Elder care joins housework, child care, food preparation, and shopping as an arena of unrecognized, unpaid work that is expected of women because they have always done it.3,4,6 This not only poses serious concerns for contemporary women and their daughters, but it also poses serious questions for the health-care community, which often sees these women, without question, as the pivotal if not primary resource for caregiving to the elderly.7,8 As the century progresses, the situation will become even more serious as we experience the consequences of fewer offspring to care for aging parents who are spending more years as aging seniors.4 The phenomenon of senior citizen children caring for very old, very frail parents will become commonplace.1 Is is obvious that these midlife daughters need attention from the health-care industry.
This article will examine the context within which contemporary midlife daughters face the challenge of parent care. Key issues that face midlife daughters as they become involved in parent care will be addressed. Interventions aimed at addressing the needs of this large but unconnected population of women will be detailed as they have occurred in a project designed specifically for midlife daughters. The issues discussed are presented from the perspective of the middle generation, not that of their parents or their own children. Were we to ask either of these other generations to describe their reality about the family situations surrounding aging parents, it would be described differently. No one perspective is any more important or "right" than another; each is simply different.
THE JOB DESCRIPTION
To comprehend what is meant by parental caregiving, it is necessary to examine the "job description" of midlife daughters engaged in this role. Like housework and child care, parent care is a complex collection of tasks and activities that changes as the frailty and dependency of the members shifts. It can include anything that assists a parent in maintaining independence or in meeting personal needs, including driving to appointments, socializing, shopping, discussions with health professionals, cooking, providing shelter and clothing, doing laundry or yard work, providing financial advice and management, doing household repairs, or performing physical care such as bathing, feeding, dressing, and toileting.9,10 This work does not necessarily fall into predictable hours or days of the week, and it changes as the health status, living arrangements, available assistance, or monetary resources change. Extensive involvement often ceases only upon death.
PARENT CARE AS AN HISTORICAL ISSUE
Midlife women have always been intimately involved with the care of their own parents and grandparents.11 Historically, family patterns that encouraged women to be primarily involved with homemaking and child care also encouraged responsibility for the unwell, frail, and elderly. Even today, few daughters escape this type of "training." Although midlife sons are involved with their parents, their involvement is marginal when compared with the hours and nature of work performed by midlife daughters.2
Although it might seem obvious that redistribution of this responsibility is necessary as well as reasonable, because elder care is traditionally unpaid women's work that is taken for granted, it is not easy to alter family dynamics or to secure remuneration for the work. It is not any simpler to engage sons in front line involvement with parent care than it has been to engage men in housework or fathers in child care. Labor that has been traditionally performed by women and has gone unrecognized in terms of money or status is hard to distribute. Quite simply, no one wants to do it. Government services are as reluctant as many brothers and husbands to join women in assuming responsibility for elder care.6,8
NOT A NEW ROLE BUT A NEW PROBLEM
The role of parent caregiver, then, is certainly not a new one for midlife daughters, but it does pose new problems.3 These problems stem from the unprecedented level of complexity that is typical of contemporary midlife women's lifestyles. In contrast to their foremothers, today's women are likely to be involved in employment and career-building activities in addition to their usual activities with partners and friends, housework, and children.4*12 It is unlikely that the addition of employment has resulted in a lessening of their domestic responsibility. Because of increases in life expectancy, the parents of these women face as much as 30 years after retirement when they may need assistance in maintaining independence,13 and because tradition has deemed it familiar, they turn to their midlife daughters with this need.
Caught between their parents and their children, these so-called "sandwich women" or "women in the middle"3,14 experience considerable strain on their emotional and physical resources. Research on caregivers of aging parents repeatedly demonstrates that the role can be extremely stressful and that women performing it go notoriously unrecognized and unrewarded. Although society expects midlife daughters to perform this role, and indeed daughters expect themselves to do so, there is as yet minimal support for these midlife women. The fact that they are providing an essential means for keeping seniors functioning independently in the community does not receive the recognition it so clearly deserves. Instead, midlife daughters are prime candidates for stress-related illnesses, and thus are the untended but future "hidden patients" in the health-care system.
The situations that face a midlife daughter of aging parents are many and vary according to the culture of the family, the family's history, and the members' ages. Whether they become defined by the daughter as problems is determined by the dynamics within the family, its resources, and how it responds to the demands aging parents place on the family system. That these typical situations are potential stressors in all families, however, seems clear.
