By Greta Shealy, MSN, RN, CCM

Case managers work with families every day who find themselves in a situation that requires a sacrifice on behalf of a caregiver. Some caregivers are willing and able to take on that responsibility. Others find it threatening, even scary, as they realize that the person they need to help does not want them around, is manipulative and abusive, or resents them for intervening. Many caregivers have spent years (and often thousands of dollars in counseling) putting up “walls” that protect them from their dysfunctional family. Consider the way ancient castles were built. Their walls create a bumper against the stinging arrows and rocks of invaders. Those “walls” are boundaries of protection meant to help family members co-exist while maintaining emotional health. What can you do to help the caregiver who faces the collapse of their boundary walls as part of their caregiving role?

Understanding family dynamics is a crucial part of the case management caregiver assessment. Sometimes you can walk into a patient’s room or home and immediately experience tension. It thickens the air. You can feel it as the caregiver sheds tears, explaining how they are “stuck” in this situation and don’t know what to do. You can hear it in the stinging comments made to the caregiver or see it in eye rolls or laser-wielding stares. It’s hard to watch, and even harder to manage.

I remember the daughter of one of my clients who sat and listened to her mother complain and criticize the daughter’s caregiving, even saying she felt that her daughter “was happy that she finally got control of everything.” Sure, that does happen sometimes. But in this case, the daughter/primary caregiver had the look of someone who was being pelted with comments that stung her like pebbles as they landed. I pulled her aside after the assessment and asked her how SHE was doing. She cried. No one had asked her that before. She told me about her mother’s narcissism and the way she had escaped as a young adult to create a life for herself and her family with healthy boundaries. Now those boundaries were down as she took on the caregiving role. She had moved into her mother’s home, leaving her family and job behind, because her mother refused to move from her own home and there were no other family members to help. The tension between them was old, thick, and unyielding; And it negatively impacted her ability to provide care for my client.

I often tell my client’s caregivers that they must take care of themselves or they will not be able to take care of their family member. That is so hard when you are stuck in a small apartment with a person who needs help but berates you all day about how useless you are. They may feel stuck inside of walls that they did not build, while losing the defenses they placed around themselves for protection. If the caregiver cannot maintain their own safety and health in their role, their ability to provide care effectively is compromised, and the case manager should consider helping them explore other options for the client’s care.

One way to combat this kind of tension is by changing your focus. In her book, Will I Ever Be Good Enough? author Karyl McBride, Ph. D., encourages her readers to “look for the gold in people,” even those who act in selfish or narcissistic ways (McBride, 2008). She explains the importance of acknowledging the need for boundaries and supporting family members who have established them, while encouraging empathy as the antithesis to narcissism. Once you identify someone’s good traits, you can allow yourself to be grateful for those parts of the relationship and focus on positive attributes. This can be harder said than done in the relentless caregiving experience. Helping caregivers look for positive traits and gifts in their family member can bring a little peace to these complicated relationships and build resilience through gratitude and forgiveness. Empathy can feed the caregiver’s soul.

The first step in identifying potential weak spots in our client’s caregiving situation is establishing a trusting relationship. I believe that kindness and empathy are the keys to building trust with both the caregiver and the client.  Listen, watch, and see what they’re telling you about their situation. Encourage caregivers to maintain their boundaries, if possible, and to be mindful of their own health and needs. Practice kindness and teach gratitude. Their walls may need to stay in place or be built back up. By strengthening and supporting our client’s caregivers, we are advocating for our clients as well.

Works Cited: McBride, K. (2008). Will I Ever Be Good Enough? Healing the Daughters of Narcissistic Mothers. New York, NY: Atria.

Bio: Greta Shealy’s 36-year RN career includes experience in Women’s & Infant Health, Faith Community Nursing, psychiatric home health and hospital and home care management. She was her mother’s full-time caregiver for several years and is passionate about the right to live and die with dignity.

For more on how to support caregivers, explore the course "Empowerment Makes a Difference: A Case Manager’s Approach to Assisting Family Caregivers Achieve Optimum Wellness" here: