Social Work With Older Adults and Their Families: Changing Practice Paradigms

Greene, Roberta R

ABSTRACT

Given the far-reaching social, economic, and demographic changes in the aging population, the authors argue for a methodological and practice-oriented transformation in future geriatric social work. The authors suggest that if they are to maintain their independence and well-being, a resilience-enhancing social work intervention will be especially effective in fostering the specific survival skills that older adults often already utilize to help them cope with difficult situations. A risk-resilience model sensitive to ethnic difference and practiced at multiple systems levels (e.g., the community) is offered as an advancement of the traditional models of social work practice. In conclusion, the authors emphasize the value of a strengths perspective to address the pressing issues that affect the aging population.

In this article, we discuss successful aging and the "new gerontology" and explore how these varying views about how people age are associated with changes in practice paradigms. We present research findings and practice strategies to support the view that risk and resilience theory can be a significant influence on future social work practice with older adults and their families.

A Climate of Change

In large measure, social work practice "is always shaped by the needs of the times, the problems they present, the fears they generate, the solutions that appeal, and the knowledge and skill available" (Reynolds, 1935, p. 233). The profession also changes from within depending on how members perceive and define what they do (Bartlett, 1970). Some social work theorists expect the new millennium to be a time of political, economic, cultural, and ideological change that will dramatically affect how practice is defined (Greene, 2005; Laird, 1993). Recent gerontological research also supports the view that the vast social, economic, and demographic changes in the aging population require a far-reaching transformation in future geriatric social work practice (Binstock, 1999; Scharlach & Kaye, 1997; Unger & Seeman, 1999). What will that transformation involve? Who will be social workers' clients? What theoretical approaches are best used to serve them?

Changes in Practice Models

The adoption of new theoretical concepts and practice strategies in social work with older adults and their families has tended to lag behind other fields of practice. Starting in the 1960s and 1970s, when psychodynamic theory was in its heyday, many practitioners believed-as did Freud-that older adults were not good candidates for intrapsychic therapies. Ironically, one of the most popular psychodynamic treatment strategies developed during this time was life review therapy. Based on Erikson's eight-stage theory-specifically the stage of integrity versus despair-life review therapy focuses on the resolution of life conflicts through the natural process of reminiscing (Butler, 1963; Erikson, 1950). However, critics of this intervention have pointed out its lack of universality (Merriam, 1993) and its insufficient attention to an individual's sociocultural context (Diehl, 1999; Kenyon & Randall, 2001). Therefore, some researchers and practitioners have proposed a different process of exploring a person's past called narrative gerontology(Polkinghorne, 1996). Narrative gerontology is based on the postmodern idea that personal stories contain "a set of larger stories or 'macro' narratives that reflect shared history, values, beliefs, expectations, and myths" (Webster, 2002, p. 143), thereby giving a broader context to reminiscing.

Subsequently, when family systems theory had become widely used to address family problems, geriatric social workers or social workers in the field of aging gradually came to see the family as central to effective treatment and took up the banner (Greene, 2000; Silverstone & Burack-Weiss, 1983). This method has appeared to be effective for understanding the stresses and strains that may occur between older adults and their families. The forms of intergenerational interventions suggested are intended to mobilize the family system on behalf of the older adult and to promote positive interdependence (Greene, 1989). Although the systems approach continues to be popular (Ephross & Greene, 1992), it too has come under criticism for its structural or strict "one-size-fits-all" family approach. This has led some practitioners to combine systems thinking with such postmodern ideas as how power within the family can be equalized (Greene & Blundo, 1999). Currently, social workers continue to turn to various theoretical practice approaches to find ways of intervening more effectively, including those that stem from a wellness philosophy. Will geriatric social workers be among them?

