Merriam-Webster defines the term sandwich generation as a “generation of people who are caring for their aging parents while supporting their own children.”

Estimates vary concerning how many Americans belong to this sandwich generation, but a recent poll from the Associated Press-NORC Center for Public Affairs Research puts the number at nearly 1 in 10 Americans age 40 and older, with another roughly 8 percent who may become “sandwiched” caregivers in the next five years.

Not all sandwiches are alike, however. Some sandwich generation caregivers have aging parents living with them, while others care remotely for aging parents who still live on their own or in assisted living facilities, sometimes in another state.

As for the “children” that sandwich generation caregivers are looking after? Traditionally, the assumed reference would have been to those younger than 18 who are still living at home. But many sandwich generation caregivers have young adult children who no longer live in the home yet still rely on their parents for financial support. Still others have adult “boomerang” children who have moved back into the house.

There’s also the “club” sandwich, which includes more than three generations. For example, a 55-year-old woman might be caring for her aging parents, while her 30-year-old son and daughter-in-law, along with their young children, live at home with her. “It’s not just a regular peanut butter and jelly sandwich, it’s a club sandwich of family members looking behind and ahead in multiple generations,” says E. Christine Moll, an associate professor and chair of the Department of Counseling and Human Services at Canisius College in Buffalo, New York. Moll is also a past president of the Association for Adult Development and Aging, a division of the American Counseling Association.

Ten years ago, Phillip Rumrill found himself in a variation of the sandwich generation. Rumrill, a professor of rehabilitation counseling and director of the Center for Disability Studies at Kent State University, was helping to care for his grandmother, who had cancer and dementia. He was also raising young children of his own and holding down a full-time job as a counselor educator.

Rumrill says there weren’t many good resources at the time for sandwich generation caregivers like himself. He and the other family members helping with his grandmother’s care “had to learn a lot on the fly.” A few years later, two rehabilitation counseling colleagues approached Rumrill. The women — one of whom had cared for her mother-in-law and the other of whom had cared for her father, both while raising their own children — were interested in writing a book on the topic.

Rumrill, Kimberly McCrone Wickert and Danielle Schultz Dresden co-authored The Sandwich Generation’s Guide to Eldercare: Concrete Advice to Simultaneously Care for Your Kids and Your Parents in 2013. Their aim was to provide the kind of practical guide they wished had been available for them.

Among other things, Rumrill says the book addresses the inherent tension and conflict involved in caring for an aging family member, especially when the tables in the relationship are turned and adult children are telling their aging parents what to do.

For Rumrill, that point is exemplified by one memory of his grandmother. He was explaining something to his grandmother when she interrupted him. “Apparently I was saying it in too much of an advisory way,” Rumrill says, “and she stopped me for a minute. And she said, ‘I want to ask you a question. … When did the change happen where you started telling me what to do?’”

Career plus caregiving 

As a life span services manager in the Office of Work, Life and Engagement at Johns Hopkins University, Meg Stoltzfus helps university staff and faculty members navigate all kinds of caregiving challenges. The biggest stressors she sees with sandwich generation caregivers are related to finances and career.

“Many caregivers, if they are working, have to cut back hours at work, or they can’t accept promotions if that would involve more travel or more hours, because they have so many commitments that they have to fulfill with their children and their parents,” says Stoltzfus, an ACA member. “Then they start to deal with their own financial difficulties if they’re not able to save as much for retirement, if they’ve cut back their hours or if they’re spending all their discretionary income on providing care and assistance for their parents.”

The impact on a sandwich generation caregiver’s career compounds the problem. “This sandwich situation happens really at the prime time in your career,” Stoltzfus explains. “And that’s the time when you have the most competence, when you’re making the most money, when you’re really on a roll — and then it kind of brings that to a screeching halt for many people.”

As it relates to taking care of aging parents, sandwich generation caregivers may also experience less understanding, collegiality and encouragement in the workplace. When someone is expecting a baby, co-workers often throw an in-office baby shower to show their excitement and support, complete with gifts and good wishes. “You do not have a similar party when you’re taking care of your dad or you have to move dad into the house,” Stoltzfus points out. “There’s still a real taboo in the workplace generally about talking about eldercare.”

