In the early era of marriage and family therapy (MFT) there were no such professionals as “marriage and family therapists.” Pioneering practitioners were drawn from a number of disciplines: psychology, social work, medicine, the ministry, and juvenile justice, and brought with them the dominant mind-set from their core training. The theory and practice of MFT comprised a hybrid of these backgrounds. Not, however, a hybrid like a Toyota Prius whose electronic and internal-combustion engine hums, almost silently, and in perfect harmony. The MFT hybrid was more like the early, clunky skateboards that were patched together by cutting a two-by-four and bolting on salvaged skate wheels that rolled down the sidewalk clicking and clacking.

Eventually, the exciting but messy early era in MFT came to a close: the combination of attrition, licensing laws, new academic programs, published theory, and conferences made MFT a discipline unto itself. Practitioners came to appreciate that, while ideas from individual psychodynamics, interpersonal theory, medicine, and sociology were relevant to MFT, a new way of working required a new way of thinking and a new way of training.

An Opportunity

Care consultation and mediation (CCM) is being practiced by those who were trained outside the field—typically, in social work, nursing, legal mediation, counseling, and even financial management. These practitioners, as did the early MFTs, bring along the mind-set from their backgrounds and must learn their CCM skills on the job. Unfortunately, it can take years for that on-the-job training to turn into competence. The practice of CCM could benefit greatly from a new way of thinking and, with it, a new way of training.

There are tens of millions of potential clients and very few skilled professionals to serve them, but you won’t find a single training program that focuses solely on care consultation and mediation—again, a situation parallel to the field of MFT prior to the 1960s.

As with marriage and family therapy before the boom, health professionals believe that the field of CCM is not unique and that it’s being sufficiently addressed. It’s not. My practice is bursting at the seams. Though I can’t come close to covering the referrals that come my way, I have no one to refer to. I no longer market. Now I duck.

Lighted is not Enlightened

The need for CCMs is no secret, so what’s being done? The solution is being searched for under lighted lamp posts. There’s an old joke: It’s dark; a person loses a coin and is searching for it under a lamp post. A stranger comes along and agrees to help. After a while, the stranger asks how far from the lamp post the coin was lost. The searcher explains that the coin was lost across the street, a good distance from the lamp. The exasperated stranger wonders, “So why are you searching for the coin here if you lost it way over there?”

“Well,” the searcher explains, “this is were the light is.”

The lighted lamp posts, in this case, are academic programs in geriatrics, staffed primarily by research professors rather than by clinicians. But a degree program in geriatrics is no more an adequate training mode for care consultation than physics and wood shop are for hitting a baseball, or would be for physicians and nurses being training solely in human biology, hold the practicum. While understanding the physical and mental changes that take place in aging is useful, it’s insufficient training for clinical work.

To be effective, a CCM must be sensitive to at least as many influences in the lives of a client as should a family therapist. Typically, a CCM is brought in when a transition becomes necessary because the client is contending with the biological and psychological effects of aging. While finding the right placement for the client often becomes the focus, it’s commonly the easiest task.

Getting all those involved, especially the client, to agree to the transition can take the most delicate of negotiations. Negotiating a transition for the client can bring up latent or not-so-latent animosity between adult children and adult step-children, between parents and their children, between step-parents and step-children, and with anyone else who may have a long-term relationship with the client. One of the most challenging conflicts to contend with is when your client has remarried late in life and the couples’ children take sides against their respective step-parent. (You’d like to believe that everyone wants to do what’s best for the client but that’s not always the case.) And when every interested party is in agreement on the placement for the client, you still may have just started your work. If the client has behavioral problems, then you may have to become an ambassador between the facility and the client’s family. While the practice of CCM often brings images of “genteel old ladies and smiling family members,” when the negotiations get tough the negotiations are as genteel as partisan politics. CCM is not for wimps, at least not untrained wimps.

