Training in improvisation techniques helps reduce caregiver burden and depression: Innovative Practice

Abstract

This study measured outcomes of a novel pilot program designed to teach improvisation skills to caregivers of family members with dementia. Fifteen caregivers completed questionnaires measuring changes in their perception of burden (Zarit Burden Interview), depression (Beck Depression Inventory), their cared-for person’s neuropsychiatric symptoms (Neuropsychiatric Inventory Questionnaire), and experiences related to caregiving. Caregivers’ depressive symptoms and sense of burden significantly decreased after completing the six-week program. Caregivers reported that their loved ones’ neuropsychiatric symptoms increased during the course of the intervention, though associated distress did not also increase. The Improv for Care program shows promise as an intervention for caregivers to improve stress, mood, and coping skills.

Keywords

caregiving dementia support group innovative practice

Introduction

Millions of individuals provide informal care to a family member with dementia in the United States, and with the growing number of individuals developing dementia, this number is expected to rise dramatically (Alzheimer’s Association, 2018). Caring for a loved one with dementia is associated with psychological and physical health risks for caregivers, and older caregivers are at increased risk for experiencing caregiving stress (Rinaldi et al., 2005). Research into group interventions for caregivers has shown that these programs reduce levels of depression and feelings of burden or stress, and improve social outcomes (Chien et al., 2011). Given the scale of caregiving for family members with dementia, risks for negative health and emotional consequences, and evidence for effective interventions, more research is warranted. Here we present a pilot study measuring caregiver outcomes after participating in an intervention teaching caregivers improvisation techniques in a group setting.

Improv for Care

Improv for Care is a course for caregivers of people with dementia that involves using improvisation (“improv”) skills and techniques applied to the challenges faced by caregivers. The program was developed by Anne Libera and Kelly Leonard of the Second City Works in partnership with Caring Across Generations with input from Ruth Almén at the Cleveland Clinic Lou Ruvo Center for Brain Health where it was first implemented. The program has the advantage of teaching communication and coping skills that can be applied across many caregiving situations while still fostering a sense of community and shared experience that would come from participating in a more traditional support group. During six two-hour weekly sessions, the caregivers participated in improvisation exercises and group discussions. The course was led by two experienced improv actors with support from a social worker (RA), the curriculum author (AL), and a caregiver advocate. The improv exercises were experiential and involved learning to work together as a team, focusing on creating new experiences with your loved one, and using the core principle of “yes, and” to increase listening and promote communication and well-being. The exercises were followed by a reflection and discussion of the experience itself and the connection and applicability to the challenges of caregiving. At the end of each session, there was a broader debriefing discussion and reflection on the participants’ caregiving experiences as well as suggestions for practicing the skills learned throughout the week. A sample of the curriculum from the first three weeks of the six-week program is provided in Table 1.

Table 1.

Sample improv curriculum.

Week	Theme	Example exercise	Debrief and apply to caregiving
1	Play and Ensemble	Red Ball: Participants stand in a circle and the facilitator introduces an imaginary red ball. Participants say “this is a red ball” and throw the imaginary ball to someone who catches it and says “thank you, red ball” Multiple different color imaginary balls are added as well as surprising items (e.g. an imaginary bag of cats)	Coping with communicating in complex situations Recognize how you feel when more and more inputs are introduced
2	Ensemble as practice	One word story: Participants gather in a circle. Sequentially, each person contributes one word at a time to make a story	It is harder to contribute and support others when you think you know what “should” happen next Small contributions (adding “and” or “the”) are important but may go unrecognized
3	Sharing and listening skills (yes, and …)	Yes, and trios: Three participants decide to plan a party Round 1: One person offers suggestions, the other two respond with many versions of “no” they can think of Round 2: One person offers suggestions, the other two respond with “yes, but …” Round 3: One person offers suggestions, the other two respond with “yes, and …”	Realize that we say no easily and often Saying yes is affirming and moves things forward, collaboratively How does “yes, but” feel compared to “yes, and”?

