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BOOK REVIEW |
Professor Emeritus Heller School for Social Policy and Management Brandeis University Waltham, MA 02454
Family and Aging Policy, edited by Francis G. Caro. The Haworth Press, Binghamton, NY, 2007, 237 pp., $39.95 (cloth), $19.95 (paper).
Supporting the Caregiver in Dementia: A Guide for Health Care Professionals, edited by Sheila M. LoboPrabhu, Victor A. Molinari, and James W. Lomax, Johns Hopkins University Press, Baltimore, 2006, 295 pp., $55.00 (cloth)
Working Couples Caring for Children and Aging Parents: Effects on Work and Well-Being, by Margaret B. Neal and Leslie B. Hammer. Lawrence Erlbaum Associates, Mahwah, NJ, 2007, 367 pp., $32.50 (paper).
The sandwich generation has to be one of the most well known and generally accepted gerontological sound bytes of all time. It is certainly more valid and benign than greedy geezer, and more evocative than baby boomer. Additionally, it has the value of awakening what the communications guru Tony Schwartz identified as a responsive chord in our brain, thus inducing an associated reaction (hopefully pleasant).
The sandwich generation concept, however, is not usually a very useful analogy for describing the situation of an individual or couple caring for both children and adults. Other than the notion of being in the middle, other characteristics of a sandwich are usually ignored. Being in the middle focuses on the filling of the sandwich, or more exactly fillings, since there are so many possibilities. But the filling wouldn't be a sandwich, if it were not enclosed between two pieces of bread, and the bread has much to do with the quality of the sandwich. Like the filling, the bread comes in nearly infinite variety—flavor, shape, texture, color, etc. Some sandwiches have been carefully designed, others just slapped together. Some sandwiches are planned, while others are the result, for example, of spontaneously stuffing a piece of turkey headed for the Thanksgiving table into a roll with the same destination. Many sandwiches are dull standard fare like peanut butter and jelly, while others are more exciting like fromage de chèvre et canard.
Caregiving by Working Couples
Margaret Neal's and Leslie Hammer's new book, Working Couples Caring for Children and Aging Parents, recognizes the varieties embedded in the sandwich analogy by focusing on the various dimensions of multi-generational caregiving. In their 1988–1999 national study of 309 dual-earner couples, they note how caring types differ by individual/couple, hands on help/financial help only, IADL/ADL help or both, long term/short term duration, mild/severe intensity, and similar dimensions. Happily for the reader, they are meticulous in defining the version of the sandwich configuration they apply in their study:
... couples (one member of both) were required to provide a minimum of 3 hours per week of care to an aging parent, step-parent, or parent-in-law; have a child aged 19 or under living in the household at least 3 days per week; and have been together for at least 1 year. In addition, both members of the couple had to be engaged in paid employment, with one member working at least 35 hours per week and the other at least 20 hours per week. A final criterion was that the couple's annual gross household income was $40,000 or higher. ... (p. 9).
This definition exemplifies one of the strengths of their book. You always know what Neal and Hammer are talking about, which makes it easier to assess their arguments.
The book has three sections that can be summarized as (a) background to the study, (b) findings, and (c) recommendations. The first chapter lays out the authors' definition of the sandwich generation and estimates the prevalence of this type of family: "between 9% and 13% of American households with a telephone and with one or more persons aged 30 to 60 are composed of dual-earner, sandwiched generation couples" (p. 10). The second chapter looks at employer and governmental initiatives affecting work and family life in the United States giving both historic and current perspectives. I was particularly interested in their review of private employer initiatives early in the twentieth century, as these are often overlooked. The third chapter examines child and elder support to working caregivers in Australia, Canada, China, Germany, United Kingdom, Japan, and Sweden. Most of the countries provide more extensive child supports and allowances than the United States, thus easing the burden of the younger generation on the sandwiched couple. There is more variation among caregiver supports for elder care. This material, along with the international section of Francis Caro's volume (discussed below), will give the reader an updated capsule of how other countries are dealing with this modern day issue. The material presented helps set the background for examining the sandwich issue.
The conceptual framework for Neal's and Hammer's research is laid out in chapter 4, beginning with the rationale for their decision to use role theory and general systems theory as the social science bases for explaining family behavior. They next present their conceptual framework specifying both the independent and dependent variables. They are interested in three effects: the work-family fit, couple well-being, and work outcomes. These effects are produced by the interaction of objective and subjective role characteristics, which are referred to as predictors. There are seven domains of role characteristics: personal role, spousal role*, childcare role*, parent-care role*, work role*, coping strategies and workplace supports. The items with asterisks include both objective and subjective measures, while those without asterisks include only objective measures. The authors define each of the predictors and justify their decisions for selecting each by citing relevant literature. Some researchers may argue with their decisions, but they will need to make a convincing case in doing so.
