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Anne Martin Matthews
Social Support in Normal Aging SUMMARY
SOMMAIRE
The role of social support in helping elderly people deal with stressful life events is quite complex. This complexity exists because it is difficult to define exactly what social support is, and because the experiences of 'normal' aging vary. This article uses the example of adaptation to widowhood to examine the relationship between normal aging and sources, types, and patterns of social support. These factors influence the extent to which support lessens the impact of age-related stressful events. The physician has a role in primary social support, and also in facilitating the supportive functions of family and others. (Can Fam Physician 1984; 30:676-680)
Le role de support social pour aider les personnes agees a faire face a des evenements stressants dans leur vie est tres complexe. Cette complexite existe d'abord parce qu'il est difficile de definir exactement ce qu'est le support social, et parce que les experiences du vieillissement "normal" varient. Aux fins cet article, l'exemple utilise est I'adaptation au veuvage pour examiner la relation entre le vieillissement normal et les sources, les types et les modeles de support social. Ces facteurs influencent le degre d'efficacite du support sur l'impact des evenements stressants dans la vie de la personne agee. Le medecin doit aider tant le patient que ses supports sociaux et collaborer 'a trouver une faqon de remplacer de tels supports s'ils deviennent inexistants.
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Dr. Matthews is Director of the effect on health".4 Gerontology Research Centre at the The Complexity University of Guelph, Guelph, ON. Of Social Support Reprint requests to: Gerontology However, the exact role played by Research Centre, 130 Macdonald Hall, University of Guelph, Guelph, social support in buffering the effect of stressful life events on elderly people ON. NlG 2W1. T HE ROLE AND function of social support in the lives of the aged is currently under extensive examination. Recent researchers 1-3 have examined the effect of particular agerelated, stressful life events on physical and mental health, and the role of social support as a mediator or buffer in this relationship. The role of social support is perceived to have a "generally salutary but unspecifiable 676
is increasingly acknowledged to be quite complex, and, for a variety of reasons, it is not well understood. For example, Gottlieb notes that "The nature, meaning, and measurement of the social support construct itself are still being intensely debated in the literature . . . and this lack of agreement about operational and conceptual definitions contributes to our present inability to compare and summarize studies that investigate the empirical
effects of social support on health".5 In a recent study, Wan1 investigated the effects of stressful life events and social support networks on health and health services utilization among a panel of aged, retired people. Wan discovered that the magnitude of the life events exerted both a direct and an indirect effect on elderly people's health and use of physician services. While the findings confirmed the author's "initial theoretical assumption that the social-support network, as a contextual variable, mitigates the adverse effects of stressful life events on gerontological health, . . . our analysis of longitudinal data suggest that this relationship is more complex than was originally anticipated".1 CAN. FAM. PHYSICIAN Vol. 30: MARCH 1984
Patterns of 'Normal' Aging Just as the concept of social support is complex and frequently ill-defined, it is difficult to generalize about 'normal' aging. The question which immediately arises is what is normal aging? Research has made us sensitive to the fact that there are indeed two cohorts over age 65; more than 10% of those over age 65 also have a child who is over 65.6 The early years of old age are typically characterized by good health, relative psychological, physical and financial independence, and community living. Advanced old age, however, is more likely to involve increasing dependence due to the onset of disease, and to force changes in living arrangements and lifestyles. The 'normal' experiences of aging and being an aged person therefore differ quite markedly, depending upon whether the individual is in 'early' or 'late' old age. There are also differences between men and women in patterns of 'normal' social aging. The case of widowhood in later life is an example of this; among Canadians over age 65, widows outnumber widowers by five to one, and 49.4% of women but only 16.7% of men over age 65 are widowed.7 Hence, the majority of aged men do not live as long as women but can expect to live out their years as married people, with a spouse's support and assistance in illness and infirmity, with the economic security of two pensions, and other benefits of a couple-companionate lifestyle. Most women, on the other hand, are widowed in old age; of those widowed by age 65, 50% typically live for 15 years, and one-third live for 20 years after their spouse's death.8 Thus, most married women in Canada not only will be widowed in later life, but most will also remain single for the rest of their lives. By virtue of their 'unattached' status, old women will have social, emotional, and economic supports which are quite different from men's. One cannot speak of 'normal' social aging as a homogeneous experience for men and women. Another factor which complicates the study of 'normal' aging and patterns of social support available to the elderly relates to generational experience. Marshall9' 10 has demonstrated that elderly people today have had hisCAN. FAM. PHYSICIAN Vol. 30: MARCH 1984
torically unique life patterns, which will make their experiences of 'normal' aging rather different from the generations which preceded them and those which will follow. People aged 70 and over today constitute the first generation in which most people lived into old age, and the first to experience mandatory retirement; as a generation they had low rates of marriage and one of the lowest birth rates in recorded history. By contrast, the next generation of the aged will be the parents of the baby boom generation, a cohort who had an exceptionally high birth rate and for whom the anticipation of retirement has become a normal life event. In terms of the availability of kin as members of a social support system, the circumstances of these two generations are quite different. For each, the definition of what constitutes 'normal' social aging will also vary considerably.
