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Relocation stress and the elderly : a review of the literature with implications for social work practice Hanvey, G. Sandra 1981

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U.B.C U BR ARIES RELOCATION STRESS AND THE ELDERLY: A REVIEW OF THE LITERATURE WITH IMPLICATIONS FOR SOCIAL WORK PRACTICE BY G. SANDRA HANVEY MAJOR PAPER SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK IN THE SCHOOL OF SOCIAL WORK We accept this paper as conforming to the required standard. THE UNIVERSITY OF BRITISH COLUMBIA SEPTEMBER 30, 1981 RELOCATION STRESS AND .THE ELDERLY: A REVIEW OF THE LITERATURE WITH IMPLICATIONS FOR SOCIAL WORK PRACTICE MAJOR PAPER SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK SUBMITTED BY: G. SANDRA HANVEY DATED: JUNE 19 8 1 TABLE OF CONTENTS PAGE INTRODUCTION 1 PART I : A REVIEW OF THE L I T E R A T U R E . . . ' R e l o c a t i o n D e f i n e d 4 S t r e s s D e f i n e d : An E x a m i n a t i o n of P h y s i o l o g i c a l , S o c i o l o g i c a l and P s y c h o l o g i c a l Concepts of S t r e s s . . 4 Measurements of R e l o c a t i o n S t r e s s 1 7 Research Design and R e l o c a t i o n S t r e s s : An Examinat ion of M o r t a l i t y Rates F o l l o w i n g R e l o c a t i o n . 18 C o n d i t i o n i n g V a r i a b l e s : I n d i v i d u a l and S i t u a t i o n a l V a r i a b l e s t h a t I n f l u e n c e Outcome F o l l o w i n g R e l o c a t i o n . 26 PART I I : STUDIES OF THE INSTITUTIONALIZED ELDERLY INTRODUCTION 45 S t a t i s t i c a l Data of I n s t i t u t i o n a l i z a t i o n of the E l d e r l y i n Canada and B r i t i s h Columbia. 46 C h a r a c t e r i s t i c s of E l d e r l y I n s t i t u t i o n a l P o p u l a t i o n s . . . . 48 P r e c i p i t a t i n g F a c t o r s C o n t r i b u t i n g to I n s t i t u t i o n a l i z a t i o n 53 When i s I n s t i t u t i o n a l i z a t i o n I n d i c a t e d ? 57 PART I I I : THE RELOCATION PROCESS: SOCIAL WORK. PRACTICE IMPLICATIONS INTRODUCTION 64 PAGE The Phase of P r e d e c i s i o n 67 The Phase of A n t i c i p a t i n g R e l o c a t i o n . . . . . . . 85 The Phase of I n i t i a l A d j u s t m e n t . . . . . 9 1 The Phase of A d a p t a t i o n 96 1. RELOCATION STRESS AND THE ELDERLY: -A REVIEW OF THE LITERATURE WITH IMPLICATIONS FOR SOCIAL WORK PRACTICE INTRODUCTION R e l o c a t i o n of the e l d e r l y has been s t u d i e d from the p e r s p e c t i v e of movement from one community s e t t i n g t o a n o t h e r ; movement from the community t o an i n s t i t u t i o n ; and movement both w i t h i n and between i n s t i t u t i o n s . There now e x i s t s an e x t e n s i v e body of r e s e a r c h documenting the p h y s i c a l and p s y c h o -s o c i a l e f f e c t of r e l o c a t i o n on the e l d e r l y . T h i s r e s e a r c h i n d i c a t e s t h a t r e l o c a t i o n almost always e n t a i l s a s i g n i f i c a n t and o f t e n s t r e s s f u l adjustment f o r the o l d e r p e r s o n . Community t o i n s t i t u t i o n r e l o c a t i o n appears t o be a p a r t i c u l a r l y s t r e s s -f u l t r a n s i t i o n , and c o n t a i n s the p o t e n t i a l f o r n e g a t i v e p h y s i c a l and p s y c h o l o g i c a l consequences. The number of e l d e r l y who have e x p e r i e n c e d t h i s community t o i n s t i t u t i o n t r a n s i t i o n i s noteworthy. Although o n l y a m i n o r i t y of the t o t a l p o p u l a t i o n of e l d e r l y r e q u i r e or e n t e r l o n g - t e r m i n s t i t u t i o n a l c a r e , the number of i n s t i t u t i o n a l i z e d e l d e r l y i s not i n c o n s i d e r a b l e . I n B r i t i s h Columbia a t the p r e s e n t t ime 2 2 , 4 5 4 o l d e r persons are r e c e i v i n g care w i t h i n l o n g - t e r m c a r e f a c i l i t i e s which p r o v i d e a continuum of s e r v i c e s r a n g i n g from minimal s u p e r v i s i o n and a s s i s t a n c e w i t h the a c t i v -i t i e s of d a i l y l i v i n g , t o e x t e n s i v e m e d i c a l management and s k i l l e d n u r s i n g c a r e . (Bayley, 1 9 8 1 ) I n the y e a r s ahead, the demand f o r t h e s e s e r v i c e s i s l i k e l y to i n c r e a s e as the 2. p o p u l a t i o n 65- ,and-over i n Canada i s p r o j e c t e d t o i n c r e a s e by more t h a n t h r e e - q u a r t e r s by the end of t h i s c e n t u r y ; and undoubtedly the number of e l d e r l y w i t h i n i n s t i t u t i o n s w i l l a l s o i n c r e a s e p r o p o r t i o n a t e l y . (Denton & Spencer, 1980) R e l o c a t i o n from the community t o an i n s t i t u t i o n can be p e r c e i v e d as a p r o c e s s t h a t b e g i n s w i t h the d e c i s i o n t h a t i n s t i t u t i o n a l i z a t i o n i s n e c e s s a r y or perhaps u n a v o i d a b l e ; and ends s e v e r a l months a f t e r the i n d i v i d u a l has a c t u a l l y e n t e r e d c a r e . T h i s r e l o c a t i o n p r o c e s s has g a i n e d i n c r e a s i n g s i g n i f i -cance through r e s e a r c h which i n d i c a t e s t h a t i n some measure the s t r e s s a s s o c i a t e d w i t h r e l o c a t i o n can be a l l e v i a t e d , and a d a p t a t i o n t o care f a c i l i t a t e d i f the r e l o c a t e e r e c e i v e s s k i l l f u l and s e n s i t i v e a s s i s t a n c e through t h i s t r a n s i t i o n p e r i o d . The u t i l i t y of r e l o c a t i o n r e s e a r c h l i e s i n i t s c a p a c i t y t o inform and d i r e c t p o l i c y s h a p e r s , p l a n n e r s , a d m i n i s t r a t o r s and p r a c t i t i o n e r s who are d i r e c t l y concerned and i n v o l v e d w i t h those e l d e r l y persons who are undergoing t h i s d i f f i c u l t t r a n s i t i o n . T h i s r e s e a r c h - g e n e r a t e d knowledge can be t r a n s -l a t e d i n t o s p e c i f i c p o l i c i e s , programs and s e r v i c e s t h a t w i l l f a c i l i t a t e the p r o c e s s of r e l o c a t i o n . The major focus of t h i s paper r e l a t e s to both t h e s e a s p e c t s : f i r s t , i t w i l l examine the r e l e v a n t r e s e a r c h on r e l o c a t i o n s t r e s s and the e l d e r l y ; and second, d i s c u s s some i n t e r v e n t i o n s t r a t e g i e s t h a t may a s s i s t the e l d e r l y person i n n e g o t i a t i n g the s i g n i f i c a n t t r a n s i t i o n from home t o i n s t i t u t i o n . P a r t 1 of t h i s paper w i l l examine some of the c o n s i d e r -a b l e body of r e s e a r c h t h a t has s t u d i e d the e f f e c t of r e l o c a -t i o n on the e l d e r l y i n terms o f ' p h y s i c a l and p s y c h o s o c i a l consequences. Most commonly, r e s e a r c h e r s have measured the n e g a t i v e e f f e c t s of r e l o c a t i o n i n terms of i n c r e a s e d m o r t a l i t y r a t e s . T h i s paper w i l l examine a number of t h e s e s t u d i e s , d i s c u s s the r e s e a r c h s t r a t e g i e s employed, and r e v i e w t h e i r f i n d i n g s . I n a d d i t i o n , r e s e a r c h has i d e n t i f i e d a number of i n d i v i d u a l or s i t u a t i o n a l v a r i a b l e s t h a t may moderate or aggravate the n e g a t i v e e f f e c t s of r e l o c a t i o n . T h i s paper w i l l a l s o examine a number of t h e s e c o n d i t i o n i n g v a r i a b l e s i n an attempt t o e x p l a i n v a r i a t i o n s i n outcome f o l l o w i n g r e l o c a t i o n . S i n c e the d e s i g n of programs and s e r v i c e s f o r any p o p u l a t i o n group must r e f l e c t the c h a r a c t e r i s t i c s and needs of the p o p u l a t i o n s e r v e d , the second p a r t of t h i s paper w i l l b r i e f l y review some of the f a c t s now known about the i n s t i t u -t i o n a l i z e d aged. T h i s w i l l i n c l u d e c u r r e n t s t a t i s t i c s on i n s t i t u t i o n a l i z a t i o n r a t e s , and the c h a r a c t e r i s t i c s of i n s t i -t u t i o n a l p o p u l a t i o n s . With t h i s background, the paper w i l l examine the c i r c u m s t a n c e s under which i n s t i t u t i o n a l i z a t i o n appears t o be an a p p r o p r i a t e or even i n e v i t a b l e response to the h e a l t h a n d / o r s o c i a l needs of an e l d e r l y p e r s o n . P a r t 3 w i l l focus s p e c i f i c a l l y on community t o i n s t i t u t i o n r e l o c a t i o n , and the r o l e of the s o c i a l worker i n the r e l o c a t i o n p r o c e s s . I t w i l l o u t l i n e some programs and s e r v i c e s t h a t might be p r o v i d e d f o r e l d e r l y r e l o c a t e e s and t h e i r f a m i l i e s t h r o u g h -out the t r a n s i t i o n p e r i o d from the t ime of i n i t i a l a p p l i c a t i o n f o r i n s t i t u t i o n a l placement, u n t i l s e v e r a l months a f t e r e n t e r -i n g c a r e . 4. PART I : A REVIEW OF THE LITERATURE ON RELOCATION STRESS RELOCATION DEFINED H a s s e l k a u s (1978) d e f i n e s r e l o c a t i o n a s : "the change i n environment t h a t t a k e s p l a c e when an i n d i v i d u a l moves from one l o c a t i o n t o a n o t h e r . " (p. 631) R e s e a r c h on r e l o c a t i o n of the e l d e r l y has p r i m a r i l y f o c u s e d on movement: 1) from one comm-u n i t y s e t t i n g t o a n o t h e r ; 2) from the community^to an i n s t i t u -t i o n ; 3) from one i n s t i t u t i o n t o a n o t h e r ; and 4) i n t r a -i n s t i t u t i o n a l moves i . e . from one room t o a n o t h e r . A number of r e s e a r c h e r s have s t r e s s e d the p r o c e s s u a l n a t u r e of r e l o c a t i o n . They have d e s c r i b e d the move as a sequence of s t a g e s or p h a s e s , b e g i n n i n g w i t h the s i t u a t i o n a l changes which p r e c i p i t a t e the d e c i s i o n t o move; and ending s e v e r a l months a f t e r r e l o c a t i o n f o l l o w i n g a p e r i o d of a d j u s t -ment. (Yawney & S l o v e r , 1 9 7 3 ) ; (Sherwood e t a l , 1 9 7 4 ) ; (Tobin & Lieberman, 1 9 7 6 ) ; (Pope 1 9 7 9 ) . Tobin and Lieberman (1976) have broken t h i s sequence i n t o f o u r s t a g e s : 1) the phase of p r e d e c i s i o n ; 2) the phase of a n t i c i p a t i n g r e l o c a t i o n ; 3) the phase of i n i t i a l a d j u s t m e n t ; and 4) the phase of a d a p t a t i o n which encompasses the f i r s t s e v e r a l months a f t e r the i n i t i a l a d j u s t m e n t . STRESS DEFINED: An Examinat ion of P h y s i o l o g i c a l , S o c i o l o g i c a l , and P s y c h o l o g i c a l Concepts of S t r e s s . The l i t e r a t u r e t o be reviewed on r e l o c a t i o n s t r e s s does not e x p l i c i t l y d e f i n e the concept of s t r e s s . I m p l i c i t i n the l i t e r a t u r e - however i s the g e n e r a l assumption t h a t s t r e s s f u l l i f e e v e n t s , such as r e l o c a t i o n , may p l a y a r o l e i n the e t i o l o g y of v a r i o u s somat ic and p s y c h o l o g i c a l d i s o r d e r s . B i r r e n , (1965) conducted a s t u d y of h e a l t h y e l d e r l y men r e s i d i n g i n the community, and examined t h e i r e x p e r i e n c e s d u r i n g a number of s i g n i f i c a n t l i f e changes a s s o c i a t e d w i t h a g i n g , i n c l u d i n g the death of a s i g n i f i c a n t o t h e r , r e t i r e m e n t and changes i n r e s i d e n c e . These l i f e e v e n t s were subsumed under a v a r i a b l e t i t l e d " e n v i r o n m e n t a l l o s s " . B i r r e n found t h a t t h i s v a r i a b l e , " e n v i r o n m e n t a l l o s s " , showed a s i g n i f i c a n t r e l a t i o n s h i p not o n l y to morale, l i f e s a t i s f a c t i o n and adequacy i n s o c i a l r e l a t i o n s h i p s ; but a l s o t o p h y s i o l o g i c a l , c o g n i t i v e and psychomotor v a r i a b l e s as w e l l . ( p . 10 8) B r i e f l y , t h i s paper w i l l review some of the r e l e v a n t l i t e r a t u r e on s t r e s s , examine a c o n c e p t u a l model of s t r e s s , and from t h i s model o u t l i n e the major v a r i a b l e s which appear t o determine the degree of s t r e s s o r p e r s o n a l d i s r u p t i o n which an i n d i v i d u a l w i l l e x p e r i e n c e d u r i n g the p r o c e s s of r e l o c a t i o n . E x a m i n a t i o n of the l i t e r a t u r e on s t r e s s r e v e a l s t h a t d e f i n i t i o n s of the phenomena of s t r e s s are o f t e n ambiguous and i n c o n s i s t e n t . Some r e s e a r c h e r s d e f i n e s t r e s s i n terms of the s t i m u l i or s t r e s s o r s t h a t l e a d t o changes i n the organism. Other r e s e a r c h e r s l i m i t the d e f i n i t i o n t o the response or o u t -come from such s t i m u l i . I n some c a s e s , s t r e s s i s d e f i n e d as the emotional s t a t e accompanying some s i g n i f i c a n t p e r s o n a l or s o c i a l change. (Levine & S c o t c h , 1970) For the purposes of t h i s paper, we w i l l a c c e p t the 6. broad d e f i n i t i o n used by L a z a r u s ( 1 9 6 0 ) , which s t a t e s : " I t seems wise t o use " s t r e s s " as a g e n e r i c term f o r the whole a r e a of problems t h a t i n c l u d e the s t i m u l i p r o d u c i n g s t r e s s r e a c t i o n s , the r e a c t i o n s t h e m s e l v e s , and the v a r i o u s i n t e r -v e n i n g p r o c e s s e s . Thus we can speak of the f i e l d of s t r e s s and mean the p h y s i o l o g i c a l , s o c i o l o g i c a l and p s y c h o l o g i c a l phenomena and t h e i r r e s p e c t i v e c o n c e p t s . " (p. 27) Research has p r i m a r i l y f o c u s e d on p h y s i o l o g i c a l , s o c i o l o g i c a l and p s y c h o l o g i c a l s t r e s s as t h r e e s e p a r a t e l e v e l s of a n a l y s i s , a l t h o u g h a number of s t u d i e s have t a c i t l y r e c o g n i z -ed the complex i n t e r d e p e n d e n c e between t h e s e l e v e l s . I n r e v i e w i n g some of the r e l e v a n t l i t e r a t u r e on s t r e s s , t h i s paper w i l l r e t a i n t h e s e somewhat a r b i t r a r y l e v e l s of a n a l y s i s , and b r i e f l y examine the c o n c e p t u a l framework employed a t each l e v e l . A p h y s i o l o g i c a l concept of s t r e s s At the p h y s i o l o g i c a l l e v e l , r e s e a r c h e r s have s t u d i e d the b o d i l y changes t h a t o c c u r as an a d a p t i v e response t o a s t r e s s -p r o d u c i n g s i t u a t i o n , t h e r e b y p r o v i d i n g the t h e o r e t i c a l l i n k s between l i f e s t r e s s and somat ic i l l n e s s . Hans S e l y e i s one of the p i o n e e r r e s e a r c h e r s i n the f i e l d of p h y s i o l o g i c a l s t r e s s . As e a r l y as 1 9 2 5 , S e l y e had observed a n o n - s p e c i f i c b o d i l y response t o a number of d i s e a s e e n t i t i e s which he termed the "syndrome of j u s t being s i c k " . ( S e l y e , 1956) H i s l a t e r r e s e a r c h was d i r e c t e d to t h i s o b s e r v a t i o n . S e l y e d e f i n e s s t r e s s as the " n o n - s p e c i f i c " response of the body t o any demand made upon i t . T h i s n o n - s p e c i f i c response he termed the " g e n e r a l a d a p t a t i o n syndrom," which i s a c t i v a t e d by a d r e n a l and p i t u i t a r y s t i m u l a t i o n mediated through the nervous system. T h i s e n d o c r i n e a c t i v a t i o n produces a d a p t i v e hormones t o combat wear and t e a r i n the body. S e l y e had d e l i n e a t e d t h r e e s t a g e s i n t h i s response syndrome which may t a k e p l a c e under c o n d i t i o n s of prolonged s t r e s s : 1) an i n i t i a l s t a g e of a l a r m , which a c t i v a t e s the r e s p o n s e ; 2) a s t a g e of r e s i s t a n c e d u r i n g which the d e f e n s i v e r e s o u r c e s of the body are m a i n t a i n e d a t the l e v e l n e c e s s a r y f o r a d a p t i v e f u n c t i o n -i n g ; and 3) a s t a g e of e x h a u s t i o n which o c c u r s when the b o d i l y r e s o u r c e s a r e so d e p l e t e d t h a t f u r t h e r exposure t o s t r e s s may l e a d t o d i s i n t e g r a t i o n and d e a t h . S e l y e emphasizes t h a t the g e n e r a l a d a p t a t i o n syndrome i s a n o n - s p e c i f i c b o d i l y response which may be evoked by e i t h e r p h y s i c a l or n o n - p h y s i c a l s t r e s s o r s . I t i s a p h y l o g e n e t i c a l l y o l d p a t t e r n of response p r e p a r i n g the organism f o r s u r v i v a l . However, under c o n d i t i o n s of extreme or prolonged s t r e s s t h i s i n i t i a l l y a d a p t i v e n e u r o - e n d o c r i n e response can produce i n the i n d i v i d u a l symptoms of d i s t r e s s , p h y s i c a l m a l f u n c t i o n or even s t r u c t u r a l damage. Other p h y s i o l o g i s t s have e l a b o r a t e d on S e l y e ' s concepts , and have i n c l u d e d w i t h i n t h e i r framework concepts e v o l v i n g out of both p s y c h o l o g i c a l and s o c i a l s t r e s s r e s e a r c h . L e v i (19 74) has developed a c o n c e p t u a l model of p s y c h o s o c i a l s t r e s s which i n c l u d e s : 1) the p s y c h o s o c i a l s t i m u l i ; 2) the p s y c h o -b i o l o g i c a l program of the i n d i v i d u a l which i s a product of g e n e t i c f a c t o r s and e a r l y e n v i r o n m e n t a l i n f l u e n c e ; 3) the 8. i n t e r n a l mechanism of t h e s t r e s s r e s p o n s e ; 4) p r e c u r s o r s of d i s e a s e which may i n c l u d e e x i s t i n g m a l f u n c t i o n s i n t h e i n -d i v i d u a l ' s mental or p h y s i c a l systems which under c e r t a i n c o n d i t i o n s p r e d i s p o s e s the i n d i v i d u a l t o d i s e a s e ; and 5) i n t e r a c t i n g v a r i a b l e s e i t h e r e x t r i n s i c or i n t r i n s i c which might a l t e r the course of d i s e a s e . L e v i has s t a t e d t h a t i n h i s model, the sequence i s not a one-way p r o c e s s , but p a r t of a c y b e r n e t i c system w i t h c o n -t i n u o u s feedback. Thus L e v i attempts t o move from a l i n e a r model t o view the i n d i v i d u a l and the p r o c e s s w i t h i n the s o c i a l c o n t e x t . P h y s i o l o g i c a l r e s e a r c h on s t r e s s has p r o v i d e d t a n g i b l e , b i o l o g i c a l e v i d e n c e of the p h y s i o l o g i c a l changes t h a t may a t t e n d s t r e s s f u l l i f e e v e n t s . I n a d d i t i o n , i t has p r o v i d e d measurable i n d i c e s t o a s s e s s those p h y s i o l o g i c a l changes. On the o t h e r hand, c r i t i c i s m has been l e v e l l e d a t p h y s i o l o g i c a l r e s e a r c h which employs a r i g i d l i n e a r or m e d i c a l model i g n o r -i n g the m e d i a t i n g i n f l u e n c e of p s y c h o l o g i c a l and s o c i a l f a c t o r s throughout the p r o c e s s . A s o c i o l o g i c a l concept of s t r e s s From the s o c i o l o g i c a l p e r s p e c t i v e , s t r e s s i s viewed as an " a d a p t i v e c h a l l e n g e " t h a t r e q u i r e s i n d i v i d u a l a d j u s t m e n t . (George 19 80) "JThis p r o c e s s of a d a p t a t i o n depends on the degree of f i t between the s k i l l s and c a p a c i t i e s of i n d i v i d u a l s and t h e i r r e l e v a n t s u p p o r t i n g group s t r u c t u r e s on the one hand, and the types of c h a l l e n g e s w i t h which they are c o n -f r o n t e d on the o t h e r . " (Mechanic, 1 9 7 6 , p . 2 ) Research i n s o c i a l s t r e s s has f o c u s e d p r i m a r i l y on the " c h a l l e n g e s " and " s u p p o r t i n g group s t r u c t u r e s " . An e x t e n s i v e body of r e s e a r c h (Rahe 1974) has examined t h e r e l a t i o n s h i p between s o c i a l s t r e s s and p h y s i c a l i l l n e s s . Rahe and a s s o c i a t e s have g a t h e r e d d a t a on n e a r l y 4000 s u b j e c t s a t the U . S . Navy M e d i c a l N e u r o p s y c h i a t r i c R e s e a r c h U n i t i n San Diego. They have examined r e c e n t l i f e e v e n t s or changes e x p e r i e n c e d by t h e s e s u b j e c t s a t the p e r s o n a l , o c c u p a t i o n a l or f a m i l y l e v e l , and a p p l i e d q u a n t i t a t i v e v a l u e s t o t h e s e l i f e events a c c o r d i n g t o a s c a l e t i t l e d "The Schedule of Recent E x p e r i e n c e L i f e Changes". T h i s s c a l e i s presumably c a l i b r a t e d t o r e f l e c t the degree of p e r s o n a l a d j u s t m e n t or a d a p t a t i o n r e q u i r e d f o r each l i f e e v e n t . Rahe has examined the r e l a t i o n s h i p between i l l n e s s and the number and i n t e n s i t y of t h e s e l i f e changes. He h y p o t h e s i z e s t h a t an a c c u m u l a t i o n of s t r e s s f u l l i f e e v e n t s , and the r e s u l t i n g a d a p t i v e responses r e q u i r e d of the i n d i v i d u a l a r e a s s o c i a t e d w i t h h e i g h t e n e d emotional a r o u s a l and p h y s i o l o g i c a l changes which i f prolonged r e s u l t i n i l l n e s s . Mechanic (1976) has argued t h a t one a c h i e v e s a more u s e -f u l p e r s p e c t i v e on s t r e s s i f i t i s viewed from both a s o c i e t a l and p e r s o n a l p e r s p e c t i v e a t the same t i m e . He has s t a t e d : " . . . p s y c h o l o g i c a l s t r e s s does not occur w i t h o u t the i n d i v i d u a l f a c i n g a t h r e a t of f a i l u r e or l o s s ; y e t the meaning of f a i l u r e or l o s s i s dependent on s o c i a l v a l u e s and the a c c e p t a n c e of c u l t u r a l d e f i n i t i o n s of what i s v a l u a b l e . I t i s the c u l t u r a l meanings i n any subgroup t h a t determine what event w i l l be e x p e r i e n c e d a s s t r e s s f u l . " (p.5) Mechanic draws o u r ' a t t e n t i o n t o the s o c i e t a l i n s t i t u t i o n ' s which p r e p a r e i n d i v i d u a l s t o cope w i t h c h a l l e n g e and a d a p t a t i o n ; support them d u r i n g t h e i r a d a p t i v e e f f o r t s ; and reward s u c c e s s f u l a d a p t a t i o n . (Mechanic, 1970) S o c i o l o g i c a l r e s e a r c h on s t r e s s as i t r e l a t e s t o i l l n e s s has p r o v i d e d v a l u a b l e i n s i g h t s i n t o the s i g n i f i c a n t r o l e t h a t s o c i a l f a c t o r s p l a y both i n i n i t i a t i n g the a d j u s t i v e demand, and i n m e d i a t i o n throughout the p r o c e s s . Some s o c i a l s t r e s s r e s e a r c h has been c r i t i c i z e d however f o r v i e w i n g the i n d i v i d u a l as p l a y i n g a p a s s i v e , r e a c t i v e and u n d i f f e r e n t i a t e d r o l e when f a c e d w i t h an a d a p t i v e c h a l l e n g e . I n d i v i d u a l s a r e d i f f e r e n t -i a l l y s e n s i t i v e t o l i f e changes or s t r e s s f u l e v e n t s . They b r i n g t o the event d i f f e r e n t p e r c e p t i o n s or i n t e r p r e t a t i o n s of the s i g n i f i c a n c e of t h o s e e v e n t s . A d a p t i v e responses a r e unique and i n d i v i d u a l , a product of both p a s t e x p e r i e n c e , and a unique r e p e r t o i r e of coping s k i l l s . (McGrath 19 70) R e s e a r c h d i r e c t e d towards the p s y c h o l o g i c a l i m p l i c a t i o n s of s t r e s s f o c u s e s our a t t e n t i o n on the i n d i v i d u a l as the a c t i v e , coping, a d a p t i v e c e n t r e of the p r o c e s s . A p s y c h o l o g i c a l concept of s t r e s s A c c o r d i n g t o McGrath (19 7 0 ) : " . . . s t r e s s o c c u r s when t h e r e i s (perceived) s u b s t a n t i a l imbalance between e n v i r o n m e n t a l demand and the response c a p a b i l i t y of the f o c a l organism under c o n d i t i o n s where f a i l u r e t o meet demand has important ( p e r -ceived) consequences." (p. 20) Research i n p s y c h o l o g i c a l s t r e s s d i r e c t s our a t t e n t i o n t o the importance of the 11. i n d i v i d u a l ' s p e r c e p t i o n of the s t r e s s s i t u a t i o n ; and i t s p o t e n t i a l s i g n i f i c a n c e t o t h a t i n d i v i d u a l . " I f an e n v i r o n m e n t a l c o n d i t i o n or event i s a p p r a i s e d as b e n i g n ( e i t h e r r e a l i s t i c a l l y or d e f e n s i v e l y ) no s t r e s s o c c u r s a t the p s y c h o l o g i c a l l e v e l , we s h o u l d not a n t i c i -p a t e the p h y s i o l o g i c a l m o b i l i z a t i o n a s s o c i a t e d w i t h s t r e s s emotions. More-over , even when harm i s a n t i c i p a t e d , e f f e c t i v e p r e p a r a t o r y coping a c t i v i t y or i n t r a p s y c h i c p a l l i a t i v e modes of coping ( e . g . defense mechanisms) may s h o r t c i r c u i t the t h r e a t , t h u s r e d u c i n g or e l i m i n a t i n g the a n t i c i p a t o r y s t r e s s emotion a t or b e f o r e the p o i n t of c o n f r o n t -a t i o n w i t h harm." ( L a z a r u s 1 9 7 6 , p. 1 1 ) An e n v i r o n m e n t a l s i t u a t i o n w i l l produce p s y c h o l o g i c a l s t r e s s when the c e n t r a l v a l u e s or g o a l s of an i n d i v i d u a l a r e t h r e a t e n e d . ( L a z a r u s 1966) Although M a r r i s (1975) speaks of "change" r a t h e r than s t r e s s he a l s o conf irms t h i s o b s e r v a t i o n . "The c o n t e x t of meaning and v a l u e s from e a r l i e s t c h i l d h o o d becomes so s t r u c t u r e d and i n t e g r a t e d t h a t i t cannot i n t ime be r a d i c a l l y changed w i t h o u t f e a r of p s y c h o l o g i c a l d i s i n t e g r a -t i o n . Our a b i l i t y t o handle the changing environment r e l i e s , t h e r e f o r e , upon c o n s e r v i n g the fundamental s t r u c t u r e of mean-i n g each of us has grown up t o . " ( p . 1 9 ) However, when t h i s fundamental " s t r u c t u r e of meaning" i s t h r e a t e n e d , i s the p s y c h o l o g i c a l s t r e s s t h a t i s engendered an antecedent t o the onset of d i s e a s e ? An e x t e n s i v e body of r e s e a r c h s u g g e s t s t h a t i t i s . (Engel 1968 & 1 9 7 1 ) ; (Schmale 1 9 5 8 ) ; (Seligman 1975) E n g e l (196 8) over a p e r i o d of f i v e t o s i x y e a r s c o l l e c t e d 1 7 0 items from newspapers around the world t h a t r e p o r t e d the o c c u r r e n c e of sudden and u n e x p l a i n e d death under u n u s u a l c i r c u m s t a n c e s . . The c i r c u m s t a n c e s under which the v i 'ct ims a r e r e p o r t e d t o have d i e d correspond w i t h c i r c u m s t a n c e s o f t e n observed t o be a s s o c i a t e d w i t h the onset of i l l n e s s i n g e n e r a l . A l l i n v o l v e d a sudden and unwelcome change i n the v i c t i m ' s environment; and a c o r r e s p o n d i n g sense of h e l p l e s s n e s s on t h e p a r t of the v i c t i m t o cope w i t h t h i s change. E n g e l observed t h a t a p s y c h o l o g i c a l s t a t e of p o w e r l e s s n e s s or h e l p l e s s n e s s i s commonly found t o precede the onset of i l l n e s s , and he has c a l l e d t h i s s t a t e "the g i v i n g up - g i v e n up complex". The f i v e c h a r a c t e r i s t i c s of the " g i v i n g up - g i v e n up complex" i n c l u d e : 1) a f f e c t s of h e l p l e s s n e s s or h o p e l e s s n e s s ; 2) a d e p r e c i a t e d image of o n e s e l f ; 3) a l o s s of g r a t i f i c a t i o n s from r e l a t i o n s h i p s or r o l e s i n l i f e ; 4) a d i s r u p t i o n of the sense of c o n t i n u i t y between p a s t , p r e s e n t and f u t u r e ; and 5) a r e a c t i v a t i o n of memories of e a r l i e r p e r i o d s of g i v i n g up. (Engel 1968, p. 296) Engel h y p o t h e s i z e s t h a t d u r i n g t h i s p e r i o d of p s y c h i c d i s e q u i l i b r i u m the i n d i v i d u a l i s b i o l o g i c -a l l y s u s c e p t i b l e t o d i s e a s e p r o c e s s e s . Schmale (1958) has documented a s i m i l a r h i s t o r y of h e l p l e s s n e s s and h o p e l e s s n e s s r e l a t e d t o s i g n i f i c a n t " o b j e c t l o s s " j u s t p r i o r t o the onset of i l l n e s s . Sel igman (1975) has argued t h a t l i f e changes t h a t produce a p s y c h o l o g i c a l s t a t e of h e l p l e s s n e s s i n c r e a s e the r i s k of death. Each of these r e s e a r c h e r s b e l i e v e t h a t e n v i r o n m e n t a l events which produce a s i g n i f i c a n t sense of l o s s and h e l p l e s s n e s s have some r e l a t i o n t o the h e a l t h and the subsequent chance of death i n an i n d i v i d u a l . 