KEY WORDS older people carereceiving family communication caregiving role expectations

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1 Communicating in family aged care dyads Part 1: The influence of stereotypical role expectations Helen Edwards, Helen Chapman. Quality in Ageing. Brighton: Oct 2004.Vol.5, Iss. 2; pg. 3, 9 pgs ABSTRACT This paper contends that dysfunctional patterns of communication can develop in family aged care dyads in response to stereotypical role expectations in the caregiving-carereceiving relationship, thus giving rise to a role predicament of caring. If this argument holds it follows that more productive and effective forms of communication and relationship are dependent upon both members of the aged care dyad understanding the expectations of their role and if necessary reconstructing them. Part 1 of this two part conceptual paper develops the Communication Predicament of Ageing Model to include role expectations. The conceptions are grounded in important conclusions drawn from data contained in a large comprehensive study of older people and their family caregivers. Part 2 of the paper (to be published in the next issue of Quality in Ageing) introduces the health promoting communication model which was developed as a framework for guiding both prevention and intervention strategies to prevent or transform a role predicament of caring. KEY WORDS older people carereceiving family communication caregiving role expectations INTRODUCTION Family caregiving for older people has received increased attention in literature over the last two decades of the 20th Century. For the most part, family caregiving research has examined caregiving from the caregiver perspective and maintained a focus on the burden and psychological distress experienced by caregivers. An underlying assumption of this research is that care provided to older people by family members can only be beneficial to the receiver. However, many costs associated with carereceiving have been identified, including depression, decline in morale and relational quality. The carereceiver's perspective is now receiving progressively more attention and more recent research has focused attention on ways of enhancing quality of life for both caregiver and carereceiver. Conceptual models and research findings concerning, for example, relationships (eg, Harris, 1998; Nunley, Hall & Rowles, 2000; Whitbeck, Hoyt & Huck, 1994) and communication (eg, Edwards, 1996; 2001; Hummert & Nussbaum, 2001; Orange, 2001; Ryan, Hummert & Boich, 1995; Ryan, Meredith, MacLean & Orange, 1995) are now well documented and in many cases have been expanded upon. However, little, if any, literature was found that addressed the expectations of either the caregiver or the carereceiver about their role in the caregiving relationship. This first part of a two part conceptual paper provides an explanation of how and why certain patterns of communication may develop in response to not only age stereotypes but also to stereotypical role expectations. In doing so, the Communication Predicament of Ageing Model (Ryan, Giles, Bartolucci & Henwood, 1986) is extended to include role expectations.