Week

Theme

Example exercise

Debrief and apply to caregiving

Play and Ensemble

Red Ball: Participants stand in a circle and the facilitator introduces an imaginary red ball. Participants say “this is a red ball” and throw the imaginary ball to someone who catches it and says “thank you, red ball”

Multiple different color imaginary balls are added as well as surprising items (e.g. an imaginary bag of cats)

Coping with communicating in complex situations

Recognize how you feel when more and more inputs are introduced

Ensemble as practice

One word story: Participants gather in a circle. Sequentially, each person contributes one word at a time to make a story

It is harder to contribute and support others when you think you know what “should” happen next

Small contributions (adding “and” or “the”) are important but may go unrecognized

Sharing and listening skills (yes, and …)

Yes, and trios: Three participants decide to plan a party

Round 1: One person offers suggestions, the other two respond with many versions of “no” they can think of

Round 2: One person offers suggestions, the other two respond with “yes, but …”

Round 3: One person offers suggestions, the other two respond with “yes, and …”

Realize that we say no easily and often

Saying yes is affirming and moves things forward, collaboratively

How does “yes, but” feel compared to “yes, and”?

Note: Adapted from Improv for Care curriculum developed by Anne Libera and Kelly Leonard of Second City Works.

Improv has previously been used to treat depression and anxiety (Krueger, Murphy, & Bink, 2017). Therapeutic improv groups have been shown to be feasible and enjoyable for participants with mood disorders and promote well-being through a positive, supportive environment (Krueger et al., 2017). In the present study, we aimed to determine if the caregivers in this group would exhibit reductions in depression, sense of burden, and perception of the severity of their family member’s neuropsychiatric symptoms after completing the six-week course.

Design and methods

Participants

Study participants were selected from the group of caregivers who participated in the pilot Improv for Care program. A total of 29 caregivers in two separate cohorts (one with 18 caregivers, the other with 11) enrolled in the program and were thus invited to participate in the present study. If a caregiver expressed interest, a member of the research team (HB, SB, or RA) obtained written informed consent at the first group session. Of the 29 caregivers, 22 completed baseline self-report questionnaires (though one individual was excluded because they were not directly caring for a family member) and of those, 15 completed follow-up questionnaires after the six-week course completion. The 15 participants with both baseline and follow-up data were included in the subsequent analyses.

Measures

Questionnaires assessing outcome measures were gathered before the start of the Improv for Care group and again after course completion. Depression symptoms were measured using the Beck Depression Inventory, second edition (BDI-II; Beck, Steer, & Brown, 1996). Scores range from 0 to 63, with higher scores reflecting greater severity of depressive symptoms. The Zarit Burden Interview (ZBI; Zarit, Reever, & Bach-Peterson, 1980) was used to measure caregivers’ feelings of burden and stress. The ZBI is a 22-item self-report measure capturing caregivers’ perception of the extent that caregiving has negatively impacted their emotional, physical, and social well-being (Zarit et al., 1980). Caregiver perception of their family member’s neuropsychiatric symptoms and associated caregiver distress was measured using the Neuropsychiatric Inventory Questionnaire (NPI-Q; Kaufer et al., 1998). The NPI-Q is a 12-item self-report measure completed by caregivers to assess the presence of various neuropsychiatric symptoms in their family members along with their severity and associated distress. Caregiver demographic variables and ratings of characteristics and experiences related to caregiving were measured with an informal questionnaire.

Analyses

Differences between the two study time points (at baseline before starting the Improv for Care program and at follow-up immediately after completing the six-week course) were measured using Wilcoxon signed ranks tests for related samples. Specifically, the total BDI-II, total ZBI, total NPI-Q severity, and total NPI-Q distress were compared between baseline and follow-up. Some NPI-Q forms were incompletely filled out, in which case the data were excluded in the specific analyses involved.

Results

The caregivers were predominantly female, older, well educated, and most were providing full-time care to their family member (see Table 2 for detailed demographic information). At baseline, the most commonly endorsed neuropsychiatric symptoms were irritability (80.0% of caregivers endorsed the presence of irritability in their family member), apathy (73.3%), appetite changes (60.0%), nighttime behaviors (53.3%), disinhibition (53.3%), agitation (46.7%), and depression (46.7%). When examining changes in severity of neuropsychiatric symptoms and associated distress from baseline to course completion, there was actually a significant increase in the total severity of neuropsychiatric symptoms measured by the NPI-Q (Z = –2.10, p = .036). There was not, however, a significant increase in caregiver NPI-Q total distress scores (Z = –1.12, p = .265).

