Devious Damage: Elder Psychological Abuse
Though it leaves no outward scars, elder psychological abuse exploits older adults’ vulnerabilities through cruel acts of omission or commission.
In contemporary society, elders are more visible, more active, and remain independent much longer than before. All individuals deserve to remain safe from those who live with, care for, or interact with them on a consistent basis. The fundamental belief that every individual, no matter how young or old, deserves to be treated with dignity and respect reflects the basic premise of human rights and gender equality.
Elder abuse is an umbrella term representing acts of commission or omission. It refers to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or serious risk of harm to a vulnerable adult over the age of 60. The Administration on Aging has defined this to include physical abuse, sexual abuse, financial and material exploitation, neglect, self-neglect, abandonment, and emotional and psychological abuse. Regardless of the type of abuse, it results in unnecessary suffering, injury or pain, the loss or violation of human rights, and a diminished quality of life for an elder.
How Prevalent Is Abuse?
Although the actual incidence and prevalence of elder abuse in this country is unknown, it is estimated that as many as 1 to 2.5 million older adults are abused annually. A summary of the best research evidence indicates that one quarter of dependent older adults report significant levels of psychological abuse, and 1% report physical abuse.
However, elder abuse often occurs insidiously, beneath the radar of those who see the effects but do not recognize the cause. Elder abuse is underreported, and the ambiguous definitions used by both legal and social service agencies contribute to the variation in estimating the occurrence. For every case that is reported, an estimated five to seven cases go unreported. Elder abuse is a complex problem with serious consequences. The risk of untimely death for abused elders is three times greater than that for nonabused elders. While abuse of any type should never be tolerated, the focus of this article revolves around issues related to psychological abuse.
What Is Psychological Abuse?
Psychological abuse wreaks mental anguish by means of threats, humiliation, fear, manipulation, or other cruel conduct. It can be inflicted via verbal or nonverbal communication cues. It is the systematic perpetration of malicious and explicit nonphysical acts against an elder. Examples include harassment, scolding, insults, denigration, and stalking. Perpetrators of psychological abuse against older adults often take advantage of elders’ vulnerability in ways that control or humiliate.
Threatening an elder with physical punishment or the deprivation of basic needs is a particularly heinous form of this type of abuse. Such actions may include denying or creating long waits for food, medication, heat, or basic care. Additional acts calculated to create an oppressive atmosphere include placing the individual’s walker, cane, glasses, dentures, or other necessary items out of reach or in inaccessible locations.
Psychological neglect deprives elders of healthy mental well-being. Prolonged periods of solitude and failure to provide adequate companionship contribute to such neglect. A caregiver may provide sufficient essentials such as food, water, and shelter but neglect to provide the elder with satisfactory social stimulation. Likewise, interfering with decision making, making false accusations, and controlling the individual’s freedom can effectively destabilize the elder and lead to isolation, feelings of low self-esteem, and psychological pain. Psychological abuse and neglect can exacerbate clinical depression from which an older adult may already suffer and may aggravate other mental health issues as well.
Context for Psychological Abuse
A continuation of long-standing domestic violence within the family is one pattern of abuse. Typically, the perpetrator is a highly stressed close relative who depends on the abused elder financially, psychologically, or both. It is also known that 95% of men who physically abuse their intimate partners also psychologically abuse them. Psychologically abusive men are more likely to use weapons against their partners, have prior criminal arrests, abuse substances, and have employment problems. Women who provide 65% or more of their households’ income are more likely to be psychologically abused.
Having a physical disability increases a woman’s risk of psychological abuse by 83%. In domestic violence situations, the typical profile of an abused elder is a female lacking the skills to deal with long-standing intergenerational conflict, who is isolated socially and perhaps geographically, and is economically and physically dependent on a family system. But as more grandfathers take on custodial roles for grandchildren, the vulnerability of such men to psychological abuse and victimization continues to increase.
Rapid social and economic change has contributed to the erosion of long-standing patterns of familial generational interdependence and has weakened the kinship and community support network, significantly affecting the lives of elders. This marked decline can evolve into both material and emotional hardships for many older adults. Thus, abuse is more commonly correlated with changes in living situations and relationships brought about by an older adult’s increasing frailty and dependence on others to meet basic needs. Abuse usually begins in the process of giving or receiving personal help.
Although the Family and Medical Leave Act allows for 12 weeks of unpaid vacation to care for a child or older adult relative, it is estimated that the act covers only 50% of working Americans. In addition, many American families cannot afford to take unpaid leave for the necessary care required by a long-term commitment. Consequently, many stressors face families and their aging members, stressors that increase the likelihood of abuse, as well as provoke fears about the occurrence of abuse.
Tensions can mount in even the most loving families and result in frustration and anger. Caring for an overly dependent older adult increases the risk of caregiver stress, particularly when the caregiver is unprepared for the duties and/or lacks resources. This is especially true when the caregiver is isolated and receives no assistance from other family members or care providers to offer support and respite.
