Evaluation ofa Model Self.Help Telephone Program: Impact on Natural Networks ELF-HELP OFFERS the strength and comfort of affiliation among people facing a common problem together. Social workers are encouraged to assess their clients' informal networks and refer clients to self-help as a support supplement for weak, inactive, or disrupted family and friend networks (Powell, 1987). Because caring for a relative with Alzheimer's disease often involves social isolation and family conflict, professionals have initiated support groups for caregivers of people with Alzheimer's disease. Recent research has shown that participants and professionals evaluated support groups as helpful, and a number of controlled evaluations demonstrated that support groups can be beneficial (Montgomery & Borgatta, 1989; Toseland & Rossiter, 1989; Toseland, Rossiter, & Labrecque, 1989). Although the literature on support groups is growing, most studies of support programs for Alzheimer's caregivers generally have not addressed the goals of selfhelp as a supplement to informal support. In this article the author reports on an evaluation of a model telephone network program for caregivers of Alzheimer's victims. The program offered two components: peer networks over the telephone that consisted of four or five caregivers, each making weekly calls in a rotating pattern over a three-month period, and an informational lecture series accessed over the telephone that covered Alzheimer's disease and care management topics. The evaluation focused on the interface between professionally initiated peer networks and naturally existing friend and family support, the differential impacts of program components, and the impact of the program over time. Types of Self-Help
and Evaluation A conservative estimate of the number of people currently involved in 556
Catherine Goodman
A studyofa model telephone network program for caregivers ofAlzheimer's disease victims considered itsimpact on caregivers' use of informal supports as wellasperceived social supports, mental health, burden, and information aboutAlzheimer's disease. Participants were randomly assigned to a peertelephone network oran informationallecture series accessed over thetelephone, and then they were reassigned to the alternative component after three months. Time series analysis of variance group-by-time interactions showed that participants learned more while listening to informational tapes and contacted family and friends more while waitingto enter a peer network. Program benefits seen after the first three months (reduced psychological distress, increased support satisfaction, andperceived social support) leveled off or declined during the second three months. Additionally, caregiver burden andsocial conflict increased during the second three months. This erosion of benefits suggests that program entry may be the period of maximum program receptivity or that overload of family networks created conflict. self-help groups is more than 6 million (Jacobs & Goodman, 1989), and the number is growing. "Self-help" generally refers to participant-initiated and participant-run organizations that help members cope with common afflictions. Such self-help groups as Alcoholics Anonymous, Synanon, and Narcotics Anonymous, in particular, unite around peer sufficiency and anti professional ideologies. However, professionals increasingly are initiating self-help programs as a means of extending social
services to well populations in crisis or transition. In fact, professionals have been instrumental in starting a wide variety of self-help groups. A study of 10 self-help organizations revealed that professionals had key roles in starting six (Recovery, Inc., Integrity Groups, GROW, the Compassionate Friends, Parents Anonymous, and Epilepsy SelfHelp) and were instrumental in the formative years of the remaining four (Alcoholics Anonymous, Mended Hearts, Naim, and Synanon) (Borman, 1979). Although the boundary between self-help and professional services is far from clear, hybrid groups started by professionals increasingly are relying on self-help processes of mutual aid and experiential knowledge (Powell, 1987). Information on the effectiveness of self-help interventions is growing gradually, and several reviews have been written (Lotery, 1987; Powell, 1987; Toseland & Rossiter, 1989). Because self-help is generally outside the control of the researcher, a number of studies use surveys or nonrandom comparison groups to assess effectiveness in spite of a self-selection bias. For example, a study of Mended Hearts, which serves heart patients, compared 473 participants with 306 nonmember heart patients (Videka, 1979). Mended Hearts appeared to help a subgroup of retired members, who showed greater coping mastery, more activity since surgery, less health restriction, and less retirement role strain. In contrast, a study of Compassionate Friends, which aids bereaved parents, showed that neither involvement in Compassionate Friends nor psychotherapy resulted in improved mental health or social functioning (Videka-Sherman & Lieberman, 1985). Several studies have focused on caregivers of frail or cognitively impaired elderly people. A survey of 501 caregivers of impaired elderly people found a relationship between self-help group participation and
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S
Goodman
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selis (1987) compared participation in support groups for Alzheimer's caregivers with family counseling and a waiting-list control group. The support groups and counseling were structured to focus on problem solving and skill development. The 119 caregivers in the study showed reduced burden, distress, and symptoms over time, but there were no differences among the participants in support groups, the caregivers in counseling, or the waiting-list control. Using a similarly focused and professionally led support group, another study (Haley, Brown, & Levine, 1987) assigned 40 Alzheimer's caregivers to a support group, a support group with stress management techniques, or a waitinglist control. There were no differences in outcome measures. Finally, in another study (Montgomery & Borgatta, 1989), family caregivers of impaired elderly people were assigned to one of five treatments (includingsupport groups) or a control. After 12 months, caregivers in all treatments showed lower subjective burden than did the controls. Some studies on support or self-help groups considered level of socialsupport in evaluation of the support group. For example, Toseland et al. (1989) found an increase in number of informal supports for more participants in peer-led groups (68.8 percent, n = 11). Fifty percent (n = 8) of those in professionally led groups increased informal supports, and 25 percent (n = 5) of those in the control group increased informal supports. Generally, however, the interface between self-help and informal supports has not been evaluated.
Self-Help and Informal Networks Self-help often is expected to supplement informal supports or to compensate for failures in family and friend relationships. Borkman (1984) suggested that family and friends are selectively unsupportive with respect to the focal problem of self-help and that self-help groups compensate for the unsupportive informal relationships. Family and friends often fail to be supportive by stigmatizing the person with problems, failing to understand the complex set of emotions associated with the problem, making role demands, and becoming
Model Self-Help Telephone Program
overcome themselves by the troubling problem. Borkman theorized that participation in self-help increases confidence in experiential knowledge and lowers expectations of family and friends. Borkman's model suggests selfhelp supplements and eventually facilitates use of informal supports.
The Program Care-Line, the Caregivers Phone Network, was a hybrid program in which professional intervention played an important role for information and referral, crisis counseling, and coordination, as well as program initiation. The network component consisted of brief telephone conversations among four or five caregivers. Participants each received a call and initiated a call weekly for 12 weeks, calling other network members in a rotating pattern. Caregivers were grouped in networks based on similarity of relationship to victim and age (older spouse, younger spouse, or adult child). Program staff monitored the progress of the networks by regular contacts with members and occasionally added new members or encouraged more active participation. The lecture component consisted of telephone-accessed taped programs on Alzheimer's disease and care management. Participants could call at any time for a short program on 12 different topics, for example, medical aspects, legal issues, problem behavior, home safety, and respite. (For a more complete description, see Goodman & Pynoos, 1988.) Like other hybrid programs under study, researchers exercised control by randomly assigning caregivers to one program component or the other to evaluate the differential impact of informational lectures or selfhelp participation. Impact on supports from family and friends was considered a possible outcome, as were impacts on mental health, caregiver burden, knowledge about Alzheimer's disease, and perceived social support.