13. A Model of S o c i a l S t r e s s One model which attempts t o i n c o r p o r a t e and i n t e g r a t e t h e s e t h r e e l e v e l s of a n a l y s i s - p h y s i o l o g i c a l , s o c i o l o g i c a l and p s y c h o l o g i c a l - has been developed by J . S . House ( 1 9 7 4 ) . I t i s d i f f i c u l t t o c o n c e p t u a l i z e e i t h e r the temporal d imensions or the complex i n t e r r e l a t e d n e s s of v a r i a b l e s i n a s t a t i c model. However, t h i s model of s o c i a l s t r e s s by House i n c l u d e s f i v e major c l a s s e s of v a r i a b l e s , and attempts t o i l l u s t r a t e t h e r e l a t i o n s h i p among the r e l e v a n t c o n c e p t s . I t i n c l u d e s : " 1) o b j e c t i v e s o c i a l c o n d i t i o n s conducive t o s t r e s s ; 2) i n d i v i d u a l p e r c e p t i o n s of s t r e s s ; 3) i n d i v i d u a l responses ( p h y s i o l o g i c a l , a f f e c t i v e and b e h a v i o r a l ) t o p e r c e i v e d s t r e s s ; 4) more e n d u r i n g outcomes of p e r s o n a l s t r e s s and responses t h e r e t o ; and 5) i n d i v i d u a l and s i t u a t i o n a l c o n d i t i o n i n g v a r i a b l e s t h a t s p e c i f y t h e . r e l a t i o n s h i p s among the f i r s t f o u r s e t of f a c t o r s . " (House 1 9 7 4 , p. 13) F i g u r e 1 i s an i l l u s t r a t i o n of H o u s e ' s model. The s o l i d l i n e s i n d i c a t e the d i r e c t i o n of the s t r e s s sequence b e g i n n i n g w i t h the o b j e c t i v e s o c i a l c o n d i t i o n s . The broken l i n e s i n d i c a t e the i n f l u e n c e of both s o c i a l and i n d i v i d u a l c o n d i t i o n i n g v a r i a b l e s which mediate d u r i n g the sequence t o moderate or e x a c e r b a t e the o r i g i n a l s t r e s s c o n d i t i o n . The model might i n c l u d e a feedback loop from the f i n a l outcome which would i n d i c a t e the r e c i p r o c a l n a t u r e of the p r o c e s s as the f i n a l outcome measured i n terms of the i n d i v i d u a l ' s p h y s i o l o g i c a l , b e h a v i o r a l and c o g n i t i v e f u n c t i o n i n g may i n t u r n i n f l u e n c e the o r i g i n a l s t r e s s c o n d i t i o n , the c o n d i t i o n i n g v a r i a b l e s 14. C o n d i t i o n i n g V a r i a H e s - I n d i v i d u a l o r S i t u a t i o n a l Coping-. a l C o n d i t i o n s Conducive ; to S t r e s s f V I Defen A/ ;e s Responses t o S t r e s s 1 . p h y s i o l o g i c a l 2 . Cognitive/affective 3 . B e h a v i o r a l > P e r c e i v e d •Stress I \L Outcomes 1 . P h y s i o l o g i c a l 2. C o g n i t i v e / A f f e c t i v e 3. B e h a v i o r a l [are 1 : H o u s e ' s model of s o c i a l s t r e s s . (From " O c c u p a t i o n a l S t r e s s and b n a r y H e a r t D i s e a s e : A Review and T h e o r e t i c a l I n t e g r a t i o n , " by J . S . Ise, J o u r n a l of H e a l t h and S o c i a l B e h a v i o r , 1 9 7 4 , 1 5 , 1 3 . ) i i l 15. and the i n d i v i d u a l 1 s f u t u r e p e r c e p t i o n s and r e s p o n s e s when exposed t o s i m i l a r or new s t r e s s c o n d i t i o n s . R e c o g n i t i o n of the complex i n t e r r e l a t e d n e s s among t h e s e v a r i a b l e s , and of the p r o c e s s u a l n a t u r e of s t r e s s a l l o w s us to examine the r e s e a r c h on r e l o c a t i o n s t r e s s from a b r o a d e r p e r s p e c t i v e . Research on r e l o c a t i o n s t r e s s has seldom t a k e n a l l of these. yariab.le.s i n t o account i n any s i n g l e r e s e a r c h d e s i g n . However, through a composite rey iew of the r e l e v a n t l i t e r a t u r e , we can examine a number of t h e s e v a r i a b l e s . For the e l d e r l y - , the degree of p e r s o n a l d i s r u p t i o n e x p e r i e n c e d d u r i n g r e l o c a t i o n t o a new environment appears t o be a f u n c t i o n of the f o l l o w i n g f a c t o r s : " , . , t h e c h a r a c t e r -i s t i c s of the a d j u s t i v e demand, the c h a r a c t e r i s t i c s of the i n d i v i d u a l , and the e x t e r n a l r e s o u r c e s and s u p p o r t s a v a i l a b l e t o him-;" (Coleman 19J73, p , 1JQ.L R e l o c a t i o n of and by i t s e l f i s a s i g n i f i c a n t a d j u s t i y e demand,.but f o r the e l d e r l y i t i s o f t e n o n l y one of a p y r a m i d -i n g number of a d j u s t i y e demands o c c a s s i o n e d by d e c l i n i n g health, and f u n c t i o n a l a b i l i t y , the l o s s through death, of s i g n i f i c a n t o t h e r s , reduced s o c i a l c o n t a c t s and d i m i n i s h i n g f i n a n c i a l r e s o u r c e s , As the work of Rahe and a s s o c i a t e s GL274I Has- shown the sheer number of demands may oyer l o a d th.e a d j u s t -i y e c a p a c i t y - of the i n d i v i d u a l . Other c h a r a c t e r i s t i c s - of the a d j u s t i y e demand which, may i n c r e a s e the s e v e r i t y - of the s t r e s s i n c l u d e the degree of change i n y o l y e d i n the p r o c e s s of r e l o c a t i o n , the p e r c e p t i o n of the moye as v o l u n t a r y or i n -v o l u n t a r y - and the d u r a t i o n of the p r o c e s s . The second f a c t o r , the c o n s t i t u t i o n a l and p e r s o n a l i t y c h a r a c t e r i s t i c s of the i n d i v i d u a l i s a l s o of key importance. The c a p a c i t y t o w i t h s t a n d s t r e s s f u l change i s i n p a r t a f u n c t i o n of the immediate p h y s i c a l and e m o t i o n a l h e a l t h of the i n d i v i d u a l ; and w i t h a d v a n c i n g age t h e s e p h y s i c a l r e s o u r c e s may be a l r e a d y s e v e r e l y s t r a i n e d through c h r o n i c i l l n e s s or d i s a b i l i t y . I t i s a l s o r e l a t e d t o the g e n e r a l s t r e s s t o l e r a n c e of the i n d i v i d u a l and t o t h e i r s u s c e p t i b i l i t y t o s p e c i f i c t y p e s of s t r e s s . A lower t o l e r a n c e f o r s p e c i f i c s t r e s s o r s may be a consequence of p a s t i l l n e s s or t r a u m a t i c e x p e r i e n c e s which may i n c r e a s e v u l n e r a b i l i t y a t a l a t e r d a t e . C l o s e l y r e l a t e d t o such s p e c i a l v u l n e r a b i l i t i e s i s the way the i n -d i v i d u a l p e r c e i v e s or e v a l u a t e s the s i t u a t i o n . L a z a r u s (1966) views the i n d i v i d u a l ' s p e r c e p t i o n of the event r a t h e r t h a n t h e o b j e c t i v e s i t u a t i o n i t s e l f as the key component, p a r t i c -u l a r l y so when the s i t u a t i o n poses a t h r e a t t o the i n d i v i d u a l ' s most c e n t r a l core of b e l i e f s or v a l u e s about s e l f . The p e r s o n a l i t y c h a r a c t e r i s t i c s of the i n d i v i d u a l a l s o p l a y a p a r t , i n c l u d i n g t h e i r s t r a t e g i e s of defense, t h e i r coping mechanisms and t h e i r assumptions about r e a l i t y and p o s s i b i l i t y . The e x t e r n a l r e s o u r c e s and s u p p o r t s a v a i l a b l e t o the i n d i v i d u a l i s the t h i r d f a c t o r which w i l l determine the degree of p e r s o n a l d i s r u p t i o n e x p e r i e n c e d by an i n d i v i d u a l d u r i n g s t r e s s . ' Dur ing r e l o c a t i o n t h e s e s u p p o r t s may i n c l u d e the q u a l i t y of t h e new environment i n both p h y s i c a l and i n t e r -p e r s o n a l terms; and the degree of p r e p a r a t i o n f o r the move. Adequate p r e p a r a t i o n must i n c l u d e both e m o t i o n a l support and p h y s i c a l a s s i s t a n c e . And f i n a l l y , the concern and support 17. pf s i g n i f i c a n t o t h e r s i n c l u d i n g f a m i l y and f r i e n d s may be a c r u c i a l f a c t o r i n a l l e v i a t i n g s t r e s s and f a c i l i t a t i n g adjustment t o the new environment. MEASUREMENTS OF RELOCATION STRESS L e v e l s of s t r e s s have h i s t o r i c a l l y be measured i n terms of p h y s i o l o g i c a l changes, a l t e r a t i o n s i n b e h a v i o r a l r e s p o n s e s , \ changes i n the adequacy of c o g n i t i v e f u n c t i o n s and r e p o r t s of d i s t u r b e d a f f e c t . ( L a z a r u s 1966) A number of t h e s e measures have been used as an i n d e x of r e l o c a t i o n s t r e s s , the most common being m o r t a l i t y r a t e s , changes i n p h y s i o l o g i c a l s t a t u s and measures of p s y c h o l o g i c a l w e l l - b e i n g . P h y s i o l o g i c a l measures: One of the most f r e q u e n t l y used i n d i c e s has measured r e l o c a t i o n s t r e s s i n terms of i n c r e a s e d m o r t a l i t y r a t e s . ( A l d r i c h & Mendkoff 1 9 6 3 ) ; ( K i l l i a n 1 9 7 0 ) ; (Markus e t a l 1 9 7 1 ) More r e c e n t l y , r e s e a r c h e r s have examined changes i n p h y s i c a l h e a l t h u s i n g measures such as p h y s i c i a n ' s r a t i n g s , s e l f -p e r c e p t i o n of h e a l t h , i n f i r m a r y a d m i s s i o n s and s e l f r e p o r t s on l e v e l s of d a i l y f u n c t i o n i n g . (Bourestom & T a r s 1 9 7 4 ) ; • (Borup e t a l 19 80) Two Canadian s t u d i e s c a p i t a l i z i n g on the e x t a n t r e s e a r c h on p h y s i o l o g i c a l s t r e s s have examined i n c r e a s e s i n l e v e l s of plasma c o r t i c o i d s f o l l o w i n g r e l o c a t i o n . (Farquhar & McCormick) ( K r a i & Berenson, 1968) K r a i and Berenson(1968) found t h a t l e v e l s of plasma c o r t i c o i d s i n c r e a s e d among males and among p s y c h o t i c s of both sexes , but decreased s l i g h t l y among 18. p s y c h i a t r i c a l l y normal f e m a l e s . For males t h i s r i s e i n plasma c o r t i c o i d s was s i g n i f i c a n t l y a s s o c i a t e d w i t h t h e development of p h y s i c a l c o m p l a i n t s ; a l t h o u g h t h i s i n c r e a s e was not n e c e s s -a r i l y accompanied by o r g a n i c changes. P s y c h o s o c i a l measures: A f r e q u e n t l y used i n d i c e s i n s t u d i e s of i n t r a - i n s t i t u t i o n -a l r e l o c a t i o n examines a l t e r a t i o n s i n b e h a v i o r i n c l u d i n g changes i n l e v e l s of p s y c h o s o c i a l a c t i v i t y and a l t e r e d p a t t e r n s of i n t e r a c t i o n . ( P a t n a i k e t a l 1 9 7 4 ) ; (Bourestom & T a r s 1974) Two l o n g i t u d i n a l s t u d i e s , have examined the e f f e c t of r e l o c a t i o n on measures of c o g n i t i v e f u n c t i o n i n g . T e s t i n g was conducted on s u b j e c t s on a w a i t i n g l i s t f o r placement, and a g a i n s e v e r a l months a f t e r e n t e r i n g the i n s t i t u t i o n . (Weinstock & Bennet, 1 9 7 1 ) ; (Tobin and Lieberman, 1976) Measures have a l s o been o b t a i n e d on l e v e l s of l i f e s a t i s f a c t i o n and morale (Sherwood e t a l 1 9 7 4 ) , changes i n s e l f esteem and s e l f - c o n c e p t (Tobin & Lieberman 1 9 7 6 ) , and a l t e r -a t i o n s i n emotional s t a t e and l e v e l s of a f f e c t . (Brody e t a l 1974) ; ( M i l l e r & Lieberman 1965) RESEARCH DESIGN AND RELOCATION STRESS AN EXAMINATION OF MORTALITY RATES FOLLOWING RELOCATION As 'mentioned e a r l i e r , a g r e a t number of s t u d i e s have examined the r e l a t i o n s h i p between i n s t i t u t i o n a l r e l o c a t i o n and m o r t a l i t y r a t e s . T h i s r e s e a r c h has focused on two t y p e s of r e l o c a t i o n : 1) r e l o c a t i o n from the community t o an i n s t i t u t -i o n and 2) r e l o c a t i o n from one i n s t i t u t i o n t o a n o t h e r . The 19. r e s u l t s of t h e s e s t u d i e s have been somewhat ambiguous and c o n t r a d i c t o r y . A number o f r e v i e w e r s (Blenkner 1 9 6 7 ) ; ( K a s l 1 9 7 2 ) ; and (Rowland 1977) have noted t h e s e c o n t r a d i c t i o n s i n the r e s e a r c h f i n d i n g s and have attempted t o e x p l a i n t h e s e i n c o n s i s t e n c i e s i n terms of d i f f e r e n c e s i n r e s e a r c h method-o l o g y . S i n c e t h e r e may be a r e l a t i o n s h i p between methodology and f i n d i n g s , an assessment of a number of t h e s e s t u d i e s i s n e c e s s a r y t o a c h i e v e an u n d e r s t a n d i n g of the e f f e c t s of r e -l o c a t i o n on m o r t a l i t y r a t e s . Three s t u d i e s have examined m o r t a l i t y r a t e s f o l l o w i n g r e l o c a t i o n f o r the community t o an i n s t i t u t i o n . F e r r a r i (1962) conducted a s t u d y on f i f t y - f i v e females w i t h an average age of 82 y e a r s who a p p l i e d f o r a d m i s s i o n t o an o l d age home. F e r r a r i asked them upon a d m i s s i o n how much freedom of c h o i c e they had f e l t i n moving t o the home, what other p o s s i b i l i t i e s had been open t o them and how much p r e s s u r e t h e i r r e l a t i v e s had a p p l i e d t o them to e n t e r the home. Of the 1 7 women who s a i d they had no a l t e r n a t i v e but to move t o the home, 8 d i e d f o u r weeks a f t e r a d m i s s i o n , and 16 were dead i n t e n weeks. A p p a r e n t l y o n l y one person of the 38 who saw an a l t e r n a t i v e d i e d i n the i n i t i a l p e r i o d . Although t h e s e m o r t a l i t y r a t e s seem e x c e s s i v e i n compar-i s o n t o m o r t a l i t y r a t e s i n the g e n e r a l p o p u l a t i o n , the r a t e s may i n f a c t be a f u n c t i o n of s e l e c t i o n b i a s . I t i s not p o s s i b l e from F e r r a r i ' s s t u d y t o determine t o what e x t e n t t h i s sample may have d i f f e r e d i n h e a l t h s t a t u s from the b e g i n -n ing when compared w i t h the e l d e r l y i n g e n e r a l . Nor i s i t 20. p o s s i b l e t o determine i f the m o r t a l i t y r a t e s were a f u n c t i o n of r e l o c a t i o n i . e . the e n v i r o n m e n t a l change; or a r e s u l t of r e l a t e d changes perhaps a s s o c i a t e d w i t h some a s p e c t of the i n s t i t u t i o n a l environment such as poor d i e t , i n f e c t i o n or poor m e d i c a l c a r e . ( K a s l 1 9 7 2 , p. 378) Other r e s e a r c h e r s have attempted t o c o n t r o l f o r s e l e c t i o n b i a s by u s i n g a w a i t i n g - l i s t c o n t r o l group, assuming t h a t the i n i t i a l h e a l t h s t a t u s of a group w a i t i n g a d m i s s i o n t o a r e s i d e n t i a l f a c i l i t y w i l l be comparable t o t h a t of a group j u s t a d m i t t e d . T h i s was the r e s e a r c h d e s i g n of C o s t e l l o and Tanaka ( 1 9 6 1 ) who r e p o r t e d a m o r t a l i t y r a t e of 38% i n the f i r s t 6 months f o l l o w i n g a d m i s s i o n , compared w i t h an 1 1 % death r a t e dur ing a 1 -month w a i t i n g - l i s t p e r i o d . As noted by Rowland (19 77) when t h e s e r a t e s are a d j u s t e d t o compare e q u a l i n t e r v a l s , the m o r t a l i t y , r a t e f o r the w a i t i n g - l i s t c o n t r o l group a c t u a l l y exceeds t h a t of the admitted group. I t has been noted t h a t the use of a w a i t i n g - l i s t c o n t r o l group f o r comparison purposes c o n t r o l s to some e x t e n t s e l e c t -i o n b i a s between groups of movers and non-movers because h e a l t h s t a t u s between w a i t i n g - l i s t and a d m i t t e d groups i s p r o b a b l y comparable. However, the s i m i l a r i t i e s i n h e a l t h s t a t u s between t h e s e two groups may be exaggerated. I t i s p o s s i b l e t h a t the more s e v e r l y i m p a i r e d a p p l i c a n t s a r e a d m i t t -ed p r e f e r e n t i a l l y , w h i l e the h e a l t h i e r a p p l i c a n t s remain on the w a i t i n g l i s t ; thus confounding comparison of m o r t a l i t y r a t e s between the two groups. From an e t h i c a l s t a n d p o i n t , c o n t r o l l i n g f o r t h i s s e l e c t i o n b i a s has not been p o s s i b l e s i n c e a d m i s s i o n p r a c t i c e s must r e f l e c t i n d i v i d u a l need. T h e r e f o r e , i n d i v i d u a l s cannot be randomly a s s i g n e d t o w a i t -i n g - l i s t or a d m i s s i o n groups. However, a s t u d y by B l e n k n e r (1967) d i d employ an e x p e r i m e n t a l d e s i g n w i t h random assignment of the community e l d e r l y t o t h r e e s e r v i c e programs r a n g i n g from m i n i m a l i n t e r v e n t i o n ( p r o v i d i n g i n f o r m a t i o n and d i r e c t i o n t o h e a l t h and w e l f a r e s e r v i c e s ) , t o maximal i n t e r v e n t i o n v(an i n t e n s i v e program of d i r e c t s e r v i c e i n which both s o c i a l workers and p u b l i c h e a l t h n u r s e s were a c t i v e ) . At 6 month f o l l o w - u p , the death r a t e on the maximal program (24%) was f o u r t imes t h a t of the minimal program (6%). I n examining the n a t u r e of the s e r v i c e , r e s e a r c h e r s found t h a t s u b j e c t s on the maximal program were much more l i k e l y t o have r e c e i v e d a s e r v i c e d i r e c t e d a t p r o v i d i n g a more p r o t e c t e d environment. That i s , s u b j e c t s on the maximal program were more f r e q u e n t l y p l a c e d i n i n s t i t u t i o n a l s e t t i n g s ; and t h e s e placements were a s s o c i a t e d w i t h h i g h e r m o r t a l i t y r a t e s . Although the numbers i n the program were too s m a l l t o permit the r e s u l t s t o a t t a i n s t a t i s t i c a l s i g n i f i c a n c e , l a t e r s t u d i e s have produced s i m i l a r r e s u l t s . The f o r e g o i n g s t u d i e s have l e d Blenkner t o c o n c l u d e "There i s a n e g a t i v e a s s o c i a t i o n between placement and s u r v i v a l among o l d e r persons which p r e v a i l s even when t h e i r p h y s i c a l c o n d i t i o n i s h e l d c o n s t a n t . " (p. 1 0 1 ) A much l a r g e r number of s t u d i e s have examined r e l o c a t i o n from one i n s t i t u t i o n t o another , or r e l o c a t i o n t o another ward or room w i t h i n the same i n s t i t u t i o n . These s t u d i e s have u t i l i z e d two r e s e a r c h d e s i g n s : 1) an e x p e r i m e n t a l - c o n t r o l 22. d e s i g n i n which t h e death r a t e s ' o f movers a r e compared w i t h the death r a t e s of r e s i d e n t s who are not moved; and 2) a base l i n e d e s i g n i n which death r a t e s a f t e r r e l o c a t i o n a r e compared w i t h death r a t e s p r i o r t o r e l o c a t i o n . S t u d i e s employing t h e e x p e r i m e n t a l - c o n t r o l d e s i g n t o examine m o r t a l i t y r a t e s f o l l o w i n g r e l o c a t i o n have produced i n c o n s i s t e n t r e s u l t s . I n one s t u d y by K i l l i a n (1970) a mass t r a n s f e r of h o s p i t a l i z e d g e r i a t r i c p a t i e n t s was arranged due t o the c l o s -ure of a s a t e l l i t e f a c i l i t y . The t r a n s f e r r e d p a t i e n t s were matched w i t h a c o n t r o l group of non-movers on the b a s i s of sex, r a c e , o r g a n i c or f u n c t i o n a l d i a g n o s i s , age, l e n g t h of h o s p i t a l i z a t i o n and ambulatory or not a t the t ime of t r a n s f e r . Both groups were f o l l o w e d f o r a f o u r month p e r i o d . K i l l i a n found a s i g n i f i c a n t l y h i g h e r m o r t a l i t y r a t e f o r the r e l o c a t e d p a t i e n t s when compared t o the matched c o n t r o l p a t i e n t s who were not t r a n s f e r r e d . An e s p e c i a l l y h i g h death r a t e d was observed f o r the o l d e r nonambulatory p a t i e n t s . I n a l a t e r s t u d y , Bourestom and T a r s (1974) a l s o matched the e x p e r i m e n t a l and c o n t r o l groups on the b a s i s of age, sex, l e n g t h of h o s p i t a l i z a t i o n and d i a g n o s i s . These r e s e a r c h e r s s t u d i e d two s e p a r a t e e x p e r i m e n t a l groups: an e x p e r i m e n t a l " r a d i c a l e n v i r o n m e n t a l change" group and an e x p e r i m e n t a l "moderate e n v i r o n m e n t a l change" group. These groups were t r a n s f e r r e d t o two d i f f e r e n t f a c i l i t i e s . The " r a d i c a l change" group was t r a n s f e r r e d t o a new f a c i l i t y c o n t a i n i n g a new s t a f f and p a t i e n t p o p u l a t i o n . The "moderate change" group e n t e r e d 23. a new f a c i l i t y , but s t a f f and p a t i e n t p o p u l a t i o n remained c o n s t a n t . Bourestom and T a r s found a s t r i k i n g l y h i g h e r m o r t a l i t y r a t e f o r the r e l o c a t e d groups; w i t h the " r a d i c a l change" group e x p e r i e n c i n g the h i g h e s t death r a t e s . I n c o n t r a s t , another group of r e s e a r c h e r s Borup e t a l (1979) found no d i f f e r e n c e i n m o r t a l i t y r a t e s between groups of t r a n s f e r r e d and n o n - t r a n s f e r r e d p a t i e n t s . However, t h e s e r e s e a r c h e r s made no attempt t o match the e x p e r i m e n t a l and c o n t r o l groups on r e l e v a n t v a r i a b l e s t h a t might have c o n t r i b u t ed t o the p a t i e n t s ' chances of d y i n g . Because t h e two groups may not have been i n i t i a l l y comparable, the r e s u l t s from t h i s study a r e open t o q u e s t i o n . The second method f o r examining whether r e l o c a t i o n i s p r e d i c t i v e of death u t i l i z e s a b a s e l i n e d e s i g n which compares m o r t a l i t y r a t e s b e f o r e and a f t e r the move. S e v e r a l of t h e s e s t u d i e s have supported t h e n o t i o n t h a t r e l o c a t i n g an e l d e r l y person r e s u l t s i n an i n c r e a s e d chance of d e a t h . One such s t u d y by A l d r i c h and Mendkoff (1963) compared the m o r t a l i t y r a t e f o r 180 r e l o c a t e d p a t i e n t s w i t h a c a l c u l -ated a n t i c i p a t e d death r a t e based on the death r a t e s f o r 10 y e a r s p r i o r t o the r e l o c a t i o n d a t e . The m o r t a l i t y r a t e f o l l o w i n g r e l o c a t i o n was s u b s t a n t i a l l y and s i g n i f i c a n t l y h i g h e r than the a n t i c i p a t e d r a t e . . I n a d d i t i o n , t h e s e r e s e a r c h e r s found: the death r a t e was c o n c e n t r a t e d i n the f i r s t t h r e e months f o l l o w i n g r e l o c a t i o n ; and the m o r t a l i t y r a t e a l s o i n c r e a s e d d u r i n g the p e r i o d when p a t i e n t s were a n t i c i p a t i n g r e l o c a t i o n but had not y e t been moved. However, t h i s l a t t e r i n c r e a s e 24. was not s t a t i s t i c a l l y s i g n i f i c a n t . J a s n a u (1967) measured the m o r t a l i t y r a t e f o l l o w i n g the mass t r a n s f e r of a group of g e r i a t r i c p a t i e n t s , and compared i t w i t h the m o r t a l i t y r a t e f o r the same p e r i o d one y e a r b e f o r e r e l o c a t i o n . The death r a t e f o r t h i s group i n c r e a s e d an a s t o n i s h i n g 35 p e r c e n t . T h i s i n c r e a s e J a s n a u a t t r i b u t e d t o —: a l a c k of adequate p r e p a r a t i o n f o r the move. Two l a t e r s t u d i e s have produced c o n t r a d i c t o r y r e s u l t s . Zweig and Csank (19 75) examined m o r t a l i t y r a t e s when an e n t i r e p a t i e n t p o p u l a t i o n of d i s a b l e d e l d e r l y v e t e r a n s was moved i n t o a new f a c i l i t y . These r e s e a r c h e r s compared p o s t -r e l o c a t i o n m o r t a l i t y r a t e s f o r t h i s p o p u l a t i o n w i t h the r a t e s f o r each of the t h r e e y e a r s b e f o r e the move, and found a s i g n i f i c a n t d e c r e a s e of 6 . 8 2 p e r c e n t f o l l o w i n g r e l o c a t i o n . Zweig and Csank c r e d i t an e x t e n s i v e p r e p a r a t o r y program f o r t h e s e low m o r t a l i t y r a t e s . A second s t u d y by Gutman and H e r b e r t (1976) a l s o found a lower m o r t a l i t y r a t e p o s t - t r a n s f e r f o r a group of e l d e r l y c h r o n i c c a r e p a t i e n t s . The m o r t a l i t y r a t e of the r e l o c a t e d p a t i e n t s f o r the y e a r f o l l o w i n g r e l o c a t i o n was lower than the m o r t a l i t y r a t e i n 4 of the 5 y e a r s p r e c e d i n g the move. These r e s e a r c h e r s i n a review of s i m i l a r r e l o c a t i o n s t u d i e s noted t h a t t h e d a t a from t h e s e s t u d i e s i s o f t e n not t r u l y comparable due t o i n c o n s i s t e n c i e s i n sample s i z e , sex and age mix, h e a l t h s t a t u s , degree of e n v i r o n m e n t a l change and the t r a n s f e r procedures employed. Borup e t a l (1979) have q u e s t i o n e d the v a l i d i t y of the 25. b a s e l i n e approach s i n c e i t i s c o n t i n g e n t on the a b i l i t y of r e s e a r c h e r s t o e s t a b l i s h a v a l i d and comparable base from which t o make a comparat ive a n a l y s i s . Borup i n examining the weakness of the d e s i g n makes the f o l l o w i n g p o i n t s : 1) m o r t a l i t y r e c o r d s which have been kept over a number of y e a r s may not n e c e s s a r i l y be a c c u r a t e or c o n s i s t e n t due t o v a g a r i e s of r e p o r t i n g and m a i n t a i n i n g s t a t i s t i c a l r e c o r d s ; 2) i n s t i t u t -i o n a l p o l i c y i n r e g a r d s t o m a i n t a i n i n g p a t i e n t s who a r e a p p r o a c h i n g death may have changed over the y e a r s , and 3) the c h a r a c t e r i s t i c s of the p a t i e n t s i n the b a s e l i n e group may not be s i m i l a r t o those p o s s e s s e d by the p a t i e n t s e x p e r i e n c i n g r e l o c a t i o n due t o d i f f e r e n c e s over t ime i n i n s t i t u t i o n a l a d m i s s i o n p o l i c i e s , and the t y p e s of s e r v i c e o f f e r e d , (p. 138) From the f o r e g o i n g review, i t i s apparent t h a t the most c o n v i n c i n g e v i d e n c e of n e g a t i v e e f f e c t s f o l l o w i n g r e l o c a t i o n has come from s t u d i e s i n which i n s t i t u t i o n a l i z e d e l d e r l y were r e l o c a t e d from one i n s t i t u t i o n t o a n o t h e r . Whi le e v i d e n c e of a s i g n i f i c a n t i n c r e a s e i n m o r t a l i t y r a t e s f o l l o w i n g r e l o c a t i o n i s not c o n c l u s i v e , nor always c o n s i s t e n t , the f i n d i n g s a r e s u f f i c i e n t l y a l a r m i n g t h a t Morton Lieberman, one of the p i o n e e r r e s e a r c h e r s i n t h i s f i e l d has concluded t h a t : " . . . n o m a t t e r what the c o n d i t i o n of the i n d i v i d u a l , the n a t u r e of the environment, or the degree of s o p h i s t i c a t e d p r e p a r a t i o n , r e l o c a t i o n e n t a i l s a h i g h e r t h a n a c c e p t a b l e r i s k t o the l a r g e m a j o r i t y of t h o s e b e i n g moved." (Lieberman 1974, p. 495) D i f f e r e n t i a l r e s u l t s i n the f o r e g o i n g s t u d i e s cannot be a t t r i b u t e d s o l e l y t o m e t h o d o l o g i c a l shortcomings i n the s t u d i e s t h e m s e l v e s . Thus, the focus of r e l o c a t i o n r e s e a r c h has e v o l v e d 2531. from s i m p l y measuring the impact of r e l o c a t i o n i n terms of m o r t a l i t y or p h y s i o l o g i c a l and p s y c h o l o g i c a l changes, t o examining under what c o n d i t i o n s , and w i t h what k i n d s of i n d i v i d u a l s a r e t h e s e n e g a t i v e e f f e c t s most l i k e l y t o o c c u r . (Bourestom & P a s t a l a n , 19 81) What i n d i v i d u a l or s i t u a t i o n a l c h a r a c t e r i s t i c s may moderate or a g g r a v a t e the n e g a t i v e e f f e c t s of the move? R e s e a r c h e r s have i d e n t i f i e d a number of t h e s e c o n d i t i o n i n g v a r i a b l e s t h a t may h e l p t o e x p l a i n v a r i a t i o n s i n death r a t e s f o l l o w i n g i n s t i t u t i o n a l r e l o c a t i o n . The c o n d i t i o n i n g v a r i a b l -es which appear t o i n f l u e n c e t h e degree of p e r s o n a l d i s t r e s s e x p e r i e n c e d d u r i n g r e l o c a t i o n were i d e n t i f i e d e a r l i e r i n t h i s paper, and w i l l be examined under the f o l l o w i n g h e a d -i n g s : 1) the c h a r a c t e r i s t i c s of the a d j u s t i v e demand: 2) the c h a r a c t e r i s t i c s of the i n d i v i d u a l ; and 3) the e x t e r n a l r e -s o u r c e s and s u p p o r t s