Religious Coping in Caregivers of Family Members With Dementia

Abstract

The degree of depression experienced by caregivers of individuals with dementia was examined in relation to religious coping strategies, religious practice, and spirituality in the framework of the stress and coping model. Caregivers of 191 persons with dementia completed the Religious Coping Scale, self-report measures of religious practices and spirituality, burden, and depression. There was no evidence that any religious coping strategy or religious practice moderated the relationship between caregiving stress and depression. Certain types of religious coping strategies had a direct effect on depression. Higher levels of religious coping working with God were associated with decreased depression, whereas higher levels of religious coping working through God were associated with increased depression. Higher burden, lower overall caregiver health rating, and worse reactions to memory and behavior problems were associated with higher levels of depression. Frequency of prayer and the importance of spirituality were weakly associated with lower levels of depression.

Keywords

religious coping caregivers dementia

Almost 15 million Americans, primarily family members, provide unpaid care for a person with Alzheimer’s disease or any other dementia (Alzheimer’s Association, 2012). Caregiving can have a negative impact on the physical and mental health, employment, income, financial security, and leisure time of many caregivers (Gallicchio, Siddiqi, Langenberg, & Baumgarten, 2002). High levels of depression and anxiety are common in dementia caregivers, with about one third of individuals meeting diagnostic criteria for depression (Schulz & Martire, 2004). In addition, high levels of caregiver burden are related to premature institutionalization of the care recipient (Choi, Tirrito, & Mills, 2008).

In caring for a family member with dementia, caregivers continually assess their coping resources and limits. Resource variables are thought to act on the relationship between the stress and burden of caregiving and depression. Coping and social support are regarded as the two principal mediators in this relationship (Pearlin, Mullan, Semple, & Skaff, 1990). The stress and coping model has been widely used to conceptualize the relationship between caregiving and adverse health outcomes (Dilworth-Anderson, Williams, & Gibson, 2002). The model proposes that objective stressors (e.g., care recipient’s cognitive functioning and behavioral problems) interact with subjective stressors (e.g., caregiver’s perceived burden) as well as with background and contextual variables, resulting in adverse outcomes (e.g., depression; Pearlin et al., 1990).

Perceived control is an important factor in the relationship between psychosocial demands and personal resources that determines whether or not an event is stressful (Steptoe, 1989). Rothbaum, Weisz, and Snyder (1982) proposed that control involves two processes. The primary control process involves attempting to change the world to make it fit the needs of the self and includes beliefs that one’s actions can have a direct impact on the situation, for example, diabetics changing their diet to manage their medical condition. Secondary control processes involve accepting one’s lack of control in the situation. These include turning to others for help (vicarious control), believing in fate or luck (illusory control), reinterpreting the event to make it more acceptable (interpretive control), or attempting to predict events so that they will be easier to accept should they occur (predictive control). The pursuit of control is rarely abandoned and individuals are likely to shift from one method of striving for control to another. Differences between primary and secondary control processes should be considered as differences in emphasis. Optimal coping is defined as the coordination of primary (i.e., extending personal control) and secondary control processes (i.e., going outside oneself for solutions [Rothbaum et al., 1982]) for the purpose of raising the caregiver’s stress tolerance.

Religion provides believers with many methods to attain a sense of control. Religious coping methods to gain control of outcomes are not exclusively secondary control processes and include access to both human initiative and divine power (Pargament, 1997, 2007). Through qualitative studies and reviews of the literature, Pargament et al. (1988), Pargament et al. (1990), and Pargament, Koenig, and Perez (2000) identified three distinct approaches in the use of religion to seek control of outcomes:

Control centered on relationship with or working with God. Examples are collaborative religious coping, which involves seeking control in solving problems through a partnership with God, and active religious surrender, which involves using personal resources and then turning control over to God. After primary control processes have been exhausted, some people may turn to active religious surrender as a secondary process of control to avoid hopelessness. Thus, active religious surrender involves accessing both primary and secondary control processes in a sequential manner, whereas collaborative religious coping involves accessing both primary and secondary control processes simultaneously. Both of these methods use primary and secondary control processes in a balanced and coordinated way.

Control centered on working through God. This approach favors secondary control processes, in that ultimate control and responsibility belong to God (Pargament et al., 1988). It includes pleading for direct intercession, which involves seeking control indirectly by praying for a miracle or divine intercession, and passive religious deferral, which entails waiting for God to control the situation. Using passive religious deferral, the individual delegates the responsibility to an omnipotent and benevolent being, reflecting greater secondary control and lower levels of both personal control and planful problem solving measures. Pleading for divine intercession may not be effective in controllable situations, but may prove useful in uncontrollable situations as it provides a sense of vicarious control and mastery; it may well be the coping method of last resort when psychological distress is heightened.

Self-directed religious coping. Based upon the belief that God gives individuals the tools and resources to solve problems, control is centered on the self and sought directly via one’s own initiative. This method favors primary control processes.

