Social Work Practice with Older People: A Positive Person-Centred Approach

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Rory Lynch

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    Acknowledgements

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    Acknowledgements

    In memory of Diarmuid Lynch

    About the Author

    Rory Lynch is a lecturer in social work at Robert Gordon University, Aberdeen. He comes from St. Johnston, County Donegal in the Irish Republic and has lived and worked in Aberdeen for forty years. During this time he has developed and worked in a range of agencies from single homelessness, substance misuse and latterly mental health services. He has published on a variety of themes related to older people including sociology and social work; need, risk and protection and social policy for social work within a Scottish perspective.

    Introduction

    The structure of this book is very much driven by some of the radical changes that have taken place within community-based support, care management, the political context and more recent downturns within the economy of the United Kingdom. The book also sets out to explore and define the nature of modern social work training within the recent Professional Capabilities Framework for Social Work and the impact this has on training and service delivery. Just as importantly, the text seeks to focus on those ethical and value-driven aspects of working with older people. While the author would not support the view that values and ethics of themselves are under attack in the modern world, it is true that financial and resource stressors will impact on service delivery and how the needs of older people are met. Most of the chapters of the book will focus on these themes and a consideration of what it is to be an older person in the twenty-first century. This book will appear at a time when there are real concerns as to how older people, without adequate resources, will manage in areas of nutrition, heating and a wider social engagement with families and local communities. Students of Maslow (1987) may wonder what the wider implications for personhood and belonging are when the basics of human existence may be under threat for some individuals. The text is permeated throughout by case studies, exercises and questions to ponder.

    The author has also attempted here to define the changing nature of the older person and Chapter 1 focuses on this within the context of the transition of growing into older age with an emphasis on law and policy. This is as opposed to youthfulness, which is more readily grown out of. The chapter addresses how older people may become hidden in full view where expressed needs are denied or not acknowledged. Older people may become increasingly worried about their perceived lack of input into society. This is particularly at odds with those older people who are still working post-retirement as well as carrying out voluntary, caring and kinship roles. Lord Birchard, former head of the benefits agency, has not helped the current debate by suggesting that retired individuals should commit to community services to reduce the burden on the state, or have their state pensions reduced (Morris, 2012). A starting premise therefore for any consideration of social work with older people is that older people are not an adjunct to the state but are the state itself. When this politically driven premise is considered as a rational debate as opposed to a consideration of the lack of resources, then older people may have cause to worry. From a social policy perspective this has to be considered within the context of the UK’s gross domestic product (GDP), which is one of the highest in Western Europe.

    Chapter 2 is concerned with values and ethics and how social work practice can remain professional and moral within what is considered the ‘rightness’ of actions. These considerations may be at a time when resources are limited and practitioners may be forced to make decisions based on this premise. Essentially, this chapter is related to need and its resolution within a context of inclusivity and engagement. The chapter seeks to explore those wider dimensions of personal values as well as a consideration of that more philosophical aspect of what it is to be. The author suggests that without this consideration the needs of all vulnerable groups may not be met. This chapter also considers something of the ‘tyranny’ of youth, although caution needs to be exercised here to ensure that youthfulness and older age are not seen as conflicting opposites. This is more related to a mutuality of respect and an acknowledgement of the psychological forces at work across the life course. These are not only stages that need to be worked through but hopefully in a collaborative way.

    Chapter 3 addresses the range of skills necessary to consider and engage with the needs of older people. This is not a static set of skills and will need to reflect the changing impact of ageing itself across the generations. The focus here will be on listening, engaging and not assuming, as part of a more personalised agenda. Even the most careful professional interaction can develop into a ‘professional knows best’ at a time of stress on finances and resources generally. This is explored here within the new social work standards and again the chapter has a strong emphasis on ethics and values in relation to a meaningful and successful communication with all older people. At the heart of this understanding is that older people are not a homogeneous group. They are as different and diverse as any equivalent group of younger people or people from different cultural or ethnic backgrounds and should be engaged with in a way that reflects this diversity.

    Chapter 4 explores community care from its inception, what it potentially sought to achieve and a critique of what this can mean in reality. The reader is encouraged to consider the history of this and, more importantly, how a community-based focus may not always meet the needs of older people. This can relate to individual choice, a lack of support networks, inadequate resources and social isolation. The chapter also addresses a range of assessment models with a critique of their value and particularly those themes that drive care management. The author cautions against an unthinking use of the language of the marketplace at the expense of the language of support and liberation. Older people are not commodities.

