Practice Concepts

Suzanne Meeks, PhD, Editor

The Gerontologist © The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America.
Cite journal as: The Gerontologist Vol. 54, No. 6, 1049–1058 All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
10.1093/geront/gnu018 Advance Access publication March 31, 2014

Benefit-Finding Intervention for Alzheimer

Caregivers: Conceptual Framework,
Implementation Issues, and Preliminary

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Efficacy
Sheung-Tak Cheng, PhD,*,1 Rosanna W. L. Lau, BSocSc,1 Emily P. M. Mak,
BSocSc,1 Natalie S. S. Ng, BSocSc,1 and Linda C. W. Lam, MD2

1
Department of Health and Physical Education, Hong Kong Institute of Education, Tai Po, N.T.
2
Department of Psychiatry, Chinese University of Hong Kong, Shatin, N.T.

*Address correspondence to Sheung-Tak Cheng, PhD, Department of Psychological Studies, Hong Kong Institute of Education,
10 Lo Ping Road, Tai Po, N.T., Hong Kong. E-mail: takcheng@ied.edu.hk

Received September 9 2013; Accepted February 14 2014.

Decision Editor: Suzanne Meeks, PhD

Purpose: To describe an intervention promoting burden. However, within-group analysis suggested

benefit-finding in Alzheimer caregivers, to discuss
key issues in implementation and ways to resolve
them, and to examine whether the intervention
reduced burden and depression in a small rand-
omized trial. Design and Methods: Twenty-
five caregivers were randomized into benefit-finding
and psychoeducation groups. Both groups had eight
weekly sessions. Outcome measures including role
overload, Zarit Burden Interview, and Hamilton
depression scale were collected at baseline and
after treatment. Results were analyzed using analy-
sis of covariance. Additionally, the challenges of
implementing such interventions, some of which
related to cultural issues, were analyzed qualita-
tively. Results: Controlling for pretest, the ben-
efit-finding group had lower depression than the
psychoeducation group at post-test, despite the fact
that some caregivers found benefit-finding challeng-
ing. The two groups did not differ on overload and
that both groups showed significant reductions in
overload from pretest to post-test. In addition, we
discussed participants’ difficulties in grasping the
technique of thought modification for benefit-find-
ing, recording such exercises at home, and shar-
ing their thoughts and experiences in groups. We
described measures undertaken in the main trial to
overcome these issues. Implications: Cognitive
approaches focusing on benefit-finding are feasible
among Chinese caregivers, with preliminary evi-
dence suggesting an effect on alleviating depression.
Key Words: Alzheimer’s disease, Positive aspects
of caregiving, Caregiver burden, Randomized con-
trolled trial, Hong Kong Chinese
Caring for a family member with Alzheimer’s
disease (AD) is a chronically stressful experi-
ence. The round-the-clock nature of caregiving

