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Journal of Elder Abuse & Neglect Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wean20

Older People’s Conceptualization of Elder Abuse and Neglect a

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Brian J. Taylor PhD , Campbell Killick PhD , Marita O’Brien PhD , c

Emer Begley PhD & Janet Carter-Anand PhD

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Institute for Research in Social Sciences, University of Ulster, Northern Ireland, United Kingdom b

South Eastern Health and Social Care Trust, Northern Ireland, United Kingdom c

Age Action Ireland, Dublin, Ireland

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Department of Social Work, Queens University, Belfast, Northern Ireland, United Kingdom Accepted author version posted online: 02 May 2013.Published online: 29 Apr 2014.

To cite this article: Brian J. Taylor PhD, Campbell Killick PhD, Marita O’Brien PhD, Emer Begley PhD & Janet Carter-Anand PhD (2014) Older People’s Conceptualization of Elder Abuse and Neglect, Journal of Elder Abuse & Neglect, 26:3, 223-243, DOI: 10.1080/08946566.2013.795881 To link to this article: http://dx.doi.org/10.1080/08946566.2013.795881

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Journal of Elder Abuse & Neglect, 26:223–243, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0894-6566 print/1540-4129 online DOI: 10.1080/08946566.2013.795881

Older People’s Conceptualization of Elder Abuse and Neglect BRIAN J. TAYLOR, PhD

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Institute for Research in Social Sciences, University of Ulster, Northern Ireland, United Kingdom

CAMPBELL KILLICK, PhD South Eastern Health and Social Care Trust, Northern Ireland, United Kingdom

MARITA O’BRIEN, PhD and EMER BEGLEY, PhD Age Action Ireland, Dublin, Ireland

JANET CARTER-ANAND, PhD Department of Social Work, Queens University Belfast, Northern Ireland, United Kingdom

This qualitative study used data from eight focus groups involving 58 people aged over 65 years in both urban and rural settings across Northern Ireland and the Republic of Ireland. Following training, four older people assisted in facilitation and analysis as peer researchers. Increasing lack of respect within society was experienced as abusive. The vulnerability of older people to abuse was perceived as relating to the need for help and support, where standing up for themselves might have repercussions for the person’s health or safety. Emotional abusiveness was viewed as underpinning all forms of abuse, and as influencing its experienced severity. Respondents’ views as to whether an action was abusive required an understanding of intent: some actions that professionals might view as abusive were regarded as acceptable if they were in the older person’s best interests. Preventing abuse requires a wide-ranging approach including rebuilding respect for older people within society. Procedures to prevent elder abuse need to take into account the emotional impact of family relationships and intent, not just a description of behaviors that have occurred.

Address correspondence to Brian J. Taylor, Institute for Research in Social Sciences, University of Ulster, Shore Road, Newtownabbey, Northern Ireland BT37 0QB, United Kingdom. E-mail: [email protected] 223

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KEYWORDS adult protection, adult safeguarding, ageism, cultural responsiveness, elder abuse, emotional abuse, Ireland, peer researchers, psychological abuse, qualitative research, social work, vulnerable adult

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INTRODUCTION This article reports on a qualitative study of older people’s conceptualization of elder abuse undertaken in the island of Ireland, including both Northern Ireland and the Republic of Ireland. There is increasing concern at the prevalence of elder abuse (Cooper, Selwood, & Livingston, 2008; World Health Organization, 2008), although there has been limited study of elder abuse in Ireland (McLaughlin & Lavery, 1999; Naughtan et al., 2010). There has been steady development of procedures and tools to support and guide practice (Anthony, Lehning, Austin, & Peck, 2009; Killick & Taylor, 2012; Taylor, 2012) although current approaches to developing policies to address elder abuse have been predominantly driven by professionals and policy makers with limited input from older people themselves (Killick & Taylor, 2009). Internationally, concepts and models of elder abuse have been developed (Harbinson et al., 2012; Lowenstein, 2009), although there is debate about whether these should be based on practice models in child abuse, in intimate partner violence, in abuse of people with disabilities, or a different model. There is some inconsistency in the professional responses to elder abuse (Killick & Taylor, 2012) and responses may relate as much to risk management within public organizations as to the actual needs of older people (Taylor, 2006; Taylor & Campbell, 2011; Taylor & Donnelly, 2006a). Elder abuse has been defined by the World Health Organization as a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust and that causes harm or distress to an older person (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). Elder abuse is defined to include financial exploitation; physical, sexual, and psychological abuse; neglect; and violation of rights (Joshi & Flaherty, 2005). The debate on elder abuse has shifted generally from defining forms of abuse to our present focus: how to understand family situations where abuse occurs and how to protect older adults against aggression, violence, and exploitation. A key step is to establish what older people think about the issue.

