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Paidéia (Ribeirão Preto)

Print version ISSN 0103-863XOn-line version ISSN 1982-4327

Paidéia (Ribeirão Preto) vol.26 no.64 Ribeirão Preto May/Aug. 2016

https://doi.org/10.1590/1982-43272664201605 

Articles

Interpersonal Conflicts Among Family Caregivers of the Elderly: The Importance of Social Skills*

Conflitos Interpessoais no Cuidado de Idosos: Importância das Habilidades Sociais do Cuidador

Conflictos Interpersonales en el Cuidado de Personas Mayores: La Importancia de las Habilidades Sociales del Cuidador

Francine Náthalie Ferraresi Rodrigues Pinto1 

Elizabeth Joan Barham1 

Zilda Aparecida Pereira Del Prette1 

1Universidade Federal de São Carlos, São Carlos-SP, Brazil


Abstract

Caring for someone, even when this person is highly regarded, can be stressful, resulting in a decrease in the caregiver's quality of life. The aim of this study was to identify the main conflicts involved in the task of caring for an elderly relative, reported by caregivers, elderly care-recipients and professionals in the field of aging, and to identify social skills (SS) considered as being important to accomplish this task, helping to minimize the conflicts in this context. We interviewed 50 caregivers of the elderly, 25 elderly care-recipients, and 25 professionals in the field of aging, who answered questions about conflicts linked to this context and about SS that are important when taking care of an elderly person. The main conflicts involved difficulties to reconcile differences of opinion, or financial issues. The SSs considered most useful included: expressing positive feelings, controlling aggressiveness, and discussing problems. It will be important to verify if caregivers who develop their SS repertoire also improve their quality of life.

Keywords  caregivers; aged; social skills; conflict; quality of life

Resumo

Cuidar de outro, mesmo sendo alguém que se estima, pode ser estressante e levar à diminuição na qualidade de vida. O estudo teve como objetivos identificar os principais conflitos envolvidos na tarefa de cuidar de um idoso, relatados por cuidadores, idosos e profissionais da área do idoso e levantar as habilidades sociais (HS) consideradas importantes para realizar esta tarefa e que auxiliem a minimizar os conflitos neste contexto. Foram entrevistados 50 cuidadores de idosos, 25 idosos cuidados e 25 profissionais da área do idoso, que responderam a um roteiro com perguntas sobre conflitos ligados a este contexto e HS importantes para cuidar de um idoso. Os principais conflitos envolviam dificuldades para conciliar opiniões e questões financeiras. As HS apontadas como importantes foram: expressar sentimentos positivos, controlar a agressividade e conversar para resolver problemas. Será importante verificar futuramente se cuidadores que aprimoram seu repertório de HS melhoram sua qualidade de vida.

Palavras-chave  cuidadores; idosos; habilidades sociais; conflito; qualidade de vida

Resumen

Ocuparse de otro, incluso alguien que se estima, puede ser estresante y conducir a disminución de la calidad de vida. Este estudio tuvo como objetivo identificar los principales conflictos en la tarea de cuidar de un anciano, reportados por los cuidadores, ancianos y profesionales de la vejez y identificar las habilidades sociales (HS) importantes para lograr esta tarea y que ayuden a minimizar los conflictos en este contexto. Fueron entrevistados 50 cuidadores de ancianos, 25 ancianos cuidados y 25 profesionales de la vejez que respondieron preguntas sobre conflictos en este contexto y acerca de HS importantes para cuidar de un anciano. Los principales conflictos fueron dificultades para conciliar diferentes opiniones y las cuestiones financieras. Las HS identificadas como importantes fueron: expresar sentimientos positivos, controlar la agresividad y hablar para resolver problemas. Será importante verificar en el futuro se cuidadores que mejoran su repertorio en HS mejoran su calidad de vida.

Palabras clave  cuidadores; adultos mayores; habilidades sociales; conflicto; calidad de vida

One of the consequences of increased life expectancy is the high prevalence of chronic diseases (Kuchemann, 2012). As such, it has become increasingly common to spend several years caring for a highly dependent elderly person (Kuchemann, 2012; Wang, Robinson, & Carter-Harris, 2014). Caring for an elderly relative is a complex task that affects the caregiver's life trajectory. Thus, the identification of conditions that contribute to obtaining positive results in this context is a way of promoting healthy adult development.

