Motivation and emotion/Book/2018/Elder abuse motivation

Overview


This chapter will provide psychological theory and research to assist in the understanding of elder abuse motivation. Elder abuse is the focus of increased international interest, amidst increased social concern and exponential growth of the overall aged population.

Theory and research in psychology relating to motivational factors of elder abuse are critical for reducing rates of victimisation, as the offending behaviour is associated with elevated levels of distress and mortality in aged populations and mental morbidity of perpetrators. Identifying the prevalence of elder abuse is inherently challenging, as offending conduct may arise from omission or commission of an act, with or without intent. Despite such challenges in definition and quantification, psychological science is required to understand the motivations of aged abuse to improve the lives of senior citizens. This chapter will examine the value and limitations of theoretical interventions of elder abuse and proposed avenues for future research.

Types
The internationally accepted definition of elder abuse is "a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person"(World Health Organisation [WHO], 2015). Elder abuse arises in several forms, such as physical or financial mistreatment, and varies according to the cultural norms imposed on caregivers of older people. Elder abuse can result from either the commission of an act or an omission of the standard of care required by senior individuals and the actions or failure to act can amount to abuse, regardless of whether the conduct was intended or unintended. Subjective standards of mistreatment are defined by characteristics such as frequency, length, severity and outcomes. This societal variance poses demonstrable difficulties in quantifying data for research and applying global theoretical approaches in the field of motivational psychology. However, all types of elder abuse share two fundamental commonalities; decreased quality of life and unnecessary harm. Extensive research has identified the five most common types of elder abuse. This five-type concept of elder abuse is the result of research conducted in Canada, the United Kingdom, and the United States. However, this model for categorising elder abuse types can be expanded and applied to population studies beyond the scope of western countries (WHO; 2015).

Financial abuse - the illegal or inappropriate exploitation or use of material resources.

Psychological abuse - the infliction of mental harm.

Physical abuse - the infliction of pain, causing physical injury or coercion, including drug-induced or material restraint.

Sexual abuse - the commission of any non-consensual sexual acts or exploitation

Neglect - the refusal or lack of exercise to satisfy a requisite duty of care. A failure to act does not require that the caregiver is aware or intends to inflict physical or emotional distress 

Prevalence


The number of Australians suffering from elder abuse is difficult to determine, due to a complete lack of prevalence studies. An estimation in 2016 suggested that the Australian prevalence is between 2-10%, with a possible higher percentage for neglect (Kaspiew, Carson et al. 2016) The differing approaches adopted between international studies have also led to variations in data estimates. One definitive finding gleaned from comprehensive research demonstrates that the global population is aging in general. The 2013 figure of 531 million people over 65 years of age is projected to triple to 1.5 billion in 2050 (United Nations World Population Prospect, 2013). Hence, the 3.2%-27.5% prevalence range of elder abuse for the general population may indicate a future crisis if left unchecked (Cooper, Selwood et al. 2008).

The most reliable, validated methodology of a general population study of elder abuse was carried out in 2008. The researchers confirmed internal reliability and validity of a newly-developed instrument (α = 0.7–0.92). The caseness of elder abuse reported ≥1 offending conduct occurring ≥2–3 times monthly. Approximately 1.9% claimed physical abuse, 4.1% occurrences of financial abuse, 3.6% instances of verbal abuse, 2.4% reports of neglect, and 4.2% cited psychological abuse. WHO (2016) reports the international prevalence of elder abuse as: financial (1.0-9.2%), psychological (0.7-6.3%), physical (0.2-4.9%), sexual (0.04-0.82%), and neglect (0.2-5.5%).

Related health outcomes
Elder abuse shares a high correlation with decreased quality of life, morbidity, mortality, and a severe negative impact on victims (Joosten, Vrantsidis & Dow, 2016). The WHO estimates elder abuse as the direct cause of death for approximately 2,500 deaths in Europe annually(2011 European Report). This type of abuse causes depression, anxiety, PTSD, fear, low self-esteem, and an array of other psychological stressors (Dong, Chang et al. 2013), substance abuse (Rosen, 2014) and suicide (Kaye, Kay et al. 2007; Joosten, Vrantsidis & Dow, 2016). Elder abuse victims face an increased risk of disability, hospitalisation, and institutional care. Additionally, abused seniors are more likely to develop disordered sleeping, chronic pain, and suicidal ideation than those who do not experience mistreatment (Glendenning, 1999).