    Chapter 5 focuses on mental health and well-being, which is, in the author’s view, one of the most significant areas of current practice with older people. This comes at a time when older people may experience the double trauma of the ageing experience allied with poor and declining mental health. When disabilities become compounded then there is a greater potential for discriminatory practice. The consideration within this chapter is, how will the more complex mental health needs of older people get addressed if the main debate is on older people and their collective drain on the national purse? This is compounded by cuts in National Health Service provision, where there has been a real decrease in spending of 3.1% within the 2011–2012 budget for older people’s mental health services (Boffey, 2012). So this chapter takes a much more focused approach to well-being in terms of individual psychopathology as well sociological forces of construct, ageism and stigma generally.

    Chapter 6 explores the complex area of dementia. While the chapter on mental health focuses on wider issues of well-being this chapter on dementia resides as much within a focus on human rights as a diagnosis of illness. Again there is a strong ethical focus here with that implicit understanding of the uniqueness of individuals. This chapter addresses the wholeness of the person and how this may support both social work understanding and intervention. A consideration of Kitwood’s (1993, 1997, 1999) ‘personhood’ is critical here to facilitate individual experience and need within an ethical and human rights perspective. The chapter concludes with a range of practical skills to consider when working with those older people diagnosed with dementia.

    Chapter 7 identifies how assessment is at the heart of any effective communication and intervention with older people. A quality assessment will consider all the relevant expressed detail of an older person’s life and needs. This chapter addresses the theoretical framework for assessment and intervention, with a strong focus on the ‘process’ of engagement. While it is not a conflict it is certainly the case that where the rules of engagement are defined then there is a likelihood for a more successful outcome! Too often practitioners become caught up within an outcome-driven focus when the actual liberating aspect resides within the simple engagement with the older person. Given the importance of this assessment, the author has worked through this aspect within practice to speculate on how older people may feel and respond to it. This chapter has also not shied away from issues of emotional pain, however difficult these may be to evaluate. The author believes that without entering into this world of potential trauma it is ultimately not possible to engage with the personhood of individual older people.

    Chapter 8 explores gerontology, the science of ageing. The author has integrated key themes of the demographic of ageing and the research basis for this. This also addresses significant issues of how ageing itself is a social construct, influenced more by social policy than individual capacity for coping. A significant emphasis here is on practitioners being able to ‘read’ the meaning of what older people may be trying to express using the theoretical underpinning knowledge contained within this chapter. This specifically seeks to engage with those themes that make for the likelihood of a more successful psychological ageing across the life course. There is a specific focus here on how areas of psychological development (or dysfunction) may be missed if older people are deemed to withdraw as a natural consequence of ageing itself. This refocusing will helpfully encourage both workers and developing practitioners to view those more individual dimensions of older people’s functioning across the life course.

    Chapter 9 addresses the meaning of care and what this means within a more formalised residential setting. While older people may have to engage with the challenge of transitions to a new environment, this is made less easy where there is a lack of choice and inclusion. The media depiction of the scandalous treatment of older people in care also needs to be acknowledged here and how this may frighten older people. A key feature of this chapter is that there is no natural correlation between ageing and vulnerability. This is something that is more likely to reside within the eye of the beholder as well as being reinforced within negative media reporting and unsympathetic social policy. A significant feature of this chapter is the destructive force of disempowerment. When the citizenship of the older person is removed then what is left may equate more to incarceration than care. This is addressed more fully within the section on privacy and the nature of institutions. An important feature of this chapter is a consideration of end of life care and the importance of addressing this within the continuum of life itself.

    Chapter 10 seeks to formalise the relationship between evidence-based practice, research and professional development. Modern social work practice acknowledges that the research base will support new and developing practice and that this should have a positive impact in working with older people. The premise for this is that working in any area or with any specific group will not remain static over time. With an increasing awareness of the role older people have in deciding their own futures it is important that there is a secure research base to support our understanding of what these needs are. The research-practitioner is a facilitator therefore who seeks out the views and opinions of older people. This encompasses a consideration of collaborative practice where there is a mutuality of learning. This can be carried out at the personal or agency level where the end remit should be a direct emphasis on developing practice or supporting policy directives. A note of caution is to ensure that where social work itself becomes the focus of research the older person is not lost with the process. There also needs to be a dialogue on who owns research (the individual or the agency) and how these research findings are utilised. Also, the author identifies a more radical feminist perspective within the research-practitioner focus. This is to ensure that when roles and expectations are being assessed, socially constructed inequalities and power differentials are acknowledged. This is particularly the case given the significant numbers of women who live into older age.

    So, in conclusion to this chapter, the author hopes that any reader will become more engaged with that totality of working with older people. It is also hoped that more practitioners view this as a significant area of practice and that there is a rejuvenation of how working with older people is valued in a modern world.

