Behavioral Health Services Are Key to Supporting At Risk Older Adults

  As a regular feature of this blog, we highlight our professional partners who have committed their knowledge, passion, skills, and time to protect older adults in their community.

Cassie Cramer, Somerville Cambridge Elder Services

photo credit:  Stephanie Becker

What do you do professionally and do you ever encounter elder abuse and self-neglect issues in your work?

I am a peer advocate, co-chair of the MA Aging and Mental Health Coalition and social worker in a mental health program at Somerville Cambridge Elder Services. Before I started this position, I worked in Elder Protective Services for 5 years. My background in elder abuse, neglect and self-neglect led me to the position I have today, providing longer-term support to people and advocating for the development of these supports statewide.

 How do behavioral health issues play a role in elder abuse and neglect?

In Protective Services I learned a lot; specifically I learned about when and why things go wrong. I found that by far, our biggest systematic failure was the lack of accessible (in-home) mental health services for older adults. Without on-going support in the community, people cycle through Protective Services- chronically “at-risk” and facing bleak outcomes.

            In Protective Services, I saw first-hand how behavioral health conditions can lead to poor self-care.  Poorly monitored diabetes or blood pressure can cause catastrophic health problems. Behavioral health conditions can cause isolation, cutting ties with would-be caregivers and social supports. Substance use among family members is often underlying abuse, exploitation or neglect.  Substance use and other behavioral health conditions among older adults can lead to problems with housing and risk of homelessness. I found that well-meaning providers are often quick to defer to institutionalization when older adults are facing crisis- people frequently called and expressed their view that an individual be “placed somewhere” because they “didn’t belong in the community.” 

            My observations are reflected in statistics: untreated behavioral health conditions among older adults are associated with higher health care use, development of preventable health problems, lower quality of life, caregiver stress, suicide and high rates of institutionalization.  Studies have shown that failure to provide mental health treatment in the community increases the likelihood of nursing facility admission by a factor of three, and that institutionalization is likely to occur at a much younger age.  Older adults with behavioral health conditions face many barriers to accessing traditional supports including lack of transportation, cost of co-pays, isolation, high levels of stigma around mental health, ageism among providers, and difficulty coordinating appointments due to co-occurring cognitive conditions, like dementia. For these reasons, older adults are least likely to receive mental health support.

What do you think is the best way to prevent elder abuse and self-neglect?

The MA Aging and Mental Health Coalition advocates for the development of a statewide network of in-home behavioral health supports, including case management, peer support, and therapy.  In the small pilot programs scattered across the state, we have already begun to see the effectiveness of these supports. In the program where I work, we are able to help people at risk of homelessness by taking referrals for people in the early stages of eviction, acting as a liaison with housing management and developing creative solutions to help stabilize tenancy. We help people in medically inappropriate housing, no longer able to climb the stairs of a walk-up apartment, move into accessible units.  We help people who are not receiving any medical care start seeing a primary care doctor or enroll in managed care programs, receiving in-home support from a nurse case manager. We also have an older adult peer specialist on staff who helps people who are isolated, often conducting visits in a local cafe or the library. Unfortunately these budding programs and success stories represent what is possible, rather than a reality for most people, who do not have access to in-home mental health support. A statewide network of in-home behavioral health supports is needed to ensure that all people- regardless of age or a mental health condition- have the opportunity to live full healthy lives in the community.

Is there anything else you would like to add about yourself or your work?

The Aging and Mental Health Coalition meets monthly in Boston and is open to anyone interested in joining our advocacy efforts. If you would like more information, you can contact me at ccramer@eldercare.org or 617-628-2601 x3089

 

 

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Creating Victims, rather than Survivors

 

flexed-bicepsRecently, I attended a training on domestic violence and elder abuse hosted by the Transition House and the Cambridge Council on Aging in Cambridge, Massachusetts. We watched a video about an elderly domestic violence survivor, “Mary,” whose husband was physically abusive. Mary attempted to leave the life-threatening situation on more than one occasion. However, due to the failure of various authorities, she was left to fend for herself. The police officers who investigated did not believe her story; rather they scrutinized Mary’s character and inquired, “What she did wrong to instigate the quarrel”. Victim-blaming is a common thread that runs deep with elder abuse victims because of their frequent inability to properly recollect the step-by-step event. Mary’s church officials denied that the violence was occurring due to her spouse’s positive reputation in the community. On one occasion, she was hospitalized because of the severity of the abuse and a social worker disclosed Mary’s whereabouts to her spouse, even though she had a restraining order in effect. The social worker believed Mary was disillusioned due to the nature of her medications and head trauma. Mary is only a survivor now because her spouse committed suicide, and she is no longer subject to his wrath.

