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BOOK REVIEW |
Assistant Professor of Health Care Administration Cleveland State University Cleveland, OH 44115
Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America, edited by Richard J. Bonnie and Robert B. Wallace. The National Academies Press, Washington, DC, 2003, 552 pp., $57.95 (cloth).
Guardianships of Adults: Achieving Justice, Autonomy, and Safety, by Mary Joy Quinn. Springer Publishing Company, New York, 2005, 332 pp., 41.95 (cloth).
Say "No!" to Elder Abuse, by the Golden Life Workgroup on Elder Abuse Prevention. SAGE Counseling Centre, Singapore, 2004, 86 pp., no price listed (paper).
Elder abuse and guardianship have kept company for more than 50 years. In the 1950s and early 1960s representatives of disciplines like social work, medicine, law, and banking convened for national and local forums on these themes, hosted by such organizations as the National Council on the Aging and the Welfare Federation of Cleveland, Ohio. They discussed the fate of mentally impaired older people living in the community, typically alone, and often distant from younger family members. The number of these adults was growing, and their possible neglect, abuse, and exploitation was feared. Two remedies often considered were guardianship and the development of a less restrictive alternative, adult protective services.
The connection between elder abuse and guardianship has remained during the half century since these early forums. It is currently illustrated in the use of guardianship by adult protective services workers when elder abuse victims are so impaired that they or their belongings are endangered. It is found in newspaper accounts of guardians financially abusing their wards or failing to provide them with needed goods and services, with headlines reading, for example, "Attorney for Elderly Accused of Theft" and "Under Court, Vulnerable Become Victims." It is seen in concepts like incapacity and undue influence that bridge elder abuse and guardianship. It is personified in the work of Mary Joy Quinn, Pam Teaster, Lori Steigel, and others whose writings and research straddle both worlds. Indeed, there is rarely a publication on elder abuse interventions that does not discuss guardianship or one on guardianship that does not consider its importance for elder abuse prevention. Yet, nothing is inherent in elder abuse that requires the use of guardianship because many victims are functioning independently and are well able to make their own decisions, no matter how idiosyncratic or risky the decisions may seem to persons around them. Likewise, some impaired adults require the surrogate decision making that guardianship provides but are never subjected to elder abuse because of a rich network of social support or other inhibitors.
A less obvious connection between elder abuse and guardianship is suggested by the poet Mary Oliver, "To pay attention, this is our endless and proper work," and evidenced in the three recently published books listed above: (1) a panel report from the National Research Council urging more and better study of elder abuse as the necessary condition for policy and program development, (2) a guide to the effective use of guardianship for health and social service practitioners, and (3) a report from the Singapore Ministry of Community Development, Youth, and Sports on the problem of elder abuse and actions to address it in that country. The books collectively seek to educate and improve both knowledge and interventions with respect to elder abuse and guardianship. Mimicking Oliver, they implore researchers, service providers, and policy makers to "pay attention" to elder abuse and guardianship, subjects given little attention in the past and have led to consequences today.
Skeptics may argue that this collective ambition, although laudable, may be hard to achieve. After all, it has been attempted many times in the past, with mixed results at best. In fact, all three books pay homage to earlier efforts, but persevere nonetheless, hoping this time someone will listen and things will be different.
A Research Agenda
Undoubtedly, the greatest challenge is undertaken in Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America, edited by Richard J. Bonnie and Robert B. Wallace, the climatic work of the National Research Council's (NCR) Panel to Review Risk and Prevalence of Elder Abuse and Neglect. Its recommended research agenda may be more extensive and detailed than those in the past. It may offer more specific suggestions for overcoming the practical and ethical barriers to systematic study that have plagued elder abuse inquiry over the past quarter century. However, the major elements of that agenda, and the premises on which they are based, differ little from national research agendas established 15 to 20 years before, including the University of New Hampshire's (1986) Recommendations from the Research Conference on Elder Abuse in 1985, and Elder Abuse and Neglect: A National Research Agenda, the report of the National Aging Resource Center on Elder Abuse (1991).
