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Caregiving and Resistance to Assistance – Keystone Elder Law

Your older adult family member living “independently” at home could benefit from some assistance such as companionship, housekeeping services, meal preparation, or personal care; but absolutely refuses to consider the idea. This scenario plagues many families with aging loved ones.  Concerns about the physical safety and emotional well-being of the older adult are present, as well as questions about the legal liability of family members who may be perceived by others as being neglectful of their loved one.

One of the first steps to dealing with an individual who is demonstrating this behavior is to determine the individual’s perceptions of the situation. Thoughts of changing one’s lifestyle may lead to feelings of anger at oneself or others at not being able to manage daily tasks any longer, fear of losing independence or guilt about being perceived as a burden.  Denial may occur as a method of coping with this potentially threatening situation.  Feelings of pride may lead the individual to view the need for assistance as a sign of weakness. Concerns about the cost of care, receiving help from strangers, and loss of privacy may also exist.

If someone’s perception is that help is unnecessary, it will be very difficult to convince him/her otherwise. A lack of insight into the need for assistance could be due to cognitive deficits resulting from Alzheimer’s disease or another dementia.  In this case, the use of logic as a tool to try to change this perception is pointless since the older person’s brain cannot effectively process a logical explanation.  Even for people without dementia who are capable of understanding complex situations, logic is not the most effective tool to use. Clifton Mitchell, of the East Tennessee State University Department of Counseling and Human Services points out that “If people changed because of logic, nobody would smoke or drink and everyone would have an exercise program and get eight hours of sleep. When people make major changes in their life, they don’t do it because of logic. They do it because they have an emotionally compelling reason.” (Counseling Today, Managing Resistant Clients by Lynne Shallcross, 2/14/2010).  Although Dr. Mitchell was referring to a counselor/client relationship, the same concept is applicable to an older adult who is resisting assistance.

So how do we help our loved ones develop an “emotionally compelling reason” to accept care?

  • Have general conversations about “what ifs” early, before a need arises, so that some background information can be gathered before a “threat” exists. This information can become a starting point for conversations later on; “You once told me that…”
  • Use your understanding of your loved one’s perceptions to guide conversations about goals and the realities of the present situation.
  • Choose a time when a relaxed conversation is possible.
  • Take a casual and slow approach which initially focuses on the individual’s strengths to set a positive tone for discussions.
  • Play dumb, and allow the individual to think and develop realizations about their situation which may seem obvious to you.
  • Avoid asking too many questions since they may be perceived as confrontational, and use “I” statements to make a point without placing blame. Instead of beginning with “Do you want help with your bills?” or “You aren’t paying your bills”; try “I notice there is a pile of bills on the table.”
  • Consider who the best person is to have these conversations with your loved one. Sometimes, older adults are more open to suggestions made by close, trusted individuals who aren’t family members, such as a physician or pastor.
  • If multiple people are involved in conversations, make sure that everyone generally agrees on the issue(s) of concern and possible solutions. If not, additional discussion is needed before approaching your loved one.
  • Do your homework. Don’t bring up an issue of concern without having some possible solutions in mind.
  • Allow your loved one to make suggestions, have choices, and develop plans as much as possible. This will reduce feelings of powerlessness and promote cooperation.
  • Start small when possible. If you are hiring outside help for home care, initially begin by having the new caregiver visit for short periods and perform non-threatening tasks, such as helping with meal preparation or housekeeping. As the relationship becomes more comfortable, then gradually lengthen hours and add personal care tasks.
  • Present the idea of a caregiver as someone to help you instead of your loved one, and explain the benefits you both will receive from the arrangement.
  • Pick your battles. Choose what is most important to address in relation to safety and care and start there.

Unfortunately, there are times when the only choice a family may have is to wait for an illness or injury to lead to a hospitalization and additional post-discharge care, or to notify protective services about an unsafe loved one.   The line between allowing an individual the autonomy to make decisions for oneself (even if these decisions might be detrimental to one’s physical or emotional well-being), and stepping in to require compliance with a plan of care is often not well defined.  In these types of cases, the capacity of the individual who is refusing services will be considered by protective services.

Overcoming a resistance to assistance requires patience and creativity. If your first approach is not successful, consider what you have learned about your loved one and yourself, then try another approach.

Karen Kaslow, RN