61
\nJournal of Women & Aging, 22:61\u201375, 2010
\nCopyright \u00a9 Taylor & Francis Group, LLC
\nISSN: 0895-2841 print\/1540-7322 online
\nDOI: 10.1080\/08952840903489094
\nWJWA 0895-2841 1540-7322 Journal of Women & Aging, Vol. 22, No. 1, Dec 2009: pp. 0\u20130 Journal of Women & Aging Effects of Three Caregiver Interventions:
\nSupport, Educational Literature, and Creative
\nMovement
\nEffects of Three Caregiver Interventions L. K. M. Donorfio et al. LAURA K. M. DONORFIO
\nUniversity of Connecticut, Department of Human Development & Family Studies,
\nWaterbury, CT
\nRHEBA VETTER
\nNorthwest Missouri State University, Health, Physical Education, Recreation and
\nDance Department, Maryville, MO
\nMARINA VRACEVIC
\nUniversity of Connecticut, Department of Human Development & Family Studies, Storrs, CT
\nThe primary focus of this study is to compare the effectiveness of
\nthree distinct intervention techniques in relieving some of the stress
\nexperienced by midlife daughters\u2019 caregiving for their frail mothers.
\nThe three techniques are: (a) a home-based literature \u201ctip of the
\nweek\u201d group, (b) a caregiver\u2019s support group, and (c) a creativemovement group. Based on a review of caregiving literature, no
\nother studies have utilized a home-based literature intervention or
\na creative-movement intervention with midlife daughters providing informal care to frail mothers. As part of the weekly assessment
\nevaluation, participants were asked to rate how helpful the previous week\u2019s session was with respect to five mental health variables:
\nirritability, depression, anxiety, stress, and concentration. Overall,
\nthe support-based group had higher average scores for each of the
\nfive mental health variables and the highest overall mental health
\nscore. Future research and promising applications of future intervention programs are discussed.
\nKEYWORDS informal caregiving, caregiving interventions,
\nmothers and daughters
\nAddress correspondence to Laura K. M. Donorfio, PhD, University of Connecticut,
\nDepartment of Human Development & Family Studies, 99 East Main Street, Waterbury, CT
\n06702. E-mail: laura.donorfio@uconn.edu
\n62 L. K. M. Donorfio et al.
\nINTRODUCTION\/BACKGROUND
\nThe United States is in the midst of a significant and growing caregiving crisis, with approximately 5.6 million Americans aged 65 plus receiving unpaid
\nor informal care at home from family members or friends (ILC-SCSHE Taskforce, 2006). According to the Older Women\u2019s League (2006), if informal
\ncaregiving had to be replaced with paid services, it would cost upwards of
\n$257 billion annually, more than twice what is spent nationwide on nursing
\nhomes and paid home care combined. Projections of the growing aging
\npopulation resulting from increasing longevity and medical advancement,
\ncontribute to increased sensitivity to the immense value of informal caregiving. Consequently, it is increasingly important to preserve the well-being
\nand provide support for family caregivers in their efforts to provide care
\n(Hebert & Schulz, 2006; Wolff & Kasper, 2006). One way to help support
\nthe well-being of caregivers is to provide intervention techniques specifically created to help alleviate some of the perceived stress associated with
\ncaregiving. The purpose of this study is to compare the effectiveness of
\nthree distinct intervention techniques in relieving some of the stress experienced by midlife daughters caring for their frail mothers: (a) a home-based
\neducational \u201ctip of the week\u201d group, (b) a caregivers\u2019 support group, and
\n(c) a creative-movement group.
\nWhile there is no universally agreed-upon definition of caregiving in
\nthe literature, a caregiver generally refers to someone who provides some
\ntype of service to people who are unable to care for themselves due to a
\ndisability or functional limitation (ILC-SCSHE Taskforce, 2006). According to
\na national survey distributed by the Opinion Research Corporation (2005),
\ncentral aspects of U.S. caregiving include the following: (a) it is prevalent
\nacross all economic levels and ethnic groups; (b) the majority of caregivers
\nare women over the age of 45; (c) most care-receivers are aging mothers;
\n(d) one person tends to provide the majority of informal care in family situations; (e) on average, caregivers spend 21 hours per week on caregiving
\nresponsibilities; and (f) the majority of caregivers work full- or part-time
\nwhile providing care.
