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Empowering African American women informal caregivers: a literature synthesis and practice strategies.

Informal caregivers are people who provide unpaid care for elderly people in the home, involving much time and energy for long periods and requiring assistance with tasks that may be physically, emotionally, socially, or financially challenging (Biegel, Sales, & Schulz, 1991). Most informal caregivers are women--primarily family members (National Alliance for Caregiving & American Association of Retired Persons [AARP], 1997; Older Women's League, 2001). Elderly African Americans rely heavily on the informal system of care (Chadiha, Proctor, Morrow-Howell, Darkwa, & Dore, 1995; Stommel, Given, & Given, 1998). African American women caregivers, under demanding circumstances of social, economic, and health challenges, demonstrate strengths through strong coping abilities in providing care to elderly African Americans (see reviews by Dilworth-Anderson, Williams, & Gibson, 2002, and Janevic & Connell, 2001). Yet, being able to cope does not mean that these women are also able to transform stressful caregiving situations into positive change. Power is the ability to access and influence control over resources to improve deleterious environmental conditions (Lee, 2001).

Caregiving can be gratifying (Kramer, 1997; Miller & Lawton, 1997). African American caregivers report high rewards and low burden in caring for elderly African Americans (Knight, Silverstein, McCallum, & Fox, 2000; Picot, 1995; Picot, Debanne, Namazi, & Wykle, 1997). These reports of high rewards and low burden are a testament to the personal strengths of African American women as a resource in caregiving. However, literature suggests the personal gains that caregivers receive may be insufficient to offset the economic, social, and psychological costs of caregiving (Arno, Levine, & Memmott, 1999). Informal caregiving, according to Arno and colleagues, may not only strain individual and family resources of the caregiver, but also may increase the caregiver's risk poor health, family destabilization, and impoverishment. Research indicates that caregiving is a known risk factor for women's hypertension, mortality, low immunity levels, and low levels of physical activity (Grason, Minkovitz, Misra, & Strobino, 2001). Unemployed caregivers run the risk of being uninsured and losing income and social insurance benefits (Arno et al., 1999). Strained resources, poverty, lack of health insurance, lost income, and poor health may also contribute to caregivers' feelings of low self-efficacy and potential powerlessness.

Sparked by social work literature on an empowerment approach to practice with vulnerable groups such as women and people who are members of ethnic and racial groups, we used an empowerment approach to address group practice with African American women caregivers.

Empowerment

Pinderhughes (1983) proclaimed that "knowing how power and powerlessness operate in human systems is a key to effective intervention. Strategies based on this knowledge offer both client and worker opportunity for constructive management of powerlessness on individual, familial, and social system levels" (p. 331).

The significance of an empowerment approach to social work practice with African American women is threefold. First, it emphasizes the need for social workers to work with clients who are vulnerable to oppression, marginality, and disenfranchisement such as women, people of various minority ethnic and racial groups, and people who are impoverished (Gutierrez, 1990; Lee, 2001). Second, it recognizes people's transactions in social, economic, and political environments as a contributing factor to individual stress, need for coping, feelings of low self-efficacy, and, in turn, feelings of powerlessness. For example, Lee regarded coping as an individual strength--a resource that clients use as an adaptive response to oppressive environmental conditions. Third, an empowerment approach emphasizes the need for social workers and other professionals to help build clients' capacity through mobilizing resources to change oppressive environmental conditions into positive change (Gutierrez, Parsons, & Cox, 1998; Lee; Simon, 1994; Solomon, 1976). Viewed through the lens of adaptation and coping, the notion of recognizing individual strengths and capacity of clients as resources that facilitate positive change in the environmental context is consistent with an empowerment approach to practice (Lee).

Earlier works have used an empowerment approach to practice with elderly people (Cox & Parsons, 1994), for mediating disputes in family caregiving (Parsons & Cox, 1989), and for working with custodial grandparents (Cox, 2002). These works contribute to empowerment practice knowledge and support the use an empowerment approach to practice with African American women caregivers of elderly African Americans.

