Words of gratitude to the Respect My Home Research Project Governance Committee for their constant support and guidance – Graeme Westaway, Dr. Paula Fernandez Arias, and Jenni Dickson.

Better Place Australia individually acknowledges all research participants and organisations for the contributions they have made to the Respect My Home Research Project consultations.

A wide range of practitioners engaged in delivering elder abuse services who have participated in the interviews and consumer focus group workshop consultations.

The following organisations from the state of Victoria and Queensland for permitting their elder abuse workforces to participate in the scoping interviews and the consumer focus group workshops:

Southern Melbourne Primary Care Partnerships-Victoria,
Uniting Care- Elder Abuse Prevention Unit – Queensland,
Monash Health-Kingston Aged Care Assessment Services-Victoria,
Peninsula Community Legal Centre-Frankston-Victoria,
First Step-Victoria,
Bolton Clark-Aged Care District Nursing Home services-Victoria,
Self Help Addiction Resource Centre (SHARK)-St. Kilda-Victoria,
Monash Hospital- Integrated Model of Care and Prevention Response
Education-Victoria, and the Better Place Australia

Introduction

The Better Place Australia (BPA) Respecting Elders Program is a frontline response service for victims of elder abuse. The service provides support through non-legal pathways to preserve family relationships and pose less risk of financial loss and emotional damage, whilst maintaining safety and advancing the rights of the older person. The service is based on multidisciplinary responses and focuses on risk management, family support and self-determination. Six years ago, BPA developed an innovative elder abuse response model for trial, which is now used to support the Orange Doors services across Victoria.

BPA is in a unique position to contribute to the development of innovation in relation to best practice addressing elder abuse and is one of the few organisations in Australia which has developed a service specifically for victims of elder abuse. However, despite our prevention and response efforts, we know through the literature that existing response models of care are inadequate in holistically addressing the needs of victims and perpetrators.

Alongside the recent release of the Australian Institute of Family Studies (AIFS) (2021) report National Elder Abuse Prevalence Study: Final Report, which evidenced a further need for program development and awareness of elder abuse with appropriate accessible services, BPA found that victims of elder abuse encounter issues accessing interconnected services and collaborative response models. One of BPA’s key findings was that there is a distinct lack of resources fit for perpetrators. Subsequently, BPA conducted a research project to gather insights into the drivers of elder abuse and service gaps. This research is discussed under the section Respect My Home Research.

Definition of Elder Abuse

Older generation Australians are classified as 65 years plus, comprising 16% of the population (AIFS, 2021). It has been acknowledged that ageism, abuse, discrimination against older people and forms of violence are risk factors that can lead to older Australians experiencing elder abuse (Ban Ki-moon, 2017)[1].

In defining elder abuse, the World Health Organisation (WHO, 2008: 1)[2], defines it as:

[a] single or repeated act, or lack of appropriate action, occurring within any relationship where these is an expectation of trust which causes harm or distress to an older person.

Acts or omissions that constitute elder abuse can range from harm through limited understanding of an older person’s needs, to harm resulting from aggression and serious physical assault (WHO, 2021). The main subtypes of elder abuse include:

Neglect
Financial Abuse
Psychological Abuse
Sexual Abuse
Abuse relating to language or culture
Physical abuse

Financial misappropriation, the most common form of elder abuse, may not reach levels of criminality; however, these acts require redress measures such as counselling, legal aid, and mediation. For the victim, a key element in experiencing elder abuse is the power imbalance in their relationship with the perpetrator and a violation of trust[3].

BPA approaches elder abuse through a lens of human rights, ageism, and prevention. Our definitions of elder abuse align with those listed; however, we also acknowledge social abuse which is inclusive of stigma and discrimination which is attributed to ageist attitudes [4]. BPA aims to empower victims through building resilience and self-determination, and by upholding the wishes of the older person. We look to relieve pressure off the victim by providing pathways for them and pathway responses for perpetrators. BPA believe that dignity and autonomy in decision-making on matters that are important to older people and their families is critical. All these concepts underpin the research project Respect My Home.