Patterns of Social
Support in Normal Aging
Obviously, the examination of patterns of social support in the process of 'normal' aging is a complex process. One must be sensitive to differences in terms of generation, gender, and cohort. Added to this is the enormous heterogeneity of the aged due to their individual life experiences. With these caveats in mind, let us consider findings about patterns of social support in old age. One way to approach such an analysis is to focus specifically on the relationship between particular life events and the role of social support in old age. This permits us to consider the neutralizing potential of social supports on behalf of populations experiencing those stressful life events known to generate adverse emotional outcomes. Gottlieb5 noted that it is "particularly advisable" to consider this function of social supports in situations where "people face life events that entail or threaten the loss of significant social ties". It is noteworthy that many of the role losses in old age involve the loss of social ties, thereby jeopardizing the social support system itself. In analyzing the sources, types, and patterns of support in old age, we will focus on the transition to widowhood as an example of the relationship between life event stress and social support. We will begin with an overview of the experience as a stressful
life event, and then consider features of the support system in relation to it. Following from this, we will consider implications for physicians who interact with patients experiencing stressful events and crises.
The Stress of Widowhood There is general consensus in the field of life event scaling that the spouse's death is among the most stressful role transitions." This was recently corroborated by my own research on the social, emotional, service and economic supports of widowed women living in Guelph, Ontario. Without exception, these widows-all of whom were interviewed a minimum of five and a maximum of ten years after bereavementindicated that the loss of their spouse had affected them more than any other single life event. 12 Similarly, among a sample of 300 recently retired men and women, the 22% who had been widowed all indicated this to be their most dramatic life change.13 In analyzing social supports of the widowed, particularly the 'natural support system', the focus is typically on such diverse types of arrangements as mutual-help groups; neighborhoodbased associations whose members exchange goods, services, information and friendly visits; and the 'kith and kin' network, a social unit that encompasses all of an individual's primary group ties.5 Research on the role of social support in the transition to widowhood has attempted to delineate precisely who participates in the support system of the widowed, and whether their support makes any difference. The answer to the first question is not at all clear. In research on a large sample of widows living in the Chicago area, Lopata'4 found that children are by far the most viable members of the widow's support system. Siblings, in-laws and other relatives were not actively involved in any of the support systems which she studied. Where widows were involved at all in support systems, they were dependent on their children for all types of support, except economic. This finding contrasts with the results of the recent Guelph study12, where over half the respondents with living siblings saw at least one as frequently as several times a month. More significantly, siblings and other extended kin 677
also emerged as important figures in the social and emotional support systems of the widowed. Of the Guelpharea widows, 54% listed at least one sibling (typically a sister) as being involved in at least one exchange in the social support system. Sixty-five percent listed an extended kin member (sibling, brother- or sister-in-law, cousin, aunt, or niece) as involved in their emotional support system. Half the respondents specifically referred to a sister as one of the three people to whom they felt closest, either currently, or in the year before their husband's death.'2 At this point there is no ready explanation for these disparate findings. It may be that because a higher proportion of the Guelph than the Chicago widows grew up in the area, they were able to retain more contacts with siblings and other extended kin over the years. It may also be that because almost half the Chicago widows had at least one child still living at home (in contrast to 15% of the Guelph widows), the presence of children made them more