Negotiating Relationship Contexts in Gerontological Social Work Practice Elsa Marziali, PhD Cindy Brcko, MSW Renee Climans, MSW Arlene Consky, MSW Mona Munro, MSW Melissa Tafler, MSW

ABSTRACT. Objectives: The objective of this study was to demonstrate the role of social workers in addressing the complex relationship and problem solving contexts typical of practice in multi-service geriatric care settings. Methods: We conducted a thematic analysis of the work of five social workers with five clients, their families, and the professional healthcare team, and extracted common themes across cases that illustrate the nature and timing of the interventions depending on the relationship context addressed. Results: While there were problems and issues common across relationship contexts, intervention strategies that were essential for optimizing client care and wellbeing were specific to resolving relationship conflicts in one or more of the identified relationship contexts. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2005 by The Haworth Press, Inc. All rights reserved.] Elsa Marziali is Professor and Schipper Chair, Gerontological Social Work Research, University of Toronto and Baycrest Centre for Geriatric Care, KLARU, 3560 Bathurst Street, Toronto, Ontario M6A 2E1 Canada (E-mail: [email protected]). Cindy Brcko, Renee Climans, Arlene Consky, Mona Munro, and Melissa Tafler are Social Workers, Department of Social Work, Baycrest Centre for Geriatric Care, 3560 Bathurst Street, Toronto, Ontario M6A 2E1 Canada. Journal of Gerontological Social Work, Vol. 46(2) 2005 Available online at http://www.haworthpress.com/web/JGSW © 2005 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J083v46n02_05

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KEYWORDS. Positive working relationships, families, long-term care

INTRODUCTION Admission to hospital care, a residential care facility, or to a nursing home constitutes a highly stressful transition for an elderly person and her/his family. During and following this transition, it is not surprising that problems and conflicts arise within and across multiple relationship contexts. The shared aim of the family and the professional care staff is to help the client to manage the transition in ways that maximize positive health outcomes. Social workers play a strategic role in coordinating the admission of clients to health care facilities. They frequently function as “door keepers” fulfilling multiple role functions, such as obtaining pre-admission assessment information from referral sources, providing information about the institution to the client and her/his family, providing information about the client and family to the multi-disciplinary care team, participating in the admission process, orienting the client and family to the policies and practices of the institution, and addressing the client’s and family’s concerns, problems, and conflicts associated with the transition. While it is true that other members of the health-care team can fulfill many of the admission/orientation functions, social workers have the knowledge, skills, and clinical training necessary for addressing the multiple relationship contexts in which problems and conflicts arise and potentially impinge on the care and health outcomes for the geriatric client. These relationship contexts include those between, (a) the referral source and the social worker, (b) the client and her/his family, (c) the client/family and the agency care staff, (d) the social worker and the client/family, and (e) the social worker and the multidisciplinary care team. The complexity of managing these varied and demanding relationship contexts effectively is rarely acknowledged partly because the strategies used by social workers to build multiple positive working alliances are rarely specified or measured for outcome effects. Yet the social work profession has historically supported theoretical frameworks and models of intervention that recognize the importance of joining, connecting, and empathically engaging with clients and their families. Similarly, in other clinical contexts there is an extensive research literature reporting studies of the importance of the therapeutic alliance in explaining post intervention outcome effects (Gaston, 1990; Gaston et al., 1994; Horvath & Greenberg, 1994). In this paper we extend the relationship context to include relationships with

