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BOOK REVIEW |
Assistant Professor Health Care Education Program Cleveland State University Cleveland, OH 44115
Elder Abuse Detection and Intervention: A Collaborative Approach, by Bonnie Brandl, Carmel Bitondo Dyer, Candace J. Heisler, Joanne Marlatt Otto, Lori A. Stiegel, and Randolph W. Thomas. Springer Publishing Company, New York, 2007, 307 pp., $45.00 (cloth).
Elder Abuse and Mistreatment: Policy, Practice and Research, edited by M. Joanna Mellor and Patricia Brownell. The Haworth Press, Binghamton, NY, 2006, 258 pp., $29.95 (cloth), $29.95 (paper).
Responding to elder abuse is not for those who favor a simple life. Situations involving the mistreatment or self-neglect of older adults are complicated, disturbing, and usually frustrating. They cannot be easily packaged and processed. As a result, it widely believed they require interventions that cross systems and disciplines.
This is nothing new. Recognition of the need for intersystem and interdisciplinary relations to detect, prevent, and treat elder abuse predates official discovery of the problem in the mid-1970s. It is found in the demonstration projects of the mid-1960s aimed at establishing a model of protection for impaired older adults incapable of managing their lives and vulnerable especially to neglect and exploitation. This intervention model, called adult protective services, represented the first and remains the only widespread program devoted to elder abuse response. As originally designed, it recognized the importance of multiple collaborators, including attorneys, physicians, and nurses. However, it also acknowledged the importance of leadership in service organization and delivery, selecting social work to fill it. As articulated by Margaret Blenkner and Ruth Weber (1974), pioneers in adult protective service development and research, "The model ... placed the social worker in a central executive position in case management. In all situations the social worker served as major evaluator, gatekeeper, and integrative agent" (p. 64). Blenkner and Weber further were empathic about having effective leadership in implementing an interdisciplinary team approach, explaining: "... it is an extremely complex and difficult field of practice and the need for highly trained professional leadership should not be minimized" (p. 93).
Fast-forward forty years. The emphasis on interdisciplinary teams remains key to elder abuse response, illustrated in the title and stated purpose of Elder Abuse Detection and Intervention: A Collaborative Approach: "This book provides the framework to begin and to build on multidisciplinary approaches at the local, state, and national levels toward ending elder abuse" (p. xi). However, the primacy of social work and established disciplinary or systemic leadership seem to have been lost. This is implied in the Foreword for Elder Abuse and Mistreatment: Policy, Practice, and Research, a book simultaneously published as a special thematic issue of the Journal of Gerontological Social Work:
Haworth's published Journals include one devoted to elder abuse. It is read by those in all disciplines who are engaged on behalf of older abused persons. It is less likely to inform the social worker whose field of interest lies elsewhere and, yet, these social workers may be the first ones to come in contact with individual cases of elder abuse. It is for this reason that we have chosen to develop this special volume. It is intended to ‘fill the gap’ and to provide knowledge and skills to social workers .... (pp. xix–xx).
These current elder abuse response characteristics—that is, interdisciplinary approach, devalued social work role, and lack of established leadership in problem resolution—reflect larger societal trends. More specifically, the prevailing view today is that addressing most problems, issues, or diseases is best accomplished through multidisciplinary cooperation. This is not how interventions took place in the past. Many years ago my sister was in a terrible automobile accident. Before widespread use of seat belts, she lost control of her car while making a sharp turn onto an interstate entrance ramp. It set her sailing through the windshield until she landed on her head and skidded across the pavement. The accident nearly severed her scalp and thumb. My sister was rushed to the hospital, where our family physician, a general practitioner, made the assessment, performed the surgery (involving more than 250 stitches to the scalp alone), and oversaw my sister's precarious recovery and my family's fears. No medical specialties, no social workers, no therapists were involved. This single disciplinary approach would be unimaginable today, when concerns ranging from Alzheimer's disease to dying to substance abuse are viewed through many lenses and subjected to the varying philosophies and strategies of multiple fields of practice.
Still, interdisciplinary cooperation often does not proceed without struggle, as Brandl and colleagues illustrate in their Introduction, describing the process of book collaboration with a team representing a half dozen kinds of practitioners. On the one hand, there are differences in language and perspective. On the other hand, as Barbara Levy Simon (1998) suggests, inter-professional rivalries and battles can occur, because:
professionals in the United States [more than Europe and other countries] must become and remain compelling to the marketplace, to philanthropists (also known as foundations and donors), and to the state if they are to survive and endure. It follows, therefore, that all American professions incessantly have jockeyed with each other for leverage, clientele, jurisdictional control, and legitimacy (p. 325).