In this article, we expand empowerment practice knowledge in two ways. First, we link broad literature and caregiving literature on factors that may predispose African American women caregivers to powerlessness to understand how powerlessness for them in other life contexts may contribute to the lack of power in the caregiving role. From the synthesis of empowerment literature, we developed recommendations for empowerment practice strategies for African American women caregivers of elderly African Americans.

Caregiving Demographics

According to a 1997 national telephone survey, the estimated number of U.S. informal caregiving households was 29 percent for African Americans compared with 23 percent for the general population (National Alliance for Caregiving & AARP, 1997). Caregiving is indeed a woman's issue among African Americans: 77 percent of African American caregivers in a national telephone household survey were women (National Alliance for Caregiving & AARP). The percentage of African American female informal caregivers in this national survey exceeded the percentage of white (74 percent), Hispanic (67 percent), and Asian American (52 percent) female caregivers. A regional study of caregivers residing in lower Michigan (Stommel et al., 1998) and a study of caregivers in the 1982 National Long-Term Care Survey (Fredman, Daly, & Lazur, 1995) reported a higher percentage of African American female caregivers--86 percent and 84 percent, respectively. The percentage of white female caregivers in these two studies roughly paralleled that in the national telephone household survey--74 percent and 72 percent, respectively. Clearly, caregiving is widely practiced among African American women.

Strong Coping View of Caregiving

A common view in literature on African American women caregiving experiences is their positive caregiving appraisal and strong coping. Drawing on the work of Moos and Schaefer (1993), appraisal is defined as the process of individual evaluation and decision making about a stressful situation, whereas coping is defined as the behavioral and cognitive strategies that an individual uses to contend with the stressful situation. Literature commonly depicts African American caregivers, compared with white American caregivers, as appraising the caregiving experience more favorably and demonstrating strong coping abilities under challenging caregiving circumstances (Fredman et al., 1995; Haley, Levine, Brown, & Bartolucci, 1987; Haley et al., 1996; Knight et al., 2000; Lawton, Rajagopal, Brody, & Kleban, 1992; Mui, 1992; Picot et al., 1997). From extensive reviews of caregiving literature, however, researchers have reported mixed but mostly consistent findings about race of the caregiver and positive appraisal of caregiving (Connell & Gibson, 1997; Dilworth-Anderson et al., 2002; Janevic & Connell, 2001).

The coping literature is prolific in and outside caregiving research, with researchers identifying different types of coping strategies that people use to resist adverse life circumstances (D'Zurilla & Chang, 1995; Heppner, Cook, Wright, & Johnson, 1995; Knight et al., 2000; Kramer & Vitaliano, 1994; Picot, 1995; Pruchno, Burant, & Peters, 1997). Picot delineated three coping types. These types included behavioral and active coping, such as problem confrontation, or instrumental coping, such as problem solving and help seeking; cognitive coping, such as reframing, logical analysis, positive self-talk, and accommodation; and emotion-focused or affective coping, such as escapism, passive response, prayer, and no response. Although African Americans use all three coping types, caregivers appear to rely more on emotion-focused or affective coping and less on active coping (Knight et al., 2000).

An important message from the caregiving and coping literature is that whereas strong coping is a resource to African American women in challenging caregiving situations, emotion-focused coping may have undesirable consequences for their mental health. Knight and colleagues (2000) found that although reports of caregiving as being less burdensome mediated levels of psychological distress among African American caregivers, reports of lower burden among African American caregivers were neutralized by use of more emotion-focused coping that increased levels of psychological distress. Researchers have speculated that African American caregivers' strong coping and positive appraisal of caregiving as being less stressful or burdensome may have cultural meaning, reflecting values and expectations held about caregiving to older African Americans (Haley et al., 1996; Knight et al., 2000; Mui, 1992). Religious coping, in the form of comfort and prayer, may be a protective factor or strength, serving to buffer African American caregivers against poor mental health outcomes (Picot et al., 1997).

