Science jc:
Monographs si."

 

New Views On Older Lives

 

 
New Views On Older Lives

A SAMPLER OF NIMH-SPONSORED
RESEARCH AND SERVICE PROGRAMS ,

I H. [Rosenfeld |

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Service
Alcohol, Drug Abuse, and Mental Health Administration

National Institute of Mental Health
5600 Fishers Lane
Rockville, Maryland 20857
Z.

 

This publication was prepared under contract number
#278-76-0044 (SP) from the National Institute of Mental

Health.

DHEW Publication No. (ADM) 78-687
Printed 1978

 

For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402

Stock Number 017-024-00796-0
PUBL Foreword

Aging is a fact of life which, as a Nation, we have tried
to ignore. Advertising has been directed toward youth;
educational systems have been devoted largely to profes-
sional and vocational rather than lifetime learning; and
modern housing patterns have, in effect, interrupted for
many the intergenerational exchange of ideas and experi-
ences which formerly enhanced family life.

The demographic facts of life are changing our focus.
American elderly are emerging as a social and political
and, indeed, economic force. Social scientists and medical
researchers are learning more about what the elderly are
really like and, in the process, are changing much of the
stereotyping of the aging. They point out, for instance,
that all old people are not alike and, in fact, probably grow
more dissimilar as they grow older; that the slowing of
physical and mental reflexes and diminished hearing and
eyesight are usually more than compensated for by great-
er patience and resourcefulness and by wisdom and
strength in meeting crises; and that old age does not nec-
essarily limit sexual activity, intellectual capacity, or in-
terest in meaningful work.

Balancing the persistence of decline and deterioration of
functioning with the optimistic and positive aspects of the
aging experience adds interest and urgency to research on
the mental health of the aging. The National Institute of
Mental Health has supported much significant research,
both basic and applied, on the relationship of physiologi-
cal, psychological, and social factors to the aging process.
Probably the most influential of early studies was a 12-
year study of normal, healthy, aged men which indicated,
among many important findings, that severe deterioration
apparently is indicative of disease rather than of aging
itself.

Research activities have extended from the study of
organic brain syndrome and depression in the elderly to
the improvement of community care, whether the aging
persons live in rundown, urban hotels, their own homes,
or in housing designed especially for them. Reducing the
need for hospitalization and improving institutional care,
whether in hospitals, nursing homes, or long-term care
facilities, are additional areas of research on the aging in
which the Institute takes pride.

Work continues on all of these and on preventive meas-
ures for the healthy aged, not only in housing and infor-
mation and referral services, but in helping to meet the
potential crisis of retirement, adding recreation and reha-
bilitative training programs to prepare elderly persons for
community service activities. Many of these Institute-
supported programs in training and research are de-
scribed in this publication; although a number of them are
still underway and final evaluations are yet to come, they
are exciting and full of promise. The book is a worthy ad-
dition to a growing, and varied, number of publications for
and about the aging, designed for both the mental health
professional and the concerned citizen of a society that
cares.

Francis N. Waldrop, M.D.
Acting Director
National Institute of Mental Health
Contents

FOT@WOTd eects eres eens iii
Chapter I. Introduction ...............vveeeennn. 1
Chapter II. Healthy Aging .........c.ccooooiiiiiiinn. 4
The Initial Study: 1956 eee eeeeeeeee 6
The 11-year Followup: 1967-1968 .......cevviirriiieiniiiiiieninneen. 12
Life in the Eighties and Beyond ......ccccoeoeiiiiiiiiiicniiincnnnnnes 13
Chapter III. Lifestyles, Satisfaction, and the
Quality of Life ........ccccoceveveviierenee. 20
The Pursuit of Happiness in Kansas City ...ccccceeeeeennnnnnnens 21
Homes and Housing: The Right Place to Live ................. 28
Retirement Housing Options—What Works for
Whom? coor eee eee eee ee ae eee eans 28
Close-Up: The Hotel Loners ...eeeeeeeeveeeencnveeeeennnes 38
Generations Apart or Together? .......cccccoviieeeeiiieeccineenennn. 45
After the Gold Watch, What? Keys to Successful
Retirement o.oo eee c ean eceaane 49
Remarriage: A New Lease on Life? .....cccccoviiniiiininniinnnnn. 54

Chapter IV. Community Services: How Can

We Help? eee 59

Service Needs and Service Gaps: Who Needs What? ........ 60

Enhancing the Well ........cooooiiiiiiiiiieeeeecceeeeecceee eens 64
Growing Old and Growing Sage: An Approach to

Greater Fulfillment ......ccceeeeieeeeiieecieeeeieeecee eee 64

From Passivity to Power ......ccccoooiiiiiiiiiieiiciieeccnnen. 72

Maintaining the Marginal Elderly ......ccccoeeeeeeiiiinnnnnenennne. 75
Community Housing: Independence and Security

in Philadelphia ......cccooeieiiecoiiiiiieeceecceeeeeeeeeeee, 77

Friendship and the Frail in New York .....cccccee....e. 88

Services for SROs: The Stratford Arms
EXPeriment ......iecieeeieceeeeeere cere 94
Outreach and Opportunity ......ccceee. frererersreesseenseanseas 101
Chapter V. Aging and Institutionalization ........... 108

Old Folks at Homes ........ccccoeeveiirnieiiiiiniecniinecccnnnneccennns 110
Life in a Nursing Home: The Resident’s Perspective ....116
Coping with Institutionalization ..........cceoeeininininncnnn. 119

To Move or Not to Move: The Hazards of Relocation ....123

Chapter VI. Depression and Senility: The Twin

Frontiers .........cccoovveeiecceceene. 127
Unscrambling Senility and Depression:

The Challenge of Diagnosis ....cccceceeeeeevereeeeeeeereeeeereneesnens 128
Depression, Senility, and Mental Functions .......... 129
A New Tool for Diagnosis .....cccceeeeeeceereeeeccneeeeeecnnnnn. 130
Treating Depression in Older People ......ccoceeeveereevrecnennee 132
Senility: Approaches to Treatment .........cccccoeeeuvvvvveennnnnn. 136

Hyperbaric Oxygen Therapy: The Miracle That
Failed ..oooeeeeeeeeeeeeeeeeeeeeee ee e eee eeees 140

The Responsive Environment: Two Experiments
in Better Institutional Care for the Mentally
IMPAITEd cence eee ene 146

Chapter VII. For Further Information ................. 176

vi
I. Introduction

Over 250 years ago, Jonathan Swift summed up in Gul-
liver’s Travels what is still our paradoxical view toward
aging:

Every man desires to live long,
but no man would be old.

Since his time, we have made great strides in lengthen-
ing life, with both men and women, on the average,
reaching the proverbial three score years and ten. But for
far too many, living long is not living well. If, as Cicero
asserted, “Old age is the consummation of life, just as of a
play,” then too often that play is a tragedy. It need not be.

Despite our technological prowess, we still cannot stave
off many of the natural biological processes we recognize
as aging. But we have found ways to lessen the disease
processes that lead to physical and mental decline, and we
are beginning to discover that much of what was once
taken for granted as part of “natural” aging is, in fact,
preventable or reversible. We are also learning that the
mental and physical aspects of aging are inextricably in-
tertwined. Aging is a state of mind, as well as of body, and
there is extensive interplay between the two. If we are
ever to live long and well, we must understand the condi-
tions that lead to physical and mental well-being.

Aging is a universal human experience that respects
neither social station, nor race, nor sex, nor the profound
wishes of many that they could be preserved in an eternal
state of effervescent youth. Yet, despite its universality
and its familiarity, it is largely a mystery. Gerontology,
the science that deals with aging, is developing a growing
body of knowledge that can help us understand how we
age and may contribute to preventing the process from
proceeding too fast, but at present there are far more
questions than answers.

Because aging affects us as total human beings, from
our cells to our psyches, its study requires the pooled tal-
ents of scientists from many disciplines. This book de-
scribes the work of many research scientists who are at-
tempting to understand the nature of human aging, partic-

1
ularly those psychosocial factors that contribute to the
quality of life in the later years. Their work, taken collec-
tively, has contributed not only to our state of knowledge,
but also, in many instances, to the climate of social policy
that may well affect today’s elderly as well as ourselves in
the years to come.

Gerontology—the study of human aging—is ironically a
very young field. Like other nascent sciences, it is current-
ly preoccupied with the formidable task of simple descrip-
tion. There are few theories to guide investigators, and
few well-worked-out tools of investigation. In a sense,
each research scientist is a pioneer, developing on his or
her own a set of hypotheses and the tools for measuring
what is observed. Because the study of aging cuts across
many disciplines, there is considerable borrowing and
cross-fertilization from a variety of fields. While this gives
the infant discipline a certain vigor, it also adds complexi-
ty; each contributing discipline also has its implicit or ex-
plicit models and approaches, and a certain intellectual
virtuosity is required to be able to skip comfortably from
one researcher’s disciplinary “language” to another or, as
often happens, to bring together the skills and viewpoints
of multidisciplinary investigators who share a common
research problem. Even within the somewhat circum-
scribed portion of gerontological research described in this
book, the range of approaches and disciplinary orienta-
tions is extraordinarily broad—including neurophysiolo-
gists, psychiatrists, psychopharmacologists, psychologists,
social workers, and anthropologists. And their subjects are
extraordinarily varied as well. While most, not surprisingly,
are over 65, they include the very healthy and the severe-
ly mentally and physically ill, many races and ethnic
groups, men and women, independent community dwellers
and residents of long-term care facilities, the happy and
fulfilled, and the deeply troubled and despairing. The per-
vasive theme binding these research studies together is
their common search for a better quality of life for the
aged.

We will review some of the major areas of research on
aging sponsored by the National Institute of Mental
Health, and we will describe some of the service and train-
ing activities of NIMH relevant to our older population.
Although this report is by no means a comprehensive
overview of all the studies and programs that have re-
ceived NIMH support, it should provide a sufficient sam-
pling to communicate our evolving understanding of older
persons and many of the questions and issues still before
us.

Many of these studies are strictly descriptive—attempt-
ing to establish how older people live in a variety of sett-
ings and how they react to their lifestyles. Others involve
direct experimental attempts to intervene in the lives of
older persons to effect changes that will benefit them.
Many of the studies selected for discussion here are too
new to have obtained their final results. The reader, like
the investigators, can share in the uncertainties of re-
search. This is not a recital of achievements, but a glimpse
into the working world of research scientists in the proc-
ess of exploration, designing and carrying out studies
that may or may not prove fruitful.

If this book succeeds in communicating the excitement,
the challenge, and the great social importance of studying
and improving the experience of life’s later years, it will
have accomplished its purpose. One of the great surprises
and pleasures in gathering the data reported here was
discovering the spirit of optimism and hopefulness that
pervades these investigators. The traditional caution and
circumspection of the research scientist cannot mask the
belief that we have just begun to tap the potentialities of
the later years. Nor can it mask the frequent anger and
frustration felt by many investigators who know that re-
alizing these potentialities will require more than knowl-
edge; it will require a change of national heart and mind
that will be sufficient to demand for our elders the same
fullness of life we demand for our youth.
Il. Healthy Aging

To live long—and well: This ancient yearning still tanta-
lizes us all. A select few manage to reach advanced old
age with vigor, good health, alertness, and joi de vivre. A
rarer coterie of legendary oldsters, often far from our
“civilized” shore, reportedly retain their youthfulness
even as centenarians, gallivanting around the mountains
of the Soviet Caucasus, Pakistan’s Himalayan Karakoram
Range, or Ecuador’s Andes at Methuselahean ages. Could
more of us join such an elite group? Some might suggest
that we, too, can match their presumed longevity if we
live at high altitudes, hide from pollution, labor hard
physically, and cut down on our intake of protein and
animal fat. However, many other factors may be involved,
such as our genetic makeup, our personalities, our general
health, and our social, cultural, and physical environ-
ments. Unsnarling the complex factors that affect the
pace and quality of aging is one of the major tasks con-
fronting today’s gerontological researchers. It is compli-
cated by the genetic, biological, social, psychological, and
environmental aspects of our lives which constantly inter-
act. Although many research scientists can and do select
only a few patterns of interaction for study (we will exam-
ine many such studies later), occasionally more ambitious
and difficult studies are undertaken that attempt to docu-
ment how an exceedingly broad range of factors affects
aging and longevity. As yet, such studies are few, but we
are the beneficiaries of the farsighted vision of a number
of research scientists from many disciplines who, in the
1950s, recognized the need for long-term multidisciplinary
studies and undertook several that now form the basis for
much of our fundamental knowledge of the physical and
psychological changes associated with normal aging.
Three of these long-term investigations are particularly
notable for their scope and depth: one at Duke University,
one at the Gerontological Institute in Baltimore (now part
of the National Institute on Aging), and one at the Na-
tional Institute of Mental Health. All three of these stud-
ies have in common:

1. Tracing patterns of aging to identify age-related
changes in people

4
2. Relating biological and behavioral characteristics to
longevity

3. Discovering and describing how people adapt to the
various stages of the aging process

4. Gaining a fuller understanding of how individuals’
functional effectiveness can be preserved and enhanced as
aging proceeds

In all three studies, a multidisciplinary team of re-
searchers carefully studied a select group of subjects and
followed their progress over many subsequent years, docu-
menting how and, if possible, why they changed. The
NIMH Human Aging Study, on which we focus here, dif-
fers from the other two in at least one major respect: It
was deliberately designed to study a special sample of old-
er men—the very healthy aged. Unlike other researchers
interested in documenting normal aging, the research
team conducting this study wanted to find out what aging
would be like when uncomplicated by the effects of illness.
Thus, the original study group of 47 American men is
rather unusual, and the results, at least of the study’s first
phase, tell us more about healthy aged people than about
the aged population in general. In a sense, the study pro-
vides a glimpse into the future when many older people
may be disease-free well into advanced years. And it sug-
gests that under these conditions old age can be extremely
rewarding for many. However, even healthy old people,
especially those with few social and financial supports, can
find life difficult and burdensome, a problem that poses a
major challenge to our society and its service systems.

Because this study spans 11 years in the lives of its sub-
jects, its later findings provide invaluable insights into the
physical and psychological character of advanced old age,
changes in individuals with the passage of time, and the
adaptive patterns of older men who must cope with the
inevitable impact of aging and the prospect of their own
mortality. This study also gives us some clues to why some
of the subjects survived through the 11-year study period
and others did not. (Surprisingly, although the subjects
initially ranged from 65 to 91, age at the time of the initial
study was not the major determinant of survival 11 years
later.)

Like many studies of this sort, the NIMH Human Aging
Study has yielded enough data to keep many researchers
busy for years analyzing, reanalyzing, and interpreting its
many findings. Although conducted many years ago, it is
still a source of new information on the nature of aging.
We will review briefly the initial study, which began in
1956, and highlight some of the major findings of this and
a subsequent followup in 1967-1968 with 19 of the 23 survi-

5
vors, concluding with some recent findings gleaned from
the original data.

The Initial Study: 1956

The NIMH Human Aging Study was initiated in 1955 by
Drs. James E. Birren, Seymour Perlin, and Louis Sokoloff
of the National Institute of Mental Health, who were
joined within a year by Drs. Robert N. Butler, Samuel W.
Greenhouse, and Marian R. Yarrow. All of them were in-
terested in understanding more about the process of nor-
mal aging, particularly the relation between brain
changes and behavior in the older healthy person. By the
time the actual clinical study was underway in 1957, many
other NIMH investigators and their collaborators had
joined the research team headed by Dr. Birren. In all,
some 22 scientists pooled their talents from the fields of
medicine, cerebral physiology, electroencephalography,
urology, psychology, social psychology, and psychiatry to
try to describe how mental, physical, and social factors
interact in old age. The study was originally intended to
be a one-time investigation of a group of healthy older
men over 65. But it raised a host of interesting and provoc-
ative questions that could only be answered by following
the same subjects over time. Thus, under the urging of
Dr. Robert N. Butler and Dr. M. Powell Lawton, an 11-
year followup was later conducted.1

The 47 men selected for the study, community-dwelling
men averaging 71 years of age, were initially housed for 2
weeks at the National Institutes of Health (NIH) Clinical
Center, an NIH research hospital in Bethesda, Maryland,
while they submitted voluntarily, and for the most part
cheerfully, to an extraordinarily complete battery of medi-
cal, psychological, and psychiatric tests and interviews.
The list cited in table 1 gives some idea of the gargantuan
diagnostic and descriptive battery.

On the basis of these tests, the volunteers, although hav-
ing fulfilled very stringent health criteria, were found to
belong to two distinct medical groups. Those in Group I,
the “optimally healthy,” were deemed to be free of any
physical pathology, while those in Group II, although clini-
cally very healthy, had laboratory results indicating sub-
clinical abnormalities that at the time were not serious.
For example, some members of Group II had evidence of
cardiovascular disease, although it was still within normal
limits. In general, membership in Groups I and II did not
depend on age; many quite old men were found to be in

Tn 1961-1962, a modest followup was also conducted but is not re-
ported here.

6
TasLE 1. Tests and examinations used in the NIMH Human Aging Study (From
Human Aging Il: An Eleven-Year Followup Biomedical and Behavior-

al Study, p. 3)

 

Examination or

Period of Study

Examination or

Period of Study

 

 

  

 

Test 1956 1961 1967 Test 1956 1961 1967
Medicine and Reaction Time ..... X X
Physiology: Rorschach .......... X X
Medical history X X X Sentence
Physical Completion Test X X
Examination Speed of Card
with Complete Sorting cece. X X
Neurological X X X Speed of Copying
Hematology ...... X X X Digits ................ X X X
Blood Speed of Copyin
Chemistry ........ X X X Words ........ ce X X
Urinalysis .......... X X X Stroop Test .......... X X
Chest X-ray ....... X X X Thematic
Skull X-ray ........ X X X Apperception
Electrocardio- Test oon X
gram ................ X X X Wechsler Adult
Electroencephalo- Intelligence
gram ................ X X X Scale ....ccceeeeene X X X
Pulmonary Weigl Color
Function Sorting ............. X X
Studies .......... X X X Wisconsin Card
Cerebral Blood Sorting ....... X
Flow Studies X X X Word Fluency
Audiometric Social
Examination X X Psychological
Click Perception (Interview):
Tests .............. X Family History
Delayed (or Interval
Auditory History) ......... X X
Feedback Educational
Tests ............. X History .......... X
Psychological: Occupational
Addition Rate ... X X X History .......... X
Arithmetic Retirement
Alternation Planning and
Rate ............. X X X Activities ....... X X X
Draw-a-Person X X X Marital History X X X
Emotional Living
Projection Arrangements  X X X
Test ovr X Use of Time ...... X X X
Family Scene ... X X Social Relations
Homonyms ....... X X and
Learning ........... X Interaction ....  X X X
Level of Aspiration X X Attitudes
Minnesota Toward Life . X XX
Multiphasic Goals and
Personality Aspirations ... X X X
Inventory ........ X Critical Turning
Mirror Tracing .. X Points in Life ~~ X X X
Perception of Line Significant
Difference ...... X X LOSSES .......... X X X
Raven Progressive :
Matrices ........ X X X
TasLe 1. Tests and examinations used in the NIMH Human Aging Study (From
Human Aging Il: An Eleven-Year Followup Biomedical and Behavior-
al Study, p. 3)—Continued

 

 

 

Period of Study a. Period of Study
Examination or -  ~  Examination or -
Test 1956 1961 1967 Test 1956 1961 1967
Observed Psychiatric
Physical and Symptom
Mental Check List .... X X X
Changes in Mental Status
Aging ........... X X X Evaluation .... X X
Psychiatric Assessment of
(Interviews): Attitudes
History of about:
Psychiatric Futurity ......... X X X
Contact ......... X X X Death ............. X X X
Personal-Social Self ........... X X X
History (or Aging ............. X X X
Interval

History) ......... X X X

 

superb health, and many relatively younger ones, although
quite healthy, had some signs of underlying physical de-
cline. (As we shall see, these seemingly minor physical dif-
ferences proved to be extremely important, relating close-
ly to the men’s behavioral capacities at the time of the
first study and to their eventual survival some 11 years
later.) Because there were age and health differences
among the initial subjects, the first study alone provided
answers, at least in a preliminary way, to some important
questions about the effects of sheer chronological age vs.
the effects of health on the well-being and performance of
older men. Among the study’s major findings were the fol-
lowing:

1. Health was an important determinant of general
well-being (although by no means the only determinant).
That is, those with no evidence of physical illness (mem-
bers of Group I) generally functioned better in all respects
than those with physical symptoms, however minimal
(members of Group II).

2. For many measures, whether physiological, medical,
or psychological, the healthiest subjects did not differ ap-
preciably from norms established for much younger peo-
ple. These findings suggest that many of the losses com-
monly thought to result from aging per se are actually the
result of illnesses commonly found among the aged. They
also provide some hope that, when we gain greater control
over some of these diseases and disorders, especially those
affecting the cardiovascular system, we may improve the
overall functional capacities of older people significantly.

3. Physiological brain functions do not necessarily de-
cline with age alone; when such declines are found, they

8
are usually associated with disorders commonly found
among the aged, such as arteriosclerosis.

4. Some aspects of psychological functioning did de-
cline with age, regardless of health status. For example, as
many other studies have also reported, relatively younger
subjects performed better than older ones on psychologi-
cal tests that depend on response speed. A certain type of
mental slowing down does seem to accompany aging, al-
though verbal ability and intelligence may stay remark-
ably intact into advanced old age.

5. Environmental deprivation was associated with a
number of relative deficiencies in physiology, cognitive
function, and psychiatric status. For some subjects, diffi-
culties and losses seemed to have taken a perceptible toll,
although all of these subjects were still extremely
healthy. These results raised, but did not answer, the in-
triguing possibility that adverse environmental events
had accelerated physiological aging processes, particularly
in the nervous system, and suggested that, conversely, we
might be able to retard some adverse changes through
environmental interventions (a thesis explored experimen-
tally in many studies to be described in this volume). As
summarized in the final report of the study’s first phase:

.... Findings of this study lead to the suspicion that psychological
reactions to the loss of friends and other environmental supports
may amplify if not initiate changes in the older nervous system and
thereby the rest of the organism.

The initial stvdy, although focused heavily on readily
measured medical, psychological, and physiological varia-
bles, also explored, through psychological and psychiatric
interviews, the more elusive and difficult-to-quantify
realm of feelings and ideas associated with aging.

Although many of these findings remain to be analyzed
and correlated with the other variables, the study pro-
vides some insight into the subjective world of these
healthy older men. What was life like, and how satisfying
was it? These men were generally characterized as “alert,
engaging, and had a great interest in understanding
themselves psychologically.” Some had volunteered ‘“be-
cause they wanted to show others how successful aging
could be.” Their morale, although generally high, was by
no means uniform: 26 were considered to have high mo-
rale, while 19 had low morale. These differences were not
related to their health status, but low morale was asso-
ciated with “new psychopathology” and “severe psycholog-
ical isolation.” We can get some feeling for the differences
in their morale and attitudes from the following excerpts

9
from interviews with these men, which range from hope-
lessness, through stoical acceptance, to sheer fulfillment:

An old man is a helpless man. It’s as natural as birth that people
should avoid you. Memory becomes bad. Nobody cares about you.

I haven’t got a thing to do and I can’t stand it. I want to occupy my

mind. . . .Igot alot of aggravation for noreason. . . .I can’t stand it.
I’m not happy.
I feel I'm a forgotten man. I don’t exist anymore.... I don’t feel old

. . . . I’m just living out my life.

About 28 percent of the group had feelings similar to
these. One-quarter of the subjects were less despondent
and showed more variation in feelings but were also dis-
satisfied with old age. The more stolid and stoical appar-
ently just grinned and bore it:

You know you're getting old. You have to put your mind to it and
take it as it comes. You can’t get out of it. Take it gracefully.

For almost half of the subjects (47%), however, life was
good, and sometimes extremely rewarding:
I go home with my cup overflowing. There are so many opportuni-
ties to do things for people. These are the happiest days of my life.
I do what I want to, when I want to, and don’t have to pinch pen-
nies. I don’t think there is anything I long for. I enjoy things.

I’ve never found time on my hands. It’s just so many things that I
want to do that I haven’t found time to do. I've got stacks of books
around that I want to read and I want to study.

Increasing chronological age seemed to have nothing to
do with the subjects’ degree of happiness and contentment,
and health factors also were negligible. But their social
environment counted significantly. Almost all (92%) had
some immediate family members available, and their fam-
ilies were the major focus of their daily lives, since all but
five were retired or semiretired. About half had retired
abruptly, while the others had eased into retirement over
many years. The 32 subjects who had wives were in rela-
tionships ranging from “poor and deteriorating,” which
characterized about one-third, through many types of
“compatible” relationships, both “satisfying” and “rag-
ged.”

Although many of these men had expressed fear of
slowly deteriorating, mentally or physically, they had not
experienced, at least at the time of the first study, appre-
ciable deterioration. They did, of course, perceive them-
selves as having changed over the years, particularly
physically, and often reported decreased physical and cog-
nitive abilities. But many other changes were viewed as
improvement, particularly in the realm of personality,
feelings, and relations with others. Physical decreases
were generally simply accepted, while social-psychological
decreases were met frequently with “compensation” such

10
as remarrying, becoming more sociable, or finding volun-
teer activities to replace paid work. Mental and emotional
decreases were met with both acceptance and compensa-
tion, such as describing some memory loss in aging as
“natural” and using a memory pad to jog recall.

Many psychosocial variables were explored, but key
among the socio-environmental influences on well-being
was the presence or loss of persons in significant close re-
lationships. Those with pronounced losses or lacks showed
“less organized and more routine-bound daily behavior, the
absence of goals, and feelings of unhappiness and useless-
ness. . ..”

In short, the study’s first phase revealed that, in con-
trast to many stereotypes of the aged, the men in this
study were, on the whole, “vigorous, candid, interesting,
and deeply involved in everyday living,” leading construc-
tive, resourceful, and optimistic lives. However, some
among their numbers showed signs of physical and mental
problems and possibly incipient illnesses not necessarily
resulting from their chronological age, but often found
among the aged, notably mild depression and mental de-
cline or the beginnings of senility. Depression was not par-
ticularly associated with health status, but impaired men-
tal function was. That is, some, but not all of those show-
ing some signs of mental decline had clear evidence of
atherosclerosis or changes in brain circulation and/or me-
tabolism. For others, deterioration seemed more closely
related to environmental loss. Taken together, these find-
ings present us with a challenging but potentially optimis-
tic prospect for the future. They suggest that “if individ-
uals retain their health with advancing age, they are
remarkably ‘young’. . . . With the promise of medical ad-
vances in the control of the now common metabolic diseases
of later life, more individuals will be seen who are old in
years but functionally young by present standards.” How-
ever, assuring good health for our elderly and preventing
debilitating conditions such as arteriosclerosis are only
part of the story. We must also find the means to
strengthen the social and economic supports available to
older people. As members of the study team have ob-
served, the resources available to these men in the Hu-
man Aging Study—good health, financial security, fami-
lies, and personal adaptability—‘“are frequently lacking in
the aged general population: One-third of the noninstitu-
tionalized people over 65 have a chronic disease so severe
that it limits their activities, and one-third live on incomes
below the poverty line. Psychiatric patients even more
frequently lack these resources.”

Among these healthy and largely “advantaged” men
there was a distressingly large proportion for whom the

11

274-912 0 - 78 = 2
later years brought less than their full fruits. While we
cannot shield our elders from some inevitable losses, there
is much we can and must do to minimize adverse environ-
mental circumstances, assure their economic stability,
reduce their isolation, and help them understand, antici-
pate, and cope with the challenges of growing older.

The 11-Year Followup: 1967-1968

Eleven years after the first study, in 1967-1968, 19 of the
23 survivors were studied again, by new team members, at
the Philadelphia Geriatric Center (PGC). The original in-
terdisciplinary research team had scattered, and it was
not possible to arrange for the work to be done at the
NIMH. Since the PGC could and would provide the neces-
sary space and facilities, and many of the subjects lived in
the Philadelphia area, this was a very favorable compro-
mise. The original investigators met with the new re-
searchers to discuss methodology and to provide specific
guidance for each examination and the various laboratory
studies, and there was a careful effort to replicate original
procedures. These could be only approximate, of course, in
part because the subjects, although cooperative, were
unwilling and unable to undergo the extensive testing
they had tolerated in their earlier years. Thus, the follow-
up study tapped only some of the variables examined ear-
lier, but was still quite comprehensive.

By this time, individual subjects could be compared as
they had changed or held steady over more than a decade.
Further, the researchers, with the wisdom of hindsight,
could now search the earlier data to see if they contained
clues to the longevity of these subjects or to the mortality
of fellow subjects who had died in the intervening 11
years. Let us look first at the issue of predicting longevity.
As it turned out, members of Group I were far more likely
to be alive by the time of the 11-year followup than those
in Group II; and among all survivors, Group I members
were more likely to be functioning well.

When the original study data were reanalyzed to com-
pare the characteristics of 11-year survivors to character-
istics of nonsurvivors, many initial differences were re-
vealed that apparently contributed to longevity. One key
health variable was chronic smoking. Subjects who were
chronic smokers were less likely to survive to the 11-year
followup than those who had not smoked or who had
stopped even after many years of smoking (as many as 30).
A more unexpected factor affecting longevity was the
subjects’ weight at the time of the initial study. Contrary
to the results of other longitudinal studies, this one re-
vealed that subjects who were initially relatively heavy

12
(although not obese) lived longer than those who were ini-
tially lighter. This result remains unexplained. Another
potentially significant and unexpected finding in the medi-
cal area emerged: Men who subsequently died of cancer
(all of the gastrointestinal tract) initially had serum albu-
min levels lower than the other subjects. This finding
might provide a clue for cancer detection and prevention
in the future.

In the psychological realm, the study revealed that non-
survivors had initially performed significantly worse than
survivors on a test of verbal ability and had fared worse
on performance-type intellectual and perceptual tests.
These two groups also differed in their initial social in-
volvement, their mental status scores, their adaptive re-
sourcefulness, their degree of planning and complexity of
typical daily activities, and their extent of environmental
loss, with the survivors having initially more favorable
test results and ratings and showing less environmental
deprivation. Thus, psychological factors, as well as physi-
cal, seemed to be closely linked to survival, although it
was impossible to determine the precise ways physical and
psychological factors influenced one another. In all, the
strongest predictors of survival or nonsurvival were smok-
ing patterns and the organization and complexity of daily
living. Nonsmokers who had the most organized and com-
plex daily behavior were those most likely to survive.

Life in the Eighties and Beyond

The 19 men who were studied during the 11-year follow-
up averaged 81.2 years of age. How had they held up over
the years? Their overall psychological performance was
impressive; it closely resembled that revealed in the first
study. Intellectually, these subjects fared particularly
well. They had started out, on the average, with relatively
high intellectual endowment and even in the followup, as
a group scored higher, on the verbal part of an IQ test than
people 15 to 20 years their juniors. However, they did
show some cognitive and perceptual problems and deficits.
The most consistent loss was in performance speed, espe-
cially when it affects psychomotor coordination. This find-
ing, consistent with results of the initial study which
showed a loss of response speed with increasing age,
seems to indicate a true age-related decline. Yet, al-
though the subjects were slower and had lost some of
their flexibility of adaptation, time had brought other
changes, sometimes even improvements in the cognitive
domain. Their overall IQ test results were about the same
in 1967-1968 as their original scores in 1956.

13
The subjects’ mental status tests also held up well over
the years, with little significant change, and their mental
health remained generally good. The prevalence of mild
depression remained what it had been earlier—about 14
percent, but the subjects were handling their feelings well
and none required treatment. Sexual activity and interest
had declined, but most had adapted comfortably to this
change. Surprisingly, certain types of mild psychopatholog-
ical traits seemed to contribute to adaptation; for exam-
ple, “obsessional” activities kept some content and busy,
while “schizoid” denial shielded others from emotional
involvements that might have resulted in shattering loss-
es.

For some of these men, the later years represented the
true culmination of their lives. One, at the age of 78, was
working almost full time as an investment counselor and
salesman. A late bloomer, he saw himself as one who had
“missed the boat in his early years.” But at age 55 he had
married (although not without sexual difficulties), at 60
had entered psychoanalysis (and had overcome many of
his marital problems), at 76 had begun a daily exercise
program at a gym (describing himself as “a regular fanat-
ic on physical fitness”), and at 78, when last studied, was
working as hard as ever, enjoying helping his clients, and
had grown emotionally even closer to his wife.

On the whole, the survivors sustained the same com-
plexity of behavior, optimism, and social patterns that had
characterized the group a decade earlier, and often individ-
ual interviews revealed an unchanged outlook toward
life. However, some of the men unquestionably had be-
come more withdrawn. One man in 1956 had said:

I’m happy around here . . . . I'm happy that I can go around and do
the things that I do.

His life then was busy with reading, going to Golden Age
Club meetings, visiting his wife in a nursing home, danc-
ing, and playing cards. But by 1967, he, too, was in a nurs-
ing home and had given up:

Have no friends... time, lots of time ...[Life as an older person] is
bad, all bad. Want to leave here [nursing home]. Nothing to do, just
sleep. No good here... Now I'm old, can’t get around.

It is difficult to say whether he might have functioned
better in a more congenial environment, but it was ob-
vious that, in his present context, this man had lost his
life spark and his morale.

One of the important changes noted in the psychosocial
sphere was a tendency toward greater interrelatedness of
functions, a sort of all-or-none phenomenon in which every-
thing seems to be either going well or falling apart. (Oth-

14
ers have called this the “one-hoss shay phenomenon” and
have observed that across-the-board functional break-
downs are more common after about 80.) The increased
vulnerability of those in advanced old age has often been
noted and is a source of particular concern to social serv-
ice workers and planners, who recognize that, as increas-
ing numbers of people are reaching these later years, we
must be prepared to attend carefully to their health and
psychosocial well-being. Although many of the very old
may still be functioning relatively well, they are more
susceptible to physical illness and less able to cope with
adverse social, psychological, and environmental condi-
tions. A loss or decrease in one area of functioning may
well have consequences that spell decreases in all.

One of the realities of the later years is also the con-
frontation with death, first that of friends and loved ones
and then one’s own mortality. Like all living creatures,
man seems to have an upper biological limit on the length
of his days—neither the few days of the mayfly, nor the
millenia of the sequoia, but something usually approach-
ing a century or slightly more. Whether we will ever be
able to extend this biological boundary is moot, but we can
undoubtedly increase the number of people who live out
man’s full potential lifespan and who do so with sustained
vigor and pleasure. Nonetheless, although we may delay
the day, or year, we all will die and, as thoughtful beings
mindful of our end, must all come to grips sooner or later
with our personal mortality. We seem to have an unspo-
ken notion of what a “fair” allotment of life is and how
the stages of life should be arranged. A person in our so-
ciety who dies at 40 seems prematurely robbed of life; one
who dies at 70 or more, who has lived out the proverbial
“threescore and ten,” seems more to be fulfilling a law of
nature (even if, theoretically, man’s potential lifetime is
much longer).

Many of our older people, raised in an era in which few
even survived to be 70, find themselves having outlived
their own expectations of longevity. For example, almost
half of the men interviewed in the NIMH Human Aging
Study followup had outlived their own predicted lifespans.
For most, the added years were pleasant, a “dividend,”
although some had already given up. Perhaps in the fu-
ture, when a century lifespan is possible for many, we will
alter our subjective schedule for living and will regard
being 80 or so as neither a bonus nor the end. It is inter-
esting that these subjects, even when initially interviewed
at an average age of 71, had already come to grips with
the prospect of dying which, given the actuarial tables for
men, was not at all unrealistic. Most had already made

15
plans for burial and the support of their wives, and many
had written wills. Few were found to be overtly afraid of
death, and those who were seemed to have attitudes
formed early which were deeply characteristic of their
entire lives. Most of the men faced their own prospective
end largely with philosophical acceptance, little bolstered
by religious belief or dogma. Many expressed satisfaction
in living out what they saw as a full life cycle and took
pride in leaving a legacy of children and grandchildren. If
some dodged direct emotional confrontation with the pros-
pect of death, it was through common defense mecha-
nisms such as humor, denial, or through “active mastery”
represented by practical planning of burial and wills.

Curiosity about the differences between the attitudes of
these men and other groups of men and women, both
young and old, healthy and ill, led Drs. Samuel Granick
and Robert Butler many years later to conduct a compara-
tive study of attitudes toward death and dying. The atti-
tudes of the 47 original subjects (as revealed by the first
round of open-ended interviews in 1957) were analyzed
and were compared with interview data probing similar
topics with 26 seriously ill institutionalized men (average
age 83); 22 severely ill institutionalized women (average
age 82), and two younger healthy groups of workers at the
Philadelphia Geriatric Center: 18 women (average age 23)
and 25 men (average age 29). This study revealed strong
general similarities among these many informants which
were greater than their differences. As summarized by
Drs. Granick and Butler:

They seemed inclined to be realistic and may well be responding, at
least intellectually, to the orientation of our scientific age toward
objectivity. Thus death is often perceived as a finality, but the hope
also comes through in their thinking that there may be something
for them beyond the grave. Their inclination is to appear brave by
denying fear of death since they recognize its inevitability. Resigna-
tion and philosophical acceptance are the main attitudes toward
death. Essentially, pain and suffering during the process of dying are
feared, leading them to wish for a speedy death when it does come.
They tend to react with mild depression or mourning to the death of
others who are close to them, and expect a more or less similar reac-
tion from others toward them when their turn arrives to die. Suicide
as a way of dying is rejected, although some ambivalence about oth-
er people’s right to it is expressed by about one-fifth of the subjects.
They typically discount it for themselves. The old, of course, seem
more prepared to die than the young. This had led them to plan for
this eventuality by preparing wills and arranging for the disposal of
their bodies.

However, some differences emerged between the healthy
older NIMH subjects and the other respondents. These
healthy old men were much more likely than ill old men to
believe in an afterlife (37% vs. 4%) and much less likely to
have made out wills (39% vs. 92%).

16
In general, the morbid fears and anxieties that lead
some young people to avoid working with the aged are
often unrealistic and unfounded. They sometimes lose
sight of the fact that for many older people life is good,
full, and interesting, and may bring many subsequent
years of added psychological growth and wisdom. For
those older people faced with the prospect of dying in the
foreseeable future, at a time when it is expected, it is nei-
ther frightening nor depressing, simply the “natural”
course of life. For many of our older people, the difficult
challenge is not how to face death, but how to face and
use well the “bonus years.” Our social attitudes, institu-
tions, and expectations have not kept pace with our growing
longevity. We retire people at 65 or younger, with little ac-
knowledgment that many may live another 20 years or more
in good health, although forced to improvise lives for which
they have been little prepared.

The NIMH Human Aging Study has yielded a wealth of
results of practical and theoretical interest and impor-
tance. The clinical study ended long ago, and few of the
subjects are now living, but they have left a vital legacy
to other people, young and old: a rich heritage of descrip-
tive data that can help us understand the later years from
many different perspectives—physical, psychological, and
social. The advent of the computer has made it possible to
analyze these data in ways that were impractical when
the study was first undertaken over 20 years ago, and to
find new patterns and interrelationships among the many
types of data. Thus, a project has been conducted at the
Philadelphia Geriatric Center, by Drs. Samuel Granick and
Morton Kleban in which the voluminous data of the total
investigation have been translated into a computer-com-
patible data file permitting other interested scientists to
use the findings in conjunction with their own interests
and investigations. Recent analyses of the original data
have already revealed some provocative relations among
the medical, neurophysiological, and psychological test
data, such as the potential significance of mild hearing
loss as a predictor of lessening brain function, and the
correlation of certain mild medical problems with behav-
ioral and personality changes. At present, one of the most
difficult tasks facing these scientists is to find a way to
preserve the richness of the psychiatric and psychological
interviews while quantifying them sufficiently to be corre-
lated with other types of data. If this problem can be mas-
tered—and it is by no means unique to this study—we
may understand more precisely how the state of our bod-
ies and brains reflects and contributes to our subjective
experience of being and becoming older.

17
To the investigators participating in the NIMH Human
Aging Study, their earlier findings suggested four key
areas “most likely to make substantial contributions to
the quality of old age and to longevity.” As summarized
by Drs. Samuel Granick and Robert Patterson:

The first area is prevention or treatment of arteriosclerosis. Its ef-
fects may underlie many of the debilitating conditions of old age.

Second is the prevention of cigarette smoking or the avoidance of its
harmful influences, even among those who are already healthy old
smokers.

A third area involves reduction of the detrimental effects of psycho-
social losses. Governments and other organizations will probably be
increasingly required to provide some of the services which nuclear
families have traditionally provided, because modern families are
smaller and they often become geographically dispersed.

Changes in cultural practices, even though they would be difficult to
bring about and would require much time, might be very important.
Examples include encouraging marriages between men and women
of more nearly equal ages, and instituting practices that foster
healthy compensations for grief and the restoration of psychosocial
losses. Early treatment of illnesses related to losses should be im-
proved.

A fourth area is that of helping the aged sustain effective life goals.
Maintenance of life goals has a significant positive influence upon
the retention of intelligence, organization of daily behavior, morale,
and adaptation. Whether or not the aged will have satisfying goals
can be influenced by many elements of a society. Such influences
include economic, business, and labor union policies with regard to
employment and retirement practices for the aged, and city and in-
stitutional planning to make possible the attainment of varied goals
within the limits of the physical and emotional requirements of the
aged.

Although articulated over a decade ago, many of these
recommendations still stand in the forefront of any agen-
da for improving the lives of older Americans. As the fol-
lowing pages will show, we have made some progress in
trying to reach some of these and other goals which are
essential to bettering the quality and length of life. But
there is still an enormous amount of work to be done, es-
pecially in the psychosocial sphere. For many of these
problems there is much more research needed, particular-
ly in the medical area. But for many others, the challenge
is to put existing knowledge into the right hands and to
make our practices consistent with our knowledge. We can
no longer excuse our inattention to our aged with appeals
to their inevitable decline, their limited prospect of life, or
their inability to grow and change. As the NIMH Human
Aging Study demonstrated, we have just begun to tap the
enormous biological and psychological potential of our old-
er citizens. Most of the barriers to fulfillment in the later
years are not inherent to the aging process; rather, they
seem to stem from potentially preventable illness and

18
from the way we have structured our expectations, oppor-
tunities, and services for those in the later years. It is
ironic that cultures far less well-developed than our own
seem to have mastered the art of living long and well. But
with dedication and care, we may one day learn to match
their longevity and love of life in all its stages.

On the following pages, we look at the lives of many
other more representative groups of older people, as de-
scribed by researchers from many different disciplines.
These studies focus particularly on the critical question of
the way aspects of the social, psychological, and physical
environment affect the quality and length of the later
years. On subsequent pages we will examine experimental
service programs designed to enhance the quality of life
for special populations of community dwelling elderly,
some of whom are still quite healthy, while others have
already declined. If we are effective in maintaining the
well and shoring up the more vulnerable, we may one day
see fewer of our elderly requiring the kinds of institution-
al care to which the latter section of this book is devoted.
And if we are wise and compassionate in the ways we
serve the impaired and institutionalized members of our
community of elders, even they may lead lives longer and
fuller than we—or they—ever thought possible.

19
lll. Lifestyles,
Satisfaction,
and Quality of Life

Twenty three million Americans share the distinction
of having lived for 65 years or more. To statisticians, social
planners, and politicians they may comprise a unified
group—‘the over 65s,” “the elderly,” or “the Senior Citi-
zen vote,” but they are strikingly diverse. Their ranks in-
clude people from all walks of life, socioeconomic classes,
educational levels, ethnic and racial groups, religions, and
geographic lifestyles. They may be married or single,
working or retired, socially integrated or isolated, reli-
gious or atheistic, fulfilled or unfulfilled, vibrantly alive or
hanging onto existence by a filament. Over 30 years—a
generation—may separate the youngest and the oldest,
with both parents and their children receiving Social Se-
curity checks and Medicare or Medicaid. If we are to re-
spond well, in our communities and our Nation as a whole,
to the highly varied needs and problems of older Ameri-
cans, we must recognize their diversity as well as their
commonalities and take the time to understand the experi-
ence of living and aging in America from their perspec-
tive.

What is life like for these older Americans? How fulfill-
ing is it? What are their lifestyles, problems, and satisfac-
tions? What factors contribute to or detract from a sense
of contentment in the later years? A number of behavioral
scientists, recognizing how little we actually know about
the ways older Americans view their lives, have directly
interviewed and observed older residents in myriad com-
munities across the country. Some have been content sim-
ply to document one particular lifestyle, while others have
sought to develop generalizations and models that might
apply broadly to many groups of older persons. Still other
researchers have used their studies as a springboard for
social change. Often, these investigations support our
commonsense notions about what older people want and

20
need, for example, adequate income, decent housing, and
good health care, but they sometimes come up with find-
ings that challenge many simplistic notions—held by pro-
fessionals and laymen alike—about the ways older people
experience the Golden Years. Let us sample a few.

The Pursuit of Happiness in Kansas City

One of our most persistent personal and societal goals is
to find fulfillment and satisfaction in life. Our sense of
justice decrees that the later years should be a rewarding
and peaceful culmination of life—indeed, the Golden Years.
Yet negative stereotypes of aging abound, confronting us
with the frightening prospect of poverty, isolation, loss,
decline, irrelevance, and the ever-present spectre of death.
How, then, are the later years actually experienced, and for
whom are they rewarding? Are there certain social condi-
tions that enhance the good morale and satisfaction of old-
er people?

These are some of the fundamental issues explored by
Dr. Forrest Berghorn and his associates at the University
of Kansas. These investigators conducted an intensive
interview survey of over 500 residents of Kansas City,
Kansas, age 60 and over, to discover their levels of life
satisfaction and the key factors contributing to them. The
study has yielded many challenging findings and provides
a good introduction to the complex interplay of personal
and environmental conditions affecting the well-being of
older persons.

Given our often negative views toward aging, and the
frequent losses and problems that are an inherent part of
growing older, we might expect a sample of urban elderly
to have low morale and to find life relatively frustrating
and burdensome. Surprisingly, just the opposite was
found. In response to a scaled measure of morale and a
battery of open-ended questions probing their satisfaction
with the past and present, the Kansas City sample, on the
average, had relatively high morale and were generally
content with their current lives. If these respondents are
indicative of our older population at large, then the prospect
of aging need not be so bleak. However, the responses were
quite varied, with some older respondents apparently quite
content and fulfilled, while others were decidedly unhappy
and unsatisfied with life.

What accounted for these differences? The answer is com-
plex, because objective factors, such as income level, housing
quality, and health, were tempered and colored by the
subjective expectations and perceptions of the respondents.
Further, many social, economic, environmental, and health
factorsinteract, although not always in expected ways.

21
Let us take, for example, the question of income levels.
There are many who, observing the precarious finances of a
substantial proportion of the elderly (about 15.7% or 3.3 mil-
lion live below the poverty level), would propose that improv-
ing the income of older people would substantially enhance
their quality of life. The results of this study raise some in-
teresting questions about the relation between income and
satisfaction. Like the elderly population at large, the median
income of the Kansas City sample was $3,306, with a mean of
$4,279. The range, however, was very wide, from $600 to
$22,000 per year, with income levels generally lessening with
age. Morale tended to be high among those older people who
viewed their income as more than adequate, and low among
those who saw it as inadequate. But money, per se, did not
buy happiness; among those whose incomes were sufficient to
cover expenses, the actual size of income was negatively re-
lated to morale, particularly among those with relatively
high incomes. To Dr. Berghorn and his associates, this sur-
prising result reflects the fact that for those used to relative-
ly high preretirement incomes, the shift to life on a much
smaller—albeit substantial—fixed income can be a major
psychological jolt. For the chronically poor, by contrast, re-
tirement brings far less change in income or spending pat-
terns.

