Beyond Good Intentions: Support Work With Older People by Anne Opie

Maree Brown
Policy Analyst
Social Policy Agency

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.

An Alternative Service Delivery Model

This book highlights the need for a service delivery model which better meets the needs of people with a dementia and caregivers. Inextricably linked to this project is the effort to re-position social work in its rightful place within the health system – to help prevent its further professional marginalisation by increasing the level of understanding about the complexities and specialist skills required in social work practice. In one telling example, Opie quotes a nurse who described the social work role as "talking about the little bits we can leave, you know". Such a diminution suggests not only one professional's devaluing of social workers' contribution to patient care but also a deeper confusion within the organisation as to the function of social work.

It is an example which is typical of Opie's methodological approach – moving from individual utterance to the broader organisational context by way of theoretical analysis. She has considerable skill in picking up the nuances of seemingly innocent, everyday statements, uncovering the attitudes and assumptions that underpin them, and teasing out the wider implications.

Part of the problem, Opie sees, is that social work has never had a clearly defined professional base, thus is vulnerable both to limited representation and inter-professional claims. Because it typically involves the problems of everyday living, social work does not have jurisdiction over its working environment nor even a real vocabulary of its own. On the contrary, because the language of social work sounds familiar, the role of the social worker is also appropriated by others who consider that they, too, can "social work" people. Opie adds that in meetings with other health professionals, social workers themselves often gave a limited – professionally disempowering – representation of their work simply through the language they used; for instance "popping in" to see people or "having a cuppa".

Given the apparent marginality and limited impact of social workers in hospitals, Opie concludes that the rationale for employing them has to be a cynical one:

Culturally, they act as an organisational conscience, to raise (with varying degrees of skill) wider social issues which, once raised, can then be subordinated to dominant economic or medical discourses. Their role is to enable health (and other welfare) organisations to present a caring dimension which is contradicted by other policies and other practices.

Although the fieldwork for the study was conducted in 1992, before the recent major health reforms, Opie suggests that there is no indication that these findings are less valid now. If anything, she concludes, the "likelihood of achieving that more complex, supportive practice with caregivers and their spouses or relatives with a dementia appears to be diminishing."

The Scope of the Study

This is a substantial work: as George Salmond notes in the preface, it is the first major piece of research on social work services in the health system in New Zealand. However, the book does seem at times almost unwieldy in the range of topics it addresses. Opie is mapping new territory and wants to make sure all the paths are signposted. She touches on topics as diverse as the changing environment of the health system, the use of "visually audible" interview transcripts, multi-disciplinary team-work, social worker training needs, and the problems inherent in the supervisory relationship.

Occasionally, as she covers all this ground, Opie risks losing the reader. There is a weight of information to be taken on here and the book certainly demands that the reader has a good memory. For instance, the chapter entitled "Social Work and Multi-Disciplinary Teams" is informed, we are told, by two assumptions. The first assumption is qualified by three further factors. It is almost four pages before we reach the main body of the chapter. At other points, however, Opie effectively presents information in list form – in fact some sections in "The Practice of Social Work" chapter read almost like a social work manual (which is perhaps the author's intention). Another useful feature is the executive summary and recommendations at the front of the book.

This book clearly has wider applications than those signalled by its sub-title. It will be of use not only to other fields of support work with older people and to all areas of social work and health services, but also to other professional disciplines generally. Anyone who has ever experienced frustrations with multi-disciplinary or inter-agency team work, for instance, will appreciate Opie's suggestions for enhancing collaborative effort.

This pioneering study offers a rich resource for future researchers. It also presents a powerful challenge to existing models of service delivery to older people and their caregivers.