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colleagues in multidisciplinary health care settings. As has been demonstrated by the Geriatric Interdisciplinary Team Training initiative (Cole, Waite, & Nichols, 2003; Fulmer, Flaherty, & Hyer, 2003) geriatric care organizations have benefited in terms of interdisciplinary team communication and decision-making regarding client care. Our purpose is to discuss the methods and results of a qualitative analysis of the work of five social workers with five clients, their families and with the interdisciplinary care team. In particular, we identify specific intervention strategies that addressed conflicts in one or more of the identified relationship contexts. Perceived effects on the psycho-social and health outcomes for the client and her/his family are summarized. Similarly the impact of within team communication on organizational care strategies is discussed. BACKGROUND In geriatric care settings the role of the social worker is to engage in multiple working relationships that address the boundaries between the client and his/her family, the healthcare staff, other health care providers, and the organization as a whole. Supportive counseling cannot progress unless the social worker, the client, key family members, and the health care team are engaged and actively participating in the intervention process (Cunningham & Henggeler, 1999; Mellor, Hyer, & Howe, 2002; Leipzig, Hyer, Ek et al., 2002). Social workers face the challenge of building positive working alliances with all family and institutional participants. For example, when families and the professional health care team have difficulty managing the boundary between family concerns and institutional regulations and policies, the social worker’s primary task is concerned with (a) tolerating the heightened negative emotions expressed by the participants, (b) conveying empathic understanding, and (c) persisting in maintaining contact with both the family and the health care team despite resistance and rejection (Dyer, Hyer, Feldt et al., 2003). It is hypothesized that until conflicted relationships among family members, client, the health care team, and the social worker are repaired no amount of information-sharing or implementation of problem-solving strategies will be effective. When the social worker is unable to manage the inevitable frustrations and anxieties of working in complex, conflict-ridden interpersonal contexts, therapeutic errors are inevitable (Petersen, 1990; Brandt, 1993; Katz, 1996). Although social work education provides initial training for

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managing difficult relationship issues with clients and their families, personal attributes of the social worker, in combination with personality characteristics of the client/family and health care team members, can contribute negatively to the ongoing therapeutic encounter. Consequently, there is the need for self-reflection and modification of subjective reactions in the context of conflicted encounters with clients and/or colleagues (Ackerman & Hilsenroth, 2001). Furthermore, social workers who work in geriatric health care settings need to understand the complex factors that affect clients, their families, and the health care team, such as, the meanings of dementia care (Kuhn, 1990), cultural issues (Brandler, 2000), adult child caregivers (Schulman, 1999; Sherrell, Buckwalter, & Morhardt, 2001), the challenges faced by nursing home staff, in particular nurses and health care aids (Vinton, Mazza and Kim, 1998; Dyer, Hyer, Feldt et al., 2003), and the sources of stress among elderly clients, their families and the formal health care team (Iecovich, 2000). Ultimately, all health care professionals need to address their own attitudes and emotions associated with working in health care environments that serve older clients, especially those environments that care for clients with neuro-degenerative diseases that are terminal. In particular, it may be important to understand the impact on families of ‘ambiguous loss’ during the progression of cognitive and physical decline, as well as the meanings of losing a spouse and/or parent (Boss, 1999). In summary, when social workers reflect on the multiple meanings of the health care challenges encountered by older clients and their families they are able to engage more effectively in positive working relationships within and between relationship contexts–with the client, his/her family, and the formal health care team. Various paradigms for working with challenging families in mental health and geriatric care settings have been proposed. McNeil and Herschell (1998) suggest a series of techniques for making counseling more effective with high stress families, as for example increasing the structure for providing the intervention, using attendance contracts, and setting realistic treatment goals. Using a systems perspective, Petersen (1990) focuses on the stresses faced by nurses working with families and residents in long-term care facilities. She describes a program, “Care-for-the-Caregiver Project’ in which formal caregivers are taught how to identify their stress-related reactions when dealing with family members who are immersed in intense emotions associated with grief: anger, fear and anxiety. While the intervention is confined to interac-