In a context of professional competition and control, only rarely has social work assumed primacy and leadership. Ordinarily it has a secondary or subordinate role in problem resolution, if included at all. Forty years ago, during Lyndon Johnson's Great Society and its war on poverty and other strains upon the human condition, social work had elevated status. Its philosophies and strategies were evident in a myriad of social welfare policies and programs related to income security, housing, employment, and other concerns. This changed when Ronald Reagan's war on welfare replaced the Johnson war on poverty. In the aftermath, social work returned to its casework interests. Michael Katz (1985) hypothesizes that historically this choice resulted in social work's inability to successfully claim professional standing; "As social workers rejected urban mediation and abandoned social reform, they become second-class therapists, inferior in standing, if not in competence, to psychologists and psychiatrists" (p. 166).
It was during the Great Society that adult protective services evolved, later spreading nationwide as a mandated program for public welfare agencies, resulting from enactment of Title XX of the Social Security Act. In keeping with recommendations from the earlier demonstration projects, social workers typically were hired to do adult protective services. I was one of them in a rural county of northern Ohio. However, even by the late 1970s the professional qualifications for adult protective service work were changing in many states. Today the educational backgrounds for adult protective service workers vary. Besides social work, they include nursing, criminal justice, gerontology, sociology, psychology, and other disciplines. After reviewing state law across the country, Jeanette Daly and her associates found neither education nor licensure requirements for adult protective service workers contained in statute. In addition, few states had requirements in regulation, with just six states (including the District of Columbia) demanding a social work degree or licensure (Daly, Jogerst, Haigh, Leeney, & Dawson (2005). These findings provide appropriate segue back to the two elder abuse books under review and their major premises—interdisciplinary collaboration and the role of social work in problem response.
Interdisciplinary Collaboration
Elder Abuse Detection and Intervention: A Collaborative Approach begins by describing elder abuse historically and conceptually. Although it pays some attention to the problem in long-term care facilities, the major focus is on elder abuse in domestic settings. The authors offer rich descriptions of elder abuse forms, dynamics, and indicators to promote problem identification and reporting, illustrated through frequent brief case studies. They introduce and discuss the duties, authority, staffing, and ethical principles of major systems that respond to elder abuse, namely adult protective services, the criminal justice system, the civil justice system, the health care system, and domestic violence and sexual assault programs. Surprising is the absence of the Aging Network under the Older Americans Act (OAA), except in an end note along with 14 "additional agencies that may offer useful services for elder abuse victims" (p. 96). The Aging Network is critical to problem prevention and clinical management through its vast array of home and community-based services, such as congregate and home-delivered meals, transportation, and telephone reassurance. Reauthorization of the OAA in 1984 required area agencies on aging to assess local need for elder abuse services, and the 1987 reauthorization provided for grants for elder abuse services and education. Moreover, the U.S. Administration on Aging (AoA), which administers the OAA, funds the National Center on Elder Abuse. AoA's grants also have supported numerous elder abuse-related research, demonstration, and training projects, including the creation of elder abuse prevention task forces and local multidisciplinary teams—the very thesis of this book.
Appropriately, more than half the book is devoted to the specifics of interdisciplinary collaboration. Collaboration examples—benefits, challenges, and applications—are examined. When the authors suggest that professional disciplines worked within silos in the past, they ignore the origins of adult protective services. Surprisingly they offer fewer benefits than challenges to collaboration, although this may reflect popular perception regarding professional resistance to interdisciplinary collaboration, and instability of teams once formed. Nonetheless, the authors' description of challenges is sufficiently exhaustive and grounded in the research literature that readers may wonder if collaboration is either possible or worth the effort. Fortunately the book offers a tool kit with a detailed set of instructions for successfully accomplishing interdisciplinary collaboration. It evidences the authors' extensive knowledge about and experience with interdisciplinary teams along with their deep conviction in the worth of such teams. Examination of team processes and case management teamwork further encourage reluctant readers that indeed collaboration has value and can be successfully accomplished.
