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BOOK REVIEW |
University of Delaware Newark, DE 19716
Elder Abuse: Selected Papers from the Prague World Congress on Family Violence, edited by Elizabeth Podnieks, Jordan L. Kosberg, and Ariela Lowenstein. The Haworth Press, Binghamton, NY, 2005. 214 pp., $49.95 (cloth), $29.95 (paper).
The Clinical Management of Elder Abuse, edited by Georgia J. Anetzberger. The Haworth Press, Binghamton, NY, 2005, 180 pp., $39.95 (cloth), $24.95 (paper).
"Abuse and neglect of elders in this country is a very real phenomenon. Unfortunately, it is a phenomenon about which we know relatively little, other than ... the existence of elder abuse and neglect within the family is well documented, and we are well-aware of the range of abusive behaviors that exist."
I wrote that statement as part of developing a national research agenda for elder abuse and neglect in 1991 (Stein, 1991). In the intervening 15 years, there has been an explosion of published works on elder abuse research and practice. A search of the database of the Clearinghouse on Abuse and Neglect of the Elderly using the keyword phrase "abuse" produced citations for 558 articles published between 1959 and 1990, and for 1,368 articles published between 1991 and 2006.
Clearly, attention has been paid. But, by whom? About what? To what end? Karl Pillemer, one of the early researchers in the elder abuse field, addressed those questions when he wrote, "... more than on many other issues, the interests of researchers and practitioners are identical here. A united effort is needed to gather information that will lead to creative solutions to the problem of elder abuse. Only by working together can we achieve the goal of a society in which all of the elderly live free from fear of maltreatment" (Pillemer, 1991, p. iii). If the end goal, then, is not solely publishing in the academy to expand knowledge and understanding of the phenomenon of elder abuse and neglect, but to actually have the results of our research lead to actions and policies that will guarantee basic rights of physical, psychological, and financial safety to elders, how are we doing? Based on the number of descriptive studies that have direct applications for professional practice—well. Based on the (far fewer) number of scientifically rigorous studies that could foster public outrage and motivate lobbyists and public interest groups, and, ultimately, promulgate effective laws, standards, and policies—not so well.
Two New Books Respond to Age-Old Questions
Two new books add to the elder abuse literature. The question is one of contribution. At first glance, it might seem that Georgia Anetzberger's The Clinical Management of Elder Abuse is aimed squarely at improving professional practice, while Elder Abuse: Selected Papers from the Prague World Congress on Family Violence, edited by Elizabeth Podnieks, Jordan Kosberg, and Ariela Lowenstein, takes a more scientific approach to the study of elder abuse. Both volumes, however, primarily address the same questions: Who are the victims? What kinds of assistance do they need? What kinds of assistance can various professionals supply? What do professionals need to work most effectively? These questions are not earthshaking or ground-breaking (which is not to say, however, that they are unimportant).
An Elder Abuse Rashomon
Anetzberger takes a novel approach to answering the above questions. She first lays out a detailed history of elder abuse research—in fact, one of the best I've come across—and puts that research into a professional, clinical management context. Anetzberger then develops three case studies, amalgams from her own files. In fact, one of the strengths of the book are the multidimensional aspects of these stories. These case studies are not the obvious examples of elder abuse in domestic settings (such as the granddaughter who steals from her grandmother to buy drugs, or the son who keeps his mother a virtual prisoner in her own home, or the caregiver daughter who routinely slaps her mother when she gets in the way). Rather, they are complex situations, fraught with complex family dynamics, in which the "bad guy" is not always so obvious and the most apparent "cures" might be worse than the disease.
Four guest authors, an attorney, a doctor, a nurse, and a social worker, analyze the three case studies from their own professional perspectives. Concentrating upon the management steps of detection, assessment, planning, intervention and follow-up, the professionals' analyses of what they should do and would do if they encountered these situations is fascinating for both their differences and similarities. For example, ethical considerations are always in play, but may have different meanings. Ethical considerations faced by the attorney are relatively clear and well-defined. As Maria Schimer notes in her chapter, "Elder Abuse: The Attorney's Perspective," once the attorney settles the question of "who is my client? ... the person who walks in the door with a question, pays the bills, or whose property or life is affected?" (p. 56), the remainder of the attorney's actions and decisions are governed by case law, state statutes, and the state code of professional responsibility. In contrast, we see the social worker struggle with the line between her professional ethical imperative of the competent client's right to self-determination (freedom over safety) and her personal ethical imperative of removing an older person from a situation likely to cause serious harm or death, even over the objections of the individual (safety over freedom). Carol Dayton, the author of the chapter on "The Social Worker's Perspective," refers to the "autonomy-paternalism dilemma" evident in social work that first appeared in the literature several decades ago (Abramson, 1985). That dilemma remains alive today and is, perhaps, even more problematic now for social workers, families, and elders because so many professionals who may be involved with an abused or neglected elder (as is apparent in this volume) defer ultimate responsibility for "resolving" abusive situations to adult protective services.
