Social Work with Older People

Mark Lymbery

• Publisher: SAGE Publications Ltd
• Year: 2005
• ISBN:
  9781446236802
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

This book provides an up-to-date and authoritative overview of the development of social work with older people in the UK. The coherent structure draws together the key themes involved in working with older people, and clearly demonstrates how to translate these into real-life practice.

Key features of the book include:

-Establishes an understanding of the policy context within which social work takes place, with particular attention to key topics such as inter-professional collaboration and ethics.

-Goes beyond other textbooks to challenge the restricted nature of social work practice, and adopts a positive view of its potential to benefit older people.

-An engaging and practice-led approach which includes student-friendly features and detailed practice scenarios.

-Satisfies the curriculum benchmarks and National Occupational Standards that structure social work training and practice.

Written by a leading academic, this is a key text for social work trainees. Its analytical depth will ensure that it will also be valuable for students undertaking post-qualifying courses, and for those in related disciplines such as health and community care, social policy and social gerontology. Its practice-based and inter-professional approach will mean it is also useful for health and social care practitioners seeking to improve the quality of practice with older people.

`Drawing on both theory and research as well as the author?s clear knowledge of current practice, this book is able to deal with practice realities in ways which many texts cannot. It offers social workers realistic options for how to approach their work? - Karen Postle, University of East Anglia

PART I

Context

Older People and Society

From the available evidence, old age would appear to be a stigmatized social identity. Even those who are chronologically old may disassociate themselves from ‘old age’. (Pilcher, 1995: 102)

This chapter focuses on the place of older people in British society. Any capable social worker must understand the nature of ageing in order to work successfully with this group of people. This implies an understanding of the physical, biological and psychological manifestations of the ageing process; however, it also requires a grasp of two elements that are perhaps less well understood, as the experience of living as an older person cannot be fully comprehended by reference to the above three factors alone. The first of these is the political, social and cultural status of older people in contemporary society. As we will see later in this chapter, there are a number of ways in which older people are perceived as problematic, and a range of reasons that have been advanced to explain this. The chapter will argue that the theory of ‘ageism’ (Bytheway, 1995) can help to explain how many views that are prejudicial to the well-being of older people are perpetuated within society. The second are the subjective experiences of older people – what Thompson (1998) has termed the ‘ontology’ of ageing. As Biggs (1993) has explained, we cannot reach an understanding of subjective experiences of ageing if we are incapable of penetrating the inner lives of people who have become old. In addition, we need to understand how the impact of structural and cultural factors can create individual problems and difficulties for older people. The chapter will argue that an effective social work practice with older people cannot be developed unless we first understand the way in which all of the above factors can combine to affect an individual older person and her/his life.

The need to examine social work with older people will be made more pressing by demographic changes in the twenty-first century. For example, there will be an increase in the numbers of older people, both in absolute terms and as a proportion of the overall population (Shaw, 2004). There will also be a higher proportion of people categorised as dependent – both children and older people – within the population. However, the ‘dependency ratio’ – the proportion of people defined as economically unproductive and hence ‘dependent’ expressed as a proportion of those of working age in society – is likely still to remain within the boundaries that had been considered normal through the twentieth century (Tinker, 1997). It is interesting that the increase in longevity which characterises modern British society is not treated as ‘one of the great successes of modern times’ (Wilson, 2001: 1). Instead, there has been a focus on the problems that this could create in terms of the increased burden on the rest of society, particularly health and social care services. A crude determinism dominates the debate, where the subtleties of demographic change are underestimated or simply ignored (Pilcher, 1995). While it is clear that there will be a gradual increase in the numbers of older people requiring some level of support and assistance from health and social care services into the middle of the twenty-first century, the increased amount of need may well not reach the levels that some have forecast. In addition, no account is taken of the positive contributions that older people make to society in a range of different ways (Wilson, 2001). However, on the basis of current knowledge, it is reasonable to assume that social work services for older people will be even more required in the future than they are at present.

The chapter commences with an analysis of the nature of ageism, as it is a concept that informs the rest of the content of both the chapter and the overall book. It then considers the various ways in which ageing can be understood, moving from individual to structural considerations. Having surveyed the subject in broad terms, the chapter then summarises the range of needs that all older people experience, before considering the specific circumstances that are liable to require the assistance of a social worker. The chapter emphasises that only a minority of older people will require this level of support. This is an important corrective to the tendency of professionals to fix their understanding of ageing on the examples of the most disadvantaged and distressed people as if they represent the totality of the ageing experience (Biggs, 1993). In conclusion, the chapter notes the deficits of current services in responding to need, setting up links between this chapter and the remainder of the book.

