The strange case of elder mistreatment and public perception

A hint that mistreatment is related to wider social attitudes can be found in a series of findings showing that while it is assumed to be more widespread than scientific studies have shown, the response does not correspond with this estimated need. A series of studies have now shown that elder mistreatment (abuse and neglect) affects between 2% and 5% of the older population (see National Centre for the Protection of Older People, at www.ncpop.ie, for a digest of the most recent national reports). However, the general public appears to see the problem as much more widespread. For example, a study conducted for the UK BBC (Hussein et al., Reference Hussein, Manthorpe and Penhale2007) found that 55% thought “a great deal” of mistreatment took place with respondents estimating that 11.4% older adults suffered from physical abuse, 4.9% from stealing (financial), 0.8% from sexual abuse, and 20.7% from humiliation (psychological). The Eurobarometer (2008) found that 47% of European Citizens “believe that poor treatment, neglect, and even abuse of dependent older people are widespread.” This varies from 86% in Romania to 17% in Cyprus and to an European average of 46%, with Sexual Assault 31%, Physical 52%, Psychological 64%, Abuse of Property 67% being the “level of risk you think dependent older people are exposed to.” This overestimation goes hand in hand with evidence of under-reporting and under-responding. In 1998, the US National Elder Abuse Incidence Study found that one in four cases goes unreported (NEAIS, 1998). Hawes (Reference Hawes, Bonnie and Wallace2003) found that 33% of agencies estimated a situation of under-reporting, while 52% thought there was over-reporting and 15% “did not know.” The UK Prevalence Study (O'Keeffe et al., 2007; Biggs et al., Reference Biggs, Manthorpe, Tinker, Doyle and Erens2009a) reported that, when scientific estimates were compared to Adult Protection caseloads, only 3% of incidents were being picked up. At the time of writing, the most recent study, from New York state (Lachs and Berman, Reference Lachs and Berman2011), reported that incidence was 24 times greater than pick up: “the findings of the study point to a dramatic gap between the rate of elder abuse events reported by older New Yorkers and the number of cases referred to and served in the formal elder abuse service system” (Lachs and Berman, Reference Lachs and Berman2011). In other words, while mistreatment is generally perceived to be widespread, there is a significant absence of responding. A parallel problem that has dogged both the understanding of mistreatment and rights discourse has been definitional inflation. Ivison (Reference Ivison and Bell2010) complains that “anything good and desirable is translated into a human right” (Reference Ivison and Bell2010), while Biggs and Haapala (Reference Biggs and Haapala2010) report that discourse on mistreatment has allowed “extensive scope to interpret a wide spectrum of events as instances of mistreatment, to a degree which may render the term meaningless” (2010). This set of anomalies poses at least two questions. How an almost complacent assumption that older age can lead to mistreatment can be connected both to ageism and to a human rights perspective. And, how relations between these three cognate concepts can be clarified?

Seeking conceptual clarity: elder mistreatment and human rights

In circumstances where a phenomenon is so contested, it does not seem unreasonable to begin by restricting the field of view to make the object of study both manageable and subject to critical analysis. This is what has happened to the modeling of mistreatment. Following clarity of definition, reconnection to wider social processes becomes a priority and the ways that various researchers have attempted this will be a key object of this paper.

Attempts to restrict the definition and use of terms such as mistreatment and rights have moved in very different directions. Perhaps the most considered attempt to restrict definitions of mistreatment has been undertaken by the US National Research Council (Reference Bonnie and Wallace2003). The Council aimed to define mistreatment as distinctive and testable, by drawing boundaries around what could legitimately be called abuse or neglect. Mistreatment, they argue, constitutes: “intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder” . . such that. . “some injury, deprivation, or dangerous condition has occurred to the elder and that someone else bears responsibility for causing the condition or failing to prevent it” (National Research Council, Reference Bonnie and Wallace2003).

