Moving the Field Forward: Elucidating the Nexus Between Elder Abuse and Trauma

ABSTRACT

At least 10% of older adults (age 60 and older) experience some form of elder abuse in a given year, with an additional 5% experiencing some form of financial fraud. However, conceptualizations of traumatic stress remain less well developed for elder abuse relative to other forms of trauma, such as child maltreatment and intimate partner violence. Incorporating a trauma framework into elder abuse research promises to deepen and expand our understanding of elder abuse, with the goal of preventing abuse and improving responses to older victims. This special section seeks to spur further research on the nexus between trauma and elder abuse. To frame the special section, this introduction describes current scholarship on this topic and multiple ways to enhance understanding of the nexus between elder abuse and traumatic stress in order to advance research, theory, and practice. The introduction offers an overview of three papers that apply trauma conceptualizations and related theories to distinct areas of inquiry: financial exploitation, criminology’s General Strain Theory, and historical trauma experienced by American Indian and Alaska Native populations.

KEYWORDS:

• Elder abuse
• traumatic stress
• financial exploitation
• polyvictimization
• general strain theory

At least 10% of older adults (age 60 and older) experience some form of elder abuse in a given year (Acierno et al., 2010), with an additional 5% experiencing some type of financial fraud (Burnes et al., 2017). Elder abuse can include financial exploitation, physical abuse, caregiver neglect, psychological abuse, and sexual abuse (CDC, 2016). Scholarship on elder abuse has advanced considerably in the past decade (Dong, 2017), though remains limited and lags behind other forms of family violence (Jackson, 2016). For example, conceptualizations of traumatic stress have informed practice, research, and theory development in the fields of child maltreatment (e.g., Briere, 1992; Kaehler, Babcock, DePrince, & Freyd, 2013) and intimate partner violence (e.g., Dutton, 1995) to a much greater degree than in the older adult and elder abuse literatures (for exceptions, see Brownell, 2019; Cook & Niederehe, 2007; Ogle, Rubin, & Siegler, 2013). Since 2009, multiple elder abuse intervention reviews decry the absence of scholarship guiding practice (e.g., Moore & Browne, 2017; Ploeg, Fear, Hutchison, MacMillan, & Bolan, 2009), although recent research empirically confirms older adults’ willingness to participate in trauma-focused research (Gagnon, DePrince, Srinivas, & Hasche, 2015).

There are multiple ways to enhance our understanding of the nexus between elder abuse and traumatic stress in order to advance research, theory, and practice. For example, the experience of elder abuse has only recently begun to be conceptualized as a traumatic stressor (Acierno et al., 2019; Jackson, in press; Ramsey-Klawsnik & Miller, 2017). Relative to other forms of trauma, such as child maltreatment (e.g., Hodgdon et al., 2018), little is known about the elder abuse characteristics that predict psychological, social, physical health, and other outcomes (Maschi, Baer, Morrissey, & Moreno, 2013). Likewise, there is a paucity of research on post-traumatic stress disorder (PTSD) among older adults (Cook & Niederehe, 2007; Cook & Simiola, 2017), despite the likelihood that the effects of elder abuse may lead to clinical levels of PTSD symptoms (Courtois & Gold, 2009). For reasons not yet well understood, the prevalence of PTSD appears to be lower for older (ages 65 to 90) compared to younger adults (Cook & Simiola, 2018).

Recent work by Ernst and Maschi (2018) as well as Ramsey-Klawsnik and Miller (2017) offer a powerful illustration of how a clearer understanding of the traumatic stress in elder abuse can inform the design of responses. Ernst and Maschi identified and eloquently applied six trauma principles to organizations to improve responses to elder abuse. Their general principles could be leveraged in combination with empirical data to refine approaches to intervening after elder abuse, where an understanding of the unique circumstances facing older adults is needed. For example, when abusers are older adults’ caregivers, then removing abusers can affect the older adults’ ability to age in place. The ability of scholars in the field to evolve trauma-informed best practices is inherently limited by the lack of empirical information on elder abuse. Indeed, the empirical base in the elder abuse literature remains small. For example, research on the effects of earlier-life traumas on older adults remains extremely limited (Cook & Niederehe, 2007; Cook & Simiola, 2017), relying heavily upon veteran populations (e.g., Cook & Simiola, 2018).