salient resources than the extended kin at this stage of the life cycle. In any event, the contradictory findings of these two studies cast some doubt on the presumption of the lack of support from the extended family network. Other researchers have attempted to clarify further the functions of members of the social support system of the widowed, by focusing on the relative importance of particular sources of support as widows move from the early adjustment phase in which they are enveloped by intense grief, to the phase in which their grief is lessened enough to allow them to begin a new life. In a study of 51 recently widowed (four to 12 weeks) older Toronto residents, Haas-Hawkings et al.'5 hypothesized that a stable, intimate, and active social network was related to the bereaved person's immediate psychosocial adjustment. In finding no support for this hypothesis, they speculate that "mobilization of the social network as a resource becomes important at a later stage in time" 15 Bankoff'6 takes this analysis one step further and claims that researchers who argue the importance of a supportive informal social network tend to assume that the widow's need for support is fixed. Bankoff examined the function of different supports by source (parent, child, neighbor, etc.) 678
and by type (attention, intimacy, etc.) for women in two phases: the crisis phase of less than 18 months after bereavement, when all the widows said they were still in the midst of intense grief, and the transition phase, 19-36 months after bereavement, when the widows reported that they'were still grieving but to a limited extent.'6 Bankoff found that the source of support does make a difference to widows in both phases. The relative importance of sources depends on the phase of widowhood. During the crisis phase, parents, followed by widowed or single friends, were the most important sources of support. Bankoff attributed this to the important nurturing function which an older parent can provide, particularly considering that, to this age group, a parent typically means a mother who has herself experienced widowhood. Such a finding indicates that widows have a great need for emotional support from people who can empathize because they have gone through the experience. This presumption is the basis of all self-help, and particularly widow-to-widow, programs. Bankoff found that the salient supports shifted during the transition phase to include, in descending order, widowed or single friends, neighbors, parents and children. The maintenance of social contact with married friends was, if anything, negatively associated with adjustment to bereavement during this stage. Bankoff suggests that the widening of the network of supports reflects the fact that the widow manifests less need for nurturance at this stage. She has a greater need for information and new social contacts to help her live as a single person. Bankoff concludes that "the role of social support for women suffering conjugal bereavement is important but complex. Whether support helps, hurts, or is inconsequential for the psychological well-being of widows during their lengthy process of adjustment seems to depend upon at least three factors: where the widow is in the adjustment process; the specific type of support provided; and the source of that support". 16 A focus on the research examining the relationship between social support and the transition to widowhood also illustrates another complicating feature of the study of social support in normal aging: the assumption of the inherent value of social support. For example,
Bankoff notes that "the implicit assumption operating in the literature has been that the more support the widow receives (and this usually has meant the more contact she has with network members), the better off she is bound to be. This inference of effectiveness from quantity is highly questionable" .*6 Indeed, some Canadian research suggests that a loose rather than a tightly supportive network-particularly of family-is a disadvantage in the initial period of bereavement, but may in fact facilitate the reorganization of social roles later in widowhood. Building upon the concept of the ''strength of weak ties", Walker et al.'7 suggest that "a closely knit network made up predominantly of relatives could become a disadvantage [to the widow] if she seeks to make new friends, find a job, or develop a new life style". Walker et al. maintain that while such networks are appropriate for maintaining a static social identity, a woman's identity "is anything but static" in widowhood.