Researchers show that caring for an elderly relative is a risk factor for caregivers' wellbeing. Tomomitsu, Perracini, and Neri (2014) investigated the association between life satisfaction and sociodemographic variables, health status, functional status, social engagement and social support for caregivers and non-caregivers of the elderly. Using a larger database, they selected 338 caregivers and 338 non-caregivers who had similar income, gender and family characteristics. They collected data using questionnaires and self-report scales. The authors concluded that, compared with non-caregivers, a higher percentage of caregivers reported insomnia, fatigue and illness, in addition to higher levels of stress and lower life satisfaction. Other researchers also found differences between caregivers and those who do not care for an elderly relative, noting that the caregivers had a higher probability of presenting negative psychological, physical and social changes, such as higher rates of depression, feelings of burden, higher likelihood of acquiring coronary disease, social isolation, and a significant increase in expenses (Gervès, Bellanger, & Ankri, 2013; Li, Cooper, Bradley, Shulman, & Livingston, 2012; Wang et al., 2014). These data point to the importance of investigating the skills that are needed, to manage the task of caring for a dependent elderly person.

In this respect, Tomomitsu, Perracini and Neri (2014) found that caregivers who reported receiving greater social support also reported lower levels of stress. Other researchers have shown that, when caregivers lack this support, problems often arise in their relationships with other people who are involved in the elderly person's or the caregiver's routines, creating resentments and a negative emotional environment (Pedreira & Oliveira, 2012; Pinto, Barham, & Albuquerque, 2013; Van Groenou, Boer, & Iedema, 2013). Pedreira and Oliveira (2012) interviewed eight family caregivers, to identify the key changes that had occurred in their family relationships, since their elderly relative developed health problems. Although their sample size was small, the results indicated a strong influence of the quality of their social interactions on the caregivers' wellbeing. A preexisting family history of cooperation was associated with greater support and more sharing of responsibilities among family members. However, most of the caregivers felt burdened and alone when facing the demands of caring for a dependent elder, and conflicts emerged when the help that the caregiver requested from a family member was denied. The key situations reported as involving conflicts included: lack of family support, decreased tolerance (reactivation of unresolved problems), having to relinquish social, leisure or paid work to care for the elderly person, as well as social isolation and new expenses.

These data about relationship problems suggest that caregiving entails demands for social skills that can contribute to minimizing conflicts and maximizing the quality of life of the caregivers, elders and other people involved in this context. Despite the lack of studies on the social skills of those who care for the elderly, research conducted in other contexts indicates that people with well-developed social skills are more likely to establish good quality relationships, leading to better health (Bandeira, Tostes, Santos, Lima, & Oliveira, 2014; Lima, Bandeira, Oliveira, & Tostes, 2014; Pinto & Barham, 2014b). Thus, research focused on the social skills of those who care for the elderly could contribute information to guide the development of programs to support caregivers who need to manage the demands and interpersonal difficulties that appear in this context, contributing to a better quality of life for caregivers.

Social Skills

The concept of social skills refers to behaviors that exist in the repertoire of an individual and that are used in interactions with other people (Del Prette & Del Prette, 2013). According to Del Prette and Del Prette (2001), the concept of social competence involves an assessment or judgment about the adequacy of a person's performance and the effects that it produces in a given situation. These authors propose that the specific situation and cultural context must also be taken into consideration, to assess people's social competence. Thus, a person who is socially competent in a professional role, may or may not be equally competent in the context of caring for an elderly family member, and vice versa.

Social skills involve various classes of social behavior, including: self expression, coping skills, expressing positive emotions, social interaction and conversational skills, establishing new relationships or adapting to new situations, and controlling aggressive reactions (Del Prette & Del Prette, 2001). To meet social competence criteria, competent caregivers must reconcile their own needs and interests with those of their elderly relative, along with those of other family members who help with the elderly person's care. As such, to be socially competent, caregivers may need to use greater self-control to avoid reacting aggressively to hostility from the other person, to identify factors that are contributing to the problem, and to calm down the other person and themselves, so they can decide the best way to solve the problem. Depending on people's emotional arousal during a conflict and causal attribution errors, based on a history of family interactions, the caregiver may be unable to analyze the problem and think of solutions, straight away. As an alternative, withdrawing from the conflict and returning to the issue after time for reflection may be a more effective, or more socially competent, response.

