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This article is part of The Future of Social Work With Older Adults, a special issue of Families in Society with

guest editor Carol Austin. www.familiesinsociety.org

CAPACITY BUILDING WITH FAMILIES

Social Work With Older Adults and Their Families: Changing Practice Paradigms
Roberta R. Greene & Harriet L. Cohen

ABSTRACT Given the far-reaching social, economic, and demographic changes in the aging population, the authors argue for a methodological and practice-oriented transformation in future geriatric social work. The authors suggest that if they are to maintain their independence and well-being, a resilience-enhancing social work intervention will be especially effective in fostering the specific survival skills that older adults often already utilize to help them cope with difficult situations. A riskresilience model sensitive to ethnic difference and practiced at multiple systems levels (e.g., the community) is offered as an advancement of the traditional models of social work practice. In conclusion, the authors emphasize the value of a strengths perspective to address the pressing issues that affect the aging population.

n this article, we discuss successful aging and the new gerontology and explore how these varying views about how people age are associated with changes in practice paradigms. We present research findings and practice strategies to support the view that risk and resilience theory can be a significant influence on future social work practice with older adults and their families.

A Climate of Change
In large measure, social work practice is always shaped by the needs of the times, the problems they present, the fears they generate, the solutions that appeal, and the knowledge and

skill available (Reynolds, 1935, p. 233). The profession also changes from within depending on how members perceive and define what they do (Bartlett, 1970). Some social work theorists expect the new millennium to be a time of political, economic, cultural, and ideological change that will dramatically affect how practice is defined (Greene, 2005; Laird, 1993). Recent gerontological research also supports the view that the vast social, economic, and demographic changes in the aging population require a far-reaching transformation in future geriatric social work practice (Binstock, 1999; Scharlach & Kaye, 1997; Unger & Seeman, 1999). What will that transformation involve? Who will be social workers clients? What theoretical approaches are best used to serve them?

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Changes in Practice Models

The Successful Aging Paradigm

The adoption of new theoretical concepts and practice Until the late 1980s, gerontology was dominated by the perstrategies in social work with older adults and their fami- spective that growing old is a time of decline and loss. In lies has tended to lag behind other fields of practice. 1987, although not alone in their opinion, Rowe and Kahn Starting in the 1960s and 1970s, when psychodynamic (and others) made a significant argument that the effects of theory was in its heyday, many practitioners believedas aging were not equivalent to disease. They contended that did Freudthat older adults were not good candidates for if individuals adopted healthy behaviors, they could intrapsychic therapies. Ironically, one of the most popular advance to old age with far fewer age-associated diseases psychodynamic treatment strategies developed during (Strawbridge, Wallhagen, & Cohen, 2002). They also this time was life review therapy. Based on Eriksons eightargued that if people minimized risk and disability, maxistage theoryspecifically the stage of integrity versus mized physical and mental abilities, and engaged in an despairlife review therapy focuses on the resolution of active life, they would lead a salutary life (Rowe & Kahn, life conflicts through the natural process of reminiscing 1998). Crowther, Parker, Achenbaum, Larimore, and (Butler, 1963; Erikson, 1950). However, critics of this in- Koenig (2002) further proposed that another prerequisite tervention have pointed out its to successful aging is maximizlack of universality (Merriam, ing positive spirituality. 1993) and its insufficient attenDuring the past decades, tion to an individuals sociogerontologists have made sigResilience-enhancing strategies cultural context (Diehl, 1999; nificant strides in advancing a Kenyon & Randall, 2001). Therewellness philosophy. A wellness fore, some researchers and approach is an umbrella term occur when practitioners learn practitioners have proposed a used to consider individual different process of exploring a well-being. Theorists such as how a client has been successful persons past called narrative Antonovsky (1998) developed gerontology (Polkinghorne, 1996). another positive approach to over the life course. Narrative gerontology is based aging. He used the phrase saluon the postmodern idea that togenesis orientation to characpersonal stories contain a set of terize his study of how people larger stories or macro narranaturally use their resources to tives that reflect shared history, values, beliefs, strive for health. In a similar vein, Atchley (1999) proexpectations, and myths (Webster, 2002, p. 143), thereby posed the idea of life continuity in which older adults giving a broader context to reminiscing. maintain their thinking patterns, activities, living arrangeSubsequently, when family systems theory had become ments, and social relationships despite changes in health. widely used to address family problems, geriatric social Thus, the new gerontology was built on a successfulworkers or social workers in the field of aging gradually aging paradigm. came to see the family as central to effective treatment and Data from the U.S. Census suggest that the future poptook up the banner (Greene, 2000; Silverstone & Burack- ulation explosion of older people will not necessarily Weiss, 1983). This method has appeared to be effective for mean that the number of stereotypically frail older adults understanding the stresses and strains that may occur will expand in the same proportion (U.S. Bureau of the between older adults and their families. The forms of Census, 2003). This paradigm suggests that many future intergenerational interventions suggested are intended to generations of older adults will be healthier and live with mobilize the family system on behalf of the older adult a spouse. Furthermore, they will often seek age-inteand to promote positive interdependence (Greene, 1989). grated opportunities for work, education, and leisure Although the systems approach continues to be popular (Riley & Riley, 2000). The successful-aging paradigm also (Ephross & Greene, 1992), it too has come under criticism envisions older adults who will have a sense of economic for its structural or strict one-size-fits-all family security and productivity, be more aggressive and eduapproach. This has led some practitioners to combine syscated about their health care, and seemingly be more contems thinking with such postmodern ideas as how power fident about growing old (Corman & Kingson, 1996). within the family can be equalized (Greene & Blundo, At the same time, it is not surprising that some theorists 1999). Currently, social workers continue to turn to vari- have suggested that the Rowe and Kahn successful-aging ous theoretical practice approaches to find ways of intermodel needs a more critical evaluation because it may vening more effectively, including those that stem from a only apply to those individuals with the economic and wellness philosophy. Will geriatric social workers be political power to achieve this normatively desirable among them? state (Holstein & Minkler, 2003, p. 787). Holstein and