The keynote of this attempt to mark the boundaries of what might legitimately be called elder mistreatment is that it places it within the realm of interpersonal relationships. Specifically, abuse and neglect appear when a “trust relationship” has been violated. It, therefore, excludes cognate issues, such as self-neglect, self-harm, crimes by strangers and also wider social phenomena such as age discrimination and social ageism. It includes relations that occur in care settings, which include formal professional help and informal caring by families and friends. There were good pragmatic, if contextually determined, reasons for the Council to do this that included variation between state legislatures and in order to retain a welfareist rather than an exclusively criminal justice-based institutional perspective. Mistreatment has increasingly been made manageable in terms of researchable risk factors arising between victims, perpetrators, and types of mistreatment. Boundaries had been clarified, at least within the scientific community, by positioning mistreatment as arising at the level of human interaction itself contingent upon the individual characteristics of participants.

Ivison's (Reference Ivison and Bell2010) review of human rights draws attention to a different trajectory, one concerned with the tension between universal rights and the particular needs of specific groups. Article 1 of the Universal Declaration of Human Rights (UN, 1948) states that “all human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act toward one another in a spirit of brotherhood.” Since the original declaration, the history of rights discourse has reflected progressive recognition of the special circumstances affecting specific groups such as children, women, or migrant workers. Older people have recently been identified as such a potential group (Doron and Apter, Reference Doron and Apter2010), with the promise that a human rights discourse will move debates about aging on from “a problem requiring functional solutions” to “an issue of justice and dignity” (Mégret, Reference Mégret2011).

The location of the problem, and therefore, the means for remedy vary markedly between this and the boundary making around mistreatment identified above. Sepulveda and Nyst's (Reference Sepulveda and Nyst2012) report is particularly interesting in this regard because it attempts to link human rights to forms of social protection. “Individuals are rights holders,” they state, “that can make legitimate claims, and states and other actors are duty bearers that can be held accountable for their acts or omissions” (Sepulveda and Nyst, Reference Sepulveda and Nyst2012).

These authors identify four advantages and follow throughs, including: a framework for practical action, establishing a clear legal duty upon states to ensure enjoyment equally and without discrimination, providing an analytical tool to examine the different levels of obligations for states, and, providing political impetus and adding legitimacy. Taken together, these advantages identify boundaries drawn to include individual–state relations that are legally expressed. They, therefore, emphasize macro level obligations rather than interpersonal ones.

In the context of older people, Morgan and David (Reference Morgan and David2002) see human rights “operating as a baseline for establishing the underlying values for aging policies and by linking older person's concerns with the other segments of society” (Morgan and David, Reference Morgan and David2002). While Tang (Reference Tang2008) claims rights legislation can act as a baseline for establishing values. She points out that General Comment 6 of UNCESCR, paragraph 17 states that “in times of recession and restructuring of the economy, older persons are particularly at risk” (Tang, Reference Tang2008), and that states have a duty to protect them. Rights, then, are linked to sociohistorical circumstances, and therefore, to the identification of both social practices such as ageism and to the recognition of social problems such as mistreatment. Both Mégret (Reference Mégret2011) and Doron and Apter (Reference Doron and Apter2010) agree that as biomedical and biological explanations of aging and disability give way to ones based on social construction, it is almost impossible to understand the position of older persons disconnected from wider sociocultural and economic trends. A distinction is made between the consequences of bodily aging and old age as viewed socially as foci for rights discourse: “it is not old age” then “that renders certain rights hard to enjoy, but a particular conception of old age that would deny the full enjoyment of their rights to the aging” (Mégret, Reference Mégret2011).

Mégret (Reference Mégret2011) goes on to identify nine priority areas linking old age and human rights. What is striking about them from the perspective of this paper is that his examples often arise in the private sphere relating to interpersonal behavior, or transitional spaces such as institutional care, even though they refer to universals such as the right to life, freedom from torture and inhuman treatment, (both of which refer to interpersonal abuse), and freedom from arbitrary detention, to privacy, and to family life (institutional abuse). Certainly, this link is being made by advocates of a Convention on the Rights of Older People who use both ageism and vulnerability to abuse, deprivation, and exclusion as reasons for the specific Convention itself (Help-Age International and Human Rights Watch, 2012). In this context, Shankardass (Reference Shankardass2012) links problems of access to literacy and financial literacy, as rights to education, which directly influence the likelihood of mistreatment.