Evaluation Methods Subjects were recruited for the CareLine program through media and agency referral and were randomly assigned to participate in a peer telephone network 557
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knowledge about Alzheimer's disease (George, 1983). Another study of caregivers of Alzheimer's victims compared those using support groups with those eligiblewho did not chooseto use groups. Caregivers using the groups institutionalizedtheir illrelatives less frequently and showed less anxiety, depression, and burden immediately after participation in the groups (Greene & Monahan, 1987, 1989). Studies of hybrid groups allowfor controlled studies of researcher-initiated self-help interventions, though many of these programs depart from a pure selfhelp ideology. Settings tend to be institutional, such as neonatal intensive care departments, oncology wards, or psychiatric hospitals. Interventions are varied and often involve professional guidance as well as peer support. For example, in a study conducted by Minde et al. (1980), 28 families of premature infants met with a nurse coordinator and an experienced mother. Parents in the support group visited more often and rated themselves more competent in infant care when compared with 29 control families. Three months after discharge, parents from the support group continued to show more involvement with their babies. Assessing another model, a study of a postbereavement adaptation program involved68 widows, each paired with an experienced widow for emotional support (Vachon, Lyall, Rogers, Freedman-Letofsky, & Freeman, 1980). Participants in the program achieved landmark stages in the grieving process more rapidly than did those in the control groups. Support groups for caregivers of Alzheimer's disease victims have varied in the extent to which they are professionally led and initiated. One study (Toseland et al., 1989)compared peer-led and professionally led groups. Researchers found that participation in either group resulted in decreased psychiatric symptoms and increased well-being. Although peer-led members of the groups decreased more on one symptom subscale, a trending pattern was toward greater symptom reduction in the professionally led groups. Several other studies have reported on professionally oriented groups in which peer support plays a role. Zarit, Anthony, and Bout-
558
scale from "not at all" to "extremely" in areas of emotional support, information and guidance, and practical assistance and then collapsed for a support satisfaction score. 6. Perceived Social Support for Caregiving and Social Conflict (Goodman, 1989) consists of a nine-item scale of peer support and a three-item scale of socialdisapproval and conflictdeveloped through factor analysis. Social support itemsjcover areas relevant to peer interaction (for example, talking to others with similar values, learning from watching how others manage stress), as well as emotional support in general (for example, information, advice, and understanding). Social conflict items cover quarrels, conflict over how to manage, and disapproval from others. 7. Family and friend support was measured by compiling a list of helpful people in the areas of emotional support, information and guidance, and practical assistance. Each list also was weighted by a five-point frequency-of-contact rating from "once a month or less" to "every day" (adapted from Vaux & Harrison, 1985). Researchers used repeated-measures analysis of variance (ANOVA) to determine group differences (networklecture sequence versus lecture-network sequence), differences over time (time 1, time 2, and time 3) and group-by-timeinteractions. They computed post hoc comparisons to determine changes over specific time intervals.
Evaluation Results The average age of the caregivers was 65.9 (standard deviation, 11.7),and most of them were wives of Alzheimer's victims. Seventy-five percent (n = 30) of the caregivers were women. Almost three-quarters were spouses (72.5 percent, n = 29), and the rest were adult children or other relatives. Threequarters (n = 30) were married, 20 percent (n = 8) were divorced or widowed, and 5 percent (n = 2) were single. The sample was predominantly white (65 percent, n = 26), although 12.5 percent (n = 5) were Hispanic and 20 percent (n = 8) were black. Caregivers had low to middle income levels, with less than one-third (n = 12)showing an income of Social Work
$10,000 or less, one-third (n = 13)in the $10,000 to $20,000 range, and more than one-third (n = 14) with an income of more than $20,000. Twenty-three percent (n = 9) of the caregivers were currently employed. Heads of households in the families usually had some college education (62.5 percent, n = 25). Most caregivers rated their health as good or excellent (65 percent, n = 26). Eighty percent (n = 32) of the impaired relatives had been diagnosed as having Alzheimer's disease; the rest had other dementias, although two relatives had not been diagnosed.
Program Impact over Time Caregivers, regardless of program component, viewed their relatives as becoming more impaired over time. An increase in patients' problems on the Memory and Problem Behavior Checklist was continuous, as shown by a significant time effect (Table 1) and increases from time 1 to time 2 and from time 2 to time 3 (post hoc comparisons [Table 2]). In spite of increases in patient impairment, caregivers experienced some psychological benefits during the first program period. Psychological distress showed a significant time effect, and analysis of post hoc comparisons indicated a decrease from time 1 to time 2. These benefits were not continued during the second period. The Mental Health Index also trended on the ANOVA for the effect of time (P = .057), but post hoc comparisons showed no significant increase for either period. The arrest of benefits on the psychological distress scale during the second period was echoed in results from the Burden Interview. The significant time effect on this variable was a result of increased caregiver burden from time 2 to time 3 (Tables 1 and 2). The program aimed at increasing the experience of social support, which it did successfully during the first period, regardless of program component. ANOVAs for support satisfaction and perceived social supports showed significant time effects. Analysis of post hoc tests revealed gains during the first period. For perceived social supports, this gain was eroded and there was
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or to listen to lectures; then, at three months, they were reassigned to the other component. Three data collections were possible for a subsample of a larger pretest-posttest study reported by Goodman and Pynoos (1989). To maximize group equivalence, caregivers were matched initiallyfor age (under 65, 65 or over), gender, and relationship to victim (adult child, spouse, sibling). Then one of each pair was assigned randomly to the network or the lecture component, and the other was assigned arbitrarily to the other component. Forty caregivers remained in the study for three data collections, 22 in the network-lecture sequence, and 18 in the lecture-network sequence. Of an original 81 subjects in the pre-post study, 32 percent (n = 13) did not complete the third data collection because of the end of the study, 37 percent (n = 15) dropped out between time 1 and time 2, and 32 percent (n = 13) dropped out between time 2 and time 3. Researchers interviewed subjects in their homes at program entry, at the three-month crossover, and at program end (six months). The following seven measures were completed: 1. The Memory and Problem Behavior Checklist (Zarit & Zarit, 1982) was used to measure impairment of the Alzheimer's victim. The checklist is a 28-item list covering such problem behaviors as "wandering" or "losing things" and loss of activities of daily living skills (for example, "unable to bathe"). 2. The Burden Interview (Zarit, Reever, & Bach-Peterson, 1980) is a 23-item measure of caregiver social and family life,finances, well-being, physical health as affected by caregiving, and relationship to the victim (Cronbach's alpha = .79). 3. The Mental Health Index (Veit & Ware, 1983), developed by the Rand Corporation, yields a global mental health index (Cronbach's alpha = .96) and subscales for psychological distress (Cronbach's alpha = .94) and well-being (Cronbach's alpha = .92). 4. The caregiver's information about Alzheimer's disease was measured by a 10-item multiple-choice quiz developed for the study. 5. Global satisfaction with supports for caregiving was rated on a five-point