The Successful Aging Paradigm

Until the late 1980s, gerontology was dominated by the perspective that growing old is a time of decline and loss. In 1987, although not alone in their opinion, Rowe and Kahn (and others) made a significant argument that the effects of aging were not equivalent to disease. They contended that if individuals adopted healthy behaviors, they could advance to old age with far fewer age-associated diseases (Strawbridge, Wallhagen, & Cohen, 2002). They also argued that if people minimized risk and disability, maximized physical and mental abilities, and engaged in an active life, they would lead a salutary life (Rowe & Kahn, 1998). Crowther, Parker, Achenbaum, Larimore, and Koenig (2002) further proposed that another prerequisite to successful aging is maximizing positive spirituality.

During the past decades, gerontologists have made significant strides in advancing a wellness philosophy. A wellness approach is an umbrella term used to consider individual well-being. Theorists such as Antonovsky (1998) developed another positive approach to aging. He used the phrase salutogenesis orientation to characterize his study of how people naturally use their resources to strive for health. In a similar vein, Atchley (1999) proposed the idea of life continuity in which older adults maintain their thinking patterns, activities, living arrangements, and social relationships despite changes in health. Thus, the "new gerontology" was built on a successful-aging paradigm.

Data from the U.S. Census suggest that the future population explosion of older people will not necessarily mean that the number of stereotypically frail older adults will expand in the same proportion (U.S. Bureau of the Census, 2003). This paradigm suggests that many future generations of older adults will be healthier and live with a spouse. Furthermore, they will often seek age-integrated opportunities for work, education, and leisure (Riley & Riley, 2000). The successful-aging paradigm also envisions older adults who will have a sense of economic security and productivity, be more aggressive and educated about their health care, and seemingly be more confident about growing old (Corman & Kingson, 1996).

At the same time, it is not surprising that some theorists have suggested that the Rowe and Kahn successful-aging model needs a more critical evaluation because it may only apply to those individuals with the economic and political power to achieve this "normatively desirable state" (Holstein & Minkler, 2003, p. 787). Holstein and Minkler (2003) went on to call for a further examination of how "new gerontology" research is itself historically and socially situated and shaped by cultural circumstances. In our view, this critique raises several questions: How will the sizable number of future generations of elders who experience various forms of emotional, social, and economic distress best be helped? Some will be without insurance and will have little access to health and human services. Others may find that available services do not fit their cultural expectations for care.

Consequently, critics ask, who benefits and who is harmed by the prevailing, successful-aging, culturally normative standards (Holstein & Minkler, 2003)? This question requires a rethinking of what is important to keep older adults productive through continued societal contributions as well as what is necessary to support those who have acute and disabling illnesses (Kiyak & Hooyman, 1999). That is, can practitioners continue to help older adults maintain their independence and wellbeing as well as assist those most in need through triage (Greene, in press)? Are resilience-enhancing social work intervention strategies a means of achieving these ends?

Moreover, what can practitioners take from a wellness philosophy? A wellness philosophy embodies a prevention approach, emphasizes the heterogeneity of the older adult population, and focuses on a continuum of functionality. Positive aspects of human development across the life course are underscored. In addition, a wellness approach highlights the older adult's adaptability and capacity to meet life challenges. That is, such an approach avoids problem-saturated client descriptions and gives attention to culturally specific personal stories. Risk and resilience theory is part of this strengths-based movement.

Risk and Resilience Theory

What is risk and resilience theory, and what does it offer practitioners? The concept of resilience has several definitions referring to a person's successful adaptation following an adverse event. Resilience is considered a dynamic phenomenon that depends on an individual's life context and is most important at life transitions. Perhaps the most comprehensive way to describe resilience among older adults is that it conveys a sense of continuity, competence, adaptability, and the inherent ability to bounce back across the life span. This definition is captured by Borden (1992), who contended that "resilience is the ability to maintain continuity of one's personal narrative and a coherent sense of self following traumatic events" (p. 125).