Theory development has also lagged in the elder abuse literature. Drawing on family violence and domestic violence theories has been useful, but only to a point given unique characteristics of some forms of elder abuse, such as financial exploitation. Only recently have scholars proffered new theories such as the integration of life-course development and stress-process theories that link life events and cognitive processes (Maschi et al., 2013). Importantly, scholars likewise have emphasized the importance of examining protective factors such as resilience, social support, self-esteem, optimism, and a supportive childhood family environment (Cook & Simiola, 2018; Maschi et al., 2013), but again, little empirical work exists in these domains.

The current state of research leaves many pressing research, theory, and practice questions unanswered. Theoretical growth in the field has been faster for conceptualizing offender behaviors and victim risk than victim outcomes. For example, scholars have pointed to the importance of theories related to family violence and white-collar crime (e.g., Jackson & Hafemeister, 2012) as well as social exchange theory (e.g., Lawler, 2001) to understanding the occurrence of elder abuse. These theories have the potential to advance understanding of the motivation for crimes (e.g., adult children who feel entitled to older adults’ resources in return for caregiving) and risk for abuse among particular older adults (e.g., with health problems), though may be less helpful in understanding victim responses.

To address gaps in the elder abuse field, Brownell (2019) offered the field a research agenda that called for research that extends feminist domestic violence work to older adult women; considers trauma-informed care following elder abuse; advances explanatory theories for elder abuse; and connects knowledge about complex trauma earlier in life to elder abuse. As illustrated by Brownell (2019), elder abuse scholars seem to be converging around the adoption of the SAMHSA (2014) definition of trauma: “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (Substance Abuse and Mental Health Services Administration, 2014, p. 7). The SAMHSA definition recognizes that elder abuse is a potential traumatic stressor. Not all elder abuse will lead to trauma-related distress and negative consequences; however, when and how trauma-related outcomes manifest among older adults has yet to be empirically clarified (Cook & Simiola, 2017; Ramsey-Klawsnik & Miller, 2017).

Identifying the conditions under which elder abuse leads to negative health (psychological, social, medical) and service outcomes and affects service use will require that the field continue to clarify and refine definitions of elder abuse as well as measurement. Key to this work will be determining what should be measured across studies to advance theory, research, and practice. For example, while empirical data point to the reality that elder abuse is often perpetrated by loved ones (Courtois & Gold, 2009; Straussner & Calnan, 2014), much remains to be elucidated about the role of the victim-offender relationship in victim health outcomes as well as engagement with law enforcement and services. Further, little is known about how previous trauma exposure – particularly interpersonal violence earlier in life – affects risk for and subsequent coping with elder abuse. Determining the degree to which trauma theories, such as betrayal trauma theory (Freyd, 1998), are relevant to understanding victims’ responses and risk will be important.

For example, betrayal trauma theory was initially proposed in the context of child abuse. The theory articulated that traumas can be characterized along at least two dimensions that affect outcomes (Freyd, 1998). One is life threat, well captured in the SAMHSA definition. The other is social betrayal, reflecting the degree to which the victim is dependent on the abuser. Articulating the characteristics and outcomes associated with abuse by someone on whom the older adult is increasingly dependent will be very important for the field. Where we know much about victim blame after traumas such as sexual assault, we have little empirical information about victim blame of older adults, particularly when abuse happens in the context of an ongoing relationship. Hints in the literature suggest that understanding victim blame and related concepts of shame and guilt will be important. For example, Olomi, Wright, Hasche, and DePrince (2019) found that nearly one in five older adults did not seek services after maltreatment allegations were reported to law enforcement because of guilt or shame.