Republic of Ireland and Northern Ireland Context To assist the reader in judging the generalizability of the findings to their own conceptual and cultural context, we give a brief background to the

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context in the two parts of Ireland—the Republic of Ireland and Northern Ireland—where this qualitative study took place. In the Republic of Ireland the definition of elder abuse outlined by the Working Group on Elder Abuse is based on that adopted by the World Health Organization (2002), where elder abuse is described as:

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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 or violates their human and civil rights. (Working Group on Elder Abuse, 2002)

The definition covers the frequency and intensity of the abuse. It recognizes acts of omission and commission as well as intentional and unintentional forms of abuse. There is a relationship between the abuser and the abused where there is some expectation of trust (Daichman, 2005). This definition does not include abuse by strangers or self-neglect. In Northern Ireland the definition of abuse was outlined in the Safeguarding Vulnerable Adults: Regional Adult Protection Policy and Procedural Guidelines, which state that abuse is: The physical, psychological, emotional, financial or sexual maltreatment or neglect of a vulnerable adult by another person. The abuse may be a single act or repeated over a period of time. It may take one form or a multiple of forms. The lack of appropriate action can also be a form of abuse. Abuse can occur in a relationship where there is an expectation of trust and can be perpetrated by a person/persons, in breach of that trust, who have influence over the life of a dependant, whether they be formal or informal carers, staff or family members or others. It can also occur outside such a relationship. (Department of Health, Social Services and Public Safety, 2006, p. 10)

This definition is much broader. The only age limit is that those under 18 years of age are excluded. It outlines various typologies of abuse including acts of omission. It recognizes that abuse can occur within a relationship of trust but also outside it, thus incorporating abuse by strangers. Problems such as financial abuse by people who target older people and crimes against older people who may suffer robbery, burglary, or crimes of violence because they are old and are perceived as easy targets can be included in this definition. A study by O’Keefe and colleagues (2007) indicated that prevalence rates in Northern Ireland (2%) were lower than in England (2.6%), Scotland (3%), and Wales (3.1%). However, due to wide confidence intervals in this study, the accuracy of estimates cannot be guaranteed (Killick, 2008). The National Centre for the Protection of Older People (Naughtan et al., 2010)

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carried out the first elder abuse prevalence study in the Republic of Ireland, identifying that 10,200 older people in the Republic of Ireland had experienced abuse in the previous 12 months, giving a broadly similar prevalence to Northern Ireland: 2.2%. Prevalence rates for some other countries are indicated in Daly, Merchant, and Jogerst (2011). In the Republic of Ireland, policies in relation to elder abuse were outlined in Protecting Our Future (Health Service Executive, 2002). This was expanded (Lyons, 2009; O’Dwyer & O’Neill, 2008) into more detailed guidance for staff in Responding to Allegations of Elder Abuse (Health Service Executive, 2008). Elder abuse case workers operate through local offices, and dedicated elder abuse officers are supported by regional steering committees. Procedures and policies are overseen by a National Steering Committee responsible to the Office for Older People at the Department of Health (Working Group on Elder Abuse, 2002). There is no statutory instrument in the Republic of Ireland regarding abuse of older people or services to address this. Older people are protected by the same laws as every other citizen. In Northern Ireland (NI), adult protection policy reflects that pertaining elsewhere in the United Kingdom (Department of Health, 2000). Detailed procedural guidance has been produced for public health and social services for cases of suspected or alleged abuse of any vulnerable adult, including older people (Department of Health, Social Services and Public Safety, 2006). The Health and Social Care Trusts, which deliver the publicly funded health and social care services in NI, have in place Safeguarding Vulnerable Adults Forums that comprise senior managers from appropriate programs of care (client groups). These monitor the implementation of the procedures and policies created under the authority of the statute: Safeguarding Vulnerable Groups (NI) Order 2007. Cases of alleged or suspected abuse are investigated in accordance with the procedures by a social worker. A designated officer (a senior professional manager, usually a social worker) then considers the report of the investigating officer and other reports in deciding on the response of the Trust, in discussion with the police as appropriate.

