Posted: February 27th, 2023

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As reviewed in Chapter 4, efforts are underway to increase the reporting

of elder abuse, under the belief that funneling victims into the system

will enable their receipt of services and interventions. As recommended by

the American Psychological Association (APA) “Guidelines for Psycholog-

ical Practice With Older Adults” (2014, pp. 37–38), this chapter is designed

to familiarize clinicians with elder abuse interventions, many of which are

relatively new. Clinicians will quickly observe that mental health inter-

ventions are essentially absent from the cache of interventions. To provide

some context for this section, a brief history of elder abuse interventions

is provided.

PERSPECTIVE ON SERVICES AND INTERVENTIONS

Historically, there have been two primary ways of responding in elder

abuse cases: (a) maintaining victim–offender relationship through

providing caregiver supports (e.g., respite care); and (b) separating

Elder Abuse Interventions

http://dx.doi.org/10.1037/0000056-006
Understanding Elder Abuse: A Clinician’s Guide, by S. L. Jackson
Copyright © 2018 by the American Psychological Association. All rights reserved.

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UNDERSTANDING ELDER ABUSE

96

victims from their offenders to obtain safety, through a change in liv-

ing arrangement, imposition of guardianship, or through offender

prosecution.

Respite Care to Maintain Victim–Offender Relationship

Family care remains the most prevalent method of eldercare, even for

those with severe disabilities such as Alzheimer’s disease (Doty, 2010;

see Larson & Kao, 2016, for a review). The caregiver stress model so

pervasive in the 1970s spurred the respite care industry as an inter-

vention for elder abuse. This intervention remains prominent today

(Ayalon, Lev, Green, & Nevo, 2016; Lindland, Fond, Haydon, & Kendall-

Taylor, 2015), even while support for the caregiver stress model is waning

(Jackson & Hafemeister, 2013d).

Separation of Victim and Offender

The other primary intervention has been to separate the victim from the

offender through various means. For example, one intervention designed

to safeguard incapacitated older adults is guardianship. However, safety

may be achieved for older adults with capacity by placement in a long-

term care facility. Although some modifications in living arrangements

are the result of safety concerns for older victims, an implicit underly-

ing purpose of changing the victim’s living arrangement is to separate

the older victim from the offender, especially when the two have been

cohabitating, a particularly common living situation among older vic-

tims of interpersonal violence (O’Keeffe et al., 2007). Not unsurprisingly,

Alon and Berg-Warman (2014) found that separating the older victim

from the offender resulted in a reduction in violence. However, separation

is not typically the desire of the older victim, especially in cases involving

family members (Harbison, Coughlan, Karabanow, & VanderPlaat, 2005;

Mariam, McClure, Robinson, & Yang, 2015).

Another approach designed in part to separate victims from their

abusers is prosecution. Prosecution has been the primary intervention

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ELDER ABUSE INTERVENTIONS

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in elder abuse cases, although prosecution rates are astonishingly low

(Meirson, 2008), and prosecution may not be the most effective inter-

vention (Jackson, 2016a). Separation through prosecution may provide

but a temporary respite for the older person, as at some point the abusive

individual will be released and may return to the older person’s home, pre-

senting a renewed risk of abuse (Jackson & Hafemeister, 2014). Further-

more, relatively few older adults are interested in pursuing prosecution

(Jackson & Hafemeister, 2013c). This stance has spurred the development

of victimless prosecution. However, Kohn (2012) admonished clinicians to

listen to voices of victims in this matter.

CURRENT STATE OF ELDER ABUSE INTERVENTIONS

The field of elder abuse has placed very little effort into intervention devel-

opment (Du Mont, Kosa, Macdonald, Elliot, & Yaffe, 2015; Pillemer,

Connolly, Breckman, Spreng, & Lachs, 2015). Several reviews of elder abuse

interventions have been published (e.g., Moore & Browne, 2016; O’Donnell,

Phelan, & Fealy, 2015). Ayalon et al. (2016) recently reviewed the elder

abuse intervention literature and found only 24 studies, 19 of which con-

cerned caregiver interventions. Another review of the literature concluded

that interventions currently being used to protect and assist the victims of

elder abuse are relatively ineffective and sometimes even counterproductive

(Moore & Browne, 2016). For example, Davis and Medina-Ariza (2001)

field tested an elder abuse intervention program in New York City based

on a successful domestic violence intervention. One of the findings was

that households that received home visits (both in project and nonproject

dwellings) called the police more often than control households. However,

by 12 months the effect had disappeared. The researchers speculate that

elder abuse victims are often dependent on their abusers in multiple ways

and, compared with domestic violence victims, may have even less hope of

gaining independence from their abusers. This study was exceptional given

that many interventions fail to even evaluate their effectiveness, let alone

unintended negative effects (Pillemer, Mueller-Johnson, Mock, Suitor, &

Lachs, 2007).

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UNDERSTANDING ELDER ABUSE

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ELDER ABUSE PROGRAMS AND INTERVENTIONS
TARGETING VICTIMS

There are a multitude of small programs across the country designed to

address elder abuse. None are large in scale, and few have been evaluated

to any extent. However, several programs warrant review here.

