Mr Tsao

It is easy to understand why Mr Sengupta is concerned about Mr Tsao. As a befriender, he is trying to help people like Mr Tsao avoid the loneliness and isolation that can accompany older age. His efforts to engage Mr Tsao in conversation or to encourage him to interact with other older people in the community do not appear to be working. Although it is reasonable for Mr Sengupta to share these concerns with the community programme director, it is not clear that Mr Tsao is experiencing loneliness, nor is it clear that Mr Sengupta or Ms Teo should do more to change Mr Tsao’s behaviour.

Hearing loss, depression, and social isolation are all serious problems that should not be ignored. It is possible that Mr Tsao’s apparent lack of social engagement reflects a decline in his mental or physical health. It is possible, however, that it simply reflects preferences. Being alone is not the same as being lonely. Some people may prefer to spend time alone. Mr Sengupta needs to balance his desire to protect Mr Tsao against the possibility of imposing his views about how much social interaction is necessary for a happy, fulfilled life.

Why should we be concerned about social isolation?

Efforts by befrienders like Mr Sengupta to address the problem of social isolation are important. It is inaccurate to assume that all older people experience isolation – many do not – but as people age they are at greater risk of becoming isolated. Increases in frailty and decreases in mobility make it harder for older people to leave their homes and engage in social activities. Hearing loss, cognitive decline, and other physical, mental and emotional problems associated with ageing can limit social activities. After people leave the workforce they may lose important social ties. As family, friends, and neighbours die, social networks may shrink further. These changes can be devastating.

Studies of older people across the world have found that older people with larger and stronger social networks tend to enjoy better health and a greater sense of belonging and well-being. In contrast, older people who experience greater social isolation are more likely to experience poor health and, in some circumstances, may be at much greater risk of death.

Are activity centres for everyone?

In response to concerns about isolation, policymakers and advocates have developed a host of programmes. The befriender programme for which Mr Sengupta is a volunteer is one type of programme designed for this purpose. Activity centres, like the one Mr Sengupta encouraged Mr Tsao to visit, are another. But should we always push older people to make use of befriending services, activity centres, or other programmes designed to create ‘communities’ for older people? This is a difficult question. One thing we don’t know from the case is whether Mr Tsao is genuinely isolated? He does not seem particularly interested in social activities when Mr Sengupta is visiting, but it is possible that the visit from his befriender is all the activity he has the energy for on that day.

Another possibility is that Mr Tsao’s lack of social engagement is not a new development. Perhaps Mr Tsao has always been a bit of a loner and has never enjoyed group activities or spending time in conversation with other ‘uncles’. Mr Sengupta is worried that the observed behaviour may reflect a change due to Mr Tsao’s age, but what if he has always behaved this way? It would not be appropriate for Mr Sengupta to pressure Mr Tsao to change the way he interacts with his community if Mr Tsao’s behaviour reflects his preferences. Even if we think that Mr Tsao would be better off by participating in social activities and developing new friendships, we have a duty to respect his views about what constitutes a good life.

This case presents an important question about the role that non-professional caregivers, acting as ‘befrienders’, play in providing home-based care to older adults. What is the nature of this kind of caregiving relationship, what responsibilities do befrienders like Mr Sengupta have, and how should a befriending service operate to support good care for the older person?

The responsibilities of befrienders

Befriending services have been established in Singapore and elsewhere with the aim of enabling older adults to remain connected to people within their communities. There is a range of evidence to suggest that befrienders provide companionship that is appreciated, and that they decrease older people’s social isolation.

Volunteer befrienders (like family caregivers, foreign domestic workers, and other kinds of volunteers) are not held to the same professional duties or standards to those who provide support to older adults in professional roles. Ethical principles that are recognised as applying in community care do not apply to these individuals as they are undertaking this activity as a matter of personal choice, and are not engaged in the same activities as professional caregivers. Having said this, it does not follow that Mr Sengupta has no obligations towards Mr Tsao. Instead, the ethical and legal duties that Mr Sengupta has towards Mr Tsao depend on the kinds of activities that Mr Sengupta engages in as part of his befriender role, sensitive to the overarching purpose of the aims of a befriending service.

In this case, it appears that Mr Sengupta is fulfilling his duties as a befriender adequately. Mr Sengupta visits Mr Tsao regularly. In his visits he communicates with Mr Tsao in ways that are focused on developing companionship with him, chatting to him about his family and life experiences. Moreover, Mr Sengupta’s interactions with Mr Tsao aim to engage him in activities that reduce his isolation and enhance his quality of life, encouraging him to visit the void deck. The fact that Mr Tsao does not wish to participate in these activities, or to engage in extended conversation with Mr Sengupta, does not mean that Mr Sengupta is failing to fulfil his duties as a befriender. There are, of course, many different ways in which companionship can be meaningful and valued by older people, and Mr Sengupta is respectful and thoughtful in how he interacts with Mr Tsao.

The role of professional caregivers to support befrienders in discharging their duties

The difficulties that Mr Sengupta reports to Ms Teo raises important questions about the duties that professionals who oversee a befriending service have in this role. Programme managers like Ms Teo are required to support both befrienders and older adults to ensure that the needs of the older person are met to the greatest possible degree through the service provided. Different duties arise at different stages in which befrienders like Mr Sengupta become engaged in voluntary work.