From a social perspective, and putting aside the view that it is simply an instance of abnormal pathology, mistreatment has been seen as either a dysfunction within a social system that is otherwise sound or as a manifestation of underlying social mechanisms (Biggs and Lowenstein, Reference Biggs and Lowenstein2011). The first would tend to push toward what rights discourse refers to as an implementation gap in which the problem is recognized but local legal instruments are not fully used or institutions are not in place; and the second, a normative gap in which the problem is not recognized in relation to a particular group, either in the legislature or as a social construction (Fredvang and Biggs, Reference Fredvang and Biggs2012). For older people to be free of mistreatment the state should create conditions where abuse and neglect need not take place, in other words, where interpersonal relationships do not occur in the context of ageist prejudice. A problem with the conceptual directions taken by debates on mistreatment and those on rights is that one has prioritized the private sphere and the interpersonal and the other has emphasized the public and the impersonal. If we want to understand the relationship between personal and social elements of mistreatment we are faced with the task of reconnection.

The relationship between ageism and civil rights is long standing and is reflected in Butler's (Reference Butler1975) association between ageism and other forms of social injustice. “Ageism,” he says, “can be seen as a process of systematic stereotyping of and discrimination against people because they are old, just as racism and sexism accomplish this for skin color and gender. . . . Ageism allows the younger generations to see older people as different from themselves, thus they subtly cease to identify with their elders as human beings’ (Butler, Reference Butler1975).

Key to this relationship is the point raised by Ardendt (Reference Ardendt1973) as “the right to have rights,” of belonging with dignity to some kind of organized human community. The price of inclusion, being as often as not, the imposition of an age group's priorities onto those of a less powerful one, such that “if one ends up on the wrong side of this equation, one lives a life according to principles that are out of kilter with ones own life priorities” (Biggs, Reference Biggs, Daatland and Biggs2004). More recently Phillips (Reference Phillips, Ajrouch and Hillcoat-Nallétamby2010) has expanded the role of “othering” as a means of discounting common aspects of humanity: “every individual has the potential to experience discrimination or prejudice based on their age if they live long enough. It produces an “othering” effect that lumps all those considered old into a category defined, first, as different and, second as inferior” (Phillips, Reference Phillips, Ajrouch and Hillcoat-Nallétamby2010). The notion of othering, as a rigid boundary between self and other based on age dominance and exclusion from a common human community, would appear to link interpersonal relationships, relations to the state, and any denigration of old age. It also begins to sharpen a focus on the relationship between social factors, mistreatment, and the boundaries between them.

Modeling social factors as permessors for mistreatment

Attempts to identify the relationship between mistreatment and wider social factors, can be found in some of the earliest academic writings on the subject, such as the environmental press model in the United States by Ansello et al. (Reference Ansello, King, Taler, Pillemer and Wolf1986), the sociological approach taken by Phillipson (Reference Phillipson and Glendenning1993) in the UK and the Public Health Agency of Canada's (1994) nesting of individual factors within family, community, and cultural ones, respectively. Perhaps the first model that provided a detailed description of the relationship is Schiamberg and Gans’ (Reference Schiamberg and Gans2000) “social ecological framework” designed to examine elder mistreatment undertaken by adult children. Here, different levels of influence are embedded, box within box, into a series of increasingly wider systems: Micro (Abuser – victim characteristics), Meso (relationship factors), Exo (degrees of social inclusion, security, and embeddedness), and Macro (cultural and governmental) in order to understand contextual risk factors. The model was used as a starting point for the US National Research Council's (NRC) model building in 2003 (National Research Council, Reference Bonnie and Wallace2003) and has been further expanded to include cultural identity categories (Parra-Cardona et al., Reference Parra-Cardona, Meyer, Schiamberg and Post2007). While the social ecological framework embeds different layers of potential analysis, one within another, it is less strong on how connection and influence takes place. The NRC model expands on this basic framework by trying to understand elder mistreatment as a system, identifying particular elements and positing interactions between them. The model identifies four resulting outcome variables: physical and emotional health; recurrent, episodic, or crisis-centered events leading to harm; the durability of the care-giving relationship; and degrees of security and trust. Risk of mistreatment is expected to vary depending upon the contents of these different elements. Biggs et al. (Reference Biggs, Stevens, Tinker, Dixon and Lee2009b), as part of a UK Department of Health study, examined the relationship between what they called the “fourth variable” in identifying risk in an “integrative model” of interactions associated with mistreatment. In addition to typologies, institutional culture is added to victim and perpetrator characteristics in order to identify the likelihood of occurring. Here, the concept “institution” can be used both in the sense of specific organizations and in the broader sociological sense, as in “the institution of the family.” A Venn diagram of interlocking circles, embedded in a field of wider cultural values, is used to identify specific relationship boundaries and the interaction between these three forms of risk. The authors recognize the distinctiveness of different types of mistreatment, for example, sexual or financial abuse, and argue that each is given a particular cultural inflection depending upon the context in which it occurs. This also determines the likelihood that mistreatment will be “made visible” and actually recognized as a form of abuse. These researchers agree with Goergen (Reference Goergen2002) who states that it can be more difficult to distinguish a single perpetrator, or responsibility that lies behind a form of mistreatment in organizational settings, a paradox given the fact that the system is more explicitly drawn, but arises from the possibility that organizational cultures “permit” certain actions or include routines that inhibit personal dignity. Organizational characteristics, which include social ageism and the degree to which that age is characterized, for example, as a medical, social, or rights problem will influence what helping professionals recognize and the perceived appropriateness of particular remedies at hand.