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tions between a nurse and the patient-family, the author acknowledges the need to focus on interactions among coworkers, and the organizational system as whole. To help families adjust to the admission of a relative to a nursing home, Peak (2000) describes an eight week education support group given to family members. The sessions are topic-driven covering the following: dementia and aging, how to interact with staff, how to communicate with one’s relative, and caregiver self-care. At the end of the project families reported having more successful visits with their relatives. A similar program places emphasis on improving communication by training families and nursing home staff to reduce and prevent conflicts (Pillemer et al., 1998). Post workshop evaluations of the program showed improved communication between families and staff. While each of these intervention programs target the needs of families that have difficulty managing a major life transition such as admitting a relative to long term care, none have focused on the importance of building and maintaining positive working relationships with family members, patients, and with the multidisciplinary formal care team. In the past decade the Geriatric Interdisciplinary Team Training (GITT) initiative funded by the John A. Hartford Foundation has had a significant impact on addressing the needs of interdisciplinary teams of health professionals who provide care to older adults (Mellor, Hyer, & Howe, 2002; Fulmer, Flaherty, & Hyer, 2003; Cole, Waite, & Nichols, 2003). The training is based on a philosophy that shifts emphasis from traditional medical model of identifying disease and cure, to addressing the health care needs of older adults with multiple chronic illnesses. Within an interdisciplinary team context each health professional contributes their specialized knowledge and skills. The social worker contributes a family systems perspective for understanding the needs of the client and her/his family and develops and sustains communication links among family members and between the family and the health care team. Thus, a key goal for the social worker is alliance building, oftentimes in challenging situations. We hypothesize that in the absence of strong alliances among all participants involved in accessing and providing care for ill older adults and their families, positive outcomes are less likely. Furthermore, in long term care facilities it is the responsibility of the social worker to insure that these multiple alliances are developed, sustained and mended when necessary from the time of referral through to admission and adaptation to the long term care facility.

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METHODS Five social workers provided descriptions of their contacts with five clients from the initial telephone contact through to problem resolution and termination of contact. Detailed reports of each session (in person or telephone) provided the data for content analysis of the interactions among the social worker, the family members, and the health care team. The five participating social workers and a clinical researcher jointly analyzed the session reports for each case to obtain a preliminary view of the issues addressed and the communication process over the course of the care contacts. Key constructs were identified, codes developed, and initial categories recorded. We used the more qualitative version of content analysis and used the codes to guide further interpretive activities rather than count codes or compute between coder agreement kappa coefficients (Morgan, 1993). This analytic procedure yielded a comprehensive analysis that included both common themes as well as themes unique to each social worker-client relationship context (Creswell, 1998). In particular, consensus on the repetition of themes across cases, coupled with the extraction of themes unique to a particular case, ensured that the final selection of clusters of themes was complete. Salient themes as to problems, interventions, and client outcomes were extracted. RESULTS The results of the data analyses are described in two stages. First, we describe each client situation. Second, we provide a description of the extracted themes and situation-specific interventions. The Clients Mr. A, a 69-year-old separated gentleman diagnosed with Alzheimer’s disease had been living with his daughter and adolescent granddaughter prior to placement in a long-term care facility. His son subsidized the costs of care despite the fact that he had maintained little contact with his father following his parents’ separation twenty-five years previously. The son harbored feelings of anger and resentment associated with early childhood experiences with his father who was an alcoholic. Mr. A’s ex-wife and a sister were interested in providing support but due to a long history of family conflicts it had been difficult for

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them to engage in resolving issues concerned with Mr. A’s financial problems, cognitive competency, and the need for substitute decisionmaking. While Mr. A’s daughter identified herself as the primary family caregiver she was also encumbered by negative feelings associated with the early childhood relationship with her father. In addition, she was a single mother of a challenging adolescent daughter. Both mother and daughter had received psychiatric treatment for mood disorders. Mrs. B, a widow and Holocaust survivor, had been living in an assisted care apartment complex for a period of 10 years. Being of German decent she spoke little English and relied on other Germanspeaking residents for support. Only one of three children (Belinda) was involved in monitoring her care and frequently accused the staff of neglect due to the problems in communication. When Mrs. B’s health began to deteriorate she was admitted to the hospital. Following treatment of acute symptoms, the hospital care team recommended that Mrs. B be admitted to a long-term nursing care facility. Belinda, joined by her siblings, was adamant that her mother would return to her apartment. She complained constantly about the care her mother was receiving, accusing the staff of being lazy, uncaring, and unprofessional. The nursing staff became increasingly frustrated and helpless because no amount of attention to the family’s concerns was satisfactory. Discharge from hospital was delayed considerably and was only possible as a result of the support and understanding provided by the social worker. Both Mr. and Mrs. C were diagnosed with early stage dementia. They had survived a life of tragedies. Both are Holocaust survivors and lost most of their family members. In addition, their only son had traumatic brain injury at age four and lived in a vegetative state cared for by his parents until age 20 when he died. The C’s primary caregiver was a daughter (Emily), married with six children. Mr. C denies that there is anything wrong with him or his wife. Historically he had taken charge of the family and his wife passively accepted his decisions. At the time of referral Mr. C had refused all outreach programs and refused help from Emily. While Emily reported having had a very positive relationship with her parents, their current relationship was strained. Emily was intimidated by her father’s proud, independent personality, but understood his fear of relinquishing control especially given his Holocaust experience. Mrs. D chose to move to a long-term care facility because of deteriorating health. Historically she had functioned independently especially following divorce from her husband 24 years previously. Four of five children chose to live with their father. The son who chose to remain

