Aging: Practice Interventions
Abstract and Keywords
Social workers address older adult issues at all levels of service planning, policy-making, and delivery and across a wide range of community and institutional settings. While various models of practice intervention with older adults exist, more recently the focus is on the integration of micro and macro strategies with an emphasis on strength-based perspectives to geriatric social work practice. The older adult population will expand dramatically and become increasingly culturally, racially, and ethnically diverse in the future and social work services will need to be sensitive to the variety of issues faced by a more heterogeneous and sophisticated older adult population.
Contemporary social work interventions with the aged (also known as gerontological services) engage practitioners at all levels of service administration and planning, policy-making, and delivery and is carried out across a wide range of community and institutional settings.
Gerontological services provided by social workers at the micro or clinical level are primarily delivered in health- and community-based services. Berkman's Handbook of Social Work in Health and Aging (2006), for example, points to extensive social work practice expertise with older adults in hospitals, long-term care institutions (that is, nursing homes, continuing care retirement communities, assisted living settings, adult foster care and adult day care, congregate housing, and residential care), senior centers, home care agencies, public welfare and social services, geriatric care management programs, substance abuse networks, managed care organizations, the workplace, and community health and mental health clinics.
In these settings, social workers address chronic physical health conditions (that is, cancer, cardiovascular disease, HIV-infected or HIV-affected, diabetes, orthopedic and mobility limitations, developmental disabilities, and sensory loss). They also address mental and psychological health conditions including anxiety reactions, depression, suicide, dementia, and substance abuse (Richardson & Barusch, 2006). In addition, gerontological social workers often work with special populations of older adults including those living in poverty, the oldest old, immigrant and refugees, abused elders, those confronting the end-of-life, and prisoners. Social work practice with older adults can also mean working with elders serving as family caregivers of grandchildren and other relatives and those for whom family, friends, and neighbors are providing care. Additionally, gerontological social workers are commonly called upon to address special social psychological issues associated with aging including issues related to living in an aging family, bereavement in later life, and the transition from work to retirement.
At the macro or policy level, gerontological social work practice focuses on both interpreting and influencing aspects of federal, state, and local legislation and regulation that can affect the economic well-being and the health status of older persons. This can mean both understanding and advocating for changes in the Older Americans Act, Social Security, Medicare, Medicaid, public health policy, private insurance, and private pensions. Macro level social workers are also engaged in developing programs for well and frail seniors and assessing community needs to assure comprehensive services, transportation networks, and a variety of formal and informal supports. They also lead and participate in Interagency Councils, community collaborations, senior leadership programs.
All facets of gerontological social work are further influenced by the cultural and ethnic context in which services are delivered. Thus working with older adults and their families means being sensitive to the possible influence played by race, ethnicity, nationality, gender, and sexual orientation. Finally, practice technique and style with older adults will likely be influenced by geography—namely, whether an older person lives in a rural versus an urban community (Butler & Kaye, 2003).
Richardson and Barusch (2006) argue that an empirically based, age-specific approach that recognizes contemporary issues in aging and social work is essential to successful practice with older adults. Central to their premise is the importance of integrating micro (individual) and macro (policy-level) content in the delivery of gerontological social work services.
The Mandate for Gerontological Services
While not explicitly identifying social workers as the providers of choice, the Federal Older Americans Act (OAA), established in 1965, served as a major vehicle for organizing, coordinating, and providing community-based services and opportunities for older Americans and their families. OAA-legislated services that social workers and other human service personnel now provide include outreach, information and referral, escort, assessment and case management, in-home, home health, chore, home-delivered meals, telephone reassurance, adult day care, senior center, legal assistance, elder protection, housing, health insurance counseling, services to support caregivers, nutrition education, and employment assistance (see Title 42, Chapter 35 of the U.S. Code—Programs for Older Americans at http://www.law.cornell.edu/uscode/text/42/chapter-35).
