The place of forgiving oneself and to an elderly parent in the transition to long-term care

The increase in life expectancy that is characteristic of the Western world has contributed, among other things, to the sharp rise in the number of senior citizens being cared for by their families. In Israel, responsibility for caring for senior citizens is shared between the State and his family. This division of responsibility includes the arrangements – in particular the financial arrangements – for nursing care. However, the process of implementing such arrangements is often wrought with complexity, due to non-cooperation on the part of the patient’s family. The objective of this study was to explore the role of forgiveness in the process of transitioning to nursing care, from two perspectives; forgiveness of oneself, and forgiveness of the parent requiring elderly care, both considered from the point of view of the adult children.

The theoretical importance of this study lies in its capacity to explicate the role of forgiveness in familial relationships between aging parents and their children, as well as with regard to the capacity for self-forgiveness by adult children. This relates to the concept of parent-care commitment with regard to nursing care arrangements, and to the capacity of the parent-child dyad to fulfil a filial maturity process. (This term refers to the ability of children to provide help and assistance to an aging parent from a position of ability and desire, in the process reversing roles in the parent-child dyad.) The applied importance of this research lies in its potential to identify obstacles to implementing set procedures for the transitioning elderly clients to long-term nursing care, on behalf of one’s children; and formulating effective policies to support the Ministry of Health and ancillary agencies, in the event of encountering resistance from the children.

A clearer conceptualization of the process, and of the role played by family relationships in connection to it, will allow for better coping with the distress that may arise from it. This will introduce a family-sensitive and flexible aspect to the process of institutionalization, and will allow for a streamlining of the requisite steps. At the same time, identifying family difficulties and conflicts, and facilitating a responsive resolution to such issues, will provide personal and emotional relief of all concerned.

The research in this area is uncommon in Israel. Where it does exist, it usually focuses on formal processes related to the systems themselves, the patient experience, or the sense of burden as felt by the primary caregiver. The family-oriented point of view, as introduced by the current research, allows for a perspective of internal processes as experienced by the family vis-à-vis the formal processes during the institutional arrangement process.

The present study was conducted using qualitative research methodology. The study population was made up of the adult children of elders in the process of being institutionalized in care facilities for senior citizens by the Ministry of Health. The data were collected through semi-structured interviews with 15 family members (primary caregivers) aged 45-75, sampled using a criterion sample, up to six months after the code was submitted to the Ministry of Health and arrangement in a nursing home.

The analysis of the findings revealed three major themes. The first theme was labelled the "time capsule". This theme explored adult parent-child relationships at point of formal institutionalization in a care home, and focused on how at this point there is Concentration of the child (who is the primary caregiver) into the parent-child dyad. In fact, during the interviews, the participants referenced no other family members. The "time capsule" seems to allow the adult child to concentrate in order to manage and understand the new relationship created by parent-child dyad at this stage of parent care.

The second theme was labelled "Good vs. Bad." This theme considered the child/carer’s sense of ambivalence vis-à-vis the parent, and the different modes of self-presentation across the interview. The theme included ambivalence presented as a means for the adult child to “split” the parent image, in order to produce a parent image that warranted "arrangement" in an institutional setting. What became clear in this stage is that in fact, this attempt at splitting did not allow for the desired process of forgiveness, and in fact prevents the complete evolution of filial maturity. This is because the splitting process prevents the adult child from engaging fully with the parent, but rather with specific, incomplete parts.

The third theme was labelled "the other as a decision maker—she said it was necessary." This theme dealt with the significant emphasis placed by the participants on the external factors as responsible for the decision to place the parent in an institutional care setting. The theme described the great burden of care placed on the primary caregiver's shoulders until the moment of the decision, and unpicked the minutiae of the decision-making process for placement in an institutional setting. The realization was that in a parent-child dyad where full-fledged role reversal has not taken place, the child will struggle to make such a crucial decision, one which involves engaging with a panoply of emotions, creating a sense of shame (described as a crisis). Deflecting responsibility for the decision to a professional or expert allows for a distancing from the process, moderating the possible experience of shame. In this study, emphasis was placed on the experience of shame: Shame with regards to the "betraying" parent; and shame with regards to themselves, the "traitors" of family values ​​and parenting, which exists among caring family members; Emotion associated with hurt and lack of forgiveness processes.

The current study highlights intra-family processes and their impact on the parent-child dyad during the process that culminates in the institutionalization of an elderly parent in a care home facility. The study examined this dyad in the light of the filial maturity model, created in the 1960s, examining the role played forgiveness—or its lack—on the ability to reach filial maturity. The findings of the present study indicate that the place of forgiveness in the process is of great importance in the ability to see the parent as a whole—and thus to perform a role reversal and reach filial maturity. Operative recommendations derived from the findings regarding a variety of treatment and guidance were drawn from the research’s findings. The expectation is that these will help in identifying difficulties experienced by the primary caregiver in the face of complex emotions, and the processes of forgiveness that can assist in negotiating such difficulties.