Early in September the following announcement appeared in the local Council on Aging Newsletter, in the Advocate-the local newspaper, and on the bulletin board of Finlay House, a drop-in center for the elderly.
The Council on Aging, together with the Mental Health Center, is sponsoring a group experience for senior citizens. This group will provide an opportunity to share feelings, thoughts, and concerns as well as the joys and sorrows of growing older.
The Health Nurse for the Elderly and a Clinical Specialist from the Mental Health Center's Service to the Elderly will co-lead this group.
There will be 12 weekly sessions held at Finlay House starting in September. A small fee to cover costs of refreshments and group expenses will be required at the time of registration.
Our goal then was to lead a support group for senior citizens in which members could talk about the issues, problems, and myths of aging. If members could express and share thoughts and feelings about loneliness, continuing life changes, and loss, so could they help one another become accustomed to these changes.. .be they physical, psychological, intellectual, sexual, or economic. Our premise is that those who choose to continue to grow and to develop may do so. It was our intention then to facilitate the creation of a group environment in which members could feel safe enough to take risks in sharing their concerns so that through confrontation, clarification, reflection, and support, the aging of each member could become a continuation of the development of each person and that each member would feel more in control of his/her aging.
The idea for a group experience for senior citizens began the previous autumn when a member of the senior citizens drop-in center requested an opportunity for the elderly to offer encouragement and support to one another as they adjusted to the challenges of aging.
In November, a formal request for such a group was presented to area personnel working with the elderly. Barbara, the health nurse practitioner of the elderly and I, the mental health nurse coordinator for services to the elderly, eagerly agreed to be co-leaders. We invited Ann, a Vista Volunteer, to be recorder. We sought internal supervision from an expert on group process, the associate director of the community mental health center.
I would like to share our experience as leaders of a time-limited, closed group for nine senior citizens.
Before the Beginning
During the summer Barbara, Ann, and I met every week to establish our working relationship. We chose a basic reference text1 and continued to study, share, and plan. We used these months to develop a comfortable open relationship among ourselves.
We planned our 12-week group schedule to begin in the fall and to continue through the holidays and beyond the new year. Holidays are a time when memories from the past intensify feelings in the present. We planned to focus on important feelings communicated by individuals or the group and to support one another throughout the holiday season. By having a time-limited group, we planned to work through some issues surrounding termination. Issues faced at the termination of a group parallel issues faced by the elderly. They include such questions as:
1. What have we accomplished in our group; in our lives?
2. What personal goals have we achieved in this group; in our lives?
3. How do we feel about what we are gaining and losing both within the group and within our lives?
4. Is this the end or a new beginning? How can we continue to be available to one another beyond this group?
We agreed to charge a registration fee of three dollars per person or five dollars per couple. The fee was symbolic of the group's value and of the members' commitment; practically, it enabled us to provide refreshments.
We held our screening interviews in mid through late September. Four people responded to our announcement; two were referred from the mental health center; three were referred by a council outreach worker and one gentleman was referred by a neighboring Council on Aging.
At the interview each applicant filled out a card listing his/her name, address, and phone number. Unfortunately, we did not ask ages as we often wondered about the exact ages of the members.
After stating our own goals for the group we asked prospective group members what they hoped to get from the group; what issues they would like to discuss; what they considered their greatest strengths and needs; what led to their moments of happiness and sadness.
During these interviews we stressed the importance of commitment and confidentiality; we emphasized that the group experience might or might not provide specific answers to their questions or solutions to their problems. We said that the group would meet for VA hours; following the group meetings we would serve refreshments. A retired home economics teacher gave us a variety of nutritious and tasty snack menus.
Of the ten applicants we accepted nine into the group. One person, who appeared to be in an acute anxiety state was referred directly to the mental health center. That afternoon he was offered crisis intervention and subsequently entered long-term individual therapy.
We were now ready to begin meeting with these three men and six women. It was our intention to clarify and to reflect themes; to be nondirective regarding specific content.
We hoped to encourage meaningful communication and expression of feelings among group members, to give valid feedback, to facilitate better coping, and to encourage supportive social contacts beyond the group.
