Effectiveness of Individual Counseling by Professional and Peer Helpers for Family Caregivers of the Elderly

Transcription

1 Psychology and Aging 1990, Vol. 5, No. 2, Copyright 1990 by the American Psychological Association, Inc /90/J00.75 Effectiveness of Individual Counseling by and Peer Helpers for Family Caregivers of the Elderly Ronald W. Toseland and Gregory C. Smith Ringel Institute of Gerontology, School of Social Welfare University at Albany, State University of New York This study of the effectiveness of individual counseling for daughters and daughters-in-law (N-S7) who were the primary caregivers for frail elderly parents revealed that participants who received professional counseling demonstrated significantly better outcomes than a no-treatment control group in regard to subjective well-being, level of psychiatric symptomatology, and perceived change in aspects of the caregiver-care-receiver relationship. Participants who received peer counseling demonstrated similar gains but did not improve significantly more than did control subjects in subjective well-being. Both forms of counseling had no significant effect on caregivers' formal and informal social support networks. There has been an increased awareness of the widespread nature of family caregiving and its importance for the well-being of frail older people. Numerous studies have documented how the stress of caregiving is associated with psychological, social, and physical problems among family caregivers (see, for review, Toseland & Smith, in press). Recognition of the importance of family caregiving, as well as the high level of distress that some caregivers experience, has led to the development of several types of supportive intervention programs (Gallagher, Lovett, &Zeiss, 1989). Most interventions for caregivers have involved group approaches (Gallagher et al, 1989; Toseland & Rossiter, 1989). Consequently, there is a paucity of knowledge regarding the efficacy of individual intervention. The few published studies of individual intervention for family caregivers have yielded mixed results. Whereas Pinkston, Linsk, and Young (1988) found that operant learning techniques effectively reduced targeted behavioral problems experienced by both caregivers and care receivers, Zarit, Anthony, and Boutselis (1987) found no significant differences in their comparison of an individual/ family intervention, a support group, and no treatment. The need for additional research is clearly evident in these limited findings. The purpose of our study was to determine whether individual counseling conducted by either professional or peer helpers would result in positive outcome for adult daughters and daughters-in-law who sought counseling services to help them Preparation of this article was funded through grants from both the Andrus Foundation of the American Association of Retired Persons and the Prevention Research Branch of the National Institute of Mental Health. We are grateful to Sheldon S. Tobin, director of the Ringel Institute of Gerontology, for his support and encouragement. Correspondence concerning this article should be addressed to Ronald W. Toseland, Ringel Institute of Gerontology, School of Social Welfare, University at Albany, State University of New York, Albany, New York cope with caring for frail elderly parents. We hypothesized that those who received individual counseling, whether from professional or peer helpers, would show significantly better outcomes on various measures than would those in a no-treatment control condition. A second objective was to compare the relative efficacy of individual counseling conducted by either professional or peer counselors. Although studies have generally reported that peer counselors are as effective as professionals (see, for reviews, Durlak, 1981; Hattie, Sharpley, & Rogers, 1984; Nietzel & Fisher, 1981), whether peer counselors can work efficaciously with family caregivers is not known. For example, professionals may be more effective than peers in counseling caregivers because the professionals' clinical experience and education have enabled them to counteract ageist and gerontophobic tendencies. Conversely, peers may be more effective at using their personal experiences in counseling. However, because studies have shown that professional and peer counselors are equally effective for other social problems, we hypothesized that no outcome differences would be observed between participants who received professional or peer counseling in this study. Caregivers Support Project Method In this study, the Caregivers Support Project (CSP) assessed the relative efficacy of individual counseling conducted by either professional or peer counselors with adult women experiencing high levels of stress from caring for a frail elderly parent or parent-in-law. No-treatment control data are from a previous CSP study that compared the efficacy of two types of group counseling for caregivers (for details, see Toseland, Rossiter, & Labrecque, 1989a, 1989b). Participant Recruitment Because both the caregiver's gender and relationship to the care receiver are believed to have an impact on the caregiving experience (e.g., see Fitting & Rabins, 1985; Horowitz, 1985), participation was limited in both studies to adult women who were primary caregivers to a frail

