Long-term Care Communication Techniques with Dementia & Alzheimer's
Aging continuing education psychologist CEUs

Section 18
Abuse/Maltreatment of Older Adults: Guidelines for Counselors

CEU Question 18 | CEU Test | Table of Contents | Geriatric & Aging
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

The literature on elder abuse offers several guidelines to assist counselors in reporting suspected cases of maltreatment (for example, Quinn & Tomita, 1997; Schwiebert, Myers, & Dice, 2000). All of these recommendations are grounded in the profession's commitment to protect vulnerable individuals from harm and to promote the welfare of clients. First, the evidence about the scope and seriousness of the elder abuse suggests that counselors ought to routinely consider elder maltreatment as a possibility when dealing with an older client who is dependent on family or others for care. Considering maltreatment as a possibility must be distinguished, however, from assuming that every older person is mistreated or neglected. Counselors need to keep a balance, recognizing that maltreatment happens frequently enough and subtly enough for them to be continuously alert to its potential presence without stereotyping all older adults as victims simply because of their age or health status. The literature on clinician age bias (the systematic stereotyping of and discrimination against people because they are old) against older clients suggests that it is a significant problem in the profession (Danzinger & Welfel, in press; James & Haley, 1995; Myers, 1989). Age bias is defined as "a process of systematic stereotyping of and discrimination against people because they are old" (Butler & Lewis, 1973, p. 27).

Second, counselors of course must provide an empathic and supportive atmosphere in which to discuss the older person's problems. A warm, nonconfrontive and nonjudgmental environment is essential if clients are to trust the counselor enough to reveal such distressing information. Early in the counseling relationship, a question such as "Do you feel safe in your home?" is more likely to produce useful and honest information than is one that sounds accusatory, such as "Do you feel endangered by the other people in your home?" Similarly, an inquiry to a caregiver about their emotional response to that responsibility is better worded as "Caring for a parent with Alzheimer's must be very difficult. Do you ever lose control?" than as "Have you ever mistreated your parent because of the stress?" Lachs and Pillemer (1995) have also recommended the following questions:

  • Who prepares your meals and helps you maintain your personal hygiene? Are you satisfied with your care?
  • Who handles your checkbook? Do you feel in control of your finances or satisfied with current arrangements for your finances?
  • Do you frequently have disagreements with ----- (person(s) who give care or may be maltreating the older adult)?
  • When you disagree with -----, what happens?
  • Do you have freedom to move about the house or to other places (as much as you are able)? (p. 439)

Myers (1989) emphasized that counselors should focus on helping older people and their families improve care and should not conduct an inquisition-like inquiry into the facts of their lives. The process of helping people feel comfortable enough to discuss such issues should not be rushed.

Third, counselors need to gather information related to the risk factors for abuse. Although there is currently no validated model for predicting who will abuse or be abused, the literature identifies many risk factors (Kapp, 1995). These include

  • the medical and cognitive condition of the older adult,
  • the older person's tendency to act disruptively,
  • the emotional stability of the people caring for the older person (including their history of psychological disorders, substance abuse problems, and excessive levels of dependence on the older person),
  • the social isolation of the family, and
  • its history of using violence to resolve conflict. (Lachs & Pillemer, 1995; Quinn & Tomita, 1997; Wolf, 1997)

Older adults whose health is poor, whose cognition is compromised, and whose frailty prevents them from living independently are at risk, especially when their caretakers bring a history of emotional problems to the task of caretaking. Family members who are addicted to alcohol or drugs, who have unresolved psychological disorders, or who exhibit abnormal levels of emotional and financial dependency on the older adult are significantly more likely to maltreat older people than are those without such problems, regardless of the health status or cognitive functioning of the elder (Wolf, 1997). The presence of any of these risk factors does not guarantee that abuse is taking place; rather, it suggests that counselors should explore further for evidence of maltreatment. Data gathering should include current problems and long-term functioning (Myers, 1989). As the American Counseling Association (ACA, 1995) Code of Ethics recommends, counselors who are unsure about whether a situation meets the criterion for reporting should consult with knowledgeable colleagues to get a more objective assessment of the situation.

Fourth, interviewing family members separately is more likely to result in honest disclosures than is a multiple-person session. An older person may feel intimidated by the presence of a family member and refrain from disclosing important information out of fear. Some are uncomfortable because of the embarrassing nature of the disclosed material and would prefer privacy for that reason. Discussing matters of personal hygiene, for example, is best done with as much privacy as possible. Caretakers may speak more frankly when alone with the counselor and may be less reluctant to reveal their problems in coping.

Fifth, counselors should educate clients about the services available to assist them. Support groups, specialized counseling services, financial advice, housing, and home care services are but a sampling of the potential resources of value in responding to elder abuse. Research suggests that many counselors are unfamiliar with these services in their community and that this ignorance is a serious problem for professionals who serve older adults and their families (Myers & Shelton, 1987).

Effects of Reporting Requirements on Confidentiality
In states that mandate reporting of elder maltreatment, the confidentiality of client communications to counselors is limited in the same way as communications about child abuse. If counselors have sound reasons to suspect that an older person is being maltreated, they must share that client disclosure with the appropriate authorities, even if the conversation is otherwise considered confidential or legally privileged. Moreover, the profession's code of ethics guides counselors to inform clients about this limit of confidentiality so that they can understand the implications of making such a disclosure to a counselor before they make it. Section A.3.a of the ACA Code of Ethics and Standards of Practice states, "Clients have the right to expect confidentiality and to be provided with an explanation of its limitations" (ACA, 1995). Failure to inform clients that information about elder abuse will be reported to legal authorities violates clients' rights to privacy and is inconsistent with their general expectation that what they tell professional counselors will be kept confidential (Welfel, 1998).

