Caregiver Coaching: Fostering Resilience in Older Adult Spousal Caregivers
About the Author
Frank Fee, PhD, CCM
Dr. Fee is a Geropsychologist and Advanced Aging Life Care Professional. He has been a Licensed Psychologist for over 30 years and has practiced in many settings that serve the aging population. He has been a trained Coach for over 12 years. He has worked in Long Term Care settings, rehabilitation hospitals, and community-based programs. He currently has a private practice in Houston, Texas and provides geropsychological services and Aging Life Care services, including caregiver coaching. He also consults with various organizations serving the aging population.
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Frank Fee, PhD, CCM
Older adult spouses who are caregivers are an overlooked group that deserves our attention. A recent study by the AARP Public Policy Institute and the United Hospital Fund (2014) found that spouses account for approximately 20% of family caregivers, and 49% are aged 65 or older. 58% of spousal caregivers received no help from family or friends. A full 70% of spousal caregivers indicated that they felt they had no choice but to take on the responsibility of performing complex medical/nursing tasks. A small, but significant, literature is emerging regarding the impact of caregiving on spouses, with recent studies providing potential guidance to inform the provision of services to this special group. Bookwala (2014) found that the psychological resources of mastery and self-esteem are particularly effective in improving adaptation to the stress of an ill spouse. The emerging field of professional coaching appears well suited to play a key role in addressing the needs of the caregiving spouse.
Over the past dozen years, I have received numerous referrals of older adult spouse caregivers who are already active participants in a support group for a period of time, but still experiencing problems making the necessary adaptations to their caregiving role. Although I have been a Geropsychologist since the early 1980’s, due to the nature of the presenting problems I found myself using the formal coach training I completed in 2003 to a greater extent than my training as a psychologist. A coaching approach helped many of these spouses engage in a process of adaptation and development of a sense of mastery with improved self-esteem, thereby meeting their goals without having to be treated as if they had a mental disorder.
My coach training might best be considered Holistic, Values-Based Action Coaching (Auerbach, 2001), which rests on a foundation of the client’s most important values. Coaches who work with clients in transition help them clarify their personal identity, integrate a new sense of purpose, and experience increased confidence. A key characteristic of coaching is the orientation to help clients “forward their actions.” By this I mean that rather than exploring pain or trauma, the coach helps the client maintain focus on their ideal vision of their future.
It is important to understand that coaching is not psychotherapy – emotional healing is not the focus of coaching. Although coaching can be used concurrently with psychotherapeutic work, it is not used as a substitute for psychotherapy (Auerbach, 2001). Coaching concentrates primarily on the present and the future. Coaching does not focus on the resolution of past trauma as a precursor to move forward. The coach helps the client through the coaching conversation in developing a coaching agenda, incorporating values clarification, identification of strengths, and articulation of the client’s current life and career/life purpose. The coach supports the client’s efforts to engage in lifelong learning, navigate any obstacles, delegate or let go of energy-draining situations, honor challenges, and celebrate successes.
In my practice as an Aging Life Care Professional™, I have observed that many Aging Life Care Professionals / care managers rely on referrals to support groups as the primary way to address the issues that spousal caregivers experience in adjusting to the stresses and insecurities related to their caregiving role. When spouses’ needs are not fully met in the support group, a referral to a mental health professional for psychotherapy often follows. I would like to encourage my care manager colleagues to consider referrals to appropriately trained and credentialed coaches with experience working with caregiving spouses as an alternative to referring these clients for psychotherapy. The following case study demonstrates how coaching can assist a caregiving spouse to become more resilient and able to manage the challenges he faced.
Case Study of Rob D
The facilitator of a support group for spouses of individuals with Alzheimer’s disease referred Rob D. to me. Rob was 75 years old at the time of referral and his wife was 77. She had been diagnosed with Alzheimer’s disease about 4 years ago, and was progressively requiring more care and supervision. He was very knowledgeable about the stages of dementia and the progression that typically occurs. However, he realized that his wife’s condition was changing and his life was about to change more than it already had since becoming the primary caregiver.
The reason for the initial referral was the challenges Rob was experiencing and his difficulty in envisioning his future life, both as a caregiver and a person in his own right. He was experiencing a general lack of support from other family members with his wife’s care, and the support group was not helping him address issues that were important to him at this stage of the caregiving role. Rob had been a successful businessman and originally had no intentions of retiring simply because he reached retirement age, and was actively working past the age of 70. However, because of his wife’s care needs, he discontinued his business travel and started working mostly from home. By the time coaching began, he had gradually reduced his work to the point that it was no longer a reliable source of income.