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Minkler (2003) went on to call for a further examination of how new gerontology research is itself historically and socially situated and shaped by cultural circumstances. In our view, this critique raises several questions: How will the sizable number of future generations of elders who experience various forms of emotional, social, and economic distress best be helped? Some will be without insurance and will have little access to health and human services. Others may find that available services do not fit their cultural expectations for care. Consequently, critics ask, who benefits and who is harmed by the prevailing, successful-aging, culturally normative standards (Holstein & Minkler, 2003)? This question requires a rethinking of what is important to keep older adults productive through continued societal contributions as well as what is necessary to support those who have acute and disabling illnesses (Kiyak & Hooyman, 1999). That is, can practitioners continue to help older adults maintain their independence and wellbeing as well as assist those most in need through triage (Greene, in press)? Are resilience-enhancing social work intervention strategies a means of achieving these ends? Moreover, what can practitioners take from a wellness philosophy? A wellness philosophy embodies a prevention approach, emphasizes the heterogeneity of the older adult population, and focuses on a continuum of functionality. Positive aspects of human development across the life course are underscored. In addition, a wellness approach highlights the older adults adaptability and capacity to meet life challenges. That is, such an approach avoids problem-saturated client descriptions and gives attention to culturally specific personal stories. Risk and resilience theory is part of this strengths-based movement.

TABLE 1. Risk and Resilience Theory: Basic Assumptions


Resilience is a biopsychosocial and spiritual phenomenon involves a transnational dynamic process of personenvironment exchanges encompasses an adaptational process of goodness-of-fit occurs across the life course with individuals, families, and communities experiencing unique paths of development is linked to life stress and peoples unique coping capacity involves competence in daily functioning may be on a continuuma polar opposite to risk may be interactive, having an effect in combination with risk factors is enhanced through connection or relatedness with others is influenced by diversity including ethnicity, race, gender, age, sexual orientation, economic status, religious affiliation, and physical and mental ability is expressed and affected by multilevel attachments, both distal and proximal, including family, school, peers, neighborhood, community, and society; consequently, resilience is a function of micro-, exo-, meso-, and macrofactors is affected by the availability of environmental resources is influenced by power differentials
From Greene (2002b, pp. 4142). Used with permision.

