Introduction
Population aging, as a general phenomenon of unfavorable demographic development in this period, creates the need for essential care of older adults also in institutional settings. In this context, the question of sustainability of older adults' quality of life, with respect to their optimal needs and acceptance of health status as a consequence of aging, is also highly relevant. It is true that in our social system, particularly in institutions of social services and therefore also in facilities for older adults, the implementation of social service quality standards in line with current legislation is taking place. This shift is an exceptional impetus for improving the quality of provided social services, which significantly affects the quality of life of seniors. In this broader process, we would like to draw attention to procedural conditions in the delivery of social services, especially regarding the use of therapeutic techniques in institutional care for older adults. Through an exploratory study, we focused on monitoring certain aspects that directly affect and at the same time point to prerequisites for professionals' use of therapeutic techniques in practice (in this article we mean social workers or social rehabilitation instructors). Given the limited scope of this contribution, we will not deal with quality of life of older adults, although we note the use of therapeutic techniques in relation to the quality of life of older adults throughout the article.
Social rehabilitation in facilities for older adults
A prerequisite for using therapeutic techniques, according to Act No. 448/2008 Z. z. on social services, is the definition of the term social rehabilitation, which focuses on supporting the independence, autonomy, and self-sufficiency of the individual through the development of skills and activation of capacities within social work. We can thus state that social rehabilitation is a professional activity whose aim is to support individuals with various types of limitations that prevent them from reaching or maintaining optimal levels of their physical, sensory, cognitive, mental, or social functioning. It is a multidimensional process that aims to improve individuals' quality of life in its full complexity by developing or sustaining the individual's bio-psycho-social and also spiritual integrity. Kuzman and Palavra (2019) state that social rehabilitation includes various strategies, interventions, and supportive measures to achieve social inclusion, participation, and improved quality of life. Therefore, social rehabilitation is a process in which the client—including the older adult—is enabled to maintain good health and social functioning. In social services, social rehabilitation is carried out through training in various skills, potential use of aids, self-care activities, spatial orientation, and independent movement. Forms of social rehabilitation may include social therapy, case social work, and therapies such as occupational therapy, music therapy, and art therapy (Mátel, Schavel, 2013).
Methods of social rehabilitation focus on reeducation to improve specific functions, compensation, development of unaffected areas and abilities of the individual, and ways of coping with aging-related changes. Techniques such as spoken word, support and development of motor functions and orientation, rehabilitation of vocational and self-care skills, relaxation, and encouragement of competitiveness are also part of social rehabilitation (Štefánková, Hulínová, 2016). Social rehabilitation in social service institutions is usually provided by social workers, social work assistants, special educators, and social rehabilitation instructors. Vacková (2020) notes that it is important for a worker in social rehabilitation to be trained in a specific activity—such as music therapy, art therapy, occupational therapy (and others)—that contributes to client development.
Social rehabilitation is an important component of social work, whose purpose is to improve individuals' lives, strengthen their capacities, and enable full integration into society. Its importance lies in providing clients with means and support to overcome their limitations and develop their potential. Social rehabilitation is part of an inclusive and supportive environment in which individuals feel accepted, respected, and able to develop or maintain their abilities and talent. Given the diversity and complexity of clients receiving or being offered social rehabilitation, it is important that approaches and methods are adapted to individual needs and situations. Instruments for achieving these goals are also the therapeutic techniques themselves (in our understanding, due to terminological inconsistency).
