The Effects of Group Work With Institutionalized Elderly Persons

Abstract

Objectives:

This research article aims to measure the effects of group therapy on institutionalized elderly in terms of reducing depression and improving psychosocial functioning.

Methods:

Thirty elderly nursing home residents were recruited, and 16 of them elected to receive group treatment for depression and 14 declined treatment. The Multidimensional Observation Scale for Elderly Subjects and the Geriatric Depression Scale were given to both groups when group work began and again when it ended.

Results:

Clients who received group treatment experienced reductions in depression and their psychosocial functioning improved.

Conclusion:

Group work intervention was followed by reductions in the depression levels and improvements in their psychosocial functions among institutionalized elderly clients.

Keywords

aging nursing homes social work with groups geriatric depression psychosocial functioning

As it is the case in many countries all over the world, the demographic structure of Turkey has been rapidly changing. As fertility rates are falling and longevity is increasing, the share of the elderly (65+) within the population is constantly increasing. Moreover, along with technological developments, economic and social development is producing a longer life span (Karataş, 1988). As of 2014, the elderly in Turkey constituted 7.7% of the population which almost equals 6 million people and this percentage is projected to reach 20.8% by 2050 (TUIK, 2014). Since old age is a phase where physiological and mental changes are at their peak (Pekcan, 2000), this can bring about some challenges regarding the adaptation process of elderly to growing old (Emiroğlu, 1995). With old age, people may experience status loss, financial difficulties, loneliness and isolation, difficulties in adaptation to social life, increases in chronic diseases, and decline in physical abilities. On the other hand, decreasing number of children and fertility rates, mobility, urbanization, and increasing female labor force participation are decreasing kin resources in terms of caring for the elderly. As a result, the need and demand for formal and institutionalized care facilities are increasing in Turkey as well as around the world. The objective of nursing homes is to provide elderly people with a healthy environment and to help meet their social and psychological needs. Nursing homes in Turkey admit socioeconomically disadvantaged people over 60 years who are able to continue their daily living activities, those who do not need medical long-term care, and who are not severely disabled or mentally ill (MFSP, 2014). Even though these older patients do not have severe health problems and limited communication with their family, isolation and difficulty in adaptation to the new environment can be mentally and emotionally challenging (Özer, 2004). For this reason, depression and impairments in psychosocial functioning are common among the institutionalized elderly.

Geriatric Depression

Depression is a pervasive psychiatric disorder that emerges due to various reasons, and geriatric depression is one type that occurs among elderly (65+). According to the Fact Sheet published by World Health Organization (2013), depression effects 7% of the elderly and this percentage may vary according to the context and country. In Turkey, the prevalence of geriatric depression is much higher. According to a study conducted in Istanbul, 17% of the elderly were diagnosed as depressed, and depression rates are even higher among the illiterate and aged 75–79 (Kulaksizoglu et al., 2005). Another prevalence study conducted in Trabzon, Turkey, also showed that 13.6% of the elderly had depression symptoms (Kavakcı, Bilici, Çam, & Ülgen, 2011). According to a study that investigated risk factors for depression, depression rates were higher among women, divorcees, people living alone, and among those having no social security (Nahcıvan & Demirezen, 2005). Given the rise in the share of elderly in the population all around the world and in Turkey, the percentage of depressed older adults is expected to increase.

Diagnosis and treatment of geriatric depression is crucial because along with other physical and cognitive declines, untreated depression can severely decrease the quality of life. Research shows that depression immensely decreases the quality of life among older people (Akyol, Durmus, Dogan, & Canturk, 2010; Hasche, Morrow-Howell, & Proctor, 2010; Reynolds, Haley, & Kozlenko, 2008). In order to increase the quality of life among elderly persons, treatment of depression is essential. However, since depression symptoms can vary according to age-groups, different diagnostic and treatment procedures may be relevant and useful with older persons. For instance, sleeping disorders and decreasing sexual activity can be a sign of depression for young adults, whereas these symptoms may not indicate depression for the elderly. Moreover, some symptoms of depression overlap with dementia and may lead to misdiagnosis of the patient. For this reason, accurate diagnosis of depression is crucial for appropriate treatment.

Geriatric depression has many treatments such as psychopharmacological therapies, electroconvulsive therapy, individual and group psychotherapy, and psychosocial interventions. Even though medical intervention may be effective, selected psychotherapies are also effective in treating geriatric depression. Moreover, group therapies can further create a synergy among group members and be more effective compared to individual therapies. These group therapies entail different kinds of interventions such as cognitive and remotivation therapies, reminiscence and grief therapy, physical exercise activities and preventive health behavior, managing medical conditions and social skill development, relaxation and imagery, pleasurable events, and positive social praise.

Psychosocial Functioning

Psychosocial functioning is a multidimensional concept that encompasses different aspects of functioning such as intellectual, social and cognitive functioning, psychosocial aptitude, and measurement of physical needs (Hill, Thorn, Bowling, & Morrison, 2012). There are five areas of psychosocial functioning that are identified:
Self-help: This area of functioning assesses the ability of the elderly to look after his or her own physical care needs, and if more physical nursing care is required.

Disorientation: This type of functioning assesses disorientation and confusion experienced by the elderly in relation to people, recent events, and past memories.

Depression: This area of functioning explores an exhibition of signs for personal distress and unhappiness.

Irritability: This area of functioning assesses cooperative and abusive behaviors of elderly toward staff and other residents of the institution.

Withdrawal: This area of functioning looks at the level of interest the resident takes in people, events, and activities.