Vol. 54, No. 6, 2014 1049

often leads to physical and emotional exhaustion,
health problems, depression, cardiovascular dis-
eases, sleep disturbances, and even early mortality
(Aneshensel, Pearlin, Mullan, Zarit, & Whitlatch,
1995; Mausbach, Patterson, Rabinowitz, Grant,
& Schulz, 2007; Vitaliano, Zhang, & Scanlan,
2003). They are often called an invisible group
because they are mostly outside of the formal
health care and social service system. They carry
the major burden of day-to-day care of relatives
with AD with little assistance from the formal
service sector. This is especially true for most
developing countries in which the kinship net-
work is the main provider of care and support
from formal services is generally lacking (World
Health Organization, 2012). Even when services
are available, caregivers may not utilize them
because they think it is their responsibility to pro-
vide care for their loved ones (Brodaty, Thomson,
Thompson, & Fine, 2005), especially when doing
so is endorsed by cultural values (Knight &
Sayegh, 2010).
There has been much research on interventions
to help family caregivers. In general, approaches to
intervention fall along these lines: providing infor-
mation, problem solving (e.g., managing behavioral
problems, environmental modification), increasing
enjoyable activities, thought modification, social
support, and family counseling (Belle et al., 2006;
Gallagher-Thompson et al., 2012; Mittelman,
2013; Wisniewski et al., 2003; Zarit & Leitsch,
2001). Other than family counseling which cannot
be easily classified, these approaches tend to focus
on managing and modifying the negative and stress-
ful aspects of the caregiving experience. Of particu-
lar relevance to this study are cognitive–behavioral
interventions (Au et al., 2010; Coon, Thompson,
Steffen, Sorocco, & Gallagher-Thompson, 2003;
Gallagher-Thompson & Steffen, 1994; Losada,
Márquez-González, & Romero-Moreno, 2011;
Márquez-González, Losada, Izal, Pérez-Rojo, &
Montorio, 2007). Based on cognitive–behavioral
principles, this line of intervention focuses on iden-
tifying dysfunctional thoughts in caregivers (e.g.,
I should dedicate myself entirely to the care of the
ill relative) and changing them. One review found
this type of intervention to be most effective among
all psychosocial interventions for reducing emo-
tional distress and depression in caregivers but that
conclusion was based on a sample of three studies
employing cognitive–behavioral approaches only
(Gallagher-Thompson & Coon, 2007). Another
review commented that such approaches are
1050
generally rare in developing countries due to the
lack of resources and cognitive–behavioral therapy
specialists (Gallagher-Thompson et al., 2012). For
instance, in a replication and adaptation of the
Stanford program in Hong Kong (Au et al., 2010),
master-level clinical psychology trainees were used
but there were only 20 such trainees per cohort in
the entire Hong Kong at the time. This 13-session
program was evaluated against a waitlist control
in a randomized trial and was found to enhance
self-efficacy in managing disruptive behaviors
and in controlling upsetting thoughts as well as
promote the use of rational problem solving and
resigned distancing. However, of the 37 caregivers
recruited in this study, six treatment and four wait-
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list control (i.e., 27%) dropped out and it was not
clear why.
Compared with the more traditional focus on
modifying dysfunctional thoughts, studies that
focus on cognitive restructuring techniques as a
means to help dementia caregivers reframe nega-
tive experiences in positive terms are relatively
rare. In the following, we describe such an inter-
vention developed for Chinese caregivers, fol-
lowed by a report on preliminary data from the
pilot study, issues of implementation revealed in
the pilot, and changes made to address the issues
in the main trial. Outcome evaluation of the main
trial, which is still ongoing, will be reported in sub-
sequent papers.
A Benefit-Finding Intervention for Alzheimer
Caregivers
Conceptual Framework
Research has demonstrated that positive gains
(a.k.a. positive aspects or benefits of caregiving)
are common experiences among caregivers, often
existing side by side with negative experiences such
as hassles (Cheng, Lam, Kwok, Ng, & Fung, 2013a;
Kinney & Stephens, 1989), as when caregivers find
benefits while dealing with day-to-day care tasks at
the same time. This should not be surprising as the
stress of caregiving is continuous and cannot be
categorically resolved (especially when symptom
manifestation changes) unless the patient deceases.
However, the situation gives rise to a possibility
in which the balance between gains and burden
can be shifted toward the former through positive
reappraisal.
In the classic two-factor model of caregiving
appraisal (Lawton, Moss, Kleban, Glicksman, &
Rovine, 1991), caregiver burden is postulated to be
The Gerontologist
determined in part by the way caregivers construe
the demands of caregiving; a negative appraisal
leads to an increased sense of burden, whereas a
positive appraisal leads to positive outcomes such
as subjective well-being. After working with human
immunodeficiency virus caregivers, Folkman
(1997) noted that caregivers reported positive cog-
nitions and emotions as often as negative ones. By
way of positive reappraisal as well as other means
such as spiritual beliefs and practice, caregivers
benefit from positive meanings, emotions, and
self-esteem that help them “get through the day.”
Positive reappraisal, a form of emotion-focused