With this backdrop, the goal of this special section of the Journal of Trauma and Dissociation is to infuse the field with new and innovative scholarship to enhance our understanding of the nexus between forms of elder abuse and traumatic stress. The special section includes three papers covering an array of topics relevant to Brownell’s (2019) persuasive call for work to advance research, theory, and practice.

The series begins with original research relevant to questions of measurement and theory from a team involving psychology and social work scholars as well as victim service providers (DePrince et al.). Over the past decade, a considerable body of research on financial exploitation has amassed (DeLiema & Conrad, 2017), though measurement of such exploitation has varied considerably (see Jackson, 2018). As communities nationally confront housing crises, DePrince and colleagues used police reports to examine exploitation of the older adults’ residences. That exploitation, they argued, has potential implications for outcomes, such as housing stability. Relocation for older adults is challenging under any circumstances (Castle, 2001), but the housing crisis resulting in few or no housing alternatives when relocation is necessary, may be life threatening in and of itself. Further, they introduced betrayal trauma theory to their discussion of findings, bridging to the trauma literature. This novel conceptualization of the housing crisis as a form of trauma in the larger context of financial exploitation provides an excellent example of the nexus between trauma and elder abuse.

Though the criminal justice discipline has been less well represented in the elder abuse field, with a notable exception (Payne, 2011), the special issue integrated criminology perspectives through the contribution of McKenna, Golladay, and Holtfreter. Specifically, McKenna et al. take an important step in applying General Strain Theory (GST), which has been so prevalent in the criminology literature, to the victimization of older adults. This set the stage for the authors to then eloquently weave trauma-informed principles into the well-established GST. Not only does this integration produce possibilities for theory, but the authors proffer a research agenda that could take decades to accomplish. Equally important, the authors suggest ways to develop trauma-informed interventions for older adults within the GST framework.

Finally, the impact of historical trauma among American Indian and Alaska Native (AI/AN) populations has been alluded to in the literature (Ramsey-Klawsnik & Miller, 2017). However, the interdisciplinary paper by Hamby, Schultz, and Elm provides a depth of understanding of this issue not previously seen. Hamby et al. apply two highly influential bodies of research, the adverse childhood experiences study (ACES) and polyvictimization, to AI/AN elderly population in the context of historical trauma to elucidate the true burden of trauma among this population. The authors balance this grim picture with an emphasis on the strength of the AI/AN community and the resiliency within the AI/AN population. Not only does the paper present a research agenda, but also opine on the implications for prevention, intervention, and policy.

As these papers illustrate, incorporating a trauma framework into elder abuse research promises to deepen and expand our understanding of elder abuse, with the goal of preventing abuse and improving responses to older victims. Framing the experience of elder abuse as a potential traumatic stressor provides a way forward in responding to these victims by changing the characterization from one of “What’s wrong with you” to one of “What has happened to you”. This simple rephrasing changes the dynamic from victim blaming to one of victim assistance and opens the possibility of advancing trauma-informed care (Bloom & Farragher, 2013).

We agreed with Cook and Simiola (2018), who recently concluded that trauma in older adults is less well-researched, under-recognized and under-treated. Filling this gap will require more than adding trauma measures to studies or trauma theories to models. Heeding the caution articulated by Becker-Blease (2017), a trauma-informed approach will require thinking about systems that underlie risk, harm, and potential for healing. As we move along that path, the articles presented in this special issue make a substantial contribution to the literature by offering new empirical evidence, avenues for future research, and the expansion of theories. Fortunately, there exists empirical evidence of older adults’ willingness to participate in trauma-focused research (Gagnon et al., 2015). It is our hope that this special issue will spur further research on the nexus between trauma and elder abuse, particularly including the voices of older victims.