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15 Elder Abuse Intervention: Lessons from Child Abuse and Domestic Violence Initiatives David A. Wolfe* D espite being in the public eye for many years, progress in all areas of research, causes, consequences, and interventions of elder abuse has been very slow. Consequently, there is a noticeable lack of intervention initiatives or evaluations in this field. A recent review of interventions in child abuse, elder abuse, and domestic violence identified 144 controlled evaluations, yet only 2 dealt with the topic of elder abuse (Chalk and King, 1998). This is not surprising, however, when one consid- ers how intervention in related areas of domestic violence developed slowly at first, hampered by a lack of research findings on causes and limited funding directives. Almost in stages, the related fields of child abuse and domestic violence grew from the voices of concerned practitioners as well as survivors, gaining the attention of the public and the recognition of researchers and professionals. Efforts to understand and deal with abuse of the elderly by family members or other caregivers are reminiscent of where the study of child abuse and woman abuse was 20 years ago. Although there is still much to be done in terms of detection and investigation in these two related fields, knowledge gained from past and recent efforts may benefit current intervention planning in elder abuse. The current chapter is intended to offer insights into intervention and *David A. Wolfe, Ph.D., is a professor in the Department of Psychology at the Social Science Center, University of Western Ontario. 501
502 ELDER MISTREATMENT prevention possibilities with elder abuse on the basis of findings in related, but somewhat more advanced, areas of child abuse and domestic violence. Importantly, this chapter does not address the full extent of the problem of elder abuse or the full range of interventions available to address it; rather, it examines intervention possibilities involving some form of elder abuse based on other forms of family violence. The common denominator for this discussion is that all three populations involve close, interdependent relationships with others, which form the potential circumstances and con- text for abuse. At the same time, there are many important differences between the contexts and consequences of elder abuse when compared to other abused populations, and these differences have important implica- tions for how one might intervene with the elderly. Nonetheless, lessons derived from progress in child abuse and domestic violence initiatives pro- vide a valid starting point for drawing more attention to elder abuse. Cynically, one could argue that little progress has been made in ad- dressing the fundamental causes and consequences of the many forms of domestic violence, as well as their effects on children, over the past three decades. These problems seem as serious as ever and major underlying causes, such as abuse of power, inequality, and modeling of violence in the home, remain largely unchanged. Unfortunately, societyâs response to these difficult problems has been largely one of detection and management, in which services are given on an individual basis only when it becomes abso- lutely necessary. Although crisis management makes sense when the inter- vention is critically needed and highly effective at a particular point in time, it is poorly suited to address fully the dynamics of woman, child, and elder abuse (Wolfe and Jaffe, 2001). Unless additional resources and strategies are brought to bear, the task far exceeds the capabilities of most crisis intervention approaches, which are a necessary but insufficient part of our response to domestic violence. From a more optimistic perspective, in less than two decades scientific, professional, and activist groups have played a prominent role in recogniz- ing the links between various forms of domestic violence and serious mental health and other issues (Peled et al., 1995). Shelters for battered women and their children have increased dramatically, there are more laws on the books, and there is consensus that family members who are maltreated by other family members must be protected (Family Violence Prevention Fund, 1998). Increased interest and understanding by researchers and clinicians in the field of domestic violence make it possible to establish a scientific foundation for implementing prevention and treatment initiatives and pub- lic policy to end elder abuse and related forms of violence. Societyâs responses to woman abuse and child abuse, in particular, took more than two decades to turn from preliminary recognition and acknowl- edgment to more uniform opposition and action. While legal changes
LESSONS FROM CHILD ABUSE AND DOMESTIC VIOLENCE 503 created an impetus for change, an initiative for change is also emerging from various professions to recognize the signs of domestic violence and to conduct proper inquiries and referrals when such cases come to their atten- tion. Despite their pivotal role, however, the training and education of health care professionals about family violence remain inadequate for proper intervention (Institute of Medicine, 2001). Mental health professions have adopted standards, procedures, and practices for dealing with many forms of domestic violence, which have been implemented sporadically at community, state, and national levels. Social service professionals have supported and often been responsible for the development of new treatment orientations and options for both vic- tims and perpetrators of domestic violence. At a preventative level, many communities have recognized their responsibility in dealing with woman and child abuse issues through training programs, education, and the allo- cation of resources to relevant individuals and families. Finally, the general publicâs level of consciousness has been raised by the widespread use of hot lines, abuse registries, and public education campaigns.1 This chapter considers how these developments in related areas of domestic violence can inform the field of elder abuse intervention. ASSESSMENT AND INTERVENTION ISSUES Screening and Detection There have been numerous attempts in the last decade to develop screen- ing instruments to identify persons at risk for elder abuse or neglect, follow- ing the lead of child welfare authorities. However, detection of abuse and neglect of the elderly is complicated by a number of factors, such as the recognition that older adults are often unwilling to report abuse due to feelings of shame, fear of retaliation, or fear of being placed in an institu- tion (Mulligan, 1990). By and large, elder abuse investigators have devel- oped screening instruments much like those aimed at detecting child or woman abuse, which are designed and put into place by persons in hospi- tals and other front-line community-based settings. The goals of risk assessments are to guide and structure decision-mak- ing, to predict future harm and classify cases, to aid in resource manage- 1Although these changes have had a dramatic impact on the problem of domestic violence, especially considering the relatively short period of time in which a social change of this magnitude has been accomplished, they have been far from universal and consistent across North America
