Welfare of Older People & People with Disabilities
Student No: 80092581
Welfare of Older People & People with Disabilities
This paper requires me to imagine myself in old age see Appendix 1 describes a fictional description of my circumstances and what I envisaged my ageing to be like. Within this paper I will briefly discuss the theories of ageing and the relevant psychological and sociological perspectives within dementia. I will discuss the impact of discrimination towards people in my situation and point towards ways in which this oppression can be alivated. Lastly the role of the social worker whose job is based within the community, therefore, is of key importance as we consider the best ways to meet the changing needs of the person with dementia and those who care for them.
The recent Audit Commission report 'Forget Me Not Mental health Services for Older People' quoted:
* The number of people over 65 is predicted to rise by 10 per cent in the next 10 years,
* The greatest increase will be among those over 80,
* One - quarter of those over 85 develop dementia,
* One - third of these people (the 25% of people over 85 who develop dementia) need constant care or supervision.
(Audit Commission 2000)
Many people caring for people with dementia are elderly themselves. Levin, Moriarty and Gorbach found in their study of 530 carers of people with dementia that 57% of the subjects were husbands or wives. Two - thirds of the sample were aged over 65, the oldest member being aged 92. (Levin, et al. 1994). More recently, in 1998, a government survey of 'informal' carers found that they were most likely to be aged between 45 and 64. Over half of all carers looked after someone aged over 75, and two out of ten carers are caring for a spouse. (Office for National Statistics 1998)
As well as these changes in the context of the health and social care environment, there is more known about dementia than ever before. There is greater understanding about the way the brain works and medical knowledge about dementia is vastly improved. Past theorists described dementia to be, ... "an irreversible, progressive, degenerative neurological condition leading inevitably to the death of brain cells and loss of the person (through catastrophic changes in the brain)".
(M. Tibbs, 2001)
At first glance dementia may seem easy to understand and define, (see Appendix 2) but there are many ways to approach it. The medical model is most widely accepted and understood, and considers dementia in terms of disease and illness or something being wrong in part of the body - in this case the brain. But to ignore other ways of considering the condition, concept or label is dangerous because it does not allow for an approach, which acknowledges the uniqueness, and worth of the individual, and this is what is important in the delivery of social work and social care. I will outline a range of sociological and psychological approaches to dementia that provide alternatives to the accepted models developed within medical settings. However there is no single approach that can explain dementia satisfactorily. Rather, an understanding, which integrates medical, sociological and psychological, thinking, is best when seeking to offer help and support to people with dementia and their families.
The Medical Model
From a biological perspective the first step towards elucidating the nature of a disease is to define the problem. During the nineteenth century, accurate clinical descriptions of many diseases of the nervous system appeared, and in 1835 James Coule Prichard described a syndrome, which he called incoherence or senile dementia. He noted, "forgetfulness of recent impressions, while the memory retains a comparatively firm hold of ideas laid up in the recesses from times long past". The Royal College of Physicians (1981) was concerned that all older people were being characterised by memory impairment, incapacity and loss of control. To counteract these misunderstandings it produced a report describing a variety of syndromes and the causes, or 'aetiology' of organic mental impairment in older people. The following operational definition of dementia resulted:
Dementia is the global impairment of higher cortical functions including memory, the capacity to solve the problems of day - to day living, the performance of learned perceptuo-motor skills, the correct use of social skills and control of emotional reactions, in the absence of gross clouding of consciousness. The condition is often irreversible and progressive.
(Royal College of Physicians, 1981, p.146)
This kind of definition is generally accepted in medical circles (Gelder et al., 1989, Lishman, 1987). Dementia affects all the person's thinking and problem solving abilities: it is global. The impairment results in a progressive ...
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Dementia is the global impairment of higher cortical functions including memory, the capacity to solve the problems of day - to day living, the performance of learned perceptuo-motor skills, the correct use of social skills and control of emotional reactions, in the absence of gross clouding of consciousness. The condition is often irreversible and progressive.
(Royal College of Physicians, 1981, p.146)
This kind of definition is generally accepted in medical circles (Gelder et al., 1989, Lishman, 1987). Dementia affects all the person's thinking and problem solving abilities: it is global. The impairment results in a progressive deterioration of all learned skills important for daily interacting and communicating with others and functioning as an individual. This approach firmly places dementia within the province of the medical profession. Correct diagnosis of the disease is essential in deciding possible treatments, especially for reversible conditions and acute confusional states. (Wilcock, 1990) It is not surprising, therefore that most people regard dementia as a clearly recognisable and describable medical condition, whilst there are others who have problems accepting this face value.
Levy & Post, 1982 content: if it is progressive and cannot be halted, ...the hope associated with the medical model for cure cannot be justified.