The cost of abuse
In the United States, the estimated healthcare costs incurred by injuries resulting from elder abuse is over USD $5 billion, in Australia, estimates placed this figure between AUD $9-30 million in 2007 (Choo, Hairi et al. 2013). These figures only account for direct health care expenses and do not relate to ancillary financial costs carried by the victim (eg. psychological treatment of mental harm or ongoing rehabilitation for physical injury) and wider community (Joosten, Vrantsidis & Dow, 2016).

Victims and perpetrators
This form of abuse is typically occurs between generations of family members. In most cases, the victim is the parent of an adult perpetrator (Alon and Berg-Warman 2014). Therefore, elder abuse is an accepted and widely-recognised class of family violence, sharing hallmarks of other types of domestic abuse, such as an over-representation of female victims and male perpetrators, and highly likelihood of non-reporting (Neave, Faulkner et al. 2016). A challenge to reporting of mistreatment is the result of senior citizens being unaware of support services or that certain acts and omissions constitute elder abuse, victims may also perceive domestic abuse as a private matter.

In addition, older individuals often experience the common sense of shame exhibited in many victims and may feel personally responsible for the mistreatment of perpetrators (Clare, Clare et al., 2014). This guilt and embarrassment is an unfortunately prevalent experience for elder abuse victims, due to the sense of parental responsibility for actions of an adult child (Moon and Benton 2000) and a desire to avoid outcomes of reporting that may negatively affect a family member (Neave, Faulkner et al. 2016). In summary, elder abuse is often suffered in silence due to a concern over possible detrimental outcomes to the perpetrator or retaliation for speaking out, specifically when the victim is socially isolated and dependent on their abuser. For many elderly persons, the possible breakdown of a familial relationship can cause fears over potential abandonment or placement in residential care (Ziminski Pickering and Rempusheski 2014). These fears are not unfounded, social isolation is an extremely strong indicator geriatric mortality. It is a risk factor on par with smoking and obesity among healthy individuals younger than 65, but it is far more deadly for the already vulnerable elderly population who report feeling loneliness more keenly than the rest of society.

Instances of elder abuse occur in institutional settings in Australia at a rate of approximately 1.1% in 2014-2015, with 2,626 notifications in 2015 relating to alleged undue use of force and sexual abuse (Department of Health, 2015). Therefore, elder abuse does not occur in a vacuum of family violence, it is committed in aged and healthcare settings, perpetuated by factors such as ageism and prejudice.

Risk factors
Figure 5. Factor checklist indicating increased likelihood of senior mistreatment

Motivations of elder abuse
In 2016, a self-completion questionnaire study found that over one third (36.8%, n=2311) reported engaging in potentially harmful behaviours toward an elder relative. The research found that 35.9% carers reported engaging in potentially harmful psychological behaviours towards older family members and 8% of the potentially harmful behaviours were physical (Lafferty, Fealy et al. 2016). These staggering figures highlight the importance of fully understanding motivational drives; delays in psychological science can stall policy-decisions and social awareness of the suffering experienced by vulnerable people, as well as no improvement to the daily suffering of abuse victims. This chapter will now explore four possible distinct, yet overlapping, motivational factors contributing to elder abuse.

