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Elder Abuse Workshop: Laying the Foundation for Theoretical Model Development in Elder Mistreatment

Introduction — Dr. Laura Mosqueda

Dr. Laura Mosqueda introduced the discussion by asking why elder mistreatment occurs and suggesting that the way we think about this will determine our interventions and intervention strategies. It is a complex issue and we must be respectful of, but not overwhelmed by, the complexity. One question is whether the issue can be broken down into studyable components. If it is too simplistic we will miss the interacting factors, but it is worth considering whether we can get a testable hypothesis that allows us to design testable interventions. Might there be a relatively small number of models that account for 80 percent of abuse? We have heard about a number of factors: caregiver stress, entitlement thinking, cycle of family violence, caregiver revenge and greed, mental health challenges, abuse-waiting-to-happen issues—is it possible that abuse might largely be a by-product of one of these factors? First, with this panel, let's explore how models have been used in other fields, particularly domestic violence.

Panel Presentations:

Joan Meier—Models of Domestic Violence

In attempting to develop a model for elder abuse, it might be helpful to consider the models of domestic violence. In terms of history, the patriarchal roots of society led to the Doctrine of Coverture under which women lost their separate legal identity once they were married. This doctrine dominated thought and action for centuries and was only overtly rejected in 1910. Even as recently as 20 years ago, police would not arrest in domestic violence cases, deeming them private matters. It is not that people were not aware of the problem, it was just that society let it go underground because grappling with trauma is so excruciating. This notion of behavior being excruciatingly painful may have some resonance in elder abuse. In the 1960s, the women's movement surfaced awareness of the prevalence of violence against women. A key point is that it is necessary that a community acknowledge the reality of the horrors—that allows us to come to grips with it.

Given this history, it may seem obvious that domestic violence is related to gender inequality and is a function of male domination, but there are many alternate theories to this feminist perspective, including that women are hooked on abusive relationships in a self-destructive way, that it is really a mutual dysfunction relationship, or increasingly the notion that women are violent, too (and there is some empirical evidence of this). A new model has been advanced by Michael Johnson to try to resolve the tension between the feminist perspective and the nonfeminist view. He posits that perhaps both are right and that there is both intimate terrorism (feminist paradigm) and situational couple violence that is less controlling and less terrorizing. The model allows for the notion of women's violent resistance in response to intimate terrorism and possibly even mutual violent control. This theory has engendered much debate and sparked the fear that if Johnson's model gains wide acceptance, we'll never be able to protect women in court.

Final thoughts: Models are both useful and double-edged. The feminist view was critical to making social and legal changes regarding the abuse of women, but now we see some pushback. How does this relate to elder abuse? Perhaps what is needed is less a model and more a political movement to generate concern, attention and action. On the other hand, perhaps a model or political analysis is essential to such an awakening or movement. In terms of a political movement for elder abuse, consciousness must be raised about how abysmally western society treats older people, and this will entail political and ideological challenges to western social norms regarding the lack of respect for elders. It will take a cultural change of awareness for people to realize that elders are us. We will all be there someday, and we are doing this to us.

Georgia Anetzberger—Caregiving: Primary Cause of Elder Abuse?

Calling herself a practitioner first and researcher second, Dr. Anetzberger noted that caregiver stress (CS) and burden has been advanced as the explanation for elder abuse. Believing that the explanation is more complex, Dr. Anetzberger developed an explanatory model for elder abuse that:

• Recognizes the problem as complex and having a variety of forms, perpetrators and victims.

• Reflects the research to date.

• Can incorporate various theories.

• Suggests intervention strategies to inform the practitioner.

• Supports interdisciplinary cooperation for effective treatment.

The model consists of five interrelated components that lead to abuse:

1. Cultural context of social values and norms—e.g., right now our society has a love affair with violence and ageism.

2. Perpetrator characteristics (primary consideration)—e.g., substance abuse, financial dependence.

3. Victim characteristics (secondary consideration)—e.g., Alzheimer's, other dementias, social isolation.

4. Context for victim-perpetrator interaction—e.g., caregiver, guardian/ward, intimate relationship.

5. Context for abuse occurrence—such triggers as the perpetrator has unrealistic expectations or the victim exhibits troublesome behavior.