Group Therapy Models

Along with the quality of life, psychosocial well-being of the institutionalized elderly is crucial and interventions to enhance their psychosocial well-being therapeutic interventions are essential. Life review therapy, reminiscence therapy, or memoir sharing are some intervention models that are used to empower and improve the psychosocial well-being of the elderly (Peck, 2001; Tufan, 2007). As Turan (1985) indicates, elderly people may enjoy reliving the past. Despite the occasional interruption of regretful feelings, reminiscing the past often brings gratification and mental satisfaction to the elderly while making it easier to live with the current facts. Social cognition and cognitive appraisal are useful concepts to understand the life review process and subjective well-being. In later phases of the life course, the schemata that an individual uses for appraisal are challenged and changed by various losses that come with age. These schemata can be activated through the creation of narratives and reminiscing about the past, which brings personal reconciliation and enables working through changes. All these processes can improve the subjective well-being of seniors (Peck, 2001). Reminiscence therapy can also help with improving emotional well-being and their socialization skills and processes (Siviş & Demir, 2007). A group study conducted with elderly persons has shown that group work improved their spontaneity, creativity, and empathy, giving way for better interpersonal communication, problem-solving, and self-expression (Oğuzhanoğlu & Özdel, 2005). In this respect, it can be argued that reminiscence therapy can decrease depression levels and enhance psychosocial functioning through enabling elderly to continue their social interaction, making them hold onto life, delaying memory loss and other age-related mental deficiencies, promoting intergenerational solidarity, and revealing interesting cultural and historical information (Turan, 1985).

Method

Research Objective

The objective of this research is to find out how group work intervention affects the depression levels and psychosocial functioning of elderly nursing home residents. It was hypothesized that psychosocial functioning and depression scores of the elderly in the treatment group will positively increase following group work and that similar improvements will not be observed among members of an untreated control group.

Research Design, Sample, and Site

We used a quasi-experimental pretest–posttest no-treatment control group study. Purposive sampling was used to recruit participants (Chao et al., 2006; Nachar, 2008). This study conducted at the Süleyman Demirel Nursing and Rehabilitation Centre, a state 240-bed elderly home in Ankara, Turkey, supported by the General Directorate of Disabled and Aged Services of Ministry of Family and Social Policies. The elderly home has two wards. One is for elderly people who are healthy and second one is for elderly people who need special care and rehabilitation. Fifty-nine beds are for healthy patients and 191 beds for patients who need special medical care. Elderly people who lived in the special care and rehabilitations ward were excluded from this project. When we conducted the study, 5 of the 59 beds were empty, 11 elderly people were away with their families or at holiday, and 5 of them were hospitalized. Because of that only 43 elderly people were potentially enrollable in this study. Ultimately, 30 elderly people participated after being informed about the content, objectives, and the project. In addition, staff members and other personnel were informed about the study.

In the scope of the project, two groups were formed. The first group consisted of 15 elderly nursing home residents who received group therapy and the second group of 15 did not receive group therapy. The study is diagrammed in Figure 1. The independent variable (treatment) of the study is the group work that has been applied to the elderly.

Figure 1.
Group work process.

Outcome Measures

Three instruments were used to evaluate the effects of reminiscence group work on elderly people nursing home residents: (1) a demographic questionnaire, (2) a psychosocial functioning scale, and (3) a depression inventory.

A Turkish version of the Multidimensional Observation Scale for Elderly Subjects (MOSES) was used to measure the participants’ psychosocial functioning level. The MOSES was developed by Helmes, Csapo, and Short (1985) to measure the psychosocial functioning of institutionalized elderly and the scale’s reliability and validity study in a Turkish context has been examined (Soygür, 2000; Soygür, Aydemir, Güzelarslan, & Akturk, 1998). The MOSES is composed of 40 items that can be completed by the caregiver in 10–15 min. However, observation of the patient by the caregiver is required for a certain period of time, generally 1 week. The scale provides five separate scores (8 items for each), and each of these scores deals with a different area of functioning. The higher the score for the rating area, the more problematic is the type of functioning. These five areas of functioning are as follows: (a) Self-Help (Items 1–8): The less able the resident is to look after his or her own physical care needs, and therefore the more physical nursing care required by the resident, (b) Disoriented Behavior or Disorientation (Items 9–16): The more disoriented and confused the resident’s behavior is in relation to people, recent events, and past memories, the higher the score is, (c) Depressed/Anxious Mood or Depression (Items 17–24): The more the resident exhibits signs of personal distress and unhappiness, the higher the score is, (d) Irritable Behavior or Irritability (Items 25–32): The less cooperative and more abusive the resident is with the staff and other residents, the higher the score is, and (e) Withdrawn Behavior or Withdrawal (Items 33–40): The less interest the resident takes in people, events, and activities, the higher the score is.

A Turkish version of the Geriatric Depression Scale—Short Form (GDS-S) was used to measure the participants’ depression level (Ertan & Eker, 2000). As indicated before, depression is characterized by a sense of hopelessness, lack of interest in life, sadness, self-criticism, self-blame, slow thinking, poor concentration, and appetite and sleep disturbances (Chao et al., 2006). The GDS-S consists of 15 items chosen from the GDS-Long Form. These 15 items were chosen for the shorter version because these items showed high correlation with depressive symptoms in former validation studies (Sheikh & Yesavage, 1986). Clients can usually complete the GDS-S in 5–7 min. There have been many studies that were conducted to test the validity and reliability of the GDS (D’Ath, Katona, Mullan, Evans, & Katona, 1994; Fuentes & Aranda, 2012; Husaini et al., 2004; Marwijk et al., 1995; Parmelee, Lawton, & Katz, 1989). The validity of the scale has also been translated into many languages including Turkish and the validity of the scale has been demonstrated in the country-specific context (Kohli, Banerjee, & Verma, 1991; Lieh et al., 1995; Niino, Imaizumi, & Kawakami, 1991).

