1

The Context of Social

Work Practice with
Older Adults

Aging in the Twenty-First Century Competencies

Applied with Practice
One of the greatest challenges of the twenty-first century will be the tremendous in- Behaviors Examples
crease in the number of older adults in both the United States and throughout the —in this Chapter
world. By 2030 when most baby boomers (those born between 1946 and 1964) have ✓
❑ Professional
moved into older adulthood one in every five persons in the United States will be Identity
over the age of 65. Social institutions, including the health-care system, education, ✓ Ethical Practice
❑
income maintenance and social insurance programs, the workplace, and particularly
Critical Thinking
social services, are bound to be radically transformed by these staggering numbers. ❑
­Current and future generations of older adults will undoubtedly forge new approaches Diversity in Practice
❑
to the aging process itself and demand services that reflect positive and productive ✓ Human Rights &
❑
­approaches to this time in their lives. As major providers of service to older adults and Justice

their families, social workers need a wide variety of skills and resources to meet these
❑ Research-Based
demands. Working with older adults is the fastest-growing segment of the social work Practice
profession. The National Institute on Aging estimates that between 60,000 and 70,000
❑ Human Behavior
new social workers will be needed to meet the demands of this growing population.
This book is intended to provide a solid knowledge base about aging as a process and ❑ Policy Practice
to introduce practitioners to a broad range of assessment and intervention techniques. ❑ Practice Contexts

❑ Engage, Assess,
Diversity within the Older Adult Population Intervene, Evaluate

Age 65 is generally agreed on as the beginning of older adulthood only because

until recently it has been the traditional retirement age, not because there is a
special social or biological reason for this choice. The population between 65 and 74
is generally referred to as the “young-old.” Many young-old do not consider them-
selves to be old. The young-old may still be working or newly retired, have few if any
health problems, and remain actively engaged in the social activities of life. These
older adults may stay in the labor market for many years beyond retirement age or
1

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 2 Chapter 1

transfer their energy and interests to creative writing, painting, music, or travel. They
are most likely to continue to be engaged in their communities through volunteer work
or political involvement.
The group of older adults aged 75 to 85, “the middle-old,” may begin to experience
health problems more frequently than their younger cohort. They may face some mobil-
ity restrictions and are more likely to openly identify as older adults. Most of these older
adults are out of the workforce and may have experienced the loss of a life-partner or
spouse. There is often a growing need for some type of supportive service to help these
older adults remain in their own homes, if that is what they choose to do. It is among
the “oldest old,” those over 85, that the greatest needs exist. This group is most likely to
have serious health problems and need assistance in more than one personal care area,
such as bathing, eating, dressing, toileting, or walking. The needs of newly retired and
healthy older adults to continue active and productive lifestyles are appreciably differ-
ent from the needs of frail older adults forced into special living situations due to failing
health. Somewhere in between the newly retired and frail older adults is the largest group
of older adults, those who remain independent and function well in most areas of their
lives but need specific social, health, or mental health services to maintain and maximize
that independence.
Culture, ethnic group membership, gender, life experiences, and sexual orientation
add to the uniqueness of the aging experience for each older adult. Some older adults
have struggled with racial, gender, or sex discrimination throughout their adult years,
factors that have a long-term effect on their socioeconomic well-being. Others bring
significant health-care problems into old age, the result of inadequate health care since
childhood. The dramatic rise in the number of divorces and fewer traditional fam-
ily structures have created a complex web of blended families, stepchildren, multiple
grandparents, and ­former spouses and partners expanding (and limiting) the support
systems available to help an individual. Some older adults are “tech smart” while ­others
have not had the opportunity or resources to access digital technology. While some
older adults have used traditional social services at other times in their lives, many
have never had to seek help until they reached their later years. The social work profes-
sion’s commitment to recognizing and valuing the uniqueness of every individual is
especially important in work with this population as will become apparent throughout
this book.

The Focus of This Chapter

This chapter is designed to introduce you to the demographic characteristics of older
adults in the United States. This chapter also describes the variety of professional s­ ocial
work roles both as direct service providers and in macro-level settings. Direct service
roles include work in community social service settings, home health-care agencies,
geriatric case management, independent and assisted-living communities, adult day
health ­settings, nursing homes, and hospitals. New social work roles are being defined in
legal settings and in the field of preretirement planning. Macro-level roles include local,
state, and regional planning; legislative advocacy; public education; research; education;
and consultancy in business and industry. These roles will be explored in depth later in
this chapter along with the unique challenges that make this area of social work practice
both rewarding and challenging.

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 The Context of Social Work Practice with Older Adults 3

The Demography of Aging

The Growth of the Older Population

As of 2009, one in eight Americans was over the age of 65, or 12.9 percent of the general
population (Administration on Aging, 2010). By 2030, when the last of the baby boomer
cohort reaches age 65, older adults will comprise over 20 percent of Americans, or 72 mil-
lion people (U.S. Census Bureau, 1996) (see Figure 1.1.). The largest growth within the older
population will be among those over the age of 85, those older adults with the greatest
health and social service needs.
The most notable growth in the older population will be among older adults of color,
who will constitute 25 percent of the older adult population by 2030, as compared to 18 per-
cent in 2000 (Federal Interagency Forum on Aging-Related Statistics, 2010) (see Figure 1.2).
This growth is due to improvements in childhood health care—increasing the likelihood
that persons of color will even reach age 65—and improvements in the control and treat-
ment of infectious diseases throughout the life cycle. Yet, the consequences of a lifetime of
economic challenge combined with a greater probability of developing chronic health prob-
lems will follow these older adults into this longer life expectancy. For older adults of color,
living longer does not directly translate into living better. The special problems and chal-
lenges of growing older as a person of color are recurrent themes throughout this book.

Life Expectancy and Marital Status

A child born in 2007 can expect to live to 77.9 years of age, compared to a life expectancy
of 47.3 years for a child born at the beginning of the twentieth century (National Cen-
ter for Health Statistics, 2011). Women have a life expectancy of 80.4 years compared to

Figure 1.1 • Number of Persons 65+ Years Old, 1900–2050 (numbers in millions)

Sources: U.S. Bureau of the Census, Population Projections of the United States by Age, Sex, Race and
Hispanic Origin, 1995–2050, Table G, Percent Distribution by Age 1990–2050 Current Population
Reports, P25-1130, 1996; Census data 1900–1990.

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 4 Chapter 1

Figure 1.2 • Percent of Population over 65 Years: By Race and Hispanic Origin, 2006
and 2050

35

30.6
30

25

22.7

18.2
20

15.4
14.9
15

12.4

10.3
10

8.3

6.2

4.7
5

0
All White Black Hispanic Other
Races Races
Sources: Data for 2006 are from the Administration on Aging (2006). A Profile of Older Americans,
2006. Washington, D.C: U.S. Department of Health and Human Services. Data for 2050 are from the
U.S. Bureau of the Census, Population Projections of the United States by Age, Sex, Race and Hispanic
Origin, 1993–2050, Current Population Reports, P25-1104, 1993.