coping, is especially relevant when dealing with
intractable stressors for which problem-focused
coping is unlikely to be very helpful (Lazarus &
Folkman, 1984).
Although the relevance of positive reappraisal
or cognitive restructuring is widely recognized, we
are aware of only one intervention study that spe-
cifically trained caregivers to use cognitive restruc-
turing for positive gains (Hébert et al., 2003;
Lavoie et al., 2005; Lévesque et al., 2002). In this
15-session group-based intervention, other than
information provision, problem solving, and pro-
moting social support, caregivers were taught four
kinds of cognitive restructuring techniques, namely
attributing symptoms including behavior problems
to pathology, identifying and changing dysfunc-
tional thoughts, identifying gratifications in car-
egiving, and focusing on and accepting the realities
of decline and loss. However, when compared with
a support group as control, this intervention did
not relieve global caregiver burden, although less
behavioral problems and reactions to them were
reported by the intervention group immediately
after treatment (Hébert et al., 2003). In an interest-
ing process evaluation study by the research team
(Lavoie et al., 2005), participants were asked to
describe what they had learned and in what way
the intervention led to improvements in their situa-
tions. The majority of the intervention participants
(22 out of 30, or 73%) found cognitive restructur-
ing to be most useful and these individuals had the
largest treatment gains. Forty percent mentioned
seeking social support as a learning but those who
sought support tended to receive decreased sup-
port (especially emotional support), rather than
increased support, from family and service provid-
ers. Few participants found problem solving to be
relevant or were able to recall the steps involved
(e.g., dissecting the problem, generating alterna-
tive solutions, analyzing pros and cons of different
Vol. 54, No. 6, 2014 1051
solutions). Thus, caregivers see cognitive restruc-
turing techniques to be most relevant.
More comments on the participants’ feedback
on the use of cognitive restructuring are war-
ranted. Most participants mentioned that they
were able to change the way they think about the
situation, most notably in terms of recognizing the
inevitability of decline and concomitant behavior
problems as well as correcting certain dysfunc-
tional thoughts such as those related to self-blame.
Some commented that the former was a result of
the educational component, which helped them
understand the disease, rather than active efforts at
reframing. However, only one participant “learned
to view her role as an opportunity for personal
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development” (Lavoie et al., 2005, p. 29); no other
support for the gratitude component was noted.
In a recent editorial, Zarit (2012) commented
that research is needed to “unravel whether posi-
tive aspects of caregiving reflect stable appraisal
styles that some people bring to the care situation,
or if positive appraisals can be enhanced through
carefully targeted interventions” (p. 673). The
reasons for the negative results in this respect in
Lavoie and colleagues’ (2005) study are not clear.
One possibility was that the caregivers were taught
too many cognitive techniques and it was not easy
for them to integrate all the techniques learned and
apply them simultaneously and integratively in
daily encounters. In view also of the fact that many
spousal caregivers in Hong Kong had had little or
no education due to historical reasons such as war
(Cheng, Lum, Lam, & Fung, 2013), which may
limit their ability to learn from a complicated inter-
vention, we have designed a benefit-finding inter-
vention that presents relevant cognitive skills in a
simpler and more focused fashion. Using a simple
diagram of the thought-emotion-behavior triangle,
we focused simply on helping caregivers under-
stand the interconnectedness of the three domains,
and how modifying thoughts could improve
emotional well-being either directly or through
behavioral change (the thought-emotion-behavior
triangle was actually drawn as a circular diagram
but we will keep referring to it as the triangle as it
is a well-known term). This aspect had the primary
goal of fostering cognitive restructuring techniques
for the purpose of benefit-finding. A caveat to note
is that we did not emphasize so much on challeng-
ing dysfunctional thoughts because calling certain
thoughts “dysfunctional” might induce caregivers
to think that they had made mistakes. In light of
Chinese’ tendency to hold back their concerns in
front of others (see below), such an approach might
further discourage self-disclosure in the group. We
simply asked caregivers to try replacing an “old”
thought with a “new” one.
Program Design
In a review of international programs to assist
caregivers, Gallagher-Thompson and colleagues
(2012) commented that resource (including exper-
tise) and cost are crucial issues in developing coun-
tries. Interventions employing cognitive–behavioral
approaches had typically used professionals, such
as clinical psychologists, as trainers (Au et al.,
2010; Coon et al., 2003; Gallagher-Thompson
& Steffen, 1994; Losada et al., 2011; Márquez-
González et al., 2007). However, such specialists
are rarely found in many developing countries
including Hong Kong. Hence we had designed an
intervention that could be conducted by parapro-
fessionals. Eventually we would target former car-
egivers as trainers as we see this to be the most