Given that social skills, as well as maladaptive behaviors (such as avoiding social contacts, not voicing opinions, attacking other people's ideas), are learned behaviors (Del Prette & Del Prette, 2008, 2013), strongly affected by immediate consequences, it is possible to understand why many caregivers exhibit behaviors that do not solve the interpersonal problems that arise in this context. Maladaptive behaviors can also generate positive, short-term consequences, such as reducing the caregivers' anxiety or momentary frustrations (Gresham, 2010), but these behaviors do not lead to medium or long-term solutions to problems.

In terms of evidence concerning the importance of social skills for people who care for the elderly, researchers have shown that socially responsible caregivers with good interpersonal relationships tend to have a higher quality of life than caregivers with a limited repertoire of social skills (Bandeira et al., 2014; Muela, Torres, & Peláez, 2001; Pinto & Barham, 2014b). In a study with 20 caregivers of elderly family members, Pinto and Barham (2014b) found that those who had better social skills reported lower perceptions of burden and better quality relationships with their elderly relative, indicating fewer care-related conflicts. The key social skills associated with these results were: self-control of aggressive reactions, expressing positive feelings, and refusing unreasonable requests. In two studies on the effects of social skills training for caregivers of the elderly (Robinson, 1988; Robinson & Yates, 1994), those who participated in training programs reported less burden, following the intervention, and demonstrated more socially competent behaviors in their daily lives.

Thus, it appears that good social skills, which translate into socially competent behaviors, can positively affect the wellbeing of those who care for the elderly, and the quality of their interpersonal relationships. However, there is still little information about this context. Thus, this study aimed to identify the main conflicts involved in the task of caring for the elderly, as reported by caregivers, elderly people, and professionals from the field of gerontology, and to identify the social skills considered as being important when dealing with this task, which help to minimize conflicts.

Method

Participants

There were three groups of participants in this study: 50 caregivers who assisted an elderly relative, 25 elderly care recipients, and 25 healthcare professionals who worked with the elderly. The participants were not matched, that is, the elders and caregivers did not necessarily belong to the same family. The inclusion criteria, for the caregivers, included being relatives or having another emotional (unpaid) relationship with the elderly person; for the elderly care recipients, to not have cognitive impairments that would invalidate their participation in the study, and to be receiving care from a family member; and for the professionals, to be working in the field of gerontology or geriatrics. All the elderly participants had received routine medical checkups via an in-home public healthcare service, to monitor their physical health and cognitive status.

The caregivers were 45 years of age, on average (44 women and 6 men), with varying degrees of kinship, including: 21 children, 12 grandchildren, 7 spouses, 6 daughters, 2 neighbors, 1 brother and 1 nephew. The caregivers' educational levels were varied: 10 who had not completed their elementary-school education, 14 who had completed elementary school, 11 who had not complete high school, 7 who had completed high school, 4 who had not completed tertiary-level studies, and 4 who had completed university studies. The elderly respondents were 73 years of age, on average (15 women and 10 men), with different degrees of kinship, including: 13 children, 10 spouses, and 2 siblings. In this group, educational levels included 10 who had not completed their elementary-school education, 7 who had completed elementary school, 4 who did not complete high school, 2 who had completed high school, and 2 who had completed university studies. The professionals (22 women and 3 men) were 39 years of age, on average, and had all completed university studies. There were five participants from each of the following professions: psychology, medicine, social work, physiotherapy, and nursing.

Instrument

Interview schedule. The interview questions were developed by the researchers, based on clinical experience, and addressed the following topics:

Participant data. Name, age, sex, level of education, relationship between the caregiver and the care recipient or, in the case of the professionals, their profession.

Difficulties and conflicts. Open-ended questions about the demands, difficulties or conflicts that arise when caring for an elderly person, and possible relationships with social skills, in this context.

Social skills. Explanation of this concept, followed by a request for examples of social skills that are important in caring for the elderly, to reduce conflicts associated with this task.

Classes of social skills. Explanation of classes of social skills, based on Del Prette and Del Prette (2001): (a) coping and self-expression (which require assertiveness skills), (b) expressing positive feelings (the expression of positive affect or of regard for another person), (c) conversational and social interaction skills (in accordance with norms for everyday relationships, and in response to demands to show social sensitivity), (d) interacting with new people or in new social situations (interactions with strangers), and (e) self-control of aggressiveness (dealing with negative situations that require controlling one's anger or aggressiveness).

Importance of social skills. Questions about the importance of each class of social skills, to minimize the conflicts that arise in the context of caring for an elderly person, and a request for examples of how to use of the social skills that they rated as being important, while caring for an elderly person.