All this is to say that the competent practice of CCM is not something that you can pick up from reading a couple of books (as if there were any) or going it alone in the “school of hard knocks—not without casualties. As with any complex professional practice, your learning experience should be backed by theory, peer support, and supervision. If you can get that strictly on-the-job then you’re probably wearing tights and a cape.

Curriculum and Programs

A framework for a training program must take into consideration its current environment. As stated above, the practice of CCM is a distinct service but, at the same time, shares expertise with other counseling-related services—no point in throwing out the cat with the cat litter. CCMs will be typically working with a family, and often with physicians and other medical professionals, attorneys, guardians, caregivers, placement specialists, and others. Understanding of personal psychology, family systems, and social systems is essential. And as they’re usually working with elders, knowledge of the effects of aging is necessary. In short, while offering a distinct service, CCMs can learn much from what they share with other professionals in medicine, law, counseling, social work, personal coaching, and geriatrics.

Nevertheless, slapping together a training program by assembling professionals from other disciplines would be a mistake—remember the clunky skateboards. What we’re after is a program that makes the best use of available expertise, while starting on the road to attaining its own identity. The profession of care consultation and mediation is sufficiently complex and unique that it will eventually have its own literature, training, and perhaps, licensing—and, I hope, a shorter name.

You, noted care consultant and mediator, and elder’s children, are moving through the session smoothly when, what seems to come out of nowhere, one sibling lashes out at another. Ouch! Where did that come from? Unless you were one of the five people on Earth who grew up without a bit of resentment towards your parents, siblings, or the family’s pet hamster (and those five people are lying), you know exactly where that came from. Family members, sitting in a room, discussing sensitive family-related issues? It feels like therapy, and we all know that during therapy it’s okay — expected — to reveal hidden and sometimes powerful emotions. Family therapy and care mediation have so much in common that both care consultants and their clientele often confuse one with the other. Care mediation suffers from the if it looks and quacks like a duck, it must be a duck syndrome. But care mediation is not family therapy.

First, the similarities. A care consultation session often includes family members of more than one generation and, nearly always, one or more siblings. Those present have been brought together to solve a problem that has proven intractable. One or two of those present may be the focus of that problem. Most participants have a history together, about which they have varying opinions and attitudes, and that history results in mixed emotions about each other. There are numerous alliances and conflicts among the members.

Now let’s look at the differences. The children are nearly always adults and are looking after the needs of their parents rather than the other way around. The client may not be present in the session. (As a family therapist, I often worked with children’s issues by working with only the parents—but that’s not typical.) The siblings don’t live together, lessening their need to get along with each other. While there may be significant cross-generational issues, everyone is a grown-up and may do as they wish — although the client may be (legally declared) incompetent to make certain decisions. Potential inheritance — money — is the tyrannosaurus rex in the room.

There’s one more major difference, and for the care mediator, it’s the one that counts. It’s the one you have to remember when a participant first confuses care mediation with family therapy, and unloads both barrels on someone in the session — maybe a sibling, maybe a parent, maybe you. Experience tells you that, once the congeniality force-field gets lowered for even a moment, the dung will hit the wind-powdered energy generator: factions among siblings and elders will pop-up so fast, and in such number, that you’ll need Deep Blue to keep tabs. If you’ve kept your wits about you, this difference will whisper in your ear that it’s time to hit the pause button before you and family fall down a rabbit-hole of such chaos that it would make Lewis Carroll renounce fantasy.

You’re going to have to jump through all the stages of, “Oh, hell!” — from denial to acceptance — in moments, because the only person that pause button works on is you. What you have to remember is that, in family therapy and care mediation, the goals are different. While, in family therapy, the “identified client” is nearly always a child who is misbehaving in some fashion — skipping school, disrupting classrooms, doing drugs, running away, and so on — the client is typically viewed by the family therapist as one who is “acting out” to take the heat off the real problem. For example, Johnny disrupts his school classes because, as long as he’s the problem his parents stop bickering and (in his mind) won’t get a divorce. The family therapist understands that Johnny won’t stop acting out until his parents’ marital issues are dealt with. Whether or not the marital issues are dealt with directly or by way of Johnny’s problems is based on the approach of the family therapist, but dealt with they must be if Johnny is going to change his behavior.

