IJCRR - 13(12), June, 2021
Date of Publication: 26-Jun-2021
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A Positive Cognitive Behavior Therapy based Intervention with a Caregiver of a Patient with Mental Illness Amidst the Covid-19 Pandemic: A Case Study
Author: Khurana R., Kumar N.
Abstract:Introduction: The Covid-19 pandemic has limited individuals to their homes and it has become increasingly difficult to consult psychiatrists and psychotherapists for already ill as well as new patients. In times of crisis, the role of a caregiver becomes even more important as they become responsible to care for their loved ones 24x7. Aim: This study aimed at exploring the impact of a Positive CBT based Intervention on caregiver burden and also to understand the driving force that motivates a caregiver to offer continued selfless care despite the task being so challenging. Case Report: Five assessment tools namely, Caregiver Strain Index, Beck's Depression Inventory, Beck's Anxiety Inventory, Satisfaction with life scale and Positive Aspects of Caregiving were administered on a caregiver R.S (55-year-old woman) of a patient with Bipolar Disorder, post which, a Positive CBT based 5-week Intervention was carried out. The intervention focused on redirecting the caregiver's attention to the acknowledgement of her strengths and building hope and resilience. The assessment tools were re-administered immediately after the intervention. There was a significant reduction in Caregiver Burden and the caregiver reported experiencing more positive aspects of caregiving post the intervention. Discussion: The research, inconsistency with previous researches stress over the importance of building effective interventions and support system for the caregivers. Conclusion: Positive CBT holds tremendous potential to be utilized as an effective intervention for caregiver stress. The study needs to be replicated on a larger sample with a special focus on cultural aspects of caregiving.
Keywords: Caregiver stress, Positive Aspects of Caregiving, Case study, Covid-19 Pandemic, Intervention, Positive CBT
Researchers have indicated that serious dysfunctional behaviour gives rise to a considerable amount of burden for the relatives of the individual suffering from the psychological ailment, particularly those people who opt for a caregiver job.1 It has been reported that individuals who take up the role of caregiving seem to undergo feelings of failure and agony, melancholy, tiredness, mental exhaustion, difficulty in sleeping, nervous breakdown, criticism, feeling liable, loneliness and monetary difficulties, linked with the repercussion of negative views that are connected with psychological ailment.2-5 Caregivers reported experiencing an increase in negative feelings like helplessness, burden, distress during the pandemic due to limited support from the healthcare, added responsibilities and abiding by the Covid norms like social distancing.6-10 Nonetheless, members of the family could be a great support in providing additional help to individuals suffering from a psychological ailment in their society, while they are being treated and also are essential in stimulating societal connections. Sadly, appropriate and due attention is not given to caregivers in the psychological health sector all over the world.11-14 A study suggests appropriate availability of treatment is not enough of a remedy, it’s equally important to create a system that could offer support to the caregivers. The interventions created to offer support to the caregivers should fulfil the criteria of being attainable, holding social and cultural significance, capable enough to uncover false and questionable beliefs, fitting well to the demands of the individual providing care and include all tiers of the society. 15-18 An interventional research19,20,21 carried out with caregivers showed positive results with a noticeable decrease in caregiver burden22 hardship, depressive and anxious feelings and better quality of life.
R.S, a 55-year-old woman who is a caregiver to her daughter, was diagnosed with Bipolar Disorder. She was administered with assessment tools namely Caregiver Strain Index,1 Beck’s Anxiety Inventory,3 Beck’s Depression Inventory,2 Satisfaction with life Scale4 and Positive Aspects of caregiving5 to understand the level of Caregiver strain, Anxiety, Depression, Satisfaction with life and positive aspects of caregiving. The caregiver, a Buddhist practitioner, has been rigorously practising chanting. However, surprisingly that did not put her mind to peace due to which she reached out for help. The family members of the caregiver were not in favour of her seeking out professional help so as not to add to the stigma they were already facing because of the daughter’s illness. Also, the disheartening side to this case was that despite the understanding that there was an urgent need for admission of her daughter into a psychiatric rehabilitation facility, she chose to not do it as the pandemic guidelines suggested a Covid-19 screening test of the entire family to rule out any possibility of risk. She expressed her concern about how the society she lived in would treat their family like untouchables and make necessities also difficult to get if any one of them tested positive. She reported high levels of stress, mild disturbance in mood, anxiety, compromised life satisfaction and a negative perception of caregiving experience. Post the initial assessment, a five-week Positive CBT based Intervention was carried out with her with proper informed consent procedures.
The first session began with a brief explanation of concerns by the client and was followed by knowing the best hopes she had from the intervention, wherein she expressed about how she wanted to feel less burdened and to be able to find some quality time for things she loved doing. She was then made to reflect on what difference it would make in her life if she chose to fulfill her desired goal. While she spoke about the obstacles that create a barrier between her and the goal, she was redirected to acknowledge what according to her was already working for her even though the task was a challenging one and also what could be the immediate sign of growth or progress. The client was made to work on a Daily Exceptions Journal and the aim was focused on knowledge of their existing abilities and potential/strengths. She was asked to reflect on when she didn’t feel the concern that day, what was better even limitedly, what was she doing distinctively to make things better, what could be done to keep the positive changes persistent and how would her future look if the changes became constant.
