Last reviewed 18 September 2018
Not all carers are invariably caring. Jef Smith tells one story.
An elderly widow lived alone but depended heavily on visits from her son who has a house nearby. From the son’s point of view, she was not an easy person to help. She was critical of many of the things he did, reflecting the poor relationship they had from his childhood. Her health was troublesome. She complained of numerous aches and pains, but in the son’s view did little to help herself, for example, often refusing to consult her GP, taking her medication erratically, and not looking after her diet.
The son became progressively frustrated with her ingratitude and cantankerousness. When she began to get confused and forgetful, he started to get angry. One day, she mislaid her door keys; when they were eventually found, he announced despite her protests that he would keep them in future and that she could go out only with his permission. His next step, perhaps because he was fearful of her telling other people how he was treating her, was to forbid visits by her friends. As time went by, the son’s control of his mother’s daily life and activities became less and less justifiable as a rationally-based if extreme response to her behaviour and something more like — what shall we call it? — psychological abuse.
We know the basic facts of the case thanks to another son. He maintained telephone contact with his mother, and initially also with his brother, but he lived several hundred miles away so was not able to take any realistic part in her care or even to visit more than occasionally. What he did manage to do was to report the matter to an elder abuse advice line and appropriate intervention by responsible bodies ensued.
I have deliberately told the story, to an extent, from the abusing son’s perspective to demonstrate that psychological abuse should not always be seen simply as the fate of innocent old people maltreated by sadistic or exploitative relatives. Some commentators indeed have used the term “interpersonal abuse”, stressing the two-way dynamics of abusing relationships. Some abuse between elderly spouses, for example — predominantly men on women, as one might expect — represents the continuation of a long pattern of bad feeling so that the histories of marital conflict and elder abuse merge. What was an unpleasant situation can be made much worse as the years advance through the increasing vulnerability of one partner, the burden of caring duties and the length of time people have to spend with each other (and to get on each other’s nerves).
In some instances, roles are reversed. Illness or disability means that a dominant spouse is weakened, both in terms of their capacity to act independently and their power within the relationship. The other partner, perhaps abused throughout a long marriage, gradually takes opportunities for retribution. A similar shift can occur when a young adult, abused by a parent during childhood, finds themselves in a position from which they now exercise a controlling authority.
Abuse, we know, takes many forms — physical violence, financial exploitation, sexual mistreatment and neglect among them — and psychological abuse is by no means the most common. The National Prevalence Study of Elder Mistreatment revealed that 0.4% of respondents reported psychological abuse, which is equal to the figure for physical abuse, below those for neglect and financial abuse, and double that for sexual abuse. These figures, however, are over a decade old and most commentators agree that they are probably underestimates. The charity Action on Elder Abuse (AEA) indeed reports that psychological abuse is one of the most common forms of abuse as measured by calls to its helpline.
It has been objected that the definition of psychological abuse is too vague to be functional, and it is often used more or less interchangeably with emotional abuse or intimidation. AEA characterises it as “identifying something — a person or an object — that matters to an older person and then threatening to endanger it unless the older person complies with demands”, and reckons that it is rare to find it in isolation from other forms of harm. Examples, it suggests, are denying the victim access to grandchildren, other family members or friends, preventing them from maintaining hobbies or taking part in activities, and refusing them access to money or possessions.
In extreme cases, a person may have details of their daily activities determined by their abuser, who controls, for example, when they are allowed to eat, sleep, wash or go to the toilet. This has been described as coercive control, a term originally coined for use in the context of domestic abuse to describe “a pattern of behaviour which seeks to take away the victim’s liberty or freedom, to strip away their sense of self”. Such behaviours, classified in law as duress crimes, can certainly be an element in the psychological abuse of older people as well as abuse between young or middle-aged partners.
Verbal abuse and constant criticism can be extremely damaging. Even more insidious behaviours include intimidating, humiliating or manipulating the victim, minimising whatever contribution they make, withdrawing from communicating with them, and withholding approval or refusing to be pleased, however compliantly they try to behave.
