ARTICLE #8: Clinical Management of Elder Abuse:
General Considerations
by Georgia J. Anetzberger, PhD, ACSW, LISW
SUMMARY
Clinical management of elder abuse situations involves five steps:
Although each clinical discipline brings a unique set of knowledge, skills, and perspectives to completing the steps, there are general considerations that universally apply in successfully identifying and treating the problem. These general considerations are described, with particular attention given to the intent behind actions, strategies for step accomplishment, and issues likely to emerge. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> © 2005 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS: Clinical management in elder abuse, abuse detection, assessment, case planning, intervention and follow-up.
There are any number of ways that clinicians encounter elder abuse
situations. In most instances, encounter will not be during actual abuse
occurrence. Only rarely, for example, will clinicians be present when acts
of physical abuse or violations of rights happen. Physicians and nurses
typically are not around to witness an elderly husband hit his wife, even
when this has been a pattern for decades and health professionals are
seen on a regular basis by the couple. Similarly, attorneys and social
workers seldom are present when a caregiving daughter denies visitors
to or opens the mail of her dependant parents, even when reports of this
problem have surfaced among neighbors in the past. Much more common
is for clinicians to encounter elder abuse situations in the aftermath
of abuse occurrence, or alternatively to come across older people whose
characteristics and circumstances suggest the possibility of elder abuse
in the future. Accordingly, the first step in the clinical management of
elder abuse situations involves detecting the problem. The other steps in
order are:
The sections below discuss each of the five steps in elder abuse clinical management, with attention given to answering several related questions:
DETECTION
The purpose of detection is for clinicians to decide whether or not elder abuse is known or suspected in a situation involving an older person who is a current client or has been referred for evaluation or service provision. Elder abuse is “known” if it is personally observed or if it is reported by the victim or some other person capable of having that knowledge. Elder abuse is “suspected” through the identification of signs which represent the consequence of abuse occurrence. Signs suggest the probability of elder abuse. However, because they can have other origins, signs alone seldom offer conclusiveness that elder abuse has taken place. Illustrations of signs include broken bones or physical abuse or dehydration for physical neglect. Yet, broken bones also can result from accidental falls and dehydration from acute illnesses.
Deciding whether or not elder abuse is known or suspected is a prerequisite for reporting the problem to authorities charged with its investigation. Most state adult protective services or elder abuse reporting laws use these criteria for case referral. More than four-fifths of the states have mandatory reporting laws that require health and social service professionals to report elder abuse. Those professionals most frequently identified in the laws as mandatory reporters are social workers, physicians, law enforcement officers, psychologists and nurses (Tatara, 1995; Teaster, 2003).
Even when elder abuse is neither known nor suspected as a result of
clinical detection, the process might reveal risk factors for abuse occurrence.
Risk factors are characteristics that have been found associated
with elder abuse through research on the subject (Anetzberger, 2001).
The identification of risk factors indicates the possibility of abuse occurrence.
The problem could happen in the future. Examples of physical
abuse risk factors include financial dependence and substance abuse for
an adult son residing with his elderly mother. Examples of physical neglect
risk factors include functional impairment and dependence for an
elderly father and caregiver stress and burden for the adult daughter
who provides him with caregiving assistance. Risk factors are like “red
flags.” They serve to alert clinicians and remind them to be on the watch
for examples and signs of elder abuse.
Detecting elder abuse usually requires awareness of the problem and a high level of suspicion (Abyad, 1996). These qualities must be sustained across time, settings, and client contexts. Otherwise, elder abuse situations will be missed (Phillips, 1983). Indications of abuse occurrence can come from observing or interviewing clients in clinical settings, such as professional offices, hospitals, and community-based services. However, the problem is most likely to reveal itself by visiting older people in their own homes. It is here that the consequences of abuse occurrence are often evidenced in a mosaic of physical and behavioral indicators, from accumulated waste as a result of elder incapacity for living alone to fear as a result of victim/perpetrator conflict. Because with time these indicators become part of life’s design, they are difficult to hide. Consequently, it is little wonder that the professionals most likely to detect and report elder abuse are those who typically see clients at home (Blakely & Dolon, 1991).
The likelihood of detecting elder abuse increases the wider the net of observation and inquiry made by clinicians. In this regard, both the victim and perpetrator should be interviewed, and interviewed both together and separately. Group interviews enable the clinician to see victim/ perpetrator interaction. Separate interviews facilitate individual candor and enable comparison of accounts.
