Still Kicking Restorative Groups for Frail Older Adults By Abby V. Brown-Watson, M.S.W. Foreword by Irene Burnside, R.N., Ph.D., FAAN

Excerpted from Chapter 1: Restorative Groups: An Overview of Still Kicking: Restorative Groups for Frail Older Adults, by Abby V. Brown-Watson, M.S.W.

Copyright © 1999 by Health Professions Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

Chapter 1
Restorative Groups: An Overview

Americans are living longer. This is a mixed blessing because living longer does not always mean living healthier. Longevity sometimes means a long, slow decline, with multiple chronic illnesses and social isolation that cause people to need an extended course of long-term care, either at home or in a nursing facility. The need for long-term care may be unavoidable, as in the late stages of Alzheimer's, Parkinson's, and other progressive diseases. However, some people are admitted to nursing facilities unnecessarily or prematurely.

The Honolulu Gerontology Program, from which this book derives, was founded in 1980 to address the needs of vulnerable, frail older adults and to show them how to maintain well-being and independence. After nearly 20 years of service to frail older adults, I believe that the program has developed some answers and service models that work. One of these models is the restorative group for frail older adults.

Restorative groups bring together frail older adults who are having difficulty because of physical, mental, or psychosocial problems that put them at risk for further decline. These older adults meet with age peers twice a week for a program of exercise (1 hour) and social support (30 minutes) that is designed to improve or maintain their physical and mental well-being. Approximately 20 members are enrolled in each group. Participation in the groups is not time limited: Clients may stay as long as they are able physically and feel the need for the support of a group of peers. Many stay for years; some join for a month or two, either feeling better and moving on or becoming too frail to continue attending. (The restorative group model is described in detail in Chapter 2.)

The use of groups with frail older adults is not new. Burnside has used group work to build self-esteem among nursing facility residents since the 1970s (Burnside & Schmidt, 1994). In 1977 Kaplan, Cassel, and Gore wrote of the need for groups designed to help older adults improve their coping and affiliative skills (their ability to take steps to maintain good social support as they age). Lewis (1984) emphasized the need to rebuild frail older adults' motivation (i.e., desire) and capacity (i.e., physical and mental wellness). Restorative groups can help them do that.

One of the hallmarks of the restorative group program is the thorough client assessment and case management process, described in Chapter 3. This information is important for programs that are reaching out to new clients in the community; administrators of programs whose members are in place or known to the staff may not need to understand this process. The restorative group program identifies and assesses suitable clients through a psychosocial assessment and plan of care, which may include links to services that remove any barriers to client enrollment. Trained interviewers visit the potential client's home to administer a psychosocial questionnaire and examine the home environment. The staff social worker develops the care plan. Once the care plan is carried out and the client is enrolled in the group program, program staff provide clients with ongoing case management. The identification and servicing of older adults for group participation is the subject of Chapter 3.

Each restorative group has two leaders: The group leader is the overall group coordinator and case manager for clients, and the exercise leader leads the group in an hour of exercise. Chapter 4 describes the two leader positions and covers a wealth of practical information on effective leadership, including working with older adult volunteers and high school and college practicum students.

Restorative groups, or variations thereof, may be started in numerous settings such as senior centers, adult day programs, churches, seniors housing, or nursing or rehabilitation facilities, or as a freestanding community program. The tasks involved in developing new restorative groups are explained in Chapter 5. Part 2 describes an illustrated series of exercises and games for improving range of motion, strength, and flexibility. Part 3 outlines 58 discussion, education, and socialization sessions that take place during the support portion. Each plan is complete, providing everything a group leader needs to conduct a 30- to 45-minute session.

Understanding the Benefits of Restorative Groups

The restorative groups are beneficial in two ways: favorable treatment outcomes and cost-effectiveness — a win-win situation for both the clients and the program. Favorable treatment outcomes were demonstrated via a formal, 6-month-long pretest-posttest study of one of the Honolulu restorative groups (Dungan, Brown, & Ramsey, 1996). The variables measured were individuals' hand strength; blood pressure; range of motion of the shoulders, knees, and ankles; self-esteem; and life satisfaction. Nearly all of the variables showed statistically significant improvement during the study, and those that did not improve initially were moving toward improvement. Dungan and associates related that merely maintaining one's level of fitness would be an accomplishment for frail older adults; improvement is a bonus.

