Rethinking the Care Needs of Older Homeless People

by Rachel Barken and Amanda Grenier

The care needs of older adults experiencing physical and cognitive decline generate much attention in political, popular, and academic debates. Yet, particular subgroups of the older population are often overlooked. Such is the case for older homeless people, whose numbers are increasing across Canada and internationally. Older homelessness is also largely invisible in academic study, although interest is beginning to turn in this direction. Few gerontological works focus on homelessness, and studies on homelessness are often organized around earlier parts of the life course (Crane & Warnes, 2005; McDonald, Dergal, & Cleghorn, 2007). As a result, we know little about older homeless adults’ needs for care.

Our research project, “Homelessness in Late life: Growing Old on the Streets, in Shelters, and Long-term Care” explores the challenges older homelessness brings for aging societies as a whole and for service providers working in housing, shelter and long-term care. It involves a critical policy analysis; qualitative interviews with service providers and older homeless people; and participant observation in homeless shelters in Montreal, Quebec. This blog reports preliminary results from interviews with 15 service providers working with older homeless people. Interviews revealed three findings relevant to the challenges and contradictions of later life homelessness: (1) the need to adapt current approaches to homelessness to better accommodate older people, (2) the need to develop and sustain affordable housing across the life course, and (3) the inherent emotional conflicts and contradictions associated with homelessness in late life.

First, homelessness tends to be approached as a rupture in the life course requiring an emergency response. Support services are often provided in reaction to a fixed event, with the aim of reconnecting people with work or housing.  Interviews with service providers, though, reveal that older homelessness is often the result of marginal and precarious positions over time. The combined implications of social marginalization and older age means that traditional solutions based on work and housing are less able to ‘fix’ the problem of older homelessness. A deeper understanding of the interconnected individual and structural forces leading to later life homelessness is necessary.

Second, older people are caught between various housing and long-term care models. Housing options for older homeless adults in Canada include affordable housing units, alternative housing models, emergency shelters, and residential and long-term care facilities. Yet there is often a disjuncture between housing policies and practices on the one hand, and older homeless adults’ experiences, needs, and abilities on the other. Older people may need to compete against younger groups for subsidised housing. Pensions provide a certain level of income, but this does not address the shortage in supported housing options. Add to this that shelters or rooming houses are not intended as spaces to grow old. They are not adapted to changes in mobility and certainly do not qualify as ‘home’. Long-term care is also often inaccessible to older homeless people. They either cannot afford long-term care, or their needs cannot easily be accommodated in institutional environments.

Our third finding is perhaps most interesting to the debates circulating on this blog. Although workers do not necessarily name it as such, their interviews convey emotional, moral, and ethical conflicts around service priorities, personal associations, and expectations of aging. Their comments that one is ‘not expected to be homeless in later life’ poignantly articulate the conflicts that they experience with regards to aging and marginalisation and a profound helplessness given the lack of service options available for older homeless people.

In sum, homelessness rarely figures in to discussions of later life care. This leaves us with few directives when attempting to care for older homelessness people. We suggest that a life course perspective could be fruitfully applied to understand major pathways into homelessness, particularly risk factors and trigger events, and their prevalence across the life course. With this in place, it is necessary to design housing and care options that suit older homeless people’s diverse needs, abilities, and interests. Finally, it is urgent for discussions of later life care to address the realities of homelessness in particular, and social marginalization more generally. Our project, grounded in empirical data, seeks to generate knowledge that will enable policymakers and practitioners to account for homelessness in their responses to later life care.

References:

Crane, M., & Warnes, A. (2005). Responding to the needs of older homeless people.         Innovation: The European Journal of Social Science Research, 18(2), 137-152.

McDonald, L., Dergal, J., & Cleghorn, L. (2007). Living on the margins: Older homeless    adults in Toronto. Journal of Gerontological Social Work, 49(1-2), 19-46.

* The results discussed in this blog are part of an ongoing study being carried out at the Old Brewery Mission in Montreal, and funded by the Social Sciences and Humanities Research Council of Canada: Homelessness in Late Life: Growing Old on the Streets, in Shelters and Long-term Care: Amanda Grenier (PI), Tamara Sussman, David Rothwell and Jean-Pierre Lavoie.

Amanda Grenier, PhD, is Director of the Gilbrea Centre for the Studies of Aging, Gilbrea Chair in Aging and Mental Health, and Associate Professor in Health, Aging and Society at McMaster University, Canada.