He had two children, a daughter on disability due to psychiatric problems, and a son who was divorced and spent all of his time working in a stressful job. Rob allowed his daughter to move back into the family home a year earlier after she ended a bad relationship. He had expected her to provide some relief to him, and companionship and supervision for her mother when he would go to the gym or out to eat with friends. Rob had experienced previous health scares in his life due to cardiac issues and had established an exercise routine that was beginning to suffer. The arrangement with his daughter had worked for a time until his wife’s behavior triggered negative behavioral responses from his daughter to the extent that she experienced another psychiatric hospitalization about the same time the coaching started.
His wife’s condition had deteriorated to the point that she only ate if someone sat and encouraged her to eat. She resisted bathing to the point that she would become combative. She increasingly wandered through the house and began saying that she wanted to go home and attempted to leave the property. She was not consistently recognizing Rob as her husband.
Prior to the first coaching session Rob completed a “new-client” questionnaire and identified his general goals for entering into the coaching relationship. He also provided a written summary of what he considered important for me to know about his family situation, caregiver role, personal life, and future vision. This information was carefully reviewed to clarify that Rob was appropriate for coaching instead of entering psychotherapy for treatment of a mental health disorder.
The initial coaching session was spent identifying and defining what Rob hoped to gain from the coaching relationship and to further clarify that coaching, rather than psychotherapy, was appropriate. Questions about mental health history, previous therapy, use of psychotropic medications, suicidal ideation, and substance misuse/abuse were asked to address this potential area of concern. It became clear early on that Rob did not have a mental health disorder. He did not meet criteria for a depressive disorder or anxiety disorder diagnosis. He simply reached the point where he needed a thinking partner to help him tap into his resilience reservoir and develop some new skills and strategies for moving forward.
Questions were asked to clarify key forces in Rob’s life by elaborating on his answers in the “new-client” questionnaire, e.g., “Tell me more about what you are hoping to get from the coaching relationship.” “Tell me about a time in your life when you felt particularly focused and energized—a period of high personal satisfaction. What was going on in your life and who was involved?” Before the end of the initial session the scope of the coaching relationship was outlined and an agreement made that if an issue arose that should be treated in a psychotherapy context, an appropriate referral would be made. In addition to establishing rapport and trust in the initial session, we conjointly began to clarify the focus of the coaching agenda.
The next few sessions were spent in the process of creating the coaching plan that would guide the rest of the coaching relationship. Additionally, energy was spent on the development of the coaching alliance. Rob indicated that he wanted to explore his future role as a caregiver and to clarify and weigh possible alternatives that he knew he would have to address in the not too distant future. He also wanted to develop an action plan for engaging in meaningful activities, including some professional and work-related ones. He also expressed motivation for increasing social contact with others who have similar interests. During the second session we discussed Rob’s most important values, his “passion areas,” to ensure that the coaching agenda was resting on a foundation of what was most important to him in his emerging life chapter. For Rob this included a strong spirituality component, mutually satisfying relationships, and a sense of meaningfulness in his activities. The latter two had suffered tremendously over the past several years.
At the beginning of each coaching session there was a focus on identifying and committing to specific actions that would move Rob forward toward his most important goals. The entire coaching process was action oriented, which was a good fit for Rob. During the early sessions it became apparent that Rob was approaching his caregiver role in much the same way that he previously addressed his work. He was attempting to explore all of the available options, look at the pros and cons, and select the one(s) that appeared best. However, at the initiation of coaching he was having trouble seeing that he had options. He experienced a breakthrough during a coaching-exercise that helped him identify steps in his reasoning that were leading to unintended consequences. He was able to realize that he was making some faulty assumptions and had been drawing conclusions based on his assumptions that were keeping him stuck. When he corrected his assumptions, he was able to see many more options than before. Rob went from seeing his only options as placing his wife in a memory care unit versus continuing to enduring the burden of caregiving on his own, to exploring in-home options that would take over some of his caregiver responsibilities.
Midway through this process the sessions focused on trying out new strategies and the development of new skills and enhancement of existing skills. For example, Rob explored having paid in-home caregivers to allow him the time to engage in more activities outside the home. This was a big step for Rob. After exploring the various options for securing in-home caregivers, Rob decided to try an alternative before hiring a home health agency for services. In keeping with his core values, he sought and found two female caregivers through referrals from his faith community. He decided to hire them for the right temperament, and believed that he could teach them about Alzheimer’s and his wife’s specific care needs. It turned out that the caregiver who worked in the mid afternoon through dinnertime was skilled in getting his wife to bathe and even enjoy the activity. She had a history of caring for her own grandmother and mother as they aged. Rob described her as a “natural” at caregiving. Rob also took the step to confide in his son that there would be times that he may need his help. This too was a big step for Rob, but he reasoned that his own health would suffer if he did not get respite, and then he would become an even greater burden on his son.