75.4 years for men. The projection of life expectancy changes as individuals get older. In
other words, under current mortality conditions, if an individual lives until age 65, he or
she can expect to live an average of 18.5 more years (Federal Interagency Forum on Aging-
Related Statistics, 2010). If an individual lives to age 85, a woman can expect to live another
6.8 years and a man another 5.7 years. Just reaching the milestones of 65 or 85 suggests the
individual is healthier in general and more likely to live longer than the general projections
for the population as a whole. This is particularly noteworthy when looking at racial dif-
ferences among black and white older adults. If a black older adult reaches age 85, the life
expectancy is higher for him or her than it is for a comparable white older adult by 1.5 years.
In 2009, men between 65 and 74 were more likely to be married than were older
women, 72 percent and 42 percent, respectively, reflecting the differences in life expec-
tancy between the genders (Administration on Aging, 2010). Although those men and
women not married are most likely to be widowed, the twofold increase in divorced older
adults from 5.3 percent in 1980 to 10.8 percent of the population by 2009 suggests that the
number of single older adults will increase as well into the twenty-first century. The pres-
ence or lack of a family support system has a dramatic effect on an older adult’s ability to
remain living independently.

Living Arrangement
Older men are more likely than older women to live with their spouses, 72 percent and
40.7 percent, respectively (Administration on Aging, 2010). Women are twice as likely to
live alone than older men. This difference reflects the differences in life expectancy with

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 The Context of Social Work Practice with Older Adults 5

older women being more likely to have outlived their spouses than older men. One of
the most significant shifts in living arrangements for older adults in recent years is the
increase in the number of grandparents raising grandchildren. Often this is due to death
or disability of the older adults’ grown children. Approximately 716,000 grandparents
over the age of 65 were the head of households in which grandchildren lived, with two-
thirds of these grandparents bearing the primary financial and child-rearing responsibili-
ties ­(Administration on Aging, 2010). These numbers are proportionately higher among
­African-American and American Indian or Alaska Native and Hispanic older adults, pop-
ulations already at risk for being low income and in poorer health. This increase in the
number of grandparents raising grandchildren presents a formidable challenge in terms of
meeting the parenting needs of the children at a time when the older adult’s economic and
personal resources are often challenged by their own needs.
In 2009, 56.5 percent of older adults lived in just 11 states: California, Florida, New York,
Texas, Pennsylvania, Ohio, Illinois, Michigan, North Carolina, Georgia, and New Jersey.
Thirty percent of older adults lived in areas considered “central cities,” with 53 ­percent liv-
ing in suburban areas. The remaining one-fifth of older adults lived in small cities and rural
areas, those areas of the country most likely to have fewer health and social services available
to the aging population (Federal Interagency Forum on Aging-Related Statistics, 2010).
Although 90 percent of nursing home residents are over the age of 65, they repre-
sent only 4.1 percent of the older population, according to the Administration on Aging
(2010). This small percentage challenges the common perception that large numbers of
older adults end up in nursing homes due to failing health. Women comprise 75 percent of
the nursing home population, another reflection of their longer life expectancy (National
Center for Health Care Statistics, 2011).

Poverty
The change from Old Age Assistance to Supplemental Security Income in 1972 and the
expansion of government-funded health-care programs for older adults have reduced the
overall poverty of older adults since the 1960s, when 35 percent of persons over the age of
65 had incomes below the poverty line (Federal Interagency Forum on Aging-Related Sta-
tistics, 2010). In 2009, 10.7 percent of older women and 6.6 percent of older men still had
incomes that categorized them as poor (National Women’s Law Center, 2010). A closer
look at the poverty statistics indicates that individuals who have low incomes throughout
their working lives are those most likely to continue to have low incomes or drop into
poverty in their later years. Older women are more likely to be widowed or living alone
than are their male counterparts—thus relying on one income, rather than two. However,
poverty is not a new experience for many women. Women experience higher poverty rates
throughout their lives whether due to the financial demands of raising children as single
mothers, disrupted labor market histories, or low-wage occupational choices (National
Women’s Law Center, 2010).
There are disproportionately high poverty rates among older adults of color, with
19.5 percent of African-American older adults showing incomes below the poverty
line. H­ ispanic and Asian/Pacific Islander older adults have poverty rates of 18.3 and
15.8 ­percent, respectively (Administration on Aging, 2010). The low lifetime earnings of
both women and persons of color are reflected in lower Social Security benefits after re-
tirement (National Women’s Law Center, 2010). Limited incomes do not enable individuals

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 6 Chapter 1

to accumulate assets, such as property or personal savings accounts, and low-wage jobs
rarely have pension or retirement plans. When a low-wage worker retires, he or she simply
does not have the financial resources to ensure an income much above the poverty line.
On the other hand, high-wage workers have higher Social Security payments, have greater
asset accumulation, and are more likely to have private pensions or employer-supported
retirement savings. Older adults’ retirement incomes mirror their lifetime earnings.

Employment
About 16.2 percent of the current population of older adults remains in the workforce
beyond the traditional retirement age of 65, with over half working part time either out
of financial necessity or because of a continued interest in employment (Administration
on Aging, 2010; Bureau of Labor Statistics, 2010). Baby boomers are expected to remain
in the workforce at much higher numbers than the current cohort of older adults, with
“more than three-quarters of boomers seeing work as playing some part in their retire-
ment” (Merrill Lynch, 2005, p. 1). However, these workers are likely to seek “bridge jobs,”
those employment arrangements that allow them to work fewer hours with more work-
place flexibility as they transition into full retirement (Cahill, Giandrea, & Quinn, 2006).
Changes in the retirement age under Social Security, the decrease in the number of guar-
anteed retirement pensions, and a decrease in the amount of private savings for retirement
contribute to both the interest in and necessity of baby boomers remaining connected to
the workforce longer (Munnell, Webb, & Delorme, 2006).

Health Status and Disability

By age 85, over half of older adults need some assistance with mobility, bathing, preparing
meals, or some other activity of daily living (Centers for Disease Control and Prevention
& The Merck Foundation, 2007). However, in 2009, three-quarters of persons between
ages 65 and 74 and two-thirds of persons over age 75 self-rated their health as good or
very good (Administration on Aging, 2010), despite a high incidence of chronic health
conditions within this population. Heart disease, arthritis, cancer, cerebrovascular disease,
chronic obstructive pulmonary disease, and diabetes are the most frequent chronic health
conditions found in persons over the age of 65 (Federal Interagency Forum on Aging-
Related Statistics, 2010). Older adults are more likely than their nonaged counterparts to
visit a physician or enter a hospital, which is consistent with the prevalence of chronic
health-care problems.
Economic well-being and health status are intricately linked in the population.
Chronic poverty restricts access to quality medical care, contributes to malnutrition, and
creates psychological stress, all of which influence an individual’s health status. For low-
income older adults of color, late life becomes the manifestation of a lifetime of going
without adequate medical care. Chronic conditions become more disabling. Prescriptions
cannot be filled or glasses purchased because of limited financial resources. Poor older
adults may have to choose between food and medicine.
The economic burden of an acute or chronic illness can devastate middle-class older
adults’ financial resources, quickly moving them from economic security to p ­ overty.
Much of this is due to the mechanics of financing health care for older adults. Medicaid,
the health insurance program for low-income persons, is available to those older adults

