Assessing the mental health needs of older people
Richards S (2000) Bridging the Divide: Elders and the Assessment Process British Journal of Social Work 30 (1) pp.37-49
This study aimed to examine how the assessment process, by privileging agency agendas and marginalizing the thoughts of older people, may lead to inappropriate interventions based on inadequate understanding of need.
The subjects were drawn from a hospital social services team covering 4 elderly units and an area social services team in one city. They included 17 assessors and 25 older people (12 women, 3 men and 5 married couples) aged 70-93 years, who were involved with 15 community care assessments and 5 home care assessments. These assessments were studied in detail.
Researchers observed and taped each assessment interview and then taped individual interviews with assessors, the older people and other participants.
Initial data analysis focused on the differing perspectives and experiences of the people involved in each case. Secondly a thematic analysis was carried out to compare the understandings and experiences of subjects occupying the same role in the assessment process.
Generally it seemed hard to ensure that the views of the older person remained focal to the assessment.
Referrer accounts often focused on presenting problems, with an emphasis on the need for help with personal care. When referrals were prompted by relatives, their own concerns were prominent. In no case were older people prepared with written information about their referral.
The accounts of older people could be grouped into three categories:
- Decided - giving a clear account of their difficulties and needs.
- Undecided - faced with complex decisions.
- Overwhelmed - struggling with the immediate situation.
During home care assessments it was sometimes evident that the form was regarded as a more reliable way of identifying need than the older person's own thinking. The form allowed for a systematic evaluation of activities of daily living.
The community care needs assessment was potentially less prescriptive. However, assessors often concentrated on perceived problems as preferred solutions. Most of the older people involved in the assessments had little information about the process and its purpose.
There was no clear distinction between user-centred and agency-centred objectives. As a consequence the assessor tried to gain an understanding of the older person through standard information gathering instead of listening to the older person's narrative and the insights it provided.
Findings indicate that assessment is affected by the pressure on assessors to make quick decisions, sometimes resulting in inappropriate care plans. Assessors need to ensure that the older person's views remain central to assessment. By marginalizing older people's insights, risk of inappropriate intervention may increase.
A user-centred approach requires information gathering and service provision meaningful to the individual older person. Efforts to manage their situation and insights are often revealed in narrative form by older people and this information is often ignored during an agency-centred assessment. Staff supervision and listening skills training can address some of the current assessment difficulties.
Older people need intelligible information on the assessment process and care options to help them make decisions. Assessors need to clarify their role and identity. Attention should be paid to the older person's 'narrative' and 'understanding', rather than on standard information gathering alone. Assessment needs to be envisaged as an intervention in itself.