Drawing the Line
Caregivers learn how to say no when consideration for others turns into chronic obligation

By Linda Childers
April 2, 2003

Carol Selby, MS, NP, was looking forward to a relaxing vacation. After a busy day, she had just fallen asleep when her pager sounded.

Selby sighed when she recognized the phone number. It wasn't the hospital or a colleague paging her. The number belonged to an elderly patient whose frequent phone calls and increasing dependence on her were turning into an unwelcome source of stress in Selby's life.

Like many health care professionals, Selby's desire to help others sometimes ushers her into situations that stretch her patience. In cases like this one, she can't help but to question the wisdom of helping others when it comes at the expense of meeting her own needs.

Selby, a behavioral health nurse for the Eastern Colorado Health Care System in Colorado Springs, Colo., admits that learning to set clear boundaries with patients and colleagues has proved to be one of the steepest learning curves in her 11-year nursing career.

She clearly remembers the first time the elderly female patient set foot in her office. An intelligent woman with no family, the patient suffered from severe depression and was desperate to connect with someone.

"We were making great progress until I took a day off or went on vacation, and then she would fall apart," Selby said. "I made the mistake of giving her my pager number and telling her to use it only in an extreme emergency."

But the phone calls persisted on a regular basis and disrupted Selby's personal life.

"She would call frequently in the middle of the night, crying," Selby said. "In the absence of family, she had literally adopted me, and I had gone way beyond the point I should have as her therapist."

Selby eventually sat down with the patient to discuss appropriate boundaries. She asked the patient to throw away her pager number and use the on-call service if she needed to call during off-hours. She also emphasized the need for the patient to use the stress relief strategies they had practiced together.

"I told her that I had allowed us to move into a friendship and that I couldn't be both her therapist and her friend," Selby said. "She respected that decision, and I truly think that setting appropriate boundaries has strengthened our professional relationship."

Selby was pleased when the patient immediately stopped making late-night calls. She also learned that being firm about her own limitations strengthened her professional relationship with the patient.

Just say no

Les Carter, Ph.D., a psychotherapist at Minirth Clinic in Richardson, Texas, has devoted much of his clinical practice to helping people pleasers like Selby change their ways.

Carter counsels many health care professionals in his practice, and is the author of People Pleasers: Helping Others Without Hurting Yourself

"I help my patients who are people pleasers to recognize traits that lead them in the wrong direction, assess how they manage their life and work to develop healthy attitudes and behaviors," Carter said.

For some nurses, the challenge involves more than setting boundaries with patients. Denise Graham, RN, a gastroenterology nurse at Kaiser Permanente in Walnut Creek, Calif., knows she has a problem saying no when colleagues ask her for help.

"Often a colleague will call and ask me to cover a shift for them and my immediate response is 'Yes,' " Graham said. "As soon as I get off the phone, I realize that I've already made plans with my 5-year old daughter or my husband, and that my need to please has put me in a no-win situation."

Graham admits that her tendency to overextend herself can be traced to her desire to be seen by others as a team player.

For nurses like Graham, Carter recommends adopting a commitment to honesty.

"When you're in a people-pleaser mode, it's easy to say you'll help when you're actually thinking to yourself that you don't have time to do this," Carter said. "People pleasers need to give up the hero complex and realize they can't be everything to everyone."

According to Carter, people who feel compelled to help others often live a life in which fear guides decision-making. They worry that if they give the wrong response, others may reject or think poorly of them. Over time, though, this cycle leads to anxiety, exhaustion and-sometimes-depression.

"The No.1 factor that causes people pleasers to change is misery," Carter said.

Carter speaks from firsthand experience when he talks about setting boundaries. His least favorite question when he's leaving a public appearance is, "Dr. Les, do you have a minute?"

His response is one he has perfected over time. He knows most people have good intentions, but want to discuss problems that will take far longer than a minute to solve.

"I hand them my business card and acknowledge they probably have a lot to share but explain that right now I'm pressed for time and don't have a minute," Carter said. "I invite them to call me at my office and, of course, they rarely do. Many people are unintentionally self-absorbed and don't factor in the needs of others when they make a request."

Free your mind

But striking a healthy balance can take time. Carter notes that many pleasers have a strong sense of duty and are driven by guilt. He encourages his patients to adopt an attitude of freedom rather than duty.

"With freedom you have choices," Carter said. "I tell people pleasers to reinvent their way of thinking. Eliminate phrases such as 'have to,' 'must' or 'got to,' and realize that you have choices."

But saying no and setting boundaries can be a daunting task for people whose natural inclination is to help someone in need. Kathy Kilpatrick, MA, a geriatric communication consultant and president of Communication Connection in Hudson, Ohio, lectures frequently to health care providers on the topic of setting effective boundaries.

"It's easier to start with little changes and examine how you set boundaries," Kilpatrick said. "If you constantly find yourself being impulsive and saying yes, tell people you want to take some time and will call them back with your decision."

For some, saying yes isn't just limited to the workplace. Many have difficulty setting boundaries in their personal lives as well.

Graham learned this when a neighbor asked her to baby-sit several days a week. Without notice, the hours became longer, the children began bringing homework that needed to be completed and Graham, who wasn't being compensated for her time, began to feel her generosity was being exploited.

"I finally had to tell her the arrangement wasn't working for me," Graham said. "She didn't take it well, but I felt good that I had been honest with her rather than to let an uncomfortable situation continue."

Letting others know your limitations is an important step in becoming a reformed people pleaser. Carter prescribes that his patients use "quiet firmness" when saying no. Although the changes may take time, the rewards are plentiful.

"When we set effective boundaries, we attract healthier relationships and we're happier with ourselves," Kilpatrick said. "It's amazing how the people who don't have your best interests at heart seem to disappear after you've established boundaries."

Contact Linda Childers at eastbaypr@aol.com