Download a PDF of this article

I came to my social work program with plenty of life experience caring for older adults. When I was young, I cared for my grandmother, and volunteered in nursing homes and for the Meals on Wheels program. Later, I cared for my elderly parents for more than ten years. Placing my mother in a nursing home was a difficult decision, but it gave her and me the opportunity to socialize with other seniors. So it was natural for me to ask for an internship working with seniors.

I have been an intern at Vitas Hospice, an agency located in Lombard, IL, since June 2012. The agency cares for older adults who are dying and who may suffer from dementia. My tasks include completing psychosocial comprehensive assessments for each new patient and providing emotional support to family members, caregivers, patient, and friends. I also help patients and families investigate available government benefits, find financial support and information on available transportation, and I help families find appropriate support in grieving. As a social worker, I can help locate facilities that offer a place of respite for caregivers, and additional resources that provide medical information and address other concerns of family members (Vitas Hospice, 2011).

During the initial visit with each patient, the social worker’s assignment is to complete a comprehensive psychosocial assessment. The assessment consists of three pages of questions that address the psychosocial and spiritual aspects of the individual. The assessment requires both questioning and observation for accurate completion. The initial assessment is undertaken on the first visit, with additional assessments made at appropriate future visits, in order to update a patient’s information. I had many questions about how to perform an assessment with my patients. Should I arrive at the appointment eager to gather the important information directed by the assessment tools? Would I begin the process of developing a trusting therapeutic relationship by using this formal approach? Would the senior immediately welcome me, a stranger, and feel secure enough to disclose personal information?

Completing the assessment can be difficult with older patients who suffer from dementia and/or depression. Eighty-four percent of people over the age of 90 have some symptoms of dementia (Hooyman & Kiyak, 2005). Alzheimer’s disease currently affects five million people in the United States, and is the fifth leading cause of death. In addition, depression, anxiety, and personality disorders are three of the most dominant disorders of late-life (Hooyman & Kiyak, 2011). Depression may alter the personality of older adults; they may become withdrawn, apathetic, and start to slow down on daily living activities (Zastrow & Kirst-Ashman, 2010). Even if they are not clinically depressed, adults can become fearful, suspicious and non-trusting, following significant losses of a spouse, home, family members, pets, friends, independence, and physical and psychological health (Hooyman & Kiyak, 2011). Finally, ageism may become a burden for older adults when they are treated as incompetent, dependent, and senile (Zastrow & Kirst-Ashman, 2010).

These factors combine to make it difficult for older adults to trust caregivers like social workers. A new face may cause fear and confusion to the patient, which may lead to avoidance and silence. Older adults may find it intimidating when a businesslike stranger enters their room, focused on getting the job done. If the older adult initially feels threatened by the social worker, establishing and building a trusting relationship may become difficult. In my internship, I came to understand that helping older clients tell their life story can be an essential foundation for a relationship of trust. I learned the skills of respectful and active listening from my supervisor, and used concepts from narrative therapy that I had learned in class.

Allowing clients to share life stories builds an alliance that is ethical, respectful, and informative (Monk, Winslade, Crocket, & Epson, 1997). My supervisor taught me valuable lessons about listening and eliciting clients’ stories. Most important was to enter the room as a “blank slate” without a preconceived agenda, despite the need to fill out an evaluation. My supervisor made practical suggestions about positioning myself in front of the client and maintaining good eye contact. I needed to ask open-ended and “brainstorming” questions to encourage the client’s narrative, and to listen respectfully and enthusiastically.

In addition to my supervisor’s guidance, certain concepts from narrative therapy helped me to co-create stories with my senior clients. In narrative therapy, the client becomes an active collaborator in sharing his or her life story, the expert on his or her own narrative (Drizin, 2011). The client can assume many roles in the story: the lead character, writer, storyteller, and reader (Miller, 2011). Narrative therapy suggested several helpful areas of inquiry. Most important was a central feature of social work: focus on strengths and successes. Self-description includes the client’s childhood, jobs, marriage, children, and current family members. There should be an opportunity for deconstruction of the client’s identity: gender, culture, sexual orientation, etc. My goal with every client is to focus on strengths and successful experiences. Exploring these features allows older adults to retell their stories in a more positive light.

Recently, I worked with a 90-year-old woman who was mistrustful, confused, and fearful. My first visit was brief in order to foster a trusting relationship. Each visit lasted a bit longer until I could see her comfort level improving. I consciously sat directly in front of her, using appropriate eye contact when she spoke, showing her respect and gratitude. Probing questions and comments such as “Tell me more” were often used to encourage further exploration. Slowly, she began to share bits and pieces of her life, including her family history. By allowing her to assume the role of storyteller, I was able to collect information necessary to complete the psychosocial assessment and share it with team members. A comprehensive plan was implemented to insure optimal safety and additional interventions to improve her quality of life.

Eliciting the client’s story is a valuable tool in forming a working alliance with the older adult. It allows the therapist to build a caring therapeutic relationship by engaging the patient in conversation. By creating a trusting, safe, attentive environment and encouraging a narrative review, the social worker is able to collect meaningful and useful information while completing a successful assessment and encourages positive ongoing engagement with the client. Learning from my supervisor and from the concepts of narrative therapy has given me a good foundation for my future work with older adults.

Alzheimer’s Association. (2012). Support groups. Retrieved: January, 2013. From:

Berthold, S. (2006). Back from the edge project evaluation. Retrieved: January, 2012. From:

Drizin, C. (2010). Narrative therapy techniques with older adults. Retrieved: October, 2012. From:

Erikson, E., & Erikson, J. (1997). The life cycle completed: Extend version with new chapters on the ninth stage of development. New York, NY: W.W. Norton & Company, Inc.

Hooyman, N., & Kiyak, H. (2011). Social gerontology a multidisciplinary perspective (9th ed.). Boston, MA: Pearson.

Miller, B. (2011). Narrative gerontology: A post reading later stage of life: A conversation with William Randal. Journal of Systems Therapies, 30(4), 64-75.

Monk, G., Winslade, J., Crocket. K., & Epston, D. (1997). Narrative therapy in practice: The archaeology of hope (1st ed.). San Francisco, CA: Jossy-Bass.

Vitas Hospice. (2001). Where do I turn for help? Lombard, IL: Vitas Hospice.

Zastrow, C., & Kirst-Ashman, K.K. (2010). Understanding human behavior and the social environment (8th ed.). Belmont, CA: Brooks/Cole.