Respect My Home Research

Rationale

Funded by the Jack Brockhoff Foundation, the Respect My Home research project aimed to design and develop a proposal for a model of care that responds to the events of non-statutory elder abuse by a perpetrator residing in the same premises of the victim. This potentially includes an older person being abused psychologically, financially, or otherwise within the carer, kinship and family matrix. We explored qualitative data generated by this research with a vision to pioneer innovative elder abuse response models for older people experiencing elder abuse, and to create pathways for both victims and perpetrators.

Research Aims

To develop an integrated elder abuse response model for victims and perpetrators.

Objectives

To explore with elder abuse practitioners, policymakers and consumers, contexts and situations around elder abuse alongside drivers, social factors and gaps in care.
To gather qualitative insights from elder abuse practitioners and policymakers to inform an integrated elder abuse response model.
Through the literature, explore the risk factors related to perpetrators and evidence-based response models for both victims and perpetrators of elder abuse.

Methodology

Procedure

Prior to data collection, we conducted preliminary scoping consultations with external elder abuse practitioners and policymakers (Subject Matter Experts (SMEs)) nationally in the fields of law, prevention, advocacy, research, and case management. Through teleconsults with SMEs, we were able to develop an equitable and ethical interview schedule for qualitative data collection suitable for older people. These consultations ensured the interview schedule included questions relating to service gaps and requested potential solutions in existing models of care.

Internally we convened a governance committee to provide oversight and guidance on the development, implementation, and data management strategies throughout the research process.

Participants

Elder Abuse Practitioners

A total of 16 elder abuse practitioners and policymakers attended the focus groups. Participants discussed their knowledge relating to service gaps, risk factors/mitigation, determinants of elder abuse and the lived experiences of perpetrators. Participants hailed from a range of elder abuse services.

We further recruited six community member participants through Better Place Australia’s elders’ program, however only three participated in the in-depth interviews. All participants provided insights into how older people victim survivors navigate services in relation to elder abuse.

Data Collection and Analysis

Elder abuse practitioner and policymakers attended a 3-hour facilitated online synchronistic focus group. A total of two focus groups were conducted with six participants in each. Data was collected through semi-structured, in-depth interviews. All discussions resulting from the focus group were recorded, transcribed, and thematically analysed.

The three community members participated in this research through telephone (as per participant preference). These were conducted by an external facilitator. All interviews were recorded, transcribed, and thematically analysed.

Literature Review

A small-scale literature review on elder abuse and intervention models for elder abuse was also conducted for this research project. Secondary data was sourced through a combination of grey literature and peer-reviewed articles. This was to identify contextual risks and intergenerational characteristics of elder abuse. Currently there remains an absence of research data on subsets of elder abuse, including neglect and intergenerational abuses. The review further identified theoretical models and frameworks of elder abuse, specifically bifocal frameworks.

Results

Following the thematic analysis of the scoping interviews, focus group interviews and community participant interviews, six key themes emerged from the data, namely:

Adult child returning home: Financial hardships and personal issues
Funds, assets, Centrelink and inheritance impatience: The psychological abuse accompanying financial abuse
Elder abuse risk factors: determinants and drivers
Barriers and gaps in care
Primary prevention
Responses for perpetrators

Adult child returning to family home: Financial hardships and personal issues

Adult children return home for various reasons including relationship breakdowns, family violence or changes in financial circumstances. Of recent, the global pandemic has seen an increase in adult children returning to the family home due to rental shortages and increases in housing costs:

At the moment…there is a massive rental shortage. Some people have said their rents are going up to 50 dollars in one go and people cannot afford it and they are moving home to live with their parents. So, in this situation there is going to be financial abuse, some sort of psychological abuse.

The results demonstrated that at times, adult children moved back home to manage personal issues including mental health issues, substance abuse and/or gambling problems. Unpredictability becomes an issue for the older person as abuse may escalate due to an adult child’s personal instability. Additionally, adult children expect the older person to provide funding for the adult child to access appropriate treatment for their personal issues:

Often we have situation where an elderly person would pay for the child … most of the clients we see are not in a financial position to pay for the adult child to seek adequate treatment and assistance or their mental health problems and they are relying on public services … especially purchase of care that is not readily available as drug rehabilitation, stays at mental health clinic engagement in treatment, purchasing pharmaceuticals or engaging in psychoanalysis, psychotherapy.