Unfortunately, this image of a broken system failing to properly serve and protect an elder in a domestic violence situation is not unique to Mary. In fact, elders must jump through many hurdles to access proper attention and “these systemic failures make it especially hard for victims to get justice — and even easier for perpetrators to get away with their crimes”. [1] This is because like Mary, many elders are not empowered, but rather are ignored and distrusted. Elders are quickly losing trust in the systems meant to care for them because they are scrutinized when they are being vulnerable and truthful.

The reality is the aging process leaves elders at a greater risk of suffering from cognitive decline and/ or social isolation which may affect the way they interact with others or express themselves. Elders may require assistance, but are often left feeling disappointed because of a lack of communication where they must repeat themselves on replay until someone listens, and helps. As a result, victims of elder abuse may shy away from asking for help or sharing their stories. Elder abuse victims also battle ageism i.e. elder advocates not believing them because of perceived cognitive decline, which causes them to feel re-victimized. This creates a divide between elders and authorities because elders start to mistrust the same representatives who are meant to protect and assist them.

To make matters worse, elders sometimes choose not to admit their abuse because of their fear that authorities or others will take over. Some elder advocates or other family members may overreact with a sense of paternalism i.e. the helper makes decisions about “what is best” for the elder. This undermines the elder’s autonomy and could lead to a loss of independence. This unbridled power over the elder builds an atmosphere where elders are re-victimized over and over again. Elders may not report their abuse because they fear that they will lose their sense of power once again, first as a victim of abuse and second as a victim of confinement. As my supervisor told me on my first day of work, “elder justice is preserving an elder’s right to live autonomously – free from abuse and neglect”. That is how we bring justice to elders, and create survivors. We work with elders, and not merely for them. We remember that elders are individuals, not just casework.

[1]   http://www.cnn.com/interactive/2017/02/health/nursing-home-sex-abuse-investigation/

The Pain and Heartache of Familial Financial Exploitation

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The other day I came across an article entitled, “Financial Exploitation: When Taking Money Amounts to Elder Abuse.”[1] In the article, an elderly woman named Mary described how her daughter had cruelly stolen her life savings while she was in the hospital. Mary was deeply hurt by this betrayal, and the trust she had had in her daughter was ruined. At the same time, however, she was also worried about her daughter. She allowed her daughter to remain in her house, explaining, “I do have unconditional love for her. She has nowhere to go. She has no income- — she would be homeless.”[2]

While Mary’s reaction may seem surprising, it is actually not unusual in cases of elder financial abuse. This is largely because this type of abuse is so often perpetrated by family members. In fact, a 2014 study found that “family members [are] the most common perpetrators of financial exploitation of older adults (FEOA) (57.9%), followed by friends and neighbors (16.9%).”[3] When an elder is financially exploited by their son or daughter, their response is unlikely to fit the stereotypical abuse narrative. It is more complex.

We rarely get calls from elders who name their family member as a “perpetrator” or “abuser.” Instead, we get calls from elders who are concerned about both their own financial situation and also their family member’s welfare. In one case that I recently handled, an elder’s housing was threatened because of her adult son’s use of drugs in her apartment. While this is not a traditional financial abuse case, the son’s actions put his mother’s stable, subsidized housing at risk and if she had ended up evicted, she could have faced extreme financial hardship. When I met with her, I found that she recognized that her son’s behavior was problematic. But when she talked about spending time with him and her grandson, her eyes lit up and her tone was warm. She knew that her son’s behavior had been harmful to her and she was genuinely worried about her own situation, but she was also worried about his.

Elders exploited by their family members also tend to seek recourse beyond punishment of the perpetrator. For example, in another case that I recently handled, a son had stolen nearly $100,000 from his mother after she gave him access to her bank account so that he could help her pay her bills. In speaking with the elder, I found that she certainly wanted her money back, but she was most hurt by her son’s duplicity. He had shown her care and attention prior to stealing her money, and the realization that he had merely been priming her stung more than the lost funds. It felt like what she wanted most of all was a call from her son, apologizing.