2 The ideas advanced in this paper are based mainly on the research of Edwards (1996). Edwards' research supported the central paradox of the Communication Predicament of Ageing Model (Ryan, Giles, Bartolucci & Henwood, 1986), confirmed the central tenets of Communication Accomodation Theory (CAT) and highlighted the importance of power relations in dyads (see Edwards & Noller, 1998; Edwards & Forster, 1999; Edwards, 2001). The predominance of the effects for role for many of the communication behaviours indicated that the roles of caregiver and carereceiver are very salient within the caring context, especially in terms of power. The patterns of behaviour related to the role suggested that the caregiver was the most powerful and dominant partner with the carereceiver adopting a more passive and subservient role. The importance of power relations within caring dyads was a major finding in Edwards' study. Caregivers, for example, frequently used control as a coping strategy by simplifying the complexity of speech directed to their carereceivers; they also frequently used reinterpretation/acceptance as a coping strategy to maintain control of the interaction; 'the lack of equity inherent in these legitimate, but power oriented, roles is likely to affect the carereceivers' (Edwards, 1996: 295). These findings add to the evidence that communication and interpersonal interactions form a significant component of the health caring role (see for example: Edwards, Weir, Clinton & Moyle, 1993; Giles, Coupland & Wiemann, 1990; Hummert, Nussbaum & Wiemann, 1994; Hummert & Nussbaum, 2001; Mclntosh, 1996). If it is accepted that 'aging is as much a communicative construction as a biological inevitability'(giles, 1999: 170), then the processes of communication and interpersonal interactions deserve special attention as older people endeavour to come to terms not only with the myriad losses and challenges associated with ageing but also with achievement of life span closure. Despite the increasing amount of literature about family caregiving in terms of the burden of care, levels of well-being and satisfaction and communication patterns, and despite increasing recognition of the importance of communication for older people and for the caregiving situation, there is little literature about communication processes in family caregiving situations. The literature that does exist (see for example Edwards, 1996; 2001; Edwards & Forster, 1999; Edwards & Noller, 1998) suggests that communication during family caregiving has certain features. COMMUNICATION FEATURES IN FAMILY CAREGIVING Avoidance The study by Edwards (1996) indicated that in family caregiving situations little emotion is expressed during conversations and emotions or deep feelings tend not to be discussed and, especially where the spouse is the caregiver, discussion of issues of real concern tend to be avoided. (Edwards, 1996; Edwards & Forster, 1999). Giles (1999: 176) suggests that while we intuitively tend to avoid discussions with older people about 'encroaching and painful events ' such as death because we feel 'uncomfortable, attribute the intent as emotional blackmail, or to sheer morbidness', the result for the older person is to become 'communicatively starved, empty, and alone '. Furthermore, discussions about controversial issues may also be actively avoided or deflected in order to minimise the many tensions experienced in caregiving situations (Edwards, 1996; Edwards & Forster, 1999; Wright, 1991).

3 Domination The communication behaviours of caregivers, regardless of gender, revealed that the caregivers dominated and led conversations through verbal strategies such as controlling topic changes and interrupting and talking out of turn, and through nonverbal behaviours such as eye contact and body language (Edwards, 1996; 2001; Edwards & Noller, 1998). Conversely carereceivers, regardless of gender, took a more passive and subservient role in conversations by agreeing with carers and continuing topics introduced by carers; they rarely initiated topic changes (Edwards, 1996; 2001; Edwards & Noller, 1998). Overly protective communication Analysis of dyadic conversations indicate that overly protective communication does occur in family caregiving situations and can be construed as having two dimensions: an overly concerned tone (eg, expressing concerns for safety, limiting and restricting activities and shielding from stress) and an overly directive tone (eg, verbal coaching, directing, dominating conversations and correcting/negating statements) (Edwards, 1996; Edwards & Noller, 1998). Data from Edwards' study (1996) suggests that an overly concerned tone was more likely when the caregiver has negative feelings about the caregiving role. Overly directive communication was more likely when the caregiver had high autonomy in their earlier relationship with the carereceiver. Directing and dominating behaviours may result from autonomy in the present caregiving relationship which, together with the implicit authorisation granted by the caregiver role, may result in a decision to provide direction (Edwards & Noller, 1998). This supports the suggestion by Thompson and Sobolew-Shubin (1993) that intrusive, restrictive and controlling behaviours may be a way for reluctant carereceivers to indirectly deal with the feeling of guilt associated with their reluctance to undertake a caregiver role. The communication of overprotection can be likened to paternalism: the belief that it is appropriate for one person to impose a decision on another if it is for the recipient's welfare (Cicirelli, 1992). Like paternalism, overly protective communication ignores the paradox that those most incompetent and in need require more, rather than less, control over their own lives (Rappaport, 1985) and serves not only as a barrier to the carereceiver maintaining independence or autonomy, but also as a barrier to the promotion of independent behaviour by the caregiver. Dependence-promoting behaviours tend to foster processes of 'learned helplessness' (Seligman, 1975), a state that occurs when events are perceived as uncontrollable. It is not difficult to understand the vulnerability - the perceived loss of control - experienced by frail older people faced with the necessity of being dependent on others for care. Nor is it difficult to understand how the increasing influence of overly protective communication might exacerbate this vulnerability to the point where an older person will believe that he/she is incapable of controlling any aspect of his/her life and so surrender independence. Our beliefs or judgements about what we are capable of doing - our perceived self-efficacy - is a better predictor of our actions and behaviours than our actual ability; 'what people think, believe, and feel effects how they behave ' (Bandura, 1986). When caregiver communication promotes dependence