Identifying Group Members

After the application of the GDS-S and Multidimensional Evaluation Scale by the institution’s nurse, the results were evaluated and the elderly were selected accordingly. The participants in the treatment group were elders who were able to share their stories with others. Criteria for potential participants for inclusion in the treatment group were being over 60 years of age, without serious psychiatric illnesses, possessing normal communication ability, being without physical discomfort or pain caused by disease or severely damaged sensory function (e.g., loss of vision or hearing), and being volunteering to participate in group therapy. Before the sessions, meetings were held with the selected elderly and they were informed about the objectives, content, time, duration, place, participants, and the anonymity of the group sessions. After these meetings, the treatment and control groups were formed. While forming these groups, MOSES and GDS-S pretest scores were taken as a measure of pretreatment functioning, along with information regarding the client’s personal demographics. These data are presented in Table 1.

Table 1.
SocioDemographic Features of Elderly (Education Level and Age).

Treatment Group Control Group

No. Age Highest Level of Education Completed No. Age Highest Level of Education Completed

1 82 Primary school 1 80 Primary school

2 70 Training institute 2 77 Illiterate

3 71 High school 3 88 Illiterate

4 83 Literate 4 65 High school

5 71 Primary school 5 66 Literate

6 80 Illiterate 6 63 Primary school

7 66 Illiterate 7 81 Illiterate

8 69 Primary school 8 64 Illiterate

9 62 Secondary school 9 64 Illiterate

10 71 Literate 10 63 Primary school

11 71 Primary school 11 65 Primary school

12 88 Primary school 12 84 Illiterate

13 72 Illiterate 13 77 Secondary school

14 78 Literate 14 65 Primary school

15 79 Literate

16 68 Primary school

Note. MOSES = Multidimensional Observation Scale for Elderly Subjects.

Group Work Procedure

Group work was conducted by the second author (G.Ş.-K.) of this study who is a specialist in clinical social work. Approximately 1 week before we started to the study, all participants in the treatment and control groups individually took the pretest measure. Immediately following the 10-week group work sessions, all participants individually took the posttest measures. The “reminiscing” group work was carried out in the library and training room of nursing home between the dates January 14, 2008, and March 17, 2008. Initially, the room was arranged in a circular way with armrest chairs but since the participants were not very comfortable with these chairs, they were replaced by sofas. Some participants used wheelchairs. The group work lasted approximately for 3 months and the sessions took place every Monday between 14.00 and 15.30. All treatment group members were reminded of group work activity during morning visit. Before each session, the participants were provided with some snacks and beverages which gave them some free time to socialize, warm up, and relax before the sessions.

An essential element of the group work is memory sharing and reminiscences of the memories as a tool for therapeutic intervention. We conducted 10 sessions. As indicated by Chao et al. (2006), each group activity centered on a topic carefully designed to avoid threatening or irritating participants.

At the beginning of each session, the participants were encouraged to read poems or sing songs to create a relaxed environment. These ice-breaking practices were accompanied by snacks, tea, and coffee. And in order to encourage interaction between the participants and initiate the conversations, the participants were asked to draw a name of a participant from a bucket and either poses a question on the week’s topic or introduces that person and comment on that person. Here is how each session was arranged:
Week 1—In the first session, the participants were asked to introduce themselves and indicate their expectations from the group work sessions. Once more, the group leader informed the participants about the content, purpose, and duration of the study. The participants slowly started to talk about their childhood memories in this session.

Week 2—In the second session, two new participants were introduced and every participant continued to share their childhood memories. The participants were asked to bring their old photo albums for the next session.

Week 3—At the beginning of this session, the participants played a memory game by trying to identify the missing objects in a tray in order to emphasize the relationship between memory, memoirs, and souvenirs. After that, old photo albums brought by the participants were distributed across the group and the members shared their memories through these photographs.

Week 4—In this session, the participants were encouraged to share their positive memoirs related to their work lives in the past. In order to remind each other’s name and personal history, the participants were asked to introduce each other before the session started.

Week 5—In this session, the participants were asked to share their “first” moments, such as starting primary school, having a child, getting married, receiving a letter, and so on. The group leader focused on shy participants to encourage them for more participation and support.

Week 6—In this session, the participants were asked to describe their happiest moments in the past and where would they want to live again. The participants were directed to talk about their happy moments, as they had a tendency to talk about unsolved problems.

Week 7—In this session, the participants were encouraged to help each other and appreciate the happiness that helping each other brings. In this session, the participants were blindfolded and given objects to identify. In the identification process, the other participants gave clues and helped the blindfolded participant.

Week 8—In the eighth session, the participants stated their favorite places and cities, their favorite activities, and their favorite people to spend time with.

Week 9—In this section, the group leader tried to push the participants to scrutinize the meaning of happiness through sharing happy moments in their lives and create a common identity. They were asked to describe the happiest moments in their lives. The participants were also informed about the final session that was coming up.

Week 10—During the last session, the group leader asked for feedback from the participants about the group therapy.

Ethical Considerations

This research was conducted after obtaining the voluntary consent of the research participants. They had a full understanding of the objective, process, and potential dangers and benefits of this research. Also, we informed the participant that they will receive no payment for taking part in this study. All information gathered from the participants were considered confidential.

