Does Caregiving Lead to Abuse?

While early work in the field of elder abuse suggested that caregiver stress leads to abuse, recent research and clinical experience of the Elder Abuse Consultation Team at the Family Service Association in Toronto and others suggests that this occurs much less frequently than originally thought. Although caregivers may report feeling unsupported, overwhelmed and/or frustrated, they rarely express these emotions in abusive actions and are more likely to feel guilty for having negative emotions about the person they are caring for.

If we continue to think of abuse in later life as caregiver stress, we do those who are abused a disservice. This point of view leads to the inevitable conclusion that the person who is being abused is frail, ill, dependent, and incapable. Interventions are framed to alleviate the abuser’s stress rather than getting at the root cause of abuse: the misuse of power and control in a relationship.

Many people who are abused were and sometimes still are caregivers to those who abuse them: parents who provide their adult children and/or grandchildren with food, shelter, spending money, love, attention, and devotion when the latter are challenged by mental-health issues, addictions, employment problems, or other difficulties; or partners who are supporting partners who have retired, lost a close friend, been diagnosed with an acute or chronic illness, and so on.

Although, initially, the abused person may appear dependent on the abuser, a closer look often reveals that the person is living in a state of ‘created dependency,’ or fear. The abuser’s control over the home, telephone, and access to friends, as well as threats to institutionalize the victim should he/she speak up, can make it appear that the older person depends on their abuser’s care.

We do not dispute that some older adults who are abused are frail, incapable of decision-making, or on the slippery slope of losing capacity. However, even when this occurs it is critical to view abuse through the lens of power and control. Framing it as caregiver stress removes responsibility from the caregiver and serves to further victimize those suffering abuse.

The "Power and Control Wheel for Older People" accompanying this article identifies common tactics of abuse. At the hub of the wheel is the abuser’s intent: to establish power and control. Each spoke of the wheel describes a tactic. The rim of the wheel, which gives it strength and holds it together, is fear and physical abuse or the threat of it. This wheel frames the actions of the abuser as purposive rather than as a byproduct of stress or anxiety.

Also accompanying this article, "Distinguishing Caregiver Stress from Abuse in Later Life" compares significant differences between caregiver stress and caregiver abuse.

Over the past two years, the Elder Abuse Consultation Team has come to understand that social isolation is the single largest contributor to abuse and/or its perpetuation. The abusive individual is able to control the older person by creating barriers to contact with the outside world. One of the most significant barriers—the weapon of choice—is often the telephone.

Following are some things to look for to identify abusive behaviours/actions in a relationship:

The older adult lacks access to a telephone.
The older adult never answers the phone.
The older adult cannot access the answering machine.
The telephone is placed out of reach of the older adult.
The ringer is turned down or the phone jack is pulled out of the wall.
Call screen is in place and family, friends etc. are being screened out.
The older adult is not connected to the outside world.
Appointments are frequently cancelled.
Necessary appointments (i.e. medical, renewing medications at the pharmacy) are not made.
Necessary health-care aids are denied or not in easy reach (i.e. false teeth, cane, walker, hearing aid, glasses, wheelchair.)
Someone is talking over the older adult.
In some cultures, lack of access to the remote control to see TV programs in the language of choice are factors in isolation and abuse.

Questions to ask to elicit details about isolation might include:

Do you feel isolated? Are you being deprived of contact with the outside world?
Are you being denied private space or time?
Who makes decisions for you? Are you allowed to make decisions for yourself?
Is anyone withholding or mismanaging your scheduled medications?
Are you being deprived of assistance when you need it?
Does your spouse or companion accuse you of things that are not true?

It is critical that an older adult understand that she is not to blame for the abusive behaviours that are occurring. Attempting to intervene in situations using a traditional model of alleviating caregiver stress by offering services such as respite care, home help, and so on can be construed as a way of letting the perpetrator "off the hook." While these services may be necessary for the older person’s well being, the perpetrator must be held to account for his/her actions and a message of zero tolerance must be conveyed.

Please contact EWA for a complete hard copy:
publications@womanabuseprevention.com
Telephone: 416.968.3422 x21