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Family Mediation in Eider Caregiving Decisions: An Empowerment intervention

HE U.S. POPULATION is getting older. In 1985, people 65 years of age or older were 12 percent of the population. The age group has tripled since 1900. It is projected that by 2000, more than 13 percent of the population wUl be in this age group, and by 2030,22 percent are expected to be older than 65 (U.S. Bureau of the Census, 1985). The life span continues to increase. Althotjgh the percentage of older persons in society will increase, incapacities are not predicted to change. An increased life span with functional impairments requires a change in status on the part of the older person from independence to some degree of dependence. The two most rapidly expanding dependent groups are women and the older elderly (Brody, 1983a, 1983b). Although only 5 percent of persons 65 to 74 years of age need assistance with basic activities of daily living, 33 percent of those 85 and older need such care (Ory, 1985). Elders who need care wiU remain in the community, not in institutions, and the family remains the prime caretaker (Ory, 1985). These population shifts will require increasing numbers offamiliesto be involved in caregiving and in difficult decisions about elder care, such as hospital discharge planning, hospice placement, nursing home placement, assisted living care arrangements, home health care, and family caregiving. Decisions to be made include what type and level of care is needed, which family members will be involved in the care and in what ways, and who will pay for the care. Participants in these decisions may include elder family members, children of the elder family member, siblings of the elder member, family members of designated caregivers, and friends or neighbors of the elder family member.

of care falls principally on a single caregiver, usually a woman (Brody, 1983a). Although women do the major A projected increase in the number of portion of caregiving, they frequently are elders who need care suggests that more considered less critical to decision makregarding the care. Those family families will be involved in caregiving ing members who are physically or emotiondecision making, which may be conflic- ally closest to the elder member usually tttal Family disputes that result may cire more active in the decision-making cause breakdoum in a family's ability process. Other family members who are to provide needed care and support to asked to contribute to the arrangement elder members. Family mediation is a may resent not being included in the family-oriented, problem-solving, task decision-maMng process. Often when completion model that empowersfami- feelings such as these are present, ly members to negotiate mutually caregiving decisions are sabotaged and agreed-on decisions. The authors argue conflicts escalate. Unresolved conflicts among family members regarding carethat mediation is an effective strategy giving arrangements result in decreased for problems presented and an appro- decision-making ability. The greater the priate role for social workers. Geron- conflict, the less family members consult tological social workers often are in with one another regarding future decia position to provide both substantive sions. This dynamic results in compartexpertise in caregiving issues and mentalizadon of efforts and reduction in mediation interventive skills. Prin- effectiveness of the family's total capaciciples and techniques of mediation are ty. Family support plays a critical and inpresented. Limitations of the approach tervening role in an elder's coping with illness and even its outcome (Berkman, are discussed. 1983). Moreover, evidence exists that breakdown in an elder's network increases the possibility of institutioncilization (Berkman, 1983, p. 745) and elder arrangements is not usually harmonious. abuse in the caregiving situation (Knight, A recent study found that family conflict 1985). Family members often become resolution was one of the five most fre- more isolated from one another and feel quent interventions by social workers in less empowered to handle the caregiving home health care agencies (Levande, decision-maMng responsibilities. In this Bowden, & Mollema, 1987). Sources of situation, everyone loses, particularly the family conflict around elder care deci- elder family member. sions include feelings of guilt, grief connected with the loss of the elder family member's health, disparate investments Family Mediation as a and interests in the caregiving arSocial Work Role rangements of elders, scarce resources for elder caregiving that demand comThe destructive potential of the probmitment and substantial sacrifice from lems presented calls for family intervenfanuly members, limited experience with tion to resolve conflicts and promote joint decision making, and the rejuvena- cooperation and communication among Sources of Conflict in tion of old conflictual family dynsimics family members in decision making Caregiving Decision Making through the decision-making process. about caregiving. Although recent literAlthough elder caregiving by families Unequal burden of caregiving is a ma- ature promotes a philosophical stance is common, decision making about such jor source of conflict infemilies.The bulk toward family-oriented approaches to

Ruth J. Parsons Enid O. Cox

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CCC Code: 0037-8046/89 $1.00 1989, National Association of Social Workers, Inc.