The signs of psychological abuse
It is obvious that a great deal of psychological abuse is never known about beyond the domestic situation in which it occurs. The victims characteristically lack power, confidence and perhaps even the ability to express themselves, while the perpetrators often have both the motive and the means to prevent their behaviour being witnessed. Given such a scenario, domiciliary care workers and their managers have a responsibility to be on the lookout for anything suspicious in their clients’ behaviour or lifestyle which would suggest psychological — or indeed any other sort of — abuse.
The relatively easy instances to spot are of course those where the abuse is overt. Not all abusers or those abused regard what is happening as particularly strange or reprehensible. In their eyes it may be no more than a continuation, or perhaps intensification, of what has been going on for many years. For a couple who have long been hostile to each other, the fact that one of them becomes dependent through dementia or other disability may be perceived as no more than an extra aggravating factor in an already very negative relationship. Many families who think of themselves as pretty normal appear seriously weird to a disinterested outsider, and psychological abuse which is objectively shocking may have become accepted and “normalised” by long practice. A social care worker, coming from a world in which quite different standards apply, may be powerfully positioned to intervene.
The more common situations in which abusers are concealing their behaviour present trickier problems of evidence, requiring great alertness from care workers. AEA suggests a range of pointers in the older person’s behaviour including unexplained fear, hesitation to talk openly, implausible stories to explain anxiety, and overeagerness to deny that anything is wrong. All of these carry a measure of ambiguity, but some of the other items on the AEA list of things to look out for are even more problematic. Sudden changes in behaviour, anger without an apparent cause, and extreme withdrawal could all have many other explanations. The clear implication is that agencies have a responsibility to give front-line staff opportunities to discuss their concerns knowing that they will be taken seriously and that further action will be initiated if necessary.
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 require providers to ensure that their service users are protected by taking steps to identify abuse and prevent it before it occurs and by responding appropriately to allegations. Articulating these responsibilities depends on local safeguarding arrangements, with which care agency managers must of course be familiar in detail and which should be incorporated into their own policies and procedures.
The lack of a comprehensive legislative framework covering elder abuse has often been deplored, so there is an onus on agencies to have well-maintained lines of communication into their local safeguarding mechanisms. Investigating instances of psychological abuse, actual or suspected, is likely to be especially complicated, and by definition time consuming.
There is still a great deal of work to be done on bringing elder abuse in general and psychological abuse in particular to wider attention. A study of Public Perceptions of the Neglect and Mistreatment of Older People, carried out by London University researchers in 2007, found that a quarter of the 1000 adult respondents — adults of varied ages — claimed to know an older person who had experienced abuse. Middle-aged people and women were more likely to report such knowledge, but the older people in the sample believed that there is less neglect and mistreatment of older people than did younger people. One explanation of this counter-intuitive finding is that a good deal of denial is going on; older people don’t want to think that they might be subject to mistreatment, far less to acknowledge that they are actually experiencing it.
A perhaps more radical interpretation came in research carried out in the USA, UK and Ireland which was reported in 2013 under the title Older People’s Conceptualisation of Abuse. This article criticised the debate around the definitions and interpretation of abuse as “professionally driven and therefore paternalistic and disempowering”. How can practitioners respond to such an allegation? It should certainly re-enforce the attempts of all concerned to listen to, involve in policymaking and take a lead from people with actual experience of being vulnerable, feeling fearful and experiencing maltreatment.
Points for action
Home care workers need to be alert to signs of psychological abuse in their service users and to pass on their suspicions to senior staff.
Supervisors and managers in home care agencies should ensure that their front-line workers have the training, confidence and time to spot evidence of psychological abuse and to share these with colleagues.
Agencies must have policies and procedures which cover psychological abuse and must maintain sound relationships and communications with local adult safeguarding bodies.