It is important to recognize that the clinicians’ perspective of victims and perpetrators or their personal values may interfere with abuse detection. For example, clinicians may overlook or misinterpret elder abuse situations where the older person’s disturbing behaviors are seen as provocative or the caregiving perpetrator’s attitude is one of cooperation or conciliation (Phillips & Rempusheski, 1986). Moreover, strong beliefs on individual privacy or family sanctity may cause clinicians to ignore elder abuse situations. Other barriers to abuse detection can exist for clinicians as well, including lack of understanding about the problem and a narrow focus on professional responsibilities because of time pressures or personal attitude.
Nonetheless, it is not just clinicians with barriers to abuse detection. Barriers can exist with the victims and perpetrators themselves (Aldeman, Siddiqui, & Foldi, 1998). For instance, victims may deny abuse occurrence. They may be unaware of it because of cognitive or other impairment. They also may redefine it as something other than elder abuse on the basis of cultural or family background. Likewise, perpetrators may see elder abuse as necessary action to protect victims, for example, in the inappropriate use of chemical or physical restraints with dependent older people who are confused and wander. They may consider elder abuse as just punishment when victims are combative and assaultive toward them or when there has been a history of family violence, with the victim assuming the perpetrator role in earlier times. Perpetrators also may attempt to hide abuse occurrence or convince victims of its necessity.
Several instruments have been developed to improve and systematize the elder abuse detection process. Typically called screening or risk assessment tools, their intent is to identify abused elders, those at risk of abuse, or both (Wolf, 2000a). Few such tools are universally accepted, and most have not been tested for reliability or validity. However, they are important in the clinical management of elder abuse because of their ability to aid in abuse detection (National Research Council, 2003). In this regard, screening and risk assessment tools insure that manifestations and risk factors for elder abuse are not missed. They formalize the process of observation and inquiry, and they provide a database for research (Sengstock, Hwalek,&Moshier, 1986; Fulmer& O’Malley, 1987; Fulmer&Gould, 1996; Neale,Hwalek, Scott, Sengstock,& Stahl, 1991; Marshall, Benton, & Brazier, 2000; Wolf, 2000).
Minimally, screening and risk assessment tools should include questions on demographics, common signs and risk factors for each abuse form, and degree of endangerment (Aravanis et al., 1993). Structurally these tools range from narrative guidelines to checklists, from comprehensive catalogues to abbreviated indices. Some tools are geared to use in particular settings, like hospitals or adult protective service agencies. Others relate to select professionals, like physicians or nurses. Examples of elder abuse screening and risk assessment tools include the following:
ASSESSMENT
The presence of elder abuse signs or risk factors indicates the need for a more thorough assessment. Conversely, a thorough assessment may be required in order to reveal elder abuse signs and risk factors (Gray-Vickrey, 2000). The purpose of the assessment process is to evaluate the person and situation of victim and perpetrator in order to determine:
Assessment involves the collection of information from multiple sources, including the victim, caregiver or perpetrator, other family members, and collaterals (All, 1994). The information is obtained through various mechanisms, such as interviews, clinical testing, and background checks.
Particularly important, and potentially difficult, are assessment interviews. They are best approached recognizing and respecting the “5 Ps” of interviewing in general: privacy, pacing, planning, pitch, and punctuality (Villamore & Bergman, 1981). Moreover, consideration for individual rights and preferences is critical, if the clinician expects client movement from assessment to planning and intervention in clinical management. Resistance to help can, and usually will, emerge from victims and perpetrators when little empathy is expressed for personal struggles, wishes are ignored, individual strengths are minimized, and interventions are rushed.
An assessment represents an organized approach for collecting information
about people and their circumstances. Its importance lies in its
ability to improve the accuracy of problem identification, provide information
for planning interventions, and avoid the inappropriate use of
services. Minimally an assessment of elder abuse victims and perpetrators
and their situations should cover: physical health problems, mental
and cognitive status changes, functional limitations, financial and environmental
issues, recent family or life crises, and diminished social resources.
In addition, the nature of the elder abuse should be evaluated,
including its forms, frequency, intent, severity, and longevity. Finally,
Quinn and Tomita (1997) recommend inquiry about a typical day and
care or assistance expectations as part of the assessment process. Instruments
employed during assessment depend upon the specific conditions
being evaluated, such as the activities of daily living scale for functional
limitations and Mini-Mental Status Examination for cognitive impairment.
In some instances, assessment and related instrument use will be
layered, with problem confirmation at one level suggesting the need for
more in-depth explanation. For example, identification of cognitive decline
using the Dementia Scale may indicate the need for a comprehensive
neuropsychological evaluation (Breckman & Adelman, 1988).