The Kansas City study also revealed that black respond-
ents, whose average income was only slightly lower than
that of whites, were disproportionately inclined to’ see
their incomes as inadequate. According to Dr. Berghorn,
this may have reflected deficiencies in money management
skills, or perhaps the problem of living and shopping in
areas characterized by ghetto pricing.

The study of economic factors in life satisfaction sug-
gests many important considerations for policymakers.
Obviously, many variables affect whether a given level of
income will be seen as adequate and whether it will result
in high morale. As the investigators note:

It is also important to remember that expenditures reflect a per-
son’s needs and desires and that these vary dramatically from one
individual to another . . . . Thus what constitutes perceived needs is

highly variable among individuals, as is the amount of money avail-
able annually to meet those needs.

A second aspect of the Kansas City study also revealed
some major findings of concern to policymakers. Many
questions were asked concerning the way older Kansas
City residents viewed their physical and social surround-
ings. A number of these environmental factors, such as
neighborhood safety, appearance, stability, and opportuni-
ties for social interaction, seemed to have a direct influ-
ence on life satisfaction. These findings underscore the
significant psychological benefits that might be reaped by

22
greater attention to improving the quality of neighbor-
hood life, including careful location of housing for the el-
derly to allow easy access to needed services and to en-
courage a high density of similar-aged people. (Some of
these issues will be explored in greater detail later in this
chapter and the next.)

For the Kansas City sample, residential patterns have
long remained highly stable; many people, at all income
levels, had lived almost 30 years in the same location. In
essence they had “aged in place,” sometimes staying in
their once-good neighborhood long after it had deteriorat-
ed. Thus, the relation between income and housing quality
was not consistent.

The respondents generally viewed the condition of their
neighborhoods as good, with 25 percent rating it as very
high, 44 percent above average, and 21 percent having
some reservations about neighborhood quality. The 11
percent who saw their neighborhoods as very unsafe and
unattractive lived in areas often regarded as transitional,
unstable, and sometimes even “blighted.” Blacks, more
than whites, tended to see their neighborhoods as inade-
quate, often with considerable justification, since they of-
ten lived in some of the least safe and most unattractive
parts of the city. Low morale was particularly strong in
inner-city neighborhoods which showed physical decline
and rising crime rates.

Among the high concerns of this sample of elderly ur-
ban residents were safety, quiet, and privacy. Although
respondents’ perceptions of neighborhood quality often
mirrored conditions objectively, they also reflected their
own physical capacity; those more able to manage their
livestendedtoview their neighborhood’s quality as high.

The morale of elderly persons is affected not only by
their neighborhood’s physical characteristics, but also by
its density of age peers. Thus, those older respondents liv-
ing in neighborhoods with a high concentration of similar-
ly aged persons reported higher levels of life satisfaction;
conversely, those in age-heterogeneous neighborhoods
often clashed with younger people—especially young chil-
dren and teenagers, who were often viewed as noisy
troublemakers.

Neighborhoods with a high proportion of elderly resi-
dents tended to have disproportionate numbers of females
and the very old. But in these settings, unexpectedly,
their reported dependence on their families was quite low.
Further, also contrary to expectations, their level of socia-
bility was quite high. These findings take on particular
importance in the light of widespread belief that, as peo-
ple age, they become increasingly “disengaged” from oth-
er people and social activities.

23
To the investigators, these findings suggest that, when
older people have a chance to socialize with age peers,
they continue to remain sociable, while those who are rel-
atively isolated essentially adjust to their situation by
withdrawing. Health and the opportunity to socialize,
rather than age alone, seem to determine people’s ex-
pressed desire for social contacts. Given the opportunity,
even the very old can show high levels of interest and
participation in social activities. (Women generally were
more likely than men to turn to relatively social activities,
such as church work, while hobbies—which, of course, can
also be social—were the core of male activity patterns.)

In this study of life satisfaction, many other factors
were also explored, including employment, patterns of
dependency, and medical health. Again, some unanticipat-
ed findings emerged, although some, such as those con-
cerning employment, were more predictable. Among those
sampled, 11 percent were working, while 89 percent were
not. The still-employed workers tended to have higher
morale than the nonworkers, but the relationship was
complicated by the fact that the workers also tended to be
younger, healthier, more active, more able to cope, and
more likely to be car owners (a factor important in mobili-
ty and independence).

The relation between medical health and morale also
proved to be complex. Although subjective and more objec-
tive ratings of health were strongly related, they showed
some interesting divergences. For example, although
health generally declines with age, respondents’ health
self-ratings did not follow this pattern. To the investiga-
tors, the discrepancies between self-rated and objective
health appeared to stem from morale. That is, some people
with good physical health but low morale might rate their
health as relatively poor, while, conversely, those in poor
health but with high morale might view their health as
relatively good. Further, the respondents also seemed to
rate their health according to expected norms for their
age group, often tolerating a degree of illness or infirmity
while still considering themselves in good health. Some-
what unexpectedly, the socioeconomic status of the re-
spondents was not related to their self-reported health, a
finding which the investigators believe may reflect the
availability of better medical care for all segments of the
elderly population.

Although self-rating of health may not be a reliable in-
dicator of an older person’s true physical condition, it can
provide many clues to mental health and morale. A more
reliable key to health status was an older person’s self-
rating of his or her capacity to handle the tasks of daily
living. These ratings do, indeed, decline with age and seem

24
to be uninfluenced by morale. This pattern of decline un-
derscoreés the need to target many types of supportive
community services for the lessening self-care capacities
of very old community dwellers. However content they
may be, they are likely to need help in everyday aspects of
living.

This survey revealed many other potential service needs
among the elderly population of Kansas City. For exam-
ple, overall, they were found to be “moderately to poorly
prepared to deal with . . . common problems.” Those elder-
ly people with high activity levels who interacted inten-
sively with other people were generally more able to cope
with life problems than their less active peers, possibly
because exposure to others gave them greater access to
needed information. However, these active people also tend-
ed to be more highly educated, a factor that may have
strengthened their problemsolving ability. Findings such
as these suggest that many of the elderly most in need of
help—the inactive, the isolated, and the ill-educated (and
often the low-income)—may not have the coping skill to
find it or the social contacts to provide it. Thus, agencies
devoted to serving the aged need to expand their efforts to
find and help many in need of their services. (In Chapter
IV we will discuss several programs designed to do just
that.)

In a society such as ours, which stresses self-sufficiency
and independence, no one likes to think of himself as de-
pendent, although we do lean on family, friends, neigh-
bors, and spouses for support, often reciprocally. Since
many of the respondents in this survey had no spouses,
their family members or friends and neighbors provided
informal support. Very few would admit to a high degree
of dependency; only 5 percent reported being highly de-
pendent on friends and neighbors, with 20 percent report-
ing high family dependence. Half of the respondents re-
ported no dependence on friends and neighbors, while 20
percent were comparably independent of their families.

For most of the respondents, the two major dependency
patterns were mutually exclusive; friends and neighbors
were usually used when family members were unavaila-
ble. However, in neighborhoods with a high density of el-
derly people, respondents tended to see themselves as rel-
atively independent of all social supports, whether family,
friends, or neighbors. Perhaps, because these are settings
in which older people socialize extensively with one anoth-
er, they see their helping relationships as reciprocal and
do not view them as “dependence.”

Elderly blacks interviewed in this survey reported more
physical and psychological dependence on friends and
neighbors than their white counterparts, possibly because

25
their children were less likely to be living in the vicinity
or because of closer neighborhood ties.

When the capacity to manage one’s own life fails, depen-
dency on family members increases—sometimes to the
extent of living with other family members. But despite
the stress in American society placed on self-reliance, the
subjects of this study did not necessarily show lessened
morale in the face of rising dependency, unless their fami-
ly or friends and neighbors made them feel like a burden.

One important key to dependence or independence is the
availability of transportation. Despite the presence of
public transportation, only 7 percent of those sampled
used it, while 48 percent drove their own cars and 40 per-
cent relied exclusively on others with cars. The heavy pref-
erence for and reliance on automobile transportation found
in this study raise some interesting questions for advo-
cates of accessible mass transit for the elderly. Perhaps
for some, automobile escort services are more suited to
their needs and preferences.

We have discussed here some of the links between so-
cial, economic, and environmental conditions and the life
satisfaction of the elderly. However, only the bare bones
of relationships have been outlined. Dr. Berghorn and his
associates undertook a complex statistical analysis of
their data which revealed the relationships among many
of the variables studied, both to one another and to the
morale of the elderly subjects surveyed. Out of this analy-
sis emerged a new model of the many paths to life satis-
faction:

[The] rather broadly defined alternative means of attaining life sat-
isfaction are: problem-solving ability; physical security (represented
by a safe and attractive neighborhood and by an income that, re-
gardless of its size, is perceived as adequate); self reliance (repre-
sented by the ability to drive an automobile—an ability of particular
significance in American culture); social activity; residing in close

proximity to other older people; and being in reasonably good physi-
cal condition.

We would expect that the more alternatives a person is capable of
realizing, the greater that person’s chance of achieving life satisfac-
tion. However, for a satisfying life, a person need not have all these
alternatives available; and, of course, not all the alternatives contri-
bute equally to morale [with] social activities and self-reliance mak-
ing larger contributions than the others. In fact, it is conceivable
that having only one or two alternatives available may be sufficient
for an acceptable level of life satisfaction. For example, one . . .
woman . . . expressed satisfaction with her life on the basis of only
two positive circumstances. She felt her neighborhood safe and rea-
sonably attractive, and it is an area in which many older people live.
She expressed a particular attachment to one elderly next-door
neighbor.

Indeed, the process of aging as it relates to continuing life satisfac-
tion may be largely a matter of flexibility in adjusting one’s empha-
sis along the lines of these alternatives in a manner which changing

26
circumstances dictate. If, as an example, one’s health and ability to
be self-reliant decline and inflation erodes one’s fixed income, then
increased contact with older people, and social participation in gen-
eral may have to become the mainstays of morale. This in turn may
necessitate, for instance, adjusting to dependence on others for
transportation, a circumstance previously considered unacceptable.
This does not mean that society may shirk its responsibility for cre-
ating and maintaining environments that optimize the alternatives
of older people. But given the reality of present environments, indi-
vidual adjustment to decreasing alternatives may be the most im-
portant constituent of life satisfaction.

Although this study is not an investigation of the socioec-
onomic and environmental determinants of mental
health, it is clear that life satisfaction or high morale is
one of the measures of mental health, and raising the lev-
el of satisfaction among the elderly is one of the goals of
mental health interventions.

The results of this study suggest that there are many
potential pathways to improving the quality of life and
the mental health of older persons, not all of which de-
pend on one-to-one interventions with a given individual.
The community mental health movement has long recog-
nized that, for many individuals, nonpsychological factors
may have a strong influence on their state of well-being,
although these are often mediated by a particular person-
ality structure and habits of interpreting one’s situation.
Among those factors that should be in the forefront of
mental health and public policyplanning are: the struc-
tural characteristics of neighborhoods, the location of
housing for the aged, crime prevention, and the facilita-
tion of family and neighborhood informal support sys-
tems. This study also suggests several direct educational
and service approaches for the elderly that deserve fur-
ther investigation. The low level of coping skills reported
among this population—especially among those living in
areas with low concentrations of other elderly persons—
suggests a need for supportive educational services to aid
in problemsolving. Further, the decline in physical capaci-
ty with age, although sometimes apparently bolstered by
family members or friends and neighbors, deserves great-
er investigation and service delivery where these informal
systems fail. It is important to remember, however, the
strong value placed by the elderly on independence and
nondependence and the suggestion that the appearance of
reciprocity in giving appears to minimize the sense of
dependency.

Another dimension for potential mental health interven-
tions is suggested by this study. If, as the research team
members believe, the task facing an older person is to
find, among a large but decreasing number of pathways to
satisfaction, those most suited to his or her own capabili-

27

274-912 O = 78 = 3
ties, then perhaps this formulation can help in developing
goals for anticipatory mental health programs such as
pre- and postretirement counseling.

One of the challenging questions for further research is
to devise a similar model for pathways to satisfaction for
that special segment of the aging population that requires
institutional care. Does the same model apply, or is anoth-
er model needed? The subjects of this study are all com-
munity dwellers who are still relatively well and capable
of taking on their world to find many sources of gratifica-
tion. However, their well-being seems predicated on the
control they can still exert on themselves and their world.
A study reported on p. 119ff., which follows community
dwellers into the world of the institution and examines the
adequacy of old coping strategies in the light of new envi-
ronmental characteristics (and changes in coping strate-
gies in accord with the new environment), may provide a
first step in understanding the differences between these
types of environments and their effects on those who live
in them.

Another issue explored by Dr. Berghorn and his asso-
ciates which deserves further study, both in community
and in institutional settings, is the effect of socialization
opportunities on older persons. Many service programs for
the elderly place a great premium on encouraging sociali-
zation. Although there are still considerable debate and
need for study concerning the degree and amount of social
participation older people want and need as their years
advance, there seems to be little disagreement that they
should have adequate opportunities to meet and share
with others if they so desire. Many of the studies reported
on the following pages place great emphasis on enhancing
the opportunities for older people to gain strength and
companionship from one another. We have not yet tackled
the formidable task of enhancing yet another source of
companionship and support—the family, particularly for
the impaired and institutionalized elderly.

Let us turn now to several other descriptive studies
which, like Dr. Berghorn’s, explore some of the major fac-
tors affecting life satisfaction in the elderly, although fo-
cused on a more narrow range of basic issues such as
housing, retirement, and the roles of family members and
spouses.

Homes and Housing: The Right Place To Live

Retirement Housing Options—What Works for Whom?

For many years, one of the major issues in the forefront
of public policy debate concerning the elderly has been the

28
provision of adequate and appropriate housing. In the late
1950s and early 1960s, there was a flurry of activity to
build new low-cost group housing for the elderly, spurred
by several enlightened financing programs sponsored by
the Federal Department of Housing and Urban Develop-
ment (HUD). Although HUD policies and programs under-
went many changes in the intervening years, many build-
ings constructed under these earlier programs still stand,
and many others are being built which attempt to provide
a living environment suitable for the low-income elderly.
In addition, many private entrepreneurs, recognizing a
fertile market in our burgeoning population of senior citi-
zens, have developed a number of housing arrangements
for the elderly with special features designed to cater to
the presumed preferences of the middle- and upper-class
retiree. As a result, although many experts still view the
housing market for older persons as overpriced and often
inappropriate to their needs, we have a plethora of models
of residential options available for the aged, ranging from
high-rise apartments to sprawling desert leisure worlds
laid out like giant playgrounds for the old.

The question for policymakers, planners, builders, and
gerontologists alike is: How well do these living arrange-
ments suit those who live there? Some studies (such as that
cited on p. 60ff.) suggest that, despite our good intentions,
subsidized housing for the low-income elderly may have
left many feeling unfulfilled. Are there better alternatives?
Of particular interest to those concerned with enhancing
the well-being of older persons are the lifestyles that
emerge in these different settings, and the degree to which
they promote the physical and mental health of the resi-
dents. Another issue concerns assuring the right match
between the individuals who find their way to a particular
form of housing and the opportunities that housing ar-
rangement offers. A growing body of research that has ex-
plored these issues in the past two decades suggests that
we cannot regard our older citizens as a uniform group and
cannot provide one type of living arrangement for “the el-
derly” that will be appropriate for all. Differences in for-
mer lifestyles, in income, in interests, and in stages of ag-
ing, health, and capacity for self-maintenance and inde-
pendence must all be taken into account, as well as the
likelihood that, as people age, their capabilities are likely to
decline. Thus, we need to make available a variety of possi-
ble living arrangements for older people, at prices that
even the low-income elderly can afford. At the same time,
we must provide sufficiently flexible arrangements so that
a person can stay in the same locale even if he or she be-
comes gradually less self-sufficient and more impaired.
There is ample documentation (including one study cited in

29
this book—see p. 123ff.) of the potentially adverse effects of
relocation on elderly people to warrant caution in design-
ing housing that is too narrowly geared to one specific level
of functional competence.

When we talk of housing for the elderly, there are three
basic components to consider: the physical plant itself, the
kinds of services and activities that, deliberately or not,
are a part of the environmental milieu, and the kinds of
social contacts the living arrangement facilitates or inhi-
bits through price, selection policies, geographical location,
and the arrangement of living, eating, and socializing
areas designed into the structure. On top of these, of
course, there is the elaborate superstructure of social
rules and roles that develop among the inhabitants them-
selves, reflecting in part their own personalities and life-
styles carried over from the past, as well as the particular
ad hoc mini-society that develops within any social envi-
ronment.

From both a theoretical and practical perspective, then,
the lifestyles of elderly people in a variety of different res-
idential settings are of considerable interest and have
been the subject of many research studies. For gerontolo-
gists and social planners, three long-standing issues have
concerned the desirability of age-segregated vs. age-inte-
grated housing: the need of older persons for extensive
opportunities for socialization and group-oriented recrea-
tional activities, and the proper balance of supportive
services that can help older people live comfortably and in
good health, while not undercutting their need for autono-
my and self-mastery. Data from a large and careful study
of residents of diverse types of group housing for the el-
derly in California provide us with some preliminary an-
swers to some of these questions.

In 1964-1969, Dr. Daniel Wilner and Mrs. Rosabelle
Walkley of the University of California, Los Angeles, sur-
veyed all retirement facilities in California, describing
their construction status, size and location, sponsorship,
costs, financial arrangements, and programs and services.
On the basis of this first study, six sites, representing a
spectrum of retirement housing arrangements for the el-
derly in California, were selected for more intensive study
between 1965 and 1968. The basic question under investi-
gation was how the characteristics of these different hous-
ing arrangements affected the physical and mental health
of their residents and their general psychosocial function-
ing. One hundred residents at each of the six sites were
interviewed, as well as 600 community residents (controls)
who were matched as closely as possible with the group
housing residents, except for their living arrangements.

30
The control subjects lived in conventional urban dwellings
(houses and mixed-age apartments). The design of the
study thus permitted comparisons to be made among var-
ious types of group housing, as well as between group
housing and conventional housing. Nearly 1,000 of the
original 1,200 experimental and control subjects were in-
terviewed a second time, 2 years after the original inter-
views, to assess changes in their well-being and lifestyles
with the passage of time.

Many of the results of this study of psychosocial effects
of housing were published by one of the original UCLA
research team members, Dr. Susan Sherman, while she
was at the New York State Department of Mental Hy-
giene. (Dr. Sherman is presently the Director of the Insti-
tute of Gerontology at the State University of New York
at Albany.) Although the study was conducted about a
decade ago, many of its findings are applicable to retire-
ment housing today.

The six types of group retirement housing studied in-
cluded a “retirement hotel,” rental apartments, purchased
homes and apartments in retirement villages, and a “life-
care home” offering a number of residential options, de-
pending on one’s level of self-maintenance. Their sizes,
locations, and the demographic characteristics of their
residents were also quite diverse, as were the services and
recreational opportunities offered.

As summarized by Dr. Sherman, the major characteris-
tics of the six sites were as follows:

The first site is a retirement hotel in downtown Los Angeles. Many
older hotels in the downtown section of the city have lost popularity
in recent years and in order to maintain reasonable occupancy,
some have specialized as senior citizen hotels. This ordinarily in-
volves little adjustment, since by this time the hotel would already
be occupied primarily with senior citizens. At this retirement hotel,
two meals are provided daily and all dwelling units are single rooms.

There is a recreation room in the basement, and on a mezzanine a
lounge, a game room, and a TV room.

The second site is a rental retirement village—not fitting the popu-
lar stereotype of country club living for the elderly, but rather pro-
viding apartments with few added frills. Federal financing was in-
volved. The site, located in a suburban area, has about 80 single-
story buildings. In addition to the dwelling units, the site includes a
large central building containing administrative offices, a cafeteria-
assembly room, a library, doctor’s clinic, recreation room, activity
rooms, and a lounge. Also on the site is a small grocery store.

The third site, a type growing in prominence in many areas of the
country, is a single high-rise building in an urban area, assisted by a
Federal program making direct loans to churches and other nonprof-
it organizations, at a much lower interest rate than they could oth-
erwise obtain. All dwelling units are apartments. The building con-
tains lounges and a recreation room.

The next two sites are retirement villages. The first is located in a
semi-arid mountain-desert area of southern California. Dwellings

31
are mostly single family houses, with a few garden apartments. Be-
sides a shopping center, there are extensive onsite recreational fa-
cilities, including golf, swimming, and specifically designed activities
buildings or areas.

The fifth site, with a cooperative financial arrangement and 40-year
mortgages is a somewhat more luxurious retirement village in
northern California. All dwellings are apartments (one to three bed-
rooms)—referred to as “manors.” On the site are a medical clinic, golf
course, swimming pools, clubhouses, and buildings or areas for arts
and crafts, games, meetings, and classes. Nurses are on duty at the
clinic at all times, and there is a visiting nurse service as well.
Group health insurance is available.

The sixth site is a church-sponsored life-care home, licensed by the
State Department of Social Welfare to give personal care and pro-
tective service. An FHA-insured mortgage is involved. (The site also
has a medical unit on the premises, although the design of the pres-
ent study excludes residents therein.) All meals are provided. The
location is a college town in urban southern California. An attrac-
tive feature of this site is the availability of three different types of
dwelling unit: cottages, apartments, and rooms, to be occupied ac-
cording to the individual’s decreasing ability to care for himself. A
central building houses the dining room, lounges, and activity rooms
(Sherman, 1971, pp. 119-120).

The interview data collected in this study included de-
mographic characteristics; interaction with relatives, age
peers, and younger friends and acquaintances; morale and
health; use of leisure time and attitudes toward retire-
ment; community organizations and integration; and fi-
nancial status and attitudes. We will concentrate here
particularly on morale and health, on the social relations
between these residents and family and friends, and on
their activity levels, as these differ from site to site and in
comparison with dwellers of conventional housing. In ad-
dition, some observations will be made on patterns of
change over time.

It should be kept in mind that the subjects under study
at the six sites were quite different in many background
characteristics: Although at four of the sites the mean
age was 75, at two it was 68. Also, at two sites there was a
heavy preponderance of married couples (and therefore
nearly equal proportions of men and women), while at the
other four, widows and singles, mostly women, predomi-
nated. As one might expect, at least three-quarters of the
residents at each site were retired, but at one site as
many as 20 percent were still working. The educational
levels of residents of the sites were also disparate, as was
income. Educational levels ranged from a median of 9th-
11th grade at one site to college graduate at another,
while median incomes at the six sites ranged from $2,000
to $11,000.

In one somewhat surprising respect, the subjects were
quite similar. Contrary to expectations, there were few
who had come recently to California to seek retirement

32
fun in the sun; between 50 and 75 percent had been Cali-
fornia residents for 20 or more years. Another commonali-
ty was their tendency to find the same kind of financial
arrangement for housing that they had prior to retire-
ment—whether as renters or purchasers. Four-fifths had
maintained the same arrangement. A further point of sim-
ilarity was the preponderance of American-born citizens
among those studied—90 percent were native born.

The people living in retirement housing obviously made
a deliberate decision to move there, one that distinguished
them from the control subjects. What differences in atti-
tudes and motivation separated these two groups? Accord-
ing to Dr. Sherman, the most common motivation for mov-
ing to retirement housing was for ease of maintenance,
sometimes also for personal care or meal preparation. Res-
idents of specific sites also cited proximity to facilities and
services, quality of dwellings relative to cost, recreation
facilities, and security, each of which was relevant at two
to four sites. The residents did not cite as particularly
important the need to be with age peers or to be near chil-
dren or relatives. The fact that a substantial number of
these persons at the time of the interview had no children
at all may provide some clue to their decision.

The control subjects who did not live in special retire-
ment housing shared a similar view of its attractions,
such as the advantages of companionship, easy mainte-
nance, and recreation facilities, but they saw it as having
many drawbacks as well, often citing a distaste for age seg-
regation per se, and a fear of regimentation and bore-
dom. “In the eyes of many of the controls, all retirement
housing facilities were institutions, and as such the facili-
ties posed the threat of regimentation.” Interestingly, al-
though the retirement housing residents found, on the
basis of their actual experience, some features unappeal-
ing, they were for the most part satisfied with their hous-
ing arrangements and did not generally object to those
features that deterred the controls—segregation and regi-
mentation. (It would, of course, be interesting to know in
greater depth the personality characteristics that differ-
entiated the two populations and accounted for their dis-
parate views toward age segregation and personal free-
dom, but this study does not answer that question.)

Although many older people are believed to be dissatis-
fied with their housing arrangements, the results of this
study reveal a relatively high sustained level of satisfac-
tion, both among those living in retirement housing and
those in more conventional community housing, with from
55 to 70 percent of all respondents saying they liked their
setting “a lot,” when they moved in,1 at the time of the

IThis retrospective item was asked only of site residents.

33
first interview, and 2 years later. The only major excep-
tions were residents of the retirement hotel.

Attitudinally, both the retirement housing dwellers and
the controls shared the belief that retired persons should
not live in the same household as their children (96% en-
dorsed this statement), but of course they differed in their
recommendations regarding special retirement housing.
Differences were also found among the retirement sites,
with over 90 percent at the life-care home recommend-
ing retirement housing, two-thirds at the hotel and pur-
chase village recommending it, and the other three sites
ranking in between.

Did the retirement housing residents find the supportive
health and social services adequate where they lived? In
general, environmental provisions and personal needs did
appear to be well matched, but at one of the six sites bet-
ter than half (561%) of the residents expressed insecurity
regarding medical provisions and support in crises, and a
large proportion (69%) expressed a desire for counseling
services. In answer to an important question regarding
the effects of service provision on independence, the study
revealed “no evidence of an erosion of independence at
the sites where services are provided.”

Although the retirement housing residents were gener-
ally quite positive about their housing arrangements,
many factors affecting the level of satisfaction emerged
from this study. For example, residents of urban sites
were generally more satisfied with their location than res-
idents of suburban or desert sites, a finding which was
even true of younger residents who could still drive. As
summarized by Dr. Sherman, “Contrary to advertised
claims, it appeared that climate per se may not be so sa-
lient in middle and old age; the proximity of the location
to medical services, shopping, church, entertainment, etc.,
may be much more relevant.”

Two additional factors were associated with dissatisfac-
tion among a few residents of the desert village. First,
there was a large amount of responsibility associated with
the independent living arrangement they had selected,
and second, a few felt dissatisfaction with the isolation
from age groups other than their own. (Urban dwellers in
an age-segregated building can more readily mix with
other groups if and when they wish.)

An issue of concern to policymakers, the provision of
rental vs. purchase housing, seemed to be resolved in this
study in favor of rental arrangements. Residents of the
three rental sites overwhelmingly (98%) recommended
that financial arrangement, while those in nonrental ar-
rangements were somewhat less enthusiastic; their own

34
financial arrangement appealed to 81 percent of residents
in purchase housing, 66 percent in cooperative housing
and 66 percent of those in life-care sites.

When residents of retirement housing expressed their
dissatisfaction by moving out, they cited the following
lacks: security and care, appealing food, physically attrac-
tive site or dwelling, convenience, transportation, enter-
tainment, favorable management, and congenial fellow
residents.

Social Contact Patterns

Although this study does not permit us to compare the
social contact patterns of older persons before and after
they move into retirement housing, it does provide some
interesting data on the differences in socialization pat-
terns and lifestyles between retirement housing dwellers
and similar older people who did not choose this living
arrangement. Despite some differences among the six sites
studied, in general the retirement housing dwellers inter-
acted less than the controls with their children, grandchil-
dren, and other relatives, and fewer had friends younger
than 40. However, compared to the controls, the retirement
housing dwellers had more new friends and visited more
with neighbors (in each other’s dwelling unit) and with
age-peer friends. It appeared as if these differing social
patterns were self-selected and satisfactory, since most of
the respondents, wherever they lived, reported that their
contact with various types of others, both friends and
family, was sufficient. As in the study reported by Dr.
Berghorn (see p. 21ff.), this study underscored the relative
independence of these elderly people and the importance of
distinguishing between contact with other people, mutual
assistance, and dependence on others.

Dr. Sherman’s study revealed no one-to-one correspond-
ence between contact and mutual assistance, with respect
either to children or to neighbors. “Retirement housing
residents generally did not suffer from a relative lack of
assistance from children, nor benefit overall from greater
assistance from neighbors.”

Retirement housing residents received help from their
children at about the same rate as the control group;
about one-third of those with children were helped “very
often,” and another received help “fairly often.” The con-
trols more frequently gave help to their children than the
retirement housing dwellers, possibly because the former
were more likely to be living in the same city or county as
their children.

35
One particularly interesting finding from this study con-
cerns the differences among the subjects studied in inter-
action patterns with friends and relatives. It had been
expected that those with children would be primarily
mutually interdependent with them and only secondarily
interdependent with neighbors; conversely, those without
children would be expected to be particularly mutually
interdependent with neighbors. (This pattern emerges in
Dr. Berghorn’s study, see p. 21ff.) However, a different pat-
tern was found: Subjects were either highly interdepen-
dent with both children and neighbors, or very indepen-
dent of neighbors, despite the absence of children.
Findings such as these raise some future research ques-
tions concerning how these patterns change as the more
independent elderly age and lose some of their self-suffi-
ciency. Unfortunately, this study did not extend over a
time sufficiently long to tell us how the childless and inde-
pendent, particularly, fare in the face of declining capabili-
ties.

Activity Patterns

Among the reasons offered by many older persons for
moving to retirement housing is the opportunity for
many leisure activities. And in some of the housing sites
observed in this study, an extensive array of facilities and
activities was offered to attract seekers of physically and
socially active retirement life. How do these services affect
the lifestyles of those who choose these settings vs. those
who remain in conventional housing?

First, it is important to note that there were appreciable
differences among the six retirement sites. Residents of
two, and in some instances four, of the retirement settings
reported more participation in leisure activities than that
of their matched controls. However, perhaps the more
important trend was that seen in the 2-year period be-
tween the initial interview and the followup. Overall, the
control subjects showed a decreased average activity level,
while, for the retirement housing residents, the activity
level increased. Did an increase in activity also reflect an
increase in morale? Apparently so. According to Dr. Sher-
man, “There was a moderately positive relationship be-
tween activity score and several measures of outlook on
life.”

The differences over time in overall activity levels be-
tween retirement housing residents and their matched
controls at the second interview were particularly striking
for residents of the apartment tower, purchase village,
and life-care home. To Dr. Sherman, these differences
stem from several factors: the kinds of recreational activi-

36
ties offered in these retirement settings, the residents’
backgrounds, and “susceptibility” to environmental influ-
ences. For example, residents of the rental village may
not have been able to take advantage of the recreational
activities offered because they could not overcome a
“threshold of inexperience and lack of interest even with
extensive recreation programs.” On the other hand, resi-
dents of the manor village, relatively young, healthy, and
financially comfortable, probably were not more active
than they would have been in a more conventional setting
where they would seek a high level of activity. However,
residents comparable to those living in manor village but
older—namely those in the life-care home—did seem to
benefit from their environment, suggesting to Dr. Sher-
man that age may be critical and that “retirement hous-
ing may not begin to exert its effect for people in this so-
cioeconomic group until residents reach a more advanced
age.”

Thus, it appears that the impact of retirement housing
on activity (and perhaps on life satisfaction) may be
bounded by certain endpoints or thresholds at both ends
of the age and socioeconomic spectrum, and that it may
benefit some, but not all, in particularly striking ways. For
certain segments of the older population, retirement hous-
ing contributes toward maintaining a relatively high ac-
tivity level (at least compared to the decline found among
controls during a 2-year period) and helps general social
life to grow, rather than decline.

As summarized by Dr. Sherman:

[It would seem that]. . . retirement housing can make, and has been
shown to make, a difference in the generation of activities, organiza-
tions, and social life for residents. The fact that the level of activi-
ties, in turn, seems to influence only moderately the retirees’ out-
look on life indicates that the activities contribute only a small por-
tion of the variance. It has been reported previously that residents
have multiple reasons for choosing retirement housing. Those who
wish to participate in activities do so and are satisfied. Those who do
not wish to participate do not and seem not to be very different in
outlook. One can conclude that, because of different styles of aging,
retirement sites may, and should, be providing desirable housing for
some persons who are not greatly interested in pursuing a high lev-
el of leisure activities, but that for those who do wish to participate,
retirement housing can offer the opportunity, facilities, program-

ming, and particularly the interactional climate making possible a
high level of participation in leisure activities.

. . . With regard to retirement housing, it would appear that there
is no one “right kind.” The critical issue is that since some advan-
tages have been demonstrated for some people, retirement housing
should be made available to those who might choose it. The best
recommendation one can give to the individual considering retire-
ment housing is that he be aware of the range of housing alterna-
tives (some of which have been sampled in the present study) and
the various dimensions on which a site can be rated, and that he

37
match these to his own needs and abilities. It appears that future
planners and residents of housing facilities for the elderly can gain
awareness and insight into these alternatives and dimensions from
interviews, such as those reported here, with persons who are at the
present time living in retirement housing. (1974, pp. 333-334)

Close-Up: The Hotel Loners

Although many types of group housing arrangements
for the elderly are being carefully designed, built, and
studied, relatively little attention has been given to un-
planned housing arrangements that have emerged sponta-
neously, such as rooming houses and single-room occupan-
cy hotels (SROs).2 Indeed, these housing options are often
eradicated in the wake of urban renewal efforts with little
consideration for the lifestyles and special populations of
elderly people they serve. Frequently, by the time the bull-
dozers and builders have left, we have airy tree-filled pla-
zas and handsome high-rises, but not a place the marginal
urban elderly can afford.

In San Diego, a team of social scientists headed by an-
thropologist Dr. Paul Bohannan have tried to understand
the role of inner-city single-room occupancy hotels for a
variety of older residents in a 15-block inner-city area
known as the Horton Plaza Redevelopment Area (and slat-
ed for urban renewal). Their study, designed to span the
period before, during, and after the renewal project, pro-
vides an intimate glimpse at a style of life on the edge of
extinction. Although the living pattern may not fulfill
many middle-class phantasies of the good life in later
years, this anthropological study makes a strong case for
preserving an offbeat environment that suits the needs of
a special group of older persons. The fate of this particu-
lar downtown complex of hotels seems to be sealed; how-
ever, the study poses the challenge of trying, in other set-
tings, to preserve, or recreate, the particular characteris-
tics of this environment that make it, despite its visible
disadvantages, a haven for the city’s low-income marginal
elderly.

The bright sun of San Diego shines kindly even on this
seamy city center, making its faded buildings and neigh-
borhood types look somewhat less battered than their
East Coast counterparts. But the drug addicts, prosti-
tutes, alcoholics, and petty and not-so-petty criminals are
all there, drawn by cheap rents, anonymity, and few con-
ventional social demands. Although transients abound,
there is also an “unseen community” of more stable long-
term residents, many of whom live in the single rooms of

2Although a single-room occupancy hotel was one of the housing op-
tions examined in the previous study, it was, unlike many, specifically
geared to the elderly.

38
decaying hotels in the area. Many are old, having aged in
place there, or perhaps coming to adopt the hotel life
when, late in life, their money ran low and social supports
ran out. It is sometimes hard to tell who is actually chron-
ologically old and who simply looks old due to ill health
and hard times. Many of these people—old or not so old—
are still functioning, albeit in a limited way and world,
always on the edge of serious illness and incapacity.

Neighborhoods such as these present a challenge to
service personnel, who recognize their high density of
people with multiple problems. However, servers other
than the Salvation Army and similar “rescue” groups are
often reluctant to enter these areas on more than a spo-
radic basis and usually prefer to lure residents to their
own service centers, often dispersed around the city. Not
surprisingly, many of the local residents who are highly
independent individuals, mistrustful of middle-class do-
gooders and their values, do not use the formal helping
system unless they are in dire need. Instead, they rely
upon an informal support system which works relatively
well as long as they do not make undue demands upon one
another.

Within the microcosm of hotel dwellers in this San Diego
neighborhood are three somewhat different groups: mid-
dle-class residents (often retired spinster schoolteachers)
who live in “good” hotels at the fringes of the area; the
largely transient types who flop at skid-row hotels; and a
stable clientele of nonwelfare poor (subsisting on fixed in-
comes between $2,000 and $2,500 per year) who occupy the
area’s working-class hotels. Dr. Bohannan’s study has
encompassed all three groups in 12 hotels in the area. But
the focal point has been the stable working-class clientele
of the Golden West Hotel, a giant concrete structure built
in 1913 by Frank Lloyd Wright's son. Here, when the
study began in the mid-1970s, some 400 people, predomi-
nantly men in their late Sixties, lived in its single rooms
and efficiency apartments, managing to eke out a strange-
ly contented life within the narrow confines of their in-
come and personal resources. Let us look at some of the
characteristics of the hotel dwellers at large and then at
the special world within the Golden West Hotel.

Although many of these individuals were self-described
“loners,” the research project staff managed, through a
combination of participant observation (taking up resi-
dence in some of the hotels) and sensitive interviewing, to
develop a detailed portrait of the lifestyles of these hotel
residents and the informal social network that sustains
them. Three successive waves of interviews3 were con-

3Data from the third were not available at the time of this report.

39
ducted with samples of residents in the 12 hotels in the
area, representing all three types of hotel and their clien-
tele.

The first panel of interviews, conducted in 1975, with 82
randomly selected downtown hotel residents (average age
69) revealed them to be generally independent and self-
reliant, although over half reported chronic illnesses or
disabilities. These older people, most of whom lived alone,
gained considerable support from those around them, par-
ticularly the hotel employees. Not surprisingly, residents
of the “middle-class” hotels were more “sociallv connect-
ed” than those in the skid-row or working-class hotels.

The second, more detailed round of interviews, conduct-
ed about a year later in 1976 with 100 residents (including
as many as possible from the first interview), incorporated
many health-related questions, including the Cornell Med-
ical Index (CMI), often used to identify physical and men-
tal health problems. This survey, which canvassed a group
of hotel residents who averaged 67 years of age, over 90
percent of whom live alone, again showed them to be fre-
quently ill, but highly self-reliant regarding their medical
needs and care. The majority of respondents (62%)
checked over 25 positive responses to the CMI, suggesting
the frequent presence of serious medical disorders. The
CMI also revealed a high rate of mental illness: Fifty-four
percent suffered from some emotional disturbances; for 98
percent of these, physical disturbances were present as
well.

Despite their many physical and emotional problems,
these hotel residents were moderate consumers of medical
care—usually delivered by private physicians (39%), hospi-
tal outpatient departments (23%), VA hospitals (15%), and
emergency wards (12%). Middle-class tenants were more
likely than the others to use private physicians and, in
one hotel, were required to have an established relation-
ship with a private physician. These hotel dwellers also
differed from the others in being healthier—both emotion-
ally and physically. Responses indicating emotional dis-
turbances were found among 63 percent of the working-
class and skid-row respondents, compared with 28 percent
of the middle-class respondents. Half the respondents said
they would talk to “no one” about an illness before seek-
ing professional medical care; 21 percent said they would
consult a relative; 16 percent would seek help from a
friend either inside or outside the hotel, and 8 percent
said they would discuss the matter with the hotel mana-
ger or desk clerk.

Although almost all of the respondents were living
alone, 81 percent had once been married. Over one-third

40
were below retirement age, but only 8 percent were em-
ployed in full-time jobs. The large majority of respondents
(91%) had job histories in manual (skilled or unskilled) or
clerical occupations, and their average educational level
was 9.5 years. Overall, the respondents’ income averaged
$316.41 per month, or slightly under $3,800 per year. The
younger men (ages 50 to 64) appeared to be in worse shape
physically, emotionally, and financially than those in the
older age categories.

The statistics gained through these interviews suggest a
population which is, by most standard criteria of need or
debility, highly needy and at risk. Indeed, Dr. Bohannan
has observed that:

SRO residents are populations of psychically and physically handi-
capped—not to say “maimed”—people. Their difficulties may have
arisen from industrial accidents, birth defects, traumatic child-
hoods, faulty education, alcoholism, many other sources. Many are
old—but that is just one more disadvantage. ...

However, this study has revealed that, despite their prob-
lems, these people have found a context in which they
“can make it.” That is, as Dr. Bohannan puts it:
They have in common only that they need an environment that does
not make too many demands. In the SROs they have found that
environment—and they are willing to put up with the difficulties of
the rundown neighborhoods that constitute that environment be-
cause they find that easier and more rewarding than putting up

with the difficulties imposed by “better”—but more demanding—
environments.

People who are poor and old but who do not fit this description live
in retirement hotels, in subsidized housing, in church or lodge-affil-
iated institutions, with families. The SROs are a very special insti-
tution and they are inhabited by people who tend to call themselves
“loners.”

Let us look more closely at the SRO life as it was set in
the Golden West Hotel. A detailed portrait of the lifestyle
of the Golden West Hotel occupants was obtained by re-
searchers who spent many months as fellow residents.
Some residents kept logs which provide additional docu-
mentation of their patterns of life. The picture that
emerges gives us many clues to the nature of a strange
but viable lifestyle which has been chosen, in part, be-
cause of what it does not provide or demand.

The Golden West residents are by most standards poor,
living on a fixed income from Social Security, disability
insurance, and retirement insurance. The “nonwelfare
poor” have enough to secure minimal food, shelter, and
clothing, but little else. Why did they come to the Golden
West, and how is life under conditions of minimal subsist-
ence? How do they organize their daily lives and structure
their “group quarters” to find some measure of well-
being?

41
Dr. Bohannan and his associates have found that many
of these hotel dwellers, although once engaged in intimate
social relationships, were hurt in one way or another, and
fled to the special world of SRO hotels. There, they have
created new lives—and even new myths about their for-
mer lives which, although often contradictory under close
questioning, seem to be accepted within this new setting.
This accepted version of their own lives, which might in
other contexts be interpreted as delusional by an outsid-
er, seems to work well for the residents. As Dr. Bohannan
observes:

This fact brings up a delicate question: When does the privately
accepted, publically projected version of one’s own life become delu-
sional? Since most of these people are coping well enough in their
environment, if there are “delusions,” they are not counter-adaptive.

Social interaction patterns among these residents also
raise some challenging questions for those concerned with
defining and identifying mental health and illness. These
self-labeled “loners” have created a tacit code of behavior
which permits superficial cordiality and mutual helping,
but precludes intimacy or responsibility. They are superfi-
cially quite cordial and cooperative with one another, lend-
ing money, and coming to the aid of sick fellow residents—
at least for a short while. At the same time, they keep so-
cial relationships to a minimum, for example, rarely going
out together to eat, even if several are going to the same
restaurant. Whatever “close” relationships exist are based
on sports, gambling, or drinking. Many of the residents
have living relatives, but they actively resist any contact
with them. For example, one resident found it annoying
that his son came to visit during a televised football
game—*‘‘the kid” should have known his father preferred to
watch the game. As for siblings, many residents say they
do not know (and some say they do not care) whether they
are alive or dead. Despite—or perhaps because of—this al-
ienation, some of these residents, like some prisoners, de-
scribe their present social relationships in family terms. For
one man, the woman at the local lunch counter was his
“mother,” the manager his “father,” and the others were
his siblings and cousins.

The social “glue” of SRO hotels is provided by the hotel
staff, who serve as a source of security and discreetly pro-
tect residents’ privacy by selectively filtering their con-
tacts with the outside world. One questionnaire distributed
to a random sample of older residents revealed that most
would ask the desk clerk for help with almost anything,
whether it was part of his job or not, before they would ask
friends and certainly more readily than they would ask po-
lice or anyone else. None considered asking a social worker
(and few saw one). Yet, despite their dependence on staff,

42
most said they would do it themselves or leave it undone
rather than even asking the clerk.

As Dr. Bohannan interprets these social interaction pat-
terns, “it is not social relationships that they avoid—it is
intimacy and responsibility.” That does not, of course,
mean that they are irresponsible. Rather, they have found
a lifestyle in which responsibility plays no part.

Much of the life of SRO residents revolves around food.
Since it is prohibited in the rooms (although some nonethe-
less bring it in), tenants frequent a variety of cheap restau-
rants in the area, apparently enjoying one of the few fac-
ets of life in which many options are available. For about
$4 a day, the residents can eat relatively well, and many do
(although one man existed almost entirely on eggs, vanilla
ice cream, and beer). In the opinion of the researchers,
whatever undernourishment exists stems from careless-
ness, miserliness, or ignorance, not lack of funds. Since
there is a complex money-lending system among the resi-
dents, few go hungry for want of money. In addition, mis-
sions and church groups in the area provide inexpensive
“Iron rations” which residents sometimes sample. (Surpris-
ingly, the residents of working-class hotels were generally
found to eat better than those in the middle-class hotels,
and spent less for food, since their local restaurants were
cheaper than the fancier chains surrounding the middle-
class hotels. The middle-class residents, bound by social
pressure, would not cross Broadway, the great psychologi-
cal divide, to find less expensive nourishment. Typically,
one would say “I have spent my entire life trying to get out
of a place like that.”)

By most standards of environmental quality, the Golden
West Hotel and its kind might rate very low, yet they pro-
vide a special environment for special people, and the match
appears, to close observers, to be a successful one. To be
sure, the researchers who have lived with these people
have found an undertone of rage, sometimes masked as
depression, accompanying their social relationships. Dr.
Bohannan describes them as “populations of the psychical-
ly or physically handicapped . . . people to whom life has
been unduly harsh.” Yet within the hotel world they have
found a place “where they can cope, at least minimally, or,
failing that, where somehow or other they will be cared
for.” He continues:

SROs are important precisely because they provide an environment
in which such residents can cope. If these people sound as if they
are living troubled, but more or less normal lives, it is because in
this context they can do so. We do not know the proportion of people
who might be added to the SRO lists, but think that probably it is
one of the best institutions yet discovered for dealing with certain
kinds of old people. They do need helping—but that does not mean

43

274-912 O = 78 = 4
moving them back into the very kind of culture and society from
which they have spent their lives trying to escape.

Dr. Bohannan believes that a significant proportion of
the almost 4 million Americans living in group quarters
are, like the Golden West Hotel residents, “marginally
subsistent individuals.” Yet strangely, they have received
little notice:

These marginally subsistent individuals have not received adequate
attention, either from research or government programs designed to
alleviate health problems associated with poverty. Perhaps this is
because they are self-reliant. Most antipoverty efforts have under-
standably focused upon those already dependent on public services,
the most destitute, with emphasis on programs that aid families

. The marginally subsistent individuals tend to be older, isolated
from family ties, and are not usually politically active. The majority
are not members of minority groups. They lead a precarious exist-
ence; they are a population at risk, subject to minor dislocations and
disruptions in their lives; their health and their economic conditions
being affected by relatively minor changes in the urban environment,
or other external factors beyond their control (such as public trans-
portation, crime, inflation).

