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Family-based therapy for dementiacaregivers: Clinical observationsV.B. Mitrani a & S. J. Czaja aa Department of Psychiatry and Behavioral Sciences , University of MiamiSchool of Medicine , Miami, USAPublished online: 09 Jun 2010.

To cite this article: V.B. Mitrani & S. J. Czaja (2000) Family-based therapy for dementia caregivers:Clinical observations, Aging & Mental Health, 4:3, 200-209, DOI: 10.1080/713649924

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Aging & Mental Health 2000; 4(3): 200± 209

Family-based therapy for dementia caregivers: clinical observations

V. B. MITRANI & S. J. CZAJA

Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine, Miami, USA

AbstractFamily caregiving for dementia patients is a major social and clinical problem. Family caregivers face major stressfulemotional, social and economic burdens, and the negative consequences associated with caregiving are well documented.Given the projected increase in the number of people with dementia, there is a need to identify approaches that will helpfamilies manage the challenges of caregiving. Social support from friends and family members has consistently been foundto mediate caregiver outcomes, yet many caregivers face problems with isolation and estrangement from family members. Inthis regard, family-based therapy is a promising intervention for increasing social support for caregivers, and enhancing theirquality of life and ability to provide care.This paper will discuss how family-based therapy can be applied as an interventionfor family caregivers of dementia patients. The clinical implications of speci® c interactional patterns will be presented viacase examples from an ongoing clinical trial with white American and Cuban American caregivers of dementia patients.Theintent is to demonstrate how identi® cation of interactional patterns is a valuable tool for implementing family-basedinterventions.

Introduction

Currently about 4 million Americans suffer fromAlzheimer’s disease (AD), and by the year 2040 thisnumber is expected to increase to 9 million or aboutone in 30 Americans (Brody & Cohen, 1989). Themajority of people with AD live at home and arecared for by family members such as spouses,daughters or daughters-in-law (Zarit et al., 1998).Caring for a family member with dementia createssigni® cant challenges, and many caregivers experi-ence considerable burden and stress. The negativeconsequences associated with caregiving are welldocumented and include depression and anxiety,increased use of psychotropic medications,immunological dysfunction and increased use ofmedical services.

Because individual caregivers respond differentlyto the stressors of caregiving situations (Zarit et al.,1998), researchers have sought to identify factorsthat impact the relationship between the demands ofcaregiving and caregiver distress.These factors includecare recipient impairment, caregiver characteristicsand contextual factors such as social support. Amongcare recipient impairment variables, the level of behav-ioral symptoms, such as wandering and repetitivequestioning, has emerged as the strongest predictorof caregiver distress (Haley et al., 1987; Teri et al.,1992). Caregiver outcomes also vary as a function ofgender (females experience more burden than males)(Schulz & Williamson, 1994), age (older caregiversexperience more burden) and ethnicity (African-

American caregivers typically report less burden thanCaucasian caregivers) (Fredman et al., 1995). In addi-tion, caregivers who employ a problem-focused copingstyle have been found to have better outcomes thanthose who employ emotion-focused coping (Kramer,1997; Rose et al., 1997).

Clearly, the relationship between caregiver burdenand outcomes is complex and there appear to beconsiderable individual differences in response to thedemands of caregiving (Schulz et al., 1995).Understanding factors that impact on caregiverburden and distress is critical to the development ofefficacious intervention strategies. As noted, socialsupport has consistently been found to have an effecton caregiver outcomes. Generally emotional supportand receiving assistance with caregiving tasks is associ-ated with lowered feelings of burden and depressionand higher wellbeing (Franks & Stephens, 1992; Teri,1994). Also, caregivers who engage in social andrecreational activities and interact with family andfriends are less depressed than caregivers who aremore socially isolated (as reported in Haley, 1997).

One critical source of social support for caregiversis the family. Family members can offer instrumentaland emotional support to caregivers and ease theburdens associated with the demands of caregiving.However, family interactions and pre-existing familycon¯ icts can also exacerbate caregiver distress.Familyvariables that are related to caregiver distress include:marital con¯ ict among caregiving daughters (Creaseyet al., 1990), family con¯ ict (Sample, 1992), boundaryambiguity (Boss, 1993), problematic communication

Correspondence to: Victoria Mitrani, Center for Family Studies, Department of Psychiatry and Behavioral Sciences,University of Miami School of Medicine, 1425 N.W. 10th Avenue, Miami, USA.Tel: (305) 243 6351. Fax: (305) 243 5577.E-mail: vmitrani@med.miami.edu

ISSN 1360± 7863 print/ISSN 1364± 6915 online/00/030200± 10 ½ Taylor & Francis Ltd

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patterns (Speice et al., 1998) and incongruence offamily members’ appraisal of the care recipient(Pruchno et al., 1997). As discussed by Cohen et al.(1998), the beliefs that family members have aboutwhat in¯ uences events and circumstances during thecourse of dementia are powerful forces in determininghow well caregivers cope with the demands of theillness.

