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3 A Theoretical Model of Elder Mistreatment T he limited research on elder mistreatment lacks an overarching framework within which to understand the multiplicity of its ill-defined manifestations. Concerned citizens, clinicians of various sorts, including emergency room physicians, social workers, nurses, the police, and even the victims themselves report incidents of apparent mistreatment to the authorities (such as state adult protective services). They, in turn, investigate and classify them according to disparate legal definitions, collat- ing them for reporting purposes but with only limited cross-state compara- bility. Academic researchers have tried their hand at identifying and cata- loguing individuals subject to elder mistreatment in the population at large. But they too lack a fully developed theoretical framework that could serve to guide data collection efforts and permit a more effective assessment of (1) the differential prevalence of elder mistreatment by significant social attributes and (2) the causal sequences leading to enhanced risk of elder mistreatment. As a result, the knowledge base about even the most elementary facts concerning elder mistreatment is incomplete, contradictory, misleading, and noncumulative. We are told, for example, that the majority of elder mis- treatment cases are women. Yet we are not in a position to evaluate whether this is simply the result of the disproportionate number of elders who are women (due to differential mortality by gender) or whether women do indeed face a higher risk of elder mistreatment than men. Most studies reporting this finding simply lack a way of properly assessing the popula- tion base from which the clinical observations were generated. 60
A THEORETICAL MODEL OF ELDER MISTREATMENT 61 RISK MODEL OF ELDER MISTREATMENT IN DOMESTIC SETTINGS Here we would like to propose, as a first approximation, a theoretical sketch for the study of elder mistreatment that in our view could help to codify the findings already in hand and to provide a framework within which to organize future research efforts.1 It is offered in the spirit of starting a conversation about theoretically meaningful next steps rather than as a fully fleshed-out theoretical model. It draws its inspiration from George L. Engelsâs (1977) challenge to the reigning biomedical model of the time. He proposed a biopsychosocial model explicitly encompassing psy- chological and social factors in explaining biophysiological conditions, such as disease or aging processes. It has attracted increasing attention, most recently providing the framework within which a task force of the Institute of Medicine organized its discussion of sexually transmitted diseases (Insti- tute of Medicine, 1997; see also Laumann et al., 1994:3-34, 541-548; Ensel and Lin, 2000). In Engelsâs view, the narrow biomedical model, with its highly individualistic, clinically centered presumptions, should be expanded to incorporate a multiperson interactional scheme with three sets of interre- lated factors: the physiological, the psychological, and the social. What is missing from Engelsâs model is a fuller consideration of the environing cultural and social contexts in which these microprocesses are embedded. The definition of elder mistreatment in Chapter 2 stipulates both a victim of mistreatment (the focal subject) and a responsible actor (a trusted other, typically the caregiver) that together lie at the center of analytic attention. The interaction between the characteristics of the potential vic- tim of mistreatment (e.g., his or her changing health status, dependency, competencies) and those of the responsible actor (e.g., his or her care bur- den, stress, financial dependence) must be an essential feature of any analy- sis. In addition, contextual risk factors, such as those referring to location (type of institution, at home, etc.), social relationship (e.g., spousal, adult child caregiver, formal role caregiver like lawyer, nurse), and the broader sociocultural context (defined by race, ethnicity, religion, region, urban/ rural location, and socioeconomic status), may set different generic levels of risk for the individuals embedded in them. Figure 3-1 provides a birdâs eye overview of the generic factors in the model of the risks for elder mistreatment, while Figure 3-2 presents a 1Several other theoretical sketches have been proposed in the research literature, including Ansello (1996); Phillips (1983); Schiamberg and Gans (1999); and Wolf and Pillemer (1989). The current framework attempts to be more comprehensive, including mistreatment both in domestic and institutional settings. In addition, it is applicable to multiple types of mistreat- ment. The sketches in the literature, however, are completely consistent in spirit and thrust with it.