504 ELDER MISTREATMENT ment by identifying service needs for children and families, and to facilitate communication within the agency and other community stakeholders (Hollinshead and Fluke, 2000). Evidence suggests that risk and safety assessments have benefited children and families in the child welfare sys- tem. Implementation of an immediate safety assessment protocol for chil- dren in Illinois, for example, resulted in a 23 percent decrease of recurrence in a six-month period; three years after the implementation of this tool the recurrence rates were down by over 28 percent (Fluke et al., 1999). The problem of woman abuse has also been approached through im- proved screening and detection, especially in relation to suspicious injury. Like elder abuse, the problem is complicated by the fact that most battered women are reluctant to volunteer the circumstances related to their injuries. However, when they are directly asked if this is the case, most women disclose the relevant information (Hotch, 1994). The conventional wisdom that women in abusive relationships are reluctant to disclose such informa- tion or that they resist efforts to change the nature of their relationship is not supportedâmore often than not, battered women will share their expe- riences with medical personnel when provided with a nonconfrontational and nonjudgmental atmosphere. Consequently, many hospitals now have protocols for screening woman abuse and other forms of domestic violence, which typically include a list of warning signs and symptoms that should prompt specific questions during the history-taking procedure. Such proto- cols may also serve as training instruments to ensure ongoing awareness and sensitivity to potential domestic violence victims. The Vancouver Gen- eral Hospital, for example, reported that their rate of correctly detecting domestic violence cases increased 2.5 times as the result of introducing such a protocol (Jaffe et al., 1996). The assessment of elderly persons who may be at risk for maltreatment by a family member is currently less formalized than is true of the other types of domestic violence. Whereas the medical system plays a prominent role in elder abuse, there are important insights that the mental health and social service systems can add to the overall assessment of persons at risk for family abuse, especially concerning victim and family characteristics. Several elder abuse-screening instruments are currently available, which direct attention toward characteristics of the person, the caregiver, or the family system (e.g., Kozma and Stones, 1995; McDonald, 1996; Reis and Nahmiash, 1995, 1998). These measures are used as brief screening tools to identify persons who may be at risk for further follow-up and assess- ment, based on known indicators of elder abuse. The 29-item Indicators of Abuse (IOA) screening measure, for example, is based on an abuse-indica- tor model comprised of three main types of abuse signals: (a) caregiver personal problems/issues; (b) caregiver interpersonal problems/issues; (c) care receiver social support shortages and past abuse. Although practical,
LESSONS FROM CHILD ABUSE AND DOMESTIC VIOLENCE 505 screening methods are limited by the few studies in this area. Some mea- sures overly focus on adult children as potential perpetrators of elder abuse or fail to recognize some of the contextual aspects of abuse, such as chronic stress resulting from long-term responsibilities of a fragile, elderly, combat- ive individual (McDonald and Collins, 2000). Moreover, most existing measures are biased toward factors related to physical abuse and neglect, with less attention paid to factors of psychological and financial abuse or violation of the personâs rights. Intervention Goals Following efforts by advocates to recognize the basic humanitarian need for assistance, most intervention and prevention efforts in elder abuse, child abuse, and domestic violence began with broadly based services of- fered within existing social networks. As greater recognition occurred, some communities introduced additional specialized services and resources, such as changes to laws and policies, training of professionals, and estab- lishing abuse registries and telephone hot lines. The next stage of interven- tion usually involves coordinated, system-integrated approaches to enhance the quality of services already available, which are in place in many North American communities for child and woman abuse, but much less so for elder abuse. Once in place, prevention programs in schools, law enforce- ment agencies, and similar organizations can begin to promote awareness and deterrence of elder abuse and related forms of domestic violence in the true prevention sense (Wolfe and Jaffe, 2001). Like child abuse, elder abuse interventions have primarily arisen from either agency- or community-based initiatives. This reflects the mandate of adult protective service agencies and their procedures for responding to abuse and neglect, whereas community-based efforts attempt to integrate or coordinate services found throughout the community in other social service agencies. Typically, intervention protocols include a variety of approaches that include legal, therapeutic, educational, and advocacy complements (Reis and Nahmiash, 1995). Throughout the 1990s some progress was made in terms of initiatives for elder abuse designed for both protection efforts and community services, although no systematic evalua- tions have been conducted. Existing approaches to elder abuse intervention focus primarily on three overlapping goals and strategies: (1) legislative, including statutory adult protection service programs, modeled after child abuse initiatives; (2) community services, based on integrated models that attempt to provide coordinated services spanning legal, medical, and psychosocial needs of at- risk seniors, modeled after domestic violence strategies; and (3) education and prevention, including advocacy and empowerment for seniors, derived
506 ELDER MISTREATMENT from the aging network (Anetzberger, 2000). Each of these approaches is discussed below, drawing heavily from child abuse and domestic violence intervention experiences in light of limited knowledge specific to elder abuse. As noted in a recent volume on violence in families (Chalk and King, 1998), major issues especially challenging to effective interventions in the area of elder abuse include the degree of dependence between offenders and vic- tims, limited funding for programming support, and striking a balance between privacy and individual rights. Legislative Intervention Over the last 30 years, the legal systemâs response to most forms of domestic violence has gradually shifted from one in which the maltreatment of family members was tolerated and even condoned to one of almost universal condemnation. This change is reflected in criminal law, tort law, family law, immigration law, and even international human rights law. During the 1970s, for example, a series of international and national con- ferences on child abuse, woman abuse, and abuse of the elderly resulted in new laws and initiatives at all levels of jurisdictions designed to cope with these concerns in both the United States and Canada. Some of these efforts represented extensions and revisions of existing civil and criminal statutes, while others were attempts at new forms of intervention and services. The end result