Q. My mother is the primary caregiver for my father, who has dementia. As my dad’s dementia continues to worsen, my mom has been getting more and more stressed. She’s been irritable, depressed, and hard to be around, and she increasingly lashes out at my father and at me and my siblings, who are all trying to support both of our parents as much as we can, but we all work full-time and have young children so our ability to provide direct assistance is very limited. I suggested to my mom that she try a support group, but she says she has, and it didn’t help her. My siblings and I are getting increasingly concerned for our mom’s mental health and well-being. Do you have any suggestions for how we can help her?
A. Family caregivers of loved ones with dementia often suffer from depression, exhaustion, and irritability from the stress and demands of their challenging role. Until now, therapy for most caregivers has usually meant group therapy through support groups, which doesn’t work for everyone, as you described with your mother. Recently, however, new research focuses on a therapeutic offering called Mentalizing Imagery Therapy (MIT), which has shown to be effective in both reducing depression and boosting well-being in caregivers.
MIT Is 40% More Effective Than Support Groups
Mentalizing Imagery Therapy aids family caregivers’ well-being more than support groups, according to a study published online on March 14, 2022, in the journal Psychotherapy and Psychosomatics. The therapy focuses on two preexisting concepts — mentalization and mindfulness — to help caretakers build their “empathetic imagination” in ways that help them better identify with the feelings of both themselves and their loved one. Research has shown that Mentalizing Imagery Therapy is more than 40% more effective than group therapy at reducing feelings of depression.
The Research Conducted on MIT
Felipe A. Jain, M.D., from Massachusetts General Hospital in Boston, and his colleagues originally developed Mentalizing Imagery Therapy to decrease depression and anxiety in dementia caregivers. The idea was to train people to use guided imagery and mindfulness to better process their emotions and emotional responses during challenging interpersonal situations.
When developing the MIT framework, Jain was inspired by techniques in mindfulness, tantra, and Upanishadic/Vedantic meditation traditions to create nonreligious meditation and imagery practices that directly promote mentalization during stressful situations.
In a study of 24 participants, researchers assessed whether Mentalizing Imagery Therapy for family caregivers would reduce depression symptoms, improve positive psychological traits, and aid brain circuitry more than a support group, consisting of 22 participants.
In the study, Mentalizing Imagery Therapy sessions began with breathing and stretching exercises that emphasized mindfulness — particularly awareness of and attention to physical and mental experience, and then followed with one of four specific MIT meditation and imagery practices.
Researchers measured levels of depression, anxiety, mindfulness, self-compassion, and well-being in both groups of participants. One week after both therapies ended, the participants who received Mentalizing Imagery Therapy had a 41% decrease in depression symptoms compared to before therapy, compared to participants who received group therapy, who only had a 15% decrease in symptoms. Similarly, participants who received Mentalizing Imagery Therapy were 20% happier after their therapy, compared to participants who received group therapy, who were only 5% happier after their therapy.
Neuroimaging results confirmed these findings. The participants who received Mentalizing Imagery Therapy had substantial increases in the area of the brain associated with emotional regulation. This increase correlated with increases in levels of mindfulness and decreases in levels of depressive symptoms in participants who received Mentalizing Imagery Therapy. No such neurological findings were present in participants who received group therapy.
One 70-year-old study participant, who had been caring for her spouse with dementia for more than eight years, described her state of mind before the therapeutic intervention: “When I came, I was feeling terribly frustrated,” she said. “I was feeling really ‘dead end,’ like nothing was going to change. I was thinking — even very rarely but it would come up –- ‘What’s the value of my even being here?’ I felt that my life was so limited and that his life was taking over mine completely, whereas [before his dementia] I had been completely independent and living my own life.”
After the four-week study during which she received Mentalizing Imagery Therapy, she said, “(m)y friends are all very happy for me … that I’m doing something for myself … I learned how to recognize the oscillations and accept them for what they are, and then try to ride along with them and also to grab the joy when I could. This is not a four-week turnaround completely for my life, but I feel like I know the direction to go.”
Jain said he has seen similar reactions from MIT participants, where MIT was instrumental in improving depression, anxiety, mindfulness, self-compassion, and well-being. The researchers also found that Mentalizing Imagery Therapy helps increase the caregiver’s ability to control their thoughts and emotions, all while enhancing their overall well-being — and that some of these changes are occurring at the neurological level.
How Does MIT Work?
Mentalizing Imagery Therapy is intended to help caregivers learn to view emotional reactions to challenging situations from different perspectives, while also encouraging a focus on self-care, stress reduction, and self-compassion.
Mentalization works well in simple and stress-free scenarios. In low-stress situations, it’s fairly easy for most of us to put ourselves in another person’s shoes, empathize with their feelings, and respond appropriately. However, in stressful situations, it’s a lot more challenging.
In stressful situations, caregivers often report acting out of irritation and frustration due to their inability to mentalize in the stress of the moment. As a result, they struggle with feelings of shame and guilt stemming from their own reactions and behaviors. Research has even shown that when caregivers disconnect with their ability to mentalize during emotional and/or stressful situations, they have a difficult time understanding other people’s behavior as well as their own. Instead, they become reactive, impulsive, and self-centered, and often lack perspective.
“MIT teaches mindfulness and guided imagery skills to help caregivers better understand the mind of their loved one and how they are reacting to that person,” Dr. Jain said. “This therapy pushes the boundaries of how we think about ourselves and interact with others and incorporates new views on self and identity.” Dr. Jain also said, “We were able to show that there is an underlying neurobiological basis for the improvements that were reported by caregivers in the MIT group. This finding helps us understand how psychotherapies work and why it is so important that caregivers receive them. MIT is now the first therapy to show beneficial changes in the brain circuitry of caregivers.”
Jain emphasizes that “MIT is designed to be a short-term intervention to help people reframe how they view themselves as caregivers and how they experience their loved ones. Support groups are longer-term interventions designed to maintain support for caregivers over the course of the disease. There is a need for both.”
Jain and his fellow researchers are planning a larger clinical trial this year that will study whether Mentalizing Imagery Therapy can be effectively delivered using telehealth and smartphones so caregivers can participate in the therapy remotely.
Where Can Someone Find MIT Locally?
Because the research supporting Mentalizing Imagery Therapy is so new, therapists nationwide are still being trained in the MIT protocols. In the meantime, another similar evidence-based therapy is available that also works with the concept of mentalizing called Mentalization-Based Therapy (MBT), which is offered fairly widely among practitioners. Click here to see which types of therapy are covered by Medicare. Do a Google search for “Mentalization-Based Therapy” for your location to find a therapist near you.
Taking Care of Yourself and Your Loved Ones Should Also Include Planning Ahead
As you can see, practices such as Mentalizing Imagery Therapy and Mentalization-Based Therapy can help bring the bodies and minds of caregivers to a better place. It may not take away stress, depression, frustration, or irritability completely, but it can help dementia caregivers cope with some of the stress they may be experiencing. Remember, as you are finding ways to cope with stress, one of the greatest ways to gain peace of mind comes with planning for your future and for your loved ones. If you haven’t yet done your estate planning, or if you don’t have a Power of Attorney with asset protection powers, or if a loved one is nearing the need for nursing home care or is already in a nursing home, please call us to make an appointment for an initial consultation:
Fairfax Elder Law: 703-691-1888
Fredericksburg Elder Law: 540-479-1435
Rockville Elder Law: 301-519-8041
DC Elder Law: 202-587-2797
About Evan H Farr, CELA, CAP