Table 2.

Sample characteristics, N = 15.

Age	M = 66.87		SD = 13.56		Min = 45			Max = 82
Sex	Women (n = 12, 80%)				Men (n = 3, 20%)
Education level	High school or GED (n = 5, 33.3%)		Associate’s degree (n = 3, 20.0%)		Bachelor’s degree (n = 3, 20.0%)			Advanced degree (n = 4, 26.7%)
Race/ethnicity	Caucasian (n = 13, 86.7%)			Asian/Pacific Islander (n = 1, 6.7%)		Prefer not to state (n = 1, 6.7%)
Annual household income^a	Under 25 (n = 2, 13.3%)	25 to 50 (n = 1, 6.7%)	51 to 75 (n = 2, 13.3%)	76 to 100 (n = 2, 13.3%)	101 to 125 (n = 1, 6.7%)	Over 125 (n = 1, 6.7%)		Prefer not to state (n = 6, 40.0%)
Hours caregiving per week	M = 104.27		SD = 61.67		Min = 5		Max = 150^b
Years caregiving	M = 13.25		SD = 17.14		Min = 1		Max = 61

^aIn thousands of dollars.

^bCaregivers who indicated they were caregiving full time were coded as 150 hours per week.

The caregivers’ mean baseline depression severity was minimal (BDI-II total score M = 12.8, SD = 6.99) and baseline level of caregiving stress was mild to moderate (ZBI total score M = 40.0, SD = 10.41). There were significant declines in depression symptoms (Z = –2.64, p = .008) and caregiving stress (Z = –2.16, p = .031) after completing the Improv for Care course. See Table 3 for descriptions of the changes before and after completing the improv program.

Table 3.

Means and (standard deviations) of pre- and post-treatment outcomes.

	Before Improv for Care (N = 15)	After Improv for Care (N = 15)	p-Value	Effect size (Cohen’s d)
BDI-II^a	12.80 (6.99)	8.93 (6.08)	.008	0.59
ZBI^b	40.00 (10.41)	34.20 (12.97)	.031	0.49
NPI-Q total severity^c	7.47 (7.63)	9.80 (7.59)	.036	0.31
NPI-Q total distress^d	8.33 (9.90)	9.14 (7.44)	.265

^aBeck Depression Inventory, second edition total score.

^bZarit Burden Interview total score.

^cNeuropsychiatric Inventory Questionnaire sum total of severity ratings.

^dNeuropsychiatric Inventory Questionnaire sum total of distress ratings.

Qualitative examples of the caregivers’ experience of the course and impact on their caregiving role reflected gaining skills related to empathy, communication, and flexibility. For example, one caregiver wrote that the course has taught them the importance of “listening –not trying to solve –simply giving space” and “empathy –feeling what he’s feeling without judgment.” Other caregivers reflected on elements that might be associated with a traditional support group, such as learning from each other’s experience. One caregiver wrote that they had a “better understanding of other caregivers’ daily battles” and that “there are better ways of acting and handling different situations” by practicing “interacting verbally and physically exercising with other caregivers.” A further example of the social bonds created in the Improv for Care course is that many of the caregivers chose to have lunch together after the session and have begun to meet informally after completing the program. Another caregiver reflected on the applicability of the improvisation skills learned stating that “using improv skills, like building off what my family member gives me, is so helpful!” and added that “using ‘yes, and’ [helps] keep the story moving to end up where we need to be.”

Discussion

This pilot study aimed to examine the outcomes associated with a novel course designed to teach improvisation-based communication and coping skills to family caregivers for individuals with neurological illnesses. The main finding from this pilot study is that caregivers’ depressive symptoms and their perception of stress significantly decreased after completing the Improv for Care program. While the participants did not, on average, report high levels of depression or feelings of stress or burden related to caregiving at baseline, a reduction in these symptoms is important as caregivers are at higher risk of depression (Alzheimer’s Association, 2018) and feelings of burden lead to negative consequences for caregivers including stress, poorer overall health, and risk for cognitive impairment (Chiao, Wu, Hsiao, & Hsiao, 2015). While preliminary, these findings may indicate potential for improving mood and well-being for caregivers.