62 ELDER MISTREATMENT Sociocultural Context Social Social Embeddedness of Embeddedness of Subject Trusted Other(s) Individual-Level Status Inequality Individual-Level Factors (Subject) Factors (Trusted Other(s)) Relationship Type Power and Exchange Dynamics Outcomes FIGURE 3-1 Summary overview of the model for elder mistreatment. detailed specification of selected variables to be operationalized in applying the model to the empirical world. It is fundamentally a model of a transactional process unfolding over time among the elder person, his or her trusted other, and other interested parties (stakeholders) concerned with his or her well-being in the context of changes in the physical, psychological, and social circumstances of the several parties as the result of the elder personâs aging process and life course. This is called the microprocess, encompassing the factors that could be associated with the risk of mistreatment. In addition, this model should be understood as being embedded in an environing sociocultural context, such as the region of the country, the institutional or organiza- tional locus (such as a nursing home, assisted living quarters, private house- hold), and race or ethnic group of the elder person that are associated with
A THEORETICAL MODEL OF ELDER MISTREATMENT 63 Sociocultural Context Social Social Embeddedness/ Embeddedness Context Ties to Family and Friends Ties to Family and Friends (Stakeholders) (Stakeholders) of Trusted Other(s) of Subject Individual Level Individual Level Factors (Subject) Factors (Trusted Status Inequality 1. Master social statuses Other(s)) (e.g., wealth, race, 1. Master social statuses Differences in gender, age, ethnicity, religion, kinship (e.g., wealth, race, ethnicity, race, education status) religion, kinship status) 2. Physical health status 2. Physical health status (e.g., chronic diseases (e.g., chronic diseases [diabetes, heart] or acute (diabetes, heart) or acute illness) illness) Relationship Type 3. Personality charac- 3. Personality characteristics Whether noncoresidential, teristics and mental health and mental health status (e.g., cohabitational or marital status (e.g., dementia, dementia, depression, social partnership, or alone depression, social competence, intelligence, competence, intelligence, certain personality certain personality characteristics) characteristics) 4. Beliefs and attitudes about 4. Beliefs and attitudes aging, kinship, and care-giving about aging, kinship, and obligations care-giving obligations Power and Exchange Dynamics Negotiation of care-giving scripts (e.g., complete, moderate, or limited dependency and need for assistance in performing daily living routines ) Outcomes 1. Physical and emotional health/happiness of subject/trusted other(s) 2. Elder mistreatment (recurrent vs. episodic vs. crisis-centered events leading to physical, mental, or social harms) 3. Durability of care-giving relationship (i.e., likelihood of termination) 4. Sense of security and trust FIGURE 3-2 A schematic outline of the model for elder mistreatment.
64 ELDER MISTREATMENT different levels of risk for mistreatment. For example, it may be the case that different organizational settings (e.g., nursing homes, assisted living quarters) may have different characteristic levels of elder mistreatment risk. This feature of the model is the macrostructure in which the microprocesses described in Figure 3-2 occur. The risk of elder mistreatment can be con- ceptualized as the varying likelihood of an event or set of events causing harm to the elder person. This risk is a function of the various sets of variables depicted in the model at both the macro and micro levels. The left side of the diagram includes the set of social, physical, and psychological attributes of the subject at risk of elder mistreatment, and the right side lists the pertinent attributes of the trusted other. The middle set of boxes represents the interaction of the two sets of individual-level vari- ables that define the level of social or economic dependence (status inequal- ity), type of social relationship in which the interaction between the elder person and the trusted other happens, with corresponding differences in the normative expectations held by different stakeholders and the power dy- namics in negotiating the operative care-giving scripts (see Simon and Gagnon, 1987; Mahay et al., 2001). Note that we have also included âsocial embeddedness,â which refers to the sets of people in the social networks of the elder person and the trusted other, respectively, constitut- ing the social capital available in the dyadic transaction (see Sandefur and Laumann 1998). These two networks may overlap or not, with attendant consequences for their efficacy in exerting social control over the dyadic interaction of focal interest. Social networks can serve critical functions of monitoring the situation and informing relevant others when shortfalls or problems arise. Their presence may also serve as a form of social control on the behavior of the focal parties. Their absence greatly enhances the vulner- ability of the elder person and the trusted other to the risk of elder mistreat- ment (see House et al., 1988; Lin et al., 1999). Finally, outcomes include the physical and emotional health and happiness of the elder person and the trusted other, the differential risks of elder mistreatment in its varied forms, and the durability (or risk of termination) of the caregiving relationship itself. We should expect that all these outcomes have feedback effects on the variables above themâthat is, the paths connecting outcomes to the boxes listing the independent variables are double-headed rather than unidirec- tional. For example, we might expect that the occurrence of an incident of elder mistreatment increases the odds of additional events of elder mistreat- ment, as it adversely affects physical, psychological, and social statuses for both the elder person and the trusted other. A mistreated elder is more likely to respond with depression, physical disability, or social withdrawal as a direct or indirect reaction to the mistreatmentâeach of which may enhance the likelihood of another incident. Similarly, the perpetrator may