Like the NRC's panel, the early elder abuse research panels brought together both elder abuse experts and prominent researchers in allied subjects. They identified research deficiencies and obstacles before setting forth recommendations that invariably surrounded definition, prevalence, risk factors, detection and assessment, and intervention policy, programming, and clinical practice. The earlier elder abuse research panels ended in excitement, with promise for a better future—this time more established scholars will engage in elder abuse research; this time the studies will focus on critical gaps in knowledge and employ sound methodology; this time funding will be made available to conduct the quality and quantity of research needed. The recent NRC panel finished its work with the same aspirations and dreams. Although there has been progress in elder abuse research during the past two decades, it has been insufficient to change the message. Previously the time may not have been right to measurably advance elder abuse research. The panel only hopes that it is now. Perhaps Thomas Jefferson's observation is applicable, "No more good must be attempted than the public can bear."
The book is organized as a government report with several parts: an executive summary highlighting the recommended research agenda, an introduction making the case for the panel's efforts, several content chapters that outline the state-of-the-art elder abuse research and offer suggestions for improving it in the future, and multiple appendices (comprising two thirds of the book) with varying purposes. The appendices are on elder abuse measures and studies, state elder abuse law analysis, biographical sketches of panel members, and six background papers on particular aspects of elder abuse or related issues (i.e., epidemiological assessment methodology, ethical and policy issues, clinical and medical forensics, domestic financial abuse, abuse in residential long-term care, and lessons from child abuse and domestic violence activities). The volume leaves readers with the inevitable conclusion that we know virtually nothing about elder abuse for certain, and the opportunities for important research in this field are nearly limitless.
The authors present well the difficulties in conducting elder abuse research and offer good suggestions for undertaking methodologically sound investigations. They systematically and specifically identify areas for inquiry. They provide essential background information and linkage with other, more established, fields. Indeed, they go further and deeper than anyone ever before in eliciting a blueprint for conducting elder abuse research.
As noted above, the NRC panel sees the necessity of elder abuse research for the "development of informed policy and programs" (p. 9). Unfortunately, so much elder abuse policy and programming already is in place, from elder abuse law and adult protective services to multidisciplinary teams and community coalitions. Most were established without supportive theory-based research or program evaluation. Some were expanded in spite of contrary research findings. It is hard to imagine shelving all of these laws, services, and initiatives, or even significantly altering them, based upon research findings, even if they would suggest this. We have enough history in elder abuse and other fields to believe that once policies and programs are established, research results do little to change them (e.g., the negligible impact of early adult protective services demonstration project evaluations).
Whenever a topic is found unattractive or people fail to "pay attention," there is a tendency to reframe it, particularly using currently popular constructs. The not-so-extreme makeover of elder abuse this time puts it in the context of ensuring quality long-term care. It remains to be seen if this is more appealing than such former constructs as family violence, public health, and caregiving.
Perhaps because of the book's importance, prestigious source, credible contributors, and comprehensive coverage, it is somewhat disconcerting to occasionally uncover errors, gaps, or bias. By way of example, the authors suggest that there are fewer than "50 peer-reviewed articles based on empirical research" (p. 18) in elder abuse. Even a cursory glance at the research holdings of the University of Delaware's Clearinghouse on Abuse and Neglect of the Elderly would suggest many, many more. In addition, the authors rightfully criticize the use of multiple elder abuse definitions and then do the same themselves (pp. 35–39, 342). Important research initiatives are ignored or undervalued, such as those focused on minority populations during the 1990s. In addition, the NRC book has a medical slant, although the majority of research and intervention activities have come from other disciplines. Finally, the background papers are infused throughout the book, giving useful insight into their particular topics and elder abuse research as a whole. However, less clear are the criteria by which the topics were selected and why these topics have preference over others integral to the field.
A Guardianship Guide
Like the NRC volume, Mary Joy Quinn's book, Guardianships of Adults: Achieving Justice, Autonomy, and Safety, acknowledges past agenda-setting initiatives, albeit related to guardianship reform. They include the Wingspread National Guardianship Symposium in 1988 and the Wingspan Second National Guardianship Conference in 2001. The conferences offer comparison to the elder abuse research panels in that they had multidisciplinary compositions, offered sweeping recommendations, and placed importance on the interrelationship of research to policy and practice. Moreover, although they resulted in important reforms, many more changes are needed. Reform areas identified in Quinn's concluding recommendations include the realms of legislation, funding, policy and practice, research, and education. However, rather than leaving reform to the legal system, as usually occurred historically, the author calls upon practitioners to take up the charge, recognizing that "Guardianships are everybody's business" (p. 235).