Hence, the goal of family therapy must always take into consideration that, since they must all live together, they need to get along well enough for that to continue. And to make that happen, your job as a family therapist may be to help them change the complex family dynamics.

In contrast, the care consultant’s job is not to be concerned with the family’s dynamics except in how it immediately interferes with the goal of setting up and maintaining care for the client. All the work in the session should be to that end. This does not mean that the care consultant can ignore family dynamics, or that a deep knowledge of family systems theory is unnecessary. It’s important to know what influences are present during the negotiations among family members. A 40-year-old adult child’s concerns may be as complex, indirect, and unconscious as is with the disruptive Johnny. However, in care consultation and mediation, your interest is in minimizing the focus on concerns that are disruptive rather than constructive to setting up care. Respectfully acknowledge those feelings, but do not let them take over the session.

When I get referrals from family members or professionals, I grab the phone to gather a sketch of the situation. Depending on the circumstances, I may or may not make phone contact with additional involved parties — i.e., family members, health professionals, lawyers, and, if he or she is capable, the client. Following the phone contact, I arrange a meeting with the involved parties who are able to attend.

Before the first meeting, I usually believe I have a grasp of the situation. During the meeting I learn that grasp is on a rickety handle. As I listen to the various points of view, the “neat sketch” I compiled earlier transmogrifies into abstract art: facts are disputed, arguments ensue, solutions are found wanting. I’ve learned — finally! — not to develop specific recommendations prior to a meeting. Instead, I carry in a general notion of the options. As the meeting progresses, I hone this general idea into a neat approach to solving the problems for the elder and family.

To my dismay, elder and family rarely jump at my neat package; don’t care that it took great pains to assemble. My ingenuity, insight, and judgment, go unadmired, underappreaciated. Why are my clever solutions rejected? Because, as it turns out, people and their circumstances aren’t neat little packages; they’re messy confusing packages, and, unfortunately, as they age, often become messier and more confusing. For elders, there are many reasons for that mess and confusion. Here are the common ones:

Fear of change: Most of us fear change, i.e., the unknown, and to the best of our ability, try to avoid it. For elders, change is even harder because more often then not, it is thrust upon them: They lose functioning and they lose family and friends. Elders are less likely to make changes voluntarily because they are forced to deal with so many changes that are not voluntary. While, for example, I might think a move from home to an assisted care setting is reasonable, elders may be reluctant to abandon the scene of their history, memories, and youth.

Family dynamics: With sufficient pressure from her children, Grandma may agree to assistance but not be genuinely committed to getting help. If one of her children is shoring up her care, Grandma may not recognize how much aid she needs and may not see a reason to make a change.

Dementia: Bills are being ignored and pots are left heating on the burner. Memory loss sneaks up on Mom but neither she nor her family take notice. Both may refuse to acknowledge that there’s a problem.

Money: Many elders are unwilling to spend much, if any, money on their care. Depression-era seniors have a unique concept of how much things “should” cost, and cannot bear to pay a penny more. They may even think services should be free. Also, they may want to conserve as much as possible to pass to their children.

Fear of losing independence: Grandpa may regard accepting help as the first step towards being seen as completely dependent and on the slippery slope to a nursing home.

Ageism: Many elders do not view themselves as old. If I recommend an adult day health center, retirement or assisted living, they’ll respond: “I don’t want to be with all those old people.”

Who’s the decision maker?: His children may be helping Dad make a change, by scheduling visits to assisted living or by setting up an assessment by a homecare agency, but the change may be thwarted by Dad if he has no intention of either moving or hiring care. While his children may believe change is necessary, Dad makes the decisions as long as he’s competent. Providers may get trapped in the middle.