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with his mother and a daughter were supportive of their mother and jointly held power of attorney for her personal care and finances. However, relationships between Mrs. D and her children had been strained since the divorce. Mrs. D was disappointed and angry with her children, yet was reluctant to let them know that she needed their support. Admission to the long term care facility precipitated a family crisis that neither Mrs. C nor her children knew how to manage. Mr. E is a 99-year-old man with advanced stages of dementia. His wife had managed his care in their home for many years but now wished to admit him to a nursing home. Although Mr. E had been on the waiting list for several years there were others on the list ahead of him. Mrs. E was furious that the admission could not be expedited. She was very frustrated with her husband’s agitated behavior and thought that he was being willfully uncooperative. However, she also took pride in the quality of care that she provided and was convinced that the nursing home would not match her standards. Mrs. E was clearly ambivalent about admitting her husband to care and after admission she was very critical of the care he received. She wished to share her ‘expertise’ in caring for him but her efforts were perceived as intrusive rather than supportive. THEME ANALYSIS AND INTERVENTION STRATEGIES A. Major Life Transitions At the point of social work involvement the main theme that was relevant to all of the clients and their families had to do with their ambivalence and anxiety about major life transitions precipitated by the clients’ changed physical and cognitive health status. Several managed the stress by denying the changes in health status. Mrs. B’s daughter delayed her mother’s discharge from the hospital because she refused to accept that her mother could no longer manage living in an assisted care apartment but needed nursing home care. Similarly, Mr. C denied that he and his wife had been diagnosed with early stage dementia and consequently refused outreach help from the hospital health care team and pushed aside his daughter’s concerns. While Mr. E’s wife acknowledged that her husband needed nursing home care and that she could no longer manage his care at home, she was enormously ambivalent about her decision. Feelings of anger and frustration associated with the decision were expressed toward the social worker during the pre-admission

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process and extended to the nursing home staff once her husband was admitted. Social Work Intervention Strategies In each of these transition situations the social workers recognized that they needed to establish trusting relationships with their clients and their families before dealing with the difficult decisions confronting the family caregiver. With Mrs. B’s daughter Belinda, the social worker was persistent in contacting her, arranging to meet at times convenient to her work schedule. Initially the social worker was the recipient of the anger and criticisms vented toward the institution. In addition, Belinda appeared to resist the social worker’s efforts to engage her in a mutually respectful, problem-solving process. When after several meetings Belinda realized that despite her constant criticisms the social worker had neither counter attacked nor rejected her, she began to talk about the strained relationship with her mother and her resentment at being the primary family caregiver although two other siblings lived in the same city. However, she was also very identified with her mother, perceiving the family as victims in an anti-Semitic society that extended to the hospital health care staff. The fact that the hospital was ethno-specific serving Jewish clients, and that the social worker was Jewish did not impact on Belinda’s negative appraisal of the care her mother was receiving. With Mr. C, the social worker made home visits despite his rejection of her and the hospital outreach team. Her approach was to listen to Mr. C’s life stories of how he had managed numerous stressful life situations beginning with surviving the Holocaust, and subsequently caring for a son who had traumatic brain injury at age four and lived in a vegetative state until his death at age 20. The social worker’s interventions were affirming of Mr. C’s life accomplishments and respectful of his need to maintain control for as long as was possible. In parallel with the home visits, the social worker also established rapport with the C’s daughter who was very receptive to having the hospital team’s involvement in the care of her parents. She was the sole surviving child and had always had a warm and supportive relationship with them but now was intimidated by her father’s adamant refusal to involve her in making decisions about their personal care and finances. Jointly, with the daughter, the social worker committed to maintain contact with the C’s and to be vigilant of the consequences of the progression in their cognitive decline.