METHODS The purpose of this study was to elicit older people’s understanding of elder abuse (reported here) and their perspectives on accessing help (reported in Begley, O’Brien, Carter-Anand, Killick, & Taylor, 2012). A qualitative approach embodying elements of grounded theory was adopted to explore meanings and understandings. The sensitivity of the topic of elder abuse and the lack of discourse in everyday conversation were important for the choice of method. Focus groups were selected to assist participants to reveal experiences and perspectives that may be more accessible with a naturalistic group interaction rather than the formality of interviews. Data were collected

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from eight focus groups across Ireland, four in the North of Ireland and four in the Republic of Ireland. The project researcher conducted all focus groups to ensure consistency. Four older people were recruited as peer researchers to assist in leading the focus groups, because of the greater similarity of their life experiences to those of respondents, and in line with Tomita’s (2000) conclusions about using culturally sensitive word choices in discussing the sensitive topic of elder abuse. The peer researchers took part in workshops to develop their knowledge and skills in the methodology. Convenience sampling was used to recruit participants from communitybased senior citizen organizations including social clubs, a luncheon club, a University of the Third Age group, and an Active Retirement Group. Recruiting from different types of community groups in urban and rural areas throughout Ireland provided diverse voices. Criteria for inclusion were being aged 65 years or over and living in the community (rather than in institutional care). A written interview guide was used to increase reliability. Questions focused on participants’ understanding of the abuse of older people, the forms of abuse, reasons why people may experience abuse, ways of preventing abuse, and support for those who have experienced abuse. The focus group sessions lasted 1 to 2 hours. With the permission of the participants, the sessions were recorded and subsequently transcribed. The eight focus groups took place between October 2010 and February 2011, mainly in community centers, in both urban and rural areas. Prior to the session, the study was explained to the participants and they were made aware of the sensitive nature of the issue. Follow-up support was offered after each session. The telephone numbers of the elder abuse information service helplines in Northern Ireland and in the Republic of Ireland were handed out with the information sheets. All participants gave signed informed consent. The study received ethical review, advice, and approval from the Ethics Committee, School of Sociology, Social Policy and Social Work, Queen’s University, Belfast for Northern Island and the Research Ethics and Approval Committee, Trinity College Dublin for the Republic of Ireland. Written information was given and formal consent obtained from the peer researchers and all focus group participants. The project researcher (MO’B) took the lead role in analyzing the verbatim transcripts of the focus group sessions. One or more peer researchers assisted in this analysis to add credibility to the findings. The meanings and patterns that emerged were compared, and operational definitions of codes were developed through this process. In addition, all the team members provided comment on the emerging material, to strengthen the rigor of the findings. Data collection and analysis used elements of a grounded theory approach (Strauss & Corbin, 1998), in that (1) themes were drawn out of the transcripts rather than being structured by any prior

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knowledge framework, and (2) data collection and analysis occurred iteratively as data were compared and contrasted with previous group sessions. Through this constant comparative approach, similar items were collated together for comparison and contrast. The meanings associated with the patterns that emerged from this process resulted in the identification of core categories or themes. We sought to “rule in” most information while seeking to understand variability. As a form of validation, the preliminary study findings were presented to two meetings of older people and professionals working in the field, one in Dublin and one in Belfast. These meetings included some respondents, peer reviewers, other older people, and professionals, and thus contained dimensions of both expert and respondent validation.

FINDINGS Overview of Respondents Fifty-eight people took part in the eight focus groups, each group comprising 4 to 12 people. Details are provided in Table 1. There were four times as many women as men, reflecting the greater longevity of women and the tendency for older people’s community groups to have a higher female membership. Pseudonyms have been used here to preserve confidentiality.

Categories of Abuse Identified and Main Themes Emerging Respondents recognized the categories of abuse used in documents by professionals in terms of physical, financial, verbal, psychological (emotional) abuse, and neglect. In no focus group was sexual abuse TABLE 1 Details of Respondents Participants

Republic of Ireland

Northern Ireland

Number Gender Age groups 65–69 70–74 75–79 80–84 85–89

21 17 female, 4 male

37 33 female, 4 male

6 6 6 3 0

Location Occupation

12 rural area,a 9 urban area 17 had worked outside the home, 4 stated housewife/homemaker

9 8 10 4 2 Age not indicated on 4 forms 19 rural area,a 18 urban area 33 had worked outside the home; 4 stated housewife/ homemaker

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Rural area = open countryside or a town or village with population less than 3,000.

