288 Client Populations and Contexts
and even losses. An empowering approach emphasizes
how people use their strengths to survive, adapt to new
experiences, and learn to appreciate the positive aspects
of these new experiences. A second concept is compe-
tence. Social workers can help older adults focus on and
emphasize what they can do instead of what they can’t
do; each individual should appreciate her or his own
level of competence. Relatedness, the third concept,
involves the sense of belonging and relating to other
people. Hence practitioners should work to strengthen
older adults’ relationships with others including friends,
family members, and professional caregivers (e.g., visit-
ing nurses, physical therapists). Support, activity, and
educational groups are other mezzo options. Finally,
autonomy involves helping people live as independently
as possible. McInnis-Dittrich (2005) comments:
One of the most frequently stated goals [older
adults] . . . voice is their desire to maintain their inde-
pendence as long as possible. This desire coincides
with the social work profession’s commitment to pro-
mote self-determination and preserve the dignity of
the individual. 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 independent living, tensions
between [older adults’] . . . desires and families’ and
social workers’ 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 struggling with stairs, a deteriorating neigh-
borhood, 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 pro-
tective 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] . . . ? These are difficult questions for
which there are no simple answers. (pp. 21–22)
Toseland (1995) suggests five strategies for social
workers to increase their sensitivity to older adults
and thus enhance their effectiveness:
1. Identify and face any preconceived notions and
stereotypes about older adults. These must be
identified before they can be eliminated or
changed.
2. Appreciate the different life situations experi-
enced by people from different age groups within
the older adult population. For example, women
seeking work in the 1930s will have experienced
very different conditions from those employed in
the 1940s (Toseland, 1995). Women in the 1930s
probably had a very difficult time finding jobs
during the Great Depression when unemploy-
ment was skyrocketing. However, women in the
1940s likely had a pick of many jobs when men
were off fighting World War II and industry was
begging women to come to work.
3. Understand that older adults are individuals with
unique characteristics, experiences, and person-
alities just like anybody else. Highlight 10.4 con-
trasts the personalities and life approaches of
two women who were friends for many decades.
4. Learn about how both gender and cultural back-
ground influence the aging experience. Both
older adult women and older adult people of
color are much more likely to experience poor
health, poverty, substandard housing conditions,
and social isolation (Toseland, 1995). Long-
term experiences with discrimination can affect
attitudes and expectations. Worker sensitivity to
cultural differences in terms of communication,
family relationships, and gender roles is critical.
(Chapter 12 discusses a range of cultural and
ethnic differences more thoroughly.)
5. Understand the developmental aspects of later
life including people’s physical, mental, living, and
socioeconomic conditions.
Cox and Parsons (1994) suggest six specific
empowerment strategies for micro practice with
older adults. First, social workers can listen carefully
to what clients are saying and work to understand
what they mean. Cox and Parsons (1994) explain
that “engaging and drawing out the emotions of
[older adult] . . . clients and helping them frame their
situations in view of past experiences and events are
effective listening techniques” (p. 112).
Second, social workers can help clients identify their
coping skills and their abilities to implement planned
change. Encouraging clients to talk about what’s
important to them, including their significant life
experiences, is helpful. Exploring how they’ve coped
with their difficulties in the past can also be valuable.

H IG HL I GH T 1 0 .4
Diversity and Individual Differences Among Older Adults
Just like younger people, older people are unique indi-
viduals. Consider one woman, Myrtle, age 84, whose
life was filled with difficulties including a decade of
tuberculosis, the abrupt death from a heart attack of
her husband at age 51 as he slept beside her, her care-
giving responsibilities for her own aging and mentally
ill mother for 15 years, and the need to pinch pennies
her entire life. Nonetheless, Myrtle remained cheerful,
optimistic, and interested in the world around her
throughout her life. One of her nieces took her to
China, Disney World, New Orleans, and Europe after
she turned 78 (not all in one trip, of course).
Contrast Myrtle with Paula, also age 84, Myrtle’s
maid of honor 65 years earlier. Paula had a long, good
life with a husband who adored her. He cooked and
Third, social workers can show clients videotapes
of other older adults talking about how they’ve
learned to cope with similar issues. As with support
group involvement, this may help clients understand
that they aren’t isolated and alone in their concerns.
Fourth, workers can share newspaper articles,
stories, and other informative materials with clients,
especially those about older adults who have initi-
ated service activities and political action. The Gray
Panthers, an advocacy organization for the rights
and socioeconomic needs of older adults, provides a
good example of how people can work together for
legislative and political change.
Fifth, practitioners can connect clients with other
older people to provide “mutual support and educa-
tion” (p. 112). Groups might include those experienc-
ing similar life issues “such as retirement; illnesses
such as Alzheimer’s disease, and chronic health or
mental health conditions; and families of older peo-
ple who have a terminal illness” (Bellos & Ruffolo,
1995, p. 171).