The San Diego neighborhood that supports the lifestyle of
these marginal individuals is already undergoing consider-
able change, with younger populations moving in, and
major urban renewal projects slated to begin. The Golden
West Hotel will be renovated, and many of the restau-
rants forming the life-support system and providing free-
dom of choice for the residents will disappear. Undoubted-
ly, the current residents will have to “move on.” Dr. Bo-
hannan’s team will continue to document the life of the
area as it is transformed and will try to follow the former
residents as they undergo the upheaval of relocation, an
experience bound to be traumatic for many, possibly a
source of decreased mental and physical health. Although
this project is not devoted to intervening in the lives of
these individuals, its data may help to sensitize future
policymakers to the very special social life demolished
when bulldozers blaze a trail to “renewed” cities.

The challenges posed by this segment of our elderly
community are great. How can we create new environ-
ments or renovate the old to preserve and enhance their
supportive strength, without eroding that crucial sense of
independence, self-sufficiency, and freedom of choice?

The most prized personality quality that these people find in them-
selves and others is independence—mot the autonomy of the psy-

choanalysts, but the independence of the loners. It is an old-fash-
ioned American virtue in their eyes.

It is ironic that such adjustments can, as our present society is con-
stituted, be made only in the run-down hotels in the rotting middle
of American cities—those districts that the SROs must share with
blue movies, porn shops, hock shops, cheap restaurants, massage
parlors, and saloons. . . .

44
To Dr. Bohannan and his associates, the next research
challenge is to find out “how we can make these people a
little more comfortable without disturbing the illusions
they have about making it on their own.” The question
still unanswered is:

. . . How many more senior Americans might find SROs [to be the
right environment], modified a little, perhaps, but with choices left—
choices about where they live and whom they talk to and what and
where they eat—so that one can still have the dignity of making
one’s own decisions, and, no matter how poverty-stricken, of paying
one’s way out of pensions or social security?

Generations Apart or Together?

Many people view having children as a hedge against
loneliness in old age. And indeed, despite the often be-
moaned demise of the close extended family, there is am-
ple research evidence suggesting that families, although
living apart, keep in contact sufficiently close to keep
many older people from feeling lonely and isolated. A 1968
study by Dr. Shanas revealed that 84 percent of elderly
persons in three industrial societies lived within 1 hour of
at least one child, and 90 percent had seen at least one
child within the previous week. Similarly high rates of
contact, although sometimes somewhat lower, have been
obtained by other researchers as well. Although there are
some older people who seem to be devoid of caring family
members, and some who do not even have the essential
backup of friends and neighbors, these are very much in
the minority. (Their minority status, however, does not
justify ignoring their plight—indeed, these isolates are
becoming the focus of intensive effort by helping agencies,
as we will see in later sections of this book.)

Today’s elderly seem to have made a pact with their
children that for the most part satisfies both: We will live
apart, because we have different lives and needs and in-
terests, and require different settings for our lifestyles.
But we will not live too far apart and will stay in touch,
available for mutual help. If and when an older person
cannot manage independently, the decision will be made
ad hoc by family members as to whether they should then
live together. Of course, there are variations on this
theme, ranging from the extended family that has always
cohabited, to the alienated parents and children who have
no contact, whether by mutual consent or because one or
the other chooses to distance himself. (As we have seen
from Dr. Bohannan’s study, older parents, like their chil-
dren, can, and sometimes do make themselves inaccessi-
ble.)

Let us concentrate for a moment on the more typical
families—the ones in touch. How and what do they share

45
with their older members? Are the presumed generation
gaps real? How mutual and how satisfying are their feel-
ings and actions toward one another? These are some of
the questions asked—and answered—by Dr. Vern Bengtson,
of the University of Southern California in Los Angeles,
who, with a team of researchers, has conducted a 4-year
study of three-generation families in contact with one
another but not living together. In general, Dr. Bengt-
son’s study has revealed a high degree of emotional close-
ness, mutual aid, and physical proximity among family
members and has dispelled the myth of abyss-like attitudi-
nal rifts among the generations.

In this study, 2,044 subjects, drawn from membership of
a large California health plan, were sampled through
mailed questionnaires and interviews. Included in the
sample were 516 grandparents (average age 67), 701 par-
ents (average age 44), and 837 youths (average age 19.7).
The study explored attitudinal similarities and differences
among family members on a variety of issues, as well as
the family members’ views and expectations of one anoth-
er (both how they felt toward the others, and how they
thought the others regarded them). We will concentrate
here on the relations between the eldest generation and
their middle-aged children, and particularly on the degree
of closeness and mutual helping between them as well as
their respective views of the relationship.

This study provides a good perspective on the mutuality
of feeling, attitudes, and expectations of older people and
their children because both parties have been interviewed.
Researchers interested in aging often rely solely on older
persons or their children as respondents and, as a result,
obtain only a one-sided view of their interactions.

One note on the overall attitudinal and value similari-
ties and differences among the three generations is in
order before we turn specifically to the two generations of
particular interest. While this study has revealed discerni-
ble differences in value orientations across the genera-
tions, they are not global. Rather, they are focused on
particular areas, such as the relative value one or another
generation gives to individuality vs. collectivity. The study
found strong similarities between grandparents and their
grandchildren, often stronger than between parents and
their own children, and uncovered sufficient variations
among members of a single generation to challenge the
meaning of generational differences per se in accounting
for attitudes and behavior. All of the subjects appeared to
be strongly influenced by today’s historical and social con-
text, as well as by familial norms and the particular val-
ues that prevailed while they were growing up. In short,
all family members learn and change as they grow up, and

46
part of the learning process consists of older people’s ac-
commodating themselves to the values and norms of
younger family members, while youngsters are concur-
rently socialized in the ways and values of the oldsters.

Although the values of teenagers may not actually de-
part radically from those of their parents, youngsters are
likely to exaggerate the importance of those areas in
which real differences exist, apparently in a bid to differ-
entiate themselves from their families. A similar, but less
vivid tendency seems to continue into later life.

Let us now see how the older two generations get along.
Dr. Bengtson and his co-workers found that, in general,
the level of affection between older parents and their mid-
dle-aged children runs high. Five aspects of mutual feel-
ings were studied: understanding, trust, fairness, respect,
and affection, as well as the quality of communication,
how well they felt they got along, and their perceptions of
the closeness of their relationship. (Liking and being liked
were major components of the affection between adoles-
cents and their parents, but respect was most important
between the older two generations.) Responses concerning
all five areas of feeling were summed to give an overall
rating of an individual's affection for his parent or child.
On the average, older parents’ affection scores were slight-
ly higher than their children’s (a mean of 50.9 on a scale
of 10-60 for the parents, while their children averaged
48.1). Thus, although there was high mutual positive feel-
ing, the parents had a higher level of emotional invest-
ment. Further, the aged parents and their middle-aged
children had somewhat different views of their mutual
closeness. The children, interestingly, tended to underesti-
mate their parents’ level of feeling toward them. As sum-
marized by Dr. Bengtson:

The [middle-aged] child tends to perceive less personal and recipro-
cal closeness than does his parent. By contrast, the parents appear
to estimate quite well the level of affect of their children [although
there is a slight tendency toward overestimation].

We will return to Dr. Bengtson’s explanation of these dif-
ferences shortly.

How did elderly parents and their children view their
mutual activities and help? Although their perceptions
were generally similar, some interesting discrepancies
were found. According to both, they often shared many
informal activities (e.g., recreation, conversation, talking
about important matters, and helping and being helped)
as well as ceremonial or family ritual activities (e.g., large
and small family gatherings, reunions, and birthdays).
Their descriptions concerning their frequency of contact
were also similar. The two generations appeared to be in

47
contact on the average of at least once a week (if not in
person, then by phone or letter).

Their reports differed, however, when it came to the
matter of mutual help. Children, in describing their help to
their parents, reported a higher level than their parents
gave them credit for; similarly, the children’s reports of
help received from their parents were higher than those
reported by the parents themselves.

Dr. Bengtson believes that this somewhat puzzling dis-
crepancy, as well as the earlier-cited differences in percep-
tions of mutual feelings can be explained by two hypothe-
ses. The tendency of older persons to report higher levels
of mutual affect than their children falls within a more
general pattern of intergenerational behavior described
by the “developmental stake hypothesis,” articulated by Dr.
Bengtson in collaboration with Dr. Kuypers in 1971. This
hypothesis is based on the observation that parents tend
to minimize the distance between generations and to
emphasize similarity, while the young tend to maximize
differences. It thus suggests that:

Parents and youth have a different “stake” or investment in the
relationship, determined by the extent to which the parent-child
relationship is viewed as a means to the attainment of personal
goals. The parents [are] concerned with the creation of social heirs
and thus are heavily invested in the socializing relationship with
the child. The young, in contrast, are more strongly invested in de-
veloping their special identities outside the family, establishing per-
sonal life styles, and forming their attitudes toward the major is-
sues and institutions. The greater the investment or “stake” on the
part of the parent in the intergenerational relationship would lead
him to emphasize similarities and closeness, while the child would
not.

Although this hypothesis was originally intended to ex-
plain the relationship between middle-aged parents and
their adolescent children, Dr. Bengtson believes that his
study supports the existence of a similar dynamic between
older parents and their children as well—at least regard-
ing subjective aspects of their relationship. However, to
explain the discrepancies regarding giving and receiving
help—a more objective phenomenon—Dr. Bengtson sug-
gests that older parents and their children may have
somewhat different criteria of high and low levels of help,
with the elderly parents perhaps having higher aspira-
tions. Thus, the older respondents would tend to report
their own giving and receiving of help lower than their
children.

Beyond the issues of affection and shared activities
among family members lies the question of their attitudi-
nal similarities and differences. How close or far apart are
retirees from their middle-aged offspring in values and po-
litical and religious beliefs? This study revealed marked

48
similarities in the latter two spheres but great differences
in the general value dimensions of humanism vs. material-
ism, and individuality vs. collectivity. Interestingly, when
asked if they see themselves as similar in these regards,
although both generally replied affirmatively, the aged
parents reported higher levels of similarity than their
children—yet another source of support for the “develop-
mental stake” hypothesis.

Dr. Bengtson’s study suggests that, at least among the
families studied, whatever value differences separate old-
er persons and their children, they do not preclude a rela-
tively high degree of contact and affection. Further, al-
though parents and children interpret their relationship
somewhat differently (with older people perhaps valuing it
more highly), it is a source of gratification for both.

After the Gold Watch, What? Keys to
Successful Retirement

To many investigators, life satisfaction is a variable
that changes over the course of time as an individual
faces and masters (or does not master) the inevitable cri-
ses of living. Each stage of life brings its own challenges,
and how an individual will respond depends both on the
external environment and the person’s own flexibility and
coping skills. One of the predictable crises of the later
years is retirement. For some, it comes as a blessed relief,
while for others, it represents unfair rejection, a cruel
denial of a meaningful role, and a much-wanted or needed
income. The transition from worker to retiree can go
smoothly and happily, or it can precipitate disastrous
physical and mental decline. At the very least, voluntary
or not, it confronts former workers—and their spouses—
with many changes in lifestyle, status, and income. Ap-
proximately 13 million older Americans will have retired
within the decade of the 1970s. Can we learn anything
from their experience that can ease the process for others
in the future?

To Dr. Robert Atchley, of Miami University, Oxford,
Ohio, what determines the course of adjustment to retire-
ment is not simply its voluntary or involuntary initiation.
While these factors are important, much depends on the
individual’s own ability to respond flexibly to a new set of
challenges. In Dr. Atchley’s view, the full transition proc-
ess spans many years before and after the symbolic
watch is presented, and it encompasses a number of dis-
crete stages. How well a given individual will master these
stages will depend on many factors, both psychological
and environmental. Based upon the research literature

49
and his own previous studies of retirement and aging, Dr.
Atchley has developed a model of the retirement process
which he is currently testing and refining to predict how
well older individuals will adjust to retirement. To test his
hypotheses, he is conducting a 6-year study of the older
residents (over 50 years of age) of Oxford Township, Ohio.
As many as possible of this rural area’s 3,000 residents
are interviewed every 2 years to identify changes in their
morale, self-esteem, anxiety, social participation, loneli-
ness, leisure preference, self-care capacity, activities of
daily living, and mental status, as well as their health,
income trends, disabilities, attitudes toward retirement,
and aging symptoms. Out of these respondents, some are
chosen for more intensive study. Some of those who have
already been through life stages which others have yet to
undergo (such as retirement, widowhood, physical decline,
and/or income decline) are interviewed to establish crite-
ria for these stages. The study’s target group, however,
consists of those younger members of the population who,
at the time of initial screening, have not yet retired or
undergone these problems.

Dr. Atchley’s study plan is to interview these newcomers
to the world of the aged; to identify critical aspects of their
personalities and retirement plans; to predict, on the basis
of these data and his model, how they will fare as retirees;
and then to follow his subjects over the next 6 years,
through bimonthly phone calls, as they progress through
retirement.

A study such as this takes many years for data collec-
tion and analysis. As of this writing, we cannot say wheth-
er Dr. Atchley’s model of retirement adjustment has been
borne out. However, we will present some of its major fea-
tures because it provides a rich and interesting view of
many of the factors likely to be involved.

To Dr. Atchley, the retirement process has seven phases
he has named “remote,” “near,” “honeymoon,” “disen-
chantment,” “reorientation,” “stability,” and “termina-
tion.” He characterizes them as follows:

1. Remote Phase: From the time people begin to work to
the time they approach retirement, they have a vague but
positive notion about eventually retiring. However, as Dr.
Atchley notes:

Information-gathering concerning retirement tends to be unsystem-
atic and only rarely intentional. The exceptions to this are those
whose employers expose them to some sort of formal program dur-
ing the remote phase. Such programs are very rare. Thus, anticipa-
tory socialization for retirement in the remote phase tends to be
informal and unsystematic . . . . Most people require a supplement
to whatever retirement pensions they receive in order to sustain
their desired life style. But in order to provide for this supplement,

50
the individual must be aware of the need during the remote phase
of pre-retirement. Developing leisure skills is another prerequisite
for the retirement role. These skills can sometimes be learned in
later phases of retirement, but the literature on learning suggests
that developing a wide variety of leisure skills is easier to accom-
plish during the early years of the remote phase of pre-retirement.
The same can be said of developing ties with organizations in the
community . . . . As haphazard as the socialization for retirement is
during the remote phase of pre-retirement, people in general are not
totally unprepared for retirement, they are merely inadequately
prepared.

2. Near Phase: When retirement actually is imminent,
the individual recognizes its impending reality, and atti-
tudes toward retirement become more negative (although
some remain positively oriented). In this phase, preretire-
ment programs are often offered, frequently stressing
financial planning and use of leisure time. (In Dr. Atch-
ley’s view, although such programs are reassuring and
allay anxiety, they offer little help for those whose prior
financial planning was inadequate.) Psychological adjust-
ments during the near phase of retirement are aided by
symbolic shifts in work roles, e.g., the presence of train-
ees, etc. The person approaching retirement is likely to
fantasize life as a retiree; depending on how realistic or
romanticized the fantasy is, it can serve as a useful “dry
run” for the future, or it may serve as a subsequent
source of disillusionment.

3. The Honeymoon Phase: Once free of his or her job,
the new retiree is usually euphoric, indulging in new-
found freedom and trying to “do all the things I never had
time for before.” For the relatively rich and healthy, it
can be a hectic time of travel, leisure sport, socialization,
all rolled into one; for those with more limited personal
and financial resources, the honeymoon phase is likely to
be a more low-key, low-budget production. How long this
phase lasts depends on the individual and his or her re-
sources, but sooner or later the pace slackens, and life
becomes more routine.

4. The Disenchantment Phase: Although some people
settle easily into a realistic routine that is satisfying, ac-
cording to Dr. Atchley, “many people experience a period
of let-down, disenchantment, or even depression ....”
People with few alternatives, those who have little money
or poor health, those who were overinvolved in their jobs,
those who are unaccustomed to running their own lives,
those who experience other role losses in addition to re-
tirement, those who leave communities where they have
lived for many years—these are the people who are apt to
experience deep and lengthy periods of depression follow-
ing the honeymoon period.

51
What it boils down to is that the failure of the fantasy represents
the collapse of a structure of choices, and what is depressing is that
the individual must start over again to restructure life in the retire-
ment role. So traveling turned out to be a drag when done constant-
ly, now what? This is the kind of question people face in the disen-
chantment phase.

In Dr. Atchley’s view, most people work their way through
this phase, but some remain.

5. Reorientation Phase: Pulling out of disenchantment
involves developing more realistic alternatives and explor-
ing new, often social avenues of involvement—perhaps
participation in group activities, sometimes in group-
sponsored programs, but usually through the help of fami-
ly and friends. The goal of this period is:

. . a set of realistic choices which can be used to establish a struc-
ture and a routine for life in retirement which will provide a mini-
mum of satisfaction. People playing the retirement role do not aim

for ecstatic bliss. They are quite willing to settle for an existence
that is satisfying at least some of the time.

6. The Stability Phase: Although not all pass through
the reorientation phase to the next, stability phase, most
do; that is, they routinize their criteria for dealing with
change, permitting them to lead predictable, satisfying
lives. As Dr. Atchley puts it:

It is the ultimate phase in terms of role playing. . . the individual
has mastered the job. He knows what is expected of him, he knows
what he has to work with—what his capabilities and limitations are.
He is a self-sufficient adult, going his own way, managing his own
affairs, bothering no one. Being retired is for him a serious responsi-
bility, seriously carried out. Adding to the challenges of this period
are often physical declines and losses of other roles, which for some
call for additional reorientation and stabilization.

7. Termination Phase: The retirement role typically
ends in one of four ways—through relatively sudden
death; through illness and disability which bring the sick
and disabled role; through loss of income and the assump-
tion of a dependent role; or through taking on a full-time
job.

The retirement process, according to Dr. Atchley, re-
quires a considerable degree of internal compromise and
“interpersonal negotiations.” A person needs to be flexible
to handle the process well and is more likely to be success-
ful if retirement does not demand an excessive reshuffling
of his or her hierarchy of personal goals. “The crucial
question . .. is whether retirement is a consequential
change . . . important enough to necessitate a reorganiza-
tion in the upper reaches of the individual’s hierarchy of
personal goals.” For some, retirement requires few such
internal shifts. People who strive mainly to develop per-
sonal qualities are particularly likely to find themselves

52
unfazed by retirement, as are people for whom roles other
than the job are more paramount. The same may be true
for people who have given the job a top priority but who
have also achieved their career ambitions.

For many people, however, retirement does involve some
amount of reorganization in their hierarchy of personal
goals. If the job is very high on the list of personal goals
and yet unachieved, the individual can be expected to try
to replace it with a substitute job:

[For a person with a] large number of personal goals, both qualita-
tive and materialistic [which] are tied to success on the job. . . re-
tirement takes out not only the job but several other goals as well.
And it leaves very little. In this situation, the individual was in-
volved in the job to the exclusion of everything else, and as a result
must find alternatives to replace the job in his hierarchy of personal
goals.

The extent to which this task can be accomplished depends again on
the individual’s having the necessary energy, skills, personal quali-
ties, and opportunities. Failure to satisfy any of these prerequisites
will necessarily result in withdrawal.

One question for future research concerns the place of
successful retirement in the hierarchy of goals. Another
question concerns the “interpersonal negotiations” be-
tween the retiree and others around him or her, as he or
she attempts to reorganize the hierarchy of goals, despite
the occasional resistance of those who are close.

When the mountains of data collected from this study
are analyzed at the end of the 6-year data-collection peri-
od, it will be possible to see if Dr. Atchley’s predictions
have been borne out. These data should also help us to
understand how a number of situational factors other
than retirement itself affect the process of aging and its
symptoms.

As of this writing, the study is in its second year, at the
beginning of the second wave of data-collection from the
total population. Considerable descriptive data about the
older residents of Oxford Township are available, but Dr.
Atchley’s predictions remain to be confirmed or denied by
the real-life events in his subjects’ lives.

Whatever the outcome of the study from a theoretical
point of view, it is likely to have substantial value as a
descriptive study of the aging process as it occurs among
members of a rather infrequently studied population: the
residents of a small-town rural setting. As can be seen
from other studies reported in this volume, much of the
research on community-dwelling elderly people has used
urban residents as subjects. This study may provide a ba-
sis for some interesting comparisons between the ways
urban and rural people cope with the problems of aging
and leaving the work world. In addition, it may shed some

53
light on the way a number of life events hasten or retard
aging declines. Although this study is not aimed at inter-
vening in the lives of people as they wrestle with problems
such as adjusting to retirement, widowhood, and economic
and physical decline, it should provide considerable data
that can be of value to service personnel and planners in
the future. Because of Dr. Atchley’s concern with the
phasing of these processes, his descriptive typology, if
borne out by his study, may be useful in helping older
people—and those professionally committed to helping
them—to anticipate and understand these processes.

Remarriage: A New Lease on Life?

More than one quarter (27%) of our Nation’s older peo-
ple live alone. While single living is not necessarily synon-
ymous with loneliness, for many older people, especially
the recently widowed, the experience can be an unfamiliar
and disquieting one. Social planners have devised and
advocated many types of congregate living arrangements
for the elderly, in part to overcome some of the isolating
effects of solo living. Others have experimented with social
centers and other organized group activities for the elder-
ly, designed to heighten their social contacts. All the
while, some of the older singles have found their own anti-
dote to loneliness—remarriage. Strangely, this quite natu-
ral solution is one rarely advocated or recommended. In-
deed, many current attitudinal and financial barriers to
remarriage among the elderly have gone unquestioned by
policymakers, and few social scientists have studied the
patterns, advantages, or disadvantages of remarriage in
the later years. Yet, with relatively little official social
support for their decision, increasing numbers of older
people are recoupling. There are now more than 35,000
marriages yearly in which at least one partner is 65 or
older.

To Dr. Barbara Vinick of Boston University, this phenom-
enon is one of intense theoretical and practical signifi-
cance which raises many interesting and socially signifi-
cant questions: How does remarriage among the elderly
come about? Who is likely to choose it? How successfully
do older people adjust to it? How does it affect their well-
being? How satisfying is it to men and women? Under
what circumstances is it most likely to work out well, or
badly? These are but some of the questions asked and
answered—at least in a preliminary way—by Dr. Vinick,
who interviewed 24 couples who had remarried late in life
(on the average at age 67 for the women and 73 for the
men). Her study was part of a larger investigation of “re-
engagement” in later life, under the direction of Dr. Ruth

54
Jacobs of Boston University, which also encompassed a
study of re-employment among those over 65.

Dr. Vinick located her potential subjects through the
marriage records of a large Boston working-class suburb.
At the time they were interviewed, her subjects had been
married for 2 to 6 years.

Judging by the reactions of this small sample of 24 cou-
ples, remarriage for most has proven to be an extremely
positive experience: Seventy-eight percent of the women
and 86 percent of the men saw themselves as satisfied or
very satisfied with the marriage. Only two women and one
man were unsatisfied, but even they could find “at least
some redeeming feature.”

Dr. Vinick found that the women and men entered re-
marriage with somewhat different backgrounds and moti-
vations. The women for the most part had long been ac-
customed to living alone—half had been single for 7 or
more years, as widows or divorcees, and many had accli-
mated to a single lifestyle, bolstered by the companionship
of “the society of widows.” (About half, 52 percent, of older
women are widows, compared with 14 percent of the men;
thus, for women there are many others in the same boat.)
Further, many of these women were close to their chil-
dren and grandchildren, yet a further hedge against lone-
liness. Many of these women had not expected to remarry,
and indeed, with a ratio of one single man to every three
single women at age 65, the odds against remarriage are
great.

The men, for the most part, had entered marriage rath-
er quickly after their spouse had died, often within a year.
They experienced more loneliness prior to their remar-
riage than the women, in part because of the recency of
their loss and also because they had fewer social supports
than the women, whether friends, fellow-widowers, or
close relatives. These lonely men, vastly outnumbered by
single women, hadn’t long to wait in finding an eligible
mate. But how did they meet one? In much the same ways
as younger people: introduction by mutual friends and
relatives, or meeting one another in public places, al-
though for these older people, a Senior Center was often a
better bet than a singles bar.

Here is how one wife told the story of her early court-
ship:

He was sitting near me at the Golden Agers, and I didn’t even know
him. He was looking so depressed. You could see the man needs
something. The trouble is, when I see someone lonely, I want to
know what’s the matter. He was sitting just like a chicken without a
head [sic]. After that, he went his way, I went my way. So [the next
meeting] he was sitting there again. So, my friend said “Let’s sit

down with him. It will warm him up a little.” It was awfully windy.
We sat down, and then we started to talk. You know how it is. . . .

55
For the most part, these remarried couples, even those
in their eighties, were sociable, active, healthy, mobile
older people, although one-third of them did have “chronic
and/or serious physical problems” before marriage, and
one woman was in a wheelchair. They were willing and
able to socialize and were not housebound. (Sadly, some of
the most lonely and isolated elderly cannot, or do not
know how to, break out of their isolation sufficiently to
meet a mate, even if they want one.)

As these couples recalled their courtship, the man of-
ten took the lead and sustained the relationship, while the
woman, not anticipating marriage, found herself surprised
that “it just worked into something.” Not all the court-
ships went smoothly, of course, and often the woman be-
came indecisive at the prospect of a definite commitment.
(Nine women and two men had undergone some indeci-
sion, but finally consented.)

For most, marriage itself proved to be remarkably calm
and comfortable and often revitalizing. A “typical” descrip-
tion of its quality was given by a bride of 2 years:

When I get up in the morning, I get up with a smile and expect to
laugh. We're very happy and enjoy each other’s company.

Or, as another put it:

We're like a couple of kids. We fool around—have fun. We go to
dances and socialize a lot with our families. We enjoy life together.
When you’re with someone, you're happy.

Many of these couples were free to enjoy themselves
without the frequent encumbrances of young marriage:
childrearing, status seeking, or in-law problems. Their
sexual relationship often seemed to make up in warmth
and closeness and tenderness what they may have lacked
in youthful passion. As one 73-year-old “lover” put it:

I don’t know if I'm oversexed, but I'm a lover. I like to pet, Kiss,
hug. I have more fun out of loving somebody I love than the ulti-
mate end. You know, some people—and this is the failure of sex,
too—some people want sex and forget the rest of it—the hugging
and the petting and I think that’s wrong. People say “what will
happen to me when I get older?” Well, I'm still alive. There’s no
thrill like that today. People try dope, they try smoking, they try
drinking. This is the one thing that’s good for the body.

The happily married majority of couples were of two
types: those whose lifestyles required little change to ac-
commodate marriage, and those who were forced to under-
go drastic change, but found compensations in the mar-
riage. In the former group were most of the men and
those women who were what Dr. Jacobs has called “re-
engaged nurturers,” that is, women who had always ac-
cepted traditional sex roles and had seen their roles as
wife, mother, grandmother, housewife, etc., as primary

56
(although they may later have taken paid or volunteer
jobs in which they would also express their nurturing
skills).

Of course, marriage was by no means idyllic for all those
studied. Indeed, one woman described her remarriage as
“having stepped into a dark room.” Often, those with mar-
ital problems had let external circumstances such as fi-
nancial insecurity or housing dissatisfaction “force” them
into marriage.

Most of the subjects had felt less need to rely on friends
and family once they remarried, but they remained in
touch. There had been some peer pressure on some women
not to remarry (perhaps motivated in part by friends’ jeal-
ousy, doubt, and fear of losing intimacy). Children and
younger relatives, however, were largely supportive. (Oth-
er surveys have shown that young people generally ap-
prove of their elders’ remarrying.)

Perhaps optimistic findings such as those of this study
will embolden other older people to try remarriage. How-
ever, as Dr. Vinick has observed, we are still far from the
day when this option is considered practicable and accepta-
ble by many who might want it. First, there are still strong
social pressures and prejudices that make many older peo-
ple feel uncomfortable about the sexuality implicit in mar-
riage; they mistakenly believe that sex is only for the
young and that erotic feelings mark them as “dirty old
men” or “dirty old women.” Others anticipate wrongly
that their children or friends will view them as disloyal to
their deceased spouses (although most, as we have seen,
welcome the prospect of the person’s happy recoupling).
Still others underestimate their own flexibility and as-
sume that they are too set to adjust to life with another
person.

Added to these psychological barriers are some formida-
ble economic ones. A widow 60 or over who remarries must
sacrifice half of her husband’s Social Security benefits,
and some pension plans still forbid a widow to remarry.
For those living on precarious incomes, the financial loss
incurred by remarriage may be too great to risk. Under
these circumstances, some older couples have resorted to
cohabitation, or what they and their peers still regard as
“living in sin.” Although the mores even among the older
generations are rapidly changing, this compromise is still
bound to stir feelings of guilt and discomfort in many who
would probably prefer to marry if it were economically
feasible.

In future years, when our social attitudes and institu-
tions have changed sufficiently to encourage remarriage
as a common option for the elderly, we may see fewer of

57
their members dependent upon the formal helping system.
While marriage is no panacea, for many it provides the
kind of psychological support and caring that sustains and
enhances physical and mental health. When it works well,
as it apparently did for most of the couples in this study,
the rewards are many and great. As one husband put it:
It’s the companionship, love, and affection and the interest and the

attention that you give each other which is truly living a married
life.

The right of older people to enjoy these pleasures is
finally being recognized, although it may take many years
of public education and legislative change to make mar-
riage as acceptable and accessible for the old as for the
young.

58
IV. Community Services:
How Can We Help?

Given the enormous differences among our elderly, some
of which have been hinted at in the preceding studies,
there are few blanket solutions to their many needs. Some
are managing extremely well; some could do far better
with some modest changes in their environment, self-con-
fidence, or social opportunities; some are fragile and floun-
dering but too independent to seek help; and some are
desperately in need of innumerable types of formal sup-
port. From the perspective of community service organiza-
tions, the question is: Is there an adequately broad range
of services available and accessible to the elderly to re-
spond to these many types and levels of need? In this sec-
tion we explore many types of service programs geared to
the community-dwelling elderly. While these by no means
exhaust the range of services needed, they do provide a
number of models, many of which are geared to special
populations of the elderly, ranging from those in good
health and functioning well to those barely able to sustain
themselves outside of an institutional setting. Some of
these focus directly on strengthening the psychological
resources and coping skills of older persons, while others
emphasize improvements in the physical and social envi-
ronment or in the accessibility of services. All of these
have been developed, with the aid of NIMH funding, with
a strong research-evaluative component. Although some
of these projects are too new to have undergone a thor-
ough evaluation, they have usually been designed as an
outgrowth of prior research, and their chances of success
seem high. We will start with a group of psychologically
oriented programs aimed at the relatively well, then dis-
cuss several whose targets are more marginally function-
ing elderly community dwellers. All of these programs can
be viewed, from a mental health perspective, as preven-
tive efforts to preserve older people at their best level of
function, to ward off or minimize mental illness, and to
avert or delay their need for institutional care.

59

274-912 0 = 78 = 5
Before examining these specific programs and approach-
es, many of which might serve as useful models for adop-
tion in a number of communities, a caveat is in order. In
many communities, services for the elderly are provided
by myriad agencies and organizations with little coordina-
tion and planning and even less consultation with prospec-
tive older clients. The result is often unnecessary duplica-
tion of some services, while other needs of older people go
unattended. A sobering study by Dr. Eva Kahana high-
lights the need for careful service planning for many dif-
ferent segments of the elderly community and confronts
us with the potential discrepancies between the ways pro-
fessional service personnel and the elderly themselves
view their service needs.

Service Needs and Service Gaps:
Who Needs What?

As the preceding studies have revealed, the older resi-
dents of a given community differ appreciably among
themselves in their expectations, their living arrange-
ments, their financial and social resources, their health,
their coping abilities, and their subjective sense of fulfill-
ment. As countless studies have documented, there are
many avenues to improving the quality of life for these
older people, but they must be carefully addressed to well-
identified populations and tailored to the specific needs
and wishes of older individuals. In most communities, min-
imal time and effort have been devoted to carefully assess-
ing the match between available services for the elderly
and the needs of those for whom they are intended, and
rarely are older people themselves consulted about their
own perceptions of how their lives and those of their peers
might be improved.

When such studies have been undertaken, the results
have sometimes been quite surprising, as they were in two
Detroit-area communities studied by Dr. Eva Kahana, her
husband and Co-principal Investigator, Dr. Boaz Kahana,
and her associates at Wayne State University and the
University of Michigan, with NIMH funding. A survey of
the service needs and resources of older residents of Ham-
tramck and Oak Park, Michigan, was conducted which
encompassed several types of comparison across and with-
in the two communities. Residents in three types of set-
ting in each community were studied: those in their own
housing, those in subsidized housing for the elderly, and
those in nursing homes. Interviews probed many dimen-
sions of their lives, including their sense of well-being,
their perceived need for services, and their actual use of

60
health services. In addition, because Dr. Kahana is partic-
ularly interested in the role of informal helping networks
(such as friends and relatives) in meeting supportive
needs, the elderly informants were asked about their help-
ing relations with “significant others,” and the degree of
reciprocity that characterized them. These perceptions
were checked against those of the significant others
named by the respondent to see how well they agreed.

Unlike many studies of this sort, which only explore
service needs, this one also looked at the other side of the
fence, to see what local services were available, how elder-
ly persons used them, and how local service providers and
significant others viewed the elderly and their needs. The
discrepancy between the views of the older consumers and
those who ostensibly serve them was an eye opener. By
most accounts, similar disparities between needs and serv-
ices exist in other communities as well.

This data-rich descriptive study yielded many significant
findings. We will review just a few here that highlight the
contrast in perspective between the community-dwelling
elderly themselves and the people devoted to serving
them. (On p. 116ff., we will examine other findings from this
study that pertain to the well-being and perceptions of
nursing home residents.)

Overall, this study revealed that for many of the com-
munity-dwelling elderly a major barrier to fulfillment was
economic. Whether measured by annual income or by self-
perceived income adequacy, there was a substantial and
often well-defined subpopulation that was barely squeak-
ing by or downright unable “to make ends meet.” Almost
40 percent of those in their own houses or apartments and
almost 88 percent of those in special housing had a family
income of less than $3,000 per year. When asked if their
income was “comfortable,” “just enough,” or “can’t make
ends meet,” less than half of all the respondents reported
that they were “comfortable,” and income inadequacy was
perceived as particularly acute by those living in special
housing, whether in Oak Park, where 9.6 percent reported
that they “can’t make ends meet,” or in Hamtramck,
where a disturbing 34 percent gave the same response.
The financial problems of many of these elderly people
resulted in many sacrifices of personal, housing, and
health care, as well as foregoing participation in some lei-
sure activities. Almost always, the residents of special
housing for the elderly, particularly those living in Ham-
tramck, fared the worst and had the greatest number of
unmet needs and the highest level of dissatisfaction.

The self-reported problems of individuals were often
related to their degree of integration into an informal so-
cial network of friends and relatives. The sheer availabili-

61
ty of help with everyday problems did not affect service
needs, but the presence or absence of a close other person,
such as spouse or confidant, had a significant effect on the
need for services. As Dr. Kahana reports:
This finding lends support to the notion that close relationships with
another person such as a spouse or other confidante may be the crit-
ical factor in helping the older person to navigate satisfactorily in
his environment rather than direct availability of helpers or the
number of significant others available.

. . .In toto—our data underscore the importance of social network
variables in experiencing problems in service-relevant areas. They
do not appear to be important, however, in predicting either attri-
buted need in the community [what an older person says other older
people need], or in personal [acknowledgement of] need for special
formal services. Perhaps this too reflects back to the preferential
reliance of our respondents on informal networks. Thus, in effect,
they say—when there is no one close to you, you experience many
problems. Nevertheless, the preferred way of solving these problems
is not through formal agency-type services.

Let us turn now to a comparison of the service needs of
the elderly as viewed by three sets of informants: the el-
derly themselves, who were asked whether they felt there
was “great need,” “some need,” or “no need” in their
community for a list of specified services; significant oth-
ers, who were interviewed about primary service needs of
older persons; and agency representatives who were simi-
larly interviewed. (The elderly respondents were also
asked whether they could use each of the listed services.)

In general, the elderly, their friends and relatives (sig-
nificant others), and agency representatives all saw the
need for financial assistance as a major priority. Agency
representatives and significant others also gave the need
for medical and health care very high priority. However,
for the elderly, the problem was not so much a lack of
health services per se as dissatisfaction with the quality
of care and/or lack of home care such as visiting nurse
services.

Beyond these general similarities of perceived need,
there were many significant discrepancies among the
three groups of informants. For example, for the elderly,
the highest-ranked service need was in the area of hous-
ing, although this need was given low priority by the oth-
er informants. Dr. Kahana believes that this ranking by
the elderly may reflect great concern with neighborhood
problems, rather than housing per se.

She bases this belief on responses to the study in which
about 40 percent of the elderly reported having some type
of neighborhood problems, with 19.6 percent showing spe-
cial vulnerability to fire and break-in, 15.1 percent to crime

Tn Hamtramck only.

62
on the street, 14.3 percent to neighborhood teenagers, and
11.1 percent to undesirable neighbors. The findings support
the view of other researchers that victimization and fear
of crime are significant concerns of the urban aged. (It is
ironic that residents of public housing were the most high-
ly victimized group.)

Interestingly, unlike agency representatives or signifi-
cant others, the elderly informants did not attribute to
themselves or their peers a great need for emotional or
psychological help. Perhaps this finding reflects the fact
that an adequate existing level of counseling services al-
ready existed. But the discrepancy in ranking by the el-
derly themselves and by service providers may indicate
different criteria for counseling service need. Many older
persons, particularly of the generation born before the
early part of this century, are disinclined to seek or value
counseling and are unlikely to perceive a need for it. On
the other hand, there may also be a tendency for many in
the helping professions to interpret nonpsychological com-
plaints and service requests as a cry for more personal
intervention. Findings such as these raise some sticky
questions about who is to be the arbiter of “needs’—the
professionals or the clients. In all probability, greater
communication, education, and sharing of decisionmaking
by service providers and consumers alike would go a long
way toward resolving this issue. It is clear, however, that
if service workers provide mental health services which
the elderly themselves do not perceive as necessary, they
are likely to have few voluntary clients.

A final point of great interest raised by this study con-
cerns the actual services available to older people in the
two communities studied. The majority of agencies sur-
veyed in this study were found to serve as referral
sources to one another. While good interagency communi-
cation is essential to help clients find their way within the
helping network, the referral chain is but a means to an
end: direct service. In this study, relatively few agencies
were found to offer direct services to older community
dwellers, and those that did offered counseling primarily
(one service ranked quite low by potential users). As Dr.
Kahana has put the issue poignantly:

A striking pattern . .. is the preponderance of referral services
(63%) and those of counseling (38%) among actual existing service
programs. In contrast, the aged consumers and significant others
did not even report referral service among service priorities. Based
on these data, it appears that one is either referring clients or help-

ing them adjust to their problems. Who, one wonders, then delivers
the actual services? [emphasis added]

Dr. Kahana has noted as well that the availability of
appropriate services is but one dimension of concern. An-

63
other is their accessibility to those most in need of serv-
ices:
Another important problem is posed when one considers the popula-
tions served by the various agencies. Although economic eligibility
criteria are diverse, it appears that in some situations, those in

financial need, and in others, those above a specific income level, are
cut off from access to needed services.

This study has underscored many of the complex factors
contributing to or mitigating the need for formal services
by community-dwelling elderly and has helped to identify
some special populations in particular need. Similar stud-
ies are needed in other communities to gain a realistic pic-
ture of how well the elderly are faring, how effectively
service agencies are reaching their intended targets, and
where there is a need to develop new services or make
existing services more accessible to those who need them.
Such studies, however informative they may be, are but
the first step in creating an effective service system; the
next step is to develop a working coalition of planners,
agency representatives, and elderly consumer representa-
tives to bolster existing informal social support systems,
wherever possible, and to direct the efforts of formal serv-
ice providers to those groups most in need of their help.
As this study has revealed, although the low-income elder-
ly are likely to be prime targets for intensified and im-
proved services of many kinds, there are many other older
persons who could benefit appreciably from new types of
service programs geared to their special needs and prob-
lems. (For example, frequently mentioned personal needs
included yardwork and repairs, legal services, and shop-
ping.)

The service programs described on the following pages
are addressed to a broad spectrum of community dwellers,
some of whom require only short-term psychological sup-
port, while others need sustained help through a broad
array of multidisciplinary services delivered on an out-
reach basis. They by no means exhaust the potential
range of programs, but they provide a glimpse at multiple
approaches geared to special target groups among the el-
derly. We will start first with programs directed toward
the well elderly and then discuss several addressed to the
more needy and impaired community dwellers.

Enhancing the Well

Growing Old and Growing Sage: An Approach to
Greater Fulfiliment

Old age can be seen as the culmination of life—the pin-
nacle of human development in which a lifetime of experi-

64
ence, growth, and learning has contributed to wisdom and
understanding of one’s self, others, and the nature of
human existence. Indeed, in the Orient, this view contri-
butes to veneration of elders. They are the repository of
knowledge and wisdom and, as such, the most respected
members of the Oriental family. That wisdom is not taken
for granted; it is nurtured through a pattern of expecta-
tions and practices in which many older persons devote the
latter part of their lives to meditation and religious prac-
tices designed to enhance spiritual growth.

In our own youth-dominated, mobile, materialistic, and
rapidly changing society, family structures are fragment-
ed, the knowledge and skills of older people are often con-
sidered irrelevant and obsolete, and the elderly have few
roles or norms to suggest how to conduct their lives.
Although some may well turn to religion, we do not have a
meditative tradition that guides individuals in a systemat-
ic development of their bodies and minds toward the
achievement of spiritual peace and understanding. Caught
in a limbo of undeveloped personal resources, many older
Americans, even those who are physically well and blessed
with adequate material resources, often find their lives
unrewarding and empty. In some instances, such condi-
tions set the stage for mental and physical illness. In oth-
ers, individuals, while falling short of clinical psychopa-
thology, may nonetheless lead lives that are purposeless and
totally lacking in joy and fulfillment; they are “tired of
livin’ and feared of dyin’.”

The Humanistic Psychology movement within our own
country had already discovered the relevance and rewards
of adapting many Eastern approaches to psychological
enrichment in which a host of techniques, including medi-
tation, massage, movement, and yoga-breathing exercises,
had for many years been explored as avenues to self-de-
velopment and enrichment. But for the most part, the
focus on self-actualization and personal growth stressed
within this movement had attracted only the relatively
young. The association of these activities with young and
“fringe” elements of society, combined with the conserva-
tism and lack of social reinforcement for “inner develop-
ment” among generations born early in this century, kept
many older persons from participating.

In addition, few older Americans are free of such physi-
cal symptoms as back trouble, heart disease, arthritis,
diabetes, headaches, and depression, symptoms which are
accepted as a function of age. SAGE, a California-based
service organization, sees the “aches and pains of age” as
often being the consequence of a lifetime of emotional
imbalances, misuse of body, faulty nutrition, and reaction
to environmental stress. Positive health implies that a

65
person is free of all these symptoms—spiritual, mental,
and emotional, as well as physical. Health requires effort
and a conducive way of life, which must be the responsi-
bility of those who wish to improve their well-being.

SAGE was conceived in 1972 by Dr. Gay Luce as she saw
the needs of her mother and felt her own forebodings
about the limitations of aging. Her long-time familiarity
with Eastern culture and meditative practices suggested
many approaches which she felt could successfully be
adapted for use with our own elders. She began, in 1972-
1973, to review what had been done in the way of pro-
grams to encourage older people to become tuned to their
own bodies and minds and to accept the concept of old age
as a purposeful time of self-development. There was al-
most nothing. A few scattered attempts had been made to
provide relaxation training for elderly people, and efforts
were underway to work with the severely mentally ill, but,
for the most part, few programs had addressed the mental
health needs of community-dwelling older people. Al-
though it was known that depression is widespread among
the elderly, relatively little was being done to alleviate it.

In 1974, Dr. Luce, with the help of Eugenia Gerrard and
Dr. Carol Spencer, founded SAGE, whose acronym stands
for Senior Actualization and Growth Exploration—*“a pret-
ty stuffy name,” as one participant put it, “but we are
actually growing and exploring.”

The living room of Dr. Luce’s Berkeley home was the
setting for the first experimental meetings with a small
“core” group of volunteers. The pioneers, in forming a
supportive and intimate group where people might begin
to heal their own symptoms and to interact openly, were
joined within a few months by other interested and ven-
turesome professionals, some of whom are still on the
SAGE staff.2

The initial core group came for a 2-4 hour weekly ses-
sion that emphasized positive new experiences rather
than personal problems. Personal bonds were forged
among members of the group during relaxation training
and the physical, interpersonal, and meditative exercises.
Participants were expected to do an hour of exercise and
meditation daily at home and to attend an individual ses-
sion with a staff member once a week.

Meanwhile, staff members developed a systematic ap-
proach to working with older persons, including a more
formal framework for the growth sessions, as well as a
structured system for transforming trainees into trainers
of other groups. SAGE grew largely because of enthusias-

2Co-Director: Dr. Kenneth Dychtwald; Institutional Group Leader:
Sarah Newbern; Core Group Leaders: David Cunningham, Joseph Garst.

66
tic endorsements from its trainees; requests came from
numerous Bay Area community groups for variations of
the format. Smaller groups were tried out in seven or eight
different places. In fact, a sizeable institutional program
in convalescent homes, nursing homes, and old age resi-
dences in the Bay Area grew out of a short contract given
to SAGE in 1975 by the Oakland Library Outreach Asso-
ciation to explore these new methods in a residence and
rest home.

In 1974, Richard Faumann, on a small contract with
NIMH, video taped the afternoon sessions of the pilot core
group, documenting the activities for almost a year so
that other organizations could have something tangible to
use in developing similar programs. With the help of
NIMH and several other contributors, SAGE made two
documentaries and a training tape on breathing between
1974 and 1977.

The tapes have been rented and used by many organiza-
tions and have been shown throughout the country in a
National Development Program created by Dr. Kenneth
Dychtwald. His presentations, workshops, and consulting
have stimulated similar groups in other areas and have
excited professionals throughout the country with the
possibility of an “alternative gerontology.” In response to
this interest, Dr. Dychtwald initiated a new gerontology
association with networks of communication as one of its
goals. Begun in the fall of 1977, the National Association
for Humanistic Gerontology is now a division of SAGE.

In 1976, with its program and procedures underway,
SAGE received an NIMH grant to develop the program
further and evaluate its impact. Until that time, SAGE
had been conducted in groups in various living rooms and
church basements. In 1977, it consolidated its program
space and offices in a faded but still elegant Victorian re-
sort hotel in the Berkeley Hills, which fit the criteria of
convenience, sufficient parking space, and safety.

In the fall of 1977, eight core groups were meeting here,
six led by staff and former core group members in training
and two by former core participants without staff. Other
“graduates” staff the offices and serve as recruiters and
training personnel; and, in the institutional program, one
institution and its intern training program were being led
by core group members alone.

What happens at SAGE? For 6 months, each participant
attends a weekly 2-hour individual session and a weekly
group session—after this, there is a followup program
consisting only of group sessions. Each group is made up
of 12-15 people, aged 60-84, who, following a medical exam-
ination, are considered to be in sufficiently good health to

67
participate in program exercises. Participants are repeat-
edly instructed neither to emulate the instructor nor to
compete, but to use their own body feelings as a guide to
their movement. This emphasis on self-reference and self-
development rather than on perfection has paid off—peo-
ple with severe arthritis and other symptoms have become
limber without hurting themselves, even though they had
not been able to exercise for years previously.

The 6 months of individual and group sessions are or-
ganized to introduce trainees to a progression of tech-
niques that teach them to relax, to enjoy their own bodies
and move more freely, to stimulate their sensory aware-
ness, to share feelings more openly with each other, and
to develop a better self-image. The techniques employed
are organized and presented in an organic, almost dance-
like way, with one flowing naturally into another.
Training sessions may range from extremely quiet and
meditative to hilarious and playful.

