A RESILIENCE TRAINING MODULE FOR CAREGIVERS OF DEMENTIA PATIENTS

As life span increases, society is facing an aging population and one of the major aging problems is dementia. Caregivers of dementia patients are usually family members who juggle work, family commitments and caring for the patients. The caregivers are at risk of depression, suicide and abusing their patients. As resilience has a positive relationship with surviving life crises, enhancing resilience will provide them with skills to cope and decrease depression. The purpose of this article is to perform a systematic narrative reviews of four resilience training modules. This analysis searched Medline via Pub Med, EBSCO host and USM library for feasible training modalities, screening over 6640000 articles for relevance regarding caregiver resilience. The training modules were screened for suitability for adult population. Studies that identified core characteristics of resilience, sample description and ways of strengthening resilience. Theory of resiliency and Applied Behavioral Analysis (ABA) are the theoretical framework found in these researches. These studies included antecedent-behavior-consequence chain of ABA and construct resilience: spirituality, leadership, problem solving, networking and self-efficacy. Items for example recognizing thinking traps, cultivating gratitude, critical thinking, conflict resolution, and creative problem solving skills are some of the review results. The findings were implemented in a training module to promote caregivers comprehension about resilience concept, and to enhance their resiliency and mental health. In conclusion, a training module is built on these core characteristics of resilience. It hopes to improve caregivers’ adaptation to adversity and quality of life for a sustainable future.


INTRODUCTION
The elderly population in Malaysia is growing, andthis increase is projected to continue over the next 20 years (NationMaster.com).By 2050 it is predicted there would be more than 5 million of Malaysia population over 65 years of age.(Reference-Nation master website) The Malaysian Psychiatric Association (MPA) states (or estimates) approximately 5 to 8 percentage of population over 65 years of age has dementia, and it doubles with every 5 year increase in age.About half of the population over the age of 80 suffers from dementia.These patients and their families need society's support to live and cope with dementia.This irreversible dementia has no cure.Medication though, is available to manage behaviors that may harm the clients themselves.Health care providers may also work with family members to manage the care of dementia clients.The spouse and children's involvement plays an important role in helping to maintain the continued functioning of the clients.Providing care for dementia clients can be overwhelming and stressful.Therapeutic interventions may help the caregivers cope with these stressors, enabling them to continue care for their loved ones.Mittelman et al (1995) have used a longitudinal study to evaluate the results of a psychosocial intervention program on mental well-being of spouses as the caregiver.This comprehensive programme has included four formal family counseling sessions for the primary caregiver and family members in the first four months.The control group was found to be more depressed after one year than the treatment group.The success of the programme included conflict resolution during the four formal family counseling sessions.The improved conflict resolution techniques among family members resulted in better family cohesion and less depression for caregivers.During individual counseling, the researchers tried to impart the reasons underlying the dementia patient's behavior.The caregivers also learned techniques to manage and interact with the patients.These two steps also have helped to reduce depression among caregivers.Furthermore, the program has increased awareness among family members of the impact of dementia on the mental health of primary caregivers.This facilitation has helped family members to provide suitable help as needed.As a result, caregivers' satisfaction has helped to reduce depression among caregivers.This study showed that long-term social support can help reduce depression in caregivers (Mittelman et al., 1995).
The caregiver can be taught to problem solve effectively and creatively according to their individual situation.Discerning when help is needed is a form of critical thinking skill.Helping caregivers to identify and develop networking would enhance their resilience (Yeh & Bull, 2010).Having the confidence and belief that they can meet their goals helps them to bounce back after setbacks.These are parts of resilience training that will reduce their risk to break under pressure.
The theories embedded in this training module are those of resilience and the theory of Applied Behavioral Analysis (ABA).These studies included antecedent-behavior-consequence chain of ABA and construct resilience: spirituality, leadership, problem solving, networking and self-efficacy.Items for example recognizing thinking traps, cultivating gratitude, critical thinking, conflict resolution, and creative problem solving skills are some of the results from this review.According to ABA theory, behavior is influenced by antecedent and consequence.Antecedent is the trigger or activating event preceding the behavior.Consequence happens after the behavior i.e. the result of the behavior.The antecedent-behavior-consequence (ABC) behavior chain is used to track and analyze problematic behaviors so that appropriate strategies can be implemented to manage the behaviors (Hill, 2008).The ABC behavior chain can be used on caregiver to help distinguish triggering events, thoughts and responses of themselves.Assisting the caregivers to manage their reactions after an issue occurs is proactive approach to help caregivers to stay calm and not be defensive.Consequently, this approach could help the caregivers to manage stress.
University of Pennsylvania has incorporated the ABA theory and developed a resilience training course for the US Army (Reivish, Seligman & McBride, 2011).It is a 10-day course where the sergeants are trained to teach their soldiers the resilience skills.This programme has been very successful.It was well received; Comments included "The skills I learned will help me improve my personal life and professional life.These resilience skills should be mandatory for all ranks, families and civilians."(Reivish, Seligman & McBride, 2011).

