How We All have to Pay the Piper with Stress, Anxiety and delayed depression
A tale of grief, caregiver fatigue and what comes after…
By Dustin Jasmer FNP
I often see patients who are are caregivers. These caregivers come in many different shape, sizes and backgrounds. Some are housewives caring for multiple children that demand their constant attention. Some are spouses, significant others or other family members whose loved one suffers from a substance abuse issue and they expend all their time worrying about whether their loved one will come home safe tonight, get another DUI or perhaps even end up overdosing. They are simply doing their best to prevent this from occurring. I see people who are caring for an extremely ill family member who has a physical or mental health issue. It is their duty and they have taken it on in stride. Others work 3 jobs because of their financial situation. They see no other choice but to care for their family financially. Maybe its a person who is drawn to emotionally unstable partners. Some term this as a “White Knight persona”. This person feels they need to save people from themselves. I've heard these people refer to themselves as “I have a big heart but my people picker is broken”. These caregivers may come in the form of a new parent who cares for their infant late at night and they go without adequate food/sleep for days or months at a time. Another caregiver I see are children who grow up in homes with parents who are abusive or neglectful. They end up caring for themselves, their pets, their parents or their siblings. There are so many different types of caregivers it would be difficult to name them all. One thing they all have in common is that they are surviving and not meeting their higher needs. Their most essential needs are being met but not much else. To understand you have to have a basic understanding of Maslows Hierarchy. Maslow was psychologist who introduced a theory that stated that there were several basic psychological needs and one must be met in order for the next to be met. I have posted a diagram below:
For example: If a person does not meet their physiological needs first, safety is of little importance. They need to have oxygen, food and water. As soon as these needs are met they move on to meeting their next need: feeling safe and secure and having shelter. Once this need is met they move on to feeling loved and belonging. Once they have met this need then they can move on to esteem or how they view themselves. At the top of the pyramid: Self actualization. This stage is rarely reached. If people do reach it, its generally not for long periods of time. Its where one reaches their full potential. Often people move between the stages periodically throughout their life.
A common theme that occurs in each of these scenarios is that the caregivers are often stuck. They are stuck in one of the stages of psychological levels of progression. They wish their loved one would have a different outcome or that their situation could be different. Eventually it does come to a head. Maybe their spouse gets clean. Maybe the abusive parent moves out. Perhaps the illness is now well managed, or their loved pass away after years of struggling with it. Regardless the of the outcome, eventually and inevitably the situation will change. Heraclitus of Ephesus a Greek philosopher, is quoted as saying "change is the only constant in life." and this is still true to this day.
What Comes After? Simple answer: Everyone must pay the piper.
It is often surprising to patients that although their partial relief after the source of their stress is no longer present the emotions often come pouring in. They have moved beyond the stage of being stuck in “survival mode”. The years of accumulated emotions and delayed depression hit them like a freight train. They think to themselves “This is the only thing I have ever wanted, why now am I feeling like this?” There are many studies that show that accumulated stresses over a life time take a toll. Take for instance the adverse childhood event (ACE) studies done by the CDC and others which show that the more traumatic experiences a child experiences in their life, the more likely they are to experience depression, substance abuse, COPD, asthma, cancer, suicide, heart disease, early death, etc. These studies have been replicated many times and its likely that the findings apply to adults as well.
I see this in my practice all the time. I see a patient who comes in and they state: “My father died last week. I expected to be very depressed but I am doing quite well. I just had the funeral yesterday”. I do standard depression/anxiety screenings, it is true, their depression is in fact doing well. I always schedule them for a 1-2 month followup. I explain that they were likely busy with the funeral arrangements, surrounded by family, and that grief is normal, depression is not expected but that grief puts them at higher risk for relapse. Sometimes on followup they are doing fine but often depression has relapsed once they get back to their everyday routine.
