Elder abuse is associated with morbid and lethal outcomes. In some cases of elder abuse, particularly involving domestic violence, uninformed or improperly executed interventions can result in serious harm to the victims. Professionals from various disciplines may themselves be at risk during encounters with perpetrators. This chapter provides an overview of potentially dangerous scenarios of elder abuse such as homicide, homicide/suicide, strangulation, and stalking. Intervention strategies such as lethality assessments and safety planning are described. A case scenario illustrates the value of an interdisciplinary response to enhance victim safety. This chapter reviews potential lethality factors and the steps that can be taken to enhance the safety of victims, their families, and the professionals who serve them.
Keywords: elder abuse; domestic violence; victim safety; strangulation; stalking; homicide
Editor's Note. The fallowing article is a chapter from the forthcoming book by Brandl et al. titled Elder Abuse Detection and Intervention: A Collaborative Approach (in press, Springer Publishing Company, New York, NY).
Elkmore Man Indicted in Wife's Slaying
Police found 72-year-old Jane Hoffman lying on her bed, dead from a gunshot wound to the head. Her husband-who had planned to kill himself-lay asleep next to her. Hoffman told police he and his wife were in "severe financial difficulty" and that "he could not have his wife learn about the financial situation because it would be unbearable for her."
Cecil Whig, June 8, 2004
No Prison in Death of Woman
Alexandra, age 37, shut her Alzheimer's-stricken grandmother, age 86, in a basement room. Four days later when she called the police, her grandmother was dead. Prosecutor Paul Parker said it appeared the victim had crawled out of bed in an attempt to reach the door. He said the woman weighed 59 pounds, was emaciated, and had been lying in a bed stained with feces and urine. The judge rejected jail time, saying Alexander "had done the best she could under the circumstances."
Salt Lake Tribune, June 29, 2004
Deaths Prompt Two Families to Sue Local Nursing Homes
The family of John Zajch Sr. is seeking $2 million in damages in a suit against Kindred Nursing Centers. The suit alleges that Zajch was admitted to the facility without bedsores. When he was moved from the nursing home to the hospital, bedsores extended through skin and muscle tissue to the bone. He died from blood poisoning caused by multiple pressure sores. The wife in another family is suing the facility, claiming that an employee improperly placed a feeding tube in her husband's stomach, leading to his death.
Virginian-Pilot, June 19, 2004
Reno Man Admits to Killing His Parents
Huntoon, age 55, admitted that he killed his 86-year-old father and 84-year-old stepmother. He claimed that he had beaten them both with a hammer, and that he may also have attempted to choke or strangle one or both of his victims. Several people interviewed suggested that there had been abuse at the home and that his parents may have been trying to kick him out.
KRNV.com, June 29, 2004
Seniors are killed or seriously harmed by abuse and neglect every day. Victim safety must be the primary goal of intervention in elder abuse cases. Previous chapters have described the benefits and challenges of collaboration and have discussed informal "practice-based" approaches and the use of formalized teams. This chapter will tie these concepts together by illustrating a multidisciplinary approach to promote safety of elder abuse victims. Lethality assessments and safety planning tools will be described. Worker safety, especially during home visits, will be discussed. A case illustration will demonstrate the concepts presented in this chapter.
ELDER ABUSE CAN LEAD TO SERIOUS HARM OR DEATH
As the newspaper articles at the beginning of this article indicate, some cases of elder abuse lead to the death of the victim. In facilities, the death may be caused by neglect, poor care, inadequate medical treatment, or malpractice. In some cases, a staff person may be a serial killer who performs so-called mercy killings.
Homicides also occur in the community. A spouse or partner who has been abusive and controlling for years commits homicide. New partners may have married for money or possessions and may kill the elder to get the estate of the older person. Adult children or grandchildren may also use lethal violence to get possessions. Some abusers have mental illness and inadvertently kill an older person. In single female victim/single male offender homicides reported for 2001, 8% (158 victims) were age 65 or older (Brock, 2003).
In many cases resulting in death, there are no external injuries (Hawley, McClane, & Strack, 2001). This creates special problems for those responding to death calls. Screening for a history of domestic violence or elder abuse and carefully investigating the scene are important. Where the death is suspicious and an autopsy is conducted, blunt trauma injuries; fingernail marks; and petechial hemorrhages in the eyes, skin, internal organs, and undersurface of the scalp may well be found (Hawley et al., 2001). An illustration of the difficulty of determining whether a death-or even just an injury-resulted from physical abuse is provided in the following discussion about the challenges of identifying strangulation.