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Shahabuddin, Noor Shafrin and Haslinda (2013) have developed their module of resiliency in the areas of developing problem solving skills, networking, self-esteem, self-efficacy, leadership and spirituality.Their work have been successfully applied and proven in the education sector.It is the programme's mission to reach out to the community, so that more people will benefit from the training resulting in more people being able to bounce back from life crises, and not break under pressure.As a loved one being diagnosed with dementia is devastating for the family members, the programme would like to equip the family members to be resilient to this life challenging event.

METHODOLOGY
A narrative review was performed to identify potential training to enhance resiliency of caregivers for dementia patients.This analysis searched Medline via Pub Med and EBSCO host for feasible modalities, screening over 6640000 articles for relevance regarding caregiver resilience.Three completed studies resulted from these search engines by using the key words 'resilience module' and 'positive psychology'.These articles are peer-reviewed with time frame set after 2006.Since the primary search failed to provide any more articles relevant to resiliency, the Universiti Sains Malaysia (USM) library search engine, OPAC Krisalis was used to expand the search.One article, a significant resource for adapting a local module was the product of search from Universiti Sains Malaysia library.This paper is a review of the above sources for existing modules in order to develop potential module for the target population.
The modules were screened for suitability for adult population.The four selected resources are Master Resilience Training for the US Army (Reivich, Seligman & McBride, 2011), Wagnild's adult resilience element (Wagnild & Collins, 2009), Harris (2008) resiliency for dementia patients and Shahabuddin ( 2010) academic resilience students.The modules were compared, and summarized based on existing theories.The resulting module is a product of systematic review.

Review of Published studies
Four selected articles for review were completed and published on or after 2008.Three of the researches are from US, and one is from Malaysia.The core characteristics of resilience from these studies could be grouped into five.The programme was designed to teach the noncommissioned officers a set of resilience skills that they would in turn later teach to other soldiers.The objectives were to raise resiliency of soldiers facing adversity as protective factors against depression, anxiety and PTSD, and strengthen mental wellbeing and performance in general.The key elements found in this study were self-awareness, creative problem solving, conflict resolution, critical thinking, thinking traps, cognitive icebergs, cultivating gratitude, self-regulation, self-reflection, and building character strength.This programme was well received, and is recommended for people from all walks of life.Wagnild and Collins (2009) developed their resilience module for middle age and older adult population in the USA e.g., aging Baby Boomers.It is a strength-based approach to help the individual to re-discover their resiliency.The core elements found are purpose of life, perseverance, equanimity, ICoLASS 2014 self-reliance and existential aloneness.Instead of focusing on the problems of aging, this resilience training enhance the mental wellbeing of individuals.Harris (2008) focused on resilience training on the dementia population.He challenged the idea of aging successfully as the goal, instead suggested that aim should be building resilience.Strengthening resilience is possible even for individuals with Alzheimer's disease.This author applies the theoretical framework of resilience for two in depth case studies of Alzheimer's patients.Despite the disabilities, the patients could recognize their resilience and enhancing this skill to face their hardships.
Shahabuddin (2010) researched on the academic resilient students regarding their problem solving skills.These students were competent in understanding the circumstances, identify the issues, seeking options, making a plan and self-reflection.Their problem-solving process involved the elements of self-efficacy, self-esteem, critical thinking and creativity.These elements of resilience are transferrable to adult population (Wagnild, 2009).

DISCUSSION AND CONCLUSION
Theory of resiliency and Applied Behavioral Analysis (ABA) make up the theoretical framework found in this researches.These studies included antecedent-behavior-consequence chain of ABAand constructing resilience via spirituality, leadership, problem solving, networking and self-efficacy.Items for example recognizing thinking traps, cultivating gratitude, critical thinking, conflict resolution, and creative problem solving skills are some of the results from this review.