In fact, Stoltzfus says, some people go to great lengths to hide their caregiving responsibilities for aging parents. They worry that it might cause supervisors to pass them over for promotions or that colleagues may think less of them for having to miss an office happy hour to go home and care for a parent, she explains.

Although some progressive employers are beginning to support workers faced with these kinds of caregiving responsibilities, Stoltzfus says it remains challenging to balance work with caregiving. She recommends that counselors working with sandwich generation clients encourage those clients to familiarize themselves with their companies’ employee policies and meet with a human resources manager to discuss supportive options with which they might not be familiar.

Stoltzfus’ employer, Johns Hopkins University, has a program that pays part of the cost of backup care. For example, if the aging parent of a university employee needs surgery and then needs an in-home nurse afterward, the university will pay part of the cost of that care, Stoltzfus says. “Employees need to see what their employer covers and what benefits they have in place for caregivers because it may be a big help to them [and] they may be able to be more successful at work if they can take advantage of those,” she says.

Rumrill suggests that clients set up a contingency plan at work concerning what will happen should they need to be absent at the last minute because of caregiving responsibilities. Clients shouldn’t assume that employers haven’t had to deal with those kinds of caregiving challenges before because, odds are, they have. “It’s a really pervasive issue,” he says.

To help clients tackle the financial stresses that accompany caregiving in the sandwich generation, Stoltzfus says counselors should be equipped to make referrals to local experts who can help. One overall referral that Stoltzfus recommends is to an “aging life care professional,” also known as a geriatric care manager. Those professionals can connect caregivers with various kinds of eldercare resources in their communities, she says.

Both Stoltzfus and Rumrill also recommend that counselors be ready with referrals to qualified elder-law attorneys and financial planners. Those professionals can help clients navigate government benefits for which the aging parent may qualify, help create wills or trusts and provide assistance with other financial and legal issues.

For everyday practical needs, such as finding transportation or adult day care for aging parents, Rumrill often suggests the Eldercare Locator (eldercare.gov), provided by the U.S. Department of Health and Human Services Administration on Aging, or connecting with a local Area Agency on Aging.

A balancing act

Another major challenge for those in the sandwich generation is meeting the caregiving needs of their children and their aging parents simultaneously, Rumrill says.

“Sometimes, those needs compete with one another,” he says. “Meeting your parents’ needs may mean that you aren’t meeting your children’s needs in the way you would like to. In many cases, members of the sandwich generation find that the skills they employ in raising children help them in providing eldercare, but being responsible for multiple generations of people can be daunting and exhausting in terms of physical energy, time and financial resources.”

And children — especially young children — often don’t possess the perspective needed to understand the situation. Sometimes children will express frustration, resentment and even anger that their parents are taking time away from them to care for their grandparents or other older relatives, Rumrill says.

Guilt is a common reaction, Rumrill adds. “The caregiver feels that he or she is letting everyone down when, in fact, he or she is keeping everyone moving along.”

Rumrill suggests that parents communicate openly and honestly with their children about the health of older loved ones. “Find ways for children to take part in the care if that is possible, encourage children to maintain a good relationship with the elderly loved one as he or she declines and maintain as much continuity as possible in terms of family customs and traditions,” he advises.

Many parents find creative ways to involve children in the caregiving, Rumrill says. “One mother assigned her 12-year-old son to go to his grandmother’s home every Saturday to mow her lawn,” he says. “While he was mowing the lawn, grandma made him lemonade, baked cookies for him and, after he finished the lawn, they visited for several hours in the afternoon, she telling him stories about her life and her memories of her family. So by helping out with a needed task, the boy was also making a value-added connection with his grandmother. Plus, his presence provided her with companionship to combat the loneliness that often accompanies aging.”

Counselors can help sandwich generation caregivers and their children in a number of ways, Rumrill says, including giving children a safe space to share their feelings about the situation. They can also help parents and children deal with feelings of grief over the changes happening to their older loved one and help them prepare for the eventual death of that person, Rumrill says. Counselors might also try to help children and parents clarify and possibly revise the expectations they have of one another considering the changes taking place in the family due to caregiving responsibilities.

