Q: Many of my older clients and their family caregivers resist accepting help from others. How can I get them to receive the care they need?
A: For those who've spent their lifetimes taking pride in giving generously to others, suddenly being on the receiving end of care because of illness or age-related infirmity can be tormenting. Stalwart seniors frequently reject offers of help without consideration, declaring, "I don't take handouts." Their baby-boomer, adult children may be just as reluctant to accept outside help, flatly stating, "Our family takes care of its own." Despite the fact that many of these families desperately need emotional, financial, and hands-on support, their reticence to accept help serves to prove the common adage, "It's easier to give than to receive."
For many people, reaching out for and accepting help aren't seen as ways of marshaling forces to fight the good fight, but rather as tantamount to admitting weakness, being defeatist, and advertising failure. By contrast, rejecting help is regarded as a measure of one's courage and determination in battling family crises brought on by old age or disease. So, accepting help is perceived as disempowering; rejecting it is empowering.
This line of thinking often dovetails with concerns about self-identity. For those who've long occupied the high moral ground of kindly caring for others, being reduced to needing care themselves is experienced as a painful loss or diminishment of who they are. It's intolerably humiliating and shameful. Therefore, they cling to what they're sure are their own best virtues by vigorously staving off any offers of aid from others—even from grateful and willing relatives and neighbors whom they've previously helped.
This is compounded by worries about others' judgments. Many seniors and their caregivers fear that going to support groups, employing home health aides, or accepting other assistance will be viewed by family and friends as signs of weakness. I recall debating a 62-year-old, Parkinson's-stricken man and his wife at an educational workshop who were convinced that their adult sons would be aghast if their father agreed to use a walker to help him compensate for his shuffling gait. I suspected that they themselves couldn't tolerate the reality of the man's increasing loss of physical self-control, and that they projected their fear and loathing of his condition onto their sons. Consequently, he refused the walker and all other assistive devices. I asked them whether their sons would think they were stronger and more independent if he struggled to walk 100 yards on his own or used the walker and traversed 1,000 yards. They steadfastly chose the former.
What are the best ways of overcoming this common tendency to refuse help? Many of the world's major religions have developed precepts for overcoming these feelings of abhorrence at our own human weakness and dependency. Within the Judeo-Christian tradition, there's the concept of acknowledging and expressing gratitude on a daily basis for the food, air, and other essentials that we receive from God that enable us to live. We're enjoined to extend this sense of gratitude for the good works and blessings we've received from our fellow human beings.
Buddhist monks from Thailand go into their communities each day to beg for alms, not because they need food—they have plenty of supplies back at their monasteries—but to engage in two spiritual practices: to learn the humility of graciously receiving whatever they're given and to provide for those who place food in their alms bowls the salutary experience of giving to others.
Therapists can effectively draw on these spiritual teachings, but first must figure out how to connect with proud seniors and caregivers who are so adept at deflecting offers of help. Right from the outset, I openly acknowledge that I understand they aren't especially happy to be visiting a psychotherapist. By being curious and receptive, I make sure I do all I can to avoid treating them like supplicants at the feet of a psychological expert. They are the experts on how well they're coping, I quickly concede. I assure them I'm just interested in hearing their stories of how they're overcoming whatever challenges they're facing.
Part of what I'm interested in learning is how they feel about landing in a life circumstance that makes them the object of others' concerns. I ask them specifically about what the idea of receiving help means to them. If they tell me it makes them feel resentful and "lousy," I empathize sincerely. But I also question the idea that receiving care is necessarily disempowering. Couldn't it increase their sense of self-efficacy, I wonder, if it lends them the capacity to do more of what they want?
If they're failing seniors who are against accepting help from their adult children, I always inquire if they themselves helped out their parents when they were declining years ago. If the answer is yes (as it nearly always is), I wonder about the example that their parents set while being the "burden" of care—did they grouse, chafe silently, or display grace? I ask them about the kind of example they want to set for their children and grandchildren. Finally, I suggest that this is an issue of generativity: teaching those next in line about how life's vicissitudes should be handled.
I point out that receiving graciously can be a teaching tool. Be magnanimous and allow your kids to reap the satisfaction of helping you, I exhort the parents. Let your children feel that they're making a substantial contribution, and they'll gain a greater sense of maturity and mastery than they've ever had before. When the idea of accepting help is placed within this relational context, many stubborn seniors finally begin to perceive the giving that's within receiving and go along with the plan.
When this, too, fails, I opt to emphasize the giving that these seniors can do—giving that has receiving built into it almost as a kind of afterthought. I learned the power of this approach years ago, when I was asked to run a support group for amputees in a hospital-based physical rehabilitation unit. The patients' tangential bantering, incessant joking, and outright hostility quickly revealed to me that none of them wanted to receive psychological advice of any sort; they weren't interested in adding the loss of dignity to their loss of limbs. It was only when I told them that I needed their help to write a manual on coping for future amputees who'd be patients in that hospital that the group members poured out their hearts with their own observations, feelings, even tears. They were certainly receiving support from each other in the group as they helped put the manual together, but only in the guise of giving me some help. That, for them, was much more palatable than the prospect of receiving what they perceived as pity or busy-body exhortations from me.
As a consequence of that experience, I now frequently ask reluctant seniors and caregivers if they'd be willing to reach out and help others in similar positions. Most readily agree. I then give them the phone numbers or e-mail addresses of other clients who are also resistant to receiving help. In this way, relationships are formed in which all parties are happily giving to each other. The fact that they're simultaneously receiving from each other is a small point that I don't bother to mention.
Barry J. Jacobs, Psy.D., is director of behavioral sciences for the Crozer-Keystone Family Medicine Residency in Springfield, Pennsylvania, and the author of The Emotional Survival Guide for Caregivers —Looking After Yourself and Your Family While Helping an Aging Parent. Contact: firstname.lastname@example.org. Letters to the Editor about this department may be e-mailed to email@example.com.