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With Mr. E’s wife the social worker absorbed numerous hostile attacks that had to do with institutional rules and policies associated with nursing home admission and care. Providing information, or explaining the reasons for the rules were counter productive and only served to heighten Mrs. E’s anger and frustration. Instead, the social worker empathized with Mrs. E’s sadness and guilt related to no longer being able to care for her husband at home. She also affirmed that nursing home care, while medically effective, would not match the care that Mrs. E had provided. Over time a tentative relationship of mutual trust was established. B. Relationships–Past and Present As expected, when facing major life transitions intra-family relationship conflicts (past and present) are accentuated. Mr. A had a long history of family conflict associated with his alcoholism, his wife’s leaving the marriage, and alienation from his two children. The family responded ambivalently to his need for institutional care. His son refused to be involved other than to provide some financial assistance. His only daughter provided care in her home during the year prior to making plans for his transfer to institutional care. However, due to her own mental health problems the daughter impulsively traveled for extended periods of time leaving her father unattended. Mr. A’s ex-wife and sister wanted to help in making decisions about his personal care and finances but both were in conflict with the daughter. Like Mr. A, Mrs. D had ambivalent relationships with four of her five children having been divorced 24 years previously. The four children who stayed with their father were reluctant to be involved in supporting their mother’s decision to transfer to an assisted care facility. The son who had chosen to stay with her was only marginally involved in supporting the transition. The situation was further complicated by the fact that in the past Mrs. D had taken great pride in her independent functioning, and now feelings of resentment toward her children’s lack of support were intermingled with feelings of needing to be in control of her situation. Social Work Intervention Strategies Mr. A’s social worker arranged to meet separately with each family member (client, his ex-wife and sister and his two children). She listened to their concerns about Mr. A’s decline in cognitive functioning

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and explored the nature of current and past family relationships. The exwife and sister presented as sad and helpless in intervening in a situation that they thought Mr. A’s daughter was managing badly. Mr. A’s son voiced resentment and anger towards his father because of negative childhood experiences associated with his father’s alcoholism. He had no contact with his father or sister and decided to withdraw the financial assistance that he had been providing because he believed that his sister squandered the money while ignoring his father’s health care needs. He wanted to have the family disown his sister so that she could not be involved in determining power of attorney and the decision to admit their father to institutional care. Mr. A’s daughter did not want to admit her father to a nursing home and expressed anger at her mother and aunt for failing to support her efforts to care for him. The social worker empathized with each family member’s perception of Mr. A and of each other. Although the social worker provided information about dementia diagnosis, progression, and care, family members were unwilling to compromise on decisions as to the appropriate care for Mr. A, with all but the daughter favoring institutional placement. With Mr. A’s health care being of primary concern the social worker negotiated with the family to accept a number of home care services and to monitor carefully his health situation. Ultimately, the decision to admit Mr. A to nursing home care would need to be made. The social worker for Mrs. D initially focussed on establishing a strong supportive relationship with her, being mindful of Mrs. D’s need to remain in control of her situation. Subsequently, she made numerous attempts to meet with each of her five children but met with resistance. Four of the five children eventually returned phone calls. Following several telephone conversations, one daughter agreed to meet initially with the social worker alone and then jointly with her mother and the social worker. The social worker’s goal was to develop a positive alliance with the daughter, being especially respectful of the daughter’s and her siblings’ perceptions of their relationships with their mother. The hope was that the daughter might be able to function as a liaison with her brothers and sisters so as to engage them in restoring some semblance of supportive relationships with their mother. Subsequently, the daughter was able to convince all but one sibling to have a family meeting with their mother and the social worker. Initially the meeting was contentious, with high volume of interrupting voices. Gradually, with empathic assurance from the social worker that everyone would be heard, each family member was able to participate in the discussion and in the end agree to tasks that would help Mrs. D make the transition to the resi-

