Beyond Good Intentions: Support Work with Older People

In her previous book, There's Nobody There: Community Care of Confused Older People, published in 1992, Anne Opie emphasised the major social and economic contribution made by family caregivers in caring for a relative with a dementia in their own home. The book also identified a lack of formal support for these caregivers from social workers and other service providers.

Opie's latest study is, in part, an attempt to account for this lack of formal support. Beyond Good Intentions: Support Work with Older People is based on a qualitative research project which evaluated the effectiveness of social work practice in supporting people with a dementia and their caregivers. Effective support work for these two groups is defined by Opie as work which meets the emotional as well as the practical or physical needs of people with a dementia and their caregivers. Because social work has both psycho-social and advocacy dimensions, social workers have a key role to play in providing this support.

Opie's fieldwork included interviews with 130 health workers and caregivers, as well as observation of several facets of social work practice. Her methodological approach is rigorous ? she even discusses her interpretation of rigour at one point ? and she is scrupulous in acknowledging the assumptions which inform her own analysis. Central to this approach is an understanding of the work of the discourses ? broadly held sets of beliefs or values ? in defining social realities and in structuring social interactions, including organisational interactions and policies. Opie examines the way competing discourses on ageing and caregiving serve to inform and constrain social work practice. She asserts that the dominant Western discourses on ageing associate old age with decline, despair and dependency, or with attempts (mostly futile) to keep decline and loss at bay. Once decline is viewed as inevitable, a reductivist approach to the needs of old people is easily justified:

Unsurprisingly, social work with older people has often been described as involving primarily 'bed emptying' ? this demeaning phrase ? suppresses the dual focus of social work on the practical and emotional needs of users; further, it places the older person in the deviant position as a 'bed blocker'.

More recently, competing discourses on ageing have emerged which question the assumption of inevitable decline, and emphasises older people's legitimate needs and rights. Some practitioners have stressed the need to move away from the linear decline model in working with people with a dementia and to develop an environment which encourages them to maintain their autonomy and their capabilities.

Opie uses examples from her own fieldwork along with existing literature to highlight the complex and sophisticated nature of effective support for people with a dementia, and their caregivers. She identifies the wide range of personal skills, training and resourcing needed by social workers working in this area. She also suggests that the definitions of some of the key functions of social worker, such as supporting or empowering the caregiver or promoting choice, need to be unpacked, because their meanings are not as transparent as is often assumed. This leads to differences in the kind and quality of service provided by different workers.

In many cases, she noted effective support work was constrained by several factors. These included organisational constraints (such as lack of resources, high workloads and worker isolation); the dominance of ageist discourses which focus on practical needs and suppress the psychological needs of caregivers and people with a dementia; other social work practice constraints, such as the difficulty in representing fully to other health professionals the nature and complexity of the social work role; and the lack of training for social work with older people, especially training in counselling for grief and loss.