services to elders, most models for in- intervention cind seeks mutually agreedtervention with elders center on in- on behavioral contracts. Family mediadividuals. Circirelli (1986) pointed out tion focuses on facilitation of the that in emphasizing the need to think problem-solving process and ability of aboutdiseases and conditions that affect the family to isolate issues, interests, the individual, the strong influence of the positions, alternatives, and resources to family system on the care, condition, and find agreed-on solutions. Connaway and outcomes of intervention with the elderly Gentry (1988) pointed out that few theofrequently is ignored. A family-oriented retical conceptualizations exist for the iaapproach to work with problems of elder teracdon process observed in mediating caregiving includes assessment of a fami- conflicts. However, these interactions ly's functioning and improving family have been explained by various theoresupport and problem-solving ability tical bases, including exchange theory, (Edinburg, 1986). Family mediation is an system linkage,fieldtheory, and negotiaappropriate intervention strategy for tion process. The focus of mediation is on meeting these goals. the process of problem solving, not on The role of mediator is not new to social the behavioral or personality issues of work. Social work often is viewed as participants. Personal changes are a mediation between clients and their en- "secondary outcome of agreement seekvironments or between^ystems wherein ing based upon an assumption that social work problems are seen as a changes in interaction create choices in dysfunction or breakdown in systems that interaction which can improve linkage (Heam, 1970; Schwartz, 1961). significantly the quality of life for parConceptualized on a continuum of social ticipants" (Connaway & Gentry, 1988, p. work roles from least to greatest contest 147). Although the potential exists in or confrontation (Middleman & Goldberg, mediation for family members to in1974), mediation lies between the role of crease their understanding of one collaborator, conferee, andenableronone another and their communication proend, and broker-advocate on the other cesses, the primary goal of mediation is end (Hernandez, Jorgensen, Judd, Gould, task accomplishment. & Parsons, 1985; Specht, 1969). What Mediation intervention has empowerdistinguishes the mediator rolefromthe ing qualities not present in other family clinical or advocate role is that the intervention modalities that address conmediator intervenes in a process of inter- flict resolution. One such quality is its action between systems as a neutral facil- educational nature. The mediator itator to assist diose systems to reach educates participants to negotiate to get agreement about disputed issues. No at- their needs met. By acting as a joint adtempt is made in mediation either to ad- vocate, the mediator empowers all parvocate for a system or to change the way ticipants to negotiate on their own behalf. that system functions (Connaway & (Sen- Chandler (1985) described mediation as try, 1988). Mediation is a recognized joint advocacy when the social worker method of organizational conflict resolu- promotes the interests of each particition (Blake & Mouton, 1984) and com- pant. Other empowering aspects include munity organization (Walton, 1969) and the emphasis placed on each particihas become a prevalent intervention in pant's own responsibility for decision divorce and child custody work during the making Eind outcome. Mediation aspast 10 years (Haynes, 1978). Mediator, assumes that participants have the capaciused in this article, refers to a social ty to examine facts and make rational worker who assumes the social work choices with assistance of a mediator mediator role. (Connaway & Gentry, 1988). Responsibility for outcome rests with the participants. Principles of Mediation It is theoretically optimal for the Mediation is an intervention between mediator to be viewed as neutral, with no conflicting parties or viewpoints to pro- interest in the outcome other than parmote reconciliation, settlement, com- ticipant satisfaction, fairness, and the promise, or understanding. It is a workability of the plan. However, combehaviorally oriented, problem-solving plete neutrality is not feasible when Parsons and Cox / Family Mediation in Elder Caregiving

