Prevention and intervention for older women at risk of neglect, abuse and violence
Suggested citation: Brownell P. Prevention and intervention for older women at risk of neglect, abuse and violence. Alban Med J 2015;1:64-71.
Prevention and intervention for older women at risk of neglect, abuse and violence
Patricia Brownell1
1 Fordham University, New York City, New York, USA.
Corresponding author: Patricia Brownell, PhD, LMSW – Associate Professor Emerita of Social Service, Fordham University, New York City, New York, USA;
Address: Fordham University, New York City, New York, USA;
E-mail: brownell@fordham.edu
Abstract
Prevention of domestic violence is an important public policy goal and strategies include public education as well as sanctions through the criminal justice system. Elder abuse prevention has lagged behind domestic violence, and public education has been conducted largely through aging service systems and through non-governmental organizations.
There are no nationally uniform response systems to address neglect, abuse and violence against older women, However, nations, states, localities, professional organizations, agencies and grass roots groups have developed innovative preventions programs and initiatives to prevent abuse of older women within different service sectors such as health and mental health, social service, criminal justice and housing. Programs and initiatives may target older women as part of a broader campaign to prevent intimate partner violence of girls and women of all ages; prevent elder abuse and mistreatment; campaign against ageism or promote protection of widows; or promote community health. It may also mandate training of workers in health, institutional or care settings to promote understanding of neglect, and abuse of care dependent older women and how to prevent it.
Interventions for older women victims of neglect, abuse and violence are still evolving and few have been evaluated rigorously for effectiveness with their targeted population. As interest in older women and abuse increases, more evidence-based intervention models will likely emerge.
Keywords: abuse, intervention, neglect, older women, prevention, violence.
Prevention of older women abuse
Prevention of domestic violence is an important public policy goal and strategies include public education as well as sanctions through the criminal justice system. Elder abuse prevention has lagged behind domestic violence, and public education has been conducted largely through aging service systems and through non-governmental organizations. Criminal justice strategies have largely focused on those who place vulnerable adults at risk of harm.
However, several current trends are changing this (1). The world is aging and increasingly frail older adults are living at home in the community. The influx of women into the workforce has meant there are fewer informal caregivers available to provide in home care. Elder abuse has been given a higher profile through media attention on abuse of the elderly. Concerns about the fiscal viability of older adults living longer on pensions and social security has also sensitized the public to the impact of scams against older adults, especially older women (2) and poor financial planning (3). Prevention of elder abuse, neglect and exploitation has taken on a new urgency (1).
A model of prevention developed by Gordon (4) is used to discuss main approaches to prevention of neglect, abuse and violence against older women. Gordon identifies three categories of prevention that can be applied to an overview of strategies of prevention for mistreatment of older women. These are universal preventive strategies targeted to the general public or a whole population group that has not been identified on the basis of individual risk for neglect, abuse or violence; selective preventive interventions targeted to individual or subgroups of older women in the population who are at high risk of experiencing neglect, abuse or violence at some point in their lives; and indicated preventive strategies targeted to high-risk older women who may not presently meet the criteria for neglect, abuse or violence, but who are identified as having minimal but detectible signs or symptoms of abuse (5).
There are no nationally uniform response systems to address neglect, abuse and violence against older women, However, nations, states, localities, professional organizations, agencies and grass roots groups have developed innovative preventions programs and initiatives to prevent abuse of older women within different service sectors such as health and mental health, social service, criminal justice and housing. Programs and initiatives may target older women as part of a broader campaign to prevent intimate partner violence of girls and women of all ages; prevent elder abuse and mistreatment; campaign against ageism or promote protection of widows; or promote community health. It may also mandate training of workers in health, institutional or care settings to promote understanding of neglect, and abuse of care dependent older women and how to prevent it.
Universal preventive initiatives:
• Screening for elder abuse at the primary health care level is recommended by the World Health Organization (WHO) (6).
