News — As populations age, the need for informal caregivers is increasing. As individuals step up to provide care for loved ones in need, they face their own mental health challenges.
In this episode, Under the Cortex features Michael Kramer from the University of Zurich who recently published an article on this topic in APS’s journal Psychological Science. Özge Gürcanl谋 Fischer Baum starts the conversation with questions on the mental health decline of caregivers. Kramer highlights that caregiving doesn’t happen in isolation and discusses how contextual factors such as family conflicts and economic struggles play a significant role in the decline of overall well-being.
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Unedited Transcript
[00:00:08.540] – APS’s Özge Gürcanl谋 Fischer Baum
This is Under the Cortex. Today, we explore a topic that impacts millions of people every day, caregiving. Whether it is looking after an aging parent, a child with special needs, or a loved one with a chronic illness, caregiving is one of the most essential roles in our society. Yet, it can take a significant toll on mental health. I am Özge Gürcanl谋 Fischer Baum with the Association for Psychological Science. I’m joined by Michael Kramer from the University of Zürich, who has a recent article on this topic published in Psychological Science. Together, we will explore how globally many caregivers experience heightened stress, anxiety, and depression over time. Michael, welcome to Under the Cortex.
[00:00:55.020] – Michael Kramer
Thank you so much. I’m happy to be here.
[00:00:57.880] – APS’s Özge Gürcanl谋 Fischer Baum
Let’s start with our classical question. What type of psychologist are you?
[00:01:02.880] – Michael Kramer
I would say I’m mostly a personality psychologist, but I have focused on social relationships and also well-being. In some of my previous work, I looked at some transitions over the lifespan and how this has for example, affected our well-being in social relationships.
[00:01:18.690] – APS’s Özge Gürcanl谋 Fischer Baum
Great. What initially got you interested in studying caregiving?
[00:01:24.300] – Michael Kramer
I think the idea came from talking to my mentor, Wiebke Bleidorn, here, who’s also a co-author. We thought about some of the previous work I did, for example, on grandparenthood and providing childcare for grandchildren. We thought about some other life domains where this caregiving might also play an important role. This also fits into some of the work I did, for example, on life events and life transitions. We thought that this topic of informal care is still a little bit under the radar in psychology. It has been researched mostly in other disciplines. Economics and sociology have focused a lot on this topic, but the psychological consequences were still a bit blurry. I think it’s a very important topic, especially in today’s society, because in a lot of the Western countries, we have this demographic change, so people are getting much older We don’t have that many young people anymore. This can, of course, also strain our healthcare systems.
[00:02:21.950] – APS’s Özge Gürcanl谋 Fischer Baum
In your study, you talk about transitioning into a caregiving role, and you found that there could be the negative effects associated with it. What are the key factors driving these well-being losses and how do they manifest over time?
[00:02:38.270] – Michael Kramer
That’s a very good question. We approach this from two angles, I would say. First of all, we looked at the transition It affects over time. Here we found that people generally decreased in their well-being when they took on this role of informal caregiver. But here in these models of the transition to caregiving, the effects were generally stronger for women For men, they were temporarily more specific and also not quite as consistent over time and over the different data sets we looked at. For this study, we looked at three data sets from the Netherlands, Germany, and Australia.
[00:03:15.290] – APS’s Özge Gürcanl谋 Fischer Baum
I will come to all that, gender differences, the global nature of your study. Before that, I would like to ask you, what are the different caregiving roles that we are talking about?
[00:03:27.070] – Michael Kramer
I think the important ones we looked at here are, first of all, the care activities that people perform. Here we differentiate it between care activities on a more personal level. This would be something like hygiene or dressing, and then any other care activities. These are more like performing chores, helping with cleaning, or also, of course, emotional support.
[00:03:51.950] – APS’s Özge Gürcanl谋 Fischer Baum
There are many different aspects of caregiving, and you tried to address all of them.
[00:03:57.650] – Michael Kramer
This was more of a moderation analysis in our paper. In our main analysis, we just looked at the general effects. Then for some of these moderation analysis, we looked at more the specific context. For example, this personal care factor I talked about, also the relationship to the care recipient. I think this also is a very important factor, whether people live together in the same household with a care recipient, or if it’s perhaps a relative that you visit once a week or something like that.
[00:04:26.550] – APS’s Özge Gürcanl谋 Fischer Baum
Yeah. Let’s start asking those questions then You hinted gender differences. Can you tell us a little bit more about that?