A THEORETICAL MODEL OF ELDER MISTREATMENT 65 feel increased stress in his or her situation and become more likely to respond in an abusive manner to another challenge to his or her caregiving capabilities. In short, the overarching conception of the model is one of a time-dependent process with feedback loops that interact with the âinde- pendentâ variables over time. Such a conception highlights the critical need for longitudinal studies to gain a better understanding of the underlying dynamics. The clinically and forensically oriented literature often characterizes the issue as one of en- hancing case identification methods so that âfindingsâ of culpability can be established. But this leads to a focus on punishment and deterrence as the principal goals of intervention. A process-oriented account of elder mis- treatment, in contrast, would lead to investigation of the reversibility of the process by providing a better understanding of the etiology of specific forms of elder mistreatment and therefore a better understanding of the preventive and remedial measures that could be undertaken. Such a perspective would benefit from knowledge gained by qualita- tively and phenomenally oriented research designed to flesh out the mean- ings of different forms of elder mistreatment. For example, how does spousal mistreatment differ from adult child mistreatment? What are the differences between one-shot or episodic mistreatment in response to a crisis situation that overwhelmed the caregiver and chronic or recurrent elder mistreatment in a long-term marriage characterized by recurrent physi- cal conflict? We often speak of the heterogeneity of the phenomena of elder mistreatment, but there are literally no studies that attempt to explore the nature of that heterogeneity. At present, we are functioning at the level of commonsense classes, perhaps informed by legal distinctions rather than scientifically informed classification. Legal categories of elder mistreatment are highly heterogeneous in their phenomenal base and may thus arise from quite different etiologies, with correspondingly various implications for the kinds of interventions that might successfully be pursued. In regard to the potential opportunities and foci for prevention and intervention, the phe- nomena may be basically independent in cases of (a) battering by an inti- mate partner that persists as part of a long-term, even life-long pattern; (b) battering by an intimate partner that begins in late life (perhaps because of a transformation in the marital relationship as a result of changes in physi- cal well-being or the social status and financial well-being of one or both spouses); (c) neglectful or abusive care by other kin who face a multiplicity of overwhelming care needs as well as other, perhaps unrelated problems; (d) neglectful or abusive care by employees of adult day programs, nursing homes, and hospitals; and (e) crimes of opportunity, in which dependent persons are exploited by caregivers who take advantage of access to finan- cial resources.
66 ELDER MISTREATMENT RISK MODEL OF ELDER MISTREATMENT IN INSTITUTIONAL SETTINGS Figure 3-2 implicitly assumes that the trusted other (the right-hand side of the figure) was a family member or friend operating in the context of the informal provision of caregiving to the elder person in a private household. Let us now assume that the trusted other is an employee or volunteer working for an organization, such as a nursing home or hospiceâthat is, let us consider the modelâs applicability to institutional settings. Figure 3-3 specifies the set of variables (on the right-hand side of the model in Figure 3-1 down through individual-level factors) that are relevant to characteriz- ing the organization as constituting the context within which trusted others (i.e., various staff members) are serving as the responsible care providers. We first note that there is a larger institutional context in which the organi- zation is foundâe.g., a particular region or state that has a stricter or more lax regulatory environment than other areas or a remote rural location (in comparison to an urban location) that hinders the access of the elder personâs social network for visiting and monitoring what is going on. Next we can characterize the specific organizational facility with respect to its size, staff/resident ratios, per capita expenditures, etc.âall of which may be expected to be associated with different levels of risk of the caregivers in their employ engaging in elder mistreatment. For example, poorly man- aged and funded facilities with inadequate staff might be expected to pose a much greater likelihood of their staff engaging in elder mistreatment than the staff at well-run, well-funded facilities. Finally, we consider the indi- vidual-level attributes of the actual care providers themselves as affecting the relative risks of elder mistreatment. Can we, for example, expect more or less risk of elder mistreatment as a function of the training and experi- ence of the care providers, or of racial, ethnic, or class differences between the elder person and the trusted other? Figure 3-4 provides another take on the model that may help clarify what we have in mind. It can be regarded as a subsidiary process nested within the overarching model depicted in Figure 3-2. In this case, we consider an adverse physical change in the elder personâs health statusâ e.g., the onset of vascular dementia. The risk of acquiring vascular demen- tia is shown to be a function of a set of prior factors, such as the subjectâs nutritional status, poverty, etc. With onset of the disease process, we expect a decline in physical function, including hypertension, depression, etc., that adversely affects the elder personâs psychological outlook and social functionality (e.g., a decline in sexual interest and attractiveness to spouse). Diminished capacity to perform daily routines and increased de- mands on the spouse for help, combined with a loss of social facility and increased depressive behavior on the elder personâs part, put increasing