was that, in one manner or another, new statutes concerning domestic violence in all its forms are now in place throughout North America. However, there are still fewer legal options available to older victims than for other victims of domestic violence (Jaffe et al., 1996). Adult Protection All U.S. states and Canadian provinces have enacted special adult pro- tection legislation (McDonald and Collins, 2000). Influenced by child welfare models, such legislation provides legal powers of investigation, intervention, and mandatory reporting. Typically, these methods give ex- tensive powers of investigation to specific agencies, including the authority to apply to the court for provision of services to those found incapable. To assist in implementation of these legal interventions, some communities have developed resource networks consisting of local health, social service, and legal agencies that provide resources to respond to elder abuse and neglect in an integrated and cooperative manner (see Coordinated Commu- nity Responses, below). Such networks provide a continuum of services to abused adults, act as a resource for service providers, and offer reliable and consistent service to consumers (McDonald and Collins, 2000). Adult protection laws relating to the elderly closely resemble the pro-
LESSONS FROM CHILD ABUSE AND DOMESTIC VIOLENCE 507 tective services model derived from child abuse legislation, in contrast to the law enforcement model of domestic violence laws. Advocates of adult protection legislation argue that older adults are safeguarded by such means, and attempts can be made to improve their level of functioning while protecting them from harm. Similar to the foster care crisis pursuant to child welfare legislation, however, an overemphasis on adult protection poses the risk of increased placement of seniors in institutions. In the absence of evaluation findings, the value of adult protection legislation is considered below in light of similar measures accompanying child welfare and domestic violence initiatives. Child Protection State intervention for children was predicated on the assumption that alternative care by the state (i.e., removing children from abusive or danger- ous family environments) was a benevolent intervention when families had failed or violated standards of care. Alternative care was assumed to re- move the child from harm and provide a stable and therapeutic environ- ment, as well as to provide a brief period for family rehabilitation. This view has been challenged more recently by the realization that not all interventions are beneficial and, in fact, can do more harm than good in some cases by introducing further victimization and disruption into the childâs life (Melton, 1990; Wolfe and Jaffe, 1991). Thus, confusion re- mains between the needs and rights of children and families. The traditional response of the juvenile court system that emerged from child welfare legislation was, generally, to maintain or reunify the entire family, including the abuser. This policy became controversial, however, as authorities argued that often the best protection for abused children is to assist their mothers in keeping the abusive father away from both the child and the mother. Some courts now advocate reunification for only the nonviolent family members. Wald and colleagues (1988) examined whether maltreated children benefit more from foster care or from home care. They found that im- proved services to families, such as counseling, health care, parent educa- tion and support, can help to keep abused and neglected children in their home residences, but not without significant costs. That is, children in both settings showed signs of emotional stress and adjustment difficulties that related to the dilemmas in their respective environments. At home, they had to deal with ongoing family disorganization and conflict, and in foster care settings children had to confront disruption and adapt to a new family system. Therefore, the impact of either placement must be evaluated not only in terms of the childrenâs personal safety, but also in reference to their social, emotional, and intellectual development (a similar argument often
508 ELDER MISTREATMENT arises in the debate concerning protection of elders from abuse). In either home or foster care these children require a high level of services for many years to cope with the trauma they have experienced. In effect, legal interventions for children were intended to provide a safety net for abused children, based on the belief that it is in their best interest to be protected from abuse and neglect. Paradoxically, such protection carries with it certain risks to the childâs ongoing development and family relationship. Domestic Violence Laws Men who are physically abusive toward their partners and/or children typically come to the attention of domestic violence specialists through either arrest or treatment referral. Unfortunately, studies on the efficacy of both arrest and treatment outcomes with this population are discouraging: Neither arrest nor treatment has been shown to have large effects on menâs violent behavior toward their partners. This finding points to the need to intervene before patterns of abusive behavior are developed. Specific legal interventions derived from the domestic violence literature are considered below in terms of their relevance to the elderly and how they might be changed to suit the elderly. Restraining (Protection) Orders. Restraining orders, an approach that emerged in both U.S. and Canadian legal systems to deal with domestic violence, are intended to ârestrainâ someone (usually a family or ex-family member) from contact with another family member. All North American courts authorize the use of restraining orders, although jurisdictions may issue them under different conditions (e.g., in some cases a restraining order may be issued simply on the basis of threats, while in others physical abuse must be alleged). They also differ in how the order is enforced and in its duration. Many states also authorize juvenile court judges to issue restrain- ing orders against one or both parents of an abused child, reducing the risk of further harm to the child. Although few studies offer a definitive conclusion, the overall effect of such orders appears to be beneficial; nonetheless, a restraining order can also increase the risk to the petitioner. Such orders apparently work best in cases where the conditions in the order are clearly specified, where the defendant understands the consequences for violating the order, and where the punishment is strictly enforced if the order is violated (Jaffe et al., 1996). Criminal Law and Arrest Policies. In the mid-1980s considerable attention was focused on arrest as a possible treatment for domestic violence offend- ers, prompted by the publication of results from the Minneapolis Domestic