• A charter for the rights and responsibilities of older people in need of long-term care and assistance was developed and disseminated as part of the DAPHNE III initiative in the UK and EU. This is intended to serve as a bill of rights for older adult clients and caregivers, which are assumed to include older women, as part of a prevention and early intervention initiative (7).
• World Elder Abuse Awareness Day, designated as June 15th, was initiated by the International Network for the Prevention of Elder Abuse (INPEA) in 2006, and ratified as a United Nations (UN) Day in 2010 by the UN General Assembly. Governments around the world, along with states, municipalities, communities and local agencies have used this as an opportunity to educate and raise awareness about mistreatment of older adults. While not specifically targeted to older women and neglect, abuse and violence, it provides an opportunity for education about this population. In Spain, localities have participated in the WEAAD to raise awareness about abuse of older women and men (8). Awareness raising initiatives around the world can be seen on the INPEA home page (www.inpea.net).
• In the USA, the federal Administration on Aging initiated a public awareness campaign designating the year 2013 as Elder Abuse Prevention year, and posting multiple educational and consciousness raising materials on its website for downloading by local and state aging and community service groups (9).
Selective preventive initiatives:
• The West Virginia (USA) Coalition against Domestic Violence launched a public awareness campaign that caregiver stress is never an acceptable excuse for violence. The campaign included an educational booklet, a video and a play, designed to be performed by school age children and senior citizens in local communities to facilitate intergenerational discussions on caregiver stress and abuse (10).
• In Taiwan, an educational support group for nursing home staff resulted in a decrease in staff psychological elder maltreatment and an increase in knowledge of gerontology (11).
• In Australia, a self-report screening scale for elder abuse was developed and validated as part of the Women’s Health Australia Study. Researchers noted the importance of early identification of elder abuse for effective early intervention and prevention of abuse against older women (12).
• Community-based paralegals are trained in Tanzania and Mozambique in inheritance and land law by HelpAge International, and disputing villagers are encouraged to consult with them. The purpose is to reduce violence against older widows who are accused of witchcraft and physically harmed or sometimes killed (13).
Indicated preventive initiatives:
• The Flemish Reporting Point for Elder Abuse is a part of a social service agency and not only registers reported cases of elder abuse, but also conducts training, provides information and advice to community residents, trains elders, professionals, home caregivers, volunteers and students increase awareness and expertise about elder abuse and how to recognize it (14).
• A psychological treatment program for caregivers who abused or neglected an elderly dependent was developed in the UK. A pre and post evaluation design found significant reductions in strain, anxiety and depression of the abusive caregivers, and reduction in problem factors were maintained during a 6-month follow-up (15).
• The National Institute for the Care of the Elderly (NICE), University of Toronto, Canada, created the Older Women and Financial Literacy Project, which was designed to address the high level of poverty and the low level of financial literacy among older women in Canada. Older women from three cities in Canada (Vancouver, Montreal and Toronto) participated in the development and delivery of financial literacy resources using a peer education model (3).
Evaluations of preventive programs and strategies have focused more on short term and process goals and objectives, as opposed to long term goals of reducing or eliminating violence against older women. For example, the evaluation of the psychological treatment program designed to reduce repeat abuse by family caregivers measured reduction in caregivers’ stress at the end of the program and during a 6-month follow-up but didn’t measure long term reduction of abuse. A preventive strategy that involves sensitizing providers to signs of elder abuse and setting up a reporting system may find increased numbers of older women who are abused. However, investment in evaluating preventive strategies and programs can lead to more effective and efficient targeting of resources to address the problem of older women and abuse.
Interventions
Interventions for older women victims of neglect, abuse and violence are still evolving and few have been evaluated rigorously for effectiveness with their targeted population (16,17). As interest in older women and abuse increases, more evidence-based intervention models will likely emerge.