2 COUNSELING FOR CAREGIVERS 257 elderly parent or parent-in-law. Participants in both studies were recruited through an extensive media campaign, which included television and radio appeals; feature articles in newspapers; announcements in newsletters and bulletins of church and community groups; and direct contacts with social service, religious, and civic organizations within a tricounty region of upstate New York, containing urban, suburban, and rural communities. Potential clients were screened to ensure that each was the primary caregiver for an elderly family member with two or more chronic disabilities, was residing in the community, was experiencing an above-average degree of stress, and was free of major psychiatric disorders. Chronic disabilities were assessed by self-report. Participants rated their level of caregiving stress on a 5-point Likerttype scale, with a score of 3 or more used as criterion for inclusion in the study. An experienced clinical social worker made judgments about major psychiatric disorders on the basis ofosm-m criteria (American Psychiatric Association, 1987). This recruitment effort, which was identical for both studies, produced 99 adult female caregivers who wished to receive counseling services from the CSP. Counselors Four professional and four nonprofessional peer counselors were recruited and trained to provide individual counseling to CSP participants. All counselors were women. The four professional counselors (M age = 42.3 years) were similar to each other in terms of their educational background, current employment, and previous experience in working with chronically ill and elderly client populations. Each had received prior graduate-level counselor education; three possessed master of social work degrees, and one had a master of science in gerontological services. All of the professional counselors had similar personal and professional experience regarding caregiving. The four peer counselors (M age = 53 years) were recruited through personal contacts with human-service professionals serving the caregiver population. Prospective peer counselors were then interviewed and screened by project staff regarding their previous experience as caregivers of frail elderly parents, their prior participation in self-help support groups for caregivers, and whether they possessed the personality traits associated with effective counseling. Before their involvement in the. CSP, none of the peer counselors had obtained any formal training or experience in counseling, and they possessed diverse occupational backgrounds. Separate group training sessions were held for the professional and peer counselors before their counseling with CSP clients began. Both groups received a total of 6 hr of training in an action-oriented model of intervention that was developed by R. W. Toseland to incorporate the use of such techniques as problem identification, problem solving, stress reduction, time management, and behavioral and cognitive coping strategies in counseling caregivers (Toseland, 1988). The peer counselors received an additional 3 hr of instruction in basic helping skills according to the training model of Carkuffand Anthony (1979). Design Participants recruited for the individual counseling study were randomly assigned to one of the eight counselors in either the professional or peer counseling conditions and were kept uninformed throughout the study about the professional status of their counselors. Eight participants were dropped from the study because they did not attend three or more counseling sessions or complete the pretest and posttest measures, leaving a total of 51 participants in the two counseling conditions. This attrition was distributed evenly across experimental conditions so that each counselor had a caseload of 6 or 7 clients. Participants in the no-treatment control condition were obtained through the same method as those in the treatment conditions, but recruitment occurred 6 months before the study. Four participants were dropped from the no-treatment control condition because they did not complete pretest or posttest measures (n = 36). Merging the two treatment conditions with the no-treatment control condition produced a quasi-experimental nonequivalent control group design with a total sample of 87 participants. The demographic data shown in Table 1 indicate that the profiles of participants in the professional, peer, and control conditions were quite similar with respect to all of the variables examined, and no statistically significant differences were found between the three conditions on any of the variables. Counseling Procedures Participants in both the professional and peer conditions met with their counselors for a total of eight weekly 1-hr individual counseling sessions. However, for some counselor-client dyads, the pattern of having sessions in eight consecutive