Pargament (1997) suggested that, for situations in which the individual does not have complete control, working with God is the most empowering choice. Theoretically, the use of both primary and secondary processes is more adaptive, because seeking a divine partnership to help cope with an uncontrollable event can reduce hopelessness and despair (Rothbaum et al., 1982).

Extant research supports that religious coping centered on working with God is associated with lower levels of psychological distress, whereas religious coping centered on working through God is associated with higher levels of psychological distress. Collaborative religious coping in particular has been consistently associated with lower levels of psychological distress in various populations (Cardella & Friedlander, 2004; Gall, Guirguis-Younger, Charbonneau, & Florack, 2009; Koenig, Pargament, & Nielsen, 1998; Molock, Puri, Matlin, & Barksdale, 2006), as has active religious surrender (Gall, 2006; Gall et al., 2009). In contrast, pleading for direct intercession was associated with greater psychological distress in some studies (Cardella & Friedlander, 2004; Gall et al., 2009), but with both positive and negative emotions in another (Belavich & Pargament, 1995). Because primary control processes are absent, passive religious deferral has been associated with greater depressive symptoms (Koenig et al., 1998). Finally, self-directed religious coping might appear to promote functioning because of its emphasis on personal control (Lefcourt, 1976), but has been associated with greater depression in various populations (Gall, 2006; Koenig et al., 1998; Molock et al., 2006).

Caregivers may also experience secondary control via religious service attendance, prayer, meditation, religious reading, and social support from church members. According to a national poll, religion/spirituality is one of the most important coping resources for caregivers, with 73% endorsing that they pray to cope with the demands of caregiving (National Alliance for Caregiving, 2004). Religious involvement and church attendance have been associated with lower perceived burden and depression in dementia caregivers (Choi et al., 2008; Hebert, Dang, & Schulz, 2007; Heo & Koeske, 2013; Herrera, Lee, Nanyonjo, Laufman, & Torres-Vigil, 2009; Leblanc, Driscoll, & Pearlin, 2004; Sun, Kosberg, Leeper, Kaufman, & Burgio, 2010). Religious attendance affords caregivers opportunities for social support from other believers (Heo & Koeske, 2013). Organizational religiosity (i.e., public practice of religious rituals) was associated with lower perceived burden, whereas non-organizational religiosity (i.e., private practice of religious rituals) was associated with poorer mental health (Herrera et al., 2009). In another study, private prayer and caregiving burden significantly influenced the variation in perceived resiliency scores (Wilks & Vonk, 2008).

The frequency of religious coping may be partially a function of gender, age, ethnicity, and severity of caregiver or recipient illness (Pearce, 2005). Research has shown that the elderly, poor, less educated, African Americans, and women tend to be more religious than males, younger adults, and European Americans (Levin, Taylor, & Chatters, 1994; Pargament, 1997). Pargament (1997) posits that in general, these groups have less access to secular resources and power in our culture. For such caregivers, religion represents an alternative resource that is more easily accessible for the purpose of raising their stress tolerance (Heo & Koeske, 2012).

Research on caregivers of dementia patients supports the extant literature demonstrating differences based on ethnicity, age, and gender. Greater reliance on spirituality was endorsed by African American and Latino caregivers in multiple studies (Napoles, Chadiha, Eversley, & Moreno-John, 2010). Participation in spiritual activities was associated with lower levels of depression among Latino caregivers, but not among Anglo caregivers (Thompson, Solano, Coon, Mausbach, & Gallagher-Thompson, 2002). Spiritual/religious coping moderated the effects of an intervention designed to reduce depression among African American caregivers but not Anglo or Latino caregivers (Lee, Czaja, & Schulz, 2010). Church attendance moderated the relationship between subjective stress and depression, in concert with a direct effect on depression in Latino caregivers (Sun & Hodge, 2012). Female caregivers of loved ones with dementia scored higher on measures of religiousness than male caregivers (Sun, Roff, Klemmack, & Burgio, 2008).

Studies examining stress and coping theory (Pearlin et al., 1990) as a model for the effects of spirituality/religion on caregiver outcomes have found mixed results. Morano and King (2005) tested a multidimensional measure of spirituality/religion as a mediator in the relationship between caregiver stress and depression, but found no confirming evidence. However, they did find evidence of a direct effect on depression. In another study, prayer, religious attendance, and self-ascribed importance of religion were tested in mediation and moderation models but not confirmed (Leblanc et al., 2004). The authors did find that higher self-ascribed importance of religion was associated with higher levels of depression. Using Lazarus and Folkman’s model (1984), researchers found that caregiver burden appraisal mediated the effect of religious coping on depression with higher religious coping resulting in lowering caregiver burden and in turn, depression among African American, Latino, and White caregivers (Heo & Koeske, 2012). The ambiguous results may reflect the multiple dimensions of religion/spirituality and range of well-being outcomes examined, as well as the use of unrefined measures of religion/spirituality (e.g., use of a single item) and atheoretical approaches to studying these variables (Hebert, Weinstein, Martire, & Schulz, 2006).