4 rather than independence, negative consequences are likely (eg, Baltes, 1995; 1996; Baltes et al., 1994; Baltes & Baltes, 1990). Patronising communication The term patronising communication is grounded in communication accommodation theory (eg, Giles, Coupland & Coupland, 1991; Giles, Mulac, Bradac & Johnson, 1987) and refers to Overaccommodation in communication with older adults based on stereotyped expectations of incompetence and dependence' (Ryan, Hummert & Boich, 1995: 145). Patronising communication is similar to overly-protective communication in the sense that it also tends to convey messages that imply declining abilities and control. Patronising communication has a negative effect on the well-being of carereceivers and on their perception of the caregiving relationship. Findings from Edwards' (1996) research indicate that carereceivers who perceive their caregivers communication as patronising report low levels of affect balance and high levels of conflict in the caregiving relationship. Moreover, patronising tones were more likely when the carer had high positive affect. Possibly this is because caregivers whose mood state is positive are likely to feel good about what they are doing and in control of the situation (Edwards, 1996; Edwards & Noller, 1998). Communication that is either overly protective or patronising - and therefore lacking in support or respect - is likely to reduce the physical and psychological health of the elderly care recipient and research indicates that both caregivers and carereceivers want changes within their caring situation that are directly related to negative communication patterns. Carereceivers want to talk about issues of concern; they want changes in behaviour and in the interactional patterns of the caring situation; they are dissatisfied with a dependent role and with overly protective and patronising communication (Edwards, 1996; Edwards & Forster, 1999; Edwards & Noller, 1998; Hummert, 1994; Johnson, 1996; Nunley et al, 2000; Pruchno et al, 1997; Ryan, Meredith et al., 1995; Thompson & Sobolew-Shubin, 1993). It is beyond question that the family caregiving situation involves 'complex interactions with potentially positive and negative consequences for both carereceivers and caregivers' (Pruchno et al., 1997). The Communication Predicament of Ageing Model (Ryan et al., 1986) provides a theoretical framework for understanding how older people can experience negative changes from conversational encounters. Based on the conclusions drawn in Edwards' (1996) study, a central premise of this paper is that a role predicament of caring exists within family caregiving relationships. It will be argued that dysfunctional patterns of communication develop in family caregiving relationships not only in response to stereotypical expectations about older people but also in response to stereotypical expectations by both caregiver and carereceiver about their role in the caregiving relationship. This line of reasoning further develops the Communication Predicament of Ageing Model (Ryan, Giles, Bartolucci & Henwood, 1986) to include role expectation. A subtext to this paper is that health providers supporting caregiving families should consider the expectations and needs of both caregiver(s) and carereceiver(s). Privileging the expectations of one over the other is not only a social injustice but