Section II presents the study's findings. Two chapters provide descriptive findings and explore the relationship between the predictors and outcomes. These findings are summarized in highlighted word tables allowing for a concise overview. A third chapter describes their development of a six-cell model of work and family coping strategies. The model has behavioral, emotional, and cognitive strategies running vertically, and how the strategy decreases demands or increases resources running horizontally. The next chapter fills in the cells with findings from the study, thus documenting what real people are doing in real situations of family caregiving. The findings summarized in the table could serve as a menu of strategies for other families to adopt. The next chapter reports on the effects of workplace supports and the final chapter in this section looks at change in work/family roles over time.
Section III includes a summary of major findings and recommendations, along with references, appendices, and author/subject index. Readers will discover many expected outcomes, but some surprises as well. I expected to find that the objective evaluation of a caregiver's role would likely differ from their own evaluation because this has been observed in studies for over 30 years. We each are our own thermometers. I was not surprised by how much family situations changed over a year, as this had been observed in the National Long Term Care Channeling) Demonstration (Mutschler and Callahan, 1990). On the other hand, I was surprised that a reduction in work responsibility increased conflict between family and work. It seems that the time gained by fewer work hours was applied to more family care giving, thus making it possible for more conflict with what work remained.
This volume does not exhaust the results that can be mined from the study. The authors state: "Additional analyses of crossover effects, as well as dyadic analyses that use the couple as the unit of analysis, although not presented here, are possible, as are numerous other analyses, given the wealth of these data" (p. 231). This book is to be studied, not just read. It is a carefully written and conceptualized package with copies of the data instruments, a three hundred plus list of references, data tables and both a subject and author index. The authors have an extensive record of publications in this field; their mastery of the material is displayed throughout. It is an essential resource for researchers, teachers and practitioners in the field of family caregiving, and can be used by teachers of research as a model research project for students.
Policies and Caregiving
Family and Aging Policy (also co-published as Journal of Aging and Social Policy, Volume 18, Numbers 3/4, 2006) is a collection of national and international papers resulting from a call for papers on family and aging. Although family and aging is a broad topic, interestingly, as noted by editor, Francis Caro, most of the papers received, and 11 of the 12 published, concerned the caregiving aspect of family policy, not economic security or social services. Gerontological authors, apparently, are voting that caregiving is the most important aspect of family policy that needs attention, although it may be only the hot button item of the times—something like sandwiched generation.
The book's first section, International View, is composed of chapters covering Sweden, Denmark, Singapore, and Quebec. Although each country or province's elder programs vary, the common theme of the balance between state and family responsibility runs through all four chapters. Clear philosophical contrasts can be found between Sweden, which builds its policy on the assumption that the state should replace family responsibility, and Singapore, which is basing all of its social policy on family responsibility. Yet, Sweden, faced with national budget problems, has had to back away somewhat from assuming more state responsibility. And in Singapore there are popular demands for more state supported services. Denmark and Quebec are seeking a state/family equilibrium. The lesson from these chapters is that there is no single right answer to what the state should do or what the family should do. Solutions first emerge from economic and political factors, and then become normative shoulds.
Steven Wisensale, in the first chapter within a section of Caro's book on the United States, argues his shoulds for the Family and Medical Leave Act of 1993 as it applies to long-term care. After reviewing experience with the current Federal law as well as state laws supporting family leave, he argues for a more generous and universalistic approach to the issue. Specifically, leave should be paid leave, not just unpaid, and it should apply to all family caretaking, not, for example, only to newborn care. Leave should be paid, because workers need the income. Leave should be more universal to reduce social envy of those now covered and to gain support of groups that would be outside of a narrower definition. It is not clear that the current economic/political situation would support Wisensale's recommendations.
Three chapters provide national overviews of U.S. program interventions supporting family caregiving. Lynn Friss Feinberg and Sandra Newman report on a 50-state study of implementing the National Family Caregiver Support Program. The program was instituted by Congress in 2000 with the intent of providing resources directly to caregivers in their own right, not just as ancillaries to care receivers. Feinberg and Newman report that this demarcation may be difficult to achieve and that care support programs differ across the states. Differences across states, along with lack of clarity within states, is the message of Gretchen Hill, in her study of rules governing financial instruments (inheritance, estate taxation, filial responsibility, etc.). The interaction of rules make it difficult to determine who benefits and who pays under various policy configurations. There is a hint in her findings, however, that states may be shifting costs to families. Phoebe Liebig, Teresa Koenig, and Jon Pynoos review trends in zoning laws supporting Accessory Dwelling Units (ADUs) as a resource in family care giving. They document the long time need and efforts to make ADUs a viable resource. The battle continues with fervent advocates and powerful local interests lined up against each other. They argue for renewed struggle on the part of advocates, and, similar to Wisensale, for expansion of the program domain from elder to family caregiving.