weeks was not possible because of scheduling conflicts. Also, 2 clients received fewer than eight sessions when the counselor and client agreed that no further counseling was necessary. These 2 clients received three and four sessions, respectively. All counseling sessions were recorded with audiocassette tape recorders, and each counselor submitted tapes weekly to a member of the CSP staff who functioned as a counseling supervisor. Supervisors were two men and one woman; each possessed doctoral-level training and experience in mental health counseling. Weekly 1-hr counseling supervision sessions were conducted with each professional and peer counselor to ensure that she accurately interpreted and implemented the procedures specified in the previously described action-oriented model of practice. Measures A 1.5-hr personal interview including the measures listed in Tables 2 through 6 was administered by a graduate student in social work to each participant at pretest and posttest. data were collected for each participant within 2 weeks before her first counseling session, and posttest data were collected within 2 weeks after her last counseling session. Effectiveness of counseling was measured by self-perceived change in four general categories: emotional response to caregiving, psychiatric symptomatology, knowledge and use of formal and informal social supports, and the caregiver-care-receiver relationship. Participants were also queried about their satisfaction with the CSP. Emotional response to caregiving. Changes in emotional response to caregiving were assessed by two standardized instruments: the Bradburn Affect Balance Scale (BABS) and the Zarit Burden Interview (ZBI). The BABS is a widely used measure of overall emotional wellbeing and has good construct validity and acceptable test-retest reliability (.76; Bradburn, 1969). The total scale consists of 10 items, 5 that tap negative affect and 5 that tap positive affect. Each item was rated on a 4-point scale ranging from not felt at all during the past couple weeks (1) to felt often during past couple weeks (4). Scores were calculated by reversing the values of negative items and then summing across all 10 items, with higher scores reflecting more positive affect. The ZBI is a 22-item measure of the perceived impact of caregiving on the caregiver's financial status, physical health, emotional health, and social activities; it is reported to have respectable test-retest reliability (.79; Zarit, Reever, & Bach-Peterson, 1980; Zarit & Zarit, 1982). The caregiver responded on a 5-point scale describing how much each statement applies to her, with responses to each item ranging from never (0) to nearly always (4). Scores were obtained by summing across all 22 items, with higher scores indicating greater levels of perceived caregiver burden. Psychiatric symptomatology. The Brief Symptom Inventory (BSI; Derogatis & Spencer, 1982), a 53-item self-report instrument, was used to measure psychiatric symptoms. For each item, respondents were

3 258 RONALD W. TOSELAND AND GREGORY C. SMITH Table 1 Demographic Variables for Caregivers and Care Receivers by Experimental Condition Variable (n = 27) Peer (n = 24) Control (n = 36) Test statistic Caregivers' age (years) Caregivers' marital status (%) Single Married Separated Divorced Widowed Caregivers' employment status (%) Employed Unemployed Retired Caregivers' ethnicity (%) White Black Length of caregiving (years) Live in same household with care receiver (%) Yes No Care receivers' gender (%) Male Female Care receivers' health 8 (M) F(2,84) =.01 X 2 (8,7V=87) = X 2 (4,JV=87) = 7.06 X 2 (2,Ar=87) = 1.39 F(2, 83) =.63 X 2 (2,AT=87) = 1.79 X 2 (2,JV=87) =.72 F(2, 84) = * Care receivers' health was rated by caregivers on a 5-point scale ranging from poor (1) to excellent (5). asked to rate how much in the past week they had been troubled by 53 symptoms of psychiatric distress on a 4-point scale that ranged from from not at all (I) to extremely (4). The BSI symptom subscales of depression, anxiety, and hostility, which have been hypothesized by Anthony-Bergstone, Zarit, and Gatz (1988) to be influenced by the situational demands of caregiving, were used in this study. Scores for these three subscales were calculated by averaging responses across items that assessed each symptom dimension. Also derived from the BSI was the Global Severity Index (GSI), an overall index of psychiatric distress, calculated by averaging all 53 responses. Acceptable test-retest reliabilities and extensive normative data are available for the entire BSI (Derogatis & Spencer, 1982). mean scores for the 87 CSP participants on the GSI were compared with those from nonpatient (N = 119) and psychiatric outpatient (N = 1,002) normative samples (Derogatis & Spencer, 1982). Multiple group-comparison t tests (Games & Howell, 1976) revealed that the sample of CSP participants had a mean GSI score (M =.75) that was significantly higher than that of nonpatients (M =. 