Elder abuse in the older adult protection frame has adopted some protective strategies from the child abuse field, including guardianship services. While guardianship is an extreme measure that can remove rights from older adults and must be used with care, it can also serve to protect older adults who have dementia and are being financially exploited, or who have care needs that are not being met by identified caregivers. Ideally, however, elder mistreatment interventions incorporate empowerment strategies. These have much in common with domestic violence services, including self-help groups for women of all ages, safe homes, use of law enforcement and legal action (18).
Depending on the conceptual frame used, older age is identified as a risk factor for neglect, abuse and violence if taking vulnerability and need for care and protection into account (Social Gerontology and Adult Protection frames), but the opposite is found in the Intimate Partner Violence (IPV) frame. In IPV and intimate homicide studies, older women up to age 65 are found to be at greater risk of abuse and violence by intimate partners than women age 75 years and older. In addition, the forms of abuse differ, with more physical violence reported against older women at the young end of the old age spectrum and more psychological abuse reported at the older end of the age spectrum. Because neglect, self-neglect and financial exploitation are not included in IPV research on women of all ages, as well as abuse by family members and others not including spouse/partners, older women appear to suffer less abuse and violence than younger women in this conceptual frame.
Social isolation and lack of social support have been identified as risk factors for women victims of all ages in IPV, SG and AP research frames. Lack of community service alternatives have been identified as salient in SG and AP research frames, and for IPV, lack of shelters and other community service supports, including access to needed health care for battered women. In reports on abuse of older women through charges of witchcraft (19) and calls for widows to engage in Sati (20,21) suggest that in some circumstances community members can serve as perpetrators of abuse. The community can also serve as a source of strength if supportive of the older woman victim.
The intervention models presented below have been developed for older women; those programs that are not intended specifically and primarily for older women victims of abuse, while intended to serve both male and female victims of elder abuse, are not included here.
Interventions for older women caregivers of abusive men
Koenig et al. (22) propose that female older adult caregivers need to understand and practice ethical decision making if they have a history of experiencing domestic abuse by the care receiver. In the feminist frame, domestic violence is defined as a distinct incident of abuse (kicking, hitting, pinching) occurring in an intimate relationship over time and located in wider social inequities between men and women; further defined as physical, sexual or psychological force by a man against his intimate female partner.
For older female caregivers of abusive and formerly abusive men, the empowerment of female survivor caregivers requires a growth process. This includes: 1) increased awareness of the effects of relational abuse and contemplation of decision to end it; 2) identification of ethical dilemma and hard choices; 3) acknowledgement of abusive spouse’s increasing frailness and development of boundary setting and assertiveness skills; 4) widening circle of support by accessing services. Koenig et al., suggest that the gerontology community has failed to address the impact of domestic violence on community caregiving relationships.
Professionals working within the feminist frame have begun to develop intervention models for older women with a history of domestic violence who were providing care for their abusive family member (22). Evaluations have not to date been published on this intervention model.
Services for older women with care needs
Some countries, most notably Japan and Britain, have established universal systems of long term care. In-home and residential care for physically impaired older women can serve as a protective strategy for prevention of family abuse. Two societal factors in Japan can facilitate early detection of family abuse of care dependent older women: social workers from Home Care Support Centers have close contact with families of older adults receiving in home care through the national long term care system. In addition, community volunteers who provide support for families with older members receiving home care services can identify early signs of abuse and neglect of care dependent older members and seek to provide education and support to family members (23).
Training and education on abuse in later life for professionals and students
Training and education programs designed to raise professionals’ awareness of domestic violence as a form of elder abuse address perceptions that intimate partner abuse in older couples doesn’t exist or isn’t as serious as abuse with younger couples. A study conducted in Florida, USA, compared attitudes of students in professions of social work, criminal justice and public administration on younger and older domestic violence and found that students tended to minimize domestic violence among spouse partners in older couples compared to younger couples (24).