This is not to say that older adults do not face risks as they age. The assessment of risk, those factors or circumstances associated with problematic behaviors or situations, should always be made. However, risk and resilience theory suggests that practitioners quickly and simultaneously assess what protective factors the older adult has in play. This assessment of existing protective factors requires the practitioner to make "a conceptual shift and changes in the models of inquiry," thereby shifting attention from risk factors themselves to "the process of how people successfully negotiate risk" (Greene, 2002b, p. 33). Attention is given to learning what circumstances moderate the effects of risk and foster adaptation.

Overcoming risk factors that stem from multiple stressful life events and nurturing protective factors that ameliorate or decrease the negative influence of risk contribute to resilience. That is, a resilience approach can lead practitioners to consider what contributes to an older adult's sense of continuity, especially in his or her ordinary routines of daily life. How can the older adult continue to live in an understandable, meaningful, and manageable world? Given the large numbers of older adults who may need to be served, what are the self-righting tendencies that are revealed in assessment that can foster survivorship (Becker, 1997; Janoff-Bulman, 1992)?

The basic assumptions of risk and resilience theory used to guide assessment and intervention incorporate traditional as well as less familiar principles of human behavior in the social environment (Table 1). Perhaps the most crucial influence on the profession's theoretical base and its approach to practice is also the key to risk and resilience theory-the person-in-environment perspective (Bronfenbrenner, 1979; Greene, 1999; Gilgun, 1996). Similarly, risk and resilience theory embodies the profession's dual mission to improve societal conditions and to enhance social functioning. A resilience-enhancing approach underscores the need to seek resources and sources of natural support within clients' environments.

Understanding the interplay of biological, psychological, social, cultural, and spiritual factors-always important to geriatric assessments-is another area of concern necessary for the practitioner to select interventions that foster resilience. For example, there is increasing evidence in health care that, given hope, people may have a natural propensity to heal. In addition, when clients are able to exercise their sense of mastery by making their own decisions, practitioners may foster their belief in themselves. Moreover, when clients are able to fulfill their "quest for personal meaning" they are better prepared to face adversity (Canda, 1988, p. 243).

Other factors usually considered in geriatric assessment and important in the resilience-enhancing approach include evaluating the balance between client stress and his or her ability to cope. Resilience-enhancing strategies occur when practitioners learn how a client has been successful over the life course (Greene & Armenia, in press) (Table 2). At the same time, it is important to remember that competence is culturally defined. Beckett and Dungee-Anderson (2000) stated, "Definitions of aging shape the perceptions, preferences, beliefs, and behaviors of all persons, and, frequently, the treatment of older persons" (p. 257), particularly older adults of color. Throughout their lives, many ethnic elders have experienced systemic discrimination and oppression, such as social stigma, poor economic conditions, lack of access to health care, and segregation (Aleman, Fitzpatrick, Tran, & Gonzalez, 2000). They have endured these challenging life conditions in a hostile environment and maintained their dignity as they have "learned to overcome adversity and scarcity" (Beckett & Dungee-Anderson, 2000, p. 258). The survival skills that ethnic older adults have utilized to help them cope with difficult situations in their younger years can be effective tools for them as they age and become resilient older adults.

Understanding cultural diversity ensures that practitioners acquire sufficient knowledge of the cultural values and experiences of minority older adults to enable them to determine culturally appropriate assessment and intervention plans. For example, the experiences of African American and Hispanic communities are shaped by family-centered values, interdependence and connectedness, and the belief in God or a spiritual presence in one's life. Asian Americans, like Hispanics and African Americans, tend to share cultural values emphasizing the importance of the family as a primary system of support (Aleman et al., 2000; Dilworth-Anderson & Gibson, 1999). Native Americans also believe in the "power of the 'spirits' to guide their perceptions and interpretations of life circumstances" (Dilworth-Anderson & Gibson, 1999, p. 42).

To effectively assess and intervene with ethnic older adults, social work professionals must acknowledge and affirm cultural values such as the importance of the family as a support, interdependence in the family system, family decision making, spirituality, and respecting the wisdom and experience of the community elders. It is also crucial to recognize that these values may be in conflict with the majority culture. These cultural values, along with positive values about the older population, may challenge the beliefs and worldview that have been internalized from the dominant culture by the social worker.