The issues reviewed here reflect current literature on caregiving and the voices of women in groups designed specifically to foster effective coping in daughters of aging parents. 15
The shift in intimacy that typically occurs when parents and midlife daughters increase contact is stressful for many daughters.9 This increase in contact occurs even when parents maintain a separate residence. The shift in intimacy results from increased involvement in the parents' daily maintenance activities, such as cooking, cleaning, personal hygiene, and eating. For many midlife daughters, this degree of intimacy has not occurred since they lived in their parents' home as a child. Most have never experienced the intimacy of bathing or feeding another adult. Exposure to parents' intimate behaviors and routines can mean becoming acquainted in ways they never were before. Both generations can end up learning things they never wanted to know about each other. It is not unusual for collisions over the "right" way to carry out the most intimate of daily routines to take place, a process that is reminiscent of the midlife daughter's adolescence.
Closely related to me shift in intimacy is a shift in dependency, also due to the parents' increasing frailty. The seniors come to literally depend on caregivers to maintain their own functioning. As the daughters help fill the gaps in self-sufficiency, previously established dynamics that maintained parents in positions of power and leadership in their own families are threatened. Midlife daughters then speak of "parenting their own parents" and perceive parents' dependency as childlike. How to maintain or create dynamics that honor the elders as mothers and fathers, and to circumvent the dangerous feeling of role reversal, becomes a struggle.16
Finances become an issue for those midlife daughters whose parents' resources are not sufficient to cover daily living, housing, and health-related expenses.17 Many contemporary seniors did not have the means or the foresight to predict the financial resources they would need to survive in today's society. Although governmental assistance and benefits from previous employment provide some financial support after employment earnings cease, most of the financial burden for maintaining health and supporting daily living is to be assumed by the aging parents and their offspring. It is, after all, the family in our society that is expected to take care of its own members. For the midlife daughter, these demands on her own financial resources come at a time when she may have expected to launch adult children, shift careers, return to school, or prepare for her own retirement. For those midlife daughters who reduce or terminate employment to care for parents, the strain of sacrificed income is particularly serious.12
Stress related to the competition and collision between roles is an issue for many midlife daughters.12 The time and energy demands of parent care can be overwhelming and often collide dramatically with being a mother, partner, employee, friend, and homemaker. The one-time "double day" of employment and child care is recycled later in life to become the double day of employment and parent care. The role of the caregiving daughter can create a wedge between marriage partners or eclipse career pursuits. The threat of burnout from role overload is a constant companion, especially when women have trouble limiting their involvement and when demands exceed personal resources to meet them. When women try to cope by compressing increasing numbers of activities into smaller amounts of time, the stress can be particularly high. This situation is particularly serious if the midlife daughter curtails self-nurturing, recreation, and relaxation activities. It is, after all, these activities that "fuel" coping with a multiple-role lifestyle and that form the basis for stress management.
Powerful emotional reactions to the changes in one's parents and the demands of the caregiving role bother many daughters.1,18 Because few midlife children anticipate the intimate details of their eventual relationship with their parents, they are surprised by and unprepared for what happens. Emotions that are the greatest source of alarm include guilt, resentment, anger, sadness, and embarrassment.
Guilt arises from the chorus of "shoulds" that direct and often control behavior. These "shoulds" about being a dutiful or "good" daughter are reflected in daughters wishing they could perform caregiving work better or with more grace or more humor, or in wishing that their history with their parents had been happier or their current relationship had more depth. Sometimes a daughter's guilt is in relation to a parent's frailty or to their own resistance to spending time with a parent. Regardless of how positive or negative the past relationship with a parent has been, guilt is often a companion as aging occurs.19 When guilt propels the daughter into doing things she does not want to do, the product is resentment. This is accompanied by a feeling of impotent rage that is masked to keep the peace or protect me parent and, no doubt, the daughter. Guilt and resentment are especially "expensive" emotions due to their tendency to silently undermine relationships.
The sadness that daughters feel reflects the losses they are experiencing as their parents age. These are different from the losses their parents are facing. Whereas parents are grieving the loss of employment, energy, health, and familiar residence, daughters feel sad about the parent they once knew who is now less energetic, less involved, or displaying unfamiliar behavior related to physical changes. They may grieve the loss of opportunities to know a parent better or to have experiences that are impossible because of agerelated restrictions. Despite the power of the grieving, it is not unusual for daughters to be unaware of the source of their feelings.
