Over 20 years ago, the Australian Liberal/National Party Federal Opposition had a set of policies with which it hoped to persuade the Australian people to return it to government in the election due in 1996. This particular collection of proposed initiatives was called “The things that matter”. When the then leader of the opposition, Alexander Downer (later Australia's Foreign Minister 1996–2007 and now Australian High Commissioner in London), launched the Opposition's policy on family violence (the Coalition parties, like their Labor opponents, were and are against it in principle), his introductory line was: “From the things that matter to the things that batter”. Not long afterwards he lost his job as Opposition Leader, his engagement with what was and is a serious and troubling issue having been deemed too glib by half by the shapers of public opinion.
Nevertheless, the things that batter, verbally abuse, neglect, and defraud people with dementia (PWD) remain a vital area of concern for those of us who want to make the lives of PWD and their carers better than they are at present. Over several years, the team of researchers at University College London (UCL), led by Professor Gill Livingston, has built a body of useful new knowledge about who abuses, what may drive them to abuse, how they abuse, the extent to which they are willing, in their desperation, to talk about why they might abuse, and their worries about the possibility of crossing a line from frustration to abuse. Following the dictum of a famous philosopher who worked for much of his life just a few hundred meters from UCL, they acknowledge that the point of developing an understanding of the world is just one stage in the process of trying to change it for the better. Their paper (Cooper et al., Reference Cooper, Barber, Griffin, Rapoport and Livingston2016), which has been chosen as paper of the month for this issue of International Psychogeriatrics, reports on the outcome of an important randomized controlled trial (RCT) which aimed to see if a psychological intervention which is effective in reducing depression and anxiety amongst carers of PWD might diminish abuse levels in those randomized to the intervention. The trial was rigorously conducted with a large sample of participants (260 in total) and outcomes were measured over two years. The intervention made no difference to rates of abuse, but at least those who were not abusive at baseline did not become abusive over the ensuing months, which has happened in other longitudinal studies.
Because it would have been unethical not to intervene where evidence of abuse was significant, the research team discussed such abuse with carers and then alerted clinical teams involved with the patient–carer dyad. This may have affected the study's outcome, but it is hard to see how the UCL staff could have done otherwise. Perhaps as the authors suggest, a lack of increase in abusive behavior over time may indeed be evidence of some efficacy for the total intervention package and shifting the focus to encouraging professionals to discuss abusive behavior and to support those who are abusing or at risk of doing so may be the way to go. Future RCTs like this may be difficult or impossible to conduct, but this seemingly negative study has helped the field to progress quite significantly.
Conflict of interest declaration
David Ames has undertaken joint research with Claudia Cooper and Gill Livingston, has published articles with them as a co-author, and was a guest of Professor Livingston on sabbatical at UCL in the first quarter of 2014.
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Over 20 years ago, the Australian Liberal/National Party Federal Opposition had a set of policies with which it hoped to persuade the Australian people to return it to government in the election due in 1996. This particular collection of proposed initiatives was called “The things that matter”. When the then leader of the opposition, Alexander Downer (later Australia's Foreign Minister 1996–2007 and now Australian High Commissioner in London), launched the Opposition's policy on family violence (the Coalition parties, like their Labor opponents, were and are against it in principle), his introductory line was: “From the things that matter to the things that batter”. Not long afterwards he lost his job as Opposition Leader, his engagement with what was and is a serious and troubling issue having been deemed too glib by half by the shapers of public opinion.
Nevertheless, the things that batter, verbally abuse, neglect, and defraud people with dementia (PWD) remain a vital area of concern for those of us who want to make the lives of PWD and their carers better than they are at present. Over several years, the team of researchers at University College London (UCL), led by Professor Gill Livingston, has built a body of useful new knowledge about who abuses, what may drive them to abuse, how they abuse, the extent to which they are willing, in their desperation, to talk about why they might abuse, and their worries about the possibility of crossing a line from frustration to abuse. Following the dictum of a famous philosopher who worked for much of his life just a few hundred meters from UCL, they acknowledge that the point of developing an understanding of the world is just one stage in the process of trying to change it for the better. Their paper (Cooper et al., Reference Cooper, Barber, Griffin, Rapoport and Livingston2016), which has been chosen as paper of the month for this issue of International Psychogeriatrics, reports on the outcome of an important randomized controlled trial (RCT) which aimed to see if a psychological intervention which is effective in reducing depression and anxiety amongst carers of PWD might diminish abuse levels in those randomized to the intervention. The trial was rigorously conducted with a large sample of participants (260 in total) and outcomes were measured over two years. The intervention made no difference to rates of abuse, but at least those who were not abusive at baseline did not become abusive over the ensuing months, which has happened in other longitudinal studies.
Because it would have been unethical not to intervene where evidence of abuse was significant, the research team discussed such abuse with carers and then alerted clinical teams involved with the patient–carer dyad. This may have affected the study's outcome, but it is hard to see how the UCL staff could have done otherwise. Perhaps as the authors suggest, a lack of increase in abusive behavior over time may indeed be evidence of some efficacy for the total intervention package and shifting the focus to encouraging professionals to discuss abusive behavior and to support those who are abusing or at risk of doing so may be the way to go. Future RCTs like this may be difficult or impossible to conduct, but this seemingly negative study has helped the field to progress quite significantly.
Conflict of interest declaration
David Ames has undertaken joint research with Claudia Cooper and Gill Livingston, has published articles with them as a co-author, and was a guest of Professor Livingston on sabbatical at UCL in the first quarter of 2014.