Useful interventions to prevent or treat elder abuse will vary by model component:

• Cultural context of social values and norms—e.g., intervention is to just say no to caregiving because it is not a good role for you.

• Perpetrator characteristics—e.g., perpetrator may have problems such as substance abuse or mental retardation and need intervention himself/herself.

• Victim characteristics—e.g., victim may benefit from geriatric assessment.

• Context for victim-perpetrator interaction—e.g., a support program through an agency of the Older American Act to help the caregiver relieve some stress.

• Context for abuse occurrence—e.g., perpetrator may benefit from anger management.

Bonnie Brandl—Why Does Elder Abuse Occur and Persist?

Ms. Brandl noted that her focus is as a person working in the field who does training and talks to elders—she is not a researcher. From comments she hears in the field it appears that this is an intergenerational problem and that giving care is very stressful, leading to elder abuse due to caregiver stress.

Who are the victims? They are persons ages 60 and older, not necessarily vulnerable, who are in an ongoing relationship with an expectation of trust that they want to maintain. They are harmed both accidentally by well-intentioned caregivers or intentionally, either through contact with persons with physical or mental health conditions that manifest themselves in aggressive or inappropriate behavior, or by being abused. Elder abuse appears to occur from a sense of entitlement that is often very much about greed. It persists, as is illustrated by the Abuse in Later Life Wheel, for complicated reasons, but at the center is power and control. One concern is that if an abuser really has an entitlement mentality, intervention to address his/her anger management or substance abuse issues may not be sufficient.

The notion of caregiver stress came from asking abusers why they do it, with their answer being "I'm stressed." Many abusers will tell the truth, but others blame the victim and manipulate. Another fact about caregiver stress is that it leads to more self-destructive behavior. Most caregivers are not abusive to other people as a result of caregiver stress.

Where does caregiver stress lead us in terms of intervention? Here is an example:

I am in the field investigating a physical abuse case with a couple in their 70s. He answers the door and says his wife is sleeping, but he will talk. He says he loves her, that she is the most important person in his life, that she can't care for herself, or him, or the house, that it happened just this one time. For this case we can do things to help if it is caregiver stress. Now picture the exact same scenario but instead of 70, the caregiver is 22. If I believe that it is caregiver stress then I act in an interventional way; that is fine if it really is caregiver stress. But if it is not, he will awaken her and scream at her and say that the social worker thinks he's right and needs respite. In this case I have encouraged his negative behavior.

The point is that not all frameworks, not all models, get us to victim safety.

Dialogue with Panel

Dr. Mosqueda asked the panelist to comment on the notion of a "time-out" for staff to counter abusive feelings or impulses. Ms. Brandl noted that establishing an ongoing relationship does not always play out in the facility setting, but that this issue implicates a mindset about how to act in stressful situations, and people generally find another outlet as opposed to abuse. Dr. Anetzberger suggested that taking a "time-out" in the facility setting is complicated by regulations and staff shortages. Dr. Mosqueda, noting that the panel had pointed to power and control issues, not simply caregiver stress as causing abuse, asked them to consider the certified nurse assistants/aides (CNAs) making $7/hour in a very stressful situation—what is leading them to be abusive if not caregiver stress? Dr. Anetzberger stated that this is a complicated matter with many variables: a cultural context that might involve racism, CNAs who may lack empathy and are stretched to the limit in other ways, staff shortages that undermine continuity of care, and often demented residents. In this context we ask a CNA to assist an individual who spits at her, pulls her hair, and we expect her to do nothing. We need to take a systematic look at this issue. Ms. Brandl added that the abuse might be driven by power and control for people who want to dominate these frail people. Ms. Lori Stiegel suggested that, no matter what factors were causing the problem, the issue should be addressed through staff training. Dr. Pamela Teaster recounted an experience where a CNA did not even have enough food, let alone being faced with child care and transportation issues. She wondered whether, for people in the situation of having their own very difficult lifestyle, training can actually address the abuse problem when personal problems run so deep. Ms. Brandl suggested that volunteers can help be the eyes and ears in the facility, as she found with her own mother who, as a volunteer, was able to make suggestions about things that she had witnessed in the facility. Dr. XinQi Dong referred to a body of literature comparing caregiving skills for a particular population, such as Alzheimer patients, with the caregiver's own issues. He suggested that it would be interesting to focus on skills by comparing caregiving skills with caregiver stress and burden to see how much the problem of abuse might be due to one or the other.