Despite the importance of understanding theimpact of family dynamics on caregiving and theobvious disruption to family life associated with Alzhe-imer’s disease, the literature on the relationshipbetween family factors and caregiver outcomes issparse (Teri & Logsdon, 1992). Furthermore, thereis little synergy between the ® elds of family systemsand gerontology. A review of articles published infamily therapy journals between the years 1986±1994 found that only 3% had an aging focus (vanAmburg et al., 1996), and reviews of the dementiacaregiving literature have yielded similar results.Although caregivers express a desire for family coun-seling (Wykle, 1996), the approach to caregiverinterventions has traditionally been via group supportor individual psychoeducational models (Teri &Logsdon, 1992). In fact, some theorists cite the`paradox’ of the lack of family interventions forcaregiving, which is a prototypical family systemsissue (Knight & McCallum, 1998).

The scarce literature notwithstanding, there issupport in the ® eld for the family therapy approachfor caregivers of dementia patients (Cohen et al.,1998; Czaja et al., 2000; Knight & McCallum, 1998;Teri & Logsdon, 1992) and reason to believe in itspromise for helping families adjust to the challengesof caregiving. Generally, family therapy can increasesupport provided to caregivers by family membersand decrease family con¯ ict associated withcaregiving. Family-based interventions have beenfound to be effective in the prevention, treatment andmanagement of various mental disorders such assubstance abuse and schizophrenia (Bischoff et al.,1996). There is also growing evidence that familyinterventions are effective for the treatment andmanagement of physical illnesses such as pediatricasthma and diabetes, cardiovascular and neurologicaldisorders, obesity and anorexia nervosa (Campbell &Patterson, 1995).

The goal of this paper is to demonstrate how family-based therapy can be applied as an intervention forfamily caregivers of dementia patients. Speci® cally,the clinical implications of family interactionalpatterns will be presented via case examples from anongoing clinical trial (REACH) with white Americanand Cuban American caregivers.REACH (Resourcesfor Enhancing Alzheimer’s Caregiver Health) is amulti-site project, funded by the National Instituteon Aging and the National Institute of NursingResearch, which is evaluating the efficacy of a varietyof psychosocial and behavioral interventions on

reducing the burden and improving the wellbeing offamily caregivers of persons with Alzheimer’s disease.These interventions encompass a variety of techniquesincluding psycho/social/educational services, behav-ioral interventions, innovations in community services,environmental modi® cations and technology-basedinterventions.

A family-based therapy, Structural EcosystemsTherapy (SET), developed by Szapocznik andcolleagues (Mitrani et al., 2000; Szapocznik et al.,1994) is one of the interventions being evaluated atthe Miami REACH site.This intervention differs fromthe other interventions being evaluated withinREACH in that it attempts to address the needs ofthe entire family within a conjoint context. It alsofocuses on transforming the process of family relation-ships as a mediator to improving caregiver support.The aim of the SET intervention is to improve thecaregiver’s interactions within her or his entire socialecosystem (family, community, health providers, etc.)to increase the extent to which the caregiver’semotional, social and instrumental needs are metand, in turn, improve psychological adjustment.

The speci® c intent of this paper is to demonstratehow the identi® cation of family interactional patternsis a valuable clinical tool for implementing family-based interventions.Attention will be also be given topotential differences in interactional patterns betweenwhite American and Cuban American families. Thispaper will focus exclusively on patterns of interactionthat occur within the family, and will not discuss theextra-familial, or ecosystemic, aspects of the interven-tion.

The application of SET within the Miami

REACH project

As noted, SET is one of the interventions being evalu-ated at the Miami site of the REACH project. Theparticipants (224 family caregivers of dementiapatients, including 112 white American caregiversand 112 Cuban American caregivers) are randomlyassigned to one of the three treatment conditions.The other intervention conditions include SETenhanced with a computer integrated telephonesystem (SET+CTIS), and a minimal contacttelephone support control. The CTIS system servesto augment the family therapy intervention byfacilitating the caregivers’ ability to communicate withfamily members, friends, other caregivers and theirtherapist. The participants are recruited from twomemory disorder clinics affiliated with the Depart-ment of Psychiatry and Behavioral Sciences, and fromthe community via newspaper and radio advertise-ment. In almost all cases, it is the primary caregiverwho makes the initial call to the project.

All participants are required to meet the REACHinclusion/exclusion criteria, as well as the site-speci® c criteria.The care recipients are 60+ years of

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age and have a DSM-IV diagnosis of dementia or ascore of 23 or less on the Mini-Mental State Examina-tion (MMSE; Folstein et al., 1975), and the presenceof two IADL or one ADL impairments.Among othercriteria, the primary caregivers are required to havebeen in the caregiver role for at least six months, livewith the care recipient, and provide at least four hoursof assistance per day. For the Miami site, at least oneother family member must participate in the project.Other family members include actual or ® ctive familywho provide emotional or instrumental support.