Embarrassment typically arises from involvement in activities that leave parents vulnerable, such as bathing, toileting, or feeding. Although daughters may have performed such intimate activities before, it was likely with her own children rather than with parents. The emotional impact is complex in the best of circumstances. Daughters are also embarrassed by behavior they consider bizarre or unacceptable, such as poor personal hygiene or housekeeping, odd mannerisms, or struggles to communicate clearly.
The aging of the parents can catalyze a confrontation with one's own aging, which leads to an evaluation of how one's life has been spent and a projection into one's future.20 This often results in a critique of the parent's behavior based on how the daughter hopes she will be as a senior. These hopes typically reflect the daughter's fear and include little of the frailty, income restrictions, loneliness, etc, that her parents are experiencing. Insidiously, the daughter's imagined future begins to pollute the present as the daughter decides, "I will do it differently when I am their age, therefore they should do it better right now." This leaves little room for the senior to age without judgment from the caregiving daughter. Again, the daughter may be unaware that the origin of her judgments is her own fear of aging.
Ignorance is an issue for many daughters, and this ignorance falls into two categories: the aging process and the workings of "the system." Limited knowledge of normal aging means daughters cannot judge whether a parent's behavior is "normal" or cause for concern. Ignorance of the formal and informal health-care systems leaves them at a loss when assistance beyond their personal capacity is needed. Many daughters are unaware of whom to contact for help with a parent's health, financial resources, or support services. Despite the well-known difficulties associated with relocation, for example,21 many offspring are ignorant about seniors' housing options until a health crisis forces them to think about it. Such knowledge gaps lead to inappropriate expectations, poor decision-making, inadvertent mistakes, time-consuming run-arounds, and inflated emotional states when health crises occur.22
Lack of involvement from key support people can lead to overinvolvement in caregiving and isolation from other people.18,20 The plethora of research on the value of support network involvement clearly establishes the risk that results when this occurs.23 Although there usually are other family members, it is not uncommon for one daughter to carry far more responsibility than is reasonable or necessary. There are many reasons why this daughter may have been "chosen": she may have been an only child or the only female child, the "most responsible" child, the one who is emotionally or geographically the closest, or the one who is in a helping profession. Sometimes, the least involved in meeting the parents' needs are the parents themselves, a situation that invites increasing dependency. When involvement in parent care is skewed too far toward the midlife daughter, strained relationships can result and significant changes in dynamics to equalize the distribution of responsibility are necessary. This is not an easy task, because the skew usually evolved over history and in the name of love or duty.
Isolation from other midlife daughters is a reflection of how hesitant midlife people often are to discuss their concerns as children of aging parents. There is a taboo against "airing the family linen" in many families that extends into adulthood, despite the pain that accompanies the silence. Daughters can end up isolated from peers as well as siblings, marooned with their feelings about changing relationships with parents. This breeds powerlessness, which in turn leads to ineffective coping.
Grappling with unfinished business from the past often interferes with effective adult-to-adult relationships between daughters and parents.20,24 History that has been ignored or escaped reawakens and assumes new power when contact between the generations increases. Family events, secrets, and unresolved struggles from decades before demand attention through their silence or when they surface during conflict. Relationships are then characterized by hypersensitivity or power struggles. Familiar but irritating, these pieces of old baggage disrupt the development of mature relationships. Equally disturbing is the tendency of families to pass the unfinished business on to the next generation, thus repeating history.
A final issue common to midlife daughters is difficulty setting limits on themselves or their parents. It is common for midlife daughters to expect more of themselves than they would of other women in their circumstance, and less of their parents than is reasonable. Even the most assertive of daughters often cannot or will not say "no" to their mothers or fathers. This reluctance to set limits surfaces in an inability to refuse requests or constructively handle criticism from parents and in reluctance to make requests of parents. Underlying this is a struggle to comfortably separate one's own rights and issues from parent's rights and issues. It can be difficult, for example, to realize that parents have the right to request anything they please and that the daughters also have the right to refuse these requests or limit how or when the requests are granted. Instead, daughters want their parents not to make the request in the first place.
