Dealing with Difficult Families

“He criticizes everything I do,” Sheila said about her mother’s older brother. “Either I’m doing whatever it is wrong or I’m not doing enough. The other day I just couldn’t hold it in any longer and I screamed at him. He yelled back and said some pretty nasty things to me. I wish he would go back to keeping the distance he used to have and not upset my mom or drive me crazy. I just don’t know what to do.” Sheila was complaining to me about her uncle, who would only visit his sister a couple of times a year until she was dying. Then he started visiting once or twice a week, always upsetting Sheila and her mother in different ways until he left.

While the situation and the characters may be different from case to case, it’s not uncommon for family issues to erupt during the dying process—and afterward—as in the above scenario. Sometimes the issues are just out there as part of the daily fabric of family life—those families where arguing and fighting are how they connect with each other. Other times family dysfunction has sunk beneath the surface of family life over years of distance, only occasionally getting reignited, but then resurfacing big time when impending death enters the picture. Even families that have been loving and supportive of each other can experience conflicts when they realize they have strong differences in ideas about treatment, the use of medications, life-sustaining measures, family involvement in care, or funeral arrangements.

Regardless of the causes of upset or conflict, you, as the end of life doula, may be faced with having to deal with the resulting turmoil, especially if you are the primary outside support for the dying person and family. If you are working alongside a clinical health care team, you might get a social worker or chaplain to help intervene. But, because you are likely to spend much more time with the family, you may still need to manage the difficult family situation as you see it playing out around you. 

Some of the difficulties you encounter can be headed off if you know they exist before they become too inflamed. When you do your intake, you want to ask the kinds of questions that might uncover conflict you wouldn’t necessarily see right away. Using open-ended questions about the family and approaches to care can help identify potential areas of difficulty. Here are some questions that can help:

• • Tell me about the relationships in your family and their history.

• • Tell me about any issues of substance abuse or mental illness I should be aware of.

• • Tell me about cultural and/or spiritual differences in the family.

• • Tell me about past deaths in the family and how people dealt with them.

• • Tell me about the most recent treatment decisions and how they were made.

• • What kinds of conversations does the family have about the care of the person dying?

• • What promises were made to the dying person; how does the family feel about them?

• • Tell me how your family handles differences of opinion.

• • Tell me about any conflicts in regards to care or after-death arrangements.

• • Tell me about the goals of care as different people in the family see them.

These questions, and others like them, will give you a sense of the historical factors that could play a part in causing family difficulties. They will also tell you how the family functions together and where problems may arise. Assessing for difficulties, in the beginning, will prepare you for conflicts that could surface later on and help you understand some of their origins. Just remember, that you cannot heal poor family dynamics that have existed for decades, nor is that your job. Your job is to help manage those dynamics so they have the least impact possible on the quality of life for the dying person and the primary caregivers.

One of the most important things you can do from the beginning of working with a family is to set boundaries and enforce them. In families where conflict is endemic, it is natural for some people to play individuals off each other. Your boundaries will help you avoid being triangulated between different factions in a disagreement or conflict. That means not showing favoritism. Make the dying person your number one priority and keep bringing the family back to that same perspective. Above all, don’t do special things for some individuals secretly. Then you will lose your neutrality and boundary, which can only add to the conflict.  

Open, honest, and transparent communication is essential. That starts with deep active listening. Let each person express their view of a situation. One sure way to add fuel to the fire of discord is to deny a person’s feelings, by refusing to hear what they have to say. Every family member deserves to be heard, supported, and valued. You also need to explore what lies beneath the surface of feelings—what causes them—and normalize the difficulties in figuring out how to address the situation. 

One of the best ways to work on a difficult family issue is to suggest a family meeting. While it may help to work with individuals separately at times, it’s always a good idea to make sure people in conflict hear each other. To start a family meeting, you want to establish ground rules, and make sure you enforce those rules if people violate them. Here are some suggestions for those ground rules:

• • Only one person will talk at a time and everyone else should be listening.

• • No whispered side discussions among people.

• • Make sure a person is completely done before you speak.

• • Respect everyone’s thoughts and feelings; no one puts anyone down.

• • The goal is to understand how people feel and the reasons for those feelings.

• • When speaking use I-statements rather than you-statements, which can be accusatory.

• • Be as honest as possible about your own thoughts, feelings, and wishes.

• • If the meeting gets heated we will take a collective breath or take a break.

As the facilitator, you want to remain even-handed, not favoring one person or another. But make sure everyone who wants to speak can, and support them if they struggle. Don’t get sucked into the drama. By remaining calm and holding the facilitator’s role firmly you will lessen the heat in conflicts. Try to find the places people agree and emphasize that. Look for examples of things that are working well, or worked well in the past, as guidance for bringing greater harmony to the current difficulty. Engage in problem-solving, not affixing blame or determining responsibility for what isn’t working well. 

The ultimate goal of the family meeting is to find a compromise that everyone feels they can live with or accept. This should be arrived at by consensus, not a majority vote. Majorities always leave some people feeling unheard and hurt. So even if for the moment the problem seems resolved, the people who couldn’t agree will become an obstacle later on.

One final suggestion: acknowledge that working through conflict is hard. The family is being called on to work together in ways they may not have before. This is challenging and uncomfortable. But if they get through this in a positive way, it will make the dying experience so much better for the person dying and everyone else involved. They will look back on this as a gift they gave the dying person and themselves. It may even soften long-standing resentments, pave the way for better family feelings in the future, and lead to greater resilience when other family crises arise.