a v a i l a b l e t o the i n d i v i d u a l . CONDITIONING VARIABLES: INDIVIDUAL AND SITUATIONAL VARIABLES THAT INFLUENCE OUTCOME FOLLOWING RELOCATION C h a r a c t e r i s t i c s of the a d j u s t i v e demand: A v a i l a b l e e v i d e n c e i n d i c a t e s t h a t r e l o c a t i o n i s a s i g n i f i c a n t and o f t e n t r a u m a t i c adjustment f o r the o l d e r p e r s o n . As i n d i c a t e d e a r l i e r t h e r e s u l t s of a number of s t u d i e s have shown t h a t e l d e r l y persons d i e a t e x c e s s i v e l y h i g h r a t e s d u r i n g the f i r s t y e a r and p a r t i c u l a r l y d u r i n g the f i r s t t h r e e months f o l l o w i n g r e l o c a t i o n ; whether t h a t r e l o c a t i o n c o n s i s t s of movement from the community t o an 2532. i n s t i t u t i o n (Blenkner 196 7) , or movement from i n s t i t u t i o n t o i n s t i t u t i o n . ( A l d r i c h & Mendkoff 1 9 6 3 ) , ( Jasnau 1967) C l i n i c a l o b s e r v a t i o n of e l d e r l y persons d u r i n g r e l o c a t i o n c o r r o b o r a t e s t h e s e r e s e a r c h f i n d i n g s . "As the r e s i d e n t - t o - b e s e p a r a t e s from i n d e p e n d -ent community l i v i n g and i n t i m a t e o t h e r s , h i s a t t e n t i o n b e g i n s t o s h i f t t o the g a i n s t h a t can a c c r u e from becoming i n s t i t u t i o n a l i z e d - p r i n c i p a l l y c a r e , people , and a c t i v i t i e s . The meaning v of the l o s s e s connected w i t h g i v i n g up independent l i v i n g i s s e p a r a t i o n ; t h e e x p e r i e n c e i s t h a t of b e i n g abandoned, and r e a c t i o n t o i t i s extreme. I n c r e a s -i n g l y , the person becomes c o g n i t i v e l y c o n s t r i c t e d , a p a t h e t i c , unhappy, h o p e l e s s , depressed, a n x i o u s , and l e s s dominant i n r e l a t i o n s h i p s w i t h o t h e r s . " (Tobin & Lieberman 1 9 7 6 , p. 213) As noted by the above a u t h o r s , the a d j u s t m e n t p r o c e s s i s composed of two p a r t s : the l o s s of f a m i l i a r e n v i r o n m e n t a l and s o c i a l s u p p o r t s ; and the n e c e s s a r y adjustment t o a new p h y s i c a l and p s y c h o s o c i a l environment. T h i s a d j u s t m e n t of and by i t s e l f may t a x the a d a p t i v e r e s o u r c e s of the i n d i v i d u a l However, a number of c h a r a c t e r i s t i c s of the a d j u s t m e n t p r o c e s s have been i d e n t i f i e d which may p l a c e a d d i t i o n a l s t r a i n on t h e i n d i v i d u a l a m p l i f y i n g t h e i r p e r c e p t i o n of s t r e s s , and o v e r l o a d i n g t h e i r a d a p t i v e c a p a c i t i e s . These c h a r a c t e r i s t i c s i n c l u d e : 1) the number of s u c c e s s -i v e a d j u s t m e n t s the i n d i v i d u a l must make; 2) the degree of change i n v o l v e d i n t h e a d j u s t m e n t ; 3) the i n d i v i d u a l ' s p e r c e p t i o n of the adjustment as v o l u n t a r y or i n v o l u n t a r y ; and 4) the d u r a t i o n of t h e a d j u s t i v e p r o c e s s . Each of t h e s e w i l l be examined i n t u r n . The d e c i s i o n t o seek i n s t i t u t i o n a l c a r e . u s u a l l y f o l l o w s a s e r i e s of p h y s i c a l and s o c i a l r e v e r s a l s . I t i s o f t e n the c u l m i n a t i o n of a p r o c e s s t h a t has a l r e a d y e x a c t e d a s i g n i f i -c a n t t o l l . The f o l l o w i n g case example s e r v e s as an i l l u s t r -a t i o n . Mr. B. i s 75 y e a r s of age. He has never m a r r i e d , and h i s o n l y l i v i n g r e l a t i v e i s a v e r y e l d e r l y and i n f i r m a u n t . For the p a s t e l e v e n y e a r s , s i n c e h i s r e t i r e m e n t , Mr. B. has l i v e d an independent e x i s t e n c e i n a s m a l l basement room i n a p r i v a t e home. Most of h i s t ime was spent a t a p r i v a t e gambling c l u b where he r e g u l a r l y p l a y e d c a r d s w i t h a group of o t h e r men. Although he s u f f e r e d o c c a s s i o n a l f i n a n c i a l l o s s e s , he a l s o managed t o win f r e q u e n t l y enough t o remain f i n a n c i a l l y s o l v e n t . The p a t t e r n of h i s d a i l y l i f e , and h i s e n t i r e s o c i a l c o n t a c t s r e v o l v e d about t h i s c l u b . However, d u r i n g the p a s t s i x months t h i s p a t t e r n has been d i s r u p t e d . A s e r i e s of gambl-i n g l o s s e s l e f t him s e v e r e l y i n debt, and he was no l o n g e r welcome a t the c l u b . A l l h i s f o r -mer s o c i a l c o n t a c t s were d i s s o l v e d , and he e n t e r -ed a p e r i o d of s o c i a l i s o l a t i o n and s e v e r e d e p r e s s i o n . A r o u t i n e p h y s i c a l e x a m i n a t i o n r e v e a l -ed a m a l i g n a n c y i n one lung, and f o l l o w i n g major s u r g e r y h i s g e n e r a l h e a l t h d e t e r i o r a t e d . The home i n which he had l i v e d was s o l d , and he r e c e i v e d an e v i c t i o n n o t i c e . He i s now h o s p i t a l -i z e d and a w a i t i n g placement i n an i n s t i t u t i o n . T h i s example i l l u s t r a t e s one man's pathway t o i n s t i t u t -i o n a l i z a t i o n . Although i t i s unique, i n some r e s p e c t s i t i s not' 3. typical . I n s t i t u t i o n a l i z a t i o n i s o f t e n the c l i m a x of a s e r i e s of a s s a u l t s t h a t have undermined the i n d i v i d u a l ' s p e r s o n a l r e s o u r c e s and independence. A d a p t a t i o n t o an i n -s t i t u t i o n then r e q u i r e s a f u r t h e r e x p e n d i t u r e of p h y s i c a l and e m o t i o n a l energy from an a l r e a d y bankrupt s u p p l y . A number of i n v e s t i g a t o r s have h y p o t h e s i z e d t h a t i t i s the degree of change e x p e r i e n c e d d u r i n g the r e l o c a t i o n p r o c e s s t h a t i s the c r u c i a l v a r i a b l e d e t e r m i n i n g how d i s r u p t i v e or d e s t r u c t i v e the move w i l l be. As Lieberman (1969) s t a t e s : "The l a r g e r the d i f f e r e n c e between o l d and new s i t u a -t i o n s , the g r e a t e r t h e p o s s i b i l i t y t h a t the aged i n d i v i d u a l w i l l need t o develop a d a p t i v e r e s p o n s e s o f t e n beyond h i s c a p a c i t y . " (p. 334) T h i s h y p o t h e s i s f i n d support i n the s t u d y by Bourestom and T a r s (1974) c i t e d e a r l i e r i n which '98 r e s i d e n t s were moved t o two s e p a r a t e f a c i l i t i e s . One group e x p e r i e n c e d a " r a d i c a l e n v i r o n m e n t a l change" moving t o a new f a c i l i t y w i t h new s t a f f and new programming. The second group e x -p e r i e n c e d o n l y a "moderate e n v i r o n m e n t a l change" moving t o a new f a c i l i t y w i t h s t a f f and programming r e m a i n i n g c o n s t a n t . M o r t a l i t y r a t e s f o r the " r a d i c a l change" group were s i g n i -f i c a n t l y h i g h e r . I n a d d i t i o n , f o l l o w i n g r e l o c a t i o n , p a t i e n t s i n t h i s group " . . . g r e w i n c r e a s i n g l y p e s s i m i s t i c r e g a r d i n g the s t a t e of t h e i r h e a l t h , withdrew from a c t i v i t i e s i n which t h e y had f o r m e r l y engaged, e x h i b i t e d lower l e v e l s of b e h a v i o r , and were somewhat l e s s i n c l i n e d t o p e r c e i v e t r u s t on the p a r t of those w i t h whom t h e y came i n t o c o n t a c t . " (p. 509) Two a d d i t i o n a l r e s e a r c h e r s r e i n f o r c e t h i s v iew. (Watson & B u e r k l e 1 9 7 6 ) ? (Gutman & H e r b e r t 1976) I n both t h e s e s t u d i e s , mass i n v o l u n t a r y t r a n s f e r s of g e r i a t r i c p a t i e n t s were not f o l l o w e d by t h e expected i n c r e a s e s i n m o r t a l i t y r a t e s . I n t h e s e r e l o c a t i o n s , t h e degree of e n v i r o n m e n t a l change was moderate - s t a f f , p a t i e n t f r i e n d s h i p p a t t e r n s , d a i l y r o u t i n e s and g e o g r a p h i c a l l o c a t i o n of f a c i l i t y remained the same. Watson and B u e r k l e (1976) note i n d i s c u s s i o n of t h e i r s t u d y : i " . . . m o r t a l i t y / i l l n e s s r a t e s i n i n v o l u n t a r y t r a n s f e r a r e 30. p r o p o r t i o n a l t o the amount of u n f a m i l i a r i t y a s s o c i a t e d w i t h r e l o c a t i o n , and when u n f a m i l i a r i t y i s minimized, i t may be p o s s i b l e t o e l i m i n a t e almost t o t a l l y the s p e c i a l r i s k r e l a t e d t o i t . " (p.282) Markus e t a l ( 1972) c o n c e p t u a l i z e the r e l o c a t i o n p r o c e s s as c o n s i s t i n g of two s e p a r a t e s t a g e s : " ' . . . ( a ) d e p r i v a t i o n of f a m i l i a r cues and e n v i r o n m e n t a l s u p p o r t s and (b) coping w i t h new s e t s of s t i m u l i i n an u n f a m i l i a r environment." (p. 376) Dur ing r e l o c a t i o n the o l d e r person must become f a m i l i a r w i t h a new p h y s i c a l and p s y c h o s o c i a l environment. W i t h i n t h i s new environment customary b e h a v i o r s and coping responses may no l o n g e r be f u n c t i o n a l . T h i s i s e s p e c i a l l y t r u e when the degree of d i s c o n t i n u i t y between o l d and new environments i s g r e a t . For example, w h i l e l i v i n g i n d e p e n d e n t l y w i t h i n the community b e h a v i o r a l c h a r a c t e r i s t i c s such as i n d i v i d u a l i t y , a s s e r t i v e -ness and independence may be n e c e s s a r y and e f f e c t i v e coping mechanisms. These same c h a r a c t e r i s t i c s may be d i s c o u r a g e d w i t h i n an i n s t i t u t i o n a l s e t t i n g t h a t f o s t e r s and rewards p a s s i v i t y , c o n f o r m i t y and dependency. There i s e v i d e n c e t o suggest t h a t i n v o l u n t a r y r e l o c a t i o n i s p a r t i c u l a r l y s t r e s s f u l f o r the e l d e r l y . T h i s a p p l i e s t o community moves as w e l l as t o i n s t i t u t i o n a l r e l o c a t i o n . Two s t u d i e s ( K a s t e l e r e t a l 1 9 6 8 ) , (Brand & Smith 1974) examined the p e r s o n a l and s o c i a l adjustment of a sample of e l d e r l y persons f o l l o w i n g t h e i r e n f o r c e d r e l o c a t i o n due t o urban renewal and highway c o n s t r u c t i o n . The r e l o c a t e d samples when compared w i t h samples of non-movers w i t h i n the community 31. showed g r e a t e r l i f e d i s s a t i s f a c t i o n , reduced a c t i v i t y and fewer s o c i a l c o n t a c t s . R e l o c a t i o n had a p p a r e n t l y d i s r u p t e d f a m i l i a r s o c i a l networks, c a u s i n g a c o n s t r i c t i o n i n f a m i l i a r a c t i v i t i e s w i t h d e l e t e r i o u s consequences f o r l a t e r l i f e a d j u s t m e n t . A s t u d y by F e r r a r i (1963) c i t e d e a r l i e r , examined the l e t h a l e f f e c t of i n v o l u n t a r y r e l o c a t i o n on a group of women e n t e r i n g i n s t i t u t i o n s . F e r r a r i found a s i g n i f i c a n t r e l a t i o n -s h i p between the l a c k of freedom of c h o i c e when e n t e r i n g an i n s t i t u t i o n ; and the subsequent death of the p e r s o n . Of the 1 7 women who s a i d t h e y had no a l t e r n a t i v e but t o move t o the home, 8 d i e d a f t e r f o u r weeks i n r e s i d e n c e and 16 were dead i n t e n weeks. The work of Sel igman i n the a r e a of " l e a r n e d h e l p l e s s -ness" and E n g e l on the " g i v i n g up - g i v e n up complex" may h e l p t o e x p l a i n t h e s e t r a g i c consequences of i n v o l u n t a r y r e l o c a t i o n . Sel igman (1975) has s t a t e d : "We s h o u l d expect t h a t when we remove the v e s t i g e s of c o n t r o l over the e n -vironment of an a l r e a d y weakened human b e i n g , we may w e l l k i l l h im." (p. 186) C l i n i c a l o b s e r v a t i o n of the emotional responses of the e l d e r l y d u r i n g an i n v o l u n t a r y i n t r a - i n s t i t u t i o n a l move a r e c o n t a i n e d i n a s t u d y by L o c k e r and R u b l i n ( 1 9 7 4 ) . When 48 r e s i d e n t s i n an i n s t i t u t i o n were f o r c e d t o r e l o c a t e due t o l e g i s l a t i v e changes, an e x t e n s i v e program was launched t o f a c i l i t a t e the move and i f p o s s i b l e m i t i g a t e any n e g a t i v e e f f e c t s . D u r i n g a group meeting t o announce the impending 32. move, the f o l l o w i n g r e a c t i o n s were n o t e d : "When we f i r s t met w i t h the groups of r e s i d e n t s t h e y were q u i e t a t f i r s t and t h e r e was a g e n e r a l f e e l i n g of apprehen-s i o n . The group communication we had hoped f o r was minimal and p r e d i c t a b l e . S i n c e t h e y had no p a r t i n making the d e c i s i o n s , t h e y f e l t p o w e r l e s s , i n -s i g n i f i c a n t and m a n i p u l a t e d . R e a c t i o n s e x p r e s s e d bore out f e e l i n g s of impotence and anger . One h a r d - o f - h e a r i n g man withdrew t o the f a r t h e s t end of the room." (p. 296) One may q u e s t i o n t o what e x t e n t i n s t i t u t i o n a l i z a t i o n i s ever t r u l y v o l u n t a r y . D e c l i n i n g h e a l t h and s o c i a l c i r c u m -s t a n c e s may n e c e s s i t a t e the move. However, f o r the m a j o r i t y of the e l d e r l y i n s t i t u t i o n a l i z a t i o n i s viewed as a s u r r e n d e r of independence, and i t i s a lmost i n v a r i a b l y approached w i t h f e a r and dread. E v i d e n c e of t h i s r e l u c t a n c e i s s u p p l i e d y by Townsend ( 1 9 6 2 ) , who noted i n h i s i n s t i t u t i o n a l s u r v e y t h a t " . . . r a t h e r fewer t h a n a f i f t h ( 1 7 percent) took the f i r s t s t e p t h e m s e l v e s . . . " (p. 230) A f i n a l f a c t o r i n f l u e n c i n g the p e r c e p t i o n s of s t r e s s concerns t h e d u r a t i o n of the w a i t i n g p e r i o d p r i o r t o i n s t i t u t -i o n a l i z a t i o n . Recent s t u d i e s have f o c u s e d on the a n x i e t y and p s y c h o l o g i c a l changes a s s o c i a t e d w i t h a n t i c i p a t i n g i n s t i t u t -i o n a l i z a t i o n . (Tobin & Lieberman 1976) ? (Sherwood e t a l 1974) ; (Zweig & Csank 1 9 7 6 ) . Lieberman (1969) n o t e s : " . . . m a n y o f the n e g a t i v e e f f e c t s a s c r i b e d t o l i v i n g i n an i n s t i t u t i o n were s e t i n motion by the d e c i s i o n t o e n t e r an i n s t i t u t i o n and o c c u r r e d w i t h maximum i n t e n s i t y p r i o r to a c t u a l e n t r a n c e . " L o n g i t u d i n a l s t u d i e s have examined changes i n p h y s i c a l h e a l t h , p s y c h o l o g i c a l s t a t u s and c o g n i t i v e f u n c t i o n i n g throughout the p r o c e s s of s e e k i n g , f i n d i n g and a n t i c i p a t i n g i n s t i t u t i o n a l i z a t i o n . They have shown t h a t the major p s y c h o l o g i c a l impact a s s o c i a t e d w i t h r e l o c a t i o n o c c u r s d u r i n g t h i s w a i t i n g p e r i o d . G i v e n t h i s i n f o r m a t i o n the p r e s e n t s i t u a t i o n of prolonged and u n c e r t a i n w a i t i n g p e r i o d s p r i o r t o placement would appear t o p l a c e an a d d i t i o n a l burden on the e l d e r l y t h a t can o n l y c r e a t e f u r t h e r d i s t r e s s . C h a r a c t e r i s t i c s of the i n d i v i d u a l : R e s e a r c h e r s have begun t o accumulate d a t a on the c h a r a c t e r -i s t i c s of t h o s e i n d i v i d u a l s who appear t o be most v u l n e r a b l e t o the e n v i r o n m e n t a l change a s s o c i a t e d w i t h r e l o c a t i o n . They have examined e l d e r l y p o p u l a t i o n s f o r s i g n i f i c a n t v a r i a b l e s -demographic d a t a ; p h y s i c a l , mental and p s y c h o l o g i c a l s t a t u s -p r i o r t o a move; and then compared s u r v i v o r s and n o n - s u r v i v o r s f o l l o w i n g r e l o c a t i o n . For the most p a r t , r e s u l t s from t h e s e s t u d i e s have been i n c o n c l u s i v e . R e s e a r c h e r s have e x p r e s s e d hope t h a t i f such v a r i a b l e s c o u l d be s u c c e s s f u l l y i d e n t i f i e d , d i f f e r e n t i a l programs might be developed t o a m e l i o r a t e the r i s k f o r s u s c e p t i b l e i n d i v i d u a l s p r i o r t o r e l o c a t i o n . E x a m i n a t i o n of demographic f a c t o r s has produced i n -c o n s i s t e n t r e s u l t s . K i l l i a n (1970)_ r e p o r t e d no s i g n i f i c a n t d i f f e r e n c e s between s u r v i v o r s and n o n - s u r v i v o r s a s s o c i a t e d w i t h s e x ; w h i l e the mean age of those dying was 8 t o 10 y e a r s h i g h e r t h a n s u r v i v o r s . K r a i and Berenson (1968) and Markus e t a l ( 1972) found s i g n i f i c a n t sex d i f f e r e n c e s , but l i t t l e age d i f f e r e n c e . I n t h e a r e a .of p h y s i c a l h e a l t h , Markus e t a l ( 1972) found a s i g n i f i c a n t a s s o c i a t i o n between p o s t - r e l o c a t i o n m o r t a l i t y and i m p a i r e d p h y s i c a l s t a t u s and s e v e r e p h y s i c a l dependence p r i o r t o the move. These r e s e a r c h e r s n o t e : " T h i s f i n d i n g l i k e l y i n d i c a t e s a g e n e r a l a s s o c i a t i o n between i n f i r m i t y and death which might be expected among any aged p o p u l a t i o n . " (p .379) K i l l i a n (1970) r e p o r t e d e x c e s s m o r t a l i t y r a t e s among nonambulatory p a t i e n t s , a f i n d i n g t h a t c o n t r a s t s w i t h r e s u l t s o b t a i n e d by Gutman and H e r b e r t (19 7 6 ) , who found t h a t the p r o p o r t i o n of d e a t h s was g r e a t e r among ambulatory than among nonambulatory p a t i e n t s . A v a r i a b l e t h a t appears t o more r e l i a b l y d i s c r i m i n a t e between s u r v i v o r s and n o n - s u r v i v o r s i s the degree of mental impairment p r i o r t o the move. Both the f u n c t i o n a l l y d i s t u r b -ed and t h o s e w i t h c h r o n i c b r a i n d i s e a s e appear to be v u l n e r a b l e t o r e l o c a t i o n . A l d r i c h and Mendkoff ( 1 9 6 3 ) , found t h a t " . . . a m o n g r e l o c a t e d r e s i d e n t s , the p s y c h o t i c or n e a r - p s y c h o t i c had the h i g h e s t death r a t e . " ( p . 1 9 2 ) Blenkner (1967) has noted: "One f a c t o r . . . emerges r a t h e r c l e a r l y and u n e q u i v o c a l l y as an i n d i c a t o r of "high r i s k " . That f a c t o r i s any e v i d e n c e of s e v e r e b r a i n d y s f u n c t i o n . When t h e r e i s e v i d e n c e t h a t the o l d e r p e r s o n ' s i n t e l l e c t i v e c a p a c i t y , h i s memory and h i s o r i e n t a t i o n t o t i m e , p l a c e and person are s e r i o u s l y i m p a i r e d , h i s chances of s u r v i v a l f o l l o w i n g r e l o c a t i o n a r e c o n s i d e r a b l y lower t h a n t h a t of a person who shows no or o n l y minimal s i g n s of such i m p a i r m e n t . . . " , (p. 103) 35. M i l l e r and Lieberrnan (1965) i n a study of 45 r e l o c a t e d women found t h a t " d e p r e s s i v e a f f e c t " p r i o r t o r e l o c a t i o n was s i g n i f i c a n t l y r e l a t e d t o n e g a t i v e outcome f o l l o w i n g the move. T h i s was supported i n the study by A l d r i c h and Mendkoff (1963) which found t h a t : "The death r a t e of n e u r o t i c , d e p r e s s e d and compuls ive r e s i d e n t s and of r e s i d e n t s who d e n i e d t h e i r p h y s i c a l d i s a b i l i t i e s was t h r e e tiities as h i g h as the death r a t e of r e s i d e n t s w i t h a s a t i s f a c t o r y a d j u s t -ment t o the Home, and more than t w i c e as h i g h as t h a t of r e s i d e n t s whose adjustment was c h a r a c t e r i z e d by h o s t i l e and demanding b e h a v i o r . " (p. 92) I n t h i s same s t u d y , the a u t h o r s found t h a t a p h i l o s o p h i c a l , angry or anxious response t o s t r e s s was more a d a p t i v e than r e g r e s s i o n , d e p r e s s i o n or d e n i a l . T h i s was conf irmed i n a study by Tobin and Lieberrnan (1976) which noted t h a t i n d i v i d u a l s who c h a r a c t e r i s t i c a l l y responded t o s t r e s s w i t h p a s s i v i t y were more v u l n e r a b l e t o n e g a t i v e e f f e c t s f o l l o w i n g r e l o c a t i o n . I n summary, the most e f f e c t i v e p r e d i c t o r s of a n e g a t i v e outcome f o l l o w i n g r e l o c a t i o n appear to be s e v e r e p h y s i c a l or mental impairment, and a p s y c h o l o g i c a l p a t t e r n of a d a p t -a t i o n c h a r a c t e r i z e d by p a s s i v i t y , d e p r e s s i o n , w i t h d r a w l , h o p e l e s s n e s s and h e l p l e s s n e s s . On the other hand, r e l o c a t e e s d i s p l a y i n g a v i g o r o u s , somewhat h o s t i l e - n a r c i s s i s t i c coping s t y l e appear t o adapt more e a s i l y t o r e l o c a t i o n . (Turner e t a l , 1972) E x t e r n a l r e s o u r c e s and s u p p o r t s : The e x t e r n a l r e s o u r c e s and supports a v a i l a b l e t o the 36. i n d i v i d u a l i s the t h i r d f a c t o r which w i l l determine the degree of p e r s o n a l d i s r u p t i o n e x p e r i e n c e d d u r i n g the s t r e s s of r e l o c a t i o n . These may i n c l u d e : the q u a l i t y of t h e new environment; the degree of p r e p a r a t i o n f o r the move; and t h e q u a l i t y of support from s i g n i f i c a n t o t h e r s . A number of s t u d i e s have examined t h e c h a r a c t e r i s t i c s of t h e e l d e r l y r e s i d i n g i n homes f o r the aged. v L ieberman (1969) i n a review of t h e s e s t u d i e s s u g g e s t s t h a t i n s t i t u t -i o n a l i z e d e l d e r l y people s h a r e the f o l l o w i n g c h a r a c t e r i s t i c s : " . . . p o o r a d j u s t m e n t ; d e p r e s s i o n and u n h a p p i n e s s ; i n t e l l e c t u a l i n e f f e c t i v e n e s s because of i n c r e a s e d r i g i d i t y and low energy (but not n e c e s s a r i l y i n t e l l e c t u a l incompetence) ; n e g a t i v e s e l f - i m a g e ; f e e l i n g s of p e r s o n a l i n s i g n i f i c a n c e and impotence and a view of s e l f as o l d . R e s i d e n t s tend t o be d o c i l e and s u b m i s s i v e , t o show a low range of i n t e r e s t s and a c t i v i t i e s , and t o l i v e i n the p a s t r a t h e r than the f u t u r e . They a r e withdrawn and u n r e s p o n s i v e i n r e l a t i o n s h i p s t o o t h e r s . There i s some s u g g e s t i o n t h a t they have i n c r e a s e d a n x i e t y , which a t t imes has as a focus t h e i r own d e a t h . " The q u e s t i o n remains, i s t h i s t r a g i c p o r t r a i t an e f f e c t o f the i n s t i t u t i o n a l m i l i e u i t s e l f ? Some s t u d i e s suggest i t may be. When o t h e r i n s t i t u t i o n a l i z e d p o p u l a t i o n s a r e examin-ed the syndrome d e s c r i b e d above i s r e p l i c a t e d i n t h e s e p o p u l a t i o n s . Bowlby (1952) has d e s c r i b e d the c h a r a c t e r i s t i c s of i n s t i t u t i o n a l i z e d c h i l d r e n i n the f o l l o w i n g way: "The e m o t i o n a l tone i s one of apprehension and s a d n e s s , t h e r e i s w i t h d r a w l from t h e environment amounting t o r e j e c t i o n of 37. i t , t h e r e i s no attempt t o c o n t a c t a s t r a n g e r and no b r i g h t e n i n g i f t h i s s t r a n g e r c o n t a c t s him. A c t i v i t i e s a r e r e t a r d e d and the c h i l d o f t e n s i t s or l i e s i n e r t i n a dazed s t u p o r . Insomnia i s common and l a c k of a p p e t i t e appears t o be u n i v e r s a l . Weight i s l o s t and the c h i l d becomes prone t o i n t e r c u r r e n t i n f e c t i o n s , (p.22) I f t h i s syndrome covers a wide spectrum of i n s t i t u t i o n -a l i z e d p o p u l a t i o n s , what a r e the c h a r a c t e r i s t i c s of i n s t i t u t -i o n s which might u l t i m a t e l y be r e s p o n s i b l e f o r t h i s e f f e c t ? The work of Goffman ( 1 9 6 1 ) o f f e r s one e x p l a n a t i o n . Goffman d e f i n e s homes f o r the aged as one of grouping of " t o t a l i n s t i t u t i o n s " . T o t a l i n s t i t u t i o n s s h a r e the f o l l o w i n g f e a t u r e s : a l l a s p e c t s of l i f e a r e conducted i n the same p l a c e and under the same s i n g l e a u t h o r i t y ; each phase of the member's d a i l y a c t i v i t y i s c a r r i e d on i n the immediate company of a l a r g e b a t c h of o t h e r s , a l l of whom a r e t r e a t e d a l i k e and r e q u i r e d t o do the same t h i n g t o -g e t h e r ; a l l phases of the d a y ' s a c t i v i t i e s are t i g h t l y s c h e d u l e d , w i t h one a c t i v i t y l e a d i n g a t a p r e a r r a n g e d t ime i n t o the n e x t , the whole sequence of a c t i v i t i e s b e i n g imposed from above by a system of e x p l i c i t f o r m a l r u l i n g s and a body of o f f i c i a l s ; and the v a r i o u s e n f o r c e d a c t i v i t i e s a r e brought t o g e t h e r i n t o a s i n g l e r a t i o n a l p l a n p u r p o r t e d -l y d e s i g n e d t o f u l f i l l the o f f i c i a l aims of the i n s t i t u t i o n , (p.6) A c c o r d i n g t o Goffman, i n s t i t u t i o n s which conform t o t h i s b u r e a u c r a t i c model produce i n the i n d i v i d u a l symptoms of w i t h d r a w l and s e l f - m o r t i f i c a t i o n . He n o t e s : " . . . t o t a l i n s t i t u t i o n s d i s r u p t or d e f i l e p r e c i s e l y t h o s e a c t i o n s t h a t i n c i v i l s o c i e t y have the r o l e of a t t e s t i n g t o the a c t o r and those i n h i s p r e s e n c e t h a t he has some command over h i s world, t h a t he i s a person w i t h " a d u l t " s e l f - d e t e r m i n a t i o n , autonomy and freedom of a c t i o n . " (p. 43) I s t h i s i n s t i t u t i o n a l syndrome an e f f e c t of the p o o r e s t of i n s t i t u t i o n s ; those homes i n which the e l d e r l y are c o n s i s t e n t l y s u b j e c t e d t o " r o u t i n i z a t i o n , i n f a n t i l i z a t i o n and d e s e x u a l i z a t i o n " ? (Brody 1977) ^ One s t u d y of the s o c i a l o r g a n i z a t i o n of c a r e i n a s i n g l e n u r s i n g home by Gubrium (1975) , p o i g n a n t l y d e s c r i b e s t h i s r e s t r i c t i o n of p e r s o n a l l i b e r t y and independence, and l o s s of p r i v a c y and autonomy. T r a g i c a l l y , the home which Gubrium d e s c r i b e s would be c o n s i d e r e d by many t o be a "good" home w i t h a m a n i f e s t b e l i e f i n " t o t a l p a t i e n t care" encompassing the p h y s i c a l , emotional s o c i a l and s p i r i t u a l needs of the r e s i d e n t s . A number of r e s e a r c h e r s have argued t h a t i t i s an o v e r s i m p l i f i c a t i o n t o a t t r i b u t e a l l of the observed n e g -a t i v e e f f e c t s t o the i n s t i t u t i o n a l regime i t s e l f . They b e l i e v e t h e s e symptoms of i n s t i t u t i o n a l i z a t i o n can be observed s h o r t l y a f t e r a d m i s s i o n , and t h e y are a product of the trauma of s e p a r a t i o n from the community. Townsend (1962) s u g g e s t s t h a t the c h i e f changes i n an i n d i v i d u a l ' s p s y c h o l o g y and b e h a v i o r o c c u r d u r i n g the f i r s t days or weeks a f t e r a d m i s s i o n t o an i n s t i t u t i o n . He n o t e s : "The i n d i v i d u a l seems t o r e c e i v e an i n i t i a l shock 39. which causes him t o a d j u s t q u i c k l y t o a new l e v e l of b e h a v i o r and t o adopt c e r t a i n new a t t i t u d e s towards h i s environment and h i m s e l f . " (p. 367) T o b i n and Lieberman (19 76) i n a l o n g i t u d i n a l s t u d y of community e l d e r l y e n t e r i n g c a r e found t h a t the most d r a m a t i c n e g a t i v e changes i n p s y c h o l o g i c a l f u n c t i o n i n g o c c u r r e d w h i l e the o l d e r person was a w a i t i n g a d m i s s i o n . "The changes i n p s y c h o l o g i c a l f u n c t i o n i n g from the " p r e d e c i s i o n " p e r i o d t o the p e r i o d w h i l e a w a i t i n g a d m i s s i o n were d r a m a t i c a l l y s i m i l a r to t h o s e g e n e r a l l y c i t e d as i n d u c e d by the h a r m f u l q u a l i t i e s of i n s t i t u t i o n a l l i f e i t s e l f . T h i s f i n d i n g amply demonstrates how s e p a r a t i o n and a n t i c i p a t i o n of l o s s can a f f e c t p s y c h o l -o g i c a l s t a t u s , e v e n t u a l l y p a i n t i n g a p o r t r a i t no more d e s i r a b l e than t h a t of i n s t i t u t i o n a l i z e d e l d e r p e o p l e . " ( p . 