Elaboration of right-hand side of Figure 3-1 for institutional care providers Sociocultural Context Social Embeddedness of the Individal-Level Factors characterizing of institutional care specific organizational facility individual employees/volunteers who providers providing care to subject provide care to subject Region of country Organizational characteristics, Individual characteristics of staff such as size of facility, resident/ care provider(s) in contact with State regulatory staff ratio, annual per capita resident subject, including environment operating expenses, proprietary relevant work experience, versus nonprofit, assisted versus stress and exhaustion, Urban-rural location full care, average age of residents, individual status characteristics average health status of residents, including race, age, gender supervision to staff ratio, staff turnover FIGURE 3-3 Model of risk factors for different levels of risk for engaging in elder mistreatment by institutional care providers. 67
68 Physical Factors Decline in physical function - Hypertension Increased dependency on - Hyperlipidemia caregiver to perform daily - Atrial fibrillation living routines Socio- Environmental Factors - Poverty Alteration in Decresed competency Elder - Education Vascular dementia social function to maintain social support mistreatment - Embeddedness Psychosocial Factors - Depression - Stress - Support Alteration in psychological function Increased depression and cognitive impairment FIGURE 3-4 Impact of vascular dementia on risk of elder mistreatment in people age 55 and older.
A THEORETICAL MODEL OF ELDER MISTREATMENT 69 stress on the caregiver, who feels captive to a deteriorating, âno-winâ situ- ation. He reacts with frustration and anger, finally physically hitting her in response to a âpettyâ demand for attentionâan act that never occurred before in their many years of marriage. The figure attempts to identify the set of variables and their probable causal order; it also stresses the interac- tive character of the process over time. It should help guide the selection and measurement of the pertinent variables in evaluating this account of elder mistreatment risk. RECOMMENDATION The problem of identifying rare events like elder mistreatment is made more difficult because of its strong social stigmatization. It is quite analo- gous to the problem faced in studying AIDS infection in the population. AIDS is such a rare event (0.61 percent prevalence rate in the United States) that it is prohibitively expensive to get a sample size large enough to recruit sufficient cases for statistical analysis, even if one could assume that people would willingly disclose their infection status. Instead, analysis has focused on the prevalence of sexually transmitted diseases (STDs) inclusively de- fined, which have an estimated prevalence of 18 percent in the U.S. adult population age 18 to 59 (see Laumann and Youm, 2001:339), a much more workable situation from a statistical point of view. This could be done because the mechanisms implicated in STD transmission approximate fairly closely those implicated in AIDS transmission in the United States. A similar strategy could be undertaken for elder mistreatment, in which we could identify more broadly inclusive adverse events, for example, frequent and intense verbal arguments between the elder person and the caregiver, which are likely to include the events that meet a stricter definition of elder mistreatment. The objective of this discussion has been to provide a comprehensive, flexible theoretical framework within which to organize research efforts employing qualitative as well as quantitative methodologies. Appropriately deployed in systematic empirical research, these methodologies can illumi- nate the fundamental processes generating the differential risks of elder mistreatment for both the elder population at large and for those who perform caregiving roles. Armed with a better understanding of the under- lying processes, we will be in a much better position to devise more effective intervention strategies to reduce these risks. In sum, we are unlikely to obtain much information relevant to preven- tion and post-mistreatment intervention in cases of elder mistreatment until the field moves toward a program of research that is grounded in an under- standing of the everyday lives of older people in relation to their intimate partners and their other caregivers; the experience (phenomenology) of
70 ELDER MISTREATMENT these relationships and their meaning to the people involved; the situational and motivational factors that tend to enhance or impair the cognitive per- formance of older people and their corollary capacity to protect their own interests; and the social factors drivingâand potentially regulatingâthe settings in which older persons live, especially those who are cognitively impaired or financially dependent. The theoretical sketch outlined in this chapter offers one approach for stimulating the thinking and research needed by the field at this stage in its development. The panel recommends systematic, theory-driven longitudinal research, both qualitative and quantitative, exploring the changing dynamics of elder peopleâs relationships and the risk of mistreatment, as they are affected by changing health status, social embeddedness, and caregiving and living arrangements, in both domestic and institutional contexts.