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dence; the son would arrange for a television, and each daughter would share the tasks of preparing the mother’s room in the residence, sorting their mother’s belongings, and accompanying her on the day of admission. Subsequent to admission, Mrs. D’s children, with the exception of one son, continued their involvement with their mother and she adapted readily to life in the residence. C. Relationships with Health Care Team Both Mrs. B and her daughter Belinda were very critical of the nursing care staff during Mrs. B’s hospitalization. They complained about the care given and efforts to meet their demands were deemed insufficient and inadequate. When the health care team diagnosed Mrs. B. as not well enough to return to her assisted-care apartment and recommended admission to a nursing home, both mother and daughter objected, escalating their abuse of staff. Discharge dates were ignored and the family refused to make alternate plans for Mrs. B. Mrs. E was similarly ambivalent about admitting her husband to a nursing home. Throughout the admission process she was critical of the policies and procedures applied to preparing residents for admission to the home. Mrs. E believed that the staff was incapable of providing the quality of care she had provided for her husband, despite the fact that she was no longer able to manage his care. Following admission, her criticisms of staff were harsh and unrelenting and all efforts to accommodate her demands were denied as adequate. Mr. C totally denied the need for care despite the diagnosis of dementia for both himself and his wife. His resistance included refusal to have involvement with the hospital outreach team. Mr. C was not abusive, he simply did not want the health care providers on his doorstep. Social Work Intervention Strategies With Mrs. B and her daughter Belinda, the social worker realized from the onset of their encounters that she needed to listen to their complaints and absorb the anger that pervaded most communications. She met with individual staff members and the care team as a whole to share information about the B family that might help explain the intensity of their negative reactions towards staff. As well, the social worker provided empathic supportive understanding of the staff’s hurt feelings and frustrations. The approach was one of mutual identification and support–‘we are in this together.’ Following numerous meetings between

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staff, social worker, Mrs. B and her daughter, agreement as to Mrs. B’s discharge was reached and in the end both mother and daughter accepted the recommendation for admission to a nursing home. The ‘working through’ process, although beneficial to the family and staff, delayed discharge by several weeks and demonstrated the hospital’s flexibility in managing the care of challenging families. With Mrs. E the admission social worker empathized with her anxiety about admitting her husband to a nursing home. She agreed that the institution would not be able to provide the individualized care that Mrs. E gave her husband, however he would receive good medical care and his health care needs would be met. Every stage of the admission process was difficult for Mrs. E When the social worker reiterated the realities of institutional life, Mrs. E would become suspicious accusing the social worker of putting up road blocks to her husband’s admission. Repeated empathic understanding of Mrs. E’s sense of helplessness, frustration, sadness and guilt associated with having to make the decision to admit her husband resulted in a tentative, trusting relationship with the social worker. The pre-admission social worker affirmed Mrs. E’s considerable skill in caring for her husband and that she truly knew what he needed and how best to approach him. However, following admission to the nursing home, the staff were unable to accommodate Mrs. E’s input to the care of her husband. Her criticism of staff escalated and communication deteriorated. Despite the admitting social worker’s attempts to share information about Mrs. E that might help resolve the impasse with staff, neither the staff nor Mrs. E was able to resolve their differences. Gradually, over time the staff began to see Mrs. E’s contributions to care as less intrusive and ultimately helpful. Concomitantly, Mrs. E acknowledged that her husband’s health was deteriorating rapidly and that there was nothing that could be done to restore his health. With the C family the social worker made her self available despite Mr. C’s resistance. The social worker shared responsibility with the C’s daughter to insure that they were continually monitored and that they were not at risk. The health care team was kept informed of the C’s health status by the social worker who functioned as the liaison between the family and the institution. D. Loss and Mourning All of the clients and their families were dealing with issues of loss and mourning. Admission to institutional care occurs with the knowledge that the relative will die there, yet this is rarely discussed at the

