Q: I have clients who feel anguish and dread about caring for parents with whom they’ve had bad relationships. How do I help them approach the caregiving experience more positively?
A: The bedraggled, beleaguered, and bereft family caregivers who come to us for therapy have a common litany of complaints. They feel overburdened by caregiving tasks, unacknowledged by those they’re caring for, and unsupported by family members who take their herculean efforts for granted. They’re part of the 38 percent of family caregivers who, according to a 2015 survey by the National Alliance for Caregiving and the AARP, find tending to aging parents or disabled spouses to be highly stressful. If they’ve been previously neglected or abused by the relative they’re now caring for, they feel even more put-upon, entrapped in an intolerable bind, in which they’re being tortuously revictimized.
Our first job with these clients, of course, is to commiserate with them for making years-long personal and professional sacrifices on behalf of family members they still experience as hurtful. But we do them only limited good if we only reinforce their view of caregiving as an unremitting ordeal. Instead, we need to find ways to identify and highlight how their work can be experienced as positive, even life-enhancing.
If this sounds like Hollywood fiction, then maybe you’ve seen The Savages, a 2007 film starring the late Philip Seymour Hoffman and Laura Linney, which depicts the kind of transformation we try to foster for our clients. Hoffman and Linney play emotionally distant siblings with intimacy problems who are suddenly asked to take care of their now demented father, who abused and abandoned them decades ago. Through their devotion to protecting him and the trust they develop for each other, they gain a sense of mastery and a rock-solid commitment that previously eluded them. By the time their father dies, they’ve grown into better people—more loving, more confident, and capable of sustaining mature relationships and creative careers.
Similarly, our client Gloria’s caregiving journey led her toward greater resilience. A 63-year-old, single nurse, she sought psychotherapy when faced with the challenge of caring for her hostile, rejecting mother, Cora, who was suffering from diabetic complications and small strokes. Gloria was plagued by childhood memories of coming home from school and finding her mother lying silent on the couch. Cora would never say hello to Gloria or ask about her day. Even as Gloria grew into adulthood, Cora never showed interest in her career, her friends, or even her romances. Despite this, Gloria still loved Cora and for years had fruitlessly attempted to please her. In caregiving, Gloria saw a final opportunity to win her mother’s approval, but she was greatly concerned that spending more time together would only reinforce their painful dynamic and cause her to become resentful, anxious, and depressed.
As therapists, we can promote positive caregiving with clients like Gloria in several ways. First, we can help them identify the positive values or meanings behind their conscious choice to serve as a caregiver. After listening to their caregiving stories and validating the challenges they face, we can ask, “Why do you do what you do for your loved one?” Their answers often reflect complex, personal, and spiritual reasons that they’ve never expressed, such as “he always took good care of me,” or “it’s what I believe a good daughter should do,” or “this is my way of doing God’s work in this world.” Whatever reason they give, our role is to offer ourselves as allies for sustaining them as caregivers who uphold those values.
Gloria’s view of herself as a healer of suffering had led her to become a highly competent nurse. The same belief underlay her commitment as a caring, if often disappointed, daughter. “It’s what you do for your mother,” she said, “no matter who she is.” Affirming her reasons for caregiving, we offered to support her mission of reducing her mother’s suffering.
Identifying and emphasizing values is only one strategy for helping caregivers view their difficult jobs in a broader, more salutary context. Another is to use what we call prospective retrospection, or “pre-hindsight,” to imagine how they’ll regard their caregiving from some point in time in the future. Specifically, we ask clients, “How do you think you’ll look back at this time in your life five years from now?” It helps to remind them that their current struggles are time-limited, and in the long run they may judge them as ultimately gratifying.
We used several methods to help Gloria gain a longer view on her caregiving. Eventually, she came to recognize that her old hopes from childhood—to have a more loving connection with her mother—would have to change to fit the current reality, now that Cora was weakened and diminished by illness. We discussed how their relationship could never be like a mother lovingly cradling her childlike daughter. Instead, Gloria began to imagine their relationship as one of two adults: the competent daughter and the failing, if still powerful, mother.
As Gloria began to care for Cora with this vision in mind, she could ignore her mother’s initial belittling comments more easily. She quickly learned that, if she stopped playing the vulnerable, overeager-to-please daughter, then her mother’s rejections would fall flat. Instead, Gloria found that the more she embodied her professional nurse persona—thorough and compassionate, but also at some emotional distance—the easier it was for her mother to accept her care and stop responding so negatively. Over time, these women forged a relationship of mutual respect and even admiration. Her mother allowed her to make decisions about her care, advise her about treatments, and manage her personal affairs. Sometimes, Gloria reported, her mother even spoke to her as she would a friend.
Another aspect of our therapy with caregivers is to work toward increasing their affect tolerance and discernment. We accomplish this, in part, by teaching them mindfulness skills to observe and accept whatever they’re feeling. But we also explicitly tell them that it’s normal to have some negative feelings—such as sadness, anger, and anxiety—about caregiving, and that no caregiver need feel guilty about being ambivalent about his or her duties. We acknowledge their past resentments about the care receiver, but we caution them about conflating their old emotions with current frustrations over the rigors of caregiving. We tell them that the present is hard enough without letting the past completely color their current experiences.
For Gloria, caring for her mother would remain challenging. At times, Cora didn’t follow directions and continued to be moody and unhappy. As her health declined and she lost more and more ability to care for herself, she became likelier to lash out. In therapy, Gloria admitted to feeling angry, resentful, and frustrated. Predictably, she also felt guilty about having these feelings. She’d believed that caregiving should come from love and dedication and that, because she’d chosen this path, she had no right to her own negative feelings. We worked to differentiate her old resentments from new ones arising from the challenges of her caregiving. And then we focused on how we all have a range of feelings, and that feelings are always acceptable. We worked to observe them, accept them, and let them pass. Then, Gloria could decide what to do with them.
Gloria’s caregiving years came to an end when Cora died from yet another stroke. When Gloria looks back today on that period in her life, she acknowledges the hurdles she had to overcome and the hours of effort she endured. But mostly, she feels what we hope to foster with all our caregiver clients: immense gratitude. She had the opportunity to forge a new relationship with her mother, one in which she could feel good about herself. Her mother had respected her professional abilities and had allowed her to ease her pain. In fact, their relationship during that time was better than at any other time in Gloria’s life, and she could feel a sense of competence and confidence that she’d done a difficult task well. In that way, her arduous experience could bolster her sense of herself as a nurse and a healer—a gift that could live on in her life long after her difficult memories with her mother had begun to fade.
Barry Jacobs, Psy.D, is the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA. Julia Mayer, Psy.D, has a private practice in Media, PA. They’re married and are the coauthors of AARP Meditations for Caregivers: Practical, Emotional and Spiritual Support for You and Your Family (Da Capo, July 2016). Contact: firstname.lastname@example.org, juliemayer23@comcast.
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