2 1 4 ) Some r e s e a r c h e r s , (Tobin and Lieberman 1 9 7 6 ) ? (Weinstock and Bennet 1 9 7 1 ) have noted s t a b i l i t y or improvement i n p s y c h o l o g i c a l f u n c t i o n i n g a f t e r e n t e r i n g the i n s t i t u t i o n . These r e s u l t s a r e s i g n i f i c a n t i f we a c c e p t t h a t i n s t i t u t i o n -a l i z a t i o n f o r some e l d e r l y i s n e c e s s a r y and u n a v o i d a b l e g i v e n t h e i r degree of p h y s i c a l i n f i r m i t y and l a c k of s o c i a l s u p p o r t s . I t i s i m p e r a t i v e t h e r e f o r e , t o examine i n s t i t u t i o n -a l environments t h a t do not appear t o produce t h e s e n e g a t i v e e f f e c t s . From a review of t h e l i t e r a t u r e , L i e b o w i t z (19 74) concludes t h a t a "good" i n s t i t u t i o n a l s e t t i n g would i n c l u d e t h e s e c h a r a c t e r i s t i c s : i t would encourage independent b e h a v i o r ; o f f e r r e s p e c t f u l a t t i t u d e s , concern and a f f e c t i o n ; p r o v i d e o p p o r t u n i t i e s f o r c o n s t r u c t i v e a c t i v i t i e s and s o c i a l 40 i n t e r a c t i o n ; and p r o v i d e a c c e s s t o the o u t s i d e community, (p. 293) y The degree of p r e p a r a t i o n f o r the move appears t o be another f a c t o r a f f e c t i n g the i n d i v i d u a l ' s p e r c e p t i o n of s t r e s s d u r i n g r e l o c a t i o n . E v i d e n c e s u g g e s t s t h a t one of the most e f f e c t i v e means of a m e l i o r a t i n g the impact of i n s t i t u t i o n a l i z a t i o n , or i n t r a - i n s t i t u t i o n a l moves r e s i d e s i n s e n s i t i v e p r e p a r a t i o n f o r the move through c a r e f u l casework s e r v i c e and p s y c h o l o g i c a l s u p p o r t . A number of r e s e a r c h e r s have c r e d i t e d improved s u r v i v a l r a t e s f o l l o w i n g r e l o c a t i o n t o e x t e n s i v e p r e p a r a t o r y programs. (Jasnau 1967) ( W i t t e l s & B o t w i n i c k 1 9 7 4 ) ; (Gutman & H e r b e r t 1976) J a s n a u (1967) found s i g n i f i c a n t l y lower death r a t e s f o r p a t i e n t s t r a n s f e r r e d i n d i v i d u a l l y t o n u r s i n g homes f o l l o w i n g an e x t e n s i v e program of p r e p a r a t i o n t h a n f o r p a t i e n t s mass-moved w i t h i n the h o s p i t a l w i t h l i t t l e or no p r e p a r a t i o n . P r e p a r a t i o n i n c l u d e d : " . . . e d u c a t i o n a l programs a t a l l l e v e l s of h o s p i t a l and nursing-home s t a f f s and p e r -s o n n e l , and i n c l u d e d the p s y c h o l o g i c and emotional p r e p a r -a t i o n of the p a t i e n t f o r the t r a n s f e r through s o c i a l c a s e -work s e r v i c e s . " (p. 284) Although J a s n a u d i d not c o n t r o l f o r o t h e r d i f f e r e n c e s which may have e x i s t e d between t h e two groups, he concluded t h a t adequate p r e p a r a t i o n " . . . c a n reduce the trauma a s s o c i a t e d w i t h change f o r the o l d e r y p a t i e n t . " An e x t e n s i v e p r e p a r a t o r y program r e p o r t e d by N o v i c k (1967) was i n i t i a t e d when the e n t i r e p o p u l a t i o n of the 41 / Maimonides H o s p i t a l i n Montreal was moved to a new f a c i l i t y , p r e p a r a t i o n s i n c l u d e d : i n v o l v i n g the r e s i d e n t s through t h e i r P a t i e n t s ' Club i n the p r o c e s s of d e c i s i o n making on important problems of d e s i g n f o r the new f a c i l i t y ; s c h e d u l i n g f r e q u e n t bus t r i p s t o the new s i t e so r e s i d e n t s c o u l d observe the p r o g r e s s d u r i n g c o n s t r u c t i o n of the new f a c i l i t y ; and c o n s t r u c t i o n a t the o l d h o s p i t a l of a l i f e -s i z e model of one of the new rooms so t h a t r e s i d e n t s c o u l d become accustomed t o them. I n a d d i t i o n , r e s i d e n t s concerns and wishes r e g a r d i n g roommates i n the new f a c i l i t y , and the t r a n s f e r of p e r s o n a l b e l o n g i n g s was g i v e n s p e c i a l a t t e n t i o n . Every e f f o r t was made t o ensure c o n t i n u i t y of s t a f f , and t o i n v o l v e f a m i l y , f r i e n d s and v o l u n t e e r s i n the p r o c e s s . I n t h i s s t u d y , not o n l y d i d the m o r t a l i t y r a t e not i n - j c r e a s e f o l l o w i n g r e l o c a t i o n , but i t was 9 . 8 p e r c e n t below the normal a n n u a l m o r t a l i t y r a t e . Novick n o t i n g t h i s u n -u s u a l d e c r e a s e i n m o r t a l i t y r a t e s c r e d i t s not o n l y the p r e -paratory program, . but a l s o the environment of the new b u i l d i n g which was d e s i g n e d t o a l l o w i n d i v i d u a l p r i v a c y , w h i l e a t the same time p r o v i d i n g a r e a s t h a t encouraged maximum i n t e r a c t i o n on an i n t i m a t e b a s i s . Although a somewhat l e s s e x t e n s i v e p r e p a r a t o r y program was employedr Zweig and Csank (1976) observed a s i m i l a r d e c r e a s e i n m o r t a l i t y r a t e s f o l l o w i n g the mass t r a n s f e r of g e r i a t r i c p a t i e n t s t o a new f a c i l i t y . These authors note t h a t : " . . . a good s t r e s s - p r e v e n t i o n program i s the e s s e n t i a l requirement f o r r e d u c i n g m o r t a l i t y and a v e r t i n g c a t a s t r o p h e . (p. 276) They have o u t l i n e d some of the f e a t u r e s which p r e -p a r a t o r y programs s h o u l d i n c l u d e : the f e e l i n g s of the p a t i e n t s a r e t h e p r i m a r y c o n s i d e r a t i o n and perhaps p r o c e d u r e s f o r f a m i l i a r i z a t i o n w i t h the environment a r e s e c o n d a r y ; the b e g i n n i n g of a s t r e s s - p r e v e n t i o n program must be u n o b t r u s i v e and keyed t o the l e v e l of the most s e n s i t i v e p a t i e n t ; the program must be i n t r o d u c e d i n a g r a d u a l and o r d e r l y manner, and s p e c i a l s t e p s s h o u l d be taken t o p r e v e n t d i s r u p t i o n of r o u t i n e s ; s t a f f o r i e n t a t i o n w i t h r e g a r d t o the needs of v u l n e r a b l e subgroups s h o u l d be the f i r s t and most important p a r t of the program; and a s u c c e s s f u l stress -prevention program s h o u l d not be h a l t e d u n t i l the danger of a f t e r -e f f e c t s of r e l o c a t i o n have d i s a p p e a r e d , (p. 276) The f i n a l f a c t o r of importance i n a l l e v i a t i n g s t r e s s d u r i n g r e l o c a t i o n i s the involvement of s i g n i f i c a n t f a m i l y members and f r i e n d s . I n the v a s t m a j o r i t y of the f o r e -going s t u d i e s , the c r u c i a l r o l e of f a m i l y members i n the r e l o c a t i o n p r o c e s s has not been c o n s i d e r e d . T h i s d e f i c i e n c y may be p a r t i a l l y e x p l a i n e d by s t a t i s t i c a l d a t a t h a t i n d i c a t e s t h a t i n g e n e r a l those i n i n s t i t u t i o n s a r e more l i k e l y t o l a c k or t o have l o s t c l o s e s u p p o r t i v e r e l a t i v e s . Townsend (1962) i n h i s U n i t e d Kingdom s u r v e y of i n s t i t u t i o n a l f a c i l i t i e s f o r the aged found t h a t more widowed o l d e r p e o p l e , more unmarr ieds , more c h i l d l e s s people, and more w i t h o n l y one a d u l t c h i l d l i v e d i n i n s t i t u t i o n s . I n f a c t , " those w i t h no s u r v i v i n g c h i l d r e n formed 5 1 p e r c e n t of the sample." (p. 290) S t u d i e s from the U n i t e d 43 S t a t e s c o r r o b o r a t e t h e s e f i g u r e s . Brody (1977) r e p o r t s t h a t o n l y about 10 p e r c e n t of the i n s t i t u t i o n a l i z e d e l d e r l y are m a r r i e d , w h i l e 63 p e r c e n t are widowed, 22 p e r c e n t have never m a r r i e d , and 5 p e r c e n t a r e d i v o r c e d . Whi le s t a t i s t i c a l d a t a on r e s i d e n t i a l p o p u l a t i o n s i n Canada i s not a v a i l a b l e , s u r v e y s of the community e l d e r l y as r e p o r t e d by S t a t i s t i c s Canada (1976) have noted a s i m i l a r t r e n d . Among the age group most s u s c e p t i b l e t o i n s t i t u t i o n a l i z a t i o n , the p r o -p o r t i o n widowed i n c r e a s e s s h a r p l y . Dur ing 19 76, 56 p e r c e n t of women aged 6 5 - 6 9 were m a r r i e d , however by age 80 and over, l e s s t h a n 1 5 p e r c e n t were m a r r i e d . <t A common m i s p e r c e p t i o n which i s not confirmed by a v a i l a b l e e v i d e n c e concerns the b e l i e f t h a t the i n s t i t u t i o n -a l i z e d e l d e r l y have been abandoned by u n c a r i n g r e l a t i v e s . I n t r u t h , i n most i n s t a n c e s the d e c i s i o n t o p l a c e an e l d e r l y f a m i l y member i n care i s made w i t h g r e a t r e l u c t a n c e and o n l y a f t e r o t h e r avenues of care have been e x h a u s t e d . I n many c a s e s , i n s t i t u t i o n a l i z a t i o n f o l l o w s long p e r i o d s d u r i n g which r e l a t i v e s have expended p h y s i c a l and emotional energy and f i n a n c i a l r e s o u r c e s i n an attempt t o m a i n t a i n the o l d e r person i n the community. When i n s t i t u t i o n a l i z a t i o n becomes an i n e v i t a b l e and n e c e s s a r y r e a l i t y , f a m i l y members must o f t e n cope not o n l y w i t h t h e i r own f e e l i n g s of g u i l t , but w i t h the e l d e r l y p e r s o n ' s f e e l i n g of anger, r e j e c t i o n and abandonment. F o l l o w i n g i n s t i t u t i o n a l i z a t i o n , a v a i l a b l e r e l a t i v e s c o n t i n u e t o p l a y an important and v i t a l - a l b e i t somewhat d i f f e r e n t r o l e . (Gubruim 1 9 7 5 ) ; ( M i l l e r & Beer 1 9 7 7 ) ; (Tobin & Lieberman 19 7 6 ) . Gubruim r e p o r t s t h a t i n v o l v e d and concerned c h i l d r e n a r e the " c u r r e n c y " of the i n s t i t u t -i o n a l i z e d e l d e r l y t h a t p u r c h a s e s s t a t u s amongst t h e i r p e e r s . T o b i n and Lieberman note the i m p o r t a n t r o l e of c h i l d r e n : " . . . i n c a r r y ( i n g ) on t r a d i t i o n s and v a l u e s (that) h e l p the e l d e r l y a c h i e v e a p e r s o n a l r e s o l u t i o n w i t h death, a f e e l i n g t h a t o n e ' s l i f e has been a m e a n i n g f u l one." (p. 231) R e l a t i v e s p r o v i d e a sense of c o n t i n u i t y amidst the d i s c o n t i n u i t y of e n v i r o n m e n t a l change; and a l s o m a i n t a i n n e c e s s a r y l i n k a g e s w i t h the community t h a t has been l e f t b e h i n d . The s i g n i f i c a n t r o l e of f a m i l y members i n s u s t a i n -i n g and s u p p o r t i n g the o l d e r person throughout the p r o c e s s of i n s t i t u t i o n a l i z a t i o n has been examined by Brody and Spark (1966) . They have s t a t e d : "The importance of " f a m i l y " t o the c h i l d has been u n i v e r s a l l y a c c e p t e d . The need of the aged person f o r " f a m i l y " i s no l e s s v i t a l . Whether the aged person l i v e s under a s e p a r a t e roof or i n a d i s t a n t c i t y , he c o n t i n u e s as a member of an o r g a n i c f a m i l y group. H i s s i t u a t i o n i n e v i t a b l y a f f e c t s and i s a f f e c t e d by each i n d i v i d u a l member of t h a t f a m i l y . " (p. 78) 45 PART I I : STUDIES OF THE INSTITUTIONALIZED ELDERLY INTRODUCTION As noted i n the f o r e g o i n g l i t e r a t u r e review, r e l o c a t i o n can under c e r t a i n c o n d i t i o n s , and w i t h c e r t a i n k i n d s of i n d i v i d u a l s pose s e r i o u s r i s k s t o the p h y s i c a l and p s y c h o l o g i c a l w e l l - b e i n g of e l d e r l y p e r s o n s . I n view of the p o s s i b l e n e g a t i v e c o n s e -quences of r e l o c a t i o n , under what c i r c u m s t a n c e s does i n s t i t u t -i o n a l i z a t i o n appear t o be i n d i c a t e d ? I n s e e k i n g an answer t o t h i s q u e s t i o n , some l i t e r a t u r e on e l d e r l y i n s t i t u t i o n a l i z e d p o p u l a t i o n s w i l l be examined. R e s e a r c h e r s have s t u d i e d i n s t i t u t i o n a l i z a t i o n r a t e s , the c h a r a c t e r i s t i c s of i n s t i t u t -i o n a l p o p u l a t i o n s , and the p r e c i p i t a t i n g f a c t o r s t h a t l e a d e l d e r l y persons t o seek i n s t i t u t i o n a l c a r e . I n P a r t I I of t h i s paper, a number of t h e s e s t u d i e s w i l l be reviewed. I t s h o u l d be noted however, t h a t the m a j o r i t y of t h e s e s t u d i e s have been g a r n e r e d from B r i t i s h and American p u b l i c -a t i o n s . When t h e y were a v a i l a b l e , Canadian s t u d i e s have been u t i l i z e d . E l d e r l y i n s t i t u t i o n a l i z e d p o p u l a t i o n s i n d i f f e r e n t c o u n t r i e s may not be s t r i c t l y comparable. I n s t i -t u t i o n a l care i s a p a r t i c u l a r s o c i a l response t o the problems t h a t may be a s s o c i a t e d w i t h a g i n g . While i n s t i t u t i o n a l i z a t i o n may be sought as a response t o the r e a l h e a l t h and s o c i a l needs of i n d i v i d u a l s , the type of c a r e p r o v i d e d , and the c i r c u m s t a n c e s under which i t i s u t i l i z e d a l s o r e f l e c t the p r e v a i l i n g c u l t u r a l norms and v a l u e s of a s o c i e t y i n r e l a t i o n t o t h e i r b e l i e f s about a g i n g , and the needs of aging p e o p l e ; and the r o l e t h a t the s t a t e and the f a m i l y s h o u l d each p l a y i n meeting those needs. 46 STATISTICAL DATA ON INSTITUTIONALIZATION OF THE ELDERLY I N CANADA AND B R I T I S H COLUMBIA I t i s d i f f i c u l t t o o b t a i n a c c u r a t e s t a t i s t i c s on the number of i n s t i t u t i o n a l i z e d Canadians 65 y e a r s and o v e r . F i r s t l y , the d a t a a v a i l a b l e from S t a t i s t i c s Canada does not s e p a r a t e s h o r t - s t a y from l o n g - t e r m c a s e s . S t a t i s t i c s are a v a i l a b l e on i n s t i t u t i o n a l r a t e s f o r the e l d e r l y , b u t s t a t i s t i c s r e l a t i n g e x c l u s i v e l y t o the " i n s t i t u t i o n a l i z e d " e l d e r l y , (which may be d e f i n e d as those committed t o i n s t i t u t i o n a l c a r e f o r a p e r i o d e x c e e d i n g two months), are not a v a i l a b l e . The second d i f f i c u l t y a r i s e s over the d e f i n i t i o n of i n s t i t u t i o n s . The d e f i n i t i o n may encompass a wide v a r i e t y of s e t t i n g s , i n c l u d i n g congregate r e s i d e n t i a l f a c i l i t i e s e x c l u s i v e l y h o u s i n g the e l d e r l y , q u a s i - i n s t i t u t i o n a l s e t t i n g s p r o v i d i n g some c e n t r a l i z e d h e a l t h a n d / o r s o c i a l s e r v i c e s , and f u l l i n s t i t u t i o n a l c a r e p r o v i d e d w i t h i n a h o s p i t a l s e t t i n g . Many s t a t i s t i c s do not d e f i n e the l e v e l of c a r e p r o v i d e d . With t h e s e l i m i t a t i o n s i n mind, the l a t e s t s t a t i s t i c s a v a i l a b l e from S t a t i s t i c s Canada (1976) e s t i m a t e t h a t i n t h a t y e a r , 8 .4 p e r c e n t of the p o p u l a t i o n 65 y e a r s and over were r e c e i v i n g some form of i n s t i t u t i o n a l c a r e . I n the same y e a r i n B r i t i s h Columbia, 1 6 , 8 0 7 p e r s o n s , or a p p r o x i m a t e l y 6 . 9 p e r c e n t of t h e e l d e r l y p o p u l a t i o n were r e c e i v i n g i n s t i t u t i o n a l c a r e i n G e n e r a l and A l l i e d S p e c i a l H o s p i t a l s , S p e c i a l Care F a c i l i t i e s and Mental H e a l t h F a c i l i t i e s . (Schwenger & G r o s s , 1980) W i t h i n the p r o v i n c e of B r i t i s h Columbia a t t h e p r e s e n t t ime, ( A p r i l , 1 9 8 1 ) , 1 5 , 9 6 5 persons are r e c e i v i n g i n s t i t u t i o n a l 47 c a r e under the Long-Term Care R e s i d e n t i a l Program. An a d d i t i o n a l 6 ,489 persons are r e s i d i n g i n extended c a r e f a c i l i t i e s which are a d m i n i s t e r e d under the D i v i s i o n of I n s t i t u t i o n a l S e r v i c e s , M i n i s t r y of H e a l t h . Extended c a r e f a c i l i t i e s p r o v i d e s k i l l e d t w e n t y - f o u r - h o u r a day n u r s i n g s e r v i c e s and c o n t i n u i n g m e d i c a l s u p e r v i s i o n . ( B a y l e y , 1 9 8 1 ) I n a d d i t i o n , a f u r t h e r 2 , 8 1 1 l o n g - t e r m c a r e beds have been approved f o r c o n s t r u c t i o n , or are under c o n s t r u c t i o n and w i l l be completed b e f o r e 1 9 8 2 . ( M i n i s t r y of H e a l t h Annual Report, 1979) Even so, the p r e s e n t c o n s t r u c t i o n r a t e cannot keep pace w i t h t h e dema.nd f o r i n s t i t u t i o n a l s e r v i c e s . As a r e s u l t , i n 1980, one i n s i x a c u t e c a r e beds i n B r i t i s h Columbia was o c c u p i e d by a long term p a t i e n t a w a i t i n g i n s t i t u t i o n a l i z a t i o n . (Padmore, 1 9 8 1 ) The above f i g u r e s bear w i t n e s s t o the h i g h l e v e l of i n s t i t u t i o n a l i z a t i o n among C a n a d a ' s o l d e r p o p u l a t i o n . Schwenger and Gross (1980) have e s t i m a t e d t h a t i n the p r o v i n c e of O n t a r i o i n 1 9 7 6 , out of the t o t a l p o p u l a t i o n 65 y e a r s and o l d e r r e -c e i v i n g i n s t i t u t i o n a l c a r e , about o n e - p e r c e n t were i n s h o r t -s t a y c a r e . I f t h a t s t a t i s t i c i s a p p l i e d throughout Canada, our r a t e of i n s t i t u t i o n a l i z a t i o n f o r aged Canadians i s a lmost 7 . 5 p e r c e n t . Although comparisons of i n s t i t u t i o n a l i z a t i o n r a t e s among c o u n t r i e s must be approached w i t h c a u t i o n because of the aforementioned i n c o n s i s t e n c i e s i n the d e f i n i t i o n of " i n s t i t u t i o n " , t h i s Canadian s t a t i s t i c ( 7 . 5 percent) i s c o n s i d e r ed e x c e s s i v e when compared t o r a t e s of i n s t i t u t i o n a l i z a t i o n i n G r e a t B r i t a i n ( 5 . 1 p e r c e n t ) , and the U n i t e d S t a t e s ( 6 . 3 percent) 48 (Schwenger & G r o s s , 19 80, p. 251) As a number of r e s e a r c h e r s have noted, s t a t i s t i c s on i n s t i t u t i o n a l i z a t i o n r a t e s a r e m i s l e a d i n g i n t h a t they a r e based on c r o s s - s e c t i o n a l r a t h e r than l o n g i t u d i n a l d a t a . The p e r c e n t a g e of the p o p u l a t i o n 65 y e a r s and over i n i n s t i t u t i o n s a t any one t ime i s not the same as the p e r c e n t a g e of the o v e r -65 p o p u l a t i o n which w i l l become i n s t i t u t i o n a l i z e d b e f o r e they d i e . I n an American s t u d y , an e x a m i n a t i o n of death c e r t i f i c a t e s f i l e d f o r i n d i v i d u a l s over 65 r e v e a l e d t h a t as many as 20 p e r c e n t o c c u r r e d i n n u r s i n g home f a c i l i t i e s . (Ingram & B a r r y , 1977) Palmore ( 1 9 7 6 ) , has e s t i m a t e d t h a t the chances of becom-i n g an i n s t i t u t i o n a l r e s i d e n t among normal aged persons l i v i n g i n t h e community i s about one i n f o u r . The t o t a l chance of i n -s t i t u t i o n a l i z a t i o n i n c r e a s e s p r o g r e s s i v e l y w i t h advancing age. For t h o s e over age 75 i n Canada, 1 5 p e r c e n t a r e e s t i m a t e d t o be i n i n s t i t u t i o n s a t any one t ime, (The S p e c i a l Committee of the Senate on Aging, 1966, p. 1 0 7 ) : and f o r the over 85 age group, the number i n s t i t u t i o n a l i z e d i n c r e a s e s f u r t h e r t o a s t a g g e r i n g 39 p e r c e n t . ( M a r s h a l l , 1 9 8 1 ) CHARACTERISTICS OF ELDERLY RESIDENTIAL POPULATIONS Any e x a m i n a t i o n of the c h a r a c t e r i s t i c s of the i n s t i t u t -i o n a l i z e d e l d e r l y must t a k e i n t o account both the v a r i a t i o n among i n d i v i d u a l r e s i d e n t s , and the v a r i a t i o n among f a c i l i t i e s which may p r o v i d e s i g n i f i c a n t l y d i f f e r e n t l e v e l s of c a r e . With t h i s r e s e r v a t i o n , t h e a v a i l a b l e l i t e r a t u r e has p r o v i d e d a f a i r l y comprehensive p i c t u r e of i n s t i t u t i o n a l r e s i d e n t s . 49 Who among the e l d e r l y a r e most l i k e l y t o seek i n s t i t u t i o n a l c a r e ? F i r s t , as noted above, i t i s t h e o l d e s t of the o l d . The average age of i n s t i t u t i o n a l r e s i d e n t s i s 82 y e a r s ; and 70 p e r c e n t of r e s i d e n t s are over 70 y e a r s of age. ( G e l f a n d & O l s e n , 19 80) Women outnumber men i n i n s t i t u t i o n a l p o p u l a t i o n s by 3 t o 1 . ( G e l f a n d & O l s e n , 1980) However, women outnumber men among the aged i n g e n e r a l , (about 5 t o 4 i n x t h e t o t a l 65 and over p o p u l a t i o n i n B r i t i s h C o l u m b i a ) . The l o n g e r l i f e e x p e c t a n c y of women makes them more v u l n e r a b l e t o widowhood and the i l l n e s s e s a s s o c i a t e d w i t h a g i n g ; and both t h e s e c o n d i -t i o n s a r e c o r r e l a t e d w i t h an i n c r e a s e d l i k e l i h o o d of i n s t i t u t -i o n a l i z a t i o n . When compared t o community p o p u l a t i o n s of e l d e r l y p e o p l e , i n s t i t u t i o n a l r e s i d e n t s have s i g n i f i c a n t l y l e s s economic r e s o u r c e s . A Canadian s t u d y c r e d i t e d t h i s d i f f e r e n c e i n p a r t t o the f a c t t h a t the community e l d e r l y are most l i k e l y t o have a l i v i n g spouse, and so r e p o r t a combined r e t i r e m e n t income. I n a d d i t i o n , t h i s s t u d y r e p o r t e d t h a t 14 p e r c e n t of t h e i r community sample i n s p i t e of t h e i r advanced age, were s t i l l employed. (Kraus e t a l , 19 76a) E l d e r l y i n s t i t u t i o n a l i z e d r e s i d e n t s s u f f e r from m u l t i p l e c h r o n i c p h y s i c a l d i s a b i l i t i e s . (Brody, 1977) Many of t h e s e a i l m e n t s r e s u l t i n f u n c t i o n a l i n c a p a c i t y which i m p a i r s a m b u l a t i o n , and o t h e r a c t i v i t i e s of d a i l y l i v i n g . Surveys of i n s t i t u t i o n a l r e s i d e n t s have found t h a t l e s s than 50 p e r c e n t of r e s i d e n t s a r e f u l l y ambulatory; 55 p e r c e n t a r e i m p a i r e d i n s e l f - c a r e a c t i v i t i e s , and 2 5 - 3 3 p e r c e n t are i n c o n t i n e n t . ( B u t l e r , 1 9 7 7 ) ; ( G e l f a n d & Olsen, 1980) 50 Mental d i s o r d e r s a r e e x t r e m e l y p r e v a l e n t amongst i n s t i t u t i o n a l i z e d r e s i d e n t s . As r e s e a r c h e r s have noted, mental impairment p a r a l l e l s p h y s i c a l f u n c t i o n a l d e c l i n e . I m p a i r e d mental and i m p a i r e d p h y s i c a l f u n c t i o n i n a l a r g e p o r t i o n of aged persons a r e s i m p l y two a s p e c t s of the same d i s o r d e r . ( G o l d f a r b , 1 9 6 1 ) S t a t i s t i c s from the U n i t e d S t a t e s i n d i c a t e t h a t the number of m e n t a l l y i m p a i r e d aged l i v i n g i n i n s t i t u t -i o n s i n t h a t c o u n t r y i s h i g h . A n a t i o n a l s u r v e y of n u r s i n g homes found t h a t 34 p e r c e n t of the p o p u l a t i o n had "advanced s e n i l i t y " , and 27 p e r c e n t " l e s s s e r i o u s s e n i l i t y " ; Another 1 7 p e r c e n t had o t h e r mental d i s o r d e r s such as mental i l l n e s s or r e t a r d a t i o n . (Brody, 1977) I n Canada, the number of m e n t a l l y i m p a i r e d e l d e r l y r e s i d i n g i n l o n g - t e r m c a r e i n s t i t u t i o n s i s d i f f i c u l t t o e s t i m a t e . P a r t of the d i f f i c u l t y l i e s i n a c c u r a t e l y d e f i n i n g the term " m e n t a l l y i m p a i r e d " . I t i s e s t i m a t e d t h a t a p p r o x i m a t e l y 7 t o 8 p e r c e n t of those over 65 y e a r s of age e x h i b i t some " c o n f u s i o n " . ( B l a c k , 1978) T h i s i s however a g l o b a l term encompassing both f u n c t i o n a l and o r g a n i c mental d i s t u r b a n c e . I n one Canadian s t u d y of a r e s i d e n t i a l p o p u l a t i o n , o n l y 33 p e r c e n t of t h e sample were s c o r e d as normal on a Dementia S c a l e developed by the r e s e a r c h e r s . (Kraus e t a l , 1976a) I n B r i t i s h Columbia, the p s y c h o g e r i a t r i c r e s i d e n t i s d e f i n e d a s : " an i n d i v i d u a l who i n a d d i t i o n t o c o n f u s i o n and i m p a i r e d comprehension e x h i b i t ( s ) a n t i - s o c i a l h a b i t s d e s t r u c -t i v e , a g g r e s s i v e or v i o l e n t b e h a v i o r , . . . c o n t i n u a l l y wander(s) away; or may endanger h i s or h e r own l i f e . " (Hanbury, 1 9 8 1 ) 51 Depending on t h e degree of mental d i s t u r b a n c e , p s y c h o g e r i a t r i c r e s i d e n t s may be r e c e i v i n g c a r e e i t h e r i n V a l l e y v i e w H o s p i t a l e s t a b l i s h e d as a t r e a t m e n t f a c i l i t y f o r t h e p s y c h o g e r i a t r i c p a t i e n t , o r i n one of t h e f a c i l i t i e s a d m i n i s t e r e d under the Long-Term Care R e s i d e n t i a l Program. The number of p s y c h o -g e r i a t r i c r e s i d e n t s i n any one Long-Term Care f a c i l i t y i s dependent on t h e c a p a c i t y o f t h e f a c i l i t y t o p r o v i d e t h e p h y s i c a l s e t t i n g , s t a f f i n g and programming t o meet t h e s p e c i a l needs of t h e s e e l d e r l y r e s i d e n t s . As n o t e d , r e s i d e n t i a l p o p u l a t i o n s a r e overwhelmingly composed of t h e v e r y o l d , w i t h m u l t i p l e p h y s i c a l a n d / o r mental i m p a i r m e n t s . However, t h e m a j o r i t y of t h e v e r y s i c k and f r a i l e l d e r l y a r e not i n i n s t i t u t i o n s ; t h e y a r e l i v i n g i n t h e i r own homes, or i n t h e homes of f a m i l y members. (Shanas, 19 79) A C a n a d i a n h e a l t h s u r v e y has r e p o r t e d t h a t t h e number of community e l d e r l y w i t h a s i g n i f i c a n t h e a l t h problem, a n d / o r f u n c t i o n a l d i s a b i l i t y r i s e s from 5 . 5 p e r c e n t of t h e p o p u l a t i o n between t h e ages of 60 to- 64; t o 3 5 . 5 p e r c e n t of t h e p o p u l a t i o n i n t h e 85 p l u s age group. ( M a r s h a l l , 19 81) I t i s a p p a r e n t t h a t t h e e l d e r l y who r e s o r t t o i n s t i t u t i o n a l c a r e must d i f f e r i n some o t h e r way from t h e i r n o n - i n s t i t u t i o n a l i z e d p e e r s . R e s e a r c h e r s have noted one s i g n i f i c a n t d i f f e r e n c e i n r e s i d e n t i a l p o p u l a t i o n s i s t h e i r l a c k of f a m i l y r e s o u r c e s . Townsend ( 1 9 6 5 ) , has w r i t t e n : " . . . t h e l i k e l i h o o d of a d m i s s i o n t o an i n s t i t u t i o n i n o l d a g e . . . i s p a r t l y c o n t i n g e n t on f a m i l y c o m p o s i t i o n , s t r u c t u r e and o r g a n i z a t i o n and not o n l y on i n c a p a c i t y , h o m e l e s s n e s s and l a c k of s o c i o - e c o n o m i c r e s o u r c e s . " F a m i l y s t r u c t u r e , ( m a r i t a l s t a t u s and l i v i n g arrangements) , p r o v i d e s one i n d i c a t i o n of the p o t e n t i a l a v a i l a b i l i t y of k i n t o p r o v i d e support s h o u l d the need a r i s e . Surveys of r e s i d e n t -i a l p o p u l a t i o n s have c o n s i s t e n t l y found t h a t widowed and unmarr ied people make up the m a j o r i t y of i n s t i t u t i o n a l i z e d r e s i d e n t s . (Brody, 1977) I n the g e n e r a l p o p u l a t i o n of e l d e r l y i n Canada, 80.4 p e r c e n t of males 6 5 - 6 9 y e a r s o f . a g e a r e m a r r i e d ; f o r women the number i s 66.6 p e r c e n t . However, f o r the 70 p l u s age group, l e s s than a t h i r d of the women are m a r r i e d , and by age 80 and over, more than 85 p e r c e n t of women have been widowed. (Abu-Laban, 1980) T h i s l a t t e r group of aged widows a r e p o t e n t i a l l y a v u l n e r a b l e c a t e g o r y w i t h i n the aging p o p u l a t i o n . I n examing l i v i n g arrangements, r e s e a r c h e r s have found t h a t the e l d e r l y most commonly l i v e w i t h f a m i l y , - e i t h e r w i t h a spouse or c h i l d r e n . I n Canada, 7 4 . 