�ֲ���ý

For Michael Mason, MEd, LPC, NCC, caregiving is both professional and personal. He has a stepdaughter with a disability, and at a community resource fair he attended with his wife several years ago, he noticed the services were geared only toward the children and not the parents caring for them.

When he launched Safe Harbor Counseling of Missouri, he wanted to support the rapidly growing population of caregivers. As of 2025, 63 million Americans care for others with disabilities or medical conditions, according to the Caregiving in the US report from AARP and the National Alliance for Caregiving. That’s one in four U.S. adults, up 45% over the prior decade.

These commitments have become longer-term, the report notes — with 30% providing care for five or more years — and intensive, requiring an average of 27 hours per week. While more than half of caregivers say the role offers a sense of purpose, their need for mental health support is still significant, with nearly two-thirds reporting moderate or high emotional stress.

“Caregivers today often carry invisible, chronic and emotionally complex burdens,” says Mason, a counselor trained in Internal Family Systems (IFS). “Many caregivers are navigating multiple parts of themselves at once: the responsible part, the guilty part, the angry part, the exhausted part and the deeply tender part underneath that may be holding grief, fear and loneliness.”

Given the significant burden, counselors need tools to identify, assess and support caregivers. “It’s just a matter of when they walk into your office, not if,” says Morgan Whittaker, LCSW, a trauma and grief therapist at Candor Therapy Network in Virginia.

What Caregiving Looks Like Today

Most caregivers — about 59 million — support adult family members. Those care recipients’ needs are significant, often involving activities of daily living such as bathing and dressing, as well as tasks that include finances, cooking, transportation and shopping.

Strained healthcare systems mean more than half of caregivers also take on medical responsibilities. “We are discharging more and more home-based care to these family members — tasks that historically would have been done by a nurse,” Whittaker says. That might include managing catheters, administering injections and even managing at-home dialysis. About one-fourth of the time, it involves dementia care, which adds emotional complexity.

In many ways, technology benefits modern caregivers. Video platforms, wearables and other digital tools help caregivers check in from afar or attend counseling or a support group meeting if they can’t leave care recipients unattended. These systems may also help manage finances, transmit health data to medical providers and share updates with distant friends and relatives.

But digital systems can pose challenges for older caregivers or others who are less technologically skilled, says Andrew Koch, LPC, of Colorado, who previously worked as a certified nursing assistant. His practice, Contemplative Caregiver, focuses on both professional and family caregivers, and he notes there’s sometimes an overlap.

Technology can also add pressure, including for the seven in 10 caregivers who have jobs. While remote work offers more flexibility, always-on access can blur lines between being on or off the clock. “That connection to the workplace can be overwhelming,” Whittaker says.

Some caregivers take time off or even lose their jobs, adding financial strain. Caregivers from marginalized communities — those who are Black, Latino, younger, lower-income or LGBTQ+ — are more likely to struggle financially, the Caregiving in the US report finds.

And work often isn’t the only other role many caregivers are juggling. About one-third care for at least one child as well.

All this means caregiving clients may feel trapped in a role that’s challenging emotionally, physically and financially and often subsumes much of their identity. “They’ll say, ‘I’m the parent of,’ or ‘I’m the son of,’ and name whoever they’re caregiving,” Koch says. “They’ve completely lost who they are.”

The Mental Health Implications

Caregiving stress can present similarly to depression, with exhaustion, isolation, persistent sadness and a loss of interest or joy, Whittaker says. Often, it’s intertwined with guilt and shame about not doing enough. Anxiety is also common and may manifest as disrupted sleep, irritability, headaches and gastrointestinal symptoms.

“Caregiver distress doesn’t always look like collapse,” Mason says. “Sometimes it shows up as over-functioning, numbness, resentment, hypervigilance and that feeling that they can never fully relax.”

Caregivers are also at elevated risk for:

• Anticipatory grief. Jonathan Anderson, LPC-S, LCMHC, founder of Gate Healing in Texas, describes this as a “double whammy” of grieving an oncoming loss while still caring for the person.
• Ambiguous loss. This is especially common when dementia is involved, and the person is physically present but no longer the same.
• Role captivity. Caregivers who didn’t choose their role — about half of them — have significantly worse mental health outcomes, according to the Caregiving in the US report.
• Compassion fatigue. This can lead to a lack of empathy and even neglect or abuse.
• Loss of place. Caregiving that requires relocation can add a dimension of separation and geographic grief.
• Political grief. Changes in laws and support systems can leave caregivers feeling isolated and hopeless.
• Existential struggle. Spiritual or philosophical dimensions — such as anger at God — can weigh on caregivers, Koch says.
• Moral distress or injury. Caregivers may be forced to choose actions that go against their own values, cultural expectations or the care recipient’s wishes, Whittaker says, such as placing their family member in a facility when they wished to die at home.

Caregiver Assessments and Interventions

While caregivers’ stories share common threads, every person is unique, with their own family history and life experiences. Approaching clients with compassionate curiosity can reveal underlying sources of distress and guide treatment, Anderson says.