Friction in the family

Caring for an aging family member can create or exacerbate interfamily conflicts among adult siblings, Stoltzfus says. “It brings up a lot of family-of-origin issues,” she says. For example, one adult sibling might tell another adult sibling, “Mom always liked you best” or “You’ve never helped; you’ve always been selfish.”

“It really taxes the family structure to get everybody on the same page about what kind of care is needed and how that care is going to be provided because many times, the siblings all have different opinions about how this should be handled,” Stoltzfus says.

Moll, who specializes in working with older adults and runs a small private practice in a suburb of Buffalo, agrees. The stress and complexities involved in family caregiving can dredge up unresolved family issues that may have germinated years, or even decades, ago. It is often important for counselors to peer beyond the issues at hand, Moll says, and instead identify and follow the roots underlying those issues to their source.

Sandwich generation caregiving can also put stress on the relationship between partners. For example, if one partner or spouse is devoting a significant amount of time to caring for an aging parent, the other partner or spouse can be left to handle the lion’s share of the household and child care duties, Stoltzfus says.

Then there is the issue of clients balancing their new roles as the son or daughter of an aging parent, Rumrill says. Part of the time, that person is still the child of a parent, while at other times, that person has to step in as the adult caregiver and tell the aging parent what to do, just as Rumrill experienced with his grandmother.

Rumrill suggests that individuals who find themselves in that situation remain as open and honest as the circumstances allow. If they have safety concerns about an aging parent, for example, they should express those concerns, while at the same time respecting and honoring the lifelong relationship they have had with that parent. Adult caregivers should also continue to honor whatever resources and capabilities that aging loved one still possesses, he adds.

“Our parents and grandparents also have the right to know exactly what it is that we’re thinking and feeling and observing,” Rumrill says. “And if it’s a good relationship, it won’t be permanently undermined by that.” In the meantime, however, clients may have to deal with the conflict and resistance that result from those honest conversations, he says.

Some sandwich generation caregivers help to care for an aging parent from afar. That circumstance often ushers in feelings of guilt among caregivers, Rumrill says. One remedy he suggests is exploring how to use technologies such as Skype to stay as connected as possible. But that can be challenging, Rumrill admits, especially if aging parents aren’t tech savvy.

Rumrill also points out that issues of grief and loss can be present among caregivers even as an aging parent is still alive. Especially in cases of dementia, caregivers might mourn the loss of that parent’s former self. “Your mother as you knew her is never going to be the way she was,” says Rumrill, citing an example.

‘We need to ask that question’

The majority of unpaid caregivers in the United States are female, according to research published earlier this year from the National Alliance for Caregiving and the AARP Public Policy Institute. But Jacqueline Smith, director of the master’s counseling program at Regent University in Virginia Beach, Virginia, says that counselors can easily overlook caregiver-related stresses among female clients if they aren’t watching carefully.

“We teach our students to ask about domestic violence, we teach them to ask about sexual assault, we even teach them to ask about trauma in [clients’] backgrounds,” says Smith, a member of ACA. “But we’re not asking [clients], ‘Are you taking care of children and parents?’ We’re not asking that question, and we need to ask that question.”

A few years ago, Smith and two graduate students from Northern Kentucky University, where Smith was working at the time as director of the counseling and human services program, conducted a pilot study with nine women who were sandwich generation caregivers. One of the things those women expressed was a sense of isolation, Smith says. They talked about feeling alone and lacking others with whom they could share their experiences. Many of the women told Smith that they would like to go to counseling but didn’t have time to spend on their own needs because they had so many other people’s needs to meet.

Smith and the graduate students provided a support group as part of the study, and it received rave reviews from the participants. “This is the type of thing that we need — a place where we can be validated and share resources and experiences with one another,” Smith says the women told her.