balanced with adherence to social work professional values. Moreover, a social worker may represent issues of an elder when the elder is unable to negotiate for him or herself, which would raise questions about the social worker's neutrality. The necessity of complete neutrality on the part of the mediator is a controversial issue in mediation. The role of mediator in social work probably is never completely neutral because of the value base of practice. A mediator should have expertise in the substantive area of the conflict that is being addressed. Consequently, mediators for fcunily disputes regarding elder caregiving should have expertise in the conditions of aging and the long-term care options for elder persons, so that they can understand or suggest alternative solutions to the conflict. Nature of Conflict. Although conflict often is viewed as negative, it is a normative part of human interactions. It is highly visible in marriages, families, groups, organizations, communities, and societies, and viewed by some as a necessary part of social change (Coser, 1956). Perhaps the negative comiotadon attached to the word "conflict" comes from the ^sodation with a win-lose outcome common in competitive conflict resolution. Mediation seeks soludons that are win-win in nature, wherein all pardes to the conflict experience some satisfacdon of their interests. Conflict may come from several sources of an issue. These may be categorized as emodonal, substandve, and values (Coser, 1956; Knesberg, 1982). Conflict usually surfaces around substantive issues, whether or not substance actually is the key element in the conflict. Substandve conflict comes from pardcipants having different data, disparate interpretadon of the same data, or disagreement on procedures. Attempts to resolve conflicts create history and often hard feelings around the conflict. The emotional arena of conflict grows out of mistrust created from the history of conflict resoludon attempts or out of old negadve reladonship components that existed before the conflict. It includes stereotypes, repetitive negadve behavior, and poor communicadon. Out of these emodons, posidons develop around the conflict resoludon. 123

At times, conflict grows out of differences in values that result in disputants' inability to define ways to agree or to disagree. The mediator's role is to move the conflictfromthe emotional and values jirenas to the substantive arena, for it is that arena in which more room for negotiation exists. Once the emotional barriers are broken down, negotiation can occur about the data juid their meaning. Mediation Process. The processes of negotiation and mediation are quite similar. Negotiation is defined as a bargaining relationship between parties who have a perceived or actual conflict of interest; mediation is an elaboration and extension of that relationship. Mediation involves the intervention of an acceptable, impartial, and neutral third party who has no authoritative decisionmaking power and who helps the parties involved to negotiate their own mutually acceptable settlement (Moore, 1986). An assumption in mediation is that if disputants could negotiate solutions to problems without the assistance of an outside person, there would be no need for a mediator.

Agreement to Mediate. AH
members of a family must be contacted and invited to participate in a mediation process. Mediation is a voluntary process for aH participantsone cannot be forced to negotiate. The process, including the role of the mediator, must be explained to each party. It is necessary for the mediator to contact each person individually and get that person's agreement to participate. At the time of the individual contact, the mediator may ask the disputant about his or her interests and concerns to get an idea of the entire process before the first mediation session. Even though a disputant may tell his or her side of the story to the mediator before the first mediation session, each disputant is asked to repeat that information during the first session. At the first session, the mediator explains his or her role as a neutral third party and lays ground rules for the interaction. Ground rules such as no name calling and giving everyone a chance to talk without interruption may be necessary. The steps for facilitating negotiation between two or more parties have been clearly and efficiendy presented in a 124

popular book called Getting to Yes the issues. Optimally, some of the in(Fischer & Ury, 1981). These steps will terests behind disparate positions have be used to frame the mediation process. commonality and will serve as the basis Separate the People from the of agreements. Some techniques for findProblem. Because confhct usually car- ing participants' interests when not apries a substantial amount of emotionali- parent include asking why participants ty with it, the conflict, in the minds of hold the positions they hold, asking what participants, becomes the people in- the impact of one participcint's position is volved in place of the issue around which on the other participants, asking what there is conflict. The perception of the participants are going to need as a result person as the problem often prevents ef- of this mediation to be satisfied with it. If fective negotiation without an outside adult children of an elder family member person. The first step in negotiation is to can agree that, behind their various inseparate these from one another. The dividual positions, their common interest mediator faciUtates this step by asking is the best care for the elder member that each participant to describe the problem the family can afford, then the mediation and his or her feelings about it separate- process is well on its way to finding soluly, and by helping each participant tions. Often, the mediator has to point out separate these two. Time is allowed for that disputants seek a common end or ineach participant to express feelings terest because commonality is hidden about the issue. The mediatorusesactive behind emotional barriers. hstening skills to reflect and validate parCreate Options that Satisfy Inticipants' perceptions and feelings. Each terests of Participants. Many opparty is encouraged to use "I" statements tions that provide mutual satisfaction and listen to others' concerns and hear should be generated and explored. One them as legitimate. This helps separate reason for doing so is to help each particithe people from the problem. The medi- pant see more than one way (his or her ator validates each participant's experi- way or the other participant's way) of ence while listening for common interest. resolution. If the social worker is ui exThe mediator works to get the percep- pert in the substantive area, he or she tions on the table for everyone to hear. An may think of alternatives and resources agenda for work is established from the farnily members had not considered. concerns and issues presented. The Brainstorming can be used to think of mediator must build trust with partici- many ways to resolve this problem, inpants in his or her ability to facilitate the cluding those that may not be feasible. process. Indeed, the mediator must take The generation of many options creates control of the situation so that the par- more possibilities for problem resolution. ticipants can perceive that the situation It loosens up the rigidity of participants' is under control and safe for participation. thinking. Within the alternatives sugFocus on Interests Instead of gested lie perhaps several feasible soluPositions. Positions are predetermined tions, but they must be decided on. solutions to a problem from a particiSelect Criteria for Choosing pant's own perspective. Interests are Alternative. Finally, alternatives must those common human needs behind the be selected. The mediator asks how the position. A position of "My mother will selection of an alternative will be made. not (or will) go to a nursing home" may On what objective standard will the reflect an underlying interest of "I need agreed-on solution be judged? In elder to feel that my mother is getting the best care mediation, that stjuidard is likely to care available," or "I need not to feel be based on a principle of economic guilty about this placement." A key in feasibility or shared economic responnegotiation is tofoldcommon interests. sibility combined with quality of care. Common interests tend to be common Once an objective standard or criteria for human needs: security, economic well- judging the chosen alternative has been being, belonging, recognition, control agreed on, the mediator can help the over one's life. Interests are the silent family choose from the alternatives. movers behind conflicts. The mediator When alternatives are chosen, they are identifies interests behind positions as written down and copies distributed to aD participants present their positions on participants for further clarification and Social Work / March 1989