30), /(102) = 6.14, p <.01, but also significantly lower than that of outpatients (M = 1.32), r(89) = 8.05, p <.01. These comparisons suggest that the CSP participants were at risk regarding psychological distress. Social supports. Several social support measures were developed especially for use in the CSP. Measures of informal social support required each participant to (a) list the number of people to whom she could turn for assistance, (b) rate her satisfaction with this support network on a 4-point scale that ranged from not at all satisfied (1) to very satisfied (4), and (c) state at posttest whether her ability to turn to these people for assistance had increased, decreased, or remained about the same. The Community Resource Scale (CRS) was developed for the CSP as a multidimensional measure of formal social support. One dimension assessed whether respondents knew how to access 14 community resources (yes or no), whereas a second dimension assessed whether each of the 14 resources had been used (yes or no). Scores for both of these dimensions were calculated by summing yes responses and thus could range from 0 to 14. For the third dimension, participants were asked at posttest to rate the extent to which their knowledge of community resources had changed as a result of participating in the CSP. This rating was done on a 5-point scale that ranged from not at all (I) to very much (5). Change in caregiver-care-receiver relationship. Three measures that were developed to assess whether participation in the CSP changed certain aspects of the caregiver-care-receiver relationship were given only at posttest. The Self-appraisal of Change Scale (SCS) consisted of five items that asked the caregivers to rate how much change had occurred within the following areas relevant to the relationship with their care receiver: knowledge of the aging process; feelings regarding being a caregiver; ideas, beliefs, values, and assumptions about caring for their elder; behaviors related to caregiving (e.g., communication and problem solving); and understanding of the relationship with their elder. Perceived change in each area was rated on a 5-point scale ranging from not at all (1) to very much (5). Total scores were calculated by summing responses to all items, with higher scores reflecting positive change. Change in interpersonal competence as a caregiver was assessed by asking participants to rate on a 5-point scale (ranging from 1, not at all, to 5, very much) the extent to which their competence at handling interpersonal concerns related to caring for their elder had changed as a result of the CSP. Participants were also asked if their relationship with their caregiver had improved as a result of the CSP, and responses to this query were scored dichotomously as yes or no. Satisfaction with the CSP. At posttest, participants were asked to rate how satisfied they felt with the help they had received from the CSP on a 5-point scale ranging from very dissatisfied (1) to very satisfied (5).

4 COUNSELING FOR CAREGIVERS 259 Table 2 Univariate Effects and Mean Scores by Condition for Emotional Response to Caregiving Variables Variable (n = 27) Peer (n - 24) Control (n = 36) F df «2 Zarit Burden Interview Bradburn Affect Balance Scale , * 2, */><.005. Data Analyses To control for any group differences that might have existed at pretest, multivariate analysis of covariance (MANCOVA) was performed with pretest scores as covariates. Analysis of covariance has been recommended for quasi-experimental, nonequivalent control group designs (Cook & Campbell, 1979). Statistical tests for the assumption of homogeneity of slope were performed on all dependent variables used in the MANCOVAS. Except for the GSI, all dependent variables met this assumption. Multivariate analysis of variance (MANOVA) was used for measures obtained at posttest only. Significant MANCOVAS and MANO- VAS were followed up by univariate analyses of covariance (ANCOVAS). Post hoc comparisons to test for differences between pairs of means were performed according to the Games and Howell (1976) method, which is robust in situations with unequal sample sizes and suspected heterogeneity of variance. Chi-square analyses were used to test for group differences regarding categorical variables. Results Emotional Response to Caregiving A MANCOVA comparing professional, peer, and control conditions on the ZBI and the BABS revealed a significant multivariate effect by condition, F(4, 168) = 3.10, p <.05. Although pretest-to-posttest change was in the expected direction among the treatment conditions for both measures, a significant univariate effect was found with the BABS but not with the ZBI (Table 2). Post hoc comparisons for the BABS revealed that whereas participants in the professional condition improved significantly more than did participants in the control group, r(61) = 3.34, p <.01, there were no significant differences between those in the professional and peer conditions or between those in the peer and the control conditions (p >.05). Psychiatric Symptomatology A MANCOVA comparing pretest-to-posttest change for the three groups on the BSI Anxiety, Hostility, and Depression subscales produced a significant multivariate effect