That Caregiver Stress Is Not the Primary Cause of Elder Abuse

GENERATIONS – Journal of the American Society on Aging

By Bonnie Brandl and Jane A. Raymond Policy Implications of Recognizing that Caregiver Stress Is Not the Primary Cause of Elder Abuse

Studies show the causes of elder abuse to be wide-ranging—and not necessarily an outcome of caregiver stress. Seeing caregiver stress as a primary cause of abuse has unintended and detrimental consequences that affect the efforts to end this widespread problem.

ach year, millions of older adults are abused, of elder abuse? And what are the unintended Eneglected, or financially exploited (Lifespan consequences of focusing on stressed caregivers of Greater Rochester et al., 2011; Acierno et al., to prevent and alleviate elder abuse? 2010). In 2009, an estimated $450 billion was spent on providing care for older individuals The Dynamics Of Elder Abuse: Historical (Feinberg et al., 2011). Burdened caregivers who Perspective and Evolving Analysis do not have adequate support and resources While early elder abuse research was linked to often experience stress. Would preventing caregiver stress, later analysis of the methodolo- caregiver stress eliminate or reduce elder abuse? gies identified several limitations that potentially skewed the findings. When studies were first done, there An historical perspective were no good baseline data or In chapter six of Elder Abuse: Conflict in the definitions for elder abuse. Family, Hudson (1986) examined research on elder abuse from 1979 to 1985. In her review of Early elder abuse research suggested that seventeen studies, she documented twelve that caregiver stress was the primary cause of elder list caregiver stress or claim stress as a cause of abuse. According to this model, “the elderly elder abuse. Some of the cites from the chapter victim is viewed as very dependent on the include the following: caregiver, usually an adult daughter, who • “Most (75 percent) abusers were experiencing becomes frustrated, angry and sometimes some form of stress” (O’Malley, 1979). abusive or neglectful because of the continuous • “Abuse was cyclical and precipitated by stress” caretaking needs of the infirm parent” (Wolf, (McLaughlin, Nickell, and Gill, 1980). 2000). But is caregiver stress the primary cause • “The elder was a source of stress to the abuser,

who was experiencing a variety of stressors” of the caregiver is often based on previous family (Boydston and McNairn, 1981). history, the amount of care required, and the • “These families were under stress 80 percent perceptions of the partner or family member of the time, with the elderly person being the about caregiving (Brintnall-Peterson, 2012). scapegoat for the caregivers’ frustrations” “Family members often undertake caregiving (Chen et al., 1981). willingly, and many find it a source of deep • “Abusers…. 67 percent were under stress” satisfaction and meaning” (Feinberg et al., 2011). (Department of Aging, 1981). Rather than focusing on what they may be • “The most frequently reported cause of elder missing, they concentrate on the gains that may abuse was frustration of the caregiver due to occur, such as in richer relationships or en- change in lifestyle and burden of the elder” hanced skills. According to Feinberg and col- (Levenberg et al., 1983). leagues, “Those who take on this unpaid role After reviewing these studies, Hudson risk the stress, physical strain, competing concluded that elder abuse researchers in the demands, and financial hardship of caregiving, early 1980s faced significant challenges: they and thus are vulnerable themselves.” were studying a problem that was rarely dis- Most stressed caregivers do not hurt or harm cussed and poorly understood. There were no older individuals. Although popular, the situ- baseline data for or common definitions of elder ational model does not explain why some abuse. Sample sizes were often small, and still stressed caregivers never harm or exploit older the results were frequently generalized. Most adults. More often, caregivers experience research consisted of retrospective studies that caregiver distress, which perhaps more aptly used convenience samples and were dependent reflects the harmful effects, burden, and other on voluntary responses (Hudson, 1986). symptoms of tension that challenge some Also, older victims often did not want to be caregivers (Brintnall-Peterson, 2012). Common interviewed about abusive incidents they symptoms of caregiver distress include engaging perceived as shameful or embarrassing; most in behaviors that are not in the best interest of studies gathered information from professionals the caregiver, such as overeating; self-medication and abusers—not the victims themselves. Yet and substance abuse; and experiencing depres- results derived from abusers’ perspectives need sion, anxiety disorders, social isolation, or to be interpreted with caution since abusers are chronic medical or mental health problems known to lie, minimize the abuse, and justify (Hoffman and Mendez-Luck, 2011). their behavior (Hudson, 1986; Bancroft, 2002; Stark, 2007). Therefore, Hudson concluded that Why Does Elder Abuse Exist and Persist? “stress could easily mask the discovery of other Elder abuse presents in various forms such as significant contributing or causative factors. physical, sexual and emotional abuse, neglect, Stress does seem to be an intensifier of potential and financial exploitation. Offenders can be mistreatment, but it is not a clear predictor, since spouses or partners, family members, care- most families providing eldercare experience givers, and other persons in positions of trust or stress and yet do not mistreat their elders” authority. Given the complexity of these cases, (Hudson, 1986). no single intervention, response, or policy initiative is going to solely address the problem. Evolving analysis: providing care—satisfying Anetzberger (2005) has observed that with for some, stressful for others “a problem as complex as elder abuse, it is Caregivers are as diverse as the older adults in unlikely that any single theoretical perspective their care. The perceived and actual stress level could explain all forms and situations.” Most