The purpose of this study was to investigate how religious coping strategies that varied in primary and secondary psychological control processes, religious practice, and spirituality related to depression in family dementia caregivers. Our analysis was guided by the stress and coping model. We examined whether religious coping strategy and/or religious practice moderated the relationship between objective and subjective stressors and caregiver depression. We hypothesized that religious coping strategies centered on working with God (i.e., collaborative religious coping and active religious surrender), engagement in greater religious practice, and higher level of spirituality would buffer the effects of caregiver stressors on depression. We also explored the influence of age and gender on these relationships.

Method

Participants

Participants were 191 caregivers of family members with dementia who were participating in a randomized, controlled trial of a telephone intervention to assist them in managing caregiver burden and psychological distress. Data from the previously conducted pilot trial found that the telephone delivered psychosocial intervention reduced burden in dementia caregivers (Tremont, Davis, Bishop, & Fortinsky, 2008). Caregivers were recruited from the community and memory disorder clinics. A diagnosis of dementia was made by a neurologist, geriatrician, or psychiatrist. In cases in which the diagnosis was made by a general practitioner, the study neurologist confirmed the diagnosis.

All caregivers provided a minimum of 4 hours of care daily to the care recipient for at least 6 months. Caregivers were required to endorse experiencing at least two of the following at any level in a screening interview: (a) feeling overwhelmed and stressed, (b) sad mood/depression, (c) anger or frustration, (d) loss of contact with family and friends, (e) conflict in family or family stress, (f) neglecting their own health, (g) demands or pressures of caregiving are too much, (h) exhaustion and fatigue, and (i) not taking care of their own needs or other significant responsibilities. Caregivers were excluded based on the following criteria: (a) major acute medical illness, (b) English was not their primary language, (c) cognitive impairment as defined by Mini Mental State Examination score falling 1.5 or greater standard deviations below age- and education-corrected normative data, (d) no access to a telephone, (e) did not believe in God or a higher power. Based on the original sample of 210, 19 individuals were excluded because they reported having no religious or spiritual beliefs. Care recipient inclusion criteria included (a) formal Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnosis of dementia by a neurologist, psychiatrist, or geriatrician; (b) family member or other adult in caregiver role for at least 6 months, and who provided at least 4 hours of supervision or direct assistance per day for the person with dementia; (c) care recipient lived in the community, including senior/retirement centers, but excluding nursing homes and assisted living centers; and (d) there was no plan for the care recipient to be placed in long-term care or the caregiver to end their role within 6 months of study enrollment. Care recipients with other major medical conditions affecting independent functioning were excluded.

Demographic characteristics of the sample are presented in Table 1. The majority of caregivers were female (n = 153) and Caucasian (n = 176). Their relationship to the care recipients was spouses (n = 91) and adult children (n = 86). The mean age was 62.4 years (SD = 12.38 years) and average education was 14.9 years (SD = 2.6). Caregivers had been providing care for an average of 43.86 months (SD = 33.05). The religious affiliation of most caregivers was Roman Catholic (53%) followed by Protestant (19%). Eight participants endorsed a belief in God, while not endorsing an affiliation to a specific organized religion.

Table 1.

Demographic and Caregiver Characteristics of Sample.

	n	%
Gender
Female	153	80.1
Male	38	19.9
Ethnicity
Caucasian	176	92.1
African American/Black	5	2.6
Hispanic/Latino	7	3.7
Native American/Alaska native	2	1.0
Other	1	0.5
Religious affiliation/spiritual belief system
Roman catholic	101	52.9
Protestant	37	19.4
Jewish	9	4.7
Greek orthodox	3	1.6
New age	2	1.0
Twelve step	2	1.0
Muslim	1	0.5
Christian scientist	1	0.5
Buddhist	2	1.0
Other	25	13.1
No specific religious affiliation	8	4.2
Relationship to care recipient
Spouse	91	47.6
Child	86	45.0
Sibling	9	4.7
Other relative/friend	5	2.6
Living with care recipient
Yes	150	78.5
No	41	21.5
Type of dementia in care recipient
Alzheimer’s disease	149	78.0
Other	42	22.0
Care recipient clinical dementia rating
Mild	118	62.0
Moderate	61	31.9
Severe	11	5.8
Unknown	1	0.5
Importance of religious faith and spirituality
Not important	8	4.2
Slightly important	22	11.5
Somewhat important	45	23.6
Very important	114	59.7
Unknown	2	1.0
Pray privately
Never	31	16.2
Less than once a month	12	6.3
Once a month	3	1.6
A few times a month	7	3.7
Once a week	4	2.1
A few times a week	27	14.1
Once a day	39	20.4
More than once a day	68	35.6

The Clinical Dementia Rating scale (CDR; Hughes, Berg, Danziger, Coben, & Martin, 1982) was administered at the baseline visit by a neuropsychologist and was used to measure dementia severity of the care recipient. Severity ratings were mostly in the mild range (n = 118). In addition, clinical diagnoses by the treating physician were used to identify dementia subtypes. Based on these clinical classifications, 78% of the sample comprised of care recipients with probable Alzheimer’s disease (n = 149).

