Preventing & Responding to Elder Abuse: Challenges and Opportunities

1. Challenges and Opportunities: Preventing and Responding to Elder Abuse, Neglect and Financial Exploitation Office of Justice Programs: Minnesota Victim Assistance Academy October, 2019 Bloomington, Minnesota

2. Welcome! This morning, I hope to: • Review definitions and statistics related to elder abuse • Discuss Minnesota’s role in intervention and prevention • Review risk and protective factors • Explore reporting barriers and common dynamics between victims and perpetrators • Share additional resources

3. Minnesota Elder Justice Centerwww.elderjusticemn.org Mission: Mobilizing communities to prevent and alleviate abuse, neglect, and financial exploitation of elder and vulnerable adults Focus on: • Public Awareness • Professional Education • Public Policy • Victim Services

4. Victim Services at the Minnesota Elder Justice Center A cornerstone of MEJC’s work is direct victim services. We work to provide victim-centered services: • Supportive Listening • Safety Planning • Systems Navigation • Domestic Violence Support • Economic Advocacy • Community Support Groups • Limited Legal Representation

5. Elder Abuse: toward a definition… • In general, elder abuse is any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to an older adult. • Defined by age, relationship, type of abuse • Victims are often on a continuum from active to having various medical, cognitive, mobility issues • 2/3 of perpetrators of elder abuse are family members, trusted individuals and/or caregivers

6. Elder Abuse Sexual Assault Domestic Violence Abuse in Later Life as a Subset of Elder Abuse, Domestic Violence, and Sexual Assault NCALL, OVW (2012)

7. Prevalence • 1,000,000 – 2,000,000 adults in later life in U.S. are victims of abuse1 • 1 in 10 persons over the age 60 are victims of elder abuse2 • Victims of elder financial abuse in U.S. lose close to $3 Billion each year3 1National Center of Elder Abuse:2005 Elder Abuse Prevalence and Incidence 2 National Institute of Justice: Elder Abuse as a Criminal Problem 3Blancato, Robert: Violence Against Older Women and The Elder Justice Act; 3/04/12

8. Prevalence • Family members are most common perpetrators of financial exploitation of older adults (57.9%).1 • And yet, 51% of news articles related to elder financial exploitation concern instances of fraud perpetrated by strangers.2 • Perpetrators of elder abuse most likely to be adult children or spouses.3 1Peterson, J., Burnes, D., Caccamise, P., Mason, A., Henderson, C., Wells, M., & Lachs, M. (2014). Financial exploitation of older adults: a population-based prevalence study. Journal of General Internal Medicine, 29(12), 1615–23. doi: 10.1007/s11606-014-2946-2 2Metlife Mature Market Institute. (2011). The MetLife Study of Elder Financial Abuse: Crimes of Occasion, Desperation, and Predation Against America’s Elders (PDF). 3Lachs, M., & Pillemer, K. (2015). Elder abuse. New England Journal of Medicine, 373, 1947–56. doi: 10.1056/NEJMra1404688

9. Elder Abuse as Domestic Violence: the call • Who is calling MEJC? • Primary victims account for 23% of calls last calendar year • 64% of individuals initiating contact with us are family, spouses, or friends • Example: Joe is calling to explain that his brother, Rick, lives with his mother, Mary: • Rick has been living with Mary for 15 years • Rick is habitually un- or under-employed • Mary and Rick have a “complicated” relationship which Joe describes as “toxic”

10. Elder Abuse: Under the Radar For every 1 case of elder abuse that comes to the attention of a responsible entity… …another 23 cases never come to light. Source: NYS Elder Abuse Prevalence Study; Weill Cornell Medical College, NYC Department for the Aging; Lifespan; (2011)Slide courtesy of Life Long Justice

11. Growth of Older Adults • The Administration on Aging expects that by 2030, the U.S. population over age 65 will have doubled from 2000, with older adults representing 19% of the population.

14. Types of Abuse • Domestic Violence Late in Life • Physical abuse • Emotional abuse • Sexual abuse • Spiritual abuse • Financial Exploitation • Neglect • Self Neglect

15. The Call • Why has Joe chosen this moment to call MEJC? • An internal point has been reached in the relationship that has pushed this person to research solutions and to reach out to find help • Joe wants to tell me that something is wrong in Mary’s life • The starting point in “Joe’s” explanation is almost always financial exploitation

16. The Gateway Report • Financial Exploitation • Can be explained • Can be traced • Concern for Mom’s future care • Closely tied to other forms of abuse: polyvictimization • Joe, Mary, and Rick’s situation

17. What is financial exploitation, again? • Using a POA to access another’s resources for anything other than the principle’s well-being • Draining or inappropriately using “joint” bank accounts • Taking loose money in the house • Checks made over, written out to cash, etc. • Reverse mortgages or home loans • Getting a credit card in another’s name/misusing credit • Changes in title of real property or stocks • Selling own car; using victim’s care to the exclusion of victim’s ability to use it • Living rent-free • …and many more!