In the United States, there is considerable pressure on daughters to provide care for aging family members, a responsibility that may result in them being placed in the stressful predicament of providing long-term care as a parent becomes increasingly dependent. Individuals who perceive their caregiving responsibilities as stressful and burdensome are more likely to commit verbal, psychological, and physical abuse. Daughters and sisters are more likely to perpetrate psychological abuse, whereas sons are more likely to be physical abusers.
Although the perpetrators of psychological abuse usually blame their victims, elder abuse is associated with perpetrators’ issues related to coping effectively. Risk factors for potential elder mistreatment, in addition to domestic violence, include caregiver characteristics such as workload or stress levels that can be identified as possible predictors of psychologically abusive behaviors.
A history of substance abuse in the caregiver, most likely alcoholism, is perhaps the single most important characteristic predictive of both physically and psychologically abusive behavior. Similarly, any mental health issue in the older adult or the caregiver increases the risk of psychological abuse. The presence of dementia significantly increases the risk of psychological abuse for elders. The progression of cognitive and memory impairment and the associated behaviors of repetitive questions or statements, toileting mishaps, and safety issues such as cooking and wandering lead to increased workload and stress for the caregiver. The greater the care needs of the older adult, the greater the risk of psychological abuse. Additionally, if the caregiver is responsible for child rearing, the pressure of divided attention and loyalties can substantially increase the likelihood of psychological abuse and neglect.
Signs and Symptoms of Psychological Abuse
The following list of indicators offers a useful guide in cases of suspected abuse. Although the presence of any one indicator doesn’t constitute proof, it should prompt further, more comprehensive exploration of an elder’s current living situation and care providers. This is especially true in light of the incidence of psychological abuse co-occurring with other types of abuse. The typical behaviors demonstrated by a victim of psychological abuse may include the following:
• passivity, withdrawal, or increasing depression;
• evasiveness or reluctance to talk openly;
• avoidance of eye contact or verbal contact with a caregiver;
• cowering in the presence of the abuser;
• hopelessness, helplessness, anxiety, or feelings of powerlessness (Anxiety and powerlessness are the most commonly expressed warning signs in grandfathers in the custodial role.);
• confusion that is unrelated to any medical condition;
• change in sleeping or eating habits;
• contradictory statements;
• missing appointments; and
• isolation from friends or other family.
When assessing whether abuse has occurred, it is also helpful to observe the behavior of and interaction with caregivers or significant others involved in the elder’s immediate situation. The following have been identified as characteristics of perpetrators of psychological abuse:
• tired or stressed appearance;
• history of substance abuse or abusing others;
• exaggerated concern or lack of concern;
• blaming the elder for acts such as dropping an item or incontinence;
• aggressive behaviors;
• treating the elder like a child or in a dehumanizing way;
• not allowing the elder to be interviewed alone;
• responding defensively when questioned or becoming hostile or evasive; and
Nearly all states have mandatory reporting laws for healthcare professionals and paraprofessionals. However, any concerned individual can report suspected abuse. Healthcare providers and concerned citizens don’t have to prove that psychological abuse has occurred, but healthcare professionals must report it to a designated authority.
To report elder abuse of any type, contact Adult Protective Services through the state’s hotline. Calls to the agency are confidential and screened. If the agency decides that the situation violates the state’s elder abuse laws, it will conduct an investigation. If the elder requires crisis intervention, it is provided. If the abuse is not substantiated, Adult Protective Services will make referrals to other community agencies to obtain services the individual needs.
An older adult has the right to refuse services offered by Adult Protective Services unless declared incapacitated by the court, in which case a guardian would be appointed. As a last resort, Adult Protective Services will take this action if it’s deemed necessary. It’s important to remember that elders have autonomy and don’t want others making decisions on their behalf without first consulting them. This can be frustrating to professionals and others trying to assist because the older adult may choose not to accept the help and continue to live in suboptimal conditions.
Preventing Psychological Abuse
Many stressors face families and their aging members, but a disparity currently exists between the money allocated to child protective services and that allocated to adult protective services. It is important to review the issues related to elder care and be a political advocate, encouraging policy makers and Congress to provide appropriate funding to make the needed services available.
Another important intervention is developing initiatives to educate the public. There is a significant correlation between required public education regarding elder abuse and higher abuse report rates. Funded by the Administration on Aging, the National Center on Elder Abuse serves as a quality resource for information and training materials for the public and professionals.
We often hear the shocking news of elders in nursing homes suffering abuse, but it is important to remember that, at any one time, approximately 4% of the nation’s elders live in nursing homes. Most have their needs met without experiencing abuse or neglect. It is the elders living at home in noninstitutional settings who suffer the most in terms of all types of abuse. The ugly specter of elder abuse spreads a dark cloud over our society. A formidable challenge lies in focusing on helping caregivers and professionals learn to identify and intervene in all types of elder abuse and to stop this tragedy from occurring both now and in preparation for the baby boomers who will present myriad special challenges to their caregivers.
— Margie Eckroth-Bucher, PhD, RN, PMHCNS-BC, is an associate professor of nursing at Bloomsburg University in Pennsylvania. With 25 years of experience in mental health, she is board certified as a clinical nurse specialist in adult psychiatric and mental health nursing.