The preceding discussion implies that the coping strategies that African American caregivers use in challenging caregiving circumstances are complex. Kramer and Vitaliano (1994), in a review of 16 studies of caregivers of people with dementia, reached a similar conclusion, although these authors did not identify the racial composition of the studies' samples. They concluded that coping is a "complex, multidimensional construct" composed of both "cognitive and behavioral strategies" (p. 166). They emphasized the need for social workers to mobilize other resources (for example, caregivers' social networks, economic assistance, and psychological resources to strengthen "coping repertoires" and mitigate stress from having a debilitating effect on caregiver functioning.

Although caregiving is commonly depicted as a form of chronic stress that may have deleterious effects on a person's social, physical, mental, and financial well-being, it is also depicted as having positive outcomes (Olshevski, Katz, & Knight, 1999). In a manner still not fully understood by researchers, African Americans appraise caregiving in a more favorable light than white caregivers, a finding that may), be interpreted as a strength in caregiving by African American women. The stress and coping framework is most frequently used to frame the strength in coping view of caregiving.

Vulnerable View of Caregiving

Accompanying the strong coping view of African American women in challenging caregiving circumstances is the view of these women as being vulnerable to health, social, and economic risks in other life spaces and in caregiving that, when coupled with stress, may induce feelings of powerlessness. Evidence for the vulnerable view is found in both the broad and the specific caregiving literature on health disparities (Fredman et al., 1995; Hummer, 1996; Jackson et al., 1996; Knight et al., 2000; Krieger, 1990; Krieger, Rowley, Herman, Avery, & Phillips, 1993; Leigh, 1995; Schneider, Zaslavsky, & Epstein, 2002; Stommel et al., 1998; U.S. Department of Health and Human Services [DHHS], 2000, 2001; Williams, 1999).

Additional evidence for the vulnerable view is found in literature on social and economic inequalities (Gibbs & Fuery, 1994; Schulz et al., 2000) as well as in literature on care responsibilities (Krieger et al., 1993). Williams, LavizzoMourey, and Warren (1994), for example, argued that African Americans in the United States, especially poor African American women, are subjected to multiple vulnerabilities of race and gender discrimination as well as low socioeconomic status that predispose them to poor health. African American women caregivers, as a subgroup of this population, experience similar multiple vulnerabilities that may, in turn, predispose them to feelings of powerlessness.

In linking literature about the vulnerabilities of African American women in the general population, it is not leap to make an extrapolation about their risk factors for poor health and a potential lack of power in the role of caregiving. Watts-Jones (1990), for example, noted the role of chronic or long-lasting stressors such as poor personal health, inadequate economic resources, racial discrimination, undesirable work conditions, intimate relationship conflicts, and demanding role functioning in the lives of African American women. Leigh (1995), in a treatise on African American women's health issues, argued that:
 African American or Black American females,
 like all women, receive health care in the context
 of the families in which they perform
 multiple caregiving roles--as wives, mothers,
 daughters, widows, single childless women,
 and so on. These caregiving roles often translate
 into interrupted employment histories
 and limited access to health insurance, and
 they place rime constraints on women's ability
 to seek care for themselves. (p. 112)


Krieger and colleagues (1993) proclaimed that the portrayal of African American women as being strong in family roles may have predisposed them to excessive caregiving responsibilities; that is,
 For black women, (their) socialization into
 woman's role as caretaker of others has often
 been framed in terms of ensuring the survival
 of entire groups of people. In other words, the
 caretaker's role and cultural image of the black
 woman as everyone's "mammy" have created
 the expectation that black women are the source
 of emotional and physical well-being for their
 own family members as well as for white
 women, men and children, and the black community.
 Conspicuously absent is any caring
 source for black women themselves. (p. 90)