promising direction. In this particular study, train-
ers were psychology graduates who had experi-
ence working with dementia caregivers and were
trained and supervised by the first author who is a
clinical geropsychologist.
The benefit-finding intervention combines
“standard” psychoeducation (information and
problem solving) with positive reappraisal cop-
ing that is intended to help caregivers construe the
demands of caregiving in more positive ways. The
name does not imply that the intervention does
nothing else except benefit-finding; the interven-
tion was so labeled in order to highlight its dis-
tinctive aspect and to propagate the message about
enhancing positive aspects of caregiving. Topics
covered included knowledge of dementia, commu-
nication skills, stress management and relaxation,
balance between self-care and caregiving respon-
sibilities, social support, managing behavioral and
psychological symptoms, home-based activities for
care recipient, personal care skills for dependencies
in activities of daily living (ADL), home environ-
mental modification, and community resources. On
top of these, caregivers discussed the thought-emo-
tion-behavior triangle and thought modification.
In this context, they first identified their emotional
reactions to different caregiving situations and
started to practice positive reappraisal using per-
sonal examples as well as hypothetical examples in
the training manual. Caregivers who were known
to have an especially positive mindset toward
1052
their caregiving experiences were asked to record
videos in which they recounted the challenges of
being a caregiver and how they were overcome,
partly through positive reappraisal. Three videos
were produced, each featuring a spouse, a child,
and a child-in-law caregiver, respectively (all hap-
pened to be women), which were shown in differ-
ent sessions (with written consent) because it was
thought that sharing by caregivers would be much
more powerful than coaching by a trainer (the vid-
eos were not available in the pilot phase; see sec-
tion on Issues of Implementation and Subsequent
Changes to Program).
Additionally, participants voice-recorded diaries
in the evening up to three times a week to reflect on
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positive experiences that day (no specific times in
the evening were given as it was unrealistic to spec-
ify such times for caregivers). We asked that they
voice-recorded the diaries because some caregivers
were illiterate. Such diaries, together with reap-
praisal exercises within the sessions, formed the
basis for mutual sharing of benefits as well as the
process by which the benefits were derived. Through
mutual sharing in groups, caregivers served as role
models of benefit-finding for each other.
Aside from initial coverage of information about
dementia and basic communication and stress man-
agement skills, contents related to benefit-finding
were included throughout, covering as much as one
fifth of the total contact time (diaries not included)
in the pilot phase and increasing to one third in the
main trial. For example, when discussing coping
with behavior problems or ADL dependencies, posi-
tive reappraisal was practiced and was given extra
attention as a way of coping. To illustrate, instead of
focusing on their worries about the relative’s wan-
dering behavior and to get annoyed when it hap-
pens, the participants were encouraged to change
their mindset, such as (a) treating it as a moment
together and walking with the relative rather than
preventing him or her from doing it, (b) cherish-
ing the memories when visiting old places, (c) using
the opportunity (child caregivers only) to reflect on
what the parent had done for them when they were
young (e.g., taking them here and there), (d) appre-
ciating nature when walking in parks, (e) treating it
as a physical exercise for relative and self, and so on.
At the last session, besides reviewing things
learned including the positive gains they had
acquired, participants reflected on their motivations
to provide care and reaffirmed their caregiving role
and relationship with the care recipient. They also
set goals for improvement in the coming year. In
The Gerontologist
the following, we present preliminary data on the
efficacy of the benefit-finding intervention and sum-
marize a few key observations from the pilot phase
and what were done to tackle them in the main trial.
Preliminary Data on Treatment Efficacy
We are in the process of running a double-blind
randomized controlled trial to evaluate the bene-
fit-finding intervention against two active controls:
(a) a “standard” psychoeducational intervention
(same topical coverage as in the benefit-finding
intervention but without the positive reappraisal
component) and (b) a “simplified” psychoedu-
cational intervention which is plain information
are available from the first author). Inclusion cri-
teria were: (a) primary caregivers of a relative
aged 65+ who had a physician diagnosis of AD
or met the National Institute of Neurological and
Communicative Disorders and Stroke–Alzheimer’s
Disease and Related Disorders Association criteria
for possible AD (McKhann et al., 1984); (b) pro-
viding no less than 14 hr of care per week; (c) care
recipient being in mild to moderate stages of AD as
determined by Clinical Dementia Rating (Morris,
1993), (d) caregiver aged 18+ years, (e) caregiver
without cognitive impairment as measured by
the Cantonese version of the Mini-Mental State
Examination (Chiu, Lee, Chung, & Kwong, 1994;
Folstein, Folstein, & McHugh, 1975), and (f) car-