Professionals may fail to identify strangulation and suffocation, serious forms of physical abuse that can lead to death. Strangulation is a form of asphyxia characterized by closure of the blood vessels and air passages of the neck as a result of external pressure on the neck (Iserson, 1984; Line, Stanley, & Choi, 1985). Suffocation is the cutting off of the airways by covering the mouth or nose or by sitting on the victim's chest. Nationally about 10% of violent deaths are due to strangulation. Women are strangled six times as often as men, though a small woman can strangle a much larger man. Unconsciousness can occur in seconds and death within minutes (Strack, McClane, & Hawley, 2001). Most strangulation is manual, that is, committed using one or both hands. However, ligature strangulation, in which the perpetrator uses a cord or other binding around the victim's neck, is not uncommon.
Strangulation is closely associated with domestic violence, especially in younger victims. No studies examine its incidence in older couples, so these data are drawn from studies of younger adults. A San Diego study of 300 strangulation cases found in 89% a history of domestic violence. Overwhelmingly (99%), perpetrators were male (Strack et al., 2001).
Not only are seniors at risk of homicide, but they also experience higher rates of homicide-suicide than younger people. In cases of homicide-suicide, the perpetrator takes the life of the victim and then kills himself. One study indicates that most (83%) of homicide-suicides are of the spouse/partner type. The balance of cases involve other familial relationships, such as adult children, siblings, or parents (Cohen, 2000).
Cohen's research suggests that there are at least three subtypes of homicide-suicide among older adults. Thirty percent involve previous domestic violence; 50% are dependent/protective long-term relationships, where the man is dominant and one or both parties have been ill; and 20% are symbiotic relationships, characterized by extreme interdependence (Cohen, 2000).
Characteristics noted from Cohen's research suggest that men are overwhelmingly the perpetrators and guns are the method of choice in 90% of cases. These are acts not of love and compassion but rather of desperation and depression. They are not suicide pacts. Often the wife was not a willing participant, even though the perpetrator had planned the event for months or years (Cohen, 2000).
Predisposing risk factors of homicide-suicide include:
* Advanced age
* A long-lived marriage
* Depression and other psychiatric problems in the perpetrator
* The perpetrator's being a caregiver
* The perpetrator's having a controlling personality
* Multiple health problems in the perpetrator
* Marital discord
* Family discord
* Social isolation
* The perpetrator's giving things away (Cohen, 2000)
Lethality Assessment
Research on lethal elder abuse and potential risk factors is scarce. Drawing on data from domestic violence literature may provide information that is useful when working with older victims. No tool can decisively predict which victims are at risk of being killed. In a few situations, friends, family, or professionals appeared not to have had any indication that abuse was occurring or that homicide was imminent (Websdale, 1999). However, professionals can look for some common risk factors that may assist in assessing lethality as a method to help victims ascertain their own level of risk. Any lethality assessment tool should not be used as a checklist that is handed out to victims. Rather, it should be used as a tool to discuss with a victim the circumstances of the abuse and to begin safety planning (Websdale, 1999).