Parameters of the SET intervention and pragmaticconsiderations

The SET intervention in REACH takes place overa course of 12 months, with weekly sessions forthe ® rst four months, bi-weekly sessions for thesubsequent two months and monthly sessions forthe ® nal six months of treatment. This schedule wasselected to provide a standard dosage and to allowsufficient time to meet treatment goals.The taperingof treatment allows for an extended treatment periodin which new caregiving problems are likely to emergeand facilitates generalization of treatment gains inthe face of these emerging problems.

The majority of sessions are conducted in thecaregiver’s home or other settings (e.g. a day carecenter, hospital or adult child’s home). Because thisis a funded research project, services are provided atno charge to the families, and cost studies are neededto determine the feasibility of offering these serviceson a fee for service basis. In the SET+CTIS interven-tion, some family sessions are conducted via thecomputer telephone system, and show promise formore economical treatment delivery.

The standard protocol is for therapy sessions to bevideotaped, although agreeing to be videotaped is nota condition for inclusion in the project. The mostcommon reason given by families for videotape refusalis concern that it will disturb the care recipient. Somefamilies have also expressed privacy concerns. Themajority of families, however, agree to be videotapedand, given the high level of disclosure of intimatematerial, do not appear to be constricted by the pres-ence of the camera. The purpose for videotapingsessions involves both research and clinical considera-tions. Research uses include treatment adherenceevaluations and process study. Clinically, sessionrecordings are useful for supervision/team consulta-tion, which is highly recommended for helping thetherapist remain true to the SET intervention.

Overview of Structural Ecosystems Therapy

(SET)

SET is a family-based intervention initially developedfor the families of adolescent substance abusers, and

adapted to enhance support for caregivers. SET isderived from a combination of two theoreticalapproaches: (1) the structural/systemic approach(Minuchin, 1974; Minuchin, et al., 1967; Szapocznik& COSSMHO, 1994; Szapocznik & Kurtines, 1989;Kurtines & Szapocznik, 1996) and (2) the ecosys-temic approach (Bronfenbrener, 1979).

As a systemic approach, the SET model views thebehavior of family members as interdependent andrepetitive. In some instances the repetitive patterns offamily interactions may be maladaptive or obsolete,leading to symptoms such as caregiver distress. Otherfamily patterns of interaction may be particularlyadaptive and relieve caregiver burden. SET isparticularly appropriate for minority families becauseit recognizes the importance of culture as a contextualvariable which can have a pronounced in¯ uence onfamily interactions.

The primary caregiver is the central ® gure in theSET intervention.This is the individual who is bearingthe most practical day-to-day caregiving burden, andtherefore is the most motivated to affect change inthe family interactions that are related to caregiving.The primary caregiver is also typically the gatekeeperwho controls access to the AD patient and her or hiscaregiving needs. Therefore, while other familymembers are typically distressed by the current familyfunctioning, and certainly the aim of SET is toenhance the adaptation of the entire family to thecaregiving situation, the primary caregiver is the initialentry point of the therapist into the family and usuallyremains the primary contact person throughout theintervention.

Generally, family interactional changes that arebene® cial to the caregiver (e.g. by increasing avail-able support) also bene® t other family members (e.g.by improving their relationship with the caregiver, orby meeting their goals for improved caregiving). Infact, it is only through this mutual satisfaction thatinteractional changes can be maintained, since theabsence of reinforcement on either side would causethe new interaction to be extinguished. There arecases (particularly among caregivers with borderlineor narcissistic features) in which primary caregivershave unreasonable expectations of family support. Insuch cases, the therapist seeks to balance the caregiv-er’s need for support while helping other familymembers to set limits on overwhelming demands fromthe caregiver.

In the initial sessions, the therapist usually meetswith the caregiver alone or the caregiver and otherfamily members, and gradually gathers the history ofthe family, AD and the caregiving experience. Thegoal of these initial sessions is to build rapport,establish therapeutic goals, and begin to assess thecaregiver’s family interactions.The therapist encour-ages family members to interact with each other insession to assess and transform interactions as theyoccur.

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A central tenet of the SET approach is its emphasison the processes of family interaction rather than oncontent. Process is comprised of how people interact,while content is the topic that they are interactingabout. For instance, suppose a therapist learns fromthe caregiver that she and her daughter are in conflictregarding the AD patient’s medication such that theyhave stopped speaking to each other. In this case, thecontent is the patient’s medication, while the processis mother and daughter’ s inability to maintaincommunication in the face of disagreement. SETaims to transform the interactional processes (e.g.the inability to negotiate disagreement) that blockthe resolution of content concerns (medicationmanagement).

The therapist assesses interactions, determineswhich of these might be targeted in treatment andestablishes a plan to transform interactions. Thisapproach involves: (1) developing a clearunderstanding of the nature of supportive andproblematic interactions, (2) understandinghow theseinteractions are related to the family’s current level offunctioning, and (3) intervening in a very deliberatefashion to enhance supportive and reduce maladap-tive interactions.

