Externalizing the Problem: A Tool for End-of-Life Providers and Caregivers

By Lisa Pahl, LCSW

There are many tools that I use in my work supporting family caregivers. Externalizing the problem, a tool well known in narrative therapy, can be a simple and effective way to shift a perspective. Externalizing the problem can help by seeing the problem as separate rather than an inherent characteristic of a person, creating a sense of agency in addressing it.

Bob was living with late stage dementia and was receiving hospice care. He was unable to ambulate and spent his days in bed, mostly sleeping. He had lost the ability to talk. I went to visit one day and his wife was angry that he had spread feces all over the wall. She had done her best to clean him up but, it was in fact, quite an explosive scene. Luckily, the hospice CNA was on her way to help get the patient clean and comfortable. 

It seemed that she would benefit from more help with caregiving, something she had resources to make happen, but thus far had been refusing. 

However, if we move to problem solving/resource management before managing the emotions underneath, we are dismissing or minimizing the experience and feelings. 

So I explored with his wife what happened.  She shared that she had no idea why he would do such a thing to her; to make such a mess that she had to clean up.  It was indeed a mess, and I understood the frustration as this was not the first time it happened. And, caregiving is just so damn hard. 

I asked his wife, “Is this something that Bob would have done before he was diagnosed with dementia?”

His wife shared, “God, no. Of course not! He would be mortified if he knew he had done this.”

I let the statement sit for a moment. 

She went on, “Bob would not do this to me.”

I asked her, “So, perhaps it is dementia that caused this mess today, not Bob.”

Her face softened and she said, “Dementia has caused so many troubles for Bob and I.” 

We then talked about how dementia had stolen many aspects of her husband’s engaging, bright self. She shared stories from their lives, years before any symptoms of dementia presented. 

Eventually, we tackled the pragmatic element of what took place today; a need for his wife to obtain more help in caregiving for Bob. She was able to bring in a caregiver for  a few hours a day. 

I continued supporting her throughout the remainder of Bob’s life and she continued to externalize dementia from Bob, saying it brought her more compassion for him.