\nWhile caregiving is recognized as an activity with perceived benefits,
\ncaregiving often carries emotional, physical, and financial burdens, and is
\nrecognized as a risk factor for illness (Vitaliano, Young, & Zhang, 2004).
\nCaregivers are more prone to depression, grief, fatigue, physical health
\nproblems, and changes in social relationships, many of which have roots in
\nstress, exhaustion, and self-neglect (Sullivan, 2004). Fifty percent of caregivers make some sort of work-related adjustment such as taking time off,
\ndropping back to part-time, or even taking a leave of absence (National
\nAlliance for Caregiving, 2004). In a study done by MetLife and Brandeis
\nUniversity (1999), the cost to caregivers over a caregiving and working career
\ncan be nearly $600,000 in lost pensions, wages, and Social Security benefits.
\nEffects of Three Caregiver Interventions 63
\nIn reviewing the current literature on interventions for family caregivers,
\nthere is a paucity of research involving educational literature or creativemovement interventions. Also, these two types of interventions have not
\nbeen compared to any other intervention format(s). Many other interventions have been utilized in the literature and evaluated for their
\neffectiveness.
\nIntervention Techniques Employed
\nThe most commonly employed intervention techniques have been support groups and educational training programs (e.g., Callahan et al., 2006;
\nClaxton-Oldfield, Crain, & Claxton-Oldfield, 2007; Drentea, Clay, Roth, &
\nMittelman, 2006; Gitlin, Hauck, Dennis, & Winter, 2005; Marziali &
\nDonahue, 2006; Smith & Toseland, 2006; Stewart, Barnfather, Neufeld,
\nWarren, Letourneau, & Liu, 2006). Positive outcomes achieved in utilizing
\nsupport groups as an intervention technique primarily involve lowering caregiver depression and stress. Similarly, educational training programs have
\nachieved effective outcomes including teaching caregivers to cope with distress, depression, and grief in the case of the death or impending death of
\nthe care-receiver. Eisdorfer et al. (2003) combined several strategies into a
\nsingle intervention. The results did not indicate that any one-intervention
\nhybrid was significantly better than any other.
\nThe second most popular intervention for family caregivers is counseling therapy (Drentea et al., 2006; Kissane, McKenzie, Block, Moskowitz,
\nMcKenzie, & O\u2019Neill, 2006; Whitlatch, Judge, Zarit, & Femia, 2006). A consistent counseling-based therapy program has been found to contribute to
\nrelieving caregivers\u2019 anxiety, depression, and distress.
\nCreative-Movement Improvisation
\nCreative-movement literature leads to a range of positive effects when used
\nwith healthy individuals and those suffering from different types of impairments and diseases (Brooks & Stark, 1989; Jeong, Hong, Lee, & Park, 2005;
\nOsgood, Smith, Meyers, & Orchowsky, 1990; Picard, 2000). Previous studies
\nfound creative movement to be effective in lowering depression, stress, anxiety,
\nand improving psychological distress (Brooks & Stark, 1989; Jeong et al.,
\n2005; Walsh, Culpepper Martin, & Schmidt, 2004).
\nApplications of creative dance movement therapy (CDMT) are relatively new and scant. Only a handful of studies have used CDMT as a caregiving intervention strategy. CDMT was shown to be effective in increasing
\nsensitivity and awareness of self and others in interpersonal relationships.
\nFor example, Picard (2000) found creative movement to be helpful in
\n\u201cexpanding consciousness at midlife, with patterns of meaning identified in
\nrelationships with others, self, and spirit, as well as challenges, loss, illness,
\n64 L. K. M. Donorfio et al.
\nand threats to relationships\u201d (p. 150). Wilson (1985) also found changes in
\nparticipants\u2019 self-awareness as a result of participating in CDMT. The goal of
\nthe current study is to assist midlife daughters in better understanding and
\ncoping more successfully with their feelings associated with providing care
\nto their older frail mothers. According to creative-movement theory, the
\nimprovisational forms of movement are means of communicating emotions
\nand feelings and can contribute to increasing one\u2019s sensitivity toward others,
\ntheir self-awareness, and their environment (Wilson, 1985).