Each of the above can interfere with elders making those changes that can help them function as independently as possible. In our brief contacts with elders and their families, these issues are not easily seen or readily solved. Lives are messy, cases are messy.

You may have heard this before: Put a frog in a pot of water and set the burner to simmer. If the change in temperature is sufficiently gradual, by the time the frog experiences pain, it will be too late to escape. (Please don’t try this at home.)

Could you be that frog? It starts simply. While shopping, you pick up a few items for your elderly, widowed father. As time goes on, you get more and more items for him and make extra stops at various stores. Before you know it, you’ve taken on all his shopping and errands. Next, the laundry becomes too difficult for Dad. So, being the dutiful daughter, you’re now washing, drying, and folding his clothes. Then, Dad begins to have difficulty cooking so you bring over a couple of meals a week. Then, well, you get the picture. Before you know it, you’re neglecting your own household and work responsibilities and are so stressed you’re ready to implode.

And what does Dad think about your help? He thinks he needn’t spend any money on his care because “my daughter takes care of it.” He has learned to take your assistance for granted and so have you. Both of you forget how much you do and how long it takes to do it. If Dad has dementia, it’s even worse; he may forget all the “little” things you handle.

While Dad is proud of his ability to live “independently,” you, being human, are growing resentful of the increasing time you spend caring for him. So you bring up the possibility of hiring help and come up against his attitude towards money; i.e., he doesn’t want to spend any. He may even play the guilt card to ensure that you continue to pick up all the chores he is no longer capable of handling. So there you are, boiling, and you can’t jump out.

Here’s another example of a caregiver in a pot. Your wife, who suffers from multiple sclerosis, is experiencing a steady decline and is becoming dependent on you for all of her care. She can no longer move from her wheelchair without help, so you must be with her all the time. Actually, someone must be with her, but she will accept help from no one but her husband. She is unwilling to recognize the amount of stress that results from providing constant aid, and you are unable to identify and state your needs. The situation moves to the breaking point when you are diagnosed with cancer and must undergo chemotherapy.

Set limits

The best way a caregiver can reduce stress is to set limits. While respite helps, it is unlikely that someone who won’t set limits will take adequate breaks. More times than I can count, I see caregivers who take far more responsibility for their disabled spouse, parent, or other loved one than they can handle. They ignore there is a limit to what they can provide without harming themselves.

Many caregivers feel guilty if they give any consideration to themselves at all. The following example from The Caregiver Help Book illustrates why feeling guilty makes no sense: “When you board an airplane, the flight attendant gives several safety instructions. One of them is, ‘If oxygen masks drop down, put on your own oxygen mask first before helping others.’” This is a vivid example of how tending to your own needs first allows you to assist others.

Setting limits is about taking care of your own needs. When you do so, you will be more competent with those you help.

And, how?

Let’s look at a couple of examples to see how setting limits can be good for all involved.

(1) Your aging mother can no longer do her laundry because the washer and dryer are in the basement and it is unsafe for her to climb stairs. Your solution is to do the washing for her. Why not? You work only part time, and visit her weekly anyway. It would be simple to do a load while you’re there and bring it upstairs for her to fold. What you could not foresee is what happens two months later. Your husband gets laid off so you must double your job hours. Now, doing your mother’s laundry — no big deal, remember? — interferes with the precious moments you have with her, not to mention the time-squeeze for your own family.

What could you do differently? Instead of taking over, why not find a way your mother can continue to do her own laundry? Can the washer and dryer be moved upstairs? Or a tandem apartment style washer and dryer be purchased? Maybe your mother would prefer a laundry service? In any event, rather than taking over the task, focus your involvement on helping your mother find a solution.

While this approach has the obvious advantage that you don’t take on the chore, you accomplish something far more significant — you set a precedent: Rather than becoming a provider of care, you identify your role as a problem solver and coordinator. It is essential that this distinction be made as soon as possible because, undoubtedly, as your mother ages her needs will increase.