1 p e r c e n t of males over 65 l i v e w i t h f a m i l y ; f o r women the f i g u r e i s 5 3 . 5 p e r c e n t . Only 1 1 . 1 p e r c e n t of males 65 and over l i v e a l o n e , w h i l e 2 4 . 6 p e r c e n t of women l i v e on t h e i r own. (Abu-Laban, 19 80) Palmore ( 1 9 7 6 ) , found t h a t the e l d e r l y l i v i n g a l o n e had a s i g n i f i c -a n t l y h i g h e r r a t e of i n s t i t u t i o n a l i z a t i o n s i n c e they were l e s s l i k e l y t o have someone t o c a r e f o r them i f they became p h y s i c a l l y or m e n t a l l y i n c a p a c i t a t e d . 1 The i n s t i t u t i o n a l i z e d e l d e r l y may a l s o l a c k the support of a d u l t c h i l d r e n . The e l d e r l y w i t h no c h i l d r e n , and those w i t h o n l y one or two have a h i g h e r r a t e of i n s t i t u t i o n a l i z a t i o n than do t h o s e w i t h s e v e r a l . C h i l d l e s s , or low f e r t i l i t y women have a 1 5 p e r c e n t h i g h e r chance of i n s t i t u t i o n a l i z a t i o n b e f o r e the age of 75 than do women who have 3 or more c h i l d r e n . ( T r e a s , 1977) A p p a r e n t l y , the e l d e r l y f a r e b e t t e r when s e v e r a l c h i l d r e n a r e a v a i l a b l e t o s h a r e c a r e g i v i n g f u n c t i o n s when such h e l p becomes n e c e s s a r y . F a m i l y support can d e l a y or p r e v e n t i n s t i t u t i o n a l i z a t i o n , even f o r those e l d e r l y with, s i g n i f i c a n t i n f i r m i t i e s . R e s e a r c h e r s c o n s i s t e n t l y note t h a t persons l i v i n g a l o n e p r i o r t o a d m i s s i o n are s i g n i f i c a n t l y l e s s i n f i r m upon a d m i s s i o n than persons l i v i n g w i t h t h e i r c h i l d r e n or o t h e r s . (Townsend, 1 9 6 5 ) ; (Barney, 1977) Of s i g n i f i c a n c e are the number of r e s i d e n t s w i t h no l i v i n g c l o s e r e l a t i v e s . An American study r e p o r t s t h a t more than 50 p e r c e n t of r e s i d e n t s have no f a m i l y c l o s e b y . ( G e l f a n d & O l s e n , 1980) T h i s was confirmed i n a s u r v e y of a sample of i n s t i t u t -i o n a l i z e d r e s i d e n t s i n Vancouver i n which 45 p e r c e n t of the sample r e p o r t e d no c l o s e r e l a t i v e s l i v i n g i n the Vancouver a r e a . (Hanvey & McLachlan, 19 81) These f i g u r e s i n d i c a t e t h a t one of the c o n t r i b u t i n g f a c t o r s t o i n s t i t u t i o n a l a d m i s s i o n s may be the l a c k of f a m i l y support t h a t might enable the o l d e r person t o c o n t i n u e l i v i n g i n h i s or her own home. PRECIPITATING FACTORS CONTRIBUTING TO INSTITUTIONALIZATION As noted above, l o n g - t e r m care i n s t i t u t i o n s are o c c u p i e d by v e r y o l d r e s i d e n t s , most of whom have m u l t i p l e c h r o n i c p h y s i c a l and mental impairments, and many of whom have no c l o s e f a m i l y on whom t o r e l y . Each of t h e s e f a c t o r s , (advanced age, d e c l i n i n g h e a l t h , l a c k of f a m i l y r e s o u r c e s ) , or more r e l i a b l y a combination of t h e s e f a c t o r s , may 5'4 p r e c i p i t a t e the d e c i s i o n t o seek i n s t i t u t i o n a l c a r e . However, p r a c t i t i o n e r s working i n the community w i t h the e l d e r l y are aware t h a t i n s t i t u t i o n a l placement i s almost i n -v a r i a b l y sought o n l y as a " l a s t r e s o r t " ; and numbers of o l d e r persons w i t h s i m i l a r i n c a p a c i t i e s and l a c k of support r e s i s t i n s t i t u t i o n a l placement t o the end. Do the e l d e r l y who seek -placement d i f f e r from t h e i r community c o h o r t s ? p r a r e t h e i r c i r c u m s t a n c e s s u f f i c i e n t l y d i f f e r e n t t h a t i n s t i t u t i o n a l c a r e i s a n e c e s s a r y and a p p r o p r i a t e s o l u t i o n t o t h e i r immediate n e e d s ? I n an attempt t o answer t h e s e q u e s t i o n s , a number of s u r v e y s of r e s i d e n t i a l p o p u l a t i o n s have been conducted i n order t o g a i n an u n d e r s t a n d i n g of the r e s i d e n t s ' s e l f -p e r c e p t i o n s of the p r e c i p i t a t i n g f a c t o r s t h a t l e d them t o seek i n s t i t u t i o n a l c a r e . Whi le some s t u d i e s have i d e n t i f i e d a s i n g l e major l i f e d i s r u p t i o n t h a t p r e c i p i t a t e d the d e c i s i o n t o move, (Beaver, 1 9 7 9 ) ; other s t u d i e s have emphasized m u l t i p l e c a u s a t i o n f o r a p p l i c a t i o n f o r a d m i s s i o n t o an i n s t i t u t i o n . (Brody, 1 9 6 9 ) ; (Tobin & Lieberrnan, 1976) These m u l t i p l e p r e c i p i t a t i n g f a c t o r s have been i d e n t i f i e d a s : 1) s o c i a l i s o l a t i o n engendered by a l a c k of c l o s e r e l a t i v e s or f r i e n d s ; the l o s s of s u p p o r t -i n g r e l a t i v e s ; or a d v e r s e changes i n r e l a t i o n s h i p s w i t h significant o t h e r s . (Townsend, 1 9 6 5 ) ; (Barney, 1 9 7 7 ) ; 2) l a c k of adequate h o u s i n g brought about through l o s s of the former home; or house a n d / o r neighbourhood d e t e r i o r a t i o n (Beaver, 1 9 7 9 ) ; 3) economic i n s e c u r i t y (Townsend, 1 9 6 2 ) ; 4) a new 55 s p e c i f i c h e a l t h problem, or a worsening of a c h r o n i c h e a l t h problem r e s u l t i n g i n t h e i n a b i l i t y o r a n t i c i p a t e d i n a b i l i t y f o r s e l f - c a r e . (Kraus e t a l , 1 9 7 6 b ) ; 5) t h e u n a v a i l a b i l i t y of community r e s o u r c e s or s e r v i c e s t h a t might m a i n t a i n t h e o l d e r p e r s o n i n t h e community. (Brody, 19 7 7 ) ; and 6) the u n w i l l i n g n e s s o r i n a b i l i t y of f a m i l y members t o c a r r y t h e burden of c a r e n e c e s s a r y t o m a i n t a i n t h e e l d e r l y p e r s o n i n t h e community. (Brody, 1966) I n a d d i t i o n , Brody and Gummer (1967) and Brody (1969) have n o t e d t h a t a l t h o u g h a p p l i c a n t s and non - a p p l i c a n t s f o r r e s i d e n t i a l c a r e s h a r e d c e r t a i n s i m i l a r i t i e s i n demographic characteristics, t h o s e a c t u a l l y making a p p l i c a t i o n d i f f e r e d i n t h e f o l l o w i n g ways. Those making a p p l i c a t i o n o f f e r e d more r e a s o n s f o r t h e i r need f o r i n s t i t u t i o n a l c a r e t h a n d i d non - a p p l i c a n t s ; t h e y had a t t i t u d e s which appeared more p o s i t i v e t o i n s t i t u t i o n a l i z a t i o n ; and a l s o had r e l a t i v e s more f a v o r a b l y d i s p o s e d toward a d m i s s i o n t h a n t h o s e of n o n -a p p l i c a n t s . A s i m i l a r s u r v e y was r e c e n t l y c o n d u c t e d i n Vancouver w i t h a sample of i n s t i t u t i o n a l r e s i d e n t s . The r e s i d e n t s were a s k e d t o s t a t e t h e i r r e a s o n s f o r moving; and a s k e d t o s p e c i f y t h e most i m p o r t a n t r e a s o n ( s ) . Out of t h i s sample, 65 p e r c e n t of t h e s u b j e c t s r e p o r t e d h e a l t h problems as t h e p r i m a r y o r s i n g l e f a c t o r f o r moving t o a c a r e f a c i l i t y . F i f t e e n p e r c e n t moved b e c a u s e of a l a c k of s o c i a l s u p p o r t ; and 1 5 p e r c e n t moved p r i m a r i l y b e c a u s e of d i s s a t i s f a c t i o n w i t h t h e i r n e i g h b o r s o r l o c a t i o n . F a l l i n g or a c c i d e n t s was g i v e n as a major 56 c o n s i d e r a t i o n by one s u b j e c t . I n the sample, h a l f a l s o p r o v i d e d a d d i t i o n a l or secondary r e a s o n s f o r moving. T h i r t y p e r c e n t r e p o r t e d t h a t t h e y a l s o moved f o r e m o t i o n a l h e a l t h r e a s o n s , 30 p e r c e n t f o r l a c k of s o c i a l s u p p o r t s , 20 p e r c e n t because of d i s s a t i s f a c t i o n w i t h the neighbourhood, 5 p e r c e n t because of f a l l s , and 5 p e r c e n t because of d i f f i c u l t i e s w i t h home maintenance. (Hanvey, & McLachlan, 1 9 8 1 ) How a c c u r a t e l y do t h e s e s u r v e y s "tap" the d e c i s i o n - m a k i n g p r o c e s s ? The "reasons f o r admiss ion" as s t a t e d by h a l f the r e s i d e n t s i n the above sample was l i m i t e d t o one r e s p o n s e ; however, t h e c a s e h i s t o r i e s which the s u r v e y uncovered were i n v a r i a b l y c o n v o l u t e d and complex r e f l e c t i n g m u l t i p l e s t r e s s o r s and changes p r i o r t o the move. I n the f o l l o w i n g case h i s t o r y , t h i s r e s i d e n t gave as the reason f o r moving an i n a b i l i t y t o l i v e on her own " f o r h e a l t h r e a s o n s " . Mrs. D. i s 76 y e a r s of age. She has had P a r k i n s o n s D i s e a s e s i n c e 19 35, and her c o n d i t i o n has s t e a d i l y worsened. She now walks w i t h a cane, and h e r speech i s b a d l y i m p a i r e d . Although she manages h e r own s e l f - c a r e , her a b i l i t y t o c a r e f o r a household or shop i n d e p e n d e n t l y i s s e v e r e l y l i m i t e d . She was widowed i n 1934, and r a i s e d h e r two c h i l d r e n a l o n e by working as a s c h o o l t e a c h e r i n s p i t e of h e r p r o g r e s s i v e l y d e b i l i t a t i n g i l l n e s s . F o l l o w i n g r e t i r e m e n t , she moved i n t o an apartment and managed on h e r own f o r 10 y e a r s . A l i t t l e over a y e a r ago, she f e l l i n h e r apartment, and h e r d o c t o r s u g g e s t e d t h a t she no l o n g e r l i v e a l o n e . She moved t o Vancouver and l i v e d w i t h h e r daughter , s o n - i n - l a w and g r a n d c h i l d r e n . D u r i n g t h a t y e a r , h e r daughter and s o n - i n - l a w s e p a r a t e d , and h e r daughter was f o r c e d t o s e l l the home and r e t u r n t o work. At t h a t p o i n t , Mrs. D. d e c i d e d t o e n t e r c a r e 57 Mrs. D. i s a remarkably c h e e r f u l l a d y i n s p i t e of h e r obvious d i s a b i l i t i e s . She s t a t e s she i s happy w i t h the d e c i s i o n she made and commented: " I t was e a s i e r t o make the d e c i s i o n now - i t s e a s i e r to adapt when y o u ' r e younger - and b e s i d e s , I ' v e had l o t s of changes i n my l i f e , so I ' m w e l l adapted t o t h i n g s " . As t h i s c a s e h i s t o r y r e v e a l s , the reasons f o r s e e k i n g placement a r e almost i n v a r i a b l y complex and m a n i f o l d . I n s t i t u t i o n a l r e s i d e n t s do not d i f f e r markedly from t h e i r community p e e r s . They have i n v a r i a b l y s u f f e r e d a s e r i e s of s e v e r e a s s a u l t s , - p h y s i c a l , s o c i a l , economic and e n v i r o n m e n t a l . G iven t h e i r p h y s i c a l , e m o t i o n a l and s o c i a l needs, t h e i r a v a i l -a b l e s u p p o r t s , and t h e i r coping a b i l i t i e s , i n s t i t u t i o n a l i z a t i o n appears a t t h e t ime t o be the o n l y a v a i l a b l e o p t i o n . The q u e s t i o n of course remains, i n Mrs. D . ' s case, c o u l d a d d i t i o n -a l f a m i l y r e s o u r c e s , or supplementary community r e s o u r c e s have been m o b i l i z e d t o postpone or p r e v e n t i n s t i t u t i o n a l p lacement? Or was i n s t i t u t i o n a l i z a t i o n perhaps the most a p p r o p r i a t e response f o r t h i s woman, a t t h i s t ime i n her l i f e ? WHEN I S INSTITUTIONALIZATION INDICATED? P r a c t i t i o n e r s working i n the f i e l d of i n s t i t u t i o n a l a s s e s s -ment and placement c o n s t a n t l y c o n f r o n t the q u e s t i o n . Barney (19 7 7 ) , has s u g g e s t e d t h a t assessment of need f o r placement s h o u l d examine f o u r a r e a s : 1) the need f o r a s s i s t a n c e ; 2) t h e a v a i l a b i l i t y .of. f i n a n c i a l r e s o u r c e s ; 3) the presence of s o c i a l s u p p o r t s ; and 4) the e x p r e s s i o n of p e r s o n a l p r e f e r e n c e . S o c i a l s u p p o r t s are here d e f i n e d as both f a m i l y and community r e -s o u r c e s . The m a j o r i t y of p r a c t i t i o n e r s working i n the community 58 w i t h the f r a i l e l d e r l y would agree t h a t f a m i l y and community s u p p o r t s can i n many i n s t a n c e s be u t i l i z e d as an a l t e r n a t i v e t o i n s t i t u t i o n a l p lacement. However, p r a c t i t i o n e r s a l s o r e c o g n i z e t h a t under c e r t a i n c i r c u m s t a n c e s t h e s e n e c e s s a r y s o c i a l s u p p o r t s a r e e i t h e r u n a v a i l a b l e , inadequate or even / i n a p p r o p r i a t e . Both r e s e a r c h and c l i n i c a l e v i d e n c e i n d i c a t e s t h a t f a m i l i e s do h e l p , p a r t i c u l a r l y i n t ime of i l l n e s s : exchange of s e r v i c e s and r e g u l a r v i s i t s are common among o l d people and t h e i r c h i l d r e n and r e l a t i v e s , whether or not they l i v e under a s i n g l e r o o f . (Shanas, 1979) The e x t e n t of f a m i l y h e l p has been demonstrated i n a number of s t u d i e s . A Canadian s u r v e y of newly a d m i t t e d e l d e r l y r e s i d e n t s , found t h a t 64 p e r c e n t of the sample who were r e c e i v i n g h e l p from the f a m i l y j u s t p r i o r t o a d m i s s i o n , had e i t h e r been t a k e n i n t o the f a m i l y home, or were r e c e i v i n g t o t a l or e x t e n s i v e h e l p . (Kraus e t a l , 1976a) A Vancouver s t u d y conf irms t h i s f i n d i n g . I n the Vancouver sample, 55 p e r c e n t of the r e s i d e n t s had c l o s e r e l a t i v e s nearby. P r i o r t o a d m i s s i o n , a l l those r e s i d e n t s w i t h c l o s e r e l a t i v e s nearby had r e c e i v e d e x t e n s i v e h e l p from them; 80 p e r c e n t of t h i s group had r e c e i v e d t h i s a s s i s t a n c e on a d a i l y b a s i s . (Hanvey & McLachlan, 1 9 8 1 ) The burden t h i s c a r e imposes on f a m i l y members i s c o n s i d e r a b l e . One r e s e a r c h e r i n a review of s t u d i e s , found t h a t t w o - f i f t h s of o f f s p r i n g c a r i n g f o r e l d e r l y p a r e n t s i n t h e i r homes devoted the e q u i v a l e n t of a f u l l t ime j o b , (with o v e r t i m e ) , t o c u s t o d i a l t a s k s . (Bengston & T r e a s , 19 80) 59 Breakdown o c c u r s when the person i n v o l v e d i n p r o v i d i n g home support can no l o n g e r cope. S a n f o r d (19 7 5 ) , i n England, found t h a t the l e a s t t o l e r a b l e problem f o r the s u p p o r t i n g person was d i s t u r b e d s l e e p , - s l e e p i n t e r r u p t i o n brought about by n i g h t wandering, i n c o n t i n e n c e and s h o u t i n g . Over a p e r i o d of t i m e , t h i s c o n s t a n t and wearing l e v e l of r e s p o n s i b i l i t y may no l o n g e r be t o l e r a b l e . O n e . s u r v e y of r e s i d e n t s ' f a m i l y members found t h a t when t h e s e f a m i l y members were asked t o s t a t e the most important reason why they had made a p p l i c a t i o n f o r the a d m i s s i o n of the p a r e n t t o an i n s t i t u t i o n a l f a c i l i t y , 5 1 p e r c e n t of i n t e r v i e w e d f a m i l y members mentioned t h a t c a r i n g f o r the e l d e r l y p a r e n t was imposing an e x c e s s i v e burden on the f a m i l y . (Kraus e t a l , 19 76b) T h i s burden i s e s p e c i a l l y onerous when the c a r e g i v e r i s a l s o a g i n g . I n c r e a s i n g l y , i n s t i t u t i o n a l i z e d r e s i d e n t s have a d u l t c h i l d r e n who a r e themselves a g i n g . When a survey of a p p l i c a n t s t o a f a c i l i t y was conducted over a 6 month p e r i o d , almost 40 p e r c e n t of the a p p l i c a n t s had a t l e a s t one a d u l t c h i l d over 60 y e a r s of age. (Brody, 1966) Due t o improvements i n m o r t a l i t y , t h e r e a r e i n c r e a s i n g numbers of f o u r - g e n e r a t i o n f a m i l i e s . ( S t r e i b , 1972) As a r e s u l t , the " c h i l d r e n " of i n s t i t u t i o n a l i z e d p a r e n t s may t h e m s e l v e s be e x p e r i e n c i n g the p h y s i c a l , s o c i a l and economic s t r e s s e s of a g i n g . Brody (1966) has noted: " . . . t h e a d u l t c h i l d r e n ' s own problems of aging have become more apparent and more f r e q u e n t as p r e c i p i t a n t s or as major c o n t r i b u t i n g f a c t o r s i n the f a m i l y d i s t u r b a n c e l e a d i n g t o the need f o r placement of the p a r e n t . " (p. 202) 60 One s u r v e y found t h a t 36 p e r c e n t of newly a d m i t t e d r e s i d e n t s had been l i v i n g w i t h r e l a t i v e s who were themselves i l l , i n f i r m or of advanced age. (Townsend, 1965) Other s t u d i e s have noted t h a t an i n c r e a s i n g number of a p p l i c a t i o n s f o r i n s t i t u t i o n -a l c a r e come about as a r e s u l t of the death or s e v e r e i l l n e s s of an a d u l t c h i l d , or an a d u l t c h i l d ' s "spouse. (Brody, 1966) Could a range of community s e r v i c e s supply-, s u f f i c i e n t r e l i e f f o r t h e s e overburdened r e l a t i v e s t h a t aging p a r e n t s c o u l d s t i l l be m a i n t a i n e d e i t h e r i n t h e i r own home, or i n the r e l a t i v e s - * home? Some s t u d i e s i n d i c a t e they cannot. When the f a m i l i e s of newly a d m i t t e d r e s i d e n t s were i n t e r v i e w -ed i n one f a c i l i t y , and asked i f they would have l i k e d , or needed more i n f o r m a t i o n on community a l t e r n a t i v e s t o placement, o n l y 33 p e r c e n t f e l t t h i s would have been h e l p f u l . T h i r t y p e r c e n t of t h i s sample had t a k e n the aging p a r e n t i n t o t h e i r home; a l a r g e p r o p o r t i o n of the remaining f a m i l i e s had s u p p l i e d e x t e n s i v e , and r e g u l a r h e l p . At the t ime of p l a c e -ment, r e l a t i v e s were exhausted and d e f e a t e d , and f o r a l a r g e m a j o r i t y o f t h e s e f a m i l i e s , no a l t e r n a t i v e s would have been a c c e p t a b l e a t t h a t t i m e . (York & C a s l y n , 1977) I n many c a s e s , community s e r v i c e s i n s u f f i c i e n t q u a n t i t i e s can supplement t h e c a r e of concerned r e l a t i v e s , and i n the absence of f a m i l y can p r o v i d e s u b s t i t u t e c a r e . However, i n o t h e r i n s t a n c e s t h i s i s not p o s s i b l e . Even w i t h a c c e s s t o day c a r e s e r v i c e s , t r a n s p o r t a t i o n and homemaker s e r v i c e s , an aging person w i t h s e v e r e f u n c t i o n a l i n c a p a c i t i e s , combined w i t h emotional or mental d i s t u r b a n c e may s e r i o u s l y j e a p r o d i z e h i s own s a f e t y , or t h e s a f e t y of o t h e r s . T r a g i c a l l y , t h i s same c o m b i n a t i o n of d i s a b i l i t i e s , (advanced age, and p h y s i c a l and m e n t a l i m p a i r m e n t ) , i s most commonly a s s o c i a t e d w i t h l e t h a l consequences f o l l o w i n g r e l o c a t i o n . C e r t a i n l y , maintenance i n t h e community i s not p o s s i b l e w i t h o u t a whole range of m e d i c a l , s o c i a l and homemaker s e r v -i c e s . Even t h e n , economic o r e n v i r o n m e n t a l h a z a r d s may l i m i t t h e e f f e c t i v e n e s s of t h e s e s e r v i c e s . An e x p e r i e n c e d a d m i n -i s t r a t o r i n t h i s f i e l d has s t a t e d : " I t i s not p o s s i b l e t o b u i l d c o n s t r u c t i v e in-home s e r v i c e s around an i m p o s s i b l e home s i t u a t i o n ; I mean i m p o s s i b l e b e c a u s e of p o v e r t y w i t h i t s a s s o c i a t e d bad h o u s i n g , i n a d e q u a t e n u t r i t i o n and g e n e r a l d e p r i v a t i o n . " ( T r a g e r , 1969) When an a g i n g p e r s o n r e q u i r e s t w e n t y - f o u r hour a day c a r e , home s u p p o r t c a r e may not be t h e most s u i t a b l e , o r f i s c a l l y r e s p o n s i b l e a l t e r n a t i v e . T h i s does not i m p l y however t h a t i n s t i t u t i o n a l c a r e i s t h e o n l y o t h e r o p t i o n . I n s t e a d , h e a l t h c a r e p l a n n e r s c o u l d d e v e l o p s h e l t e r e d and s p e c i a l h o u s i n g a l t e r n a t i v e s , such as f o s t e r home c a r e and o t h e r congregate n o n - i n s t i t u t i o n a l h o u s i n g t h a t would p r o v i d e t h e n e c e s s a r y s u p p o r t i v e s e r v i c e s , and some measure of p r o t e c t i o n and s u p e r v i s i o n , w h i l e s t i l l p r e s e r v i n g f o r t h e e l d e r l y p e r s o n t h e g r e a t e s t p o s s i b l e degree of independence and s e l f - d e t e r m i n a t i o n . An a d d i t i o n a l c o n s i d e r a t i o n i n t h e d e c i s i o n - m a k i n g p r o c e s s i s of c o u r s e t h e p e r s o n a l p r e f e r e n c e of t h e e l d e r l y p e r s o n . M i l l o y ( 1 9 6 4 ) , has s t a t e d : " . . . p l a n s f o r l i v i n g arrangements s h o u l d be b a s e d on the p r i n c i p l e t h a t as long as a person g a i n s more g r a t i f i c a t i o n than p a i n from l i v i n g i n t h e community, i t i s b e t t e r t o h e l p him remain t h e r e . " (p. 454) R e s e a r c h e v i d e n c e i n d i c a t e s t h a t n o n - v o l u n t a r y placement of the aged can have l e t h a l e f f e c t s . P r a c t i t i o n e r s i n the f i e l d have a l l had e x p e r i e n c e w i t h the e l d e r l y person* who i n s p i t e of s e r i o u s p h y s i c a l l i m i t a t i o n s , i n a d e q u a t e h o u s i n g and support s e r v i c e s , i s so adamant about remaining i n h i s f a m i l i a r s e t t i n g t h a t placement appears t o be c o n t r a -i n d i c a t e d i n s p i t e of concerns f o r h i s s a f e t y . Can the worker b a l a n c e the wishes of t h i s aging person a g a i n s t the needs of an a n x i o u s and overburdened f a m i l y and h e l p them a l l a r r i v e a t an adequate and e q u i t a b l e s o l u t i o n ? The o f f i c i a l p o l i c y of the Long-Term Care Program i n B r i t i s h Columbia as s t a t e d i n the p h i l o s o p h y of the program i s : " . . . t h e program m u s t . . . r e s p e c t the r i g h t of the f a m i l y t o r e q u e s t the t r a n s f e r of i n d i v i d u a l s from the f a m i l y ' s home t o approved f a c i l i t i e s i n the community, when t h a t i n d i v i d u a l ' s c o n t i n u e d p r e s e n c e i n t h e i r home i s d e t r i m e n t a l t o the h e a l t h of t h e i r f a m i l y . " ( I n t r o d u c t i o n t o the Program f o r Long-Term Care, 1978) The r o l e of the community s o c i a l worker i n t h e s e i n s t a n c e s i s p a r t i c u l a r l y d i f f i c u l t and s t r e s s f u l as she attempts t o s t a b i l i z e the system by g e n e r a t i n g f u r t h e r community s e r v i c e s w h i l e p r o v i d i n g emotional support f o r a l l concerned through h e r c o n t i n u e d presence and empathic u n d e r s t a n d i n g . The f i n a l d e c i s i o n on who "should" be i n s t i t u t i o n a l i z e d , and a t what t ime, cannot be e s t a b l i s h e d by o f f i c i a l p o l i c y , nor 63 d e c i d e d on p h i l o s o p h i c a l grounds. I t i s a h i g h l y i n d i v i d u a l -i z e d d e c i s i o n . As Brody ( 1 9 7 7 ) , has s t a t e d : "The u l t i m a t e d e c i s i o n i s based on e v a l u a t i o n of the t o t a l s i t u a t i o n : the o l d e r p e r s o n ' s r e s o u r c e s ( p h y s i c a l , mental , f u n c t i o n a l , s o c i a l ) , the f a m i l y ' s r e s o u r c e s and the a v a i l a b l e community r e s o u r c e s . " (p. 120) Once the d e c i s i o n has been made however, i t i s i m p e r a t i v e t h a t s e r v i c e s e x i s t so t h a t the p r o c e s s of i n s t i t u t i o n a l i z a t i o n i t s e l f can be h a n d l e d w i t h s k i l l and s e n s i t i v i t y . 