\nPURPOSE
\nThe primary purpose of this study is to investigate the effectiveness of three
\nintervention techniques in lowering caregiving daughters\u2019 perceived
\namounts of irritability, depression, anxiety, stress, and overall strain. The
\nthree techniques administered weekly include: (a) a home-based educational literature \u201ctip of the week\u201d group (LG), (b) a caregiver\u2019s support
\ngroup (SG), and (c) a creative-movement group (MG). Based on a review of
\ncaregiving literature, no previous studies have utilized an LG intervention
\ntechnique. Also, while creative movement is a newer intervention technique
\nfor family caregivers, it has not been specifically used with midlife daughters providing informal care to frail mothers. The support-group intervention is the most commonly used, proving to be effective in relieving
\ncaregiver\u2019s stress. The main goal of this research is to explore the benefits of
\neach of these interventions, as well as to compare the effectiveness of each
\nin relieving stress for midlife daughters providing care for their mothers.
\nThe three specific research questions are:
\n1. Are LG, SG, and MG strategies effective in reducing caregiver irritability,
\ndepression, anxiety, stress, and increasing concentration levels?
\n2. If so, which of the three intervention strategies is most effective in reducing
\nirritability, depression, anxiety, stress, and increasing concentration levels?
\n3. How is each intervention helpful and\/or not helpful for midlife daughters
\nproviding informal care to their frail mothers?
\nMETHODS
\nRecruitment
\nParticipants were recruited through flyers, e-mail, radio and newspaper
\nadvertisements, telephone calls, and in-person visits to caregiver agencies,
\nhospitals, the Osher Lifelong Learning Institute (University of Connecticut
\nWaterbury Campus), and the University of Connecticut regional campuses.
\nParticipants were selected based on the following qualifications: (a) individuals
\nEffects of Three Caregiver Interventions 65
\nwere primary caregivers, (b) the caregivers were female and had to be at
\nleast 40 years of age, and (c) the care-receivers were the mothers of the
\ncaregiver. The caregivers were not randomly assigned to each of the intervention groups; rather, they volunteered to participate in the intervention
\ngroup of their choice. All participants signed a consent form and received
\ninstructions concerning their particular intervention group as well as the
\nquestionnaires used to collect information each week.
\nParticipants
\nThe final sample (N = 16) consisted of middle-aged women, aged 42\u201372,
\nwho were the primary caregivers for their frail mothers. The number
\nof daughters in each intervention group was: SG = 6, LG = 6, MG = 4. The
\nlength of caregiving ranged between 3 to 18 years. The daughters assisted
\ntheir mothers in at least three of the following eight activities: personal care
\n(62.5%), emotional support (87.5%), housekeeping (75%), transportation
\n(87.5%), meal preparation (62.5%), laundry (66.3%), financial support
\n(43.8%), and helping with bills and paperwork (87.5%). The majority were
\nunable to carry out all tasks of daily living on their own (56.3%), and onequarter had some cognitive impairment (25%). The care-receivers ranged in
\nage between 63 and 95. See Table 1 for additional demographic information.
\nThe study focused on midlife daughters as caregivers because research
\nshows that females make up 80% of all family caregivers, with daughters
\nmost likely being the primary caregivers to their mothers (Cohler, 1997).
\nMeasurement Instruments
\nIn addition to a demographic questionnaire and a caregiver qualification
\nscreener, two data-collection instruments were constructed by the research
\nTABLE 1 Participant Demographics
\nWhite 87.5%
\nCatholic 65.3%
\nMarried 62.5%
\nEmployed
\nFull-time 31.3%
\nPart-time 31.3%
\nRetired 37.5%
\nHousehold income of $50,000 63.0%
\nGraduate level education 43.8%
\nMother\u2019s living arrangement
\nOwn home 37.5%
\nLiving with daughter 31.3%
\nLiving with other relatives 6.3%
\nSenior housing 6.3%
\nMother\u2019s widowed 75.0%
\n66 L. K. M. Donorfio et al.
\nteam. The first was a weekly assessment consisting of five Likert-scale
\nquestions and two open-ended questions asking participants to rate their
\ncurrent levels of irritability, depression, anxiety, stress, and concentration.
\nThe second was an end-of-program evaluation form consisting of three
\nopen-ended questions aimed at evaluating participants\u2019 perceptions of the
\ninterventions.
\nProcedures
\nThe participants in the LG were sent a weekly caregiving tip for 8 weeks,
\ncompiled by the researchers and based on the popular literature targeted
\nfor caregivers. They were asked to answer their questionnaires immediately when they arrived the next week with the next week\u2019s \u201ctip,\u201d and to
\nmail their responses back in the enclosed self-addressed envelope. Some
\nof the caregiving tips concerned why it is important to take care of yourself, defining the help you need, and techniques for relaxation and stress
\nrelief.