Reducing or eliminating the period of institutionalization, acute hospitalization, and/or confinement to bed/home is a goal of the restorative group program. Some clients die each year, but only a few are admitted to long-term nursing facilities. This is a key indicator of the success of restorative groups. Ensuring that frail older people remain independent until they die is commendable. That so few need bear the high cost and indignities associated with institutionalization before death is impressive.

Group leaders report improvements in their group members' moods and physical fitness. On arrival at their first group session, some older adults may be groomed poorly and may keep their heads down. Their level of participation is minimal, if they participate at all. Attendance early on may be spotty. With continuing help and encouragement from the group leader, their attendance improves. As their strength increases and their spirits lift, they begin to look forward to the group sessions, and they attend more regularly, chatting with new-found friends before the day's program begins. They begin to care about regular attendance and their fellow members. Older adults whose motivation and capacity are improving will, for example, bring a treat for the group, help one another during the exercises, or telephone when someone in the group misses a session to check on him or her.

Group leaders use client-satisfaction questionnaires to determine whether group members believe that the program is effective. The questionnaire elicits specific comments about whether and how the group helps them physically, psychologically, and socially and whether they have realized improvements in carrying out everyday activities. Reported improvements include strength, endurance, and flexibility; a sense of wellness; the ability to complete everyday chores more effectively; and a sense of belonging, a purpose in life. An arthritic former physician in her mid-80s wrote, "Meeting friendly, outgoing, intelligent people in my age range has improved my outlook, my appetite, and my zest for living." Other group members wrote, "better muscular strength"; "better balance"; "able to do chores and activities for longer, more complete periods"; "sharing aches and pains, laughing out our pain, talking, singing, sharing"; and "when I do not attend I feel left out-my shoulder begins to hurt again"; "emotionally, it has helped me to feel better about myself; socially, it has helped me to talk to people more in my age group"; "speech is more clear; arms are stronger; no longer feel depressed."

The benefits of restorative groups extend to home life as well. Many family members report that their loved ones' mood and behavior at home have improved as a result of the group experience. As one adult daughter commented, "Now, my dad has something to contribute during dinner conversations. He, too, has a life."

In terms of cost-effectiveness, the restorative group is much less expensive than most long-term care services. One month's residence in a nursing facility in Hawaii costs from $3,000 to $6,000. One month's stay in a board and care home is $1,200 to $2,500. One month's participation in adult day programs costs a family from $500 to $800 more if health or hospital services are provided. One month's attendance at a restorative group costs approximately $65. Preventing or even postponing the need for higher levels of care by attending a restorative group saves families and/or the state a great deal of money.

Identifying and Compensating for Losses

A restorative group is a powerful medium that is particularly suited to helping frail older people cope with the losses that they experience, such as loss of fitness, health, social support, purpose in life, and personal power (Mosher-Ashley & Barrett, 1997; Toseland, 1995).

Fitness

Although not a part of traditional group work with older adults, exercise is an important component of restorative groups, not only for its health benefits but also because offering exercise is one way to lure depressed and reclusive older people out of their homes. Research indicates that regular exercise improves the quality of life of older people and helps to prevent premature aging and physical and mental decline (Strawbridge, Shema, Balfour, Higby, & Kaplan, 1997; Zimmer, Hickey, & Searle, 1997). Shephard (1993) stated that exercise improves older adults' ability to carry out the everyday activities that are essential to living independently, which leads to a substantial reduction in demand for both acute and chronic care services. Studies conducted since the early 1990s showed that even old old adults (age 85 and older) with impairments improve in strength and functional capacity by exercising, including resistance training with handheld weights (Berdit, 1995; Fiatarone et al., 1990, 1994; Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995; McAuley, 1993; Munnings, 1993). Studies by Dungan et al. (1996), Sharpe et al. (1997), and Stevenson and Topp (1990) regarding older adults who participated in exercise classes reported improvements in physical and psychosocial indicators in as little as 6 months to 1 year. Perkins-Carpenter (personal communication, 1998) has said that older adults can do much more than they think they can and much more than younger people think they can.