Problem solving
Problem solving is a process of developing self-awareness.One would identify the triggering event, its effects on the caregivers' thought, and the impact of thought on emotions and response.Evaluation would be made as to whether the thought pattern was productive or counterproductive.Thought patterns that weaken the decision making process would be identified and effective creative problem solving strategies implemented (Reivich, Seligman & McBride, 2011).
Creativity is to solve problems via original, authentic, unique and diverse solution (Torrance, 1966).Caregivers are encouraged to generate new relevant ideas, and adding details to existing ideas.This flexibility enables caregivers to explore alternate options that fit the situation (Reivich, Seligman & McBride, 2011;Shahabuddin 2010).
Critical thinking skills are vital in the process of problem solving.Individuals can think from different perspectives, using emotions, facts, creative, negative and positive aspects in order to have the whole picture of situation (Thompson, 2011).Identification of problems and evaluation from different views would improve decision making (Reivich, Seligman & McBride, 2011;Shahabuddin, 2010, Harris, 2008).
Resilient individuals persevere in the process of problem solving.Despite discouragement, they stay focused, instead of distraught, disengaged and without a plan.They put aside their fears, and choose to stay on track (Wagnild & Collins, 2009;Harris, 2008).Dementia is a chronic illness that may last for twenty years.The quality of perseverance is vital in this long caregiving journey.

Networking
Family, friends and community are assets and protective factors of resilience in the face of adversity.A committed spouse, positive family relationships, strong parental role models, social support networks and community resources and understanding from health care personals would counterbalance the risks and vulnerabilities.Risks and vulnerabilities can include other health concerns, caregiver role strain, denial, disabilities, loneliness and financial instability.The support from this network towards a person-centered living environment would strengthen the individual's resilience, and thrives in adversity (Reivich, Seligman & McBride, 2011;Shahabuddin, 2010;Harris, 2008).
A tight knitted family know and treasure their family history and heritage, shared experiences and support each other through up and down.It is this continuity which links the past, present and future in family context (Landau, 2010).This family tradition and continuity enhance resilience of individual and family.The same process to build resiliency in larger context is applicable to circle of friends and community.
Connectedness in a family and community plays an important role in resilience of individual.Frequent family get together, learn about life stories of grandparents, and involve in community events help connect theirmembers and keep them grounded.This connectedness helps them to draw on life experiences of their ancestor and make informed choices, hence strengthen resilience (Landau, 2010).Community that stay close and supportive will have the connectedness that sustain resiliency.Caregivers from such family and community background would have more resources and supports for their caregiving challenges.

Leadership
Leaders are not just someone who leads, but who also serves.They have vision and recognize some experiences must be handled alone, which is existential aloneness.They accept their weaknesses and strengths, live according to their faith.If the situation requires for it, they are willing to carry out the mission alone, which makes them unique (Wagnild & Collins, 2009;Harris, 2008).This resilience skill of existential aloneness empowers caregivers to take charge, and improve decision making.
Conflict resolution is one of the tasks of many leaders as well as caregivers.Conflicts can occur among family members or with patient regarding caregiving, medical or financial issues.Conflict resolution helps caregivers to listen respectivefully to others, trying to understand their perspective, and collaboratively work towards a win-win solution.This effective communication helps to strengthen relationships (Reivich, Seligman & McBride, 2011) between caregivers and their patients and families.
The Master Resilience Training (MRT) of Reivich et al. (2011) helped leaders to identify their thinking traps and the causes.Some of the thinking traps were overgeneralizing, judgmental, mind reading, emotional driven assessment, lopsided evaluation and blaming self for everything.After identify the thinking traps, one would evaluate the impact of thinking traps on emotions and behaviors.Caregivers would benefit from this training to get rid of thinking traps and improve both relationships and problem solving.
MRT also taught their leaders to identify and evaluate own iceberg type thinking.Cognitive Icebergs are deeply held beliefs that may drive emotion out of proportion.Examples of cognitive icebergs are, "Asking for help is a sign of weakness" or "We should strive for forgiveness and mercy" (Reivich, Seligman & McBride, 2011).Caregivers would learn to recognize cognitive icebergs, and analyze if the belief is feasible or too rigid for the situation.This skill helps individuals to make sound decision.