Domestic violence
Family violence can be regarded as arising through a power imbalance existing between individuals, this can frequently be observed in conflicts between genders in domestic abuse circumstances. This analysis will focus largely on the parent-child, or guardian-ward, relationship. Extrinsic stressors, such as social isolation and support systems, can further aggravate pre-existing hostility and tension (Walsh, Ploeg et al. 2007; Joosten, Vrantsidis & Dow, 2016). Examination and identification of the defining factors that tip family conflict into aggressive and violent territory could be a deciding factor in understanding and reducing elder abuse. Long-standing tension and underlying grievances can inhibit relatives from adapting proactively to changing situations, particularly in circumstances of cohabitation between senior parents and adult children (Tindale et al. 2003). A history of defective communication operating between parties appears to increase instances of elder abuse, specifically in circumstances where the conflicting needs of independence and reliance shift over time (Band-Winterstein, 2015)

In Australia, elder abuse has been largely placed within the scope of family violence, with policy-makers and academics poring over considerations of the relationship between older persons and elderly abusers, attempting to discover the existence of violent acts and aggression throughout the lifespan and through generations. This is clearly a logical place to start, however, this narrow approach suggests that elder abuse predominantly results from familial conflict, largely precluding significant considerations of behaviour motivated by discrimination, stress of caregiving, and cultural influences (Harbison, Coughlan et al. 2011). The instances of offending conduct in healthcare and aged settings signifies a notable degree of social influence in the motivation of senior mistreatment (Joosten, Dow et al. 2015).

Ageism
Discrimination against aged individuals may manifest in a number usual ways; such race and gender biases; but particularly by means of ageism. Ageism is defined as discrimination due to age and the associated negative views of elderly persons heavily promulgated by most cultures. Ageism is a pernicious form of discrimination that recent research suggests is now more extensive than sexism and racism, relegating older individuals to the outskirts of society, limiting employment and resources, and leading to social outcomes of loneliness and isolation (Sutin et al., 2015). Psychological, political, and social intervention and protections should be implemented to ensure that senior citizens receive a measure of the dignity and respect that they deserve.

Promising research into cognitive and physical differences among older populations have suggested that chronological measures of age should be set aside in favour of methods that gauge subjective levels of frailty, dependency, and cognitive impairment. This could assist in providing faster assistance and protections to elder citizens whose mental faculties or physical disabilities have deteriorated at an accelerated rate, leaving these individuals more vulnerable than expected by age alone (Joosten, Dow et al. 2015)(Clare, Clare et al., 2014).

Gender
The majority of elder abuse victims are female, however, the aged male population is at a greater risk of falling victim to this form of abuse than any other type of domestic abuse. Hence, senior mistreatment lacks the sharp gender contrast of other types of abuse, such as violence between intimate partners. Elder abuse is typically different across male and female populations, elderly women have an increased likelihood of neglect or sexual, physical, and psychological maltreatment, but both sexes are equally at risk of financial exploitation by either family or professional caregivers (Biggs, Manthorpe et al. 2009). Some research has suggested that men are more commonly perpetrators of elder abuse (Joosten, Dow et al. 2015), although subsequent review has demonstrated no clear delineation between male and female abusers, indicating that gender is not a risk factor (Johannesen and LoGiudice 2013).

Burden of caregiving
The burden and stress associated with caregiving was previously hypothesised as the main reason for elder abuse. It was assumed that elder abuse could largely be attributed to frustration resulting from carer duties or ignorance of elder care requirements, however, new research has revealed that this is untrue (Brandl and Raymond 2012). This does not suggest that caregiving is not a significant aspect in understanding elder abuse motivations, it is particularly relevant in mistreatment instances within families. Non-professional caring does not often occur beyond the family unit and spousal care among elderly is more frequently a family matter that occurs between generations. The provision of care through family is typically the determining factor in whether a senior person can choose where to live, rather than being obliged to move into a nursing facility. Unfortunately, this ideal situation and familial support can ultimately lead to outcomes of elder abuse (Schiamberg and Gans 1999).

There comes a time when elderly parents must face and adjust to greater dependency on caregivers, but it is difficult to know where the boundaries lie between supportive functions and constraining personal agency. The aforementioned situation can breed contention, as elderly individuals often sacrifice greater levels of autonomy to keep the peace, and adult children may resent the increasing burdens of caregiving (Joosten, Dow et al. 2015). Unfortunately, the resultant conflict can cause underlying resentments and anger to resurface. In addition, the usual caregiving role was traditionally carried out by females, but in modern times women often already have to balance employment and home life. Some people view caregiving as an unwelcome burden and resent the responsibility of additional "work" that has no financial benefit (Joosten, Dow et al. 2015) (Lowenstein, 2010).