Results

Pre- and posttest data for the clients in the treatment and no-treatment conditions were analyzed using a 2 (time periods) × 2 (groups, treatment vs. no-treatment) analysis of variance (ANOVA). As seen in Table 2, the average GDS-S scores of the 16 elderly people who accepted to participate in the group work was 12.44 (SD = 3.72) where the average score for the 14 elderly people who did not participate was 10.57 (SD = 4.60). These two means did not significantly differ. Posttest the average GDS-S score of the 16 older people who participated in the group application is 10.81 (SD = 2.86) where the average of the 14 who did not is 11.07 (SD = 3.05). ANOVA results depicted in Table 3 show that the only statistically significant posttreatment difference occurred in the “Withdrawn” subscale of the MOSES, which declined in the treatment group and became elevated in the nontreatment group. Multiple comparison analyses on MOSES scores are displayed in Table 4 and favor the patients who received group therapy on the variables of Disoriented, Irritable, and Withdrawn.

Table 2.
MOSES and GDS-S Scores Before and After Group Work.

State Group n Before After

Mean SD Mean SD

GDS-S SWI group 16 12.44 3.72 10.81 2.86

Control group 14 10.57 4.60 11.07 3.05

Self-care SWI group 16 12.44 5.63 12.19 4.94

Control group 14 15.00 7.17 15.00 7.08

Disoriented SWI group 16 9.94 2.89 8.31 0.79

Control group 14 11.79 5.28 12.29 6.80

Depressed SWI group 16 13.94 5.98 11.06 3.30

Control group 14 13.00 4.51 13.07 4.80

Irritable SWI group 16 11.81 3.37 9.81 1.68

Control group 14 11.71 4.55 12.64 3.39

Withdrawn SWI group 16 14.38 5.51 11.19 2.51

Control group 14 16.71 6.57 18.36 7.32

Note. GDS-S = Geriatric Depression Scale—Short Form; MOSES = Multidimensional Observation Scale for Elderly Subjects; SWI = Social Work Intervention.

Table 3.
ANOVA for Comparing MOSES and GDS-S Scores.

Sum of Squares df Mean Square F Sig.

Depression Between groups 32.518 3 10.839 0.835 .480

Within groups 726.732 56 12.977

Total 759.250 59

Self-care Between groups 108.358 3 36.119 0.935 .430

Within groups 2162.375 56 38.614

Total 2270.733 59

Disoriented Between groups 149.394 3 49.798 2.541 .066

Within groups 1097.589 56 19.600

Total 1246.983 59

Depressed Between groups 70.446 3 23.482 1.041 .381

Within groups 1262.804 56 22.550

Total 1333.250 59

Irritable Behavior Between groups 65.904 3 21.968 1.950 .132

Within groups 630.946 56 11.267

Total 696.850 59

Withdrawn Behavior Between groups 437.741 3 145.914 4.519 .007

Within groups 1808.259 56 32.290

Total 2246.000 59

Note. ANOVA = analysis of variance; GDS-S = Geriatric Depression Scale—Short Form; MOSES = Multidimensional Observation Scale for Elderly Subjects.

Table 4.
Multiple Comparisons in MOSES and GDS-S Scores.

Dependent Variable Group Name (I) Group Name (J) Mean Difference (I − J) SE Sig.