(2) Your wife has had a stroke and, due to partial paralysis, can no longer cook or do housework. While you know how to make simple meals, you have never enjoyed cooking, let alone eating your own cooking. And, after decades of an old-fashioned marriage, housework is a mystery to you. Your life has become a bowl of chores.

Although you can afford it, your wife doesn’t want to spend money on help. Remember, the cared for may not be able to recognize the adverse effect the changes are having on the care giver. Is your misery good for either of you? Set limits for the sake of both of you — for the sake of your own well-being and for the sake of how your attitude effects your behavior towards your wife. If you have it, spend the money. Hire help for meals and housekeeping. You will both be better off if you don’t have to do chores you hate, and if you have time to pursue interests that sustain you.

We help others for many and often complex reasons but, for the most part, we feel good when we care for those we love. Nevertheless, if we neglect to set limits on how much we are able and willing to do, we risk feeling resentful rather than good about the help we provide.

A 78 year old woman, living alone in her condominium, begins to notice that her keys sometimes aren’t where she recalls she left them. She is uncertain if she paid her phone bill and can’t find her checkbook. She puts a pan of soup on the stove to heat, remembers that she was cooking only when she smells burnt food. She forgets a lunch date with a friend. Although these incidents of forgetting are occurring more and more, she doesn’t mention them to anyone. She certainly wouldn’t want her children to think she needs help managing the details of her life. And she is not interested in making any changes. No big deal, she thinks. She finds her keys. She finds her checkbook and pays her phone bill. She throws out the burnt pan. She apologizes to her friend and schedules another date to meet for lunch.

Still, the mishap with the pan makes her anxious about using her stove; she stops preparing meals and turns to snacking. She has never had a large appetite anyway. No problem, she rationalizes.

To family, friends and neighbors, she seems to be doing well. She is in good health and remains physically and socially active. She continues to read regularly and discuss current events. She is proud that she has always been regarded by friends and family as competent, independent, and above all, smart. It is distressing to her, however, when she realizes that she can no longer follow the plot of a novel from the beginning to end. She forgets who the characters are and gets their motivations confused. Nothing like this has ever happened to her. And still she tells no one.

Eventually, her poor nutrition lowers her resistance; she catches pneumonia. She is hospitalized and a dramatic change in her behavior is noted. She doesn’t want to take medications and attempts to leave the hospital. They transfer her to a geropsychiatric unit where she undergoes an extensive evaluation. The verdict: she suffers from dementia. She continues to try to escape the confines of the hospital; they put her on medications to calm her. Once stable, she is transferred to a nursing home — a nursing home with a secured dementia unit.

Rose, from the inside

Rose had been undergoing a gradual cognitive decline. She did such a good job hiding it, from herself and from those who love her, she accelerated her decline by not taking adequate care of her health. What followed was a rapid physical decline and a dramatic change in behavior leading to equally dramatic medical intervention.

Now I want you to step inside Rose’s head with me:

You’re living on your own and have tricked yourself into believing that the changes you see in yourself do not require any changes in your daily habits. You continue to be proud of your intellect and competence and want to make damn sure that others continue to be proud as well, especially your children.

Then, suddenly, you’re sick, delirious. Complete strangers force you to take pills, force you to stay in the hospital. You want very much to go back to your condo and resume your life. The life you enjoy. And you desperately want to get back to your old self, the self you are proud of. There is nothing familiar about this place, nothing that reminds you of who you are. But you’re surrounded by people — doctors, nurses, aides — who are in your face with their ignorance of who you are. “Take your medications. You have to stay here. No, you can’t leave. We’re just trying to help you.” They see you as sick and suffering, unappreciative and uncooperative. They have no idea who you are, who you have been. They do not know your story. They do not see your self.

Now you are in a locked unit. You have never had to wonder what was on the other side of a door. You just went over, opened it, and walked to the other side. And your mind, your innate intelligence, has always allowed you to open many figurative doors to other worlds. Now, an all too real door is closed.

Now I ask you: Wouldn’t you want to go out that door?