Abstract
Whilst the majority of research on caregiver burden has focused on physical support as the answer to caregiver burden, the following project defends the case for emotional support(Mills, 1997). In exploring the overwhelming situations that lead to caregiver burnout, this study identified the key predictors through a process of facilitated mediation.Eight caregiving dyads of which one was a sufferer of dementia, the other their primary caregiver, completed a combination of methodologies. Narrative biographies and questionnaires were used to monitor the effects of mediation, assess the reliability of previous predictors, and identify factors not previously addressed. Diary entries were made as a record of emotional distress. Thematic analysis was used to transcribe contextual data and in the clarification of themes, while triangulation between methodologies strengthened factor validation. Previous risk factors were present, but overshadowed by more influential factors including: resentment, loss, communication fear and timeout. The role of mediation was explored with a view to reducing the occurrence of burnout and continuity of care in the home.

Research Question
This research was aimed at recognising the core predictors of caregiver burnout in dementia, while identifying if previous factors were still core influences of relational breakdown. A combination of counselling and psycho-educational skills was used to facilitate mediation where the intention was to guide and support the re-structuring of overburdening situations in the prevention of caregiver burnout.

Introduction
Emotional burden and its relation with dementia caregiving has never been suitably addressed (Mills, 1997, Arksey, Johnson, Mason, Wallace & Weatherly, 2004). Whilst the majority of focus has been on the sufferer, the role of the primary caregiver is undoubtedly paramount to the richness and quality of life experienced by the dependent person. From a research perspective this study provided a rare opportunity for the exploration of dementia from the caregiver perspective (Pusey & Richards, 2001). Despite its increasing prevalence, burnout is not new to dementia; relational breakdown has become a dominant factor in the antipathy that influences the caregiver’s decision of institutional care (Miesen & Jones, 1992). This has not been helped by a psychological tendency to rehash old theories without testing their validity, where most findings are interpreted in terms of depression (Takahashi, Tanaka & Miyaoka, 2005). Professional disagreement on the definitive context of ‘burnout’ addressing its avoidance has never been successfully achieved (Brodaty & Green, 2002). With 85% of the caregiving population at risk this study highlights the role of psychology in recognising the need for determining intervention and prevention (Scott, Schulz, Williamson, Miller, Weiner & Lance, 2005, Miesen & Jones, 2006).

Sampling
Whilst random sampling would have been ideal, circumstance dictated the purposeful recruitment of volunteers, where all but one couple were spouses. Included were six wives caring for their husbands, and one husband caring for his wife. The eighth pair, both males, had been long-life friends. Caregivers were aged 70-92, dependents 78-92.

Design
Due to the invasive nature of the research a multi-method approach was considered as the most appropriate design (Arksey, Johnson, Mason, Wallace & Weatherly, 2004). Eight caregivers volunteered to partake in a study of caregiver burnout over a period of six-months incorporating facilitated mediation, recorded conversation, kept diaries and a battery of questionnaires. Facilitated mediation was explained as a conversational dialogue in which the researcher takes an active role, mediating communication where necessary (Bornat, 2005).

Method
As a way of introducing the benefits of the research, couples were advised of the purpose of positive interaction encouraging personal growth through the restoration of identity(Goffman, 1967) . Fortnightly interviews took place in the home with the caregiver and their dependent, or with the caregiver alone, and included up to fourteen visits. Mediated conversation incorporated a combination of counselling skills and psychosocial education, facilitated where necessary by the researcher. Caregivers were also asked to complete diary entries between visits, detailing situations they found particularly emotional or challenging. As a comparative measure, all caregivers gave a narrative biography at the beginning and the end of the research with a view to monitoring change. In order to establish the presence of previous predictors, six questionnaires were scored at baseline and completion

Results
Caregiver accounts were evaluated using thematic analysis in the interpretation of consistently occurring themes (Smith & Liehr, 2005). Thematic coding was used to summarise the narrative biographies, diary entries, and observations documented during mediated visits. Whilst the author had some predetermined scenarios generated from the specific questions asked, a coding manual was developed that described the content of each conversational dialogue in the absence of preconceived ideas.

Diary Method
In comparison with other methods, diaries proved invaluable as a self-report measure of emotion, enabling the caregiver to express a more personal version of events as well as a means for emotional release. Reading their own account of an event or situation helped the caregivers to clarify the experience and how it was handled, providing the necessary medium for change (Gergen, 1990). Diary accounts were particularly useful in highlighting emerging themes, being non-affected by how the caregivers were feeling at the start of the study.

Questionnaire Measures
The purpose of the questionnaire analysis was to establish the presence of previous factors believed to contribute to burnout and included the s elf-report attachment style prototypes (Bartholomew & Horowitz, 1991), the Rosenberg self-esteem scale (Rosenberg, 1965), Satisfaction with life scale (Diener, Emmons, Larson & Griffin, 1985), Zarit caregiver burden interview (Zarit & Edwards, 1996), Geriatric depression scale (Yesavage, Brink & Rose, 1986) and the Profile of mood states ( Diener, Larson, Emmons & Griffin, 1985). While previous factors thought to predict caregiver burnout were present, triangulation exposed more influential predictors of burnout: resentment, fear, loss, an unmet need for communication and supported timeout.