Several lethality assessment tools created by experts in the domestic violence field may provide information that is also applicable to many elder abuse victims. According to Campbell (1995), experts in the field have identified the following key risk factors associated with perpetrators:
* Access to/ownership of guns
* Use of weapon in prior abusive incidents
* Threats with weapons
* Serious injury in prior abusive incidents
* Threats of suicide
* Drug or alcohol abuse
* Forced sex
* Obsessiveness/extreme jealousy/extreme dominance
More recent research by Campbell, Webster, Kozoil-McLain, and Block (2003) on high-risk factors for intimate partner homicide found that (1) women threatened or assaulted with a gun were 20 times more likely than other women to be murdered; (2) women threatened with murder were 15 times more likely than other women to be killed; and (3) when a gun is in the house, an abused woman is 6 times more likely to be killed than other abused women. Although drug and alcohol abuse increase risk, other factors such as threats to kill, extreme jealousy, attempts to choke, and forced sex represent greater risk. Threatened or attempted suicide was not found in this study to be a predictor of intimate partner homicide (Campbell et al., 2003). Other researchers and experts in the domestic violence field have had similar findings. Hart (1988) identified attempts, threats, or fantasies of homicide or suicide as key indicators of a risk of possible serious or lethal assaults. Other factors include "availability/access to willingness to use or history of using weapons; obsessiveness; isolation of the batterer and his degree of dependence on the battered woman; rage; depression; drug and alcohol consumption; and access to the victim" (Websdale, 1999, p. 2). Block (2003) found that risk factors for lethal domestic violence where there has been a history of abuse are (1) the type of past violence, such as prior incidents resulting in permanent injury, a severe beating, strangulation, burning, internal or head injuries, and the threat of or actual use of a weapon; (2) the number of days since the last incident; the closer the time between the new incident and the previous one, the greater the danger (lethal homicide typically occurs in the 30 days after an incident, though some occur within 1 or 2 days); and (3) the frequency or increasing frequency of past violence. Finally, Websdale (1999) found that the most prominent factors in both multiple and single killings, in order of importance, are:
* A prior history of domestic violence
* An estrangement, a separation, or an attempt at separation, nearly always by the female party
* A display of obsessive possessiveness or morbid jealousy on the part of the eventual perpetrator; often accompanied by suicidal ideation, plans, or attempts; depression; sleep disturbances; and stalking of the victim
* Prior police contact with the parties, more so in cases of single killings; often accompanied by the perpetrator's failing to be deterred by police intervention or other criminal justice initiatives
* The perpetrator's making threats to kill the victim, often providing details of the intended modus operandi and communicating those details in some form, however subtle, to the victim, family members, friends, colleagues at work, or others
* The perpetrator's being a family member who has used violence before and sometimes has a prior criminal history of violence; included in this group is a small but significant number of killers who have both access to and a morbid fascination with firearms
* The perpetrator's consuming large amounts of alcohol or drugs immediately preceding the fatality, especially in cases of single killings
* The victim's having a restraining order or order of protection against the perpetrator at the time of the killing (Websdale, 1999)
Seeking help or separating from an abusive relationship is a significant risk factor for serious injury or death. Abused women who were killed or killed their abuser were more likely to have sought outside help than women who were severely beaten but not killed. Seventy-five percent of homicide victims and 85% of victims of severe but nonfatal violence had left or tried to leave in the preceding year. In 45% of lethal domestic violence cases, a woman's attempt to leave the abuser was the precipitating factor for the killing (Block, 2003).
Another factor worth exploring is substance abuse by the perpetrator. Risk of lethal or nearly lethal domestic homicide is increased when associated with alcohol and drug use by the offender. A violent intimate relationship, in which the abuser is described as a problem or binge drinker or drug abuser, is extremely dangerous. In a review of lethal homicide cases, researchers found that in the year before the homicide, female victims used alcohol and other drugs less frequently and in smaller amounts than their abusive male partners. Two-thirds of female homicide victims tested negative for the presence of alcohol. In this study, more than 75% of female homicide and attempted-homicide victims and 90% of abused victims did not consume alcohol prior to either the homicide or the more recent violent incident. More than 80% of abusers who killed or seriously abused female partners were problem drinkers and tended to binge drink. More than two-thirds of homicide and attempted-homicide perpetrators used alcohol, drugs, or both during the incident; fewer than 25% of victims did (Sharps, Campbell, Gary, & Webster, 2003).
The availability of weapons was identified as a significant risk factor in all studies. The picture that emerges from the article "When Men Murder Women" is that "women face the greatest threat from someone they know, most often a spouse or intimate acquaintance, who is armed with a gun. For women in America, guns are not used to save lives, but to take them" (Brock, 2003, p. 13).
Stalking
In addition to the risk of being killed, perpetrators may stalk older victims. Stalking has rarely been thought of as an issue in elder abuse. National studies have focused on the general population, and in particular, younger persons. These studies showed that nearly 5% of women and 0.6% of men are stalked by a current or former intimate partner during their lifetime. This translates into approximately 503,485 women and 185,496 men who are stalked annually in the United States by current and former intimate partners (U.S. Department of Justice, National Institute of Justice, & the Centers for Disease Control and Prevention, 2000).
Most victims (78%) are women. Women are significantly more likely than men (60% vs. 30%, respectively) to be stalked by an intimate partner; 80% of women stalked by former husbands are also physically assaulted and more than 30% are sexually assaulted (Tjaden & Thoennes, 1998; U.S. Department of Justice, National Institute of Justice, & Center for Policy Research, 1997). Where stalking victims obtained restraining orders, 69% of women and 81% of men said their stalker violated the order (Tjaden & Thoennes, 1998).