LESSONS FROM CHILD ABUSE AND DOMESTIC VIOLENCE 509 Violence Experiment (Sherman and Berk, 1984; for detailed review see Chalk and King, 1998). However, replications of the Minneapolis experi- ment largely revealed that arrest has, at best, a small deterrence effect for domestic violence offenses; menâs history of assault is, by far, the strongest predictor of future domestic violence offences (Scott and Wolfe, 2000). Since enactment of the Violence Against Women Act, communities have increased coordination and cooperation among police, prosecutors, victim advocates, the judiciary, and other community institutions related to domestic violence (Sullivan and Allen, 2001). Although controversy over the relative benefits of arrest in domestic violence cases continues, many state and provincial legislatures and local police departments have adopted pro-arrest, warrantless arrest, or mandatory arrest policies in such cases. Some policies have mandated arrest for violations of restraining orders; others do not mandate arrest for spouse abuse or restraining order viola- tions but do require the investigating officer to file a report stating why an arrest was not made. In some jurisdictions, mandatory arrest policies have led to high numbers of battered women being arrested; the current trend is to require officers to determine which party is the primary aggressor, so that victims acting in self-defense are not arrested (Edleson, 1999). Finally, many states and police departments have mandated training programs on domestic violence as part of their initial and ongoing advanced officersâ training programs. Increasingly, policies also call for law enforcement to provide a resource card to victims, arrange for medical help, and provide transportation for the victim to a safe place. Implications Domestic violence laws, aimed at protecting abused women (and some- times men) from abusive partners remain controversial and untested in relation to elder abuse. On the one hand, the nature of the dependency relationship between older persons and their caregivers is different from other forms of domestic violence. For example, an older person may de- pend on a relative for survival in the community, with relatively few alter- native residential options. Abused partners sometimes have other options with respect to leaving an abusive relationship and/or having the abuser removed without jeopardizing their own survival. The nature of the depen- dency relationship, therefore, has important implications for the relevance of domestic violence laws such as restraining orders or criminal law and arrest policies. On the other hand, approaches to elder abuse that underscore power and control issues (rather than caregiving stress or other contributing fac- tors) remain viable (Harbison, 1999). In this regard, courts may need to
510 ELDER MISTREATMENT protect older persons while considering their best interests in terms of existing family and community supports and living arrangements, including necessary accommodations (e.g., for mobility, hearing, or memory impair- ments) to improve the experiences of older victims with the court system (Brandl and Meuer, 2000). Although elder abuse laws are viewed by practitioners as more effective when mandatory reporting is included (Bond et al., 1995), opponents argue that mandatory reporting to identify elder abuse must be accompanied by appropriate programs and services (Macolini, 1995). Recent evaluations of the benefits derived from mandatory child abuse reporting laws that have been in place for four decades provide some direc- tion to this issue. Due to mounting criticisms of the lack of services follow- ing child protection investigations and the ensuing family disruption (U.S. Advisory Board on Child Abuse and Neglect, 1993), efforts at reform were initiated in the 1990s. Several states have implemented a dual response system in which only the most serious cases are investigated and less serious cases are referred to community-based services. The states of Florida and Missouri have both conducted major evaluations of these reforms and have found that a dual response system can result in positive changes in child safety, family satisfaction, and community involvement in child protection. Child protective services reforms in both of those states were related to lower rates of re-referral, improved family satisfaction, and increased use of community services (Gordon, 2000). Community Services Community services for child abuse and domestic violence have been widely used, and similar approaches to elder abuse and neglect have gained proponents in recent years. Community responses are usually integrated to reduce costs and oversights and involve crisis intervention services (such as hot lines, police involvement in laying charges, protection orders, and emer- gency and secondary shelters) as well as legal clinics and ongoing support groups. Such methods usually involve educating the public and the abuse victim about their rights as well. Although this approach has considerable strength, some practitioners caution that some components, such as the use of crisis intervention, are problematic with the elderly because their problems tend to take a longer time to sort out (McDonald and Collins, 2000). Moreover, community services tend to focus primarily on cases of physical abuse and thus may be less geared to the needs of the neglected elderly. Below we consider medical and psychological efforts to address elder abuse, followed by the beginnings of a coordinated community response to elder abuse.
LESSONS FROM CHILD ABUSE AND DOMESTIC VIOLENCE 511 Medical/Psychological Because few high-risk elderly people are involved in social networks (e.g., school, employment, etc.), opportunities to respond to suspected cases of abuse and neglect are limited to those who come into contact with the family (e.g., physicians, visiting nurses, hospital staff, caseworkers, and others). These professionals have often received training in detecting abused women and children, which suggests that a similar campaign could be implemented to enhance their ability to detect and report suspected cases of elder abuse. Changes in medical practice related to improved assessment in domes- tic violence cases include refined standard medical procedures as needed for domestic violence assessment and improved history taking and assessment as needed to complement the medical examination (McDonald and Collins, 2000). These efforts have resulted in physicians, nurses, and ancillary personnel being more skilled in recognizing and reporting relevant cases of woman or child abuse, and providing medical testimony when needed. In many communities physicians and nurses have been instrumental in mobi- lizing resources, supporting shelters, and volunteering their expertise in a variety of ways. With the growing acknowledgment of the magnitude of elder abuse, medical practitioners have also developed systems to inform doctors and nurses regarding procedures for examining suspected cases of maltreatment in elderly patients. Kingston and Penhale (1995), for example, provide a list of physical findings and risk factors that are related to physical abuse, sexual abuse, and neglect in elderly patients who come to the attention of emergency room staff. The need for further expansion in this area has been recently documented (Institute of Medicine, 2001). Although very few psychosocial interventions for elder abuse have been evaluated, two studies warrant discussion. Scogin and colleagues (1992) conducted a controlled treatment study designed to assist abusive caregivers, in which participants received didactic presentations, group discussions, role-playing, and guided practice. They were compared with caregivers who did not receive training, based on measures of general mental health, anger, self-esteem, and degree of burden. Although the program had only a minor impact on anger and self-esteem, caregivers in the treatment program reported reduction in personal costs associated with caregiving. An impor- tant finding was that the no-treatment group experienced an increase in symptoms of distress while treatment participants experienced a decrease. Anetzberger and colleagues (2000) focused their evaluation on an edu- cational curriculum on issues of elder abuse, cross-training initiatives on Alzheimerâs disease, and additional materials to aid caregivers in identify- ing their own risk of abuse and how to access resources. Although the