Table 1. Repeated-Measures ANOVA for Network and Lecture Components F
p
Patient's impairment level Memory and Problem Behavior Checklist
Group Time Group x time
721.6 405.2 29.3
.80 7.05 .51
.378 .002 .603
Burden and mental health measures Burden Interview
Group Time Group Group Time Group Group Time Group Group Time Group
19.6 268.1 62.5 699.5 390.5 3.7 8.4 44.2 2.1 867.3 753.4 .5
.03 4.35 1.01 .93 4.53 .04 .02 .04 .42 2.99 .00
.853 .016 .368 .340 .014 .959 .885 .469 .965 .520 .057 .998
Psychological distress Well-being Mental Health Index
Information, social support, and social network measures Information quiz
x time
3.2 19.9 6.1 7.1 24.0 4.8 128.0 203.5 17.3 .3 65.6 3.4 55.2 31.3 9.5
.24 13.22 4.08 .39 4.53 .91 1.49 6.11 .52 .05 5.24 .27 4.76 7.95 2.40
.630 .000 .021 .536 .014 .409 .230 .044 .597 .830 .007 .766 .037 .001 .099
Global support satisfaction Perceived social support Perceived social conflict Family and friend emotional support Family and friend emotional support and frequency
Group Time Group x time
179.5 176.2 135.1
1.25 6.48 4.97
.272 .003 .0lD
Family and friend information and guidance
Group Time Group x time Group Time Group x time
.1 6.8 2.9 .7 8.7 1.9
.01 3.08 1.32 .07 2.67 .60
.913 .054 .276 .796 .077 .553
Family and friend practical assistance
Group Time Group Group Time Group Group Time Group Group Time Group Group Time Group
x time x time x time x time
x time x time x time x time
.77
NOTE: Number varies from 31 to 39, depending on missing data.
a significant decline from time 2 to time 3. Social conflict also showed a significant time effect, which was caused mostly by an increase in conflict from time 2 to time 3. Backsliding in subjective assessments of social support as well as caregiver burden characterized the second period. Although caregivers appeared to do less well over the second period, their informal supports grew. The numbers of family members and friends providing
emotional support were affected significantly over time, though informationand guidance and practical assistance supports only trended on the ANOVA for time effect. For emotional support, post hoc comparisons showed an increase from time 2 to time 3. The frequencyweighted scores for emotional support particularly showed gains from time 2 to time 3 (Table 2). A significant time effect on the ANOVA for the information quiz re-
Goodman / Model Self-Help Telephone Program
Impact of Program Components The program design called for a crossover from the network component to the lecture component and vice versa after the first period. Because the lecture was designed to provide informationand the network was designed to provide peer support, researchers expected group-by-time interactions for the information quiz, support satisfaction, and perceived social support measures. There was a significant group-by-time interaction for the information quiz, in addition to a general time effect. Post hoc comparisons showed significant group differences during the second period and a trend during the first period (P = .094), indicating that caregivers gained more information while listening to lectures. However, researchers did not find anticipated interactions for support satisfaction and perceived social support. These variables showed only time effects, indicating that caregivers listening to lectures gained as much as those participating in self-helpnetworks. An explanation comes from an unexpected trend for group-by-time interaction on emotional supports from family and friends. The frequency-weighted score showed a significant group-bytime interaction resulting from group differences for both periods. Whereas caregivers starting out in the networks (network-lecture sequence) decreased family and friend contacts for emotional support and subsequently reestablished them, those starting in the lecture component (lecture-network sequence) increased contacts with family and friends during both periods (Table 3). Discussion and Implications Interface between Self-Help Program and Natural Networks Results from the first program period suggested that caregivers substituted self-help for informal supports, with a decline in use of family and friends for those initially in the peer networks. 559
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Mean Square
Measure
sulted from consistent gains throughout the program. Both time 2 and time 3 showed significant increases on post hoc comparisons.
Table 2. Means and Standard Deviations Showing Post Hoc Differences over Time, Combined Groups Time 2
Time 1 Measure
SD
M
SD
54.2
19.3
55.7*
17.5
60.5**
18.3
63.5 67.1 41.0 139.2
13.4 17.0 10.5 26.0
61.1 60.5* 43.1 148.2
15.7 16.7 14.8 29.9
66.3** 64.2 42.3 143.6
15.7 18.1 13.0 30.7
6.2 8.6 30.2 7.9 3.8 13.3 1.4 2.5
2.7 3.1 8.0 3.2 2.1 7.4 1.5 1.9
2.4 3.2 6.5 2.9 2.5 8.6 1.6 2.2
7.6* 10.1 32.9* 9.9** 5.3** 17.4** 2.0 3.4
1.8 2.9 6.9 3.6 3.2 8.8 2.0 2.8
7.0*** 10.0** 34.8** 7.5 3.7* 13.5 1.2 2.5
M
SD
NOTE: Number varies from 31 to 39, depending on missing data. *P < 05. **P < 01. ***p < 001. Asterisks on time 2 means indicate significant T1-T2 differences. Asterisks on time 3 means indicate significant T2-T3 differences.
Social support substitution has been discussed in the literature as related to adjustment under specific circumstances (Lieberman, 1986). Zarit et al. (1987) also noted a simultaneous decrease in visits from family and friends as perceived social support increased during participation in their study. In contrast, caregivers who started in the lecture
component turned to family and friends for emotional support while they waited for contacts within a peer telephone network. During the second program period, increases in social conflict went hand in hand with increased use of family and friends for emotional support in both program components. Caregivers who
Table 3. Means and Standard Deviations for Network-Lecture Sequence and Lecture-Network Sequence, Showing Change over Time
Measure Information quiz Time 1 Time 2 Time 3 Family and friend emotional support Time 1 Time 2 Time 3 Family and friend emotional support, frequency weighted Time 1 Time 2 Time 3
Network-Lecture Sequence M SD
Lecture-Network Sequence SD M
6.8 6.9 7.6*
2.4 2.7 1.8
5.5 7.1 7.6*
3.0 2.2 1.7
3.6 3.0 4.3
1.7 2.4 2.0
4.0 4.6 6.8
2.6 2.3 4.0
14.2 10.6* 15.6*
6.6 8.1 7.6
12.3 16.9* 19.6*
8.3 8.2 10.0
NOTES: Number = 40, network n = 22, and lecture n = 18, with some variation because of missing data. Asterisks on time 2 means indicate significant T1-T2 differences. Asterisks on time 3 means indicate significant T2-T3 differences.