PLANNING
The purpose of the planning step in clinical management is to delineate a course of action based upon assessment findings. This is not easy. Sometimes clinicians err in their associations between problem identification and intervention decision (Phillips & Rempusheski, 1985). This can happen because they fail to understand underlying abuse etiology or to unravel the consequences of abuse occurrence, both of which help facilitate sound intervention selection (Adelman & Breckman, 1995).
Other times, the paradigm clinicians use to guide action is inappropriate
(Phillips, 1988). Nerenberg (2000) discusses several paradigms
or approaches used to address elder abuse. They include: protective services,
elder rights, domestic-violence, criminal justice, and multidisciplinary
team. Other observers offer additional paradigms, such as
family-oriented (Rathbone-McCuan, Travis, & Voyles, 1983), social
network (Hooyman, 1982), environmental press (Ansello, King,&Taler,
1986), inadequate care (Fulmer & O’Malley, 1987), and systems (Segal &
Iris, 1989). Each paradigm or approach tends to have its own philosophy,
intervention strategies, and preferred services or other resources.
Given the complexity of elder abuse as a problem and as it manifests itself
in individual instances, it is probable that every approach fits some
abuse situations and that multiple approaches may apply in select ones.
Unfortunately, professional orientation, agency policy, personal bias,
or ignorance may undermine appropriate paradigm selection, making
choice automatic rather than a thoughtful consideration of the dynamics
of the elder abuse situation in question.
Two goals are employed in planning elder abuse interventions: preserving
victim autonomy and promoting victim safety. Although sometimes
at odds with one another, these goals are primary in clinical management
(Lachs & Pillemer, 1995). Achieving them is often dependent
upon two factors. The first concerns the ability and willingness of the
victim and perpetrator to accept assistance. Case planning will be different
for competent, consenting clients than it will be for competent,
nonconsenting or incompetent ones (Villamore&Bergman, 1981). The
second factor surrounds the quality of the intervention resources themselves.
The adequacy and effectiveness of specific treatments, services,
or benefits can affect client outcome and therefore influence case planning.
In this light, it is noteworthy that evaluative research on elder
abuse interventions has been minimal, and when specific programs or
services have been tested, they frequently have not been shown effective
(Wilber & Nielsen, 2002, Fulmer & Anetzberger, 995).
INTERVENTION
The intervention step in clinical management involves the application of services, laws, and clinical procedures to treat the consequences of elder abuse or prevent occurrence or reoccurrence of the problem. It surrounds the implementation of the case plan.
Elder abuse service interventions have been organized in several different ways. For example, Collins (1982) arranges help for victims by service type:
Podnieks (1985) describes three levels of prevention:
Baumhover, Beall, and Pieroni (1990) divide interventions
by targeted group (i.e., victim, abuser, or community) and response
level (i.e., social policy, community, and professional). Quinn and
Tomita’s (1997) organization of interventions considers time duration
(i.e., crisis intervention, short-term, or long-term) and targeted person
(i.e., victim or perpetrator). Finally, Anetzberger (2000) offers an integrative
framework for elder abuse intervention that has three intersecting
components: approach (i.e., protection, empowerment, or advocacy),
target (i.e., victim-perpetrator dyad or family system), and basic intervention
function (i.e., emergency response, support, rehabilitation, or
prevention).
Research on specific service or program interventions used in elder abuse situations suggests variation by abuse form and targeted person. For example, Sengstock, Hwalek, and Petrone (1989) found that victims of confinement/deprivation and financial abuse received the most services and victims of physical abuse the least. Services almost exclusively went to the victims; very few went to the perpetrators. Moreover, choice of service to victims mirrored that extended to frail older people in general, and reflected types of services found in social work and home care settings.
In studying service delivery to competent, self-neglecting elders in Wisconsin, Vinton (1991) found that typically only one service was offered to each victim, although other services existed in the community. Additionally, among 25 different services planned for 227 victims, the most common were:
In a comparison study of physically abusing caregivers and noncaregiving abusers, Vinton (1992) discovered that few perpetrators were offered any services. However, when services were offered, caregiving abusers received more than noncaregiving abusers, even when the latter demonstrated greater need.
Lastly, Nahmiash and Reis (2000) found that abuse victims were most likely to accept and benefit from concrete services, like medical care and homemaking, or empowerment strategies, like support groups and advocates. Perpetrators most accepted and benefited from individual counseling and education/training. Furthermore, in comparing victims and perpetrators, perpetrators both accepted and benefited from services more than victims.