512 ELDER MISTREATMENT study lacked a control group, benefits were deduced on the basis of positive changes in knowledge, attitudes, and behavior of staff that participated. Coordinated Community Responses A number of coordinated programs designed to improve services for the elderly have emerged in the United States and Canada. These programs are characterized by efforts to assess overall needs and then integrate them into a plan that best meets consumer priorities. In most cases, optimal independent living status is the preferred outcome, which is dependent on financial, health, and emotional support. To assist in this effort, many communities have moved toward development of multidisciplinary teams composed of workers from many different community agencies. These teams provide consultation on abuse cases and help coordinate and assist agencies in providing services, especially those that may not be readily available in the community (Wolf, 1992). This approach is modeled after interagency domestic violence task force teams, which serve as the means by which various relevant players (e.g., legal services, child protection, shelters, service providers, and educators) can communicate and solve prob- lems. A program described by Adele Weiner of Long Island University illus- trates a coordinated approach for elderly victims in a large urban area (Weiner, 1991). Her program brought together representatives from sev- eral resources, including health care professionals, community leaders, reli- gious groups, and families with elderly members. A series of workshops and consultation/referrals served as the means for training the participants in identifying and preventing elder abuse, and in providing them with infor- mation regarding the availability of services. Although not all the projectâs goals were realized, Weinerâs experiences serve as a practical guide to the problems one might encounter in developing such programs, especially in urban communities. The multiservice program by the San Francisco Consortium for the Prevention of Elder Abuse represents another state-of-the-art approach to dealing with this problem. A team consisting of representatives from the major service entities meets once every month to review and assess elder abuse cases that involve a coordinated combination of needs. Professionals from case management, family counseling, mental health, geriatrics, civil law, law enforcement, financial management, and adult protective services organize an integrated plan for assisting even the most difficult cases. Al- though the benefits of this and similar programs have not been scientifically evaluated, the advantages to such a systematic approach are evident and may serve as a model for other communities (Goldman Institute on Aging, 2001).
LESSONS FROM CHILD ABUSE AND DOMESTIC VIOLENCE 513 Contributions from Child Abuse and Domestic Violence Offender Treatment: Child Abuse. Psychosocial interventions with re- ported maltreating parents developed gradually from an individual-focused pathology model to a more encompassing ecological model, with an evolv- ing emphasis on the importance of the parent-child relationship and its context. Simultaneously, the orientation toward treatment shifted gradu- ally away from a deviance viewpoint and more toward one that accounts for the vast number of stress factors that impinge on the developing parent- child relationship (Wolfe, 1999). This shift toward a more contextual theory of maltreatment places greater emphasis on the importance of pro- moting parental competence and reducing the burden of stress on families. Although intervention models have greatly improved and have contrib- uted to encouraging gains in treatment outcomes, the field remains split between promising research findings and the realities of child protection and welfare. Unfortunately, the dominant theme in most services to mal- treating families remains that of protection, not treatment (Azar and Wolfe, 1998). This conundrum leaves inadequate services available to the larger number of parents who are at risk of child abuse or neglect and who could benefit the most from early intervention. Nonetheless, important strides have been made in ways to reduce child abuse and neglect among high-risk samples of parents and children. Most relevant to elder abuse intervention is the finding that multileveled programs, that is, programs offering addi- tional services tailored to individual and family needs over time, are worth the additional effort and expense, compared to less intensive services. Early methods of treatment for physical abuse (e.g., lay counseling, psychotherapy, and provisions of support services) were too narrow in scope to produce changes in the disturbed family interaction patterns that are central to child abuse and neglect. By the late 1970s, national evalua- tion studies indicated high recidivism rates both during and after treatment (Cohn, 1979; Herrenkohl et al., 1979), which prompted strategies that targeted child-rearing attitudes, skill deficiencies, and anger control. Inter- vention techniques for the kinds of deficits exhibited by physically abusive families were modified for this population on the basis of well-developed behavioral training methods, such as child management skills training, stress and anger management training, and cognitive restructuring approaches (Wolfe, 1999). Based on an awareness that child abuse may arise from poor parental preparation and assistance, especially in the early years, intervention strat- egies for physical abuse have emphasized education, training, and resources for at-risk families and community service providers, as well as direct assis- tance to caregivers to reduce stress, anger, and similar issues. Evaluations of interventions for child physical abuse and neglect indicate that cognitive-
