A survey of psychiatrists specializing in care for elderly patients in Ireland in 2010 regarding self-neglect revealed significant exposure, with 92 percent having seen a case in the past year. Personal characteristics, loss of self-care, and poor hygiene were the most common presentations. Medication non-compliance and hoarding were the next most common. In contrast with the geriatricians, 59 percent believed the outcome for the patient was unsatisfactory. Nearly three-quarters, 72 percent, believed the outcome for themselves as psychiatrists was unsatisfactory (O’Brien et al., 2013b).
Apparently, at least in Ireland, using reports from physicians as an indication of involvement in abuse and neglect may seriously underestimate their contributions. Perhaps the same applies in the United States and other countries.
Another area of unrecognized abuse occurs within the health care system with multiple examples of overtreatment (not indicated/futile) constituting abuse. The corollary occurs when indicated treatments are withheld because of age, resulting in neglect. These situations rarely come to the attention of any agency and stay below the radar. This is an area that urgently requires more investigation.
The abuse of older people is a global issue that has been receiving increased attention as the aging population grows. Although progress has been made, there is still a lack of scientific research, and limited policies and tools for interventions. This paper reflects on some perspectives from the field since the publication of the landmark study by Dr. Alexandre Kalache (WHO, 2002), Missing Voices. That study, for the first time, actually asked older people to tell their stories, recorded and published them, and invited the elder abuse community to build on these stories and seek ways to incorporate them into interventions and practice initiatives. One of the strongest, most poignant comments—“respect is better than food and water”—resonates through the concepts discussed here: elder abuse
prevention networks, support groups, global awareness, engaging youth, social media, and the need for an elder abuse conceptual framework.
Networks: Demonstrated Leadership
The 1980s and 1990s saw the emergence of networks for the prevention of elder abuse. They began as small grassroots initiatives that brought together people who were concerned with the growing reports about elder abuse and neglect both in the community and in long-term care facilities. Members included researchers, educators, practitioners, and advocates dedicated to protecting the safety, security, and dignity of older persons. The organizers were passionate visionaries who developed effective ways of providing support to individuals and families caught in abusive situations. The networks lobbied the government and set up hotlines with volunteers. It was not unusual for a victim to call a network member at 1 AM with the question, “Can’t the police just get my money back?” Meeting minutes were kept in a filing cabinet at a university and meetings were held in empty classrooms. The police were among the most generous network members and would bring supplies for workshops and provide transportation, much to the appreciation of the people who were being helped. Today, networks have been established in most developed countries; there are funding, offices, and available resources. The initial goals remain strong; networks are a force for connection, communication, and sharing. They seek to achieve a clearer understanding of elder abuse and provide leadership to prevent it.
Networks have assumed an important role in identifying and supporting regional, national, and local activities related to World Elder Abuse Awareness Day (WEAAD) and in providing links to the international scene. The planning for this annual event has indeed become a core event of many networks. Today, networks serve to promote elder abuse prevention through education, professional training, advocacy, and service coordination, and in so doing, bring the safety, protection, and respect that was called for in Missing Voices.
Support Groups: A Chance for Human Connection
Support groups have been helpful to victims of elder abuse (Podnieks, 1999). The early networks organized support groups because they were inexpensive and accessible, and they filled a huge need in the lives of victims by providing guidance in handling difficult situations. Support groups are able to relieve the tensions, resentments, and stress that accompany elder abuse. They also provide a safe and caring environment as victims navigate the health, legal, and social systems and address their own needs and concerns. Support groups provide a safe environment, allowing victims to ask
questions such as, “Why does my son abuse me?” Counseling should be offered to those who need it. The groups encourage members to express their feelings of anger, frustration, guilt, resentment, and hopelessness, and assist participants in asserting more control in their own situations (Kaasaslainen, 2000). Support group members often can heal, find resolution, and return as volunteer support group facilitators.
Support groups for caregivers promote an opportunity to discuss circumstances that may lead to mistreatment, such as stress, anger, feelings of entrapment, anxiety, sense of disruption in life, and role changes (Podnieks, 1999). The informal nature of the group establishes a setting for free and safe conversations about situations that abused older persons, caregivers, and staff in long-term facilities had not been able to discuss with others. Support groups encourage people to speak of the unthinkable, to bolster each other, and to help solve each other’s problems.
World Elder Abuse Awareness Day
Clearly one of the most significant accomplishments of network collaboration was the launching of WEAAD on June 15, 2006. The goal was to build momentum at international, regional, and national levels to raise awareness of elder abuse and the need to prevent it. WEAAD has heightened global consciousness and strengthened leadership networks: It has been a compelling force on human rights, aging, and the prevention of family violence. The concept of World Day was spread across all nations, absorbing influences from other traditions. What began as a small gathering at the United Nations in 2006 has evolved into a multicultural, multilingual movement that is redefining the meaning of collective power for a world audience. WEAAD has helped people understand what elder abuse is, the importance of human and civil rights, and the need for research, education, advocacy, and policy development. In 2011, the United Nations officially designated June 15 as WEAAD, an idea that has been embraced by nongovernmental organizations, government agencies, health and social care providers, law enforcement professionals, aging advocates, and many others. In a historic moment on June 15, 2012, President Obama held a workshop on elder abuse at the White House and issued a Presidential Proclamation.
Power of Youth
Children and youth are an untapped resource for preventing elder abuse; they are society’s most engaging and powerful change agents. If they are taught about elder abuse and given the opportunity to become engaged in community-based work with older adults, they can help to prevent it.