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mentioned until raised by the researcher. Two broad categories relating to older people’s understanding of elder abuse emerged from the data. The first category of understanding of abuse of older people related to broader “societal abuse,” encompassing notions of respect and the qualities that confer distinct individuality, including attributes such as agency to act, selfawareness, and having a past and a future. Second, the concept of the abuse of older people was understood at the level of the individual, which was seen to affect the minority of older people. Key issues in this latter category were (1) the emotional underpinning of most or all abuse, (2) the vulnerability of the older person, (3) the intention of the (alleged) perpetrator, and (4) concepts of family duties and relationships. These concepts are explored in turn below.

Broader Concept of Respect in Society A fundamental category to emerge from the data was elder abuse understood as the diminishment of older people’s personhood. Attributes of personhood include self-awareness, agency, having a past and a future, rights, and duties. Participants felt older people were targeted for abuse because they looked or behaved like an “old person” or by “outliving their usefulness.” Participants believed that an older person may “not [be] treated as a normal person who still thinks; still learns; [and] still works as much as you can” (Ann, RoI, urban). This disrespect, and sense of not having worth or value as a person, permeated much of the groups’ discussions. Participants believed that once a person appears old, they are perceived as stupid and incompetent by some family and wider society. I would extend it [the meaning of abuse] to the area where you retire at 65 or so and you have got grey hair and suddenly one day you are capable of holding down an important job and the next day then you are considered as having no valued opinion, you’re not clever enough to understand what we are doing and we’re here to help you . . . . (Jack, NI, urban)

The dismissal of the older person as a person was reflected in the way younger people “have a tendency of talking across older people as if there was nothing in here [pointing to head], that just because we have a few wrinkles and might need a stick that this [brain] is completely gone” (Gerry, RoI, urban). Others concurred with this: “they will go to other people in the group and say what do you think, [but] they don’t consider you having anything to contribute in a particular topic” (Pat, NI, Urban); “the decision can be taken from you” (Ciara, NI, rural). Regular references were made to the lack of respect for older people, typified as younger people not giving up their seat on the bus.

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Parents . . . won’t dream of taking up the child on their lap. I’ve stood on buses and trains with children sitting on seats and . . . they are hopping about but you daren’t sit down. No I feel it’s a general lack of respect in the community at large. (Bernie, RoI, urban)

Lack of respect was also associated with grandchildren being rude or unkind to their grandparents. Participants put this change in society down to “the way [children] were brought up; if they were respecting their grandparents . . . they won’t do that” (Freda, NI, urban). The disregard of older people’s rights was seen as fundamental to the abuse of older people, as summed up by Patsy (NI, urban): “Denying them of their basic rights and I would go as far as to say even the knowledge of their basic rights; a total indifference to their dignity.” In a similar way to how all forms of abuse were viewed, the transition of the older adult from person to nonperson is subtle and progressive, gradually eroding belief in their ability to act for themselves, and they come to accept rather than fight back, as Bess (NI, rural) explained: Older people haven’t the confidence to . . . fight back. If you were younger you probably could do something about it, but you get older and they make you lose your confidence and then you don’t think you can do anything, no matter what you do.

The experience of loss of respect in society extended from public transport to experiences in health and care facilities. Becoming a pensioner sometimes led to feelings of being discarded, ignored, and abused. Diminishing or weakening the personhood of older people in society seems to have similar outcomes to that of the common understanding of elder abuse at an individual level: loss of confidence, self-esteem, isolation, and fear for the future.

Abuse and Family Relationships What is and what is not abusive was generally defined within the context of “normal” family relationships, the ability of the older person to answer back, and the impact on the person’s psychological well-being. Within each form of abuse there was a continuum: if you are living in the care of your own family and you are having abuse, you would be reluctant to report them or to say anything about it because you don’t want to hurt them and at the same time you need the help, you probably even do not understand it’s abuse or treat it as abuse you see, because from the start it is very insidious. It’s not something that suddenly happens, it’s very gradual. (Grace, ROI, urban)

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In relation to physical abuse, there was less uncertainty. For instance, Joan (RoI, urban) put it to the group, “physical abuse, how do you define that?” Joan responded, “pushing, rough handling in the sense of just helping them with their clothing, not doing it [intentionally], you know they’re stiff . . . that’s abuse . . . abuse can go from the slightest thing down to actual wallop.” Neglect was understood as the failure to meet older people’s basic needs, such as for food, warmth, care, and safety. Family neglect was viewed as leaving an older person alone and not seeing that the older person needed support. This was viewed in the main as unintentional and related to pressure on families caring for an older relative, or family living at a distance from their relative and not being aware of changes in health. [There was] . . . unintentional neglect by her daughter. Her daughter worked abroad and the funny part of it is, you can’t really blame her daughter completely because every time she come[s] home, her mother brightened up . . . . The girl couldn’t see the problem, but I did have to [tell her] in the end. I did say to her: “it can’t go on like this.” . . . When [mother] took [Alzheimer’s disease] she wasn’t responsible for what she was doing. (Laura, NI, urban)