Procedure

As part of a baseline assessment for a large-scale psychosocial intervention study, caregivers reported on their religious or spiritual beliefs and practices as well as on how often they used specific religious coping strategies to deal with their caregiving challenges. Participants also completed a battery of self-report questionnaires pertaining to their mood, perceived burden, overall health rating, and their reactions to the care recipient’s memory and behaviors. Informed consent was obtained from all participants prior to participating in the study. The study itself was approved by the institutional review board of Rhode Island Hospital.

Independent variables

Participants first endorsed a specific religious or spiritual affiliation, if any. Those reporting religious beliefs were asked to respond to 10 items created by the investigators measuring one’s frequency of participating in various aspects religious practices, for example, religious or spiritual services, private prayer, reading from a holy book, and meditation. For example, “How frequently do you pray about your caregiving challenges and demands?” and “If you pray about your caregiving challenges, what is the content of your prayers?” All items were rated on a 9-point Likert-type scale (i.e., more than once a day, once a day, a few times a week, once a week, a few times a month, once a month, less than once a month, never, or not applicable).

The Religious Coping Methods to Gain Control Scale (RCOPE) is one of five psychometric scales in the RCOPE test battery (Pargament et al., 2000) and measures the degree to which respondents use any of five distinct religious coping methods to gain control of outcomes. Each coping method has its own subscale made up of five items measured on a 4-point Likert scale ranging from 0 (not at all) to 3 (a great deal). Religious coping method scores can range from 0 to 15; higher scores reflect greater use of each coping method. Items include, for example, “Worked together with God to relieve my worries” (collaborative) and “Prayed for a miracle” (pleading). The internal consistency reliabilities (Cronbach’s coefficient α) for these subscales of the RCOPE ranged from .64 to .91 in our sample (collaborative religious coping = .90, active religious surrender = .91, pleading for direct intercession = .80, passive religious deferral = .64, and self-directed religious coping = .86). Factor analysis of the data as well as theoretical considerations led us to combine the first two of these coping methods into a single scale measuring coping strategies centered on working with God (α = .93) and the next two coping strategies into a single scale measuring coping strategies centered on working through God (α = .83). Self-directed coping was left as a separate coping method, resulting in three-factor solution.

Dependent variable

Center for Epidemiologic Studies–Depression Scale (CES-D)

CES-D (Radloff, 1977) is a 20-item self-report questionnaire designed to measure common symptoms of depression that have occurred over the past week (Radloff, 1977). All questions are answered on 0 to 3 Likert-type scale, with 0 indicating no symptom presence and 3 representing frequent symptom presence. Higher scores indicate higher severity, with scores of 16 or higher reflecting clinical levels of depression. The CES-D had high reliability in our study (α = .88).

Control variables

Zarit Burden Interview (ZBI)

The ZBI (Zarit, Reever, & Bach-Peterson, 1980) is a 22-item, self- report measure of perceived burden. The instrument measures caregivers’ psychological health, emotional well-being, social and family life, finances, and degree of control over one’s life. Each question is scored on a 0 to 4 Likert-type scale. Total scores range from 0 (low burden) to 88 (high burden). Internal reliability was high (α = .90).

EuroQoL 5 dimension visual analog scale (EQ5D VAS)

The EuroQoL questionnaire measures five distinct aspects of health-related quality of life (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) as well as an overall health rating across these domains based on a visual analog scale (“How would you rate your health on 0-100?”). We used this latter measure (EQ5D VAS; The EuroQoL Group, 1990) to assess caregiver health status.

Revised Memory and Behavior Problem Checklist (RMBPC)

The questionnaire is a 24-item checklist that requires caregivers to rate both the frequency of disruptive behaviors, memory difficulties, and depression in care recipients during the previous week (RMBPC-F; Teri et al., 1992), and their own reaction to each of these issues (RMBPC-R). Individual items are rated on a 5-point Likert-type scale. RMBPC-F item scores indicate frequency of patient behavior problems, ranging from 0 (never occurred) to 4 (occurs daily or more often), while RMBPC-R item scores measure severity of caregiver reaction to these problems, ranging from 0 (not at all bothered/upset) to 4 (extremely). Higher scores on RMBPC-R reflect higher levels of perceived caregiver burden. Internal consistency for frequency and reaction reached .84 and .86 for Memory-Related Problems, .75 and .77 for Disruptive Behaviors, and .85 and .87 for Depression, respectively. For both patient frequency and caregiver reaction, factor analysis confirmed three first-order factors, consistent with the subscales just named. Overall scale reliability across these three domains was adequate (α = .86 for RMBPC-F and α = .88 for RMBPC-R).