A word on terminology is important here. Over time, the language that refers to older people has undergone a gradual transformation. For example, the phrase ‘the elderly’ was used in health and social care for many years in an unreflective way, without consideration of the fact that it depersonalised the people to whom it referred. As a result, an alternative conception was long overdue – but agreeing what such a term might be was problematic, given the contested nature of language. In many ways, the changes in terminology reflect a similar shift that has occurred in relation to other groups, notably people with physical or learning disabilities. While it is in the nature of language to have a certain measure of elasticity, these changes came about largely because the terminology deployed by professionals was challenged by the people to whom it referred. This has encouraged a greater degree of caution about language, and a wider understanding about the impact of previously unchallenged constructions. As a result, in line with most authors in the social work/social policy field, I have fixed on the term ‘older people’ as being the most accepted current usage. For example, two standard texts in this area (Marshall and Dixon, 1996; Tinker, 1997) have changed their titles as successive editions have been produced, both (currently) deploying the phrase ‘older people’ that is suggested here. The use of ‘older people’ may well prove unacceptable in future, reflecting the continuing growth of language; however, it seems sensible to deploy similar terminology to that which is most current both in academic and practice circles.

AGEISM

Ageism has been simply defined as the unwarranted application of stereotypes to older people (Bytheway, 1995). In the way it is used in this book it is different from a more generalised form of age-related discrimination, which could affect people at all ages. The distinctive quality of ageism, in British and other western societies at least, is that it is a process whereby older people are systematically disadvantaged by the place that they occupy within society. Thompson (1995) has argued that the discrimination faced by older people can be manifested at three levels, the ‘structural’, ‘cultural’ and ‘personal’ (Thompson, 1995; see also Thompson, 2001, for a more general application of this analysis).

While this position does have considerable analytical clarity, it fails to engage satisfactorily with the fact that these levels are interconnected in terms of an individual’s actual lived experience. For example, the way in which an older person could be treated when raising a question about her/his pension may easily contain aspects of all three of Thompson’s levels. The way in which the pensions system operates is part of the overall ‘structural’ oppression of older people; the fact that their demands for a decent standard of living are seen as representing a burden on the state is indicative of the way in which the presence of older people is seen as problematic. The idea that we are living with a ‘demographic time bomb’, further explored below, is an example of an ageist construction of older people, as it completely ignores the positive contribution that older people can make within society in favour of seeing them as creating a forthcoming crisis (Pilcher, 1995; Wilson, 2001) through their continued existence. At the ‘cultural’ level the people charged with responding to the individual’s question may carry stereotypes about older people that inform the way in which they act. If the stereotype is that older people become unable to deal with relatively simple matters, the behaviour at the ‘personal’ level is likely to be patronising; if a contrasting stereotype is held that older people are awkward and cranky, the behaviour might shift to be more defensive and obstructive. In such a case, the three levels at which ageism might be manifest continually reinforce each other and can become indistinguishable in practice.

The following bullet points give an indication of the more common and insidious ways in which ageism can be made manifest, with particular reference to the provision of health and social care services.

• In the policies of government, both at national and local levels. As an example of this, it has been argued (Grimley Evans and Tallis, 2001) that the National Service Framework for Older People is inherently ageist because it works on the assumption that older people do not merit expensive hospital care. (This is particularly ironic given that the reduction of age-related discrimination is a key aim of the framework!) Similarly, given that the primary motivation for community care was to curb the social security budget (Lewis and Glennerster, 1996; see also Chapter 3), this can be seen as a policy constructed on the ageist basis that cost considerations have precedence over the quality of lives of older people, the majority of people affected by the policy. At the local level, it is worth noting that while the bulk of a social services department’s budget is spent on the care of older people, this amounts to the smallest amount per capita of all the main service user groups.
• In the way in which services for older people are organised and staffed. As Chapter 3 will argue, the development of health and social care policy for older people has often been poorly organised and developed, with ageist assumptions at its heart (Means and Smith, 1998). The scandalous treatment of older people in institutional care in the immediate post-war years, highlighted by Townsend (1962), was a particularly striking example of this. The development of social work for older people, addressed more fully in Chapter 6, is another example of how policy and practice have had an ageist underpinning, as it has long been the least professionally developed of the various forms of social work practice (Lymbery, 1998a). Much day-to-day practice with older people is in fact carried out by staff without professional qualifications, often paid on an hourly basis, many of whom work in the independent sector where the pressure to carry out tasks within a defined time period is intense. These sorts of arrangement are scarcely in the best interests of older people, and attest to the fact that they are treated in a way that reinforces their relatively low social value.
• In the differential development of understandings about the abuse of older people as opposed to the abuse of other groups, particularly children. While the abuse of children has become a preoccupation within social services, the abuse of adults and older people has never been given the same level of priority. Although the publication of No Secrets (DoH, 2000a) has ensured that policies have been put in place the better to manage issues related to adult protection, their impact has been variable (Mathew et al., 2002). The ‘discovery’ of the abuse of older people occurred many years after the equivalent discovery of the abuse of children, and yet was trivialised by the ageist terms (‘granny-bashing’!) by which it was originally described. Even now, it does not have the shock value of child abuse; there are fewer headlines if an older person dies as a result of abuse or neglect than if the same fate befalls a child.
• In the attitudes and values of those staff employed to work with older people. As noted above, a wide range of staff are employed to work with older people, both in residential and nursing homes and in the community. The fact that many of these staff do not have professional qualifications renders them more susceptible to stereotyped and demeaning impressions of older people.
• In the language deployed to describe older people. This issue ranges from the casual stereotyping in everyday parlance (variations on the themes of ‘silly old fool’ and ‘old dear’) to the more insidious and dehumanising references to older people by professionals. There is also a tendency, particularly in health care settings, to refer to people by their condition rather than their names, another depersonalising and essentially dehumanising act.