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provision without hands-on exercises on skills egiver at least mildly depressed, operationalized as
application or rehearsal. The latter is representa- a score of ≥3 on the Hamilton Depression Rating
tive of interventions in the local context which scale (Hamilton, 1960). Although the conventional
tend to be brief and education focused (hence cutoff score is 8, it was not empirically established
treatment-as-usual), whereas the former resembles and many researchers consider it too high (Möller,
similar interventions reported in the mainstream 2008). Two studies by Zimmerman and colleagues
international literature. Further details about the (Zimmerman, Posternak, & Chelminski, 2005;
characteristics of the control groups can be found Zimmerman et al., 2012), each having about 300
in Cheng and colleagues (2012).
Although the main trial is still ongoing, we
Table 1. Sample Characteristics
report below results from the pilot study so that
preliminary efficacy of the benefit-finding interven-
Benefit-finding Psychoeducation
tion can be discerned. In the pilot, only the benefit-
finding and the traditional psychoeducation were Age (M/SD) 54.2 / 7.0 53.8 / 10.8
Sex (women %) 85 92
attempted because the simplified psychoeducation Married (%) 69 75
was simply a watered down version of the latter Education (%)
and because of recruitment concern. Other than Primary or below 31 17
known barriers to recruiting caregivers such as Secondary 69 50
the lack of time, exhaustion, and unwillingness to Tertiary 0 33
leave the relative to the care of someone in order Relationship to care
recipient (%)
to attend intervention, the lack of screening and Spouse 23 8
diagnostic services in developing societies such as Child 69 64
Hong Kong means that family members and even Daughter-in-law/ 8 17
community agencies are often uncertain about the niece
cognitive status of the patient and uninformed Living with care 69 50
recipient (%)
of the diagnosis. Because of these difficulties, we
Dementia severity of care
designed a smaller scale pilot to avoid drawing too recipient (%)
many potential participants from the main trial. Mild 23 25
Twenty-six caregivers, recruited from psychiat- Moderate 77 75
ric clinics and seniors’ centers, were randomized Zarit burden (M/SD)
by clinic/center to benefit-finding (n = 14) or psy- Pretest 41.15 / 15.80 36.83 / 9.35
Post-test 36.15 / 17.01 34.08 / 11.66
choeducation (n = 12) group, with two clinics/
Role overload (M/SD)
centers in each group. However, one participant Pretest 11.38 / 2.81 11.17 / 2.17
from the benefit-finding group dropped out, leav- Post-test 9.77 / 2.80 9.25 / 2.34
ing 13 in this group. Sociodemographic charac- Depressive symptoms
teristics of the sample can be found in Table 1 (M/SD)
and there was no significant difference on any of Pretest 7.54 / 5.24 6.42 / 4.01
Post-test 3.46 / 1.51 6.00 / 5.46
these variables between groups (detailed statistics