Each of these models arise primarily from academic research and tend themselves to approach the problem as one of identifying risk factors that make certain forms of action more or less likely to happen. Taken together, they also mark a conceptual trajectory that starts by identifying different levels of analysis, identifying the links between them, and a move away from identifying boundaries per se to an examination of the processes that mediate them. If, in other words, the relationship between levels and risk comes to be seen as a process of boundary management, then the quality of the boundary becomes an important factor in how mistreatment itself comes into being.

Having identified simple descriptions of contexts: the individual, the family, the community, and society; to interactions and risk factors occurring within and between these contexts; thinking has now progressed to examine the quality and processes that occur at the boundaries between those contexts that have been identified.

Making sense of the boundaries: looking for connective concepts

In this attempt to combine the intuitively related and much associated concepts of mistreatment, rights, and social ageism, it at first appears that at least two important discourses, those of mistreatment and of rights, have been traveling in different directions. While the former has increasingly focused on interpersonal relations, the latter has focused on the role of the state. And while ageism has a nebulous ability to make a conceptual link between the two, this link has more often been described than explained. A way out of this somewhat frustrating situation, it is argued, might be to pay closer attention to the points of connection and boundaries between them. And here, rather than explain the nature of boundaries themselves, their permeability, rigidity, proneness to othering, and binary opposition (see, for example, Gold and Klein, Reference Gold and Klein2004), the current paper will be used to explore a number of concepts that may give insight into their nature in the particular context of old age. Two examples are explored below: those of ambivalence in intergenerational relations and the concept of dignity.

The quality of ambivalence has been particularly associated with intergenerational relations and old age. Ambivalence can be structural and emotional. Structural ambivalence has been described by Connidis and McMullin (Reference Connidis and McMullin2002) as arising from contradictions within existing social structures, made manifest in interaction and produce “simultaneously held opposing feelings or emotions that are due in part to countervailing expectations about how individuals should act.” If an elder is expected, for example, to behave in a dependent manner when feeling the capacity to be independent, or independent when being in need of support, these create emotional and interpersonal conflicts which themselves depend on social expectations to be passive or active in old age. Emotional ambivalence may be particularly near the surface in families due to “the simultaneous existence of positive and negative sentiments in the older parent–adult child relationship” (Pillemer et al., Reference Pillemer and Suitor2008). It may occur as a result of multiple relations within families, tensions over dependency and interdependence, and through changed status. Managing the boundary between parties, as explained by Biggs and Lowenstein (Reference Biggs and Lowenstein2011) “requires the simultaneous holding in mind of two seemingly incompatible aspects of the same thing. . . . It is necessary to act knowingly, by being open to the possibility that one can feel both conflict and solidarity, love and hate in the same space” (Biggs and Lowenstein, Reference Biggs and Lowenstein2011). The degree of empathy present in the interaction, an ability to place oneself in the position of the age-other, is viewed by these authors as a key component of successful interaction. The permissibility of mistreatment would be seen, here, to vary depending on the structural contradictions shaping the context within which boundary transactions take place and the capacity of that system to contain ambivalent relations that arise.