Risk and Resilience Theory


What is risk and resilience theory, and what does it offer practitioners? The concept of resilience has several definitions referring to a persons successful adaptation following an adverse event. Resilience is considered a dynamic phenomenon that depends on an individuals life context and is most important at life transitions. Perhaps the most comprehensive way to describe resilience among older adults is that it conveys a sense of continuity, competence, adaptability, and the inherent ability to bounce back across the life span. This definition is captured by Borden (1992), who contended that resilience is the ability to maintain continuity of ones personal narrative and a coherent sense of self following traumatic events (p. 125). This is not to say that older adults do not face risks as they age. The assessment of risk, those factors or circumstances associated with problematic behaviors or situations, should always be made. However, risk and resilience theory suggests that practitioners quickly and simultaneously assess what protective factors the older adult has in play. This

assessment of existing protective factors requires the practitioner to make a conceptual shift and changes in the models of inquiry, thereby shifting attention from risk factors themselves to the process of how people successfully negotiate risk (Greene, 2002b, p. 33). Attention is given to learning what circumstances moderate the effects of risk and foster adaptation. Overcoming risk factors that stem from multiple stressful life events and nurturing protective factors that ameliorate or decrease the negative influence of risk contribute to resilience. That is, a resilience approach can lead practitioners to consider what contributes to an older adults sense of continuity, especially in his or her ordinary routines of daily life. How can the older adult continue to live in an understandable, meaningful, and manageable world? Given the large numbers of older adults who may need to be served, what are the self-righting tendencies that are revealed in assessment that can foster survivorship (Becker, 1997; Janoff-Bulman, 1992)? The basic assumptions of risk and resilience theory used to guide assessment and intervention incorporate traditional as well as less familiar principles of human behavior in the social environment (Table 1). Perhaps the most crucial influence on the professions theoretical base and its approach to practice is also the key to risk and resilience theorythe person-in-environment perspective (Bronfenbrenner, 1979; Greene, 1999; Gilgun, 1996). Similarly, risk and resilience theory embodies the professions dual mission to improve societal conditions and to enhance social functioning. A resilience-enhancing approach underscores the need to seek resources and sources of natural support within clients environments.

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FAMILIES IN SOCIETY | Volume 86, No. 3 TABLE 2. Intervention Strategies: The REM Model
Practitioners who use a resilience-based approach to social work practice acknowledge client loss, vulnerability, and future identify the clients source of stress recognize client stress stabilize or normalize the situation help clients take control provide resources for change promote client self-efficacy collaborate in client self-change strengthen a clients problem-solving abilities address positive emotions listen to client stories make meaning of clients critical events help clients find the benefits of adverse events assist clients in transcending the immediate situation From Greene & Armenta (in press). Used with permission.

Understanding the interplay of biological, psychological, social, cultural, and spiritual factorsalways important to geriatric assessmentsis another area of concern necessary for the practitioner to select interventions that foster resilience. For example, there is increasing evidence in health care that, given hope, people may have a natural propensity to heal. In addition, when clients are able to exercise their sense of mastery by making their own decisions, practitioners may foster their belief in themselves. Moreover, when clients are able to fulfill their quest for personal meaning they are better prepared to face adversity (Canda, 1988, p. 243). Other factors usually considered in geriatric assessment and important in the resilience-enhancing approach include evaluating the balance between client stress and his or her ability to cope. Resilience-enhancing strategies occur when practitioners learn how a client has been successful over the life course (Greene & Armenta, in press) (Table 2). At the same time, it is important to remember that competence is culturally defined. Beckett and Dungee-Anderson (2000) stated, Definitions of aging shape the perceptions, preferences, beliefs, and behaviors of all persons, and, frequently, the treatment of older persons (p. 257), particularly older adults of color. Throughout their lives, many ethnic elders have experienced systemic discrimination and oppression, such as social stigma, poor economic conditions, lack of access to health care, and segregation (Aleman, Fitzpatrick, Tran, & Gonzalez, 2000). They have endured these challenging life conditions in a hostile environment and maintained their dignity as they have learned to overcome adversity and scarcity (Beckett & Dungee-Anderson, 2000, p. 258). The survival skills that ethnic older adults have utilized to help them cope with difficult situations in their younger years can be effective tools for them as they age and become resilient older adults. Understanding cultural diversity ensures that practitioners acquire sufficient knowledge of the cultural values