\nThe SG met once a week, 1.5 hours per week, for 9 consecutive weeks.
\nThe sessions were led by a trained facilitator. The format consisted of one
\ntopic being presented each week (based on the same caregiving tips used
\nfor the LG), short exercises, group discussions, and weekly readings
\nassigned for the next week. Participants were also offered an opportunity
\neach week to discuss any topics they deemed relevant. The questionnaires
\nwere administered at the beginning and end of each session to assess the
\neffectiveness of the intervention group.
\nDue to conflicts beyond the control of the researchers, two different groups of women were involved in the MG intervention group. The
\nfirst MG met once a week for 1 hour for 9 weeks (n = 3). Toward the
\nend of the 3-month period, the research team decided to end this intervention wave and to recruit another wave. The second MG began 1
\nmonth after the first group ended and initially consisted of three participants. Within the first 3 weeks of the study, two of the participants
\ndropped out (n = 1).
\nBoth MGs were led by a novice improvisational-movement facilitator
\nand guided through various movement exercises to help participants work
\nthrough the stressors and emotions associated with caregiving over time. A
\nfunction of creative movement is to provide an opening for expression by
\ntransferring thoughts, feelings, and stressors, from memory to physical
\naction. The facilitator sought to guide the participants through movement
\nimprovisations designed to tap into their memories and feelings associated
\nwith events related to their caregiving experiences. The nature of the MG
\nintervention was to replace verbal discussions with movement experiences
\nto express thoughts. Weekly topics and tips, consistent with the previous
\ntwo groups, were also provided and discussed at the end of each session
\nEffects of Three Caregiver Interventions 67
\nbefore they went home. The questionnaires were administered at the
\nbeginning and end of each session to assess the effectiveness of the
\ncreative-movement intervention.
\nFINDINGS
\nThe findings are divided into three sections. The first section presents the
\nfindings from the weekly assessment Likert-scale questions for both the LG
\nand SG; because the MG was conducted with two waves over two periods
\nof time, these findings were not seen as being comparable for this assessment. The second and third sections present for all groups the findings from
\nthe weekly assessment open-ended responses and the end-of-program
\nevaluation assessment.
\nWeekly Assessment Likert-Scale Questions: Comparing Educational
\nand Support Groups
\nAs part of the weekly assessment evaluation, participants were asked to rate
\nhow helpful the previous week\u2019s session was with respect to five mental
\nhealth variables: irritability, depression, anxiety, stress, and concentration.
\nHelpfulness was rated on a Likert-scale from 1 to 5 (1 = minimally helpful
\nto 5 = extremely helpful). Overall, the SG had higher average scores for
\neach of the five mental health variables than the LG.
\nLooking at each of the variables individually, the LG (see Table 2)
\nfound their intervention most helpful with anxiety, while the SG found
\ntheir intervention most helpful with stress, depression, and anxiety (see
\nTable 3). An overall mental health score was compiled using all five variables. Results indicate that the SG (mean = 3.41) found their intervention
\nto be more helpful than the LG (mean = 1.72). Based on the results of the
\ndata analysis, it can be concluded that the SG intervention was the more
\nTABLE 2 Literature Group Weekly Assessment Scores
\nVariables
\nParticipants Irritability Depression Anxiety Stress Concentration
\nOverall Mental
\nHealth
\nLG1 1.33 2.83 2.50 2.50 2.00 2.23
\nLG5 1.57 1.00 1.14 1.29 0.43 1.09
\nLG6 0.00 1.00 1.14 1.29 0.43 0.27
\nLG7 2.00 2.00 2.80 2.00 2.00 2.16
\nLG8 2.71 2.86 2.71 2.86 2.71 2.77
\nLG10 2.20 1.20 3.40 2.20 0.00 1.80
\nAverage 1.64 1.73 2.15 1.81 1.27 1.72
\n68 L. K. M. Donorfio et al.
\neffective in reducing irritability, depression, anxiety, stress, and improving
\nconcentration than the LG.
