CLIP OF INTERVENTION/PROGRAM: Contact PI for availability.

DOWNLOADABLE FACT SHEETS: Contact PI for availability.

BRIEF DESCRIPTION OF EVIDENCE: Evidence demonstrating the efficacy for this group-based caregiver intervention has been demonstrated. In a recent randomized controlled trial of 158 participants (n = 79 intervention group; n = 79 control group), results indicate that study caregiver participants presented a 14% decrease in their reactions to the behavioral problems of the care-receivers as opposed to a 5% decrease in the control group (p = .04) (Hébert et al., 2005). The frequency of behavior problems also decreased (p = .06), as did the cross-product frequency/reaction (p = .02). There were no significant effects on secondary outcome variables. In a qualitative process evaluation study using semi-structured interviews with 30 participants recruited from the intervention group, overall results showed that the group delivered educational and support processes with support processes complementing educational processes. Participants learned coping strategies with reframing playing a more important role than problem-solving or seeking social support. Additionally, daughters benefited more than spouses from educational processes (Lavoie et al., 2005).

REPRESENTATIVE PUBLICATIONS/REFERENCES:

Folkman, S., Chesney, M., McKusick, L., Ironson, G., Johnson, D. S., & Coates, T. J. (19 Translating coping theory into intervention. In J. Eckenrode (Ed.), The social context of coping (pp. 239-260). New York: Plenum Press.

Hébert, R., Lévesque. L., Genron, C., Vézina, J., Ducharme, F., Lavoie, J. P., Gendron, M., Préville,M., & Voyer. L. (in press). The program “ Learning to feel better…and care better” for family caregivers of community-dwelling older persons with dementia. Revue québécoise de Psychologie.

Hébert, R., Lévesque, L., Vézina, J., Lavoie, J.-P., Ducharme, F., Gendron, C., Préville, M., Voyer, L., & Dubois, M.-F. (2003). Efficacy of a psychoeducative group intervention program for caregivers of a demented persons living at home : A randomized controlled trial. Journal of Gerontology, Social Sciences, 58B(1), S58-S67.

Lavoie, J.P., Ducharme, F., Lévesque L., Hébert, R., Vézina, J., Gendron, C., Préville, M. St-Laurent,C., & Voyer, L. (2005). Understanding the outcomes of a psychoeducational group intervention for caregivers of persons with dementia living at home: A process evaluation. Aging and Mental Health, 9(1), 25-34.

Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.

Lévesque, L. Gendron, C., Vézina, J., Hébert, R., Ducharme, F., Lavoie, J.-P., Gendron, M., Voyer, L., & Préville, M. (2002). The process of a group intervention for caregivers of demented persons living at home: Conceptual framework, components, and characteristics. Aging & Mental Health, 6(3), 239-247.

KEYWORDS/SEARCH TERMS:
Coping skills, group interventions, caregivers, dementia, support groups