Funds, assets, Centrelink, and inheritance impatience: The psychological abuse accompanying financial abuse

According to the results, the most common subtype of elder abuse was financial abuse. This type of abuse has been shown to be inextricably linked with psychological abuse. When the perpetrator does not financially benefit from living with the older person, they may threaten to withdraw their care, potentially leaving the older person in social isolation and/or neglect. Withdrawing of care and support, particularly in relation to medical decision making can become critical:

The medical decision making around that person would be compromised for the impatience of her next of kin for her to not be around … I have seen a situation where for instance medical or life-determining instruments or what interventions do, we want for this person (or this person’s mother) [compromised]. I am sure she doesn’t want any medications. An elderly person who might be within the close range of dying for six months or year … still was entitled to antibiotics when she gets flu to get through. I have seen that sort of withdrawal of support

Perpetrator inheritance impatience, exchanging of assets and ability to access carers allowances was identified as a driver of elder abuse. Perpetrators may manipulate the older person requiring care and support for financial gain. This results in the exchange of assets for care of the older person:

This usually results in one or two situations where the adult child moves in with the parent and provides the care. The adult child(ren) may ask that the older person’s house be signed off to them for providing the care through ‘will’ or ‘probate transfer’. Often assets for care arrangement kind of thing.

Other example of obtaining financial benefits is when perpetrators move into the family home and declare their status as the carer of the older person to access additional Centrelink payments. This at times can result in the abuse of the older person as they may not realise the extent of the care required:

Because you get money if you receive carer allowance, and also free rent, usually what happens is that they may not provide adequate care or they may not contribute to the bills. And sometimes it may be that they are not able to manage the older person’s care needs. It might not be deliberate neglect, but sometimes they can’t cope with the level of care required. So, the situation in that was the adult children convince the older person to move in with them.

The following participant demonstrates the manipulation that can be used by the perpetrator to gain finances. This can eventuate in abuse if there is a relationship breakdown between the parent and the adult child/ren:

The older person is asked to pay for a granny flat to be built, or they sell their house and ask to put money into the adult child’s mortgage. The older person’s name is not usually put on the title documents and often no legal agreement. When the relationship breaks down the older person would be asked to leave…then they have nowhere to go…

Results identified that the net worth of the older person and the adult child/s sense of entitlement towards it [parents’ wealth] as a driver of elder abuse. In this context, entitlement can emerge once the adult child/ren feel they have looked after the mother all these years and therefore, they deserve payments/assets, etc. This can also lead to inheritance impatience where the adult child is of the belief that it is unnecessary for the older person to have assets:

The nature of so called ‘inheritance impatience’ of adult children was described in a way that, at times, the adult child(ren) predicts when their parents die, they are going to get the money anyway, so they (the parent) don’t need it.

Elder abuse risk factors: determinants and drivers

Of significant importance was the acknowledgement that a lack of resources and pathways for perpetrators with mental illness, gambling/substance abuse placed older people at higher risk, particularly when co-habiting. Financial hardship (as discussed above) was also identified in the results as a risk factor. In these circumstances, participants reiterated that older people, mainly mothers of perpetrators, were reluctant to report their abuse for fear of damaging the relationship with the child/ren:

The risk to the older parent escalates when the child has a drug and alcohol and gambling issues. There is a lot of undue pressure on the family and the parent, in particular, to be getting money for support…and it can be quite severe…the maternal instinct comes in very strong even though there is family violence…the mum is very hesitant to act and call the police because that maternal instinct is so strong that she doesn’t want the boys to end up in jail.

The study found some common demographical observations in relation to perpetrators. The largest cohort of perpetrators tend to be adult child/ren, usually with a substance abuse problem, or mental health problems. Intimate partner violence is usually from a small cohort, which is attributed to the male partner experiencing substance abuse or cognitive impairment:

About 75 % elder abuse in terms of an older person is usually a son or daughter. The majority of them definitely have a female victim usually the mum and a son who has a drug and alcohol issue or mental health issue. That’s probably the largest cohort. Then you get a smaller cohort say about 25% is the older intimate partner violence. Usually, there is an underlay of the male having drug and alcohol issue or dementia issues in the mix as well. The most common scenario is the son with some type of vulnerability or a daughter (less so) … obviously, there is far more female perpetrators in elder abuse because at the end of the day the drivers are different.