Procedure

Data collection. The study was conducted in a city in the interior of the state of São Paulo, Brazil. The director of a publicly-funded in-home healthcare-service in this city agreed to provide information to contact service users who met the inclusion criteria. A home visit was arranged to interview the caregivers and the elderly people who agreed to participate in the study. Interviews with the professionals were performed at the healthcare centers where they worked. Initially, all participants signed an Informed Consent Form.

After answering the sociodemographic questions, each participant was asked to describe conflicts that occur when caring for a dependent elderly person. Next, the definition of social skills was read aloud, and any doubts about this concept were clarified. The researcher then asked if the participant considered it important that caregivers of the elderly use these skills in their daily lives, and if they could give any examples of social skills that are important to use, in this context. Next, the interviewer read the definitions of the five classes of social skills, one at a time, and, for each one, asked the participant if it would be important for a caregiver to use these skills when interacting with an elderly care recipient. If the participant said yes, the researcher asked for an example of a behavior from this class. All interviews were recorded and, in addition, the researcher took note of the key information provided by each participant.

Dada analysis. Two experts in the field, working individually, were asked to perform a content analysis of the responses (examples of conflicts and of important social skills) given by the participants (Anfara Jr., Brown, & Mangione, 2002; Strauss & Corbin, 1994). For the social skills, they were asked to categorize each response into one of the social skill classes used in the IHS-Del-Prette (Del Prette & Del Prette, 2001); if they felt that some of the responses did not fit in any of these classes, they were to group these into new categories. After this, the experts were asked to compare their decisions and, when in disagreement, to reach a consensus on how to classify each answer and on any additional categories to include, such as "obtaining information about a health condition". Based on the consensus reached by the experts, this material was then analyzed to identify the major conflicts involved in the context of caring for a dependent elderly person, and the social skills that were identified as being important, according to the study participants.

Ethical Considerations

This project was approved by the Ethics Committee of the Universidade Federal de São Carlos (Protocol n. 144507/2012 - CAAE n. 02010312.0.0000.5504.).

Results

In Table 1, the conflicts involved in the context of caring for a dependent elderly person are presented, based on the analysis of the participants' responses, along with examples of some of the responses provided, in each group of participants.

Table 1 Examples of Conflicts Reported by Caregivers, Elderly Care-Recipients and Geriatric or Gerontological Professionals 

Conflict Caregivers Elderly Professionals
Lack of support from other family members "Overwork, lack of support, understanding, interest" (P 39) "The others [siblings] do not visit" (P48) "She [caregiver] thinks that the other children have to pay more attention" (P53) "Lack of respect and understanding of each other, lack of moral support" (P76) "Difficulty in asking for ... help" (P84)
Financial "Financial" (P1) "She [caregiver] spends a lot" (P58) "Lack of financial support" (P76)
Uncooperative care recipient "Stubbornness of the elderly person" (P15) "The elderly person wants everything her own way" (P22) "My stubbornness" (P62) "When I complain" (P63) "Elder does not accept his dependence on the caregiver" (P96)
Different ways of thinking, among caregivers "Taking care of her in a different way: bathing, food, changing clothes, getting her out of bed" (P6) "Thinking differently than the other" (P30) "Differences of opinion" (P54) "The siblings who always seem to criticize" (P57) "Family does not agree" (P80)
Caregivers' lack of time for themselves "Having time for themselves" (P13) "Parallel demands faced by the caregiver" (P83)
Care recipient's preference for one child "His [elderly person's] preference for a child, and the other is hurt" (P4) "Preference of the elder for a child" (P81)
Alcoholism "Alcoholism, excessive drinking" (P59)
No conflicts "I have no conflicts, because people trust me" (P19) "I went through this situation. There is a lot of exchange of love and affection" (P61)

In general, the conflicts involved issues such as insufficient support for the caregivers, lack of financial support, lack of cooperation on the part of the elderly care recipient, lack of time for the caregivers to look after themselves, and the elderly people's preference for only one of their children. A comparison of the conflicts reported by each group of respondents indicates that the elderly care recipients did not mention problems owing to a lack of time among the caregivers, or due to their preference for one of their children. Some caregivers and elderly respondents reported that they did not experience conflicts in their family. In Table 2, the frequency of these conflicts is indicated, as reported in each group of participants.

