Effective Intervention with Dementia and Difficult Bahaviors  

Developmental stage
Families, like individuals, go through a series of developmental stages, each with its own tasks that must be completed. There are expected life cycle events such as marriage, the birth of children, retirement and death in old age. Other significant life cycle events are not so expected such as divorce, untimely death, migration and illness. The onset of dementia marks the beginning of a new developmental stage for the family, which involves both expected and unexpected life cycle events.

Stress is often greatest at transition points from one stage to another of the family developmental process (Carter & McGoldrick, 1989). This stress is due in large measure to the need to renegotiate and otherwise adjust to some fundamental changes in roles within the family. The ease or difficulty of the family in incorporating these new roles determines their adjustment to the reality of living with a dementia patient.

There are several types of interactional adjustments that a caregiver family must make. The first type of adjustment is the filling of family roles that the patient played prior to her or his illness. While families may be attentive to instrumental roles (e.g. cooking or paying bills) that need to be filled, they are often less aware of relational roles (e.g. leadership, arbitration, communication, nurturing or family gathering). This type of adjustment consists of several processes, including recognizing the need to fill the roles once played by the care recipient, coming to terms with the need to 'displace' the care recipient from prior roles, managing the care recipient's resistance to giving up old roles and functions, and moving other persons into the roles once filled by the care recipient, without unduly burdening the caregiver. A common symptom of developmental adjustment difficulties is unrealistic expectations regarding the functioning of the AD patient, or inappropriately low expectations from other family members.

Resonance
An important factor in the caregiver's ability to successfully balance her or his own personal needs with the demands of caregiving is the nature of the boundaries between the caregiver and care recipient. A high degree of emotional and psychological closeness, or enmeshment, between caregiver and care recipient makes it difficult for the caregiver to be an effective manager of the caregiving system because of a loss in objectivity and unwillingness to delegate caregiving tasks.
The resonance dimension is strongly influenced by culture. Whereas American culture places a high value on individuality and independence, Cuban culture values collectivism and gives precedence to the needs of the family over the needs of the individual (Santisteban et al., in press). Therefore, the degree of interdependency found in Cuban families is typically much greater than that found in white American families. Fittingly, the pattern of caregiver-care recipient 'enmeshment' is observed more frequently among the Cuban families in the sample.
 
Conflict resolution
Having a family member with dementia presents a multitude of logistical problems, and precipitates crises that may cause friction and disagreement between and among family members. In many cases, family members naturally search for a person or thing upon which to direct their anger, pain and frustration, leading to negativity that can be diffuse or directed at one particular person. Sometimes family members blame others with little recognition of their own contribution to the problem. Conflict resolution refers to the family's capacity for effectively resolving differences of opinion with low levels of negativity and without the use of intermediaries or the forming of destructive coalitions. This includes the extent to which family members: (1) allow differences of opinion and painful issues to emerge, (2) can manage these differences without personal attacks or losing sight of the issue to be resolved, and (3) can find adequate solutions that have the support of the family members involved. An important aspect of conflict resolution is the capacity of the family to allow the caregiver to assert disagreements and/or criticisms clearly and directly, without leading to the dissolution of relationships.

Although we have found conflictive family interactions in both ethnic groups, these appear to be more common among the white American families, particularly between the caregivers and their adult children. Problems of conflict resolution among Cuban American families are often manifested in a pattern of denial of AD symptoms or reluctance of family members to discuss this topic.

Conclusion
Caring for a family member with an illness such as dementia is extremely challenging, and many caregivers and family members experience negative outcomes such as depression and stress. Given the projected increase in the number of people with dementia, and the fact that most dementia patients are cared for at home by family members (Schulz & O'Brien, 1994), there is a need for strategies that help caregivers meet the demands of caregiving. Social and instrumental support from family members has been found to mediate caregiver outcomes such as feelings of depression or burden (e.g. Aneshensel et al., 1995), yet many caregivers are isolated and estranged from family members and friends. Despite the importance of family support for caregivers, we have a limited understanding of strategies which are efficacious in terms of maximizing family resources.

Although there is an extensive literature documenting the effectiveness of family therapy for various mental and health-related problems, the effectiveness of family therapy for caregivers is largely understudied. The intent of this paper was to demonstrate how a family-based therapy may be applied to family caregivers of dementia patients. Specifically, we sought to delineate several family interactional patterns that are particularly relevant to caregiving situations, and illustrate how these patterns could be addressed via a theoretically-based family therapy approach.

Assessment of family interactional patterns provides a road map for identifying maladaptive processes to be targeted in treatment. These maladaptive patterns block the ability of the caregiver to receive support from family members, and the ability of family members to offer relief to the caregiver. Assessment of interactional patterns also necessitates understanding contextual factors such as ethnicity which shape these interactions. Therefore, one focus in the reported case studies was on differences between white American and Cuban American caregivers. Attention to ethnic differences in attitudes towards caregiving and responses to caregiving responsibilities is critical given the increased ethnic diversity of the population. As illustrated, Cuban American caregivers have different perceptions of family and family obligations, as well as different family structures than white Americans. In addition, it is important to tailor interventions so that they are culturally congruent.

The REACH study illustrates an attempt to apply a family therapy model to caregiver populations. As such, the results from this project will provide valuable insight into the role of family support in caregiver outcomes. Furthermore, we will gather information on the protective/risk impact of family interactional patterns for caregiver distress. This type of information will provide guidance for refining the family therapy approach to better meet the specific needs of caregiver populations.
- Mitrani, V.B.; Czaja, S. J.; Family-based therapy for dementia caregivers: clinical observations; Aging & Mental Health, Aug2000; Vol. 4 Issue 3

Personal Reflection Exercise #5
The preceding section contained information about Structural Ecosystems Therapy for caregivers.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
The feasibility, acceptability, and preliminary efficacy of an mHealth mindfulness therapy for caregivers of adults with cognitive impairment

Kozlov, E., McDarby, M., Pagano, I., Llaneza, D., Owen, J., & Duberstein, P. (2022). The feasibility, acceptability, and preliminary efficacy of an mHealth mindfulness therapy for caregivers of adults with cognitive impairment. Aging & mental health, 26(10), 1963–1970. https://doi.org/10.1080/13607863.2021.1963949

Peer-Reviewed Journal Article References:
Martin, K., Lang, F. R., Rupprecht, R., & Nömer, J. (2021). Dementia worry and the perception of personal risk: A longitudinal study. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 34(1), 23–30.

Maxfield, M., Cui, R., Roberts, J. R., & Fiske, A. (2021). Interest in dementia testing: Family history, dementia-related anxiety, and coping. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 34(1), 5–11.

Wilson, R. S., Barnes, L. L., Rajan, K. B., Boyle, P. A., Sytsma, J., Weuve, J., & Evans, D. A. (2018). Antecedents and consequences of unawareness of memory impairment in dementia. Neuropsychology, 32(8), 931–940. 

QUESTION 12
According to Mitrani, what is an important factor in the caregiver's ability to successfully balance her or his own personal needs with the demands of caregiving? Record the letter of the correct answer the Test