In the example given above, once the therapist hasdetermined that there is a caring bond betweenmother and daughter, or at least between each ofthem and the AD patient, a planned set of interven-tions might include: (1) speaking individually withthe women to engage and prepare them for a conjointsession, (2) strengthening their alliance by havingthem talk together about a common concern (e.g. thepatient’s agitation which is resulting in complaintsfrom the day care center), (3) having the women

work together on a practical problem-solving planwhile helping them maintain their communicationdespite disagreement (e.g. by blocking escalatingcon¯ ict or personal attacks), (4) following up on theplan in a subsequent session and congratulatingmother and daughter on their teamwork, or exploringbarriers that impeded progress (these might bepractical, relational or intrapsychic barriers), and soon.

Family interactional patterns and case examples

The assessment of interactional patterns is conductedalong four dimensions of family functioning that areparticularly related to caregiver functioning:structure(family roles), developmental stage, resonance(interpersonal boundaries), and con¯ ict resolution.Table 1 gives examples of maladaptive family interac-tions that fall within these four dimensions.

This section will describe the interactional patternslisted inTable 1 and provide case examples to illustratetheir impact on the caregiver and how they can beapproached in therapy. Identifying details in the caseexamples have been changed to protect clientcon® dentiality. For purposes of highlighting aparticular dimension of interactional functioning,eachcase presents only one problematic interactionalpattern. Although some families have a single ordominant problematic pattern, most families havemultiple problematic patterns. Moreover, a problemin one dimension of family interaction typically hasan impact on other dimensions. For example, thelack of direct verbal communication (structure) mayindicate disengagement (resonance) and has an

TABLE 1. Caregiver family interactional patterns

Pattern Interaction

StructureHierarchy Family functions not accomplished due to a leadership void

Family members usurp the caregiver’s leadershipPower struggles

Alliance Lack of collaboration among family membersFamily members frequently pulled into each other’s con¯ icts

Communication Lack of direct verbal communication between any two family membersIneffective communication (e.g. vague, lecturing, over-emotional)

Developmental stage Adjustment difficulties related to dementiaAdjustment difficulties related to other transitions (e.g. retirement, relocation, divorce)A family member is expected to function beyond his or her capacityA family member is expected to function below his or her capacity

ResonanceEnmeshment The caregiver is emotionally over-involved with the care recipient (e.g. is personally offended

by dementia symptoms, unable to separate)Emotional over-involvement between other family membersFamily members invade each other’s boundaries (e.g. eavesdropping)Family members speak simultaneously or interrupt each other

Disengagement Pre-existing detachment between the caregiver and care recipientDetachment between the caregiver and care recipient due to dementiaDetachment between other family members

Con¯ ict resolution Family denies or avoids con¯ icts/problemsCon¯ icts/problems remain unresolved because focus shifts across issuesFamily interactions are frequently negative/con¯ ictive

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impact on the family’s ability to confront problems(con¯ ict resolution). Fortunately, a single interven-tion can often tackle interrelated problems acrossdimensions.

Structure

The caregiving system, which consists of allindividuals who play caregiving roles, must be organ-ized to distribute caregiving responsibilities and formutual support. Caregiver wellbeing is related to thecaregiver’s ability to serve, and be validated by thefamily, as a leader of the caregiving system. Caregivingstructure involves family hierarchy, alliances andcommunication ¯ ow. In a family with effectivestructure, the caregiver is able to successfullydistribute caregiving tasks, lead decision-making andcollaborate with other family executives, and maintainalliances with other family members.

Culture can have an impact on caregiving structure.Cuban families often hold a hierarchical relationalorientation (Szapocznik et al., 1978) and adhere totraditional gender roles. In Cuban families, olderfemale caregivers may have particular difficulty inadopting some of the leadership roles of caregiving,especially vis-aÁ -vis their care recipient husbands.Longstanding family roles can also have an impacton the ability of other family members, even thosewho are relatively acculturated, to accept the leader-ship of an older female caregiver.

An example is the case of Mrs L, the primarycaregiver for her husband. The L’s were a CubanAmerican couple, who, like many of their genera-tion living in Miami, were not highly acculturated.Mr L had formerly been the capable anduncontested leader of the family, commandingsubmission from his wife because of his intimidatingmanner. AD exacerbated Mr L’s aggressive anddemanding style, so that Mrs L feared for herphysical safety if she were to attempt to restrict MrL’s access to the car or to the household ® nances.Despite the fact that Mr L was clearly incapable ofdriving or managing ® nancial matters (hismismanagement had already cost the familydevastating losses), Mrs L felt helpless in control-ling her husband’s behavior.The L’s son had gradu-ally taken the reins of the family business and couldnot understand why his mother could not do thesame at home. Feeling helpless and invalidated,Mrs L was depressed, anxious and suffereddebilitating gastro-intestinal problems. She ceasedall social interactions due to her fear of leaving MrL alone, since he refused any substitute companion.Mrs L’s relationship with her son was strained dueto her frequent complaints about Mr L (often inthe form of desperate telephone calls), and theson’s minimization of the problem.