The weekly group sessions are supplemented by an hour
a day of “homework” and structured exercises, in twos
and threes, on such themes as “How do I spend my time?”
or “How do I expect to spend the last 5 years of my life?”
All of these mean a lot of participation and a commitment
of at least 9 months. Dr. Luce believes that such commit-
ment enables a slow, steady change in living habits and in
negative attitudes and symptoms acquired over a 50-60
year period.

During the first individual session, participants are in-
troduced to the biofeedback apparatus and its uses, learn-
ing that the machine monitors muscle tensions on the
forehead through electrodes and feeds back an audible
signal, through earphones, which indicates the level of
tension. While the trainee is lying down, the trainer in-
structs him or her in deep abdominal breathing which can
aid in relaxing facial, neck, and shoulder muscles. Trainer
and trainee discuss the subjective experience, then contin-
ue the same breathing lesson. Subjects are asked to prac-
tice this exercise daily at home, upon rising, and whenever
tension-producing situations arise. They also begin a daily
journal of feelings, dreams, and memory to be used later
in gestalt dream interpretation.

The first group session, held later in the week, elabo-
rates on the theme of relaxation approaches, reviews ab-
dominal breathing, and explores group-unison breathing,
with opportunities for group discussion and feedback.
Trainees are then introduced to some helpful ways to car-
ry out everyday movements, such as sitting and rising
from a chair or horizontal position, and then begin some
exercises aimed at body revitalization. The training ses-

68
sion concludes with a demonstration and trial of self-mas-
sage of face, neck, and shoulders, to be practiced at home.
Dr. Luce notes:
The intent of this exercise is to promote a change in attitude toward
a more positive image of one’s own body, by the palpable pleasure

and stimulation immediately following the massage, and the inevi-
table improvement in face and neck tissue tone.

After the initial meeting, trainees are encouraged to so-
cialize briefly.

The second individual session opens with a discussion
between trainer and trainees of reactions to home prac-
tice, both negative and positive, and reassurance that new
sensations, even if unfamiliar, are evidence of progress.
Biofeedback training continues, with trainer and trainee
monitoring the relaxation resulting from deep breathing.
Alternative approaches to relaxation are suggested, if
necessary, and progress is encouraged and supported. As
closeness develops between trainer and trainee, the stu-
dents are encouraged to ventilate their feelings and prob-
lems.

When the group reconvenes for its second session, group
breathing is again explored, followed by old and new lim-
bering exercises and a new posture exercise for home
practice which straightens posture and permits greater
air intake. Then group members lie back, relax, and parti-
cipate in “a kind of sensory awareness and reconditioning
experience’ in which the sounds of bells or drums are
played, and these older learners attempt to re-experience
the sound tactilely, receiving it, as it were, with the soles
of their feet or palms of their hands. Following this “sur-
prising and restful exercise,” trainees are invited to lim-
ber their facial muscles through playful facial imita-
tions, done in pairs, of biting lemons, winning millions of
dollars, being a bulldog, etc., while vocalizing appropriate-
ly. Giggles, laughter, and fun invariably follow—“a legiti-
mate and revitalizing momentary return to childhood
which is also good exercise.” “Homework” consists of mak-
ing faces in the mirror, continuing face massage, and add-
ing the “Alexander rest position” to home breathing prac-
tice. Again, the trainees socialize once the session ends.

In the third and fourth individual sessions, biofeedback
training continues, and, when trainees can lower their
muscle tension on command without feedback, desensitiza-
tion training begins, in which they learn to relax even
while discussing stressful thoughts. Subsequent individual
sessions focus on learning to relax in the presence of mus-
cle soreness, aching joints, and pain.

The third and subsequent group sessions begin with
exercise to music, expanding to dance and body-movement

69
communication. Meditative exercises are introduced, fo-
cusing on hands and flowers, adding chanting and visuali-
zation as preparation for classical meditation instruction
if the participants want it. Massage and touching exercis-
es are also used, such as ritualized hand and foot mas-
sage, proceeding to mutual face, neck, and shoulder mas-
sage, and, for those who want it, whole body massage.
Other approaches used in later sessions include instrue-
tion in a few movements of Tai Chi Chu’an, which aid in
balance and self-awareness of movements.

Touching exercises are also used, including nonverbal
communication by pairs of trainees who “speak” to one
another through movements of their touching feet.
Gestalt dream analysis may be employed to explore fanta-
sies and inner feelings. Throughout training, group discus-
sion and support are encouraged, as participants become
more willing to discuss hidden fears and anxieties, espe-
cially regarding illness and death.

Special sessions, such as music therapy or art communi-
cation, are planned for each group. Many people, who had
been telling themselves since first grade that they could
not draw and were not artistic, have discovered in these
sessions that a new attitude—not caring about the prod-
uct, merely the process—generates creations of surprising
beauty. Moreover, by introducing their lives to each other
in imagery, rather than in words, they begin to express
and feel more fully who they are.

As Dr. Luce has observed, people need help in overcom-
ing awkwardness, shyness, and strong resistance to trying
new things. The group dynamics, exercises, relaxation
training, and sharing of experiences all help. She especial-
ly advocates roll breathing, which usually begins around
the second or third core session. Typically, when the group
reconvenes for the second or third time, there may be a
centering exercise or brief discussion to center the partici-
pants. The group may now begin a unison-breathing prac-
tise, followed by the limbering and fitness exercises of the
previous session to which some new ones are added. They
may be taught an Alexander position to improve posture
and breathing while at rest. Autogenic, or roll breathing,
is one of the most fundamental and valuable methods
used in SAGE. It is usually taught in pairs, so that one
person acts as a guide while the other, lying down, inhales
deeply into the lower abdomen and then the chest, in
lengthening sequences and in rhythm. Following 15-50 roll
breaths, the breather is instructed to lie still, breathing
normally and noticing all sensations. This may range from
mild prickling in the extremities to deep emotions of ecsta-
sy or grief, for the method simply allows the person to
relax and release whatever lies just beneath the surface.

70
Participants practice roll breathing together in groups
and alone at home, and many of them use the method to
fall asleep, to become energized, or to help in healing.

There are enjoyable and worthwhile “extras,” as well.
At various times in the year, often in the evening, experts
give special sessions in nutrition, acupuncture, posture
exercises, group encounter and process, the nature of in-
tuition and psychic ability, alternative medicine, and self-
healing. By and large, the invited speakers have some-
thing of special relevance to an older group, and at pres-
ent they are not people who are usually easily available
to an older audience.

At the end of the third year, an evaluation made by a
visiting anthropologist from the University of California
confronted the staff with the fact that SAGE methods
were producing signs of undue dependency on the staff
and the participants were acting like grateful patients in
therapy. This evaluation inspired a change in approach.
Individual sessions were dropped, and in their place an
experimental procedure was tried—that of assigning core
group members to meet in pairs or triads during the week
to explore deep emotional and spiritual questions. In 1976-
1977, one core group substituted the dyads for triads. The
latter appeared to be more interdependent than dependent
upon staff, and so the procedure was adopted for the sub-
sequent four groups.

Throughout sessions the participants are progressively
asked to lead more exercises, to critique each other, and to
work together to increase confidence and independence.
Core-group participants have joined in presentations, pan-
els, radio and television programs, and workshops where
they have performed with the staff, even though many of
them had never spoken to audiences before and at first
found the prospect frightening. Interested graduates have
always been encouraged to become trainers themselves,
and three or four members of each core group have done so.
Indeed, one woman of 75 went to another city where she
began leading similar groups and training young profes-
sionals. Others have found new roles teaching in SAGE, or
in other institutions, and slowly the older people of the
early core groups are beginning to play a significant role
in running SAGE.

In 1977, the death of a woman participant generated
deep feelings about the need for group support of sick
members or members in crisis, and about the need for a
greater community. After searching discussions about the
kind of community they wanted to form, these graduates
began to meet on a continuing basis, creating their own
programs with their own instructors, meeting socially, and

7
initiating and sponsoring a new fitness program for other
graduates, as well as providing a model community of older
people whose values and self-images differ considerably
from those of the elderly community at large.

Although the program brings together a heady mix of
disparate techniques and approaches to relaxation and
growth, it often seems to convey an atmosphere of peace-
ful happiness, sparked by both laughter and deep feeling,
as participants begin to open up to one another long-bur-
ied experiences and emotions. The sight of older adults
making faces at one another, massaging one another, and
performing a host of exercises is at once strange and nat-
ural. Their movements are supple, their laughter whole-
hearted. The program provides an opportunity for many
older people to fulfill universal human needs almost auto-
matically answered for children, but not for grandparents:
to touch and be touched, to move freely, to experience
their bodies as a vivid sensory organ, and to communicate
openly fears and joys.

Taken at face value, and judging by the enthusiastic
response of its participants, SAGE works well. For the
tougher minded, a more formal evaluation is underway
comparing the changes in participants with a matched
group of would-be participants over the program’s 9-
month span. By 1977, at the end of an initial test group
which included four core groups of 12-15 people, aged 60-
84, questionnaires already revealed that experience at
SAGE definitely helped people cope and improve their
memory.

From Passivity to Power

If one of the problems of today’s elderly is an inability
to relax and enjoy the later years, another is their fre-
quent inability to stand up for their legitimate rights,
whether individually or as a group. All too often, older
people are shunted aside, or even victimized, by individ-
uals who take advantage of their passivity in social situ-
ations. A group of researchers at the University of Wis-
consin, in searching for ways to strengthen the coping
skills of older people, have conducted an exploratory study
that suggests that, with a modest amount of training,
many elderly can learn to deal more successfully with
others, defending their valid “turf,” yet doing so in appro-
priate, nonaggressive ways. The study, which compares
the effects of three different types of small-group training,
has shown that, while all three approaches yield impor-
tant behavioral change, one, termed “behavioral role
play,” is particularly effective.

72
Dr. Sheldon Rose and his associates in the Interpersonal
Skill Training Program recruited 53 community volun-
teers, aged 55 and over, and assigned them to small
groups of three to five participants. Each group was led by
a trained group leader and met for six 90-minute sessions.
The 15 small groups were randomly assigned one of three
training approaches, so that five groups were exposed to
the behavioral role-play method, five participated in “so-
cial group work,” and five used a “problemsolving” ap-
proach.

In all groups, the leaders presented examples of effec-
tive responses which participants would find useful in dai-
ly interpersonal relations—initiating interactions; con-
fronting others; handling service situations and making
requests; responding negatively, when necessary; respond-
ing to criticism and turning down requests; and, finally,
expressing opinions. The leaders tried to involve all group
members equally in each session, beginning with request-
ing each person to volunteer situations in daily life which
corresponded to the circumstances being discussed.

The essential difference between the behavioral role-
play approach and the others was its emphasis on demon-
strating and acting out ways to handle problem situations,
rather than simply talking about them. The leader would
show how to respond, participants would rehearse appro-
priate responses (with feedback and coaching from the
leader and fellow trainees), and group discussion of the
rehearsal would follow. Several tests were used to com-
pare participants’ ability to handle problem situations,
both immediately after training and several months later.

The results of this small study, although preliminary,
were very encouraging. As reported by Drs. Toseland,
Berger, and Rose, the ability of participants to handle
difficult social situations, as measured by a role-playing
test immediately after training, was greatest among those
who had undergone behavioral role training. Their per-
formance was significantly better than those who under-
went the social group work method and better (although
not with statistical significance) than the problemsolving
group participants. A retest, some 3 months after the end
of training, showed no significant differences among the
three types of trainees, although the role-play and prob-
lemsolving method participants still performed somewhat
better than their peers who were exposed to social group
work training. (Interestingly, the passage of time resulted
in appreciable gains for the members of this latter group,
although not sufficient to overcome the post-training lag.)

When training participants were asked to indicate their
degree of satisfaction on a five-point scale, ranging from

73
“not at all” to “totally satisfied,” participants in all groups
averaged just short of totally satisfied. Three months af-
ter training, a sustained “moderate amount” of change in
their social skill was reported.

Those who had engaged in behavioral role play de-
scribed a wider array of situations to which their training
might be applied than those in the other groups, suggest-
ing to these researchers that “behavioral role play train-
ing is more effective than the other training methods in
helping older persons use the skills learned in the group
meetings in daily interpersonal interaction.” Examples
cited by the behavioral role play participants included ask-
ing physicians health-related questions they had shied
away from in the past, speaking up in public meetings,
handling salesmen more effectively, confronting others
who were annoying or inconsiderate in public places, and
responding to inappropriate behavior with less anger.
Many attributed their behavioral and attitudinal changes
directly to skills learned in their training sessions.

A study such as this is heartening, because it suggests
that, with a relatively small investment of time and pro-
fessional effort, even paraprofessional effort, many of the
well elderly can enhance their ability to handle the social
challenges of daily living. However, many questions re-
main. In the absence of any assessment of how well these
people functioned prior to training, and no comparison of
the performance of a comparable but untrained group, we
do not know how much progress the three techniques ac-
tually yield. Nor, of course, do we know what effects these
presumably new-found skills have on the quality of life—
and mental health—of these older trainees. Additional
questions concern the applicability of these techniques,
particularly behavioral role play, to widespread use. Given
severe shortages of mental health professionals to provide
such training, however brief, and the great numbers of
older people who might potentially benefit from these
techniques, it would be interesting to know whether train-
ees themselves might be transformed into trainers. If so,
it might be possible, through creation of chains of self-
help groups led by older people themselves, to reach rela-
tively large numbers. If, in addition, the group sizes could
be increased somewhat without mitigating the effective-
ness of techniques such as role playing, still greater num-
bers might benefit.

In an area as new as this, perhaps the most significant
development is the recognition of a widespread problem
that has long been unheeded, and the willingness to seek
a solution. It has taken many years to realize that the
elderly, like many members of other minority groups, have
been socialized to assume an inappropriate and detrimen-

74
tal posture of passivity. Perhaps, with further refinement
and expansion of techniques such as those explored in this
study, we will see more of the well elderly marshaling
their considerable numbers, abilities, and potential politi-
cal power on their own behalf and that of their less fortu-
nate peers. There is much to be done, and a more confi-
dent and self-assertive group of elders might well spark
and guide the creation of a society in which long life and
good life are one.

Maintaining the Marginal Elderly

A small but substantial minority of community-dwelling
older persons in our country needs many kinds of suppor-
tive services it is not now receiving, particularly mental
health services. However, discovering appropriate and
practical solutions to remedy the situation raises many
theoretical, policy, and organizational issues which seem
difficult to resolve. There has been widespread mutual
avoidance between human service workers and the elder-
ly, fed by misunderstanding and ignorance on both sides,
and a lack of adequate funding to facilitate and motivate
greater contact. There is a dearth of mental health work-
ers specifically trained to work with the elderly, stemming
in part from institutionalized avoidance and neglect which
is just beginning to be dispelled. Further, we have inherit-
ed a highly fractionated service delivery system consisting
of poorly coordinated social, medical, and mental health
services attempting to respond in isolation to the needs of
elderly people who frequently require multiple services.

Adding to the complexity of the situation is increasing
recognition that, while underservice and “benign neglect”
often seem to characterize our treatment of the needy
aged, there exists the distinct possibility of over-service as
well—that is, of the bombardment of elderly individuals,
whether institutionalized or not—with an excess of protec-
tive and nurturant services that erodes their remaining
independence and self-maintenance ability. One highly
controversial study often cited by sophisticated research-
ers and service personnel is that of Dr. Margaret Blenken-
er, who found, as reported by one researcher, “that el-
derly people who received services in a program providing
protective services for the aged died more quickly than
those elderly who were able to keep out of sight and out of
the clutches of the ‘do-gooders’.”

A further problem arises from current confusion con-
cerning the identification of the actual problems confront-
ing elderly persons and the appropriate personnel and
techniques used to solve them. Because physical, mental,

75

274-912 0-78 - 6
and social problems are often intertwined in the elderly,
and guidelines for sorting these out are presently rather
crude and sparse, it is fairly easy to mislabel problems
and to resort to inappropriate solutions. (Case in point:
the frequent misreading of confused, disoriented behavior
in the elderly as a sign of irreversible “senility” when it
may in fact stem from treatable depression or from a
readily reversible medical problem.)

Obviously, many different lines of attack will be needed
to create a service system in which knowledgeable people
are available in appropriate numbers and locales to help
older people in ways that are acceptable and truly benefi-
cial to them. This system requires developing new ap-
proaches to service delivery that build on interagency
cooperation and coordination to create many types of
comprehensive service programs for the elderly. In addi-
tion, new training programs are needed to develop a cadre
of people who are willing and able to understand the spe-
cial needs and characteristics of older people and to deliv-
er services they want and need.

Given the inability and unwillingness of many older
people to wend their way to and through the complex
service system, the servers .will often have to come to
them, whether in a common residential setting (pp. 94-101),
in a common neighborhood meeting place (see pp. 88-94), or
in the privacy of their own scattered houses and apart-
ments (see pp. 101-107).

If these experiments in service delivery and training are
to reap their greatest benefits, they must be carefully
studied and evaluated so that others can learn from their
strengths and weaknesses and improve upon them. The
following experimental service and training programs rep-
resent current efforts to respond more effectively to the
many needs of elderly persons who, for the most part, are
too well to require institutionalization but too impaired
or socially isolated to manage well entirely on their
own. Many may still be clinging to their independence but
are perilously close to losing their capacity for self-man-
agement. If they suffer one major decline in their health
status, their environment, or their economic or social situ-
ation, they may find themselves totally unable to sustain
their relatively independent style of life. Some of these
people have had lifelong bouts with mental illness, while
others are confronting the first symptoms of mental im-
pairment. Others, still mentally keen and emotionally well,
suffer from chronic physical illness and minor disabilities
which drain their energy reserves and hamper their mo-
bility. The chances of joining this group of frail or margin-
al elderly increase with age. It is these people who are the
focus of considerable recent effort on the part of service-

76
oriented researchers who recognize that, if we are to stem
the rising tide of nursing home admissions, we will have
to find new ways to sustain these marginal elderly as
community dwellers.

Within this group there are many subpopulations with
special needs and characteristics that must be recognized:
the elderly former mental patient, the “mentally frail,”
the physically ill and housebound, and the poor and mar-
ginal person who is still moderately healthy but unable to
cope well in a hostile urban environment. No one program
is likely to meet the needs of all these people, but the fol-
lowing programs suggest a range of notable service and
training options currently being developed.

Community Housing: Independence and
Security in Philadelphia

In the crumbling core of our major cities live many long-
time residents—single, insecure, and sometimes sick—
fending for themselves in an environment at once familiar
but frightening. Their incomes are small, their options
few. They huddle in their houses and apartments, fearing
the robber and rapist, foraying out for occasional shop-
ping trips, always afraid. Many dream of getting out, of
moving to ‘someplace nice,” but the waiting lists are
long for the housing they can afford. Some simply stick it
out; others, seeking any route out of constant anxiety,
sign into nursing homes. In a more congenial environ-
ment, they could manage; but where they are, it is all too
much.

For some of these marginal urban elderly in Philadel-
phia, another option is available: Community Housing,
developed and operated by the Philadelphia Geriatric Cen-
ter (PGC) as part of its comprehensive services and care
facilities for the elderly.3 There, an older low-income per-
son in moderately good health can rent an efficiency
apartment in a renovated old rowhouse for $106 a month
(more since the first tenants moved in), live in the compa-
ny of other older persons in the same or adjacent row-
houses, and have access to just enough services to make
life comfortable and secure, while maintaining an inde-
pendent lifestyle. Although the Community Housing pro-
gram is small, serving about 27 tenants in its nine reno-
vated houses, it provides an inexpensive and feasible ap-
proach to housing for the elderly that can be widely adopt-
ed in many communities, under many types of sponsor-
ships. Indeed, in 1973, Senator Harrison Williams intro-
duced Senate Bill S2181, the Intermediate Housing for the

3For further discussion of PGC, see pages 147-156.

77
Elderly and Handicapped Act, which proposes housing and
supportive services modeled after those of PGC’s Commu-
nity Housing (then called Intermediate Housing).

Widespread national interest in the project stems from
the fact that, although there has been a proliferation of
noninstitutional housing for the aged since the 1950s,
many of these dwellings have been too expensive for the
low-income aged who form a significant proportion of the
over-65 population. Renovation is far less expensive than
building high-rise and other types of housing from
scratch, with savings that can be passed along to tenants.
By offering only limited services based on individual need,
additional savings are possible. The basic rental of $98
and $95 for first- and second-floor efficiency apartments,
respectively, includes:

. janitorial and building maintenance services; cleaning of the
common areas; a “hotline” phone connected to the PGC switchboard
for medical or other emergencies; and social services offered during
the application and moving phases, at crisis points, and when ten-
ants need to move elsewhere. The Center’s group recreational, reli-
gious, and social activities are open to tenants. Home delivered fro-
zen main meals and light housekeeping are optional “extras” that
can be purchased from the PGC at nominal, nonprofit prices. Medi-
cal care is not provided; the tenants retain their own personal phy-
sician.

This housing model is predicated on the assumption that
tenants will shop, cook, and care for themselves and their
apartments, and essentially conduct their lives as any ful-
ly independent community dweller would. No attempt is
made to provide common dining, transportation, or recrea-
tional services, or to help tenants cope with most problems
of daily living. This restraint in service provision is quite
deliberate, dictated both by a desire to maintain low rents
and by a perspective on the service needs of the elderly
developed in part through the research of Dr. M. Powell
Lawton, founder and director of the Philadelphia Geriatric
Center’s behavioral research department.

Dr. Lawton, long interested in the burgeoning field of
ecological psychology, undertook a broad study of housing
arrangements for the elderly, attempting to identify what
attracts them to certain settings, how the services offered
met their needs, and how the match between services and
needs affects their well-being. Out of his investigations
emerged the important recognition that there must be a
careful match between the services offered and the capa-
bilities of those who use them. Dr. Lawton’s findings have
suggested that, although we are used to thinking about
the harmful effects of inadequate services, we must also
consider the possibility that older persons can be equally
ill serviced by an overprotective environment that de-

78
mands too little of them. As a person ages, he or she
should have access to a range of environmental options
and services, to be called on as needed. But independence
should be encouraged to the extent that the individual is
able to manage. In a pattern typical for PGC, where geriat-
ric research, training, and service are closely integrated,
these research lessons fed directly into practice and guid-
ed the design of Community Housing.

Community Housing provides a living arrangement that
may suit the needs of many marginal community dwellers.
However, it is not appropriate for all. Included among its
tenants are many who had considered themselves ready
for institutional living (some of whom had applied, as well,
to PGC’s nursing home facility). However, on careful
screening, they were found to be able to manage a rela-
tively high level of self-care. Some of the tenants, al-
though initially moderately healthy, subsequently became
severely ill and had to move into settings providing more
intensive care. Others also had to leave because progres-
sive mental impairment led to forgetful and dangerous
behavior which jeopardized their own safety and that of
others. The best target group for this type of housing is
still being determined. However, it appears that it appeals
to, and works well with, a special sector of the aged popu-
lation: those in the middle ground between health and
severe mental and physical illness but who can function
independently in self-care and the activities of daily liv-
ing. Judging by the reactions of potential tenants, its ap-
peal to eligible elderly persons is not universal (many who
were accepted chose, nonetheless, to live elsewhere). But
for those who do choose it, Community Housing offers an
opportunity to retain one’s privacy and independence
while sharing a secure lifestyle close to many others of
similar age and background. It seems to encourage a spirit
of community living without destroying personal independ-
ence and self-reliance.

Let us now look at the origins and effects of this innova-
tive approach to housing.

Background

The idea of sponsoring community housing came about
somewhat by accident in the mid-1960s. A neighborhood
townhouse came up for sale, and some of the Philadelphia
Geriatric Center’s own aging staff members needed better
housing. In 1965, PGC bought two rowhouses, renovated
one slightly, and offered it for rent to a group of tenants
drawn from the waiting list of applicants to the PGC’s in-
stitutional facility. It remained the single-family dwelling
it had been, with the kitchen, bathroom, living room, and
dining room to be shared, and only the bedroom private.

79
It soon became obvious from the squabbles that erupted
among the tenants that the living quarters did not offer
enough privacy. Having four cooks in the kitchen spoiled
not only the broth, but the bonds of friendship. The sec-
ond house then was renovated to provide each tenant with
a private kitchen and bedroom, but with a shared living
room and bathroom. This, too, had its difficulties.

The final model, now in use, consists of three efficiency
apartments per house, each with its own kitchen, bed sit-
ting room, and bathroom, but sharing a common first-floor
living room. As other houses on the block were bought by
the Center, they were renovated accordingly, with mort-
gages insured under the 236 Rehabilitation Program of
the FHA which was designed to stimulate the develop-
ment of low-cost housing for the elderly. This now-defunct
program also provided rent supplementation funding
which permitted 40 percent of the apartments to be of-
fered at reduced rates to tenants who met public housing
financial criteria.

The renovated buildings were comfortable, clean, and
attractive and, despite some modernization, retained their
old-fashioned Edwardian architectural details such as
stained-glass windows, large front porches, and oak ballis-
ters and trim. The bathrooms were supplied with guard-
rails and updated to include a stall shower, but no bath-
tub. The kitchens, although small, were fully equipped
with all but dishwashers.

In 1970, with nine houses now renovated, the PGC began
an NIMH-funded research project, under the direction of
Mrs. Elaine Brody and Dr. Morton Kleban, to study the
short-term impact of this new housing arrangement on
tenants. A subsequent grant permitted these investigators
to extend their study to a 3-year followup.

Of the 300 older Philadelphians who applied for Commu-
nity Housing, only 87 were selected who met HUD criteria
for age (62 and over) and income, were reasonably healthy,
could cook and care for their own apartment, and could
climb the houses’ steep stairs. (This latter quite practical
requirement also served well to screen out the excessively
infirm.) As anticipated, although the 87 applicants to
whom apartments were offered had expressed great inter-
est in moving to the new units, not all actually accepted
the offer. As it turned out, some 22 moved to other hous-
ing instead, a larger group of 41 simply stayed put (at
least for the first 6 months of the study), and 24 moved
into PGC’s newly renovated houses.

Given this natural distribution of the prospective tenant
population, Mrs. Brody and Dr. Kleban had three groups
of somewhat similar subjects whose short- and long-term

80
well-being could be compared: the primary focus of the
study, the Experimental Group of 24 who moved into the
new housing; Control Group 1, the 22 movers who found
other housing; and Control Group 2, those 41 who, at least
initially, did not budge. If Community Housing was indeed
an advantageous living arrangement, then the 24 tenants
could be expected to fare better than those in either con-
trol group.

All 87 of the research participants were given intensive
initial interviews and tests, were restudied 6 months after
the experimentals moved into Community Housing, and
were followed up 2 years and again 3 years later.

Research Findings

Since the subjects in the three study groups were essen-
tially self-selected, the first question to be asked was: To
what extent were they initially similar or different? Their
incoming characteristics had to be identified as a basis for
assessing later changes. The first questionnaire and test-
ing battery revealed that, as a whole, the 87 subjects aver-
aged 74 years of age (ranging from 63 to 94), were mostly
women (78%), primarily widowed (80%), who had been liv-
ing alone, either in apartments (58%) or in their own
homes (12%). None had been living in institutions. These
low-income Philadelphia residents came either from the
immediate neighborhood or from ‘“high-crime’” depressed
areas in other parts of the city. While most of the appli-
cants had been married and had at least one surviving
child, almost 40 percent had no living children. The major-
ity (70%) were foreign born and had limited educational
backgrounds (better than half had no more than a sixth-
grade education). Judging by their health status, they
represented an “in-between” group among the aged: in
better shape generally than those who are institutional-
ized, but by no means totally well. Although all of the ap-
plicants were seeking to move at the time of the study,
their prior living arrangements had been very stable. In
the 20 years preceding their application to PGC, 22 per-
cent had not moved at all, 25 percent had moved once, and
35 percent had moved twice.

While members of the experimental and the two control
groups were largely similar in background characteristics,
there were some minor differences. Members of Control
Group 1 (those who subsequently moved to other housing)
were somewhat less active than those in the other two
groups and had slightly more limited morale, self-care
ability, and cognitive functioning than members of the
other groups. Judging by their self-reports, they were also
in slightly worse health.

81
Why did these older people want to move? When first
interviewed, all the subjects were similarly dissatisfied
with their neighborhoods, their apartments, and their
overall living arrangements; all wanted to move, and all
reported similar degrees of “enjoyment of life” and simi-
lar “numbers of good friends.” As summarized by Mrs.
Brody, their reasons for moving reflected “deteriorated
properties in neighborhoods with high crime rates from
which family and friends have fled, leaving those who
remain lonely, isolated, and fearful.” Fear and anxiety
about crime headed the list of factors; it was the major
reason for two-thirds of the subjects, ranking first for 34,
and second most important for 24. The following “vi-
gnette” of the life of one who subsequently became a PGC
tenant gives some of the flavor of what these people
sought to escape:

Mrs. A. and Mrs. B. both lived in a high-crime redevelopment area.
Both had been mugged and burglarized, had no locks on their doors,
and had even had food stolen from their refrigerators. The redevelop-
ment authorities said that they had to move. Mrs. A., overstressed,
used to scream at children from her window. She eventually moved
into Community Housing, but continued her pattern of screaming.
Once, when her Social Security check was late, she thought it had
been stolen, and screamed herself into a heart attack. Nonetheless,

upon her recovery she returned to Community Housing, and has
been doing better.

Mrs. B., against all advice, stayed in her old neighborhood, and was
eventually murdered.

Loneliness and distance from friends and relatives were
next in importance as reasons for changing housing.

While there were compelling reasons for most of the
subjects to want to move, there were some, but fewer,
reasons cited by them for not wanting to move to Commmu-
nity Housing. Most reasons had to do with the specific
physical characteristics of the newly renovated buildings,
such as the lack of a tub, the excess number of stairs, or
the need to share the living room. Applicants did not ob-
ject to the prospect of age-segregated housing or to the
condition that they would be research subjects. Other,
more psychological, reasons cited for not moving included
reluctance to leave familiar surroundings and the view of
moving as too hard in the face of decreasing physical
strength. Social workers who interviewed the subjects
perceived and reported these psychological deterrents to
moving more frequently than the subjects themselves. As
it turned out, the social workers’ ratings were the only
significant predictors of who would or would not actually
move.

The resistance of potential Community Housing resi-
dents to moving was sometimes the result of complex mo-

82
tivations. Witness the case of one Tl-year-old widow who
was living rent-free in an apartment building willed to her
by her husband, and using the other apartment rents as
income. Although she was in frail health, her application
for Community Housing was accepted; however, she then
declined the offer. Under a social worker’s probing, it was
discovered that the woman’s ambivalence stemmed from
two competing factors: a desire to retain her rent-free
apartment and a desire to escape from a situation in
which two of the building’s tenants operated a “brisk”
prostitution business. The woman’s apartment had been
accidentally broken into by unhappy customers who had
mistaken her apartment for her neighbor’s. Eventually,
she did move in.

The 6-Month Followup

Six months after the 24 Community Housing tenants
had moved in, they and the other research subjects were
again tested and interviewed to discover their reactions to
their living arrangements and lifestyle. During this same
period, the members of Control Group 1 had moved into a
variety of other types of housing, while those in Control
Group 2 had stayed.

Although initially none of the subjects had been living
in institutional settings, by the time of the 6-month fol-
lowup, five of those who moved had done so to enter nurs-
ing homes. Another five had entered high-rise apartments
that offered many services and opportunities to socialize.

All of the subjects initially had been equally dissatisfied
with their environment and wanted to move. But 6
months later, significant differences in satisfaction
emerged which favored those who entered Community
Housing. Not surprisingly, those who had never moved
were still dissatisfied with their living arrangements and
neighborhood, while those who moved, whether to Commu-
nity Housing or other settings, were more satisfied. The
rise in satisfaction was greater, however, among those in
Community Housing. Further, those in Community Hous-
ing expressed little desire to move, while a rather high
percentage of those who had found other accommodations
(41%) wanted to move again. Of course, the desire to move
was still high among 84 percent of those who had not
moved. The 6-month followup findings also indicate that
Community Housing residents reported more “enjoyment
of life” and “number of good friends” than members of
either of the control groups.

A careful statistical analysis of some 50 different varia-
bles entering into the lifestyles and satisfaction of the
subjects revealed that, by the 6-month followup, those

83
who moved into Community Housing fared much better
than either of the control groups. In addition to a lessened
desire to move, these residents had higher ratings in the
following dimensions of their living patterns: happiness
and enjoyment of life; self-rated health; sleeping well;
proximity and use of synagogue, post office, grocery store,
and supermarket; relief from fear of crime, and feelings of
safety; proximity to hospital and physician; instrumental
activities such as housekeeping, food preparation, and
cleaning; possession of their own household appliances;
use of library and laundromat; less frequent hospitaliza-
tion; less worry; more use of stairs (and less use of po-
diatrists); enjoyment and cleanliness of apartment; and
socialization.

Interestingly, regarding the “relief from fear of crime,
and feelings of safety,” the community housing tenants
felt relatively secure from the threat of crime, probably
because their houses were patrolled by the Center’s secu-
rity force, but they were actually by no means immune.
(One tenant, for example, was the victim of a purse
snatching. Police subsequently staked out the area and
caught another thief attempting the same crime. Howev-
er, the victim, probably fearing reprisal, would not testi-
fy.)

Compared to the Community Housing tenants, those
who stayed put suffered the greatest disadvantages. Their
homes and apartments had deteriorated, they wanted
more than ever to move, they felt even worse than at
baseline about their living conditions, and they were even
less happy. Although initially the self-perceived health of
the Community Housing tenants and the nonmovers was
similar (with the movers showing slightly worse health
and functional capacities), 6 months later the nonmovers
also showed signs of somewhat poorer health. The self-
reports of some may have reflected lowered morale rather
than a decline in health, but it is significant that within
the 6-month period, five of the nonmovers had died.

The 3-Year Followup

The short-term study results provided heartening evi-
dence that Community Housing yielded many types of ad-
vantages for its tenants. However, the PGC staff and re-
searchers were also concerned with the longer-term im-
pact of Community Housing on its residents. A 3-year fol-
lowup permitted them to follow their subjects as they
aged somewhat, accommodated to their new environ-
ments, or sought others, and as some succumbed to dis-
ease and death.

84
Given the high dissatisfaction reported by the nonmover
group at the 6-month followup, it is hardly surprising that
many of these did move later. In this section, we will des-
ignate as “slow movers” this 22-person subgroup of the
original 41 nonmovers. The 3-year followup revealed that,
of the 22 slow movers, six had moved to Community Hous-
ing, ten had moved to high-rise buildings for the elderly,
while five had entered age-heterogeneous apartments (the
latter two living arrangements were more costly than
Community Housing). One had moved to a nursing home.
By the end of the 3 years, there were only five surviving
nonmovers still in their original settings. Two had become
lost to the study, and ten had died in the old homes they
never left.

Of particular concern and interest to Mrs. Brody and
Dr. Kleban were the differences in survival rates between
those who moved during the 3 years (regardless of setting
chosen) and those who did not. Other research studies,
such as that cited on pp. 123-126, have suggested that
moving is extremely stressful for older people and, in the
case of institutionalized populations, can even lead to
death. The results of this study suggest that, at least for
community dwellers living in adverse environments, just
the opposite may be true. Looking at those who moved
within the 3-year period, 70 of the original 87 subjects had
moved (with two unlocated), and seven, or 10 percent,
were known to have died. The Community Housing resi-
dents had the highest survival rates of all groups, with
only two (8.3%) deceased at the time of the 3-year followup.

On the basis of these preliminary followup findings, Mrs.
Brody has suggested that the study may have uncovered
what she terms an “immobilization effect.” That is, when
older persons face a lack of options, psychological inability
to move despite acute need, or subtle declines that hamper
their ability to mobilize needed psychic or physical energy,
they may “give up.” The problem can also be viewed as
arising from a changing or unresponsive environment
that does not meet with the person’s own capabilities and
needs.

Since this study was not designed to probe deeply into
the actual health status or psychological strengths and
weaknesses of subjects, or their real day-to-day stresses, it
can only hint at the dynamics that may have led to these
differential death rates. However, the results are provoca-
tive, and the phenomenon deserves far more close study.

The results of this study underscore the interdepend-
ence of physical and mental well-being among the elderly,
as well as the strong contribution made by the social and
physical environment to health and possibly even to sur-
vival. Although for many older persons a move to a new

85
environment might have many advantages, there appear
to be some who, for a variety of reasons, cannot cope with
the prospect of moving. The Community Housing model
obviously is but one of many ways of responding to the
needs of the elderly and can serve only those with the
motivation and capacity to give up their old lifestyle and
attempt a new one. For those who cannot, and remain
rooted in settings which both comfort and threaten them,
other alternatives are obviously required, such as those
explored on the following pages. We have no way of know-
ing from this study who should or could be helped to move
and who should be supported in place. Perhaps if we knew,
some of the deaths reported in this study might have been
delayed.

Community Housing: The Quality of Life

The relatively low death rates among the Community
Housing residents suggest that, although the self-selec-
tion process by its very nature may have favored those
with relatively strong emotional and physical resources,
the environment may be contributing to maintaining the
psychological and physical strength necessary for surviv-
al. Although hardly scientific evidence, some brief samples
of life in Community Housing may suggest the strong
spirit of self-reliance and survival supported by this set-
ting:

Mrs. X is a thin, spry, bright-eyed woman who appears to be in her
late 70s. She stands on the porch steps of her house, holding a cane
in one hand, and a sweater in the other. She calls to a passing
member of the PGC service staff by name, and asks him to give the
sweater back to the woman who just came to visit her. She asks,
with a characteristic Yiddish accent and shrug “So why does she
come to visit me? What do I need her for? I'm not sick. I was in the
hospital for three months but I'm OK now.” Big grin. She then asks
the man for his address, so she can send a note to the Social Serv-
ices Office. He takes out a piece of paper, writes very big, and says:
“Can you read this?” She peers at the address through her glasses
and says, again smiling and nodding emphatically, “Of course!” Her
smile turns wry as she observes, “You know, around here every-
body’s a boss.” He responds, “You’re your own boss.” She flashes a
triumphant smile and straightens up tall. Everything about her
exudes good humor, independence, and vigor.

As we leave, the man explains to the observer that the sweater be-
longs to a physiotherapist who came to work with the woman follow-
ing surgery. Mrs. X has cancer and is not expected to live long. The
staff of the hospital where she had stayed for three months believes
that she should not remain at Community Housing, since too few
services are available to support her. The observer asks whether she
will be transferred somewhere else. “She can stay here till she
dies,” the staffer responds softly. He later describes the strong spirit
of communal interdependence that has grown up among the ten-
ants, with those stronger and more able caring for those who have
failing health or adaptive capacities.

86
The pattern of community support that has arisen among
the Community Housing tenants has many examples.
Consider the following:

Another Community Housing tenant, Mrs. Y, had been admitted de-
spite her rather frail health, but soon developed a cardiac condition.
At her request, her place was held while she was hospitalized, and
she returned to her apartment in a few weeks. She refused the serv-
ices of a housekeeper, obtained for her by a social worker, saying
that with the help of housemates. and friends she could get along
“quite nicely.”

As most of these anecdotes illustrate, the Community
Housing arrangement seems to provide a supportive envi-
ronment that permits older people to have a sense of self-
mastery even in the face of the inevitable problems of
growing older. Within this setting, even some people with
frank psychopathology can manage to do well, as the fol-
lowing anecdote illustrates:

Mr. C, a highly intelligent man in his upper 70s, a bookkeeper by
trade, was isolated and sad in his old home. He was tormented by
children in his high-crime negighborhood who, knowing about his
phobia about germs, would give him “presents” of garbage. His
brother talked Mr. C into using his ability to help average odds in
an illegal betting operation. He was later arrested, but released by
the judge. Mr. C was subsequently accepted as a Community Hous-
ing tenant and flowered. Although he would not shake hands, for
fear of germs, he participated in many activities and developed a
rich circle of friends. (He continued to be phobic, however, and had
great difficulties when a nurse in a community mental health center
he was visiting sneezed.)

Although there is an air of tolerance among the staff
and residents of Community Housing, certain forms of
deviant behavior are unacceptable, and residents who
show signs of behavioral deterioration that are likely to
endanger themselves or others are not permitted to stay.
Four of the original residents of Community Housing have
since moved to nursing homes, with three going to PGC’s
own facility. The proximity of Community Housing to the
Center’s other facilities, combined with the tenants’ fre-
quent participation in social activities of the Center, make
a transition to other care units, when needed, relatively
untraumatic, as it was in the following case:

Mrs. Y, a Community Housing tenant who had no family, spent con-
siderable time at the Center’s other facilities, visiting with friends,
using the cafeteria, ete. During her stay at Community Housing she
became increasingly forgetful and disoriented, leaving pots burning
on the stove, and walking around with a shopping bag full of thou-
sands of dollars. On the advice of Community Housing staff, she
applied to PGC’s Home for the Jewish Aged, and was accepted. Al-
though she initially resisted moving, the transition went relatively
smoothly since she entered an environment she already knew quite
well.

87
The Community Housing experiment is still underway,
with the full results of its 3-year followup still not yet
available. At present it appears to be both a viable alter-
native in long-term supported living and a practical, low-
cost approach to housing for the low-income elderly.
Community Housing is an option only for those initially
well enough to mobilize themselves to move to a new envi-
ronment. However, once they do, it seems to provide a
balance of safety and challenge that enables them to mar-
shal their own psychological and physical strengths in the
service of fulfillment and survival, sometimes even in the
face of serious illness. This environment cannot mold new
personalities or prevent or reverse the inevitable ravages
of time and disease, but it seems to sustain that spark we
intuitively recognize as the will to live.

Friendship and the Frail in New York

Walking in the East Village in New York next to Tomp-
kins Park is almost like being in any small city in Eastern
Europe. The buildings are low, mom and pop stores
abound, street life is active, and the park is filled with
crowds of black-coated, older men huddled around chess
tables. If you follow one of the men from the park across
the street into an unassuming corner storefront, he seems
to be entering a neighborhood bar or club. Indeed, the
building once housed a bar. But now it has a new and
unexpected function.

Inside, dense clusters of old men and women are seated
in low chairs ringing the room, or crowded around small
tables playing cards. There is an air of lively conversa-
tion—in English and in several Slavic languages, mostly
Ukranian. A friendly young woman invites visitors to
have tea and a snack served by an older woman with the
grace of one entertaining in her own home. Past the snack
area is another room filled with smoke and more clusters
of people from varied ethnic backgrounds. These, too, play
cards or chess, or talk, or watch TV. A few sit silently,
seeming to enjoy the bustle but content simply to enjoy
the atmosphere and company without chatting. A few look
morose. Some young women move about the lounge and
banter with the older folks; they obviously know and like
one another. One of the men follows a young woman to
the front of the first room and joins her at a desk strewn
with forms. They chat, and she writes down some notes
while others stand or sit nearby, obviously interested in
the conversation, and seemingly waiting for their turn.
Other people, college-aged, stand behind a bar-like counter
near the front, also talking with some of the clientele. A
middle-aged woman, clearly someone in authority, alter-

88
nates between discussions with the youngsters and the
oldsters.

What is this place, and why is it here? To the people who
come here it is simply “The Club.” To those who run it, it
is “The Friendship Center.” To its sponsors, the New York
City Department for the Aging, the Community Services
Society of New York, and the Geriatric Unit of Bellevue
Hospital, it is an innovative experiment in community
service. To its Federal funders, the National Institute of
Mental Health and the Administration on Aging, it is a
possible model for more widespread implementation, one
mode of supporting the fragile coping skills of the “mental-
ly frail elderly,” thereby enabling them to remain in the
community instead of being institutionalized.

The Friendship Center feels like one of those gathering
places that has traditionally served its neighborhood
since time immemorial. In fact, it has been in existence
only a few years, founded by the three sponsors to provide
a vehicle for three important services for the marginal
urban elderly: socialization, casefinding, and social and
medical service delivery. The Center was established, in
part, in recognition of the difficulties faced by many older
ex-mental patients in reestablishing themselves as com-
munity residents. But it also was intended to serve older
community dwellers who, although never institutionalized,
have become particularly vulnerable over the years be-
cause of ill health, isolation, poverty, and the difficulties of
urban living. The East Village was selected as the site for
the Center because of its high density of marginally func-
tioning elderly and because it falls within the service area
of Bellevue Hospital’s Geriatric Unit.

Although Friendship Center is distinguished by what it
does provide—namely, a lounge program staffed by skilled
social and paramedical personnel able to respond to the
many problems of this marginal population—it is also dis-
tinguished by what it does not provide. Long experience
had shown that, although many relatively intact older
people are attracted to senior centers and enjoy the struc-
tured busyness of group activities typically offered by
such centers, the mentally frail individuals for whom the
Friendship Center was designed are not usually attracted
to highly structured activity programs. It was decided,
therefore, that the new center would offer an unstruc-
tured lounge program which would put no pressure on
clients and would permit them to do whatever they want-
ed, rather than offer them a varied, ready-made program.
Resources would be made available, but the level of activi-
ty would be up to the clientele. If some simply wanted to
come and sit, fine. If others wanted to talk or play games
or watch TV, fine too. The object would be to create a com-

89
fortable and attractive meeting place for many people
who, without the Center, might have few other sources of
support and help.

As the Center was initially planned, the lounge program
would be open for three afternoons a week. Case workers
would circulate among the clients, gain their confidence
and learn about problems, and then would schedule follow-
up counseling and service sessions on alternate days at
the Center, when it would be closed as a lounge. The origi-
nal plan turned out to be appropriate, with one exception.
The elderly members of “The Club” did not want to wait a
day to discuss their problems; they looked to the staff for
immediate reassurance and assistance. Thus, a style of on-
the-spot service delivery evolved. A high proportion of
requests for service emerged during lounge sessions, and
thus the bulk of the consultations were conducted right in
the midst of the lounge program’s bustle. Instead of a
quiet téte-a-téte in the privacy of an office, staff met with
their clients in a crowded two-room social club filled with
100 or so lively old people, some of whom might even listen
in on the conversations between aide and client. While the
evident absence of the need for personal privacy might
have come as a surprise, the warm, informal nature of the
lounge made it like a family setting and seemed to embold-
en many of the “listeners” to share their own problems as
well.

The Center has held to its schedule, however, and on
days when the lounge is closed it also provides counseling
services for those who want them, whether they are
lounge regulars or people who walk in off the street. But,
as subsequent analyses of the Center’s service patterns
have shown, the bulk of casefinding occurs during the
lounge hours.

The Center also offers a health mini-clinic served by a
nurse who administers blood pressure tests, is available to
talk with Center members about their health problems,
and makes medical referrals when necessary, usually to
Bellevue. The Center’s service program thus encompasses:
the basic socialization opportunities offered by the lounge;
social and psychological counseling; medical and social
referral; help in locating other needed services; aid in ob-
taining full benefits from city, State, and national pro-
grams for the aged; and, when required, escort service.

Taken at face value, the Friendship Center program
appears to be highly successful in attracting and servicing
the people for whom it was designed. However, its found-
ers recognized from the inception of the project that
they would not actually know its impact unless certain
questions could be systematically answered. First, was it

90
indeed attracting the “mentally frail” who lived in the
neighborhood? Second, did its services have any signifi-
cant effect on these people? The Research Division of the
New York Department for the Aging, under the direction
of Mrs. Marjorie Cantor, was assigned the difficult task of
answering these questions.