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 The Context of Social Work Practice with Older Adults 7

who qualify on the basis of low income and limited assets. Low-income older adults
may be ­eligible to combine Medicaid coverage with Medicare, the federal health insur-
ance p ­ rogram that covers 95 percent of persons over age 65 and does not have a means
test. With the combination of both programs, most major health-care costs are covered,
­although accessibility to health-care services may still be a problem for low-income older
adults (Administration on Aging, 2010). Medicare covers only a portion of health-care
costs for older adults and is not sufficient to provide adequate coverage. For middle- and
upper-­income older adults, Medicare is frequently supplemented with what are known
as medigap policies—private insurance that covers what Medicare does not. For those
older adults who do not qualify for Medicaid and cannot afford supplemental policies,
a ­significant gap in coverage exists. The National Center for Health Statistics estimates
that almost 10 percent of older adults, most of whom are poor, female, and of color, have
­unmet health-care needs due in part to the gaps in the Medicare system (National Center
for Health Care Statistics, 2011). This population is least likely to have routine physical
­exams, be immunized against the flu and pneumonia, have early screening for diabetes and
hypertension, or take medications that prevent the development of more serious medical
conditions. Therefore, when illness occurs, it is more likely to be serious. Prevention costs
less than treatment for most chronic conditions, but a portion of the older population
cannot afford preventative measures.
This overview of the demographics of aging shows a population of persons over the
age of 65 that is growing and will continue to grow rapidly during the twenty-first century.
Despite a higher incidence of chronic health problems, most older adults are not sick, not
poor, and not living in nursing homes. The vast majority of older adults struggle with
­occasional health problems but continue to be active, involved, and productive members
of society, defying the stereotype of sick, isolated, and miserable old people. The economic
picture, however, is bleakest for older adults of color, women, and the oldest of the old
in the United States. If current trends continue, older adults will continue to live longer
but not necessarily healthier lives unless chronic poverty and health-care inadequacies are
addressed.

Using the Strengths Perspective

in Work with Older Adults
The demographic overview of the older adults may leave you wondering how the social
work profession can even begin to help this population, which faces so many problems
with limited income and chronic health problems. If a social worker focuses on all the
things that are “wrong” in an older adult’s life, the challenges are indeed overwhelm-
ing both to the social worker and the older adult. This book uses the strengths perspec-
tive, which focuses on what is “strong” in an older adult’s ability to rally personal and
social assets to find solutions to the problems he or she faces in the aging process. The
strengths perspective is based on the philosophy that building on strengths, rather than
problems and personal liabilities, “facilitates hope and self-reliance” (Fast & Chapin,
2000, p. 7). To work effectively with older adults, the social worker has to believe that
older adults continue to have the power to grow and change as they face challenges of
aging and that they want and need to continue to be involved in decisions and choices
about their care.

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 8 Chapter 1

The focus of this book is on very specific challenges facing older adults, including
health and mental health issues, substance abuse, abuse and neglect, family relationships,
and end-of-life issues, but incorporates the strengths perspective as an underlying theo-
retical approach to practice. The strengths perspective focuses on the ways in which clients
have overcome challenges throughout their lives using a broad repertoire of coping and
problem-solving skills (Glicken, 2004). An older adult who is experiencing the difficult
decision to sell a much cherished family home and move into independent or assisted living
has had to make painful decisions before and found the inner strength and social support
to do so. An older adult struggling with a late-onset drinking problem has the physical and
emotional ability to overcome an unhealthy reliance on alcohol. The strengths perspective
affirms a basic tenet of social work practice: self-determination. If the social worker sets the
goals for an intervention and those goals are not those of the older adult, the worker should
not be surprised when the older adult is resistant or uncooperative. “Clients create change,
not helpers” (Glicken, 2004, p. 5). The social worker’s roles are to help older adults identify
strengths, resources, and goals, connect the older adult with personal and community re-
sources to meet those goals, and facilitate and coordinate the process, if necessary. You will
see how this approach is used throughout the book in specific areas of gerontological social
work. There are other excellent resources that present the strengths perspective in more de-
tail and you are encouraged to consult those sources for a more in-depth discussion of this
approach (Fast & Chapin, 2000; Glicken, 2004; Saleebey, 1992).

Settings for Gerontological

Social Work
Older adults’ need for social services falls along a broad continuum from the need for a lim-
ited number of support services such as housekeeping and meal services to extensive needs in
a long-term or rehabilitation setting. Likewise, social workers’ roles range from the traditional
assistance as broker, advocate, case manager, or therapist to nontraditional roles such as exer-
cise coach, yoga teacher, and spiritual counselor. Nursing homes and hospitals are often seen
as the most familiar settings for gerontological social work practice, but these settings repre-
sent a small part of the variety of opportunities available for social workers with passion for
and knowledge about the older adult population. With only 4.1 percent of the older popula-
tion in nursing homes, social service agencies, home health-care agencies, geriatric care man-
agement, adult day health, and independent and assisted-living settings are more common
settings for direct service or clinical practice. Social work roles in legal settings and in the ex-
panding field of preretirement planning are additional settings for ­gerontological social work
that function in a complementary role to the existing social service system. Social workers
serve important roles in macro-level settings that serve older adults such as community orga-
nizations and public education, local, state, and regional planning agencies, and organizations
that engage in legislative advocacy. The future roles of social workers in the field of aging are
limited only by practitioners’ imagination and initiative.

Community Social Service Agencies

In large communities, social service agencies offer a wide range of counseling, advocacy,
case management, and protective services specifically designed for older adults. These ser-
vices may be housed in the local Council on Aging, Area Agency on Aging, or Department

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 The Context of Social Work Practice with Older Adults 9

of Social Services, or may be provided by sectarian agencies, such as Catholic Social Ser-
vices, Lutheran Social Services, Jewish Family and Children’s Services, and so forth. Older
adults or their families may feel more confident working with agencies that reflect their
own religious affiliation. In small communities or rural areas, services to older adults may
be contained within a regional agency that serves as an Area Agency on Aging (AAA) or
an agency serving other populations that has a social worker with particular expertise in
working with older adults. The purpose and organization of AAAs will be discussed in
detail in Chapter 13.
Contact with a social worker at a social service agency is frequently initiated by a con-
cerned family member who is unsure about how to begin the process of obtaining services
for a family member. In addition to conducting the assessment process to determine what
services might be helpful to an older adult, social workers can play an important role in
initiating and coordinating services from a variety of agencies in a care management role.
In some cases, the family of a frail older adult becomes the client. Although families can
successfully provide caregiving, they may feel the strain of this responsibility and benefit
from a support or educational group and respite services. As the contact is often precipi-
tated by a crisis, families and older adults may need reassurance and support as well as
solid information to stabilize a chaotic situation.