Sixth, social workers can encourage clients to help
others. For example, one social services agency orga-
nized a number of older adult clients and helped them
assess their special competencies. They were then
organized as volunteers to help each other. Those
who could drive chauffeured others who couldn’t for
grocery shopping and medical appointments. People
Social Work and Services for Older Adults 289
cleaned for her in addition to holding a lucrative engi-
neering job. He died when she was 78. At that time,
Paula remained financially well off. Paula began experi-
encing health problems including hearing loss and dia-
betes at age 80. Complications from the diabetes forced
her to enter a nursing home at age 83. Paula had always
been persnickety. She demanded that she get her own
way, and usually she did, thanks to her devoted spouse.
She was never interested in the world around her,
despite the many innovations developed during her life-
time (e.g., television, jetliners, computers). She was
always a complainer; everything was always wrong.
Myrtle visited Paula faithfully every Sunday for
years and endured her endless whining and complain-
ing. There could hardly be two more different people.
with good eyesight read to those who could not see
as well. People with exceptional organizational skills
organized and oversaw the volunteer activities. Many
people put their strengths to use and became produc-
tive members of the community.
Empowerment for People Facing Death
The prior section addressed empowering older adults
by maximizing their social support, involvement in
activities, and quality of life. Another important
issue facing older adults, especially as they advance
in age, is the idea of preparing for and coping with
their eventual death. Social workers can empower
clients by playing important roles that include coun-
seling, offering emotional support, providing infor-
mation, and assisting loved ones as they cope with
ensuing death. McInnis-Dittrich (2005) introduces
the issue of death when working with older adults:
Coming face-to-face with the reality of dying and
bereavement is an inescapable part of social work
with [older adults] . . . and one of the most chal-
lenging for both novice and experienced profession-
als. Losing a client to death or helping an [older
adults] . . . or family cope with the loss of a loved
one is a constant reminder of the way death will
touch everyone’s life, if not now, then certainly in
the future. (p. 346)
290 Client Populations and Contexts
Phases of Emotion
Kubler-Ross (1969) developed a five-stage model
of emotions that appear to be involved when peo-
ple face death or extreme loss (James, 2008; Kanel,
2007). These stages include the following:
1. Denial and isolation. An initial response to bad
news is refusal to believe the new is true. “That
just can’t be!” “There must be some mistake.”
“The case records were confused.” “The test
results must have been flawed.”
2. Anger. Another emotional response is anger that
“it had to happen to me!” “It’s not fair.” “It isn’t
right.” “Why me?!!!”
3. Bargaining. Still another emotional response
involves bargaining, trying to make deals to get a
better outcome. “Maybe there’s something I can
do to make the problem stop or go away.” “I’ll
pray really hard.” “I’ll take the right vitamins
and go through all the experimental treatments.
I’ll do anything to make it go away.”
4. Depression. Depression involves feelings of
extreme sadness, fatigue, and hopelessness.
“It’s no use. It’s over anyway.” “Nothing will
improve.” “Poor me.” “I might as well lie down
and die right now.”
5. Acceptance. A final stage involves accepting
the inevitable and more objectively looking at
the end. Acceptance involves people who “are
in the process of disengaging from this life if they
are dying or disengaging from a loved one if that
person is dying or has died” (Kanel, 2007, p. 136;
Kubler-Ross, 1969, pp. 35–77).
A significant aspect of Kubler-Ross’s phases is that
they focus on how normal it is to express strong emo-
tions when you find out you’re dying or that someone
close to you is dying. Note that not all of these stages
occur for everyone, however, nor do they occur in the
same order they’re presented here. Many people vac-
illate back and forth among emotional stages. Hope-
fully, these people finally experience acceptance.
McInnis-Dittrich (2005) describes the potential
emotional turmoil involved when addressing death:
It is not uncommon for a relative of a dying per-
son to become extremely angry at the dying person,
blaming him or her for not seeking medical treat-
ment earlier or for persisting in self-destructive
behavior, such as heavy smoking or drinking. This
intense anger may seem incongruous with the sad-
ness and deep affection a family member really feels
for a dying [older adult]. . . . [Older adults] . . . may
also lash out at family caregivers, which may seem
alarmingly ungrateful. The emotional roller coaster
that accompanies the dying process is unpredictable
and disconcerting to both an [older adult] . . . and
the family support system. (p. 350)
Empowerment of a Person Who Is Dying
There are several suggestions for empowering and
helping a person who is dying cope with his or her own
impending death. First, encourage the client to talk
about his or her feelings, even the negative ones. Peo-
ple must let their feelings out before they can deal with
them. Convey that you are willing to talk about even
difficult matters. Don’t discourage crying. This is just
another means of coping with sadness. Sometimes,
when talking about feelings and establishing a per-
spective, it’s helpful to examine one’s life. A life review
of both positive and negative events can help a person
find acceptance and set his or her mind at peace.