by condition, F(6, 166) = 2.35, p <.05. Significant univariate effects were found on all three symptom subscales (Table 3). Post hoc comparisons revealed that participants in the professional condition improved significantly more than did controls on all three subscales, whereas those in the peer condition improved significantly more than did controls on only the Anxiety subscale. No significant differences were found between the professional and peer conditions on the three symptom subscales (p >.05). Because of the linear dependencies that exist between the BSI symptom subscales and the composite GSI, a separate ANCOVA was performed with the GSI as the sole dependent variable. Although the assumption of homogeneity was not met for this variable, inspection of pre- and posttest means revealed that parallel regression slopes were not found because of the effectiveness of the intervention. Participants in the control group reported higher GSI scores from pretest to posttest, whereas participants in both treatment conditions reported lower scores during the same period. Moreover, participants in all conditions had nearly identical mean GSI scores at pretest, diminishing the concern over violating the assumption of homogeneity of slopes (Campbell & Stanley, 1969). Thus, the ANCOVA produced a significant group effect, F(2, 83) = 9.53, p <.001. Post hoc comparisons revealed that both the professional and peer conditions showed significantly more improvement on the GSI than did the control condition (Table 4). No significant difference was found between the two counseling conditions on this measure. Social Supports No multivariate effect by condition was found regarding the formal and informal social support variables, F( 10,160) =.81, ns. Also, no significant group differences were found regarding the social support variables that were collected at posttest only (Table 5). Changes in the Caregiver-Care-Receiver Relationship Significant group differences were found for all three posttest measures of change in aspects of the caregiver-care-receiver relationship. A MANOVA comparing the three conditions on the SCS and the interpersonal competence measure was significant, F(4,168) = 4.48, p <.005, and the significant univariate effects are summarized in Table 6. Post hoc comparisons revealed that participants in both the professional and peer conditions showed significant improvement when compared with control on the SCS, tf58) = 3.35, p <.01, and #57) = 2.95, p <.05, respectively, and on the measure of interpersonal competence,

5 260 RONALD W. TOSELAND AND GREGORY C. SMITH Table 3 Univariate Effects and Mean Scores by Condition on the Brief Symptom Inventory (BSI) BSI index (n = 27) Peer (n = 24) Control (n = 36) F a, 2 Depression Anxiety Hostility Global severity ** 5.27* 5.19* 9.64*** Note. There were 2 and 84 dfi, for the univariate analyses. *p<.01. **p<.005. ***p<.ooi. r(46) = 3.46, p <.01, and?(57) = 3.29, p <.01, respectively. However, no significant differences were found between the professional and peer conditions on these two measures (p >.05). The analysis also showed that a higher percentage of participants in the professional and peer conditions reported an improved relationship with the care receiver than did controls (Table 6). Satisfaction With the CSP A chi-square analysis revealed no significant difference between the two treatment conditions regarding the participants' satisfaction with the counseling they received from the CSP (p >.05). Ninety-six percent of participants in both the professional and peer conditions reported that they were either satisfied or very satisfied with their counseling. Discussion Efficacy of Individual Counseling Individual counseling, whether conducted by professional or peer helpers, was effective in helping caregivers cope with the stress of caring for a frail elderly parent. Compared with participants in a no-treatment control condition, those who received Table 4 Results of the Post Hoc Comparison for the Brief Symptom Inventory (BSI) Indexes BSI index Depression Anxiety Hostility Global severity vs. peer t *p<.05. **p<.01. df vs. control t 3.63** 2.92* 3.15** 3.88** df Peer vs. control * ** df professional counseling demonstrated significantly better outcome with respect to their subjective well-being, all four measures of psychiatric symptomatology, and perceived change in aspects of the caregiver-care-receiver relationship. Participants who received peer counseling demonstrated the same improvements, except they did not improve significantly more than controls in either subjective well-being or the BSI symptom subscales of depression and hostility. Effects on Subjective Well-Being The finding that professional counseling was found to enhance subjective well-being is noteworthy because Lovett and Gallagher (1988) are the only other investigators who have reported gains in this variable as a result of clinical intervention. There are at least two plausible explanations for the changes in well-being that were found in these two studies but not in others. One is that the samples from our study and