Home Health-Care Agencies

Home health-care agencies, such as the Visiting Nurses Association, often have geron-
tological social workers on staff as part of a team approach to providing services to
older adults. Although the primary focus of home health care is to provide health-­
related services, such as checking blood pressure, changing dressings following sur-
gery, or monitoring blood sugar levels for diabetic older adults, social workers can
also play an important role in addressing older adults’ psychosocial needs. An older
adult who has suffered a stroke may not only need medication and blood pressure
monitoring from a health-care provider but also need help with housekeeping, meal
preparation, or transportation. The social worker can arrange for these support ser-
vices and coordinate the total care plan. Older adults who are essentially homebound
due to chronic health problems often experience intense isolation and may benefit
from regular phone calls from an older adult call service or friendly visitor volunteer.
­Gerontological s­ ocial workers who work in home health care often provide supportive
or psychotherapeutic counseling services or arrange for those services from another
agency in the community.
Social workers also play an important role in helping older adults work out the finan-
cial arrangements for home health care. Advocating for the older adults to receive the care
they are entitled to under private insurance, Medicare, or Medical Assistance can involve
myriad phone calls and personal contacts that are difficult for an ill older adult to handle.
When older adults are not eligible for needed services under existing insurance coverage,
creativity is often needed to obtain additional financial resources, including working with
older adults’ families or identifying low-cost community services that older adults can
afford. If an older adult’s illness becomes more debilitating, the social worker may need to
work with the older adult to identify care arrangements that offer greater support, such
as assisted-living services or adult day health care. It is the social worker’s knowledge of
community services and financial aid programs that makes him or her a valuable asset to
home health care.

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 10 Chapter 1

Geriatric Care Management

Families in the twenty-first century are increasingly juggling the demands of full-time
­employment, hectic family schedules, and geographical separation from aging family
members. An option available to families who may not have the time, knowledge, or avail-
ability to negotiate with community social services agencies or home health-care agencies
is that of using a geriatric care manager. Geriatric care management has emerged as one of
the newest and most rapidly growing professional settings for gerontological social work.
Most geriatric care managers are social workers, nurses, or other specially trained coun-
seling or health-care workers who may work as independent professionals or in ­conjunction
with a health-care facility or social service agency. Geriatric care managers offer family mem-
bers or other caregivers services in planning, implementing, and coordinating a wide range of
services for older adults (National Association of Professional Geriatric Care Managers, 2011).
These professionals have a specialized knowledge in assessing the biopsychosocial needs of
an older adult and in locating the appropriate service in the community to meet those needs.
The overall responsibilities of the geriatric care manager are to suggest the most
­appropriate supportive services needed to enhance the older adult’s well-being. This may
be as simple as arranging for health-monitoring services for an older adult who is recuper-
ating from surgery or as complex as relocating the older adult to an assisted-living facility
or a nursing home (Stone, Reinhard, Machemer, & Rudin, 2002). Geriatric care managers
provide assessments and screening, arrange and monitor in-home help, provide support-
ive counseling to the older adult and the family, support crisis intervention, and even offer
family mediation and conflict resolution when families have opposing views of what an
aging parent needs or wants. They may also act as liaisons to families separated by long
distances to report on the older adult’s well-being or alert the family when an older adult’s
physical, psychological, financial, or social health changes.
The cost of geriatric care management can be substantial, with fees running between
$60 and $90 per hour, depending on the type, complexity, and location of the services
provided and the credentials of the care manager (National Association of Professional
Geriatric Care Managers, 2011). These care management fees are typically not covered
by Medicare, Medicaid, or traditional private health insurance, although the cost of the
­support services identified by the care manager are often part of the home health-care
services financed by public and private health insurance programs.

Independent and Assisted-Living Settings

Specialized independent living settings for older adults in the community, such as low-
income or moderate-income housing, frequently have social workers on staff to provide
a variety of services. Helping older adults secure transportation to appointments or shop-
ping centers, arranging opportunities for social activities such as plays and concerts, and
promoting on-site activities are frequently under the auspices of a social worker in an inde-
pendent living center. The social worker may be instrumental in helping the older adult to
make the decision to add additional home care services or transition to a housing setting
that offers more support as the older adult’s needs change with changing health conditions.
Another option in the range of services available to older adults in the community is
the assisted-living center. Assisted living is defined as a residential, long-term arrangement
designed to promote maximum independent functioning among frail older adults while

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 The Context of Social Work Practice with Older Adults 11

providing in-home support services (Assisted Living Federation of America, 2011). The
assisted-living model fits in between completely independent living and the intensive care
provided in a skilled nursing home. Some assisted-living facilities are part of a larger com-
plex known as a continuum of care facility. Older adults may purchase or rent an apart-
ment while they are still completely independent. As their health changes, necessitating
increasing levels of support, older adults may need to move within the same complex to
semi-independent living and perhaps eventually into an adjacent skilled nursing facility.
It should be noted that the quality and quantity of services available to older adults to
support independent living varies widely among assisted-living facilities (Assisted Living
Federation of America, 2011). Although some facilities are more accurately described as “real
estate commodities with food service and social activities,” others are comprehensive health-
care settings offering a wide range of physical, health, and social supports that truly do offer
seniors healthy, high-quality care (Franks, 2002, p. 13). The assisted-living industry does not
require nor regulate the use of professional social workers, although positions such as the
care or service coordinator utilize the skills associated with professional social work practice.
In high-quality assisted-living facilities, the focus is on as much self-maintenance as
possible for each resident. Residents live in private or semiprivate rooms that have a private
bathroom and, in some facilities, a small kitchen. The monthly fees include rent, utilities, a
meal plan, and housekeeping services. Other services such as laundry, personal care s­ ervices,
and transportation are provided on an individual basis as part of a total care plan. Assisted
living is expensive, usually between $3000 and $5000 a month, making it affordable only for
middle- and upper-income older adults (Metlife Mature Market Institute, 2006). However,
some states are working to obtain Medicaid waivers to demonstrate the cost-saving effect of
using the assisted-living model for low-income persons as opposed to placing these older
adults in skilled nursing facilities (Salmon, Polivka, & Soberson-Ferrer, 2006).
The purpose of assisted living is to help older adults maintain and improve their psy-
chosocial functioning through a variety of activities that maximize choice and control. Social
workers conduct intake assessments to review the medical, functional, and psychological
strengths and weaknesses of incoming residents. These assessments play an important role
in identifying those areas in which an older adult may need supplementary services, such as
chore services, assistance with bathing or dressing, or social activities to ease isolation.
Families and residents may need both information and support to make a success-
ful transition to the facility. The decision to leave one’s own home, even to move into
the privacy of an apartment, is a traumatic experience for older adults and may require
­professional support to work through the grief and depression (Edelman, Guihan, B ­ ryant, &
­Monroe, 2006). Assisted-living centers can offer a variety of challenging social and
­recreational activities that help older adults make the center their new home. Helping a
resident find the right balance between private time and social activities is another impor-
tant role for a social worker in this setting. In assisted-living centers, social workers often
function as part of a multidisciplinary team composed of nurses and occupational, physi-
cal, and recreational therapists (Vinton, 2004).