In the early sessions, the therapist determinedthat Mrs L’s low status in her family’s hierarchy

was a central problematic interaction andcontracted with Mrs L to work on enhancing hereffectiveness at managing Mr L’s behavior, andgaining respect and support from her son. Thetherapist recognized that the L’s son would be avaluable member of the family leadership structureand aimed to facilitate an executive alliance betweenMrs L and her son. Mrs L, however, was hesitantto include her son in family therapy. She said thathe was too busy and politely refused the therapist’soffer to call and invite him to a session.The therapistrecognized Mrs L’s reluctance as a symptom of thestatus quo in the hierarchy, and deferred chal-lenging this behavior until the therapeutic alliancewas more solidly established.

The therapist recognized an opportunity forchange when Mrs L reported that her son wasgoing to take Mr L on a business trip.The trip hadan eye-opening impact on the son’s perspectiveregarding Mr L’s level of functioning. With ® vedays of constant contact, the son was able to experi-ence Mr L’s difficulties in managing his own care,his disorientation and his insistence that he couldbe self-reliant. Mrs L gained tremendous satisfac-tion from her son’s acknowledgement of her dailystruggle, and agreed to allow the therapist to callhim.

The L’s son was appreciative of the therapist’sexpression of sympathy regarding his experienceson the business trip, and accepted her invitation toattend a session.The therapist’s goal in this sessionwas to engage Mrs L and her son in a collaborativerelationship on managing Mr L’s behavior and othercaregiving needs, and to strengthen their supportivebond and alliance. Potential barriers included MrsL’s helpless manner, as well as the son’s impatienceand invalidating stance.

To overcome these barriers, the therapist lookedfor opportunities to highlight the son’s dedicationand Mrs L’ s successes in bypassing Mr L’sunreasonable demands. The therapist helped MrsL and her son discuss her complaints, helping theson describe his frustration at not being able tosolve the problems that Mrs L related, and helpingMrs L describe her feelings of abandonment whenher son hurried her off the telephone.To help buildthe caregiving alliance and lessen the negativity,the therapist focused on Mrs L’s and her son’scommon goals (e.g. the L’s safety and ® nancialsecurity, Mrs L’s need for a sense of control andthe son’s need to be relieved of his mother’s franticphone calls).

With the therapist’s guidance, mother and sonworked together to generate a solution to theproblem of Mr L’s driving (the son would take thecar keys and they would tell Mr L that the car wasbeing repaired). The issue of household ® nanceswas more challenging as the son’s solution was totake over their management, while Mrs L wanted

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to be more involved.The therapist was encouragedby the assertive manner in which Mrs L expressedher desire to participate in this leadership function.She guided Mrs L and her son in creating a list of® nance tasks, dividing up some short-term tasks(e.g. consulting an attorney, searching for lost docu-ments) and offered to follow-up in a subsequentsession.

The son continued to participate in the therapyprocess intermittently until termination. Latersessions were aimed at maintaining and continuingto build the collaborative caregiving alliancebetween Mrs L and her son. By termination, theL’s son accepted the role of ® nancial advisor’ tohis mother while Mrs L established a routine forpaying bills. Mrs L hired a housekeeper who shecould trust to watch over Mr L (and whom Mr Laccepted, since she was obstensibly present forhousekeeping rather than as his companion), freeingher for social contacts and to maintain regularattendance in a support group. Mrs L’s contactswith her son were also more positive, and he visitedmore regularly.

In this example, the problematic family interactionalpattern was primarily one of ineffective structure.The caregiver lacked credibility as a family leader,did not have her son’s collaboration in leadershipfunctions and therefore was overwhelmed by thepatient’s behavior and needs. By gaining access to theson and highlighting mother and son’s common goalsand complementary strengths, the therapist helpedto form a new `executive sub-system’ that was betterequipped to manage caregiving.

Developmental stage

Families, like individuals, go through a series ofdevelopmental stages, each with its own tasks thatmust be completed. There are expected life cycleevents such as marriage, the birth of children, retire-ment and death in old age. Other signi® cant life cycleevents are not so expected such as divorce, untimelydeath, migration and illness. The onset of dementiamarks the beginning of a new developmental stagefor the family, which involves both expected andunexpected life cycle events.

Stress is often greatest at transition points fromone stage to another of the family developmentalprocess (Carter & McGoldrick, 1989). This stress isdue in large measure to the need to renegotiate andotherwise adjust to some fundamental changes inroles within the family. The ease or difficulty of thefamily in incorporating these new roles determinestheir adjustment to the reality of living with a dementiapatient.