Caregivers indicated that their loved one’s neuropsychiatric symptoms actually increased in severity following the six-week intervention, which may be attributed to the natural course of neurodegenerative disease with increasing severity of these symptoms over time (Brodaty, Connors, Xu, Woodward, & Ames, 2015). We might also speculate that participating in a class or support group may increase awareness of their difficulties in coping with these symptoms resulting in a perhaps temporary increase in caregivers’ perception of their severity. However, while severity of neuropsychiatric symptoms increased following the six-week intervention, the distress associated with these symptoms did not significantly increase. Caregiver experience of neuropsychiatric symptom severity and distress are highly correlated (Kaufer et al., 1998) and thus with an increase in severity we may have expected an increase in distress. The fact that distress associated with these neuropsychiatric symptoms did not increase in step with severity could indicate that the Improv for Care intervention attenuated this relationship by providing coping skills and social support to mitigate distress.

Prior research into therapeutic improv interventions for patients with neurological or psychiatric disorders has implied several possible mechanisms for the benefits of group improv practice. The positive social interactions are an important component in behavioral activation, which may explain the beneficial effects of improv on mood (Krueger et al., 2017). Additionally, group interventions for caregivers that included a social component and promoted active coping showed the most positive outcomes and reductions in depression (Gilhooly et al., 2016). The informal comments from caregivers who participated in Improv for Care underscored these themes and described the benefits of social interaction, positive feedback, and the supportive environment.

While there are several limitations to this pilot study including small sample size, relative homogeneity of caregivers, and lack of control group, the findings nonetheless show promising evidence that the Improv for Care program can reduce caregiver symptoms of depression and perception of stress or burden. These benefits have the potential to meaningfully impact caregiver well-being and overall health.

Footnotes

Acknowledgements

We would like to thank our partners at Caring Across Generations along with those at The Second City Works for their generosity and help implementing and designing the Improv for Care program.

Author's note

Sarah J Banks is now affiliated with University of California San Diego, San Diego, USA.

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 work was supported by the Director’s Innovation Fund, a philanthropic donation awarded to the Cleveland Clinic Lou Ruvo Center for Brain Health’s director emeritus, Jeffrey Cummings, MD, ScD. Banks’ salary was supported in part by a Center of Biomedical and Research Excellence (COBRE) grant (reference number: 1P20GM109025-01A1). This research was approved by the Institutional Review Board (IRB) of the Cleveland Clinic Foundation (CCF) under protocol #18–201.

Hannah E Brunet earned a PhD in clinical psychology from Palo Alto University and is currently a neuropsychology postdoctoral fellow at the Cleveland Clinic Lou Ruvo Center for Brain Health. Her current research interests include aging, dementia, and interventions for patients and caregivers.

Sarah J Banks completed a PhD in clinical neuropsychology at Northwestern University and is an associate professor at the University of California San Diego. Her research interests include examining the neural and cognitive underpinnings of neurodegenerative diseases.

Anne Libera earned a Bachelor’s Degree in theater from Northwestern University and is currently the director of Comedy Studies for the Theater Department at Columbia College. Her research focuses on the connections between improvisation and behavioral sciences.

Melanie Willingham-Jaggers earned an undergraduate degree in political science and is the Program Associate Director at the Worker Institute of the School of Industrial and Labor Relations within Cornell University. She also serves as a consultant to a caregiver advocacy group, Caring Across Generations, and has been involved in overseeing the Improv for Care curriculum.

Ruth A Almén earned a Master’s Degree in social work from Temple University and currently serves as the director of social work services at the Cleveland Clinic Lou Ruvo Center for Brain Health. She has extensive experience with nonprofit social service agencies, community collaboration, and program development. Her current research interests include evaluating the efficacy of various novel interventions for caregivers.

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