Vol. 54, No. 6, 2014 1053

depressed patients, converged to an optimal cut-
off of 3, based on criteria for remission, psychoso-
cial functioning, and quality of life. We therefore
adopted this as our criterion. Exclusion criteria
were the care recipient having parkinsonism or
other forms of dementia (e.g., mixed cases).
The groups met weekly for 2 hr and were led
by a trainer. Standardizing exposure (or dosage)
has the advantage of providing additional controls
(such as for expectancy effects) when analyzing
outcomes, although it may mean reduced time for
certain topics in the benefit-finding group in order
to make room for positive reappraisal training.
Ethics approval for the study was obtained from
the Joint Chinese University of Hong Kong-New
Territories East Cluster Clinical Research Ethics
Committee and the Central Research Committee
of the Hong Kong Institute of Education.
Outcomes measures for the pilot study were
burden and depression. Burden was measured by
Pearlin, Mullan, Semple, and Skaff’s (1990) 4-item
measure of role overload (rated on a 4-point scale
of 1 = not at all to 4 = completely) and the 22-item
Zarit Burden Interview (rated on a 5-point scale
of 0 = not at all to 4 = extremely; Zarit, Reever,
& Bach-Peterson, 1980). Depression was meas-
ured by the 17-item Hamilton Depression Rating
scale (Hamilton, 1960). These three scales have
all been translated into Chinese, with alpha coef-
ficients equaling 0.78, 0.86, and 0.84, respectively,
in a larger Chinese caregiver sample (Cheng et al.,
2013a). The measures were obtained at baseline
and again approximately eight weeks later after
treatment.
Gallagher-Thompson and Coon’s (2007)
review suggested a rather large average effect size
(d = 1.20) for cognitive–behavioral approaches.
We hypothesized better outcomes among benefit-
finding than among psychoeducation participants
and assumed a similar effect size, f = 0.50 (equiva-
lent to d = 1.00). According to GPower 3.17, for
the present sample size, alpha should be set at 0.10,
two tailed, to maintain power at 0.80 in analysis of
covariance with one covariate.
Pretest and post-test mean scores of the out-
come measures are displayed in Table 1. There
were no group differences in the pretest scores of
role overload, Zarit burden, and depression; t(23)=
−0.22, −0.82, and −0.60, respectively, all ps > .41.
Analysis of covariance was performed to examine
between-group differences in each of the post-
test measures, with the respective pretest score as
covariate; for instance, when analyzing post-test
1054
depressive symptoms, pretest depressive symp-
toms was the covariate. Results did not reveal any
group difference in role overload and Zarit bur-
den, both Fs < 0.2. However, a significant group
difference in depressive symptoms was found;
F(1,22) = 3.56, p = .073, ηp2 = 0.14. As one can see
from Table 1, the difference was due to substantial
reduction in depressive symptoms from pretest to
post-test in the benefit-finding group, but not the
psychoeducation group.
To further illustrate the impacts of the inter-
ventions, we performed paired sample t tests
comparing group-specific outcome measures
between pretest and post-test. For the psychoedu-
cation group, there was significant change in role
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overload, but not in Zarit burden and depression;
t (p values) = 2.15 (.055), 1.18 (.265), and 0.28
(.783), respectively, all dfs = 11. For the benefit-
finding group, the corresponding t and p values,
with dfs = 12, were 1.99 (.070), 1.29 (.220), and
3.06 (.010). Thus, both groups showed reduc-
tions in role overload, but only the benefit-finding
group had reduced depressive symptoms, lead-
ing to the analysis of covariance results reported
above.
Issues of Implementation and Subsequent
Changes to Program
Although the pilot study suggested that the
benefit-finding intervention is efficacious in reduc-
ing caregiver depression, certain issues of imple-
mentation were identified. We describe these issues
below as well as modifications made to enhance
treatment implementation in the main trial. The
discussion below serves to shed light on the chal-
lenges of conducting such interventions, especially
among Chinese/Asian and low-income caregivers.
Understanding the Connections Among
Thoughts, Emotions, and Behaviors
This important conceptual framework was
introduced in week 2, following the initial ses-
sion in which information on dementia and basic
communication skills were introduced. Although
the thought-emotion-behavior triangle was not
difficult to understand, a few caregivers found it
difficult to apply the concepts to reframe a stress-
ful incident in more positive ways. It is generally
recognized that cognitive therapeutic approaches,
especially brief ones, are more suited for those with
better education and intellectual capacities (Key &
The Gerontologist
Craske, 2002). However, Hong Kong spousal car-
egivers tend to have little education due to histori-
cal factors; for instance, in one such sample, over
one third had no education and half had some pri-
mary education only (Cheng, Lam, Kwok, Ng, &
Fung, 2013b).
In the main trial, more examples were provided
to illustrate how certain thoughts could trigger
negative emotions and how reframing an event in
a positive light could neutralize or reverse the dis-
tress. Common everyday examples that were easier
to understand were used first, followed by examples
relevant to the caregiving context. Exercises were
added during initial group sessions to provide oppor-
tunities for positive reappraisal practice. Initially,