That’s critical because generic self-care or stress management guidance often backfires. “For many caregivers, the barrier is not just finding time; it is that some part of them believes resting is selfish, unsafe or irresponsible,” Mason says. “If we jump too quickly to advice without understanding the fears underneath, we can accidentally increase the shame rather than help.”

Assessments such as the Caregiver Self-Assessment Questionnaire developed by the American Medical Association and the Zarit Burden Interview can quantify emotional and role strain and identify barriers to resources, Whittaker says. Koch suggests a genogram, a more descriptive family tree, to chart family relationships and dynamics.

For Whittaker, counseling caregivers involves systems theory and problem-solving. “ Rather than treating stress in the abstract, you are mapping that system,” she says. “Where is the pressure coming from? What buffers exist, and where are the gaps we need to fill?”

Familiarize yourself with resources available in your state, along with your client’s strengths and weaknesses. It’s not helpful to suggest a support group or respite care if they’re inaccessible. Motivational interviewing can help clients access resources even when shame gets in the way, Whittaker says.

Behavioral activation can restore other parts of their identity — if they can’t leave the house for a knitting group, could they knit alongside the care recipient? “Think of small, meaningful things that could add purpose to their life again,” Whittaker says.

Cognitive behavioral therapy and acceptance and commitment therapy can address concerns such as self-blame, ambiguous loss and moral distress. That said, overburdened caregivers are unlikely to complete homework between sessions.

Instead, Whittaker uses Socratic questioning to help clients see they wouldn’t hold another person to the same standard. Practice patience: “They might be positive when they leave your office one day and then come back, and they’re right back in that same place,” she says. They’re not bad clients and you haven’t failed them. “They just went back to the same trauma.”

Neurodivergence — diagnosed or not — is another factor to consider, says K.D. Holmes, LPC, founder of KDH Counseling in Louisiana. Autistic clients or those with attention-deficit/hyperactivity disorder will need tailored supports, such as tools for executive dysfunction and sensory overload.

Sometimes, even individual counselors may find it helpful to work with dyads or facilitate family meetings to problem-solve, Whittaker says. And group work can be especially beneficial, validating difficult emotions and allowing caregivers to share solutions and resources.

Koch blends creativity and outdoor experiences into both group and individual work. Making art can help caregivers externalize emotions such as grief and guilt, and sharing makes them feel heard, he says. For the right client, nature may offer peace or a connection to prior experiences, such as fishing with a grandparent. “That creates its own access point for relationship discussions and early childhood memories,” he says.

Meanwhile, an IFS approach asks clients to invite in all the parts of themselves — including those that are numb, using protective coping strategies or resentful — and explores what they’re protecting. “It’s not about pathologizing; it’s about really helping the person and their parts feel seen and heard,” Mason says. “Healing happens when every part is welcome without judgment.”

Helping with Boundaries

Another critical piece is helping clients set healthy boundaries, which Anderson visualizes as shifting, sometimes overlapping, zones that allow people to maintain relationships while avoiding toxic enmeshment. “Boundaries, inherently, are designed to protect your sense of self, your well-being and your energy supplies,” he says.

For family caregivers, mapping boundaries often begins by helping them understand and accept dual roles — one as a caregiver with specific responsibilities and expectations, and another as a child, spouse or parent who has a history with the person they’re caring for, says Pauline Botchway, PhD, LPC-S, LMHC, founder of Assert Your Boundaries Counseling in Oregon.

From there, counselors can help clients:

• Heed warning signs. Recognize early signs of burnout — for instance, forgetting to eat or experiencing disrupted sleep — to identify where boundaries may be nonexistent or unenforced, Botchway suggests.
• Start small and build. An initial boundary may be as simple as a minute alone in the bathroom, Holmes says. From there, clients can build empowering patterns.
• Learn tools. Protocols from dialectical behavioral therapy offer step-by-step guides to saying no and holding firm.
• Express boundaries affirmatively and specifically. For example, clients could tell the care recipient, “I need personal time after 8 p.m.” and emphasize that unless there is a genuine emergency, which should be explicitly defined, they should contact a backup caregiver, Anderson says.
• Use “I” statements and describe emotions. For example, “I feel angry when you keep me up late at night to watch TV or play a game, especially if we have a morning appointment.” This advice is classic because it works, Botchway says.
• Respect others’ boundaries. Ask clients to consider the care recipient’s perspective — someone losing autonomy. Allowing them freedom, such as asking permission before touching them or letting them handle tasks safely, if imperfectly, can restore trust and balance, Anderson says.
• Tolerate discomfort. Setting boundaries, especially when breaking old patterns, can trigger sadness or anxiety. Help clients understand they may feel worse before they feel better but that boundaries are essential to sustainability, Holmes says.

Through individualized interventions, counselors can help clients navigate caregiving challenges and reframe the narrative, connecting to the value and beauty of the experience without losing themselves in the process, Whittaker says.

“I would want clinicians to approach caregivers with deep respect,” Mason says. “They need more than coping tips. They need understanding, support and help relating to themselves with more compassion.”