The medical model leads to optimism about 'curing' or at least retarding progress, although medical advances continue, this view is not borne out in practice, and may create false hopes. The search for a cure may detract from the search for quality of care in the longer term.
Sociological Approaches
The three major sociological approaches to dementia are:
* Structural approaches,
* Interactionist approaches,
* Ethnomethodological approaches.
Structuralists' theorists view mental illness (those who believe that an individual's behaviour is dependent upon their social environment and the prescriptions and prohibitions of that society) as the result of particular aspects of their social structure, such as class, gender, age and race. (Bond, 1987). Dementia could be seen as part of a response to changing roles in society, and as an adaptive process of disengagement from social activities as the individual's ages. This view implies that dementia is part of 'normal' ageing. Withdrawal from social roles and a rationalisation of inequalities in power and staues by virture of age are also implied in the structuralist view. This view was popular in the 1960's but is criticised as giving credence to the claims of ageism in associating age with deterioration, decline and withdrawal. (Cumming & Henry, 1961)
In contrast with structuraists, interactionist sociologists provide a different view. Mental illness is not thought to be clearly defined, rather it is a social status conferred upon an individual by other members of society, usually on the basis of a judgement about the individual's behaviour. It is dependent on social interaction in which a label is applied - in this case, dementia - and future behaviour towards that person takes place in the context of that label. In social life some people occupying particular roles have more power than others when it comes to labelling people as 'demented'/mentally ill. Szasz (1971) noted in the area of mental illness it is psychiatrists who categorise and apply labels that define mental illness. However it is the individual's interpretation and meaning that they give to their own actions and those of others, which are of importance to interactionists (Bond et al; 1990).
Psychological Theory
In the last thirty years a clearer picture has emerged about the destructive factors acting upon older peoples' mental abilities. Diseases of the brain account for most cases of intellectual decline, it is now generally accepted that the mental deterioration of dementia, including memory failing and clouding of understanding, is associated with brain disease and is not typical of the fate of most old people. The experience of dementia means different things to different people, above all dementia must be placed within the context of the personality, the relationships the person is having, the life history and the physical health of the person.
Social worker play a pivotal role in the lives of people with dementia and their families and others who care for them. Their intervention at various key points in the 'dementia journey' is crucial. Significantly, a large percentage of older people who fall within the high priority group, as defined under current social services eligibility criteria, are people with dementia. Competence in working with people with dementia - which is the focus of this discourse - demands, among other knowledge, the acquisition of knowledge about dementia, the functioning of people with dementia, about carers their location in wider social structures, the availability of resources and access to them. This is essential before one can provide effective intervention. However knowledge about what constitutes social work practice. The skills to apply this knowledge and to recognise the impact of personal, clients, carer, agency and cultural value systems are important to the purpose of social work.
In relation to my pen picture (Appendix 1) the social would have drawn up a list of issues highlighted within my situation:
* Knowledge of the National Health Service and Community Care Act 1990, to consider whether Margaret is entitled to an assessment and/or services
* The needs of the carer - perhaps especially Trevor - important, therefore an understanding of the implications of the Carers (Recognition and services) Act 1995, Disability Discrimination Act 1995 is needed.
* Each local authority has different needs and services, so knowledge of how local procedures and policies implement and operate this legislation is fundamental to applying the knowledge.
It is clear that community care remains a problematic area of practice, which has become dominated by concerns over inadequate resources. 'Modernising Social Services' (1998) describes (at Para. 2.3) the challenges faced in 1998:
"Decisions about who gets services and who does not are often unclear, and vary from place to place. Eligibility criteria are getting ever tighter and are excluding the most dependent categories. Decisions about care can still be service driven, and concentrate on doing things for people according to what is available, rather than tailoring services to the needs of individuals and encouraging those who are helped to do what they can for themselves. Overall, people feel ill-informed about how they should find out about services, what they may be asked to contribute themselves, who will be providing the care, and how they can influence it. This is particularly true for certain groups such as older people from ethnic minorities".
* An understanding of family processes, patterns, scripts is important, to determine the impact of the present situation and needs arising from it
* Also important in this regard is a knowledge of the importance and impact of cultural factors on family functioning
* A knowledge of dementia, it may help in providing information, support, understanding and advice to the Trevor, myself and family
* Knowledge of the impact of dementia on families and individuals, to help plan effectively, an up-to-date and comprehensive knowledge of what in available and how access can be gained to these resources
* A comprehensive knowledge of recent research, innovation and development in practice, to enable you to assist this family in the most effective way possible.