Assessment of ethnic older adults is based on their perceptions of aging within their own cultural context, the life events they have experienced, and how they have made meaning of their earlier experience (McInnis-Dittrich, 2005). Resiliency can be found in these older adults, regardless of their level of care or amount of support needed (Guthreil & Congress, 2000). As the practitioner listens to clients' beliefs, perceptions, and cultural values, they together can develop mutual goals.

These life experiences and the meanings these older adults have made of them are expressed in the stories they tell. According to Kenyon, Clark, and de Vries (2001), "It is important, moreover, to listen to people's stories not as irrelevant ramblings that waste high-priced healthcare time but as essential sources of information" (p. 48). It is through active listening that we hear individuals' stories that powerfully express not only their personal narrative of resiliency but also the larger interpersonal, sociocultural, and structural dimensions of resiliency (Kenyon et al., 2001). An African American older woman explained, "When you went to the [town] square you could not use the water fountain. We knew better. My mother said 'No, NO. Don't drink; don't sit there.' I'm sure she did not want our feelings hurt." By paying close attention to her story, one learns how life events at an early age helped her to sustain the personal knowledge and skills of resiliency as an older adult. In fact, older adults are "role models for resilience. Generally, they are continuing lifelong patterns of coping and adaptation" (Guthreil & Congress, 2000, p. 50). How much more significant is this for ethnic older adults?

Research and Resilience

Resilience research came to the fore in the 1980s and 1990s when developmental theorists conducted largescale longitudinal studies on children in high-risk situations such as sexual abuse, poverty, drug abuse, and teenage pregnancy. As studies continued to document successful (e.g., resilient) outcomes for these children, researchers as well as practitioners in some fields shifted their focus. They wanted to know why so many children who faced adversity became competent, resilient adults (Fraser, 1997). Studies of adult survivors of such adverse events as the Nazi Holocaust also support the view that people appear to have a natural tendency to overcome adversity and to be resilient (Greene, 2002a; Moskovitz, 1983). Thus, research demonstrated that even people who have undergone extreme hardships have natural propensities to overcome them. These findings have resulted in professionals' promoting the use of risk and resilience theory in practice in the belief that resilience may be fostered through practitioner intervention (Borden, 1992; Higgins, 1994; Neimeyer & Stewart, 1996).

Yet despite its growing popularity, the idea of resilience has not yet been able to overcome the stereotypic image of the frail, if not debilitated, older adult (Lewis & Harrell, 2002). However, a research paradigm shift has revealed that older families are resilient, often using effective problem-solving and emotional coping skills (Garity, 1997; Wagnild & Young, 1993). A small body of literature currently provides insight into resilience in old age (Lewis & Harrell, 2002; Wagnild & Young, 1993). For example, Lewis and Harrell (2002) have devised a relational framework that suggests that resilience among older adults is associated with safety and support, affiliation, and altruism.

Wagnild and Young (1993) suggested that resilience among older women is associated with living through the experience of returning to health after illness or loss. They attribute this capacity to equanimity, balancing one's response to adversity; perseverance, continuing to persist in spite of adversity; self-reliance, exhibiting independence and confidence after loss, existential aloneness, engaging in creativity and self-acceptance; and meaningfulness, deriving insight from experiences and gaining new value in life.

Another example of the research paradigm shift is the change in focus from caregiving burdens to caregiving rewards. Although the caregiving burden intervention approach alleviated stress for many families, it did not give credence to how people may benefit from caregiving experiences (McMillen, 1999), nor did it tap positive indicators of well-being (Kramer, 1997; Pierce, Lydon, & Yang, 2001). One such study by Pierce et al. (2001) that employed a resilience approach examined the perceptions of primary caregivers for family members with dementia. They found that well-being was sustained by those who had a greater identification with the caregiving role and therefore were more enthusiastic. These family members also were associated with appraising difficult situations as less threatening and considering them more of a challenge.