Table 2 Frequency With Which Each Type of Conflict Was Reported, in Each Group of Respondents 

Conflict Group of Respondents
Caregivers (n = 50) Elderly (n = 25) Professionals (n = 25) Total (N = 100)
Lack of support from other family members 20 (40%) 8 (32%) 10 (40%) 38 (38%)
Financial 10 (20%) 5 (20%) 11 (44%) 26 (26%)
Uncooperative care recipient 13 (26%) 4 (16%) 2 (8%) 19 (19%)
Different ways of thinking, among caregivers 12 (24%) 3 (12%) 1 (4%) 16 (16%)
Caregivers' lack of time for themselves 3 (6%) 0 (0%) 1 (4%) 4 (4%)
Care recipient's preference for one child 2 (4%) 0 (0%) 1 (4%) 3 (3%)
Alcoholism 0 (0%) 2 (8%) 0 (0%) 2 (2%)
No conflicts 3 (6%) 4 (16%) 0 (0%) 7 (7%)

Considering the statements of all the participants (total), the most frequent conflicts involved a lack of support for the caregiver, financial issues and a lack of cooperation on the part of the elderly care-recipient. The conflicts that the caregivers most commonly reported involved a lack of support from other family members, a lack of collaboration on behalf of the elderly care recipient, differences of opinion with other caregivers about what care to provide, and financial issues. For the elderly care recipients, the conflicts most frequently reported involved their reluctance to collaborate, differences of opinion with or among those who cared for them, a lack of support from family members, and financial issues. Note that 16% of the elderly participants reported no conflicts in their families, compared with 6% of the caregivers. The perceptions of the professionals were similar to those of the caregivers; their responses highlighted conflicts related to the lack of support for the caregivers and difficulties involving financial issues.

In Table 3, the examples provided illustrate the social skills that the participants said should be used when someone is assisting a dependent, elderly, family member.

Table 3 Social Skills Identified as Important for Those Who Care for an Elderly Person, in Each Group of Respondents 

Skills Group of Respondents
Caregivers Elderly Professionals
Obtain information about the health condition "To better take care of the elderly person, for example, [find out] about treatment" (P31) "Yes...how the illness works, what you're thinking, so you can understand" (P51) "Looking for information, knowledge, understanding the situation" (P82)
Express positive feelings "Giving kisses, being playful and affectionate to make her feel better" (P5) "When the other is taking good care" (P6) "Making food for myself, even though I am old and have health problems" (P54) "When the health condition of the elderly person improves, or he can stay calm" (P82)
Control aggressiveness "When the person who helps me talks too much, and irritates the elderly person; with family members who do not help" (P25) "When I don't want to do the things that she wants to do" (P62) "Aggressiveness of the elderly person, family members who criticize, patients who shout and talk a lot" (P84)
Talk through problems "Sitting down and talking to other family members to solve the problems" (P4) "Say what you think calmly , without getting angry, caring with love" (P53) "Sitting down and talking and trying to resolve the situation as best as possible, listening to the other" (P76)
Use coping strategies "Take the elderly person to a skilled physician, even if my siblings do not want me to" (P19) "With me, because I am a difficult person" (P56) "Check what is important for the elderly person, even if the family is against it" (P80)
Ask for help "To dialogue, talk, ask for support when you need it" (P32) "Asking for help from the children, when needed" (P55) "Asking for help from siblings..." (P97)
Arrange time for yourself "[Time] with friends, at the gym... it is important to maintain your life, so you don't get sick" (P37) "Getting out to talk to others, explain what is good for her, going to church, praying" (P60) "Opportunity for the caregivers to interact socially and de-stress, have time for themselves" (P97)
Express opinions "Telling him [care recipient] that he has to shower, take his medicine" (P29) "To express his feelings" (P80)

Most of the social skills indicated as being important for someone who cares for an elderly family member involved dealing with conflict (control aggressiveness, talk through problems, use coping strategies), together with skills that contribute to organizing adequate and sustainable routines (obtain information about the care recipient's health condition, express positive feelings, ask for help, and make arrangements with others in order to have some "time for themselves").

Obtaining information about the elderly person's health problems and the caregivers being able to have time to themselves are not social skills, per se. However, accomplishing these tasks involves communication skills (to gain information, or to arrange with others to stay with the elderly person). The perceptions of the professional group were very similar to those of the other two groups. However, it is noteworthy that no elderly respondents stated that it was important for caregivers to express their opinions.

In Table 4, information is presented about the frequency with which the skills presented in Table 3 were used, and how important they were, for each group of respondents.