The first question was difficult, in part, because the
meaning of the term “mentally frail” was not well spelled
out, certainly not with the specificity required for re-
search purposes. Further, there were no accepted meas-
ures for “mental frailty.” The term is usually applied to
older persons who seem to be just at the edge of their cop-
ing ability, still managing to care for themselves and sur-
vive independently, but highly vulnerable, with relatively
little ability to manage one more major crisis, be it a flare-
up of illness, a street mugging, a serious problem with a
landlord, or a missing Social Security payment. The fact
that many of these people are poor and live alone adds to
the precariousness of their existence. Such people are, as
one of the project’s sponsors put it, “a truly forgotten
population.” Although often there may be resources avail-
able, they do not have the knowledge and skill to find
them, especially when they must thread their way in a
city like New York through a maze of hard-to-reach medi-
cal centers and social agencies.

At first glance, the people attending the Friendship Cen-
ter do not look like the picture of mental frailty—like peo-
ple on the edge of institutionalization. However, as the
Center staff discovered, although they seem well in the
comforting and undemanding environment of the Center,
many are likely to panic over even small challenges to
their coping skills. For example, one woman was at her
wits end when confronted with a statement clearly
marked “This is not a Request for Payment.” She could
not comprehend its meaning, and took it to represent a
serious drain on her meager funds. Others are prone to
serious depressive episodes in the face of small losses
which more intact people might brush off lightly.

Many of these people were in one way or another men-
tally frail, but it is clearly difficult to find an operational
definition of common characteristics on the one hand, or
to differentiate them either from other more competent
community dwellers or from the more impaired individ-
uals who actually require institutionalization on the other.
Thus, one ongoing aspect of the research project is to develop
a useful way of measuring mental frailty and of characteriz-
ing the various forms it takes.

The research program developed by the New York City
Department for the Aging has several facets. To find out

91

274-912 0 - 78 = 7
whether the community’s mentally frail individuals ac-
tually use the Center, random samples of each of several
populations were compared: community dwellers, regular
attendees at Friendship Center, attendees at the local
Senior Center, and outpatients of the Bellevue Geriatric
Center. If the Friendship Center was reaching its target
population, then its users should show more signs of men-
tal frailty than any of the other populations, except, per-
haps, the Bellevue group. Although the full research re-
sults are not yet available, preliminary findings have con-
firmed these expectations. Judging by a number of indica-
tors of need, the Friendship Center population indeed
appears to be in a much more precarious state than the
community members at large and to be appreciably worse
off than the older people who attend senior centers.

These preliminary findings have also indicated differ-
ences among the four populations on measures of mental
health and mental status. Although the final criteria for
mental frailty are still being developed, it appears that
the Friendship Center participants are in a much more
fragile state of mental health than the other populations.
It seems strange, perhaps, that a service program devoted
to helping people function better is pleased to discover
that its clients represent the poorest functioning segment
of the community it serves, but in this case, since the Cen-
ter was established as a magnet to attract just these peo-
ple, these findings are a source of considerable pleasure.

Sparking the creation of the Friendship Center is the
hope that, if particularly vulnerable and needy older peo-
ple are attracted to a readily accessible spot in their
neighborhood and receive a wide array of needed services,
many of which are delivered instantly on the spot (includ-
ing crisis intervention), they may be better able to sustain
their fragile physical and mental health. The Center’s
efforts may serve to strengthen clients’ tenuous coping
ability and extend their days and years as community
dwellers. Obviously, not all need the support equally, not
all are likely to benefit equally, and not all are likely to be
able to sustain themselves indefinitely, given the handi-
caps they already endure and the erosion of mental and
physical strength aging can bring. However, the right
medical, psychological, social, or other intervention at the
right time can often do much to avert the precipitous col-
lapse of an older individual’s physical and mental health
and to retard the more insidious processes of decline. The
question still to be answered is whether these hoped-for
benefits will arise from the Friendship Center experiment.

To answer this question, two main types of information
are needed. First, in what ways do Friendship Center par-
ticipants change over time after they have had contact

92
with the Center and its services? And second, so that some
basis for comparison can be established, what kinds of
changes occur over a similar time period for the general
community population? Consequently, subsamples of both
the Friendship Center and the community were selected
and reinterviewed 1 year after the original contact.

At present, since this final phase of the project has not
been completed, we do not know whether the Center has
averted or softened the impact of many of the problems
that plague this particular population. In the opinion of
Mrs. Cantor, many of the positive effects of participation
in the Center may be too subtle to be detected by the
usual measures, i.e., readministration of the standardized
measures used in the questionnaire to both population
samples and by a comparison of mortality and morbidity
rates and the rate of institutionalization in both popula-
tions. But some aspects of the questionnaire, particularly
those pertaining to activities of daily living, members’ lev-
el of interaction with other members outside the Center,
and members’ perception of the role of the Center as a
supportive agency in their own and other members’
lives, may reveal some of the benefits of the model which
would be missed by standardized tests alone; these parts
of the questionnaire should show the Friendship Center
participants to better advantage than the community resi-
dents who did not attend. Of particular interest will be
whether those who attend most frequently represent the
most needy of its needy population. Furthermore, it is un-
likely that these individuals, who are often seriously vul-
nerable, can be expected to show appreciable improve-
ments in health and general well-being. Rather, if the
overall condition of such elderly persons can be stabilized
through the Center’s intervention and its highly suppor-
tive environment at a time when they seem to require it,
the model can be said to have been successful.

Whatever the final outcome of this study, its prelimi-
nary findings already suggest that the unstructured
lounge program performs a vital function: bringing to-
gether fragile older people who can help one another
maintain themselves in the community and bringing them
to a convenient place where many vital services can be
dispensed. This aspect of the program has already cap-
tured the attention of a number of service agencies inter-
ested in discovering more effective ways to find and help
the hard-to-reach elderly. In particular, the program is
being carefully watched as a possible model for implemen-
tation by community mental health centers. These impor-
tant mental health care resources have often had difficul-
ty in attracting and providing services for the older popu-

93
lation, in part because of their own staffing problems, but
also because older people tend to shy away from services
labeled as “mental health.” They are of a generation that
views seeking mental health care as tantamount to admit-
ting that one is “crazy.” (This problem of stigmatization
of mental health services is found among other popula-
tions, notably some people in rural settings and some
poorly educated urban dwellers.)

It is hoped that by replicating this unstructured store-
front lounge which offers comprehensive health, mental
health, and social services geared to vulnerable older per-
sons, the mental health stigma can be bypassed, and help
can be given in a way that is acceptable to this proud but
often illness-prone population. To accomplish this goal, the
model has already been replicated in the New York area
and will be replicated again and again as more mental
health centers augment the knowledge and skills of their
staff to serve the aged—a process already underway
across the country through training programs instituted
under NIMH sponsorship.

Services for SROs: The Stratford Arms Experiment

For older city dwellers who are poor, single-room occu-
pancy hotels (SROs) provide an affordable refuge that
offers a modicum of company and basic services, while
making few demands on their social skills. Some of these
older SRO residents, like many of the nonwelfare tenants
described in the San Diego study reported on pp. 38-45
seem able to patch together a lifestyle to suit their needs
and abilities. Other SRO tenants, however, seem unable to
manage well in the laissez-faire environment of their ho-
tels. This seems to be particularly true of many older ex-
mental patients, who were released “to the community”
during the past decade of “deinstitutionalization.”
Although the motives to return these individuals to com-
munity living were in many respects humane, a lack of
careful planning and coordination of their aftercare left
countless people (often “burned out” schizophrenics) hid-
ing in the cracks and crevices of big cities like New York,
unwilling and unable to seek out the kinds of care they
needed, whether medical, social, or psychiatric. While
some of these older ex-mental patients have found their
way to the protective environment of nursing homes (see
pp. 110-116), many others are living in SROs which pro-
vide only a room and perhaps maid service. The SRO life-
style may suit those who are relatively well physically, and
the self-sufficient loners, but it often demands more coping
skills than many quite impaired tenants actually possess.

94
Recognizing that many of these individuals might never
receive the ongoing help and support they need unless it
is brought directly to them, the City of New York began in
the 1960s to experiment with a number of types of onsite
delivery to selected SRO hotels in Manhattan. Serving as
a model for several innovative programs for SRO tenants
was the Stratford Arms Hotel, a 400-bed hotel on Manhat-
tan’s West Side.

Like many hotels of its type, the Stratford Arms is lo-
cated in a rather squalid neighborhood, harboring the
usual complement of prostitutes, drug pushers, ete. It, too,
has seen better days, as its grand but unfurnished lobby
bears mute testimony. The hallways are grim on its 10
floors, arranged with 40 rental units to a floor, with six
communal bathrooms and four showers for residents of
each floor. The modest rent of $140 a month buys a single
furnished room, about 8 by 12’, and maid service. Tenants
usually live alone (except for the roaches), often cooking
on hotplates and storing food in small refrigerators or
using the traditional windowledge. Normally, tenants
living in such hotels have little opportunity for recreation,
save watching their own TVs, listening to the radio, or
congregating in the bare lobby.

The typical tenant of Stratford Arms is a woman usual-
ly in her late 50s or older (ranging from 19 to 93) and on
welfare. Educationally, tenants range from those with
only a grammar school education through a striking 18
percent with some college background. Like the Golden
West residents, they tend to be stable tenants, averaging
3 years at the hotel, with some oldtimers totaling as long
as 20 years. Only a small percent will admit to being ex-
mental patients, but according to their records, almost
one-third have been State hospital patients. About one-
fifth of the tenants have drinking problems. Almost all of
the tenants are single, having never married or having
lost their spouses through death or divorce. A 1970 survey
of the tenants revealed that 250 of the hotel’s 400 rooms
were rented to welfare clients: 90 were on Old Age Assist-
ance, 128 received Aid to the Disabled, 3 received Aid to
the Blind, and 26 were receiving Home Relief. Thirty-five
of those receiving Aid to the Disabled (because of severe
mental illness) were 60 years of age or older, and another
30 receiving Old Age Assistance were former recipients of
Aid to the Disabled. Many of these people required far
more than financial aid but were in minimal contact with
the service system.

With the cooperation of the hotel’s management, the
innovative Stratford Arms experiment began under the
joint sponsorship of the New York City Department of

95
Social Services and the Roosevelt Hospital, which serve
the area in which the hotel is located. Between 1965 and
1971, staff members of the two organizations initiated
several projects together at the hotel, becoming familiar
with both tenants and management, discovering the ten-
ants’ many needs, and starting up several types of hotel-
based services designed to enhance tenants’ mental, physi-
cal, and social well-being.
Early contacts with the tenants revealed a welter of
problems. As noted by some pioneer visitors to the hotel:
Unable to use effectively the health and recreational facilities avail-
able in the community, the public assistance residents tend to lead
isolated lives and spend much of their time in their rooms. Those
who have been seen medically have been frequently unable to keep
follow-up appointments, or to take their medications as prescribed.
Most of them will not approach hospital services at all, fearing that
once they enter the hospital, they will be incarcerated there against
their will. Their nutritional status tends to be poor. Feeling too
weak to go to a neighborhood restaurant to eat, they will frequently
subsist on one meal a day sent to them from a local restaurant. In-
deed, their single-burner hot plates do not allow them to cook ade-
quate meals in their room. Loneliness also is a major complaint.
Many tenants are fearful of strangers, and lack basic social skills.
Therefore, they often remain alone in their rooms, bereft of any so-
cial involvement.

The cost to the community of these aged, marginally functioning
individuals has been large. This cost resides, in part, in the large
number of ambulance and police calls which result from these peo-
ple’s inability to use existing services properly. In addition, there
results a more intangible, yet very real neighborhood problem, such
as increased tension, fear, distrust, and suspicion. These all combine
to present the picture of the “decaying neighborhood.”

Many tenants were severely debilitated individuals,
highly fearful of strangers and interlopers—particularly
those with the potential authority to send them back to
mental institutions. However, over the years, as various
programs were instituted at the hotel, the tenants began to
respond and participate.

The multifaceted service program, geared at first only to
the welfare recipients, had several features with interlock-
ing benefits for the tenants. A “work-oriented therapeutic
community” was forged out of two important elements: a
Tenant Council and a tenant “Job Corps.” Recognizing that
many of the tenants suffered from a sense of powerless-
ness and inability to control their lives, their environment,
or their fate (a status exacerbated for many by their status
as welfare recipients), the staff organized the Tenant
Council to serve as a sounding board for tenants and a
rallying point for the creation of a tenant community:

The therapeutic community approach with its focus on social and

group interaction, and on communication client-to-client, client-to-
staff, and staff-to-staff, has but one goal in the hotel setting: to help

96
the individual begin to play a more active role in the determination
of his fate, and in doing so, to gain greater awareness and use of his
capacities. This approach then emphasizes the need to create within
the hotel a new social subsystem which allows peer group autonomy
to flourish and to be rewarded when evident.

The Tenant Council met weekly to discuss issues rele-
vant to the lives of the tenants. All those who attended
meetings were automatically members with full voting
privileges. Both staff and tenants suggested agenda items
and discussed them with the staff serving in a consultant
role. Often, to resolve specific problems, a tenant commit-
tee would be elected to represent tenants through negotia-
tions with hotel management or outside agencies.
Problemsolving committees were addressed to such issues
as tenant rights and relations to management; social
and recreational events; tenant rights regarding welfare;
and guidelines for appropriate tenant behavior in the ho-
tel “community.”

The tenant “Job Corps’ evolved out of recognition that,
given an opportunity to test and sharpen job skills, many
of the tenants could gain status and self-respect through
paid work in the hotel, whether as project clerical help,
aides to aged and handicapped fellow tenants, teachers
and leaders of recreational and social groups within the
hotel, or as trained aides to the Department of Social
Services staff and Roosevelt Hospital personnel. The Ten-
ant Council was given responsibility for developing the
Job Corps as well as dispersing funds for the hotel’s recre-
ational programs.

Many of the project’s activities were held in a large low-
er lobby (formerly used for storage) which a working coali-
tion of tenants and staff had converted into a tenant
lounge. It was attractively decorated and sufficiently fur-
nished to seat 90 tenants. The lounge housed the Tenant
Council meetings, recreational events, a small library, and
breakfast and lunch programs which were developed for
tenants.

In addition to the “therapeutic community” programs,
onsite medical and psychiatric services were offered. The
psychiatric service evolved out of requests from members
of the Tenant Council who, after developing a feeling of
trust toward the staff, requested private sessions with
some staff members. The psychiatric consultation service
was staffed by two psychiatrists, a social work supervisor,
a psychologist, and a psychiatric nurse, all part-time staff
of Roosevelt Hospital. Tenants were seen either in their
rooms or in a treatment room rented in the hotel.

The medical service, staffed by an internist accompanied
by a nurse from the visiting nurse service, offered a mini-
clinic at the hotel every 3 weeks for 3 hours to examine

97
tenants referred by the staff, the Tenant Council, or other
residents.

These diverse programs had many complementary, and
sometimes overlapping functions, and the staff members,
whatever their discipline, were sensitized to encourage
growth, health, and confidence in the tenants. One of the
early benefits of the miniclinic went beyond improved
physical health: Some of the tenants, in response to their
miniclinic visits, seemed to become more sociable and
sometimes less prone to erratic or withdrawn behavior.

Although the Tenant Council and the Job Corps had at-
tracted many of the more active and able members of the
hotel community, there were many other residents who,
according to their peers, were too feeble, debilitated, or
asocial to venture forth from their rooms. In 1971, an esti-
mated 70 tenants were participating in the “therapeutic
community,” but another 180 under Department of Social
Service supervision were nonparticipants. As described by
the project staff:

Many are not only aged, but also have a history of State hospitaliza-
tion for psychiatric reasons. Coloring this is the fact that since dis-
charge, these individuals have suffered from poor health habits and
bad nutrition, and consequently, frequent bouts of severe physical
illness. Indeed, it would not be a gross exaggeration to state that

the project hotel is in fact a structured communal residence for an
aged psychiatric population.

In 1971, with NIMH funding, an applied research proj-
ect was begun under the direction of Dr. Bernard Hall, of
Roosevelt’s Community Mental Health Service, to expand
and evaluate the service program already underway. To
reach the particularly needy and isolated tenants (and to
provide additional services to those already participating
in the “therapeutic community”), several old programs
were enlarged and new service programs were added.

An enlarged medical service was established to assure
accurate diagnosis of tenants’ health problems (and to
avoid confusion of medical and psychiatric problems), to
provide some onsite treatment, to aid tenants in health
maintenance, and to make appropriate referrals to other
health resources (particularly Roosevelt Hospital) when
necessary. The miniclinic program was intensified to oper-
ate 2 days a week, under the supervision of a physician
from the Department of Ambulatory Care at Roosevelt
Hospital. It was staffed by a physician’s assistant (M.D.),
medical students, and a public health nurse.

The program’s broadened psychiatric component includ-
ed a psychiatrist, psychiatric residents in training, a psy-
chiatric nurse, and a psychiatric social worker. The psy-
chiatrist and residents saw tenants on a regular weekly
basis, both at the hotel and at their offices, and prescribed

98
medications as needed. They were also available for emer-
gencies and crisis intervention. A weekly clinical confer-
ence was conducted by the psychiatric nurse, and staff
members also attended a weekly 2-hour seminar at the
hotel. In addition, a full-time alcoholism counselor provid-
ed support and counseling, on a one-to-one basis, to hotel
residents with drinking problems.

The hotel’s recreation program, supervised by a full-
time recreation therapist, continued to be planned and
conducted with the help of tenants. Activities and classes
were conducted weekly, sometimes led by tenants who had
special skills. Monthly birthday parties, holiday celebra-
tions, trips and outings were also organized. In addition, a
monthly tenant newsletter, written by tenants and staff
and edited by seminarians working part-time at the hotel,
kept tenants abreast of project news, Tenant Council af-
fairs, and recreation programs, and also provided profiles
of tenants and staff. (The seminarians, in addition to di-
rect work with residents, also conducted religious services
at the tenants’ request.)

The new grant also permitted a significant addition to
the project’s comprehensive services: a floor counselor
program. Each staff member, in addition to his or her rela-
tively specialized role (e.g., psychiatric nurse, social work-
er, researcher, etc.), took responsibility for helping the
tenants on a particular floor with their problems, some-
times providing counseling or referral to other staff mem-
bers or offering aid for concrete problems such as arrang-
ing a room change. A weekly problem-oriented group ses-
sion for counselors, maids, and people from the floor in-
creased socialization and provided a further vehicle for
discussion and problemsolving. (Additional help also came
from caseworkers from the Department of Social Services
who were present at the hotel 5 days a week. They not
only helped welfare recipients to deal with the welfare
system, but functioned as counselors and referral agents.)

In its expanded form, the Stratford Arms Project was
designed to provide a broad range of multidisciplinary
services required by this multiproblem population and to
serve as ‘“a model for the development of comprehensive
treatment and rehabilitation programs for elderly welfare
tenants and psychiatric patients living in residence hotels
in urban settings.” Its broad purpose was to “improve the
quality of life of the tenants and to establish a sense of
community as well as personal autonomy among the resi-
dents.” One of its more immediate goals was to assure
that many of the neediest and most difficult to reach of
the urban elderly gain ready access to essential profes-
sional services.

99
In many respects, the project indeed accomplished its
stated goals, bringing many tenants out of their rooms
and into a lively community of others, strengthening their
sense of self-worth, and facilitating contact between ten-
ants and helping professionals. For example, between
January and June, 1972, when the expanded project was
in effect, tenant use of professional services increased
dramatically. During that period, tenants’ contacts with
medical personnel rose from 215 a month to 356; psychiat-
ric contacts increased almost five-fold, from 52 to 255
monthly, and increasing numbers of tenants participated
in recreational activities. The greatest gains were in the
area of social service, with contacts rising from 398 in
January to 2,022 in June. The floor counselor program
apparently sparked much of the intensified service use;
abrupt increase in tenants’ service contacts followed the
program’s introduction, an indication of its strong impact.

The members of the research team evaluating the proj-
ect (Robert Plutchik, Martin McCarthy, Bernard Hall,
and Shirley Silverberg) have noted that “It is often not
possible to know in advance what the requirements for
services will be until the services are offered.” Once serv-
ices were made readily available (and their use became
socially sanctioned), a growing number of tenants used
them. The establishment of services was guided, however,
by careful study and documentation of the residents’ char-
acteristics, problems, and needs. Throughout the project’s
latter phase, research and service delivery were often
concurrent and intertwining activities, with data gleaned
from the research side serving as a basis for improved
service.

The Stratford Arms Project represents not only a suc-
cessful collaboration among several agencies and multidis-
ciplinary personnel, but also a model of a service setting
that became a training ground for new health, social serv-
ice, and psychiatric workers. Through the cooperation of a
complex of local educational institutions, students in the
service professions came to the hotel as part of their field
placements and coursework. Many of these students con-
fronted for the first time the real problems and needs of
the isolated elderly poor and ex-mental patients. Those who
stayed long enough learned that effective intervention is
possible through intensive outreach efforts and that even
the aged mentally ill can, in a congenial environment,
regain some of their health, sociability, and self-respect.

The Stratford Arms experiment poses many interesting
questions for future researchers and policymakers. Like
many ambitious government-funded programs, it showed
that many needy people will respond well when an inten-

100
sive effort is made to reach and help them. However, the
project represents an investment of people, time, and
money unlikely to be found in most parts of the country
and, indeed, even in most SRO hotels in New York. In
effect, the Stratford Arms Hotel was transformed from a
typical SRO hotel into a residential psychiatric facility,
minus the stigma of institutionalization. In the absence of
comparison groups, it is difficult to assess the merits and
drawbacks of this model of service delivery to the margin-
al urban elderly, or to determine which tenants seem to ben-
efit most from such a setting. There seems to be little
doubt that for many, but not all, SRO tenants, a room, a
maid, and a welfare check are not enough. One question
still to be answered is: How can needed services be made
available to elderly SRO residents most economically and
effectively to yield the greatest benefits with the least
amount of intervention?

Outreach and Opportunity

Every big city has its complement of older people who
live alone, experience periods of impairment, or suffer
from chronic illness. They need a variety of kinds of help,
are reticent about seeking it, or cannot find their way
through the myraid of agencies. They need someone who
can interpret their needs and intercede for them. Each
city also has its share of unemployed, desperate for work
and income. Rarely do the twain meet, but in Cleveland
they have, through a unique program designed and con-
ducted by Mrs. Goldie Lake and her associates at Cleve-
land College of Case Western Reserve University. The
program stemmed from an insight at once obvious, but
rarely perceived:

...Vast numbers of people, mainly minorities suffering from discrimi-

nation, were unemployed, while other equally vast numbers of peo-
ple needed health care and other kinds of human services.

Mrs. Lake and her coworkers, long experienced in con-
ducting manpower training programs, recognized a major
service gap and designed a training program to fill it—and
to transform the unemployed into useful paraprofession-
als with new careers. They had perceived that many mar-
ginal elderly people could probably remain outside of insti-
tutions if they had greater access to support and services.
However, the link between available services and those
needing them was often never made, because the elderly
lacked the ability to find the agencies, and the agencies
lacked the staff to reach out to the elderly.

The new role of Geriatric Outreach Worker (GOW) was
created to forge the needed link between elderly communi-
ty dwellers and service agencies. There were many types

101
of home-based aid these new paraprofessionals might ren-

der:
Some elderly, living alone and neglected, had to be located—the
services they needed had to be identified and then secured for them;
older people who were withdrawn, isolated, or depressed needed ei-
ther to be visited or helped to participate in some form of social life.
There were problems of nutrition, proper medication and medical
attention that had to be attended to—normal and abnormal changes
in the older person that indicated a change in treatment or care
should be recognized and reported to appropriate agencies or per-
sonnel for immediate response; information about available finan-
cial benefits had to be imparted. People on waiting lists of homes for
the aged required care and attention until they could be admitted;
families sometimes needed a measure of relief until an opening in
an institution became available for their older relative.

Results of previous manpower training programs indi-
cated that, with a specially designed curriculum and sup-
portive services presented through a total approach or
package of education (rather than course-by-course tradi-
tional classroom education), the participating disadvan-
taged adults in a very short time could become trained
and educated to provide these needed services directly or
to be liaison to services, while working for an agency al-
ready serving the elderly.

With funding provided by NIMH, the Department of
Labor through AIM-JOBS (Cleveland’s Concentrated Em-
ployment Agency), and the Greater Cleveland Associated
Foundation, this idea was put to the test through a 3-year
demonstration training program.

Under the coordination of Western Reserve University’s
Cleveland College staff, headed by Mrs. Lake, 13 local
agencies agreed to provide on-the-job training experience,
while eight of these further committed themselves to em-
ploy the graduates once they had successfully completed
the program. Trainees were recruited from various man-
power programs, through welfare staff recommendations,
participating agencies, local associations, and through
community advertising.

Each of the 65 initial recruits was screened through
four separate staff interviews (using a specially devised
questionnaire) to determine the “sensitivity to the com-
plexity of the problems and his or her objectivity.” Their
academic and achievement levels were also screened. The
majority of those accepted tested above the eighth grade,
but others, with a history of personal experience that led
to compassion and commitment but whose educational
level was lower, were also accepted. Of the 25 who sur-
vived this rigorous selection process, 22 were women, 19
black and 3 white; and 3 were men, 2 black and 1 white.
All had worked previously—primarily in the lowest grades
of restaurant, factory, domestic, or hospital work—and

102
some had prior experience as aides in institutions working
with the elderly. Although their average age was 34, the
range was wide, from 18 to 57. Most had children, and 65
percent were on welfare.

Experience with previous training programs suggested
to the Cleveland College staff that a relatively long train-
ing period—10 months and approximately 40 hours per
week, would be needed to communicate all of the knowl-
edge and skill required to carry out the role of Geriatric
Outreach Worker.

A formal academic curriculum was combined with field
experiences to provide a foundation and then to reinforce
it and broaden the trainees’ knowledge and skills. The
academic curriculum, developed through discussion with
geriatric specialists and consultants, covered technical
skills (first aid, budgeting, meal planning, transfer tech-
niques, etc.), concepts of aging, social work skills, and
knowledge of community resources, as well as courses and
special classes for general knowledge and personal develop-
ment; psychology, related sociology, group dynamics, basic
education (reading, writing, and math), community and
personal problems such as drugs, consumer protection, ete.

A curriculum coordinator developed the Social Work
Skills and Concepts of Aging curriculum which served as
the basic course throughout the 40 weeks. In addition,
professional experts in many technical skill areas planned
curricula and recommended supplemental lecturers, ma-
terial, and field trips.

The program’s educational methods were the culmina-
tion of successful prior experience in working with similar
trainee groups. The director always acted as job develop-
er, recognizing that the greatest motivator was the
knowledge that actual jobs existed; lecturers were briefed
on how to address the trainees and at what level to pre-
sent their material so as to eliminate condescension or
disrespect; trainee decisionmaking on policy issues and
stimulation through a combination of academic and field
work were built in. To reinforce learning, trainees were
divided into “cores,” small groups of 10 to 13 people, each
guided by an experienced indigenous person, with whom
they met between courses to discuss and review the ma-
terial just presented, to exchange experiences and reac-
tions to field training and the relationship between these
and the course work, and to discuss relevant topic issues.
Core groups also served as a vehicle for airing and solving
trainees’ personal problems.

Before their assignment to field placements and job-
training agencies, trainees participated in field trips, visit-
ing homes for the aged, social agencies, and community

103
institutions. Students and agency representatives then
met together to determine training assignments.

To assure clarity and consistency between agency as-
signments and the classroom educational component and
to assure that the trainees would receive a clear picture of
their assigned agencies’ roles and their own roles within
them, a series of meetings was held between the training
center staff and agency representatives. At these meet-
ings, trainee needs were articulated and training agency
roles clarified. In the light of general training goals
worked out together, each agency developed individual
and varying on-the-job assignments. On-the-job training
was phased in gradually, starting with 2 days a week and
proceeding to 4 days, with the remaining time spent at
the training center. In order to broaden their experi-
ences, students had an opportunity to work 1 day a week
in another setting as well, with work assignments
matched to their individual needs.

Because of the program’s innovative nature, the role of
the Geriatric Outreach Worker in each agency had to be
carefully spelled out, with careful attention to sustaining
the pride and professionalism of the trainees. As noted by
Mrs. Lake:

Each agency and each trainee had their own ideas of what the role
of the GOW was, and what kinds of work this called for. For exam-
ple each questioned, at the outset, how much homemaking service
was to be rendered. Should the GOW wash dishes or not? The men-
tion of helping with household tasks was guaranteed to bring about,
understandably, a totally negative response from many black train-
ees. At first, it was difficult for them to see activities of this type as
an opportunity to socialize with the client, or to teach or reteach a
skill as a means of salvaging whatever remained of the clients’ inde-
pendence, or to see a task as a one-time activity that could ease a
situation until a Homemaker could be obtained. The historical stig-
ma attached by many to anything resembling domestic work could
not be underestimated. By the end of the training program, howev-
er, the value of these activities was recognized and earlier reluc-
tance forgotten.

Once in practice, many of the trainees appreciated more
and more the value of the “academic” curriculum, fre-
quently referring to their notes and books, and became
increasingly interested and involved in their new jobs.
Often their “mother wit” or “street knowledge” strength-
ened their ability to develop practical solutions to their
clients’ problems. As their roles became better defined,
and the trainees gained in experience and confidence, they
rendered a broad array of much-needed personalized serv-
ices to their elderly clients. The following excerpts from
the trainees’ notes communicate some of the flavor of
their day-to-day contacts with the elderly:

-.A client was acting strangely—she refused to leave her house,
even to buy food because “there were barriers outside which were

104
set up to hurt her.” Reported, after consulting with supervisor, to
Protective Services about the behavior of client. They investigated
and found the woman needed a psychiatric examination. She was
found to be disturbed to the point that it was considered unsafe for
her to be left in the community and she was admitted to Cleveland
Psychiatric Institute.

...Client was very lonely, said she didn’t know anybody. Explained
about Golden Age Center—found out about activities for client and
took her to the Center. Client enjoyed the activities and now goes by
herself.

...Client was blind—filled out forms for application for financial as-
sistance. Client needed dental care. Obtained permission for den-
tures. Had to find dentist living in neighborhood or close to trans-
portation who would accept health card. Called five or six dentists in
the yellow pages before finding one who would see client. Set up
appointment, arranged transportation to dentist for client.

..Reported funny odor in corridor—emanated from apartment
where resident had been lying dead for two weeks. Reported death.
This was followed by a number of other deaths in a short space of
time. Meeting was held—started Operation Alert: five people on
each floor check each day to see if all is well.

...Took client downtown to buy shoes and bag—client hadn’t been
out of house ever since she moved into housing project—was con-
fused after move. Found out that she liked to go downtown—go to
Kresge’s for lunch, etc.—and we did those things on trip.

..One client fell and had ten stitches—house was in disorder.
Rearranged furniture so client wouldn’t fall. Got homemaker. Client
hadn’t changed clothes for months. Helped her. Showed interest in
her. Sent her card. Brought her Easter eggs. Found out she liked to
read the Catholic Universe Bulletin. Ordered it and had it mailed to
client. Client responded to interest. Now is cleaner—takes care of
herself.

Many trainees in this program were not particularly
interested in working with the elderly when they began
but developed a strong commitment to take over the
course of training. Mrs. Lake describes their transforma-
tion thus:

Many, during the early stages of the program, would have preferred
working with a different age group. Yet, at some point in the pro-
gram, possibly through a combination of factors, their natural con-
cern for fellow sufferers, the education that made them more under-
standing and accepting of the idiosyncracies of the elderly, the rela-
tionships with clients that captured their emotions—they began to
care about the people they served and began to feel the satisfaction
which derives from confidence—from acquiring competence in a field
of work, and the gratification from being of service, of being valued
and of having some power to do good. Added to these came the slow-
ly growing belief that a respectable, fairly well-paying job would
materialize. All these combined to make people change from their
initial lack of interest so that, by the end of the program, most real-
ly wanted to work with the elderly.

An evaluation of the Geriatric Outreach Worker pro-
gram by Dr. Donald Hull, of Case Western Reserve Uni-
versity, based on extensive interviews with trainees and
agency representatives, sought to identify the program’s

105
impact on trainees and the agencies they served. General
consensus was that the Geriatric Outreach Worker pro-
gram had facilitated changes in some agencies toward
provision of outreach services in the community and made
it possible for an agency to expand or supplement its serv-
ices. One hundred and five people received training in three
10-month cycles conducted from 1970 to 1973. During this
time, while in training, as part of their field experiences
and afterward when employed, they had brought a variety
of services to several thousands of elderly people. An esti-
mate of the number of people served (based on an analysis
of available agency statistics) indicated that the trainees
and GOW graduates combined had 720 clients and made
1,600 visits during the first cycle; 2,016 clients and 4,480
visits in the second cycle and 2,572 clients and 5,670 visits
in the third cycle; 78 graduates were employed by 17 agen-
cies and served the elderly in a variety of ways according
to the purpose of the agency. The salaries ranged from
$4,800 to $6,500 annually with a median of $5,800.

Agency supervisors rated the trainees highly on per-
formance and ability. The trainees adapted well to their
specific agency roles and felt secure and comfortable in
their positions. The evaluation also uncovered many prac-
tical problems that interfered with optimal functioning of
the trainees. For example, some of the agencies that em-
ployed these workers were oriented only toward providing
“acute” care of problems, such as arranging for clinic vis-
its, food stamps, or shopping. In such contexts, the Geriat-
ric Outreach Workers could not develop long-term rela-
tionships with their clients. As Dr. Hull has observed:

This state of affairs poignantly underlines the need for a manpower
pool of sufficient size to handle the large elderly population in need
of service....

Another obstacle, in many highly bureaucratic agencies,
was the lack of an occupational “slot” for this new type of
paraprofessional. Resolving this problem required such
agencies to broaden their formal staffing patterns to in-
clude this novel role.

The outreach aspect of being a Geriatric Outreach Work-
er required adequate automobile transportation so that
GOWs could be mobile. Again, agencies unaccustomed to
offering such services were often ill-equipped to provide
needed transportation, and many of the trainees lacked
cars and licenses.

In a few agencies, before there was a realization of the
extent and quality of education, problems were encoun-
tered when trainees were asked to perform work they
viewed as demeaning, such as only cleaning and cooking.
Also contributing to lowered trainee morale was the rela-

106
tively low rate of starting pay they were offered, some-
times as low as $1.80 an hour. The wage structure was
determined by the agencies, not the training project staff,
and often reflected the agencies’ own funding problems.
Obviously, if Geriatric Outreach Workers were to be re-
cruited and retained on a long-term basis, they would
have to receive salaries more appropriate to their status
as paraprofessionals.

There is little doubt that many communities could bene-
fit from the presence of well-trained paraprofessionals
who can deliver home-based care for the elderly and are
sensitized to the special mental health needs of their older
clients. As this experimental training program has shown,
many of the long-term unemployed can successfully learn
and adapt to this role and perform extremely well. Other
communities interested in developing similar programs
and enhancing the outreach capabilities of local agencies
serving the elderly will have to anticipate and address
many of the structural problems discussed here to assure
that Geriatric Outreach Workers will have ample job op-
portunities, pay, and agency assignments that permit
them to establish ongoing close ties with their clientele.

Mrs. Lake and her co-workers have developed an effec-
tive way to fill a major service gap. The remaining task is
to integrate these new human service workers into the
existing service system so that they can become a perma-
nent community resource for the fragile and homebound
elderly.

107

274-912 O - 78 = 8
V. Agingand Institutionalization

About one million older adults in the United States now
live in institutions, with about 80 percent in nursing
homes and old age homes and 20 percent in mental or oth-
er chronic disease hospitals. For many of the chronically
mentally and physically ill, institutional living has long
become familiar through many years of hospital residence.
For most, however, institutionalization is an unfamiliar
living style (or, for some, a dying style) that was adopted
relatively late in life when, for a variety of reasons, they
could no longer manage well as independent community
dwellers.

Overall, among the 65-plus population, only 5 percent
live in institutions, but the chances of institutionalization
rise appreciably with age. Thus, only 2.1 percent of those
65 to 74 live in institutions, compared to 9.2 percent of
those 75 and older. Looked at from a slightly different
vantage point, almost two-thirds of the institutionalized
elderly are 75 and older. Thus, any discussion of aging and
institutionalization is addressed particularly to the well-
being of a small but substantial population of our elders,
often the oldest segment.

The cost to the Nation for institutional care of our el-
derly is in the billions annually—and rising—due both to
inflation and an increased population receiving institu-
tional services. Concern has arisen in many quarters that
this large investment has not resulted in appreciable im-
provement in the quality of life for the older dependent
population. Indeed, some would argue that it has merely
reinforced the use of an unsatisfactory solution to the
many complex problems faced by these individuals: failing
physical and mental health and the absence of an ade-
quate system of social supports.

Unquestionably, there are some individuals whose service
needs could be met effectively outside of an institutional
setting. As the preceding pages have illustrated, we are
just beginning to try to discover who these people are and
to provide other arrangements so that they can remain
community dwellers. However, we will always have some

108
elderly people too feeble and sick to remain at home, even
with the support of many helping services. The question
for these is: How can we make institutional living more
fulfilling for those who require it?

There have been important pioneering studies addressed
to this question, a few of which will be discussed in this
chapter. Some of them deal with the processes and choices
that bring older people to institutions, some with the char-
acteristics of the institutions themselves, and some with
the effects of institutionalization on older residents, partic-
ularly effects related to mental health and well-being.

The studies reported here focus on the nursing home as
a locus of institutional care for the elderly. This emphasis
reflects the fact that nursing homes now represent the
primary long-term care setting for the institutionalized
elderly. Prior to 1965, when Congress passed Medicare and
Medicaid legislation, the mentally ill elderly who needed
institutional care were admitted to public mental hospitals.
But since 1967, with Federal support available for nursing
home care, the pattern has shifted appreciably. Many
public mental hospitals essentially closed their doors to
new admissions of elderly mentally ill patients, and a
great effort has been made ‘to place even their long-term
residents in other settings, often nursing homes.

The thrust behind the movement of the aged mentally
ill away from State hospital care represents the conflu-
ence of many good intentions: to shift State hospitals
toward care which is more rehabilitative than custodial, to
provide more appropriate care for individuals whose fail-
ing physical health requires a strongly medically oriented
setting, to return long-term mental patients to community
living. However, the net effect for many older individuals
has been unfortunate. In some areas where adequate fa-
cilities for long-term care were unavailable, older mentally |
ill persons have been placed in settings no better, and
sometimes worse, than the State mental hospitals. In oth-
er instances, they have been placed in facilities that pro-
vide good physical care but have no resources or skill in re-
sponding to residents’ mental health needs.

We are in an awkward stage in the development of insti-
tutional care for the elderly. Our nursing homes—and the
funding arrangements that support them—are geared to
providing physical health care to the aged. They have not
been structured to care for the mentally ill or to provide
an environment conducive to sustaining mental health
and well-being in their aged residents. As a result, many
mental health problems and needs go undetected and
unheeded and sometimes worsen in an inhospitable envi-
ronment. The widespread incidence of mental impairment
among the institutionalized elderly, estimated to run as

109
high as 50 percent, represents, in part, their advanced age
and pre-existing conditions that initially led to their insti-
tutionalization. But it may also represent the effect of liv-
ing in an environment that provides little stimulation or
motivation to keep alert, intact, and growing. Many of
these supposedly mentally impaired nursing home resi-
dents may be suffering more from depression than from
true organic brain disease (see pp. 128-132). This situation
has inspired many mental health advocates to search in-
tensively for “alternatives to institutionalization,” while
others are seeking ways to make nursing homes more re-
sponsive to their residents’ mental health needs—ampli-
fying the mental health training of their staff, making
mental health consultants more readily accessible to nurs-
ing home residents, and instituting a variety of recrea-
tional and therapeutic programs to stimulate patients’
mental and emotional growth and restoration.

Let us look at several descriptive studies of institutional
care of the elderly that give us some feeling for how their
residents are faring and where new approaches are need-
ed. We will start with a “field” study designed to explore
the fate—and well-being—of older people with known
mental illness who were sent to nursing homes by mental
health facilities. Some of these had been long-term mental
hospital residents, while others were simply “diverted”
from these settings, once diagnosed. The study looks at
residents of both nursing homes and ‘“board-and-care”
homes—the latter being something like a boardinghouse
but offering some modest medical services.

Old Folks at Homes

In 1975, a survey and field study was conducted by the
Joint Information Service of the American Psychiatric
Association and the National Association of Mental
Health (partially funded by NIMH) to explore the place-
ment and quality of care of mentally impaired older per-
sons discharged or diverted from mental hospitals to nurs-
ing and board-and-care homes. A survey was conducted to
determine the criteria used by State hospitals for “admit-
ting or declining to admit people 65 or over; the role(s)
they play in placing people out into nursing homes, board-
and-care homes, and foster homes; the services if any
which they provide to people after they have placed them
out; and some of the problems that confront them.” In
addition, visits were made to 91 facilities throughout the
country which were used for residential placement of old-
er persons.

These residential settings included board-and-care facili-
ties, skilled care nursing homes, intermediate-care nursing

110
homes, and nursing homes providing mixed levels of care.
The facilities differed considerably in size, type of sponsor-
ship, age, and geographic locale, having in common only
the fact that a mental health institution had referred
some patients to the home. The Joint Information Service
survey provides a qualitative overview of the state of
nursing home care as viewed by a panel of mental health
specialists which included psychiatrists, psychologists,
nurses, and social workers interested in how well such
placements serve the needs of mentally ill older persons.

As reported in “Old Folks at Homes,” the final report of
the survey group, the state of nursing home care in Amer-
ica is far better than many prior reports have indicated.
Flagrant instances of inhumane care, crumbling and
crowded physical plants, and medical incompetence were
found to be quite uncommon. However, from the perspec-
tive of mental health care, many rather widespread and
disturbing problems were observed. First, little distinction
in care was made on the basis of psychiatric diagnosis, for
example, between those with chronic brain syndromes (se-
nility) and schizophrenia:

. . . As we visited the facilities, there appeared in most cases to be
little difference in the way patients were managed on the basis of
diagnosis. At least some of the site visitors felt that management of
senility, especially concerning its downhill course, and the concomi-
tant problems of depression had definite implications for treatment,
and that the nursing home operators were not in fact making what
could be, as one site visitor put it, “a useful distinction,” Some be-
lieved that the distinction is useful in terms of management, treat-
ment, and working relationships with family members of the pa-
tients. It does not seem unreasonable to assume that this failure to
differentiate program and planning for the various diagnoses stems
from lack of knowledge of what could be accomplished with certain
types of older patients. This lack of knowledge can perhaps be at-
tributed not only to the nursing home staff but to the attending
physicians as well. It should be noted that most of the schizophren-
ics we saw had spent twenty, thirty, or forty years in state mental
hospitals. We asked those nursing home operators whom we brought
together for consultation if there was, “in truth, any difference be-
tween the two groups, and do they have different management prob-
lems?” All of the nursing home operators either said that “there is
no difference, the problems are the same,” or that the question must
be approached not categorically but on an individual patient-to-pa-
tient basis.

The survey team found medication errors and excesses
to be relatively rare, at least as far as an examination of
patient records could reveal. However, there appeared to
be many depressed patients whose illness went unnoticed
and untreated:

... one of the most distressing aspects of what we saw in our nursing
home visits [was] ... the hordes of persons who gave obvious evidence

of full-blown clinical depression.... much has been written about the
high incidence of depression in old people, and of the good potential

111
for successful treatment, provided available medications are, in the
first place, prescribed, and in the second place, prescribed in effica-
cious dosages. Our recollection of so many old people exuding the
common symptoms of depression in many of the nursing homes we
visited is a haunting one.

Although a high proportion of nursing home patients is
mentally ill, psychiatrists were found to play a negligible
role in their care. Indeed, the survey team found that most
residents came to nursing homes without any contact with
the mental health system. The team members acknowl-
edged, however, that, given the current inadequate state of
knowledge concerning psychogeriatrics among psychiatrist
and nonpsychiatrist physicians alike, the contributions
psychiatrists might make to these care settings are debat-
able:

The medical care of the patients is in the hands, almost exclusively,
of general practitioners, few of whom have any formal preparation
for working with the aged population. Our own field study revealed
that in our sample of facilities these general practitioners rarely
call for consultations from psychiatrists and internists—who, in
turn, are for the most part untrained for and inexperienced in deal-
ing with this population, inevitably raising the question of how
much their contributions would contribute.

The general lack of trained staff to deal with the prob-
lems of an aged population was repeatedly highlighted in
the survey report. Of particular concern was the lack of
staff skilled in dealing with psychosocial problems of nurs-
ing home residents:

While most of the nursing homes we visited provided various activi-
ties occasionally or frequently, it seemed evident that a large per-
centage of the nursing home patients participated in them scarcely
at all. A part of the problem is no doubt cultural. As one of the most
impressive nursing home officials we met put it, “How, in a culture
that does not teach young people how to use leisure time construc-
tively, can we realistically expect that old people will do so?” Yet in
certain more comprehensive facilities which some of the authors
have subsequently visited, impressive! numbers of the residents
were busily and happily engaged in many activities which clearly
gave them satisfaction. The difference, as we saw it, lay in the avail-
ability of staff.

In the view of the survey team, the problem stems from
the nature of current reimbursement patterns for nursing
home care:

Most nursing homes, irrespective of size, are reimbursed for one or
two or three staff members—often untrained—to head up the activi-
ties (i.e., psychosocial) programs. If, as in some states, there is re-
quired to be one nursing assistant for each ten patients, it would
seem just as reasonable to require one psychosocial assistant for
each ten. We have seen in some model settings, adequately staffed
with activity staff, how young people, with an enthusiasm that does
not dampen, can draw out the shy, the withdrawn, the unconfident,

 

10ne of these facilities is described in this report on pages 156-175.

112
and involve them in cooking meals, quilting bees, current events
discussions, and innumerable other activities—usually, in the more
successful situations, in small groups of no more than half a dozen
residents each.

In addition to expanded psychosocial staff, the survey
team members view the addition of social workers to be
essential:

The requirements for skilled social worker service have had their
ups and downs in the legislation and regulations, but in general
requirements have been minimal. To cite a single but poignant
example of a crucial point at which the training of a skillful, compe-
tent social worker would undoubtedly have a favorable impact is
that of entry of the new patient into the nursing home. The social
worker could also be engaged in ongoing efforts to keep family mem-
bers interested in their relatives—a problem often cited to us; spe-
cifically, many families that show considerable initial interest quick-
ly lose it, and after a few visits to assure themselves that “all is
well” rarely if ever come again. The social worker who is trained, as
many are, in dealing with community and state agencies, could in-
tervene on behalf of patients who need services that must be au-
thorized and paid for by a variety of outside agencies. The social
worker might also play a beneficial role in emphasizing the impor-
tance of nursing home residents becoming more independent and
moving to less restrictive styles of living.

The lack of involvement of family members in the care of
nursing home residents represents a widespread problem
encountered by the survey team. Nursing home adminis-
trators and nursing directors questioned by the team
members estimated that better than half the residents in
skilled care and intermediate facilities had relatives who
indicated at least some interest in them. Yet relatively lit-
tle effort is made to use this important resource:

It was interesting and somewhat surprising that so few nursing
homes had made any effort to involve relatives systematically,
through such events as “family night,” open house, or other pro-
grammed events. Indeed, only a handful reported that they had
done so—usually with pronounced success. A handful of others said
they were “thinking about it.”