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time of admission. Nor is the loss and mourning associated with admission to a nursing home processed by the family as a whole. Mrs. B and her daughter Belinda no doubt resisted transfer to a nursing home because it would mean accepting that Mrs. B’s health was deteriorating and that she would die in the home. Neither appeared prepared to acknowledge the sadness and sense of hopelessness about the fact that not only would Mrs. B not improve but that she might not have long to live. Similarly, Mrs. E’s fragile emotional state was most likely associated with the fact that her husband’s health was deteriorating and that he would die in the nursing home. Her sadness was no doubt compounded by the fact that their only son had sustained serious injury in childhood and died at age 20. Prior to his admission to care Mrs. E had not dealt with feelings of ambiguous loss of her husband due to cognitive decline typical of late stage dementia. He was no longer the man she had admired for his numerous accomplishments despite many life tragedies and losses. Social Work Intervention Strategies The social workers did not take up the issues of loss and mourning associated with admission of a relative to institutional care. At point of admission all five families may not have been able to acknowledge the painful feelings associated with loss. This would have been especially difficult for Mr. A’s and Mrs. D’s families who had many unresolved family relationship issues. On the other hand, one might speculate that underlying many of the negative reactions to admission to institutional care, are unresolved emotions about the loss of a family member. Would addressing the loss issues de-escalate the highly negative reactions displayed by Mrs. B, her daughter Belinda, and Mrs. E? Ultimately, the task for all of the families would require reflection on feelings of loss as well as finding ways to say goodbye to their institutionalized relative. DISCUSSION Analyses of problem themes and interventions with five families in a geriatric care setting show a range of challenging issues addressed by social workers. In each case, the social worker accepted the client families’ versions of the problematic issues at the interface between family and institution at the time of admission to the institution. Communica-

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tion conflicts were associated with the stress of making major life transitions that included admission to institutional care, historical and current family relationship issues, relationships with the health care team, and unresolved mourning of the loss of the relative. The importance of developing and maintaining positive working alliances between the social workers and the families was clear in all five case analyses. Despite the paucity of studies of the importance of the therapeutic alliance when working with older clients, several studies (Gaston, Marmar, Thompson et al., 1988; Hyer, Kramer, & Sohnle, 2004) have shown that the efficacy of counseling with older adults is largely dependent on nonspecific factors such as the therapeutic alliance rather than on the use of specific intervention strategies. In other words, in the absence of a positive working relationship between the health professional and the client, meaningful outcomes for the client are unlikely to occur. Similarly, Safran and Muran (2000) have shown that building and maintaining a positive therapeutic alliance over time requires that the health care provider possess the knowledge and skills for repairing ruptures in the alliance. Our analyses of the case data showed how the social workers managed difficulties in engaging with some clients at the onset of their meetings, and in other cases how they absorbed criticisms without retaliation or withdrawal. In addition, discussions that accrued during the case report content analyses showed that the social workers valued self-reflection in situations with clients that evoked anxiety and frustration. A natural response when encountering hostility and rejection would be counter attack and withdrawal, whereas a professional therapeutic response requires containment of these reactions, reflection on their meaning from the client’s perspective, and responses that are empathic as to the client’s situation and feelings. In terms of forming ‘bridging’ therapeutic alliances between the family and the health care team, the social workers relied on their working relationships with each member of the health care team. The degree to which each health care team was able to coordinate each member’s specialist knowledge and skills to ensure optimal care of the client varied across the institution. The interdisciplinary teams at the host institution consist of physicians, nurses, social workers, physiotherapists, occupational therapists, recreation therapists, and dieticians. Although not consistent across teams, the aim of each team is to (a) provide comprehensive assessments of client health care needs at intake and at regular intervals following admission, and (b) provide specialized interventions focused on maintaining optimal health outcomes for the client. The so-