560
Social Work
already had been in peer networks turned to family and friends when the networks ended. However, those entering peer networks at three months continued to increase reliance on family and friends instead of substituting peer support. Possibly, the habits and values surrounding use of informal supports were already well established. Peer networks may have been anticlimactic or disappointing after three months in the program, or the decline in the ill relative may have required support from everyone available. Self-help theorists suggest that group participation enhances involvement with informal supports through education to the values of support (Borkman, 1984). This may have been the case, but the result appeared to be an overload, with increased conflict and caregiver burden. Some literature on social supports has related negative aspects of informal relationships to symptoms, and some has established an inverse relationship between relationship upset and well-being (Fiore, Becker, & Coppel, 1983; Rook, 1984; Sandler & Barrera, 1984).For example, Fiore et al. (1983) found that negative or upsetting aspects of relationship among informal supports were related to depression, whereas helpful aspects were not.
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Patient's impairment level Memory and Problem Behavior Checklist Burden and mental health measures Burden Interview Psychological distress Well-being Mental Health Index Information, social support, and social network measures Information quiz Support satisfaction Perceived social support Perceived social conflict Family and friend emotional support Family and friend emotional support, frequency weighted Family and friend information and guidance Family and friend practical assistance
Time 3
M
Period of Maximum Receptivity Although conflictual social relationships and network overload may have been responsible for the second-period backslide, an alternative explanation is that program benefits eroded over time. Improvement followed by diminishing gain is a pattern also found in studies of psychotherapy, suggesting a period of maximum program receptivity. Wells (1982) stated, "There is highly suggestive evidence from studies of the therapeutic process that the most significant changes occur early in treatment and are followed by a period of diminishingeffectiveness" (p. 19).Follow-upstudies often show a similar pattern. Greene and Monahan (1989), in their study of caregiver support groups, showed weaker decreases in depression and anxiety at six-month follow-upthan at two months, when the groups ended. Burden, which had been reduced at two months, was no longer significant at follow-up. This short-term effect or follow-up decline may be partially a result of a participant's expectations upon entry into a program. According to Priddy (1987), participant expectancy effects generally are ignored in group research and may have an impact quite apart from the structure of the intervention. A mix of initiating participation, staff support, access to new service resources, peer support, and greater family support could result in hope and a sense of effectiveness that dissipates once changes are integrated into the life-style of caregiving.
Impact of Impaired Relative's Decline Caregivers experienced some gains during the first program period in spite Goodman /
of the declines in their ill relatives. The second program period saw even greater declines in patients' functioning. Several researchers have found that caregiver burden is not related to level of impairment in Alzheimer's victims (Greene & Monahan, 1989; Zarit et al., 1980; Zarit, Tood, & Zarit, 1986), but the finding is not without dispute. In a recent study, Pearson, Verma, and Nellett (1988) found a positive relationship between caregiver burden and level of impairment. The researchers reconciled discrepancies in the literature by suggesting that caregivers of psychiatric patients are more affected by their relatives' levels of impairment than are caregivers of Alzheimer's victims. Hope for recovery and type of impairment (activity of daily living, cognitive incapacity, or disruptive behavior) may playa role. In view of the evidence that caregivers experienced some benefits during the first period in spite of patient decline, patient level of impairment cannot be a major explanation for greater caregiver burden during the second program period.
Program Evaluation Six months of program involvement left participants with increased information and support satisfaction and greater involvement with family and friends for emotional support. These benefits, however, were accompanied by increased social conflict and caregiver burden. This mixed picture is familiar from other studies of support groups. In Haley et al. (1987), for example, no gains were found for depression, life satisfaction, patientcaregiver relationship, social activity, or social network satisfaction, though participants rated the groups as helpful. In contrast, a three-month program presented a rosier picture, with increased information, increased support satisfaction and perceived social support, and a decline in psychological distress. Program developers may find it worthwhile to establish short-term self-help-oriented programs that socialize participants to the values of social support, encourage use of informal supports, and help participants deal constructively with family and friends.
Model Self-Help Telephone Program
Components of the telephone network are ideally combined into a three-month program. The telephone network model as a self-help format offers a means of bringing together people who are overloaded, who are housebound, or who desire anonymity. People suffering from rare disorders or who are geographically dispersed also can have contact through a telephone network. The telephone has a unique capacity to connect people on the basis of their interest or affliction, regardless of their "sense of place" (Meyrowitz, 1985), their neighborhood, their socioeconomicand ethnic background, or their physical mobility. Telephone networks can be developed in a variety of formats to bring information and emotional support to people suffering life crises and experiencing major transitions.
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groups for coping withcrisis: Origins, members, processes and impact (pp. 362-386). San Francisco: Iossey-Bass. Videka-Sherman, L., & Lieberman, M. (1985). The effects ofself-helpand psychotherapy intervention on child loss: The
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Catherine Goodman, DSlV, isProfessor of Social Work at California State University, LongBeach, 1250 Bellflower Boulevard, Long Beach, CA 90840-0902. Accepted November 29, 1989
impact ofelectronic media onsocial behavior. New York: Oxford University Press. Minde, K., Shosenberg, N., Marton, P., Thompson, J., Ripley, ]., & Bums, S. (1980). Self-help groups in a premature nursery: A controlledevaluation.Journal of
Pediatrics, 96(5), 933-940. Montgomery, R. ]. V., & Borgatta, E. F. (1989). The effects of alternative support strategies on familycaregiving. The Geron-
tologist, 29(3), 457-464. Pearson,]., Verma, S., & Nellett, C. (1988). Elderly psychiatric patient status and caregiver perceptions as predictors of caregiver burden. The Gerontologist, 28(1), 79-83. Powell, T. J. (1987). Self-help organizations and professional practice. Silver Spring, MD: National Association of Social Workers. Priddy, ]. M. (1987). Outcome research on self-help groups: A humanistic perspective.
Journal for Specialists in Group Work, 12, 2-9.
Rook, K. S. (1984). The negative side of social interaction: Impact on psychological well-being. Journal ofPersonality andSocial
Psychology, 46(5), 1097-1108. Sandler, I. N., & Barrera, M. (1984). Toward a multimethod approach to assessing the effects of socialsupport. American Journal
of Community Psychology, 12(1), 37-52. Toseland, R. W., & Rossiter, C. M. (1989).
Social Work Practice Theories A Comparison of Selected Attributes CHART -A chart is now available that compares twenty-one social work practice theories along a spectrum of thirty-three variables.
