Supporting older people in a strengths-based way
Updated on 11/10/2016
Written by Imogen Blood, Director of Imogen Blood & Associates
There is a lot of interest right now across the UK in 'strengths-based' approaches to care and support. The Care Act 2014 requires English local authorities to 'consider the person's own strengths and capabilities, and what support might be available from their wider support network or within the community to help'. Parallel legislation in Wales is prompting a radical shift from assessments which focus on 'what's wrong' to conversations which aim instead to draw out 'what matters'.
It seems pretty clear from my conversations with practitioners both in and outside the training room that few need converting to the ethos and principles of this culture shift. But many are feeling overloaded with cases, short of time, restricted by existing paperwork and processes, and some are struggling to find the 'strengths' of older people with ever-higher levels of need who are often coming to them at the point of crisis.
I'm currently co-authoring a book aimed at frontline practitioners (across social care, housing and health settings) which looks at how we can use strengths-based approaches and attachment theory to support older people. As part of this project, I've been reading, thinking, and listening to practitioners in an attempt to distill research and practice wisdom to answer the question: 'how do I actually take a strengths-based approach in practice?'
Here are my top ten tips so far - please get in touch (contact details at the end) if you have comments, additions or queries. I would love to hear your views.
Ask the right questions
Hard though it is, try to move away from feeling you should have all the answers. Asking the right questions is more important. All questions carry assumptions and invitations. Sure - our assessment forms require us to ask questions about what people are having difficulty doing - when these problems began and what impact they are having - but supplementing these with one or two of the sorts of questions that open up possibilities can take the conversation in a very different direction.
Examples might include:
'What are you doing that you would like to continue doing?'
'What have you thought of trying but haven't tried yet?'
'What has helped you stay strong?'
Take a detective-like approach to understanding the function of behaviour. I've recently read Graham Stokes' excellent book 'And Still the Music Plays', which tells the stories of people with dementia. The book reminds us that, even where people are experiencing advanced dementia and behaving in ways that can seem completely inexplicable, there is almost always a rational explanation (and often a simple solution flowing from it) if we take the time to empathise and understand what the behaviour means.
Seek out what makes each person unique
Look for what makes people different, rather than looking for the common features that enable you to place someone in a category with others. Don't forget how powerful it can be to ask for and listen to people's own stories. A couple of years ago, when I was going into care homes as part of a research project for Age UK Gloucestershire, I started talking to a man in his nineties about his experiences of living in the home. I asked him to tell me his story - how he had come to be there. He told me about his French wife who had died a few years ago, about his horrendous experiences as a prisoner of war in the Second World War, about his passions - for motorbikes and country music. At the end of this conversation, I felt that I had a real sense of him - what made him tick, the traumas and losses he had come to terms with and what brought him pleasure day-to-day. If I had rushed into trying to complete a questionnaire with him on his needs and views of the service (the researcher's equivalent of an assessment form), I would only ever have seen him as a frail man who needs help to get out of an armchair - someone who needs 'caring for' and 'entertaining' - not as a real survivor and a rather rebellious Francophile.
Start with what matters most to people
Rather than which services are available and whether or not they are eligible for them. This might be music, gardening, or their relationships, and what they want to be different in their lives. Try to step outside of 'serviceland' and its referral pathways - for instance, explore people's existing friendships and what might be getting in the way of these, before you start referring people to a lunch club.
Understand and support people's relationships
This is absolutely central to supporting people - not a nice-to-do-it-if-you-have-time or an only-going-there-if-there-is-a-crisis. Often, and perhaps especially in later life, this may be as much about our past relationships (with people we have lost or become distanced from) as it is about who is in our daily lives now. Attachment theory can help in understanding people's styles and 'problem' behaviours in their relationships (including with us!). Once we see these as learnt responses to loss, trauma or difficult childhoods, in which people can get stuck, we can begin to understand - intuitively and from a place of empathy - how we can support them to feel safe.
Start from an assumption of 'can-do'
Let's look at what people can do rather than immediately focusing on what they can't and take a solution-focused approach to how this can be made to happen rather than defaulting to 'can't do' and associated rationales as to why it shouldn't be attempted. I'll be covering more about this in my forthcoming webinar on positive risk taking for RiPfA in October.
Take a strengths-based approach to yourself as a practitioner
Ask yourself (or discuss in supervision, case discussions or with colleagues) what you hope to accomplish from a particular visit, activity or intervention. If you accomplish this, how will it be helpful to the person and/or their family? What do you think your clients would say is most useful about the support you give? How do you achieve this in practice and how do you keep yourself strong?
Social contribution is key
However unwell or depressed a person is, start to think about how they might be supported to make a contribution, not just what they might need from others. I was recently speaking to a woman who lost her husband a decade ago - she told me how she had closed down socially through her grief and found it very difficult to ask for help or even talk about her overwhelming sense of loss. An opportunity to volunteer as a befriender for others coming to terms with bereavement had been the turning point for her and she was now getting out, rebuilding her life and starting to reframe her own emotions whilst supporting others.
Consider all the senses
Think about how music, recordings of voices and sounds, images, smells, colours, and touch can be used to improve a person's quality of life; especially where they find it hard to communicate verbally and/or they have more advanced dementia. All these can be used to promote a sense of safety, predictability and wellbeing.
Mind your language!
Learn to recognise the impact of the language we use in relation to older people - in our conversations with them and about them (with colleagues, family members and other professionals), and in the notes and assessments we write. Common examples include 'dependency', 'frailty', 'vulnerability', 'wandering', 'risky/ unsafe', 'sweet old dear', 'cantankerous', 'still driving, etc', 'a burden', 'the elderly', 'refusing help', 'fiercely independent/proud', 'struggling/not coping', 'incapable', 'gone downhill/declined rapidly'.
The Dementia Words Matter: Call to Action also highlights words used to describe people with dementia, such as 'sufferer', or 'senile'. This is not about creating an environment of political-correctness-gone-mad, but it is about recognising how much our language can steer, influence and ultimately limit the aspirations, hopes and expectations of the older people we support and the ways in which others view them.
This blog was co-published by the Housing LIN and RiPfA on Monday 10 October 2016.