Resentment
By far the strongest predictor of emotional discontent, resentment seemed to override all other themes, highlighting the negative aspect of over-attachment. Generally viewed as a positive influence (Bowlby, 1968) deeper evaluation revealed attachment to be a major source of burden, described as stifling and claustrophobic in 80 % of dyads. There were many reasons for this. While most of the caregivers had accepted loss of sexual attachment, the loss of shared memories and experiences had negatively affected them all. Most agreed they still loved their partner, but that attachment was platonic. Others had grown more hostile reflecting the loss of intimacy. One caregiver had not just considered ending the life of the dependent, but had planned its action with intent, wanting them removed from their life by whatever means necessary. All cases admitted to instances of neglect.

Communication
Immediately apparent was the caregivers’ urgency to talk with someone other than the dependent, where communicating their particular caregiving situation seemed important to the caregivers, as did talking to others in a similar circumstance (Graham, 1999). More profound was the way visits were consciously extended. All caregivers expressed distress at providing continual care for someone unable to reciprocate their feelings or show gratitude for their care (Homan, 1958, Foleya, Tung, & Mutran, 2002). Gaining little recognition from the role themselves, caregivers felt undervalued by a society they felt no longer needed them.

Loss
Loss would transcend into conversation whenever situations got difficult. Caregivers blamed God, society, health teams, social and respite services and finally the dependent. Most felt deserted by religion, family and inevitably by their partner (Chang, Noonan & Tennstedt, 1998). Spiritual loss affected caregivers in different ways (Nightingale, 2003). While recipients tended to keep their religious faith, caregivers had either turned away from God or expressed indifference. Loss of their partner and of a shared retirement was simultaneous with loss of self and self-identity (Cohen & Eisdorfer, 1986).

Fear
Fear was never dwelt upon but always introduced into conversation. Fear accompanied caregiver concerns about how long they could continue to cope with limited support (Hall & Buckwalter, 1987). These concerns grew as time went on. Elderly themselves, caregivers felt they could cope up to a point, but it was in times of crisis that weariness and frustration became overwhelming. It was at these times the conversation would turn to institutional care and how much longer they could emotionally continue without additional support. Often they would turn to family members for justification; again this seemed to make the situation worse, complicated by disagreements and accusations over care.

Timeout
An overwhelming sense of hostility surrounded the mention of timeout. Isolated, and longing for freedom, caregivers felt limited in the choice of support they received, not least because of rules governing respite through means testing. While many argued that standards of respite care were unacceptable, others claimed there were rarely placements available. All were dissatisfied with the respite they received, but were more concerned about their emotional welfare without it. Day-care suffered from government policies restricting security. Some, but not all, relied on a sitting service. Sitters were paid £13 per hour to sit but contact was to be avoided. Doctors and hospital staff were criticised for their lack of understanding and knowledge of the caregiver situation

Facilitated Mediation
Mediation allowed caregivers a rare opportunity to express ‘their’ side of the story, providing them with a sense of importance and a feeling of being valued (Gergen, 1990). Making the caregiver a part of the decision-making progress became an integral role of mediation, particularly in relation the development of alternative strategies for managing the dementia care role(Berger & Luckmann, 1966). I nterventions during mediation involved considerable trial and error, where perseverance was a crucial factor; ideas that worked for one dyadic relationship would often fail with another. Facilitation became exceptionally useful, not just in introducing the different interventions, but in allowing the caregivers to come to their own decisions (Abma, 2001).

Contribution to an Ageing Agenda
Caregiver burnout is one of the most contemporary explanations for the breakdown in relations in dementia, paramount in the decision for institutional care, and an escalating drain on psychosocial resource (Lima & Allen, 2001). Reducing the socio-economic burden displaced on providing community-funded substitutes for home-care allows finance and mental health resource to focus on alternative areas of research, in proviso of a better quality of life for caregivers of dementia and their dependents.

Summary
In exploring the causal influences of relationship breakdown in dementia, the aim of this research was to identify the key predictors of the burden that precedes caregiver burnout. Five dominant themes emerged including resentment, loss, fear, communication and timeout, of which resentment was the most related to ‘risk’. Invariably, caregivers reported an increased understanding of dementia and accompanying challenges, as well as in acquiring the confidence to instigate change. Caregivers agreed that facilitated communication and mediated sessions had benefited their emotional heath, where they expressed the need for a counselling service on a regular basis, with an on-call service suggested as an inexpensive long-term goal. All felt that unexpressed resentment was a major contributor to burnout, which had influenced their decisions of care. As these findings reveal, respite, day-care, timeout and mediated counselling were among the most requested interventions, perceived as amenable, low-cost alternatives to institutional care. Most felt that with this support, they would feel encouraged to continue with care in the home. In addressing the increasing prevalence of caregivers psychologically at risk, this research ensures that preventing the occurrence of burnout is an issue of immediate and ongoing debate.

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