African American caregivers, in a national household telephone survey, were more likely to care for a relative other than an immediate family member or grandparent (14 percent compared with 9 percent white, 7 percent Hispanic, and 6 percent Asian caregivers) (National Alliance for Caregiving & AARP, 1997). They were less likely than Hispanic, Asian, or white caregivers to report that other relatives were assuming their responsibilities for caregiving. Caregiving among African American women is complicated by knowing that unprecedented numbers of African American women may also be caring for grandchildren without the help of adult children (Casper & Bryson, 1998). African American grandparents, particularly older ones, may face the risk of social, emotional, physical, and financial strain even though they may report positively about caregiving (Whitley, Kelley, & Sipe, 2001).

Knowledge of African American women's excessive care responsibilities, in light of findings that show elderly African Americans may have multiple helpers (Dilworth-Anderson, williams, & Cooper, 1999; Stommel et al., 1998), point to the need for further research. The assistance from multiple helpers may serve as a resource to African American women caregivers. For example, researchers speculated that the multiple informal helper system of elderly African Americans may serve to mitigate stressful caregiving for African American caregivers (Mui, 1992; Stommel et al.). Assistance from multiple helpers in the elderly person's support network may lessen caregiving stress and, in turn, contribute to better caregiver outcomes. Conversely, when multiple helpers disagree about caregiving decisions their disagreements may escalate caregiving stress.

Gibbs and Fuery (1994) noted that "[b]lack women, as members of three low status groups, represent the epitome of powerlessness in American society as compared to white middle-class males" (p. 559). The three low-status variables include gender, race and ethnicity, and socioeconomic status. The literature links women's socioeconomic vulnerability and multiple social roles to poor mental health outcomes. For example, the National Institute of Mental Health has highlighted women's relatively low socioeconomic status and multiple social roles as risk factors for psychological distress (Belle, 1990; McBride, 1990).

Two government reports have cited poverty and race as contributing factors to the poor physical and mental health of African Americans (U.S. Department of Health and Human Services, 2000, 2001). Brown and colleagues (2000) argued that the relationship between women's low economic status and depression, particularly for African American women, may translate into economic strain that operates through multiple processes (for example, daily hassles and chronic stressors such as poor housing and unsafe neighborhoods) to negatively affect mental health. They noted that economic strain may also undermine women's sense of efficacy in family roles. Strong self-efficacy is essential to feeling a sense of personal empowerment (Gutierrez, 1990).

Evidence for African American women caregivers' potential economic strain is also found in literature on racial differences in income. Income differences between African American and white caregivers are profound, with the former reporting statistically significant lower incomes than the latter in both regional and national studies (Fredman et al., 1995; Older Women's League, 2001; Stommel et al., 1998).

With regard to the vulnerable view in caregiving literature, Dilworth-Anderson and colleagues (2002), in a 20-year review, found inconsistencies about the consequences of caregiving for African Americans and white Americans. Some studies reported African American caregivers as being less affected by negative outcomes in caregiving than white caregivers; other studies reported no racial difference at all in such outcomes. Dilworth-Anderson and colleagues (2002) concluded that inconsistent findings about racial differences in caregiving may be explained by the different sampling and measurement methods of studies.

Notwithstanding inconsistencies in earlier caregiving literature, a consideration of the prevalence for risk of vulnerability to poor mental health in caregiving for both African American and white caregivers is revealing. Mui (1992), for example, found a high prevalence of role strain among both African American caregiving daughters and white caregiving daughters in a national sample: 88 percent and 91 percent, respectively. Both African American and white caregivers, in a study by Cox (1993), reported high levels of relationship strain. Regarding risk of poor mental health, a study of low-income caregivers of people with chronic mental illness found that more than 25 percent of African American caregivers and more than 40 percent of white caregivers were at risk of clinical depression (Song, Biegel, & Milligan, 1997). These caregiving facts suggest that strong coping for African American women caregivers may not mean they are invulnerable to poor mental health in caregiving.