\nWeekly Assessment Open-Ended Responses: Comparing All Three
\nInterventions
\nBased on the majority of open-ended weekly responses gathered from
\nparticipants in the LG, the following two general themes emerged: (a)
\nNew Information, and (b) Reinforcement of Existing Information. Common participant responses included: \u201cInteresting information shared about
\ncaregiving for it brought my attention to many new ideas and strategies\u201d;
\n\u201cIt [the weekly tip] gave many different suggestions\u201d; and \u201cThe information was helpful because it reinforced what I already know.\u201d No one particular weekly tip was found most useful by the majority of the
\nparticipants. While one participant found one or two tips extremely helpful, others commented that it did not apply to their specific situation or
\n\u201cbeen there and done that.\u201d Even though the participants gave very positive feedback concerning the usefulness of receiving the caregiving tips,
\nmany wished the tips were more specifically applied to them and their
\nunique situation.
\nAs compared to the LG, the SG had only one strong overarching
\ntheme, labeled \u201cValidation.\u201d The majority of participants in this group found
\nthis intervention rewarding because it was an opportunity to \u201ctalk, listen,
\nand share,\u201d to be able to \u201cvent in a safe environment,\u201d and to \u201crealize I am
\nnot alone.\u201d
\nLike the SG, the MG had only one overarching theme, labeled \u201cRelaxing.\u201d This actual word appeared most often in the participant\u2019s weekly
\nresponses. Some participants commented that this intervention \u201chelped my
\ndepression,\u201d was \u201ctime to myself,\u201d and \u201cloosened me up and warmed my
\nstiff muscles.\u201d Another shared, \u201cI was able to express myself in different
\nway, and it helped me relax in a different way.\u201d
\nTABLE 3 Support Group Weekly Assessment Scores
\nVariables
\nParticipants Irritability Depression Anxiety Stress Concentration
\nOverall Mental
\nHealth
\nSG1 2.17 1.67 2.17 2.50 2.17 2.14
\nSG5 4.88 4.88 4.88 4.88 4.88 4.88
\nSG6 5.00 5.00 5.00 5.00 5.00 5.00
\nSG7 3.40 4.00 3.40 4.00 3.50 3.66
\nSG8 3.25 3.50 3.50 3.25 3.25 3.35
\nSG10 1.50 1.75 1.50 2.25 0.00 1.40
\nAverage 3.37 3.47 3.41 3.65 3.13 3.41
\nEffects of Three Caregiver Interventions 69
\n2End-of-Program Evaluation: Comparing All Three Interventions
\nQUESTION #1: WHAT DID YOU LIKE MOST ABOUT PARTICIPATING IN YOUR SPECIFIC
\nINTERVENTION GROUP?
\nThe LG indicated that they liked the reinforcement, knowing they were not
\nalone, and the helpful tips. They liked to learn new information that could
\nhelp them in their caregiving situation. They also were glad to see that some
\nof what they were doing was considered the \u201cright thing\u201d and that others
\nwere going through similar problems while caregiving. The SG indicated
\nthat both interaction and comradery were provided and that the sharing of
\npositive and negative caregiving experiences with each other was their
\nfavorite aspect of this particular intervention. As one participant shared, \u201cIt
\nwas very meaningful for me to share with the others, especially because
\nthey knew what I was going through because their situations were similar.
\nWe had this unspoken connection.\u201d The MG indicated that their intervention served as an \u201cexpressive outlet.\u201d Participants felt the creative movement
\nsessions helped them relax and feel energized.
\nQUESTION #2: WHAT DID YOU LIKE LEAST ABOUT PARTICIPATING IN YOUR SPECIFIC
\nINTERVENTION GROUP?
\nThe LG indicated that many of the caregiver tips were not \u201cspecific enough\u201d
\nor \u201cdid not apply enough\u201d to their caregiving situation to be useful. They
\nsuggested that future LG participants receive tips that are more individualized. The SG felt that the intervention was too short, in terms of the number
\nof meeting sessions, and that future groups should last longer. Because of
\nthis request, it was suggested that the women form relationships outside of
\nthe weekly support group meeting. A phone and e-mail tree was created
\nthat they began to utilize after intervention ended. The MG did not list any
\nresponses for what they liked least about participating in their specific intervention group.
\nQUESTION #3: WOULD YOU PARTICIPATE IN YOUR INTERVENTION GROUP AGAIN
\nAND WHY?