The Family As A Support System Other researchers suggest that we have over-emphasized the role of social support in ameliorating the impact of stressful life events, and particularly, the impact of family in providing a primary support role. Gottliebs decries the fact that 'family' is virtually assumed to be part of the social support system, and yet "one need not be a clinician to recognize that family members and friends do not always merit the appellation 'support system', and the fact that this sort of labeling is wide-spread in the literature reveals something about the romanticism or myopia that has seeped into research on the topic of social support". Arling's'8 findings that "contact with family members . . . does little to elevate morale" among the widowed aged support Gottlieb's observation. Other researchers such as Bowling and Cartwright2 find essentially no differences between the childless elderly and those with children in overall adjustment to bereavement. Kuypers and Bengtson'9 observe that "despite a cultural bias toward cordial and intimate family life, there is surprisingly little evidence from surveys that older people without such supportive kin are at a psychological disadvantage. Research has shown that intense interacCAN. FAM. PHYSICIAN Vol. 30: MARCH 1984
tion need not lead to greater happiness ate. Perhaps the study's most disturbing for family members." finding relates to physicians' lack of Other Sources of Support knowledge about their widowed patients' drug use. If the information Recently, Chappell20 has argued for from the widowed themselves is acsocial network analyses of the elas valid, then doctors were only cepted derly's often neglected relationships 50% of patients who aware of about with age peers who are not relatives. tranquillizers. The were taking mild In data collected on a stratified random that pflysicians the study also tound sample of elderly people living in the community, she finds some validity widowed defined as "unsympathetic" for the observation that since friend- were most likely to prescribe psychoship rests on mutual choice and need, tropic drugs to the recently bereaved. it sustains a person's sense of useful- Bowling and Cartwright2 interpret this ness and self-esteem more effectively as a tendency to prescribe pills rather than family relationships, which are than to give supportive care to the bereaved. At the same time, the aumore obligatory. There are other potentially viable thors note there is anxiety among members of elderly people's social many elderly widowed about becomsupport systems, particularly in times ing dependent on drugs, and a relucof transition or crises. We have al- tance to take drugs. Bowling and Cartwright's2 research ready alluded to the particular function suggests that the family physician pomutual in the of supself-help groups has an important role to play tentially port of the recently bereaved. in the support systems of the aged, particularly the bereaved. Although The Physician's Role the family physician was the profesOther potentially viable players in sional person the widowed were most the social support systems of the aged likely to contact during their bereaveare, of course, the physician and other ment, just under 25% of the elderly health care professionals. In discus- widowed had been visited by a general sions of the role of formal and infor- practitioner after their spouse died but mal social supports in the transition to before the funeral. About 40% of the widowhood, the role of the physician doctors thought that elderly people either directly in the support system, should be visited at home when they or in facilitating the establishment and were widowed, and most doctors functioning of other social support is thought this should be done as soon as rarely mentioned. Bowling and possible. However, even when doctors Cartwright2 are the only investigators felt this was the right thing to do, less to explore in depth the physician's role than half of their elderly widowed pain the support systems of the widowed. tients had such a visit. While for the They view the experience of widow- most part, family practice is based on hood from the perspectives of the wi- patients' initial self-referral, when an dowed themselves, their general prac- elderly person loses a husband or wife, titioners and a supporting individual feelings of helplessness and hopelessdescribed as the "familiar". The study ness may make it difficult for them to contains information on the physi- recognize their needs in the first place cian's view of the assistance they pro- or to do anything about such needs if vided the widowed, and the widowed they are aware of them.2 Bowling and Cartwright2 conclude patient's and the familiar's view of that assistance. In general, the wi- that elderly widowed patients need dowed themselves were less critical of personal care, family care, home care, the doctor than were the familiars. and continuity of care-four fundaOverall, however, the study found that mental and distinguishing aspects of general practitioners typically abrogate family practice. Bowling and any involvement in the support sys- Cartwright therefore contend that famtems of the widowed. Bowling and ily physicians who wish to give this Cartwright2 found evidence that even type of care should visit the homes of those physicians trained in a climate all their patients when they are where the importance of pastoral care widowed, or contact a social worker or is emphasized have a typically narrow nurse, known to the widowed, who concept of their role, and regard a siz- has done so. The researchers' recomable proportion of their consultations mendation that all widowed people as trivial, unnecessary, or inappropri- should be visited stems partly from CAN. FAM. PHYSICIAN Vol. 30: MARCH 1984