Health

Many older adults can expect to cope with numerous chronic conditions, such as stroke, arthritis, hypertension, osteoporosis, diabetes, heart disease, vision and hearing losses, and cancers. Zimmer et al. (1997) reported that people with arthritis decreased their level of activity in accordance with the severity of their pain. Losses of vision, hearing, and speech also have negative effects on activity levels and the ability to engage others socially (Verbrugge, 1997). Numerous studies have found that health problems and disability are predictors of depression in older adults (Burnette & Mui, 1994; Mosher-Ashley & Barrett, 1997; Roberts, Kaplan, Shema, & Strawbridge, 1997; Robinson, Lipsey, & Price, 1984).

The restorative group helps older adult members cope with physical decline by providing a place where they can experience feelings of universality, can exercise to improve their health, and can become educated about health-related aging issues. They derive comfort in learning that they are not alone in struggling to maintain well-being despite their physical decline; many realize that "it could be worse." One restorative group graduate wrote, "I've lost my mobility, but Joe can't speak, and Theresa can't remember anything. Each of us has limitations, but we still can adjust, cope, and grow." The social support that they receive in the group helps to protect them against the effects of stress and illness (Berkman, Leo-Summers, & Horwitz, 1992; Mor-Barak & Miller, 1991; Thompson & Heller, 1990). Becoming educated about aging issues heightens their awareness of their health and self-care (Bonder & Wagner, 1994; Dychtwald, 1986; Haber, 1994; Lorig, 1993; Mazzuca, 1982). Learning and change come slowly to frail older people, so an ongoing group experience helps to encourage and reinforce learning and maintaining helpful knowledge, attitudes, and behaviors.

Social Support

Individuals who survive to an advanced age become less active socially and lose the support that had been provided by spouses, siblings, friends, children, and co-workers. Some older people find it difficult to accept their need to lean on family members and others. The loss of their social network and/or the struggle to cope with difficult family relationships leaves many older adults feeling isolated and lonely. The restorative group helps to alleviate their isolation and loneliness by creating a new social network of age peers. In Zimmer et al.'s study (1997), the older adults who maintained strong social networks through illness were likely to replace previous activities with those that were adapted to their remaining strengths. They also found that preserving a strong social network had a positive effect on older adults' health. Among older heart surgery patients who had strong social support systems, Oxman and Hull (1997) found less depression and less impairment in performing the activities of daily living. Individuals who did not maintain a social network (or never had one) and did not replace their former activities responded less flexibly to their illnesses, which affected their well-being.

Purpose in Life

The loss of purpose in life has been reported by nearly all of the older adults referred to the Honolulu Gerontology Program. They speak of feeling useless, feeling that being frail means saying goodbye to the things that they used to enjoy, and feeling that no one needs them anymore. The restorative group helps its members cope with this loss of purpose in life and, in many cases, to regain it. Group members say that they have a reason to get up in the morning and look forward to their future. As they begin to interact in the group setting and come to care about one another, they begin to feel needed once again.

Personal Power

As people become dependent on others because of impairments of vision, hearing, mobility, or cognition, they lose power, or control, over their own lives. No longer being able or allowed to drive a car means depending on others for transportation or staying home; being unable to handle the checkbook means letting someone else gain control over money; having to move closer to one's adult children means losing control over daily routines and social life. Participation in a restorative group of peers in similar circumstances helps older adults adjust to these losses of personal power. Together they seek ways to compensate, regain control, or maintain self-esteem. Along with good health, a sense of identity, self-reliance, and mastery are considered by older people to be important factors in helping them continue to live independently, which is one of the goals of the restorative group (Femia, Zarit, & Johansson, 1997; Mack, Salmoni, Viveras-Dressler, Porter, & Rashmi, 1997).