18. Why does financial exploitation matter? • The paper trail • Gateway abuse • Polyvictimization

19. Abuse Warning Signs • Physical – bruises, pressure marks, broken bones, burns, weight loss, malnutrition, poor hygiene, signs of restraint, infections, pain or bleeding in genital areas, over- or under-medication • Financial – abrupt transfers, changes to Power of Attorney or will, unpaid bills, valuable items removed from elder’s home • Spiritual – elder prevented from participating in ceremonial and spiritual events • Changes in Behavior – strained relationships between caregiver and elderly person, withdrawal from normal activities, unusual depression, change in alertness

20. Warning Signs Present for Older Victims • Isolation • Hints at being alone or afraid (or fearful in presence of particular person) • Repeated “accidental” injuries • Presents as “difficult” patient or client • Has vague, chronic complaints • Is unable to follow-through on treatment plans; misses appointments* *http://www.ncall.us/sites/ncall.us/files/resources/Victim%20Centered%20Safety%20Planning-2014.pdf

21. Perpetrator Profile / Signs • Provides conflicting explanations about the older adults injuries • Deliberately isolates victim • Controls and dominates • Portrays self as victim; or as the only caring person in the older or vulnerable adult’s life • May be charming and helpful toward professionals OVW, FLETC and NCALL training (2012)

22. Duluth Power and Control Wheel Domestic Abuse Intervention Project 202 East Superior Street Duluth, MN 55802 218-722-2781 • www.duluth-model.org NCALL, OVW (2012)

23. NCALL Abuse in Later Life Power and Control Wheel Wheel adapted with permission from Domestic Abuse Intervention Project, Duluth, MN in 2006. NCALL, OVW (2012)

24. Similarities • Threatens • Isolation • Use of family member • Power and control in the center of the wheel • Physical and sexual abuse on the outer rim NCALL, OVW (2012)

25. Differences • Using “Family Members” rather than “Using Children” • “Uses Privilege” rather than “Uses Male Privilege” • “Targets Vulnerabilities and Neglects” • “Denies access to spiritual and traditional events” • “Ridicules personal and cultural values” • “Emotional Abuse” and “Psychological Abuse” as inner spokes NCALL, OVW (2012)

26. Common Abuser Justifications • Blames the victim • “She’s clumsy.” (it was an accident) • “He didn’t do what I wanted.” (victim’s behavior) • “She started it.” (mutual abuse) • “He hit me when I was I child.” (learned behavior) • “He is too difficult for me to care for.”

27. Reframing Caregiver Stress and Abuse • Everyone experiences stress, but most do not abuse. • Abusers target only the older adult – not others. • Abusers tend to use caregiver stress as an excuse to create sympathy for themselves. OVW, FLETC and NCALL (2012)

28. Outcomes if Perpetrators’ Justifications Are Believed • Offenders are not held accountable • Message to abusers: no consequences • Offering services to address perpetrator stress, anger or substance abuse doesn’t address power and control or greed as motive • Victims may not seek help again • Victim safety is not addressed OVW, FLETC and NCALL (2012)

29. Minnesota’s Statutory Protections • Definition of “Vulnerable Adult” • Criminal Neglect • Financial Exploitation

30. Minnesota’s Statutory Protections • Vulnerable Adult: Minn. Stat. 626.5572 • Categorical and Functional Definitions • Inpatient at a Facility • Receives services at or from a facility • Receives services from a home care provider, or person that acts as a personal care/medical assistant • Possesses a physical, mental, or emotional infirmity/dysfunction

31. Minnesota’s Statutory Protections • Criminal Neglect: Minn. Stat. 609.233 • Intentionally permit conditions that allow abuse/neglect • Knowingly fail to provide food, clothing, shelter, health care, supervision • Felony: substantial harm; or extended time

32. Minnesota’s Statutory Protections • Financial Exploitation: Minn. Stat. 609.2335 • Breach of fiduciary duty - ie Power of Attorney • Use of property for something other than the benefit of the vulnerable adult • Fails to use property for benefit for vulnerable adult • Deprives vulnerable adult of financial resources

33. The Unique Needs and Perspectives of Older Victims and Survivors • Note that many older adults do not prefer to use the terms: “victim” or “survivor” and do not perceive that those terms apply to their situations • For our purposes, we will use these terms interchangeably, but some older adults may prefer that we simply speak to their situation individually whenever possible.