and experiences of minority older adults to enable them to determine culturally appropriate assessment and intervention plans. For example, the experiences of African American and Hispanic communities are shaped by family-centered values, interdependence and connectedness, and the belief in God or a spiritual presence in ones life. Asian Americans, like Hispanics and African Americans, tend to share cultural values emphasizing the importance of the family as a primary system of support (Aleman et al., 2000; Dilworth-Anderson & Gibson, 1999). Native Americans also believe in the power of the spirits to guide their perceptions and interpretations of life circumstances (Dilworth-Anderson & Gibson, 1999, p. 42). To effectively assess and intervene with ethnic older adults, social work professionals must acknowledge and affirm cultural values such as the importance of the family as a support, interdependence in the family system, family decision making, spirituality, and respecting the wisdom and experience of the community elders. It is also crucial to recognize that these values may be in conflict with the majority culture. These cultural values, along with positive values about the older population, may challenge the beliefs and worldview that have been internalized from the dominant culture by the social worker. Assessment of ethnic older adults is based on their perceptions of aging within their own cultural context, the life events they have experienced, and how they have made meaning of their earlier experience (McInnis-Dittrich, 2005). Resiliency can be found in these older adults, regardless of their level of care or amount of support needed (Guthreil & Congress, 2000). As the practitioner listens to clients beliefs, perceptions, and cultural values, they together can develop mutual goals. These life experiences and the meanings these older adults have made of them are expressed in the stories they tell. According to Kenyon, Clark, and de Vries (2001), It is important, moreover, to listen to peoples stories not as irrelevant ramblings that waste high-priced healthcare time but as essential sources of information (p. 48). It is through active listening that we hear individuals stories that powerfully express not only their personal narrative of resiliency but also the larger interpersonal, sociocultural, and structural dimensions of resiliency (Kenyon et al., 2001). An African American older woman explained, When you went to the [town] square you could not use the water fountain. We knew better. My mother said No, NO. Dont drink; dont sit there. Im sure she did not want our feelings hurt. By paying close attention to her story, one learns how life events at an early age helped her to sustain the personal knowledge and skills of resiliency as an older adult. In fact, older adults are role models for resilience. Generally, they are continuing lifelong patterns of coping and adaptation (Guthreil & Congress, 2000, p. 50). How much more significant is this for ethnic older adults?

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Research and Resilience

credence to how people may benefit from caregiving experiences (McMillen, 1999), nor did it tap positive indicators Resilience research came to the fore in the 1980s and of well-being (Kramer, 1997; Pierce, Lydon, & Yang, 2001). 1990s when developmental theorists conducted largeOne such study by Pierce et al. (2001) that employed a scale longitudinal studies on children in high-risk resilience approach examined the perceptions of primary situations such as sexual abuse, poverty, drug abuse, and caregivers for family members with dementia. They found teenage pregnancy. As studies continued to document that well-being was sustained by those who had a greater successful (e.g., resilient) outcomes for these children, re- identification with the caregiving role and therefore were searchers as well as practitioners in some fields shifted more enthusiastic. These family members also were assotheir focus. They wanted to know why so many children ciated with appraising difficult situations as less threatenwho faced adversity became coming and considering them petent, resilient adults (Fraser, more of a challenge. 1997). Studies of adult survivors Another study of Alzheimer of such adverse events as the Nazi family caregivers (Garity, 1997) Holocaust also support the view showed that resilience was assoAs the practitioner listens to that people appear to have a natciated with effective problemural tendency to overcome solving and emotional coping. clients beliefs, perceptions, and adversity and to be resilient Still another study (Paun, 2003) (Greene, 2002a; Moskovitz, 1983). explored the caregiving expericultural values, they together Thus, research demonstrated ence of wives who had successthat even people who have unfully cared for their husbands can develop mutual goals. dergone extreme hardships have with Alzheimers disease at natural propensities to overcome home for at least 3 years. them. These findings have resultAlthough all of the wives felt ed in professionals promoting they had no choice in becoming the use of risk and resilience thecaregivers, all had made a delibory in practice in the belief that resilience may be fostered erate choice to care for their husbands at home. Most of the through practitioner intervention (Borden, 1992; Higgins, women described what would be considered good mar1994; Neimeyer & Stewart, 1996). riages based on love and mutual respect. All of the wives Yet despite its growing popularity, the idea of resilience were committed to continuing to care for their husbands at has not yet been able to overcome the stereotypic image of home for as long as possible (Riley, in press). the frail, if not debilitated, older adult (Lewis & Harrell, Other researchers have examined caregivers exit transi2002). However, a research paradigm shift has revealed tion when the care recipient dies or is institutionalized that older families are resilient, often using effective prob(Schulz et al., 2001, 2004; Schulz, Mendelsohn, & Haley, lem-solving and emotional coping skills (Garity, 1997; 2003). One such study substantiated the remarkable Wagnild & Young, 1993). A small body of literature curresilience of caregivers and their recovery in response to rently provides insight into resilience in old age (Lewis & the death of their loved one. Will practice strategies follow Harrell, 2002; Wagnild & Young, 1993). For example, Lewis these research findings? and Harrell (2002) have devised a relational framework that suggests that resilience among older adults is associat- Implications for Practice ed with safety and support, affiliation, and altruism. Wagnild and Young (1993) suggested that resilience Resilience-enhancing interventions begin with the belief among older women is associated with living through the that clients can effect positive change (Greene & Armenta, experience of returning to health after illness or loss. They in press). The practitioner also believes in the clients selfattribute this capacity to equanimity, balancing ones righting processes, with some individuals only needing time to heal. Resilience-enhancing models have several response to adversity; perseverance, continuing to persist approaches in common: that practitioners adopt a philoin spite of adversity; self-reliance, exhibiting independence and confidence after loss, existential aloneness, sophical stance involving client renewal and transformation, that practitioners build on a clients innate capacities, engaging in creativity and self-acceptance; and meaningfulness, deriving insight from experiences and gaining that practitioners select interventions that promote client well-being, and that practitioners explore growth-producnew value in life. ing issues. These aims are realized as practitioners and Another example of the research paradigm shift is the change in focus from caregiving burdens to caregiving clients balance truthfulness about hardships with hope, rewards. Although the caregiving burden intervention having positive expectations for the future (Greene & Armenta, in press). approach alleviated stress for many families, it did not give