Family members providing care for a relative with Alzheimer’s disease in particular had to make difficult decisions about caring for their relative while coping with their own family commitments. Mary (RoI, urban) describes how she had “more bolts on the door and people used to think that it was to keep people out, but it wasn’t; it was to keep my mother in.” Families living away from relatives or rarely visiting may not see the deterioration in their relative’s health. Sometimes the older person may hide a problem they have with activities of daily living, such as shopping or preparing food. However, in some instances this type of neglect can be motivated by financial gain, where accessing appropriate care for the older person, such as nursing home care, reduces relatives’ future inheritance. The issue of trust and duty in financial transactions within families occurred in all of the groups’ deliberations around financial abuse. Much of this discussion related directly to relationships within families. For family and neighbors looking on, their interpretation of actions can differ from those directly involved. Well, I know for a fact that my brother robbed my mother blind, but my mother thought the sun shone out his backside, but . . . there is nothing you can do about it . . . as far as she was concerned she wasn’t being abused. He was coming to visit her. (Rita, NI, urban)

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There was a sense of an underlying right or unspoken agreement regarding older people’s property and money on the part of family, especially if they were providing any form of support. One example was grandchildren doing the shopping and taking money for themselves from their grandparent’s purse. Clare (RoI, urban) wondered “if you could put it down to abuse.” Financial issues seemed to highlight aspects of family relationships such as duties, rights, and trust.

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Vulnerability of Some Older People The older person’s life experience, personality, health status, family relationships, and cultural norms were factors participants felt needed to be considered in terms of conceptualizing elder abuse. Life experiences can “make [older people] hard and able to take abuse” (Gina, NI, rural); they have “tougher skins.” In this extract Joan and Pete discuss what can make some older people susceptible to abuse. Joan (RoI, urban): Personality comes into it and physical mental capabilities also play a major part in these things . . . . Would you like me to tell you [what to do]? Let’s be honest and use myself [as an example] . . . . It wouldn’t be worth it; you’d be in trouble. Pete (RoI, urban): Anyway the weak were always abused; not just elderly people but the weak, whether they were young or different or anything. If they were weak they were always the butt of jokes, and the butt of one form of abuse or the other. Joan: Back to the personality. If you are very demure and vulnerable, then they are more at risk, let’s face it, always. Pete: If you display any traits of weakness at all, you are vulnerable.

Joan contrasted the confidence and ability she had to do what she wants with other older people who may lack confidence: We’re alright. We’re all healthy and we’re active. Look at those old dears, in sheltered housing place . . . . I’m sure they have family elsewhere. We’re OK; we’re never there. We’re out doing our own thing, but any of the old folk, now down the country, if there are in a house down a bohereen [a local expression for a small rural road] . . . . There is nobody out there would have the nerve to abuse us now face it. (Joan, RoI, urban)

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Those identified as particularly vulnerable were older people with physical or cognitive impairment, who have to depend on others for care. Their dependency gives their carer a certain degree of power, and participants believed that this power can be used by carers whose nature is to control, and “if there is a bully of a person looking after their things, sometimes their [older person’s] voice can’t be heard” (Una, RoI, rural). The person requiring care may have no option but to trust this person and, as Paula (RoI, rural) pointed out, give them “the freedom to go into their home generally and gain their trust to a certain degree and then in certain cases will abuse the older person.” Often older people do not choose their family carers; circumstances at the time determine who takes on the role and the shift of power: Shadows of childhood still motivate behaviour, if you have a strict parent who was strict on you when you were a child, you’ll harbour still the basic resentment into your adulthood and come the situation that now roles are reversed, I’m the boss now, that can motivate unconsciously unknown to themselves it can motivate their behaviour to their parent. (Tom, RoI, rural)

Participants perceived the biggest threat to their well-being was deterioration in their health, either physical or mental. Being dependant on others for care created opportunity for older people to be mistreated, as Paula (ROI, rural) observed: “you become more vulnerable as you become older for the simple reason that maybe your health isn’t good [and you] become dependent on people for things.”