Statistical Analysis

Descriptive statistics were calculated for demographic variables and caregiving characteristics in the sample including religious affiliation. Pearson product-moment correlations were calculated between religious coping strategies scores, religious practice, importance of spirituality, demographic and dementia severity characteristics, and depressive symptoms, caregiver burden, frequency of care recipient memory and behavior problems, and overall health rating. A series of regression analyses were used to determine whether religious coping and religious practice variables moderated the relationship between caregiving stressors and depression or had main effects on depression. After standardizing the predictors by the sample mean and standard deviation, interaction terms were created between religious coping methods and caregiver stressors, as well as between religious practice/spirituality variables and stressors. Finally, we examined whether gender and age had any effect on these relationships by including them in the regression models as both main effects and interactions.

Results

Mean values and standard deviations for dependent and control are presented in Table 2. Table 3 presents correlations among religious coping methods, importance of spirituality, praying frequency, demographic and caregiving characteristics, dementia severity indicators, and measures of caregivers’ depressive symptomatology. Higher levels of religious coping strategies that centered on working with God (i.e., collaborative & active surrender) showed moderate-to-strong associations with other types of religious coping, praying frequency, and importance of spirituality (ρ = .32 – .57). There were no significant relationships between these religious coping strategies and any other caregiver or care recipient variable. In contrast, higher levels of religious coping centered on working through God (i.e., passive deferral, pleading for direct intercession) showed small-to-moderate associations with higher levels of depressive symptoms, caregiver burden, frequency of behavior problems in the care recipient, and caregiver reaction to behavior problems (ρ = .20 – .26), and lower caregiver quality of life (ρ = – .17). Greater frequency of praying and importance of spirituality was weakly associated with lower levels of depressive symptoms. Results showed that 24.6% of caregivers prayed more than once per day, 21.5% just once per day, and 25.7% a few times per week. The most frequent content of these prayers were requests for strength to handle caregiving challenges (73.8%) and for guidance from God for managing caregiving demands (48.2%). Less frequent prayers were for God to intervene (27.2%), expressions of gratitude (30.4%), and forgiveness for caregiver (15.2%).

Table 2.

Mean and Standard Deviations of Dependent and Control Variables.

Variable	M	SD
Religious coping working with God	13.74	10.58
Religious coping working through God	4.32	7.66
Self-directed coping	1.61	1.27
CES-D^a	3.83	1.37
ZBI	38.71	14.25
EQ5D VAS	78.04	16.57
RMBPC-F^a	34.94	13.35
RMBPC-R^a	4.60	1.69
CDR SOB	7.90	3.73
Caregiver age	62.37	12.38
Length of caregiving (months)	43.86	33.05
Time since symptom onset (months)	52.33	40.28

Note: CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; EQ5D VAS = EuroQol 5 dimension visual analog scale; RMBPC-F = Revised Memory and Behavior Problem Checklist–Frequency; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction; CDR SOB = Clinical Dementia Rating Sum of Boxes.

Square-root transformation.

Table 3.

Correlations Among Dependent and Control Variables.

	2	3	4	5	6	7	8	9	10	11	12	13	14
1. Religious coping working with God	.32**	−.36**	.54**	.57**	−.05	−.01	.06	.03	−.12	.07	.10	.06	.03
2. Religious coping working through God		.05	.15*	.18*	−.07	.12	.05	−.06	.26**	.26**	.20**	.24**	−.17*
3. Self-directed coping			−.33**	−.39**	−.20**	.08	−.03	−.02	.17*	.18*	.04	.06	−.13
4. Praying frequency				.54**	−.03	.04	.09	.10	−.15*	.03	.09	.01	.01
5. Spirituality					.04	.08	.07	−.02	−.16*	−.02	.01	−.01	.14
6. CG age						.13	.07	.01	−.10	−.22**	−.14	−.16*	.02
7. Length of CG							.65**	.20**	.08	.13	−.02	−.01	−.08
8. Time since Sx onset								.36**	.09	.13	.08	.07	−.07
9. CDR SOB									.07	.11	.01	−.04	.12
10. CES-D										.54**	.28**	.41**	−.47**
11. ZBI											.42**	.52**	−.33**
12. RMBPC-F												.72**	−.27
13. RMBPC-R													−.26**
14. EQ5D VAS

Note: CG = Caregiver; Sx = dementia symptoms; CDR SOB = Clinical Dementia Rating sum of boxes; CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; RMBPC-F = Revised Memory and Behavior Problem Checklist–Frequency; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction; EQ5D VAS = EuroQol 5 dimension visual analog scale.

p < .05. **p < .01.

Tables 4 to 6 present results of regression analyses. We initially included objective (dementia severity, frequency of behavior problems) and subjective stressors (perceived burden, perceived health, reaction to behavior problems) in the model to test whether religious coping moderates the relationship between stressors and caregiver depression. However, dementia severity (CDR sum of boxes; CDR SOB) was not a significant predictor of depression, and frequency of behavior problems (RMBPC-F) demonstrated multi-collinearity with reaction to behavior problems (RMBPC-R). In addition, results of the moderation analysis showed no significant interactions between stressors and religious coping or religious practice.