The chart, which measures 36 x 40 inches, is designed for teachers, students, and practitioners. This resource provides an efficient and rapid method of comparing a rich range of theories in a manner to assist learning and practice. The chart can be ordered from:
Dr. Francis J. Turner 186 Claremont Avenue Kitchener, Ontario N2M 2P8 Canada Price (including mailing): $35.00
AD-13 9/90
Group interventionsto support familycare562
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Gerontologist, 29(3), 472-477. Haley, W. E., Brown, S. L., & Levine, E. G. (1987). Experimental evaluation of the effectiveness of group intervention for dementia caregivers. The Gerontologist,
givers: A review and analysis. The Geron-
tologist, 29(3), 438-448.
and Evaluation A conservative estimate of the number of people currently involved in 556
Catherine Goodman
A studyofa model telephone network program for caregivers ofAlzheimer's disease victims considered itsimpact on caregivers' use of informal supports as wellasperceived social supports, mental health, burden, and information aboutAlzheimer's disease. Participants were randomly assigned to a peertelephone network oran informationallecture series accessed over thetelephone, and then they were reassigned to the alternative component after three months. Time series analysis of variance group-by-time interactions showed that participants learned more while listening to informational tapes and contacted family and friends more while waitingto enter a peer network. Program benefits seen after the first three months (reduced psychological distress, increased support satisfaction, andperceived social support) leveled off or declined during the second three months. Additionally, caregiver burden andsocial conflict increased during the second three months. This erosion of benefits suggests that program entry may be the period of maximum program receptivity or that overload of family networks created conflict. self-help groups is more than 6 million (Jacobs & Goodman, 1989), and the number is growing. "Self-help" generally refers to participant-initiated and participant-run organizations that help members cope with common afflictions. Such self-help groups as Alcoholics Anonymous, Synanon, and Narcotics Anonymous, in particular, unite around peer sufficiency and anti professional ideologies. However, professionals increasingly are initiating self-help programs as a means of extending social
services to well populations in crisis or transition. In fact, professionals have been instrumental in starting a wide variety of self-help groups. A study of 10 self-help organizations revealed that professionals had key roles in starting six (Recovery, Inc., Integrity Groups, GROW, the Compassionate Friends, Parents Anonymous, and Epilepsy SelfHelp) and were instrumental in the formative years of the remaining four (Alcoholics Anonymous, Mended Hearts, Naim, and Synanon) (Borman, 1979). Although the boundary between self-help and professional services is far from clear, hybrid groups started by professionals increasingly are relying on self-help processes of mutual aid and experiential knowledge (Powell, 1987). Information on the effectiveness of self-help interventions is growing gradually, and several reviews have been written (Lotery, 1987; Powell, 1987; Toseland & Rossiter, 1989). Because self-help is generally outside the control of the researcher, a number of studies use surveys or nonrandom comparison groups to assess effectiveness in spite of a self-selection bias. For example, a study of Mended Hearts, which serves heart patients, compared 473 participants with 306 nonmember heart patients (Videka, 1979). Mended Hearts appeared to help a subgroup of retired members, who showed greater coping mastery, more activity since surgery, less health restriction, and less retirement role strain. In contrast, a study of Compassionate Friends, which aids bereaved parents, showed that neither involvement in Compassionate Friends nor psychotherapy resulted in improved mental health or social functioning (Videka-Sherman & Lieberman, 1985). Several studies have focused on caregivers of frail or cognitively impaired elderly people. A survey of 501 caregivers of impaired elderly people found a relationship between self-help group participation and
CCC Code: 0037-8046/90 $1.00 © 1990, National Association of Social Workers, Inc.
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S
Goodman
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selis (1987) compared participation in support groups for Alzheimer's caregivers with family counseling and a waiting-list control group. The support groups and counseling were structured to focus on problem solving and skill development. The 119 caregivers in the study showed reduced burden, distress, and symptoms over time, but there were no differences among the participants in support groups, the caregivers in counseling, or the waiting-list control. Using a similarly focused and professionally led support group, another study (Haley, Brown, & Levine, 1987) assigned 40 Alzheimer's caregivers to a support group, a support group with stress management techniques, or a waitinglist control. There were no differences in outcome measures. Finally, in another study (Montgomery & Borgatta, 1989), family caregivers of impaired elderly people were assigned to one of five treatments (includingsupport groups) or a control. After 12 months, caregivers in all treatments showed lower subjective burden than did the controls. Some studies on support or self-help groups considered level of socialsupport in evaluation of the support group. For example, Toseland et al. (1989) found an increase in number of informal supports for more participants in peer-led groups (68.8 percent, n = 11). Fifty percent (n = 8) of those in professionally led groups increased informal supports, and 25 percent (n = 5) of those in the control group increased informal supports. Generally, however, the interface between self-help and informal supports has not been evaluated.
Self-Help and Informal Networks Self-help often is expected to supplement informal supports or to compensate for failures in family and friend relationships. Borkman (1984) suggested that family and friends are selectively unsupportive with respect to the focal problem of self-help and that self-help groups compensate for the unsupportive informal relationships. Family and friends often fail to be supportive by stigmatizing the person with problems, failing to understand the complex set of emotions associated with the problem, making role demands, and becoming
Model Self-Help Telephone Program
overcome themselves by the troubling problem. Borkman theorized that participation in self-help increases confidence in experiential knowledge and lowers expectations of family and friends. Borkman's model suggests selfhelp supplements and eventually facilitates use of informal supports.
The Program Care-Line, the Caregivers Phone Network, was a hybrid program in which professional intervention played an important role for information and referral, crisis counseling, and coordination, as well as program initiation. The network component consisted of brief telephone conversations among four or five caregivers. Participants each received a call and initiated a call weekly for 12 weeks, calling other network members in a rotating pattern. Caregivers were grouped in networks based on similarity of relationship to victim and age (older spouse, younger spouse, or adult child). Program staff monitored the progress of the networks by regular contacts with members and occasionally added new members or encouraged more active participation. The lecture component consisted of telephone-accessed taped programs on Alzheimer's disease and care management. Participants could call at any time for a short program on 12 different topics, for example, medical aspects, legal issues, problem behavior, home safety, and respite. (For a more complete description, see Goodman & Pynoos, 1988.) Like other hybrid programs under study, researchers exercised control by randomly assigning caregivers to one program component or the other to evaluate the differential impact of informational lectures or selfhelp participation. Impact on supports from family and friends was considered a possible outcome, as were impacts on mental health, caregiver burden, knowledge about Alzheimer's disease, and perceived social support.