The owner of one very good nursing home in New York City told us
of how a “family council” had been developed, to complement a “res-
ident council” of patients. At first the family council was “nothing
but a complaint bureau,” but with time it became more useful. Its
members ran a snack bar on weekends. The profits have gone into a
bank account, which is used to buy small gifts for the patients at
holidays.

Correcting many of the nursing home deficiencies re-
vealed in this survey is likely to add considerably to the
cost of nursing home care. However, changing even one
wasteful and possibly harmful practice might result in
significant savings. The survey team members found fre-
quent instances of residents’ being “overplaced”—that is,

113
living in facilities that offer higher levels of care than
they needed:

Our index patients in the nursing homes—that is, those whose place-
ment had caused the particular home to be included in our sample—
range from those so totally deteriorated that we could not elicit any
meaningful responses from them to those who were entirely intact,
fully aware and whose prior psychiatric disorder was not now mani-
fest. Certain of them who had no significant, intercurrent physical
illness and no problems of ambulation, incontinence, and so on did
not seem to require nursing home care and seemed to be good candi-
dates for board-and-care placement or even for independent living.
The matter of level of placement is an extremely complex one, how-
ever, and frequently a problem. Sometimes board-and-care facilities
are unavailable or are of unacceptable quality. Sometimes the phy-
sician opts for nursing home placement because he feels the patient
will be better cared for in this setting than in one that provides
less intensive care. Accurate placement was hampered variously by
over-diagnosis or inadequate diagnosis by the physician, inappro-
priate state and federal regulations, excessive emphasis on medical
rather than a social-environmental model, patterns of reimburse-
ment, and fear of any “risk-taking” in the placement process. Legal-
ly speaking, it may be “safer” to overplace a patient, though ulti-
mately the patient may suffer and the taxpayer will have to support
a higher price tag. The patient may suffer in the sense of increased
and unnecessary dependency, identification with terminal patients,
social isolation, unnecessary depression, and lack of activity, partic-
ularly that with a rehabilitative focus.

It is risky to generalize from so small a number of facilities and pa-
tients, but we were inclined to feel that some proportion of the peo-
ple we saw both in nursing homes and in board-and-care homes
would have done well at one lesser level of placement; this seemed
important because of the persuasion of all those who participated in
the field trips that the most desirable level of placement is the low-
est level consistent with the patient’s condition and need. One nurs-
ing home administrator estimated that forty percent of the patients
in his facility were overplaced.

As reported by the survey team, the current criteria for
differentiating patients requiring “skilled” vs. “interme-
diate” levels of nursing home care are often arbitrary:

At certain mixed facilities having wings both for skilled and inter-
mediate patients, we were told by the administrators and nursing
directors that they simply could not comprehend why one particular
patient was designated “skilled” and another “intermediate.”

The team members found that an estimated 33 percent
of patients in intermediate facilities and 45 percent of pa-
tients in skilled facilities cannot move about unassisted;
further, 35 percent of patients in intermediate facilities
and 62 percent of patients in skilled facilities had bowel
and/or bladder incontinence.

Thus, it appeared to the team members that, to some
extent, level of placement is determined by residents’
ambulation and continence:

Since placing a patient in a wheel chair and cleaning up a patient
who has soiled himself are things usually done by the least skilled,

114
least trained, and lowest paid employees—the aides—it seems cu-
rious that not being ambulatory and not being continent should
define one as a “skilled” [care] patient. Nonetheless, this seems to be
the case.

The economic consequences of overplacement are stag-
gering:

. . . Since by recent federal regulation the care of intermediate
Medicaid patients must be at least 15 percent less than the care of
skilled Medicaid patients. In some places the differential is much
greater; in New York City, for example, intermediate care in mid-
1975 cost approximately $12,000 per patient per year, while skilled
care cost about $18,000. One may observe that if the only difference
between being an intermediate or a skilled patient is continence,
that $6,000 per year is a high price to pay for cleaning a soiled pa-
tient.

The economic and human price paid for overplacement
raises many questions about better ways to match older
mentally ill individuals with care appropriate to their
needs. Members of the survey team recommended explora-
tion of a comprehensive psychogeriatric screening pro-
gram such as one being used in England. Similar pro-
grams have been tried in the United States, but have been
used largely to reduce State hospital admissions, rather
than to seek the best options for the particular individ-
ual’s needs.

As noted by the survey team:

To develop such a system would be extremely complicated in this
country when one considers that the vast majority of people get into
nursing homes “privately”’—that is, on the signature of a private-
practice physician working in collaboration with relatives or social
agencies. At minimum, the English effort should be carefully stud-
ied as it gains experience. At maximum, one might hope that one or
two or three target communities in the U.S. with federal funds,
could develop saturation services, with the broadest possible range

of dispositions, and studied for the effect upon the rate of new ad-
mission to institutions.

The Joint Information Service survey provides a good
impressionistic overview of many of the problems and
challenges arising from the use of nursing homes as a
care setting for the mentally ill older person. And it pro-
vides a framework for understanding the pioneering as-
pects of many of the service-oriented research programs
described in this volume, which address several major
problems:

1. Identifying the actual problems, needs, and
strengths of older persons, viewed from a number of di-
mensions—medical, economic, social, psychological, and
psychiatric—to assess more accurately the types of care,
institutional or community-based, most appropriate to
their needs and abilities

2. Developing community-based supportive programs

115
for those who, with some help, can remain outside institu-
tions

3. Enriching the institutional environment for those
who require it and personalizing service so that it is more
responsive and appropriate to the requirements of specific
individuals

4. Developing training programs to provide those who
serve the aged with greater knowledge and sensitivity to
the special needs and capabilities of older persons, both
within and without institutional settings

5. Enriching the scientific knowledge base necessary to
accomplish the above tasks efficiently, effectively, and
economically

Life in a Nursing Home: The Resident's
Perspective

Nursing homes have increasingly received intensive
study and criticism, but relatively little attention has been
given to the way their residents view their institutional-
ized lifestyle. How satisfied are they with their environ-
ment? How much do they resemble community dwellers in
their needs and fulfillments? To answer some of these
questions, in Dr. Kahana’s comparative exploration of the
service needs and resources of the elderly (described on
pp. 60-64) interviews were conducted with 50 residents
from each of the two Michigan communities under study
(Oak Park and Hamtramck) who were living in 14 different
nursing homes in the area. As described by Dr. Kahana,
who directed the study, a wide variety of nursing homes
were represented:

The homes included in our sampling of nursing respondents varied
in size from 20 to 480 residents, and ranged from 70% to 100% in
the proportion of facilities devoted to the care of older people. Six
homes served the Hamtramck population primarily; five more
homes served the Oak Park community. Staffing size ranged from 4
to 300 staff members among these homes. Six basic skill units,
twelve skilled care units, and seven extended care units were repre-
sented. There was one public facility, nine proprietary facilities, and
a total of three non-profit institutions. Only one home was located in
the actual community studied. This was because no other homes
were in existence in these communities. Most of the homes were
located in urban areas. There was one home located in a rural set-
ting.

Let us look at two major issues explored in this study:
(1) how the personal characteristics and social supports of
nursing home residents differ from older people maintain-
ing independent lifestyles; and (2) the special needs and
problems of nursing home residents.

First, let us examine some of the differences in back-
ground characteristics between the nursing home resi-

116
dents and the community dwellers. Compared to the com-
munity-dwelling sample, the nursing home residents tend-
ed to be older (averaging 76.8 years), and had a relatively
high proportion of unmarried (widowed, divorced, separat-
ed, or never married) people (almost 85%) who were fre-
quently childless.

In many respects, the nursing home residents resembled
subsidized housing dwellers in their social support re-
sources. Only 10.6 percent of the nursing home residents
reported having no one they were close to (a figure compa-
rable to community dwellers living in subsidized housing),
and they were far less likely than the housing residents to
report having no one with whom to share important prob-
lems (6.7% vs. 16.5%). Yet when asked ‘“do you see enough
of friends and relatives?” the majority of nursing home
residents (53.5%) said “no.” (Their sense of isolation was
shared by the housing residents, 45 percent of whom gave
a similar response, compared to 22.7 percent of the inde-
pendent community dwellers.) A similar pattern emerged
when the elderly informants were asked “How lonely do
you feel?” Among the nursing home residents, almost half
(46.6%) reported “a lot,” as did 43.8 percent of the housing
residents.

The nursing home residents were asked why they had
entered their residence, their perceptions of the home be-
fore and after moving in, and their expectation of life in
the home. According to Dr. Kahana:

Results suggest that most of the elderly who enter homes do so for
health reasons, are encouraged by others to move into a home, and
view themselves as having little or no active part in the decision.
Most have a neutral attitude toward life in a nursing home and are

dissatisfied with the lack of mental stimulation, lack of freedom, and
poor food in the home.

Let us look more closely at some of these findings. Al-
though 75 percent of the respondents cited health reasons
for coming to the nursing home (and rarely cited psycho-
logical decline or behavioral problems), when asked how
they came to the home, 30 percent said they were brought
or forced to come, and only 17 percent said they came for
health reasons. Two-thirds of the residents cited someone
else as involved in the decision to come, with equal propor-
tions mentioning either their children or professionals
such as doctors, hospitals, or agencies; only 14 percent
said they themselves were directly involved. For most of
the residents, living in a nursing home had been unexpect-
ed: Seventy percent “had never thought they would move
to a nursing home.” Before moving in, 14 percent had
generally viewed nursing homes favorably, while only 8
percent had viewed them negatively.

117
Their current attitudes toward life in a nursing home
were quite varied, with 26 percent “very positive,” 13.3
percent “somewhat positive,” 27 percent “passive/neu-
tral,” 19 percent “somewhat negative,” and 15 percent
“very negative.” Several questions concerning how the
nursing home differed from the respondents’ expectations
received relatively few responses, but the pattern of an-
swers from those who did respond was quite provocative:
Over half (56%) said the nursing home was worse than
they had expected, particularly regarding reduced mental
stimulation (29%), lack of freedom (14%), a general nega-
tive feeling (15%), and poor food (11%).

Among the problems frequently cited by residents, the
most common complaint concerned food—particularly its
low quality. Lack of privacy was also frequently cited,
stemming from staff intrusiveness and the need to share
the bathroom or their own room.

Surprisingly, the vast majority of respondents (92.3%)
had no complaints about understaffing or conflicts with
staff members. Those few who complained cited insuffi-
cient attention, but not lack of humane treatment. Howev-
er, Dr. Kahana warns that such findings are to be viewed
with some caution:

In understanding the reported high satisfaction of residents in this
sample, it should be noted that in response to direct questioning by
an outside interviewer, residents living in an institutional setting
are often found to be reluctant to voice their dissatisfaction for
fear of retribution from the staff if their reports should become
known to those who are taking care of them.

The generally high level of satisfaction reported by resi-
dents extended as well to their relations with fellow resi-
dents; the majority (82.6%) reported no problems with
roommates. Those who did have a problem often attribut-
ed it to incompatible personalities, rarely to physical or
mental disability.

As summarized by Dr. Kahana:

The major thrust of the data indicates that the residents in the
nursing home sample expressed relatively high degree of satisfac-
tion and were very reluctant to cite problems in any areas of their
daily living, with the notable exception of food.

Findings such as these, while comforting in a way, raise
many difficult questions for researchers and service per-
sonnel alike. There is something disquietingly “pat” about
the ostensibly high level of satisfaction reported by these
residents, especially if, as it seems, such residents are un-
likely to be fully candid in their responses for fear of staff
reprisal. Their high level of loneliness suggests that they
may not be as content as they seem. There is also a dis-
turbing passivity among the respondents in the face of a

118
decision largely made for them by others. It is possible, of
course, that the majority of nursing homes canvassed are
responding well to the needs of their residents or that the
residents have accommodated well to the constraints of
their environment.

Another more recent study by Dr. Kahana (to follow)
has focused in greater detail on the dynamics involved
when older people enter and adjust to the nursing home
environment. When the study is completed, it should give
us a better understanding of the ways older people cope
with the demands of institutional living. One of the impor-
tant questions asked by this study is the adaptive value of
various coping strategies. It may well be that passive ac-
ceptance is a wise and efficient strategy in the face of di-
minished energy and a total environment that cannot be
shaped to suit one’s personal preferences. If, as it appears
from the earlier study, nursing home residents are unlike-
ly to complain appreciably about their life style, however
inadequate it may be, this fact places a special burden of
responsibility on families and concerned friends, on nurs-
ing home administrators, and on the regulatory agencies
responsible for the quality of nursing home care to assure
that nursing home residents indeed live in an environ-
ment suited to their needs and their ongoing development.

Coping with Institutionalization

Despite efforts to avoid unnecessary institutionalization,
there are bound to be some individuals for whom this is a
necessary choice of living arrangement. We must ask,
however, for whom this is appropriate and how institu-
tional life can be arranged to best serve the human needs
of those who require a relatively sheltered environment.
Complaints have long been lodged against a variety of in-
stitutional settings housing the aged because they tend
not only to restrict freedom, but to deny people the oppor-
tunity to exercise whatever strengths and abilities re-
main, encouraging a kind of dependency that stifles growth
and the retention of self-maintenance skills and self-
worth. The rather rapid decline of many older persons
once they are institutionalized is a common observation
which, once taken for granted, is now undergoing more
intensive scrutiny. As in mental hospitals, in nursing
homes, too, the question is now being asked: Does the en-
vironment itself contribute to the decline of residents? If
so, how can it be changed to become a more positive force
to encourage residents’ continued well-being?

Dr. Eva Kahana has added another dimension to this
question. She believes that, to understand how older peo-
ple fare in a nursing home environment, it is necessary to

119
look not only at the environment’s physical and social
characteristics but at the psychological characteristics
and coping strategies of the residents. Faced with the
challenges of institutional living, an older person has a
number of possible responses, many of which represent
continuations of coping strategies adopted earlier in life.
Some of these may be well suited to healthy survival in an
institutional setting, and some of these may be very disad-
vantageous. Dr. Kahana starts with the assumption that
the match between what an institution provides and an
individual needs is likely to be less than optimal, given
that institutions, by their very nature, have a limited ca-
pacity to personalize and individualize the services they
offer to a relatively large population housed and fed to-
gether. The question then becomes one of how the individ-
uals living in such settings can nonetheless arrange their
lives to achieve the greatest amount of satisfaction of
their own needs while conforming to the demands of the
institutional setting.

To uncover the coping strategies actually used by nurs-
ing home residents, Dr. Kahana has deliberately chosen to
study those with the widest range of behavioral options
open to them: the relatively physically and mentally well
residents of homes for the aged. Dr. Kahana believes that,
by studying these rather healthy individuals, she can un-
cover more clearly coping mechanisms that might also be
used by other older institutionalized individuals.

One of the interesting sidelights to this study is the
difficulty Dr. Kahana and her co-workers had in finding
subjects for this study. Many years ago, homes for the
aged were a common form of protective environment for
physically well older persons who could no longer live
alone. However, our older population and the helping in-
stitutions serving it have changed considerably over the
years. Older persons are now more likely to seek institu-
tional care only when they are physically and/or mentally
ill. And as the size of the older population increases and
more chronically ill old men and women survive, there are
increasing demands on long-term care institutions to serve
the ill elderly rather than the well. During the past two
decades, many facilities that began simply as homes for
the aged have expanded their services to include multiple
levels of care, including intermediate and skilled nursing
care, and many others are following suit. Although homes
for the aged are licensed to provide care for only the rela-
tively well, there are increasing pressures to admit individ-
uals who fall short of the health criteria. As a result, it is
difficult to find, even within these care settings, the kinds
of very intact individuals Dr. Kahana requires for her
study.

120
Dr. Kahana’s research design is an ambitious one, re-
flecting her interest in the complex interplay between in-
dividuals and institutional characteristics. A total of 140
older subjects in ten homes for the aged in the greater
Detroit area, as well as four in Cleveland and one in Tole-
do, have been chosen for study. An investigative team fol-
lows newcomers to the institution from the time they are
accepted (while they are still living at home) through their
move to the institution and a subsequent year of resi-
dence. A battery of questionnaires is administered in the
home soon after admission and on subsequent occasions to
ascertain (1) baseline coping strategies and capabilities
before institutionalization; (2) coping strategies used dur-
ing institutionalization; and (3) the well-being of the resi-
dents after they have acclimated to the institution. In
addition, trained observers study the resident’s initial
home setting and the physical and social environment of
the institution. Data on other institutional characteristics
such as sponsorship, staff structure, etc., are also ob-
tained. In addition, resident behavior in the institution is
observed, and staff ratings of resident behavior are also
requested.

Although Dr. Kahana has developed some hypotheses
concerning the outcome of her study, she regards it as
highly exploratory. Since there are relatively few studies
of coping strategies used by members of any age group,
and fewer still that attempt to explore those used by the
elderly in institutional settings, many of the measurement
tools used in this study had to be specially developed.
Thus, the study represents in part an exploration of cop-
ing strategies and institutional well-being of aged resi-
dents, but it is also an attempt to find satisfactory ways to
measure these phenomena.

Since Dr. Kahana’s study is still in process, we cannot
yet say what coping strategies—or mixtures of. strate-
gies—seem to work best for a given type of individual or
institutional setting, However, the study has already re-
vealed one unanticipated and interesting finding. Al-
though it is generally assumed that the road to institu-
tionalization for the elderly is a one-way street2, this was
not true for the population studied here. A surprisingly
large proportion of newly admitted residents adopted a
very independent type of coping strategy: They simply left
when they were dissatisfied with the institution. Some
went to other homes for the aged, some returned to inde-
pendent living or their families, and some went into nurs-

2Dr. Kahana’s earlier study had revealed almost no movement back
into the community once older people were placed in nursing homes.

121
ing homes. It will be interesting to see whether and how
these individuals differ from those who stayed.

One of the very important findings this study may
yield is a better understanding of the best match between
a given type of individual and institution. It may also
provide some insight into the frequently cited battle be-
tween the independent and somewhat aggressive individ-
ual and the constraints of the institution. (One study at
the Philadelphia Geriatric Center, cited on page 150, re-
vealed that, although institutional staff tend to conflict
with such residents, preferring those who are passive, it is
the ornery ones who, with appropriate staff approaches,
are likely to make the greatest therapeutic progress in
overcoming “excess disabilities.”) Dr. Kahana’s study may
provide new insights into the ways residents and institu-
tions can and should adapt to one another, as well as re-
vealing the combinations that spell trouble. It seems like-
ly, given the current state of relative unenlightenment of
most institutional staffs serving the aged, that in most
settings the residents, not the staff, will be called upon to
do most of the adjusting. Perhaps, when the study is com-
pleted, we will have a better picture of which individuals
are suited to institutional life, as institutions are now
organized, and will also gain a clearer picture of the pat-
terns of care that must change if a diverse patient popula-
tion is to be served adequately.

One of the other important contributions of this study is
its emphasis on the older person as an active participant
in determining his or her well-being. Too often there is a
tendency to overlook the personal style and preferences
of, and differences among, older individuals and to lump
them according to diagnosis or perhaps functional ability
or care requirements. By attending to personal differences
among older individuals and their reactions to common
environmental stimuli, Dr. Kahana is contributing to the
dissolution of stereotypes and the recognition of individ-
uality among the elderly. She is also calling attention to
a dimension of life for older persons that is frequently
overlooked: their ongoing active learning and acclimatiza-
tion to a changing world. We tend to assume that older
people are rigid and set in their ways, unwilling and un-
able to change as time and circumstances require. And yet,
they often manage to cope extremely well with more in-
tense and disruptive changes than younger people con-
front: the loss of loved ones, major changes in physical
well-being and self-maintenance ‘ability, and, as in the
case of institutionalization, the shift not only to a new
locale, but to one that demands a total change in lifestyle.
Anyone who has ever spent even a short while in what
one sociologist, Goffman, has called a “total institution”—

122
such as a hospital, a prison, or the army—recognizes the
severe differences between such a setting and normal liv-
ing. A nursing home, or a home for the aged, is also a total
institution. Although there are some anarchists among
the geriatric experts who consider any such institution as
inherently dangerous for the elderly, Dr. Kahana’s study
may reveal some for whom this is a benign and, indeed,
ideal environment. It is highly unlikely that this will be
true for all the subjects studied. For them, there are sev-
eral critical questions: (1) Can and should they be helped
to make a better adjustment to institutional living and, if
so, how? (2) How could institutions become more respon-
sive to the varied needs and styles of their residents? (3)
What would be better settings for those who are unlikely
to fare well in institutions? (4) Can we learn to predict in
advance the best match between the individual and the
modalities of care?

On pp. 147-174, we observe two nursing homes that
have made a special effort to recognize and accommodate
themselves to their aged residents, and to identify those
residents most responsive to their particular approaches.
Studies such as these and Dr. Kahana’s provide guidelines
for assuring a better “fit” between residents and institu-
tional placements, whatever levels or types of care they
may require.

To Move or Not to Move: The Hazards
of Relocation

The search for better care for the institutionalized el-
derly has resulted in strengthened Federal, State, and
local regulations of nursing home care, and in many ef-
forts to shift institutionalized older persons to more ap-
propriate care settings. However, both types of effort, al-
though humane in their intent, have often had painful
consequences for the debilitated elderly. Enforcement of
safety and other regulations has forced many nursing
homes and other residential facilities for the aged to close
down and relocate their residents. Similarly, shifts to
presumably better care settings (such as from State men-
tal hospitals to nursing homes) also involve the trauma of
relocation. While many older people can benefit from a
move, some, particularly the very old, frail, and mentally
impaired, are too physically and mentally fragile to adjust
easily to great changes, and, as many researchers have
documented, for some the move itself can be lethal.

Until the early 1970s, although the potentially devastat-
ing effects of relocation were known, they were not suffi-
ciently well documented or publicized to stimulate public

123

274-912 O - 78 = 9
interest. But in the succeeding years, largely through the
efforts of a team of researchers at the University of Mich-
igan who have conducted a series of careful studies of
the effects of relocation, the problem has attracted consid-
erable legal, legislative, and public interest. Had these
researchers simply shown that relocation can be harmful
to the fragile elderly, we would be left with a dilemma of
considerable proportions, since in some instances there is
no choice but to move older residents out of substandard
living conditions. However, these researchers have also
come up with an effective way to anticipate, and largely
avert, the hazards of relocation. Let us skim some of the
highlights of the original NIMH-funded study that sparked
intensive interest in the problem of relocation, and let us
review some of its significant consequences.

In 1971, Drs. Norman Bourestom, Leon Pastalan, and
James Carpenter,3 of the University of Michigan, took
advantage of a “natural experiment” in their community
to conduct a study of relocation effects. A substandard
county long-term hospital for the chronically ill and indi-
gent was forced to send its residents to a new care setting.
The research team, aware that the move would be forth-
coming, decided to observe the hospital's 61 aged residents
before the move and during the year after they were relo-
cated, to discover how they reacted to relocation and the
factors that contributed to successful or unsuccessful re-
sponses to the experience. Unlike other researchers who
had studied relocation effects, the members of this team
also selected a comparison group of similar older people
(living in another long-term care hospital) who would not
be relocated but who would be studied over a similar time
period. (When the study was underway another compari-
son group was added: residents of another long-term hos-
pital who were physically relocated, but with the same
staff members and fellow residents. Thus, it would be pos-
sible to compare the effects of what we might call “total
relocation,” involving a shift to an unfamiliar physical
setting which had new staffing and patients, with sheer
physical relocation in which only the physical setting is
changed.)

These investigators had predicted that the relocated
patients would generally fare worse than unrelocated pa-
tients, showing greater signs of illness and deterioration
and greater mortality rates. They proposed that not all
patients would react alike, however. Those most likely to
be affected adversely would be those in the worst health,
with limited adaptive capacity. These investigators be-
lieved that the effects of relocation would also be tem-

3Laterreplaced by Dr. Sandra E. Tars.

124
pered by several other factors, key among which were
staff attitudes prior to the change and the way patients
were prepared for the move. The major factors affecting
relocation outcomes were posited thus:
This research will test the hypothesis that the fate of the patient
following relocation is not determined by chance, but is a complex
function of the characteristics of the patient himself, the attitudes
of staff members who serve him prior to relocation, changes in char-
acteristics of the physical environment, changes in relationships
patients have with their physical environment, changes in services

the patient receives, and the extent of formal preparation of pa-
tients for relocation.

The patients to be relocated were followed for 1 year in
their old and new settings and were assessed once before
and four times after the move. Similar observations and
measurements were made on the unrelocated group of
controls through a similar time period.

Ethically it was not possible to compare the effects of
preparation vs. nonpreparation of patients for the move.
But two subgroups of patients were given different types
of pre-move preparation: One group made many visits to
the new setting before they moved in, while the other vis-
ited once and subsequently was shown color slides and
photos of the new setting on several occasions.

The study yielded many important findings, a few of
which will be reported here. First, as expected, the mortal-
ity rate of patients who underwent relocation was signifi-
cantly higher than the normal death rate for patients in
their old facility and was exactly double that of the unre-
located matched controls. Further, the death rates among
those who underwent total relocation was particularly
high during the 3-month period following the move, while
the control group’s mortality rates were consistent year-
round. Mortality rates among those relocated also rose
before the move, suggesting that the anticipation of relo-
cation can also be lethal.

Relocated patients who died tended to be female, over
75, and, surprisingly, relative newcomers to the hospital
setting (hospitalized under 1 year). Many of the patients
who died would not have been considered particularly
vulnerable on the basis of physician’s examinations prior
to the move, although they were not particularly physical-
ly well.

Patients who survived total relocation were less active
in their new setting than in the old, participating less in
activity programs and showing more “nonpurposive be-
havior.” However, those who simply shifted to a new phys-
ical surrounding actually became more active participants.

Dr. Bourestom reports another finding, the relationship
between the residents’ ways of handling stress and their

125
survival following relocation. The team presented the resi-
dents a set of hypothetical problems which an elderly per-
son might face in a nursing home, and they found that
patients who behaved passively in regard to those prob-
lems died, after relocation, at a rate over three times
greater than patients who were more assertive. They ob-
served, also, that the more assertive patients among the
survivors made a better adjustment following relocation.

The Bourestom team confirmed an hypothesis made by
other groups: Defensive reactions to anger are associated
with vulnerability to the stress of relocation. In other
words, more than half of the patients who retreated from
conflict situations by denying their anger subsequently
died at a rate twice as great as that found among patients
who expressed their anger openly.

The findings from this and subsequent studies conduct-
ed by these researchers and others from the University of
Michigan between 1971 and 1975 have underscored the
potentially devastating effects of relocation and the ne-
cessity for preparation when relocation is unavoidable.

In 1974, an experimental service program led by Dr.
Pastalan in Pennsylvania was undertaken when some 150
substandard nursing homes in that State were forced to
close. Patients were offered intensive pre-move prepara-
tion through counseling, group discussion, and visits to
the new settings to aid their relocation adjustment. The
impact of this program was dramatic: A sample of 400 of
those relocated had a lower mortality rate (22%) than the
general Pennsylvania nursing home population in that year
(26.6%)! As in the earlier study, certain patients emerged
as particularly high-risk individuals, despite efforts at pre-
move preparation: the very old, the very feeble ill, or the
very mentally impaired and confused. (Findings such as
these understandably make service and research person-
nel faced with the necessity to relocate such patients very
uncomfortable; however, as we shall see from the study
cited on pp. 146-156, with adequate preparation, even
high-risk institutionalized elderly can fare relatively well.)

Studies such as these have made an important contribu-
tion in actually and potentially saving the lives of count-
less institutionalized older people who must be relocated.
Their results have had considerable impact on policymak-
ers, legislators, and lawyers, stimulating several public
interest lawsuits, 11 legislative proposals in Congress, and
development of new guidelines by two Federal agencies.
The next frontier will be to assure that their new setting
is indeed appropriate to their needs so that the quality of
their lives, and not merely the length of their days, i
enhanced.

126
VI. Depression and Senility:
The Twin Frontiers

The vast majority of our Nation’s elderly stay psycho-
logically well—even into advanced old age. But a small
proportion, perhaps 10 to 15 percent, have significant emo-
tional or mental handicaps. This population, while a decid-
ed minority of the elderly, represents some two million or
more troubled and troubling individuals. The major men-
tal health problems of the aged are senility and depres-
sion, which, although very different types of diseases,
have symptoms that make them sometimes hard to distin-
guish diagnostically; sometimes both will coexist in the
same person. Both problems represent a major challenge
to our health care system, especially to our system of in-
stitutional care. Half or more of our institutionalized el-
derly suffer from some form of mental impairment or se-
nility.

At present there are countless older people suffering
needlessly from these diseases who could, with proper di-
agnosis and treatment, recover fully or at least function
far more happily and effectively. Unfortunately, a long
history of “therapeutic nihilism” concerning the elderly,
compounded by confusion concerning mental illness in the
later years and mutual avoidance by the elderly and men-
tal health personnel, has deprived many mentally and
emotionally ill older people of the chance to realize their
full functional potential. Many lead lives that are unne-
cessarily sad, confused, and abbreviated.

At present our capacity to cure depression far exceeds
our ability to overcome many forms of senility. But as we
will see on the following pages, even those suffering from
severe forms of senility (often described as “chronic or-
ganic brain syndrome,” or “senile dementia”) can respond
to treatment. Let us explore several approaches to mental
illness in the aged that may lead to more accurate diagno-
sis and treatment in the days ahead.

Enhancing our state of knowledge concerning the diag-
nosis and treatment of depression and senility, while es-

127
sential to progress, is only part of the battle. A parallel
challenge lies in applying our knowledge in the day-to-day
conduct of health care, whether in communities or in insti-
tutional settings. We currently know far more about the
diagnosis and treatment of mental illness in the elderly
than we are using. Perhaps when more people, profession-
als and laymen alike, realize that most of our mentally ill
elderly can be helped to lead richer, fuller lives, we will
redouble our efforts to see that they do.

Unscrambling Senility and Depression: The
Challenge of Diagnosis

It is axiomatic in medicine that appropriate treatment
begins with accurate diagnosis. For those who work with
the aged, diagnostic problems can be particularly difficult,
since concurrent mental, physical, and social problems
abound, and some can give rise to similar clinical symp-
toms. A nonpsychiatrist physician who looks only at a per-
son’s physiological condition or a psychiatrist who attends
only to behavioral cues may miss important aspects of the
person’s total condition that might aid in diagnosis. Many
of today’s physicians, both psychiatric and nonpsychiatric,
are insufficiently trained to understand how the subtle
interplay between body, mind, and environment affect the
older patient, and they often lack the knowledge and moti-
vation to search carefully for the cause of behavioral
complaints. Accurate diagnosis of mental illness in older
patients is also hampered by the expense and difficulty of
assessing actual brain function. For the most part, clini-
cians rely upon medical and social histories and physical
examinations in arriving at a diagnosis. Although there is
a rapidly improving technology for direct physiological
assessment of brain function, we still do not have a simple
physiological test that can be given in a physician’s office
to determine precisely whether, where, and how cerebral
circulation or cell function may be damaged. Techniques
such as brain scans and measurement of cerebral oxygen
and metabolism are now available which permit research-
ers such as those described on pages 130-132 to establish
some correlations between the behavior of an individual
and the condition of his or her brain function. Out of such
studies may emerge reliable techniques for determining
the state of the brain from more readily accessible data
which an office-based physician can obtain. At present,
however, given the diagnostic approaches usually used,
when a physician says that an individual has “chronic or-
ganic brain syndrome” (senility), we cannot be sure the
person actually has the brain impairment implied by the
diagnostic label.

128
We do not know how many older people are misdi-
agnosed yearly, but a comparative study of the rates of
depression and senility in England and the United States
has revealed some provocative findings. Researchers partic-
ipating in the U.S.-U.K. Cross-National Project! (partially
funded by NIMH) have found that, compared to their
London counterparts, New York hospital psychiatrists
“had a much wider concept of dementia [senility] and a
much narrower concept of functional disorder [such as
depression].” This finding helped to explain why the rate
of chronic organic brain syndrome diagnosed among elderly
first admissions to mental hospitals in the United States
was almost twice that reported in the United Kingdom.
Research team members found that, when consistent clas-
sification methods were used crossculturally, these differ-
ences disappeared, suggesting that indeed they stemmed
from divergent diagnostic practices and not inherent dif-
ferences among older citizens of the two nations.2

Depression, Senility, and Mental Functions

Since depressed older people may behave very much like
those with true organic brain damage, how can they be
distinguished? According to Dr. Robert Kahn, a psycholo-
gist at the University of Chicago, one important indicator
is memory function. He found that, when given a battery
of memory tests, depressed patients usually performed
quite well, while those with true mental impairment per-
formed badly. However, the patients’ complaints about
their own memory function followed an opposite pattern:
Depressed patients frequently complained about memory
loss, while mentally impaired individuals usually did not.
Dr. Kahn warns that, if physicians base their assessment
of memory function on what patients say about their
memory, without actually testing it, they may be misled
into a diagnosis of organic brain disease when a patient is
actually depressed. His study has yielded a further cave-
at: Patients’ spouses may also prove to be unreliable infor-
mants about their mate’s memory function. When Dr.
Kahn tested memory function of a depressed or mentally
impaired person, he frequently used the spouse as a ‘“nor-
mal” control. Often, both husband and wife would agree,
say, that the wife suffered from memory loss. On testing,

IM. Kelleher, J. Copeland, B. Gurland, and L. Sharpe.

2[ronically, however, the U.S.-U.K. Cross-National Project revealed
that, despite misdiagnosis, an elderly New Yorker with an affective disor-
der is more likely than his London counterpart to be rapidly released
from the mental hospital and will recover as well as or better than those
in London who receive proper diagnosis and antidepressive medication!

129
however, it would often turn out that the “normal” spouse
performed worse on memory tests than the patient—par-
ticularly if the latter was depressed.

Not surprisingly, Dr. Kahn recommends that physicians
use an objective technique to assess memory function and
mental status, such as a well-known questionnaire he de-
veloped with Dr. Alvin Goldfarb, a psychiatrist. This short
and simple-to-administer assessment tool consists of 10
carefully chosen questions addressed to several aspects of
mental function: orientation for place and data, and sim-
ple questions on personal and general information. The
Kahn-Goldfarb Mental Status Questionnaire (MSQ) results
correlate well with thorough clinical judgments made by
psychiatrists, and the MSQ appears to provide a useful
frame of reference for judging the overall mental capacity
of an older person. Dr. Kahn reports that it was designed,
and is being used, as a test for organic brain damage and
provides one of many types of data that enter into a diag-
nosis.

According to Dr. Kahn, the MSQ was designed to differ-
entiate acute and chronic brain syndrome, one of the most
common clinical problems in the aged, chronic brain dys-
function being demonstrated by difficulty with simple in-
formation questions and acute brain disorders by errors
on orientation questions. He believes that this procedure
distinguishes well between organic and functional sources
of impaired mental status and that its questions are suffi-
ciently elementary that three or more errors are an over-
whelming indication of organic impairment and not of
functional disorder. Drs. Kahn and Goldfarb constructed
the test to be readily applicable to the heterogeneous aged
population requiring clinical evaluation, so that neither
stress nor cultural background would affect the results.

Although the Kahn-Goldfarb MSQ is widely used in
many settings to obtain a quick picture of mental func-
tion, it has many limitations that have led other research-
ers to attempt to refine or improve upon it. For one thing,
some feel that it does not allow for fine gradations in
mental status to be identified. Of course, many of the
complaints leveled at the MSQ can be applied to other
approaches to assessing mental status. Thus, researchers
often tend to use a variety of measurement tools, such as
the Wechsler Memory Scale, the Guild Memory Test, or
the Mini-Mental State by Folstein, Folstein, and McHugh,
as well as the Kahn-Goldfarb, in establishing the mental
capacity of their subjects.

A New Tool for Diagnosis

In the foreseeable future, physicians’ diagnostic acumen
may be greatly enhanced by a new assessment tool being

130
developed by a team of researchers at Duke University to
distinguish organic brain disease from depression. Dr. Wil-
liam Zung and Dr. H. Shan Wang, with NIMH support, are
pooling their respective areas of expertise in depression
and organic brain disease to establish physiologically
based diagnostic criteria for the two conditions.

These researchers have engaged in a 3-year study in
which they have reviewed the existing literature on as-
sessing psychopathology, cognitive function, and activities
of daily living in older persons; have developed new rating
scales for assessing these aspects of functioning; and have
conducted laboratory tests to see how behavioral meas-
ures correlate with direct physiological measures of brain
function over time. To assess brain function in their older
subjects, the investigators use two primary techniques:
electroencephalogram (EEG) recordings of the brain’s
electrical activity, and measurements of cerebral blood
flow. The latter measurements are made through 133-
Xenon inhalation, the “brain-child” of Walter Obrist. The
technique has been under development at Duke since
1965, with Dr. Wang, an assistant of Dr. Obrist, as one of
the original members of the investigative team. For 1
minute, subjects inhale a mixture of air and 133-Xenon, a
radioactive gas. Radiation counters placed over various
brain areas then read out the position of the radioactive
gas which has circulated to these brain regions. With the
help of a computer, it is possible to identify blood flow
through the brain’s grey and white matter, as well as
through extracerebral tissue. This technique, which pro-
vides a picture of blood flow in both brain hemispheres, is
quite safe, even for older subjects, although its major re-
striction at present is the requirement that a patient lie
very still and breathe regularly for about 15 minutes.

The investigators believe that both EEG and cerebral
blood flow measurements are necessary to assess brain
function. Although the two techniques yield results that
are correlated somewhat (that is, patients with a slower
overall EEG rate tend also to show greater circulatory
impairment through the Xenon technique), the correlation
is imperfect. Further, since abnormal EEGs are not al-
ways correlated with the degree of mental impairment,
the Xenon technique may provide another avenue for link-
ing behavior to brain function.

The clinical study itself consists of performing a battery
of assessments on 80 subjects (all 65 and older) at the be-
ginning and end of a 6-month period. The subject groups
consist of 20 normal elderly persons, 20 elderly patients

131
with dementia, 3 20 elderly depressed patients, and 20 with
both depression and dementia, all selected from the Geriat-
ric Psychiatry group of Duke Hospital. All subjects un-
dergo rigorous interviewing and testing to evaluate their
past history (medical as well as life events and experi-
ences), their emotional status, cognitive impairments, and
their physiological brain function. To gather additional
data for the study concerning past histories, current emo-
tional status, and evaluation of social activities, a larger
group of subjects is studied as well.

When this study is completed, we should have a better
understanding of the backgrounds, behavioral characteris-
tics, and patterns of neurophysiological functioning that
distinguish depressives from brain-impaired individuals,
and these from normal persons or those with both condi-
tions. In addition, the study should provide a check on the
reliability of many assessment tools currently in use (in-
cluding the clinical judgments of psychiatrists, which until
now have formed the primary basis for validation). Those
nonphysiological diagnostic techniques that prove most
accurate will be recommended for use in clinical practice.
Perhaps in the future, when physicians can identify more
accurately the mental problems of older people, we shall
see a change in the reported patterns of mental illness
among the elderly (with perhaps proportionally more de-
pression and less organic brain disease) and a change in
our patterns of care as well. A person recognized to be
depressed is less likely to be sent to a nursing home than
one who is regarded as hopelessly senile. However, unless
we expand our treatment resources for the community-
dwelling elderly and improve the rehabilitative potential
of our long-term care institutions, better diagnostic tech-
niques still will not result in better care for the elderly.

Treating Depression in Older People

Depression is one of the most widespread forms of men-
tal illness among the aged, accounting for as much as half
of all mental disorder among them. As our diagnostic tech-
niques improve, we may find that many of those now la-
beled as having organic brain disease are more properly
viewed as depressives.

There is considerable debate concerning the causes of
depression. Some patients seem to be depressed for psy-

3As in all studies of this sort, one is caught in a kind of circular log-
ic. To describe the characteristics of depressives, one must study a group
of depressives. However, if one recognizes in advance that current diag-
nostic criteria may be inadequate, then the subjects may be incorrectly
labeled from the beginning. The answer in this study, as in many others,
is to use as many measures as possible to make the initial diagnosis, in
the hope that some reliability can be achieved.

132
chological reasons (such as the loss of a loved one), while
others seem more clearly to be the victims of aberrant bio-
logical processes; yet others show signs of a mix of psycho-
social and biological causes. Some investigators have pro-
posed that depression among the aged is different from
that found in younger patients. From a clinical psychiatric
perspective, Dr. Ewald Busse, a geriatric psychiatrist at
Duke University, has proposed that, while depression in
younger adults frequently arises from anger at others
displaced within themselves, in older adults it frequently
stems from a loss of self-esteem in the face of lessened
ability to obtain basic gratifications and to defend them-
selves against threats to security.

Although nonpsychotic depression is generally regarded
within the mental health community to be a readily treat-
able condition with a very good prognosis, depressed older
adults are frequently regarded as poor candidates for psy-
chotherapeutic treatments. This view seems to stem more
from prejudice and misunderstanding—ageism, if you
will—than from a careful perusal of the research litera-
ture. The majority of studies conducted in the past 20
years has shown no relationship between age and outcome
of therapy. In addition, there is ample evidence to demon-
strate that many older persons can benefit from antide-
pressive medication, provided that it is administered with
sensitivity to the particular physiological drug responses
characteristic of older patients and to the effects of coex-
isting medical problems and medications.

Putting aside for the moment the formidable question of
changing the attitudes of mental health workers toward
the aged, we are faced with a large number of older per-
sons in need of help for depression, a relatively short sup-
ply of providers, and an insurance system likely to be in-
creasingly intolerant of long-term psychotherapeutic ap-
proaches. In the face of these realistic constraints, what
therapeutic approaches to depression and other affective
disorders in the elderly seem most promising? Short-term
group therapies naturally commend themselves, as do psy-
chopharmacological approaches. The question then be-
comes, which of these approaches are most likely to benefit
older depressed persons and which are most acceptable and
feasible for them?

This is the question asked by Dr. June E. Blum, a clini-
cal psychologist working at the Postgraduate Center for
Mental Health in New York. She has devised a compara-
tive research project to compare the effects on depressed
older persons of three types of group psychotherapy4 with

4Theme-oriented psychotherapy, psychoanalytically oriented psy-
chotherapy, and counseling.

133
one another, and with psychopharmacological treatment
of depression. We will concentrate here on the compara-
tive psychotherapy aspect of the study.

Subjects 60 years and older living in New York were
recruited through referrals from senior citizen centers,
through social service agencies, and through public an-
nouncements. Those selected for the study had to be in
relatively good health, able to come independently to their
sessions, free of a history of prior psychiatric hospitaliza-
tion or diagnosed organic brain disease, English speaking,
and of average intelligence. Selection criteria also re-
quired the presence of at least two major symptoms such
as depression, anxiety, bodily complaints, intrapersonal
sensitivity, and obsessive compulsive characteristics. Sub-
jects meeting the initial criteria met with a psychiatrist
for psychiatric evaluation and a psychologist for assess-
ment of symptomatology, social adjustment, and cerebral
integrity. All but the test used to screen for organic brain
damage were repeated four times: during initial testing,
after 15 and 30 weeks of treatment, and 6 months after
completing treatment. Demographic information on pa-
tients was also collected, to be used as variables in out-
come evaluation.

Therapy groups were formed with two groups per treat-
ment type, and seven to eight patients per group, assigned
to achieve a balance of patients’ demographic characteris-
tics in each group. The groups, which met once a week for
30 weeks, lasted 172 hours per session.

One group of patients was selected from the applicant
pool to serve as controls. These individuals, some. of whom
subsequently became patients as well, were delayed ad-
mittance to therapy until the initial 6-month therapy
group was concluded. During the time they were on the
waiting list, they were periodically assessed, as were the
treatment patients.

The therapists conducting theme-oriented therapy and
psychoanalytic psychotherapy were all graduates of a
postgraduate training program who had undergone super-
vised training in analytic psychotherapy and person anal-
ysis. As noted by Dr. Blum:

This is the first study on psychotherapy with the aged which re-
quires personal analysis for the clinicians involved. It is hoped that

such a requirement will minimize the confounding effects of coun-
ter-transference.

Psychotherapists working with older patients sometimes
find themselves caught in unresolved problems, such as
parent-child relationships, that can interfere with thera-
peutic progress with older patients.

134
The therapists providing counseling were trained para-
professionals who were graduates of the Postgraduate
Center’s 2-year counseling program.

According to Dr. Blum, the orientations of the three
types of therapy were expected to differ in the following
ways:

1. The psychoanalytically oriented group will focus on the character
traits and personality development of each participant. The char-
acter conflicts which cause tensions, catastrophic feelings of help-
lessness, worthlessness, i.e., depression, will be mutually ex-
plored. As a consequence, the aim of the psychoanalytically ori-
ented group is to facilitate the group members to overcome unre-
solved conflicts, strengthen their ego, and enable the participants
to experience satisfactions with themselves and in their relations
with others.

2. The focus of the theme-oriented group will be the specific con-
cerns of the group participants. In general, the themes of the
aging revolve around diminution of physical activities, sexual
expression, loneliness due to loss of family members and friends,
and anxiety reactions to dependency needs and impending death.
There will be active therapeutic involvement of the participants
to effect an understanding and deactivation of the themes, and
their immobilization effects.

3. The counseling group will lead with conscious processes concern-
ing specific problems in the here and now. The relationship be-
tween the counselor and the clients will be used in different ways,
from offering suggestions as to available resources to the inter-
pretation of the attitudes and feelings of the client. The counsel-
or and the client will examine, explore, and find alternate solu-
tions to problems the client faces in his present reality.

To date, 74 patients have participated in the project. As
of January, 1978, all except one psychotherapy group will
have completed the 6-month followup, and a third psy-
choanalytic group is at the midway point in treatment. It
is still too soon to say how the groups differ in bringing
about both behavior change and symptom change. The
psychopharmacology assessment is ongoing.

In Dr. Blum’s view, all of the approaches under study
have merit, and any one, if shown to be particularly effec-
tive, has certain social and economic benefits. For exam-
ple, if the counseling groups appear to have the greatest
impact on patients, this might suggest, as other studies
have intimated, broader use of the less highly trained and
freeing of highly trained therapists for patients requiring
intensive treatment, and for training and supervision. On
the other hand, a particularly favorable response to psy-
choactive drugs might suggest for some patients the effi-
cacy of pharmacological intravention.

Dr. Blum has hypothesized that patients in the psy-
chotherapy groups will develop insight regarding their
behavior patterns reflected by improvement in their social
adjustment. However, if the hypothesis is not borne out,

135
certainly other studies replicating the above would have
to be carried out before any generalizations can be made.

Therefore, a relatively small study such as this should
perhaps be regarded more as pilot investigation than as a
definitive test of the efficacy of various forms of therapy
for older patients. Possibly its greatest value lies in the
attempt to offer help to depressed elderly patients and to
study the impact of various ways of achieving these goals.
Since it is somewhat uncommon for psychotherapists to
submit their efforts to objective assessment, this study
represents an important opportunity to learn and improve
current therapeutic options through careful observation,
evaluation, and followup.

Senility: Approaches to Treatment

As foolish as monkeys till twenty and more
As bold as a lion till forty and four,

As cunning as foxes till threescore and ten,
We then become asses, and are no more men.