Training manuals and tool kits for providers serving older women who are victims of abuse have been developed in both Canada and the USA. Bridging Aging and Woman abuse: A Resource for Service Providers Working with Older Women Experiencing Abuse was developed by the National Institute for the Care of the Elderly (NICE) at the University of Toronto. It provides an overview of what is unique about older women abuse, gives practice tips and information, explains informed consent, outlines safety planning guidelines and includes planning charts and other tools (3). In their Own Words: Domestic Violence in Later Life is a manual that can be used for training and conducting groups with older women victims of abuse (25).
Legal services for older women victims of abuse
Legal services for older women victims of abuse may be different based on whether the older woman is considered cognitively capable of making decisions on her own or not. For neglected or self-neglecting older women who may also be financial exploited or physically abused, guardianships and related services may be most appropriate. For older women who are cognitively intact, legal services to obtain orders of protection, divorce proceedings, eviction protection and related services can be obtained through the domestic violence systems. Legal protections against financial abuse and scams are accessed through the aging service system.
Support groups for older women victims of abuse
Support groups for older women struggling with IPV are important resources (25-28). According to Kaye (29), support groups are considered crucial in providing a buffer against the negative consequences of aging. Cited benefits of support groups for older women victims of family mistreatment include mutual feedback, empowerment, assistance with coping strategies, and social support (28).
Social support provided by groups for older women struggling with IPV is considered especially important in view of tactics used by their abusers to socially isolate them (27). Key issues in planning support groups include timing of the day (holding group sessions when older women are likely to be able to attend), providing transportation and food, ensuring freedom to leave the group, and funding. Confidentiality and safety have been identified as important considerations as well; underlying assumptions of support groups with IPV victims in later life include power and control as the underlying motive in the abusive treatment unless proven otherwise (27).
IPV support group models can range from peer led groups without set topic agendas to those centering on activities like sewing, quilt making or art with discussions about abuse secondary, to professionally led groups with structured learning content. One psycho-educational support group model that has been evaluated for effectiveness was developed for a battered women’s shelter (30), and tested in the community (26).
Domestic violence shelters for older women victims of abuse
Battered women’s shelter programs have not always been successful for older battered women. This is because of limited resources that have led to prioritizing shelter beds for younger battered women and their dependent children, as well as a general lack of fit between shelter programs and the needs of older women victims (31). Outreach and education of providers in service systems like aging service networks including senior centers and adult protective service systems are also considered critical to effective utilization of shelter services by older women. Most domestic violence shelters were found not to offer special programs for older women (31). A very few shelters have been developed in long term care facilities (32), due to expense and lack of reimbursement by government and other funders. A shelter in a long term care facility can accommodate older women victims of abuse who are also physically or cognitively impaired.
Interventions aimed at perpetrators
Treatment programs for elder abuse perpetrators fall primarily into two categories: domestic violence/intimate partner abuse and elder mistreatment (gerontology). In the USA, most states have legislated batterers’ treatment programs as part of domestic violence prevention strategies, and these models are readily available online. While few focus entirely on older adult abusers, they suggest the inclusion of information on elder abuse as part of a focus on special populations, for example, in their curricula.
The State of Rhode Island, USA (33) encourages but does not mandate programs to develop group tracks and/or particular sessions that are geared toward certain specialized populations (for instance repeat offenders, female offenders, elder abuse, non-partner violence, or others). A model similar to this, the Elder Abuse Perpetrator Program, was implemented in Australia (34). Another model has been developed for abusive and stressed caregivers. As discussed earlier, one psychological treatment program for caregivers who abused or neglected an elderly dependent was developed in the UK (15).
Treatment programs for substance abusing and mentally ill abusers may be utilized by the criminal justice system as part of a court diversion sentence for family abusers if the victim requests this and the abuser agrees. Perpetrators of abuse against older adults in need of protection are most likely to be sentenced to jail or prison terms as opposed to treatment programs.
Conflicts of interest: None declared.
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