Evaluation Methods Subjects were recruited for the CareLine program through media and agency referral and were randomly assigned to participate in a peer telephone network 557
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knowledge about Alzheimer's disease (George, 1983). Another study of caregivers of Alzheimer's victims compared those using support groups with those eligiblewho did not chooseto use groups. Caregivers using the groups institutionalizedtheir illrelatives less frequently and showed less anxiety, depression, and burden immediately after participation in the groups (Greene & Monahan, 1987, 1989). Studies of hybrid groups allowfor controlled studies of researcher-initiated self-help interventions, though many of these programs depart from a pure selfhelp ideology. Settings tend to be institutional, such as neonatal intensive care departments, oncology wards, or psychiatric hospitals. Interventions are varied and often involve professional guidance as well as peer support. For example, in a study conducted by Minde et al. (1980), 28 families of premature infants met with a nurse coordinator and an experienced mother. Parents in the support group visited more often and rated themselves more competent in infant care when compared with 29 control families. Three months after discharge, parents from the support group continued to show more involvement with their babies. Assessing another model, a study of a postbereavement adaptation program involved68 widows, each paired with an experienced widow for emotional support (Vachon, Lyall, Rogers, Freedman-Letofsky, & Freeman, 1980). Participants in the program achieved landmark stages in the grieving process more rapidly than did those in the control groups. Support groups for caregivers of Alzheimer's disease victims have varied in the extent to which they are professionally led and initiated. One study (Toseland et al., 1989)compared peer-led and professionally led groups. Researchers found that participation in either group resulted in decreased psychiatric symptoms and increased well-being. Although peer-led members of the groups decreased more on one symptom subscale, a trending pattern was toward greater symptom reduction in the professionally led groups. Several other studies have reported on professionally oriented groups in which peer support plays a role. Zarit, Anthony, and Bout-
558
scale from "not at all" to "extremely" in areas of emotional support, information and guidance, and practical assistance and then collapsed for a support satisfaction score. 6. Perceived Social Support for Caregiving and Social Conflict (Goodman, 1989) consists of a nine-item scale of peer support and a three-item scale of socialdisapproval and conflictdeveloped through factor analysis. Social support itemsjcover areas relevant to peer interaction (for example, talking to others with similar values, learning from watching how others manage stress), as well as emotional support in general (for example, information, advice, and understanding). Social conflict items cover quarrels, conflict over how to manage, and disapproval from others. 7. Family and friend support was measured by compiling a list of helpful people in the areas of emotional support, information and guidance, and practical assistance. Each list also was weighted by a five-point frequency-of-contact rating from "once a month or less" to "every day" (adapted from Vaux & Harrison, 1985). Researchers used repeated-measures analysis of variance (ANOVA) to determine group differences (networklecture sequence versus lecture-network sequence), differences over time (time 1, time 2, and time 3) and group-by-timeinteractions. They computed post hoc comparisons to determine changes over specific time intervals.
Evaluation Results The average age of the caregivers was 65.9 (standard deviation, 11.7),and most of them were wives of Alzheimer's victims. Seventy-five percent (n = 30) of the caregivers were women. Almost three-quarters were spouses (72.5 percent, n = 29), and the rest were adult children or other relatives. Threequarters (n = 30) were married, 20 percent (n = 8) were divorced or widowed, and 5 percent (n = 2) were single. The sample was predominantly white (65 percent, n = 26), although 12.5 percent (n = 5) were Hispanic and 20 percent (n = 8) were black. Caregivers had low to middle income levels, with less than one-third (n = 12)showing an income of Social Work
$10,000 or less, one-third (n = 13)in the $10,000 to $20,000 range, and more than one-third (n = 14) with an income of more than $20,000. Twenty-three percent (n = 9) of the caregivers were currently employed. Heads of households in the families usually had some college education (62.5 percent, n = 25). Most caregivers rated their health as good or excellent (65 percent, n = 26). Eighty percent (n = 32) of the impaired relatives had been diagnosed as having Alzheimer's disease; the rest had other dementias, although two relatives had not been diagnosed.
Program Impact over Time Caregivers, regardless of program component, viewed their relatives as becoming more impaired over time. An increase in patients' problems on the Memory and Problem Behavior Checklist was continuous, as shown by a significant time effect (Table 1) and increases from time 1 to time 2 and from time 2 to time 3 (post hoc comparisons [Table 2]). In spite of increases in patient impairment, caregivers experienced some psychological benefits during the first program period. Psychological distress showed a significant time effect, and analysis of post hoc comparisons indicated a decrease from time 1 to time 2. These benefits were not continued during the second period. The Mental Health Index also trended on the ANOVA for the effect of time (P = .057), but post hoc comparisons showed no significant increase for either period. The arrest of benefits on the psychological distress scale during the second period was echoed in results from the Burden Interview. The significant time effect on this variable was a result of increased caregiver burden from time 2 to time 3 (Tables 1 and 2). The program aimed at increasing the experience of social support, which it did successfully during the first period, regardless of program component. ANOVAs for support satisfaction and perceived social supports showed significant time effects. Analysis of post hoc tests revealed gains during the first period. For perceived social supports, this gain was eroded and there was
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or to listen to lectures; then, at three months, they were reassigned to the other component. Three data collections were possible for a subsample of a larger pretest-posttest study reported by Goodman and Pynoos (1989). To maximize group equivalence, caregivers were matched initiallyfor age (under 65, 65 or over), gender, and relationship to victim (adult child, spouse, sibling). Then one of each pair was assigned randomly to the network or the lecture component, and the other was assigned arbitrarily to the other component. Forty caregivers remained in the study for three data collections, 22 in the network-lecture sequence, and 18 in the lecture-network sequence. Of an original 81 subjects in the pre-post study, 32 percent (n = 13) did not complete the third data collection because of the end of the study, 37 percent (n = 15) dropped out between time 1 and time 2, and 32 percent (n = 13) dropped out between time 2 and time 3. Researchers interviewed subjects in their homes at program entry, at the three-month crossover, and at program end (six months). The following seven measures were completed: 1. The Memory and Problem Behavior Checklist (Zarit & Zarit, 1982) was used to measure impairment of the Alzheimer's victim. The checklist is a 28-item list covering such problem behaviors as "wandering" or "losing things" and loss of activities of daily living skills (for example, "unable to bathe"). 2. The Burden Interview (Zarit, Reever, & Bach-Peterson, 1980) is a 23-item measure of caregiver social and family life,finances, well-being, physical health as affected by caregiving, and relationship to the victim (Cronbach's alpha = .79). 3. The Mental Health Index (Veit & Ware, 1983), developed by the Rand Corporation, yields a global mental health index (Cronbach's alpha = .96) and subscales for psychological distress (Cronbach's alpha = .94) and well-being (Cronbach's alpha = .92). 4. The caregiver's information about Alzheimer's disease was measured by a 10-item multiple-choice quiz developed for the study. 5. Global satisfaction with supports for caregiving was rated on a five-point
Table 1. Repeated-Measures ANOVA for Network and Lecture Components F
p
Patient's impairment level Memory and Problem Behavior Checklist
Group Time Group x time
721.6 405.2 29.3
.80 7.05 .51
.378 .002 .603
Burden and mental health measures Burden Interview
Group Time Group Group Time Group Group Time Group Group Time Group
19.6 268.1 62.5 699.5 390.5 3.7 8.4 44.2 2.1 867.3 753.4 .5
.03 4.35 1.01 .93 4.53 .04 .02 .04 .42 2.99 .00
.853 .016 .368 .340 .014 .959 .885 .469 .965 .520 .057 .998
Psychological distress Well-being Mental Health Index
Information, social support, and social network measures Information quiz
x time
3.2 19.9 6.1 7.1 24.0 4.8 128.0 203.5 17.3 .3 65.6 3.4 55.2 31.3 9.5
.24 13.22 4.08 .39 4.53 .91 1.49 6.11 .52 .05 5.24 .27 4.76 7.95 2.40
.630 .000 .021 .536 .014 .409 .230 .044 .597 .830 .007 .766 .037 .001 .099
Global support satisfaction Perceived social support Perceived social conflict Family and friend emotional support Family and friend emotional support and frequency
Group Time Group x time
179.5 176.2 135.1
1.25 6.48 4.97
.272 .003 .0lD
Family and friend information and guidance
Group Time Group x time Group Time Group x time
.1 6.8 2.9 .7 8.7 1.9
.01 3.08 1.32 .07 2.67 .60
.913 .054 .276 .796 .077 .553
Family and friend practical assistance
Group Time Group Group Time Group Group Time Group Group Time Group Group Time Group
x time x time x time x time
x time x time x time x time
.77
NOTE: Number varies from 31 to 39, depending on missing data.