Research has shown that caregivers have a higher incidence of depression, Smith says. “While we as counselors and as behavioral health care practitioners may be diagnosing depression, I think the depression may look different for individuals who are caught in this sandwich generation syndrome because they can’t get out of it,” Smith says. “This is not acute; this is long term, this is ongoing. This is a long-term, life-altering, everyday stressor. And I think it’s something that needs to be addressed and not medicated.”

In addition to support groups, Smith recommends resilience-building techniques as being particularly helpful to sandwich generation caregivers. “I believe that many sandwich generation women could handle their circumstances with a supportive, optimistic, hope-filled counselor who was looking to build upon the women’s strengths,” Smith says.

Among the ways Smith says counselors can foster resilience among these female caregivers include giving them a place to express strong emotions, helping them identify their strengths and encouraging them to advocate for themselves within their families.

Women who are caring for aging parents may also need help managing boundaries. “It’s definitely a balancing act between being [both] a daughter and caregiver to an aging parent,” Smith says. Beyond helping the individual caregiver client work on boundary setting in session, Smith says that in some cases, family counseling sessions can be helpful so that the caregiver can clarify changing roles and boundaries with her family members.

Another area in which counselors can offer assistance is helping these women to reaffirm their own personal identities. Between outside employment and their caregiving responsibilities to children
and parents, Smith says, women can easily lose a sense of their own identities as individuals.

Especially among African American women, Smith suggests that counselors take note of the importance of spirituality, both as a way to support these clients during the counseling process and in reaching out to them in the first place. Smith calls the church the center of the African American community and says that counselors might be able to connect with many sandwich generation caregivers by partnering with local churches.

Smith says support groups are “vitally important” to female caregivers as a whole because the groups offer women a place to be heard and validated as they share resources. Smith suggests that counselors consider partnering with either adult day care providers or child care providers when creating support groups for caregivers so that clients can participate in the groups without having to find alternative care for aging parents or young children.

Smith says counselors should be careful not to pathologize women who are facing challenges and stressors related to their caregiving responsibilities. Sometimes, there can be a tendency among mental health practitioners to “slap a diagnosis” on everything, she says. “As opposed to looking at what it is they’re doing right and how they can do more of [it].” Counselors must support resilience among these women instead, Smith emphasizes.

No one can do it alone

If caregivers are approaching burnout, Rumrill says, counselors might start hearing them say things such as “This is more than I can handle” or “I just can’t do this.” Other hints of burnout can include conflicts with other family members and signs of strain at work, he says. Ideally, counselors would encourage clients to seek help from their support networks to avoid burning out, Rumrill says.

Family caregivers can balk at seeking and accepting help, however, and their hesitancy isn’t necessarily connected to financial worries. Sometimes, Stoltzfus says, sandwich generation caregivers think they should be able to handle all the family’s needs on their own. In other instances, an aging parent may accept help only from certain people, such as a spouse or adult child. In the latter case, Stoltzfus suggests that counselors attempt to brainstorm other options with clients, such as identifying a friend the aging parent is comfortable with who is willing to pitch in and help.

In addition, there are services that can organize volunteer help from friends, Stoltzfus says. Lotsa Helping Hands (lotsahelpinghands.com) is one example. It offers a calendar at which people can post requests for help with anything from the provision of meals to being transported to medical appointments.

Counselors can also encourage caregivers to look within the family for additional assistance, Stoltzfus says. Sometimes caregivers make themselves feel responsible for seeing that everything gets done or, alternately, feel that everything has been dumped in their lap. It can be difficult to get clients to zero in on other family members who can help, but Stoltzfus says counselors should help caregivers see that no single person can manage everything on his or her own. Delegation is key, she says.

The counselor and client can work together on setting boundaries and being more assertive, Stoltzfus says. For example, if the caregiver works full time but the caregiver’s aging parent calls often during work hours, Stoltzfus might suggest setting one specific time to talk every day that fits within the caregiver’s work schedule.