Therapeutic techniques in social rehabilitation
The conceptual delimitation of therapeutic techniques is not clear, and in this contribution we also acknowledge some terminological inconsistency in Slovakia. In practice, terms such as expressive therapies, projective techniques, activity therapies, supportive therapies, therapeutic methods, therapies in helping professions, etc., frequently appear in connection with the use of therapies in the social field, although they share identical nature, common content, and goals. We would state that the principle of therapy is not understood in social practice as treatment in the full sense, for example in psychotherapy or psychiatric practice. It is therefore not possible to speak of treatment through therapy, but of techniques used in therapeutic practice without establishing a therapeutic relationship (which may rather be trust) and without a curative effect. In social practice, these are activities that aim to support or sustain the optimal quality of life of older adults in relation to their health status and quality of life, in our case often conditioned by the developmental period of aging. Terminological inconsistency and the use of therapies in social practice would require precise definition and unification with respect to both theoretical delimitation and actual social practice. For this reason, we currently prefer the term therapeutic techniques. We can then point to the fact that among the most commonly used therapeutic techniques in residential social care for older adults are those used, for example, in reminiscence therapy, occupational therapy, play therapy, art therapy, music therapy, and movement therapy. In this connection, and without extensive comment, we also note Medňanská’s (2014) claim that, in the period of aging, art also has its place—particularly elements of art therapy or music therapy in our case—which is one of the ways to sustain social and societal ties. According to her, each form of art has its own specific ways of contact with people and its own circle of participants.
In our discussion of terminological inconsistency, we only briefly cite statements of several authors that also support our ambivalence. For example, Šoltésová, Bosá, and Balogová (2016) point out that therapy fields and social work concepts are often informed by therapeutic pedagogy, psychotherapy, psychology, and also medicine. By being integrated into social work, they take on a new form adapted to direct practice and appear to be effective and inspiring. More specifically, Kuzyšin and Legdan (2014) state that these are not standard forms of psychotherapeutic interventions, although they are increasingly effective in work with clients. Their view also corresponds to our view that from a scientific perspective, there is terminological and theoretical inconsistency in defining them because several different definitions exist, often contradicting each other. On one hand, this is seen as ambiguity of these procedures; on the other hand, according to them, it allows these procedures or their parts to be systematized for practical use in client work. Similarly, Rusnáková (2017) also points to the terminological ambiguity of many interventions or activities in social practice, which on one hand overlap, but on the other hand are explained differently by other authors using the same terms.
In every institution of social services, according to Hrozenská (2011), we find specialized workers, namely occupational therapists, whose aim is to actively fill older adults' free time as far as possible. Participation in these activities is voluntary, which for some clients can in fact have the opposite effect, leading to passivity, loneliness, a feeling of abandonment, and even depression. It is worth mentioning here, in the therapeutic context, that therapy is unique in being oriented toward a process in which one person conveys attitudes of congruence, empathy, and positive acceptance, and the other person receives these attitudes (Meador, Rogers, 1991). Šoltésová, Bosá, and Balogová (2016) similarly state that therapy begins with trust between professional and client. For a client to begin trusting the professional, they need to feel the worker’s interest in them, expressed through acknowledgment and respect.
In social work, this therapeutic element is expressed mainly in that the professional focuses especially on strengthening the individual resources of the client, as well as potential resources, with the goal of gaining new and primarily positive experiences. The period of adaptation to institutional care should be a challenge for professionals to facilitate that transition and help clients adjust to new living conditions. It is important to ensure that love for the person is not lost, that loneliness and social isolation are not deepened. Each client should be treated with dignity and respect. It is important to stress that in providing social services, professionalism must be combined with expertise of all employees together with ethical decision making. When using therapeutic techniques, it is essential that a positive relationship exists between the professional and the older adult. The foundation of that relationship is effective verbal and nonverbal communication, conveyed through an appropriate tone of voice, gaze, gestures, and facial expression, which often say more than words. Basic principles of effective communication with older adults can include awareness—acceptance, greeting and addressing by name, creating an atmosphere of kindness and trust (Hrozenská, Dvořáčková, 2013).