These issues, then, represent the world in which midlife daughters live as they explore their role of caregiver to their own parents. Typically, the issues intertwine and shift over time. To appreciate the impact of these issues, it is critical to respect how personally they are experienced. The sensitivity of the issues is rooted in the daughter's belief that if she were "doing it right," her relationship with her parents would not be awkward or difficult. This belief is fueled by her isolation from other daughters' experience and her ignorance about aging and the "system." This makes her vulnerable to the myth that everyone else has figured out the "right" way and that she alone has failed in this task. Any interventions with midlife daughters should incorporate a respect for this context.
It is well documented that group work is a valuable and powerful intervention for helping caregiving relatives cope with their situations.20,25"27 Most caregiver groups accommodate all caregivers regardless of generation or family role and thus could include spouses as well as children, and both men and women. Some groups are oriented around a particular illness experience, such as Alzheimer's disease.
The interventions described below have evolved in groups designed specifically for midlife daughters and are not restricted to any one health issue. The groups involve 8 hours of contact, either over 4 weeks or during 1 day, and focus on decreasing intergenerational stress as experienced by the midlife daughter. The goals of the groups include:
* Examining how aging affects family relationships;
* Exploring issues central to midlife daughters;
* Developing coping strategies useful for setting limits, avoiding burnout, and involving others in caregiving;
* Increasing awareness of community resources.
All of these interventions take advantage of the multiple viewpoints of and the support available from the group participants. They are built around both didactic and experiential group techniques and demand an active role by the group facilitator. All group experiences evolve from multigenerational family systems theory. From this perspective, although an issue may be felt most poignantly by the midlife daughter, it is owned and experienced on some level by the entire family group, reverberates across generations, and needs to be resolved by the family as a group.28 Although some of these interventions would obviously be pertinent in a one-to-one situation, this context is not addressed here.
Normalizing the feelings that accompany the evolving caregiving role is an intervention critical in setting the stage for effective coping. This is accomplished through group members engaging in structured "storytelling" to each other about their current situation and the key issues with their parents that are most poignant at the time. Through hearing other women's stories, daughters are exposed to family situations similar to and more challenging than their own. Validation of feelings and drawing attention to similarities in family situations results in a drop in anxiety and a lessening of embarrassment and sensitivity; this in turn sets the stage for problem solving and creative coping.
Appreciating the historical context from which their relationship with their parents evolved is important in helping daughters come to grips with the nature of their involvement, their unfinished business, and their issues with other family members. Through helping daughters identify those past events and situations they believe shaped their relationships with their parents and analyzing how this history continues to affect their relationship, a respect for the power of history is fostered. A raised consciousness about one's own history often leads to an understanding, for the first time, of why they were "chosen" for the parental caregiving role, or why they are so reluctant to be involved at all. During the discussion, it is emphasized that within any one family there are multiple perspectives about what "really happened" during any one historical event and why it happened, thus their parents or siblings may have very different ideas about the same situations. That everyone's perspective is "right" is repeatedly established. This reduces very common but destructive competition across and between generations for the last word on what "really" took place.
Coming to terms with one's own aging is accomplished by participating in exercises that allow the daughters to come to know their own thoughts about being eventual seniors themselves and the roots of their imaginings.29 By anchoring the women in their own hopes and fears about the future, the stage is set for discussing how these affect the current dynamics between them and their parents. As information about normal aging is included in the discussion, daughters are encouraged to assess the quality of their own knowledge about the topic.
Specifying what the "job description" of parental caregiver is in their family is necessary for women to identify and respect the activities they are involved in with their parents. This awareness is also necessary for negotiating with others when they wish to delegate responsibility. Typically, because caregiving tasks have been assumed gradually over time, women do not have a clear sense of all they are doing. By writing this out in behavioral terms, the emotional component of the role is separated from the behavioral and women become able to articulate, to themselves and others, the expectations of caregiving.
Separating their issues from their parents' issues is critical for the eventual designing of appropriate solutions to problems, and thus is a pivotal intervention that is integrated throughout the group experience.22 Because issues are usually tangled, leaving daughters involved in problems that belong to parents and parents involved in problems that belong to daughters, participants are coached in describing specifically what each generation is grappling with and in examining the differences in perspective. For example, while a daughter may be struggling with how to react to a parent who requests more contact time than she can comfortably provide, her parent may be struggling with loneliness. The solutions to the problems are quite different, depending on the generation and the perspective. Daughters are reminded that because their parents are not there to tell us, their ideas about their parents' issues are conjecture until they explore, with their parents, what the world looks like from their perspective. It is emphasized that an issue described specifically is easier to grapple with than one defined globally or not at all.30
Fostering an appreciation of different perspectives about issues is an intervention that extends beyond appreciation of parents' points of view. By including the differing perspectives that can exist for siblings and health-care workers, daughters come to appreciate varying sides of me situation; this loosens rigid definitions of problems, fosters a respect for others' behaviors,22 and sets the stage for collaboration.