a significant decline from time 2 to time 3. Social conflict also showed a significant time effect, which was caused mostly by an increase in conflict from time 2 to time 3. Backsliding in subjective assessments of social support as well as caregiver burden characterized the second period. Although caregivers appeared to do less well over the second period, their informal supports grew. The numbers of family members and friends providing
emotional support were affected significantly over time, though informationand guidance and practical assistance supports only trended on the ANOVA for time effect. For emotional support, post hoc comparisons showed an increase from time 2 to time 3. The frequencyweighted scores for emotional support particularly showed gains from time 2 to time 3 (Table 2). A significant time effect on the ANOVA for the information quiz re-
Goodman / Model Self-Help Telephone Program
Impact of Program Components The program design called for a crossover from the network component to the lecture component and vice versa after the first period. Because the lecture was designed to provide informationand the network was designed to provide peer support, researchers expected group-by-time interactions for the information quiz, support satisfaction, and perceived social support measures. There was a significant group-by-time interaction for the information quiz, in addition to a general time effect. Post hoc comparisons showed significant group differences during the second period and a trend during the first period (P = .094), indicating that caregivers gained more information while listening to lectures. However, researchers did not find anticipated interactions for support satisfaction and perceived social support. These variables showed only time effects, indicating that caregivers listening to lectures gained as much as those participating in self-helpnetworks. An explanation comes from an unexpected trend for group-by-time interaction on emotional supports from family and friends. The frequency-weighted score showed a significant group-bytime interaction resulting from group differences for both periods. Whereas caregivers starting out in the networks (network-lecture sequence) decreased family and friend contacts for emotional support and subsequently reestablished them, those starting in the lecture component (lecture-network sequence) increased contacts with family and friends during both periods (Table 3). Discussion and Implications Interface between Self-Help Program and Natural Networks Results from the first program period suggested that caregivers substituted self-help for informal supports, with a decline in use of family and friends for those initially in the peer networks. 559
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Mean Square
Measure
sulted from consistent gains throughout the program. Both time 2 and time 3 showed significant increases on post hoc comparisons.
Table 2. Means and Standard Deviations Showing Post Hoc Differences over Time, Combined Groups Time 2
Time 1 Measure
SD
M
SD
54.2
19.3
55.7*
17.5
60.5**
18.3
63.5 67.1 41.0 139.2
13.4 17.0 10.5 26.0
61.1 60.5* 43.1 148.2
15.7 16.7 14.8 29.9
66.3** 64.2 42.3 143.6
15.7 18.1 13.0 30.7
6.2 8.6 30.2 7.9 3.8 13.3 1.4 2.5
2.7 3.1 8.0 3.2 2.1 7.4 1.5 1.9
2.4 3.2 6.5 2.9 2.5 8.6 1.6 2.2
7.6* 10.1 32.9* 9.9** 5.3** 17.4** 2.0 3.4
1.8 2.9 6.9 3.6 3.2 8.8 2.0 2.8
7.0*** 10.0** 34.8** 7.5 3.7* 13.5 1.2 2.5
M
SD
NOTE: Number varies from 31 to 39, depending on missing data. *P < 05. **P < 01. ***p < 001. Asterisks on time 2 means indicate significant T1-T2 differences. Asterisks on time 3 means indicate significant T2-T3 differences.
Social support substitution has been discussed in the literature as related to adjustment under specific circumstances (Lieberman, 1986). Zarit et al. (1987) also noted a simultaneous decrease in visits from family and friends as perceived social support increased during participation in their study. In contrast, caregivers who started in the lecture
component turned to family and friends for emotional support while they waited for contacts within a peer telephone network. During the second program period, increases in social conflict went hand in hand with increased use of family and friends for emotional support in both program components. Caregivers who
Table 3. Means and Standard Deviations for Network-Lecture Sequence and Lecture-Network Sequence, Showing Change over Time
Measure Information quiz Time 1 Time 2 Time 3 Family and friend emotional support Time 1 Time 2 Time 3 Family and friend emotional support, frequency weighted Time 1 Time 2 Time 3
Network-Lecture Sequence M SD
Lecture-Network Sequence SD M
6.8 6.9 7.6*
2.4 2.7 1.8
5.5 7.1 7.6*
3.0 2.2 1.7
3.6 3.0 4.3
1.7 2.4 2.0
4.0 4.6 6.8
2.6 2.3 4.0
14.2 10.6* 15.6*
6.6 8.1 7.6
12.3 16.9* 19.6*
8.3 8.2 10.0
NOTES: Number = 40, network n = 22, and lecture n = 18, with some variation because of missing data. Asterisks on time 2 means indicate significant T1-T2 differences. Asterisks on time 3 means indicate significant T2-T3 differences.
560
Social Work
already had been in peer networks turned to family and friends when the networks ended. However, those entering peer networks at three months continued to increase reliance on family and friends instead of substituting peer support. Possibly, the habits and values surrounding use of informal supports were already well established. Peer networks may have been anticlimactic or disappointing after three months in the program, or the decline in the ill relative may have required support from everyone available. Self-help theorists suggest that group participation enhances involvement with informal supports through education to the values of support (Borkman, 1984). This may have been the case, but the result appeared to be an overload, with increased conflict and caregiver burden. Some literature on social supports has related negative aspects of informal relationships to symptoms, and some has established an inverse relationship between relationship upset and well-being (Fiore, Becker, & Coppel, 1983; Rook, 1984; Sandler & Barrera, 1984).For example, Fiore et al. (1983) found that negative or upsetting aspects of relationship among informal supports were related to depression, whereas helpful aspects were not.