Social Work Clinical Approaches
There are many different types of clinical social work therapeutic approaches to working with older adults. Models of practice intervention with older adults and their caregivers include cognitive behavioral therapy, family and group interventions, psychodynamic psychotherapy, reminiscence and life review, strengths-based and solutions-focused approaches, spiritual strategies, advocacy and empowerment models, and interdisciplinary team practice (Berkman, 2006). Historically, it was felt that elders would not benefit from individual counseling, operating on the premise that learning in later life was difficult to achieve. However, research has shown this to be inaccurate (Davis & Collerton, 1997). It has been suggested that elders feel less stigmatization when treatment is brief (Corwin, 2002). Reminiscence may be a helpful tool in the social work counselors' practice with older adults. Reminiscence group work has been used to cope with grief, reinforce sense of life meaning, and improve social relationships (Adamek, 2003).
Social Group Work Services
It was not until the early 1950s that the social work profession began focusing on group therapy in a variety of settings. Today, group work with older adults is informed by a well-established theory base, structure, range of services provided, and roles that social workers assume (Garvin, 1997; Toseland, 1995).
There are many different types of groups used in social work practice. Most groups fall into one of two categories in terms of purpose: groups that provide direct treatment or service to their members and those that do not. Social work treatment-centered groups meet to focus on the individual needs of the members. Examples of treatment-centered groups include therapy groups, education groups, socialization groups, and support groups (Kirst-Ashman & Hull, 2002).
Groups that meet for purposes other than direct service, sometimes called task-centered groups, are created to complete a specific task or set of objectives. In terms of practice intervention, this area overlaps with community organizing methods and strategies. The purpose of these groups is not to focus on the individual needs of their members (Henry, 1992). Committees, boards of directors, legislative bodies, supervision, staff development, consultation, interdisciplinary teams, and social action groups are all examples of social work task-centered groups. Social work functions in these groups will vary depending on the needs and structure of each group. Possible social work roles include facilitator, leader, and consultant.
Changing Philosophies and Practice Interventions
Social work counseling and support services for older adults highlight some of the changing philosophies concerning gerontological practice interventions over time (this discussion is abridged from Ruffin & Kaye, 2006). Older adults access counseling and support services through a combination of public and private, community-based, and institutional organizations. The counseling services system consists of private providers funded by third party insurers and private pay consumers, and publicly mandated, not-for-profit, and privately owned providers funded by the federal government as well as states, counties, and municipalities. Institutional or facility-based counseling services include those provided by acute and long-term providers, residential treatment centers, and foster, boarding, or group homes. Community-based mental health services include outpatient psychotherapy, partial hospitalization/day treatment, crisis services, case management, and home-based and “wraparound” services (U.S. Department of Health and Human Services [USDHHS], 2001).
Other community social service organizations provide nonmental health counseling services including Area Agencies on Aging (AAAs), health care facilities, community action programs (CAPs), and senior citizen centers. Services may be offered directly at an agency or delivered in the elder's home. Over time there appears to have been a tendency to offer services more centrally at the agency site. At the same time, increasing use of video, tele-health, and Internet technology has figured in making such services more available remotely (see, for example, Aycrigg, 2006).
Classic techniques of counseling intervention for social workers include supportive counseling, where the worker uses supportive listening techniques to help the client feel understood; financial counseling, in which the worker or agency helps the client set a budget or plan for future expenses; and entitlements counseling, where the worker helps the older person understand which social service programs, benefits, and services he or she may be eligible for.
Counseling programs are often combined with other services including assessment, case management or coordination, and referral. Many agencies provide counseling and support services via telephone hotlines. For example, the Alzheimer's Association, with local offices situated throughout the United States, staffs a 24-hour support and referral service for persons with Alzheimer's disease and their caregivers. The Alzheimer's Association also employs clinical social workers to provide more in-depth counseling support (see http://www.alz.org/national/documents/topicsheet_safereturn.pdf).
Special geriatric care managers may also provide counseling services, depending on the qualifications of the worker. These are commonly master's level professionals in social work, nursing, and other helping professions who have demonstrated competencies in geriatric case management and are affiliated with a professional care management association. Geriatric care managers are often self-employed or employed by a private fee-for-service organization.
Faith-based counseling programs are also an option for elders. Some faith communities employ social workers as a unique method of delivering health and social service information and referral services to their congregants (Kirkland & McIlveen, 2000).