Dr. Ron Acierno suggested that there is a danger in the early stages of research in allowing too much theory or too much politics to intrude, because these can drive the questions instead of the other way around. He stressed the need in the early phase of the study to look at the component pieces first and find the extent of the problem by getting the numbers. He wondered whether stress data were dismissed because caregiver stress did not fit the model. Ms. Brandl replied that in her work of training people who are on the front lines there is a need for immediate answers. Dr. Kerry Burnight agreed that people in abuse situations need to have their problem addressed now, so it is important to have practical tools on the table even as the research goes forward. Ms. Meier felt that models could be helpful in peeling away layers, but she noted from her perspective as someone outside the field of elder abuse that it seems very clear that many things—not just one thing—are going on. The problem is that there is not yet widespread sentiment that elder abuse is unacceptable. We discount the worth of nursing aides' service so there is a social willingness to ignore the fact that they make $7/hour for very difficult work. The greater need is for a movement to coalesce around elder abuse, as happened for domestic violence when women latched on to the domestic violence problem, moved it forward into social consciousness, and thereby gained money and support for the fight. Dr. Ken Conrad stated that articulating the best theory is essential in directing the study of elder abuse, rather than letting the numbers guide the study. He noted that science involves developing a hypothesis and testing it; the same must be true for elder abuse where the theory guides the data collection. Dr. Shelly Jackson agreed that science is the world of competing ideas and it is valuable to get as many theories as possible and test them all. Ms. Erica Smith suggested that theory testing and hypothesis testing should be separate from data collection. Knowing what one wants to test will guide the instrument used, and this could be a barrier to capturing all the data. Today's discussion has been illuminating in asking how much abuse is attributable to caregiver stress versus power and control. It would be interesting if we could explain 80 percent of abuse with one theory, but we can't do that by choosing one perspective over another. Dr. Jeffrey Hall commented that the application of theory depends on the character of the situation. What is needed is a multilevel approach with all theories on the table. Dr. Solomon Liao suggested that it is not so important to get the model correct as it is to have a unifying model. He expressed surprise that the mutual control model in domestic violence was not more accepted, saying that mutual control and dependency is more common than power and control. Ms. Meier stated that there is so much going on that it will be difficult to develop a model for elder abuse. There is more need for a movement based on how we devalue older people. She found the mutual control model inherently contradictory because the way power and control works in the domestic violence field is if one side has the power, the other side doesn't. Dr. Liao suggested that there are issues of mutual control in end-of-life decisions, with dying persons sometimes accepting treatment based on their desire to please family members and doctors. Ms. Meier suggested that these issues were different from the notion of mutual control that she was describing. The power and control to which she was referring, she posited, could not be mutual because it was about non-normal levels of control that approached the pathological.

Ms. Lori Stiegel suggested that in the effort to quantify elder abuse with the goal of getting more research money, there has not been a universal definition of elder abuse. Perhaps instead of trying for a universal definition, we should produce a definition that works for quantifying the issue and not be concerned that it does not necessarily drive theory or what the practitioners do. Dr. Anetzberger asserted that we have to have definitions in order to collect the numbers. The problem is that the definition of elder abuse keeps expanding, and so it is harder and harder to do prevalence studies. There is a need to contain the definition. Dr. Wendy Verhoek-Offendahl stated that it was premature to try to nail down a definition at this time. There is still much that is unclear, and if we keep data collection simple and collect variables carefully, we can restrict our definition but get a better idea of who are the victims, the perpetrators and the trusted others. We need to evaluate what we have and get a better understanding of what we are seeing. If we came up with a definition now, Dr. Wilbur observed, she was not sure that much of the data that she has at this time would even fit it. Dr. Dong asserted that writing a grant without a theory or hypothesis would be "suicidal," but he cautioned that there is still a need to be open to a broader scope. We need the numbers and must have a theory to guide us, but still must be willing to adjust the theory as the numbers come in. What would be very valuable is a rigorously designed, national, population-based study. Dr. Scott Cunningham suggested that theory must be involved at the front end, such as exploring whether the domestic violence model applies to elder abuse and, if so, incorporating the relevant portions in terms of victim safety, harm, law enforcement and increased risk of early death. Theory must also be involved at the back end, which is where methodology is implicated in terms of qualitative approaches and early interventions. Dr. Fred Newman stated that every time we go out and collect data an implicit theory is there. The question is: is the theory testable and deniable? He differed with Dr. Cunningham that a lot of qualitative things are going on preceding the collection of data. Dr. Conrad asserted that theory is how things work, so practitioners want theory. When we hand them a ruler to measure psychological abuse we are handing them a tool based on theory. Dr. Sid Stahl stated that we don't do research without theory with a practical background behind it. He urged everyone to forget about closure for a definition. The key is to bring people to share theoretical structure and research issues that make sense to those in the trenches. Dr. Acierno clarified his point, noting that theory is necessary but there should not be too much theory. It is better to assume as little as possible to minimize how much theory gets in the way of asking critical extra questions. It is better to minimize the theory and the politics and maximize the description of the event. Scientists should not be the ones doing the political movement.