514 ELDER MISTREATMENT behavioral approaches are the most widely supported methods for assisting maltreating parents (Corcoran, 2000; Hansen et al., 1998). These methods are effective (relative to standard protective-service interventions involving brief counseling and monitoring) in modifying parental behaviors that are most relevant to child maltreatment, such as appropriate child-rearing and self-control skills. Techniques such as relaxation and self-management skills training, cognitive restructuring (viewing child behavior more appro- priately), problem-solving training, and stress and anger management train- ing are often combined with structured training in basic child-rearing skills. These methods, either singly or combined, have been successful at teaching coping and problem-solving skills to abusive as well as neglectful parents (Fantuzzo et al., 1986; Kolko, 1996; Wolfe and Wekerle, 1993). Regard- less of these advances in treatment, however, the prevailing view for pre- venting child abuse and neglect is to act earlier rather than later. Offender Treatment: Woman Abuse. Counseling centers for abusive men are now regarded as an important addition to community services for domestic violence. Offender treatment programs originated in the early 1970s as voluntary programs for men whose partners were seeking the aid of shelter services. In recent years, the criminal justice system has been making increasing use of treatment programs for sentencing men arrested for assaulting their partners. Currently, an average of 80 percent of clients in such programs are referred by probation officers or are attending treat- ment due to a court mandate (Scott and Wolfe, 2000). Many of these programs use group approaches that encourage participants to take respon- sibility for their behavior and to find new ways to relate to their partners and to any children involved. The central characteristics of these programs involve accepting responsibility for oneâs behavior (in contrast to blaming victims), confrontation from other batterers familiar with evasion and de- nial, challenging attitudes and behaviors that promote male dominance and sexist values, and training in self-control and alternative approaches to dealing with anger, stress, and frustration. Intervention for abusive men is usually conducted in small groups that emphasize pro-feminist explanations for partner violence and use cognitive- behavioral or psychotherapeutic techniques to bring about change. Al- though the overall effectiveness of these efforts is still a matter of debate, existing studies endorse their efficacy over alternative models, such as treat- ment for drug abuse, one-on-one psychotherapy, insight therapy, etc., espe- cially if these alternative approaches do not require the man to accept responsibility for his behavior or if he remains unaccountable for his ac- tions. However, the major limitation of these new programs is that most men refuse to participate unless court-ordered. Moreover, even those who do make an initial inquiry on their own, or are court-mandated, rarely
LESSONS FROM CHILD ABUSE AND DOMESTIC VIOLENCE 515 continue to complete the entire program once the crisis has passed or the courtâs authority has been withdrawn (drop-out rates for batterer treatment programs vary from 20 to 80 percent, depending on how rates are calcu- lated; see Scott and Wolfe, 2000). Even those men who are court-ordered to attend treatment drop out at rates similar to voluntary clients. More- over, among the few evaluations of batterer intervention programs judged to be methodologically sound, small and generally nonsignificant differ- ences are found in recidivism rates of those who attend intervention and those who do not. Approximately one-third of men participating in various programs re-assault in the year following intervention (32 percent to 39 percent re-assault rates; see Gondolf, 1998). Coordinated Community Response. The domestic violence movement sparked innovative programs, such as support and advocacy services, which elder abuse efforts have begun to emulate. Importantly, domestic violence intervention models adhere to the belief that victims or potential victims should not be treated as patients, but rather should be empowered through supportive groups, advocacy in the legal system, and awareness of the entire range of options available (Jaffe et al., 1996). Furthermore, advo- cacy initiatives maintain that the least restrictive and intrusive interventions should be applied to an older personâs situation. In practice, advocates advise clients of their rights and alternative services available and can assist in carrying out plans. An important feature of advocacy is the advocateâs independence of any formal delivery system, which allows him or her to establish a positive relationship. Studies suggest that when victims have advocates they report less social isolation, are better linked to community services, achieve more goals, and are less likely to suffer abuse (Filinson, 1999). Nonetheless, many older adults may not know how to act on the rights they now understand they have and may not get the assistance they deserve. A systems-based response to violence against women and children may be of direct benefit to prevention initiatives regarding elder abuse. Each of these issues carries the added complexity of involving not only multiple social service organizations but also other systems such as health care, criminal justice, education, and government, religious, and business organi- zations. A principal component of such initiatives in domestic violence is a well-developed and coordinated community response, involving commu- nity-wide efforts to bring together relevant stakeholders to respond to do- mestic violence comprehensively. A coordinated community response typi- cally involves a coordinating council, with the goal of enhancing the response by reducing fragmentation and facilitating a shared vision among community members. These councils often consist of representatives from service systems organizations involved in child abuse or woman abuse.
516 ELDER MISTREATMENT One of the benefits of such coordinating councils is to encourage exchange among persons throughout the community and working in different organi- zations and settings, as well as developing more highly integrated service delivery systems and enhancing communication (Sullivan and Allen, 2001). Conclusions and Implications Although the field of elder abuse clearly lacks scientific evaluations of effective interventions, several implications may be drawn from interven- tion studies involving child abuse and domestic violence. First, there is evidence to suggest that interventions aimed at assisting caregivers in their important role hold promise for this population. Interventions that have been successfully used with abusive parents, in particular, have a clear parallel to elder abuse. Importantly, both forms of abuse emerge in the context of a dependency relationship, whereby the caregiver must learn about and respond appropriately to the needs and demands of the depen- dent child or adult. Cognitive-behavioral methods addressing misunder- standings about the reasons for a childâs behavior, misattributions, and limited knowledge of normal development, for example, have been particu- larly successful with abusive parents and would likely apply to elder abuse caregivers as well. In addition, there is converging evidence supporting the utility and acceptance of certain interventions for elder abuse, based largely on clinical reports, uncontrolled studies, and practitioner surveys. Based on profes- sional consensus, Nahmiash and Reis (2000) conclude that the most suc- cessful strategies involve concrete services such as nursing care and home- making assistance, followed by empowerment strategies such as support groups, education, and volunteer buddy/advocates (e.g., Hiatt and Jones, 2000). Moreover, similar to abusive parents discussed above, caregiver abusers require individual supportive counseling to reduce anxiety, stress, and depression, as well as education and training concerning care of the elderly. These valuable clinical impressions and accepted practices from the field point to areas of important intervention priorities and evaluation. The intervention literature for caregivers of older adults with dementia offers further insights into promising psychosocial interventions. Although these studies do not, for the most part, focus on elder abuse populations, they provide valuable guidance on ways in which caregivers can be helped to minimize their distress and presumably decrease the likelihood of elder abuse. In a recent review, Schulz and colleagues (2001) concluded that caregiver intervention studies show promise of achieving clinically signifi- cant outcomes in improving depressive symptoms and reducing anxiety, anger, and hostility, symptoms that have been causally linked to various forms of domestic violence. As in the child abuse literature, intervention