Literature indicates two realities of African American women--strong coping and vulnerability in caregiving. Gibbs and Fuery (1994) argued persuasively that both views represent the reality of African American women's experiences. Gibson (1982) cautioned researchers not to mistake strong coping skills that serve as an important psychological resource to older African Americans to mean they require fewer economic resources. Likewise, social workers must not mistake the strong coping that serves as a strength to African American women in challenging caregiving circumstances to mean they are invulnerable to powerlessness and do not need formal resources.

The low use of formal services under conditions of expressed high need for help in caregiving that some studies report for African American caregivers (Cox, 1993) may result from feeling powerless over resources in the services sector. Gutierrez (1990) argued that "powerlessness has direct and concrete effects on the experiences of women of color" (p. 149), contributing to their poor well-being, lack of access to resources, and failure to seek services. Social workers need to consider an empowerment approach to help African American women caregivers strike a balance among strong coping, self-care, and use of resources in the service sector to transform stressful caregiving circumstances into positive change.

Overview of Theoretical Frameworks

Stress and Coping Framework

Rooted in the field of psychology, the stress and coping framework used to understand caregivers' stress and coping is based on work by Lazarus and colleagues (Folkman, Lazarus, Pimley, & Novacek, 1987; Lazarus & Folkman, 1984). According to Moos and Schaefer (1993), the framework holds that stressors and resources, as well as the ability to appraise and cope with stressors, affect a person's health and functioning. Stressors and resources are contextual and may be located within the person and environment as well as in life-course events such as life crises and transitions. People can react to stressors in adaptive ways by using coping strategies that, in turn, may shape health and functioning outcomes. Stressors are problematic and challenging conditions, experiences, and activities that threaten a person's health and functioning; coping resources are those tangible and intangible resources that people use to respond to stressors.

Stress and coping models are used in the caregiving literature (Haley et al., 1987, 1996; Knight et al., 2000; Lawton, Kleban, Moss, Rovine, & Glicksman, 1989; Pearlin, Mullan, Semple, & Skaff, 1990, Picot et al., 1997). These models include contextual variables (for example, gender, race, age, and relationship of caregiver to elderly person) and demands on the caregiver resulting from problematic behaviors or the poor functioning of the elderly person. Other aspects of the caregiving stress and coping model include the person's appraisal of the experience as stressful or satisfying, mediators of stress such as the person's coping styles and social support from others, and the consequences of caregiving as both positive and negative outcomes (for example, meaning, mastery, and psychological distress).

Research on stress and coping in caregiving has led researchers to use the stress and coping framework more than any other framework for caregiver interventions (Bourgeois, Schulz, & Burgio, 1996; Olshevski et al., 1999). Although we do not use this framework for recommending practice strategies for African American women caregivers, we recognize its usefulness in the development of interventions to prevent and reduce caregivers' stress. The sociocultural stress and coping model of Knight and colleagues (2000), for example, has potential for development and implementation of culturally and ethnically sensitive interventions with African American women caregivers.

Empowerment Framework

Solomon (1976) defined empowerment as a "process whereby persons who belong to a stigmatized social category throughout their lives can be assisted to develop and increase skills in the performance of valued social roles" (p. 6). According to Gutierrez (1994), empowerment is the "process of increasing personal, interpersonal, or political power so that individuals, families, and communities can take action to improve their situations" (p. 202). Lee (2001) argued that people empower themselves on a personal level to deal with social status and racial and ethnic oppression through the development of strong coping abilities. People acquire interpersonal power through building collective relationships in families, groups, and communities. Power on the political level, according to Lee, involves building coalitions and joining hands with larger forces (for example, advocacy groups) to influence the political process. Empowerment as a process, according to Parsons and colleagues (1998), encompasses attitudes, values, and beliefs about the self, especially beliefs about the ability to exert control over one's destiny.