Successful performance of the developmental tasks of aging confers a sense of personal power on older adults. Peck (1968) believed that older adults must adjust to aging and the inevitability of death, that they should try not to become preoccupied with their limitations and discomforts but to focus on the positive aspects of their lives, and that they should find ways to gain a kind of immortality through social interactions and emotional giving. Research indicates that the generativity issues of caring, nurturing, and maintaining, described by Erikson as a task for adulthood, continue into old age (de St. Aubin & McAdams, 1995; Erikson, 1963; Erikson, Erikson, & Kivnick, 1986; McAdams, de St. Aubin, & Logan, 1993). Erikson recognized that older people need to reflect on their lives and reach a sense of integrity; that is, despite ups and downs, mistakes, and disappointments, they accept their life's journey (Erikson, 1963). If this conclusion is not reached, then older adults may feel despair about their lives. Butler called the process of reflecting on one's life "life review" and believed that reminiscing is necessary for older adults in order for them to adjust to the inevitability of the end of their lives (Butler, 1963, 1975, 1981; Butler & Lewis, 1982). Tobin (1988) believed that just surviving is a task of old old adults and that this entitles them to be who they are, needing no excuses. Older adults need to feel good about themselves as they are, which may not be the message that they receive from their families and the community.

Understanding the Curative Powers of Restorative Groups

We know that restorative groups can help older adults to identify and cope with the losses that they experience, but we may not understand what causes this to happen. Yalom (1985) identified 12 curative factors that operate during the peer-group psychotherapeutic process. At least 10 of these factors are particularly appropriate for restorative group work with frail older adults:

• Cohesiveness — Yalom perceived cohesiveness, or a sense of belonging, as a preparatory stage that allows for more effective work in the actual group sessions. In the restorative groups achieving cohesiveness is also an end in itself. Older people who are socially isolated once again feel as though they belong to a community of people who are like themselves.
• Universality — To learn in the group setting that their pain is universal, that they are not the only ones going through hard times is comforting for most older adults. Because participants share a variety of diagnoses and psychosocial problems in a restorative group, they also learn that "it could be worse," and they gain relief from that knowledge.
• Instillation of hope — Instillation of hope is a powerful factor for many group members. In the group setting, participants learn that their lives can, in fact, improve, that they do not need to "give up" on life, that they can enjoy life despite their limitations.
• Catharsis — People who feel misunderstood at home and/or in the community are permitted emotional release in the safe environment of the restorative group. Some members arrive at the first meeting with a long list of complaints, which, once aired, dissipate; other members need to work for months in the group in order to achieve this result.
• Interpersonal learning: Input—In contrast to the cliche, an old dog can learn new tricks. Members of restorative groups learn by listening to the problems of other participants and by sharing their own experiences.
• Interpersonal learning: Output — In sharing their own experiences and the coping mechanisms that have worked for them, older adults find that they are helping other group members and that it feels good to do so.
• Altruism — Participation in a restorative group allows members to find opportunities to fulfill their own needs for helping others by giving of themselves.
• Identification — Group members may become sensitive to and adopt the positive attitudes and behaviors of other group members as well as the group leaders. These attitudes and behaviors include high self-esteem, positive regard for others, effective coping skills, and open sharing of concerns.
• Reenactment of family — The group replaces a lost feeling of family for many participants. They nurture and support each other in the same way as they were supported and nurtured throughout their lives. In turn, sometimes a group member misbehaves as he or she may have in the family and finds that these behaviors also are not acceptable in the group, and group members reprimand him or her.
• Insight — It is never too late to gain insight into some past event or behavior. In one of my groups a gentleman who had led a rather flamboyant life said, "If only I had known I was going to live so long, I would have taken better care of my body."

These curative factors find practical application in the restorative group setting, as the following vignettes demonstrate.

Aletha

While recuperating from a moderate stroke and feeling vulnerable emotionally, Aletha, 82, had been persuaded to sell her house in Oregon and move in with her daughter, Randa, and her family in Hawaii. Living with Randa was stressful for Aletha and for Randa and her husband, Josh, who worked more than full time in their family business. Aletha missed her home and her friends in Oregon and was desperately lonely, depressed, and angry. She wanted to go home to Oregon, but her home was gone. In despair, Randa called the Honolulu Gerontology Program looking for help. During the in-home assessment Aletha was able to express her feelings of frustration. The senior advisor told her that she might enjoy attending a restorative group two mornings a week with other people her own age. She would be able to exercise to improve her strength, learn about self-care, talk with group members about mutual concerns, socialize, and play games. Reluctantly, Aletha agreed to try the group.