Therapeutic techniques certainly deserve much greater attention from both a theoretical and practical perspective. A sufficient number of trained professionals in these techniques and clear standards for the application of these techniques would allow more efficient practice and enable better understanding of client needs. Institutions of social services in Slovakia increasingly integrate them into their processes, but in actual implementation we encounter several problems, among which are insufficient legislative anchoring, which does not specify their exact classification or detailed description. The Social Services Act mentions them only marginally and defines them as supplementary activities. Another problem is the lack of qualified experts who would ensure practical use of therapeutic techniques, and of course financing for training these actors. According to Kuzyšin and Legdan (2014), education in supportive therapies (from our perspective in therapeutic techniques) is neither systematically organized nor firmly anchored in Slovakia. In further education there are several accredited institutions offering training in therapeutic techniques in art therapy, occupational therapy, psychomotor therapy, drama therapy, play therapy, dance and movement therapy, among others, but their content focus and educational level can, in our view, be quite varied.
For these reasons, we undertook an exploratory study as a tool for identifying certain aspects related to the use of therapeutic techniques in practice.
Results of the exploratory study focused on the use of therapeutic techniques in facilities for older adults
Our aim was to monitor several aspects of applying therapeutic techniques in social service organizations—specifically in facilities for older adults. The basic goal was to examine the possibilities for use of therapeutic techniques by social workers and social rehabilitation instructors in facilities for older adults and the value these techniques bring to clients. We also addressed the legislative anchoring of therapeutic techniques in our context. Based on our research objective, we established a core research question focused on identifying the use of therapeutic techniques in facilities for older adults, and the professional competence of social workers and social rehabilitation instructors in implementing these techniques in practice.
To obtain answers, we used a standardized interview with open-ended questions, followed by more detailed probing questions directly related to deeper reflection by participants so that we could obtain the clearest and most precise answers.
In terms of participant involvement, for the narrower sample we used random sampling, focusing on facilities for older adults in the Bratislava and Nitra regions. As a sample, we contacted all types of facilities for older adults, both public and non-public providers of social services. From these institutions, we managed to obtain 14 participants.
Through the exploratory study, we sought to present the perspective on the use of therapeutic techniques in facilities for older adults, whose aim is primarily to improve the quality of life of this target group in residential care.
For a visual overview of the research areas, we provide the following figure corresponding to the questions formulated in the interview.
Figure 1 Individual areas of research
In reinterpreting the obtained answers in the education area, we explored participants’ highest level of formal education and which participants had completed a social rehabilitation instructor course. One participant had completed secondary education in the healthcare field. One participant with completed first-cycle university education also had a social work degree. Twelve participants had completed second-cycle university education: 8 participants had a social work degree, 2 had studied social services and counseling, and 2 had completed another field, namely psychology and evangelical theology.
In the area focused on information about opportunities for further education, we found that six participants had completed a social rehabilitation instructor course. Participants indicated that attending this course was mainly due to a degree of advancement, gaining a new perspective, and getting inspiration to improve the quality of their professional work, while they only marginally familiarized themselves with therapeutic techniques.
The second area was devoted to obtaining information on opportunities for further education in therapeutic techniques. Each participant knew that additional training was possible, but only three institutions offering such training were named. Participants also stated that they lack a comprehensive overview of further education options. This awareness—or lack of awareness—of institutions providing training in supportive therapeutic techniques is also confirmed by the research of Kormaník and Kuzyšin (2019), according to which up to 57.93% of social service facilities in the study did not know that educational institutions in Slovakia operate to prepare qualified therapists for social practice. The same authors also note that it is quite costly to train a worker into a qualified expert because social service institutions do not have sufficient financial resources for such training. Perhaps the largest issue captured in interviews was that our participants often did not know whether they were applying the individual techniques correctly in work with older adults. Here we may add that in university studies in social work, therapeutic techniques are introduced only marginally and only in part. This is also confirmed by the information from the Institute for Further Education of Social Workers (2020) published on its website, which states that social workers often use therapeutic techniques intuitively in practice because they acquire only minimal information on these techniques during their studies. At the same time, Kuzyšin and Legdan (2014) claim that education in supportive therapeutic techniques is not systematically anchored or arranged in Slovakia. Our participants also see another problem in carrying out therapeutic techniques: sources of inspiration. Because they have, in practice, “free rein” and there is no defined procedure, no clear rules, and limited professional literature, they mainly look for ideas and inspiration on the internet or from older more experienced colleagues.
