Back in the early 1990s, researcher Judith Moskowitz began her work with caregivers of people with AIDS. She has since studied the experiences of those taking care of children and people with dementia.
But Moskowitz doesn’t study the negative aspects of caregiving or how to reduce them. Instead, she and her team at Northwestern University focus on helping people build positive emotions.
For example, in a study published this month in Health Psychology, Moskowitz and her colleagues recruited 170 caregivers of people with dementia. In one group, the caregivers received video calls every week where a facilitator taught them skills like these:
Noticing positive events: Being aware of the good things in your life, an antidote to narrowly focusing on the negative.
Capitalizing on positive events: A way of extending and savoring your good feelings, such as by telling someone else, writing them down, or remembering the event later.
Mindfulness: Being aware of the present moment without judgment. Participants learn a guided mindful breathing exercise and incorporate mindfulness into daily activities like brushing teeth and washing dishes.
Noting personal strengths: Recognizing the personal resources you have at your disposal and how you enact them in your life, an antidote to feeling helpless.
Setting attainable goals: Choosing aims that are challenging but not too challenging, allowing you to feel accomplished and successful.
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During the week, the caregivers practiced those skills on their own. The other group simply reported what emotions they were feeling every day in a survey.
Ultimately, Moskowitz and her team found that the caregivers who learned positive emotion skills ended up experiencing more positive emotions and (in turn) less depression. They also felt less anxious and experienced more positive aspects of caregiving (like feeling useful, appreciated, and connected) compared to the other group.
I had the chance to speak with Moskowitz about why she and her colleagues developed this program, how it helps caregivers, and what we should all do when we’re really feeling down.
Kira Newman: Can you talk about the experience of caregiving and some of the stresses it involves?
Judith Moskowitz: Dementia caregiving is really tough because you lose the relationship and the psychological bond with the person, in many ways. As the dementia progresses, there are lots of physical needs that the caregiver has to provide. I think the stress comes from having to spend the time doing those things, often in addition to their own day-to-day work. But, then, there is also this loss of the relationship, loss of your partner [or relative], loss of the psychological connection, as the dementia progresses. It also tends to affect emotional responding. So, the person with the dementia can get almost mean, which is triply devastating when you lose that emotional connection, as well.
KN: In cases like this, a common approach would be to try to reduce these negative emotions and experiences. Why do you choose to focus on positive emotions?
JM: It’s not to say that trying to reduce the negative is not an important goal of any intervention or therapy. It’s just that we’ve seen that positive emotion and negative are not simply opposite ends of a continuum so that you’re either high negative/low positive or high positive/low negative. They are somewhat independent and have independent effects.
In our observational work, we were finding, first of all, that positive emotion could occur in the context of stress even when depression and distress were really high. And positive emotion had unique benefits independent of the effects of negative [emotion], so that led us to start thinking about ways to target positive emotions specifically.
It’s related to the “broaden and build” perspective, which shows that increasing the positive can help boost your reservoirs of personal resources to cope better with whatever it is that you’re coping with.
We’re really clear in this intervention—or we try to be—that this is not about pretending like things aren’t bad or difficult, or that you’re not distressed or stressed. It’s about understanding that you can experience positive emotion alongside the negative. The negative is what it is; it should be acknowledged and addressed if it’s at high levels that are unsustainable.
KN: When caregivers start learning these skills and cultivating some positive emotions, how do things change for them?
JM: The caregivers are so used to neglecting themselves that even something as simple as noticing positive events, or taking a moment to know what they’re grateful for, is a huge shift for them. And by participating in the interventions, they’re giving themselves permission to focus on themselves even if it’s just for a few minutes a day.
We’ve had some great feedback from caregivers about how they’ve changed in the wake of the intervention. When we were studying AIDS caregivers, the positive events they told us about sometimes had to do with their caregiving, but oftentimes did not. They were really little things like a beautiful sunrise, or a walk on the beach, or a lot of outdoor nature-related things, or a friend had sent a kind note.
One person had this complete mind shift about their caregiving, whereas before it was all burden and stress and deterioration. They started to see the small positive moments and really savor those, and that was really helpful for them. When they started, there was dementia in these giant neon-flashing letters. And through this intervention, they have been able to scale down the letters and turn off the light—which always strikes me as such a beautiful illustration of what we’re trying to do.
So, the stress isn’t taking over their lives anymore. This is a huge thing hanging over them—it’s still there, and it’s still something they have to deal with—but it doesn’t color all aspects of their life anymore, which to me makes the intervention a huge success regardless of the effect sizes (and sometimes we get significant effects and reasonable effect sizes and sometimes we don’t). It’s these individual experiences, with the occasional statistically significant finding, that keep me going in doing this research—seeing that it definitely impacts people’s lives for the better.