Education about elder abuse begins with instilling positive images of aging and older persons in children, beginning with preschool so that it becomes a way of thinking that grows through life. Elder abuse awareness education should continue throughout secondary school and higher. Elder abuse advocates recognize the importance of changing ageist attitudes in both young and older generations. The good news is that most children are willing to help to raise awareness in their community if they are asked and included in the planning. Some examples of student participation include developing posters and slogans, visiting nursing homes, handing out pamphlets, speaking to banks, working with the police, and participating in social media. When students learn about elder abuse at school, they can take the information home to their parents. Young people often have strong ties to their grandparents, and these feelings must be nurtured. Findings from the World View Environmental Scan (Podnieks et al., 2010) indicated that older people desperately want to be connected to the world of technology. The lack of resources to foster these connections is a gap that needs to be addressed. Young people can help, and benefit in return. One such example is that of a teen teaching an elder how to use the computer while she helped him with his math homework, showing reciprocity in action, or exchange theory.
Projects both in schools and in the community are being developed to make young people aware of and sensitive to old age. In so doing, it is hoped that children and young people will develop greater respect for the elderly and will be much less inclined, now and in the future, to mistreat them. Schools also are including the topic of conflict resolution in their curriculums, and teachers have found that a discussion of elder abuse can be introduced as part of this topic (Podnieks, 2002).
Changing the World, One Click at a Time
The social media offers unique opportunities to engage a worldwide audience in the challenge of addressing elder abuse and neglect. Through global communication we can reach people and places that have been unable to access tools, resources, and network meetings. Cyberspace has become a resource for ongoing elder abuse prevention strategies. The possibilities for knowledge transfer through virtual learning are exciting and far reaching. Cyberspace promises to create an expansive Internet platform reaching millions of people. In using all the tools of social media, a groundswell can be generated that will lead to a greater sense of community, of citizenship, and of human connection. A challenge is to ensure that older people, who have been left out of the technological revolution, can use the Internet and have the opportunity to access information that greatly affects them.
Another area of global technology applicable to elder abuse awareness and prevention is Geo Mapping. Online mapping and information tools can facilitate opportunities for people from a wide geographic area to share information. Members of the community can share strategies in multiple settings. The tool can allow successful projects, research, and policies to be shared through an online forum. The Geo Map can visually show the location of elder abuse networks, organizations, and individuals throughout the world, as well as their activities, projects, and resources. The map can be a powerful visual tool to display for government and others the potential locations of leadership (McKee, 2010).
Generating a Conceptual Framework
For many years, scholars, researchers, practitioners, policy makers, and others have been calling for a conceptual framework that is specific to elder abuse and neglect. Elder abuse has been referred to as “a-theoretical,” borrowing from theoretical models from sociology, psychology, feminism, health promotion, and the fields of child abuse and domestic violence (Podnieks, 2002). Tremendous strides have been made in the field, and now is an opportune time to develop a framework that will consolidate these elements from useful theories that have been guiding elder abuse work.
It is difficult to work without a common frame of reference in addressing and understanding the complexity of elder abuse and neglect. Existing theories have not been tested and evaluated within the context of elder abuse. A theory must be developed that includes the characteristics of both victims and their abusers—their cognitive statuses, the nature of their relationships, the types of abuse, settings, and protective factors (Jackson and Hafemeister, 2013). It is important to examine existing models as we search for our own theory. For example, elder abuse can be considered a health care issue. The Determinants of Health model proposed by WHO offers valuable insights into factors that impact elder abuse. Other factors may be relevant to theory development, such as caregiver stress or dependency. Ageism may be a factor (McDonald, 2011).
Exchange theory suggests that abuse can result through dependency and reciprocity between the abused and the abuser. Social learning theory refers to behaviors learned in childhood that are repeated in adulthood. The ecological model sees abuse as the result of the complex interplay among a person’s individual characteristics, the community, and social factors. The lifecourse approach links the individual and the social structure to accumulative advantage/disadvantage over time (McDonald, 2013). Missing from many theories but critical to a new elder abuse theory is a human rights approach, which will frame social justice and health equity and reinforce the civil and human rights of all people. The restorative justice approach
has been used with some success in Canada. Researchers continue to debate on conceptual frameworks. At a recent workshop, a participant stated, “we don’t use a model … we prefer to go out and just do it.” That approach may work in some situations, but the time has come for those in the elder abuse prevention field to articulate a solid conceptual framework. How can we teach students and beginning practitioners without a road map and without guidelines?
This paper calls for the formation of a global work party to generate a conceptual framework that belongs to and reflects the philosophy of elder abuse. It has been talked about by many scholars, researchers, and practitioners—it is an idea whose time has come, and the commitment and passion are there to accomplish it. A call has gone out to the international community; an action plan will be generated and the concept will become a work in progress. Garrison (2000, p. 3) best articulates why elder abuse researchers must now generate a framework for elder abuse: “Theoretical inquiry is central to the vitality and development of a field of practice—not to mention its recognition and credibility from those not yet initiated into the field. The theoretical foundations of a field describe and inform the practice and provide the primary means to guide future developments. It influences practices and research, reveals new knowledge and suggests alternatives.”
Elder abuse is a universal problem. Research shows that it is prevalent in both the developed and developing world. Enhancing understanding and raising awareness is the responsibility of all countries, and the more that can be shared the more effective the outcomes. The strategies described in this paper can be applied at a global level. The use of social media makes it possible to communicate around the world and to be connected with programs and practice in many countries.
This paper has been a brief reflection of the historical field of elder abuse and some milestones: the evolution of networks and support groups, initiatives such as WEAAD, and the emergence of the role of technology. This paper closes with a call and a vision for the theorists of the field to describe what we have learned and map what we know in order to discover what is not known.