Why is it that so many elders respond to familial financial abuse in these ways? One reason is obvious. It is very difficult to cut ties with, much less bring charges against, one’s own son or daughter, niece or nephew. If an elder has raised their family member from childhood, they may feel some responsibility for that family member’s actions. Moreover, they may love them. It is a real challenge to reconcile that a person who one loves has been deceitful.

Additionally, in some cases, the financial exploiter is the elder’s only caretaker or companion. Many elders (particularly recent immigrants) are socially and physically isolated, and they may feel they have no choice but to put up with some level of financial exploitation in order to have someone to help them prepare food, manage their medications, or just talk with them. Isolated elders are more likely to be preyed upon in the first place, and after abuse has occurred, they may be more inclined to maintain a relationship with the perpetrator.

Further complicating matters is the fact that the perpetrators of elder financial abuse often have root problems stemming from drug addiction and/or mental illness. If an adult child is stealing from his father in order to feed a heroin addiction, the father’s first concern may be helping his son to overcome the addiction, and he may put his own needs second. He might write off the abuse as a symptom of the larger addiction issue.

Given the complexities of elder financial abuse, it is important to understand why elders might not accept assistance or might want their situation handled in a unique manner. These elders should still be offered services to help improve matters, even if they aren’t the services typically provided in abuse cases. Listening to elders, even when their requests differ from what we expect them to be, is the essence of true elder justice.

 

[1] Michael O. Schroeder, “Financial Exploitation: When Taking Money Amounts to Elder Abuse,” http://newamericamedia.org/2017/03/financial-exploitation-when-taking-money-amounts-to-elder-abuse.php.

[2] Id.

[3] Peterson, 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.

Access to Healthcare = Elder Abuse Prevention

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One of the most crucial tools of elder abuse prevention is access to quality, affordable, health care.  In 2010 the Affordable Care Act (ACA) expanded health care access to over twenty million people across the country including many older adults.  This includes increased access to wellness visits; long term supports and services (LTSS); substance abuse treatment; increased access to behavioral health services; and much more.  The Republican controlled Congress, along with President Trump, have made it their mission to repeal the ACA and to radically change Medicaid.  While there is great uncertainty about how or when any changes will take place, there is no doubt about the positive impact that increased access to affordable healthcare has on the lives of older adults.

How Does Access to Healthcare Intersect With Elder Abuse Prevention?

Access To Medical Professionals – The ACA greatly increased access for older adults to healthcare providers.  This means they now receive routine monitoring for physical, cognitive, and functional problems – all of which can assist in identifying and preventing elder abuse.

The Opioid Crisis  – I have written several prior posts on how the opioid crisis has adversely affected so many older adults in Massachusetts and their younger family members as well. One Republican plan would end substance abuse and mental-health coverage that’s now used by at least 1.3 million Americans in the expanded Medicaid program.  This is a huge mistake –  treatment options are already difficult to come by and this particular change will only increase the costs of the epidemic for some of our most vulnerable citizens.

Self Neglect/Behavioral Health Services – Many older adults who suffer from self neglect are at great risk of losing their home, their income, or face increased risks to their safety or health.  Often at the root of self neglect situations are untreated mental health issues.  It is difficult now for many older adults to receive quality, accessible, behavioral health services.  The threatened cuts would greatly exacerbate this problem and leave many very vulnerable elders with inappropriate, unsafe, and much more costly options such as homeless shelters, nursing home placement, or hospitalization.

LTSS – An accessible LTSS system is critically important in preventing elder abuse.  LTSS are often what allows an older adult to stay in their home safely, to receive needed help such as chore services or home care services, and to keep them out of more costly institutions like nursing homes.  Medicaid is the primary payer of LTSS, covering approximately two-thirds of all LTSS costs nationwide. Proposed changes to the Medicaid program would put access to LTSS at risk and inevitably lead to less healthy and much more costly outcomes for many older adults.

Expanded access to healthcare through the ACA, along with the many other positive changes to improve the quality of healthcare and produce better outcomes for patients, has been an essential link in promoting elder justice.  We don’t know what future changes to the ACA and Medicaid will entail, but it is clear that decreasing access to basic health care services will have a devastating impact on older adults and hinder ongoing efforts to prevent elder abuse.