LESSONS FROM CHILD ABUSE AND DOMESTIC VIOLENCE 517 methods with nonabusive but stressed adult caregiver populations include a variety of educational and psychotherapeutic interventions such as problem solving, coping skills training, behavior management training, support groups, cognitive-behavioral therapy, and other types of counseling. In general, caregivers of adults with aging impairments are likely to benefit from enhanced knowledge about the disease, the caregiving role, and re- sources available. Caregivers may also benefit from training in general problem-solving skills and specific anger-management skills related to their role (Schulz et al., 2001). EDUCATION AND PREVENTION Similar to child abuse and woman abuse, prevention of elder abuse focuses on educational initiatives, which are believed to be critical elements in any comprehensive approach to domestic violence. These strategies have focused on education of older adults concerning their rights and how to seek help, as well as educating professionals, caregivers, and the general public regarding the nature of elder abuse and its prevention. Educating the Elderly Educating older adults provides them with knowledge as to how to protect themselves and their rights, which contributes to feelings of in- creased control and self-efficacy. Some communities offer support and problem-solving assistance as an adjunct to broader education strategies. For example, Project Care in Montreal incorporates both individual and group support to empower clients (Reis and Nahmiash, 1995). This pro- gram involves volunteer âbuddiesâ who meet regularly with abused seniors on a one-to-one basis, in an effort to reduce social isolation and inform seniors of their rights. In addition, the program offers an empowerment group that meets weekly to help victims discuss feelings and brainstorm ways of dealing with specific problems they are encountering. Similar strategies have been used in other cities (Wolf and Pillemer, 1994). Similar to child sexual abuse prevention initiatives that teach children about safety and protection (Wolfe et al., 1995), education programs for seniors have also attempted to make them active players in the development and day-to-day operation of their services. Seniors can be assisted in reduc- ing abuse in a number of ways, including professional recognition of their contributions, collaboration between seniors and professionals, generating their interest and commitment, ensuring a meaningful experience, brain- storming, using seniors as advisers, and central coordination (ARA Con- sulting Group, Inc., 1994). Moreover, significant progress has been made to increase professional awareness and involvement through training ses-
518 ELDER MISTREATMENT sions and seminars on abuse, with the specific aim of examining bias or fears concerning treatment of the elderly among staff and administration (McDonald and Collins, 2000). Educating Caregivers and the General Public Because caregiversâ stress has been implicated as a risk factor of abuse and neglect of the elderly, education and training programs are seen as a vital aspect in prevention. Available in most communities, such programs offer mutual support, stress reduction, and problem-solving strategies. The underlying assumption is that some social support and education/training works to reduce the likelihood that anger, aggression, and conflict will emerge in the caregiving relationship (Schulz et al., 2001). Public education campaigns geared toward seniors as well as those in positions to assist have been implemented in recent years. These include a wide variety of pamphlets on the topic of advocacy for resources, lobbying activities, public media, and conferences. Coalitions consisting of service providers have also been established to educate community members about other abuse issues. Moreover, some communities are attempting to develop preventive programs to teach children to respect older adults and create opportunities for intergenerational relationships (Podnieks and Baillie, 1995). Others have taken the lead by offering public educational efforts, such as billboards, TV commercials, and newspaper ads, informing families of the necessity to provide care and support to seniors living at home. Nonprofit corporations or health care facilities that serve a geriatric popu- lation typically sponsor these efforts. Although formal evaluation is lack- ing, these efforts base their support on the success of similar initiatives in the fields of child abuse and domestic violence, described below. Child Abuse and Domestic Violence Initiatives Child abuse prevention has been approached through both universal efforts (e.g., educating the general public about its various signs; learning healthy childrearing skills) and more selected and targeted approaches, such as efforts to assist young parents who may or may not be at risk of abuse due to socioeconomic or other factors. An example of selected prevention that may share some common elements with elder abuse preven- tion is the recent work of David Olds and his colleagues. This program seeks to build on personsâ strengths and abilities, rather than their deficits, and as such is a plausible approach to preventing physical abuse, neglect, and related social problems in different age groups. The program itself involves prenatal and postnatal home-visitation services for first-time (un- der age 19) parents to establish resource linkages and learn about their
LESSONS FROM CHILD ABUSE AND DOMESTIC VIOLENCE 519 childâs developmental needs. Fifteen years after receiving these services these parents maintained gains over controls on important dimensions: better family planning concerning number and spacing of children, less need for welfare, less child maltreatment, and fewer arrests of their children during adolescence (Olds et al., 1997). Although elder abuse clearly in- volves a different focus and timing of intervention, any of its components fit with existing knowledge of this issue, such as establishing community link- ages, supporting families during stressful periods, teaching basic caregiver skills, and building on strengths of the target adult as well as caregivers and others. Public awareness campaigns, such as public service announcements and advertisements, have been widely used throughout North America to com- bat child abuse and domestic violence. These campaigns are usually di- rected at recognizing the warning signs of such violence, as well as special- ized community resources such as shelters for abused women. The Family Violence Prevention Fund (FVPF) in collaboration with the Advertising Council (Klein et al., 1997) developed an illustrative and comprehensive campaign that included