Copyright © 2012 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson St., Suite 1450, San Francisco, CA 94105-2938; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. Fall 2012 • Vol. 36 .No. 3 | 33 GENERATIONS – Journal of the American Society on Aging Pages 32–39 researchers and practitioners have moved away (NCJRS, 2010; Lundy and Grossman, 2004; from a single causation theory (NCJRS, 2010; Lachs and Pillemer, 2004; Wolf and Pillemer, Ramsey-Klawsnik, 2000; Sklar, 2000). Ramsey- 1997). Often the victim and abuser are living Klawsnik suggests that a small percentage of together, but the older individual is providing abusers are overwhelmed or impaired caregiv- financial resources for food, clothing, and ers; some caregivers have medical or mental housing and taking care of the home. In some health conditions that make it difficult or cases, the caregiver was the victim of the care impossible to provide adequate care. In these recipient’s abusive behavior—reinforcing that situations, the older adult may experience abuse the adult who is often defined as “vulnerable or neglect, but the harm is due to the inability of or at risk” may not be the victim. the caregiver to provide adequate care without Penhale (2003) suggests that “the general assistance. The remaining offenders are narcis- concept of ‘elder abuse’ should be more closely sistic, domineering, or bullying and sadistic examined and that more emphasis should be (Ramsey-Klawsnik, 2000). given to the nature of power within relationships.” In some cases, Some studies suggest the abuser is dependent on the elder abuse is intimate- partner violence or victim in some way—perhaps financially or emotionally. domestic violence, with all the classic Several studies and articles have debunked dynamics, well into old age (Fisher and Regan, the popular notion that elder abuse is primarily 2006; Zink et al., 2005; Zink et al., 2006; Lundy caused by caregiver stress (Acierno et al., 2010; and Grossman, 2004). Other studies have sug- Fischer and Regan, 2006). Vinton’s 1991 litera- gested that the dynamics of elder abuse are ture review found that “there appears to be similar to the power and control dynamics consensus in the areas of spouse and elder experienced by younger battered women abuse that life stressors alone cannot account (Harris, 1996). Similar to the experiences of for violence.” Reis and Nahmiash (1998) found younger battered women, often an offender is that “the caregiver stress theory of abuse is using a pattern of coercive tactics to gain and not supported by the findings of this study. Nor maintain control over the victim. Family mem- does caregiver burden consequent to increased bers or caregivers will also use various methods impairment or need for ADL (activities of daily of power and control over an elderly victim of living) assistance signal abuse.” In their 2004 abuse. Forms employed by abusers include article, Lachs and Pillemer documented a isolation, threats, intimidation, taking charge of similar finding: “…an old person’s dependence all household money matters, and physical, on the carer and resulting stress has not been sexual, and emotional abuse. In addition, greed found to predict the occurrence of elder abuse in appears to be a primary driver in cases of elder most studies to date. Case-comparisons studies financial exploitation (MMI, 2011). have failed to find either higher rates of depen- dency in the old person or greater carer stress Is Caregiver Stress an Explanation for in elder abuse situations.” Inexcusable Behavior? In fact, rather than the older adult being Even with these studies on elder abuse, too often dependent on the caregiver or family member, practitioners, researchers, and policy makers some studies suggest that in many cases the focus on remedies to address caregiver stress as abuser is dependent on the victim in some if these interventions and policies will enhance way—perhaps financially or emotionally older victim safety and hold offenders account-