Outside of adult protective services (which, as earlier observed, may or may not represent social work), there is scant mention of the social worker's role in elder abuse collaboration. Social work is not even listed in the Index. The role of this once primary profession in protecting vulnerable older adults is nearly absent, despite the fact that two of the book's six authors have social work credentials. In its place as dominant perspectives are domestic violence programming and law enforcement. These leanings are first evident in Section One, with the portrayal of female gender as a risk factor for abuse occurrence, the special considerations of sexual abuse, and financial exploitation under elder abuse etiology (self-neglect also is discussed), and the look into why victims maintain relationships with perpetrators. Although those leanings occur throughout, they are highlighted at the end with chapters on enhancing victim safety (including abuse-lethality assessment, stalking, and victim-centered safety planning) and holding abusers accountable (including prosecution and court orders).
The change in professional dominance in elder abuse response is not peculiar to this book. It is evident elsewhere, such as in key provisions of the bill for an Elder Justice Act currently before Congress, and recent research funding opportunities issued by the U.S. Institute of Justice, to mention just a couple. These leanings began in the late 1980s for elder abuse and, like so much else about the field, mirror the larger cultural milieu, with its emphasis on individual empowerment, personal responsibility, and criminalization of unacceptable behaviors.
The authors conclude their book by discussing the importance of interdisciplinary collaboration for systemic change and strategies to end elder abuse. In this way they echo Michael Katz (1986) and his urgings that social work return to its social reform interests. Clearly interdisciplinary collaboration is essential to effective case intervention. However, it always will be reactive and inefficient without at least an equal commitment to expanding knowledge, improving systems, developing better public policy, filling resource gaps, and increasing professional and public awareness—in general, advocating for social change. Ultimately, if social work no longer can be counted on for social reform in protecting older adults, then are we not fortunate that other disciplines are willing to take this on? Perhaps; however, certainly the philosophies and strategies of reform undergo change as well, which may or may not always suit a problem as complex as elder abuse.
Sadly, although perhaps understandably, the authors' interdisciplinary leanings never translate into defined leadership. Brandl and colleagues do not tag any profession to lead the charge in interdisciplinary collaboration. Leadership considerations are sufficiently absent from their approach that, like social work, leadership is not listed in the book's Index, although it is periodically mentioned under team formation and roles. A different course is taken in The Community Role: Improving Protective Services for Older Americans, by Freda Bernotavicz (1982), one of the first publications on achieving elder abuse interdisciplinary collaboration. Bernotavicz argues: "Finding the right person to take the lead is crucial to ... success" (p. 12). However, she does not show favoritism for one discipline over another. Rather, she stresses specific leadership qualities, like systems thinking, democratic style, knowledge of local resources, credibility in the community, time, and energy.
The Role of Social Work
In their edited volume, Elder Abuse and Mistreatment: Policy, Practice, and Research, Joanna Mellor and Patricial Brownell, both social workers, attempt to inform others in their discipline about elder abuse across three broad domains. Their book differs from the former work in four ways. First, it never represents a writing collaboration. Even the Forward and Introduction are separately authored. Second, although various disciplines are represented among chapter authors, most have social work backgrounds. Third, because this is an edited volume, there is sometimes overlap in content between chapters and even sections. This problem particularly surfaces among chapters in discussions of elder abuse definitions and forms. For sections, overlap is illustrated in the inclusion of a pilot study on support groups for older women victims under Practice, rather than Research. And fourth, there is missing information that social workers would find valuable in "assessing elder abuse when it is encountered and in knowing what, and from whom, help may be sought" (p. xx). The problem here lies less in any failure of the editors to cover desired topics than the process of producing an edited (as opposed to authored) book, which necessitates reliance upon contributing authors to develop specific content once general themes have been established. Still, information would be useful, but is either absent or insufficient, on such topics as cultural variation in meaning or response to elder abuse and strategies for interviewing victims or perpetrators. A concluding chapter that both summarizes the book's contents and fills in the gaps would have helped overcome this frequent problem of edited volumes.
The chapters in this book offer varying perspectives on elder abuse. Some provide new insights on the problem and responses to it; others attempt to synthesize existing information. There is some unevenness in the quality of writing and content among the chapters. Moreover, with the exception of only a few, there are little compelling reasons for the inclusion of these particular chapters over others in order to achieve the book's stated purpose. On the other hand, after completing the 12 chapters, most readers will conclude that collectively they do well in unveiling the soul of elder abuse.