[00:04:35.920] – Michael Kramer
I think it’s interesting here because the two analysis differed a little bit. First of all, we looked at the transition models, and then in the second set of analysis, at the time spent on caregiving. This would analyze more the intensity of this caregiving role that people took on. We found some gender differences in these transition models. Once people took on this role of caregiver for the first time, men and women showed some different effects here, and women were generally more affected here. This was quite consistent across the different aspects of well-being we looked at. For example, life satisfaction, positive and negative affect, but also mental health and loneliness. But then in these transition models, we also tested for gender differences here and found that generally, the effects were relatively similar here, and men and women did not really differ significantly. For these models, it would be more the effect of within one person increasing the amount of time they spend per day or per week on informal care tasks. I think this was quite interesting that we found this difference here. I think it might have something to do with the fact that women tend to take on more caregiving tasks and generally tend to spend more time providing care.
[00:05:51.380] – Michael Kramer
This is a finding you can see in a lot of previous work from economics or sociology.
[00:05:57.900] – APS’s Özge Gürcanl谋 Fischer Baum
Yeah. Let’s talk about that over time effect a little bit. You discovered that spending more time on caregiving tasks results in more pronounced decreases in life satisfaction and mental health. How significant is the role of caregiving intensity in shaping these outcomes? What happens over time?
[00:06:19.030] – Michael Kramer
That’s a very good question. I think oftentimes in the caregiving context, it maybe starts out with less intensive care, but then over time, especially, I think with older relatives, There may be further decline in the health situation. Then people, even though they already perform some care tasks, maybe they increase in intensity over time because maybe the illness exacerbates or there are some other factors that come into play here and then require the caregiver to perform more intensive care work. We found that this was a very important factor in shaping these well-being effects. In the data we had, and this was from a relatively broad representative panel studies. In this data, I would say most people had relatively low intensity. There we also found some well-being effects, of course. But I think the most severe effects are then driven by the subgroups of high-intensity caregiving, I would say.
[00:07:15.980] – APS’s Özge Gürcanl谋 Fischer Baum
There are, of course, individual differences. Let’s talk about the ones that you mentioned in your article. There are individual differences in caregiving roles as well as in terms of experiencing loan illness, depression, and anxiety. Why do you think these effective experiences differ between caregivers and what contributes to these emotional fluctuations?
[00:07:40.470] – Michael Kramer
I think there are definitely important individual differences, but our paper did not really find a significant influence of these once we examined the effect of the caregiving intensity. It seemed that once people increase their time spent on caregiving and become more involved, the effect was relatively similar across these different contexts. But yeah, I think that does not necessarily mean that there are no other important individual differences. For example, I think something like personality could play a role. We also looked at this in a second paper that’s currently under review. There, for example, we found that different personality traits also have an influence on who initially takes on this role of informal caregiving. Then once people were in this role for a given time, it might also affect their personality over time. But yeah, these selection effects were more consistent. I think the differences between people definitely play a role here. But in this paper we’re talking about now, we mostly looked at the changes within each person. Here we found that these were relatively similar, for example, depending on the household context or also one other factor I haven’t mentioned yet was the employment situation.
[00:08:55.460] – Michael Kramer
We also differentiated between people who had full-time employment and people who were in part-time or no formal employment.
[00:09:03.790] – APS’s Özge Gürcanl谋 Fischer Baum
Yeah, interesting. Then we are talking about a shared experience for your participants in your study. Let’s talk about those contextual factors that you just mentioned. Could you tell us about them and how they are relevant to your research questions?
[00:09:18.510] – Michael Kramer
When we selected these moderators, I previously mentioned, so the care within households, the different care tasks, also full-time employment, we really wanted to focus on the ones that were also mentioned by theory and that were assumed to be very relevant in shaping this context in which caregiving takes place. But I think at the end, because we use these already available data sets, these representative panel studies, we, of course, also had to work with the data that was available in these data sets. I think there could be a lot of different contextual factors that we could not really incorporate in this analysis. I think one especially important context, I think, is the healthcare system in each country. There are, of course, very large differences here. What’s also, I think, been happening over the last couple of decades is that we often have, especially in the countries we looked at here, so Germany, the Netherlands, and Australia, We very often have these combined forms of care. This means that people are providing informal care to a relative or loved one at home. But then there are also professional care workers who visit them maybe on a daily basis or maybe several times a day.
[00:10:31.770] – Michael Kramer
Often these professional workers then take on more intensive care tasks such as hygiene or dressing. But there are, of course, also other relevant care tasks that are still taken by relatives or loved ones. I think this could be a very important contextual factor that we haven’t really looked at so far. What level of care is already provided by professional healthcare workers?