Copyright © 2012 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson St., Suite 1450, San Francisco, CA 94105-2938; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join. 34 | Fall 2012 • Vol. 36 .No. 3 Pages 32–39 Elder Abuse and the Elder Justice Movement in America able. This leads us to consider: Is stress an policies and services based on an inaccurate acceptable justification for abuse? Or is care- assumption that caregiver stress is the primary giver stress often used as “smoke and mirrors” cause of elder abuse. Some consequences include to distract professionals from focusing on the blaming of the victim, minimizing offender needs of victims? Consider the following: accountability, and devaluing social action that • Everyone experiences stress, yet few people, responds to the problem of elder abuse. especially caregivers, respond by intentionally abusing, neglecting, or exploiting loved ones. Blaming the victim • Under stress, most people experience some Linking caregiver stress to abuse implies that if anxiety and may be impatient or tense. When older victims were easier to care for, not so sick, most people have a bad moment, for example, or not “demanding,” the abuse would not occur yelling at a family member, they apologize and (Whittaker, 1995). Often, well-meaning profes- make amends. They see others as deserving of sionals suggest that the older victims must respect and kindness, and do not believe it is change certain behaviors or be less difficult to right to treat others badly. avoid harm. For example, victims may be told to • Abusers who claim stress as an excuse generally do more for themselves, be more patient with do not lash out at everyone they meet. Often the caregiver, help the caregiver feel better, they are charming and kind to neighbors, increase emotional closeness in the relationship, friends, and professionals. Abusers who claim or provide extra help around the house (Wil- to be out of control due to anger or stress can liamson and Schaffer, 2001). This advice is not control their behavior—it is rare for law enforce- helpful, because the responsibility for the abuse ment to see enraged abusers. Typically the is inaccurately placed on the victim rather than victim is hysterical and the abuser is calm as acknowledging that only abusers can choose soon as law enforcement arrives on the scene. their behavior, words, and actions. • Abusers who claim to be out of control due to anger or stress are often strategic, hiding Minimization of offender accountability physical evidence of blows by directing them When service providers focus on “…provoking at areas usually covered by clothing so no one and controlling characteristics of ‘non-compli- will see marks and bruises. For an offender ant’ dependent victims and ‘the caregiver is seen who suspects his partner is having an affair, as driven to helplessness, rage and frustration,’ blows may be directed at the face so she will these indicators of carer stress can be used to not go out in public. explain and justify abusive behaviors and • Often the abuse is not an isolated incident as prompt compassionate responses which reported by the offender but part of a larger absolve the abuser from responsibility” pattern of behavior. (Whittaker, 1995). • Stress, anger, and substance abuse may According to Straka and Montminy (2006), coexist with abusive behavior. Abusers may “The caregiver stress model of elder abuse tends have been abused or were child witnesses of to promote quite a sympathetic view of over- domestic violence. None of these issues cause whelmed caregivers who are provided with help the offender to engage in abusive behavior. and support, with a consequently lesser focus on victims and their need.” Inaccurate Assumptions Can Cause Abusers know how to prey on the strengths Unintended Consequences and weaknesses, not only of their victims but There are a number of unintended consequences also professionals, family, and friends. Abusers when policy makers and practitioners create recognize it is part of peoples’ nature to see the

Excuses, Excuses: How Abusers Justify Their Behavior

Abusers do not want to get caught or be held accountable for their behavior. They lie, excuse their behavior, minimize the violence, blame the victim, and justify their actions. Common justifications may include the following assertions: • “She is so hard to care for.” • “It was an accident. I didn’t mean for it to happen.” • “I was doing the best I could to provide care, but she [just] fell.” • “This is the first time this ever happened. It will never happen again.” • “She makes me so mad sometimes. She deserved it.” • “I had to defend myself. See this scratch? She did that to me.” • “I’m the victim here. You don’t know what I have to put up with.” • “She gave me her money because she wants me to have it.” • “That nurse needs to mind her own business.” These justifications follow a pattern: they blame the victim or others for the behavior, or for report- ing the incident. Abusers often portray themselves as victims and deflect responsibility for their behavior (Whittaker, 1995). best in others—a human quality that can allow management counseling, respite care, or abusers to persist undetected. As early as 1978, substance abuse treatment. there were more than 1,000 articles on “positive illusions”—the tendency of people to soften the Devaluing social action that responds to world, ignoring and minimizing its bad aspects the problem of elder abuse and over-generalizing its good ones (Salter, 2003). While programs for stressed caregivers, such Research indicates that repeating a false assertion as support groups and respite care, are vitally will increase the chances that people will believe important, they are not elder abuse prevention it. Studies show that people immediately, auto- programs. Given the few resources allocated matically, and unconsciously assume statements specifically for elder abuse prevention and are true, and only afterward do they evaluate intervention, it can be enticing to count the them for possible falsehood (Salter, 2003). much more significantly funded caregiver Therefore, one reason people are vulnerable to support programs as efforts directly addressing predators is because they think they can detect elder abuse. But by doing so, funders and policy liars better than they actually can (Salter, 2003). makers may rely on this falsehood to justify a As a result, professionals too often mini- current lack of action. mize physical evidence and reports by the older As M. T. Connolly wrote in “A Hidden adult victim of abuse, neglect, and exploitation. Crime” (2008): Instead, they believe abusers’ manipulative Why has there been no public outrage? statements, not holding abusers accountable Perhaps the twin culprits of ageism and for their actions by involving the criminal denial are to blame. Perhaps the constella- justice system—even when crimes such as tion of phenomena that make up elder financial exploitation, physical assault, or abuse—elders beaten by crack-addled sexual abuse have been committed. Instead nephews, going unfed in assisted-living abusers are offered stress reduction or anger facilities, impoverished by sending checks to