Stevens et al. (Reference Stevens, Biggs, Manthorpe, Dixon and Tinker2013) have taken the integrative approach further, explicitly linking mistreatment, dignity, and rights approaches. Dignity and mistreatment are depicted as being alternative descriptions of the same dimension of care, with human rights in later life forming an important factor affecting the balance between the two. What tips the scales in favor of mistreatment may be a form of “malignant positioning,” an attack on selfhood which does not necessarily qualify as mistreatment, but acts as a permessor for reduced dignity and increased abusive behavior. An operational model, developed in The Dignity and Older Europeans Study (2001), articulated how different forms of dignity were threatened by certain kinds of treatment, which Stevens et al. (Reference Stevens, Biggs, Manthorpe, Dixon and Tinker2013) propose can become mistreatment. The model identifies dignities of merit, moral stature and identity, which in turn generate self-respect, and while not using the discourse of rights per se, produces a very close to echo. Elder mistreatment becomes, here, a radical example of restriction of potential. And as such suggests interesting associations with the work of Nussbaum (Reference Nussbaum2003) on capabilities and care, where rights are interpreted as “what people are actually able to do and to be.” Degrees of dignity might best be thought of as an embedding feature which makes mistreatment more or less likely to occur. Thus, a relative lack of dignity may be permissive of institutional practices that approach mistreatment. The number and frequency of incidents lacking dignity will, at a certain threshold, constitute mistreatment. The degree to which ambivalence can be contained and negotiated solutions found, would mark a dignifying of self and other and the hope that capabilities can be achieved for each party.

Rather than seeing dignity and ambivalence as conceptual contents, then, it might be more helpful to approach them as qualities of a boundary transaction that arises at the intersection of societal, interpersonal, and individual relations. They should help us, in other words, not so much to fill a conceptual box, but chart the type of relationship that exists between different levels of explanation. A move here from the identification of categories to the quality and relationship transactions across boundaries might, at a practical level increase our understanding of issues such as willingness to disclose mistreatment, the possibility of trust, and an ability to negotiate sustainable solutions. They tell us what “othering” and belonging might be like.

Concluding comments

Three related arguments have emerged from this paper. First, that in order to understand the relationship between rights, ageism, and mistreatment, we need to refocus on the quality of the boundaries between them in addition to their contents. Second, that the connective quality of boundary relations form an important part of understanding just how abusive situations operate. Third, examining the degree of ambivalence and dignity associated with boundary transactions may form connective concepts between the three existing discourses.

The relationship between mistreatment, ageism, and human rights, seems at first glance to be logical. A rights approach assumes a level playing field (all humans have the same basic rights), then if there is a context that is biased toward one group (social ageism) rather than another, there is some sort of yardstick other than social convention, on which to make a judgment of legitimacy or violation. If, also, an ageist environment increases the likelihood of extreme negative behavior toward the disadvantaged group, then there is a link between taking a rights approach to intergenerational relations and the likelihood of mistreatment taking place. However, the relationship is also one that is marked by emotion and value, and to understand how older persons can be excluded to the extent that they become targets of mistreatment, the quality of the boundary between society, self and other needs to be critically assessed. What becomes clear is that this relationship is by no means simple. Ivison (Reference Ivison and Bell2010) says that relationships, rights, and duties in rights-speak must be justified such that others accept the claim or duty. The right holder also has a choice to demand or waive their right in certain circumstances. Mistreatment happens in the context of adult–adult relationships where autonomy (as an element of dignity) plays as great a role as a state's duty to protect. Further, if the state changes social expectations by withdrawing services that change a choice to care to a duty, it is difficult to maintain too rigid a boundary between changing interpersonal relations and a wider social context. There are many examples, unfortunately, that militate that we should find the tools to re-establish the relationship between the personal, the interpersonal, and the social. Looking at boundary negotiations allows the reintroduction of ambiguity and ambivalence into our thinking about any relation between mistreatment, ageism, and human rights. Hopefully, it will help us to manage such boundaries in this age of complexity.

Conflict of interest

None.

Description of authors’ roles

Both authors have contributed to writing the paper. S. Biggs drafted the majority of the paper, I. Haapala added valuable detail, and both authors approved the final version.