those of Lovett and Gallagher (1988) consisted of caregivers who were caring for elders with a wide variety of disorders and disabilities. In contrast, most other studies have included individuals who cared for patients with Alzheimer's disease or other severe cognitive impairments. Perhaps caregivers of the cognitively impaired elderly "comprise a group with special needs who respond differently to psychoeducational interventions than do other caregivers" (Lovett & Gallagher, 1988, p. 328). This speculation points to the need for future studies to determine whether intervention approaches produce differential outcomes among caregivers who care for frail elderly family members with different medical and psychiatric problems. An alternative explanation concerns the similarity of intervention procedures used in both studies. Unlike most other intervention studies, where the focus has been either on behavioral strategies to manage care receivers' disruptive behaviors or on support groups, the intervention described by Lovett and Gallagher (1988) consisted of structured programs designed to teach specific skills for better coping. While supervising the counselors in this study, we found that the professionals tended to spend more time on caregivers' feelings and on the use of

6 COUNSELING FOR CAREGIVERS 261 Table 5 Univariate Effects and Mean Scores by Condition for Formal and Informal Social Support Variables Variable Peer Control (n = 27) («= 24) (n = 36) Test statistic w 2 Formal supports Knowledge of community resources (posttest) F(2,83) = Use of community resources F(2,83) = Knowledge of access to community resources F(2,83) = Informal supports Number of people in support network Satisfaction with support network Change in ability to use support network (%) Increased Decreased Remain same F(2, 83) = F(2,83)= X 2 (4,AT=87) = 2.61 Note. Neither the multivariate Fnor any of the univariate effects were statistically significant. specific coping and problem-solving skills than did the peers. Thus, the focus on these skills by the professional counselors may explain why they were found to be more effective than peers at increasing caregivers' feelings of well-being. As a whole, these findings offer preliminary evidence that a focus on the development and use of effective problem-solving and coping skills has a positive impact on feelings of well-being. However, future studies that contrast skills-oriented and non-skills-oriented interventions are needed to verify this speculation. I- I S" Effects on Psychiatric Symptomatology Individual counseling by professional and peer helpers significantly reduced psychiatric symptomatology. It is noteworthy that this study used multiple indexes of psychiatric distress, rather than a single measure of either global disturbance or of a particular symptom dimension (e.g., depression). This distinction is important because individual counseling not only decreased the global psychiatric distress reported by respondents (GSI) but also significantly reduced scores on the three BSI symptom subscales thought to be influenced by the demands of caregiving (Anthony-Bergstone et al., 1988). Although both types of counseling were found to be significantly more effective than no treatment at reducing scores on the GSI and the Anxiety subscale, only the professional counseling was significantly more effective than no treatment for reducing hostility and depression. Peer counseling also caused reductions in these symp- Table 6 Differences on Caregiver-Care-Receiver Relationship Variables by Experimental Condition Variable (» = 27) Peer (n = 24) Control (n = 36) Test statistic a, 2 Self-appraisal of change scale (M) Interpersonal competence (M) Did relationship with care receiver improve? (%) Yes No */><.05. **p<.001. F(2,84) = 7.20** F(2,84) = 8.37**.12.14

7 262 RONALD W. TOSELAND AND GREGORY C. SMITH toms, although it fell just short of reaching statistical significance. Effects on the Caregiver-Care-Receiver Relationship and peer counseling were also found to be significantly more effective than no treatment for changing aspects of the caregiver-care-receiver relationship as perceived by caregivers. Higher scores on the SCS for participants in the two treatment conditions suggest that individual counseling helped participants change their cognitive, affective, and behavioral response to caregiving and enhanced their knowledge and understanding of their role as caregivers. Participants in both counseling conditions also experienced more positive changes in their perceived competence at handling interpersonal concerns related to caring compared with control subjects, and a significantly higher percentage of participants who received counseling reported that their relationship with the care receiver had improved. Together, these findings provide support for the conclusion that individual counseling has a positive impact on aspects of the caregiver-care-receiver relationship. Satisfaction With Counseling Given the positive findings discussed so far, it is not surprising that participants in both counseling conditions reported