5'4 PART I I I : THE'RELOCATION PROCESS: SOCIAL WORK PRACTICE IMPLICATIONS INTRODUCTION The f i r s t two s e c t i o n s of t h i s paper have been p r i m a r i l y research -oriented, concerned w i t h examining a number of r e -s e a r c h s t u d i e s on r e l o c a t i o n s t r e s s , and a l s o s u r v e y s of the i n s t i t u t i o n a l i z e d e l d e r l y . T h i s f i n a l s e c t i o n w i l l focus s p e c i f i c a l l y on c l i n i c a l p r a c t i c e , and one p a r t i c u l a r type of r e l o c a t i o n - t h e t r a n s i t i o n from the community t o an i n s t i t u t i o n . There i s g e n e r a l agreement amongst r e s e a r c h e r s t h a t community t o i n s t i t u t i o n r e l o c a t i o n i s p o t e n t i a l l y more s t r e s s -f u l than e i t h e r r e l o c a t i o n from one community s e t t i n g t o a n o t h e r , or r e l o c a t i o n w i t h i n or between i n s t i t u t i o n s . The e l d e r l y person encounters profound e n v i r o n m e n t a l d i s c o n t i n u i t y f o l l o w i n g t h i s t r a n s i t i o n from home t o i n s t i t u t i o n . He p r o b a b l y e x p e r i e n c e s a r e d u c t i o n i n f a m i l i a r r o l e s and c o n t a c t s w i t h s i g n i f i c a n t o t h e r s . He a l s o e x p e r i e n c e s the l o s s of i n t i m a t e e n v i r o n m e n t a l supports f o l l o w i n g the d i s p o s i t i o n of home and b e l o n g i n g s . F o l l o w i n g t r a n s f e r to the i n s t i t u t i o n , he must become f a m i l i a r w i t h a new p h y s i c a l and p s y c h o s o c i a l environment. T h i s r e q u i r e s a d a p t a t i o n t o an i n s t i t u t i o n a l m i l i e u w i t h u n f a m i l i a r r e s i d e n t s and s t a f f , and an i n s t i t u t -i o n a l r o u t i n e t h a t c o n s t r a i n s and d i r e c t s h i s a c t i v i t i e s . I n a d d i t i o n , he may have t o d e a l w i t h the emotional p a i n t h a t accompanies the sense of h a v i n g been r e j e c t e d or abandoned by f a m i l y members; and the c u l t u r a l st igma t h a t i s a s s o c i a t e d w i t h i n s t i t u t i o n a l l i v i n g - a st igma t h a t connotates d e f e a t i n t h e s t r u g g l e t o m a i n t a i n an independent l i f e . ( A u l i n g e r , 1979) R e s e a r c h e v i d e n c e i n d i c a t e s t h a t t h i s s t r u g g l e t o adapt t o p e r c e i v e d l o s s e s and s e p a r a t i o n from the f a m i l i a r o c c u r s w i t h maximum i n t e n s i t y d u r i n g the w a i t i n g p e r i o d p r e c e d i n g a d m i s s i o n t o i n s t i t u t i o n a l c a r e . T h e r e f o r e , a number of r e s e a r c h e r s have d e s c r i b e d the r e l o c a t i o n p r o c e s s i n terms \ of a sequence of s t a g e s or p h a s e s , b e g i n n i n g w i t h t h e s i t u a -t i o n a l changes which p r e c i p i t a t e the d e c i s i o n t o move; and ending s e v e r a l months a f t e r r e l o c a t i o n f o l l o w i n g a p e r i o d of a d j u s t m e n t . Tobin and Lieberman (1976) have broken t h i s sequence i n t o f o u r s t a g e s : 1) the phase of p r e d e c i s i o n ; 2) the phase of a n t i c i p a t i n g r e l o c a t i o n ; 3) the phase of i n i t i a l a d j u s t m e n t ; and 4) the phase of a d a p t a t i o n which encompasses the f i r s t s e v e r a l months a f t e r the i n i t i a l a d j u s t m e n t . U t i l i z i n g the phases or s t a g e s developed by t h e s e a u t h o r s , t h i s s e c t i o n of the paper w i l l examine p a r t i c u l a r i n t e r v e n t i o n s t r a t e g i e s t h a t might be a p p l i e d throughout the p r o c e s s of r e l o c a t i o n t o f a c i l i t a t e the t r a n s i t i o n from community t o i n s t i t u t i o n . As noted e a r l i e r i n t h i s paper, the focus of r e l o c a t i o n r e s e a r c h has e v o l v e d from s i m p l y measuring the impact of r e -l o c a t i o n i n terms of m o r t a l i t y or p h y s i o l o g i c a l and p s y c h o l -o g i c a l changes, t o examining under what c o n d i t i o n s , and w i t h what k i n d s of i n d i v i d u a l s are t h e s e n e g a t i v e e f f e c t s most l i k e l y t o o c c u r . R e s e a r c h e r s have i d e n t i f i e d a number of f a c t o r s , or c o n d i t i o n i n g v a r i a b l e s which appear t o most s i g n i f i c a n t l y a f f e c t the outcome of r e l o c a t i o n , and t h e s e 66" have been d i s c u s s e d . The u t i l i t y of t h i s r e s e a r c h l i e s i n i t s a b i l i t y t o i n f o r m and d i r e c t s o c i a l workers who are a c t i v e l y a s s i s t i n g i n t h e r e l o c a t i o n p r o c e s s . The i d e n t i f i c a t i o n of s i g n i f i c a n t v a r i a b l e s a f f e c t i n g t h e outcome of r e l o c a t i o n p r o v i d e s t h e framework f o r t h e e v o l u t i o n of s t r a t e g i e s t h a t w i l l h o p e f u l l y m i t i g a t e t h e n e g a t i v e consequences of r e l o c a t i o n - The worker can t h e n g i v e t h a t framework s u b s t a n c e through t h e d e v e l o p -ment of s p e c i f i c p o l i c i e s and programs t h a t w i l l f a c i l i t a t e t h e p r o c e s s of r e l o c a t i o n . I n a d d i t i o n t o t h i s r e s e a r c h -g e n e r a t e d knowledge, t h e s o c i a l worker b r i n g s t o t h e p r o c e s s , knowledge of t h e r e s o u r c e s and s e r v i c e s t h a t a r e p r e s e n t l y a v a i l a b l e i n t h e community; t h e p a r t i c u l a r v a l u e s and s k i l l s t h a t a r e a p a r t of h i s or h e r p r o f e s s i o n ; and t h e use of s e l f w i t h i n t h e h e l p i n g r e l a t i o n s h i p . However, workers a r e a l s o o f t e n c o n s t r a i n e d by i n a d e q u a t e or non - e x i s t e n t p o l i c i e s , programs and r e s o u r c e s ; and a l a c k of s u f f i c i e n t s t a f f , t i m e or agency s u p p o r t . W h i l e t h e p a r t i c u l a r i n t e r v e n t i o n s t r a t e g i e s t h a t w i l l be d i s c u s s e d have not e x p l i c i t l y r e c o g n i z e d t h e s e c o n s t r a i n t s , the w r i t e r i s aware t h e y do e x i s t , and i s a l s o aware of t h e f r u s t r a t i o n t h e s e c o n s t r a i n t s produce f o r workers i n t h e f i e l d . The e v o l u t i o n of t h e i n t e r v e n t i o n s t r a t e g i e s t h a t f o l l o w d e v e l o p e d out of both p r a c t i c e e x p e r i e n c e and numerous d i s -c u s s i o n s w i t h workers i n v o l v e d i n community s e r v i c e s w i t h t h e e l d e r l y , a s s e s o r s working out of P u b l i c H e a l t h U n i t s i n t h e p r o v i n c e , and a d m i n i s t r a t o r s , n u r s e s and s o c i a l vrork staff in a number of f a c i l i t i e s . Whi le some of t h e recommendations may appear i m p o s s i b l y removed from t h e r e a l i t i e s of the p r e s e n t s i t u a t i o n , t h e y a l s o e x p r e s s the r e a l hopes and concerns of t h e s e workers who are a c t i v e l y i n v o l v e d i n the assessment and placement p r o c e s s , and who a l s o wish t o see changes i n the p r e s e n t system. T h e i r c o n t r i b u t i o n t o t h i s paper i s g r a t e f u l l y acknowledged. I n a d d i t i o n , I would l i k e t o acknowledge a debt t o the c l i e n t s who a l l o w e d me t o s h a r e t h e i r e x p e r i e n c e s throughout the p r o c e s s of r e l o c a t i o n . They gave the r e s e a r c h on r e l o c a t i o n both s u b s t a n c e and new meaning. THE RELOCATION PROCESS: SOCIAL WORK PRACTICE IMPLICATIONS The Phase of P r e d e c i s i o n For a m i n o r i t y of the community e l d e r l y , t h e r e i s a s t a g e i n the p r o c e s s of aging when the c u m u l a t i v e s t r e s s e s and l o s s e s a s s o c i a t e d w i t h t h i s p e r i o d of l i f e are too heavy a burden t o be c a r r i e d i n d e p e n d e n t l y . The p r o c e s s has u s u a l l y been g r a d u a l . The e l d e r l y person has been a b l e t o make the n e c e s s a r y a d a p t a t i o n s t o r o l e l o s s e s , t o p h y s i c a l decrements, and t o the l o s s of f r i e n d s and f a m i l y members. The most r e c e n t c r i s i s , - perhaps the l o s s of a s i g n i f i c a n t source of s u p p o r t , a r e c u r r i n g i l l n e s s , e v i c t i o n from a home-w h i l e o n l y one i n a s e r i e s of c r i s i s , i s s u f f i c i e n t l y d e v a s t a t i n g t h a t h e l p i s sought from o u t s i d e s o u r c e s ; and an a p p l i c a t i o n i s made f o r i n s t i t u t i o n a l c a r e . Although s i g n i f i c a n t d i f f e r e n c e s e x i s t among a p p l i c a n t s , the c h a r a c t e r i s t i c s of the i n s t i t u t i o n a l r e s i d e n t s as noted e a r l i e r a r e a l s o f a i r l y t y p i c a l a t the p o i n t of a p p l i c a t i o n . The a p p l i c a n t i s p r o b a b l y v e r y o l d , has s e v e r a l c h r o n i c p h y s i c a l c o n d i t i o n s , w i t h a c o n s i d e r a b l e degree of f u n c t i o n a l d i s a b i l i t y , and may s u f f e r some mental impairment, n o t a b l y memory l o s s and c o n f u s i o n . Only a m i n o r i t y of a p p l i c a n t s have a l i v i n g spouse; and a p p r o x i m a t e l y h a l f of. the a p p l i c a n t s w i l l have a d u l t c h i l d r e n n e a r b y . (Brody, 1977) F o r t h o s e w i t h a d u l t c h i l d r e n , t h e r e i s r e l i a b l e e v i d e n c e t h a t i n the v a s t m a j o r i t y of c a s e s , t h e a d u l t c h i l d has been a c t i v e l y i n v o l v e d i n e f f o r t s t o m a i n t a i n the e l d e r l y p a r e n t i n the community. As the p a r e n t ' s c a p a c i t y f o r s e l f - c a r e d e t e r i o r a t e d , t h e c h i l d has p r o v i d e d e x t e n s i v e i n s t r u m e n t a l and a f f e c t i v e s u p p o r t , o f t e n on a d a i l y b a s i s . T h i s has i n c l u d e d i n about h a l f the c a s e s moving the e l d e r l y p a r e n t i n t o the c h i l d ' s home. (Shanas, 1960) By the t ime a p p l i c a -t i o n f o r c a r e i s made, the a d u l t c h i l d has o f t e n exhausted t h e i r own p h y s i c a l and emotional r e s o u r c e s , and t h i s f i n a l d e c i s i o n t o seek i n s t i t u t i o n a l care i s made w i t h g r e a t r e l u c t a n c e , and o n l y as a l a s t r e s o r t . I n o t h e r i n s t a n c e s , the assessment and placement procedure t a k e s p l a c e w i t h i n an acute c a r e h o s p i t a l s e t t i n g . A l a r g e number of a p p l i c a t i o n s are made through a c u t e care h o s p i t a l s f o l l o w i n g a f a l l , or a sudden and d e b i l i t a t i n g i l l n e s s . The number of p a t i e n t t r a n s f e r s d i r e c t l y from h o s p i t a l s t o i n s t i t u t i o n a l f a c i l i t i e s i s p r o b a b l y e x t e n s i v e , s t a t i s t i c s v a r y from 25 p e r c e n t t o 59 p e r c e n t . (McPhee,1977) , (York & 69 C a s l y n , 1977) , (Cape, 1977) , (Hanvey & McLachlan, 1 9 8 1 ) I n t h e s e i n s t a n c e s , the p h y s i c i a n and h o s p i t a l s o c i a l worker i n c o l l a b o r a t i o n w i t h f a m i l y members a r e i n s t r u m e n t a l i n making the d e c i s i o n t h a t i n s t i t u t i o n a l c a r e i s n e c e s s a r y a t t h i s t i m e . Sudden and s e v e r e i l l n e s s can produce i n the e l d e r l y person temporary d i s o r i e n t a t i o n and c o n f u s i o n . T h i s mental s t a t e , i n combinat ion w i t h the p r e s e n t i n g i l l n e S s can p r e s e n t an a l a r m i n g p i c t u r e t o f a m i l y members concerned about the e l d e r l y p e r s o n ' s c a p a c i t y f o r s e l f - c a r e upon d i s c h a r g e . Dur ing t h i s c r i s i s p e r i o d , p r e c i p i t a t e and u n i l a t e r a l d e c i s i o n s may be made w i t h t r a g i c consequences. At the p r e s e n t t ime, r e h a b -i l i t a t i o n f a c i l i t i e s f o r the e l d e r l y are inadequate or non-e x i s t e n t . These f a c i l i t i e s would p r o v i d e an i n t e r i m p e r i o d f o r r e s t o r a t i o n and r e - e v a l u a t i o n , f o l l o w i n g which t h e a s s e s s -ment of need e i t h e r f o r i n s t i t u t i o n a l or community c a r e c o u l d be c a r r i e d out under l e s s s t r e s s f u l c i r c u m s t a n c e s . y Whether i t t a k e s p l a c e i n the community, or i n a h o s p i t a l s e t t i n g , the a p p l i c a t i o n f o r a d m i s s i o n t o c a r e i s o f t e n i n i t -i a t e d under c o n d i t i o n s of s e v e r e s t r e s s . I t i s seldom the e l d e r l y person h i m s e l f who s u g g e s t s placement, or i n s t i g a t e s t h e a p p l i c a t i o n p r o c e s s . S t u d i e s have shown t h a t o n l y 1 7 t o 1 9 p e r c e n t of a p p l i c a t i o n s are i n i t i a t e d by the e l d e r l y person h i m s e l f . (Townsend, 1 9 6 2 ) , (Kraus e t a l , 1 9 7 6 b ) , (York & C a s l y n , 1977) One s t u d y noted t h a t 46 p e r c e n t of the e l d e r l y persons who were e n t e r i n g c a r e were i n v o l v e d i n the d e c i s i o n -making p r o c e s s "very l i t t l e or not a t a l l " . (Kraus e t a l , 1976b) Considering the i n f o r m a t i o n t h a t i s now a v a i l a b l e on t h e n e g a t i v e consequences of i n v o l u n t a r y a d m i s s i o n , the i m p l i c a t i o n s of t h e s e s t a t i s t i c s a r e a l a r m i n g . From the moment of a p p l i c a t i o n , the p r i m a r y focus of the assessment worker s h o u l d be t o o b t a i n the p a r t i c i p a t i o n and involvement of a l l concerned p a r t i c i p a n t s , - both the o l d e r p e r s o n , and a l l f a m i l y members. P a r t i c i p a t i o n must be more than mere a c q u i e s c e n c e t o the wishes or d e c i s i o n of o t h e r s . Whi le the o l d e r p e r s o n ' s p a r t i c i p a t i o n may be l i m i t e d by h i s p h y s i c a l and mental c o n d i t i o n ; and h i s o p t i o n s may be c i r c u m -s c r i b e d by p r e s e n t c i r c u m s t a n c e s , t o whatever e x t e n t p o s s i b l e the worker must encourage h i s a c t i v e i n v o l v e m e n t . The same h o l d s t r u e f o r f a m i l y members. Whatever d e c i s i o n i s reached, i t w i l l u l t i m a t e l y a f f e c t a l l f a m i l y members; and t h e i r needs and concerns must a l s o be r e s p e c t e d , and taken i n t o account . / Whether the p a r t i c i p a n t s d e c i d e on i n s t i t u t i o n a l placement, or a community a l t e r n a t i v e , the f a m i l i e s c o n t i n u e d c o o p e r a t i o n and p a r t i c i p a t i o n w i l l be e s s e n t i a l t o the f u t u r e w e l l - b e i n g of t h e o l d e r p e r s o n . The seeds of t h i s c o o p e r a t i o n s h o u l d be sown d u r i n g the assessment p r o c e s s . During t h i s p r e d e c i s i o n phase of the r e l o c a t i o n p r o c e s s , the w o r k e r ' s t a s k s a r e t o c o u n s e l , a s s e s s , and s c r e e n . (Brody, 1977) I n r e a l i t y , t h e s e t a s k s cannot be s e p a r a t e d , but a r e c a r r i e d out c o n c u r r e n t l y . Assessment s h o u l d i n c l u d e an e v a l u a t i o n of t h r e e a r e a s : the c l i e n t ' s p r e s e n t p h y s i c a l , mental , f u n c t i o n a l and s o c i a l s t a t u s ; the f a m i l y ' s c u r r e n t f u n c t i o n i n g and c a p a c i t y f o r s u p p o r t ; and the a v a i l a b i l i t y of both community and i n s t i t u t i o n a l s e r v i c e s . C o u n s e l l i n g s e r v i c e s s h o u l d a s s i s t both t h e e l d e r l y p e r s o n , and t h e f a m i l y t o a p p r a i s t h e v a r i o u s a l t e r n a t i v e s , and r e a c h d e c i s i o n s on t h e s e r v i c e s t h a t a r e most a p p r o p r i a t e t o t h e i r n e e d s . Case - work s e r v i c e s f o r both c l i e n t and f a m i l y s h o u l d be an i n t e g r a l p a r t of t h i s p r o c e s s . I f i n s t i t u t i o n a l c a r e i s t h e s e r v i c e chosen, s c r e e n -i n g c o o r d i n a t e s t h e c l i e n t ' s f u n c t i o n a l s t a t u s and needs w i t h t h e e l i g i b i l i t y c r i t e r i a and s e r v i c e s of a p a r t i c u l a r f a c i l i t y . The s k i l l s of t h e worker d u r i n g t h i s p e r i o d w i l l be c r i t i c a l i n p r e v e n t i n g u n n e c e s s a r y or premature a d m i s s i o n t o a f a c i l i t y . A s t a t e m e n t by Barney ( 1 9 7 7 ) , i s b a s i c t o a l l l o n g - t e r m c a r e p l a n n i n g : " . . . n o degree of need f o r long term h e a l t h c a r e and o t h e r s u p p o r t i v e s e r v i c e s a u t o m a t i c a l l y i n d i c a t e s t h e s e t t i n g i n which t h a t c a r e s h o u l d be p r o v i d e d . A l l l e v e l s of c a r e can be g i v e n , (and f r e q u e n t l y a r e g i v e n ) a t home" (p. 3 0 9 ) . The number of e l d e r l y p e r s o n s who a r e i n a p p r o p r i a t e l y p l a c e d i n f a c i l i t i e s has been w e l l documented. ; American s t u d i e s e s t i m a t e f i g u r e s of from 1 5 t o 47 p e r c e n t . (Holmes & Holmes, 1 9 7 9 ) . Recent C a n a d i a n s t u d i e s c o n f i r m t h e s e f i g u r e s . I n - L o n d o n , O n t a r i o , a r e c e n t s t u d y examined f a c i l i t i e s p r o v i d i n g t h r e e l e v e l s of c a r e . C o n s i d e r i n g each l e v e l s e p a r a t e l y , r e s e a r c h e r s found t h a t 25 t o 54 p e r c e n t o f t h e r e s i d e n t s had been i n a p p r o p r i a t e l y p l a c e d . (Cape, 1 9 7 7 ) A s t u d y of 1 9 3 a p p l i c a n t s f o r i n s t i t u t i o n a l c a r e noted t h a t n o n - i n s t i t u t i o n a l placement would have been more s u i t a b l e f o r a lmost a t h i r d o f t h e a p p l i c a n t s . (Kraus e t a l , 1976b) E v e r y worker i n v o l v e d i n t h e a p p l i c a t i o n phase of t h e r e l o c a t i o n p r o c e s s s h o u l d c o n s t a n t l y keep t h e s e s t a t i s t i c s i n mind. 72 The f i r s t r e q u e s t f o r a p p l i c a t i o n t o a f a c i l i t y w i l l p r o b a b l y be i n i t i a t e d by a f a m i l y member, or a p h y s i c i a n . I t s h o u l d be viewed i n i t i a l l y w i t h o u t p r e j u d i c e s i m p l y as a r e q u e s t f o r a s s i s t a n c e . The f i r s t f o c u s of the worker s h o u l d be t o e x p l o r e whether t h i s i s i n d e e d the c h o i c e of the e l d e r l y p e r s o n . Are the p a r t i c i p a n t s knowledgable about community a l t e r n a t i v e s ? Have t h e s e a l t e r n a t i v e s a l r e a d y been s u g g e s t e d and r e j e c t e d out of hand; or have they been a t t e m p t -ed p r e v i o u s l y w i t h o u t s u c c e s s ? I f t h e c h o i c e of the e l d e r l y person, (and/or f a m i l y ) , i s t o f i r s t e x p l o r e the p o s s i b i l i t y of "independent" community l i v i n g , the p r i m a r y g o a l of the worker i s t o s t r u c t u r e a community support system. When the c l i e n t i s e l d e r l y and f r a i l the d i f f i c u l t y of d e v e l o p i n g , and m a i n t a i n i n g a s u p p o r t -i v e community environment s h o u l d not be u n d e r e s t i m a t e d , as the f o l l o w i n g case example w i l l i l l u s t r a t e . Mr. B. i s 78 y e a r s of age. He i s s i n g l e , and the o n l y f a m i l y support c o n s i s t s of a young n i e c e who i s both r e s p o n s i b l e and concerned, but i s not a v a i l a b l e on"any c o n s i s t e n t b a s i s . Mr. B. has a s e r i o u s h e a r t c o n d i t i o n , and i s almost t o t a l l y b l i n d . He has r e c e n t l y been h o s p i t a l i z e d f o l l o w -i n g a s t r o k e which has l e f t him d i s a b l e d t o the e x t e n t t h a t he now walks w i t h two canes . H i s income i s b a r e l y adequate t o cover food and the c o s t of a w a l k - u p , one room apartment. A c c e s s t o t h i s apartment i s v i a a s t e e p s t a i r -c a s e , w i t h o u t h a n d r a i l s . H i s o n l y cooking f a c i l i t i e s c o n s i s t of a two-burner hot p l a t e . Over t h e p a s t few y e a r s , h i s h e a r t c o n d i t i o n and f a i l i n g v i s i o n have l i m i t e d h i s s o c i a l p a r t i c i p a t i o n , and he i s now s o c i a l l y i s o l a t e d . He i s however, f i e r c e l y independent, and i n s i s t s t h a t h i s o n l y c h o i c e would be t o r e t u r n home. 73 D e v e l o p i n g a community s u p p o r t p l a n f o r t h i s man r e q u i r e d t h e c o o p e r a t i o n of a g e r i a t r i c r e h a b i l i t a t i o n team c o n s i s t i n g of t h e p h y s i c i a n , n u r s i n g s u p e r v i s o r , s o c i a l worker, o c c u p a t i o n -a l t h e r a p i s t and p h y s i o t h e r a p i s t . I t a l s o r e q u i r e d c o l l a -b o r a t i o n w i t h community workers i n c l u d i n g , a community s o c i a l worker, home c a r e n u r s e , homemaker s u p e r v i s o r , meal s e r v i c e s u p e r v i s o r and a d a y - c a r e s u p e r v i s o r . The a s s i s t a n c e of h i s n i e c e was a l s o e l i c i t e d both f o r o c c a s s i o n a l s u p e r v i s i o n , and f o r s o c i a l i z a t i o n . The l a n d l o r d i n t h e b u i l d i n g was c o n t a c t e d t o o b t a i n h i s agreement t o p r o v i d e h a n d r a i l s f o r s t a i r s and bathroom. Few h o s p i t a l s e t t i n g s p r o v i d e t h e s e r v i c e s of a g e r i a t r i c a s s e s s m e n t team i n s p i t e of c l i n i c a l e v i d e n c e t h a t i t i s not p o s s i b l e t o s t r u c t u r e adequate community s u p p o r t s w i t h o u t i n f o r m a t i o n on t h e c l i e n t ' s m e d i c a l , s o c i a l , f u n c t i o n a l and e n v i r o n m e n t a l n e e d s . Moreover, once a s u p p o r t i v e environment has been d e v e l o p e d , i t must be m a i n t a i n e d , (and when n e c e s s a r y / m o d i f i e d ) , w i t h i n t h e community through r e g u l a r s u p e r v i s i o n and c o l l a b o r a t i o n w i t h a l l t h o s e concerned. At t h e p r e s e n t t i m e , community workers are s i m p l y not a v a i l a b l e t o p r o v i d e t h i s c o n s i s t e n t case-management and f o l l o w - u p s e r v i c e . R e c e n t l y a s u r v e y was conducted i n Vancouver of a sample of e l d e r l y p e o p l e r e c e i v i n g homemaker s e r v i c e . The sample was asked how o f t e n t h e y had f o l l o w - u p c o n t a c t w i t h t h e community worker or a s s e s s o r who had conducted t h e i r i n i t i a l a s s e s s m e n t . S e v e n t y -n i n e p e r c e n t of t h e sample r e p o r t e d no f o l l o w - u p c o n t a c t ; s e v e n t y - f o u r p e r c e n t were u n a b l e to p r o v i d e t h e name of t h e i r /4 a s s e s s o r ; and s i x t y - n i n e p e r c e n t d i d n o t know how t o make c o n t a c t w i t h t h e a s s e s s o r . (Haramia & Hanvey, 1 9 8 1 ) At t h e p r e s e n t t i m e , many e l d e r l y p e r s o n s i n B r i t i s h Columbia have a c c e s s t o b o t h p r o f e s s i o n a l c o n s u l t a t i o n , and t o a wide range of h e a l t h and s o c i a l s e r v i c e s t h r o u g h t h e i r l o c a l community P u b l i c H e a l t h o f f i c e s , Human R e s o u r c e s o f f i c e s and v o l u n t e e r o r g a n i z a t i o n s . However, t h e f u l l range of s e r v i c e s t h a t a r e r e q u i r e d i n o r d e r t o d e v e l o p a comprehensive community s u p p o r t system f o r t h e e l d e r l y may n o t be a v a i l a b l e i n e v e r y community. These s e r v i c e s f o r c o n v e n i e n c e can be a r b i t r a r i l y d i v i d e d i n t o f i v e c a t e g o r i e s . (Barney, 1 9 7 7 ) i t i n c l u d e s : 1 ) a " f a c i l i t a t i n g " c a t e g o r y comprised of c o u n s e l i n g , advocacy and t r a n s p o r t a t i o n s e r v i c e s ; 2) a " l i v i n g a t home" c a t e g o r y i n c l u d i n g homemaker and handyman s e r v i c e s and meals - o n - w h e e l s ; 3) a h e a l t h c o n c e r n s c a t e g o r y p r o v i d i n g a range of home h e a l t h c a r e s e r v i c e s , i . e . n u r s i n g , speech t h e r a p y , p h y s i o -t h e r a p y ; 4) an economic c o n c e r n s c a t e g o r y which p r o v i d e s i n f o r m a t i o n and r e f e r r a l w i t h r e s p e c t t o government income s u p p l e m e n t s , r e n t a l s u p p l e m e n t s , and s u b s i d i z e d h o u s i n g ; and 5) a s o c i a l i n t e g r a t i o n c a t e g o r y comprised of s e r v i c e s s u c h as f r i e n d l y v i s i t o r s , t e l e p h o n e r e a s s u r a n c e and day c a r e c e n t r e s . Some of t h e s e s e r v i c e s , ( i . e . meal s e r v i c e and h e a l t h c a r e ) , can be d e l i v e r e d e i t h e r on an i n d i v i d u a l i z e d home-d e l i v e r e d b a s i s , o r on a s e m i - i n s t i t u t i o n a l o r c o n g r e g a t e b a s i s . They can be d e s i g n e d t o c o v e r a wide range of h e a l t h c a r e needs, from p r e v e n t i v e c a r e t o maintenance o:r r e h a b -i l i t a t i o n c a r e . The above s e r v i c e s can supplement the c a r e p r o v i d e d by f a m i l y members; or p r o v i d e s u b s t i t u t e c a r e when f a m i l y a r e not a v a i l a b l e . As noted e a r l i e r however, t h e y may not p r o v i d e the c a r e g i v e r w i t h s u f f i c i e n t s u p p o r t , p a r t i c u l a r l y when a s i n g l e f a m i l y member has assumed the r e s p o n s i b i l i t y of l o o k i n g a f t e r a v e r y f r a i l i n c a p a c i t a t e d p a r e n t ; and t h i s r e s p o n s i b i l i t y has been c a r r i e d over a long p e r i o d of t ime w i t h no p r o v i s i o n f o r r e l i e f . At the p r e s e n t t ime, t h e r e i s an inadequate s u p p l y of the more i n t e n s i v e b a c k s t o p p i n g s e r v i c e s f o r f a m i l i e s t h a t would b u t t r e s s the home care f a m i l i e s p r e s e n t l y p r o v i d e . Sussman ( 1 9 7 6 ) , has c a l l e d t h e s e the "halfway t o i n s t i t u t i o n -a l i z a t i o n " s e r v i c e s t h a t u t i l i z e an i n s t i t u t i o n a l s e t t i n g t o p r o v i d e e i t h e r temporary, i n t e r m i t t e n t or o c c a s s i o n a l i n s t i t u t i o n a l c a r e as r e q u i r e d . These s e r v i c e s might i n c l u d e : s h o r t - t e r m c r i s i s c a r e d u r i n g an i l l n e s s , or i n t e n s i v e c o n v a l e s c e n t or r e h a b i l i t a t i o n care t o r e s t o r e former f u n c t i o n -i n g ; the p r o v i s i o n of day a n d / o r n i g h t i n s t i t u t i o n a l beds t o p r o v i d e h a l f - t i m e r e l i e f ; and the p r o v i s i o n of r e s p i t e beds d u r i n g s h o r t v a c a t i o n p e r i o d s . These s e r v i c e s would o p e r a t i o n a l i z e the "theory of shared f u n c t i o n s " , which s t a t e s t h a t formal o r g a n i z a t i o n s and f a m i l i e s must c o o r d i n a t e t h e i r e f f o r t s i n order t o p r o v i d e optimum c a r e f o r the a g i n g . ( S t r e i b , 1972) The f i l i a l r e s p o n s i b i l i t y of a d u l t c h i l d r e n toward t h e i r aging p a r e n t s has been w e l l documented. (Sussman, 1977) S u r v e y s have con-s i s t e n t l y noted t h e c o n s i d e r a b l e number of f r a i l e l d e r l y who manage t o remain i n the community, c a r e d f o r by t h e i r f a m i l i e s w i t h v a r y i n g degrees of supplementary support s u p p l i e d by p u b l i c and v o l u n t a r y a g e n c i e s . These supplementary s e r v i c e s can be d e f i n e d a s : " . . . t h o s e t h a t p r i m a r i l y s u b s t i t u t e f o r the f a m i l y and t h o s e t h a t attempt t o support the f a m i l y " . (Moroney, 1 9 7 6 , p. 1 1 8 ) At the p r e s e n t t i m e , we l a c k adequate d a t a on the type of support which f a m i l i e s would f i n d most h e l p f u l i n o r d e r t o o b t a i n some r e l i e f from the p r e s s u r e of p r o v i d i n g f u l l - t i m e c a r e . We need i n f o r m a t i o n on which s o c i a l s e r v i c e s and programs, ( i . e . f i n a n c i a l a s s i s t a n c e , p r a c t i c a l h e l p ) , would most e f f e c t i v e l y support and r e i n f o r c e the s e r v i c e s which f a m i l i e s now p r o v i d e , t h e r e b y f r e e i n g a d u l t c h i l d r e n t o p r o v i d e the a f f e c t i v e and s o c i a l s u p p o r t s which b u r e a u c r a c i e s cannot p r o v i d e . ( T r e a s , 1977) When e f f o r t s t o m a i n t a i n the e l d e r l y person i n the community have f a i l e d t o p r o v i d e the n e c e s s a r y s u p p o r t , or when i n s t i t u t i o n a l c a r e i s the p r e f e r r e d c h o i c e of the a p p l i c a n t , the w o r k e r ' s t a s k i s t o p r o v i d e assessment, c o u n s e l i n g and s c r e e n i n g s e r v i c e s t o f a c i l i t a t e placement i n an i n s t i t u t i o n . Lawton ( 1 9 7 0 ) , has d e f i n e d the major t a s k of assessment a s : " . . . o n e of o p t i m i z i n g the congruence of p e r s o n a l c h a r a c t e r -i s t i c s and e n v i r o n m e n t a l r e s o u r c e s . The p a t i e n t ' s p h y s i c a l and mental w e l l - b e i n g depend on h i s not b e i n g c h a l l e n g e d beyond h i s r e s o u r c e s . T h i s i s the whole r a t i o n a l b a s i s f o r t h e s e a r c h f o r a s s e s s m e n t i n s t r u m e n t s t h a t w i l l s c r e e n a p p l i c a n t s or p r o v i d e f a v o r a b l e placement d e c i s i o n s . " (p .39) I n e f f e c t , f o r m a l a s s e s s m e n t measures t h e i n d i v i d u a l ' s s t a t u s and a b i l i t i e s i n o r d e r t o d e t e r m i n e t h e l e v e l or t y p e of i n s t i t u t i o n a l c a r e t h a t w i l l b e s t meet h i s needs. The a s s e s s m e n t p r o c e d u r e i s s i m p l i f i e d and a t t a i n s g r e a t e r o b j e c t i v i t y i f s t a n d a r d i z e d i n s t r u m e n t s a r e u s e d ; and i f t h e y a r e a p p l i e d by t r a i n e d p r o f e s s i o n a l s . There i s c o n s i d e r a b l e c o n t r o v e r s y over the u t i l i t y and v a l i d i t y of v a r i o u s assessment i n s t r u m e n t s . However, t h e r e i s g e n e r a l agreement t h a t a s s e s s m e n t of need f o r l o n g -term c a r e f a c i l i t i e s s h o u l d i n c l u d e f u n c t i o n a l c a p a c i t i e s i n a d d i t i o n t o a m e d i c a l e v a l u a t i o n . F u n c t i o n a l a s s e s s m e n t i s " . . . a n y s y s t e m a t i c attempt t o measure o b j e c t i v e l y t h e l e v e l a t which a p e r s o n i s f u n c t i o n i n g i n any of a v a r i e t y of a r e a s s u c h as p h y s i c a l h e a l t h , q u a l i t y of self -maintenance, q u a l i t y of r o l e a c t i v i t y , i n t e l l e c t u a l s t a t u s , s o c i a l a c t i v i t y , a t t i t u d e toward t h e w o r l d and towards s e l f , and e m o t i o n a l s t a t u s " . (Lawton, 1 9 7 1 ) The a s s e s s m e n t i n s t r u m e n t p r o v i d e s an o b j e c t i v e method of e v a l u a t i n g t h e s t a t u s of t h e i n d i v i d u a l and t h e i r c a p a c i t y t o perform a range of t a s k s , - i . e . s e l f - c a r e - , t h a t a r e r e l e v a n t t o f u n c t i o n i n g i n a p a r t i c u l a r i n s t i t u t i o n a l e n v i r o n m e n t . However, i n d i v i d u a l s a r e more t h a n t h e sum of t h e i r f u n c t i o n a l c a p a c i t i e s , and workers must be c o n s t a n t l y aware t h a t i n s t r u m e n t a t i o n o n l y supplements, and does not r e p l a c e t h e w o r k e r ' s s k i l l and s e n s i t i v i t y i n i n d i v i d u a l i z i n g t h e a s s e s s m e n t and placement d e c i s i o n . As noted e a r l i e r when d i s c u s s i n g assessment f o r community placement, the v a l u e of team assessment has been w e l l document-ed. The problems of the e l d e r l y s e e k i n g placement a r e " m u l t i -symptomatic", and t h e s o l u t i o n s t o t h e s e problems a r e b e s t found by a team of a s s e s s o r s , each w