Dr. Kate Wilbur suggested that the outcome must be victim safety. She said that her focus groups have shown that elders are afraid to acknowledge abuse because they fear that they will be sent to a facility. The question is what does it mean to be safer, and given the fear of the facility, is safer better? Ms. Brandl noted that the word "safety" means many different things, and there must be a balance between safety and protection in terms of how we view rights taken away in the name of safety. This may be different from domestic violence where, if there is a power and control imbalance, you restore power to the victim so she regains control. Ms. Jane Raymond noted the work in her state in trying to bring older battered women into the APS universe, sparking questions about whether these victims need services different from elder abuse victims. It was noted that there are differences among states in handling these cases. In some states it is felt that it is dangerous to contact perpetrators, so it is not required. The focus is on the victim with no identification of the perpetrator. Other states focus on the perpetrator and are driven by perpetrator rights. Dr. Anetzberger responded about the interface between elder abuse and battered women, noting that previously none of her state's shelters were accessible to the handicapped and now they are. These nuances are important. Dr. Post stated that the women's movement had neglected older women. Older women were excluded from the Violence Against Women Act, which applies to ages 18-65. Abuse is abuse, but older women face additional challenges, including stereotyping, lack of access to shelters, different types of abuse against elders, cultural bias against divorce and the onset of dementia in their partners. Ms. Janice Green noted that the Office on Violence Against Women has a program for older women, but the challenge is adapting outreach and the definitions of success and safety, which are geared to younger women, to the older population. It is not a matter of not being willing to help older women, but of not helping because we are not responding properly to their needs. We might say, "we serve everyone," but we are not really serving older women because they are not calling themselves "battered." How you define whom you are working with defines how you do outreach. We need information from researchers to help us develop things like training programs for law enforcement officials who respond to elder abuse. Ms. Brenda Uekert noted the divide between social science theory and law enforcement practice in elder abuse, noting that it is not likely that the basic law enforcement response is going to change. Ms. Page Ulrey noted that her office is engaged in a massive training effort to combat the denial of elder abuse in the courts and by law enforcement.

Dr. Jerry Silverman discussed the political movements around domestic violence and child abuse. He noted that the issue of child abuse had an early history of supporters but was mainly driven in the early 1950s by doctors. He asked who represents or advocates for battered children and suggested that there is not a strong constituency for that. Domestic violence has a constituency, although it only goes so far. The question is where will the constituency for elder abuse come from? Who will speak out for vulnerable elders? Ms. Fran Henry agreed, noting that battered women themselves came forward. There has not been the same advocacy for child abuse because it is hard for the victims to come forward, just as it is hard for elder abuse victims to come forward. It behooves the professionals in the field to take a stand. Ms. Kathleen Quinn suggested that the AARP consider taking up this cause.

Dr. Mosqueda informed the participants about an organization that she and Dr. Burnight are starting in California called ElderPeace, which will bring together victims of elder abuse, family members, and those outraged by elder abuse with professionals in the field to generate an outraged public to advocate effectively. Drs. Mosqueda and Burnight also propose to write a white paper outlining the theories and models for elder abuse and devise testable hypotheses so that we can stop reinventing the wheel. They invited all participants to e-mail them with comments and ideas.