Informing an integrated elder abuse response model: Responses from participants

Barriers and Gaps in care

The results indicated that mothers of perpetrators tend to be the most apprehensive in reporting elder abuse. Results determined that the maternal instinct for the mother to protect the adult child is a barrier for accessing help, despite extreme cases of elder abuse that has “consequently even end up being in and out of hospital”. This can also be compounded by the mothers’ “embarrassment of the situation”. It is common for older people to be “not accepting services for fear of damaging relationships such as grandchildren, other children”. Privacy barriers are also issues as the older person feels that once services are aware of their situation, legal proceedings may result in the loss of employment for the perpetrator, the perpetrator being apprehended, or other succeeding hardships for the perpetrator. The guilt and shame that accompanies elder abuse is also a recognised barrier in accessing appropriate services:

If someone could just help him/her (adult child). Then everything would be okay. The guilt around that … It’s my fault that he is not doing well, it’s my fault that he is behaving like this, I should have been able to do something better.

It was found there was a notable absence of support groups for victim survivors of elder abuse. Support groups would potentially reduce older people’s social isolation, loneliness and feelings of shame associated with the abuse. Reasons why older people may not participate in the groups, for example accessibility and physical ability, should be considered. Notwithstanding, coping skills and self-determination can be fostered in these groups as being able to express their feelings and experiences have been evidenced by practitioners as important. Similarly, a strong neighbourhood watch to support older people who may be subjected victims of elder abuse would also increase support mechanisms on a community level.

Systemic issues such as housing and respite referrals for both the older person and the perpetrator is also a gap in models of care. Co-habitation of the older person and the perpetrator would mean the need for immediate housing or respite (outside of Residential Aged Care Facilities to not compromise self-determination) in the face of abuse.

Primary prevention

The results indicated a substantial gap in primary prevention for elder abuse. Currently there are no real connections or integration between the various levels of prevention either primary, secondary or tertiary. There is no appreciation or understanding among the workforce of how each of the levels interact to help prevent elder abuse occurring. Currently the workforce operates at the secondary and tertiary levels. Participants acknowledged there is a need to strengthen primary prevention through the provision of funding and workforce development. Gaps exists in the availability of elder abuse-specific specialists (or counsellors) either with interest in this area, or who have specialised in this area of practice. All focus group participants broadly acknowledge the shortage of knowledge, and the breadth of skills possessed the elder abuse practitioners. The postgraduate-level knowledge base and the expectation of skillsets for an elder abuse practitioner were identified across many sectors. These include the combinations of family violence, aged care, health, community services and legal sectors. There are no higher education courses addressing elder abuse in Australia. Advocating for such as skill is required.

Responses for perpetrators

The provision of services and resources perpetrators of elder abuse was thematically salient across the data. Currently, there is minimal[1] to no support mechanism in place for perpetrators. This can have ominous consequences as some significant risk factors of perpetrators are not addressed. Adult children living with substance abuse or mental health issues are currently not accessing adequate support, indicating a need for a more organised and multi-disciplinary response. Affordable housing, mental health services, alcohol and other drug services are not readily available, or are accessible.

If we are not going to address their needs, we are not going to address the older person’ s need. There is a very strong focus on preventative mental health prevention awareness.

I had a few people … where the son is on ice and the son might have applied to go to rehab, but there is a 12-month waiting list.

Additionally, it was acknowledged that there is no additional support for carers which is also important in the prevention of elder abuse:

With elder abuse you need to be working with the perpetrators. Because of the nature of older person and the abuse (intimate partner abuse has a different flavour to elder abuse from an adult child or a carer). Often the older person is reliant upon the perpetrator and also wants to maintain that relationship. Because they are family. So, we have to work with them in many ways. And if they won’t work with us, we are really stuck.

Better Place Australia Informing a new Integrated Elder Abuse Response Model: Response from the literature

Through securing funding from the Jack Brockhoff Foundation to undertake the above research in identifying gaps in response models to elder abuse, Better Place Australia (BPA) is now positioned to pilot an innovative elder abuse response model.