Victim Services Programs

The need for victim services in the context of elder abuse has been publicly

proclaimed (U.S. Senate Special Committee on Aging, 2015). Elder Care,

Inc., in Louisville, Kentucky, is an elder abuse victim service program

responding to the needs of victims of all forms of elder abuse. All police

reports where the victim is over the age of 60 are automatically electroni-

cally relayed to Elder Care. The victim advocate reaches out to the victim to

provide traditional victim services (e.g., court accompaniment, accessing

victim compensation, orders of protection, victim impact statements).

One unique way in which Elder Care responds to the needs of older adults

is by driving or transporting them to court to get an emergency protective

order and any follow-up hearings. However, if the older adult is physi-

cally unable to go to court for a protective order, a hearing over the phone

can be arranged. One advocate stays with the victim in their home while

another advocate is in the courtroom. Elder Care also employs a social

worker who ensures the older victim is linked with needed services in the

community. The program, however, has yet to be evaluated.

Elder Abuse Shelters

The use of domestic violence shelters for older victims has been problem-

atic in that they fail to meet the unique needs of older adults (Fisher, Zink,

Pabst, Regan, & Rinto, 2003). For example, medically and/or psychiatri-

cally dependent older adults are not able to function without assistance,

a service not offered by most shelters. However, The Harry & Jeanette

Weinberg Center for Elder Abuse Prevention developed wraparound

services for older victims that includes shelter within an established

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ELDER ABUSE INTERVENTIONS

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long-term care facility, a model that is being replicated in other communi-

ties (Solomon & Reingold, 2012) but has yet to be evaluated.

Civil Legal Assistance Program

A notable shortcoming in our response to elder abuse has been the lack

of civil legal assistance to older adults. Pennsylvania, however, through

its Senior Law Center, provides civil legal assistance to older adults. The

National Association of Senior Legal Hotlines, of which Pennsylvania is a

member, provides assistance to seniors over the phone initially, and then

where appropriate, refers the older adult to assistance in their local area.

Maine Legal Services for the Elderly likewise provides civil legal assistance

to victims of elder abuse and is working tirelessly to remedy financial

exploitation cases. Los Angeles also has a notable program, Bet Tzedek

Legal Services, which provides free legal services to seniors and employs a

social worker to do a quick assessment of older callers and make referrals

if warranted (Morris, 2010).

Hospital-Based Elder Abuse Examiner Program

Building on the success of Sexual Assault Nurse Examiner (SANE) pro-

grams across the county, Canada has developed a program in which SANEs

are being trained to become Elder Abuse Nurse Examiners (EANEs) in

hospitals. A curriculum is being developed to ensure EANEs are able to

recognize elder abuse, understand the dynamics of elder abuse, and know

how and where to report suspected elder abuse (Du Mont et al., 2015).

High-Risk Victims

Persuading older victims to accept services has proven challenging in cer-

tain circumstances, for example, in cases in which there is long-standing

and repeated abuse (Dunlop, Rothman, Condon, Hebert, & Martinez,

2001; Reeves & Wysong, 2010). Recidivism is thought to be one indicator

of a high-risk victim. Therefore, efforts are underway to identify high-risk

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UNDERSTANDING ELDER ABUSE

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victims (National Council on Crime and Delinquency, 2013; Sommerfeld,

Henderson, Snider, & Aarons, 2014). Once identified, more oversight and

resources targeting those individuals is provided (Terracina, Aamodt, &

Schillerstrom, 2015).

Eliciting Change in At-Risk Elders

As mentioned previously, one of the most cited risk factors for elder abuse

is social isolation (e.g., Acierno et al., 2010), and yet only one intervention

has incorporated isolation reduction (Mariam et al., 2015). Using a stages-

of-change framework, Eliciting Change in At-Risk Elders (ECARE) is an

intervention that aims to reduce or eliminate risk factors while empowering

victims through the use of trained outreach specialists—a model that has been

successfully used in other fields (DePrince, Labus, Belknap, Buckingham, &

Gover, 2012). When victims are reluctant to engage in services, staff actively

engage in alliance building. Once an alliance is developed, specialists guide

victims using motivational interviewing-type skills to assist older victims in

identifying needs, thinking through options, and taking steps toward change.

They then connect victims with sustainable services in the community that

enhance their safety. These interventions are time consuming and resource

intensive. For example, to meet the basic needs of at-risk older adults, out-

reach specialists may serve as an advocate between older adults and their

apartment managers, utility companies, and sometimes financial institu-

tions, as well as helping older adults access additional resources. Mariam

et al. (2015) found that a working alliance can be forged with intensely

ambivalent older adults (p. 28). The majority of participants (70.9%) made

some movement in their change stage.