The first meeting was held in October. Nearly one year had elapsed since the first request for the group! After outlining the general structure of the meeting and sharing some information about ourselves we invited members to introduce themselves. Many were brief, some were factual, others apologetic. One man told us exactly who he was, dating back to his ancestry, while Mrs. B introduced herself by role only. Mrs. M told of her recent move to this town and of her isolation and loneliness as a displaced and replaced person. Mrs. S was able to be supportive in sharing her feelings over a move to this area with loss of her former career and status. This loss was more pronounced as her husband took over the household chores. Mrs. M told us about an "old woman" she had seen in the city that morning. Things could be worse-or get worse. Members shared feelings of loneliness and fear of increasing limitations and compromise.
Some members expressed difficulty in trusting one another, the group leaders, public officials, and even God. The central question was, "Who here can I trust?" "On whom can I rely?" "Who will be my enemy.. .my friend?"
Some members vied for position and acceptance while others sat quietly or asked obliquely yet profoundly, "Why am I here?" "Am I the only one who thinks, feels, fears this way or are there others?"
Our second meeting assembled slowly and reluctantly. Two empty chairs in our open circle accentuated absences. We noticed that the members acknowledged the emerging importance of the group by wearing more formal and stylish dress. Mrs. R took off her hat and dark glasses. As soon as Barbara and I recalled the themes of the first meeting, Mrs. R stated that "no one wants an old person." Members talked of fear of rejection, of loneliness, and of unmet needs. They then launched the inevitable attack on the leaders. Members expressed anger and then they reprimanded us for serving a sweetened drink when there were two (previously unknown) diabetics in the group. "And, anyhow, what did we get out of picking peoples brains?"
Mr. J took time to grieve the recent death of his wife-never once referring to her illness, but talking of cures in Belgium and the awful mistakes some doctors make. General anger over loss of loved ones was directed to health professionals. We heard people talk about feeling helpless and sometimes hopeless and often angry. Yet Mrs. R. stormed the group with optimism, faith in God, and the "might of right" as she avoided and denied her anxiety and sadness. At the end of this meeting, shy Mrs. Κ began to whisper a few words to the coleaders.
The predominant theme of the third meeting was grieving the death of loved ones and anticipating the death of self. Mrs. S made several attempts to change the subject introducing ideas of flight or escape, but again and again the group returned to the theme of death. Someone coughed and a group member sitting nearby moved across the room! Death shall be denied and defied.. .at least for the moment.
By the fifth meeting the positive value of the group to individuals became apparent as a diabetic unilateral amputee stumbled in late after making an heroic effort to be with us. By now group members were offering one another rides to and from meetings; one member donated a matched set of mugs; members exchanged telephone calls, cards, and visits. We were fast becoming one group made up of several individuals.
Mrs. R, who once wore dark glasses and kept her hat on, no longer wore glasses; she wore stylish clothes and had a new, flattering hairstyle. Mrs. S talked about her sexuality-now, and "once upon a time." Other statements such as, "I have a bright grandchild" and, "Have I said the right thing?" showed both her ability to relive earlier moments vicariously as well as her present need for acceptance.
Mrs. J asked for more attention by asking to be seen alone and Mrs. ? seemed to be saying "Notice me," "Help me!" as she noisily scratched her dress with a broken fingernail.
Group members continued to be supportive of one another while looking to the leaders for approval. The sixth meeting was to be one member's last. She was hospitalized for surgery and never returned to a group meeting. She was our one "lost" member. When she entered the hospital, a few members sent cards; several weeks later some members could not recall her name or what she looked like. Her seat always remained present-and empty. This woman had shared data in an angry, hostile manner, but revealed little of herself or of her feelings, thus it was "easy" to forget.
The co-leaders talked of termination of the group for the first time halfway through the sessions. This idea was ignored by members. By the seventh meeting ours was a "safe place" to tell secrets. Issues became deeper and more personal. On a deeper level, and more directly, members spoke of regrets, reexamined their own identity, what they had wanted and had missed from their lives, and they talked openly about death. There was nostalgia and talk of how the past looks brighter and how short the future of the group and their own lives had become. Some members began questioning what we had accomplished in the group-perhaps asking what they had accomplished in their own lives.
As the final meeting drew closer, the members continued to talk about illness, infirmities, forgetfulness, old age, death and how little time was left for them. Some previously guarded members spoke openly about regrets and mistakes of earlier years.
Occasionally, the issues of termination were overtly avoided and denied. One elderly gentleman, who had lost several toes, said he would walk once again without a cane. He also stated that he was dating a 26-year-old girl. Some of our group members began repeating tales shared once or twice before. No one pointed out this phenomenon. As the end approached, repeated bargaining was done to extend the time of the meetings and the number of sessions. Having a reunion was suggested by one member as he continued to "hang on." Mrs. M said aptly as we neared the end, "As you get older, you go to pieces."