Through our research, BPA consulted with elder abuse practitioners alongside community members acting as supports to victims of elder abuse. Following our literature review, we identified a range of theoretical response models for elder abuse to articulate a cohesive model, by addressing current gaps across service delivery. Our model is based on the socio-ecological model of health and is inclusive of person-centred and place-based principles.

From the research, BPA discerned that elder abuse victims encountered issues accessing interconnected services and collaborative response models. One of BPA’s key findings was a distinct lack of resources fit for perpetrators. Subsequently, BPA has developed an integrated response model that is designed for both victims and perpetrators that is collaborative, integrated, person-centred and place based.

The model is focused on self-determination for both victim and perpetrator. Operationally, from the point of entry, the victim and perpetrator will work through a journey that will include referrals for mediation, care coordination and service linkages. Victims and perpetrators can attend a facilitated family meeting to identify future relationship outcomes. Existing services involved in elder abuse primarily support the interests of the victim, leaving the needs and management of perpetrators and their risk factors unresolved. This model recommends and triages victims and perpetrators through their respective pathways of need and support services, whilst operating simultaneously.

We know that familiar perpetrators tend to be the primary perpetrators of elder abuse and generally reside under the same roof as the victims. Intergenerational dynamics are evidenced as 91% of family members perpetrating abuse, with two-thirds perpetrated by a son or daughter. Among identified perpetrators, it has been shown that carers, friends, and neighbours/acquaintances account for the remaining 9% of elder abuse.

Congruent with literature, our research determined several perpetrator risk factors attributed to elder abuse:

Mental health issues
Substance abuse
Financial hardship
Gambling addiction
Family violence
Criminal history
Relational dependency

To enable a responsive model of care for both victims and perpetrators, BPA identified through literature that using the theoretical model of interacting systems would underpin our innovative elder abuse response model. Articulated by Engstrom’s third generation Activity Systems, the Cultural and Historical Activity Theory (CHAT) model (see below) enables the development of features for a place-based overlay approach to elder abuse which provides pathways for both victims and perpetrators[5].

Figure 1: Two interacting activity systems based on Engstrom’s Third Generation Activity Model[6]

BPA further identified limitations in primary research data available to determine the extent of elder abuse relating to economic abuse in Victoria. By understanding the types of abuses perpetrated in Victoria, we will be able to further refine our proposed model and capture data in relation to the extent of abuse types.

Conclusion

By obtaining the funding through the Jack Brockhoff Foundation, BPA was able to undertake exploratory research into elder abuse contexts and services in gaps. BPA identified prevalent experiences of victims such as financial abuse and how other subsets of abuses are interlinked such as financial abuse and psychological abuse. Risk factors of perpetrators including mental health issues, financial hardships, substance abuse and problematic gambling have high associations with elder abuse victims. Our interviews captured rich data from elder abuse practitioners and individuals supporting victims. Subsequently we were able to gather seminal insights into the service gaps and barriers to access. This has contributed to the development of an innovative elder abuse response model which incorporates pathways for both victims and perpetrators.

Through the focus groups and interviews, BPA was able to gather direct insights from subject matter experts and consumers in relation to the drivers, social factors, and gaps in care. It was identified that financial hardships and personal issues were the most significant risk factors for potential elder abuse. Subject matter experts noted that adult children returning to the family home due to financial hardship and/or mental health issues, substance abuse or gambling problems tend to be the highest risk factors associated with elder abuse. This was commensurate with the National Prevalence Report findings that perpetrators were most likely to experience issues with mental health, followed with substance abuse[7].

Aligned with broader literature, it was revealed that financial abuse and psychological abuse tend to be interlinked, mainly when adult child/ren have ‘inheritance impatience’ or attempt to obtain Centrelink payments and/or assets from the older person[8] [9]. Medical decision-making can be compromised as an adult child may threaten to withdraw caring for the older person in exchange for financial gain. However, the results also revealed that at times, the adult child is unaware of the extent and requirements in being a carer leading to abuse of the older person[10].