Adult Day Health Care

A setting for older adult care that falls between independent living and skilled nursing care
is adult day health care. Adult day health care can provide individually designed programs
of medical and social services for frail older adults who need structured care for some

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 12 Chapter 1

portion of the day. Older adults who live with their families or other caretakers or even
live in semi-independent living situations and have some physical, cognitive, emotional,
or social disability are typical users of adult day health care. These older adults do not
need full-time nursing care or even full-time supervision but do require assistance with
some of the activities of daily living. This type of care provides a valuable role as respite
care for caregivers as well. Adult children may be willing and able to have older adults live
with them if they can obtain supplementary care during the day while they work or for
­occasional respite (National Adult Day Services Association, 2011).
Many adult day health centers only take older adults who are able to be active partici-
pants in the development of their own service plans and consent to placement in the adult
day health center. This type of care focuses on maximizing an older adult’s sense of choice
and control in their own care. A smaller number of centers work exclusively with older
adults who suffer from dementia, including Alzheimer’s disease, who may be less able to
be full participants in the decision-making process.
Social workers are involved with an older adult from the extensive preplacement
process through the execution of a service plan. Social workers and older adults explore
the older adult’s needs and interests together and select from a variety of rehabilitative
and recreational services available at the adult day health center. An older adult may need
physical or occupational therapy to compensate for losses due to a stroke or heart attack.
Others may need supervision to take medication. The social worker in adult day health
care is instrumental in coordinating all the physical needs frail older adults require during
the day. In this setting, social workers may serve as care managers.
Group work is an essential role for social workers in adult day health centers. In most
centers, older adults belong to a specific group that meets on a regular basis to talk about
the issues they face. This may involve problems with families and caregivers, concerns
about friends and members of the group, or more structured topics such as nutrition, foot
care, or arthritis. The group becomes a focal point for older adults in the adult day health
setting. It gives them an opportunity to maintain social skills or renew them if they have
been socially isolated. The group is helpful in making new older adults feel welcome and
helping them access all of the services available to them.
In addition to running a therapeutic group and a variety of social and recreational activi-
ties, the social worker meets individually with each older adult for counseling, advocacy, or
problem solving. This individual attention plays an important role in maintaining the dignity
of the older adult in what is predominately a group setting and in helping the worker moni-
tor the older adult’s mental and physical health status. At times, older adults may be reluctant
to share deeply personal issues such as family problems, depression, and incontinence with
members of their group and benefit more from a private discussion with the social worker.
When older adults are not meeting with their group or social worker, they are usu-
ally involved in a wide variety of activity groups geared to their special interests. Physical
­fitness, music, education, current events, arts and crafts, and creative writing are among
the types of groups found in adult day health centers.

Nursing Homes
One of the greatest fears of older adults is that they will end up living in a nursing home.
This fear explains why older adults fight so hard to maintain their independence. Nurs-
ing homes are seen as a place older adults are sent to die, neglected and forgotten by their

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 The Context of Social Work Practice with Older Adults 13

families. Although this fear may be legitimate for some older adults, nursing homes serve
an important role in the continuum of care for frail older adults. When independent living
becomes impossible and more structured nursing care is needed, a nursing home may be
the most appropriate service.
With a growing older population, it would be expected that the number of nursing
homes would be increasing proportionately. However, between 1995 and 2004, the actual
number of nursing homes decreased by 16 percent. The number of beds has increased by
9 percent, meaning that today’s nursing home is likely to be bigger than in previous years
and that nursing home care is available in fewer locations (National Center for Health
Care Statistics, 2004). The decrease in the overall number of nursing homes reflects the
improvement in choices available to older adults for health care. Older adults are opting
to stay in their own homes longer with the help of less-costly home-based alternatives to
skilled nursing care.
The primary role of the social worker in a nursing home is to serve in both a support-
ive and an educational role to older adults and their families (Vourlekis & Simons, 2006).
Social workers begin to work with older adults and their families prior to admission to
a nursing home—arranging preadmission visits, doing a preliminary assessment of what
kinds of services will best meet the needs of the older adult once admitted, and working
out financial arrangements. Nursing home care can cost more than $6000 a month and
is not routinely covered by private insurance or Medicare. (Metlife Mature Market Insti-
tute, 2006). Some older adults will spend only a few months in a skilled nursing facility—
for instance, recovering from an acute illness or surgery—so the social worker’s job may
­include discharge planning as well.
Nursing home social workers also assume a supportive role in their work with the
friends and families of residents. Placing a family member in a nursing home frequently
generates guilt and anxiety among family members. They may feel they are abandoning
their older adults, despite the fact that less drastic measures have already failed. Main-
taining the relationship with the resident, identifying resources for handling the financial
demands of placement, and processing the conflicting feelings that accompany placement
are common responsibilities for nursing home social workers.

Hospitals
Over one-third of hospital admissions are persons over the age of 65, and this population
used 44 percent of the total days of care in the hospital setting (DeFrances & Podgornik,
2004) due primarily to the presence of chronic health-care problems in this population.
The complexities of chronic health problems make hospital social work with older adults
an essential part of the recovery process. Hospital social workers provide a wide variety of
services, including crisis intervention, patient advocacy, patient education, family liaison
work, care management, and discharge planning (Volland & Keepnews, 2006).
Hospitalization is a crisis for anyone of any age, but with older adults there is a­ lways
the fear that the hospital is the gateway to either a nursing home or the grave. Older
adults may be anxious about upcoming surgery or be lost in the maze of medical jar-
gon they hear. They may be concerned about what happens to them during the recovery
process when they return home by themselves. Families may be concerned that their loved
ones will receive too little care or be hooked up to life-sustaining equipment against their
will. In sum, the hospital setting can be a very chaotic environment for older adults and

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 14 Chapter 1

their families. Crisis counseling in a hospital setting involves helping the older adult and
­families reestablish an emotional equilibrium, begin to understand the medical condition,
prioritize tasks, and develop a short-term action plan. The primary focus of the social
worker is to help with the psychosocial needs of the older adult in the hospital setting
while medical personnel attend to physical health.
Patient advocacy is another appropriate role for hospital social work with older adults.
Older adults may find the cold, impersonal atmosphere of the hospital frightening and con-
fusing. They may need help in making their needs known or advocating on their own behalf.
For example, a Chinese woman may need a translator, require a special diet, or wish to meet
with an herbal healer. Social workers can work with other health-care professionals to find
the best match between what the client wants and what the health-care system can tolerate.
A part of patient advocacy is patient education, working with older adults and their families
to better understand the presenting illness and its course of treatment. Patient education
is aimed at empowerment of the older adult. The more older adults know and understand
about their illness, the better their own sense of ­control. When they feel they are part of the
treatment process, they are more likely to be active participants in their own healing.
Social workers may also serve as family liaisons for the hospitalized older adult. The
older adult’s family needs to understand what is happening to the older adult, the prog-
nosis for the illness, and what plans need to be made following the hospitalization. For
many families, contact with a hospital social worker is the first contact they have had with
the social services system. Up until that point, they may have struggled to provide care
on their own, unaware of the range of community services available to them. The process
of discharge planning, another important hospital social work role, involves developing
and coordinating the support services for post-hospitalization. Meals-on-Wheels, home
health care, chore services, and homemaking services can be very effective in helping
older adults to maintain their independence while providing invaluable support.
Social workers can provide both educational and supportive presence in helping
older adults and their families make difficult end-of-life decisions. Helping older adults
make choices about what circumstances warrant being connected to life-support equip-
ment, whether they want to be resuscitated after a heart attack, or who should make those
choices when they are unable to are sensitive issues. Facilitating the discussion between an
older adult and the family about these questions may be among the most difficult tasks in
hospital social work.