The group decided that the last meeting should be the scene of a party. In planning, the party became increasingly elaborate. It seemed to be highly symbolic of a "rite of passage." All members arrived early. After a lavish luncheon, Mrs. R read a poem. She recited themes of health, wealth, strength, grace, patience, charity, love, faith, and ... hope.
Conversation turned to babel, voices became louder and more intense. Each one wanted to be heard on the last day. There was a prevailing sense of urgency as excited behavior covered a deeper sadness. At the last moment many eyes glistened and each member in some way reached out to touch or be touched as we said "good-bye."
Our group for nine senior citizens was in direct response to the expressed need of one elderly woman. She was the spokeswoman for her contemporaries. I believe her request speaks for others today. By becoming a member of a group each member begins to overcome the isolation experienced by many elderly. The group provides both opportunity and permission for members to experience openness and closeness. Such a group provides a forum in which elderly members can share concerns of loss, rejection, deprivation, separation, and isolation, and in so sharing, work out some tenable solutions both individually and collectively.
Nurses who are experienced group leaders and who have a theoretical understanding of group process are in an excellent position to facilitate growth and support groups for the elderly. Nurses who have an understanding of continuing growth and development as well as the aging process are often visable and trusted members of the community health team.
I would encourage an interested group leader for the elderly to establish clear goals for herself and for the group; to seek a co-leader and consultant in group process. I would then encourage the leader to extend an invitation to the elderly in the community to join a timelimited, personal growth and support group. The invitation may be sent through the local newspapers, churches, Councils on Aging, and local drop-in centers for the elderly.
The response from one to the other may lead to one of life's more meaningful moments for facilitators and members alike.
To evaluate this experience it would be well in the beginning for leaders to present and members to establish individual goals, and for the group to discuss at an early meeting what they as a group hope to achieve. At the end of the group sessions, as part of the termination process, the members and leader must then deal with the following issues:
1. What have we accomplished in our time together?
2. Have our goals been achieved, or have we failed?
3. How do we feel about leaving one another?2
And I would ask the members: "Is this the end or a new beginning? How? In what ways do you experience yourselves as a new or different person? How have you grown? What have you gained? Lost? What was least meaningful about this group for you? What was most meaningful about this group for you?"
In her recent book, Group Process for Nurses, Loomis devotes one section to evaluation-small group outcomes. It is beyond the scope of this article to discuss specific methods of clinical and research approaches to group evaluation. For a systematic approach to evaluation methods for both clinician and researcher, I refer readers to Loomis' work.
Let it suffice to state my agreement that "good clinicians evaluate the effectiveness of their practice."3 Of the several sources of information sited by Loomis for evaluating a group: individual members, the group leaders, other group members, others in the member's environment, and an external supervisor, our main source was through use of supervision with the associate director of the mental health center. We met with this expert on group process and group dynamics on a weekly basis using verbation process recordings written during each session.
Ultimately we had to determine if we had met our stated goals. Certainly members talked directly and indirectly, sharing personal thoughts and feelings about their own aging. Certainly members talked of issues, problems, and myths of aging. Positive behavioral changes were observed and support for one another reached beyond Finlay House and the moments of our formal meeting.
I offer this review of our group as a model, and hopefully, an inspiration to others who anticipate facilitating a group for the elderly in our communities.
- 1. Yalom ID: The Theory and Practice of Group Psychotherapy. New York, Basic Books. Inc, 1970.
- 2. Sampson EE, Marthas MS: Group Process for the Health Professions. New York, John Wiley and Sons, 1977, p285.
- 3. Lommis ME: Group Process for Nurses. St. Louis. CV Mosby Company, 1979, ρ 10.
- Burnside IM: Nursing and the Aged. New York. McGraw-Hill Book Company. 1976.
- Burnside IM, Ebersole Ρ, Monea HE: Psychosocial Caring Throughout the Life Span. New York, McGraw-Hill Book Company. 1979.
- Huyck MH: Growing Older. Spectrum Book, 1974.
- Loomis ME: Group Process for Nurses. St. Louis, CV Mosby Company. 1979.
- Sampson EE. Marthas MS: Group Process for the Health Professions. New York, John Wiley and Sons, 1977.
- Yalom ID: The Theory and Practice of Group Psychotherapy. New York, Basic Books, Inc. 1970.