agreement. Fischer and Ury (1981) sug- best be represented by the social worker gested that effective negotiation pro- acting as mediator. The social worker duces a wise agreement, which is one ttotcan present herself or himself as a neutral satisfies the interests of all participants. par^ whose only interest is that arChoosing options based on objective rangements are made that meet the criteria helps to produce a wise agree- needs and interests of the elder. A third ment Objective criteria on which to base alternative is that the elder member is the solution in a dispute about elder care represented by a guardian ad litem or outmight include affordability of the solu- side person, which often is the practice tion, compatibility with medical opinion in child protection mediation. An outside regarding the elder's condition, and person may be appointed to serve in the agreement from the assumed competent best interests of the elder member, and elder. The mediator helps family- thus leave the social worker-mediator members reach solutions that help each free of anyone's interest to represent. member to save face and not be embar- This may be the preferred option if the rassed by participation in this conflict. conflict is intense and complicated. All family conflicts may not be mediable. To be appropriate for mediation.

Effectiveness of Family Mediation

An important question from the perspective of both effectiveness of this approach and ethics in practice is the role of an elder family member in the mediation process. Elders in need of family caregiving cannot be viewed as a group in terms of ability to participate in decisions regardingtheir care. Theymustbe viewed on a continuum of capacity to incapacity. Adhering to the principle of empowerment of clients toward selfdetermination, and in the interest of due process .elder family members should be involved in the mediation process to the extent that they are able and willing to participate. However, elder members may not be included in family conflict resolution. That is, elders may be reluctant to participate in an open discussion of conflicts. The strong socialization in our society against open discussion of conflict, particularly among the aging cohort, may mitigate against the acceptance of family mediation on the part of elder members. Elders are likely to feel bad about being the perceived cause of family conflict, and, as a result, downplay, disregard, or deny its existence. Recognizing this, a decision must be made about how to involve the elder member in mediation. Three different approaches are possible. The first and most desirable way is direct involvement, in which case the conflict may have to be minimized if some elders are to feel comfortable. Second, if the elder member cannot or will not participate in the mediation, his or her interest may