Emotional Underpinning of Abuse Abuse that impacted on older people’s emotional well-being was deemed the most damaging, described as “the worst”: “there are many types of abuse . . . there is emotional abuse, the love of another person’s abuse . . . down to physical abuse” (Joe, ROI, rural). The concept of abuse represented an insidious process rather than something that suddenly happened, like being robbed. Abuse, Una (RoI, rural) believed, is “living with something in your mentality.” Hence each form of abuse was usually associated with an element of psychological pressure, referred to as “mental torture” by some participants. Psychological pressure can be exerted through bullying or manipulating older people to do things like sign over property, give relatives their pension, keep quiet, or be pressured into moving into a nursing home. It can include or result in other forms of abuse, such as financial abuse and possibly physical and verbal abuse and neglect. Abuse was associated with a person’s inability to say no without fear of repercussions for their safety or daily well-being.

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Intent Participants recognized that older people could contribute to their own neglect by wanting to be independent and refusing to see the reality of their situation. “Your independence can be your ruination” (Clare, RoI, urban). Neglect perceived as abuse depended on individual circumstances and the motivation of those involved. For example, bolting the doors while a family member caring for a person with Alzheimer’s disease went out for 5 or 10 minutes to calm down or pick up milk was acceptable, but keeping an older person with Alzheimer’s disease at home without support because of the financial implications for inheritance if the person was admitted to longterm care was not acceptable. There is a delicate balance between informal financial arrangements within families and financial abuse. Where capacity was not an issue, the older person’s understanding of their situation was important for the defining abuse: Well you see it’s our definition perhaps of neglect, but equally if we infringe on their dignity, surely that is abuse . . . . It’s a difficult balance. Hopefully it’s not a rat-ridden house or whatever. There are extremes that somebody will have to intervene, but I think sometimes people rush in and think “What’s best for this lady; oh, residential care!” They don’t sit down and ask “what do you think?” (Amy, NI, urban)

In no group did the participants raise the issue of sexual abuse during the discussion about different forms of elder abuse. When the issue was raised by the facilitator at the end of the discussion, participants generally reported that they hadn’t even thought about sexual abuse. They acknowledged that it did happen but they believed it was not as prevalent as other forms of abuse. Occurrences were thought of as associated with being robbed by people who had taken drugs or alcohol: It does happen, doesn’t it? You hear about it, you read it in the paper. I don’t know anybody in this district . . . . You do hear of people coming into rob . . . and then they’ll sexually abuse the person. (Vera, NI, rural)

The central feature in conceptualizing abuse seemed to be emotional impact, particularly betrayal of the expected caring relationship (in the family) and loss of respect (in society), emphasizing the “trust” aspect of the WHO definition of elder abuse. What might be regarded within a formal procedure as abusive might be acceptable if it were done in the best interests of the older person. The perceived intent of the perpetrator of the action was a key to the perception as to whether this was abuse. At the same time there was recognition that some older people were more vulnerable than others, such as through ill health and dependency on others for care.

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Loss of respect in society

Family relationships

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Vulnerability of older person

Expectation of trust and care

Intent of abuse perpetrator

Emotional experience of being abused

FIGURE 1 Model conceptualizing abuse of older people.

Overview of Themes The main themes are captured diagramatically in Figure 1. The expectation of the older person regarding trust and care is the point where the understandings of family duties and relationships interface with the particular vulnerabilities of the older person and the intent of the perpetrator of the abuse. The experience of being abused is shaped by these expectations, by the experience of vulnerability, and by the older person’s perception of the intent of the perpetrator. Underpinning these family dynamics is the over-arching sense of personhood and being respected, which depends on the experience of wider society. It was beyond the scope of this study to explore further the interplay between the loss of respect in society generally and the behaviors of perpetrators of abuse. It may be that the loss of respect within society at large impacts on the feeling of vulnerability of the older person, on the motivations of people who may abuse them, and on the concept and experience of family duties and relationships. These in turn may influence the experience of being abused, which is regarded fundamentally as emotional pain where a caring and trustworthy relationship was expected.

DISCUSSION Innovations and Limitations of the Study All participants were involved in their communities as members of social clubs or groups and may not be representative of older people in Ireland in general. The experiences of older people who are marginalized (e.g.