their belief that when people are widowed it is not only helpful for them to have the support of people who care, but also to re-define and establish their relationship with people who are meaningful to them. In the researchers' view, the relationship that family physicians have with their elderly patients should be important enough to need this recognition and emphasis. Another aspect of the potentially supportive role which physicians may play in the normal aging of their patients relates to the physician's and the health care professional's role in supporting not only the patient but other members of the support system. Recently, Eckenrode and Gore2' argued that life events exert a significant impact not only on the focal individual but also on his or her network of ties, and the researchers maintain that any assessment of social support must therefore consider how such "network stress" constrains the mobilization of support. Some innovative work by Kuypers and Bengtson'9 has led to the development of a conceptual framework for understanding some problems and processes involving family networks and aging. This framework deals specifically with the issues raised by Eckenrode and Gore.2' Kuypers and Bengtson postulate the development of a family support cycle in response to the 'social breakdown syndrome' to problems of aging. They specifically identify what professionals can do to reduce the vulnerability and increase the competency of families of older individuals 'in crisis'. It is noteworthy that Kuypers and Bengtson found that the situations which typically precipitated the need for crisis intervention were not necessarily such normative life events as widowhood, but events such as strokes and Alzheimer's disease-situations in which the physician is involved. But Kuypers and Bengtson'9 also support the notion that professional intervention in the early stages of mobilizing the family support system is crucial-and time-consuming. They note that, in order to break the family crisis cycle in response to vulnerabilities of normal aging, the attending professional must clarify the event with the family. For example, he or she must realistically discuss the level of the probable impairment after a stroke or the progression of Alzheimer's disease. This is especially 679
important because most families operate in a total information vacuum as they confront a disabling event. The second phase in the cycle is the reduction of dependence on external and inappropriate labels-specifically, moralisms and a sense of obligation, which lead to guilt. Professionals can assist by fostering open dialogue with families and the individual about expectations, resources, and conflicts, which family members are frequently fearful of confronting openly. Subsequent stages involve the collective redefinition of the event which has been labelled as hopeless; the professional can help identify feasible, appropriate goals for assisting the family as well as the older patient. Finally, there comes a mobilization of realistic coping skills, a focus on strengths and emphasis on what family members can do versus what they might or should do. Kuypers and Bengtson conclude that "By looking at the family as a unit, and recognizing the aging individual as a member of an on-going spiral, we see some hope for intervention to what is usually regarded as a relatively hopeless family situation". 19 While it may not always be feasible, or even appropriate, for the physician to be the professional involved in this cycle of family social support, it is important for the physician to be aware of the necessity for this type of intervention, and to be sensitive to the fact that someone in the health care system should provide it. The physician can then play a valuable role in monitoring support. Such a function becomes all the more crucial when one realizes that in many instances, the family member who is the most viable member of the support system is the spouse. Usually this spouse is the wife, and, as Fengler and Goodrich22 note in their research on the wives of elderly disabled men, she herself is often frail and ailing.
Conclusion This article has attempted to briefly address the myriad of issues related to social support in normal aging. We have seen how the construct of social support is complex. This complexity is increased when social support is examined in relation to 'normal' aging,
680
which is itself an elusive concept. Nevertheless, by using one of the most disruptive age-related transitions, the transition to widowhood, as an example, we have shown that the mitigating effect of social support on stressful life events is by no means direct. The effect depends on the phase of adjustment to the life event, the specific type of support provided, and the source of that support. While the physician as a source of support has been largely neglected in North American studies of support systems, we have observed that he or she has a viable role to play, whether it involves direct contact with the elderly patient, or facilitating the families' or the primary careproviders' supportive efforts in crises. Particularly in facilitating the family's efforts to provide support, physicians must recognize the important role which adult children assume as intermediaries between the aged person and the health care system.23 Although this paper has acknowledged that families are not necessarily the most appropriate or most willing supporters, there is considerable empirical evidence24' 25 that the aged prefer help from their children to help from any other provider. The physician must help support such bonds in normal aging, and help to replace such bonds when they are severed or altered through death and bereavement.