Elder family members should be involved in tlie mediation process to the extent that they are able and wiiling to participate.
the issues involved must be negotiable. That is, there must be more than one way to approach or settle the issues. Family members must be competent to negotiate. Persons with serious and longstanding alcohol or drug addictions are not considered reliable risks for keeping mediated agreements. Persons who are mentally incompetent cannot be expected to negotiate agreements and keep them. Obviously, life-threatening situations are not amenable to mediation intervention but, instead, must be handled in a more direct and expedient manner. Chandler (1985), in her comparison of mediation and other social work interventive strategies, proposed that mediation is most successful when there is ongoing personal interaction between disputants, when all parties are willing to express personal wants and needs, and when there is a relatively egalitarian relationship between the disputants. Even when the parties do not have an egalitar-

ian relationship, mediation serves as joint advocacy and tends to equalize status differences among parties. An important factor in whether mediation is an effective strategy is the presence of a "shadow of the future." That is, to what extent are the disputants required to interact with one another in the future? If the shadow of the future is large (family members wiU be in constant interaction with one another), the motivation for negotiating good or wise agreements is increased. If, on the other hand, there will not necessarily be substantial interaction in the future, the shadow of the future is smaller and motivation for families to enter into negotiation is reduced. Therefore, families whose shadow of the future is greater may be better candidates for mediation than those whose shadow of the future is smaller. A related and important concept is what Fischer and Ury (1981) referred to as BATNA, or the "Best Alternative To a Negotiated Agreement." If a disputant's BATNA is quite positivethat is, there Eire some desirable alternatives to negotiatingthe disputant may be less motivated to negotiate, and therefore less of a good candidate for mediation intervention. The reverse is true if the BATNA is quite negative. Family members and the elder person tend to lose a great deal if family conflicts are not resolved. The question is whether alternatives to a negotiated solution are as good or better, or worse than a negotiated agreement Some family members may believe that litigation is a better alternative than a negotiated solution. However, with most families, the shadow of the future is such that litigation or other more coercive forms of resolution are not desirable in the long run. These two concepts should be considered in care selection and used as leverage to help families stay in mediation when it become imcomfortable. Finally, the goal of mediation is to assist disputants to find workable agreements for resolving disputes. It is not a good strategy when clients have a different goal such as securing resources, creatiag new resources, or internal change. Empirical evidence for the efficacy of this approach does not exist, except in what can be concludedfromother family mediation. Empirical evidence exists 125

Parsons and Cox / Family Mediation in Elder Caregiving

to suggest that mediadon is a sound and effecdve strategy in divorce and child custody disputes. Kelly and Gigy (1988) found that divorcing spouses perceived that the mediadon process had a more salutary effect on their ability to be reasonable and communicate with each other compared with adversarial clients using attorneys, perceived that the mediators had led them to more workable compromises, and believed that mediadon intervendon resulted in greater increases in cooperation between spouses over time than did the adversarial experience. Furthermore, they found pardcipants to be more sadsfied with mediadon than the adversarial process in nearly all outcome measures. Finally, they found no evidence for the often-voiced concern that women are disadvantaged in the mediadon process because of lack of power inamarital reladonship. These findings confirmed the findings of other studies (Folberg & Taylor, 1984, pp. 147-189; Pearson & Thoennes, 1984). Mounting evidence suggests that mediadon is an effecdve strategy choice in conflicts between parents and adolescents (Lemmon, 1985, pp. 140-142). It appears that this behaviorally oriented approach increases commiinicadon and posidve interacdon betweenparents and adolescents in a way that insight-oriented counseling does not.