After a discussion of the individual perspectives, Anetzberger then gathers the group together and, based on another excellent literature review pertaining to multidisciplinary teams, asks them to operate as a multidisciplinary team jointly responsible for reviewing the case studies and recommending further actions. It is here that the realities hit home: Is it a case of too many cooks in the kitchen, or is it a case of the more views on the table, the less the groupthink? Anetzberger doesn't answer (or even raise) that question, but it should be given consideration by researchers who, as a whole in the field, recommend and support multidisciplinary teams as a model method for effective casework.
Taken as a whole, this book provides an in-depth treatment of a circumscribed subject: improving the ability of attorneys, doctors, nurses, and social workers to make practical decisions and take actions that serve the real-world interests of abused and neglected elders. The book's prime contribution to the reader, regardless of whether he or she is in one of the above professions, is its effectiveness in fostering interdisciplinary sensitivity.
Across the Spectrum
In contrast to Anetzberger's book, which clearly and accurately defines itself within the realm of improving professional practice to better serve abused and neglected elders in complex environments and relationships—and does so in a unique and creative fashion, the selected papers from the Prague World Congress on Family Violence are more difficult to categorize. The collection of 10 research papers that would have been presented at Prague at a special session on elder abuse (if the conference had not been cancelled) present a broad view of a variety of initiatives and programs. Some of the papers describe small or pilot research projects, some describe intervention approaches, and some describe the development of risk assessment/screening/documentation instruments. For the most part, the studies and writings constitute small steps in building a body of literature. Some of those small steps have obvious connections to the professional practice focus of the Anetzberger book, illustrated by the following four examples. Podnieks and Wilson describe findings from a pilot and an early exploratory study of the potential role that clergy could have in elder abuse prevention and intervention efforts. Teaster, Nerenberg, and Stansbury surveyed 31 multidisciplinary teams to gain descriptive information about team functions, composition, policies and procedures, administration, and funding. Kosberg, Lowenstein, Garcia, and Biggs describe how elder abuse is viewed and considered in three different cultures. The Brownell and colleagues chapter on the risks of caregiving by grandparents should serve to remind practitioners that cultural values and attitudes largely influence how services should be delivered and how likely they are to be accepted. The papers by Koin (the development of a forensic medical examination form) and by Erlingsson, Carlson, and Saveman (agreement on risk indicators and screening questions) have potential for assisting the medical community in efforts to recognize and document instances of elder abuse.
It is difficult to discern a theme that ties these papers together, nor is the review process delineated so that the reader has some external validation that the papers underwent a peer-review process before acceptance. Some papers are intellectually thought provoking, while some are program descriptions. Some have potential for improving future professional practice, while some retread ideas introduced long ago. Someone new to the field can find value in this volume, as it covers a spectrum of topics related to elder abuse and neglect. None of the studies have great impact, but I doubt that they were designed to give the reader that "Aha!" moment of This Is What the Field Has Been Waiting For.
What Does the Field Need? Take What You Can Get
Tellingly, a recurrent theme among the World Congress papers is that "more research is needed." Is it? And is all research equal? That is, when calling for "more research" to advance the field, should we differentiate between Research (big R), requiring large funds and resources and adhering to the highest standards of scientific inquiry, and research (little r), which may be of imperfect design but can be implemented with relatively few dollars on a limited scale to produce some knowledge quickly? Does more research really make a difference if our ultimate goal on a societal level is to enact and enforce actions and policies that guarantee basic rights of physical, psychological, and financial safety to elders?
We could start with the common premise that the first step to resolving a problem is to recognize that the problem exists. And if, as Tip O'Neill said, "all politics is local," one could make the case that the way to make elder abuse and neglect studies "do good" is through small, localized, descriptive studies—of which the field abounds—that, individually, may have small impact but collectively constitute a body of knowledge that can be usefully employed by agencies, organizations, volunteer groups, and so forth, to improve their own delivery of services to community elders. Thus, if small-scale research projects with questionable research designs, and/or descriptions of successful programs, and/or studies of professional practice, can ultimately improve the life condition of even a very small number of elders, those efforts are worthwhile and valuable. Backman-Turner Overdrive sang, "Any love is good love, so I took what I could get." The same could be said for elder abuse and neglect research: Any research (even that with a little "r") is good research if it tells us something we didn't know before or leads us to think about a new, interesting question or has implications for improving community services. It follows, then, that given the paucity of major funding for large-scale studies and the difficulty of using primary sources of data (abused elders themselves or general population studies), we should take what we can get. These two new books fall into this camp. Their contribution lies in their informing the reader of the complexities and variations among those affected by mistreatment and among those asked to intervene. They are circumscribed in their scope, methodology, and purpose, and not intended to contribute toward creating a groundswell of public support so important to a field's ability to influence public policy.