However knowledge alone cannot deliver effective services. The social worker needs to able to apply this knowledge effectively; this demands a degree and level of skill, which forms part of the competence for social work practice. A major challenge in working with people with dementia is in understanding the depth of the client's human distress and its impact on the worker's awareness of 'self'. In dealing with the painful stories expressed by the family, there may be an understandable temptation by the social worker to ignore these emotions and, at times, their strange and bizarre thought processes. This response may have a number causes. The psychoanalytical concepts of transference and contertransference (Yelloy 1980) for example, help explain how our past lives create psychological blocks, which prevent us from listening to the needs of others. Sociological perspectives can also reveal popularised discourses on 'madness, which may mistakenly inform social work practice' (Dallos and Boswell 1993). It is essential that the social worker recognises complex influences affecting his/her professional judgement; this will help in refraining from making generalized assumptions about the family's' experience of mental illness. As part of a commitment to sound value base for practice it is crucial that the social worker should not reinforce or replicate Margaret's experiences of being deprived of freedom and opportunities for decision-making. In the early stages of engagement the social worker should enter the relationship with Margaret with an openness and willingness to listen. This sense of honesty, combined with a genuine commitment to helping, will lay the foundation for promoting Margaret's rights and wishes and enabling the family to continue with their lives.
In the initial communication with Margaret the social worker should be competent in using generic, interpersonal skills which are just as appropriate for interventions with people who have mental health problems as other group - in this case dementia (Tilbury 1993). The social worker should be careful to describe the purpose of their involvement in language which is non-threatening, jargon-free and which makes sense to Margaret. It may be that her capacity to understand the social worker may be limited by her reducing mental state, skills in active listening, clarifying and restating the purpose of the social work intervention between the social worker, Margaret and the family. By communicating effectively within the family system (Dallos, 1991) this allows Margaret, Trevor the son and daughter to have space to speak for themselves in turn, concentrating on all the needs of the family members.
It has been argued that the social construction of images of disability shape professional discourses about the behaviour of clients and reinforce wider systems of discrimination (Foucault 1965; Oliver 1993). The social worker should therefore be able to move beyond oversimplified explanations for Margaret's behaviour and begin to understand the way in social inequalities shape the services she and her family receives. There is, for example, evidence that social class influences the diagnosis and treatment of dementia (Goldberg & Huxley 1980; Pligrim & Rodgers 1993). The fact that may people with mental health problems are over the age over 65 years and in receipt of welfare benefits indicates a de facto of unequal opportunity.
Racism and sexism are pernicious influences on the provision of many services for people with dementia problems (Brown & Harris 1978; Corob 1987; Dominelli & McLeod 1988; Fernando 1988). What emerges from such literature is evidence of multi-layered systems of inequalities, the effects of which may have to be contended with by the family in their everyday lives. Theories of user empowerment (Braye & Preston-Shoot 1995; Croft & Beresford 1993) for example offer the social worker a framework, which can address discrimination within organisations in purposeful ways, which can empower service users. In this case the social worker should consider a number of opportunities for promoting the rights' of this family, bearing in mind that careful attention must always be paid to establishing agreement and moving at the Margaret's pace. For Margaret, as with other women, she may have fears about her medical condition which may have left her feeling stigmatised and degraded; subjected to stereotypical ideas about loss of physical/mental capacity to make decisions. There needs to be careful attention to how the social worker recognises the internalised prejudices they may be bringing to practice. For example in the way she/he views the roles and relationships, they may be using assumptions, which reinforce the 'patriarchal ideology'. Attention to Susan's needs can be achieved through a sensitive, non-judgemental interviewing style, which acknowledges this history of discrimination.
Much of the literature on empowerment describes how the failure of adequate information, and a lack of technical knowledge about how to access services, results in structured inequality for social work clients. Discrimination cause by generalised prejudices about disability, gender, race class sexual orientation, age and religion further compounds theses failing of systems of welfare. The social and economic circumstance of this family suggests that social worker has further opportunities to demonstrate competent anti-oppressive practice. Trevor's role as carer for Margaret should be readily acknowledged as legitimate and meaningful. Resources from both statutory and voluntary sectors should be assessed and used to support him.
To conclude, the social worker for Margaret Peters and family needs to be aware of their own values base, fears and thoughts of ageing and illness in order to practise without hidden agendas influencing the course of the work. It is important in this case to be aware of the potential impact of cultural factors on the family functioning, the ways in which matters are dealt with and the impact of the dementia and deterioration in functioning seen. It is also important to recognise that cultural stereotypes must not be imposed on the basis of different ethnic origins. Each person or family worked with should be seen as unique, and the response and needs also as unique. Thus values of anti-oppressive practice need to be at the forefront of social work practice to be effective and competent. It is important for the social worker to find out the wants, wishes and needs of all involved, and work towards some way of addressing theses, which maintains privacy, dignity, choice and independence, and also protect from harm and danger. Margaret Peters must be allowed her chance to determine her needs, and Trevor Peters also has needs as a carer, which will influence care planning. By practising within a framework of knowledge, skills and values that underpin social work practise only then can we promote the independence the family needs to function within the community.
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