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Patient's impairment level Memory and Problem Behavior Checklist Burden and mental health measures Burden Interview Psychological distress Well-being Mental Health Index Information, social support, and social network measures Information quiz Support satisfaction Perceived social support Perceived social conflict Family and friend emotional support Family and friend emotional support, frequency weighted Family and friend information and guidance Family and friend practical assistance
Time 3
M
Period of Maximum Receptivity Although conflictual social relationships and network overload may have been responsible for the second-period backslide, an alternative explanation is that program benefits eroded over time. Improvement followed by diminishing gain is a pattern also found in studies of psychotherapy, suggesting a period of maximum program receptivity. Wells (1982) stated, "There is highly suggestive evidence from studies of the therapeutic process that the most significant changes occur early in treatment and are followed by a period of diminishingeffectiveness" (p. 19).Follow-upstudies often show a similar pattern. Greene and Monahan (1989), in their study of caregiver support groups, showed weaker decreases in depression and anxiety at six-month follow-upthan at two months, when the groups ended. Burden, which had been reduced at two months, was no longer significant at follow-up. This short-term effect or follow-up decline may be partially a result of a participant's expectations upon entry into a program. According to Priddy (1987), participant expectancy effects generally are ignored in group research and may have an impact quite apart from the structure of the intervention. A mix of initiating participation, staff support, access to new service resources, peer support, and greater family support could result in hope and a sense of effectiveness that dissipates once changes are integrated into the life-style of caregiving.
Impact of Impaired Relative's Decline Caregivers experienced some gains during the first program period in spite Goodman /
of the declines in their ill relatives. The second program period saw even greater declines in patients' functioning. Several researchers have found that caregiver burden is not related to level of impairment in Alzheimer's victims (Greene & Monahan, 1989; Zarit et al., 1980; Zarit, Tood, & Zarit, 1986), but the finding is not without dispute. In a recent study, Pearson, Verma, and Nellett (1988) found a positive relationship between caregiver burden and level of impairment. The researchers reconciled discrepancies in the literature by suggesting that caregivers of psychiatric patients are more affected by their relatives' levels of impairment than are caregivers of Alzheimer's victims. Hope for recovery and type of impairment (activity of daily living, cognitive incapacity, or disruptive behavior) may playa role. In view of the evidence that caregivers experienced some benefits during the first period in spite of patient decline, patient level of impairment cannot be a major explanation for greater caregiver burden during the second program period.
Program Evaluation Six months of program involvement left participants with increased information and support satisfaction and greater involvement with family and friends for emotional support. These benefits, however, were accompanied by increased social conflict and caregiver burden. This mixed picture is familiar from other studies of support groups. In Haley et al. (1987), for example, no gains were found for depression, life satisfaction, patientcaregiver relationship, social activity, or social network satisfaction, though participants rated the groups as helpful. In contrast, a three-month program presented a rosier picture, with increased information, increased support satisfaction and perceived social support, and a decline in psychological distress. Program developers may find it worthwhile to establish short-term self-help-oriented programs that socialize participants to the values of social support, encourage use of informal supports, and help participants deal constructively with family and friends.
Model Self-Help Telephone Program
Components of the telephone network are ideally combined into a three-month program. The telephone network model as a self-help format offers a means of bringing together people who are overloaded, who are housebound, or who desire anonymity. People suffering from rare disorders or who are geographically dispersed also can have contact through a telephone network. The telephone has a unique capacity to connect people on the basis of their interest or affliction, regardless of their "sense of place" (Meyrowitz, 1985), their neighborhood, their socioeconomicand ethnic background, or their physical mobility. Telephone networks can be developed in a variety of formats to bring information and emotional support to people suffering life crises and experiencing major transitions.
References Borkrnan, T. (1984). Mutual self-helpgroups: Strengthening the selectively unsupportive personal and community networks of their members. In A. Gartner & F. Riessman (Eds.), The self-help revolution (pp. 205-216). New York: Human Sciences Press. Borman, L. D. (1979). Characteristics of development and growth. In M. A. Lieberman & L. D. Borman (Eds.), Self-help
groups for coping with crisis: Origins, members, processes and impact (pp. 13-42). San Francisco: Iossey-Bass. Becker,]., & Coppel, D. B. (1983). Fiore, Social network interactions: A buffer of a stress. American Journal of Community Psychology, 11(4),423-439. George, L. K. (1983). Caregiver well-being:
r.
Correlates and relationships with participation in community self-help groups. Final report submitted to the American Association of Retired Persons Andrus Foundation, Washington, DC. Goodman, C. C. (1989). Perceived social sup-
portfor caregiving: Measuring the benefit of self-help/support group participation. Unpublished manuscript, Department of Social Work, California State University, Long Beach. Goodman, C. C., & Pynoos.}. (1988). Telephone networks connect care giving families of Alzheimer's victims. The Gerontologist, 28(5), 602-606. Goodman, C. C., & Pynoos.]. (1989). Impact
ofa model telephone information andsupport programforcaregivers ofAlzheimer's victims. Unpublished manuscript, Department
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The failure of participants in the lecture-network sequence to repeat the support substitution pattern suggests that use of the program was dynamic, affected by participant expectations and the timing of experiences. These findings leave program developers with unanswered questions: When is peer substitution a benefit? When does increased use of family and friends offer benefits or create overload and conflict?
of Social Work, California State University, Long Beach. Greene, V. L., & Monahan, D.]. (1987). The effect of a professionally guided caregiver support and education group on institutionalization of care receivers. The Geron-
tologist, 27(6), 716-721. Greene, V. L., & Monahan, D. J. (1989). The effect of a support and educational program on stress and burden among family caregivers to frail elderly persons. The
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chology and self-help groups: Predictions on a partnership. American Psychologist, 44(3), 536-545.
Lieberman, M. A. (1986). Social supportsthe consequences of psychologizing: A commentary. Journal of Consulting and
Clinical Psychology, 54(4), 461-465. Lotery, J. L. (1987). A review of self-
help/mutual support group theory and research with an emphasis on the role of the mental health professional. Unpublished manuscript, Department of Psychology, University of California, Los Angeles. Meyrowitz, ]. (1985). No sense of place: The
limits of recovery. American Journal of
Orthopsychiatry, 55(1), 70-81.
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Catherine Goodman, DSlV, isProfessor of Social Work at California State University, LongBeach, 1250 Bellflower Boulevard, Long Beach, CA 90840-0902. Accepted November 29, 1989
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Social Work Practice Theories A Comparison of Selected Attributes CHART -A chart is now available that compares twenty-one social work practice theories along a spectrum of thirty-three variables.
The chart, which measures 36 x 40 inches, is designed for teachers, students, and practitioners. This resource provides an efficient and rapid method of comparing a rich range of theories in a manner to assist learning and practice. The chart can be ordered from:
Dr. Francis J. Turner 186 Claremont Avenue Kitchener, Ontario N2M 2P8 Canada Price (including mailing): $35.00
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Gerontologist, 29(3), 472-477. Haley, W. E., Brown, S. L., & Levine, E. G. (1987). Experimental evaluation of the effectiveness of group intervention for dementia caregivers. The Gerontologist,
givers: A review and analysis. The Geron-
tologist, 29(3), 438-448.