KN: Have any participants talked about how it affects their actual caregiving, or their relationship with the person they are caring for?
JM: They say that it makes them better caregivers. And our quantitative data show improvements on positive aspects of caregiving, which I guess is not surprising since that’s what the intervention is about. So, if they’re finding more positive aspects of caregiving, that’s a really good thing; it means we’re doing something right.
There’s literature [by other researchers] showing that caregivers who have higher levels of well-being are less burdened and stressed, do actually care better, and their care recipients live longer. Theoretically, that should be the case: If we can reduce the burden of stress on caregivers so that their well-being is higher, they’re going to do a better job caregiving, and that certainly improves the quality of life of their care recipient.
KN: Do you have any evidence that certain skills you teach are more beneficial than others?
JM: From a theoretical perspective, I actually don’t think any one is going to be generally better than the others. I think different things work for different people, and that’s why we give them this buffet of skills. We want them to try each one and see which one works best for them, and then those are the ones that they’re going to continue doing—which is one key to having this work, right? The intervention is not going to work if people don’t do it, so they need to find the one that fits best for them.
We do ask people at the end of our interventions which one they liked better and which one they’re going to continue to practice, and we get votes for all the skills. I think mindfulness is the most disparate one—people tend to love it or hate it—but all the skills seem to get at least some votes. We haven’t come to a point where we’re like, well, this one is clearly the one so let’s just do that one skill from now on. At the same token, we’re never finding that one is particularly bad and never works.
KN: When we’re experiencing some kind of life stress, how do we figure out whether we should focus on the positive or attend to our negative emotions at any given moment?
JM: I think you just have to get a feel for it, starting with at least being aware of all the different options you have. There is some evidence for matching skills to the context. If you look at our grouping of skills, if it’s a situation where you don’t have any control—there’s nothing you can do—then something like mindfulness or gratitude (focusing on what is good in the moment) might be the way to go. Whereas if there might be something you can do, then maybe the attainable goal setting would be more the way to go.
When I’m having a particularly stressful moment, positive reappraisal is something that I do automatically and that’s easy to do in the moment ([and] lots of mindful breathing). If you have some sort of agency at the moment, an act of kindness to lift you out of your own situation can be good.
The bottom line is start by building your toolbox and having all these things at the ready and know what you would do to engage with them—so learn a little bit about mindfulness and mindful breathing, and maybe have some mindful breathing apps or recording on your phone, so they’re at the ready when you’re in the moment and need them. Maybe having to practice them in less stressful situations can be helpful so they can come more naturally.
KN: What should we do when we don’t feel like being positive, when we’re just not in the mood?
JM: I would definitely go back to [the idea that when] you’re experiencing something stressful right now, feeling crappy is totally appropriate. [In that moment], I’d probably recommend some self-compassion. The problem with many of these happiness-inducing activities is this “tyranny of the positive.” If you can’t manage to happy-think your way out of your cancer diagnosis, then you’re a failure—you’re an additional failure, right?
Whenever we’re working with anyone—whether it’s in person or self-guided online—we really try to drive home the point that this is not about pretending you’re not experiencing negative emotion. That’s normal, and that’s valid.
We also get this response: “Oh yeah, I’m always grateful, I’m always practicing gratitude.” So, we just encourage people to try it again in the context of the intervention so they might learn something more about themselves or learn a different way of practicing the skill, so that they’ll be more likely to take it up the next time.
Sometimes in our data, we see people saying things like, “Well, I wasn’t stressed, so I didn’t try it.” And, in reality, these are skills that could help you in your day-to-day life because we all always have something stressful, whether we admit it or not. I think these work just as well and maybe even better in the context of daily hassles. I’m working on doing a better job of helping people realize that these are daily practices that you can do, and you don’t have to wait until your world falls apart to start practicing.
When I’m having a bad day and it’s just like one annoyance after another, I will actually text the annoyances to myself, so I’m listing the things that are annoying me. Just writing them down reveals it for what it is—as minor, stupid stuff. But then I’ll come up with good things. Like we experienced a polar vortex in Chicago a few months ago, and it was miserable, and so cold. And then my positive reappraisal was, “I’ve got this great parka, and it’s this beautiful color and it makes me happy every time I put it on”—which seems trivial, but it actually is really helpful in moving you out of that negative downward spiral that these daily hassles can get you into.
KN: Is there anything else that you want to share about your intervention, positive emotions, and caregiving?
JM: I’d want to make sure people know that the caregiving work is one part of a broader program where we’re trying to get funded to do the intervention in lots of different types of stress. These skills can help you no matter what type of stress you’re experiencing—that’s something I always try to get across. And this isn’t about ignoring, or suppressing negative emotions, or pretending they don’t exist; it’s about being able to experience positive emotions alongside the negative emotions.