\nAll three groups indicated that they would enroll in their respective intervention group again. The LG expressed that they would participate again
\nbecause the intervention was \u201cinformative\u201d and \u201creflective.\u201d The SG
\nexpressed that they would participate again because of the \u201csupport\u201d they
\nreceived while in the group, both inside and outside of the meeting. It
\nseemed that the meetings created a reservoir from which they could draw
\nuntil the next meeting. Some even indicated that when they became frustrated, they would think about what the other caregivers would do or recommend. Some would think ahead to the next meeting, \u201ccounting the days
\n70 L. K. M. Donorfio et al.
\ndown,\u201d to help them get through the week. The MG indicated that they
\nwould participate in their intervention group again because they found the
\nsessions to be a \u201crelaxing,\u201d \u201cenergizing,\u201d and an \u201cexpressive outlet.\u201d
\nLIMITATIONS
\nA major limitation of the current study was the overall small sample size,
\nespecially for the creative-movement intervention group (MG: n = 4). Such
\na small sample size did not allow for comparisons to be made among the
\nthree intervention strategies. In addition, the small sample did not allow the
\nfindings to be generalized to the larger population of midlife daughters caring for their elderly mothers.
\nA second limitation of this study was that it concentrated only on
\nmother and daughter caregiving pairs. Although the caregiving literature at
\nlarge also concentrates on daughters and mothers, with very little on other
\ncaregiving pairs, future research will benefit by examining the dynamics
\nbetween other caregiving pairs and identifying the most beneficial interventions (Cohler, 1997). Future research should approach this area from a family perspective, rather than just the caregiving dyad, since informal
\ncaregiving often involves many family members and secondary caregivers.
\nA third limitation is that there was no way of knowing how thoroughly
\nthe LG read and understood the caregiving tips and how this affected the
\nweekly assessment survey. A fourth limitation was the homogeneous sample. The majority of the sample was White, highly educated, and had an
\nincome of $50,000 per year or more. Consequently, the findings cannot be
\ngeneralized to other populations of caregiving daughters and care-receiving
\nmothers of other ethnic and socioeconomic backgrounds.
\nDISCUSSION
\nThe review of the caregiving intervention literature shows that the home
\nliterature and the creative-movement formats are new to the family caregiver intervention field. On the other hand, the support group format is the
\nmost commonly employed intervention targeting individual family caregivers (Callahan et al., 2006; Claxton-Oldfield et al., 2007; Drentea et al., 2006;
\nGitlin et al., 2005; Marziali & Donahue, 2006; Smith & Toseland, 2006; Stewart
\net al., 2006). Only one study by Eisdorfer et al. (2003) used education materials in conjunction with a support group as part of the intervention. Previous studies have found positive outcomes for support groups lowering
\ndepression and stress among family caregivers. The weekly Likert-scale
\nawareness surveys showed that the women benefited from being in their
\nrespective intervention groups.
\nEffects of Three Caregiver Interventions 71
\nThe review of the literature also showed that the most common goal of
\nthe previously used interventions was teaching caregivers stress management and problem-behavior management skills. The main goal of this
\nresearch was to evaluate which of the three interventions was most effective
\nin reducing caregiver irritability, depression, anxiety, stress, and in increasing concentration levels among midlife daughters. Results of the weekly
\nassessment instrument indicated that the SG had higher average scores for
\neach of the five mental health variables. Participants in the LG found their
\nintervention most helpful with depression and anxiety, while the SG found
\ntheir intervention most helpful with stress, depression, and anxiety. The five
\nmental health variables were combined to produce an overall mental health
\nscore. The overall mental health scores were 1.72 for LG and 3.41 for SG,
\nindicating that the support-group intervention had a more positive effect on
\nthe caregivers\u2019 mental health than the home-based intervention. As mentioned previously, the MG was not compared to the other two groups due
\nto recruitment difficulties.
\nWhen asked what they liked most about participating in their specific
\nintervention group, the LG participants indicated that they liked learning new
\ninformation, knowing they were not alone, and glad to see that what they
\nwere doing was considered the \u201cright thing\u201d by other caregivers participating
\nin their group. The intervention seemed to provide reinforcement for their
\nexisting knowledge about caregiving practices and to provide new caregiving
\ninformation. It is important to point out that while the participants gave very
\npositive feedback concerning the usefulness of receiving the caregiving tips,
\nmany wished the tips more specifically applied to them and their unique situation. The SG participants specifically liked the interaction and comradery
\nand the sharing of positive and negative caregiving experiences.