It is particularly important that practitioners are enabled to understand the ways in which older people’s lives are affected by factors at the structural and organisational levels, hence avoiding a reductive biologically-based view of ageing. Social workers have an occupational tendency to focus first on the needs of the individual, and can easily allow themselves to ignore wider structural issues. Practitioners must also identify other forms of power and oppression to which older people could be subject. Ageism does not operate in a vacuum and hence in isolation from other forms of oppression. Instead, these forms of oppression can combine to create even more difficulties for the older person. As a result, it is important for social work practitioners to be able to recognise and challenge multiple forms of oppression, of which ageism will be a major element.

SECTION SUMMARY

This section has explored the issue of ageism and its impact on older people.It has discussed the following issues:

• The nature of ageism and its centrality as a concept in respect of the needs of older people.
• Drawing on Thompson (1995) the various ‘structural’, ‘cultural’ and ‘personal’ aspects of ageism.
• The connections between ageism and other forms of oppression that older people might experience.
• The various ways in which ageism can be made manifest.

WAYS OF UNDERSTANDING THE AGEING PROCESS

This section will summarise different approaches to understanding the ageing process. It will start at the individual level, working outwards from this to focus on older people in the context of society. The content of this section is a necessarily condensed version of material that can be found in standard texts on gerontology and social gerontology (see, for example, Bond et al., 1993a). Its purpose is to examine the experiences of ageing through a variety of theoretical prisms. The overall intention is to present the issues of which social workers need to be aware if they are to pursue their roles successfully.

A note of caution is appropriate at this point: while the chapter does start its survey with the impact of biological ageing it is imperative not to perceive older people only in terms of what happens to them physically as they age. Such an attitude can lead to what has been termed ‘biological reductionism’ (Biggs, 1993), where the complexity of an individual’s life and experiences is reduced to the apparent verities of what will inevitably occur to the physical body. Of course, there are observable physical changes when one ages; it is important to know what these are and to understand the impact that these might have on the individual and others. Although ageing is a physical fact, it is not inherently problematic. The vast majority of people are quite able to manage the process of ageing without requiring the support of social workers. It is therefore important to see older people in a more rounded light, not simply as the collection of problems that a purely physical/biological approach might seem to encourage.

PHYSICAL/BIOLOGICAL CHANGES

The process of human ageing is affected to a large measure by certain universal truths, which have their basis in biological fact (Briggs, 1993). For example, there are four facets of ageing that have been generally accepted:

• That it is universal, in that it will inevitably affect all people.
• That it is progressive, a continuous process throughout life.
• That ageing is intrinsic to the human organism.
• That it is degenerative in a biological sense (Strehler, 1962; in Bond et al., 1993b).

However, while particular diseases may be associated with the process of ageing, ageing is not in itself a disease, although Briggs (1993) points out that the distinction between ‘ageing’ and ‘disease’ is often quite narrow and arbitrary. For the sake of clarity, this sub-section will focus on those processes that can clearly be accounted as part of the ‘normal’ process of ageing, not all of which will necessarily involve the intervention of health and social care services. Indeed: ‘Decline in physiological function may be of little consequence to an older person until they cross some threshold so that they are no longer able to carry out necessary activities’ (Briggs, 1993: 56). However, some aspects of biological ageing – for example, recovery from a stroke, the onset of dementia – will almost certainly require this form of assistance.

The first sub-group of issues is concerned with decline in sensory functioning. For example, many older people – approximately one in three people over the age of 65 (Briggs, 1993) – experience some measure of hearing loss. While there are numerous ways in which this loss can be compensated, it can also create some practical and psychological problems, particularly when the loss of hearing has an impact on day-to-day living. An even higher proportion of older people experience some impairment of vision: indeed, practically all older people need spectacles to assist them in some aspect of their lives (Briggs, 1993). For the majority, the difficulties that the impairment creates can be managed relatively easily; however, approximately one in four older people have continuing difficulties that the use of spectacles alone cannot resolve. In particular, older people are much more likely to develop cataracts (a compression of the lens in the eye, leading to reduced vision) or to experience problems due to the onset of glaucoma, raised pressure of the fluid in the eyeball, usually leading to a gradual loss of peripheral and later central vision.

Similarly, there are a number of ways in which changes to our biological makeup affect the bodily appearance as we age. Two of these represent the most obvious physical signs of ageing. The first of these is wrinkling of the skin, due to a gradual degeneration in its elastic tissues. This is more severe where an individual has been extensively exposed to strong sunlight, and also varies ...