Developing Areas for Direct Practice

Although social workers will be needed in the most traditional areas already discussed,
there is unlimited potential for direct practice in other areas with older adults with the
growth of this population. Two specific areas that will need a greater number of social
workers are the legal services area and preretirement planning programs in both the
­public and private sectors.

Legal Services
Law and social work have had a long and sometimes tumultuous history. Although the
professions share the joint goal of problem solving, the clash between legal and social work
professions’ foci in the resolution of problems is a major challenge to interprofessional

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 The Context of Social Work Practice with Older Adults 15

cooperation. Whereas law uses strict interpretations of existing laws and legal precedents,
the confines of administrative rules and regulations, and a much more factual, not feeling,
approach to problems, social work’s approach is more deeply rooted in the consideration
of the biopsychosocial factors that influence the development and perpetuation of a prob-
lem facing a client (Madden & Wayne, 2003; Taylor, 2006). However, these professions can
work together very effectively once each profession’s expertise is clarified. This is particu-
larly beneficial in areas of elder law. Helping an older adult and his or her family make pro-
visions for Durable Powers of Attorney for Health Care or determine competency in the
case of dementia are good examples of the necessity of social workers and lawyers working
collaboratively. When an older adult is competent but needs assistance in managing prop-
erty or finances, lawyers and social workers are both important members of a team that
will set up (and explain) guardianship (Joslin & Fleming, 2001; Sember, 2008). Another
example is when an older adult is facing a problem that has very distinct social and legal
implications, such as housing. What may have started out as an occasional lapse in the
older adult’s ability to remember to pay the rent may escalate into an eviction proceed-
ing. The immediate legal action necessary to halt the physical removal of the older adult
from the residence is the lawyer’s role. The social work role involves long-term solutions
to the housing crisis, such as finding a way to pay back rent, identifying another party to
act as a fiscal agent, or considering the move to a safer, more structured living situation.
One of the fastest-growing areas of elder law is that of the legal issues facing grandparents
raising grandchildren. Issues in custody of dependent grandchildren, financial support,
and discrimination in housing lead the list of sociolegal challenges facing this population
(National Academy of Elder Law Attorneys, 2011; Wallace, 2001). Lawyers are invaluable
in navigating the complex system of child welfare law, whereas social workers are better
prepared to handle the social and mental health challenges facing these older adults and
their dependent grandchildren. The best solutions to these challenges will come only by
interprofessional teamwork.

Preretirement Planning
Preretirement planning often is equated with financial planning; however, an adequate
income is only half of the challenge of retirement. It is easy to see how the demand for
services in this area is growing as the first group of baby boomers is facing retirement. The
area of preretirement planning that receives the least attention is the psychosocial aspect
of the transition from full-time employment to whatever is next. For people who have de-
fined themselves in terms of their jobs or have relied almost exclusively on the workplace
for social contacts, retirement can be very challenging. What do people do now? How
will they redefine their lives to create a balance between the joys of leisure activities and
continued productivity? How will couples manage relationships when they are together
all the time as opposed to having separate lives at work? Most important, what challenges
face individuals who simply cannot afford to retire, even in the face of serious chronic
health conditions? These questions embody the very essence of social work’s expertise in
the biopsychosocial dimensions of people’s well-being. The social work profession is only
now beginning to define its role in this process, usually in the context of Employee Assis-
tance Programs available in both the public and private sector. The most exciting aspect of
this area of practice is that the roles for social workers are yet to be clearly defined. How
social workers can facilitate a healthy adjustment to retirement will be shaped by the next
generation of gerontological social workers.

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 16 Chapter 1

Macro Settings for Gerontological

Social Workers
The role of social workers in direct service settings is readily apparent, but gerontological so-
cial workers also play an invaluable role in macro settings, such as community practice, plan-
ning, and legislative and political advocacy. The United States has a well-developed federal
aging services and programs network, authorized by various titles of the Older Americans
Act of 1965. These include an authorization for a national, regional, state, and local structure
to plan and deliver a wide range of services to older adults as well as to s­ ystematically plan for
the future needs of older adults and advocate on behalf of this population in the legislative
setting. Some of the macro practice roles for social workers fall directly within this network.
The aging services network and the programs it oversees will be discussed in detail in Chap-
ter 13. Other gerontological social workers practice within private and community agencies
specifically dedicated to the planning and legislative ­advocacy interests of older adults.

Community Practice
The major foci of community practice with older adults is to mobilize and empower the
older adult population to take an active role in their own problem solving by emphasizing
the shared concerns of a community, rather than solving one individual crisis at a time.
Community work with older adults encompasses a wide variety of settings. Community can
mean something as specific as a congregate housing setting or as broad as a city or town. In
smaller community settings, organizers can be instrumental in mobilizing older adults to
get improved public transit, organize a building crime watch network, or improve snow re-
moval in front of a housing development (Massachusetts Senior Action, 2011). Social work-
ers can also help mobilize older adults to petition a city government to grant a property tax
exemption, improve access to health and social services through development of neighbor-
hood centers, or develop an emergency plan for weather or health-related emergencies.
Public education is another function within the general category of community prac-
tice for macro social workers. For example, when Medicare Part D, the prescription drug
program, was being implemented in 2006, older adults desperately needed simple, clear
information about the program. Providing this education either on an individual level or
within the context of a community setting was often the responsibility of a social worker,
who had a strong knowledge base in all aspects of Medicare and was particularly sensitive
to older adults’ needs and concerns. Likewise, social workers are currently involved in
offering educational campaigns about HIV/AIDS, fraud and financial abuse prevention,
home safety, and advance directives, all of which are discussed later in this book. Public
education is not just “telling” people what they need to know. It involves a comprehensive
and understandable presentation of why the information is crucial and the patience to
listen to the questions and concerns of older adults.

Planning
Social workers also practice in the planning offices of State Offices on Aging and Area
Agencies on Aging. Social planning involves the process of exploring both community
needs and assets, developing plans of action, and evaluating future and existing policies

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 The Context of Social Work Practice with Older Adults 17

and programs (Wacker & Roberto, 2008). The answer to the growing population of aging
baby boomers is not to simply build lots of new senior centers. The real crisis lies in areas
such as developing alternative housing, health, and leisure programs that reflect the needs
of a very different generation of older adults. Planning involves comprehensive needs
assessment, an in-depth understanding of changing demographics, and sensitivity to how
new and existing services will be financed. How do the needs of urban older adults differ
from those of suburban older adults? What kinds of emergency programs need to be de-
signed to adequately protect older adults in case of natural disaster, a health epidemic, or
weather crisis? What kinds of programs need to be developed to meet the needs of older
adults who still need to work but require more flexible work arrangements or training to
keep up with technological advances? These are the challenges to public planning officers
who must not only know what is currently working but what will be needed in the future.