5 may also reinforce stereotypical expectations by both caregiver and carereceiver about their role in the caregiving relationship. THE COMMUNICATION PREDICAMENT OF AGEING MODEL This model applies to general communication with older people. The model proposes that a communication predicament arises when older people have to overcome not only changes in their own communication skills but also the extra barriers imposed by their conversational partners (Ryan et al., 1986). The model suggests that whenever there is interaction between an older person and another a particular self-fulfilling cycle occurs. That is to say, when encountering an older person old age cues are recognised and these elicit stereotyped expectations. Speech and other communication behaviours are then modified in accordance with the stereotypes elicited. Common modifications include baby talk, patronising talk, controlling paternalistic talk and simple sentence structure. This reinforces age stereotypes and constrains opportunities for the older person to communicate and to gain satisfaction from the encounter. Moreover, such negative experiences may further reduce the older person's chances for successful interactions in the future. For example, negative interpersonal experiences may lead an older person to believe that they are actually in decline; a belief that can lead to reduced self-esteem and independence, withdrawal from social interaction and, ultimately, adoption of some of the stereotypical behaviour - a selffulfilling cycle (Ryan, Meredith et al., 1995). The Communication Predicament of Ageing Model has proven to be an effective theoretical framework for understanding the psychosocial features and functions of communication. Several modifications have been presented (eg, Coupland, Coupland & Giles, 1991; Coupland, Coupland, Giles & Harwood, 1988; Edwards, 1996; Harwood, Giles, Fox, Ryan & Williams, 1993; Hummert, 1994). The remainder of this paper is focused on a further modification of the Communication Predicament of Ageing Model to include role expectation. ROLE EXPECTATION Family caregiving is not a role typically aspired to, anticipated or chosen (Moen, Robison & Fields, 1994). Family members usually find themselves undertaking the caregiver role with little consultation, much less education or preparation for the undertaking. Authorisation to undertake the role is largely determined by willingness and availability. 'Taking on the caregiving role involves changes in established patterns of behavior and expectations and often the acquisition of new knowledge and skills' (Schumacher, 1995). Although both caregiving and carereceiving roles are individually constructed, they are mutually supportive and develop through shared interaction: 'caregiving and carereceiving are appropriately conceptualised as mutually interdependent, reciprocal roles that are taken on through concomitant role-making processes' (Schumacher, 1995). Both caregivers and carereceivers tend to construct their roles according to their preconceptions about what the roles entail and, not unnaturally, they draw upon their experiences and observations of caregiving and carereceiving. For example, the carer may come to the caregiving situation believing that the primary role of caregiver is to help, guide and direct; the carereceiver may believe that as the person needing

6 help his/her role is to passively accept help, guidance and direction. Such preconceptions are understandable given that these are the caregiving-carereceiving roles exemplified in the caregiving relationship most individuals are familiar with - that of doctor and patient. Role expectations such as those outlined above are underpinned by perceptions of the carereceiver as being sick and frail and comfortable in the role of passive recipient of care and perceptions of the caregiver as being capable and enthusiastic about actively providing and directing care. If these perceptions are both accurate, all may be well. However, the contention of this paper is that when caregiving-carereceiving roles are based on stereotypical role expectations dysfunctional patterns of communication may develop. This extension to the Communication Predicament of Ageing Model proposes that when caregiving-carereceiving roles are based on negative stereotypical role expectations a role predicament of caring arises and older people have to overcome not only changes in their own communication skills and the extra barriers imposed by their conversational partners (Ryan et al., 1986), but also adapt to a role that may be neither desirable nor appropriate. The Communication Predicament of Ageing Model suggests that when encountering an older person old age cues are recognised and these elicit stereotyped expectations of older people with a resultant modification of language and other communication behaviour. However, according to the role predicament of caring hypothesis, communication is modified in accordance not only with age stereotypes but also with role expectations. Figure 1: A Communication Predicament of Ageing Model based on Role Expectation (Adapted from Ryan, Giles, Bartolucci & Henworth, 1986)