Although Quinn offers guardianship reform recommendations, her primary purpose in writing the book is to reduce the confusion that has characterized guardianship for practitioners. She largely is successful, because she knows and understands her targeted audience, being a nurse herself, with more than 25 years of probate court experience. Quinn (and three contributors: Erica F. Wood, Pamela Teaster, and Sally Balch Hurme) dissects and analyzes the various facets of guardianship, including models, history, alternatives, accountability, and court involvement. She details the guardianship process, including due process protections and stages like guardian and attorney selection, petitioning, court hearing, and termination. She delineates aspects of working with guardianships, such as determining decision-making capacity, dealing with safety issues, handling estates, and providing court testimony and documentation. In all, Quinn extends to practitioners essential recipes for both understanding guardianship and using it more appropriately.
Case studies are employed throughout to both illustrate and inform. Because her intent is to educate rather than convert, Quinn offers a balanced perspective. This is especially noticeable in her description of guardianship alternatives and newer guardianship-related programs.
Quinn leaves readers with many of the same impressions about guardianship that Bonnie and Wallace leave about elder abuse. For instance, there is much variability among the states in how guardianship is applied and monitored. Those interested in the field are few and often connected. Little research has been conducted about guardianship. Therefore, we do not understand such fundamental matters as the effects of guardianship, the elements of successful guardians or guardianship agencies, and the relationship between nursing home placement and guardianship, such as whether the appointment of a guardian increases the likelihood of a ward being placed in a nursing home.
The Singapore Report
Quinn's perception of universal responsibility for problem solving and change is found, as well, in Say "No!" to Elder Abuse, a report by the Golden Life Workgroup in Elder Abuse Prevention. Elder abuse recognition has come late to Singapore. There is only one published study on the subject, and it appeared in 1997, 20 years later than the first elder abuse investigation undertaken in the United States. Additionally, there is no elder abuse law in Singapore, and abuse does not even appear in the criminal statutes. Retrospective case review by two service agencies indicated the probability of elder abuse occurrence. Still, with no mandatory reporting, documenting, or handling of elder abuse situations, the nature and scope of this problem in Singapore is uncertain. The report notes these gaps in knowledge and interventions, draws upon the work of other countries, and recognizes Singapore's unique service systems in proposing a set of recommendations aimed at policy, training, and community education.
The report offers a clear and concise look at one country's approach to elder abuse. It highlights two years of work by representatives of 26 public and private agencies. Together the report's six chapters justify government consideration of elder abuse, describe the problem, identify how elder abuse presently is handled in Singapore, and recommend how it can be addressed more effectively in the future. Those most likely to benefit from reading the report are Singapore public officials and persons interested in elder abuse prevention internationally. On the surface, others may find the report interesting but narrowly conceived. Beneath the surface, however, the contents of the report are instructive in how a country newly interested in elder abuse assesses the worldwide landscape of related research, policy, and practice in order to conceptualize its own response to the problem. In this, the report holds much broader appeal and use.
The Singapore report has qualities found in the other books under review. Like the NRC volume, its primary intent is agenda setting. Only secondarily is it to raise awareness or educate. Like Quinn's book, it incorporates case studies to make abstract constructs understandable, and it offers specific guidance for interventions. Similar to both books, the report crosses elder abuse and guardianship, and it underscores the importance of more and better research.
Concluding Thoughts
Albert Einstein observed, "Nothing happens until something moves." Clearly the three books reviewed in this essay are attempting to set things in motion with respect to elder abuse and guardianship, hoping to stimulate change of a certain order. It may happen that they are more successful than their predecessors. After all, time and momentum are on their side. On the other hand, change often takes more than thoughtful dialogue, analysis, or instruction. As Ralph Waldo Emerson suggested, "Sometimes a scream is better than a thesis." In family violence, early child abuse interventions were sparked by publicity about Mary Ellen, a foster child mistreated in New York City, and funding for domestic violence programs improved following the media frenzy over the O. J. Simpson trial. In guardianship, the shocking findings by Associated Press reporters appearing in newspapers across the country in 1987 led to Congressional hearings, the Wingspread Symposium, and eventual state law reforms.
Although elder abuse has had its share of horror stories, exposés, and Congressional hearings, somehow they have failed to capture the attention required for significant research funding, federal policy, or comprehensive programming. Elder abuse and guardianship benefit from the "thesis" offered by the three books discussed in this essay, but it will probably take a "scream" to accomplish their agendas.
References
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