Another scenario would be a spouse who for years has worried about her husbands addiction to pain pills or alcohol. She had often found him passed out and often worried about the fact that he might die. He had been in and out of jail and even considered leaving him. Eventually he goes to detox and treatment. She prayed for this for years. Suddenly she is depressed; She is anxious that he might relapse but he is such a different, a better man. For so many years she had exhausted all of her emotional resources on him that she had forgotten about her own needs and emotions. Now that survival mode is over, the emotional inner turmoil begins…
What is the Solution?
This scenario plays out in so many different ways that it would be impossible to name them all but I think you get the idea. So what is the solution?
1. See a good therapist: I recommend seeing a good therapist that knows how to deal with your specific scenario. Our staff can make a recommendation if you need.
2. Put yourself First No matter your situation, put yourself first. There is a reason that airlines tell you to put oxygen on yourself before your child if a plane loses compression. If you put it on your child first, you will pass out and your child will get anxious remove their oxygen in their disoriented state. Both of you will perish. If you put on yourself first, your child will go without briefly, get lightheaded and then you can attend to them. In the end you both will survive. For the same reason there is a rope on the end of life saving buoy. If you jump in to save a drowning person, the drowning person will frantically grab on to you. Both of you will drown. If you throw out a buoy, they have the option to grab it or not. Ultimately it is their choice. The point is, never let someone drown you. Offer a buoy but don't jump in. People are better caretakers when they make themselves a priority. Get your sleep, eat well, take your medicine and minimize your stress.
3. Plan: Knowing that you are at risk for deferred depression or accumulated stress/anxiety/depression reactions down the line can help you better prepare for when they do occur. Be ready. Know that when you are taking on other peoples problems and you aren't fully dealing with your own lets you prepare. Your own issues will eventually come creeping back. Don't make impulsive decisions and never act on emotion. One thing I tell my patients is that “You can't do math when you are running from a bear”. People who have high amounts of anxiety tend to make worse decisions during higher periods of anxiety. Only make decisions when you are calm and collected and remember that anger and anxiety are synonyms. Don't ever speak to anyone when they are angry, try to think of a time when you have changed someones mind when they are angry or when your mind has been changed when you are upset or anxious. It doesn't happen. Angry people aren't rationale in that moment and anger is simply anxiety but further on the spectrum.
4. Set boundaries- Don't take on others emotions. Your emotions should be yours and others should be their own. Nobody can “make you feel” anything. Stick to your boundaries. If people cross them ,then you have then hold then you have to make let them know they can't. Don't set boundaries that you aren't willing to stick to or others won't take you seriously. You need clearly communicate what your boundaries are and what the consequences are for stepping over them and then be a person of your word at all times.
5. Don't expect anything of other people, only of yourself- Both in the bible and Buddhist there are similar passages with similar and wise words “Expectations are premeditated resentments”. I believe it is wise to follow this advice. I believe it is better to have hopes than expectations for people. Hope that a person will do certain things but know that nobody will EVER live up to EVERYTHING that you desire. It is impossible that someone can be everything you desire them to be. If you expect them to, you will only resent them when they aren't. Change your own outlook on life and people to hopes and boundaries. Hope they will do things and if they don't then you have to determine if when those hopes were not met if boundaries were crossed. If so then you have to make a decision about your expectations for yourself, not another. It is impossible to control people and often the outcome of certain situations and attempting to do so will only increase your both your anxiety, frustration and turmoil. You will find that your anxiety with others will decrease when you realize that it is impossible to change another person if you change your own reaction to a person. That person may decide to change on their own, but maybe not. Either way, it isn't an expectation so there is no need to resent them for not doing so.
You would never pet a badger. You would never expect a zebra to have different stripes. A rabid dog will always bite you when you approach them no matter your intentions. Some people won't change, don't want to or simply don't have the resources to. Don't treat them in a way that they they aren't capable of handling. Only YOU can change. They must make the decision for themselves. In all my years of working with people, I have never changed anyone, they have always changed themselves because they expected it of themselves and that’s all I could ever hope for.