Legal interventions to address elder abuse vary by state. However, nearly all states have available civil and criminal remedies as well as common law and law specific to elder abuse (Moskowitz, 1998). In Ohio, for example, criminal remedy exists in the abuse or neglect of an elderly or disabled person by a caretaker law, and civil remedy in the protective services law for adults, which exclusively considers abuse, neglect, or exploitation experienced by impaired persons age 60 years and older. Situations of elder physical abuse also may be covered as statutory crimes under such laws as those dealing with assault and battery. However, it has been noted that tort law is deficient with respect to elder abuse in that it does not always consider the various abuse forms experienced by older adults nor does it always consider abuse consequences as legally actionable (Polisky, 1995). In Ohio, as elsewhere, financial abuse may be covered by laws addressing theft, fraud, or larceny, among others. In addition, the Ohio General Assembly enacted legislation a few years ago that provided greater penalty against those who violate select exploitation laws by victimizing either elderly adults or those with disabilities. Finally, protection for incompetent or incapacitated older adults is available through court appointment of surrogate decision- makers, such as guardians (Kapp, 1995; Moskowitz, 1998).
In Ohio, as in most states, the criminalization of elder abuse began in the late 1980s (Heisler, 1991; Stiegel, 1995). Prior to that, the emphasis was placed on assisting victims through a wide range of services and, if needed, through involuntary protective intervention or appointment of surrogate decision-making authority. The criminalization of elder abuse reflects many factors. These include the following:
Nonetheless, with a problem as multidimensional as elder abuse, typically with complex relations between victims and perpetrators and limited available or acceptable care options for dependant older adults, intervention strategies often must combine the application of law with services, even in admittedly criminal cases. Otherwise, the arrest and imprisonment of the perpetrator may leave the victim without needed assistance, socially isolated, and at risk of self-neglect or institutionalization (Wolf, 2000b).
As an alternative to punishment or deterrence through the criminal justice system, victims or their families more and more are seeking restitution in the form of monetary damages from perpetrators, or those who fail to report their acts, through the civil justice system. Most such initiatives have focused on abuse or neglect in institutional settings, like nursing facilities (Jackson, 1999). However, this remedy can apply to domestic elder abuse as well (Payne, 2000).
It is not possible within the confines of this article to describe all the various clinical procedures that might be appropriate in elder abuse situations. Instead, some of the specific aims they should have are delineated.
FOLLOW-UP
Follow-up in elder abuse cases can have different purposes. Among the most important are evaluation of intervention effectiveness, reassessment of need, and situation monitoring to prevent abuse reoccurrence. In every instance, follow-up suggests the establishment of an ongoing relationship between victim (or perpetrator) and clinician, minimally characterized by a recognition that elder abuse and its effects typically do not end quickly or simply.
Elder abuse intervention requires a commitment to change on the part of the victim or perpetrator. Change is rarely easy, but it is particularly difficult in abuse situations of long duration and strong family bonds. Respecting client pace and degree of change can challenge clinicians not firmly rooted in principles for intervening on behalf of abused elders, such as those suggested by Anetzberger and Miller (1999). Hierarchically ranked, they are:
Elder abuse situations often require long-term or intermittent intervention
before resolution (Quinn & Tomita, 1997). As a result, client
dependency on the clinician and client inability to remain focused on the case plan are not uncommon practice issues. More troubling, however,
are instances where clients refuse needed help. In Ohio during fiscal
year 2003, 24 percent of older adults found in need of protective
services because of substantiated abuse, neglect, or exploitation refused
services (Ohio Department of Job and Family Services, 2003). An Illinois
study on substantiated elder abuse reports to adult protective services
discovered that victims who refuse services tend to have perpetrators
who are substance abusers, have mental illness, or are financially
dependent on the abusers (Neale, Hwalek, Goodrich, & Quinn, 1997).
Some victims lack the mental capacity to consent to services. In
Ohio, and many other states, involuntary protective services can be offered
through court order. In a national study of involuntary protective
services, Duke (1993) found that among states which provide involuntary
services, an average of 8 percent of adult protective services clients
are served involuntarily.
Documentation is an essential component to elder abuse detection, assessment, planning, intervention, and follow-up (Rosenblatt, 1996). It provides an historical account, important for identifying trends. It enables clinicians to determine which practices are effective and which ones are not. It offers evidence that may be useful in legal actions. It is a reference for other clinicians who might follow, to facilitate coordinated care or service delivery. Documentation must be accurate and complete. It also should be timely and reflect the “regular course of business” during clinical contact. Finally, it may take multiple forms, from written records to photographs to clinical test results.
s
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