Canada for mythical sweepstakes winnings— interventions, based on the false assumption that are so disparate that the problem lacks a if you address caregiver stress you attend to coherent public identity. Perhaps, although elder abuse victims. For example, using monies millions of Americans are grappling with the allocated to elder abuse prevention to promote challenge of protecting themselves, their messages to caregivers about reducing stress is a parents and others, elder abuse remains misuse of the limited funding there is to address relegated to a family predicament rather elder abuse, and may have minimal impact on than a national one. preventing harm to older adults. Focusing Which brings us to this question: How do interventions on anger management, stress we as individuals and as a nation measure reduction, or respite care for caregivers often the value of life in old age? And why have we does little to enhance victim safety or quality of not done more to protect and defend our life. Programs and prevention initiatives that most vulnerable elders? truly address elder abuse, neglect, and finan- Ultimately, to end elder abuse, commonly cial exploitation would fund remedies such as held societal values must be challenged through victim-centered services and inter-disciplinary prevention, education, and social action. As a training and interventions. society, we must recognize that behaviors such as sexual abuse in nursing homes, threatening an Elder Abuse Is a National Crisis older adult with a weapon, or stealing money As a society, we do not recognize elder abuse as a and possessions are crimes—not the result of a national crisis. In a 2000 study in Canada, when caregiver who could not handle stress. We must respondents were asked “What comes to mind understand that elder abuse can cause signifi- when you think of family violence?”—81 percent indicated child abuse, 80 percent indicated part- When we continue to perceive elder ner abuse, while only 9 percent indicated the abuse of older adults (Bradford, 2000). We do abuse as a family problem, we focus not designate the resources necessary to en- on individual remedies rather than a hance safety for older individuals and give social justice response. elderly victims of abuse more viable options and choices (GAO, 2011)—a situation that will cant injury and death. As a society, it is time for become more problematic as the baby boomers us to respond to cases of elder abuse with the age and the number of older adults increases. outcry and outrage we see when the victim is a America must recognize that elder abuse is child or a pet. Too often, with elder abuse cases, not caused by a few stressed caregivers: we must there is only silence. support a social movement promoting dignity, When we continue to perceive elder abuse respect, and justice for all older adults. as primarily a family problem involving a few stressed caregivers, we focus on individual Bonnie Brandl, M.S.W., is the director of the National remedies rather than a social justice response. Clearinghouse on Abuse in Later Life, Wisconsin Yet current research and experience in the field Coalition Against Domestic Violence, in Madison, do not support caregiver stress as a primary or Wisconsin. She can be contacted at bonnieb@wcadv. sole reason for elder abuse. Therefore, it is not org. Jane A. Raymond, M.S., is an advocacy and only dangerous, but also irresponsible for policy protection systems developer (retired) for the Wis- makers to continue to build and fund program- consin Bureau of Aging and Disability Resources matic responses, and practitioners to provide in Madison, Wisconsin.

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Care Transitions and the Older Adult Robyn Golden and Gayle Shier, Guest Editors Over the past decade, transitions from one care setting to another have been associated with heightened risk, particularly for elders. Adverse events associated with poor care transitions can include medication errors; compliance and continuity of care problems; nursing home placement; caregiver burden; and increased healthcare costs. Complex care transitions—particularly those from hospital to home—can often result in re-admission—with a costly impact on Medicare. Now, transitional care interventions have emerged as an COMING UP IN important strategy for improving health outcomes and preventing adverse events for elders; these interventions have also become Winter critical for aging network providers who are seeking to effect much- needed change to the U.S. healthcare system. This issue of Generations 2012–13 will parse the myths, opinion, and realities of care transitions. Generations