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cial workers reported experiences within their respective teams showed that positive relationships with team members were especially important for addressing the needs of those families who were suspicious about the care provided to their family members, and those families who had unresolved intrafamilial conflicts that were exacerbated by the admission of a parent to long-term care. The social workers frequently provided the communication link between family members and the health care staff, and between various family members who had many unresolved relationship conflicts with each other. The failure of organizations to recognize the importance of building positive working alliances among interdisciplinary team members may determine, to a large degree, the quality of care received by clients (Schmitt, 2001). As the GITT program (Fulmer, Flaherty, & Hyer, 2003) has shown, health care teams in geriatric care settings do not naturally evolve into cohesive working groups. Rather, demands on the health care system for the care of older adults in the context of managed care and health services cost containment health, result in professionals experiencing the strain of increased workloads, fewer staff, and lower standards of care. The GITT program addresses health team issues concerned with providing care to older adults (Reuben, Yee, Cole et al., 2003). Four organizational factors essential to the establishment of the GITT program have been identified: (1) organizational readiness, including whether there is a need for the training program; (2) existing partnerships among academic and clinical organizations; (3) tangible and intangible institutional support; and (4) organizational structure to sustain team training programs. Not all health care organizations that serve older adults are willing or prepared to examine whether their interdisciplinary teams function adequately to insure quality care for their clients. In contrast to the model of interdisciplinary team leadership, McCallin (2003) suggests a shared leadership role of ‘practice leader’ may be needed if organizations are to integrate changing organizational values with new models of service delivery. Whether traditional models of teamwork are functional in current systems of health service delivery is unknown. However, social workers have much to contribute in understanding within team communication and communication between the health team and the clients they serve. In particular, their expertise in relationship building and managing strained relationships is a valuable asset for positive interdisciplinary team function.

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CONCLUSION The overall results of our analyses show that the task of initiating, building, and maintaining positive working alliances amongst clients, family members, formal care staff, and the social worker is imperative for insuring effective care outcomes for clients in geriatric care settings. While we identify the social workers’ reluctance to focus more specifically on issues of loss and mourning during the work with each client and family, it was unclear whether this would have been helpful. It is possible that unresolved issues concerned with the loss of a loved one at the point of admission to nursing home care are associated with family anxiety and frustration. However, whether the topic of mourning and loss can be addressed productively by families during the admission process is unknown. We conclude from our analyses of five case studies that social workers play important roles in resolving problems at the interface of multiple relationship contexts and contribute to positive outcomes for clients and their families in a geriatric health care setting. REFERENCES Ackerman, S.J., & Hilsenroth, M.J. (2001). A review of therapist characteristics and techniques negatively impacting the therapeutic alliance. Psychotherapy, 38, 171-185. Boss, P. (1999). Ambiguous Loss. Cambridge, MA: Harvard University Press. Brandler, S. (2000). Practice issues: Understanding holocaust survivors. Families in Society, 81, 66-75. Brandt, P. (1993). Negotiation and problem solving strategies: Collaboration between families and professionals. Infants and Young Children, 6, 79-84. Cole, K.D., Waite, M.S., & Nichols, L.O. (2003). Organizational structure, team process, and future directions of interprofessional health care teams. Gerontology & Geriatrics Education, 24, 35-49. Cunningham, P.B., & Henggeler, S.W. (1999). Engaging multiproblem families in treatment: Lessons learned throughout the development of multisystemic therapy. Family Process, 38, 265-286. Dyer, C.B., Hyer, K., Feldt, K.S., & Lindemann, D. (2003). Frail older patient care by interdisciplinary teams: A primer for generalists. Gerontology & Geriatrics Education, 24, 51-62. Fulmer, T., Flaherty, E., & Hyer, K. (2003). The Geriatric Interdisciplinary Team Training (GITT) Program. Gerontology and Geriatrics Education, 24, 3-12. Gaston, L. (1990). The concept of the alliance and its role in psychotherapy: Theoretical and clinical considerations. Psychotherapy, 27, 143-153. Gaston, L., Piper, W.E., Debbane, E.G., Bienvenu, J.P., & Garant, J. (1994). Alliance and technique for predicting outcome in short- and long-term psychotherapy. Psychotherapy Research, 4, 121-135.

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MANUSCRIPT RECEIVED: 11/07/04 MANUSCRIPT REVISED: 01/10/05 MANUSCRIPT ACCEPTED: 05/0505