Settings boundaries with other family members such as adult siblings can be challenging as well. Counselors can work with clients on assertiveness training, encouraging them to clearly communicate to family members what roles they are able to fill and what roles other family members need to step up and take on. In some cases, Stoltzfus coaches clients about how to discuss the financial responsibilities of caregiving with family members. For instance, in some circumstances, families have money available to pay for caregiving but prefer for that care to be provided by a family member. Although Stoltzfus acknowledges that it is a tricky conversation to have, she says that the designated family caregiver might consider talking with other family members about being compensated for the work that he or she is doing.

Caring for the caregiver

Caring for children and aging parents can leave little time for anything else, including self-care. Stoltzfus heard recently of something called the “bobblehead effect,” which she says applies to the topic of self-care. A counselor might suggest that the client take time out for self-care, and the client might nod and smile, just as a bobblehead would do. “But in their mind, they’re really saying, ‘How on earth am I going to do that? I have absolutely no time left in my day and no energy,’” Stoltzfus says.

Embracing self-care is something that clients have to do in their own time and in their own way, Stoltzfus says. Counselors should still bring up the concept of self-care in sessions, she says, but they need to understand that the solution isn’t as easy as the client simply agreeing with what they said.

For instance, she might suggest that clients overburdened by caregiving responsibilities should take one night per week to go out with friends, go to the gym or take the dog for a walk. “I’m going to say these things, and they’re going to be looking at me like I have no idea what their life is really like,” Stoltzfus says. “But over time, they realize that there’s absolutely no way they can make it without it.”

Stoltzfus will ask clients to rate their readiness for self-care activities on a scale from 1 to 10. “If they’re a 2, I say, ‘What would it take to get you to a 4?’” She’ll then check in with clients during sessions and help them set attainable goals. For example, Stoltzfus might ask clients to name one self-care action they can follow through on in the upcoming week. “Don’t impress me, don’t try to bite off more than you can chew,” she’ll tell them. “But, realistically, is it just lunch with a friend one day?”

At times, success comes when counselors appeal to the selfless side of caregivers, even as a way of nudging them toward caring for themselves. “Sometimes people won’t do it just for their own sake,” Rumrill says. “But those same people will resonate with the fact that if you don’t take care of yourself, then you’re compromising the care you’re providing to your children or your grandchildren or to your mom or to your grandma.”

Counselors can frame self-care as a necessity for being the best caregiver a person can be for other family members, Rumrill says. “Sometimes that works for people who are [otherwise] like, ‘Well, I wouldn’t do this just for me.’”

 

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To contact the individuals interviewed for this article, email:

• E. Christine Moll at moll@canisius.edu
• Phillip Rumrill at prumrill@kent.edu
• Jacqueline Smith at jrsmith@regent.edu
• Meg Stoltzfus at megstoltzfus@verizon.net

 

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Want to work with sandwich generation families? 

If you are interested in working with sandwich generation caregivers, there are many ways to increase your level of expertise and find clients.

Educational opportunities for counselors are all around, says Meg Stoltzfus, a life span services manager in the Office of Work, Life and Engagement at Johns Hopkins University. For example, she says, the local Department of Motor Vehicles office might offer a seminar on how to talk to older drivers about when it is time to give up their driver’s license. A local Area Agency on Aging will often sponsor seminars on aging and caregiving topics as well.

Phillip Rumrill, a professor of rehabilitation counseling and director of the Center for Disability Studies at Kent State University, suggests checking out continuing education classes at a local university. Classes in human development or gerontology, as well as classes on grief and loss, can be particularly helpful, he says.

Connecting with eldercare lawyers, financial planners who specialize in estate planning and physicians who specialize in treating older adults can be beneficial to counselors in different ways. First, being familiar with these kinds of professionals will allow counselors to provide informed referral options when they’re needed by clients, Stoltzfus says. In addition, she says, those connections can result in new client referrals for the counselor.

— Lynne Shallcross

 

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Lynne Shallcross is a contributing writer to Counseling Today. She recently graduated with a master’s degree in journalism from the University of California, Berkeley, where she won a 2015 Online Journalism Award for best work in the small student projects category from the Online News Association. Her winning project was a master’s thesis titled “Mobile Health: Apps for Every Age and Ouch.” Contact her at lshallcross@gmail.com.

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