Legislative and Political Advocacy

Advocacy and empowerment are central tenets of the social work profession, both in their
role of acting on behalf of individuals and on behalf of specific vulnerable client popula-
tions in the political arena. Most programs and services for older adults are funded by
federal and state funds and thus require both supporting legislation and administrative
authority to operate. The social work role in legislative advocacy involves creating public
awareness among older adults about pending legislation that may affect them and mobi-
lizing this population to pressure legislators to act on their behalf. The legislative process
is complex and may be confusing to older adults without access to the inside issues around
the legislation. State chapters of the National Association of Social Workers (NASW) have
rallied both member and client support for such issues as mental health coverage parity
laws, loan forgiveness for social work education, immigration rights, age and gender dis-
crimination, and property tax relief for older adults.
NASW’s Political Action for Candidate Election (PACE), the political action arm of
the organization, works on behalf of candidates whose views on a variety of social welfare
issues support the organization’s policy agenda. They support these candidates through
fund-raisers, campaign contributions, and public endorsement of the candidates dur-
ing the elective process (National Association of Social Workers, 2011). The social work
profession’s role in legislative and political advocacy is a combination of local, state, and
­national efforts, all aimed at advocating for and empowering clients who are directly af-
fected by the policy framework affecting policies and programs.

Personal and Professional Issues

in Work with Older Adults
Although deeply rewarding both personally and professionally, work with older adults re-
quires a high level of self-awareness on the part of the social worker. In all intervention
efforts, workers bring their own emotional baggage to the helping process. However, in
gerontological work, the issues are more complex. Unlike social work practice in the a­ reas
of alcoholism, drug abuse, family dysfunction, or domestic violence—social problem
­areas that may or may not personally affect the worker—everyone must eventually face

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 18 Chapter 1

the experience of aging and death for themselves and their families. Aging is not a social
problem; it is a developmental stage. The universality of the aging experience influences
work with older adults on both a conscious and subconscious level. Among the most sig-
nificant issues workers will face are the subtle influences of lifelong social and personal
messages about ageism, countertransference of feelings toward older adults, and conflict-
ing issues surrounding independence versus dependence.

Ageist Personal and Social Attitudes

The term ageism refers to the prejudices and stereotypes attributed to older persons
based solely on their age (Butler, 1989). These stereotypes are usually negative and convey
an attitude that older adults are less valuable as human beings, thus justifying inferior
or ­unequal treatment. These attitudes develop early in life as children observe parental,
­media, and social attitudes toward older adults. Parents may unintentionally send the
message that aging parents and grandparents are a nuisance to care for, demanding, needy,
or unpleasant. Even simple comments, such as “I hope I never get like Grandma” or “Put
me to sleep if I ever get senile,” may be interpreted literally by children. Every time ­parents
refer to aches and pains as “I must be getting old,” the subtle message becomes clear that
aging is destined to be painful and debilitating. Although ageism is an attitude that hin-
ders everyone’s ability to adjust to the normal changes of aging, it also serves a more
destructive social justification. Ageism rationalizes pushing people out of the labor market
in the name of maintaining productivity without much thought to what happens to people
when their lives are no longer centered on work as an organizing principle. Ageism justi-
fies ­segregated living arrangements, substandard medical care, and generally derogatory
attitudes toward older adults. Blatantly racist or sexist comments and open discrimination
would not be tolerated in today’s business and social arenas, yet ageist attitudes and com-
ments are rarely challenged.

Countertransference
Countertransference is defined as the presence of unrealistic and often inappropriate
­feelings by the social worker toward the older adult that distort the helping relationship
(Nathan, 2010; Reidbord, 2010). The worker displaces feelings or attitudes onto the c­ lient
based on a past relationship rather than on the real attributes of the older adult with whom
he or she is working. Countertransference develops from two primary sources in working
with older adults. Internalizing ageist attitudes reflected in society can lead a social worker
to intensively dislike working with older adults because they are subconscious reminders
of death and illness. On an unconscious level, the social worker may believe his or her
work is wasted because the older adult will soon die, benefiting minimally from the social
worker’s time and attention. Countertransference can also develop when a social worker
is unaware that positive or negative relationships from the past are distorting the present
relationship.
For example, a young social worker is assigned to work with an older woman in iden-
tifying an appropriate assisted-living facility, a painful but necessary move for the older
woman. When she goes to the woman’s house, the older woman insists on serving cookies
and tea to her and they end up visiting for several hours rather than attending to the task
at hand. When her supervisor inquires as to the decision about assisted living, the young

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 The Context of Social Work Practice with Older Adults 19

woman hesitates and responds that she thinks it is “mean” that the family is making her
go to assisted living, that this older woman wants to stay in her home and maybe with
enough services she could stay there. She hasn’t actually had the discussion about which
assisted-living facility the older woman might select as it is just too awkward to bring up
the topic. After the supervisor explores the situation with the worker, it becomes appar-
ent that the worker overheard her own mother arguing with her grandmother a few years
ago about the same kind of decision. She remembers her grandmother saying “if I have to
leave my house, I might as well just die!” which in fact she did shortly after moving into
assisted living. The older woman struggling with the decision to leave her own home was
a subconscious reminder to the social worker of a painful situation in her own life. In
order to alleviate her own pain and guilt, the worker was trying to avoid her client facing
the same situation. The worker’s need to “save” the older adult may rob the older adult un-
intentionally of his or her self-respect and personal dignity. It is essential to explore issues
in countertransference with supervisors.

Ageism and Death Anxiety

Internalized negative attitudes toward the process of aging and older adults contribute to
a pervasive presence of “death anxiety” in contemporary society. Death anxiety is a highly
agitated emotional response, invoked by reference to or discussion of death and dying
(Peck, 2009). Working with older adults is a constant reminder to the social worker of the
logical progression of the life cycle—from youth to aging and death. American society
does not deal well with death or any discussion of death. Consider all the phrases used to
avoid saying the word death, such as “passed on,” “expired,” “gone on to the next world,”
and many others not quite so polite.
Facing a variety of situations surrounding death is an inevitable part of work with
older adults. Many older adults will admit that death does not frighten them as much
when they are older as it did when they were younger. They see friends and family mem-
bers dying. Throughout their lives, they have thought about what death means to them,
whether they believe there is an afterlife, and what their lives have been all about. If they
have escaped the discomfort of chronic medical problems, they consider themselves lucky.
If they live with a disabling or painful condition, they may welcome death as an end to
the physical discomfort. Older adults often want to talk about funeral arrangements or
make plans for disposing of their personal possessions even when family members do not.
Although older adults’ families may cling to denial as a means of warding off a critically
ill older adult’s death, hospital policy may simultaneously ask the family to make difficult
end-of-life decisions. All these issues are examples of how social work with older adults
requires some level of comfort on the part of the social worker in acknowledging and pro-
cessing death not only with clients but also in one’s own work in self-awareness.