  • Conclusion

    It is a privilege to work with older people. Those people who are engaged with the world will take pleasure, not only in their own accomplishments, but in the accomplishments of others. Where better therefore than to engage with this repository of human experience and understanding developed across the lifetime of older people?

    The main focus of this text is to focus and refocus on the individual experience, personal narratives and individuality of older people. Whereas I understand that social policy in relation to older people may have to have something of a generic nature, it is the process of how this is rolled out to meet individual need that is of most concern. It is certainly a truism that at times of societal stress and economic decline the vulnerable are more likely to be discriminated against. This incremental aspect of oppression can take on structural values where the common voice may ask ‘why shouldn’t older people contribute more’ to their future care and well-being? Practitioners may then consider whether the nature of older people services needs to be re-evaluated within a modern world. It cannot be satisfactory for older people to have individual need and more generic support services tied into a boom and bust culture of care.

    So what is the answer? Firstly there needs to be a more formal, considered affirmation of the role that older people have played within the formation of any modern society. Ironically, those older people who lived through post-Second World War society, with its limited resources and opportunities, may now be at the receiving end of increased poverty in older age. A significant step forward here would be to actively engage at a personal, cultural and structural (PCS) level (Thompson, 2006) with how older people are depicted generally. There could be a formal process of depicting older age as a time of opportunity and growth. This is particularly the case given the very significant contribution that older people make to society in terms of volunteering, caring for siblings and kinship care. Any practitioners who think that this draws undue attention to older people, even through positive discrimination, should ask themselves how wider ideas of discrimination on ethnicity, multiculturalism as well as sexual orientation have changed over the years. There is clear evidence that where discrimination is legislated for and discriminatory language addressed, this has a significant impact on the way society engages with those who may feel disenfranchised. Time will tell as to how this will develop.

    The argument is certainly not helped by demonising the baby boomer generation. Nor is the suggestion that older people should contribute more to society to access their state pensions. There is certainly a deeper and more philosophical aspect here of when older people can expect to retire irrespective of any understanding of the social construct of retirement itself.

    The most surprising aspect, from a pragmatic view, is how government agencies in the future hope to deal in a meaningful way with the ageing demographic, particularly in view of the fact that there will be an increased number of older voters. Agencies that hold older people in poor regard and particularly as net ‘takers’ from the public purse may find themselves at the receiving end of older people opprobrium as opposed to votes.

    A key feature of any understanding of future support needs is a move away from the ‘deficit model’ (Ray et al., 2009) where older people are consistently viewed as the sum of their needs as opposed to their contribution. Unfortunately, this is frequently compounded by the poor status that working with older people has within society generally and, more specifically, within social work services. A recent straw poll of approximately 70 students identified only two who would consider working with older people as part of their future careers. It is therefore difficult for individual practitioners to pursue this when there is a lack of support within the profession.

    Permeating all of this is the paradox that the process of engagement with older people may be more important than the outcome itself, whereas care management may be overly focused on process and driven by outcomes. So it is about finding more of a balance of the role and needs of older people generally. Neither can an evolving society deny the ageing demographic and the impact that this will have on resources and taxation generally. What is certain is that the demographic of itself raises serious questions about the future role that older people will play in political decision making. In a more optimistic world I would hope that the experiential knowledge that older people have acquired over a lifetime would engender a note of caution and reflection in how future state resources are accrued and utilised. Perhaps the only real certainty is that in the future uncertainty will exist (Brown and Rutter, 2006). Any contingency for this is likely to lessen a sense of defensiveness. The problem arises when this potential uncertainty begins to erode the ethical sense of who and what older people are. I am proposing a more radical rethinking of the nature of collective being with all that entails in the form of uncertainty and progress for the future. More important is the evolution of a collective and societal sense of belonging and a mutuality of support that the young and old should develop as different faces of the same societal coin.

    An important part of this text is the consistent challenge identified in relation to a biological sense of ageing. This challenging of the ‘common sense’ view (Gaine, 2010) throughout the text will hopefully enable and encourage readers and practitioners to question any commonly accepted views of older people and older age. This rationale is couched within an understanding that commonly held views may prevail but are frequently wrong. A fairly typical theme is where older people are more often characterised as needy or a drain on finances when there is no evidence to support this.

    While the role of older people may be constantly evolving in a changing world, the same is no less true of the role of the practitioner. Therefore a focus of these developing roles will be an engagement with continuous professional development particularly through evidence-based practice and research.

    I hope that any readers find the format, case studies and questions a useful support in a consideration of the nature of working with older people in a modern world. As someone with a fair accumulation of years I have something of a vested interest here. I can only hope that the energy expended in writing this book will permeate the practice of all willing, current and future, practitioners.

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