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cognitively impaired, unwell) or socially excluded were beyond the scope of this study. However this study provides unique insights about how elder abuse is conceptualized by a wide range of older people living across the island of Ireland. The study is limited to what is in effect a convenience sample, although the endeavors to ensure a spread geographically and in terms of urban–rural mix mitigated this. Although we have confidence in the major themes emerging, the study did not reach saturation of themes. The study focused on abuse rather than neglect or self-neglect, and these are areas for further research. The design of this study was innovative in its involvement of peer researchers. Their contribution was valuable in facilitating more open discussion on a sensitive topic in the focus groups, and also through their insights during analysis. Rather than seeing the involvement of peer researchers as a panacea, this experience led us to the conclusion that their involvement added a greater richness and therefore validity to the data. The involvement of peer researchers also involves taking some risks. It might be that the presence of a peer researcher added a bias to the focus group discussions, for example if they were regarded as opinionated and were seen to be expressing their own views rather than facilitating sharing of views of group members.

Typologies of Abuse The types of abuse identified by older people living in Ireland generally fitted into the typologies outlined by professionals, such in national policy documents (DHSSPS, 2006; HSE, 2002), broadly confirming the work of Hudson (1994). Elder abuse understood at the level of individual relationships included physical, psychological, verbal, and financial abuse, and neglect. Sexual abuse was not mentioned except when prompted, echoing the conclusion of Teaster and Roberto (2004, p. 788): “Sexual abuse is the least perceived, acknowledged, detected, and reported type of elder mistreatment.”

Personhood or Societal Abuse What emerged as a primary theme was a concept of “personhood abuse” or “societal abuse,” referring to the loss of respect in society that filters down to a personal level. This was reported particularly in relation to lack of respect in health and care facilities, and feelings of being worthless once a pensioner. This linking of the challenges of ageism to issues of abuse echoes the findings of the systematic review by Imbody and Vandsburger (2011). Abusive attitudes not only affect the person’s confidence, autonomy, and agency but also reflect a fear of the repercussions of saying no or standing up for oneself

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against abusive acts, words, and pressures. This study confirms the findings of the WHO (2002) study, which noted the devaluing of older people in families and communities, and the study by Hudson, Armachain, Beasley, and Carlson (1998), which noted how expectations of respect were fundamental to the concept of elder abuse among Native American tribes. It was not possible within this study design to explore intercultural differences. However, this study confirmed the general finding regarding the influence of cultural norms in relation to family relationships in conceptualizing abuse (cf. Moon & Williams, 1993; Pablo & Braun, 1998; Shibusawa & Yick, 2007). The conceptualization of elder abuse varies across countries and cultures (Podnieks, Penhale, Goergen, Biggs, & Han, 2010). A World Health Organization study (WHO, 2002) in eight countries found that older people gave particular emphasis to the themes of rights, choice, dignity, and respect. These issues were raised in the current study and formed part of a wider contextualization of elder abuse at a macro level, where older people’s status in society determined their personhood. Unlike in the study discussed by Montoya (1997), the church received little mention in the focus groups, perhaps because the cultural influence of the Christian church over centuries is subconscious rather than recognized explicitly. In their study in Sweden, Erlingsson, Saveman, and Berg (2005) highlighted how social decline may be a primary cause of abuse. This link between older people’s status and value to society, personhood, and abuse is a significant finding from the present study.

Emotional Impact of Abuse, Intent, and the Family Abuse that impacted on the older person’s emotional well-being was deemed the most damaging, confirming the study by Helme and Cuevas (2007) in Australia and the studies in the United States by Anetzberger, Korbin, and Tomita (1996) and by Nandlal and Wood (1997). The National Center on Elder Abuse (NCEA) in the United States defines emotional or psychological abuse as the infliction of anguish, pain, or distress through verbal or nonverbal acts (NCEA, 2003). Psychological abuse was perceived as central in determining the severity or impact of abuse on an older person, underlying the importance of developing our understanding of this (Conrad et al., 2011). Quyen Le’s (1997) study of Vietnamese elders identified “silent treatment” as an extreme form of punishment, and noted that “the use of silence and avoidance may be more emotionally devastating than physical abuse” (Le, 1997, p. 53). This echoes Nagpaul’s study (1997) of abuse among Asian Indians, in which respondents identified ignoring and neglecting as the worst thing that family can do. Emotional abuse may be particularly an issue when an older person is isolated socially (Brozowski & Hall, 2004). What the present study has highlighted is how abuse, in its different forms, was not seen as a standalone event but a subtle, gradual process that usually involved an element