a high level of satisfaction with the CSP. This result is consistent with the findings of previous studies that indicate that caregivers appear to be highly satisfied with programs regardless of the specific type of treatment program that is offered (Toseland & Rossiter, 1989). Interestingly, there was virtually no difference in degree of satisfaction reported for professional and peer counselors. This finding might have been considerably different, however, had participants been informed of the professional status of CSP counselors. Variables Not Changed by Individual Counseling The finding that individual counseling had no statistically significant effect on perceived caregiver burden is consistent with results from previous studies. The slightness of impact may be explained by the observation of Haley, Brown, and Levine (1987) that many caregivers seem "more concerned with the goal of improving their effectiveness as caregivers than with decreasing their current levels of distress" (p. 381). However, perhaps the physical condition of the care receiver and other objective demands of the caregiving situation are the primary determinants of how much burden is experienced by caregivers. Because individual counseling did not alter the objective demands of the caregiving situation, the counseling may have been less able to produce a statistically significant reduction in overall burden. Intervention programs that incorporate a case-management component, including concrete services to alleviate objective burden, might significantly diminish caregiver burden. Also, an approach to the measurement of caregiver burden that takes into account its multifactorial composition may prove useful in the future, because it may reveal that a caregiver intervention program can effectively reduce some components of caregiving burden but not others (Lawton, Kleban, Moss, Rovine, & Glickspan, 1989; Zarit, in press). Findings that individual counseling had little effect on caregivers' use of formal social supports are also consistent with previous research (e.g., Toseland et al., 1989a). Regardless of which type of intervention is used, participation in caregiver support programs does not seem to increase caregivers' use of community resources and services. In contrast, the finding that individual counseling had no effect on caregivers' informal support networks differs greatly from the results of other studies that showed that participation in support groups increased the informal support network of caregivers (e.g., see Toseland et al., 1989b). A likely explanation for this differential outcome is that group counseling enabled clients to add group members to their support network, whereas this benefit did not occur in individual counseling. Versus Peer Counseling As hypothesized, no significant differences were found between professional and peer counseling on any of the outcome measures included in this study. This finding is consistent with prior studies in which the effectiveness of professional and peer counseling for clients other than caregivers were compared (Durlak, 1979, 1981; Hattie et al., 1984). This study also confirms the results of a recent comparison of support groups for caregivers, which showed very few differences between peer and professional leaders (Toseland et al., 1989a, 1989b). Thus, peer counseling appears to be a viable alternative to professional counseling. This is not to suggest, however, that peer counseling is some sort of magical panacea. Considerable effort was devoted by experienced mental health professionals to the training and weekly supervision of peer counselors in this study, and the effectiveness of their counseling was probably dependent on this guidance. When using the findings of this study, investigators should keep in mind several methodological limitations. Although care was taken to recruit participants for the three conditions in an identical manner, because the control group participants were recruited for an earlier study, there is always the possibility that time-related factors, such as changes in staff, historical events, seasonal variations, and other subtle changes in recruitment, could affect the internal validity of the design. Also, because self-report measures were used in this study, the results may have been affected by response sets or demand characteristics. Investigators for future studies should consider using behavioral measures to avoid these threats to measurement integrity. Future Research Our findings suggest that with the exception of improving informal supports, individual counseling is an effective modality to help caregivers cope with the demands of caring for frail elderly parents. A comparison of the efficacy of peer and professional counseling revealed virtually no outcome differences between these two modalities. To be determined, however, is whether individual counseling is more or less effective than other supportive interventions for caregivers. Further research also is needed to determine whether the effectiveness of inter-

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