Rachel Barken is a doctoral candidate in the Department of Sociology at McMaster University and Research Assistant on the Homelessness in Late Life research project.

‘Dangerous Care’ by Ann Stewart

Last week, three care workers from Hillcroft nursing home were jailed and a fourth given a community sentence for tormenting and abusing elderly residents with dementia. Their actions were described by the trial judge as “gratuitous sport at the expense of vulnerable victims”.  This high profile case adds to a depressing list of abuse of frail elderly and vulnerable people amounting in many instances to criminal behaviour on the part of care workers.

This blog is a personal reflection on these events although I do have an academic interest in body work and the regulation of care.  My first reaction when I read or see the coverage is to feel sick.  I am taken back instantly to the emotions I experienced in relation to my own parents.  They lived until their late 80s together in their council bungalow in a village until my mum’s physical health deteriorated significantly.  Dad was not able to look after her adequately and I took over responsibility for them.  Eventually they came to live with me and for two years or so I became immersed in the world of ‘care’ – high intensity emotional contexts, exhaustion and persistent low level frustration caused by every day events coupled with constant anxiety about their wellbeing.  I hated to think of their vulnerabilities being exposed.  I wanted everyone around them – care workers, nurses, my friends, neighbours and adult children to see them for what they were – simple ordinary people – nothing special – at the end of their lives.  I wanted people to like them – to see through all the stuff that comes with frailty in old age – and to treat them well and with respect.  I can’t bear to think about what has happened to people like my mum and dad, although neither had the added vulnerability of dementia in the situations described in these cases. I am of course not alone in this – the relatives and friends of those who experienced the abuse say the same: they are angry and feel guilty.  I understand the guilt while recognising that it is inappropriate.

My second reaction focuses on the pictures of the workers, described as bullies, monsters, callous and hard hearted and a disgrace.  I find it difficult to join in the ‘how could they?’ responses.  I was constantly anxious about the demands that my mother in particular presented to those who cared for her.  I worried all the time that they were unreasonable – I often found them unreasonable when I was doing the caring – while at the same resisting this way of thinking about her – why was I expecting her to be reasonable?  What did that mean – complying with my idea of what she wanted or needed?  I would mentally grit my teeth, draw on a joint history (not uncomplicated) and my love for her and find a way through although I would feel furious at times.  I didn’t always stop myself saying and doing callous things or neglecting her.  But how would those who only knew her in this last stage of her life, and through a work relationship, cope?  What did I expect of them?  What was reasonable?

I hoped to manage relationships between care workers and my parents and between the care workers themselves (we always had a minimum of 2 at any one time because of the complex needs of my mother) by throwing as many resources as possible at the situation – decent wages and generous conditions – plenty of substantial and paid breaks away from her during working hours, long holidays, constant attention to individual worker’s needs and pressures,  flexible arrangements between the workers themselves and so on.  I am no saint. I wanted the arrangements to work.  I liked all the people involved.  I could be ‘generous’ because my parents received substantial financial support through direct payments at that time because my dad had been a farmer worker and they had no assets.  I could add to this from my professional salary.  I lived in a very large house with a big garden providing ‘space’ for workers.  It was still far from easy.  Tensions between workers would emerge which had to be sorted out.  But by having a mix of part time postgraduate students, full time directly employed workers and some agency workers coming in at peak times we managed somehow.

I look at the pictures of the ‘homes’ that always seem to accompany the reports of these institutional abuse cases and think about the financial and managerial regimes that underpin them.  The reports provide glimpses of the position of the care workers – often from marginalised groups in society, under pressure, vulnerable, untrained, unsupported and under-resourced – and I can see how the abuse happens quite easily and I find it hard to join in the general condemnation while sharing the anger at what has happened.

It seems to me that we as a society abuse these workers and when they abuse others we send them to prison. We create a ‘moral panic’ about institutional care and put these body workers at its heart.  Labour law seems totally unable to provide an adequate framework for protecting care workers and for managing these really difficult relationships.   The structural problems associated with the commodification of caring particularly in a context of ‘austerity’ are being mis framed as the individual responsibility of marginalised workers within the law. These workers’ (often physically and emotionally exhausted) culturally identified bodies are made invisible for these purposes while increasingly made subject to surveillance by managers and regulators through other forms of regulation deemed necessary to prevent the abuse which results from the means through which such care is provided.  The state punishes them for our collective lack of responsibility.

Ann Stewart, School of Law, University of Warwick, Coventry CV4 7AL, UK