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of psychological pressure. This emotional pressure placed older people in a position where they believed that saying no would have significant negative repercussions on their well-being and safety. The study by Lafferty Treacy, Gealy, Drennan, and Lyons (2012) in Ireland identified the primary impact of abuse as being on the victim’s physical and emotional health; in the present study the physical effects of emotional distress were perhaps not so readily recognized. However, the study by Lafferty and colleagues was with victims. Determining what was perceived as abusive behavior requires an understanding of family dynamics. Chang and Moon (1997) noted how elderly Korean Americans’ concept of elder abuse was based on their cultural norms relating to family relationships, including expectations of family obligation and loyalty. Hudson et al. (1999) and Mouton et al. (2005) have highlighted the influence of social expectations in family relationships that became abusive. Further intercultural discussion is in Phelan (2013). This emphasis on the psychological aspect of abuse being central presents particular challenges for professionals seeking to address issues of elder abuse. Concrete behaviors are more easily observed, documented, reported, and adjudicated for their acceptability than intentions and emotions. Giving increased attention to emotional aspects will require higher levels of professional skill in areas such as effective communication with older people and understanding their perspective on the behaviors of concern (Begley et al., 2012), as well as greater challenges in managing risk for professionals (Taylor, 2013). More attention may need to be given to psychosocial symptoms, such as anxiety and depression, as indicators of possible abuse (Begle et al., 2011). Being able and willing to stand up for oneself was also relevant in determining elder abuse. Older people may fear being ostracized, criticized, rejected, or mocked by other family members if they speak out. This ability was related to the older person’s life experience; personality, family relationships, circumstances, and health status. There may also be a cultural dimension in treating abuse as a private matter rather than seeking help. Significant physical or cognitive impairment in combination with these factors was said to place older people in vulnerable situations. This identification of the vulnerability of some, but by no means all, older people may be viewed as an application of the theoretical development of cumulative inequality, and increasing vulnerability (Ferraro & Shippee, 2009). The findings have resonance with those of Brozowski and Hall (2004), who found that older people who were isolated from external supports were more likely to experience emotional elder abuse, supporting interpersonal risk theory. This vulnerability gives credence to the development of procedures for the protection of “vulnerable adults,” conceptualized more broadly than just for “older people.” However, defining vulnerability in this context may not be straightforward, and it may be a key professional task to explore the perception that the older person has of the abusive person (Phillips, 1983).

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This finding suggests that there may be merit in statutory and voluntary organizations focusing some attention on building assertiveness among older people where necessary, so as to reduce the likelihood of abuse. The delineation between neglect and keeping an older person safe while caring and meeting the older person’s wishes to remain in their own home requires an understanding of intentionality, echoing Morbey (2002). An action might be regarded as acceptable as a way for a relative to enable an older person to continue living at home, while the same action might be regarded as unacceptable if it were done with malice (Taylor & Donnelly, 2006b). The motivation of those involved and the individual’s circumstances were thought to determine if an act or inaction was abusive. The focus on intent, rather than objective behavior, raises issues of determining the capacity of the older person to evaluate intent, and the freedom to speak openly about what is occurring. This underlines the need for professionals to have the knowledge, skills, and resources to enable such assessments to be completed without coercion. The major desire of many older people to remain living at home echoes previous research (Taylor & Neill, 2009). The discussion of intent was sometimes in relation to a family member enabling an older person to achieve this.

CONCLUSION Three key messages emerged from this study. First, the loss of respect within society was raised by participants as a feeling of being abused, and this has implications for relationships within families. This broader conceptualization of elder abuse suggests that both statutory and voluntary organizations should focus more on strengthening respect for older people, and enhancing their status within society, as a means to reducing elder abuse. Second, although the standard range of abuse in professional documents was recognized, emotional abuse was seen as underpinning all other forms of abuse, almost as its essence. Third, the intentionality of the perpetrator was important in respondents’ views of what was or was not perceived as abusive. All three issues should inform the development of policy and practice to help professionals to understand, prevent, and respond appropriately to abuse of older people.

ACKNOWLEDGEMENTS The research team thank the people who took part in the focus groups and the community organizations that facilitated these. Special thanks to the four peer researchers: Evelyn Moran, Evelyn Doyle, Sam McCrossan, and Mary McCarthy, whose time, commitment, and experience have added depth to the research.

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FUNDING This work was supported by the Centre for Ageing Research and Development in Ireland, to which we are grateful for support throughout the project.

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Older people's conceptualization of elder abuse and neglect.

This qualitative study used data from eight focus groups involving 58 people aged over 65 years in both urban and rural settings across Northern Irela...
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