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Focus Group With Social Workers In The Field Of Aging
Overcoming Mistrust and Isolation To Save Lives
At a gathering of 11 professional gerontological social workers who work
almost exclusively with older adults in New York City, the question was
asked as to whether their work is a matter of life and death.
One social worker jumped in, ready to respond. She said that she works
several days a week at a site where congregate meals are served to 142
seniors in northern Manhattan. She said that one day a call came into
the program from a woman asking to speak to a social worker, and she got
on the phone.
Most people are probably reluctant to ask for help, and the caller was
no exception. The social worker listened closely. What was discovered
is that the caller had a history of bad experiences in seeking assistance
and had basically given up. In desperate need, she was now trying again.
In fact, the woman, who said she had no family, had not even been out
of her apartment in over a year. During this period a friend had arranged
for someone to shop for her.
The social worker made an appointment with the woman to visit her at her
apartment.
As some people get older, and eventually more limited in what they can
do for themselves, it is not uncommon to become isolated and allow one’s
living environment to deteriorate. Nevertheless, what this social worker
said she saw was unbelievable: broken furniture, and instead of a bed,
a mattress on the floor, but no sheet. And the place was infested with
roaches.
Instead of using a walker, which was clearly needed, the woman pushed
a stool across the floor in order to get around. Mobility was so impaired
that it took her 10 minutes to answer the door.
The woman was clearly malnourished and shared that she had not been to
a doctor in over a year. The social worker recommended that they develop
a plan for what needed to be taken care of, and agreed that getting medical
attention should be the top priority.
The problem was that the woman did not want to go to the health facility
around the corner from her home. She said that she had had a negative
experience there at some point in the past, feeling that she had been
treated disrespectfully.
The social worker told the woman that she knew some of the staff at the
facility and would make sure that she would be treated well. The social
worker then contacted and worked with the staff to anticipate this woman’s
coming, and sensitized them to her concerns. She also managed to get the
facility to lend a wheel chair, and the social worker brought her to the
health facility herself.
The key was developing trust. Without it, the woman would never have accepted
the assistance.
The outcome of this experience was that the woman was diagnosed with breast
cancer, for which she was subsequently treated. Home assistance was then
arranged for.
It was clear that without the social worker’s sensitive and perceptive
interventions, the woman would not have accepted the medical attention
that she required and would likely have died without treatment. Instead,
she was able to face her last few years with a greater level of comfort
and support than would have otherwise been the case.
A key element in the success of this work was the capacity of the social
worker to understand that this woman felt that service providers encountered
in the past were insensitive to her needs. The social worker was especially
careful to engender a sense of trust. Without it, the intervention would
not have been possible.
Additionally, the social worker took the time to raise the awareness of
the health care personnel who ultimately became involved to appreciate
the woman’s concerns, so that she would feel comfortable enough
to utilize the medical services that were available.
Shocking Conditions – Not Uncommon
The story that this social worker shared was part of a focus group convened
by the New York City Chapter of the National Association of Social Workers
(NASW-NYC). The purpose of the group was to clarify how professional social
workers contribute to the services that are available to older New Yorkers,
especially those who are in the greatest need.
The social workers were brought together in April at the NASW-NYC office.
They were all involved in the direct delivery of services, in senior centers,
home care agencies, hospitals, nursing homes, adult residences, and in
services to the blind, representing communities throughout New York City.
Subsequent to the above story being shared, several of the other social
workers who were present said that they have had many similar experiences
working with men and women who ultimately became very isolated, living
in conditions that most people would consider to be shocking.
One social worker, who works in what is now a relatively affluent community,
said that she makes many home visits to people who would be considered
“shut-ins”, people who originally came to the United States
from Eastern Europe and are at this point relatively suspicious of strangers.
Developing trusting relationships is key to her work, as it was with the
first social worker. Without trust, service provision, including life
saving medical care, would not be possible.
Getting Closer When Others Push Away
Another social worker who works in a senior center especially designed
to serve the Chinese elderly, cultivated the trust of a 90 year old man
who was coming into the center each day, smelling of urine. No one wanted
to be near him, and it would not have been surprising if under other circumstances
staff would have simply encouraged the man not to return.
The social worker asked if she could accompany the man to his apartment
to determine how he was living and to obtain greater insight into his
circumstances. Once at his home, she discovered that his apartment was
in terrible condition, that his adult life consisted of working in restaurants
and laundries, and that he was frightened of dealing with formal institutions.
After several weeks, the social worker was able to convince the man to
go to the nearby health clinic, which arranged for him to be evaluated
by a doctor and to get homecare services.
Depression Amid Family Problems
Another social worker told of making phone contact with a woman who was
eligible for her agency’s specialized visual rehabilitation services
following the significant loss of her eyesight.