i t h t h e i r own a r e a of p r o f e s s i o n a l e x p e r t i s e . ( B r e a r l e y , 1977) When the Long-Term Care Program i n B r i t i s h . C o l u m b i a was f i r s t e s t a b l i s h e d , the program was d e s i g n e d t o conform t o t h i s p r i n c i p l e of team a s s e s s m e n t . Assessment teams making recommendations on i n s t i t u t i o n a l placement were t o be composed of the l o c a l l o n g - t e r m c a r e a d m i n i s t r a t o r , a n u r s e , a s o c i a l worker, the f a m i l y p h y s i c i a n , a mental h e a l t h worker (when r e q u i r e d ) , and a r e p r e s e n t a t i v e of the F a c i l i t y where t h e a p p l i c a n t was t o be p l a c e d . T h e o r e t i c a l l y , t h i s composite team would p r o v i d e d e t a i l e d i n f o r m a t i o n on the i n d i v i d u a l needs of the a p p l i c a n t s e e k i n g placement, and whether those needs were congruent w i t h the s e r v i c e s and programs of the f a c i l i t y the i n d i v i d u a l had chosen. T h i s i s s t i l l the d e s i g n of c h o i c e . Both community and h o s p i t a l s e t t i n g s s h o u l d p r o v i d e t h i s assessment s e r v i c e . U n t i l such t ime as t h i s s e r v i c e i s e s t a b l i s h e d , workers must t a k e r e s p o n s i b i l i t y f o r i n d i v i d u a l i z i n g the placement p r o c e s s through t h e i r r e c o g n i t i o n t h a t l o n g - t e r m c a r e a p p l i c a n t s are not an homogenous p o p u l a t i o n . Assessment and s c r e e n i n g f o r placement s h o u l d not be l i m i t e d t o e s t a b l i s h i n g c a r e l e v e l requirements and then s i m p l y g i v i n g the a p p l i c a n t a l i s t of f a c i l i t i e s t h a t meet those r e q u i r e m e n t s . I n d i v i d u a l s 79 have u n i q u e h i s t o r i e s , p e r s o n a l i t i e s , i n t e r e s t and needs. These must be c o n s i d e r e d when recommending s p e c i f i c f a c i l i t i e s . Recent r e s e a r c h has e x p l o r e d the p o s s i b i l i t y of r e d u c i n g m o r b i d i t y and m o r t a l i t y f o l l o w i n g r e l o c a t i o n by s e l e c t i n g an i n s t i t u t i o n a l environment t h a t i s congruent w i t h the p e r s o n a l c h a r a c t e r i s t i c s of the i n d i v i d u a l . (Tobin & Lieberman, 1976) i n t h e o r y , p e r s o n a l i t y / e n v i r o n m e n t a l congruence, s h o u l d reduce the e n v i r o n m e n t a l d i s c o n t i n u i t y t h a t has been i m p l i c a t e d as a f a c t o r i n r e l o c a t i o n s t r e s s . One r e s e a r c h e r , Kahana ( 1 9 7 3 ) , has attempted t o i d e n t i f y t h e most s a l i e n t d imensions of congruence. She r e p o r t s : "When t h e r e i s a l a c k of congruence between the i n d i v i d u a l s ' needs f o r p r i v a c y and f o r immediate need g r a t i f i c a t i o n t h e s e incongruences (are) e s p e c i a l l y l i k e l y t o l e a d to u n h a p p i n e s s " . (p. 288) E n v i r o n m e n t a l d i f f e r e n c e s between i n s t i t u t i o n s a r e not s i m p l y a q u a l i t a t i v e i s s u e . I n s t i t u t i o n s of s i m i l a r q u a l i t y may d i f f e r s i g n i f i c a n t l y due t o the c h a r a c t e r i s t i c s of the r e s i d e n t i a l p o p u l a t i o n , and t o a d m i n i s t r a t i v e p h i l o s o p h y i n r e l a t i o n t o i s s u e s such as programming and i n s t i t u t i o n a l c o n t r o l . (Tobin & Lieberman, 1976) I n r e a l i t y , s c r e e n i n g f o r i n d i v i d u a l / i n s t i t u t i o n a l " f i t " i n v o l v e s some v e r y p r a c t i c a l problems i n c l u d i n g the a v a i l a b i l -i t y , g e o g r a p h i c a c c e s s i b i l i t y and a c c e p t a b i l i t y of the i n s t i t u t i o n . S t u d i e s have shown t h a t a p p l i c a n t s a n d / o r f a m i l i e s a r e most l i k e l y t o choose an i n s t i t u t i o n on the b a s i s of the a v a i l a b i l i t y of a bed, on the l o c a t i o n of the f a c i l i t y , or on t h e recommendation of t h e i r p h y s i c i a n or f r i e n d s . (York & C a s l y n , 1 9 7 7 ) , (Kraus e t a l , 1976b) Whi le t a k i n g t h e s e a p p l i c a n t / f a m i l y c o n s i d e r a t i o n s i n t o a c c o u n t , t h e worker s h o u l d a l s o base h e r recommendations on t h e i d i o s y n c r a t i c l i f e s t y l e and needs of i n d i v i d u a l a p p l i c a n t s . I f an a p p l i c a n t has a w e l l - e s t a b l i s h e d p a t t e r n of watching t e l e v i s i o n a l l n i g h t , and then dozing i n t e r m i t t e n t l y t h r o u g h -out the day, he w i l l r e q u i r e e i t h e r a p r i v a t e room, or a v e r y t o l e r a n t n i g h t s t a f f . The a p p l i c a n t who has never adhered t o r e g u l a r meal hours w i l l p r o b a b l y be h a p p i e r i n an i n s t i t u t i o n t h a t p r o v i d e s k i t c h e n f a c i l i t i e s f o r the use of r e s i d e n t s , r a t h e r than i n one t h a t i n s i s t s on r i g i d c o n f o r m i t y t o meal t i m e . I n o r d e r t o make t h e s e recommendations, workers must have comprehensive and c u r r e n t i n f o r m a t i o n on each l o n g - t e r m care f a c i l i t y . T h i s .should i n c l u d e i n f o r m a t i o n on: the p h y s i c a l f a c i l i t i e s and l a y o u t ; s t a f f / r e s i d e n t r a t i o s and the number and type of p r o f e s s i o n a l s t a f f on s i t e ; the programming and s e r v i c e s a v a i l a b l e ; the a c c e s s i b i l i t y of the i n s t i t u t i o n t o community f a c i l i t i e s and a c t i v i t i e s ; whether the p h y s i c a l l a y o u t p e r m i t s both s o c i a l i z a t i o n and p r i v a c y ; the e x t e n t of r e s i d e n t freedom and i n f l u e n c e ; and the degree of f l e x i b i l i t y or r i g i d i t y i n the i n s t i t u t i o n a l r o u t i n e . Instrumentation e x i s t s t o make t h i s type of i n s t i t u t i o n a l assessment, (Moos e t al, 1 9 7 9 ) ; but it would r e q u i r e both f u n d i n g and direction from Long-Term Care a d m i n i s t r a t i o n t o permit the collection and p u b l i c a t i o n of t h i s d a t a . I n a d d i t i o n t o h a v i n g a c c e s s t o t h i s p r i n t e d m a t e r i a l , workers s h o u l d a l s o be encouraged t o make o n - s i t e v i s i t s t o f a c i l i t i e s 81 . i n t h e i r g e o g r a p h i c a r e a . T h i s i n f o r m a t i o n on f a c i l i t i e s s h o u l d a l s o be made a v a i l a b l e t o a p p l i c a n t s and f a m i l i e s s e e k i n g placement. R e s e a r c h e r s have found t h a t f a m i l i e s r e q u i r e guidance i n a s s e s s -i n g the q u a l i t y of i n s t i t u t i o n s . I n one s t u d y , when f a m i l i e s were asked t h e r e a s o n s f o r s e l e c t i n g a p a r t i c u l a r f a c i l i t y , o n l y 10 p e r c e n t mentioned the q u a l i t y of p h y s i c a l c a r e ; 1 2 p e r c e n t the q u a l i t y of the a c t i v i t y program; and 35 p e r c e n t the q u a l i t y of t h e s t a f f . (York & C a s l y n , 1977) T h i s i s c o n s i s t e n t w i t h another study t h a t found t h a t the q u a l i t y of meals was a h i g h l y s i g n i f i c a n t f a c t o r i n f a m i l y judgements of the q u a l i t y of a f a c i l i t y . (L inn & G u r e l , 1969) The Committee on Aging of the S o c i a l P l a n n i n g and Review C o u n c i l of B . C . produced a b o o k l e t i n 1976 e n t i t l e d , " C i t i z e n ' s Guide t o A d u l t Care R e s i d e n c e s i n B . C . " . I t was produced as a s e l e c t i o n guide f o r a p p l i c a n t s and f o r f a m i l i e s t o use when choosing a f a c i l i t y . The Guide drew a t t e n t i o n t o a r e a s such a s : the c a r e p r o v i d e d ; the l o c a t i o n ; the a d m i s s i o n p o l i c i e s and r e g u l a t i o n s ; the l i v i n g s p a c e ; the communal a r e a s ; and the s e r v i c e s w i t h i n the f a c i l i t y . I t o f f e r e d c h e c k - l i s t s f o r f a c i l i t y comparison, and g e n e r a l l y a s s i s t e d i n d i v i d u a l s and f a m i l i e s i n making more knowledgable d e c i s i o n s on placement. Although i t i s an e x c e l l e n t b o o k l e t , i t has become outdated f o l l o w i n g implementat ion of the Long-Term Care Program. A s i m i l a r b o o k l e t s h o u l d be produced t o a i d a p p l i c a n t ' s i n the s e l e c t i o n p r o c e s s . A s i g n i f i c a n t number of a p p l i c a n t s , (from 40 t o 50 p e r c e n t ) , have never v i s i t e d the f a c i l i t y p r i o r t o t h e i r a d m i s s i o n . (Pope, 1 9 7 9 ) , (York & C a s l y n , 1 9 7 7 ) , (Kraus e t a l , 1976b) T h i s i s p r o b a b l y not uncommon f o r those i n d i v i d u a l s who are a s s e s s e d i n a h o s p i t a l who do not have r e l a t i v e s a v a i l a b l e t o a r r a n g e t r a n s p o r t a t i o n f o r the v i s i t . With the e x c e p t i o n of s e r i o u s l y i l l or i n c a p a c i t a t e d i n d i v i d u a l s , h o s p i t a l p o l i c y s h o u l d encourage workers t o arrange f o r f a c i l i t y v i s i t s . P o s s i b l y h o s p i t a l v o l u n t e e r o r g a n i z a t i o n s c o u l d p r o v i d e t h i s s e r v i c e . A s i m i l a r p o l i c y s h o u l d a p p l y i n the community. A p p l i c a n t s a r e e n t e r i n g a permanent l i v i n g arrangement. The f a c i l i t y w i l l be t h e i r f u t u r e home, and they must have e v e r y o p p o r t u n i t y t o f a m i l i a r i z e themselves w i t h the s e t t i n g and p e r s o n n e l i n order t o ease the shock of t r a n s i t i o n . When a p p l i c a n t s are ambulatory and moving from t h e i r home to an i n s t i t u t i o n , f a c i l i t y v i s i t s s h o u l d i n c l u d e more than a c u r s o r y t o u r of the i n s t i t u t i o n . A p p l i c a n t s c o u l d j o i n other r e s i d e n t s f o r a c t i v i t i e s , or f o r a meal. A room s h o u l d be a v a i l a b l e i n the f a c i l i t y t o a l l o w f o r o v e r - n i g h t v i s i t s i f a p p l i c a n t s so choose. These s e r v i c e s would a l l o w e l d e r l y persons t o r e a l i s t i c a l l y a p p r a i s e and a n t i c i p a t e i n s t i t u t i o n a l l i f e . A l l of the f o r e g o i n g s e r v i c e s : comprehensive i n f o r m a t i o n on a v a i l a b l e f a c i l i t i e s ; a guide t o the s e l e c t i o n p r o c e s s ; and the o p p o r t u n i t y t o v i s i t f a c i l i t i e s p r i o r t o the move s h o u l d be an i n t e g r a l p a r t of the p r e - d e c i s i o n p r o c e s s . Any measure which i n c r e a s e s the a p p l i c a n t ' s a b i l i t y to make a m e a n i n g f u l c h o i c e , or p r e p a r e s him f o r the move, a l l o w s t h e e l d e r l y person t o g a i n some sense of c o n t r o l i n a s i t u a t i o n t h a t i s g e n e r a l l y marked by f e e l i n g s of extreme h e l p l e s s n e s s and p o w e r l e s s n e s s . Throughout t h i s p r e - d e c i s i o n phase, casework a s s i s t a n c e s h o u l d be a v a i l a b l e t o both the e l d e r l y person and t o f a m i l y members t o p e r m i t e x p r e s s i o n of the f e e l i n g s , problems and r e a c t i o n s t h a t i n e v i t a b l y accompany the d e c i s i o n - m a k i n g p r o c e s s . Although the p o t e n t i a l f o r both p e r s o n a l and f a m i l y d i s r u p t i o n e x i s t s d u r i n g t h i s p e r i o d , the worker must be aware t h a t the f e e l i n g s of l o s s , h e l p l e s s n e s s and g r i e f t h a t a r e so o f t e n p r e s e n t a r e not n e c e s s a r i l y p a t h o l o g i c a l , but / are a n a t u r a l component of t h i s major l i f e change. The m a j o r i t y of f a m i l i e s manage t o n e g o t i a t e t h i s t r a n s i t i o n as they have o t h e r s , not w i t h o u t p a i n , but w i t h l o v e and r e s p e c t i n t a c t . The d e c i s i o n t o seek placement i s almost never i n i t i a t e d by t h e e l d e r l y person, and seldom have p h y s i c a l or emotional p r e p a r a t i o n s been made f o r t h i s e v e n t u a l i t y . While the o l d e r person may r e c o g n i z e a t one l e v e l the n e c e s s i t y f o r placement, f e e l i n g s of r e j e c t i o n , l o s s , and anger predominate. F e a r i n g t h a t e x p r e s s i o n of t h e s e f e e l i n g s w i l l o n l y a l i e n a t e the f a m i l y support so e s s e n t i a l t o h i s w e l l - b e i n g , he may i n s t e a d respond w i t h s e l f - b l a m e , d e p r e s s i o n and w i t h d r a w l . Dur ing t h i s p e r i o d , the worker can be i n s t r u m e n t a l i n h e l p i n g the e l d e r l y person r e c o g n i z e and a c c e p t t h e i r anger; and can p r o v i d e a s a f e focus f o r the v e n t i l a t i o n of t h e s e f e e l i n g s . E v i d e n c e has shown t h a t e x p r e s s i o n of t h e s e f e e l i n g s i s not o n l y n e c e s s a r y , but i n d e e d may be l i f e - s a v i n g . ( A l d r i c h & Mendkoff, 1963) F a m i l y members may a l s o be t o r n by f e e l i n g s of g u i l t arid s e l f - b l a m e . These are p o i g n a n t l y e x p r e s s e d i n the words of a 64 y e a r o l d woman f o l l o w i n g the i n s t i t u t i o n a l i z a t i o n of her 9 2 - y e a r - o l d mother. "The g u i l t f e e l i n g s s u f f e r e d by some c h i l d r e n have d i f f e r e n t s o u r c e s : t h a t the i n d i v i d u a l i s n ' t l i v i n g up t o h i s or her e g o - i d e a l , some e t h i c a l concept of f i l i a l b e h a v i o r t h a t d i r e c t s one t o be l o v i n g , a t t e n t i v e , p a t i e n t and d e d i c a t e d t o the p a r e n t ' s c a r e . I n c o n f l i c t w i t h t h i s i s t h e n a t u r a l need f o r o n e ' s own growth and s u r v i v a l which when f r u s t r a t e d r e s u l t s i n resentment, anger even h a t r e d which i s t u r n e d inward. The r e s u l t i n g d e p r e s s i o n hampers f u r t h e r the h e a l t h y h a n d l i n g of the s i t u a t i o n . " (Bengston & T r e a s , 1 9 8 0 , p. 419) F a m i l y members can be h e l p e d t o a c c e p t the r e a l i t y of both t h e i r own, and t h e i r p a r e n t ' s needs. A c c e p t i n g t h i s r e a l i t y may h e l p t o a l l e v i a t e any p e r v a s i v e sense of g u i l t , inadequacy and b e t r a y a l . A d u l t c h i l d r e n are o f t e n l a b o u r i n g under a deeply i n t e r n a l i z e d c u l t u r a l b e l i e f t h a t r e s p o n s i b l e c h i l d r e n do not abandon t h e i r p a r e n t s t o i n s t i t u t i o n a l c a r e . I t i s the r o l e of the worker t o h e l p the f a m i l y r e c o g n i z e t h a t f i l i a l responsibility can take many forms. By r e l i n -q u i s h i n g the wearing p h y s i c a l care of an aging p a r e n t , c h i l d r e n can be f r e e t o g i v e the i n v a l u a b l e emotional support which o n l y they can p r o v i d e ; and which i s so c e n t r a l t o t h e p a r e n t ' s w e l l - b e i n g . While i n s t i t u t i o n a l i z a t i o n may modify e x i s t i n g r o l e s and r e s p o n s i b i l i t i e s , the r e l a t i o n s h i p 85 between p a r e n t and c h i l d can c o n t i n u e t o be m e a n i n g f u l w i t h i n the i n s t i t u t i o n a l s e t t i n g . THE PHASE OF ANTICIPATING RELOCATION 7 ^ ^ L o n g i t u d i n a l r e s e a r c h d a t a on the p r o c e s s of i n s t i t u t i o n -a l i z a t i o n i n d i c a t e s t h a t t h i s a n t i c i p a t o r y phase i s a c r i s i s p e r i o d f o r the e l d e r l y p e r s o n . Tobin and Lieberrnan ( 1 9 7 6 ) , have w r i t t e n : "The changes i n p s y c h o l o g i c a l functioning from the " p r e d e c i s i o n " p e r i o d t o the p e r i o d w h i l e a w a i t i n g a d m i s s i o n were d r a m a t i c a l l y s i m i l a r t o those g e n e r a l l y c i t e d as i n d u c e d by the h a r m f u l q u a l i t i e s of i n s t i t u t i o n a l l i f e i t s e l f . T h i s f i n d i n g amply demonstrates how s e p a r a t i o n and a n t i c i p a t i o n of l o s s can a f f e c t p s y c h o l o g i c a l s t a t u s , e v e n t u a l l y p a i n t i n g a p o r t r a i t no more d e s i r a b l e than t h a t of i n s t i t u t i o n a l i z e d i e l d e r p e o p l e " , (p. 214) C o n s i d e r i n g the s t r e s s and changes a s s o c i a t e d w i t h t h i s p e r i o d t h e s e f i n d i n g s a r e not s u r p r i s i n g . G e n e r a l l y , the w a i t -i n g p e r i o d f o r i n s t i t u t i o n a l i z a t i o n i s not o n l y prolonged, but a l s o u n c e r t a i n . The s t r e s s o r s which p r e c i p i t a t e d the d e c i s i o n t o move, - i l l n e s s , inadequate h o u s i n g , f a m i l y c o n f l i c t - , have not been r e s o l v e d . p r e p a r a t i o n s f o r the d i s p o s a l of t r e a s u r e d b e l o n g i n g s must b e g i n and arrangements a r e made t o l e a v e the f a m i l y home. A s s i s t a n c e and p h y s i c a l energy are r e q u i r e d f o r t h e s e t a s k s , both of which may be i n s h o r t s u p p l y . Whi le Canadian s t u d i e s are not a v a i l a b l e , American s t u d i e s have i n d i c a t e d t h a t t h i s p e r i o d i s marked by frequent moves, p r o b a b l y p r e c i p i t a t e d both by the u n c e r t a i n t y of the w a i t i n g p e r i o d , and by i n c r e a s i n g p h y s i c a l d e t e r i o r a t i o n . One s t u d y found t h a t d u r i n g t h e f i r s t y e a r a f t e r a p p l i c a t i o n , w h i l e on t h e w a i t i n g l i s t , 7 3 p e r c e n t moved a t l e a s t once, and many moved s e v e r a l t i m e s . These a p p l i c a n t s moved a t l e a s t f i v e t i m e s as o f t e n as o l d e r p e o p l e i n t h e g e n e r a l community. (Brody, 1 9 77) G e n e r a l l y , t h e s e moves a r e i n t o t h e home of a f a m i l y member. A n o t h e r s t u d y which o b s e r v e d t h i s s h i f t i n l i v i n g arrangements found t h a t f u l l y 68 p e r c e n t of t h e a p p l i c a n t s a w a i t i n g i n s t i t u t i o n a l i z a t i o n were l i v i n g w i t h f a m i l y j u s t p r i o r t o p l a c e m e n t . ( M i l l e r & H a r r i s , 1965) These temporary l i v i n g arrangements r e q u i r e f u r t h e r p e r s o n a l a d j u s t m e n t , and may a l s o be t h e s o u r c e of f a m i l y s t r a i n or c o n f l i c t . programs and s e r v i c e s can e a s e t h e s t r e s s of t h i s w a i t -i n g p e r i o d , and i n some measure p r e p a r e t h e e l d e r l y p e r s o n f o r t h e impending move. A worker s h o u l d be a v a i l a b l e t o e v e r y a p p l i c a n t t o e n s u r e c o n t i n u i t y of s e r v i c e t h r o u g h o u t t h i s p e r i o d . As n o t e d , t h e w a i t i n g p e r i o d i s a l m o s t i n e v i t a b l y p r o l o n g e d due t o c h r o n i c bed s h o r t a g e s , and t h e c o n d i t i o n and needs of t h e c l i e n t and f a m i l y s h o u l d be r e g u l a r l y m o n i t o r e d t o keep a b r e a s t of changes or sudden e m e r g e n c i e s . Both c o n c r e t e s e r v i c e s and casework s u p p o r t s h o u l d be p r o v i d e d . D u r i n g t h i s p e r i o d arrangements s h o u l d be made f o r home s u p p o r t s e r v i c e s as needed, ( i . e . meals -on-wheels , homemaker a s s i s t a n c e ) , e s p e c i a l l y i f t h e c l i e n t i s l i v i n g on t h e i r own. Day c a r e s e r v i c e s can e i t h e r s u p p l y i n t e r i m r e l i e f f o r f a m i l i e s o r p r o v i d e needed s o c i a l i z a t i o n f o r the i s o l a t e d o l d e r p e r s o n . The c l i e n t who i s a l o n e w i l l a l s o r e q u i r e a s s i s t a n c e w i t h t h e p a c k i n g and d i s p o s a l of h o u s e h o l d b e l o n g i n g s . I t i s most i m -p o r t a n t t h a t i f p o s s i b l e t h e - c l i e n t f e e l i n c o n t r o l of t h i s p r o c e s s ; t h a t s u f f i c i e n t t ime i s a l l o w e d , and t h a t i t i s h a n d l e d w i t h c a r e and s e n s i t i v i t y . Community r e s o u r c e s t o a s s i s t w i t h t h i s t a s k a r e a l m o s t non - e x i s t e n t , and i t o f t e n r e q u i r e s c o n s i d e r a b l e r e s o u r c e f u l n e s s on the p a r t of t h e worker t o f i n d v o l u n t e e r a s s i s t a n c e . The worker can p r o v i d e c o n s u l t a t i o n on t h e b e l o n g i n g s t h a t can be moved t o t h e i n s t i t u t i o n . These f a m i l i a r p o s s e s s -i o n s i n v a r i a b l y p r o v i d e a v a l u a b l e l i n k w i t h t h e community, and w i t h t h e p a s t , and a r e p a r t i c u l a r l y s i g n i f i c a n t i n t h e f a c e of so many l o s s e s . I n a d d i t i o n t o t h e s e c o n c r e t e s e r v i c e s , exposure t o t h e i n s t i t u t i o n a l s e t t i n g p r i o r t o the move may h e l p t o reduce t h e a n x i e t y and f e a r t h a t a r e a s s o c i a t e d w i t h t h e u n f a m i l i a r . When p o s s i b l e , l i n k a g e s w i t h t h e f a c i l i t y s h o u l d be encouraged by o c c a s s i o n a l v i s i t s , and p a r t i c i p a t i o n i n i n s t i t u t i o n a l a c t i v i t i e s . The a p p l i c a n t can become f a m i l i a r w i t h t h e i n s t i t u t i o n a l s e t t i n g , t h e s t a f f , t h e a v a i l a b l e r e s o u r c e s and s e r v i c e s , and a l s o w i t h t h e r e s i d e n t s . D u r i n g t h e s e v i s i t s , s p e c i f i c concerns and problems and concerns can be d i s c u s s e d w i t h t h e f a c i l i t y worker. The a p p l i c a n t g a i n s a more r e a l -i s t i c p i c t u r e of i n s t i t u t i o n a l l i v i n g , and may p o s s i b l y p e r c e i v e t h e move as p r o m i s i n g g a i n s to o f f - s e t t h e many l o s s e s . Formal p r e p a r a t o r y programs have been developed f o r 8 b i n t r a - i n s t i t u t i o n a l moves on the o c c a s s i o n of f o r c e d r e l o c a t i o n of l a r g e numbers of r e s i d e n t s . The v a l u e of t h e s e programs i n terms of reduced m o r t a l i t y has been documented. (Gutman & H e r b e r t , 1 9 7 6 ) , (Zweig & Csank, 1976) More r e c e n t l y , r e -s e a r c h e r s have begun t o develop formal i n t e r v e n t i o n programs f o r t h e p r e - a d m i s s i o n p e r i o d u t i l i z i n g s i m i l a r t e c h n i q u e s . These programs a r e based on the t h e o r e t i c a l p e r s p e c t i v e t h a t i n -c r e a s i n g c o n t r o l and p r e d i c t a b i l i t y , w i l l i n t u r n reduce the s t r e s s of r e l o c a t i o n . ( S c h u l z & Brenner, 1977) Two such programs have been s u g g e s t e d by r e s e a r c h e r s i n B r i t i s h Columbia. The f i r s t of t h e s e programs, e n t i t l e d P r e p a r a t i o n f o r R e l o c a t i o n of t h e E l d e r l y , (PREP), was developed f o r the non-ambulatory, housebound c l i e n t who i s r e l o c a t i n g t o an extended c a r e f a c i l i t y . These e l d e r l y persons due t o p h y s i c a l i n -c a p a c i t y a r e most o f t e n unable t o v i s i t the f a c i l i t y p r i o r t o t h e i r move. To t a k e the p l a c e of t h e s e o n - s i t e v i s i t s , a s l i d e -tape p r e s e n t a t i o n i s d e l i v e r e d t o the e l d e r l y p e r s o n ' s home by a t r a i n e d t h e r a p i s t , who i s a l s o a v a i l a b l e t o answer q u e s t i o n s and p r o v i d e f u r t h e r i n f o r m a t i o n . The PREP program has t h r e e main components: 1) the a p p l i c a n t ' s sense of p r e d i c t a b i l i t y i s i n c r e a s e d through f i l m s t h a t p r o v i d e f a m i l i a r i z a t i o n w i t h the p h y s i c a l l a y o u t , the s t a f f and r e s o u r c e s of the i n s t i t u t i o n ; d u r i n g t h e s e f i l m s , some t y p i c a l problems t h a t are o f t e n a s s o c i a t e d w i t h e n t e r i n g c a r e a r e a l s o d i s c u s s e d ; 2) the a p p l i c a n t i s taught s p e c i f i c s t r e s s management t e c h n i q u e s , i n c l u d i n g p r o b l e m - s o l v i n g , p o s i t i v e t h i n k i n g and r e l a x a t i o n t o i n c r e a s e t h e i r sense of 89 p e r s o n a l c o n t r o l ; and 3) a group meeting i s h e l d f o r the sponsors or f a m i l i e s of a p p l i c a n t s t o p r o v i d e them w i t h r e l e v a n t i n f o r m a t i o n on r e l o c a t i o n , t o t e a c h them the s t r e s s -management t e c h n i q u e s , and t o e l i c i t t h e i r c o o p e r a t i o n and involvement throughout the p r o c e s s . PREP was developed as p a r t of a r e s e a r c h s t u d y t o examine the e f f e c t of p r e p a r a t o r y programs on the e l d e r l y p e r s o n ' s subsequent a d j u s t m e n t w i t h i n the i n s t i t u t i o n . F i n a l outcome d a t a on the s t u d y i s not p r e s e n t l y a v a i l a b l e . The second program suggested by Grant and Gutman ( 1 9 8 0 ) , i s i n i t i a t e d p r i o r t o a d m i s s i o n , but i s s p e c i f i c a l l y des igned t o h e l p a p p l i c a n t ' s cope w i t h the i n s t i t u t i o n a l environment once t h e y have e n t e r e d c a r e . T h i s program i s a l s o d i r e c t e d t o i n c r e a s i n g t h e a p p l i c a n t ' s sense of p e r s o n a l c o n t r o l by i d e n t i f y i n g coping s k i l l s t h a t w i l l f a c i l i t a t e a d a p t a t i o n t o a new environment. While the PREP program attempts t o t e a c h new coping s k i l l s through t h e i r stress-management t e c h n i q u e s , t h i s program u t i l i z e s coping s k i l l s which a r e a l r e a d y p a r t of the e l d e r l y p e r s o n ' s r e p e r t o i r e . The worker e l i c i t s from the a p p l i c a n t s p e c i f i c r e c o l l e c t i o n s about how the e l d e r l y person coped i n the p a s t . By r e - l i v i n g such e v e n t s , both good s t r a t e g i e s (to u s e ) , and bad s t r a t e g i e s (to a v o i d ) , a r e evoked. These f a m i l i a r s t r a t e g i e s can then be employed by the e l d e r l y person d u r i n g r e l o c a t i o n , and a f t e r e n t e r i n g c a r e . Components of t h e s e programs c o u l d be adapted by workers and s e l e c t i v e l y used w i t h i n d i v i d u a l c l i e n t s . The most 90 s i g n i f i c a n t e lements of t h e s e programs appear t o b e : a c c e s s t o adequate i n f o r m a t i o n about t h e mechanics of t h e move, and about t h e new s e t t i n g ; t h e o p p o r t u n i t y f o r v e n t i l a t i o n of c o n c e r n s and a n x i e t y i n r e l a t i o n t o t h e move; and an i n d i v i d -u a l i z e d program of p r o b l e m - s o l v i n g s t r a t e g i e s . W h i l e f a m i l y members can be an i n v a l u a b l e r e s o u r c e to t h e e l d e r l y p e r s o n d u r i n g t h i s w a i t i n g p e r i o d , t h e i r own needs and c o n c e r n s must a l s o be c o n s i d e r e d . I n one f a c i l i t y , a f a m i l y group program was e s t a b l i s h e d f o r f a m i l y members d u r i n g t h e pre - a d m i s s i o n p e r i o d t o meet both t h e s e o b j e c t i v e s . (Manaster, 1967) The f i r s t g o a l of t h e program was t o i n c r e a s e t h e a d u l t c h i l d ' s awareness of what i t means t o e n t e r an i n s t i t u t i o n i n o r d e r to i n c r e a s e t h e i r u n d e r s t a n d i n g of the a g i n g p a r e n t ' s b e h a v i o r and f e e l i n g s . The second g o a l was t o h e l p t h e a d u l t c h i l d become aware of t h e i r own f e e l i n g s and r e a c t i o n s , and t h e manner i n which t h o s e f e e l i n g s were . a f f e c t i n g t h e r e l a t i o n s h i p between t h e m s e l v e s and t h e i r p a r e n t s . Group members found t h e y were a b l e t o a t t a i n a g r e a t e r s e n s e of o b j e c t i v i t y by s h a r i n g e x p e r i e n c e s and r e a c t i o n s t h a t were common to a l l . W i t h i n t h e group t h e y c o u l d acknowledge f e e l i n g s of anger and f r u s t r a t i o n a t the e n d -l e s s r e s p o n s i b i l i t y , and a l s o f e e l i n g s of r e l i e f a t the p r o s p e c t of t h e p a r e n t ' s impending move, w i t h o u t f e e l i n g t h e s e r e a c t i o n s were e i t h e r unique or a b e r r a n t . They c o u l d a l s o r e c o g n i z e t h e u n i v e r s a l i t y of t h e p a r e n t ' s f e e l i n g s and b e h a v i o r s as t h e t ime f o r a d m i s s i o n drew n e a r . 