Another study of Alzheimer family caregivers (Garity, 1997) showed that resilience was associated with effective problemsolving and emotional coping. Still another study (Paun, 2003) explored the caregiving experience of wives who had successfully cared for their husbands with Alzheimer's disease at home for at least 3 years. Although all of the wives felt they had no choice in becoming caregivers, all had made a deliberate choice to care for their husbands at home. Most of the women described what would be considered good marriages based on love and mutual respect. All of the wives were committed to continuing to care for their husbands at home for as long as possible (Riley, in press).

Other researchers have examined caregivers' exit transition when the care recipient dies or is institutionalized (Schulz et al., 2001, 2004; Schulz, Mendelsohn, & Haley, 2003). One such study substantiated the remarkable resilience of caregivers and their recovery in response to the death of their loved one. Will practice strategies follow these research findings?

Implications for Practice

Resilience-enhancing interventions begin with the belief that clients can effect positive change (Greene & Armenta, in press). The practitioner also believes in the client's selfrighting processes, with some individuals only needing time to heal. Resilience-enhancing models have several approaches in common: that practitioners adopt a philosophical stance involving client renewal and transformation, that practitioners build on a client's innate capacities, that practitioners select interventions that promote client well-being, and that practitioners explore growth-producing issues. These aims are realized as "practitioners and clients balance truthfulness about hardships with hope, having positive expectations for the future" (Greene & Armenta, in press).

As with most aspects of social work practice, resilienceenhancing interventions can be made at multiple systems levels. For example, Walsh (1998) has provided a family resilience framework that aims to identify and strengthen those family processes that help family members withstand and bounce back from difficult circumstances. A similar concept, community resilience, is characterized by the qualitative elements of a community, which include personal relationships, shared vision, and the opportunity for everyone in the community to participate (McKnight, 1995).

McKnight (1987) identified six factors for the practitioner to observe in determining a community's resiliency. They are (a) community capacity, including the strengths and weaknesses of the community; (b) collective effort, or the manner in which people work together and appreciate individual talents; (c) informality, which recognizes the value of meaningful relationships; (d) stories that share the community's history and future vision; (e) celebrations to incorporate joyous social events into everyday life; and (f) tragedy, including how communities adapt to grief, loss, and change. These six factors, which are important in providing a qualitative understanding of the resiliency of the community, impact the quality of life for individuals and families living in the community.

Family resiliency, including intergenerational families, and community resiliency, which involves elder-friendly service-delivery systems and informal support systems, are interdependent and reinforce the individual in the social environment concept in social work practice. One ethnic older adult explained,

What I experienced of people who wanted to do something and change their situation was their sense of hope. And that's what kept them going. Both a sense of hope and a sense that things could change for their children and grandchildren. And the hope came from the organizations; well, it came from two places. One was that the congregations, the religious congregations they worked with and were connected to, were connected to a larger organization that showed them what kind of change could be brought about. And so that, in my experience, it gave them your word: the "resiliency" and stick-to-it-ness to be with the organizations and continue this work over a fairly long period of time.

By listening to clients' stories, especially during these times of great uncertainties, practitioners can foster client resilience that prepares them to realize their potential.

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Roberta Greene, PhD, MSW, is Louis and Ann Wolens Centennial Chair, School of Gerontology and Social Welfare, University of Texas-Austin, and is editor of the forthcoming book, Social Work Practice From a Risk and Resilience Perspective (Monterey, CA: Brooks/Cole). Harriet L. Cohen, PhD, MSW, is assistant professor, Texas Christian University. Correspondence regarding this article may be sent to the first author at [email protected] or University of Texas-Austin, School of Social Work, 1 University Station D3500, Austin, TX 78712-0358.

Manuscript received: November 3, 2004

Revised: February 18, 2005

Accepted: February 24, 2005

Copyright Families in Society Jul-Sep 2005
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