An empowerment approach to practice requires that social workers provide clients with knowledge and skills to think critically about their problems and to develop strategies to act on and change problems (Gutierrez, 1990; Lee, 2001). Clients and social workers work collaboratively to help clients take charge of their lives. For example, clients define their problems and engage in the decision-making process to solve problems through collective action in a group. Social workers help facilitate problem solving and decision making by building on the strengths of clients. Among a litany of strengths that clients may possess, Saleebey (1992) noted their knowledge about their personal situations, knowledge about others, knowledge about the world around them, personal attributes, and "personal and cultural stories" (p. 51). Recognizing the strengths of clients as a resource, an empowerment approach also suggests that social workers facilitate collective action on the part of the group to help clients obtain critical environmental resources (Lee). In the words of Perkins and Zimmerman (1995), "Empowerment suggests that participation with others to achieve goals, efforts to gain access to resources, and some critical understandings of the sociopolitical environment are basic components of the construct" (p. 571).

Integrating the Stress and Coping and Empowerment Frameworks

An important goal of the stress and coping framework in practice is to manage clients' stress through stress reduction techniques, to teach clients cognitive skills such as reframing or replacing negative thoughts, and to change clients' negative appraisal of caregiving to a positive one (Olshevski et al., 1999; Toseland, 1995). Whereas the stress and coping framework recognizes the role of environments in engendering stress, intervention strategies based on the framework tend to target individuals or the family for change. The prototypical group intervention model is the support group (Bourgeois et al., 1996), although other group models such as stress relaxation, cognitive-behavioral modifications, psychoeducation, and psychosocial interventions are used (Olshevski et al.; Toseland).

The empowerment approach is more proactive; social workers using an empowerment approach target individuals, families, and the sociopolitical context. The empowerment approach aims to help people develop a sense of shared fate with similar others in a small group, to use the strengths of clients as a resource, to critically evaluate the stressful conditions in which people find themselves, to become active change agents, to advocate for change, and to build capacity through coalitions in order to effect change (Cox & Parsons, 1994; Gutierrez, 1990, 1994; Lee, 2001).

Both frameworks use the small group modality and target individuals in the change process. Both frameworks emphasize control and mastery over the environment, social support from others, a strong sense of self-efficacy, strength from individual coping, use of knowledge, and use of educational information in social work practice (Cox, 1989; Gutierrez, 1994; Lee, 2001; Perkins & Zimmerman, 1995).

Social workers have a long tradition of helping to empower vulnerable people by working to change oppressive environments and help make them more responsive to people's needs (Cox, 1989). There is theoretical evidence and emerging empirical evidence for using an empowerment approach to practice with African American women caregivers. Guided by this approach, social workers are in an ideal position to use empowerment evidence to develop ethnically and culturally sensitive practice strategies with these caregivers.

An Empowerment Practice Group Model

The concept of empowerment recognizes an individual's capacity for adaptation and change in an undesirable situation or environment (Hirayama & Cetingok, 1988). Proponents of an empowerment approach to practice regard the small group modality as an underpinning of practice (Gutierrez, 1990; Lee, 2001). They further note that promoting dialogue, critical thinking, and action in the small group are key elements to individual and group empowerment. For example, Lee argued that allowing participants to go beyond the "sharing of experiences and catharsis" and to "think, see, talk as well as act for themselves" (p. 37) are essential components in empowerment practice. According to Lee, participants in the small group may focus on helping one another, offering social support to group members, taking collaborative social actions, and developing problem-solving skills and competences. Drawing on the empowerment approach to social work practice outlined in this article, we recommend three strategies of empowerment for working with African American women caregivers.

Strategy 1: Raising Critical Group Consciousness through Storytelling

Cox (1989) defined critical group consciousness as "people's ability to perceive critically the way they exist in the world with which and in which they find themselves" (p. 118). Caregivers often feel alone when helping an older adult (National Alliance for Caregiving & AARP, 1997); they also may neglect their own self-care when caring for others (Krieger et al., 1993; Toseland, 1995). Thus, helping African American women develop a sense of shared fate or critical consciousness about a debilitating caregiving situation with other caregivers of the same race in the small group may be a vital first step in personal empowerment.