PRoviding Options To Elderly Clients Together (PROTECT)

The need for depression screening among older adults is gaining promi-

nence (Dong, Simon, Odwazny, & Gorbien, 2008; Roepke-Buehler, Simon,

& Dong, 2015). Under the theory that depressive symptoms hamper an

older adult’s ability to self-protect, Sirey et al. (2015) developed PRoviding

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ELDER ABUSE INTERVENTIONS

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Options To Elderly Clients Together (PROTECT), an intervention designed

to identify elder abuse victims who are experiencing depression or anxiety

and then to offer them treatment designed to alleviate depressive symptoms

and enhance personal resources. PROTECT combines problem-solving

therapy with anxiety management techniques and offers education about

the effect of depressive and anxious symptoms in general, as well as the

potential impact of symptoms on taking steps to resolve the mistreatment.

Women (N = 68) were randomly placed in either an elder abuse resolu-

tion services combined with PROTECT or a mental health referral group.

Although mental health symptoms were not significantly different at the

16-week follow-up, those in the PROTECT group were more likely to

report having all or most of their needs met, were more satisfied with the

services they received, and had a greater sense of self-efficacy. However,

there was no difference between the two groups in perceived improvement

in the abusive situation.

GUARDIANSHIP AND CONSERVATORSHIP

Guardianship can be conceived of as a preemptive strike against elder

abuse or as an intervention to stop elder abuse that has already occurred.

States differ in their use of the terms guardian and conservator. As dis-

cussed previously, involuntary interventions such as court appointment

of a substitute decision maker (guardianship) are legally authorized in

most states if the client is exposed to a substantial risk of harm or if the

client lacks the capacity to make an informed decision to accept or reject

protective services (Moye & Braun, 2010). Guardianship is governed by

state law (for a review, see Demakis, 2013b) and requires a formal determi-

nation of decision-making capacity.1 A petition is submitted to the court,

and the judge makes a determination regarding capacity. Guardians may

be public programs; private nonprofit or for-profit agencies; individual

professional guardians; attorneys; and perhaps most frequently, family

1 For more information on guardianship state law, visit the website (http://www.americanbar.org/
groups/law_aging/resources/guardianship_law_practice.html) of the American Bar Association
Commission on Law and Aging, “Guardianship Law and Practice.”

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UNDERSTANDING ELDER ABUSE

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members or friends (see Demakis, 2016, for guidance on interviewing

potential guardians and making recommendations to the court).

The prevalence of older adults under guardianship is unknown as most

states have incomplete guardianship data (Wood, 2006); the extent of the

misuse of guardianship is also unknown (U.S. Government Accountabil-

ity Office, 2010). Guardianship monitoring of some form—at least the

filing of reports and accountings with the court—is required in all states,

although improvements in monitoring have been recommended (Karp &

Wood, 2007). Guardianship should be used as a last resort, as it removes

fundamental rights (Kohn, 2010; Wright, 2010). However, guardianship

can be a necessary solution to elder abuse, offering vital protection for a

victim who lacks decision-making capacity. Recent trends are toward

limited guardianship in which a guardian has decision-making power

only in domains in which the older adult has diminished decision-making

capacity, which allows older adults to retain as much decision-making

power as possible (Moye, Butz, Marson, Wood, & the ABA-APA Capacity

Assessment of Older Adults Working Group, 2007).

INTERVENTIONS FOR ABUSIVE INDIVIDUALS

By statute, APS has had a singular focus on older victims to the exclusion of

abusive individuals. More recently, the field has acknowledged the impor-

tance of responding to the needs of abusers (Jackson, 2016a; Mosqueda,

Burnight, et al., 2016; Pillemer et al., 2015; Reeves & Wysong, 2010). The

exclusion of abusers from the elder abuse dialogue dis regards the role they

play in maintaining abusive relationships (Alon & Berg-Warman, 2014;

Henderson, Varble, & Buchanan, 2004). In addition, it has contributed to our

lack of empirical understanding of those who abuse older adults (Moore &

Browne, 2016). Possible interventions for abusers that have been identified

in the literature include counseling and treatment, creating barriers to the

victim’s finances, respite and assistance, education, criminal justice inter-

ventions, limited or no contact with the victim, alternative living arrange-

ments, supervised visitation, and vocational training to reduce financial

dependency (Breckman & Adelman, 1988; Wolf, 2001). However, no specific

program for elder abuse abusers (or its subtypes) has been developed.

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ELDER ABUSE INTERVENTIONS

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CONCLUSION

The two predominant responses to elder abuse have been (a) maintaining

the victim–offender relationship by assisting caregivers and (b) separat-

ing the victim and offender. As this review reveals, the field is gradually

realizing the need to develop interventions that go beyond these dichot-

omous and limited responses. Elder abuse interventions generally, and

interventions focused on mental health specifically, are urgently needed

to meet the demand associated with increases in reporting. Clinicians can

make an extraordinary contribution to this field by developing mental

health interventions that not only assist older adults with recovery but

also promote their general well-being and ability to thrive.

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Review attached article.

250 words

APA formatting

· Examine two principal ways to responding to elder abuse.

· Analyze the details of two elder abuse programs of the four highlighted.