34. The Unique Needs and Perspectives of Older Victims and Survivors • The impact of age and stage of life: Service between ages 50 and 62 A matter of economics: income and earning vs. ageism; eligibility for benefits

35. The Unique Needs and Perspectives of Older Victims and Survivors • The impact of relationship: • When the perpetrator is a child or grandchild • When the perpetrator is an intimate partner

36. The Unique Needs and Perspectives of Older Victims and Survivors • The physical and emotional impacts of sexual abuse on older victims: Sexual abuse and older victims • Increased morbidity, premature mortality experienced by victims of all forms of abuse* *Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998; Dong, Simon, et al., 2009; Dong, Simon, Rajan, et al., 2011; Yan & Tang, 2001; Higgins & Follette, 2002; Dong, Simon, and Evans, 2012. See: http://gerontologist.oxfordjournals.org/content/early/2013/11/18/geront.gnt139.full

37. The Unique Needs and Perspectives of Older Victims and Survivors • Understanding the impact of historical trauma for older adults • History of oppression • Historical gender roles • History of violence

38. What can we do when we suspect abuse is happening? • Share our suspicions – talk to someone – make a report… • To emergency services: 9-1-1 • To law enforcement • To adult protection • To a Tribal Court or other court • To an advocacy organization

39. Reporting Barriers for Older Adults • Ageism impacts older adults’ reporting experiences related to abuse and other forms of maltreatment • Attitudes about older adults’ sexuality • Taboo, resistance or discomfort related to discussions of “private” matters (family relationships, financial issues) • Use of coded language; uncertainty related to terminology

40. Barriers to Reporting • Cognitive impairment • Denial • Fear (of escalation, isolation, destruction of property, injury to pets, death) • Incredulity of others • Pride and desire to maintain autonomy • Shame or embarrassment

41. Barriers to Reporting • Desire to protect relatives • Cultural boundaries • Attitudes toward/experience with technology • Belief that institutional care is only alternative • Depression and/or grief • Feeling that abuse is somehow appropriate response to victim’s own action recently or prior in life See: http://elderabuse.Stanford.edu/screening/pt_barriers

42. Case Studies: • Lonny and Kayla • Fred and James • Miriam and Jerry

43. Victim Service Response • First question: what can we do to meet this person where they are? • Victim centered advocacy is grounded in two principles: Empathy and humanity • Recognize and validate the caller’s experience • Focus on the primary victim • Emergency/immediate needs, mid-term needs, long-term needs • Address the humanity of the caller: are their needs being met for this long-term work?

44. Victim Service Response • Strategies for working with victims of elder abuse • Clarify and ask open-ended questions without judgment • Recognize the experience of the person contacting you • Focus on the goals and well-being of the victim • Speak realistically about broad options • Mary, Joe, and Rick • Ask Joe questions without judgment; hear him out to the extent possible • Talk about Joe’s goals, the pivot to Mary: • Mary’s relationship with Rick • Rick’s needs/problems • Mary’s needs and her own wishes

45. Victim Service Response • Focus in on each individual component of the solution—the Broad Plan: • What are Mary’s: • Immediate safety needs • Short-term goals • Long-term options • Be realistic and prepare them for how each resource can be part of the broader plan

46. Systems Navigation • What is systems navigation? • The complex world of vulnerable adult assistance includes: • Legal representation (private or public) • Domestic violence programs • Consumer-based advocacy (AARP, MN Attorney General, OJP, etc.) • Facility-related responses (OHFC, Ombudsman) • Guardianship/SDM models • Adult Protective Services • …and more!

47. Soft Advocacy • Focus on the soft-advocacy possibilities • Listen • Involve community • Make conversation • Offer to help • Be present • Be gentle but persistent

48. Quick review of available resources: • The Ombudsman’s Office • Adult Protective Services /MAARC • OHFC • Social Security Administration • Courts • Banks • Consumer Financial Protection Bureau • Other advocacy organizations…

49. Long Term Care Ombudsmen • Long Term Care Ombudsmen advocate on behalf of the residents of Medicare/Medicaid licensed nursing facilities, care homes and residences. • Every state has a full time State Ombudsman; many (like Minnesota) have regional offices • Ombudsman duties to elder clients are bounded by federal law

50. The Minnesota Adult Abuse Reporting Center Mandated reporters are professional or a professional’s delegate while engaged in the provision of: • Social services • Law enforcement • Education • Direct care • Licensed health and human services professionals  (MS 214.01, subdivision 2) • Employment in a licensed facility • Medical examiner or coroner activities