Research suggests that same-race group membership may facilitate a higher comfort level for African American women caregivers (Henderson, Gutierrez-Mayka, Garcia, & Boyd, 1993). Achieving personal power enables these women caregivers to exert personal responsibility for their self-care and problems they experience in caregiving. Gutierrez (1990) stated that when clients take responsibility for the resolution of problems, "clients are more apt to make an effort to improve their lives" (p. 150).

When seeking to help African American women caregivers raise their level of critical group consciousness, social workers may rely on the narrative or storytelling approach. An assumption underpinning a storytelling approach is that when people tell stories, they are making sense of life experiences, raising awareness of those experiences, re-evaluating life experiences as a motive for life change, and identifying personal strengths in adverse life experiences (Borden, 1992; Mishler, 1986). A storytelling approach embraces elements of empowerment by fostering collaborative effort and inclusiveness--essential elements in the empowerment process (Gutierrez, 1990, 1994; Lee, 2001; Mishler; Pinderhughes, 1983; Rappaport, 1995). It is compatible with a strengths perspective that views "cultural and personal stories" as profound sources of clients' strength, guidance, stability, comfort, or transformation (Saleebey, 1992, p. 51). Rappaport (1995) argued: "The goals of empowerment are enhanced when people discover, or create and give voice to, a collective narrative that sustains their own personal life story in positive ways" (p. 796). Adopting Rappaport's conceptualization of the "community narrative," a common story shared among a group of African American women may then become ammunition for helping them develop critical group consciousness or shared fate in the role of caregiving.

Accepting the client's definition of the problem and identifying and building on his or her strengths are important elements in the empowerment approach to practice with women of racial and ethnic groups (Gutierrez, 1990; Lee, 2001). Social workers may assess these elements of empowerment by having participants in the small group engage in telling a personal story about caregiving or other related experiences that happened within the past month. After a caregiver has told her story, group members may comment, ask questions, and relate similar experiences. Lee emphasized that it is important for participants engaged in the empowerment process to share, talk, and think for themselves. Playing the role of facilitator, the worker may seek to engage all group members, although it may not be necessary or possible to engage all members in storytelling. Empowerment research with Latino groups suggests the social worker should focus caregivers on thoughts, shared values, and feelings about the meaning of similar experiences in discussions (Gutierrez & Ortega, 1991).

Strategy 2: Teaching Concrete Problem-Solving Skills

Theoretical evidence from empowerment literature suggests that dialogue and critical thinking in the small group is an essential step to building concrete problem-solving skills (Gutierrez, 1990, 1994; Lee, 2001). To help empower caregivers, social workers should help caregivers increase capacity to acquire concrete problem-solving skills (Gutierrez, 1990; Lee). Problem-solving skills can help empower caregivers at the individual, interpersonal, or group level--a necessary step regarded by Gutierrez (1990) in producing change in an undesirable situation.

Rather than focusing on problems that social workers may assume caregivers to have, research suggests focusing on problems identified by caregivers that they wish to address (Smith, Smith, & Toseland, 1991). Allowing caregivers to solve problems based on the content of their personal collective stories is consistent with accepting the client's definition of the problem, constructing knowledge, and building capacity through problem-solving skill development (Gutierrez, 1990; Lee, 2001).

When working with African American women caregivers, social workers may), adapt the group problem-solving goals outlined in the research of Gutierrez and Ortega (1991). These goals include problem identification, selection of one problem, the choosing of a goal to solve or minimize the problem, generation of activities to achieve goals, and identification of available resources to assist in goal attainment. Techniques of small group practice in the work of Gutierrez and Ortega include self-disclosure, exploration, encouragement, direction, and explanation.