Carrie Levin and Rosalie Kane present the results of a study of congruence between resident and care giver perspectives in assisted living facilities in six states. They report that, depending on the item, congruence ranged from 29% to 71%. They argue that the study supports the notion that resident and caregivers are two distinct constituencies and their respective interests must be taken into account in both program and policy decisions.
The remaining four chapters in Caro's volume look at welfare reform challenges for grandparents, family and friends as respite providers, the family work-fit, and the need for longitudinal research on the family caregiving career. This book belongs on the gerontologist's shelf and in the classroom as a resource. The international section is particularly useful in generating thinking about alternative ways to conceptualize family policy, and the overview chapter provide a quick update on national trends.
A Caregivng Guide for Health Care Professionals
Supporting the Caregiver in Dementia: A Guide for Health Care Professionals, edited by Sheila M. LoboPrabhu, Victor A. Molinari, and James W. Lomax is, as the title says, a guide to dementia for health care professionals. The authors aim to summarize current research and translate it into state-of-the-art clinical practice. This they do quite successfully.
The book is organized into five sections: Introduction, Individual Aspects of Caregiving, Interpersonal Aspects of Caregiving, Implications for Treatment, and, Societal Issues of Caregiving. Each section contains three to four chapters on the section topic. The topics cover; caregiving in dementia, transition from home to nursing home, caregiving burden, affective bonding, religion and caregiving, caregiving and sex, grief and loss, pharmacotherapy, care of the caregiver, caregiver supports, health care policy, ethnic elders, and ethics.
Eighteen authors combined their talents in producing this work. Steven Zarit provides a helpful overview on the history of caregiving in dementia, which gives the reader a tool for assessing present interventions. He demonstrates how the present state of the field emerged from both practice and research over the past 30 years. Over that time we have learned to focus on the whole family and involve the disabled person in their own care. He argues that carefully designed longitudinal and intervention research is a necessary component to continued learning and improving care.
Each chapter follows a general outline of background, research findings, and implications, with some variation usually consisting of explaining concepts or adding substantive content. They are clear and interesting to read, although it takes some adjustment of the lenses after focusing on policy. Most of the chapters have a hefty set of peer-reviewed references. Zarit's, for example, has close to eighty, while David Chiriboga's on social supports for the caregiver has nearly 120. Their use is reflected in the text and validates the expertise of the authors. This is not a book that is slap dashed together.
Parts II, III and IV will be of specific value to clinicians. Yet, I also found them helpful in contributing to my general knowledge of the subject and in reminding me of the consequences (both good and bad) at the personal level of impersonal policy making. Part V on societal issues is of interest to all readers. Michele Karel's and Jennifer Moye's chapter on the ethics of dementia caregiving cuts across clinical care and policy. They note that people become caregivers often not by choice. They ask what is reasonable to expect? How much sacrifice may be extracted from one human being in the interests of another? These questions bring us back to the policy question identified above, namely, what is the balance between state and family responsibility. A policy supporting more state responsibility is likely to reduce expectations regarding what is reasonable to expect of caregivers, while one supporting more family responsibility will multiply the personal predicaments facing caregivers. Policymakers can create ethical dilemmas at the clinical level just as can the clinical situation, itself. Karel and Moye conclude their chapter with a framework for clinicians to help families negotiate ethical dilemmas and a listing of tool and resources to aid ethical dementia caregiving. This work should be on the bookshelf of any clinician serving caregivers and persons with dementia.
Concluding Thoughts
I have asked myself the question; how much will these three books help gerontologists and policy makers understand and resolve family caretaking problems? Neal and Hammer show that the sandwich generation is much more complicated than simply being in the middle. And while the sandwich generation sound byte evokes sympathy for someone trying to balance two worlds of care giving, there are more difficult situations than being a couple in the middle. Long-duration spousal care, the unmarried live-in daughter, and low-income status are examples of circumstances that demand understanding. Being in the middle usually doesn't last a long time and often means that there is a wider social network to call upon. Policy making by sound byte may neglect opportunities for more necessary social interventions.
References
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