Depression Treatment pretest Control pretest 1.87 1.32 0.162

Treatment posttest 1.63 1.27 0.207

Control posttest 1.37 1.32 0.305

Control pretest Treatment pretest −1.87 1.32 0.162

Treatment posttest −0.24 1.32 0.856

Control post test −0.50 1.36 0.715

Treatment posttest Treatment pretest −1.63 1.27 0.207

Control pretest 0.24 1.32 0.856

Control posttest −0.26 1.32 0.845

Control posttest Treatment pretest −1.37 1.32 0.305

Control pretest 0.50 1.36 0.715

Treatment posttest 0.26 1.32 0.845

Self-care Treatment pretest Control pretest −2.56 2.27 0.265

Treatment posttest 0.25 2.20 0.910

Control posttest −2.56 2.27 0.265

Control pretest Treatment pretest 2.56 2.27 0.265

Treatment posttest 2.81 2.27 0.221

Control posttest 0.00 2.35 1.000

Treatment posttest Treatment pretest −0.25 2.20 0.910

Control pretest −2.81 2.27 0.221

Control posttest −2.81 2.27 0.221

Control posttest Treatment pretest 2.56 2.27 0.265

Control pretest 0.00 2.35 1.000

Treatment posttest 2.81 2.27 0.221

Disoriented Treatment pretest Control pretest −1.85 1.62 0.259

Treatment posttest 1.63 1.57 0.304

Control posttest −2.35 1.62 0.153

Control pretest Treatment pretest 1.85 1.62 0.259

Treatment posttest 3.47 1.62 0.036

Control posttest −0.50 1.67 0.766

Treatment posttest Treatment pretest −1.63 1.57 0.304

Control pretest −3.47 1.62 0.036

Control posttest −3.97 1.62 0.017

Control posttest Treatment pretest 2.35 1.62 0.153

Control pretest 0.50 1.67 0.766

Treatment posttest 3.97 1.62 0.017

Depressed Treatment pretest Control pretest 0.94 1.74 0.592

Treatment posttest 2.88 1.68 0.092

Control posttest 0.87 1.74 0.620

Control pretest Treatment pretest −0.94 1.74 0.592

Treatment posttest 1.94 1.74 0.270

Control posttest −0.07 1.79 0.968

Treatment posttest Treatment pretest −2.88 1.68 0.092

Control pretest −1.94 1.74 0.270

Control posttest −2.01 1.74 0.253

Control posttest Treatment pretest −0.87 1.74 0.620

Control pretest 0.07 1.79 0.968

Treatment posttest 2.01 1.74 0.253

Irritable Treatment pretest Control pretest 0.10 1.23 0.937

Treatment posttest 2.00 1.19 0.097

Control posttest −0.83 1.23 0.502

Control pretest Treatment pretest −0.10 1.23 0.937

Treatment posttest 1.90 1.23 0.127

Control posttest −0.93 1.27 0.467

Treatment posttest Treatment pretest −2.00 1.19 0.097

Control pretest −1.90 1.23 0.127

Control posttest −2.83 1.23 0.025

Control posttest Treatment pretest 0.83 1.23 0.502

Control pretest 0.93 1.27 0.467

Treatment posttest 2.83 1.23 0.025

Withdrawn Treatment pretest Control pretest −2.34 2.08 0.265

Treatment posttest 3.19 2.01 0.118

Control posttest −3.98 2.08 0.061

Control pretest Treatment pretest 2.34 2.08 0.265

Treatment posttest 5.53 2.08 0.010

Control posttest −1.64 2.15 0.448

Treatment posttest Treatment pretest −3.19 2.01 0.118

Control pretest −5.53 2.08 0.010

Control posttest −7.17 2.08 0.001

Control posttest Treatment pretest 3.98 2.08 0.061

Control pretest 1.64 2.15 0.448

Treatment posttest 7.17 2.08 0.001

Note. GDS-S = Geriatric Depression Scale—Short Form; MOSES = Multidimensional Observation Scale for Elderly Subjects.

The Difference After Group Work

Table 3 shows the differences between treatment group and control group. The ANOVA analysis shows that the differences between the withdrawn behaviors were statistically significant at p < .05 level. However, differences between the other behavior types (self-care, depression, disorientation, self-help, and irritable behavior) were not statistically significant.

In addition to the ANOVA analysis, Fisher’s least significant difference (LSD) test (Meier, 2006) was employed. Table 4 shows an LSD analysis and compares each post- and pretests of the control and treatment groups according to each behavior category. According to the analysis, the difference between control pretest and treatment posttest is significant for disoriented behavior at p < .05 level. The positive relationship shows that control group mean scores were higher than the treatment group. On the other hand, the difference between control posttest and treatment posttest for the disoriented behavior was statistically significant at p < .05 level. The positive sign of the mean confirms that the scores of control group posttests were higher compared to the treatment posttest. In short, this result shows that the group work therapy was useful in reducing disoriented behavior among participant elderly.

Discussion and Application to Social Work

In this work, we intended to evaluate the possible effects of group therapy on a sample of elderly nursing home residents. In addition to the statistical analysis, behavioral changes like improvement in self-expression and increase in the joy of living are observed in the treatment group. The participants of the treatment group were observed to support each other with emotional sharing and giving and exchanging advice on getting through tough situations. Also, giving meaning to life became more consolidated with the help of sharing memoirs and reminiscence therapy. Empathy with other participants who had been experiencing similar situations formed a connection between each other and made them reconsider and realize what happened in their own lives. This also enhanced the communicative, expressive, and assistive skills of the participants of the group work. Moreover, group work was seemingly effective for developing relationships, sustaining friendships, gaining a more constructive self-perception, and gratifying senses. All of these outcomes support the therapeutic factors that Yalom describes (1995). According to Yalom (1995), there are 11 therapeutic factors that are “the actual mechanisms effecting change in the patients” (p. 1). For instance, the group work conducted in the scope of the project promoted cohesion and gave the participants a sense of belonging to a group. Moreover, not feeling alone in the experiencing of the problems (universality), helping and supporting others (altruism), encouragement for recovery (instillation of hope), providing support and assistance (guidance), interpersonal learning, and developing social skills were among the therapeutic benefits of the group work that was conducted with the elderly.

As far as the benefits of the group therapy from a preventive social work point of view are concerned, it can be argued that the group work has provided the participants with secondary prevention and tertiary prevention. The objective of the secondary prevention is to aim for early diagnosis and treatment (Mant, 2004; McWhinney & Freeman, 2009). In our study, we used GDS-S for early diagnosis and intervened with group work, which helped to treat the older participants and reduce their depression levels. Similarly, the group work helped by serving as a tertiary preventive intervention, which aims to prevent the further development or deterioration of the disease (Sheafor & Horesji, 2003). The elderly participants, who already had high levels of depression according to the GDS-S scores, stopped developing further depression. On the other hand, the control group, who did not receive any treatment, turned out to have higher GDS-S scores, which is a sign of increasing depression.

Regarding the benefits of group work that are described above, the therapeutic power of the group should be transferred to other areas of social work. For instance, previous research in Turkey shows that working with earthquake victims, the disabled, and the detained children showed that their depression levels and psychosocial well-being have improved (Baykara-Acar & Acar, 2001; Duyan, 1997; Duyan & Gökçearslan, 2004; Duyan & Sahin-Kara, 2010). Since the usage of group therapy has been very limited in the Turkish context, the usage of the group work therapy should be expanded to other fields of social work.

To conclude, we found that group work was followed by improved depression and social functioning among treated nursing home clients, compared to clients who did not receive group work. We believe that continuing with group work is crucial, as is with individual therapies. MOSES and GDS-S scales are also useful for measuring the change after the group work is conducted. In this study, we only used reminiscence therapy; however, other types of group work should also be expanded and used in the treatment of depression and decreased psychosocial functionality. As the number of nursing homes and care homes is very much likely to increase in the future due to demographic and structural changes, mental health of the institutionalized elderly will be at stake. For this reason, the need for individual and group therapies will also increase. Considering the cost of individual therapy, group work therapies will be more cost- and resource efficient. In this respect, studies on group therapies should also be expanded.