Increasing the awareness of choice in one's caregiving behaviors is accomplished by having daughters examine the expectations that guide their relationships with their parents. Consciousness raising about the origin of "shoulds" about what a "good daughter" is "supposed" to do and examination of what is and is not reasonable to expect of oneself are central to an evolving sense of control over one's behavior. Because these "shoulds" are powerful in their prescription for behavior and feed on guilt, it is important to extend a discussion of "shoulds" to include the word "could," thus moving daughters into a position of choice rather than being limited to obligation. A daughter can thus shift from saying, "I (a 'good daughter') should have dinner with my parents every Sunday," to "I could have dinner with my parents every Sunday, and I will do that this Sunday," or "and I won't do that this Sunday." This shift in wording is critical. It evokes the realization of choice, which increases feelings of control over one's life and reduces feelings of powerlessness. This, in turn, catalyzes more creative and effective coping.
Content and experiences related to assertiveness provide daughters with concrete tools they can use to alter communication sequences with their parents, especially in relation to limit setting, refusing requests, and making requests. When helping daughters become more assertive with their parents, it is important to exercise a healthy respect for the time it took to evolve to the current awkwardness as well as the practice and commitment it takes to learn different ways of responding to familiar family patterns. Participants are reminded of the importance of practice and support from others who are also working on limit setting with parents.
Increasing involvement with significant others is done through delineating all the decisions that will be made in relation to aging parents between now and the settlement of the last surviving parent's estate. This is followed by discussion of who other than the daughter, both inside as well as outside the family, needs to be involved in decisionmaking or in any of the activities or obligations that are related to it. It is critical that the parents are seen as integral to decision making about their own future. Some decisions include where a parent will live and under what circumstances a change in residence might occur; who will assume responsibility for daily maintenance tasks parents can no longer do for themselves; who has what type of personal or financial resources to draw on as the parents age and need assistance; whether lifesaving measures are to be used when a parent is dying; and what type of funeral rituals are to be carried out.
Because the list can incorporate any topic a group member feels is appropriate for her family situation, a wide array of decisions are represented. This brings to light decisions that have already been made "silently" in some families, that is, without any discussion or negotiation. The participants need to be reminded repeatedly that most decisions inevitably are the responsibility of more than one person because they will involve the time, energy, and resources of more than one person. This is particularly important for overinvolved daughters who need to shift their perspective toward group ownership of problems and thus toward a broader resource network. Discussion about when and how to gather the attention and response of significant others includes consideration of letters and phone calls as well as family gatherings. Because it typically takes families considerable time to discuss sensitive issues such as those on this agenda, the importance of approaching this task over time is emphasized.
Ignorance is decreased by including content about normal aging and community resources and by providing bibliographies and written material about resources for both seniors and midlife children. Participants are encouraged to begin developing their knowledge base in these two arenas even if they do not need it at the moment, and they are reminded that it takes time to become knowledgeable of the ins and outs of "working the system."
Although there are certainly additional interventions that are useful and appropriate for midlife daughters, these represent some that have been found particularly effective in a group situation organized especially for midlife daughters interested in improving their relationships with their aging parents.
The graying of North America has begun to highlight not only the seniors who are leading the Seniors Boom, but also those who are involved with them as they age. This includes their midlife children, who often become instrumental in helping aging parents maintain as much independence as they can as long as possible. Because it is daughters in our society who are socialized into caregiving, it tends to be the midlife daughter who is most often called on to be involved with aging parents. Given the life context of the contemporary midlife woman's life, this caregiving, if it is not shared by other family members, leaves her at risk for burnout and a host of stress-related illnesses.
This article has addressed the key issues for these women. It has also identified and discussed selected interventions found to be effective in group work designed specifically for midlife daughters who want to improve relationships with their aging parents and cope more effectively with the demands of caregiving. Group-focused interventions are seen as pivotal in providing support for midlife daughters.
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