For example, Lisa Nerenberg in "Communities Respond to Elder Abuse" briefly describes the problem, including lesser-named forms in statutes, like abandonment and abduction. She then identifies agencies that investigate elder abuse, services needed by victims and challenges in providing them, and innovations and best practices in community response to the problem. Her focus is on the last twenty years. Within that time span, many of the "brightest and best'" practices seem to have come from the criminal justice system, including initiatives that assist victims through the court system, build forensic expertise, and improve prosecution.
One of the most provocative chapters is by Elizabeth Podnieks, "Social Inclusion: An Interplay of the Determinants of Health—New Insights into Elder Abuse." She suggests that most explanations for and interventions with elder abuse are designed for the individual. Although essential to practice, this approach reduces the problem to "a private, rather than public concern" (p. 76). Instead, Podnieks recommends using social inclusion and the determinants of health to understand and respond to elder abuse. This approach provides both an action goal (i.e., the complete social and economic inclusion of older people in society) and a tool for facilitating its achievement (i.e., an Inclusion Lens). Social inclusion has been used in Europe and elsewhere as a framework for addressing poverty and inequality. The approach may have limitations in application to elder abuse, given its etiology and dimensions. However, it does return the field to the social reform interests of social work, and appropriately place the problem in a larger context for intervention. With American core values more firmly anchored in individualism and independence, however, social inclusion may resonate less here than in other countries.
These dominant cultural values are captured again in L. Rene' Bergeron's chapter, "Self-Determination and Elder Abuse: Do We Know Enough?" The author explores and then challenges the notion of self-determination for elder abuse victims, concluding that the principle is overly simplified and "may be misused by allowing abused older victims to choose to remain in often life-threatening situations" (p. 81). Employing case examples, she unfolds the many factors that can compromise rational choice and, therefore, render self-determination a hollow concept.
Competing values also is a theme of Marie Beaulieu and Nancy Leclerc's chapter, "Ethical and Psychosocial Issues Raised by the Practice in Cases of Mistreatment of Older Adults." Their qualitative research with 16 community practitioners seeks to identify issues and ethical dilemmas in working with elder abuse victims. The study findings lead the authors to propose a practice continuum that considers factors perceived most important in case movement from detected problem (negative autonomy) to added to regular caseload (accompaniment) to directive intervention (extreme measure). The factors include the elder's loss of autonomy, dangerousness of the situation, and collaboration between victim and perpetrator.
"Hearing the Voices of Abused Older Women," by Jill Hightower, Gerta Smith, and Henry Hightower and "Psycho-Educational Support Groups for Older Women Victims of Family Mistreatment: A Pilot Study," by Patricia Brownell and Deborah Heiser return readers to the domestic violence program leanings of Brandl and colleagues. The first study considers the victim experiences of 64 women age 50 years and older in supporting a feminist and age-based framework for elder abuse analysis and intervention, ending in advocacy for more safe havens, peer support, and information and referral. The second study uses experimental design to evaluate the effectiveness of support group use by 16 women ages 69–83. Interestingly, there were no significant differences within or between groups with respect to outcome measures. Although the authors acknowledge research limitations, the results do raise questions as yet unanswered with respect to elder abuse interventions in general: What works? What does not work? The need for research on elder abuse interventions is widely recognized, but well-designed studies to evaluate program effectiveness are minimal (e.g., Family Research Laboratory, 1986; Stein, 1991; Fulmer & Anetzberger, 1995; Wolf, 1997; National Research Council, 2003).
Concluding Thoughts
Intervention dilemmas return us to the central concerns that frame this review article. The books by Brandl and colleagues, and Mellor and Brownell identify and discuss elder abuse interventions largely unsupported by empirical research. They beg answers to multiple questions: Is interdisciplinary collaboration the most effective response to the problem, or does it only add complexity and confusion? If collaboration is the answer, what system or discipline should lead? Does lack of defined leadership produce indecision and instability, or does it necessarily reflect the varying needs of elder abuse victims and perpetrators and a problem that has many forms and manifestations? What should be social work's role in elder abuse response? Should it be primary, as it was historically, or has the profession's standing so declined and its focus so narrowed that social work is no longer suited to a primary role?
The two books under review do not answer these questions. However, they take us on a path where the questions are better understood and their answers have more importance. Hopefully it is a path that will inspire research on the key elder abuse responses, leading to effective interventions for future victims and perpetrators. They deserve nothing less.
References
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