Table 4.

Religious Coping Strategies and Subjective Stressors Predicting Caregiver Depression on the CES-D (N = 191).

Variable	B	SE B	t value	p
Intercept	0.02	0.06	0.42	.680
ZBI	0.35	0.07	4.84	.000
EQ5D VAS	−0.28	0.06	−4.39	.000
RMBPC-R^a	0.15	0.07	2.24	.026
Religious coping working with God	−0.21	0.07	−3.06	.002
Religious coping working through God	0.17	0.07	2.52	.013
Self-directed coping^a	−0.04	0.07	−0.65	.519

Note: CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; EQ5D VAS = EuroQol 5 dimension visual analog scale; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction.

Square-root transformation because of skewed distribution.

Table 5.

Prayer and Subjective Stressors Predicting Caregiver Depression on the CES-D (N = 191).

Variable	B	SE B	t value	p
Intercept	0.01	0.06	0.20	.843
ZBI	0.37	0.07	5.25	.000
EQ5D VAS	−0.29	0.06	−4.84	.000
RMBPC-R^a	0.16	0.07	2.35	.020
Frequency of prayer	−0.15	0.06	−2.63	.009

Note: CES-D = Centers for Epidemiological Studies–Depression Scale; ZBI = Zarit Burden Interview; EQ5D VAS = EuroQol 5 dimension visual analog scale; RMBPC-R = Revised Memory and Behavior Problem Checklist–Reaction.

Square root transformation because of skewed distribution.

Table 6.

Gender-Specific Predictors of Caregiver Depression on the CES-D (Females = 153, Males = 38).

	Females				Males
Variable	B	SE B	t value	p	B	SE B	t value	p
Intercept	0.05	0.06	0.67	.503	−0.15	0.16	−0.93	.361
ZBI	0.33	0.08	4.28	<.001	0.32	0.19	1.65	.111
EQ5D VAS	−0.26	0.07	−3.96	<.001	−0.36	0.17	−2.04	.051
RMBPC-R^a	0.16	0.08	2.06	.041	0.10	0.17	0.59	.561
Religious coping working with God	−0.25	0.07	−3.43	.001	−0.03	0.17	−0.15	.884
Religious coping work through God	0.22	0.07	3.00	.003	0.01	0.20	0.06	.953
Self-directed coping^a	−0.13	0.07	−1.79	.076	0.32	0.16	1.95	.061

Square root transformation because of skewed distribution.

For religious coping strategies, we are left with the model presented in Table 4 (R² = .44), demonstrating that religious coping centered on working with God and religious coping centered on working through God made unique contributions to the prediction of caregiver depression. That is, lower levels of religious coping centered on God and higher levels of religious coping through God were associated with increased depressive symptoms. Self-directed religious coping did not contribute to the model. The model also shows that higher caregiver burden, lower overall health rating, and worse reaction to memory and behavior problems are associated with increases in depressive symptoms. Similarly, Table 5 shows that frequency of prayer also made a unique contribution to the prediction of caregiver depression (R² = .41), along with the subjective stressors. However, once religious coping centered on God and religious coping through God were added to this model, frequency of prayer was no longer significant, leading us back to the model shown in Table 4 as our best model across the entire set of predictors.

We also examined potential moderation by caregiver age and gender. Age was not a significant contributor to the model shown in Table 4, either as a main effect or in interaction with other model covariates. Table 6 presents the gender-specific models. Although the strength of these predictors differed by gender, only the interaction of self-directed coping with gender attained statistical significance (p < .009). The interaction suggests that higher levels of self-directed coping predicted worse depressive symptoms in men, but not for women.

Discussion

Previous research using Pearlin and colleagues’ (1990) stress and coping model to examine the effects of spirituality and religion on caregiver stress and depression have not been successful in demonstrating either direct or indirect effects (Hebert et al., 2006; Leblanc et al., 2004; Lee et al., 2010; Morano & King, 2005). The results of this study also do not support the presence of moderating effect of religious coping in caregiver stress, although religious coping centered on working with God can independently lead to lower depression. This may be explained by the multidimensional nature of religious coping. Findings may vary depending on how researchers choose to operationalize religious coping and spirituality (Sun & Hodge, 2012) as well as the complexities and variations in caregiving. It cannot be assumed that individuals are dealing with the same stressors as part of their caregiving role (Hebert et al., 2006). In addition, poor physical health of caregivers may inhibit their ability to participate in religious services and thus limit their exposure to the protective effects of religious practices (Sun & Hodge, 2012).

The results underscore the relationship between the use of religious coping methods and depression in caregivers of dementia patients. Although a causal relationship cannot be inferred, the findings are important, because they suggest that individual differences in religious coping may play a role in how much depression caregivers experience in the face of this significant stressor.

