After my father died, I became increasingly aware that my mother was suffering from dementia. She had never known how to turn on the air conditioner or the television, those were my father’s jobs. This was different. Each time I visited her, I found another piece of evidence. The kitchen table was full of crumbs and sticky from various meals; the refrigerator was full of spoiled food; her clothing had stains on it. I had no idea if she was taking her medication or not and she was not a reliable narrator. I did not want to take responsibility for my mother, but both my brother and sister were dealing with family and health issues. They did not want to know that my mother had dementia. Finally, I hired a geriatric social worker to come to the house and observe my mother for an afternoon. He verified that she had dementia and should not be left alone. I knew I had to take action. I was 55 years old, but all the feelings I had avoided during the years I was raising my children flared up again. I knew I was going to have to struggle with my feelings about my brother getting special dispensations because he is a boy; my wish to have my mother appreciate me; and anger at my mother for being so needy.


Middle-aged caregiving is a stage of life that can be a painful re-enactment of old unresolved feelings about parents, or an opportunity to resolve them. In this stage of the life cycle, the major conflict is between acceptance and resolution of disappointments vs. repetition and holding on to old wishes. Ambivalence is central to the experience—and yet so many of us have difficulty tolerating our ambivalence. We love our parent(s) but feel angry at what we did not get from them; we want to help, but feel resentful about what we have to give up in order to do so.

Psychotherapists can help patients cope with this conflict by helping them tolerate their ambivalence, and resolve rather than repeat old patterns with parents. Patients may seek help because taking care of an elderly parent is making them depressed or angry. Of course being a caregiver may be a heavy burden under any circumstances. But many caregivers are suffering more than they have to because they are repeating dysfunctional patterns from childhood. The therapist needs to help the patient identify the dynamic that is being repeated. But, while there is a large literature about caregiver selection, there is little attention to the unconscious motives for caring for elderly parents.

These are four common patterns that make caregiving more difficult and painful.

1. The co-dependent caregiver needs to be needed and is used to organizing her life around the chaotic moods and needs of a parent. While all caregivers have to make some sacrifices to care for their elderly parents, co-dependent caregivers sacrifice their happiness for others when it doesn’t require it. Typically, co-dependent caregivers are the children of alcoholics, drug addicts, depressed or mentally ill parents.
2. Daddy’s girl wants to take care of her father and feels that she will do a better job than her mother. She has always felt that her relationship with her father is more special than the relationship between her parents. Caring for her father involves competing with her mother; she needs to show her mother’s inadequacy. Similarly, Mommy’s boy wants to take care of his mother in a way that his father did not. The triangular relationship, a remnant of early childhood, gets repeated in the caregiving experience.
3. The angry/guilty child never felt loved or appreciated by her parent(s). Her caregiving is based on guilt and the guilt is a response to feeling angry. This is a repetitive cycle: the more she does to offset her guilt, the angrier she gets for giving so much to someone who never took care of her as a child.
4. The child who was sent away or abandoned often experiences the parent’s inability or unwillingness to parent as a reaction to his/her being a bad child. For example, when parents divorce and one moves away, the child often feels that the parent left because she was bad. For some, middle-aged caregiving is an opportunity to be good and get the parent who left or sent her away to love them.

Paula is an example of a co-dependent caregiver. She complains that the time and energy she is spending caring for her mother makes her angry and depressed, but she feels she has no choice but to continue. Paula’s mother had re-occurrent breast cancer six years ago. She lives in independent housing, but her dementia is increasing. When her mother goes to the doctor, she cannot remember why she’s there. She’s safe right now, but only because Paula keeps her medication and gives it to her every day. Each time her mother is hospitalized Paula says she is going to put her in a nursing home, but she never does.

Paula says she always felt like she had to be the mother. She did the shopping and cooking because her mother was working or with a boyfriend and Paula was the oldest girl. When her parents’ marriage fell apart, Paula felt that she had to be even more grown-up.

So why is Paula taking care of her mother when her mother did not take very good care of her? Paula needs to be needed, but she’s confused about who needs her most. She is neglecting herself, her husband and her daughter in order to keep her mother out of a nursing home. Paula also cannot accept that her mother can be taken care of in a nursing home. Paula wants to feel indispensable—she wants help, but she resists changing.

Breaking this self-destructive loop requires time and patience. In my experience, the patient’s insistence that there are no alternatives can be intense because of the underlying unconscious dynamic. The patient may express rage at the therapist suggesting there are alternatives to staying in the same painful pattern, and the therapist may get frustrated at a patient who begs for help but refuses to change. Take heart and take your time.
 


File under: The Art of Psychotherapy, Musings and Reflections