In jurisdictions where the reporting requirement includes all persons past a certain age, regardless of health or dependence, the need for clear and complete informed consent is especially compelling. A healthy, competent 65-year-old, for example, would have little reason to suspect that a disclosure about physical abuse from a spouse would not be held in confidence unless explicitly informed by the counselor. Moreover, because revelations about elder maltreatment may come from a client of any age, discussion of this limit to confidentiality should be a routine part of informed consent with all clients. A child or adolescent may reveal evidence of abuse or neglect just as easily as an adult.

If a client reveals information that must be reported, counselors have five major tasks in maintaining the counseling relationship. First, counselors should work to include the client in the reporting process (Welfel, 1998). The client should be informed that a report will be made, unless such a disclosure is likely to put the older adult at immediate risk of maltreatment. The client can be encouraged to contact authorities him or herself while in the counselor's office or to be present when the counselor calls. Second, a discussion of the practical and emotional consequences of the report will help the client understand the next steps in the process. This step is especially important because so many people are unfamiliar with elder abuse reporting laws. Sharing such information allays client misconceptions and fears and helps to maintain the therapeutic alliance between counselor and client. It is common for clients to erroneously conclude that they will be arrested immediately or that the older person will be removed from the home before the complaint is investigated. A counselor who believes an older person is in immediate danger should communicate that judgment to the authorities and should actively advocate for the welfare of that individual. Third, because clients experience feelings of anger, betrayal, and disappointment toward their counselors when a report is flied, counselors should immediately focus on the expression and discussion of those negative feelings to minimize the damage to the counseling relationship. Fourth, when confidential information is disclosed, counselors should provide only relevant data. The report should cover all material that relates to the abuse but no client information that will be of no import to the authorities (ACA, 1995). Such an approach communicates to the client that the counselor is committed to protecting the privacy of the client as much as possible. Finally, a counselor's responsibility to a client or older person is not completed when the report is filed. The counselor is obligated to follow up to ensure that needed services are being offered. The patchwork nature of services for maltreated older adults makes follow-up particularly important (Quinn & Tomita, 1997). Frequently, many agencies are involved in providing services to older adults with no one body responsible for their coordination. In this circumstance, the quality and continuity of service may be jeopardized without active advocacy by the referring person.

Currently, nearly 600,000 documented cases of elder maltreatment occur in the United States annually, and that number will increase as the older population expands. Older adults often suffer serious physical and psychological consequences from such abuse. Counselors who want to provide competent and responsible service to older adults are bound by both ethical and legal mandates regarding elder abuse. Professional ethics require all professional counselors to intervene to safeguard the welfare of clients, and laws in many jurisdictions mandate that counselors report suspicions of elder abuse to authorities in a timely fashion. This mandate applies to clients and to third parties.

Identifying potentially abusive situations is not as straightforward as it first seems. Physical evidence of maltreatment is not always obvious, even in cases of physical abuse, and older adults and family members are reluctant to disclose such information for fear of the consequences. Furthermore, the definitions of behaviors that constitute abuse differ in important ways in different jurisdictions. Nevertheless, counselors who fail to report maltreatment of an elder as defined by the statute in their state risk criminal penalties for their failure.

In light of these circumstances, counselors are well advised to (1) carefully read the statute in their jurisdiction and seek legal consultation for any aspects of it that seem unclear; (2) develop skills to competently assess for elder abuse but recognize that the purpose of that assessment is to determine whether there is a basis for reporting, not to conduct the investigation itself; (3) initiate an informed consent process with all clients that explains elder abuse as another limit to confidentiality; and (4) attend to the potential damage mandated reporting of elder abuse can inflict on the counseling relationship and develop strategies to minimize the damage and repair the relationship. When these actions are taken, counselors are more likely to be able to protect older adults from harm and foster the welfare of their clients.
-Welfel, Elizabeth, Danzinger, Paula, & Sheila Santoro; Mandated Reporting of Abuse/Maltreatment of Older Adults: A Primer for Counselors; Journal of Counseling & Development; Summer 2000; Vol. 78, Issue 3.

Personal Reflection Exercise #9
The preceding section contained information about abuse/maltreatment of older adults and counselor guidelines. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Malinowski, S. D., Nicosia, F., Mehling, W., Woodstock, R., & Barnes, D. E. (2021). Guys and dolls: Two case reports of spontaneous interactions with dolls in male veterans with dementia. Psychological Services. Advance online publication.

Martin, K., Lang, F. R., Rupprecht, R., & Nömer, J. (2021). Dementia worry and the perception of personal risk: A longitudinal study. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 34(1), 23–30.

Maxfield, M., & Greenberg, J. (2021). Anticipated stigma and dementia-related anxiety in middle-aged and older adults. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 34(1), 13–22.

Online Continuing Education QUESTION 18
According to Welfel, what are the five guidelines to assist counselors in reporting suspected cases of elderly maltreatment/abuse? Record the letter of the correct answer the CEU Test.

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