Current results extend the literature on religious coping to a population that is dealing with a serious and worsening stressor. Theoretically, because individuals, personal resources, and possibilities in any situation are finite, sole reliance on primary or personal control processes may lead to frustration and a sense of failure (Cole & Pargament, 1999). When dealing with the uncertainty concomitant with a care recipient’s declining health and functioning, attempts to exert both primary and secondary control in a coordinated and balanced way via religious coping may be more helpful than attempts that favor either primary control or secondary control. This proposition was supported by the finding that those who employed religious coping centered on working with God (i.e., collaborative religious coping and active religious surrender) reported fewer depressive symptoms. Through the perceived partnership with God in problem solving, this method may offer caregivers a sense of ultimate reassurance and support (Pargament et al., 1999). Consistent with previous research (Cardella & Friedlander, 2004; Gall, 2006; Gall et al., 2009; Koenig et al., 1998; Molock et al., 2006), collaborative coping and active religious surrender were uniquely associated with fewer depressive symptoms in various populations.

Higher levels of religious coping on working through God (i.e., pleading for direct intercession and passive religious deferral) were associated with higher levels of depression. Passive religious deferral was related to higher levels of depression in other samples (Friedel & Pargament, 1995; Pargament, Smith, & Brant, 1995; Rutledge & Spilka, 1993) as was pleading for direct intercession (Cardella & Friedlander, 2004; Gall et al., 2009). The use of these religious coping methods may reflect the perception that the stressor overwhelmingly exceeds the person’s personal resources. For instance, pleading for direct intercession may be the coping method of last resort when psychological distress is heightened, such as when care recipients fall and injure themselves.

Higher levels of self-directed religious coping were modestly related to higher levels of depression, which is consistent with previous research (Friedel & Pargament, 1995; Pargament et al., 1995; Rutledge & Spilka, 1993). Whereas expectations are that people whose religion influences their thoughts and feelings would include God in one way or another in coping, those using the self-directed approach have excluded God from the process instead relying on personal responsibility for problem solving (Ross, Handal, Clark, & Vander Wal, 2009). Because self-directed religious coping was negatively correlated with religious coping centered on working with God and uncorrelated with religious coping centered on working through God, our findings suggest that self-directed religious coping may not be a true measure of religious coping. We further surmise that those who endorse high importance of religion that uses the self-directed approach may be experiencing cognitive dissonance or internal conflict, which in turn contributes to their high levels of depression. The conflicting findings warrant further investigation related to the true nature of this religious coping method.

In addition, we tested Pargament’s original theory of religious coping methods (Pargament et al., 1988; Pargament et al., 2000) and found that higher self-directed coping predicts worse depressive symptoms in men, but not for women. In general, men may have more access to secular resources and power in our culture than women (Pargament, 1997). Therefore, men may use religious resources less frequently in coping with life challenges in general. This pattern is likely established prior to the experience of caregiving. Self-directed coping appears to be a generally competent way of life and is associated with a greater sense of personal control in living and higher self-esteem, but is associated with poorer outcomes among some groups in certain situations (Pargament, 2007). The authors posit that these situations may occur when the individual has very little control, such as in the case of the declining capacity of a loved one with dementia. In addition, there are gender differences in the way dementia is conceptualized, the perceived benefits of caregiving, and the manner in which care is provided, which in turn may shape the unique coping styles used by women or men (Corcoran, 1992; Miller, 1987; Neufeld & Harrison, 1998). Women use a wider variety of strategies and appear to use coping patterns that encompass social-support-seeking and perspective-taking (DeVries, Hamilton, Lovett, & Gallagher-Thompson, 1997). It may be that women have a larger repertoire of religious coping strategies in their coping system and are more able than men to call upon other methods of religious coping when dealing with major stressors. In addition, it is important to be mindful of the conceptualization of religious coping methods as continuous variables with use of each coping method varying in degree across situations or time rather than as categorical variables. Thus, men who rely more on self-directed coping and may not have other religious coping methods in their repertoire could become more vulnerable to depressive symptomatology in caregiving a loved one with dementia.

Endorsement of greater prayer frequency was modestly associated with lower levels of depressive symptoms. Our results indicate that when religious coping working with God and through God are added into the model, frequency of prayer is no longer significant, bringing us back to the aforementioned model. Nonetheless, prayer may be both a successful active coping method and a protective factor allowing caregivers to feel confident in using their skills and resources. Chang (1998) reports that caregivers who use religious or spiritual beliefs to cope have a better relationship with their care recipients, a factor associated with lower levels of depression.

The design of the current study, with a single measure of coping and single measures of depressive symptoms and caregiver burden perceptions at one point in time, does not fully capture the continuous interplay of religious coping methods with psychological adjustment. A dynamic understanding of this construct may be necessary when studying responses to a progressive illness. Indeed, in their seminal work, Lazarus and Folkman (1984) argued that coping responses change continually with a person’s ongoing appraisal and reappraisal of a stressful situation. The study of potential mechanisms involved in the religiosity/spirituality–well-being relationship (e.g., the quality of the caregiver-care recipient relationship, positive reappraisal, filial responsibility, cognitive restructuring, social support) could refine conceptual models (Hebert et al., 2006).