Feedback: The caregiver felt very motivated and was willing to work towards a positive goal and was grateful to me for sparing time and energy for her. When asked to rate how she felt on a scale of 0-10 (0 being low and 10 being happy), she said 9.
The session was inclined towards helping the client recognize the problem through gratitude. The client was encouraged to pen down a letter to her daughter who she looks after, which would generate positive aspects towards caregiving and also strengthen her relationship with her daughter making the task less strenuous. Through this activity, the aim was to create feelings of gratitude in the client and also make her reflect how being a caregiver made her evolve as an individual.
Feedback: The client expressed how the journey of being a caregiver despite being demanding compelled her to recognize her strengths and made her more appreciative.
The objective of the session was to find solutions towards reaching closer to her desired goal. She was asked to recollect an immensely disturbing event and what was her plan of action or go-to technique to evolve out of it. She was encouraged on the aspects that were previously working for her and insisted on practising more of what seems to be already working. The session concluded by helping the client reflect on the insights of how things were working for her even in the worst-case scenarios and what she considers are the three blessings that drive her through the hardships.
Feedback: She brought in a spiritual aspect by saying, “The blessing that God has sent for me is you in the form of an angel”. She also realized that she has the in-built capabilities and strengths to keep going.
It focused on helping the client recognize her best self. The objective was to make her aware of the strengths and capabilities she possessed and how she can increase the positive emotions by recalling when she was at her best. She was asked to journalize her story by describing her behaviour, emotions, and thoughts in an event that caused her distress and yet she successfully sailed through it. Thereafter, she highlighted and read aloud the phrases or words that stated her strengths and found what benefits that event had for her. Her attention was driven towards how she can bring these strengths into use while dealing with her current issues.
Feedback: She speculated that therapy has helped her develop the capabilities to look into oneself about the abilities she already possesses as a caregiver, which has and will further help her deal with challenges.
The last session began by asking the client “What’s better even a bit?” This shifted the mood of the client towards positive and instead of talking about problems she spoke about how things have been better. She was asked to identify what she was doing differently while things seemed to have become better and she expressed about looking at things in a different light and generating benefit out of her miseries. Thereafter, she was made to contemplate how her future would look if these positive changes continued and what she should keep doing differently to keep them going.
Feedback: The client expressed that she never saw her problem as a blessing and also was grateful for instilling hope and positivity in her life. She stated that the pandemic had worsened her stress due to difficulty in the availability of psychiatrists and psychotherapists for her daughter and there was an additional burden on her as she had to provide care for 24 hours living under the same roof. A feeling of contentment of providing care to her daughter kept her going.
The caregiver reported a remarkable decrease in caregiver strain, depression, anxiety, greater satisfaction with life and high positive aspects of caregiving (As shown in Graph 1).
The current study revealed that a Positive Cognitive Behavior Therapy Intervention helped lower the levels of caregiver strain, depression, anxiety and the client had an enhancement of satisfaction with life and positive aspects of caregiving. The findings of this study were found to be consistent with two pilot studies which suggest that psychotherapies based on a positive framework reduces depressive symptoms and promotes well-being in people suffering from depression of mild and moderate category. 23 This study strongly recommends that counselling services and efficient interventions should be made available for caregivers. Researchers have amplified the need for adequate guidance, counselling, encouragement and knowledge for caregivers especially those who offer care to individuals suffering from mental illness as they are confronted with higher levels of distress. Caregivers are potentially at threat of developing any illness if their issues are not addressed well in time. 24
In the Pandemic, the hospitals and clinics reserved themselves for Covid-19 patients and individuals dealing with psychological illness were restricted to their homes and the duty of caregiving primarily became a job of the family members. While providing care for patients, family members too faced a tremendous amount of burden which was not addressed due to the limitation of doctors and resources. This study recognizes an immediate need for adequate interventions for caregivers as they are the neglected and unsung warriors behind the recovery of an individual suffering from mental illness. It also showed the plight of individuals as they cannot get tested for Covid-19 due to fear of discrimination in society. Positive CBT based Intervention showed promising results in creating hope and resilience in the caregiver while making them aware of their strengths and recognizing that every experience is to be learnt from and grateful for.
Declaration of patient consent: It is certified by the authors that proper informed consent through a form has been obtained by the participant. The participant understands that her identity would be kept confidential and the study is purely for research and awareness purposes.
Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles and journals from where the literature for this article has been reviewed and discussed.
Conflict of Interest: NIL
Funding: The authors of this research received no specific grant/funding from any funding agency in the public, commercial, or not-for-profit sectors.
Author Contribution Statement: The authors confirm contribution to the research as follows: The research was conceptualized by both the authors, the data collection was done by Rati Khurana and analysis of results was done by Nimisha Kumar. The manuscript was prepared, reviewed and finalized by both authors collaboratively.
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