tionof conflict. San Francisco; Jossey-Bass. Knight, B. G. (1985). The decision to institutionalize. Generations, 10, 42-44. Kriesberg, L. (1982). Social conflicts (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall. Lemmon, J. A. (1985). Family mediation practice. New York: Free Press. Levande, D. I., Bowden, S. W., & Mollema, J. (1987). Home health services for dependent elders: The social work dimension. foumal of Genmtological Social Work, 11 (3 References & 4), 15-17. Berkman, L. F. (1983). The assessment of Mayer, B.{1987).Mediationandcompliancein social networks and social support in the child protection. Unpublished doctoral elderly.foumalof the American Geriatrics dissertation. University of Denver. Society, 31, 743-749. Middleman, R., & Goldberg, G. (1974). Social Blake, R., &Mouton, J. (1984). Solvingcostly service delivery: A structural approach to social organisational conflicts. San Francisco: workpractice. New York: Columbia UniverJossey-Bass. sity Press. Brody, E. M. (1983a). Women in the middle Moore, C. (1986). The mediation process. San and family help to older people. GertmFrancisco: Jossey-Bass. tohgist, 21, 471-480. Ory, M. G. (1985). The burden of care: A faBrody, E. M. (1983b). Women's changing milial perspective. Generations, 10.14-18. roles and help to elderly parents: Attitudes Pearson, J., & Thoennes, N. (1984). A of three generadons of women, foumal of preliminary portrait of client reactions to Gerontology, 38, 597-607. three court mediation programs.MofiafeiM Chandler, S. M. (1985). Mediation: Conjoint Quarterly, 3, 21-40. problem solving. Social Work, 30,347-349. Schwartz, W. (1961). Between client and Circirelli, V. G. (1986). The helping reladonsystem: The mediating function. In W. Mayer.(1987) studied the effects of ship and family neglect in later life. In K. RobertsandH.Northen(Eds.), Theoriesof mediation on compliance with treatment Pi]lemer&R.Wolf(Eds.),.Eiferaft!e.-0)sodalworkwithgroupsipp. 171-197). New plans by parents whose children were flict in the family (pp. 61-62). Dover, MS: York: Columbia University Press. subjects of child protecdon invesdgadon. Alburn House. Specht, H. (1969). Disruptive tactics. Social Mediadon was offered to parents and oc- Connaway, R. S., & Gentry, M. E. (1988). Work, 14, 5-15. Social work practice. Englewood Cliffs, NJ: U.S. Bureau of the Census. (1985). Democurred between social service intake Prentice-Hall. workers and the parents during the in^xiphic and sodoeamomic aspects ofaging in take process. The findings were that Coser, L. (1956). Thefunction of social conflict. the United States (Current Population New York: Free Press. Reports, Series P-23, #138, pp. 1-16). mediadon tended to increase parents* Washington, DC: U.S. Government Printpositive orientation and decrease Edinburg, M. A. (1986). Developing and in tegrating family-oriented approaches in ing Office. parents' negadve orientadon toward care of the elderly. In K. PDlemer & R. Wolf Walton,. R. E. (1969). Two strategies of social compliance. A reducdon occurred in (Eds.), Elder abuse: Conflict in the family change and their dilemmas. In R. Kramer parents' alienadve orientadon toward (pp. 267-281). Dover, MS: Album House. & H. Specht (Eds.), Readings in community child protecdon intervendon. Inaddidon, Fischer, R., &llry, W. (1981). Getting toyes. organization: Practice (pp. 337-345). parents felt they had been listened to in New York: Penguin Books. Englewood Cliffs, NJ: Prentice-Hall. the contracting process with the agency. Folberg, J., & Taylor, A. (1984). Mediation. Journals such as Journal of Conflict San Francisco: Jossey-Bass. Ruth J. Parsons, PhD, is Assistant ProResolution and Mediation Quarterly areHaynes, J. M. (1978). Divorce mediator: A fessor, Graduate School of Social Work, new role. Social Work, 23, 5-9. devoted to the development of theoredcal Heam, G. (1970, April). Socialworkas boun- University of Denver, Denver, CO 80208. concepts and evaluation of this strategy dary work. Paper presented at the Third An- EnidO. Cox, DSW, is Associate Professor, in human services. The specific approach nual Institute on Services to Families and GraduateSchoolofSodalWork, University suggested here requires empirical study Children, School of Social Work, Universi- of Denver. before claims can be made regarding its ty of Iowa, Iowa City, IA. outcome potential. However, if general- Hernandez, S. H., Jorgensen, J. D., Judd, P., Accepted November 28,1988 126 Social Work / March 1989

izadons can be drawn from other studies of the effecdveness of the approach, mediadon with families engaged in conflictual ddercare decision making could be expected to result in better communicadon and cooperadon among family members and in better outcomes in the decision-making process. Divorcing spouses in mediadon sometimes comment that if they tad been able to communicate the way they learn to communicate during the negodadon process of mediadon, they might not have split up. Perhaps intervendon with conflictual families can prevent splitdng up of families and promote their capacides to support and give care to their elder members.

Gould, M. S., & Parsons, R. J. (1985). Integrated practice: Preparing the social problem specialist through an advanced generjLlist's airriculum. foumal of Social Work Education, 21,28-35. Kelly, J. B., &Gigy, L. (1988). Divorce mediation: Characteristics of cUents and outcomes. In K. Kessel & D. Pruitt (Eds.), The mediationofdi^>utes:Empiricalstudiesontheresolu-