7 NEGATIVE IMPACT ON FAMILY CAREGlVlNG RELATIONSHIP When communication is modified in accordance with stereotypical role expectations, age stereotypes are likely to be reinforced and many opportunities for the older person may be constrained. The communication features of family caregiving previously discussed such as avoidance, domination, overly protective and/or patronising communication are likely to predominate resulting in restricted opportunities for the older carereceiver to communicate, to gain satisfaction from the encounter and to actively participate in, or control, aspects of their life. Moreover, such negative experiences may further reduce the older person's chances for successful interactions or attempts at autonomous behaviour in the future. For example, observation of the interpersonal interactions may lead the older person to conclude that he/she is not only declining but also incapable of controlling any aspect of his/her life. This conclusion may in turn result in reduced self-esteem and independence, withdrawal from social interaction and ultimately adoption of some of the stereotypical behaviour such as passive dependency and adoption of the 'sick role' (Parsons, 1951) - a self-fulfilling cycle. Individuals may adopt the sick role when they are ill and need care. By adopting the sick role responsibilities and obligations are given up in return for becoming a passive, cooperative recipient of care. The care recipient is expected to want, and also try, to get better and to take advice and direction from the care provider, who is seen as the expert and vested in authority (Cott, 1999). The adoption of sick role type behaviour may be seen as not only appropriate but also inevitable to the present generation of older people who grew up in a time when professional caregiving relationships were predominantly paternalistic. The tendency towards such dominant-passive relationships in family caregiving situations is understandable given that the carereceiver is often frail with serious health problems and that caregivers, by nature of their work, are there to help. Certainly, it is not unnatural for caregivers to feel that they should actively take a dominant, guiding and protective role in the caregiving situation and for the carereceiver to feel that they should passively comply with caregiver directions. In many situations such a relationship may be mutually satisfying and desirable. All may be well if the patterns of communication are not perceived to be dysfunctional by either the caregiver or the carereceiver. However, the nature of communication in the family caregiving-carereceiving situation is dynamic and complex and the negative cycle that develops when communication is inappropriately modified is difficult to avoid. When assisting families to move towards more productive and effective forms of communication and caregiving relationships it is essential that both caregivers and carereceivers be helped to better understand their role expectations in the caregiving relationship, and if necessary assisted to reconstruct their roles. Furthermore, while health providers supporting caregiving families should consider the expectations of both caregiver(s) and carereceiver(s) it is crucial that they respond to individual needs and expectations of clients rather than imposing their own stereotypical expectations in terms of both older people and the caring roles.

8 CONCLUSION This paper has extended the Communication Predicament of Ageing Model (Ryan et al., 1986) to include role expectation. Underpinned by important conclusions drawn from data contained in a large, comprehensive study of older people and their family caregivers (Edwards, 1996), this paper contended that a role predicament of caring exists within family caregiving relationships. It was argued that dysfunctional patterns of communication develop in family caregiving relationships not only in response to stereotypical expectations about older people but also in response to stereotypical expectations by both caregiver and carereceiver about their role in the caregiving relationship. The paper culminated in the presentation of a modification of the Communication Predicament of Ageing Model (Ryan et al., 1986) to include role expectation. The challenges associated with promoting more productive and effective forms of communication and caregiving relationships through modification of role expectations and behaviours are the focus of Part 2 of the paper, which introduces the Health Promoting Communication Model. This model was developed as a framework for guiding both prevention and intervention strategies to prevent or transform a role predicament of caring. References Baltes MM (1995) Dependencies in old age: Gains and losses. Current Directions in Psychological Science Baltes MM (1996) The Many Faces of Dependency in Old Age. Cambridge: Cambridge University Press. Baltes MM, Neumann EM & Zank S (1994) Maintenance and rehabilitation of independence in old age: An intervention program for staff. Psychology and Aging Baltes PB & Baltes MM (1990) Psychological perspectives on successful aging: The model of selective optimization with compensation. In: PB Baltes & MM Baltes (Eds) Successful Aging: Perspectives from the behavioural sciences. Cambridge: Cambridge University Press. Bandura A (1986) Social foundations of thought and action: A social cognitive theory. Englewood Cliffs: Prentice Hall. Cicirelli VG (1992) Family caregiving: Autonomous and paternalistic decision making. Newbury Park, CA: Sage. Cott C (1999) Long-term care: Living with chronic illness. In: E Ramsden (Ed) The Person As Patient: Psychosocial perspectives for the health care professional (pp ). London: WB Saunders Company Ltd. CouplandN, Coupland J & Giles H (1991) Language, Society and the Elderly. Oxford: Basil Blackwell.

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