There is a significant gap in the provision on pathways for perpetrators of elder abuse. The results indicated that providing appropriate referrals and care pathways for adult children is essential in managing elder abuse and in preserving the relationship of the older person and adult child/ren[11]. Mothers of perpetrators also experience maternal guilt and shame for reporting abuse therefore becoming a barrier to accessing services and assistance[12]. Mothers tend to fear the prosecution of the adult child/ren which could subsequently leave the perpetrator homeless, incarcerated or exacerbate existing mental health/substance abuse/gambling issues[13].

To address some the above, participants indicated that there is a need for primary prevention initiatives that are robust and universal. There is a current lack of workforce that have skills in managing the complexities related to elder abuse. Advocating for tertiary education to upskill practitioners or to provide expertise in the area is critical[14].

To address these identified gaps of the Respect My Home research, BPA has developed a model of care that will provide referrals and pathways for both perpetrators and victim survivors of elder abuse. This model is based on self-determination and integration.

Ref.

[1] Better Place Australia’s Elder Abuse Prevention Service currently provide referrals for perpetrators. However, uptake has not been measured.

[1] Ban Ki-moon., 2017.The Drivers of Ageism Report. Section 2: The Literature Review. Every Age Counts. Website. Retrieved January 2022: TBS_Ageism_Report_2017_-_Literature_Review.pdf (d3n8a8pro7vhmx.cloudfront.net)

[2] World Health Organization. (2008). A global response to elder abuse and neglect: Building primary health care capacity to deal with the problem worldwide. Geneva: World Health Organization.

[3] Joosten, M., Vrantsidis, F. and Dow, B., 2017 Understanding Elder Abuse: A Scoping Study, Melbourne: University of Melbourne and the National Ageing Research Institute. Retrieved February 2022: Elder-Abuse-A-Scoping-Study.pdf (unimelb.edu.au)

[4] Ibid

[5] Blundell, B et al. 2017. Review into the Prevalence and Characteristics of Elder Abuse in Queensland. Perth WA: Curtain University and Murdoch University.

[6] Engestrom, Y 2001, Expansive learning at work: Towards an activity theoretical conceptualisation, Journal of Education and Work, 14, 1, 133-156

[7] Australian Institute of Family Studies. 2021. National Prevalence Study on Elder Abuse. Retrieved May 2022: Elder Abuse Prevalence Study | Australian Institute of Family Studies (aifs.gov.au)

[8] Joosten, M. 2021. Seniors Rights Victoria at COTA Victoria. Elder abuse, mental health and wellbeing: Discussion paper. Melbourne: SRV. Retrieved 2021: https://seniorsrights.org.au/wp-content/uploads/2021/11/SRV-Elder-abuse-mental-health-and-wellbeing-November-2021.pdf

[9] Cartillier, V. 2021. (Dis)respect your elders. The Guardian. Informit, 1987, 4

[10] Gillbard, A. 2019. Differences of Risks and Experiences of Familiar Elder Abuse for Victims with Cognitive Impairment. Peer Review from the FRSA Conference. Retrieved May 2022: https://www.researchgate.net/profile/Anna-Gillbard/publication/347515886_Differences_in_Risks_and_Experiences_of_Familial_Elder_Abuse_for_Victims_with_Cognitive_Impairments/links/60d92d1892851ca9448fe015/Differences-in-Risks-and-Experiences-of-Familial-Elder-Abuse-for-Victims-with-Cognitive-Impairments.pdf#page=18

[11] Australian Institute of Family Studies. 2021. National Prevalence Study on Elder Abuse. Retrieved May 2022: Elder Abuse Prevalence Study | Australian Institute of Family Studies (aifs.gov.au)

[12] Dow, B., et al. 2020. Barriers to Disclosing Elder Abuse and Taking Action in Australia. Journal of Family Violence, 35, 853-861.

[13] Ibid

[14] Australian Institute of Family Studies. 2021. National Prevalence Study on Elder Abuse. Retrieved May 2022: Elder Abuse Prevalence Study | Australian Institute of Family Studies (aifs.gov.au)

Outcomes of the Respect My Home research project

Informing an integrated response model of care for victim survivors and perpetrators

Acknowledgements