Interventions Using Cognitive–Behavioral Therapy Techniques for Caregivers of People With Stroke (January 1,1999– December 31,2019)

Full Systematic Review Question

This systematic review addressed the question, “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice for caregivers of people who have had a stroke that facilitate maintaining participation in the caregiver role?”

Current Theme Reported

The main theme of the articles included in this Systematic Review Brief is caregiver interventions using cognitive–behavioral therapy (CBT) techniques (e.g., problem solving, cognitive reframing).

Clinical Scenario

Although caregiving is often reported to have negative effects on caregivers of people who have had a stroke (Collinson & De La Torre, 2017; Loh et al., 2017; National Academies of Sciences, Engineering, and Medicine, 2016; National Alliance for Caregiving & AARP Public Policy Institute, 2015), caregivers have also reported positive experiences when they are successful at coping with and mastering their situation (Mackenzie & Greenwood, 2012). To facilitate positive experiences, health professionals can use CBT techniques to assist caregivers in adopting problem-solving and coping strategies.

CBT can significantly improve outcomes and satisfaction for caregivers of people with stroke (Chi & Demiris, 2015). CBT encompasses techniques such as developing problem-solving skills, restructuring thoughts, and acquiring coping skills (McCraith, 2019). Problem solving is a CBT stress management technique in which the practitioner trains the caregiver to identify problems, perceive them as manageable, generate solutions, and implement the solutions. Problem solving is also a constructive coping strategy that caregivers can use to cope with stressful life events (Grant et al., 2002; King et al., 2012; Pfeiffer et al., 2014).

Occupational therapy practitioners’ training in psychological and cognitive interventions qualifies them to provide interventions using CBT techniques to caregivers. The systematic review theme presented here is interventions using problem-solving training and other CBT techniques for caregivers of people with stroke to determine whether such interventions can improve caregiver outcomes such as depression, burden, coping, and self-efficacy.

Summary of Key Findings

Five Level 1b and 5 Level 2b randomized controlled trials met the inclusion criteria. Risk of bias ranged from medium to high. We used the Oxford Centre for Evidence-Based Medicine (2009) levels of evidence in this review. Subthemes are synthesized and reported in Table 1.

Bottom Line for Occupational Therapy Practice

To facilitate continued participation in the caregiver role by caregivers of clients with stroke, occupational therapy practitioners should provide problem-solving training and either stroke education or other CBT techniques. When determining appropriate interventions to relieve caregiver burden, practitioners should consider combining problem-solving training with stroke education. The results of this Brief Systematic Review support caregiver intervention recommendations by the American Heart Association and American Stroke Association to provide problem-solving counseling and education or training to caregivers of clients with stroke (Miller et al., 2010; Winstein et al., 2016). Problem-solving training paired with other CBT techniques, such as cognitive restructuring, reframing, or relaxation, can help alleviate symptoms of depression and physical complaints in caregivers.

Occupational therapy practitioners are well suited to deliver interventions using problem-solving training and other CBT techniques because of their education in mental health intervention (McCraith, 2019), their understanding of activity analysis, and their expertise on the impact of context on occupational performance. If feasible, practitioners should consider delivering these interventions over a period of time (1–12 mo) to allow caregivers to develop their problem-solving skills and attend refresher trainings. Interventions can be delivered in a hybrid model or entirely by telephone or other virtual means to ensure that caregivers can access services on a regular basis.