The next area—the conditions for implementation—focused on identifying conditions for delivering supportive therapeutic techniques in practice. Appropriate conditions were confirmed, including spatial, material, and time resources. Financial conditions for ensuring the implementation of some therapeutic techniques depend on budgetary funds from the founding authority. Financial problems in this broader context are also confirmed by Kormaník and Kuzyšin (2019), according to whom up to 70% of subjects pointed to reasons for insufficient quality service together with a lack of qualified staff due to inadequate financial resources.
The area assessing client interest in different kinds of activities indicated a preference for reminiscence therapy and music therapy. In this context, Janečková and Vacková (2010) state that reminiscence therapy helps staff get to know and understand clients better, which can be considered a multiplier effect for subsequent high-quality care of older adults. We also point to the fact that interest in various activities is conditioned by clients' health status, the specific character of institutions, and professional potential, as well as technical and material equipment in facilities for older adults. According to participant responses, clients in facilities for older adults often have movement limitations and weaker vision; for this reason, they are more interested in receptive components of implemented therapeutic techniques.
In the area of our interest focused on the impact of implemented supportive therapeutic techniques on the quality of life of older adults, participants confirmed that therapeutic techniques have a positive effect on clients’ quality of life, with the most frequent responses indicating feelings of personal fulfillment, safety, usefulness, and support of memory and psychomotor abilities. Ružička (2010) notes in this context that appropriate activities help clients cope with loneliness and find a new meaning in life. Results of Kormaník and Kuzyšin (2019) also confirm that supportive therapies have a positive effect on clients, as in their study this was supported by 91.60% of respondents. Within the different areas of older adults’ lives, participants pointed out that therapeutic techniques most strongly influence mental well-being, social well-being, and emotional well-being. This is also confirmed by the above-mentioned study of Kormaník and Kuzyšin (2019), according to which up to 45.12% of social subjects believe that therapeutic techniques have a positive effect on social well-being and 44.51% on mental well-being of clients.
The final area of our interest was oriented toward identifying impulses within legislation, professional preparation, or greater interest in therapeutic techniques on the part of providers.
Responses confirmed that ambiguity, different understandings of terminology, as well as insufficient methodology for using each intervention and activity also affects, among other things, legislation. Reflections of participants in courses for social rehabilitation instructors indicate the absence of practical tasks that include the use of therapeutic techniques.
Conclusion
From the results of our exploratory study and analysis of statements by individual authors who address this issue, we reached conclusions that we see as a prompt for further discussion of the topic. We conclude that professional staff in facilities for older adults work with clients in the use of therapeutic techniques based on their own intuition, or in cooperation with more experienced colleagues who guide them. At the same time, professional literature on the use of therapeutic techniques in working with older adults is neither sufficiently developed nor sufficiently available. Despite workers’ interest, completing additional courses and educational activities is hard to realize because providers of social services do not have enough financial resources to cover courses for all employees who could use therapeutic techniques in their work, and staffing to keep facilities operational during employee training is also problematic.
Legislation in our context regarding provided therapeutic techniques is neither consistent nor clear. Institutions do not have a unified methodology for the practical use of therapeutic techniques. Connected to this is the supply of accredited educational courses, so that interested participants can more easily find offerings from multiple providers, for example via one web platform. From the results of our exploratory study, we found that the use of therapeutic techniques in practice has a positive effect primarily on older adults’ mental and physical health.
We believe that the topic of implementing therapeutic techniques together with their conceptual inconsistency deserves a systematic professional discussion among experts in academic circles and among practitioners.
Author: prof. PaedDr. Milan Schavel, PhD. Prešovská univerzita v Prešove, Pravoslávna bohoslovecká fakulta, Katedra kresťanskej antropológie a sociálnej práce
This contribution is one of the results of the implementation of the research project “Vplyv implementácie podmienok kvality sociálnych služieb a ich hodnotenia v ZSS pre seniorov na kvalitu života ich prijímateľov”. (VEGA 1/0339/22)
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