During the phone conversation, at which time the social worker conducted
an assessment of the woman’s capacity to benefit from rehab services,
the social worker became concerned that the woman’s apparent depression
would undermine the will power required to benefit from the program.
As a result, another social worker was assigned to visit the woman in
her home. This worker determined that the woman’s adolescent granddaughter,
who was living with her, was probably abusing her.
The situation turned out to be rather complex. The woman felt that the
granddaughter could not live at home with her own parents, and needed
her. Therefore, she would not acknowledge being abused.
The social worker, concerned that the visual rehabilitation would only
work if the depression could be addressed, developed a plan to be carried
out over several weeks. This would require that other family members address
the intricate relationships within the family. Knowledge of family systems
and dynamics would be key to a successful outcome.
Enlisting Support When None is Apparent
Several of the social workers who shared stories of making home visits
to isolated seniors told of discovering that there were relatives living
in other areas outside of the City that were not aware of the condition
of their family members. Once contacted by the social workers, these relatives
made significant efforts to make a difference in their relatives’
lives. One social worker told of going to some lengths to find a relative
in Massachusetts by using contacts she had made in a social service agency
in the Boston area. The staff there provided assistance in finding the
family member.
In another instance, the social worker discovered that a diabetic woman
was having her meals prepared by her daughter who did not understand her
mother’s special dietary requirements. Given the daughter’s
belief that the food she was preparing was beneficial and that it reflected
her own loving care, the social worker recognized the need to proceed
carefully with the daughter in order to help her understand how she might
modify the ingredients in order to help her mother. If the social worker
had lost the trust of the daughter, help would have been impossible and
the mother’s condition would have worsened.
Perspective on Nursing Home Placements
In discussing the benefit of their work, many social workers said that
their efforts to help people often included helping them to avoid being
placed in a nursing home. Being able to remain in one’s home is
an enormous value to most people. Nevertheless, there are times when having
to enter a nursing home is unavoidable.
Two social workers participating in the focus group talked about their
roles in nursing homes. They said that they work with patients, along
with family members, to address the reaction to being placed in what is
frequently experienced as the end of the line.
Adjustment to living in a nursing home often means acknowledging the significant
losses that one has experienced, ranging from losing one’s capacity
to live alone, loss of health, and often the loss of contemporaries. These
losses can bring on or exacerbate depression, which may add to the challenges
of a chronic and possibly terminal illness, as well as some degree of
memory loss.
The social workers said that their job might include helping anticipate
being discharged home if the goal is short term rehabilitation and, if
not, becoming integrated into the community of the facility. They said
that their work also includes the development of advanced health care
directives as well as addressing the significance of death and dying.
Ethics and Attention to Culture
Many of the social workers said that ethics plays a significant role in
their work. In the nursing home, for example, the social worker said that,
in relation to end of life care, she strives to assure that the wishes
of the patient are heard and respected along with the perspectives of
the physician, the administration, and family members.
Other social workers said that ethical considerations prompted them to
act on what they saw was needed, even when acting meant dealing with very
difficult circumstances, such as entering an apartment in “deplorable”
condition.
Bringing an understanding of the cultural backgrounds of the people they
worked with was raised by almost every social worker who was participating.
Whether the person was African American, from Eastern Europe, or Asia,
social workers said that a person’s need to feel understood in terms
of their culture and experience was essential to trust being developed.
In one of the stories, the person seeking service specifically requested
a social worker of her same cultural background. Similarly, being able
to speak the person’s native language was also essential to being
able to provide services.
The Challenge to Gerontological Social Work Practice
Prior to ending the focus group, the social workers were asked what they
felt were challenges in doing their work. Ten challenges that were identified
are listed below:
1. There is a lack of recognition of social work within the broader field
of gerontology.
2. Salaries are low, resulting in high staff turnover. Social workers
who stay might wind up making $40,000 a year after 10 years.
3. Social work services are not billable as they are for psychiatry or
psychology; they are part of the daily service. As a result, the services
command less respect.
4. Many community based programs face, on an annual basis, real and threatened
budget cuts, making the programs themselves unstable.
5. Working conditions in community based agencies are often unpleasant;
the same was said of the conditions in many institutional settings.
6. High caseloads undermine the work. Doing assessments with older adults
can take time. Once an assessment is done, there is too little time to
do the work that is deemed important. High caseloads also mean additional
paperwork, further reducing time with each client.
7. Language is often a barrier, given the number of people who do not
speak English in New York City. Working through an interpreter compromises
the quality of the work.
8. The bureaucracy that oversees programming tends to be inflexible in
terms of how social workers might be more responsive to their clients’
needs.
9. The pool of students wanting to enter gerontological social work is
small, and the number of social work interns is low. Since the schools
often lack specific curricula, skills need to be learned in the field.
(It was pointed out that the graduate schools are making improvements.)
10. There are no gerontological social work think tanks, and there is
little research examining the effectiveness of programs.