Treatment Group	Control Group
1	82	Primary school	1	80	Primary school
2	70	Training institute	2	77	Illiterate
3	71	High school	3	88	Illiterate
4	83	Literate	4	65	High school
5	71	Primary school	5	66	Literate
6	80	Illiterate	6	63	Primary school
7	66	Illiterate	7	81	Illiterate
8	69	Primary school	8	64	Illiterate
9	62	Secondary school	9	64	Illiterate
10	71	Literate	10	63	Primary school
11	71	Primary school	11	65	Primary school
12	88	Primary school	12	84	Illiterate
13	72	Illiterate	13	77	Secondary school
14	78	Literate	14	65	Primary school
15	79	Literate
16	68	Primary school

State	Group	n	Before	After
GDS-S	SWI group	16	12.44	3.72	10.81	2.86
Control group	14	10.57	4.60	11.07	3.05
Self-care	SWI group	16	12.44	5.63	12.19	4.94
Control group	14	15.00	7.17	15.00	7.08
Disoriented	SWI group	16	9.94	2.89	8.31	0.79
Control group	14	11.79	5.28	12.29	6.80
Depressed	SWI group	16	13.94	5.98	11.06	3.30
Control group	14	13.00	4.51	13.07	4.80
Irritable	SWI group	16	11.81	3.37	9.81	1.68
Control group	14	11.71	4.55	12.64	3.39
Withdrawn	SWI group	16	14.38	5.51	11.19	2.51
Control group	14	16.71	6.57	18.36	7.32

		Sum of Squares	df	Mean Square	F	Sig.
Depression	Between groups	32.518	3	10.839	0.835	.480
Within groups	726.732	56	12.977
Total	759.250	59
Self-care	Between groups	108.358	3	36.119	0.935	.430
Within groups	2162.375	56	38.614
Total	2270.733	59
Disoriented	Between groups	149.394	3	49.798	2.541	.066
Within groups	1097.589	56	19.600
Total	1246.983	59
Depressed	Between groups	70.446	3	23.482	1.041	.381
Within groups	1262.804	56	22.550
Total	1333.250	59
Irritable Behavior	Between groups	65.904	3	21.968	1.950	.132
Within groups	630.946	56	11.267
Total	696.850	59
Withdrawn Behavior	Between groups	437.741	3	145.914	4.519	.007
Within groups	1808.259	56	32.290
Total	2246.000	59

Dependent Variable	Group Name (I)	Group Name (J)	Mean Difference (I − J)	SE	Sig.
Depression	Treatment pretest	Control pretest	1.87	1.32	0.162
Treatment posttest	1.63	1.27	0.207
Control posttest	1.37	1.32	0.305
Control pretest	Treatment pretest	−1.87	1.32	0.162
Treatment posttest	−0.24	1.32	0.856
Control post test	−0.50	1.36	0.715
Treatment posttest	Treatment pretest	−1.63	1.27	0.207
Control pretest	0.24	1.32	0.856
Control posttest	−0.26	1.32	0.845
Control posttest	Treatment pretest	−1.37	1.32	0.305
Control pretest	0.50	1.36	0.715
Treatment posttest	0.26	1.32	0.845
Self-care	Treatment pretest	Control pretest	−2.56	2.27	0.265
Treatment posttest	0.25	2.20	0.910
Control posttest	−2.56	2.27	0.265
Control pretest	Treatment pretest	2.56	2.27	0.265
Treatment posttest	2.81	2.27	0.221
Control posttest	0.00	2.35	1.000
Treatment posttest	Treatment pretest	−0.25	2.20	0.910
Control pretest	−2.81	2.27	0.221
Control posttest	−2.81	2.27	0.221
Control posttest	Treatment pretest	2.56	2.27	0.265
Control pretest	0.00	2.35	1.000
Treatment posttest	2.81	2.27	0.221
Disoriented	Treatment pretest	Control pretest	−1.85	1.62	0.259
Treatment posttest	1.63	1.57	0.304
Control posttest	−2.35	1.62	0.153
Control pretest	Treatment pretest	1.85	1.62	0.259
Treatment posttest	3.47	1.62	0.036
Control posttest	−0.50	1.67	0.766
Treatment posttest	Treatment pretest	−1.63	1.57	0.304
Control pretest	−3.47	1.62	0.036
Control posttest	−3.97	1.62	0.017
Control posttest	Treatment pretest	2.35	1.62	0.153
Control pretest	0.50	1.67	0.766
Treatment posttest	3.97	1.62	0.017
Depressed	Treatment pretest	Control pretest	0.94	1.74	0.592
Treatment posttest	2.88	1.68	0.092
Control posttest	0.87	1.74	0.620
Control pretest	Treatment pretest	−0.94	1.74	0.592
Treatment posttest	1.94	1.74	0.270
Control posttest	−0.07	1.79	0.968
Treatment posttest	Treatment pretest	−2.88	1.68	0.092
Control pretest	−1.94	1.74	0.270
Control posttest	−2.01	1.74	0.253
Control posttest	Treatment pretest	−0.87	1.74	0.620
Control pretest	0.07	1.79	0.968
Treatment posttest	2.01	1.74	0.253
Irritable	Treatment pretest	Control pretest	0.10	1.23	0.937
Treatment posttest	2.00	1.19	0.097
Control posttest	−0.83	1.23	0.502
Control pretest	Treatment pretest	−0.10	1.23	0.937
Treatment posttest	1.90	1.23	0.127
Control posttest	−0.93	1.27	0.467
Treatment posttest	Treatment pretest	−2.00	1.19	0.097
Control pretest	−1.90	1.23	0.127
Control posttest	−2.83	1.23	0.025
Control posttest	Treatment pretest	0.83	1.23	0.502
Control pretest	0.93	1.27	0.467
Treatment posttest	2.83	1.23	0.025
Withdrawn	Treatment pretest	Control pretest	−2.34	2.08	0.265
Treatment posttest	3.19	2.01	0.118
Control posttest	−3.98	2.08	0.061
Control pretest	Treatment pretest	2.34	2.08	0.265
Treatment posttest	5.53	2.08	0.010
Control posttest	−1.64	2.15	0.448
Treatment posttest	Treatment pretest	−3.19	2.01	0.118
Control pretest	−5.53	2.08	0.010
Control posttest	−7.17	2.08	0.001
Control posttest	Treatment pretest	3.98	2.08	0.061
Control pretest	1.64	2.15	0.448
Treatment posttest	7.17	2.08	0.001