Table 4 Frequency With Which the Social Skills Were Rated as Important, in Each Group of Respondents 

Social skill Group of Respondents
Caregivers (n = 50) Elderly (n = 25) Professionals (n = 25) Total (N = 100)
Obtain information about the health condition 35 (70%) 15 (60%) 17 (68%) 67 (67%)
Express positive feelings 34 (68%) 14 (56%) 11 (44%) 59 (59%)
Control aggressiveness 33 (66%) 9 (36%) 14 (56%) 56 (56%)
Talk through problems 15 (30%) 10 (40%) 9 (36%) 34 (34%)
Use coping strategies 11 (22%) 4 (16%) 6 (24%) 21 (21%)
Ask for help 12 (24%) 1 (4%) 7 (28%) 20 (20%)
Arrange time for yourself 10 (20%) 3 (12%) 6 (24%) 19 (19%)
Express opinions 11 (22%) 0 (0%) 1 (4%) 12 (12%)

Based on Table 4, the social skills considered as most important, according to the caregivers, were: obtaining information, expressing positive feelings, and controlling aggressiveness. Among the elderly care-recipients, the social skills considered as most important for caregivers were: obtaining information, expressing positive feelings and talking through problems.

Discussion

The aims of this study were to identify the conflicts that most commonly arise when a family member cares for a dependent elderly person, from the point of view of caregivers, elderly care recipients, and professionals working in the field of geriatrics or gerontology, and to identify the social skills that are considered important in accomplishing this task, to minimize these conflicts. The three groups of respondents reported similar sources of conflicts. However, an important difference was that no elderly person reported problems related to the caregivers needing to take time to care for themselves, which may indicate difficulties that the elderly care recipients had, to understand the caregivers' needs.

Considering the responses of the study participants, collectively, the most frequent conflicts involved: lack of support from other family members, financial issues, the uncooperative behavior of the elderly care recipient, and conflicts of opinion about caring. These results are consistent with findings reported by Pedreira and Oliveira (2012) and by Carneiro and França (2011). The lack of support from other family members can cause perceptions of caregiver burden (Gratão et al., 2013; Novelli, Nitrini, & Caramelli, 2010; Pinto & Barham, 2014a; Wang et al., 2014) and over time, this can contribute to the caregiver developing health problems (Horiguchi & Lipp, 2010; Pedreira & Oliveira, 2012; Wang et al., 2014.).

With respect to financial conflicts, caregivers often have to quit their jobs or decrease their hours of paid work to take care of elderly relatives, reducing their income just when financial expenses tend to increase, to purchase medicines and geriatric diapers, for example, along with other specialized products and services (Gervès et al., 2013; Pedreira & Oliveira, 2012; Smith et al., 2010). Thus, the family's financial reserves tend to be depleted, after an elderly family member develops health problems (Gervès et al., 2013; Smith et al., 2010; Wang et al., 2014). According to the literature, it is relatively common that one person is left largely on their own to take full responsibility for caring for the elderly family member and for managing this person's financial resources (Pinto et al., 2013; Smith et al., 2010). This situation leads to conflicts with other family members who do not help, who have different opinions, or who expect some share of these resources (Areosa, Henz, Lawisch, & Areosa, 2014; Carneiro & França, 2011; Gervès et al., 2013; Pedreira & Oliveira, 2012). These same sources of conflict also emerged in the present study: the participants reported conflicts due to differences of opinion among family members, disagreements over the management of financial resources, divergences between the elderly person and the caregivers themselves with respect to the caregivers' needs, among others.

The lack of cooperation on the part of the care recipient, and the fact that either the care recipient or the caregiver may be willing to accept help from only certain people, can also contribute to the occurrence of conflicts (Areosa et al., 2014). In the current study, 16% of the caregivers admitted to having difficulty accepting the opinion of or help from others. Even caregivers who willingly chose to undertake this role can end up feeling burdened by incompatibilities with their elderly family member, or feeling discouraged, if their elderly relative is frequently upset or constantly criticizes them (Areosa et al., 2014; Carneiro & França, 2011; Pedreira & Oliveira, 2012). Moreover, only 6% of the caregivers and 16% of the elderly care recipients did not report conflicts related to eldercare issues in their families, which strengthens the hypothesis that caring for a dependent, elderly, family member usually involves conflicts and difficulties, as many of the interpersonal strategies that people use in this context are not very effective in handling these problems.