Spirituality
Spirituality involves the development of inner self or moral, knowing there is a purpose in life.There is meaning in life, and something to live for.One would feel content and a life well lived if they travel their lives journey with a purpose.Those who keep their eyes on their purpose of life will thrive in adversity (Wagnild & Collins, 2009).It is not simply pursuit of happiness, but meaningful life that involves self-sacrifice and attitude of giving instead of taking.
Cultivating gratitude is another aspect of spirituality.Counting our blessing helps individuals to enhance positive emotions, benefiting their health, sleep, and relationship (Reivich, Seligman & McBride, 2011;Harris, 2008).It helps one to find treasures in trials.It is a mind turning process.
Religious beliefs, God the omnipotent, gives strength to an individual (Harris, 2008).The caregivers will hand over their worries to God.Reading and believing Bible, Quran, Buddhist or Hindu religious books, help to calm the anxious heart, because the caregivers know that they are protected by the higher power.They will not be forsaken by the higher power; hence they are less likely to be overwhelmed by stress.Consequently, they are more likely to perceive adversities as ways to promote their spiritual growth.
Equanimity is facing adversity without extreme response (Wagnild & Collins, 2009).One has come to peace of the situation and adapted to the new environment.Caregivers who have accepted their situation, can move forward in life.Acceptance of situation and self are important to the well-being of individuals, hence moderate their responses to triggers.Recognizing life will have its up and down, enable one to survive the hardship because there is hope.

Self-efficacy
Self-efficacy is the self-confident to accomplish a task (Margolis & McCabe, 2006).It is selfreliance on individuals' strengths, capabilities, achievements and experiences to support and guide their decision making (Shahabuddin, 2010;Wagnild & Collins, 2009;Harris, 2008).Seeing other's success, would raise self-efficacy and can help motivate caregivers to persevere.Seeing other's failure, would lower self-efficacy and may discourage caregivers (Bandura, 1997).Dementia support group is valuable community resource to assist caregivers to seek help, support and build self-efficacy.Knowing the resources and learning ways to enhance self-efficacy strengthen their resiliency.
Self-regulation is control of impulses, emotions and behaviors to reach goals.Learning to selfregulate also means to express feelings properly and cease counterproductive thinking patterns (Reivich, Seligman & McBride, 2011;Shahabuddin, 2010).Effectively expressing oneself and respecting others are the cores of assertive communication.Being assertive raises one's confident, and reduce stress (Pipas & Mohammad Jaradat, 2010).Self-regulatory and assertive communication are life skills that will promote effective problem solving and decision making.
Self-reflection is part of the cognitive process of self-efficacy, where the consequences of observed or own actions would influence learning and behavior.Self-reflection also helps one to minimize catastrophic and counterproductive thinking that could increase anxiety and reduce confident (Reivich, Seligman & McBride, 2011).Catastrophic thinking is thinking of the worse outcomes.

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Minimizing, rationalizing and denial are common counterproductive thoughts that reduce self-efficacy.Self-reflection helps to identify individual strength and weakness, and improves problem solving skills.
Part of the resilience training is identifying character strengths, build on these and rely on them to solve problems.It is "believing in oneself" to overcome challenges and achieve goals and not be overwhelmed (Reivich, Seligman & McBride, 2011;Wagnild & Collins, 2009).Helping caregivers to build self-confident, enhances their resilience and reduce stress.
In conclusion, a training module is built on these core characteristics of resilience.It hopes to improve caregivers' adaptation to adversity and quality of life for a sustainable future.Health economic benefits such as reduced the health care cost by empowering the caregivers to work and care for the patients.Thus, reduce financial burden for the caregivers.A resilience caregiver would problem solve efficiently and maximize the patient independent daily living and cognitive function; and indirectly help slows down progression of disease.The bed ridden stage can be delayed further.Caregivers that equipped with resilience skills able to engage proactive strategy to minimize the risk of fall and take preventative action that reduced the need of acute care.Consequently, reduced acute health care cost and mental health problem.Building the resilience of caregivers help country to reduce health economic cost.Countries which implemented these strategies of building resilience, would keep the health care cost manageable and sustain the economic growth.
Three of the resilience training modules involved adult populations, and one adolescents.Reivich, Seligman and McBride (2011) developed Master Resilience Training (MRT) module for United States Army.Core characteristics of resilience training from Penn Resilience Program of University of Pennsylvania were incorporated into MRT.