An Alternative Conceptualization
An alternative practice paradigm for working with older adults reflects a productive orientation to life (abridged from Kaye, 2005). Rather than a focus on traditional practice dimensions that are problem based and deficit oriented, such a paradigm is closely aligned with a strength-based perspective to geriatric social work practice. It embraces growth, capacity, and potential, and the continuing aspirations of people over time regardless of their relative age and health. This approach is explicitly geared to promoting the maintenance of productive behaviors. It requires that social workers have a major role to play in a variety of nontraditional settings including retirement planning, travel and recreational programming, employment training and counseling, volunteer services, self-help programming, health promotion and exercise programs, and continuing education and lifelong learning programs. These programs emphasize active engagement in community life. Table 1 summarizes the range of these nontraditional social work programs.
Table 1 Human Service Programs with an Orientation Toward Productive Aging
Volunteer, employment, and civic engagement programs
Continuing education and lifelong learning
Elder mentor/tutor programs
Social action programs
Gero-therapy and counseling
Self-help/mutual aid support groups
Health and wellness promotion projects
Travel and elder hostelling programs
Recreation and exercise programs
From Perspectives on Productive Aging: Social Work with the New Aged (p. 9, Table 1–3), by L. W. Kaye (Ed.), 2005, Washington, DC: NASW Press.
Adoption of a diverse skill set and perspective is particularly relevant for a productive aging orientation to social work practice. Referred to here is a proactive orientation to intervention (that is, intervening before problems and challenges have surfaced or risen to crisis proportions); creative problem solving; interdisciplinary team practice; comfort working at multiple practice levels (that is, micro and macro); and familiarity with nontraditional community resources and services (for example, recreational, travel, educational, exercise programs, and so on) (see Table 2).
Table 2 Contemporary Gerontological Social Work Intervention Skills Sets
Client empowerment strategies
Knowledge of traditional and nontraditional community resources
Proactive (early) outreach activities
Interdisciplinary team building and assessment
Creative problem solving
Engagement in micro, mezzo, and macro client issues
Expansive perspectives on the life course
From Perspectives on Productive Aging: Social Work with the New Aged (p. 12, Table 1–5), by L. W. Kaye (Ed.), 2005, Washington, DC: NASW Press.
Trends and Future Directions
As new legislation is drafted, opportunities for social workers to intervene on behalf of older adults will surface. Such legislation may not explicitly identify social workers as the designated professional to deliver the service, but, depending on the service described and the education and expertise deemed necessary to deliver the service effectively, social workers will be prominent among those helping professionals expected to provide such services. For example, in 2003, the U.S. Administration on Aging and the Centers for Medicare & Medicaid Services jointly established the Aging and Disability Resource Centers (ADRCs) meant to represent part of a state's system of long-term care that promotes a convenient point of entry for such programs. ADRCs now exist in a number of states, and social workers are among those personnel that provide comprehensive information, personal counseling, and consumer access to the range of publicly supported long-term care programs.
Legislative developments in the areas of income maintenance, personal rights, competency and proxy issues, Medicare and Medicaid, health, mental health, and caregiving, private retirement benefits, long-term care, end-of-life care, community-based social services, housing, and transportation have the capacity to impact on the social work needs of older adults and the venues in which gerontological social work services are delivered (Berkman, 2006). In the future, attention should also be directed to the anticipated increase in the number of NORCs, or naturally occurring retirement communities in various regions of the country. The healthy evolution of NORCs will be promoted by social workers and other human service professionals who bring macro planning perspectives that consider the program planning and policy development implications of local settings in which high proportions of older adults make up the resident population.
Leading edge baby boomers entering retirement will represent a generation quite familiar and comfortable with using social work counseling and support group services. There will be fewer stigma attached to their use. A positive, strengths-based, productive aging philosophy should be reflected in such interventions with the focus on active older adult community engagement and personal growth. The term “vital aging” reflects this trend. It can be expected that certain subgroups of older adults will continue to exhibit greater resistance to participation in programming than others (for example, minority ethnic groups, older men) (Kaye, 1997). As the older adult population becomes increasingly culturally, racially, and ethnically diverse in the years to come, such services will need to be sensitive to the variety of issues faced by a heterogeneous older adult population. And all services will need to be planned with rather than for the senior population.
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