scenarios prepared by the research team were used.
After participants became more familiar with the
technique, they were encouraged to bring up per-
sonally relevant examples and work out reframing
using the thought-emotion-behavior triangle and
the think-aloud technique. Because caregivers often
shared similar experiences, it was not unusual for
participants to share similar thoughts at the same
time, serving as mutual reinforcement for each other.
Engaging in Benefit-Finding
To provide a more focused anchor for cognitive
restructuring and positive reappraisal, we asked
caregivers to think “how providing care to a family
member has been a rewarding experience,” start-
ing from week 3. The concept of benefit-finding
itself was difficult for a number of participants
who could not contemplate what constitutes a
“benefit” from caregiving, especially for older car-
egivers with little or no education. To explain the
concept to caregivers, we adopted a commonly
used Chinese term that is more or less equivalent
to the concept of “gain” in English. We explained
to the participants that a benefit or gain repre-
sents changes in positive ways as a caregiver. Such
positive changes can be seen when one finds new
perspectives about the illness and their relatives;
develops skills or new attitudes in dealing with the
relative; being more able to relax or to avoid emo-
tional upset; acquires insights about one’s strengths
as well as limits; experiences personal changes for
the better, and so on.
To reinforce the discussion and to demon-
strate that benefits are achievable through chang-
ing one’s perspectives, the videotaped testimonies
from other caregivers aforementioned were added
in the main trial. Hearing these testimonies
Vol. 54, No. 6, 2014 1055
directly from other caregivers was a boost to the
participants’ confidence that they could also find
benefits for themselves. Additional exercises were
introduced at the training sessions using hypo-
thetical scenarios, in which participants, divided
into groups, competed for the largest number of
alternative benefits generated. In the second-to-
last (seventh) session, participants were asked to
review all the benefits they had acquired in order
to consolidate their orientation toward positive
aspects of caregiving.
Mutual Sharing in Group Sessions
It has been well documented that Chinese tend
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to avoid open expression of emotions, especially
negative ones. The lack of emotional control is
believed to be detrimental to health and to disrupt
social harmony (Bond, 1993). Asking caregivers to
share emotion-laden experiences with each other
and to record such experiences on diaries may be a
challenge to some caregivers. Finally, as the tradi-
tional Chinese saying “don’t wash your dirty linen
in the public” goes, discussion of family problems
(such as not getting enough support from other
family members; Cheng et al., 2013b) in front of
outsiders is discouraged in the Chinese culture due,
for example, to the cultural emphasis on family
unity and solidarity.
One of the reasons of introducing the caregiver
videos was to provide role models in sharing per-
sonal stories. Nevertheless, a few participants still
found it difficult to talk about their personal issues
in front of others. As said, open emotional disclo-
sure, especially in relation to family issues, is not a
typical Chinese behavior.
In the main trial, we dealt with it by setting
clearer grounds rules about mutual sharing right
from the start and used lots of encouragement
throughout. Like in any group, some participants
were more outspoken than others initially, but
gradually all participated. Most importantly, no
caregiver was known to drop out due to the need
to share personal experiences.
We also noticed that caregivers who were par-
ticularly troubled by their relatives’ disruptive
behaviors were more outspoken at the beginning,
reflecting their desires to find ways to deal with these
behaviors. This was consistent with data elsewhere
suggesting that Hong Kong Chinese caregivers are
most distressed by overt behavioral problems dis-
played by their relatives (Cheng, Kwok, & Lam,
2012; Cheng, Lam, & Kwok, 2013).
Acceptability of the Diary Exercise designs, suggested moderate effect sizes on psycho-
logical distress but no effect on burden (Brodaty,
In Cantonese, which is the main Chinese dia-
Green, & Koschera, 2003). As mentioned before,
lect in Hong Kong, the spoken and the written lan-
Hébert and colleagues’ (2003) intervention with
guages are somewhat different. If both spoken and
specific emphasis on cognitive reframing also had
written records are used, bias would be introduced
no effect on global burden, although reactions
when the diaries are subject to linguistic analysis at
to behavioral problems were subdued, compared
a later stage. As some of the caregivers were illiter-
with a support group. Our results were consist-
ate, we asked all participants to record the diaries
ent with this general pattern of effects reported in
on a voice recorder provided by the research team.
the Western literature. Despite being a pilot study,
Some caregivers, however, commented that it felt
the positive results on relieving depression were
“unnatural” to speak to a voice recorder.
encouraging.
Other than discomfort with the procedure,
The negative results on burden need to be quali-
the most common obstacle to the diary exercise
fied. They were characterized by parallel reduc-
was the lack of time, especially those who were
tions in role overload in the two groups, but no