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As with most aspects of social work practice, resilienceenhancing interventions can be made at multiple systems levels. For example, Walsh (1998) has provided a family resilience framework that aims to identify and strengthen those family processes that help family members withstand and bounce back from difficult circumstances. A similar concept, community resilience, is characterized by the qualitative elements of a community, which include personal relationships, shared vision, and the opportunity for everyone in the community to participate (McKnight, 1995). McKnight (1987) identified six factors for the practitioner to observe in determining a communitys resiliency. They are (a) community capacity, including the strengths and weaknesses of the community; (b) collective effort, or the manner in which people work together and appreciate individual talents; (c) informality, which recognizes the value of meaningful relationships; (d) stories that share the communitys history and future vision; (e) celebrations to incorporate joyous social events into everyday life; and (f) tragedy, including how communities adapt to grief, loss, and change. These six factors, which are important in providing a qualitative understanding of the resiliency of the community, impact the quality of life for individuals and families living in the community. Family resiliency, including intergenerational families, and community resiliency, which involves elder-friendly service-delivery systems and informal support systems, are interdependent and reinforce the individual in the social environment concept in social work practice. One ethnic older adult explained,
What I experienced of people who wanted to do something and change their situation was their sense of hope. And thats what kept them going. Both a sense of hope and a sense that things could change for their children and grandchildren. And the hope came from the organizations; well, it came from two places. One was that the congregations, the religious congregations they worked with and were connected to, were connected to a larger organization that showed them what kind of change could be brought about. And so that, in my experience, it gave them your word: the resiliency and stick-to-it-ness to be with the organizations and continue this work over a fairly long period of time.

By listening to clients stories, especially during these times of great uncertainties, practitioners can foster client resilience that prepares them to realize their potential.
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Roberta Greene, PhD, MSW, is Louis and Ann Wolens Centennial Chair, School of Gerontology and Social Welfare, University of TexasAustin, and is editor of the forthcoming book, Social Work Practice From a Risk and Resilience Perspective (Monterey, CA: Brooks/Cole). Harriet L. Cohen, PhD, MSW, is assistant professor, Texas Christian University. Correspondence regarding this article may be sent to the first author at rgreene@mail.utexas.edu or University of TexasAustin, School of Social Work, 1 University Station D3500, Austin, TX 78712-0358. Manuscript received: November 3, 2004 Revised: February 18, 2005 Accepted: February 24, 2005

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