Our findings may not generalize to caregivers dealing with other stressors, such as other types of chronic medical conditions or financial crisis. Because the sample was not selected at random, the caregivers who chose not to participate in the study may differ in important ways from those who did volunteer. For example, caregivers who were extremely distressed and preoccupied with their loved one’s dementia may have opted not to take part. In addition, the limited distribution of religions precludes us from providing a general outcome of coping and religiosity. With further respect to external validity, more women than men participated in the study, which is consistent with epidemiological studies showing a preponderance of female caregivers (National Alliance for Caregiving, 2004). In addition, within the population of individuals with dementia, there may be significant variation because of the severity of the illness and the existence of other comorbid medical and/or psychiatric conditions.

Although a cross-sectional approach reduces the complexity of assessing coping behavior, it assumes that people have fairly stable coping preferences. For this reason, a repeated measures design could provide valuable information about the covariance of coping resources and situational variables (Lazarus, 1993). Furthermore, qualitative research with family caregivers could suggest how religious coping activities change over the course of the care recipient’s dementia and how the success or failure of early coping strategies influences later coping efforts (Pargament et al., 1999).

Caregiver endorsement of the importance of religion and spirituality in coping with their caregiving demands may structure the way that these demands are anticipated, interpreted, and handled. However, it is unclear how this way of relating to their world would present itself in terms of specific religious coping behaviors. Different types of prayer (e.g., petitionary, intercessory, gratitude) also can have different effects on well-being, which may not have been entirely captured in our measure (Krause, 2003). Being more specific about the nature of prayer and the importance of religion may be necessary to avoid ambiguous results.

Finally, with respect to clinical practice, clinicians need to acknowledge that caregivers are not in total control of their own fate and recognize that religious coping may be an appropriate response to human limitations. Comments by caregivers about turning to God or a higher power for help or guidance in the midst of their most challenging moments may raise concerns about overdependence, passivity, or avoidance (Pargament & Park, 1995). The present findings suggest that some methods of religious coping may be valuable for caregivers. The higher than average levels of depression in our sample suggest that many caregivers of dementia patients may be suffering greatly even when they appear to be managing day-to-day caregiving tasks.

Effective spiritual assessment using a multimethod, multilevel process is a prerequisite to responsible treatment decisions (Pargament & Krumrei, 2009). This includes use of open-ended questions and quantitative measures. Not only asking about caregivers’ levels of depression and burden, but inquiry into the kinds and usefulness of coping methods they employ, especially if they hold religious beliefs and use religious coping, could inform treatment. Sole endorsement of religious coping strategies that are unbalanced and uncoordinated in primary and secondary processes (e.g., passive deferral) could alert mental health providers to the need to address caregivers’ religious struggles and distress (Pargament et al., 2000). Research has highlighted the potential of spiritual struggles to elicit positive transformation and growth (Pargament, Murray-Swank, Magyar, & Ano, 2005). Clinicians may encourage the use of beneficial religious coping strategies already in a caregiver’s repertoire and enhance religious coping methods not yet well developed (Kelly, 1995).

Overall, this study shows that religious coping methods working with God may assist caregivers of dementia patients in coping with the protracted depressive symptoms often experienced. Because of the gradual decline of dementia patients, the readjustment of family roles, problem solving, and emotional coping requirements are continually taxed. Family members are unlikely to experience periods of relief from the demands of caregiving a dementia patient, and therefore, believers would benefit from the use of beneficial religious coping.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant from the National Institutes of Health to Geoffrey Tremont (5R01NR010559).

Author Biographies

Lucille A. Rathier is Clinical Assistant Professor of Psychiatry at the Warren Alpert Medical School of Brown University and Interim Director of Clinical Behavioral Medicine Services at Lifespan Hospitals. Her research focuses on the use of religious coping on uncontrollable stressors.

Jennifer Duncan Davis is Associate Professor of Psychiatry at the Warren Alpert Medical School of Brown University. Her research focuses on modifiable factors that contribute to caregiver stress and psychosocial interventions to reduce stress in dementia caregivers.

George D. Papandonatos is Associate Professor at the Department of Biostatistics, Brown University. He received his doctorate in Statistics from the University of Minnesota (Twin Cities) and has expertise in randomized clinical trials ofbehavioral interventions to promote smoking cessation, weight loss, and physical activity. He has also participated in studies related to longitudinal changes in driving ability among cognitively impaired subjects.

Christine Grover was the study coordinator at Rhode Island Hospital in Providence, RI, where this study was conducted.

Geoffrey Tremont, PhD is Associate Professor of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University and Director of Neuropsychology at Rhode Island and The Miriam Hospitals. He conducts research on interventions for dementia caregivers and early detection of cognitive impairment in older adults. He served as the principal investigator on the recently completed Family Intervention: Telephone Tracking - Caregiver (FITT-C) trial.

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