Knowledge about aging and about workable strategies to respond to the needs of older people are still insufficient, in Brazil, especially with respect to helping elderly people with health problems, perhaps because the aging of the Brazilian population is a relatively recent phenomenon (Kuchemann, 2012). However, laws to protect the rights of the elderly have already been established (Estatuto do Idoso [Statute for the Elderly]) by the Brazilian Ministry of Health (1999), which aim to ensure that family members, particularly adult children, support their elderly relatives. This legal obligation is positive, on the one hand, as a way to guarantee that older people receive assistance. On the other hand, it may contribute to increased conflict in families with weak emotional ties, as caring for the elderly person is nothing more than a requirement, and is not a choice based on a history of positive family relationships (Pinto et al., 2013).

Given the likelihood of needing to manage conflicts, a caregiver who has stronger social skills and who uses them in a socially responsible way should be better able to deal with difficult interpersonal issues (Lima et al., 2014; Muela et al., 2001; Pinto & Barham, 2014a; 2014b; Robinson, 1990). For example, caregivers with greater social competence developed a better relationship with the elderly care-recipient and reported lower levels of burden, to the extent that they were able to express positive feelings, turn down unreasonable requests, ask others to change their behavior, ask for help from friends, and control aggressive reactions (Muela et al., 2001; Pinto & Barham, 2014b; Robinson, 1990). The data from the current study confirm these earlier findings, as the social skills considered most important for someone who cares for an elderly family member included: obtain information about the care recipient's health condition, express positive feelings, control aggressiveness, talk through problems, use coping strategies, ask for help, and arrange some time for yourself.

The ability to obtain information entails requesting this information from other people, such as other caregivers or professionals who work in the field of geriatrics or gerontology. Arranging time for yourself may depend on the caregiver's ability to request other people's help to take care of the dependent, elderly person, or to require other family members to share these tasks. When thinking about the caregiver's role in assisting someone who has health problems, it is clear that the caregiver could benefit from learning more about their elderly family member's health condition. Having the ability to do this was considered highly relevant for caregivers, mentioned by 67% of the participants in this study, and requires that the caregiver is able to gain information through interactions with other people, such as physicians, other caregivers and other family members. When these other people interact with the caregiver using socially competent behaviors, these exchanges also create opportunities for the caregivers to improve their social skills.

Another skill reported as being important was expressing positive feelings. This ability, in conjunction with the caregivers' ability to control aggressive reactions, assists them in establishing healthier relationships, because, the warmer they are, the more likely it is that they will receive help, compared to those with a more forceful approach (Pinto & Barham, 2014a; Robinson, 1988, 1990; Robinson & Yates, 1994). As such, controlling aggressive reactions when criticized, even if the criticism is unwarranted, is highly relevant to the caregiver's ability to establish good quality relationships with their elderly relative and with other people who are also involved in caring for the older person (Pedreira & Oliveira, 2012; Pinto & Barham, 2014b; Robinson, 1990).

In the present study, although the majority of participants reported needing more support, only 20% stated that the ability to ask for help is important. That is, although they realized they needed more support, 80% did not think of the ability to ask for help as a skill that a caregiver should use. As such, in addition to helping caregivers develop their ability to ask for help, it may also be important to help caregivers evaluate their situation, so they can more clearly discriminate when they should ask for help. In the current study, only 4% of the elderly care-recipients reported that caregivers should use their ability to ask for help, which, once again, seems to reflect the difficulty they have to understand the caregiver's perspective. In previous studies, the ability to ask for help was depicted as essential to caregivers' quality of life (Muela et al., 2001; Pinto & Barham, 2014b; Robinson, 1988, 1990; Robinson & Yates, 1994), and those who could ask for help in an appropriately assertive manner obtained more frequent assistance and felt less burdened, compared with those who did not have this ability or in whom this skill was poorly developed (Muela et al., 2001; Pinto & Barham, 2014a; Robinson & Yates, 1994). In addition, caregivers with more highly developed social skills had higher self-esteem (Robinson, 1988, 1990; Robinson & Yates, 1994).

Considering some of the difficulties that the elderly care-recipients seemed to have, to understand the caregivers' perspective, and the sense of burden that caregivers feel when they can't find a way to ask for help and are not able to express positive feelings towards their family members (creating an emotional distance between themselves and other people involved in this context), it may be possible to improve this situation using intervention programs to help both caregivers and elderly care-recipients improve their social skills. Given this demand, programs to help professionals develop their social skills would also be of critical importance, as healthcare workers act as models for elderly people and their caregivers. Professionals who are adequately qualified to work on relationship issues would then be able to offer the intervention programs that would help caregivers improve their social skills.