Culture


Elder abuse must be examined in the context of diversity and culture, as understandings and definitions of abuse often vary significantly between international communities, which presents a complex challenge in how best to define and approach this issue. Studies have found that older individuals that are unable to speak English in Australia are at a higher risk of financial abuse due to the additional handicap of illiteracy. The majority of Australian residents are distinct from ethnic minorities that are unable to communicate effectively through the predominant English language of this country, these individuals are likely to request assistance in the form of economic management from immediate family (Wainer, Owada et al, 2011). Therefore, complete faith is vested in the hands of adult children and relatives and a breach of trust would be difficult for the individual to discover, particularly in a timely manner to prevent further economic harm.

As stated in Figure 4. risk factors, identifying with a minority group increases the likelihood of an elderly person experiencing mistreatment, due to reliance on adult children or immediate relatives to assist in overcoming literacy or language barriers and the possibility of such translators to behave unscrupulously. Conversely, some senior citizens of culturally diverse backgrounds would not consider the appropriation of a parents' funds as financial abuse in any way, as some societies view families as collective owners of of shared wealth (Wainer, Owada et al. 2011). Therefore, more research and understanding is required to ensure elderly individuals do, in fact, wish to distribute personal assets amongst relatives or whether social isolation has increased the dependence of a victim on a financially-motivated perpetrator (Joosten, Dow et al. 2015)(Dong et al, 2013)

Additional data into the factors that cause assistance-seeking among elderly persons of minority backgrounds necessary must be collected, as well as the full effects of post-migration stress. Migration stress is currently understood to stem from drastic changes of social status, financial hardship, desire to satisfy traditional expectations of the original culture in the contemporary new setting (Zannettino, Bagshaw et al. 2015). However, the full extent of elderly abuse of Australian minorities is not possible until these concepts have been confirmed and rigorously tested through psychological research and theory.

Applied ecological model
The most effective method of consolidating motivational factors is by adopting an applied ecological approach(AEC), which frames the problem of elder abuse as a class of contextually-based risk factors. This model applies an ecological approach to best ascertain risk factors of possible victims, perpetrators, the relationship between parties and within community. The human ecological perspective developed by Bronfenbrenner examines the individual as existing within four environmental levels: the microsystem (family), the mesosystem (relationship between family and other key settings), the exosystem (a level separate from the individual, but connected to immediate family), and the macrosystem (the definition of overarching ideals, values, norms, and institutional patterns of a culture (Schiamberg and Gans 1999)

An application of the AEC model to elder abuse is useful for considering how the victim behaves with others nearby, and within the larger ambit of the community and society in which the subjective players operate. This model takes into account that instances of elder abuse most frequently occur on the individual level and the family unit and its associated privacy. The AEC sets out a bifocal approach in focusing on the victim and abuser as a familial pair. Each individual is viewed as being influenced and motivated by other people, the communities of those individuals, and the beliefs of a society in relation perceptions of age (whether chronological or assessed by factors such as frailty or cognitive impairment), domestic abuse and conflict, the financial position of individuals in each generation of a family, caregiving, and the responsibilities of aged parents and adult children. In its designed operation as an applied ecological model, AEC makes allowances with regard to the distinct and disparate frameworks, for example: caregiving, sexism, family violence, and interdependency, in addition to matters such as gender and sexuality. This framework fits well with the motivational factors addressed in Overview sections 5.1-5.6 of this chapter, specifically relating to types of motivation.

Leading motivational theory for elder abuse
The research and study for this chapter will now recommend the best theory for studying motivational factors of elder abuse in the field of psychology and other future explorations into this subject. Intergenerational transmission (IGT) theories of family violence has been a key psychological theory relied upon to explain the connection between interparental aggression and violence originating in the familial context and elderly abuse in subsequent familial relationships (Black, et al. 2009).