\nThe MG participants indicated that the most important outcome for
\nthem was that their intervention served as an \u201cexpressive outlet\u201d and helped
\nthem feel relaxed and energized. These responses were similar to responses
\nmade by caregivers in the most recent dance improvisation research of
\nVetter and Myllykangas (2008). Caregiving participants called it \u201cthe hour of
\nfreedom.\u201d They indicated that it helped with relaxation and better sleep. It
\nwas difficult to determine if the end results of the MG in the present study
\nwere due to the creative-movement exercises alone. Frequently, participants
\nbegan with movement and then added verbal expression, which was a natural response for individuals unfamiliar with movement improvisation. This
\nis not atypical in the dance-movement literature. In one of Sandel\u2019s (1994)
\ndance-movement therapy groups, a participant began singing while moving
\nand the others in the group joined and formed a chorus. Similarly, Truitt
\n(1996) found dance combined with verbal expression completed the recollections of the actors and actresses used in the script for the audience.
\nOverall, each of the intervention groups was considered successful to
\nsome degree, with all participants indicating that they would enroll in their
\n72 L. K. M. Donorfio et al.
\nrespective intervention group again in the future. The LG enjoyed gaining
\nnew knowledge related to caregiving but wished it were more specific to
\ntheir particular situation. The SG enjoyed each other\u2019s company, the open
\nand nonthreatening atmosphere, and the knowledge that others were going
\nthrough the same thing they were. They felt the length of the intervention
\nwas too short and hoped it was longer or could be started up again after a
\nshort break. The MG thought their intervention was relaxing and enjoyed
\nthe time to themselves, but because it was the first time they participated in
\nsuch an intervention, they were unclear about where the sessions were
\ngoing or what they were expected to achieve by the end.
\nFUTURE RESEARCH
\nFuture research needs to recruit larger and more representative groups of
\nparticipants in all of the intervention conditions. A larger sample would
\nallow comparisons among groups as well as increase the generalizeability
\nof results to more caregivers. In addition, because the creative-movement
\nand home-based interventions are relatively new in the field, future research
\nshould modify these programs to best fit the specific needs of diverse populations. In an effort to create a more individualized intervention, future
\nresearch could recruit more diverse types of caregivers, such as caregivers
\nfor individuals with Alzheimer\u2019s or Parkinson\u2019s disease.
\nAlso of particular interest is the use of creative-movement improvisation
\nwith caregiving dyads. Only one previous study implemented a creative-arts
\nintervention with family caregivers of patients with cancer (Walsh et al.,
\n2004). This intervention consisted of caregiver and care-receiver pairs engaging in drawing, painting, and making collages. The study showed a significant
\nreduction in stress and anxiety and an increase in positive emotions of the
\ndyads following their participation in the study. Also, caregivers and carereceivers expressed an increase in positive communication as a result of the
\ncreative-art processes. Future research is needed to explore the potential that
\ncreative movement can have the same impact as other art therapy.
\nFuture research should consider combining strategies into different
\nhybrid interventions in order to target more specific populations of caregiving dyads. Combining this approach with targeting different caregiving
\npopulations will increase effectiveness for the greatest number.
\nAPPLICATION OF THE STUDY
\nThe current study does have promising application for the development of
\nfuture intervention programs for family caregivers. The weekly assessment
\ninstrument evinces that the SG intervention is effective in reducing irritability,
\nEffects of Three Caregiver Interventions 73
\ndepression, anxiety, and stress. Also, all participants indicated that they
\nfound their intervention helpful in coping with caregiving. Consequently,
\nbecause participants generally had positive feedback regarding their interventions, it is believed that similar types of intervention programs can be
\nbeneficial to caregivers. These interventions, or a hybrid form combining
\nmore than one intervention, could be easily implemented in different institutions found in communities, such as senior centers, recreational facilities,
\nwork environments, and assisted living facilities.
\nAlthough support groups are the most common intervention method
\nused for caregivers (Claxton-Oldfield et al., 2007; Marziali & Donahue, 2006;
\nSmith & Toseland, 2006; Stewart et al., 2006), other types of interventions
\ncan also be useful. For example, some caregivers may prefer a type of intervention that is similar to the LG because of its convenience and flexibility,
\nwhile others may prefer an intervention that requires more physical involvement such as the MG intervention. Zwerling (1989) argues that because
\ncreative-art therapies employ nonverbal techniques, they more directly connect to emotional processes than more traditional verbal therapies. He
\nargues that creative-art therapies directly evoke responses at a level that
\npsychotherapists may not reach.
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