There are several types of interactional adjust-ments that a caregiver family must make. The ® rsttype of adjustment is the ® lling of family roles thatthe 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 ® lled, they areoften less aware of relational roles (e.g. leadership,arbitration, communication, nurturing or familygathering).This type of adjustment consists of severalprocesses, including recognizing the need to ® ll theroles once played by the care recipient, coming toterms with the need to `displace’ the care recipientfrom prior roles, managing the care recipient’s resist-ance to giving up old roles and functions, and movingother persons into the roles once ® lled by the carerecipient, without unduly burdening the caregiver. Acommon symptom of developmental adjustmentdifficulties is unrealistic expectations regarding thefunctioning of the AD patient, or inappropriately lowexpectations from other family members.

The case of Mr F illustrates this latter pattern. MrF was a frail 87-year-old caregiver for his wife, whowas in an advanced stage of AD. Although Mr Fwas a competent manager of Mrs F’s care, hiringand supervising round-the-clock aides and makingsound choices in her health care, his own healthwas faltering.The F’s had two grown children livingnearby. Although the children wanted to assist incaring for their parents, Mr F did not trust theirjudgement due to errors they had made inmanaging their own lives.

The therapist’s assessment was that this familypattern of under-functioning adult childrenpresented a severe threat in the event that Mr Fwould become incapacitated, and prevented thechildren from playing the caring role in their familyof origin that they very much desired.To motivateMr F in transforming this interaction, the therapistallied himself with Mr F’s practical side, whichdictated that the family be secure in the event of anemergency. Mr F agreed with this preventive goal,and contracted to work with the therapist to helpelevate the children to productive adult status inthe family.

Mr F’s only son, who lived with his parentsfollowing a divorce and business failure, wasparticularly available for assistance and regrettedhis father’s lack of con® dence. Two months afterthe start of treatment, the therapist led a sessionwith Mr F and his two children in which the sonexpressed his wish to be closer to Mr F and toreceive his guidance on personal matters. For the® rst time ever, Mr F and his 50-year-old sondiscussed sex, the son’s alcoholism, and his busi-ness failure. With much emotion, Mr F alsoexplained his philosophy about hard work andfrugality. As the discussion ensued, Mr F gained anew understanding of the choices that had led tohis children’s troubles, and the children expressedtheir respect for Mr F and their desire to help. Atthe following session, Mr F again met with his twochildren and spontaneously began to give detailedburial instructions for himself and Mrs F. This

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discussion marked the promotion of these twoincompetant’ children to adult roles in the family.

The developmental stage dimension is concerned withthe family’s adjustment to role transitions made neces-sary by the dementia of one of its members. In thepreceding example, the adult children werefunctioning at a level that was not commensuratewith their abilities, their desire to be of help, nor theneeds of the caregiver and care recipient.This patternof under-functioningwas transformed via an approachwhich rede® ned the family as `at risk’ in the event ofcaregiver disability, and guided intimate communica-tion, which increased the father’s con® dence in hischildren.

Resonance

An important factor in the caregiver’s ability tosuccessfully balance her or his own personal needswith the demands of caregiving is the nature of theboundaries between the caregiver and care recipient.A high degree of emotional and psychological close-ness, or enmeshment, between caregiver and carerecipient makes it difficult for the caregiver to be aneffective manager of the caregiving system because ofa loss in objectivity and unwillingness to delegatecaregiving tasks.

The resonance dimension is strongly in¯ uenced byculture.Whereas American culture places a high valueon individuality and independence, Cuban culturevalues collectivism and gives precedence to the needsof the family over the needs of the individual (Santiste-ban et al., in press). Therefore, the degree ofinterdependency found in Cuban families is typicallymuch greater than that found in white Americanfamilies. Fittingly, the pattern of caregiver± carerecipient `enmeshment’ is observed more frequentlyamong the Cuban families in the sample.

An example is the case of Mr S, the primarycaregiver of his wife, who suffered later stage AD.Both Mr and Mrs S were Cuban American.Thirtyyears earlier, Mr S. had left his ® rst wife andchildren to marry Mrs S, who he described as `thelove of my life’ . Mr S was ® ercely protective of MrsS. In the ® rst session, the therapist was moved byMr S’s tender and constant attention to Mrs S.Although she could not respond and seemedcompletely oblivious to the content of the conversa-tion, Mr S. attempted to include her in the discourseand whispered protectively when speaking with thetherapist about his concerns for Mrs S’s health.

Mr S’s devotion to his wife came at the expenseof considerable personal sacri® ce. He was with herconstantly and had completely cut off a normallyactive social life due to Mrs S’s increased infirmity.Mr S. would not entrust his wife to the care of anaide, and only left the house for brief errands whilea trusted neighbor sat with Mrs S. Mr S had also

failed to attend to his own health needs, havinggone years without a check-up, and showing visiblesigns of poor health.

Mr S was isolated from his family. He had adistant relationship with the children from his ® rstmarriage and with his brother, who lived reason-ably nearby. Mr S felt close to Mrs S’s daughterand consulted with her regarding Mrs S’s healthneeds, but she lived in another state. It was thisdaughter who had sought our services.