At her first group meeting, she met another woman who had moved from her longtime home to be near her children, and she met several other people who were dealing with stroke effects. In the first few meetings Aletha could do only the first 15 minutes of exercise, but within 2 months, her strength had improved to the point that she could participate in the entire hour of exercise. During the half-hour support periods she learned useful information about preventing stroke and about housing options for older adults. She was able to express her feelings and learned to give herself permission to be sad about leaving her home and friends behind. At some of the support sessions she and the other members participated in life review, sharing stories of good times and bad. During the monthly group socials and during the informal visiting that group members did before group started each day, Aletha made new friends and enjoyed chatting with them. Within a few months her mood improved, and she began to feel a sense of control over her life. With her new-found sense of self, she made the decision to move into a nearby retirement residence, where she is now living quite contentedly. She did not return to the restorative group.

It is easy to see many of Yalom's principles at work in Aletha's case. Participation in the group addressed Aletha's need for friendships and community (cohesiveness). She noted that other group members' situations were worse than hers was, but that they were able to adjust to these new stages in their lives. She benefited from meeting another person who had left her roots behind and several others who were recuperating from stroke (universality), and thus was able to make adjustments herself. Through her group work, Aletha began to feel hopeful (instillation of hope) about her future. With fellow group members supporting her, she was able to carry out life review and come to accept life as it is, not as it used to be (insight). Although she had the support of her family, Aletha resented being dependent on them. She needed peer contact to feel a real sense of support, and thus she felt less dependent. In the group Aletha was able to vent her anger and frustration at her situation and felt that others understood (catharsis). Aletha listened to the stories of group members who were learning to cope with their problems, and this helped her understand new ways of dealing with her difficulties (interpersonal learning: input and identification). As some additional benefits, Aletha improved her strength through exercise, she overcame her anger about leaving Oregon, and she learned practical information about preventing stroke through exercise and nutrition and finding different housing options.

Rita

A telephone call to the Honolulu Gerontology Program from Rita's daughter, Sally, sounded desperate: Sally said that her mother was driving her crazy. Rita, 84, had Alzheimer's disease. Mother and daughter had never gotten along, and now this situation was even more difficult. An in-home assessment showed that Rita had fairly advanced cognitive losses. Program staff decided to place Rita in a restorative group on a trial basis. In group she was pleasant and could contribute appropriately to discussions. Rita gained great satisfaction from reminiscing about her adventurous life on a Wyoming ranch. Because of her short-term memory loss she tended to repeat stories, but group members did not seem to mind, and the group leader was able to gently shift her away from too much repetition.

After 2 years in the group, Rita's condition deteriorated and she began to disrupt discussions. The group leader helped Sally to consider other resources for her mother. For a time, a volunteer companion brought Rita to group and then removed her when she became disruptive. Rita was also enrolled in an adult day program, attending once a week. Eventually, Rita was no longer appropriate for the group and was enrolled in the day program on a full-time basis. When her condition deteriorated further, she was placed in a board and care home.

Rita benefited in a more limited way than did Aletha from participating in the group. The exercise helped her to maintain physical fitness. Clearly, she enjoyed the peer support (universality). She enjoyed being a part of the group (cohesion) and was able to vent her problems with Sally (catharsis). She often shared her wisdom, using charming cliches, such as "laugh and the world laughs with you; cry and you cry alone" (interpersonal learning: output). Her dementia probably prevented her from working on developmental tasks or learning better self-care skills. The other beneficiary in this case was Rita's daughter, who was greatly relieved by having the program's support in providing care for her mother.

Roy

Healthy and independent until his only daughter died of cancer, Roy was without family support. Now in his 90s, he became depressed and began experiencing back pain, which kept him from pursuing what he loved best: helping homeless people. His physician recommended the restorative group.

The exercises helped to reduce his back pain and to increase his strength. The support period gave him a chance to be with others who were old and alone (universality). He found a sense of belonging (cohesion) and the group became his family and his community (reenactment of family). He found ways to help others by holding a chair for a female group member or reminding a forgetful member to bring a snack for the meeting (altruism). When he fell at home and fractured his hip, group members telephoned and sent cards, and the group leader arranged for in-home personal care. These supportive acts helped Roy to anticipate returning to the group (instillation of hope), and he did so in just 8 weeks.

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Cases like these illustrate the benefits of restorative groups. Turn to Chapter 2 for a description of the components of a restorative group program.