Clinical Social Work Practice with Older Adults
Ann Burack-Weiss, DSW, LCSW and Barbara Silverstone, DSW, LCSW, Co-Founders, SBW Partners (Silverstone & Burack-Weiss, LCSW, PLLC)
Clinical social work with older adults challenges any assumption that “one size fits all.” The cultural diversity of the population, the three generation (65-100+) age span, the frequent involvement of children and grandchildren, and the multiplicity of health issues require a sound gerontological knowledge base and call upon a full range of practice skills. Although some older adults present with long-standing psychosocial difficulties, most often they seek social work services (or others seek it on their behalf) for the first time in their long lives—the multiple, cumulative, and interactive losses of late life overwhelming the coping strategies that have helped them survive so far. Anxiety, depression, feelings of helplessness and hopelessness are common.
The False Dichotomy Between Concrete Services and Counseling
A major constraint on clinical social work with older adults is a false dichotomy that exists in the profession between “concrete” services and “counseling”—a dichotomy often fostered by reimbursement protocols and agency policies. The “Person-in-Environment” paradigm—a traditional definition of social work—is particularly applicable to clinical practice with older adults because it recognizes the inter-relatedness of bio/psycho/social needs.
Further constraints are imposed by the workplace. The older adult and family may present at a variety of settings: in-patient and out-patient health or mental health services, assisted living and nursing homes, senior centers, home care and/or case management agencies, rehabilitation facilities, meals programs, or in private practice.
Interviews rarely take place within the 50 minute office hour. Contacts may range from a 5 minute phone call, to a half hour bedside visit, to a 2 hour family conference. The skilled clinical social worker recognizes the effect of time and place on the client-worker relationship and makes the most of every client contact, however brief.
While the reimbursement and service structure of the setting will determine what interventions are offered, the social worker is responsible for a holistic assessment—a view of the older adult and his situation that looks beyond the presenting problem to its precipitant, and that recognizes the lifelong strengths and outstanding issues in the older adult and family, with sharp attention to age-related medical issues. Even when agency guidelines do not allow for following through on all the issues raised, it is the responsibility of the clinical social worker to understand the totality of the situation, and point the way for clients to receive services elsewhere.
The Case of Mrs. S.
Consider the case of Mrs. S., an 84-year-old post-stroke widow, who lives alone. She is at great risk without in-home care but finds fault with and dismisses every aide sent to her. The clinical social worker refuses to categorize the behavior as “resistance,” and recognizes that the underlying reason for Mrs. S.’s behavior could lie in feelings about her loss of ability to care for herself, the emotional lability sometimes associated with stroke, or some as yet undiscovered cause. The clinical social worker collects, integrates and interprets bio/psycho/social/cultural information into a holistic assessment, provides individual and family counseling, and helps in accessing and coordinating services.
The holistic assessment looks beyond deficits to identify strengths within client and family, as well as the resources available to them. It is not a compilation of facts about a client, but an interpretation of these facts. The assessment is not limited to the here and now, but includes discovering what in the past might help in understanding the present. Also included are the client’s and family’s hopes and fears for the future. In the case of Mrs. S., the clinical social worker discovered that Mrs. S. had been widowed as a young woman, and had been a successful real estate agent who raised two daughters on her own. One of these daughters had died a few years earlier; the other lived an hour away and was in close contact.
The ability of older adults—free from disabling cognitive disorders—to benefit from counseling, psychotherapy, or family therapy is no less than that of younger cohorts. Unresolved issues of earlier years often re-emerge in response to current stressors. In Mrs. S.’s case, she blamed herself for not providing more care for her dying daughter and that the giving and receiving of help was a major issue throughout her life. A one- hour session with Mrs. S. and her surviving daughter corrected misperceptions. Outreach to the home care agency, frustrated in its attempts to provide a suitable home aide, resulted in a team effort to address Mrs. S.’s needs.
This case illustrates that access and use of health and social services is not limited to matching needs and community services. Exploring past experience with receiving help, anticipating difficulties within client and systems, and mediating them as they arise is a crucial aspect of the clinical role.
The Privilege of Working with Older Adults
Aging is not a social problem. It is a fact of life. All of us grow older. Working with the population evokes feelings not encountered with other populations: feelings about growing old, illness, disability, dying, and death; feelings about parents and grandparents. It is not the easiest work but those of us who practice with older adults find it the most rewarding. It is an honor—hearing stories of far away times, places, and situations, meeting individuals who have weathered life challenges, and enhancing the last years of a long life with timely and appropriate aid. Most of all it is our privilege to receive lessons on living from those who have gone before us.