Mr S was initially very wary of the therapist’sinvolvement.The therapist was careful not to chal-lenge Mr S’s extreme dedication to his wife, yetrecognized that this pattern was undermining MrS’s mental and physical health as well as his abilityto sustain long-term caregiving. It was this latterpoint that the therapist employed to interest Mr Sin seeking additional support.

After a month of cultivating a cordial relation-ship with Mr S, the therapist had an opportunity tointervene when Mrs S was hospitalized for apulmonary problem. The therapist noted Mr S’sagitation when he called to cancel their appoint-ment, and offered to meet Mr S in the hospitalwhere he found Mr S complaining loudly andbitterly to a nurse for her allegedly callous treat-ment of Mrs S.When they were alone together, thetherapist persuaded Mr S to adopt a `strategic’stance (to make requests in a manner which wouldnot alienate others) toward the hospital so that hiswife would receive the best possible care.

This hospital visit helped the therapist gain MrS’s con® dence, who invited the therapist to callMrs S’s daughter. The therapist expressed hisconcerns to the daughter regarding Mr S’s failinghealth and mobilized her to reinforce Mr S’s posi-tive communications with health care workers andto act as intermediary whenever possible.

The consequences of Mr S’s negligence of hisown health care became evident in the fourth monthof therapy when Mr S was diagnosed with advancedprostate cancer. Mr S accepted the therapist’ssuggestion to contact his brother and son to informthem of his condition (he could not bring himselfto contact his daughter). While the son did notrespond to Mr S’s overture, the brother did beginto visit Mr S more frequently and evenaccompanied him to radiation treatments.

By the seventh month of therapy, Mrs S’s condi-tion deteriorated and she was placed in hospicecare. Despite the gravity of Mrs S’s condition, MrS was able to maintain assertive and appropriateinteractions with the hospice workers. Mrs S diedshortly thereafter. Mr S’s brother and stepdaughtermaintained their support, but he died six monthslater.

Family patterns regarding boundaries are typicallydeeply entrenched and tied to culturally-based values.Transforming resonance, therefore, requires a delicate

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approach. A therapist who threatens the family’s dearlyheld beliefs regarding boundaries, whether they becohesiveness or independence,will quickly be ejectedfrom the therapeutic system.The reader is directed tothe case of the R’s below for an example of a relativelydisengaged caregiver± care recipient dyad.

Con¯ ict resolution

Having a family member with dementia presents amultitude of logistical problems, and precipitatescrises that may cause friction and disagreementbetween and among family members. In many cases,family members naturally search for a person or thingupon which to direct their anger, pain and frustra-tion, leading to negativity that can be diffuse ordirected at one particular person. Sometimes familymembers blame others with little recognition of theirown contribution to the problem. Con¯ ict resolutionrefers to the family’s capacity for effectively resolvingdifferences of opinion with low levels of negativityand without the use of intermediaries or the formingof destructive coalitions. This includes the extent towhich family members: (1) allow differences ofopinion and painful issues to emerge, (2) can managethese differences without personal attacks or losingsight of the issue to be resolved, and (3) can ® ndadequate solutions that have the support of the familymembers involved. An important aspect of con¯ ictresolution is the capacity of the family to allow thecaregiver to assert disagreements and/or criticismsclearly and directly, without leading to the dissolu-tion of relationships.

An example of a problematic pattern of con¯ ictresolution is found in the case of Mrs R, who wascaring for her husband in the early stages of AD.Mr R had been forced to leave his law practicebecause of his dementia. Over the years, Mrs Rhad developed many independent interests and afull social life of her own. Mrs R was deeplydistressed by Mr R’s new need for her companion-ship and was unwilling to accept the reality of hisdisability. Mrs R became impatient whenever MrR could not keep up with their conversation andwould press him for a response, causing Mr R tobecome agitated to the point of violence.

The R’s had two daughters living nearby. Mrs Rhad a tense relationship with one daughter and hadcompletely cut off ties with the other due to aperceived slight several months earlier. Mrs Rcriticized her daughters for their sel® shness andinsensitivity. She felt that they did not give her andMr R their due respect and attention.

The therapist had great difficulty in establishinga working relationship with Mrs R, whom she founddemanding, hostile and disdainful. The therapistwas also dismayed by Mrs R’s harsh and disparagingtreatment of Mr R. In supervision, the therapistwas helped to see Mrs R’s behavior as a symptom

of her despair at the upheaval in her life, and wasable to return to the next session with a moresupportive stance. Mrs R responded well to thetherapist’s support and the opportunity to freelyexpress her distress without being reminded of herobligation to Mr R. She admitted that shesometimes acted impulsively and inappropriatelytowards Mr R and thanked the therapist forlistening to her.