A second suggestion for helping a client who is
dying involves focusing on spirituality, if that client
has religious or spiritual beliefs. “The social work-
er’s responsibility is to be especially responsive to
and respectful of the client’s unique religious and
spiritual traditions”; such beliefs may help the client
“prepare to leave this life and enter the transforma-
tion of death” (Derezotes, 2006, p. 252).
A third suggestion for empowering a dying per-
son involves providing assistance in making any
necessary decisions that may be of concern to the
client. Does the client have opinions about his or
her funeral or other treatment near or after death?
Are there certain items that the person would like
to give to loved ones? If so, encourage the client to
indicate what they are and who should receive them.
You might also provide the client with needed infor-
mation such as that about medications, treatments,
or pain relievers. Some clients might benefit from
information about hospice care as a possible choice
for them. A hospice is a homelike residence, empha-
sizing residents’ comfort and peace, where a person
can reside and interact with loved ones in the days or
weeks preceding death.
Social workers can also help older adults complete
documents that make decisions about their future in
the event they lose mental competence. Advanced

directives are “written instructions by the individual
[who is mentally competent] to health care provid-
ers and family members about end-of-life decisions”
(McInnis-Dittrich, 2005, p. 366). Two types of
advance directives include living wills and Durable
Power of Attorney for Health Care (McInnis-Dittrich,
2005). “A living will is a written document that states
what the patient does or does not want in medical
treatment should he or she become incapacitated”
(McInnis-Dittrich, 2005, p. 366). For instance, a liv-
ing will could indicate whether or not an individual
chooses to live on life support when brain functioning
has ceased. The Durable Power of Attorney for Health
Care “is a legal document that designates another
person to make decisions about health care when a
patient becomes incapacitated” (McInnis-Dittrich,
2005, p. 366).
Helping Loved Ones Cope
Kanel (2007) provides eight suggestions for helping
survivors of a loved one after that person has died.
This is another task of social workers who work in
nursing homes and other settings such as hospitals
where death is often experienced.
1. Help survivors actualize the loss. Talk about the
loss. What happened? Ask.
2. Help them identify and express feelings. If they
are dealing with anger, be indirect (what do
you miss the most/least?). Four common dif-
ficult emotions are anger, guilt, anxiety, and
helplessness.
3. Help survivors in living without the deceased.
The problem-solving approach works well for
this. Discourage major life changes for a while.
4. Facilitate emotional withdrawal from the
deceased. Encourage survivors to go on.
5. Provide time to grieve. Crucial times include
3 months and 1 year after the death, anniversa-
ries of the death, and holidays. Help clients pre-
pare in advance for these.
6. Educate clients about customary grieving reac-
tions of other individuals to help normalize the
experience.
7. Allow for individual differences [including cross-
cultural differences]. Be sensitive to individual
styles.
8. Provide for continuing support. Encourage
clients to join support groups. (pp. 141–142)
Social Work and Services for Older Adults 2 91
Empowerment of African American
Grandparents Who Become Primary
Child Caregivers
Multiple examples exist of how social workers and
social welfare programs can empower older adults.
Various facets of the older adult population can be
targeted and assisted in many creative ways.
Okazawa-Rey (1998) describes one approach
to empowerment for African American grandpar-
ents who have become primary caregivers for their
grandchildren. This reflects one type of program-
ming social workers can initiate, develop, and pro-
vide. The problem addressed is one well established
at the community and national levels. Many people
have become addicted to crack cocaine or metham-
phetamine and are ignoring their responsibilities as
parents and productive citizens to pursue drug use.
“Grandparents have always played major roles in the
lives of their grandchildren, but in recent years this
role has magnified in intensity, as more and more
grandparents have become the primary caregivers of
grandchildren” (Cox, 2005, p. 128).
An example of a program responding to this
problem is the Grandparents Who Care Support
Network of San Francisco. Most members are “poor
and working class, middle-aged and [older adult] . . .
African-American women” (Okazawa-Rey, 1998,
p. 54). They have gained custody of their grandchil-
dren because of their own children’s neglect. This
is due to drug abuse, incarceration because of drug
convictions, and an unwillingness to relinquish their
grandchildren to strangers in the public foster care
system (McAdoo, 2007).
These grandparents have found themselves in the
strange and unusual circumstance of suddenly hav-
ing responsibility for small children at a stage in
life when they thought they were done with all that.
This situation is compounded by the health prob-
lems many of these children suffer due to poor pre-
natal care, parental drug use during pregnancy, and
child neglect. These grandparents “desperately need
day care, special education services, transportation,
respite care, and money” (Okazawa-Rey, 1998, p. 54).
To get services, they find themselves trying to negoti-
ate the confusing maze of bureaucracies governing
service provision.
Two health care workers, Doriane Miller and Sue
Trupin, identified the problems and needs and estab-
lished Grandparents Who Care (Okazawa-Rey, 1998).