Strategy 3: Teaching Advocacy Skills and Mobilizing Resources

Caregivers of elderly people interact with broader systems, such as the aging services delivery system, that reach beyond caregivers' interactions with the informal support system of family and friends. Literature suggests that caregivers need advocacy skills to mobilize environmental resources within broader systems (Estes, 2001; Lee, 2001). Therefore, it is critical for social workers to help arm caregivers with political power, a necessary element for influencing change at the macro level (Gutierrez, 1990, 1994; Perkins & Zimmerman, 1995). Gutierrez (1990) said: "Through advocacy and resource mobilization, the worker and client together ensure that the larger social structure provides what is necessary to empower the larger group" (p. 152).

To teach advocacy skills and help caregivers mobilize resources, social workers may draw on the work of Amidei (1992), which outlines specific types of advocacy (for example, self-advocacy, administrative or regulatory advocacy, and legislative advocacy) and which types of advocacy work best in which situations. In addition, social workers may use Amidei's work to teach caregivers the basic tools of advocacy (for example, writing, calling, and lobbying a legislator or policymaker) and how to build a collective advocacy base. In short, helping caregivers advocate through building a collective base and providing caregivers with information about community services is essential in an empowerment approach to practice.

Empowering Principles and Social Workers' Roles

In keeping with the empowerment approach to practice, the social worker, when working with African American women caregivers, should be cognizant of the empowering roles of the worker. Drawing on Lee (2001), we recommend the following principles for working with African American women caregivers: building on their natural strengths, helping them empower themselves, sharing common ground with them, assisting them through groups, encouraging them to speak in their own words, and helping them maintain a focus on social change. We emphasize the following roles for social workers to consider in empowerment practice with these women caregivers: partner, facilitator, collaborator, coteacher, coinvestigator, dialogist, question poser, bridge builder, guide, ally, power equalizer, cobuilder, coactivist, and coworker.

Conclusion

Paralleling trends in the U.S. elderly population, the African American population is growing older, and more elderly African Americans are living longer than ever before. Projected growth in the African American elderly population, increasing disability in old age, and prevailing expectations that family members will care for elderly relatives portend the continuing significance of African American women's role in caregiving. To see caregiving as women's work rather than men's work does not deny the contributions of male caregivers (Older Women's League, 2001).

The empowerment framework bridges the stress and coping framework by facilitating a more proactive social work practice with African American women caregivers. The strategies recommended for an empowerment approach to practice described herein represent the first step toward helping African American women empower themselves on the personal, interpersonal, and political levels. To ensure that the strategies are effective, applicable, and feasible, social workers need to empirically evaluate and validate them.

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Letha A. Chadiha, PhD, is associate professor, School of Social Work, University of Michigan, Ann Arbor, 1080 South University Street, Ann Arbor, MI 48109-1106; e-mail lethac@umich.edu. Portia

Adams, PhD is assistant professor, Graduate School of Social Service, Fordham University, New York.

David E. Biegel, PhD, is Henry L. Zucker Professor of Social Work Practice, Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland. Wendy Auslander, PhD, is professor, George Warren Brown School of Social Work, Washington University, St. Louis. Lorraine

Gutierrez, PhD ACWS, is a professor, School of Social Work, University of Michigan, Ann Arbor. An earlier version of this article was presented at the 62nd annual conference of the National Council on Family Relations, November 2000, Minneapolis. Dr. Chadiha received support from the John A. Hartford Foundation for this article as a Geriatric Social Work Faculty Scholar, 1999-2001. Emmanuel Akuamoah, Alice Ansah-Koi, Alexis Bruce, Marcia Schnittger, and Penny Stein provided technical assistance.

Original manuscript received May 10, 2002

Final revision received January 15, 2003

Accepted February 3, 2003
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Author:Chadiha, Letha A.; Adams, Portia; Biegel, David E.; Auslander, Wendy; Gutierrez, Lorraine
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Date:Jan 1, 2004
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