[00:10:54.940] – APS’s Özge Gürcanl谋 Fischer Baum
Yeah. What you are saying is, in a nutshell, caregiving doesn’t happen isolation. It is in the middle of the life that people are trying to live. There are economic struggles, there are other factors, and they are all contributing to this mental health decline. Let’s talk about the theories that you are addressing. You talk about two theories in your article, Stress Theory and the Role-strain Theory. What is the main difference between them in general?
[00:11:28.520] – Michael Kramer
These were the theories we identified from prior research, and they are also mostly coming from other fields than psychology. But yeah, I would say the main difference is in the mechanisms or causes these theories assume. I think both of them are quite similar in the predictions they make. Both of them would say that on average, caregivers’ well-being declines over time. But yeah, stress theory puts more emphasis on the intensity, the time, and also, of course, the stress that the different caregiving tasks risks exert in a caregiver’s daily life. They say that these are the main factors here, the primary stresses, you could say. Of course, then there are also some secondary stresses that are mentioned in the theory. But yeah, I would say the main difference then with role strain theory is that this one really focuses on the different responsibilities or roles that a person already has in their life. For example, a person could already be very much involved in full-time employment or maybe other care work with children. For example, with children, you sometimes talk about these sandwiched caregivers that have different care tasks in different generations, so to say. Role strain theory focus more on these potential conflicts with other roles that people are responsible for in their daily life.
[00:12:50.120] – APS’s Özge Gürcanl谋 Fischer Baum
Yeah, thank you. Can you explain then how your findings align with or diverge from these theoretical perspectives on caregiving and well-being?
[00:12:59.530] – Michael Kramer
Yeah, I think it was quite interesting because on the surface, I would say we found evidence for both of these theories because we found these general declines in well-being. But looking a bit deeper, I think that maybe we found some more evidence or stronger evidence for the stress theory because it seemed to us that the most important factor was this time span or intensity of caregiving. This was the most consistent predictor of further losses in well-being. But on the other hand, something the additional full-time employment did not make much of a difference here. It’s maybe not answered definitively. Maybe there are some other ways you could look at this, and of course, also with other data. I think, especially because these theories also assume some different causal processes. It might be very valuable to look at data with a more fine-grained temporal resolution and then maybe also look at the processes as they really occur in daily life. Maybe really ask people about potential conflicts they have between different social roles or ask them about their stress levels over time.
[00:14:07.890] – APS’s Özge Gürcanl谋 Fischer Baum
Yeah, it is a stressful task. Some studies mention well-being gains, but contrary to those studies, you find little evidence of well-being gains from caregiving. Why do you think previous research has reported well-being benefits, and what sets your findings apart?
[00:14:28.030] – Michael Kramer
This was also one of the main motivations for our study because when I initially read the literature here, I had the feeling that it was very mixed and quite inconsistent in both the findings and also the theories. Some of these assumed that caregiving also has its positive side, that people fulfill an important role, and maybe this additional role provides some meaning and some purpose in their lives, and that this then also translates into maybe higher life satisfaction or also some other positive well-being outcomes. There’s, for example, also a scale for positive aspects of caregiving. This was not used in this study, but the scale, for example, also measures some of these meaning or purpose-related constructs. This is definitely a caveat for our study. We included aspects of well-being that are more related to, as some people say, the hedonic side of well-being. This would be something like life satisfaction, positive and negative affect, but also mental health and loneliness. In these studies, we looked at we did not have data on constructs such as purpose in life, meaning in life. But it still surprised me, I would say, because also some of these theories then also said that maybe if people have increased meaning and purpose, then this would also translate into higher hedonic well-being.
[00:15:49.850] – Michael Kramer
But we did not really find this.
[00:15:52.690] – APS’s Özge Gürcanl谋 Fischer Baum
That’s interesting, and that is your paper’s contribution to the literature. Maybe it also explains the decline a little bit Maybe those effects are there initially when people just start their caregiving role, but maybe over time, they lose that life satisfaction.
[00:16:11.940] – Michael Kramer
Yeah, that’s definitely possible and would be very interesting to examine in further studies. I think these constructs from the psychological well-being side, meaning in life or purpose, they are not so often included in these longitudinal studies, which makes them a bit harder to study, I would say. But yeah, I think it’d be very interesting to look at them. Generally, they are a bit more stable over time compared, for example, to life satisfaction. So yeah, I’m still a bit- Surprised? Surprised. I’m maybe a bit torn in what to expect if people study this in the future. I think on the one hand, maybe people do indeed find some meaning in this role. But yeah, on the other hand, these constructs seem to be relatively stable if you look at other studies that have extended them.