Old Mother Goose Rhyme

One of the most harmful myths about aging is the deep-
seated belief that “senility” is a natural and unavoidable
part of growing older. Many people frequently seem sur-
prised when older people demonstrate that they are alert,
competent, and still quite able to learn and remember;
they are supposed to become forgetful and senile entering
that second childhood that is part of our folklore about
aging. The senility of our collective nightmares and myths
is a relative rarity among the aged, even among the very
old, in whom it occurs more frequently. However, it indeed
exists and can transform many formerly quite normal
people into lost souls who cannot even recognize their own
name.

The term “senile” is an old word that once simply meant
“of, relating to, or characteristic of old age.” By an unfor-
tunate linguistic accident, the term has taken on special
meaning: “marked by the weakness of old age: decrepit,
especially: exhibiting a loss of mental faculties associated
with old age.” In the eyes of some laymen, the mental
impairment sometimes found among the aged has become
equated with old age in general. (Physicians have attempt-
ed to be more precise in their use of the term “senile,”
applying it as an adjective, as in “senile dementia” to re-
fer to mental impairment found among the “senile,” that
is, older population, as opposed to ‘“presenile dementia”
which occurs among younger patients.)

For the sake of discussion here, let us clarify a few basic
facts and terms. As people age, normal physiological
changes occur in many parts of the body, including the

136
brain. In general, these changes, most of which start in
our early twenties, proceed slowly, but accelerate some-
what over the years. They generally result in less effective
functioning, as any athlete past the age of 30 can attest.
Impairments of brain circulation and loss of brain cells
normally do occur over time, but as we have seen from the
NIMH Human Aging Study, even among the very old
these need not interfere appreciably with mental alert-
ness, agility, and memory, although there is a loss of re-
sponse speed with age. Further, the accumulated wisdom
and experience of older people often permit them to use
their abilities wisely and well, in ways that may offset or
compensate for many of their cumulative physical and
mental decrements.

When we look at the population of older people, there
are some who do show signs of lessened mental function,
whether compared to their former selves, or to other people
of comparable ages. Their behavioral symptoms may be
slight, such as small memory slips, or so severe that they
are seriously confused and disoriented and essentially in-
capacitated. In some, serious intellectual disturbance may
be accompanied by schizophrenic symptoms and/or by oth-
er behavioral problems such as incontinence or aggression.

To many laymen, all of these strange forms of impaired
behavior in older people are viewed as “senility.” Further,
it is generally assumed that, once an older person’s mind
begins to falter, there will be an inevitable decline until
he or she is totally incompetent. While it is true that some
older people do have irreversible conditions that will prob-
ably worsen with the passage of time, some can and do
stabilize at a level of mild impairment, and others can, if
diagnosed and treated properly, recover fully.

Let us look more closely at the different types and caus-
es of senile or mentally impaired behavior. First, it is im-
portant to remember that depression can cause an older
person to act in ways that seem senile. If depression is
recognized and treated, many older people can return to
their normal level of mental function. Second, senile be-
havior such as memory loss, confusion, and disorientation
can accompany physical illnesses such as heart disease
and diabetes, or can arise as a side effect of many types of
drug treatment. When an alert physician recognizes what
is called an “acute organic brain syndrome” in an older
person and institutes appropriate treatment for the un-
derlying cause—such as giving insulin treatment or
changing medications—the older patient can often re-
cover fully from temporarily altered brain function. An
estimated 15 percent of patients with organic brain syn-
dromes are considered to have the acute form and have
readily reversible conditions.

137

 
Among the elderly, and particularly the very old,
there is a small but sizable group whose senile behavior
stems largely from irreversible brain damage. Some show
signs of serious impairment of brain circulation, while
others appear to suffer from a form of brain cell degenera-
tion different in extent and kind from the type that nor-
mal aging might bring. The prevailing view among today’s
researchers is that these people suffer from disease proc-
esses, not aging per se. In theory, “chronic organic brain
syndrome,” whether in its circulatory or degenerative
form, may one day be prevented and/or treated. Recent
research findings suggest that the degenerative form of
chronic organic brain syndrome in the elderly may be
identical with a condition known as Alzheimer’s disease or
presenile dementia found in younger people and may have
a viral origin. Although it will probably require many
more years of study before this line of investigation yields
a testable treatment, and even more to discover whether
an effective preventive technique can be developed, there
is at least a glimmer of hope. Another avenue that may
yield productive future results is the study of circulatory
diseases, particularly those of the cerebrovascular system.
Many patients with chronic organic brain syndrome show
signs of impaired brain blood circulation. As the NIMH
Human Aging Study and others have shown, the correla-
tion between organic impairment and behavioral impair-
ment is by no means perfect. But some older people who
appear to be mentally impaired may be helped in the fu-
ture by techniques developed to prevent circulatory prob-
lems or facilitate blood flow to the brain. Recent advances
in developing more accurate clinical techniques for study-
ing brain function and circulation should greatly facilitate
the search for more effective prevention and treatment.

While we search for new options, our best current strat-
egy is to assure that health and mental health care work-
ers are adequately educated and motivated to recognize
and respond to readily reversible mental illness when it
occurs and to stimulate long-term care institutions to de-
velop the types of psychosocial programing needed to bring
out the existing capabilities of those whose conditions
cannot now be reversed.

Although at present chronic organic brain syndrome is
irreversible and may indeed worsen over time, many of its
victims can be helped to use their remaining functional
capacities to greater advantage, especially if diagnosis
and treatment are begun when impairment is relatively
mild. Some suffer from the unnecessary double handicap
of chronic brain syndrome and depression; others have
developed additional psychological and physical problems
that add to their distress and incapacity. If these “excess

138
disabilities” are minimized through proper treatment,
many older people with chronic organic brain syndrome
sometimes can show significant gains in day-to-day behav-
ior, even if their underlying physiological condition is
unimproved.

On the following pages we will discuss several approach-
es to improving the functional capabilities of senile older
people: one, an important but unfortunately unproductive
attempt at physiological treatment, and, two, explorations
devoted to creating a physical and social environment that
may enhance the well-being and overall performance of
senile nursing home residents. These studies by no means
exhaust the range of current research devoted to the
causes and treatment of senility. However, they do repre-
sent, in many respects, the current state of the art: At
present, we seem to be more effective in improving the
behavior of senile people through psychosocial efforts than
through physiological techniques. Many lines of physiolog-
ical research are underway, however, that may one day
keep older people from ever becoming senile and requiring
the kinds of intensive institutional care currently under
development. The history of medicine has many examples
of diseases which, prior to the discovery of their causes
and prevention, necessitated an elaborate structure of
human services devoted to the care and rehabilitation of
incurable victims. The case of polio is perhaps the most
dramatic example: There was once an elaborate rehabili-
tative system for polio victims which is no longer needed
because an effective vaccine has been developed. Although
we do not know whether chronic organic brain syndrome
will ever go the way of polio, it seems likely that with a
future combination of early diagnosis, more effective pre-
vention and treatment of circulatory disorders, and per-
haps the development of a vaccine for what may be a viral
source of one form of the disease, we may see an apprecia-
ble lessening of senility in the years to come.

In the immediate future, however, the problem of pro-
viding care for the senile is likely to increase dramatically,
as rising numbers of old people reach the advanced years
when frank senility is most likely to become apparent.
This trend, combined with the tendency for nursing homes
to become the major locus of care for senile people, places
a great burden of responsibility on them to respond appro-
priately to a growing population of mentally ill residents.
While, given the present state of our scientific knowledge,
we cannot expect nursing homes to cure their senile resi-
dents, we can expect them to offer the kinds of care that
enhance these people’s capacities to function as well as
their biological handicaps permit. We are at present far

139
from this goal. However, the nursing-home-based studies
described on the following pages may provide some foun-
dation for hope.

Before turning to these studies, one final note is in or-
der. Many researchers and service workers concerned with
studying and improving the functional capacities of senile
people focus more on behavioral symptoms than on the
medical or neurophysiological conditions that underlie
them. Thus, from a behavioral and service perspective, the
issue is “mental impairment” (whatever its cause). A
study of “mentally impaired” nursing home residents may
include individuals with several different medical diagno-
ses, who may be mildly or severely functionally handi-
capped. Unfortunately, since at present we do not have a
uniform system for describing precisely functional capaci-
ties of the “mentally impaired” (and medical diagnostic
labels can sometimes be misleading), it is difficult to say
whether the subjects of one study are comparable to the
subjects of another, or to predict whether techniques that
are effective with one group of mentally impaired older
people will work with another. A person’s score on the
Kahn-Goldfarb Mental Status Questionnaire is often used
to give a gross picture of the level of impairment (none,
mild, moderate, severe), but as we have seen, this is a rath-
er crude measure, and often multiple assessment tools
must be used when precision is needed. The studies cited
on pp. 128-132 are important because they may help to
standardize and clarify the medical diagnosis of senility.
Similarly, a descriptive technique developed in the study
described on pp. 156-175 may help to describe more accu-
rately the behavioral characteristics and functional capaci-
ties of older people—senile or not—so that treatment pro-
grams can be more appropriately addressed to their indivi-
dual needs and abilities.

Hyperbaric Oxygen Therapy: The Miracle That Failed

Regardless of myths and labels, anyone who has wit-
nessed the decline of an intelligent, alert, well-oriented
older person into the husk of a human is likely to wish
that a magic cure might suddenly restore memory and
clear out the cobwebs seemingly spun by time. In 1969, a
research report appeared in the August New England
Journal of Medicine that seemed to herald that dream
come true. A team of researchers headed by Dr. E.A. Ja-
cobs had found a rapid way to improve cognitive function-
ing in senile men with chronic organic brain syndrome.
For 15 consecutive days, 13 patients were placed twice dai-
ly in a special pressurized (hyperbaric) chamber and were
given pure oxygen to breathe through a mouthpiece. After

140
30 of the 90-minute treatments, these subjects showed
significant improvement, both on memory tests and on
tests measuring organic brain damage. A control group of
five comparable subjects who went through the same pro-
cedure but were given pressurized air to breathe instead
of pressurized pure oxygen did not show similar improve-
ment. However, these latter subjects showed gains compa-
rable to those of the first group when they too underwent
the entire experimental procedure with pure pressurized
oxygen.

Dramatic findings such as these naturally excite both
researchers and clinicians alike. To researchers, the exper-
iment suggested that chronic organic brain damage may
indeed be reversible, an important finding in its own right.
To clinicians, the experiment heralded the possibility that
within a fortnight of treatment, senile patients could come
out of their cognitive fog if they regularly breathed pure
oxygen under increased atmospheric pressure. The poten-
tial beneficiaries of this treatment were many, both those
already severely impaired and the less impaired who
might be spared further deterioration.

A flurry of research activity followed the 1969 report, as
did direct application of the procedure in many institu-
tional settings. Hyperbaric chambers, large submarine-like
tanks, although expensive to operate and maintain, were
in great demand. If indeed they could reverse senility,
then they were worth their considerable weight in gold.

Some researchers explored the possibility that inhaling
pure oxygen at normal atmospheric pressure might im-
prove cognitive function. If this proved effective, then the
procedure might have widespread use, since it would not
require the special chamber. The results of some studies
in which subjects simply inhaled pure oxygen were en-
couraging but equivocal. Since these studies were conduct-
ed without the benefit of a comparison group, it was hard
to assess the treatment’s efficacy. Other researchers ex-
plored the possibility that normal individuals, both old and
young, might boost their cognitive abilities by whiffing
oxygen in the pressurized chambers. This line of investi-
gation proved unproductive.

A few researchers embarked on the unglamorous but
necessary task of simply replicating the original study, to
demonstrate that the procedure could indeed work in set-
tings and in hands other than those of the original inves-
tigators. For the most part, these replication studies were
unsuccessful. But interest in the new procedure remained
undampened, since each replication study had flaws that
might have undermined its success. One of the most inter-
esting of these was that of Dr. Alvin Goldfarb and his co-
workers (the same psychiatrist-researcher who had devel-

141
oped the Mental Status Questionnaire with Dr. Kahn).
These investigators reported in 1970 that their replication
study had failed. However, they had not administered
treatment consecutively for 15 days, as had the Jacobs
group. In addition, they had run into a peculiar and poign-
ant problem: Many of their subjects, although suffering
from failing memories, were Jewish immigrants who had
not forgotten Hitler's gas chambers; for them, the re-
semblance between the hyperbaric oxygen chambers and
the infamous vehicles of extermination understandably
created great anxiety, and not all could cooperate fully
with the experiment.

Given the obvious potential importance of the initial
Jacobs et al. study and the fact that after many years it
still had not been satisfactorily replicated, some scientists
remained concerned that the effects of hyperbaric oxygen
might be illusory. There had been many precedents in the
history of medicine of apparently effective treatments
that, on closer inspection and careful study, did not sup-
port the claims of their discoverers. Not because there
was deception—although such cases have arisen—but
usually because the initial sample was small, or somehow
skewed, or perhaps because factors extraneous to the ex-
perimental procedure somehow biased the results. The field
of drug research is particularly prone to such false leads
in the early stages of drug testing, so much so that one
investigator once quipped: “If a new drug comes up, use it
quick before it loses its efficacy.”

A team of investigators at the National Institute of
Mental Health—Dr. Allen Raskin, a psychopharmacologist,
and Mr. Thomas Crook, a research psychologist, both of
whom were familiar with the hazards of trying to improve
human cognitive functioning through physiological inter-
ventions—remained in the agnostic camp concerning hy-
perbaric oxygen therapy. However, the Jacobs experiment
had been too well designed and was potentially too signifi-
cant to dismiss out of hand. What was needed, they rea-
soned, was a meticulously designed study that would defin-
itively demonstrate the procedure’s efficacy—if it had
any—and would answer many of the questions raised by
other studies. Thus it would be a replication study, but
with added features designed to account for possible
sources of error and bias.

After thoroughly searching the research literature and
discussing the current state of hyperbaric oxygen re-
search with leading investigators throughout the country,
these two scientists sought and found a research collabo-
rator: Dr. Samuel Gershon of New York University Medi-
cal Center. The two NIMH investigators assumed respon-

142
sibility for selecting the tests for measuring cognitive per-
formance and analyzing the data, while Dr. Gershon con-
ducted the actual experimental procedures used with ex-
perimental and control subjects. The new study would
compare the effects of oxygen under pressure (hyperbaric
oxygen) with air under pressure (hyperbaric air), as well
as with unpressurized (normobaric) oxygen and air, and
would identify specific differences in subjects’ responses to
the various types of treatment.

Although in major outline it resembled the original
study in the new design, greater care would be given to
subject selection and screening. Taking a cue from the
failed replication by Goldfarb and co-workers, subjects
who, on pretesting, were fearful of the hyperbaric cham-
ber were excluded from the new study’s sample. Many
studies had suggested that individuals suffering from
impaired cerebral circulation might be particularly re-
sponsive to hyperbaric oxygen, since it permits more oxy-
gen to reach the brain than might ordinarily be possible.
However, prior studies had not carefully identified which,
among their subjects, had cerebral arteriosclerotic dis-
ease or different sources of impaired brain function. The
researchers hoped to remedy this defect by using a medi-
cal history and a neurological examination of each pa-
tient. They feel, however, that the techniques and diag-
nostic tools available at the time of the tests were crude
by today’s standards and that they were not entirely suc-
cessful in making the desired differentiations.

The new study would also offer a more precise descrip-
tion of subjects’ cognitive capacities before and after
treatment, through use of an expanded battery of assess-
ment devices. Added to the tests originally used in the
Jacobs study would be others addressed to many aspects
of cognitive function, such as memory, orientation, intel-
lectual capacity, and information processing. Symptoms
accompanying organic brain disease such as depression,
anxiety, paranoid reactions, apathy, and withdrawal
would also be studied.

The experience of many investigators using hyperbaric
oxygen therapy had suggested that it works best with in-
dividuals who are only moderately impaired. Indeed, some
had attributed the inefficacy of some of the replication
studies to the inclusion of some patients presumably too
severely impaired to be helped. Thus, in selecting subjects
for their new study, the investigators deliberately used
mentally impaired but community dwelling, rather than
institutionalized, subjects and excluded those with signs
of extreme impairment. Nevertheless, all subjects prior to
treatment had memory losses significantly greater than

143
one might expect from their age peers. Despite these dif-
ferences, in many important respects, particularly initial
memory functions and age, the new subjects would resem-
ble those of the original study.

After potential subjects were carefully screened during
an exploratory period in which they were introduced to
the hyperbaric chamber and the experimental procedure,
82 subjects were chosen. They were randomly assigned to
four treatment groups: 21 would receive normobaric oxy-
gen, 21 normobaric air, 20 hyperbaric oxygen, and 20 hy-
perbaric air administered in all cases through a full-face
mask while they were in the hyperbaric chamber. The
treatment regime followed that of Jacobs et al.: 15 consec-
utive days of treatment with two 90-minute sessions per
day. Also in accord with the original study, four psycholog-
ical tests were administered on the day before treatment
and on the morning of the day following the final treat-
ment session. However, a battery of additional tests was
also given repetitively at various points before, during,
and after treatment. The continuation of testing, which
occurred at 1 day after treatment, then at 1, 2, 3, and 8
weeks after treatment ended, was designed to assess
whatever relatively long-term effects the treatments
might have.

When all the results were in, yet another replication
study had failed to find the hoped-for effects of hyperbaric
oxygen. In the original study, subjects who had received
hyperbaric oxygen for 2 weeks had shown statistically
significant gains on a memory test (Wechsler Memory
Quotient) compared with their original performance, while
those receiving hyperbaric air did not. The new study did
not reproduce these critical findings. Those receiving hy-
perbaric oxygen showed no greater memory improvement
than controls receiving hyperbaric air. When subject
scores were compared for the 101 tests run, only eight sta-
tistically significant differences were found among the
four groups of subjects, and these could have arisen by
chance. Further, differences in subjects’ responses to
treatment did not appear to arise from differences in their
initial levels of cognitive or neurophysiological impair-
ment. That is, relatively less severely impaired subjects
responded no better than the more severely impaired.
(However, it should be remembered that these subjects
were selected to exclude the extremely impaired.)

One puzzling set of findings has yet to be resolved. Sub-
jects treated with hyperbaric oxygen, as well as the con-
trol, or hyperbaric air-treated subjects, tended over time
to report feeling less anxious, less depressed, and less fa-

144
tigued than those receiving normobaric oxygen or air.
Since such differences were apparent during the acclima-
tion phase before the actual treatments had begun, they
may have resulted from hyperbaric subjects’ high expec-
tations of treatment benefit. However, since they persist-
ed through and long after the treatment ended (much
longer than most placebo effects usually endure), they
may not seem to stem wholly from the patients’ expecta-
tions. Whatever the reasons for these good feelings, they
did not contribute to better cognitive performance by the
group receiving hyperbaric oxygen.

Although it had been suggested that patients with cere-
brovascular disease might respond particularly well to
hyperbaric oxygen, those with this diagnosis responded no
better to hyperbaric oxygen than subjects with a noncir-
culatory cause of mental impairment (cortical atrophy).

In summary, the best that could be said for hyperbaric
oxygen therapy, at least as revealed by this study, was
that it did not, as some had feared, have deleterious phy-
siological effects for aged subjects and that unexpectedly,
for some unknown reason, it made them feel better and
more energetic. Its presumed benefits for cognition were
not demonstrated. Normobaric oxygen fared no better.

Findings such as these are discouraging, especially in
view of a prevailing prejudice that already views senility
as incurable. However, this study is important because it
challenges complacency and may serve to direct research
and therapeutic efforts in new and more productive direc-
tions. While it is important to sustain hope that senility
can be cured, that hope must be well founded. If, as it
appears, hyperbaric oxygen therapy has, at best, limited
utility for a small percentage of the mentally impaired,
then the issue shifts to identifying those whom it can help
and to finding other, more effective methods for the re-
mainder. Since hyperbaric oxygen therapy does carry
some risks, requires special and expensive equipment, and
is not universally well received by aged patients, it seems
best confined to use as a research tool at present. If this
study suggests that widespread use of the technique may
be premature, it may save effort, time, and money better
spent exploring new directions.

Of course, there may be many diehard researchers who
are not satisfied that even this carefully designed study
has fairly assessed—and questioned—the value of hyper-
baric and normobaric oxygen therapy. If it stirs some to
redouble their efforts and their rigor in trying to demon-
strate its beneficial effects, the study will also have proven
useful.

145
The Responsive Environment: Two Experiments in Better
Institutional Care for the Mentally Impaired

The search for physiological approaches to the preven-
tion and treatment of chronic brain syndrome continues,
although at present we have no miracle cures. Must we,
then, continue to regard our senile elders as hopeless and
simply relegate them to the back wards of State hospitals
and nursing homes? The answer is an unequivocal no.
Although these unfortunate older people do suffer from
irreversible brain damage and can, when impairment is
severe, look hopelessly deteriorated, many who have taken
the time and effort to work with them have found that
striking improvements in behavior and well-being are pos-
sible. Many researchers have recognized that the institu-
tionalized elderly often suffer from a self-fulfilling prophe-
cy: Since it is assumed that they cannot improve, no one
tries to help them, and they soon decline as everyone had
predicted.

No one is saying that many of those now living in nurs-
ing homes and State mental hospitals can be miraculously
returned to full mental functioning, or that we have a
cure for arteriosclerotic brain changes or brain degenera-
tion, but we have often rushed prematurely to pessimistic
prognoses that have precluded even trying. This premise
is both scientifically and humanistically untenable. And as
a practical matter, its consequences are disturbing.

Dr. Robert Kahn had suggested many years ago that
many mentally impaired older people suffer from “excess
disabilities,” that is, functional impairments greater than
their physiological condition warrants. A research team at
the Philadelphia Geriatric Center headed by Mrs. Elaine
Brody put the thesis to the test with a group of mentally
impaired residents of PGC and showed that great progress
was possible, even in the face of severe impairment.

This study provided an important opening wedge be-
cause it demonstrated that psychosocial interventions
could appreciably improve the lives of many patients for-
merly considered hopeless, and it inspired many at PGC
and other nursing homes to intensify their efforts on be-
half of these residents. To be sure, many institutions still
essentially let their “seniles” stare blankly at the walls—
incontinent, disheveled, and incoherent. But recognition is
growing that to do so is to deprive older people of whatever
fullness their later years might bring. Now that some of
the hopelessness has been dispelled, there are still many
practical barriers to better psychosocial services and men-
tal health care for the institutionalized mentally impaired
or senile. Many nursing homes lack the staff to provide
intensive programs, and our funding patterns for Medi-

146
care and Medicaid—a major source of support for nursing
homes—still do not provide adequately for psychosocial
staff and services.

Thus, leadership in the care of the mentally impaired
still comes largely from large nonprofit nursing homes
that have sufficient support from their local community
(augmented by government research grants) to mount and
explore improved methods of care. The following two stud-
ies, conducted by the research staffs of two such institu-
tions—the Ebenezer Society and the Philadelphia Geriat-
ric Center represent pathbreaking efforts on behalf of the
mentally impaired that are still undergoing evaluation.
Whatever their final outcome, they attest to a new spirit
of optimism, combined with rather rigorous research
standards, that may point the way to more effective ways
to help the mentally impaired. As these studies will illus-
trate, conducting applied research in a service setting for
the elderly is by no means easy. “Ideal” research designs
must often give way to considerations of administrative
convenience and subject well-being. However, both of
these studies reflect a high degree of cooperation between
the institution’s administrative, service, and research per-
sonnel. The willingness of these nursing homes to undergo
rigorous study in the interest of improved service stands
in marked contrast to many other institutions. The differ-
ence stems, in part, from the ongoing presence of re-
searchers who are viewed not as “outsiders” from a local
university, but as a part of the institutions’ own staff.

Let us look now at these two ambitious experimental
service projects which are devoted to creating a better life
for the most debilitated and least understood members of
our community of elders.

Accent on the Environment

“Honor thy father and mother” is the legend inscribed
at one entrance to the Philadelphia Geriatric Center. The
ancient commandment is heeded there in ways that are at
once traditional and strikingly contemporary. Founded in
1952 as the Home for the Jewish Aged, a voluntary, non-
profit “home” for the well elderly, it has grown over a
quarter century into a major multifaceted hub of geriatric
research, service, and training.

The Philadelphia Geriatric Center (PGC) that meets the
eye is a dense cluster of largely new buildings command-
ing a park-like city block in Northern Philadelphia, bor-
dered by the modest turn-of-the-century semidetached
rowhouses characteristic of much of Philadelphia architec-
ture. What is not obvious is the careful research, plan-
ning, and administrative wisdom that transform these

147

274-912 O - 78 = 10
structures into a responsive network for meeting the
many needs of the elderly. Among the diverse structures
that make up PGC are two high-rise apartment buildings,
an older building still housing many of the original resi-
dents of the Home for the Jewish Aged (HJA), and the
most recent addition, the Weiss Building, a handsomely
designed and decorated structure incorporating among its
many facilities a 56-bed acute care hospital, a diagnostic
center, and the 120-bed Sley Pavilion devoted to the men-
tally impaired aged. Ten of the row houses adjacent to the
main campus serve as the setting for the Community
Housing experiment described on pp. 77-88. In all, some
1,000 older persons are residents of the Center’s buildings,
and countless more use its diagnostic and medical services
and are touched by its many community outreach pro-
grams. The Center provides options for the aged ranging
from the independent community dweller to the severely
mentally and physically deteriorated and ill.

PGC’s administrators realized quite early that quality
care requires not only a service orientation but commit-
ment to improved knowledge and practice through re-
search. Its investigative activities span basic biomedical
research as well as applied social and psychological re-
search. Many of these studies, often stemming from the
Center’s own knowledge needs, have yielded findings
broadly applicable to other settings as well.

We will focus here on a major PGC research project,
addressed to the impact of the physical and social environ-
ment on mentally impaired or senile residents. It follows
from years of research and service addressed to environ-
mental impact on the elderly and from PGC’s longstanding
concern for the creation of a human and physical milieu
that brings out the fullest potential of older people, what-
ever their capabilities or impairments. Mentally impaired
residents, who in other nursing home settings might be
relegated to a back ward, unkempt, incontinent, and
blank-eyed, are treated with dignity, addressed by their
proper names, encouraged to dress as well as they are
able, and invited to participate, to the extent possible, in
an array of activities designed to stimulate their self-ex-
pression and continuing social and intellectual engage-
ment. The PGC’s rehabilitative approach to the care of the
mentally impaired has developed through the years as
staff members have sought better ways to enrich the lives
of their residents. Let us look back, for a moment, at an
earlier PGC research project which sets the stage for the
major study under discussion.

In the early 1970s, an NIMH-funded project was initiat-
ed under the direction of Mrs. Elaine Brody and Dr. Mor-
ton Kleban, to design individualized treatment programs

148
for mentally impaired residents that might enhance their
day-to-day functioning. In developing their approach to
treatment, the project staff members were guided by the
Kahn-Goldfarb notion of “excess disabilities.”

Mrs. Brody and her staff assumed that “excess disabili-
ties,” which could be found in any or all of the physical,
psychological, or social spheres of a resident’s functioning,
could be reduced by a carefully designed multidisciplinary
intervention program. To test this thesis, 64 women who
were moderately to severely mentally impaired were se-
lected as subjects (few men were available), with half
randomly assigned as experimental subjects and half as
controls. All subjects underwent broad initial evaluation
which provided information about their personality, ad-
justment, health status, and behavioral, cognitive, social,
and self-care functioning. The evaluation also served as
one guide for developing individualized treatment pro-
grams for the experimental subjects. (The controls contin-
ued to receive the same good care that characterized the
Home for the Jewish Aged, but no specific efforts were
made to tailor a treatment regimen for them.)

A multidisciplinary staff meeting was held to discuss
each experimental subject individually, to identify excess
disabilities, and to design specific treatments to overcome
them. The treatment goals were very clearly and precisely
stated. For example, as reported in one summary of this
study:

...If a subject was wheel-chair-bound, the goal would not be stated
vaguely as “to improve ambulation,” but in concrete terms such as
“the goal is to help Mrs. A. ambulate with a walker.” Or if the sub-
ject was apathetic and inactive, the goal would not be “to engage
Mrs. B. in activities,” but rather a specific goal selected in terms of
Mrs. B’s own background and personality would be set, for instance
“interest and engage Mrs. B. in simple sewing activities.”

Having determined the specific goal, appropriate team members
would be assigned specific tasks in relation to the goal. Any or all of
the staff might be required for work on each excess disability. For
example, to get Mrs. A. (a very obese woman) from wheelchair to
walker might require the physician (to prescribe reducing diet and
physiotherapy), food manager (to prepare special diet), social worker
(to help motivate Mrs. A. and work with her family so they do not
continue to bring her candy.)

In the latter case, which was extremely successful, it
was later reported that:

The social worker and Mrs. A. walking down the hall became such a
familiar sight to the other residents that they took to making en-
couraging comments. At one point, Mrs. A. mentioned that between
the loss of weight and the increasing ability to walk, she looked for-
ward to putting on a corset, a nice dress, and walking to meals like a
“mensh”—a person.

149
Evaluation by project staff, HJA staff, and outside rat-
ers 1 year after the treatment program started revealed
that, in 82 percent of the experimental subjects and 47
percent of the controls, excess disabilities lessened; 4 per-
cent of the experimentals and 30 percent of the controls
stayed the same, and 14 percent of the experimentals and
23 percent of the controls showed even worse excess disa-
bilities.

Improvements often took place despite some decline in
general health, sometimes even in the face of serious med-
ical illness. Progress among the experimentals was ex-
tremely heartening, but another hoped-for benefit did not
emerge: There was no ‘“spill-over effect” from improve-
ments on the excess disabilities to other areas.

One somewhat unexpected finding was the correlation of
“aggressive” personalities in patients with improvements,
although this occurred more frequently among the experi-
mentals than among the controls. Stubborn, nonconform-
ing, and negative behavior of residents often invites staff
hostility and/or avoidance, since it conflicts with an envi-
ronment that usually demands resident cooperation and
passivity. Apparently the struggling spirit of these men-
tally impaired people, channeled by a staff motivated by
the project to approach their problems constructively,
helped to stimulate progress.

The “excess disabilities” approach to patient care adopt-
ed in this research project could not reverse brain dam-
age, but it did help residents to use whatever capacities
they had to a greater extent. The study was crude, but its
influence at PGC and elsewhere was strong. The project’s
message was clear: Severely mentally impaired people are
by no means hopeless. Although there are limitations to
their recovery potential, they can grow, change, and over-
come many problems that interfere with full functioning
and enjoyment of life. Recognizing that these residents
can be helped is an important first step in helping them.

The encouraging results of this project stimulated even
greater interest at PGC in enhancing the institution’s
capacity to provide rehabilitative care for the mentally
impaired. However, the physical environment in which
these residents were housed was obviously less than opti-
mal. The original structure of the Home for the Jewish
Aged, built in 1952, was a confusing maze of long corri-
dors, presenting an undifferentiated row of endless doors
and indistinguishable rooms. Residents were squeezed in,
three to a room, and had to traverse the long, confusing
corridors to reach the cafeteria or other activity areas. An
armada of wheelchair-bound residents lined the corridors
to eat, and traffic jams were frequent. Despite the best

150
efforts of the staff to provide good care, this classically
institutional building created problems for the mentally
impaired, adding an incomprehensible and overcrowded
environment to their preexisting disorientation.

Since the old Home for the Jewish Aged was an unsatis-
factory environment for optimal care, a specially designed
milieu for mentally impaired residents was planned as
part of PGC’s long-range building program. A long period
of careful research and consultation preceded the design
of what was to become, many years later, the Sley Pavil-
ion, a three-floor structure housing 120 senile residents,
located within the new Weiss Institute building. The new
structure’s design was to incorporate the best available
knowledge concerning the special characteristics of the
mentally impaired elderly and the environmental features
most likely to sustain and enhance their full functioning.
As Arthur Waldman of PGC put it, “We tried to identify
the problem, and then wrap a building around it.”
Although it might seem strange, in a world of limited
funds and resources, for the Philadelphia Geriatric Center
to give high priority in its building program to those resi-
dents seemingly least able to appreciate a magnificent
new structure, this choice was based in part on recogni-
tion that it is precisely those with limited adaptive capaci-
ties who need the support of an environment carefully
designed for them. The environment was intended to be,
at the very least, “prosthetic,” that is, to compensate for
defects in the residents’ capacities, much as eyeglasses or
artificial arms or legs compensate for other types of disa-
bilities. A particular focus of the design was to free the
visual environment of cues that might add to an already
confused person’s problems of spatial orientation and to
provide, instead, clear landmarks that could help them
find their way in the small world that was to be their
home. A second goal was to provide a setting that would
enhance therapy by providing staff and family members
with a congenial environment in which to carry out their
therapeutic roles.

The “sociopetal” design that emerged was a radical de-
parture from conventional corridor-ridden institutional
design; instead, resident’s rooms were wrapped around a
large open activity area which had distinctive visual fea-
tures to mark off its many functional sections. As the de-
sign has been translated into an actual structure (built in
1974), the Sley Pavilion’s three floors follow an identical
plan: One enters through a low gate (placed to prevent
residents from wandering out) into a very well-lit, large
(40’ x 80’) room, appointed throughout with groupings of
colorful, handsome, specially designed Scandinavian con-

151

274-912 O - 78 = 11
temporary furniture. At the near end of this central activ-
ity area is a lounge, with comfortable seating and a TV.
Next is an eating and work area, marked off by a lattice-
work that defines it but retains the openness of the total
space. Toward the center is another grouping of chairs
and, off to one side, a nursing station with full view of all
the residents. Toward the back is an open gazebo filled
with plants, seats, and an aquarium. A set of bridge-like
low stairs next to the gazebo serves both as a small stage
and as a locale for physical therapy. The area behind the
gazebo, designed for scheduled activities such as occupa-
tional therapy, discussion groups, or music therapy per-
mits some isolation from the larger area. A small kitchen
also opens onto the activity area, for use in resident cook-
ing projects.

The atmosphere of the main activity room is light,
cheery, clean, and comfortable, sparked by many gay wall
hangings and by the distinctive primary hues used to col-
or code the entryways to the residents’ rooms, whose door-
ways face the open central area. Other carefully planned
features of the environment include:

e large-size three-dimensional room numbers and large-
lettered names of occupants on room doors, sized and
placed for easy reading

e handrails especially designed for the elderly

personal bulletin boards for all residents

e daylight-equivalent lighting that can be reduced as de-
sired

e tables designed to accommodate wheelchairs and per-
mit many regroupings

e chairs designed for the height, width, depth, and slope
requirements of the elderly, with removable wings for
headrests and tables

e “reality orientation boards” indicating the building
name and floor, date and day of the week, season, next
meal, and the weather

One other design feature represents an inventive solu-
tion to a difficult legal problem. The building code requires
that an 8-foot corridor be provided. Since the new design
explicitly attempts to avoid conventional long-corridor
plans, how could the archaic code requirement be satis-
fied? The answer was an 8-foot “corridor” indicated
around the periphery of the center space by a darker floor
and a slightly lowered ceiling. Since the corridor area helps
also to demarcate the central activity area from the resi-
dents’ rooms, it may also help them find their way.

Residents are roomed in pairs and share a relatively
large bedroom and bathroom. Within each bedroom, color
coding is again used to distinguish one resident’s bed, ta-

152
ble, chair, etc., from those of his or her roommate. The
rooms are somewhat spare, but residents are encouraged
to bring some of their own possessions. Thus, in some,
faded gilt-framed family photos contrast markedly with
the contemporary flair of the decor.

The basic intent of the design was to provide an envi-
ronment that provides for resident comfort, security, and
stimulation with a minimum of confusing environmental
cues. The open design permits them to move about freely,
but in full view of the staff. Residents can see a large vis-
ual expanse that provides many orienting landmarks, and
they have ready access to a variety of activities and peo-
ple, whether they simply watch or participate with others.
The proximity of residents’ rooms to one another and to
the central activity area is intended to encourage sociali-
zation, although residents can retreat easily if necessary.
Since staff offices are also located around the central ac-
tivity core, staff and residents are readily accessible to one
another.

The physical environment, of course, is but one part of
the residents’ world. In this setting, an intensive array of
services is offered to guard their often fragile health,
stimulate their minds and bodies, and sustain their social
life and self-respect. Although residents spend most of
their time in this single setting, they are also taken out-
side, both on the PGC grounds and elsewhere for trips.

One might think it obvious that any environment as
carefully planned as this would be better for residents
than the old Home for the Jewish Aged building. Yet to
PGC’s researchers and administrators this was an as-
sumption to be tested, not a foregone conclusion. Perhaps
the designers had attended to variables that, while rele-
vant, would not directly affect residents or staff signifi-
cantly. Perhaps residents were simply too impaired to be
helped by inbuilt environmental aids. Perhaps, inadver-
tently, other features had been created that were disad-
vantageous to staff and residents. And if residents did
show some progress (or a slower rate of decline), it would
be important to identify precisely in what domains it oc-
curred. Would their cognitive ability improve? Their social
behavior? Their capacity for self-care? All of these? It was
also essential to identify how the old and new environ-
ments affected the social interactions of those within
them. If residents did or did not show some improvement,
or declined even further, these results would have to be
linked to the impact of the environment on others in the
residents’ social milieu.

In 1969, when the design of the new structure was still
being developed, the Philadelphia Geriatric Center re-

1563
ceived NIMH support for a study, directed by Dr. Morton
Kleban, to compare the effects of the old and new facilities
on residents, staff, and others who came in contact with
residents. One key goal, of course, was to discover whether
the new structure would appreciably benefit residents. A
second goal was to identify how the two settings for the
treatment of the mentally impaired elderly would differ-
entially affect people’s behavior.

The research study began in 1973. As is common in the
real world of applied research, an initially rather classical
comparative research design ultimately had to be modified
to accommodate unavoidable administrative problems.
Construction delays shifted the scheduling and logistics of
moving residents from the Home for the Jewish Aged to
the new Sley Pavilion. Nonetheless, it was possible to fol-
low the main outlines of the research design which called
for:

1. Assessment of HJA residents well in advance of the
move and observation of social interaction patterns at
HJA

2. Comparison of two groups of these HJA residents
over a 2-month period while one group (early movers) were
transferred to Sley and the other group (late movers)
stayed

3. Ongoing studies of the two resident groups after both
had moved to Sley and study of social interaction patterns
at Sley

This research design permitted several types of compari-
sons to be made between the old and new settings:

1. A comparison of residents’ cognitive ability, self-care
ability, and institutional behavior before and after they
moved to the Sley Pavilion

2. A comparison of the behavior patterns of staff, resi-
dents, and others in the two settings

3. A comparison of the reactions of staff and family
members to the physical features of the two settings

4. A comparison of resident decline or progress during
the 2-month period while the early movers were adjusting
to the Sley Pavilion and the late movers were still at HJA,
prior to their own move

The second comparison was the one to which the great-
est research effort was devoted. The researchers assumed
that the most sensitive measure of environmental impact,
whether on residents or others, would be to make repeated
observations of exactly how people behaved within well-
defined areas of the two settings. Toward this end, in-
tensive use was made of two observational techniques,
“streams of behavior” and “behavior mapping,” to de-

154
scribe specifically the ongoing behavior of residents and
the way they and others interact in given micro-environ-
ments, such as the nursing station, lounge, or bedrooms.

The project’s data collection period spanned from July
1973 (while all subjects lived at the Home for the Jewish
Aged) through June 1975, when all of those who had
moved to the Sley Pavilion had lived there at least 6
months. Subjects chosen for study were 135 of the 325
HJA residents who, on testing and interviewing, were
deemed moderately to severely cognitively impaired. They
were randomly assigned to the early- and late-move
groups. However, some members of the original study
group did not actually move to Sley, since some died before
the move, and others, because of illness or other reasons,
had to remain at HJA. One of the disheartening aspects of
aging research with such a fragile population is the contin-
ual loss of subjects. However, such studies, if carefully
conducted, can gain needed information that might at an-
other time contribute to the enhanced survival of other
residents.

A major concern of the research and service staffs of
PGC had been that the move itself, although presumably
in the residents’ best interest, might endanger their
health, even survival. The already cited results of pre-
vious studies had suggested that this was a potential haz-
ard, especially among institutionalized populations. As a
result, every effort was made to ease the residents’ trans-
fer to the new building, with residents, staff, and family
members well-prepared, and the transition smoothed as
much as possible through personalized care to assure that
these disoriented individuals understood that this very un-
familiar and different environment was their new home.
All of the early-move subjects were assigned to the first
floor of the Sley Pavilion, and the same caution was used, 2
months later, when the late-move subjects became resi-
dents of the identical third floor. (Both research floors had
a mixture of old staff members as well as new ones necessi-
tated by an increase in the total bed space of PGC.)

Although the results of this study are still being ana-
lyzed, some preliminary findings can be reported. First, let
us look at how staff and family members reacted to the two
settings. As reported by Dr. Kleban and Mr. Samuel Agger,
the physical facilities of the Sley Pavilion generally re-
ceived much higher ratings by staff members than the
Home for the Jewish Aged, especially concerning the resi-
dents’ rooms, eating place, the hall center space, nurses
station, staff lounge, and the general ease of service. Of the
50 staff members who had worked in both settings, 74 per-
cent preferred Sley. The new physical plant was not with-

155
out its faults, however, and staff reported rather consistent
difficulty in manipulating wheelchairs and in operating
bedroom curtains, bathroom problems, noisiness of the
central space (to which the paging system added further
annoyance), and odor problems that still were not solved.
(Incontinence is a frequent problem among the mentally
impaired elderly.) For the most part, responses by resi-
dents’ family members to some of the same questionnaire
items similarly favored the Sley Pavilion.

As yet we do not know whether residents fared better in
the new settings than in the old. Since this study is not
complete, many other questions remain. However, it
should yield a very precise description of the way nursing
home activities are affected by the physical environment,
and their ultimate impact on a very special population:
the mentally impaired elderly. Whether the new physical
environment can provide a sufficient boost to make a per-
ceptible difference in the quality of their daily lives re-
mains to be seen. But the commitment and effort have
been made, and the study should pinpoint salient factors
contributing to its outcome. PGC has charted new ground.
Its experience should help others to create a home for the
mentally impaired that can preserve and enhance their
flickering humanity. If we cannot yet preserve or restore
their full intellectual capacities, we can at least organize
our care settings—socially and physically—to bring out
their best functional abilities. The Philadelphia Geriatric
Center may show us one way.

Accent on Individuals

For many older residents of Minneapolis, particularly
those of Lutheran Scandinavian origin, the Ebenezer So-
ciety is a familiar and welcome presence. This Lutheran
nonprofit corporation, sponsored by 47 Lutheran congre-
gations in the county encompassing Minneapolis and its
suburbs, operates an extraordinary range of integrated
services and facilities for the aged, most of which are clus-
tered in five main buildings on a downtown city campus.
About 800 residents occupy its multilevel care facilities,
which offer a range of care levels from a highrise apart-
ment unit through board-and-care and intermediate care
to skilled nursing care. The Ebenezer Society also sponsors
outreach and protective community services for the elder-
ly, including day care programing, coordination and
staffing of 16 senior centers, and sponsorship of a Model
City Protective Service Project which provides medical,
psychiatric, legal, and social services for community dwell-
ing elderly, too disoriented to act on their own behalf. Its
facilities and programs serve as a training ground for

156
numerous practicing and student professionals and para-
professionals from the Minneapolis area.

The Ebenezer Society has developed over the years an
approach to the aged that is comprehensive and flexible,
providing services responsive to a wide range of individual
needs and permitting individuals to transfer within its
services as the need arises. To carry out its many residen-
tial and community functions, Ebenezer has a staff of
over 675 part-time and full-time persons, augmented by a
dedicated group of volunteers. Its staff members’ skills are
sharpened through a variety of inservice training pro-
grams.

Although the Ebenezer Society has always provided
high-quality services for its elderly residents, its service
emphasis had initially been given largely to the relatively
well among its elderly residential population. The mental-
ly impaired or “senile” were considered unable to respond
to many of the activities other older people enjoy. But
under the leadership of Rev. Almon J. Brakke, this group
of residents began to receive concerted attention. Taking
a cue from developments in the milieu therapy for the
elderly and residential care of the mentally ill, experi-
ments began at Ebenezer to create a therapeutic milieu
for the mentally impaired in which staff teams would in-
teract with residents to stimulate responsibility and partic-
ipation, rather than passive dependence. Rev. Brakke,
like a few other pioneers in the late 1960s, believed that
the mentally impaired aged could regain considerable
functional capacity, despite their physiological deficits,
through a carefully structured program based on assess-
ing individual needs and responding with a broad spec-
trum of multidisciplinary services carried out in an envi-
ronment devoted to rehabilitation, not custodial care. His
optimism concerning the rehabilitative potentialities of
the mentally impaired was reflected in a 1969 Annual
Report of the Ebenezer Society:

Mental impairment in the older person, which is generally spoken of
as senility, is recognized as one of the national crises in our rapidly
changing time of stress and emotional unrest. It is essentially a
condition of organic deterioration and loss. We see daily the effects
of deterioration formerly thought to be irreversible, but now recog-
nized as treatable. That is why Ebenezer feels primary considera-
tion needs be given to prevention of mental impairment and con-
tinuing evaluation of mental health....Ebenezer has for years served
countless numbers of mentally impaired residents. We continue to
do so. What is changing, however, is our commitment to the preven-
tion and reversal of mental impairment, not only a custodial in-
volvement.

5Developed by University of Michigan faculty with Ypsilanti Hospital
staff.

157
In that same year, a pilot program, appropriately named
“Maintaining the Growing Edge,” was initiated, using a
variety of private funding sources. primarily a grant from
the Lutheran Brotherhood, to test this article of faith
through direct exploratory programing. The first target
group consisted of the 31 residents of the fourth floor of
Luther Hall, a skilled nursing care facility (SNF) on the
main Ebenezer campus. These residents, primarily wom-
en, averaged 85 years of age and were severely disorient-
ed. With a special mental health staff, consisting of Rev.
Brakke, a project secretary, a program coordinator, three
full-time and two part-time mental health assistants, and
a remotivation-activities therapist, the pilot program was
launched. Through cooperative planning and evaluation
between mental health and services staff (both profession-
al and nonprofessional), an intensive array of intervention
approaches was offered, including reality orientation ther-
apy, remotivation, forms of behavior modification, physical
therapy, occupational therapy, social group work, and cri-
sis intervention, all integrated within a milieu therapy
environment. The active participation of family members,
a special resource in this Midwestern community, as part
of the therapeutic team was sought and obtained.

In 1971, the somewhat more disoriented and severely
physically impaired residents of Luther Hall’s third floor
were also added to the program, as were selected residents
from other Ebenezer facilities in need of these extra serv-
ices. As reported later by Rev. Brakke, the pilot program
yielded many rewarding changes in residents’ behavior:

During the pilot study a number of residents progressed sufficiently
to return to their former community, while a number of others pro-

gressed to varied levels of adjustment within the comprehensive
program at Ebenezer Society.

Some persons who were, for their own protection, restrained in
wheelchairs are now walking and active again. Others who were sit-
ting in chairs or lying on their beds are again involved. Some per-
sons with guidance can now assist with arranging tables and chairs
for their meetings. Some push wheelchairs, set up bowling pins, play
games, participate in exercises, and express joy and a helping spirit.

One person no longer feels the need to tear off her clothes. New re-
lationships have added meaning to her life. Another elderly person
who sometimes wandered away and got caught between cars on the
street, has progressed to relationship in another living unit. One
woman who would not come out of her room now meets regularly
with her group.