It was clear that the therapist’s initial interactionwith Mrs R mirrored the interactions that Mrs Rhad with her family. Mrs R felt her own pain sodeeply that she failed to see the impact of herbehavior on others and then blamed them for theirinsensitivity. Interactions between Mrs R. and herfamily were such that even seemingly minordisagreements or disapointments could easily leadto escalating con¯ ict or a complete shut-down incommunication.The therapist developed a strategyfor intervening in Mrs R’s interactions with herchildrenÐ if she could construct situations in whichMrs R was free to express her own needs, then theground would be set for Mrs R to be more recep-tive to the input of others.

Managing the con¯ ict between Mrs R and herdaughters required a delicate and patient approach.There was a history of negativity and intermittentcutoffs between Mrs R and the daughters whichwas exacerbated by their distress regarding Mr R’sillness. The therapist planned to use the ® rstconjoint session to highlight the women’s commonloss as a way to bring them closer. Mrs R had adifferent agenda in mind, however. Her goal was touse the session to list all of her complaints abouther daughters, especially the one who had slightedher by canceling a dinner invitation. The therapistfeared that the negativity would become so intensethat the daughters would no longer be willing toparticipate in therapy and that the rift betweenthem and their mother would widen.

Fortunately, the therapist was able to offersupport to the daughters without antagonizing MrsR, and once Mrs R had ® nished with her laundrylist’ of complaints, the therapist guided her inexpressing her pain regarding Mr R’s conditionand her lost independence. The daughters joinedin this expression of grief and each one offered aspeci® c act of support (one daughter offered totake Mr R to an event at her son’s school thefollowing day; the other made plans for a mother±daughter shopping trip). More conjoint sessionsfollowed in which Mrs R was guided in presentingher needs in a less aggressive manner and thedaughters were guided in supportively presentingtheir dissenting opinions to Mrs R (e.g. about MrsR’s treatment of Mr R). By termination, onedaughter was regularly attending a caregiver supportgroup with Mrs R, and the other had linked Mrs Rto her synagogue.

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Although we have found con¯ ictive family interac-tions in both ethnic groups, these appear to be morecommon among the white American families,particularly between the caregivers and their adultchildren. Problems of con¯ ict resolution amongCuban American families are often manifested in apattern of denial of AD symptoms or reluctance offamily members to discuss this topic. This processwas illustrated in the case of Mrs L, above.

Conclusion

Caring for a family member with an illness such asdementia is extremely challenging, and manycaregivers and family members experience negativeoutcomes such as depression and stress. Given theprojected increase in the number of people withdementia, and the fact that most dementia patientsare cared for at home by family members (Schulz &O’Brien, 1994), there is a need for strategies thathelp caregivers meet the demands of caregiving.Socialand instrumental support from family members hasbeen found to mediate caregiver outcomes such asfeelings of depression or burden (e.g. Aneshensel etal., 1995), yet many caregivers are isolated andestranged from family members and friends. Despitethe importance of family support for caregivers, wehave a limited understanding of strategies which areefficacious in terms of maximizing family resources.

Although there is an extensive literaturedocumenting the effectiveness of family therapy forvarious mental and health-related problems, theeffectiveness of family therapy for caregivers is largelyunderstudied. The intent of this paper was todemonstrate how a family-based therapy may beapplied to family caregivers of dementia patients.Speci® cally, we sought to delineate several familyinteractional patterns that are particularly relevant tocaregiving situations, and illustrate how these patternscould be addressed via a theoretically-based familytherapy approach.

Assessmentof family interactional patterns providesa road map for identifying maladaptive processes tobe targeted in treatment.These maladaptive patternsblock the ability of the caregiver to receive supportfrom family members, and the ability of familymembers to offer relief to the caregiver. Assessmentof interactional patterns also necessitatesunderstanding contextual factors such as ethnicitywhich shape these interactions.Therefore, one focusin the reported case studies was on differencesbetween white American and Cuban Americancaregivers.Attention to ethnic differences in attitudestowards caregiving and responses to caregivingresponsibilities is critical given the increased ethnicdiversity of the population. As illustrated, CubanAmerican caregivers have different perceptions offamily and family obligations, as well as different

family structures than white Americans. In addition,it is important to tailor interventions so that they areculturally congruent.

The REACH study illustrates an attempt to apply afamily therapy model to caregiver populations. Assuch, the results from this project will provide valu-able insight into the role of family support in caregiveroutcomes. Furthermore, we will gather informationon the protective/risk impact of family interactionalpatterns for caregiver distress. This type of informa-tion will provide guidance for re® ning the familytherapy approach to better meet the speci® c needs ofcaregiver populations.

Acknowledgement

This research was supported through the Resourcesfor Enhancing Alzheimer’s Caregiver Health(REACH) project, which is supported by the NationalInstitute on Aging and the National Institute ofNursing Research (Grants: U01-NR13269,U01-AG13313, U01-AG13297, U01-AG13289,U01-AG13265, U01-AG13255, U01-AG13305).

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