Footnotes

Acknowledgement

The authors would like to acknowledge with appreciation the helpful and co-operated way of conducting data analysis of ANOVA of the current manuscript by Dr. Hasan Atak, Faculty of Education, Kırıkkale University, Kırıkkale, Turkey.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Akyol

Durmus

Dogan

Canturk

(2010). Quality of life and level of depressive symptoms in the geriatric population. Turkish Journal of Rheumatology, 25, 165–173.

Baykara-Acar

Acar

(2001). Group work with young earthquake victims: Doğukışla Tent City Example. In Erkan

Demiröz

Çetin

(Eds.), Social work symposium, earthquake and social work (pp. 288–293). Ankara, Turkey: HUSHY Publication.

Chao

S. Y.

Liu

H. Y.

C. Y.

Jin

S. F.

Chu

T. L.

Huang

T. S.

Clark

M. J.

(2006). The effects of group reminiscence therapy on depression, self esteem, and life satisfaction of elderly nursing home residents. Journal of Nursing Research, 14, 36–45.

D’Ath

Katona

Mullan

Evans

Katona

(1994). Screening, detection and management of depression in elderly primary care attenders, 1: The acceptability and performance of the 15-item GDS (GDS-15) and development of a shorter version. Family Practice, 11, 260–266.

Duyan

(1997). The effects of social group work on the individual and social adaptation of orthopaedics patients. Ankara, Turkey: Aydinlar Publication.

Duyan

Gökçearslan

(2004). The effect of social group work on psychological needs. Journal of Society and Social Work, 15, 61–74.

Duyan

Sahin-Kara

(2010). The effect of social work with groups on self-esteem and life satisfaction of a group of elderly who live in a nursing home. Geroscience, 2, 33–44.

Emiroğlu

(1995). Old age and social adaptation of elderly (Extended Print). Ankara, Turkey: Şafak Publication, Hacettepe University.

Ertan

Eker

(2000). Reliability, validity, and factor structure of the geriatric depression scale in Turkish elderly: Are there different factor structures for different cultures? International Journal of Psychogeriatrics, 12, 163–172.

10.

Fuentes

Aranda

M. P.

(2012). Depression interventions among racial and ethnic minority older adults: A systematic review across 20 years. American Journal of Geriatric Psychiatry, 20, 915–931.

11.

Hasche

Morrow-Howell

Proctor

(2010). Quality of life outcomes for depressed and non-depressed older adults in community long-term care. American Journal of Geriatric Psychiatry, 18, 544–553.

12.

Helmes

Csapo

K. G.

Short

J. A. C.

(1985). History, development and validation of a new rating scale for the institutionalized elderly: The Multidimensional Observation Scale for Elderly Subjects (M.O.S.E.S.). London, Ontario: University of Western Ontario, Department of Psychiatry.

13.

Hill

R. D.

Thorn

B. L.

Bowling

Morrison

(2012). Geriatric residential care. New York, NY: Psychology Press.

14.

Husaini

B. A.

Cummings

Kilbourne

Roback

Sherkat

Levine

Cain

V. A.

(2004). Group therapy for depressed elderly women. International Journal of Group Psychotherapy, 54, 295–319.

15.

Karataş

(1988). Factors that affect life-satisfaction among elderly (Unpublished master’s thesis). Hacettepe University, Institute of Social Sciences, Department of Social Work, Ankara, Turkey.

16.

Kavakcı

Ö.

Bilici

Çam

Ülgen

(2011). Prevalence of depression and cognitive impairment in old age in Trabzon. Anatolian Journal of Psychiatry, 12, 258–265.

17.

Kohli

Banerjee

S. T.

Verma

S. K.

(1991). Adaptation of a geriatric depressive scale in simple Hindi. Indian Journal of Clinical Psychology , 18, 63–64.

18.

Kulaksizoglu

I. B.

Gurvit

Polat

Harmanci

Cakir

Hanagasi

… Emre

(2005). Unrecognized depression in community-dwelling elderly persons in Istanbul. International Psychogeriatrics, 17, 303–312.

19.

Lieh

Y. T.

Cheng

L. I.

Kuay

Y. Y.

Chen

K. H.

Jen

C. C.

F. H.

(1995). Geriatric Depression Scale (Taiwanese and Mandarin translations). Clinical Gerontologist, 15, 58–60.

20.

Mant

(2004). Principles of prevention: Textbook of primary medical care. New York, NY: Oxford University Press.

21.

Marwijk

H. W.

Wallace

de Bock

G. H.

Hermans

Kaptein

A. A.

Mulder

J. D.

(1995). Evaluation of the feasibility, reliability and diagnostic value of shortened versions of the Geriatric Depression Scale. British Journal of General Practice, 45, 195–199.

22.