a small research component. The campaign in- volved television ads with the message, âThere is no excuse for abuse,â and offered local contacts for domestic violence resources. The evaluation involved public opinion data prior to the campaign in 1992 and follow-up data gathered between 1994 and 1996. The findings suggest that Ameri- cans at the time perceived domestic violence as an important social issue that required state intervention. Of additional interest is the fact that many Americans excused domestic violence on the basis of alcohol or other cir- cumstances, and they were uncertain and fearful about how to assist or intervene if they knew someone experiencing partner violence. RECOMMENDATIONS FOR PRACTICE AND RESEARCH Traditional approaches to child welfare and domestic violence were largely designed for protection rather than assistance, which leaves inad- equate services available to a significant number of persons at need and who could benefit from early intervention. With some important excep- tions, domestic violence policies related to child, woman, and elder abuse have focused primarily on identification of offenders, which paradoxically reduces the chances for assisting the much larger majority of potentially abusive or inadequate caregivers or partners. That is, if treatment services are tied to an offence and the individual must be identified and labeled, it is understandable that many individuals will perceive them as threatening and undesirable. Moreover, there is often a large gap between what families need in terms of treatment and what is actually delivered in practice. Help
520 ELDER MISTREATMENT should be more easily available to a family or individual before a crisis or tragedy occurs. Connected to this strategy of earlier family assistance for all forms of domestic violence must be the acknowledgment that intervention after the fact is seldom satisfactory to the individual, the family, or the community. The realities of adult protection, on the one hand, require firm guidelines and legal authority. Individual autonomy and special needs, on the other hand, profit from stability, continuity of caregivers, and a supportive family and community environment. Unfortunately, by the time official attention is drawn to the problem (due to the victims or othersâ reluctance to seek help, failure of family members or professionals to identify a burgeoning problem, offences that fall below the threshold for official response, etc.), it may be very difficult to reverse some of the patterns that have formed. To combat the negative connotation associated with treatment and prevention services, policy planners need to study ways to make the avail- able services more attractive to the elderly and those who care for them. As one illustration, prevention and early intervention efforts based on social learning theory have shown considerable promise in addressing the contrib- uting factors related to child abuse; because child and elder abuse share some fundamental features (e.g., a dependent, caregiving relationship), these approaches seem well-suited for elder abuse prevention as well. Public Health Models Emerging changes in public policy, legislation, and service delivery illustrate a commitment to finding ways to reduce the prevalence and harm- ful effects of all forms of domestic violence. Still, strategies that address the issue at a broader level need to be more fully developed and evaluated. Such strategies must take into account the large number of factors that influence the likelihood of elder abuse, as well as factors that promote proper care and well-being. Significantly, there are established precedents for addressing complex public health issues facing children and adolescents, such as domestic vio- lence (Wolfe and Jaffe, 2001), substance abuse and peer violence in schools (Cunningham and Henggeler, 2001; Farrell et al., 2001), and personal safety and injury prevention (Tremblay and Peterson, 1999). These ap- proaches, adopted primarily for known health and behavior problems among youth, hold considerable promise for the elderly as well, because they recognize that change occurs through finding positive ways to commu- nicate messages about healthy families and healthy relationships. Alterna- tives to violence can be activated in each community in a manner that stimulates interest, informs choices, and promotes action to decrease vio- lence and abuse in the lives of children, youth, and families.
LESSONS FROM CHILD ABUSE AND DOMESTIC VIOLENCE 521 Implicit throughout this chapter is the presumption that public health and health promotion approaches to prevention of various forms of domes- tic violence, including elder abuse and neglect, are promising strategies. Such strategies should not undermine existing efforts at treatment and early intervention but rather would be designed to approach the widespread problem of elder abuse from a broader, more fundamental vantage point. Government fiscal incentives, for example, should be reoriented to empha- size prevention and treatment rather than detection, investigation, and al- ternative placement. A key health promotion policy issue concerns the need of all families for some degree of support and education (an âenhance- mentâ strategy rather than interception; see Melton and Barry, 1994). In conjunction with health promotion efforts, program development should focus on providing information for caregivers of the elderly that is easily understood, practical, and accessible to all present and potential populations. In particular, attention should be directed to societal influ- ences that play a role in elder abuse and neglect, especially in circumstances where families are exposed to major effects of poverty, health risks, and environmental conflict. Such a cross-cultural perspective would redirect the focus away from individuals and families and explore societal and cultural conditions that attenuate or exacerbate these problems. In a simi- lar manner, policy planners need to advocate for the establishment of mini- mum standards of care for their own communities, taking into account the cultural diversity of the community and the imbalance in child-care and elder-care responsibilities on women. SUMMARY In sum, the absence of theory-based treatments and outcome research in the area of elder abuse remains striking. Similar to related family vio- lence interventions such as child abuse and women abuse programs, exist- ing elder abuse programs have been largely aimed at individual needs based on victim accounts of abuse and violence, rather than a theory of change based on population based epidemiology (Chalk and King, 1998). This victim response approach has been effective at attracting public attention and resource commitments, but it is inadequate in terms of providing a foundation for measurement and evaluation of long-term outcomes or pro- gram effects. Funding for university-based research efforts is indicated to gather in- formation on ways to address the needs of the elderly, as well as to enhance caregiver(s) functioning enough to ensure safety and proper care. This review points to the conclusion that behavioral and cognitive behavioral approaches show promise as effective means of assisting caregivers and reducing the stresses of caring for an elderly member. Small- and large-
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