Rob planned and took a long-weekend trip to visit an old friend out-of-state. He left his son in charge to oversee the caregivers and spend the nights at the family home since caregivers were only scheduled from 8 AM-7 PM. Although his son did not volunteer before he was asked, Rob became more comfortable asking for respite when needed or if he wanted to take a trip. Rob developed a routine that provided him with both alone time and opportunities to spend time with old colleagues and friends. He quickly increased contact with acquaintances and friends. On several occasions during coaching he attempted to take his wife to church, out to eat, or to previously enjoyed activities such as theater and symphony, but realized that her cognitive status had deteriorated to the point that she was no longer able to tolerate these settings for more than a few minutes. This reality testing was part of the process of Rob letting go of the notion that things they formerly enjoyed as a couple could still bring positive experiences to them both. Although he already knew this in his heart, the act of “experimenting” was helpful in helping him get his head and his heart aligned.
As a homework assignment, Rob reduced to writing his own criteria that would indicate that he was no longer able to care for his wife at home with the added caregivers that he hired. Once he had a clear understanding of all of the care options in the home, as well as local facilities with memory care programs, he was able to factor in his personal feelings and values and write out the observable criteria that would lead him to make the decision to place his wife into a full time care environment. This accomplishment was huge for Rob as he had struggled with this issue in the support group for quite some time. The group’s feedback was “You’ll know when it’s time.” Rob now felt comfortable that he would “know,” but it was no longer based primarily on emotional factors, but a holistic perspective and a checklist based in reality.
Rob was seen for a total of sixteen coaching sessions over a six month time period. The first twelve sessions were weekly, then bi-weekly for a month, then monthly for the last two months. Contact was made three months after the final coaching session and then a year later. At a follow-up conversation three months following the end of the formal coaching sessions, Rob had checked off another criterion on his list that indicated another step closer to out-of-home placement. He had become more self-confident in his ability to be a caregiver as well as maintaining a meaningful life. And his self-esteem was much higher. A year later his wife had been placed in a memory care program and he visited her daily when he was in town. He had not reclaimed his old life, but had created a new one. Coaching met Rob’s needs in a way that surpassed what a support group could provide, and there was no need to seek psychotherapy since there was no mental disorder present.
Aging Life Care Managers should, of course, consider the individual circumstances of the spouse/caregiver and make appropriate referrals as part of the overall care plan. I suggest that you consider referring spousal caregivers to a coach with the appropriate background and experience. Getting to know local qualified coaches with expertise in caregiving and aging issues is highly recommended. Virtually no states license coaches, so it’s important to engage in due diligence before adding a professional coach to your roster of referral sources. Many experienced coaches do not have certifications from national or international organizations since the coaching profession is an emerging one, although many have already been credentialed in a related profession. Additionally, there is no recognized organization that specifically credentials caregiver coaching or coaching for older adult care needs. However, there are organizations which are similar to the credentialing process for care managers: requiring passing a standardized examination, adhering to a code of ethics, and completing a minimum amount of continuing education before recertification.
The International Coach Federation (ICF), and the Center for Credentialing & Education are two such organizations. The ICF was founded in 1995 and is the oldest and leading global body that credentials coaches. They have some 17,000 credentialed coaches in more than 130 countries worldwide. In addition to demonstrating completion of formal coach training, passing a written examination, submitting evidence of paid coaching experience, and providing evidence of formal coaching by a mentor, ICF requires candidates to submit two recorded coaching sessions with verbatim transcriptions that are reviewed by trained “reviewers” as part of the credentialing process. Credentialed coaches must adhere to the ICF code of ethics and obtain a designated minimum amount of continuing education between recertification periods (https://coachfederation.org).
The Center for Credentialing & Education (CCE) is a nonprofit organization that provides practitioners and organizations with credentialing in six specialties, most recently adding the BCC credential (Board Certified Coach). Created in 1995, CCE credentials more than 25,000 practitioners globally in a variety of fields. The BCC is the newest credential (established in 2012) and demonstrates that the BCC has met professional coaching competency standards established by CCE and subject matter experts. The BCC certification also requires demonstration that the coach has met educational and training (coaching specific) requirements, passed a psychometrically sound coach-specific examination, obtained experience in the field of coaching, provided professional peer references (coaching specific), is accountable to an enforceable ethics code, and makes a commitment to continuing education between recertification periods