McWhinney

I. R.

Freeman

(2009). The enhancement of health and the prevention of disease: Textbook of family medicine. New York, NY: Oxford University Press.

23.

Meier

(2006). A note on the power of Fisher’s least significant difference procedure. The Journal of Applied Statistics in the Pharmaceutical Industry, 5, 253–263.

24.

MFSP [Ministry of Family and Social Policies]. (2014). Retrieved May 30, 2014, from http://www.eyh.gov.tr/tr/8157/Turkiye-de-Sosyal-Hizmet-Uygulamalari

25.

Nachar

(2008). The Mann-Whitney U: A test for assessing whether two independent samples come from the same distribution. Tutorials in Quantitative Methods for Psychology, 4, 13–20.

26.

Nahcivan

N. O.

Demirezen

(2005). Depressive symptomatology among Turkish older adults with low income in a rural community sample. Journal of Clinical Nursing, 14, 1232–1240.

27.

Niino

Imaizumi

Kawakami

(1991). A Japanese translation of the Geriatric Depression Scale. Clinical Gerontologist, 10, 85–87.

28.

Oğuzhanoğlu

N. K.

Özdel

(2005). Old age, nursing home and life journeys: A psychodrama work. Turkish Journal of Psychiatry, 16, 124–132.

29.

Özer

(2004). Investigating the life-satisfaction among elderly who live with their families or in nursing homes. Turkish Journal of Geriatrics, 7, 33–36.

30.

Parmelee

Lawton

Katz

(1989). Psychometric properties of the Geriatric Depression Scale among the institutionalized aged. Psychological Assessment, 1, 331–338.

31.

Peck

M. D.

(2001). Looking back at life and its influence on subjective well-being. Journal of Gerontological Social Work, 35, 3–20.

32.

Pekcan

(2000). Anthropology and ageing. (Ed. Erkan

Gönül

Işıkhan

Vedat

). Ankara: Hacettepe University Journal of Social Work, 6, 51–54.

33.

Reynolds

S. L.

Haley

W. E.

Kozlenko

(2008). The impact of depressive symptoms on chronic disease on active life expectancy in older Americans. American Journal of Geriatric Psychiatry, 16, 425–432.

34.

Sheafor

B. W.

Horejsi

C. R.

(2003). Techniques and guidelines for social work practice (6th ed.). Boston, MA: Allyn & Bacon.

35.

Sheikh

J. I.

Yesavage

J. A.

(1986). Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist, 5, 165–173.

36.

Siviş

Demir

(2007). The efficacy of reminiscence therapy on the life satisfaction of the elderly. Turkish Journal of Geriatrics, 10, 131–137.

37.

Soygür

(2000). Aged care and psychological assessment in elderly home. Journal of Dementia Serials, 2, 32–40.

38.

Soygür

Aydemir

Ç.

Güzelarslan

Akturk

(1998). Multidimensional observation scale for elderly subjects: A study of inter-rater reliability, internal consistency reliability and correlations of subscales. Paper presented at the Joint Meeting of International Psychogeriatric Association & Turkish Society of Psychogeriatrics, May, 21-23, Istanbul, Turkey.

39.

Tufan

(2007, 11 22-23). Old age and value of memoirs. IV. National Ageing Congress, Ankara, Turkey.

40.

TUIK [Turkish Statistical Institute in Turkey]. (2014). Turkish Statistical Institute, Main Statistics. Retrieved May 30, 2014, from http://www.turkstat.gov.tr/UstMenu.do?metod=temelist

41.

Turan

(1985). Old age and memoirs. Hacettepe University Journal of Social Work, 3, 33–38.

42.

World Health Organization. (2013). Mental health and older adults. Retrieved May 22, 2014, from http://www.who.int/mediacentre/factsheets/fs381/en/

43.

Yalom

L. D.

(1995). The theory and practice of group psychotherapy (4th ed., pp. 1–18). New York, NY: Basic Books.

Treatment Group			Control Group
No.	Age	Highest Level of Education Completed	No.	Age	Highest Level of Education Completed
1	82	Primary school	1	80	Primary school
2	70	Training institute	2	77	Illiterate
3	71	High school	3	88	Illiterate
4	83	Literate	4	65	High school
5	71	Primary school	5	66	Literate
6	80	Illiterate	6	63	Primary school
7	66	Illiterate	7	81	Illiterate
8	69	Primary school	8	64	Illiterate
9	62	Secondary school	9	64	Illiterate
10	71	Literate	10	63	Primary school
11	71	Primary school	11	65	Primary school
12	88	Primary school	12	84	Illiterate
13	72	Illiterate	13	77	Secondary school
14	78	Literate	14	65	Primary school
15	79	Literate
16	68	Primary school

State	Group	n	Before		After
State	Group	n	Mean	SD	Mean	SD
GDS-S	SWI group	16	12.44	3.72	10.81	2.86
GDS-S	Control group	14	10.57	4.60	11.07	3.05
Self-care	SWI group	16	12.44	5.63	12.19	4.94
Self-care	Control group	14	15.00	7.17	15.00	7.08
Disoriented	SWI group	16	9.94	2.89	8.31	0.79
Disoriented	Control group	14	11.79	5.28	12.29	6.80
Depressed	SWI group	16	13.94	5.98	11.06	3.30
Depressed	Control group	14	13.00	4.51	13.07	4.80
Irritable	SWI group	16	11.81	3.37	9.81	1.68
Irritable	Control group	14	11.71	4.55	12.64	3.39
Withdrawn	SWI group	16	14.38	5.51	11.19	2.51
Withdrawn	Control group	14	16.71	6.57	18.36	7.32