[00:16:59.650] – APS’s Özge Gürcanl谋 Fischer Baum
Yeah, Let’s talk about your population a little bit. You hinted that in the beginning of our conversation. You tested people from three countries, Netherlands, Germany, and Australia. How do differences in healthcare systems and cultural expectations shape these caregiving experiences?
[00:17:19.010] – Michael Kramer
I think that’s a very interesting question and especially very relevant for caregiving. Our study can only, I think, address this to some extent. Overall, we found that the declines in well-being and the general patterns of the results were relatively similar across these three countries. I think in a way this makes sense because we also selected the three countries because they are relatively similar in their, you could say maybe cultural and also healthcare contexts. All of them have systems for universal healthcare, for example, other than the United States. They also have, I think all of them support some forms of these combined caregiving structures. So, yeah, context where people provide informal care, but then they are also supported by professional care workers. I think this is similar in all the three studies. But, yeah, I think our study is only a first step here. We did not really test for these differences between countries and more wanted to see whether the results generally replicated. In our context, they mostly replicated with, of course, some exceptions. I think another important factor here might also be the different instruments or measurements that were used. There were some differences here.
[00:18:36.980] – Michael Kramer
For example, in the Dutch study, they had a different instrument for a positive effect. Here we did not really see these decreases in positive effect. I mean, this might have, of course, several different reasons, but the explanation that sounds quite realistic to me is that this might have something to do with the measurement that was used here.
[00:18:58.470] – APS’s Özge Gürcanl谋 Fischer Baum
Like you said, this is just the beginning. I’m really curious about the results coming from other countries. United States is one, APS, his headquarters in United States. Also, I am from Turkey originally, so I would We have to see results from both of those countries, and I would like to continue this conversation with you in the future. Let’s talk about implications a little bit. Your study definitely have a lot of important implications for policies, and that alleviating the burden on informal caregivers? What specific policy changes do you think could most effectively support caregivers and protect their well-being?
[00:19:41.550] – Michael Kramer
I think this is an area where we still have to be quite careful because I think we need further studies before we can give really definitive answers. But I can maybe give some suggestions that have to be taken, of course, with a grain of salt. I think the policy changes, recommendations are relatively pressing I think, because of demographic change. For example, in Germany, maybe the context that I know most about, there are also some recent developments. For example, the care insurance has recently reported that they are almost bankrupt, so they have to increase the insurance premiums. Another reporting that you often see in Germany is that we don’t really have enough skilled workers to provide formal care. The hospitals or care facilities are just really understaffed. I think this is then also one of the incentives why policymakers now try to incentivize the informal care or the combined forms of care more, because we can’t really support everyone in formal care facilities. This tends to be more expensive. I think I haven’t mentioned this yet. If you ask the care recipients, most of them also prefer to stay in their own homes for as long as possible.
[00:20:57.410] – Michael Kramer
I think this is also a very important factor to consider. Because of this, I think it definitely makes sense to further support these combined forms of care because they tend to be more cost-efficient and also align more with what the families or the care recipients really want.
[00:21:17.380] – APS’s Özge Gürcanl谋 Fischer Baum
Right. I mean, as a world, we have an aging population in many countries, not all countries. But for those countries who have aging populations, this is something that should be addressed. Sooner than later with a strategic plan because it is coming, the trends are there. Is there anything else that you would like to share?
[00:21:36.840] – Michael Kramer
I think for the last question, I focused a bit more on the policy or the context side. But I think, of course, what our paper also shows is that it’s very important to also consider the psychological side and not really blend out or forget how taxing and how difficult this can really be for informal caregivers. I think they definitely need further support. The support can, of course, come from other family members members. Maybe our study also shows in some first steps that we might maybe promote more gender-equal ways of providing informal care. Maybe men have to take on more of that care work in the future. Then I think there might also be some ways that perhaps psychological interventions can also play a role, maybe at the community level or maybe online, to further support informal caregivers.
[00:22:27.350] – APS’s Özge Gürcanl谋 Fischer Baum
Yeah. Michael, thank you very much. This It was a pleasure.
[00:22:31.390] – Michael Kramer
Yeah, thank you so much for inviting me.
[00:22:34.340] – APS’s Özge Gürcanl谋 Fischer Baum
This is Özge Gürcanl谋 Fischer Baum with APS, and I have been speaking to Michael Kramer from the University of Zurich.
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