Intergenerational transmission of family violence
The aetiology, preventative measures, and violence in intimate relationships has been examined through IGT for over 30 years. Consistently high reliability across cultural groups and gender is demonstrated in this IGT studies (physical abuse = 86%, psychological abuse = 79%)(Bell et al., 1996; Fischbach & Herbert, 1997). IGT concepts relating to intergenerational transmissible of family violence indicate that abused children may develop into adults who believe aggression or violent behaviour is a solution to conflict and a way of controlling the individuals ancillary to themselves. Hence, minors with a family background of domestic abuse would likely develop into adults whose only means of conflict resolution is violent behaviour, possibly perpetuating cycles of familial abuse (Lowenstein, 2010). Hitherto the IGT models were predominantly applied to adults whose childhoods were abusive and their subsequent aggressive relationships with partners and children, rather than interactions with elderly parents. However, one contemporary psychological report found that abuse of elderly mothers by adult daughters occurred in circumstances where daughters reported instances of neglect or abuse in childhood. Psychological researchers have hypothesised that adult children with violent backgrounds do seem aware of the requirements of caregiving for elderly parents, however, these individuals lack the desire or cognitive resources to behave in accordance with such expectations.

Senior individuals with a history of abuse from others appear to be more at risk of being targets of elder abuse as well, due to studies demonstrating that those abused as children are subject to increased rates of recurrent physical abuse and neglect as seniors. Unfortunately, the reoccurrence of abuse is likely to result in higher chances of financial abuse. Senior persons that suffered from family violence in childhood seem to face instances of abuse in the course of old age, as well as childhood age: specifically, physical and financial abuse. Older people who themselves have been victims of childhood family violence may be more likely to experience elder abuse: research shows victims of childhood violence are more likely to be victims of physical abuse and neglect as adults, and more likely to experience co-occurring financial exploitation. In light of the complex nature of elder abuse and how the roles performed in the familial unit change and develop over time, such as the interaction between the actors of parent and children, requiring further psychological research of IGT theories and elder abuse must first take place.

Elderly abuse interventions
This list of interventions will provide options that those with elder abuse concerns should be aware of; for example, legal action, counselling services, and respite care.


 * Crisis care: hospital admission, nursing care; hostel arrangements
 * Community support services: home nursing, housekeeping and incontinence assistance, transport
 * Respite care: at-home respite care available, day or night care, residential respite
 * Counselling services: family therapy, individual sessions
 * Treatment offered to the perpetrator: psychological counselling in a judgment-free environment, hospital admission for the perpetrator
 * Alternative permanent residence: institutional placement, such as nursing homes, available for both abusers or victims
 * Legal interventions and action: last resort measures for the safety of victims, AVOs, different types of protection orders

Conclusion
Difficulty in defining elder abuse and its factors has led to difficulty in many areas, such as psychological theory and research. Understanding and defining the motives of elder abusers is critical for providing solutions for this harmful phenomenon. However, the international leaders, policy makers, psychologists, concerned community members, and victims worldwide can agree that two common features of elder abuse confirm its illegality and universal condemnation: negative quality of life of elderly victims and the commission unnecessary and unacceptable harm to this already vulnerable class of people. Psychological research and theories of family violence can aid in defining, understanding, and reducing instances of senior mistreatment, particularly those based on IGT model. The IGT approach to elder abuse was recommended for its high reliability, validity, and a main theoretical method that has provided consistently robust findings over three decades of psychological research. Much work has to be done in a wide number of professional fields to provide more effective protections of vulnerable elderly persons, however, it can be argued that the global community has arrived at a consensus that this type of abuse is a widespread issue of grave concern. The international focus into elder abuse has resulted in more studies, interventions, theories, and community awareness, suggesting that the rate of elderly abuse worldwide has hopefully reached its zenith and that these numbers will not only plateau, but reduce, within a few generations.

Reference List

 * Joosten, Melanie & Vrantsidis, Freda & Dow, Briony & Melbourne Social Equity Institute & National Ageing Research Institute (2017). Understanding elder abuse : a scoping study. Melbourne Social Equity Institute, [Carlton, Vic.]