9'i These group sessions within the institution also provided an opportunity for family members to meet with facility staff and perceive the facility as a resource, not only for the elderly person, but for the family as well. At the same time, facility staff were able to gain a more complete picture of the aging parent, not simply as a future resident, but as a member of a functioning family unit. -r, THE PHASE OF INITIAL ADJUSTMENT > It is doubtful whether even the most conscientious I V—7 / preparation and support prior to admission can adequately prepare the elderly person for the initial shock of institutionalization. Moreover, it is the fortunate older person who has had access to this pre-admission preparation. There are still instances where elderly persons are transferred alone from hospital, and deposited on an unfamiliar institut-ional doorstep with no more than a paper bag containing their few personal possessions. What does the elderly person experience during this stage of initial impact? What adjustments must he make? First, the new resident's familiar environment is replaced by an institutional room that may be clean and functional, but bears no similarity to the treasured familiar clutter of home. In most instances, that room must be shared, with all the problems of accommodation and tolerance entailed in adapting to the preferences and life style of another older person. The institutional environment itself is a constant re-9'2 minder that the residence has been designed to accommodate the sick and elderly; and it usually resembles a hospital setting more than a home. The variety and hierarchy of the institutional staff is confusing, and these people must be sorted out in order to obtain the necessary services. One of the most difficult adjustments for the new residents involves adapting the familiar rythmn of his days to the,inflexible institutional routine of established hours for sleeping, eating, bathing and socializing. He must not only become familiar with the formal rules and regulations of the institution, but also with the informal order and conventions of the residential population. Informal and regular contact with neighbours, friends and family is reduced to the ritual of scheduled visits. The residential population is composed of other infirm and possibly confused elderly residents, and association with this population in itself may promote a self-perception of ill health and inadequacy. In the midst of this residential life, privacy becomes a precious commodity, which often must b e a c t i v e l y s o u g h t . A d m i s s i o n t o a n i n s t i t u t i o n h a s b e e n l i k e n e d t o p r o f o u n d c u l t u r e s h o c k . (Yawney & S l o v e r , 1 9 73) A d a p t a t i o n t o t h i s u n f a m i l i a r c u l t u r e r e q u i r e s a n e x p e n d i t u r e o f p h y s i c a l a n d e m o t i o n a l e n e r g y t h a t h a s a l r e a d y b e e n d e p l e t e d b y i l l h e a l t h a n d t h e s t r e s s o f r e l o c a t i n g . T h i s i s t h e s t a g e i n t h e r e -l o c a t i o n p r o c e s s t h a t i s o f t e n m a r k e d n o t o n l y b y i n c r e a s e d m o r b i d i t y a n d m o r t a l i t y , b u t a l s o b e i n c r e a s e d a n x i e t y , d i s -93 o r i e n t a t i o n and d e p r e s s i o n . P r e p a r a t i o n f o r t h e a d m i s s i o n of a new r e s i d e n t s h o u l d b e g i n p r i o r t o t h e a c t u a l date of a d m i s s i o n . I f a h o s p i t a l or community worker was r e s p o n s i b l e f o r t h e i n i t i a l a s s e s s -ment and s c r e e n i n g p r o c e d u r e s , t h e f a c i l i t y worker must o b t a i n t h i s a s s e s s m e n t d a t a . T h i s i n f o r m a t i o n i s e s s e n t i a l i f t h e worker, i n c o o p e r a t i o n w i t h r e l e v a n t f a c i l i t y s t a f f i s t o d e v e l o p a comprehensive t r e a t m e n t p l a n , and d e c i d e on a s u i t a b l e placement w i t h i n t h e f a c i l i t y . I f t h e new r e s i d e n t i s t o s h a r e a room, c o n s i d e r a t i o n must be g i v e n t o t h e s u i t -a b l e m a t c h i n g of roommates which t a k e s i n t o c o n s i d e r a t i o n t h e need and p e r s o n a l c h a r a c t e r i s t i c s of each i n d i v i d u a l . I n r e a l i t y , a s s e s s m e n t i n f o r m a t i o n i s o f t e n u n a v a i l a b l e t o t h e f a c i l i t y s t a f f p r i o r t o the r e s i d e n t ' s a d m i s s i o n ; and t h e new r e s i d e n t i s p l a c e d i n t h e o n l y a v a i l a b l e bed. T h i s o f t e n r e s u l t s i n a d d i t i o n a l room changes a t a l a t e r d a t e , l e a d i n g t o f u r t h e r d i s r u p t i o n and s t r e s s f o r t h e new r e s i d e n t . When t h e r e s i d e n t i a l worker has c o n f i r m e d t h a t a d m i s s i o n i s p e n d i n g , an inter - d i s c i p l i n a r y s t a f f c o n f e r e n c e s h o u l d be h e l d i n c l u d i n g r e p r e s e n t a t i v e s from the n u r s i n g , r e c r e a t i o n , r e h a b i l i t a t i o n , d i e t e t i c and housekeeping s t a f f . The g o a l s of t h i s c o n f e r e n c e a r e t o rev iew t h e new r e s i d e n t ' s m e d i c a l and s o c i a l h i s t o r y , and u t i l i z i n g t h i s i n f o r m a t i o n d e v e l o p a c o o p e r a t i v e and i n t e g r a t e d t r e a t m e n t p l a n . The p r i m a r y g o a l of t h e worker a t t h i s t i m e s h o u l d be t o p r e s e n t a s o c i a l h i s t o r y t h a t i n c o r p o r a t e s both t h e c o m p l e x i t y and i n d i v i d -u a l i t y of t h e new r e s i d e n t . 94 One r e s e a r c h e r , Kahana ( 1 9 7 3 ) , i n a study of r e s i d e n t i a l homes has noted t h a t i n s t i t u t i o n a l s t a f f tend t o view the new r e s i d e n t as someone who f o r a l l p r a c t i c a l purposes has been c u t o f f from the p a s t . When e l d e r l y r e s i d e n t s were asked f o r a s e l f - d e s c r i p t i o n , they c h a r a c t e r i z e d themselves i n terms of t h e i r p r e v i o u s s o c i a l r o l e s . I n c o n t r a s t , d e s c r i p t i o n s by r e s i d e n t i a l s t a f f were r e s t r i c t e d t o an a p p r a i s a l of the r e s i d e n t s ' p h y s i c a l s t a t u s or m a n a g e a b i l i t y i n the home. ( " S h e ' s a d i a b e t i c " , or "She d o e s n ' t g i v e us any t r o u b l e " ) As Kahana has n o t e d : " . . . i f communication i s t o o c c u r between the e l d e r l y r e s i d e n t and those i n the i n s t i t u t i o n who are e n t r u s t e d w i t h h i s c a r e , i t appears most d e s i r a b l e t h a t t h e r e s h o u l d be some common ground between the way t h a t the e l d e r l y person view h i m s e l f and the way t h a t he i s viewed by those who c a r e f o r h i m . " (p. 283) I f the new r e s i d e n t i s t o share a room the p r e s e n t occupant s h o u l d be prepared, and r e l e v a n t a s p e c t s of the new r e s i d e n t ' s s o c i a l h i s t o r y s h o u l d be s h a r e d . When the date of a d m i s s i o n has been e s t a b l i s h e d , the new r e s i d e n t i s n o t i f i e d , and when n e c e s s a r y arrangements s h o u l d be made f o r t r a n s p o r t a t i o n and the t r a n s f e r of p e r s o n a l b e l o n g i n g s . I f a community worker has been working w i t h the e l d e r l y person p r i o r t o a d m i s s i o n , she i s n o t i f i e d . When p o s s i b l e , the community worker should m a i n t a i n c o n t a c t f o r a p e r i o d of time f o l l o w i n g a d m i s s i o n . She can p r o v i d e some sense of c o n t i n u i t y and s t a b i l i t y d u r i n g "this p e r i o d of profound change. D u r i n g the f i r s t few days of a d m i s s i o n , one c o n s i s t e n t person s h o u l d be a v a i l a b l e t o a s s i s t w i t h unpacking and t o p r o v i d e the n e c e s s a r y emotional support and o r i e n t a t i o n t o the f a c i l i t y s e t t i n g , s t a f f and a c t i v i t i e s . T h i s s e r v i c e can be p r o v i d e d by the worker, a s t a f f member, a v o l u n t e e r , or a r e s i d e n t . Some i n s t i t u t i o n s have e s t a b l i s h e d a r e s i d e n t welcoming committee. (Friedman, 1975) Such a committee can b e n e f i t not o n l y t h e new r e s i d e n t , but a l s o the committee members t h e m s e l v e s . I n a d d i t i o n t o p r o v i d i n g peer support f o r the newly a d m i t t e d r e s i d e n t , i t p r o v i d e s an o p p o r t u n i t y f o r p u r p o s e f u l v o l u n t e e r a c t i v i t y f o r the e s t a b l i s h e d r e s i d e n t s . A l l s t a f f members s h o u l d be aware t h a t the new r e s i d e n t . w i l l p r o b a b l y a r r i v e a t the i n s t i t u t i o n p h y s i c a l l y and e m o t i o n a l l y e x h a u s t e d . The i n d i v i d u a l pace of the r e s i d e n t must be r e s p e c t e d . Whi le some new r e s i d e n t s may t h r i v e on an immediate i n t r o d u c t i o n i n t o the a c t i v i t i e s of the i n s t i t u t i o n , the m a j o r i t y w i l l r e q u i r e an extended p e r i o d to i n c o r p o r a t e the many changes they are e x p e r i e n c i n g . If family members are available to the new resident, they can be actively involved during this phase of relocation. Studies have shown that family members are a valuable resource following admission; and they carry a significant role in providing emotional support, a sense of continuity with the past, and an active link with the community. (Miller & Beer, 1 9 7 7 ) , (York & Caslyn, 1 9 7 7 ) , (Smith & Bengtson, 1 9 7 9 ) Family members may display a natural anxiety during 9 6 t h i s p e r i o d of a d j u s t m e n t . I f the aging p a r e n t ' s i n i t i a l response t o a d m i s s i o n i s one of anger, a g i t a t i o n , c o n f u s i o n or d e p r e s s i o n , the f a m i l y may e x p e r i e n c e f e e l i n g s of a n x i e t y and g u i l t which may r e s u l t i n f u t i l e attempts t o compensate through o v e r l y s o l i c i t o u s b e h a v i o r or e x c e s s i v e demands on f a c i l i t y s t a f f . Adult children can be helped to recognize that the elderly parent's reactions, (which can be attributed to physiological changes, environmental stress, and the dynamics of loss), are not unnatural, deliberate, or necessarily permanent. Timely intervention during this period can prevent family problems from becoming firmly entrenched, and support the family's continued involvement. Dye and R i c h a r d s ( 1 9 8 0 ) , have d e s c r i b e d the v a l u e of f a m i l y groups i n f a c i l i t a t i n g the t r a n s i t i o n t o an i n s t i t u t i o n . These groups c o n t a i n e d both new r e s i d e n t s and those f a m i l y members who were most important i n making the d e c i s i o n f o r placement. The groups i n c l u d e d no more than f i v e f a m i l y u n i t s , and were t i m e - l i m i t e d . Group d i s c u s s i o n centered on the p a r t i c i p a n t ' s f e e l i n g s and concerns about placement; and s h a r i n g s o l u t i o n s t o some of the problems t h a t arose i n the i n s t i t u t i o n . The groups appeared t o s u c c e s s f u l l y promote both mutual u n d e r s t a n d i n g and s u p p o r t . THE PHASE OF ADAPTATION Within a period of several weeks the initial impact of , relocation diminishes and a period of adaptation to institu-tional life begins. The advantages of institutional living are weighed a g a i n s t the d i s a d v a n t a g e s , and some accommodation i s sought. The b e n e f i t s of i n s t i t u t i o n a l l i v i n g , (maintenance of , h e a l t h and f u n c t i o n a l c a p a c i t y , a c t i v i t i e s , p e o p l e ) , are b a l a n c e d a g a i n s t the l o s s of independence and f a m i l i a r e n v i r o n m e n t a l and s o c i a l s u p p o r t s . T y p i c a l l y , the r e s i d e n t ' s response i s a m b i v a l e n t . " I needed the c a r e , . . . b u t t h e r e a r e n ' t many people around here l i k e me." " T h e r e ' s some good and some bad t h i n g s . . . I ' 1 1 s u f f e r a long h e r e . . . b u t , I do miss my i n -dependence". (Hanvey & McLachlan, 1 9 8 1 ) The need f o r p h y s i c a l c a r e has been met, but not without c o n s i d e r a b l e p e r s o n a l and s o c i a l c o s t . The p r i c e has been the freedom t o s t r u c t u r e h i s own days, t o m a i n t a i n h i s p r i v a c y , t o choose whom t o share h i s l i f e space w i t h . The c o s t has i n c l u d e d s e g r e g a t i o n from community, f a m i l y and f r i e n d s ; and the l o s s of f a m i l i a r r o l e s and a c t i v i t i e s . Are t h e s e c o s t s an i n e v i t a b l e component of i n s t i t u t i o n a l l i v i n g , or can they be e l i m i n a t e d or reduced by an i n s t i t u t i o n a l environment t h a t attempts to meet both p h y s i c a l and s o c i a l needs. Tobin and Lieberman (19 76) , have noted: "The l o s s of p h y s i c a l or p s y c h o l o g i c a l s e l f - s u f f i c i e n c y does not a u t o -m a t i c a l l y mean the l o s s of s o c i a l needs, the s a t i s f a c t i o n of what can be d i s t i n c t l y t h e r a p e u t i c . The consequences w i l l indeed be d i r e i f we r e t r e a t t o "warehousing" t h e s e most needy e l d e r l y and do not make every e f f o r t t o p r o v i d e l i f e -s u s t a i n i n g s o c i a l as w e l l as p h y s i c a l s u p p o r t s . " (p. 238) D u r i n g t h i s f i n a l r e l o c a t i o n phase the i n s t i t u t i o n a l environment i t s e l f becomes a c r i t i c a l f a c t o r i n a c h i e v i n g s u c c e s s f u l a d j u s t m e n t . Can we d e f i n e the dimensions of the i n s t i t u t i o n a l environment which might promote or undermine a d j u s t m e n t ? I s i t a f u n c t i o n of the p h y s i c a l s e t t i n g , the p o l i c i e s and r e g u l a t i o n s , the programs and s e r v i c e s , or the c h a r a c t e r i s t i c s of the s t a f f ? A number of r e s e a r c h e r s have attempted t o d e f i n e the s a l i e n t dimensions of a t h e r a p e u t i c environment. P i n c u s ( 1 9 7 6 ) , has i d e n t i f i e d f o u r such d imensions : a p u b l i c -p r i v a t e dimension which r e f e r s t o the degree t o which the environment p e r m i t s the r e s i d e n t to e s t a b l i s h a p r i v a t e a r e a f r e e from i n s t i t u t i o n a l t r a n s g r e s s i o n ; a s t r u c t u r e d - u n s t r u c t u r e d dimension which r e f e r s t o the degree to which the r e s i d e n t must a d j u s t t o i n s t i t u t i o n a l r u l e s and d i s c i p l i n e , or may e x e r t p e r s o n a l c h o i c e ; a r e s o u r c e s p a r s e - r e s o u r c e r i c h dimension which r e f e r s to the degree t o which the environment p r o v i d e s o p p o r t u n i t y t o engage i n a c t i v i t i e s and s o c i a l i n t e r a c t i o n w i t h s t a f f and other r e s i d e n t s ; and an i s o l a t e d -i n t e g r a t e d dimension which r e f e r s t o the degree t o which the i n s t i t u t i o n a f f o r d s o p p o r t u n i t y f o r i n t e r a c t i o n and i n t e g r a t -i o n i n t o the o u t s i d e community. Moos e t a l ( 1 9 7 9 ) , have developed a S h e l t e r e d Care E n v i r o n m e n t a l S c a l e (SCES), which attempts t o o p e r a t i o n a l i z e a number of t h e s e d imensions . These r e s e a r c h e r s suggest t h a t t h i s s c a l e s h o u l d be used by r e s i d e n t s and s t a f f t o d e f i n e the type of s o c i a l and o r g a n i z a t i o n a l environment they now have, (not ing d i s c r e p a n c i e s • b e t w e e n s t a f f / r e s i d e n t p e r c e p t i o n s of t h a t environment) , i n order t o i d e n t i f y and implement p o s s i b l e changes t h a t would improve the s o c i a l c l i m a t e . SCES i s composed of seven s u b s c a l e s which a s s e s s : 1) c o h e s i o n - how h e l p f u l and s u p p o r t i v e s t a f f and r e s i d e n t s a r e w i t h each o t h e r ; 2) c o n f l i c t - the e x t e n t t o which r e s i d -e n t s e x p r e s s anger and are c r i t i c a l of each o t h e r and of the f a c i l i t y ; 3) independence - how s e l f - s u f f i c i e n t r e s i d e n t s are encouraged t o be i n t h e i r p e r s o n a l a f f a i r s , and how much r e s p o n s i b i l i t y and s e l f - d i r e c t i o n they are encouraged t o e x e r c i s e ; 4) s e l f - e x p l o r a t i o n - how the environment encourages r e s i d e n t s t o openly d i s c u s s t h e i r f e e l i n g s and c o n c e r n s ; 5) o r g a n i z a t i o n - how important order and r e g u l a r i t y are i n the i n s t i t u t i o n , and the e x p l i c i t n e s s of the r u l e s and p r o c e d u r e s ; 6) r e s i d e n t i n f l u e n c e - the e x t e n t to which r e s i d e n t s can. i n f l u e n c e and change the r u l e s and p o l i c i e s ; and 7) p h y s i c a l comfort - the degree t o which comfort, p r i v a c y , p l e a s a n t decor and sensory s a t i s f a c t i o n are p r o v i d e d by the p h y s i c a l e n v i r o n -ment. (p. 76) I m p l i c i t i n the u t i l i z a t i o n of these s c a l e s i s the assumption t h a t the r e s i d e n t s themselves must be i n v o l v e d i n d e f i n i n g and c r e a t i n g the " i d e a l " or t h e r a p e u t i c e n v i r o n -ment. I t i s the r e s i d e n t s ' s e l f - p e r c e p t i o n of the e n v i r o n -ment, and the degree of congruence between the environmental r e s o u r c e s and i n d i v i d u a l need t h a t are the s i g n i f i c a n t f a c t o r s . R e c o g n i z i n g the g l o b a l dimensions of a t h e r a p e u t i c environment, (the o p p o r t u n i t y f o r s o c i a l i z a t i o n and p r i v a c y , p e r s o n a l 10 u autonomy and c h o i c e ) , i s not s u f f i c i e n t . Means must' be found t o i n d i v i d u a l i z e t h e s e dimensions f o r s p e c i f i c r e s i d e n t s t a k i n g i n t o c o n s i d e r a t i o n t h e i r p a r t i c u l a r c h a r a c t e r i s t i c s , background, needs and p h y s i o l o g i c a l d e f i c i t s . I t i s h e l p f u l f o r i n s t i t u t i o n a l s t a f f t o ask themselves t h e f o l l o w i n g s o r t s of q u e s t i o n s . When i n s t i t u t i o n a l a c t i v i t i e s a r e p r o v i d e d , has c o n s i d e r a t i o n been g i v e n t o those r e s i d e n t s who a r e b l i n d , or b e d - r i d d e n ? A r e s i d e n t i a l committee i s an a d m i r a b l e v e h i c l e f o r r e g i s t e r i n g r e s i d e n t c o m p l a i n t s , but can p r o v i s i o n be made t o reach f o r the concerns or needs of the f e a r f u l or r e t i r i n g r e s i d e n t who would not be p a r t of such a committee? Can we make p r o v i s i o n s t o p r o t e c t the p e r s o n a l s a f e t y of the confused or d i s o r i e n t e d r e s i d e n t , w h i l e s t i l l p r o t e c t i n g t h e i r p e r s o n a l autonomy? With a focus on i n d i v i d u a l need, the type of environment t h a t f a c i l i t a t e s a d a p t a t i o n f o l l o w i n g r e l o c a t i o n might more a p t l y be c a l l e d a "humane environment" r a t h e r than a t h e r a -p e u t i c environment. The r e s i d e n t s ' c a p a c i t y t o a c h i e v e a s u c c e s s f u l adjustment may w e l l depend on the e x t e n t t o which i n s t i t u t i o n a l s t a f f can look beyond d i s a b i l i t y , d i m i n i s h e d f u n c t i o n , and i l l n e s s and see a person. (Kahana, 1973) Without negating the significance of the physical setting, its primarily people who create and sustain the humane environ-ment, - staff, residents, families, volunteers and society i t s e l f . Each have a r o l e t o p l a y . The h e a l t h and s o c i a l needs of i n d i v i d u a l r e s i d e n t s cannot be met u n l e s s the q u a l i t y and t r a i n i n g of s t a f f are 101 p r i m a r y a d m i n i s t r a t i v e c o n s i d e r a t i o n s . The v a s t m a j o r i t y of i n s t i t u t i o n s today do l i t t l e more than p r o v i d e c u s t o d i a l c a r e : i n s t i t u t i o n s p r o v i d i n g s o c i a l , r e c r e a t i o n and r e h a b i l i t a t i o n s e r v i c e s a r e the e x c e p t i o n r a t h e r than the r u l e . S t u d i e s have found t h a t n u r s e s a i d e s perform s e r v i c e s w i t h r e s i d e n t s about four t imes as o f t e n as members of the p r o f e s s i o n a l s t a f f , u s u a l l y without b e n e f i t of pre-employment or i n - s e r v i c e t r a i n i n g . (Handschu, 1973) While t h e r e i s o f t e n c o n s c i e n t i o u s a t t e n t i o n t o the p h y s i c a l needs of r e s i d e n t s , t h i s c o n t r a s t s markedly w i t h the l a c k of a t t e n t i o n g i v e n t o the r e s i d e n t s ' p s y c h o s o c i a l needs. T h i s seldom r e f l e c t s a c a l l o u s l a c k of i n t e r e s t or concern. I t i s more o f t e n a f u n c t i o n of inadequate s t a f f i n g , l a c k of t r a i n i n g and m i s -d i r e c t e d o p e r a t i o n a l e f f i c i e n c y . One r e s e a r c h e r has w r i t t e n : "The s t a f f r e a l i z e d t h a t they were a c e n t r e of human warmth and t h a t b e i n g a l lowed to s i t near the desk or being a l lowed t o l i s t e n t o s t a f f c o n v e r s a t i o n was a comfort f o r many p a t i e n t s . The more competent e l d e r l y managed t h e i r own networks of e l d e r l y f r i e n d s , the l e s s competent c l u n g t o the nurses ". (Putnam, 1973) When the i n s t i t u t i o n does have a s o c i a l worker on s t a f f , one of h e r pr imary t a s k s s h o u l d be t o promote and p a r t i c i p a t e i n i n - s e r v i c e t r a i n i n g of other p e r s o n n e l , w i t h the focus being ways t o meet the r e s i d e n t s ' p s y c h o s o c i a l needs. Residents can be a source of service, comfort and support to each other. However, the opportunity for socialization, the privacy for shared confidences depends to a large extent on 102 the p h y s i c a l s e t t i n g and the a t t i t u d e s of the i n s t i t u t i o n a l s t a f f . The f o l l o w i n g quote w i l l i l l u s t r a t e : " I t h i n k t h e s t a f f regarded c o n v e r s a t i o n between p a t i e n t s as s i l l y and m e a n i n g l e s s because they b e l i e v e d the p a t i e n t s i n c a p a b l e of t h o u g h t . . . I saw on more than one o c c a s s i o n , p a t i e n t s a r b i t r a r i l y s e p a r a t e d i n the middle of a q u i e t c h a t . I o b s e r v e d two o l d women, moved, perhaps, by a dim memory of t ime spent w i t h f r i e n d s long ago, b e g i n t o t a l k as they w a i t e d t o have t h e i r h a i r done. One of them suddenly t o l d she would have t o w a i t u n t i l next week and wheeled, s t i l l i n m i d -s e n t e n c e , t o her room. There was no apparent m a l i c e i n the a i d e ' s a c t i o n ; she seemed to be e n f o r c i n g some u n w r i t t e n r u l e , responding t o an i n s t i t u t i o n a l credo t h a t s a i d p a t i e n t s m u s t n ' t c h a t . ( C u r t i n , 1 9 7 2 , p. 1 5 1 ) Institutions can provide the climate in which friendships can flourish: through activity programs that draw residents together; small group programs that foster intimacy and sharing; resident volunteer programs that encourage mutual concern and support; and residential committees that provide the opport-unity for a sense of shared community. Family relationships not only survive institutionalization; the possibility also exists for renewed and strengthened close-ness. (Smith & Bengtson, 1 9 7 9 ) These two researchers examined family relationships from the perspective of both generations in an institutional setting over a period of two years. Over half of the families interviewed had experienced a renewal or continuation of family closeness. 103 There were s e v e r a l reasons commonly c i t e d f o r t h i s p o s i t i v e outcome f o l l o w i n g i n s t i t u t i o n a l i z a t i o n . P r i o r t o a d m i s s i o n , a number of t h e s e f a m i l i e s had i n v e s t e d c o n s i d e r a b l e e m o t i o n a l and p h y s i c a l energy i n t o m a i n t a i n i n g the e l d e r l y p a r e n t i n the community. I n s t i t u t i o n a l i z a t i o n had r e l i e v e d -t h e s e f a m i l i e s of the p h y s i c a l burden of c a r e , p e r m i t t i n g them t o focus t h e i r e n e r g i e s i n t o p r o v i d i n g the n e c e s s a r y emotional s u p p o r t . A second f a c t o r was the improvement i n the p a r e n t ' s mental or p h y s i c a l s t a t e , p o s s i b l y c o n f i r m i n g the f a m i l y ' s b e l i e f t h a t i n s t i t u t i o n a l i z a t i o n had indeed been n e c e s s a r y and u n a v o i d a b l e . A f i n a l f a c t o r was the p a r e n t ' s involvement w i t h o t h e r r e s i d e n t s , which i n t u r n r e l i e v e d f a m i l y members of the n e c e s s i t y t o s u p p l y a l l t h e p a r e n t ' s s o c i a l and emotional needs. Other s t u d i e s support t h i s e v i d e n c e t h a t f a m i l i e s do m a i n t a i n the p a t t e r n s of involvement t h a t they had e s t a b l i s h e d b e f o r e placement. ( M i l l e r & Beer, 1977). , (York & C a s l y n , 1977) However, f a m i l i e s r e q u i r e support i n m a i n t a i n i n g t h e s e t i e s . I n s t i t u t i o n s can develop programs t h a t i n c o r p o r a t e f a m i l y members i n t o the i n s t i t u t i o n a l s e t t i n g . These i n c l u d e : o r i e n t a t i o n programs; e d u c a t i o n a l programs on the p r o c e s s of a g i n g , and on ways i n which f a m i l i e s can cont inue t o g i v e care t o t h e i r p a r e n t s ; v o l u n t e e r a c t i v i t i e s ; and programs t o mark h o l i d a y s or s p e c i a l f a m i l y o c c a s s i o n s . The r o l e of the i n s t i t u t i o n can expand t o i n c l u d e s e r v i c e s f o r the f a m i l y as w e l l as f o r aging p a r e n t . I n the absence of f a m i l y t i e s , v o l u n t e e r p a r t i c i p a t i o n i n i n s t i t u t i o n a l programs can p r o v i d e much needed companion-1U 4 s h i p and a s s o c i a t i o n w i t h t h e o u t s i d e community. I n a d d i t i o n , v o l u n t e e r s can s e r v e a watchdog f u n c t i o n , m o n i t o r i n g the q u a l i t y of i n s t i t u t i o n a l c a r e . V o l u n t e e r a c t i v i t i e s r e q u i r e the d i r e c t i o n and support of i n s t i t u t i o n a l s t a f f . A worker must be a v a i l a b l e t o p r o v i d e o r i e n t a t i o n , t o develop programs, t o s u p e r v i s e the s e r v i c e s , and p r o v i d e emotional support to the v o l u n t e e r s t h e m s e l v e s . Without t h i s worker investment, v o l u n t e e r programs a r e seldom s e l f - s u s t a i n i n g . The i n s t i t u t i o n cannot be d i v o r c e d from the s o c i e t y a t l a r g e . The q u a l i t y of care we p r o v i d e f o r our aging p o p u l a t i o n r e f l e c t s our c u l t u r a l b e l i e f about the v a l u e of t h a t p o p u l a t i o n . We do not wish to r e c o g n i z e the r e a l i t y of a g i n g , and our own m o r t a l i t y , and we h i d e the e v i d e n c e of t h a t r e a l i t y b e h i n d i n s t i t u t i o n a l doors. " U n t i l s o c i e t y can say "We are t h e y , " t h i n g s w i l l remain much as they a r e . The o l d do not want o u t r e a c h , they want a s s o c i a t i o n . Even the b e s t o l d p e o p l e ' s home i s marked by d i s a s s o c i a -t i o n , and the o l d know i t . What they come t o terms w i t h when they e n t e r t h e s e doors i s t h i s mark of d i s a s s o c i a t i o n . I t i s not always an unhappy t h i n g to have w r i t t e n o f f o n e ' s independ-e n c e ; o f t e n i t i s a r e l i e f . But i t i s p r o f o u n d l y d i s t u r b i n g t h a t by doing so one has severed l i n k s which h e l d one t o the c e n t r e , however p r e c a r i o u s l y . We have t o admit t h a t our own p o t e n t i a l agedness grows w i t h i n us as a f i r s t s t e p towards d e s t r o y -i n g the i s o l a t i o n of t h e s e convenient f a s t n e s s e s . 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