• Prior to a befriender starting to volunteer: Ascertain whether the older person is socially isolated, and whether there is evidence that he would benefit from companionship offered by a befriender. Establish what the older person would like from the befriender, and take steps to match people with similar interests and personalities. Ensure that the befriender does not have a criminal record and that he/she understands the requirements of the role.
• At the point the befriender begins volunteering: Meet with the befriender to clarify the requirements of the role, and whether his/her support is an additional component to a range of services provided. This is important to ensure that the befriender understands the nature and limits of his/her responsibilities, including when information about evidence about risks or harms should be passed on to the programme manager. Determine the degree of commitment he/she is able to fulfil, and whether this meets the needs of the older person, given any additional supports or services the older person is receiving. Pass on relevant information about the older person’s interests and values, and discuss how the befriender should interact with the older person in ways that are dignified and respectful.
• During the befriending process: Meet with the befriender regularly. Report and investigate any issues raised by the befriender, or by the older person or members of his or her family expressing concern about the befriender’s behaviour. Is there evidence that the goals of befriending, i.e. reducing social isolation and enhancing quality of life through companionship, are being met? If not, as looks to be the case here, establish whether different care and support arrangements are appropriate.
• At the conclusion of the befriending process: Meet with the befriender to review his/her experiences and to prepare him/her for another voluntary role. Meet with the older person (and with the older person’s family with consent) to explain that his/her friend will no longer visit regularly, and clarify the new care arrangements that are being provided to him/her.

Befrienders like Mr Sengupta have a unique role within the eco-system of care for the older person. It is critical that volunteer befrienders understand that their role is one among many different care roles that include care managers, social workers, counsellors, and medical professionals. Hence before a volunteer is deployed as a befriender, it is important that programme directors like Ms Teo set correct expectations of the outcome of help that is offered through a befriending service.

Being vs doing

Volunteers who take on the role of a befriender to an older person should recognise that their role is mainly to provide companionship for the older person. The process may not necessarily translate into doing anything tangible such as providing solutions to the issues that the older person may have.

It is not easy for most volunteers at the beginning since they may, as Mr Sengupta does,feel helpless and doubtful that their visits to clients are helpful. Feeling unsure about why Mr Tsao is unresponsive to suggestions to socialise with others in the void deck, coffee shop, or day activity centre, he grasps for ideas from newspaper stories about elderly people who live alone. Hence it is critical for programme directors like Ms Teo to guide befrienders towards learning what constitutes help to an older person before assuming a problem-solving role.

Relationships take time to develop

In addition, the befriender needs to understand that they are starting the relationship with the older person as a complete stranger and that it would take a fair amount of time before the older person would open up and become more responsive. Depending on the personalities of both the befriender and the older person, relationships can sometimes take weeks or months to develop. The older person may also have had experiences in the past where befrienders came and went so they may have already developed a certain resistance or perception towards this kind of engagement. This could be true of Mr Tsao’s experience, a possibility for which Mr Sengupta should be prepared before meeting his client.

Befrienders should receive guidance on the need to be patient and to allow time for meaningful relationships with clients to develop. The befriender should first seek to be a non-judgemental, accepting and supportive presence for the older person.

Matching and training

While it might seem like common-sense knowledge, community organisations should pay more attention to the initial process of setting up the engagement between the befriender and the older person. Issues like language, age group, and personality should be considered and taken into account during the matching process as these will have an impact on how the relationship would develop. In addition, community organisations should also provide guidance to befrienders on what they should try to achieve during their interaction with their clients.

Supporting and guiding volunteers

The community organisation should also develop a support system for the befriender that is based on achievable outcomes. As mentioned earlier, much of the befriending service may not result in tangible outcomes, hence appropriate training and a robust support system would be beneficial to the befriender in setting up checkpoints while they are on the journey with the older person. This would help prevent feelings of aimlessness, confusion, or disappointment in the helping process. In the longer term, this would also enable the volunteer to become a more effective befriender.

Reflecting on personal experience and values

An individual’s perceptions of older persons and the ageing process may greatly influence his/her work as a befriender. Another important area that has to be addressed is providing befrienders opportunities to reflect on their outlook and personal experience of ageing and older persons.  Volunteers need to learn to draw the boundary between befriending work and personal life. Mr Sengupta appears to be affected by his own relationship with his father and he may bring this frustration and helplessness into his visit with Mr Tsao. Those negative feelings might have been triggered especially when Mr Tsao was not so responsive to Mr Sengupta’s questions. It is helpful for programme directors like Ms Teo to guide Mr Sengupta in his relection in this aspect so that he is able to be more mindful and separate his personal feelings from the befriending work. This will lead to a more open and expanded view on Mr Tsao’s life.

In order to understand Mr Tsao’s needs, we need to refer back to the baseline which is how he was leading his life before all the changes happened and how he has made meaning and felt about the changes. Each older person deals with life changes in his/her unique way. It’s important to explore with clients before we can understand the impact on them.

Community organisations should try to include personal reflection when providing support to volunteers, and help volunteers understand the principle of person-centred care in working with older persons – choice and dignity are two very important factors to consider. Through regular reviews and debriefs, befrienders should learn to cultivate sufficient trust in the older person and not try to take over the older person’s life.

By providing an environment focused on the strengths and resources older persons have, befrienders can enable these older individuals to continue making their own choices and help to transform their ageing experience into a time of fulfilment and joy.