Other individuals who wandered away and could not be depended
upon—who wanted to “get out” are now in sufficient relationship to
feel needed and wanted, related and involved. There is reading,
singing, baking, making coffee, playing games, taking part in Bible
study and worship, doing art work, bowling, taking trips, sharing in
parties, and so on. The emphasis is always on options and choices
for the individuals.

158
Given these encouraging beginnings, the pilot program
was extended to other Ebenezer facilities, with the help of
nursing students receiving geriatric mental health train-
ing at Ebenezer. As they gained in experience and skill,
the mental health staff initiated inservice education for
all of Ebenezer’s service personnel to “stimulate aware-
ness of how mental deterioration can be deterred in the
course of routine patient-staff interaction and objective
planning.”

In 1972, the Ebenezer Society received NIMH funding to
develop further and, equally important, to test systemati-
cally their approach to working with the mentally im-
paired aged. If, as it appeared, they had developed a via-
ble way of discovering and enhancing many lost functions
among these residents, then the approach might well be
applicable to other settings as well. But first there were
many questions to be answered. Primary among them, of
course, was the actual effectiveness of the program.
Although the anecdotal evidence cited above was extreme-
ly encouraging, the program had not undergone any sys-
tematic assessment. Which residents, with which charac-
teristics, could it help? Although it appeared that mentally
impaired residents made more progress with the program
than without it, exactly what was the program’s impact?
And what, precisely, were the essential components of the
program? If it was to have value for others, essential pro-
gram features would have to be systematically identified
and described so that others could use it. How effectively
could it be taught and transmitted to staff members who
would be called upon to implement it? The Ebenezer staff
members had absorbed a special perspective and approach
to care almost by osmosis, as it had become integrated
into ongoing programing. But how well would others, who
started afresh or worked in other settings, absorb it?

The advent of the NIMH grant represented a new phase
in the project’s evolution. The largely intuitive fledgling
program was coming of age; although still developing, it
was ready to be evaluated. Attention was to be focused
not only on the residents, but on the process and rationale
that guided the project and on the relationship between
its intended and actual effects. The advent of a more
objective and scientific spirit did not dampen the innova-
tive enthusiasm of staff members. If anything, they be-
came charged with a new sense of dedication: Their efforts
might benefit not only the residents they worked with, but
others as well.

In keeping with the project’s more scientific orientation,
its leadership changed. A research staff was added, direct-
ed by Ms. Lorraine Hiatt Snyder, a psychologist serving as
Project Director, with Dr. Janine Pyrek serving as Re-

159
search Associate. Over a 3-year period the research proj-
ect would be addressed to several goals:

e to refine and expand the basic social model used in the
pilot program

eo toinvolve, sensitize, and train staff at Ebenezer who are
not directly involved in the program in methods and
techniques to prevent and delay mental impairment in
the elderly residents with whom they work

eo to monitor and evaluate the effectiveness of these tech-
niques and methods according to established criteria

e to derive a social model that is applicable to a variety of
settings

Initially, the program’s effectiveness was to be assessed
by comparing residents’ progress over time against staff-
developed goals for each resident (an approach similar to
that used at the Philadelphia Geriatric Center in their
“excess disabilities” study). However, a unique combina-
tion of circumstances provided an opportunity to evaluate
the program more stringently by comparing the progress
of program participants with other impaired residents
receiving more conventional care.

Increasing demands for Ebenezer’s residential facilities
had stimulated a search for more space for skilled nursing
services. A newly built but half-completed nursing home
some 20 miles away from the main campus, in Burnsville,
suited Ebenezer’s expansion needs. The well-constructed
building, which had stood unoccupied (except for hippie
squatters) for over a year, was purchased by Ebenezer,
and its interior completed (to the extent that funding and
pre-existing design features permitted) to provide a bar-
rier-free, resident-oriented environment. Floors were car-
peted, walls were gaily decorated, lighting was carefully
chosen to be bright but glare free, and resident rooms,
singles or doubles, were designed for easy access even for
those in wheelchairs. Through the use of specially de-
signed chairs and other furniture and low placement of
closets and drawers, the environment was designed to
accommodate the limitations of the physically and mental-
ly impaired elderly sufficiently to permit them some mas-
tery of their surroundings. Many of the design features
were suggested by Ms. Snyder, whose background as an
environmental psychologist had sensitized her to the po-
tentially supportive role the physical environment could
play.

Ms. Snyder realized that Ebenezer’s new skilled-care
facility, dubbed “Ebenezer Ridges,” might provide a
unique opportunity to put the Ebenezer mental health
program to an experimental test. Since the Ridges would
have to be filled and staffed essentially from scratch, why

160
not use it as a demonstration site for the project? Its
identical two floors could be organized so that one could
serve as a control floor, providing good standard care,
while the other could be an experimental floor housing
residents receiving good care amplified by the mental
health program developed on the Central Ebenezer Socie-
ty campus. The experimental comparison could be con-
ducted for a year, after which residents of both floors
would receive whatever programing the project had re-
vealed to be most effective.

Such a proposal, although sound from a researcher’s
viewpoint, is foreign to most nursing home administrators.
In fact, a key factor missing from most such evaluation
research is random assignment of residents to treatment
programs. Opening and staffing the new facility to accom-
modate a research project of such magnitude would add
immeasurably to the stress of startup and day-to-day
functioning. Nonetheless, the administration of the Ebe-
nezer Society, recognizing the potential benefits the proj-
ect might yield, agreed. And the new director hired to
head the new facility enthusiastically supported the plan.

Recognizing that it might be difficult to maintain the
purity of two different approaches carried out within a
common setting, Ms. Snyder made another request to the
Ebenezer administration. Could another nursing home,
comparable in scale and approach to the control floor, be
found to serve as an additional control? It would have to
provide very good nursing care, be reasonably nearby, and
be willing to have its residents and its care program stud-
ied. It would also have to be willing to undergo possible
unflattering comparison, since, presumably, if the experi-
mental Ebenezer program were successful, residents on
the experimental floor of Ebenezer Ridges would show
greater progress than its own. In exchange for its partici-
pation, however, Ebenezer would share with it, through
staff training, approaches shown by the project to be par-
ticularly beneficial to the mentally impaired. Surprisingly,
with the assistance of several Ebenezer administrators,
the appropriate setting was found which filled all specifi-
cations: Careview Nursing Home, not far from the main
Ebenezer campus in Minneapolis.

During the time these negotiations were being carried
out, the research staff at Ebenezer were conducting a
number of studies and developing approaches to systema-
tize the program and measure residents’ progress. (By
this time, the project staff and program had been re-
named. Recognizing that older people are sometimes
threatened by the psychiatric overtones of the term “men-
tal health,” the staff had substituted the more neutral,
but equally appropriate, term ‘human development.”

161
Thus, they became the “Human Development Staff,” and
their program, the “Human Development Program.”)

One of the primary tasks of the research staff, working
in conjunction with the service staff, was to develop a sys-
tematic way to describe the characteristics of residents
with whom they were working. Both service and research
staffs needed a point of reference that would enable them
first to describe the functional capacities of residents,
then to develop appropriate programs suited to their par-
ticular needs and capabilities, and, finally, to assess resi-
dents’ progress over time. Existing charts kept on resi-
dents provided insufficient information on essential as-
pects of their psychosocial functioning: A few lines on
their medical diagnoses and medications and some longer
entries gleaned by a social worker at intake concerning
their families and past, but very little that could specifi-
cally suggest a given individual's capabilities or could
provide guidelines for programing.

A search of the research literature revealed a scattering
of measurement tools addressed to psychosocial function-
ing of the mentally impaired, but most were quite narrow
in focus, stressing only one of the many dimensions con-
sidered important at Ebenezer, such as mental status, ac-
tivities of daily living, or life satisfaction. The most com-
prehensive assessment tool,6 developed at Duke Universi-
ty, did seem to be addressed to the whole person, but es-
sential aspects of individual function, such as communica-
tion, sensory capabilities, and life satisfaction were not
specifically included. Thus, its applicability to Ebenezer’s
needs was limited by the generality of many of its catego-
ries; it could not be readily used as a guide to individual-
ized programing.

It became apparent that the research staff would have
to develop their own comprehensive assessment tool, one
that matched Ebenezer’s broad approach to treating men-
tal impairment and could be used both as a research and
programmatic tool. After extensive staff deliberations, the
Human Development Inventory (HDI) was created. Some
28 essential aspects of psychosocial functioning were
enumerated, with space to indicate a given resident’s
“need” or “no need” for special services and development.
It was subsequently modified to include a range of six lev-
els of need for each area of function, to permit finer de-
scriptions of individuals’ functional capabilities and needs.

The HDI is addressed to six major dimensions of psycho-
social functioning: alertness, satisfaction with present life,
socialization, inner peace, sensory adjustment, and com-
munication. Within each of these categories there are sev-

 

6The OARS Multidimensional Functional Assessment Questionnaire.

162
eral subcategories. For example, the dimension of alert-
ness includes recent memory, remote memory, orientation
to time and to place, self-reliance (psychological), and deci-
sionmaking ability.

As a programmatic aid,” the HDI has several potential
benefits. First, because it requires an itemized assessment
of a broad range of psychosocial functioning, it focuses
attention on the whole person, subtly undermining the
tendency of service staff to assume that, because a person
is impaired in one area of functioning, he or she is totally
impaired in all. Second, by providing an opportunity to
score all 28 aspects of psychosocial function on a six-point
scale, it encourages precise identification of both strengths
and weaknesses of the individual. Rarely, on close inspec-
tion, is a mentally impaired person so debilitated that he or
she obtains an HDI “profile” indicating high need (or low
capability) in all areas of functioning. More commonly, the
HDI profile indicates some areas of severe deficit and oth-
ers of relative competence, although the latter may be
short of “normal” functioning.

With a quite detailed balance sheet in hand which essen-
tially itemizes aspects of behavior in need of development,
program staff have a useful guideline for their efforts,
enabling them to tailor their activities to the particular
strengths and weaknesses of their residents. In addition,
HDI provides a tool for institution-wide evaluation and
planning; it can be used to present a composite picture of
the functional capabilities and needs of residents in a va-
riety of levels of care. When applied to the total resident
population of Ebenezer, HDI assessments revealed strik-
ing patterns of need. Recognition of these has led to
stronger programing in two prevailing areas: socialization
and sensory function.

The HDI provides a useful starting point for service, but
how does a profile become translated into a personalized
program that helps a mentally impaired person function
better? Let us look at the process that forms the core of
Ebenezer’s special approach to its mentally impaired resi-
dents, starting with the way the initial assessment is made
and then looking at the kinds of psychosocial programing
based upon it.

Mentally impaired older people feel threatened by a bat-
tery of “objective” tests given in a formal testing situa-
tion and often can be highly uncommunicative and unable
to follow even seemingly simple instructions. Investi-
gators at Ebenezer decided that the most feasible ap-
proach to obtaining information for the HDI would be

The HDI also has important potential uses as a research tool. Toward
that end, the research staff have conducted extensive studies of its validi-
ty and reliability.

163
through a relaxed conversational interview, structured,
however, to elicit responses to questions probing a number
of key functional dimensions. One interview, however,
might be deceptive, since the functional capacities of these
residents often vary considerably from day to day, even
within a day. (Their mental alertness, for example, tends to
be greatest in the morning.) Thus, two interviews provide
much of the basic information upon which the HDI is
based. Interviews, however, are not the only source of in-
formation. The interviewer also observes each resident’s
behavior in the residential floor, taking note of day-to-day
activities and charting them on a “Behavior Map.” Addi-
tional information pertinent to the HDI is gained from
sensory and occupational therapist’s testing, audiological
screening and visual screening (some testing seems
unavoidable), and from a social history conducted by a so-
cial worker when the resident is first admitted. In all, some
3 hours per resident are devoted to the interview proce-
dure.

As the procedure has evolved, the two HDI interviews
are usually carried out after a new resident has had a
period of about a month to become accustomed to the new
environment. The interviewer introduces himself or her-
self, asks for permission to interview, explains the purpose
of the visit, asks the resident how she or he wishes to be
addressed, and launches into a conversation which may
vary from individual to individual but usually touches on
major aspects of the HDI categories.

The results of the interview are recorded, with direct
quotes from the resident’s responses. The interviewer also
fills out an HDI form for each resident, after completing
the interviews and behavior mapping. Later, in conference
with other project staff members, a preliminary HDI is
developed at a ‘goal-setting meeting,” using multiple
sources of information to complete the picture. Major
areas for future programing are identified and placed in
residents’ charts for consideration at later conferences
with service staff members.

The HDIs of new residents are regularly reviewed at
case conferences attended by the Human Development
staff members, as well as by nursing, activities, social serv-
ices, rehabilitation, and housekeeping staff. (The addition
of housekeeping personnel follows from recognition that
many residents are more open with them about their feel-
ings and complaints than with higher status personnel,
before whom they often try to “save face.”) The impres-
sions of the various staff such as nurses, social service pro-
fessionals, aides and housekeepers are added to the inven-
tory, and suggestions are made regarding specific program-
matic activities and approaches that might be useful. At

164
these meetings, major goals for each resident are devel-
oped, and particular activities to be conducted by Human
Development staff members are “prescribed.”

For a resident initially incapable of relating to a group,
one-to-one interaction with a Human Development assist-
ant might be recommended, with specific treatment goals
itemized. For those who are more able, a number of group
activities might be “prescribed,” depending on the individ-
ual’s needs. Nursing staff members are sensitized to the
particular goals of the psychosocial program and are
encouraged to use the HDI to guide their own potential
contribution to the resident’s development.

Periodically, as staff members and residents become bet-
ter acquainted, the HDIs are updated and amplified, prog-
ress is monitored, and modified goals and activities are
recommended. Progressive HDIs on given residents pro-
vide a measure of change and a guide to further program
refinement. Sometimes an incoming resident is too con-
fused and upset to provide sufficient information for a
useful HDI. It may require a period of basic one-to-one
contact and support before the individual is sufficiently
communicative to provide adequate clues to his or her
psychosocial status. However, there are very few who
remain unreachable and unrecordable. The use of behav-
ior mapping as well as interviewing provides some means
of assessment even when the individual cannot verbally
answer questions.

At present, for research purposes, the HDI is usually
administered by a trained interviewer, but the Human
Development research staff have developed a modified
HDI that can be used by nursing staff after some training.
Toward this goal, they have developed a functional guide
to HDI rating, suggesting behavioral characteristics of
residents for each area and level of psychosocial function-
ing. They have also developed guidelines for selecting
approaches and programs to stimulate growth in particu-
lar need areas.8 For example, for residents whose recent
memory is impaired, the guidelines currently under devel-
opment suggest general approaches such as:

Increase cues (signs, clocks, photos, labels, name tags, placecards,
calendars, schedules, lists, etc.) Provide practice doing things and
verbally reviewing them. Increase motivation to remember by pro-
viding significant events to remember. Offer memory helps [such] as
“my name is Daisy, just like the flower, Daisy.”

Similarly, staff guidelines suggest that residents with a
high need to develop self-reliance can be helped through
the following approaches:

8Many examples of programing and assessment were presented dur-

ing 1977 at two national conferences, Creative Approaches to Aging and
Mental Health, New Orleans and Denver, sponsored by NIMH funding.

165
Provide opportunities for controlling one’s life and environment.
Provide opportunities for playing an adult capable role rather than
the role of the patient or the helpless one who must always take and
never be the giver or the helper. Make available situations where
residents help residents, resident helps staff, or resident partici-
pates with staff as an equal. Encourage and allow independence.
Provide an environment that is conducive to independence (low ele-
vator buttons, handrails in bathrooms, etc.) Evaluate activities of
daily living and provide adaptations and compensations as needed.
Be honest about potential for improvement and set realistic goals.
Give praise and support for achievements. Offer concrete measures
of achievement and progress. (“One week ago you walked 4 feet, just
now you walked 10 feet.”)

Specific suggestions for activities to foster self-reliance
include:

Resident’s Council, resident’s newspaper, resident attendance at
staff inservice, resident participation in care conferences. Ice cream
cart for residents and staff, resident and staff joint coffee breaks,
resident-planned and -hosted parties. Dances, dinners, and parties
with staff and family participation. Physical therapy. Occupational
therapy.

~ The Human Development staff members have identified
over 100 different types of program activities that can be
used to foster the development of mentally impaired resi-
dents, ranging from conventional activities such as crafts
and sing-alongs, through accepted therapeutic approaches
such as modified forms of reality orientation, to more
unexpected offerings such as working with electric trains,
reading love stories or poetry, stag parties, cruiser rides,
and Scandinavian folk dancing. Activities related to food
and eating are frequently used and seem to be particular-
ly effective. However, participation in group activities is
but one of many means of accomplishing treatment goals,
and activity groups must be carefully selected, organized,
and conducted with individual residents’ needs and
abilities in mind.

From this perspective, eating, for example, can be trans-
formed from a simple means of gaining nourishment into
a chance to develop a number of psychosocial skills. High
on the list of activities assignments for many residents is
participation in special luncheon groups that regularly
meet for a special meal. The table is set with tablecloth,
silverware, and centerpiece. A carefully composed group
of about 10 residents is invited, and a Human Develop-
ment staff member dines with them, working simulta-
neously with the overall group and with individual mem-
bers whose particular needs have been identified as likely
to respond to such an activity. The return to a family-like
dining setting seems to revive many long-forgotten habits
of social interaction. It encourages many residents to
speak and share ideas and feelings. Those less able to
communicate verbally nonetheless can interrelate socially

166
through such simple activities as passing food to one an-
other. The Human Development Assistant, aware, through
the HDI, of the particular skills to be developed in each
diner, might help one who is blind to try feeding herself
and might work with another to develop the confidence to
share in group discussion. For luncheon group members
who have memory deficits, the Human Development As-
sistant makes a point of stressing their large-lettered
place tags and their names, emphasizing verbally the
characteristics of the food they are now eating, relating it
to other meals they have had, and establishing anticipa-
tion of future dining experiences. The meal itself is
planned to provide considerable contrast in color, texture,
and temperature to stimulate sensory awareness. After
repeated meals of this sort together, formerly uncommuni-
cative residents often come out of their shells, and a sup-
portive group spirit can emerge. If one resident becomes
overwhelmed and fearful, others are likely to lend their
support. Residents who are competent to assume a role in
planning and serving the meal are encouraged to exercise
their hospitality and leadership. Thus, a luncheon group
may be made up of many individuals, each of whom has
something different to contribute to it and gain from it.

The Human Development Assistant records progress of
each group member, and the HDIs are periodically re-
viewed by staff to see that the prescribed activity program
indeed is having its intended effects. If it is not, other ac-
tivities are suggested. At regular intervals, residents are
reassessed and their HDI profiles are drawn more accu-
rately as staff members know them better.

Although participation in specific activities programs is
an essential part of the overall Human Development Pro-
gram, the actual amount of time spent in such organized
activities is relatively small, perhaps averaging a few
hours a week per resident. Project staff therefore do not
lean exclusively on this type of programing as the sole
source of resident psychosocial development. They recog-
nize that the key contacts with residents are made by the
nursing staff, by other residents, and by the residents’
own families who must be integrated into the program if
it is to be effective. Entries will often be made in the HDI
chart suggesting work with family members to achieve
certain therapeutic goals. For example, if initial testing
reveals that a resident has a hearing deficit, family mem-
bers might be encouraged to purchase a hearing aid, or, if
a resident is having memory problems, family members
might be requested to bring old family albums, perhaps
create a “family tree,” and talk with their relative at
Ebenezer about their past experiences together.

167

274-912 O - 78 = 12
A crucial part of the program consists of training the
nursing staff to understand the HDI and to develop ap-
proaches to nursing care that reinforce Human Develop-
ment Program goals. The Geriatric Aides are a particular-
ly important target group, since they are the nursing staff
members with the greatest amount of direct contact with
residents. However, all nursing staff members must un-
derstand and participate in the program and recognize
that their own everyday behavior can contribute to or
undermine the program’s therapeutic goals. A nurse who
rushes through her duties and does not take the time to
let residents try to gain some independence and compe-
tence is robbing her charges of a vital opportunity to grow.
Similarly, one who places potentially ambulatory residents
in a geriatric wheelchair, instead of working to develop
walking skills, is inhibiting growth. Nurses must also be
trained to deal with the more overt behavioral problems
that arise at Ebenezer through a deliberate attempt to
keep tranquilizing medication to a minimum (thanks to
the special understanding and cooperation of the medical
director, and cooperation of clinical pharmacists). Ebenezer
residents do receive medication when it is required, but
they are not drugged into passivity and compliance. Rath-
er, they are encouraged to be alert participants in their
world. In such an environment, problem behavior which is
usually ill-tolerated among nursing home residents is
viewed as a problem to be understood, not as a signal for a
higher dose of medication, or transfer to a State mental
hospital. Wandering is permitted, and staff members at-
tempt to deal with it through a variety of nonpharmacolog-
ical approaches, perhaps joining some residents in their
rounds or encouraging family members to take residents
on accompanied outings on the Ebenezer grounds. Similar-
ly, incidents of aggressive behavior are not necessarily
viewed as signs of total intractability. Again, an effort is
made to understand why and under what particular cir-
cumstances some residents behave aggressively. Such be-
havior is recognized as a challenge, not necessarily a cause
for rejection or demeaning restraint. When problems arise,
Human Development staff members might be assigned to
work with certain residents on a one-to-one basis or to help
nursing staff members cope more effectively with difficult
residents.

The Human Development Program at Ebenezer thus
has many facets: careful assessment of residents’ func-
tional capacities (through the use of the HDI); prescrip-
tive, individualized programing; family involvement as
part of the therapeutic team; special activities conducted
by trained psychosocial staff members; and inservice train-
ing for nursing staff members to aid them in assessing and

168
programing for residents and in carrying out their roles in
ways consistent with residents’ needs and abilities. This
combination seems to offer an approach almost guaranteed
to bring out the best in older nursing home residents and
to encourage them to use every bit of their remaining capa-
bilities. But does it? And how much better do they fare
than when they receive good, but more conventional, care?
These are some of the issues currently being put to the test
at Ebenezer Ridges. Although the experiment is still not
completed, let us look at the comparative study in progress,
to sense the flavor of research in a service setting.

In December 1976, Ebenezer Ridges was officially opened
for occupancy, and the experimental phase of the Human
Development Project began. Groundwork for the institu-
tion’s opening and for the research methodology that
would guide the experiment had proceeded in parallel well
in advance of that date. As we have described, facilities on
Ebenezer’s main campus, particularly Luther Hall, had
provided a training ground for program development, im-
plementation, and evaluation as staff members continually
explored, assessed, then codified many aspects of the
program for transport to Ebenezer Ridges’ second (experi-
mental) floor. The HDI, which would serve as a programing
guide for the second floor and as an evaluative tool for both
floors, had to a great extent been validated and its adminis-
tration procedures largely worked out. Staff training meth-
ods and materials were readied, based again on long expe-
rience working with staff and residents on the central
campus. The research staff realized that, although Ebene-
zer Ridges would be administratively linked to the main
campus and served by some Human Development staff who
had worked with the project already, the new facility, be-
cause of its physical separation and new staffing and resi-
dents, presented many challenges similar to those that
might be faced in exporting the program to an entirely new
setting outside of the Ebenezer Society.

A fresh staff, coming from a variety of backgrounds,
would have to be imbued, at least on the experimental
floor, with the values, knowledge, and techniques that to-
gether make up the Human Development Program. They
would have to learn to use the HDI, to acclimate them-
selves to an expanded perspective toward the needs and
capabilities of the mentally impaired aged and to work
toward goals and through means that might be unfamiliar
to them, even if they were trained professionals with prior
geriatric care experience. (In addition, of course, the new
staff members would have to accommodate themselves to
the somewhat peculiar rules of Ebenezer Ridges that were
dictated by the research project and designed to minimize
“spill-over” between the two floors. For example, contact

169
between the second and third floor staffs, on all shifts,
would have to be severely limited, with staff and residents
from the third (control) floor discouraged from going to
the second, and staff conversations between those as-
signed to the two floors confined to communications that
would not include details of their work.

Before the Ridges opened, its new staff members had to
be hired and trained, and potential residents located, ac-
cepted, and prepared for participation in the experiment.
Most of the residents were drawn from Ebenezer’s own
waiting lists, from other nursing homes, and from medical
facilities in the area. As a skilled care facility, Ebenezer
Ridges was open to individuals who required round-the-
clock nursing care, many, but not all of whom required
support for their mental functioning.

Incoming residents were randomly assigned either to
the experimental or control floor, once the purpose of the
project was explained and permission granted for partici-
pation. There was almost no resistance to the project,
since residents and their families knew that good care
would be given on both floors, and, once the experiment
ended, those assigned to the control floor would receive
whatever types of programing the experiment showed to
be most effective. (A year might seem to be a long time to
wait in the life of a very old person, but, as earlier studies
at Ebenezer had shown, their residents tend to be ex-
tremely long-lived, so that a person entering at, say, age
80, might still have many years in which to receive Ebene-
zer’s improved care.)

Despite widespread staff shortages at many other nurs-
ing homes, there was little difficulty in recruiting new staff
members for Ebenezer Ridges. In fact, given a surfeit of
applicants, it was possible to select only those who seemed
extremely well motivated and qualified. Many seemed to
be particularly attracted by the project’s novelty and
promise and, understanding the basic nature and purpose
of the experimental design, cooperated with their random
assignment to one or the other floor, although they real-
ized that those on the experimental floor were somehow
“special,” and would have access to an approach which
would be shared only with them.

Rather than reacting like second-class citizens, the staff
on the control floor quickly developed a somewhat compet-
itive spirit: Knowing that the point of the experiment was
to stimulate the growth of their residents, they brought
heightened dedication to their task. Many wondered: How
does the Human Development Program differ from simple
loving and caring? From the vantage point of the research
staff, it became obvious that, given the high motivation of
staff on both floors, the Human Development Program

170
would indeed have to provide a substantive advantage
over the formidable offering by the third-floor staff of tra-
ditional competence, combination, dedication, and caring.
What, then, were the advantages that were expected to
distinguish the experimental from the control floors and,
ultimately, to provide for greater progress among the sec-
ond-floor residents? In the opinion of the research staff, if
the training program for the experimental floor staff were
successful, they would have the following advantages:

1. Exposure to the HDI, its rationale, and its use in day-
to-day caring and program planning

2. Training in developing sensitivity to the whole person
and in utilizing everyday activities in the service of resi-
dents’ psychosocial development

3. Support from a staff of Human Development profes-
sionals and paraprofessionals who would work with them
and residents, both on a one-to-one and group basis, to
plan and carry out individualized programs geared to the
specific needs and capabilities of each resident

It was believed that the integration of HDI charting
into the standard nursing floor recordkeeping, combined
with appropriate training, would focus staff attention and
efforts on salient aspects of psychosocial functioning that
might normally go unperceived and unaddressed. In addi-
tion, the HDI would provide a means to develop meaning-
ful activities programing which, rather than providing
“busyness,” would be specifically selected and targeted to
meet the therapeutic needs of individual residents. The
essential advantage lay in the focused way essential infor-
mation about residents and their needs would be obtained
and used to guide staff interaction with residents.

The experiment was designed to equalize major aspects
of staff activity, so that staffing-patient ratios, inservice
training time, and even staff meeting time would be equiv-
alent on the two floors. What differed, however, would be
the content and orientation of these activities. The staff-
resident contact time was also equalized, so that, although
residents on the experimental floor might have a different
quality of interaction with nursing and activities staff
members, their contact time would not exceed more than
the conventional average of 2.9 hours per day. If their
program was enriched, it would be so within the usual
structure of a nursing home skilled care facility.

Initialiy, these contraints worked to the disadvantage of
the experimental floor; it became obvious, first, that the
time allotted for preliminary inservice training of all in-
coming staff members had not been sufficient to communi-
cate, to the experimental floor staff, both the essential ori-
entation information necessary for all staff members and

171
the Human Development Program principles and prac-
tices. Further training, for both staff groups, was there-
fore indicated (since the experimental floor staff were not
to have more training time than the control floor staff). In
addition, the experimental floor staff, bound by law to
complete the same charts as those on the control floor,
had, because of the HDI, additional paperwork which, at
least initially, detracted from their time with residents.
These problems were being ironed out at the time this
author visited Ebenezer Ridges, 1 month after it had
opened. Applied research in a service setting is notorious-
ly difficult, with constant tension between the demands of
good research design and the constraints imposed by the
realities of human behavior within organized settings.
This study is no exception. However, to the extent possi-
ble, a concerted effort was made to equalize the two floors
in all respects but the Human Development Program.

A tour of the second and third floors of the Ebenezer
Ridges revealed few obvious differences between them.
Both were obviously spankingly new, well-lit, attractively
decorated, and laid out identically, with most of the activi-
ty areas and the nurses station in the center of each floor
(where the elevators are also located), and with three dis-
tinctively colored residential wings extending from this
core. Although each wing has a somewhat long corridor,
its length is broken up by a nursing substation area,
which also has space for lounging. The ambiance was
more motel-like than hospital-like, due to the carpeting,
bright wallpapers, and indirect lights. Residents’ rooms
also reflected a noninstitutional theme, decorated with
pleasant colors, modern furniture, and beds with low guard-
rails, made homey with residents’ own afghans, quilts,
and plants. At half its intended occupancy rate, the
Ridges had none of the crowd of residents often seen in
nursing homes. A few residents could be seen in their
rooms, but most were participating in activity groups,
undergoing admissions procedures, preparing for lunch in
the first-floor dining room, or perhaps walking around
learning their way in their new home.

On the second floor, two very elderly women made their
way down the corridor from their rooms. One, well over
100 years old, cautiously held onto the long handrail with
one hand, her other clasping a new-found, more competent
friend in her eighties. (Such friendships among the able
and the impaired, developed at Ebenezer Ridges within the
first month, are apparently rare among the mentally im-

9Fears that being part of a “research project” would discourage appli-
cants were unfounded—full occupancy was achieved in the record time of
4 months after opening.

172
paired elderly.) The only readily visible evidence that the
second and third floors differed was the presence of individ-
ual photographs of the entire staff pasted up on the sec-
ond-floor nursing station and huge welcome signs that
greeted all in the lobby area near the elevator. Both floors
had large-lettered activity and orientation boards near the
nursing station giving the date and time of scheduled ac-
tivities.

The major differences lay largely in the residents’
charts (those on the second floor contained an HDI chart
for each resident) and in the minds of staff members who
had or had not been exposed to the institution’s holistic
approach to working with the mentally impaired. (As not-
ed earlier, at 1 month after the Ridges had opened, the
experimental floor staff had not yet fully absorbed the
program’s approach; more training and experience would
be needed before the approach would be understood and,
for some, would become second nature. As the Ridges’
director put it: “Some folks get it right away, others take
longer, and still others never get it.”)

Presumably, over the experimental period, the behavior-
al differences between the two staffs would become more
evident, with the experimental floor staff creating a se-
quence of social experiences for residents that would fos-
ter their unique capabilities.

In the best of all possible worlds, by the time the experi-
ment is through, all of these differences should add up to
demonstrably different patterns of progress of residents of
the experimental floor, compared both with those on the
Ebenezer Ridges control floor and those residing at the
external control site, Careview. If their composite HDIs at
the beginning and end of the study are compared, using
an outside rater, the experimental floor residents should
show greater gains beyond their initial HDIs than the
control subjects. Because the study used a random assign-
ment of residents to the experimental and control floors,
theoretically they should have contained approximately
equal amounts of residents at various levels of initial fune-
tioning. Thus, not only should the composite progress for
experimental group residents be greater, but their final
scores, as well. (If, for some reason, the randomization
tended to favor the control group, by placing fewer seri-
ously impaired subjects in it, it would still be expected
that experimentals, compared with their initial scores,
would make more progress than controls.)

Although the Human Development Program is deliber-
ately designed to stimulate growth in all dimensions ad-
dressed by the HDI, the researchers recognize that its
effects may, in fact, be evident in only some aspects of

173
functioning. For example, despite staff efforts, certain
cognitive losses may not respond particularly well to inter-
vention efforts, since they may be determined more by bio-
logical than by social conditions. However, other dimen-
sions of the total functioning of individual residents may
be particularly responsive, such as socialization. Life sat-
isfaction and inner peace are difficult to predict, since it is
not clear to what extent these depend on internal temper-
ament vs. social circumstances. It appears, however, that
a sympathetic and congenial social milieu can contribute
to improving these dimensions of living. Because the HDI
taps a multitude of dimensions, it provides a very sensi-
tive measure of program effectiveness and may, on close
analysis, suggest which types of residents, in which as-
pects of their lives, are most likely to benefit from the
Human Development Program. The comparative study
may also suggest some aspects of resident development
that seem to be resistant to either traditional skilled care
or the Human Development approaches, thus stimulating
a new area for inquiry. At present, since we know very lit-
tle about the limitations to development in the mentally
impaired aged, such information, although discouraging,
would be invaluable. If some individuals fail to progress in
certain areas of their lives, why? Is the program insuffi-
ciently responsive to their needs? Does their lack of re-
sponsiveness reflect insurmountable biological handicaps
that must be overcome through other approaches? These
are some of the questions that might arise once the basic
study has been completed. It is also possible, of course,
that members of the experimental group will fare no bet-
ter than, or worse than, control group members. If this
occurs, it will raise a host of other fascinating questions.
Was the training program adequate? Did the HDI simply
provide more paperwork, without sufficiently yielding its
potential programmatic benefits? Even with the HDI,
were the staff members unable to devise and deliver activ-
ities for residents that would truly have a significant
bearing on their well-being? Is the notion of individualiza-
tion and systematization of psychosocial diagnosis and
treatment ill-founded? Is it simply easier for staff mem-
bers to deliver their best services within a wholly tradi-
tional mode? Were there differences in the motivational
levels of the different staffs? Did the control staffs, re-
sponding to the challenge of competition, spontaneously
come up with an even better approach to care? Were few
differences found among the residents because they were
too severely impaired to show appreciable progress, what-
ever approach was used? Can a program of this kind be
integrated into an existing, fully operative facility?

174
At the time of this writing, it is too soon to tell. Had the
Ebenezer Society been content to develop a programmatic
approach, believe in its value, and build it into its overall
programing without such an experiment, as many institu-
tions do, none of these provocative questions would have
been asked in a systematic way, and the administration
and staff could have rested secure in the belief that they
were being effective. Instead, they have chosen to take a
more challenging approach that is difficult and nerve-
racking. Its potential yield, however, is appreciable; truly
effective services for its residents and an approach which,
if effective, will be sufficiently understood to be realistical-
ly communicated to many other settings.

Participating in a research experiment such as this is
not easy for staff members. Accustomed to feeling compe-
tent in their own roles and used to doing, but not neces-
sarily thinking deeply about what they are doing, it is a
strain to be placed in a situation that, by its very design
as a research experiment, stimulates self-doubt and ques-
tioning. As one Human Development Staff member, who
works with residents on the experimental floor, put it:

It’s very hard to explain to them what we're doing. I don’t like to
say to Mrs. Olson “We're studying you . ..” that sounds so clinical,
detached. But that’s what we’re doing. And I’m bothered by the idea
that I can’t do what I know is best with all of them. But then I say
to myself: “But how do you know it’s best until we complete the
study?” Maybe it’s not the best way...and that’s a mindben ler right
there. At least I know that when the study is over, all the residents,
experimentals and controls, will get the program—or parts of the
program that work best. And that makes me feel good, because 1
know we are improving care for everyone.

The young man, in his early twenties, an eager, sympa-
thetic “people person,” like many other staff members
participating in the study, is wrestling with some of the
growing pains of applied research in a service setting. Self-
consciousness, doubt, and some guilt color his basic opti-
mism. He is used to caring about and for older people—
and young ones as well. He is now learning that caring—
and even loving—may not be enough. There is another
dimension to his concern: curiosity and the dawning reali-
zation that his daily efforts in enriching the lives of the
old people in his charge are part of a larger effort that
may eventually benefit not only them, but possibly other
older people. As time and the project go on, he may find
that the strange structure of his working environment,
guided by rules of scientific methodology he might normal-
ly dismiss as antihuman and antiethical to natural, spon-
taneous, intuitive interaction with fellow-humans, can
help him to be more effective in the role he has chosen for
himself: helping older people regain their dignity and
competence.

175
VII. For Further Information

Since many of the studies mentioned in this book have
not been completed, information describing their design
and progress has been gleaned from interviews with the
investigators and from unpublished material. For those
seeking further information, we suggest contacting the
principal investigators, whose names, addresses, and proj-
ect titles are given below, in the order in which they ap-
pear in the book. A few citations of books and articles re-
sulting from the research are included.

Chapter ll: Healthy Aging

Birren, James E.; Butler, Robert N.; Greenhouse, Samuel W.; Soko-
loff, Louis; and Yarrow, Marian R., eds. Human Aging I: A Biologi-
cal and Behavioral Study. DHEW Pub. No. (ADM) 77-122, 1971, re-
printed 1974 and 1976. 328 pp.

Granick, Samuel, and Patterson, Robert D., eds. Human Aging II: An
Eleven-Year Followup Biomedical and Behavioral Study. DHEW
Pub. No. (ADM) 77-123, 1971, reprinted 1976. 144 pp.

Chapter Ill: Lifestyles, Satisfaction, and the
Quality of Life

MH 27619
Life Satisfaction in the Urban Elderly
Forrest J. Berghorn, Ph.D.
University of Kansas
Lawrence, Kansas 66045
Berghorn, Forrest J.; Schafer, Donna E.; Steere, Geoffrey H.; and

Wiseman, Robert F. The Urban Elderly. Montclair, NJ: Allanheld,
Osmund and Co., 1978.

MH 20959

Modes of Retirement Housing for the Elderly
Susan R. Sherman, Ph.D.

Institute of Gerontology

School of Social Welfare

State University of New York at Albany
Albany, New York 12206

176
Sherman, S.R. The choice of retirement housing among the well-el-
derly. Aging and Human Development, 2:118-138, 1971.

Sherman, S.R. Satisfaction with retirement housing: Attitudes, rec-
ommendations, and moves. Aging and Human Development, 3:339-
366, 1972.

Sherman, S.R. Leisure activities in retirement housing. Journal of
Gerontology, 29:325-335, 1974.

Sherman, S.R. Mutual assistance and support in retirement housing.
Journal of Gerontology, 30:479-483, 1975 a.

Sherman, S.R. Patterns of contacts for residents of age-segregated
and age-integrated housing. Journal of Gerontology, 30:103-107,
1975 b.

Sherman, S. R. Provision of on-site services in retirement housing.
Aging and Human Development, 6:195-213, 1975c.

MH 25996
Unseen Community: Old Nonwelfare Poor in Urban Hotels
Paul J. Bohanan, Ph.D.
Western Behavioral Sciences Institute
La Jolla, California 92037
Erickson, Rosemary, and Eckert, Kevin. The elderly poor in downtown
San Diego Hotels. The Gerontologist, 17(5):440-446, 1977.
MH 18158
Generational Differences: Correlates and Consequences
Vern L. Bengtson, Ph.D.
Gerontology Center
University of Southern California
Los Angeles, California 90007

Black, K. Dean, and Bengtson, Vern L. “Solidarity Across Genera-
tions: Elderly Parents and Their Middle-aged Children.” Paper
presented at the Annual Meeting of the Gerontological Society,
November 1973.

MH 26121

Impact of Retirement on Aging and Adaptation
Robert C. Atchley, Ph.D.

Scripps Foundation Gerontology Center

Miami University

Oxford, Ohio 45056

Atchley, Robert C. Adjustment to loss of job at retirement. Interna-
tional Journal of Aging and Human Development, 6(1):17-27, 1975.
Atchley, Robert C. The Sociology of Retirement. New York: Halsted,
1976.
MH 26932
Remarriage in Old Age
Ruth H. Jacobs, Ph.D.
Department of Sociology
Boston University
Boston, Massachusetts 02215
Jacobs, Ruth H., and Vinick, Barbara. Re-engagement in Later Life:

Re-employment and Re-marriage After 65. Stamford, CT: Greylock
Press, 1978.

177
Chapter IV: Community Services: How Can We
Help?

MH 21464
Roles of Homes for Aged in Meeting Community Needs
Eva T. Kahana, Ph.D.
Department of Sociology
Wayne State University
Detroit, Michigan 48202
Kahana, Eva; Felton, Barbara; and Fairchild, Thomas J. Community
services and facilities planning. In: Lawton, M. Powell; Newcomer,
Robert J.; and Byerts, Thomas O. Community Planning for an Ag-
ing Society: Designing Services and Facilities. Stroudsburg, PA:
Dowden, Hutchinson & Ross, 1976.
Kahana, Eva; Liang, Jersey; Felton, Barbara; Fairchild, Thomas J.;
and Harel, Zev. Perspectives of aged on victimization, “ageism,”
and their problems in urban society. The Gerontologist, 17(2):121-
129, 19717.

MH 27606

SAGE: A Program for Revitalizing the Elderly
Gay G. Luce, Ph.D.

Institute for Research in Social Behavior
Berkeley, California 94705

MH 27903

Assertive Training with the Elderly
Sheldon D. Rose, Ph.D.

School of Social Work

University of Wisconsin

Madison, Wisconsin 53706

Berger, Raymond M., and Rose, Sheldon D. Interpersonal skill train-
ing with institutionalized elderly patients. Journal of Gerontology,
32(3): 346-353, 1977.

MH 23755
Longitudinal Study: Intermediate Housing for the Elderly
Elaine M. Brody, MSSA
Home for Jewish Aged
Philadelphia, Pennsylvania 19141
Brody, Elaine. Long-Term Care of Older People. New York: Human
Sciences Press, 1977.

Brody, Elaine, M.; Kleban, Morton H., and Liebowitz, Bernard. Inter-
mediate housing for the elderly: Satisfaction of those who moved in
and those who did not. The Gerontologist, 15(4):350-357, 1975.

MH 24889

A Community-Based Program for the Mentally Frail El-
derly

Marjorie H. Cantor, M.A.

New York City Office for the Aging

New York, New York 10007

178
 

MH 19883

Rehabilitation of Elderly Tenants of a Welfare Hotel

Bernard H. Hall

Roosevelt Hospital

New York, New York 10019

Plutchik, Robert; McCarthy, Martin; Hall, Bernard H.; and Silver-

berg, Shirley. Evaluation of a comprehensive psychiatric and
health care program for elderly welfare tenants in a single-room
occupancy hotel. Journal of the American Geriatrics Society,
21:452-459, 1973.

MH 12382

Geriatric Outreach Workers

Goldie Lake

Case Western Reserve University

Cleveland, Ohio 44106

Chapter V: Aging and Institutionalization

Contract 278-75-0011 (OD)

Evaluation of Data Relating to Placement Procedures of
Quality of Care Provided Aged Mental Impaired in
Nursing and Boarding Homes

Joint Information Service of the American Psychiatric
Association and the Mental Health Association

1700 18th Street, N.W.

Washington, D.C. 20009

Glasscote, Raymond, et al. Old Folks at Homes: A Field Study of
Nursing and Board-and Care Homes. Washington, D.C.: Joint Infor-
mation Service, 1976. 148 pp.

MH 24959

Strategies of Coping in Institutional Environments

Eva T. Kahana, Ph.D.

Department of Sociology

Wayne State University

Detroit, Michigan 48202
Kahana, Eva. Matching environments to needs of the aged: A concep-

tual scheme. In: Gubrium, J., ed. Late Life: Recent Developments in
the Sociology of Aging. Springfield, IL: Charles C Thomas, 1975.

MH 20746

Forced Relocation: Setting, Staff and Patient Effects
Norman C. Bourestom, Ph.D.

Institute of Gerontology

University of Michigan

Ann Arbor, Michigan 48104

Bourestom, Norman, and Tars, Sandra. Alterations in life patterns fol-
lowing nursing home relocation. The Gerontologist, 14(6):506-510,
1974.

Gottesman, Leonard E., and Bourestom, Norman C. Why nursing
homes do what they do. The Gerontologist, 14(6):501-506, 1974.

179
Chapter VI: Depression and Senility: The Twin
Frontiers

MH 09191

Mental Disorders in the Aging in the United States and
the United Kingdom

Barry J. Gurland, M.D.

New York State Department of Mental Hygiene

Research Foundation for Mental Hygiene, Inc.

Albany, New York 12229

Copeland, J.R.M.; Keller, M.J.; Kellett, J.M.; and Gourlay, A.J. (UK);
and Gurland, B.J.; Fleiss, J.L.; and Sharpe, L. (US). A semi-struc-
tured clinical interview for the assessment of diagnosis and mental
state in the elderly: The Geriatric Mental State Schedule I. Devel-
opment and reliability. Psychological Medicine, 6(3):439-449, 1976.

Gurland, Barry J. A broad clinical assessment of psychopathology in
the aged. In: Eisdorfer, C., and Lawton, M.P., eds. The Psychology
of Adult Development and Aging. Washington, D.C.: American Psy-
chological Association, 1973. pp. 343-377.

MH 22566
Depression and Memory Function in the Aged
Robert L.. Kahn, M.D.
Department of Psychiatry
University of Chicago
Chicago, Illinois 60637
Hilbert, Nancy M.; Niederehe, George; and Kahn, Robert L. Accuracy

and speed of memory in depressed and organic aged. Educational
Gerontology: An International Quarterly, 1:131-146, 1976.

Kahn, Robert L.; Zarit, Steven H.; Hilbert, Nancy; and Niederehe,
George. Memory complaint and impairment in the aged: The effect
of depression and altered brain function. Archives of General Psy-
chiatry, 32:1569-1573, 1975.

MH 27547

Depression and Dementia in the Aged
William W.K. Zung, M.D.

Duke University Medical Center
Durham, North Carolina 27710

MH 25258

Comparative Treatments of Emotional Problems of Aging
June E. Blum, Ph.D.

Postgraduate Center for Mental Health

New York, New York 10016

MH 24337
Hyper- and Normobaric Oxygen in Senility
Samuel Gershon, DPM
New York University Medical Center
New York, New York 10016
Raskin, Allen; Gershon, Samuel; Crook, Thomas; Sathananthen, Gre-
gory; and Ferris, Steven. The effects of hyper- and normobaric

oxygen on cognitive impairment in the elderly. Archives of General
Psychiatry, in press.

180

 

 

 
MH 16139
Architecture and Behavior: The Mentally Impaired Aged
Morton H. Kleban Ph.D.
Philadelphia Geriatric Center
Philadelphia, Pennsylvania 19141
Kleban, Morton H.; Lawton, M. Powell; Brody, Elaine M.; and Moss,

Mariam. Characteristics of mentally impaired aged profiting from
individualized treatment. Journal of Gerontology, 30(1):90-96, 1975.

MH 23924

Maintaining the Growing Edge
Lorraine Hiatt Snyder, M.A.
Ebenezer Society

Minneapolis, Minnesota 55455

Snyder, Lorraine H. Living environments, geriatric wheelchairs, and

older persons’ rehabilitation. Journal of Gerontological Nursing,
1(5):17-20, 1975.

Snyder, Lorraine H.; Pyrek, Janine; and Smith, K. Carroll. Vision and
mental function in the elderly. The Gerontologist, 16(6):491-495,
1976.

Snyder, Lorraine H., and staff. Human Development Inventory.
Available from author.

181

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. DHEW Publication No. (ADM) 78-687

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* Printed 1978
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