Such training programs would be important because the use of social skills affects an individual's ability to maintain positive relationships (Bandeira et al., 2014; Lima et al., 2014.). Caregivers who can be assertive and talk through problems with the elderly care- recipient, as well as with other people involved in the situation, are usually more successful and feel less burdened by their routine of caregiving activities (Muela et al., 2001; Robinson, 1990). Thus, social skills may be a protective factor for caregivers' health, helping them to establish positive connections with others and to obtain greater social support in performing tasks related to their elderly relative's needs, as well as in other situations outside this context (Braz, Del Prette, & Del Prette, 2011; Carneiro & Falcone, 2013; Lima et al., 2014). Maintaining healthy relationships that allow caregivers to engage in other activities can help them improve their self-esteem, develop a greater sense of personal efficacy, and construct a positive identity during this stage of their lives (Carneiro & Falcone, 2013; Robinson, 1988, 1990). In addition, a well-developed repertoire of social skills that are specific to caregiving (such as being able to raise the spirits of an older person who is experiencing an irreversible health decline, to express positive feelings in this context, and to be empathic) may be essential in mitigating the psychological impacts of dealing with the challenges that are inherent in this activity (Pinto & Barham, 2014a, 2014b).

Thus, studying the specificities of the social skills that are needed in the context of caring for a dependent elderly relative is needed, given that research shows that socially competent people have a better quality of life, as well as lower rates of anxiety and depression, compared to the general population (Carneiro & Falcone, 2013; Del Prette & Del Prette, 2013). The caregivers' coping strategies, which are affected by their social skills, in conjunction with support from their social network, affect their resilience and self-efficacy in managing the demands of caring for a dependent elderly person (Horiguchi & Lipp, 2010). In addition, helping caregivers improve their social skills can increase their ability to obtain support from a greater number of people, which can relieve some of the pressure on their relationships. It is also essential to develop a reliable and valid instrument to assess caregivers' social skills, which can also be used to evaluate the effectiveness and efficiency of interventions to improve these skills among those who care for an elderly relative.

One of the key strengths of this study was its focus on an issue that has received little attention in the scientific literature, even at an international level. Although the results are clearly important, the limitations of this study must also be recognized. One such factor is the small number of elderly care-recipients and professionals who were interviewed. Elderly people who have no cognitive impairments, and who depend on a family member for assistance, constitute a population that is difficult to access; many of them prefer to have the caregiver answer questions for them. Most older people have a full-time caregiver only when they begin to develop some form of dementia or a disabling disease that leads to a state of dependency. The number of professionals who participated in the study was also small, as there are still relatively few trained professionals working in the field of geriatrics and gerontology, in Brazil, which makes it difficult to recruit these participants.

A further limitation was the fact that the interview schedule had to be developed based on the clinical experience of the researchers, as the number of publications on the social skills of caregivers is very meagre. However, this situation also points to why it is important to develop a tool to evaluate social skills in the specific context of caring for an elderly family member, as a person who is socially skilled in one context may not be skilled when performing other tasks, given the situational nature of social skills (Del Prette & Del Prette, 2013; Lima et al., 2014; Pinto & Barham, 2014b). A standardized instrument to assess the social skills resources and difficulties of caregivers who assist an elderly family member would contribute to obtaining more accurate and valid data that can guide the work of professionals. Thus, professionals conducting social skills training programs could increase the quality of their efforts to help caregivers manage their responsibilities and, at the same time, enable them to better care for themselves, avoiding or reducing declines in their physical and emotional wellbeing, and contributing to a greater quality of life for these caregivers.

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*Article derived from the first author's doctoral dissertation, under supervision of the second and co-supervision of the third co-authors, and defended in 2016 in the Graduate Program in Psychology at the Universidade Federal de São Carlos.

São Paulo Research Foundation (FAPESP Grant # 2012/00907-3).

Received: February 18, 2015; Revised: June 02, 2015; Revised: July 31, 2015; Accepted: August 03, 2015

Correspondence address: Francine N. F. R. Pinto. Rua Novo Horizonte, 164, apt. 224, Chácara da Barra. CEP 13090-768. Campinas-SP, Brazil. francinenaty@yahoo.com.br

Francine Náthalie Ferraresi Rodrigues Pinto is a Doctoral-student Researcher at the Universidade Federal de São Carlos.

Elizabeth Joan Barham is an Associate Professor at the Universidade Federal de São Carlos.

Zilda Aparecida Pereira Del Prette is a Full Professor at the Universidade Federal de São Carlos.

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