The Independence/Dependence Struggle

One of the most frequently stated goals older adults voice is their desire to maintain their
independence for as long as possible. This desire coincides with the social work profes-
sion’s commitment to promote self-determination and preserve the dignity of the indi-
vidual. On the surface, there appears to be no conflict. In reality, as older adults require
more and more support services and experience increasing difficulties in maintaining

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 20 Chapter 1

independent living, tensions between older adults’ desires and families’ and social work-
ers’ perceptions of need are inevitable. A worker can appreciate the desperate efforts on
the part of an older adult to stay in his or her own home. Yet when an older adult is strug-
gling with stairs or a deteriorating neighborhood, and difficulties in completing the simple
activities of daily living challenge the feasibility of that effort, professional and personal
dilemmas abound. Who ultimately must make a decision about an older adult’s ability to
stay in his or her own home? Who decides that an older adult is showing poor judgment
about financial decisions? When does Protective Services step in to remove an older adult
from a family member’s home due to neglect or abuse, despite the older adult’s objections?
When do the wishes of the family supersede the wishes of the older adult, or do they ever?
These are difficult questions for which there are no simple answers.
While functioning an entire lifetime as an independent adult, a single illness can
reduce an older adult to dependency more quickly than he or she can emotionally pro-
cess. In an effort to counteract a diminished sense of self-esteem, older adults may fight
dependency to the point that they put themselves in physical jeopardy rather than risk
relying on others. They may act out, show extreme anger, or make excessive demands on
both social workers and family members that cannot be met. Maintaining independence
should be a critical goal of all gerontological social work, and throughout this book, vari-
ous ways of promoting independence, even among the most disabled older adults, will be
presented.
Other older adults react by assuming dependent roles sooner than they need to and
become more passive and resistant than their physical condition warrants, assuming a
kind of “learned helplessness.” Rather than fighting for their own independence, they give
up and willingly relinquish the decision-making issues in their own care. Although giving
up their own rights to decision making may make case planning easier for workers and
families, this situation lends itself to the development of other, more subtle problems. One
of the fundamental concepts of social work practice is the importance of clients’ choice
of goals for intervention and their personal commitment to work on those goals, a basic
tenet in adapting the strengths-based perspective discussed earlier in this chapter. For ex-
ample, a social worker may decide an older adult needs to attend a senior center program
to decrease personal isolation. Even though the older adult may agree so as not to offend
the social worker and out of gratefulness for all the worker has done for the older adult,
the older adult will not go to the senior center and participate if he or she does not want
to go. The older adult may not blatantly refuse to go, but rather will make appropriate
excuses for nonattendance. Although well intentioned, the social worker has decided on a
goal for the older adult that is the social worker’s goal, not the client’s. It is not surprising
that family and workers become frustrated when older adults find ways to avoid doing
something that is not their goal in the first place.
The process of relinquishing independence is the beginning of a very delicate pro-
cess, even among those older adults who are sincerely willing to let others make decisions
for them. Older adults become reactors rather than actors in their lives. Perceiving that
they have little control over their lives, older adults may fall into a deep depression and
relinquish their will to live along with their independence. Families and caregivers, who
perceive that older adults have given up even when they are capable of some independent
activities, may react with anger and hostility. The social worker’s role is to help the older
adult and family find common ground that promotes self-determination and meets the
need for services.

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 The Context of Social Work Practice with Older Adults 21

Self-Awareness and Supervision

The challenges of working with older adults within a societal context of ageist attitudes—
which contribute to deeply seated fears about one’s own aging and death—may seem a
bit overwhelming at this point in the book, but there are resources for resolving these
issues. Through developing self-awareness with professional supervision, social workers
can effectively work through these issues. They are discussed early in the text because they
should be clearly present in your mind as you study this field of practice. Developing self-
awareness is a process that takes time and continues to challenge professionals throughout
their careers. It may take a lifetime of working with older adults (and one’s own relatives)
to recognize your own personal triggers for problematic feelings.
Workers need to take a critical look at any concurrent challenges they are facing in
their own lives that could contribute to professional problems. A social worker who is also
balancing the demands of an aging spouse, parents, or grandparents may feel such exces-
sive demands on his or her own resources that working effectively with older adults may
not be possible. Although such experiences may be helpful to the worker in developing
compassion for an older adult’s family, it may be counterproductive in the intervention
process.
The ability to keep feelings at a conscious level is one of the most important
parts of the process of developing self-awareness in working with older adults. One’s
­p ersonal feelings toward a client, family members, and the quality of the professional
relationship are important clues to the worker about his or her own emotional issues.
Supervisors can be helpful in diversifying tasks for the worker in an effort to defuse the
emotions generated by intense cases. Working exclusively with highly dependent older
adults or those with Alzheimer’s disease can tax even the most well-adjusted, experi-
enced workers.
Most gerontological social workers, including this author, would emphasize that
working with older adults has tremendous rewards. It is a professional and personal joy to
work with older adults who have lived through the most interesting of times and delight
in retelling their life stories. Seeing the power of the human spirit in older adults who have
survived and thrived through raising families, struggling with careers inside and outside
the home, and reframing the meaning and purpose of their lives during the later years
is a very positive and revitalizing experience for any professional. Older adults can be
­delightfully humorous, frustratingly stubborn, amazingly persistent, but always the most
powerful reminder of the resiliency of the individual to grow and flourish throughout the
life span.

Summary
One of the greatest challenges to society and the profession of social work is the dramatic
increase in the number of persons over age 65 in the twenty-first century. Although the baby
boomer generation will no doubt forge new ways to meet the demands of this developmen-
tal stage, quality health care, a productive postretirement lifestyle, and adequate financial re-
sources pose challenges to today’s and tomorrow’s older adults. For some older women and
older adults of color, the devastating effects of a lifetime of poverty and substandard health
care will follow them into old age. These groups are the most vulnerable older adults.

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 22 Chapter 1

The future of gerontological social work is bright not only because of the growing
demand for specially trained practitioners but also because of the variety of settings in
which social workers will be needed. In addition to traditional settings, such as hospi-
tals and nursing homes, social workers can be found in community settings, legislative
offices, and legal settings. These settings will demand a high level of skill in specific
practice techniques and a willingness to engage in the self-awareness necessary for pro-
fessional work with older adults. Working with older adults can trigger powerful feelings
about death, the aging of family members, and one’s own attitudes about helping this
vulnerable population. However, this population is also one of the most rewarding for
social workers.

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 Chapter 1Chapter
24 Review
1 Q uestions
The following questions will test your application and analysis
of the content found within this chapter.

1. Professional supervision is critical to social workers b. call the man’s physician to get a prescription for
but especially to those working with older adults antidepressants.
because c. contact a family member to alert him or her to the
a. many older clients will die and increase the likeli- recent change.
hood of depression for the social worker. d. see if one of the neighbors has a key to the man’s
b. older adults are the most difficult client population home.
to work with.
c. every social worker will need to confront the real- 3. An older adult with many physical and cognitive
ity of his or her own and family members’ aging. problems adamantly insists on staying on in her own
home despite her family’s wishes that she consider an
d. there are few solutions to the problems of older assisted-living facility or a nursing home. The family
adults. cannot provide direct assistance but can pay for ser-
vices. What should the social worker do?
2. A geriatric care manager has been working with an
85-year-old man who is able to live alone but needs 4. A wealthy older woman is facing nursing home place-
housekeeping and home health services. Suddenly, ment but her family wants to keep her assets from
he becomes very hostile and refuses to let the care being spent for her care to protect their inheritance.
manager into his home. The first thing the social If she has fewer assets she will be eligible for medi-
worker should do is cal assistance and her care will be free in a nursing
a. call Adult Protective Services to force the man to home. The family asks you for advice. What should
let her in his home. the social worker do?

24

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