What Does the Field Need? The Scientific Shocker
Then there's another view. We still start with the same premise that the first step to resolving a problem is to recognize that the problem exists. But, for elder abuse and neglect research to be truly effective as a social force rather than as an academic field of inquiry, that recognition has to occur at the national level. And, if we want to learn from history about how social issues get on the national agenda, a necessary ingredient is sound research that frames the issue in ways that provoke public attention.
Sixteen years ago, Straus and Gelles (1990) published their landmark book, Physical Violence in American Families, based upon their findings from two national surveys of 8,145 families. The first scholarly analysis of domestic violence toward spouses and children, the study allowed us to move beyond the "individual pathology" explanation for domestic violence toward an investigation and a bringing forth of the underlying social causes. Although a scholarly work that adhered to rigorous scientific methodology, the findings were shocking enough to galvanize a "citizen's movement" that put domestic violence on the national agenda. In the years since publication, the strength of the issue has not diminished.
Is there anything comparable in the elder abuse research field? To date, three studies have attempted to estimate the number of abused and neglected elders in the United States. The National Aging Resource Center in collaboration with Westat, Inc. (1998) commissioned a national incidence study based upon data supplied by Adult Protective Services agencies in 15 states and by community sentinels. The analysis led to their estimate of nearly 450,000 older adults subjected to abuse or neglect in 1996. A study, conducted by researchers at the University of Iowa's Department of Family Medicine, collected data from adult protective services administrators in 47 states (Jogerst et al., 2003). According to their analysis, during fiscal year 1999–2000, a total of 102,879 substantiated cases were identified from 35 states (2.7 per thousand). A survey conducted by the National Center on Elder Abuse (2006) found that there were 253,426 incidents involving elder abuse brought to the attention of Adult Protective Services in 32 states in 2004. All of these studies rely on cases reported to agencies, a methodology that Straus and Gelles discounted over 15 years ago, rather than on general population surveys. All of these studies indicate that the figures they report are likely the tip of the iceberg: The National Research Council (2003), in reviewing relevant studies, estimates that "between 1 and 2 million Americans age 65 or older have been injured, exploited or otherwise mistreated by someone on whom they depended for care or protection" (p. 1).
But do we have valid, reliable data that inform us of the extent of elder abuse and neglect in our communities? No. Unlike spouse abuse and child abuse, the elder abuse field does not have seminal research that adheres to the highest standards of scientific inquiry.
However, if we don't have the science, history tells us that social issues can still become part of the national agenda, through descriptive scholarship that galvanizes the public and policymakers alike, that is, "the shocker." Ralph Nader's Unsafe at Any Speed led to legislation that fundamentally improved the health and safety of every automobile driver and pedestrian, and revitalized the consumer movement. Rachel Carson's Silent Spring led to a national awareness of the dangers in our water and air, spawned the environmental movement, and influenced the passage of environmental laws and policies that, again, fundamentally improved our national health and safety. It would seem that elder abuse and neglect, with its connotation of Granny Bashing, has the same potential to shock our national consciousness. More important, if there is a generation that is not likely to go gently into that good night, let alone take abuse and neglect lying down, it is the Baby Boomer generation just now entering the age of potential vulnerability.
So, the time might be right for making elder abuse a political issue—one in which remedial policies and actions are informed by research that policy makers can rely upon because it stands up to scientific scrutiny. What does the field need? We need to reliably know the true national incidence and prevalence of elder abuse and neglect. We need to know the effects of changes in public policy on elder abuse. We need to develop an accurate methodology for measuring, and then measure, the true public and private costs of elder abuse and neglect. And we need to present what we learn in a manner that shocks—not merely educates—the American public into action about a socially deplorable phenomenon that harms, directly or indirectly, all of us.
Echoing Pillemer from the beginning of this essay, if the field is to advance and if the field is to achieve the goal of shaping a society in which all elderly persons live free from fear of maltreatment, then what the field needs is a coalition of researchers and practitioners to produce scientifically sound research on the important questions: Research with a big "R." And we need to use that research to galvanize public attention to force the issue on the public agenda. This year, Ralph Nader is 72. Ralph, if you're itching for your next "good fight," complete with ammunition, here it is.
References
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