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employed. This was not unexpected given the day-
to-day demands of caregiving. Another reason,
mentioned by one caregiver, concerned privacy
issues and the possibility that the recording might
be overheard by the care recipient or other fam-
ily members who might be disturbed by the con-
tent. In Hong Kong, most people live in small or
crowded apartment units which may make finding
a private space to do the recording difficult. This
limitation was not preconceived by the research
team. Partly because of these issues, 23% of the
caregivers enrolled in the benefit-finding group did
not produce any diary, although they would still
share their experiences at the group meeting. The
remaining benefit-finding participants turned in
8.40 (SD = 5.72) diaries.
In the main trial, we gave them opportunities to
practice recording recent events during group ses-
sions so that they became more comfortable and
familiar with the procedure. Some caregivers who
appeared to need more help were allowed more
practice before or after sessions. For noncomply-
ing participants, the trainer would phone them on
a weekly basis to remind them to do the diaries
and bring the recordings back to the next session.
Discussion
The only major difference between the two
interventions was the positive reappraisal and ben-
efit-finding component. Therefore, any difference
between the two groups may be attributed to this
component. Results showed that the two groups
did not differ in terms of burden and overload, but
the benefit-finding group had significantly lower
depressive symptoms than the psychoeducation
group at post-test. A widely cited meta-analysis of
psychosocial interventions for dementia caregiv-
ers, which included true and quasi-experimental
significant change of the Zarit Burden Interview
from pretest to post-test. Measures of global bur-
den may not be appropriate outcome measures
for all types of intervention studies. For instance,
Whitlatch, Zarit, and von Eye (1991) suggested
that the Zarit Burden Interview might tap two
dimensions, namely personal strain and role strain.
The role strain items are similar to Pearlin and
colleagues’ (1990) measure of role overload. The
personal strain items tap perceptions of patient
dependency and personal responsibility, which are
not areas specifically addressed by the interven-
tions. In fact, in a culture emphasizing one’s fam-
ily obligations, caregivers might feel a heightened
sense of responsibility “to take good care of the
relative” after going through a training course.
Future research should explore whether effects of
intervention are not the same for different dimen-
sions of burden.
The results on role overload also raised the
question of what constitutes an appropriate con-
trol group for intervention studies. Many previous
studies had used waitlist controls (e.g., Au et al.,
2010; Coon et al., 2003; Losada et al., 2011;
Márquez-González et al., 2007). However, ideally
the control should be a credible placebo (Zarit
& Leitsch, 2001). In developing countries where
formal support to caregivers and care recipients
are lacking (World Health Organization, 2012),
a waitlist control may be inappropriate ethically
as well as methodologically as there is no usual
care available in general. Nevertheless, the psych-
oeducation group in this study might have been
an overly rigorous comparison group, affecting
the outcome analysis. Nevertheless, without it, it
would not be possible to say for certain that the
effect on depression was due to the benefit-finding
component per se. In the main trial, a third group,

1056 The Gerontologist

namely an information-provision-only version of
the psychoeducation group will be included, which
may allow more refined analysis of the effects of
the different treatment components.
Despite the limitations, this study suggests that
caregiver interventions are feasible among Chinese
caregivers and cognitive approaches with a focus
on benefit-finding can alleviate their depression.
Unlike the study by Au and colleagues (2010), there
was a low dropout rate and caregivers’ participa-
tion and responsiveness suggested that the benefit-
finding intervention was acceptable to them. The
intervention does not require psychotherapists to
serve as trainers, making it more sustainable than
imported programs. Such intervention programs
are urgently needed as China and Hong Kong will
witness a very rapid growth of the dementia popu-
lation in the next two decades or so (Alzheimer’s
Disease International, 2013). Research is needed to
see whether the present interventions are applica-
ble and effective in actual clinical settings in China
as well as other cultural groups.
Funding
This study was supported by Strategic Public Policy Research Grant
No. HKIEd1001-SPPR-08 of the Research Grants Council of Hong Kong.
Acknowledgments
We thank the medical practitioners, clinics, and NGOs for referring
participants to the project.
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