References 1. Wan TTH: Stressful Life Events, Social-Support Networks and Gerontological Health. Lexington, MA., D. C. Heath Co., 1982. 2. Bowling A, Cartwright A: Life After a Death: A Study of the Elderly Widowed. London, Tavistock Publications, 1982. 3. Lopata HZ: Women as Widows: Support Systems. New York, Elsevier, 1979. 4. Bloom BL: Prevention of mental disorders: Recent advances in theory and practice. Community Ment Health J 1979; 15:179-191. 5. Gottlieb BH: Social networks and social support in community mental health, in Gottlieb BH (ed): Social Networks and Social Support. Beverly Hills, Sage Publications, 1981, pp 11-42. 6. Atchley RC: The Social Forces in Later Life, ed 3. Belmont, CA., Wadsworth Publishers, 1980, p 352. 7. Martin Matthews AE: Women and widowhood, in Marshall VW (ed): Aging in
Canada: Social Perspectives. Toronto, Fitzhenry and Whiteside, 1980, pp 145153. 8. Riley MW, Foner A: Aging and Society. New York, Russell Sage Foundation, 1968, vol 1, p 159. 9. Marshall VW: The Changing Family Relationships of Older People. Hamilton, ON., McMaster University, Program for Quantitative Studies in Economics and Population, Report #5, 1981. 10. Marshall VW: Generations, age groups and cohorts: Conceptual distinctions. Can J Aging 1983; 2:51-61. 11. Holmes TH, Rahe RH: The social readjustment rating scale. J Psychosom Res 1967; 11:213-218. 12. Martin Matthews AE: Canadian research on women as widows: A comparative analysis of the state of the art. Resources Feminist Res 1982; 11:227-230. 13. Martin Matthews AE, Brown KH, Davis CK, et al: A crisis assessment technique for the evaluation of life events: Transition to retirement as an example. Can J Aging 1982; 3, 4:28-39. 14. Lopata HZ: Contributions of extended families to the support systems ofmetropolitan area widows: Limitations of the modified kin network. J Marriage Fam 1978; 40:355-364. 15. Haas-Hawkings G, Ziegler M, Reid DW: An exploratory study of adjustment to widowhood. Read before the Gerontological Society of America Annual Meeting, San Diego, CA., Nov 1980. 16. Bankoff EA: Social support and adaptation to widowhood. J Marriage Fam 1983; 45:827-839. 17. Walker KN, MacBride A, Vachon MLS: Social support networks and the crisis of bereavement. Soc Sci Med 1977; 2:35-41. 18. Arling G: The elderly widow and her family, neighbours, and friends. J Marriage Fam 1976; 38:757-768. 19. Kuypers JA, Bengtson VL: Toward competence in the older family, in Brubaker TH(ed): Family Relationships in Later Life. Beverly Hills, Sage Publications, 1983, pp. 211-228. 20. Chappell NL: Informal support networks among the elderly. Res Aging 1983; 5:77-99. 21. Eckenrode J, Gore S: Stressful events and social supports: The significance of context, in Gottlieb BH (ed): Social Networks and Social Support. Beverly Hills, Sage Publications, 1981, pp 43-68. 22. Fengler AP, Goodrich N: Wives of elderly disabled men: The hidden patients. Gerontologist 1979; 19:175-183. 23. Marshall VW, Rosenthal CJ, Synge J: Concerns about parental health, in Markson EW (ed): Older Women: Issues and Prospects. Lexington, MA., D. C. Heath Company, 1983, pp 253-273. 24. Brubaker TH (ed): Family Relationships in Later Life. Beverly Hills, Sage Publications, 1983. 25. Shanas E: The family as a social support system in old age. Gerontologist 1979; 19:169-174.
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