Current or former husbands are perpetrators 38% of the time, current and former cohabitating partners are the perpetrators 10% of the time, and current and former boyfriends are the perpetrators 14% of the time. Intimate partners who stalk are four times more likely to physically assault their victims and six times more likely to sexually assault their victims (U.S. Department of Justice, Office of Justice Programs, 1998).
Until recently, little was known about elder stalking. Jasinski and Dietz (2003) studied elder domestic violence and stalking rates among persons 55 and older. Using a study group of 3,622 older adults drawn from the National Violence Against Women Survey, they found that domestic violence and elder stalking share many similarities with similar conduct involving younger persons. Rates of domestic violence and stalking were consistent with those in the younger population. In both age groups, significantly more women are victimized than men. In stalking, women are victimized more than three times as often as men. Income was not a factor in either category in elderly adults.
The average age of elder victims was 66.4 years. More than two-thirds were unemployed, and one-third had a disabling chronic disease or condition. Being female and married and having a partner in poor health was associated with greater risk of domestic violence.
Stalking is a pattern of conduct that produces fear. Although statutory definitions vary, elements typically include willful and repeated following or harassing of a particular person, accompanied by a threat or behavior that is threatening and would be so perceived by a reasonable person. Many states require for the crime of stalking that the target be placed in actual fear and that the perpetrator have the apparent ability to carry out the threats, even if there is no actual intent to carry them out. Harassment is understood to mean a course of conduct, that is, a series of acts over a period of time, however short, that evidence a continuity of purpose (U.S. Department of Justice, National Institute of Justice, 1993). It is conduct, often criminal in nature, involving acts of pursuit and "behavioral intrusion" that are threatening and may be dangerous. Every state and the District of Columbia have enacted criminal laws prohibiting it. It is also prohibited under federal law (Meloy, 1998).
Contrary to public impression, most stalking does not involve celebrities. Rather, most stalking is between persons who know each other, including current and former intimate partners (Meloy, 1998; Zona, Palarea, & Lane, 1998). It is often associated with the souring of a relationship (U.S. Department of Justice, National Institute of Justice, 1996) and is an effort to win the victim back or exact revenge for the perceived slight of leaving (Hall, 1998). In about 60% of cases, stalking began before the relationship ended (Tjaden, 1997). In the context of domestic violence, it begins when the batterer believes he is losing or has lost power and control over the intimate partner. The batterer, unable to accept rejection and her leaving, will harass, threaten, and assault her (U.S. Department of Justice, National Institute of Justice, 1996). Tjaden (1997) found that about half of female victims had been stalked by a current or former marital or cohabirating partner. Eighty percent had been physically abused and 31% were sexually abused by their intimate partner. "Stalking is how some men raise the stakes when women do not play along. It is a crime of power, control, and intimidation very similar to date rape" (DeBecker, 1997, p. 198). It occurs across the life span (Jasinski & Dietz, 2003).
Perpetrators, in an attempt to instill fear, may send unwanted letters, cards, and gifts; make telephone calls at all hours; survey the victim; break into the victim's home to steal personal items, rearrange furnishings, or vandalize property; wiretap the victim's telephone; read or steal mail; send the victim magazines; file false police reports and lawsuits against the victim; spread rumors and gossip; harass the victim's family, friends, and neighbors; send e-mail transmissions; and post Internet messages about the victim. Some stalkers will make overt threats; about three-quarters will spy on or follow the target; about a third vandalize the victim's property; and about 10% threaten to kill or kill the victim's pets (Tjaden, 1997). This campaign of conduct is profound and life changing for the victim, in that it typically persists for months or even years (Meloy, 1998). "The ominous threats, constant surveillance, and intrusion into the victims' lives have long-term, damaging psychological effects. Living in fear takes a toll on the quality of human life" (Hall, 1998, p. 136).
Victim-Centered Safety Planning
Given that some older victims are in danger of being stalked, seriously injured, or killed, safety planning is a crucial component of any intervention. The term safety may have different meanings for various professionals. Too often, safety involving older persons focuses on household safety, such as ensuring that rugs and cords are placed so that no one trips and falls. Although strategies that focus on the physical health and well-being of older persons are important, safety planning for victims of elder abuse involves additional components.
A safety plan considers issues necessary to enhance the security of current victims of abuse. Safety planning is a proactive process of how to respond to abuse in day-to-day living, as well as in crisis situations. Anyone can talk with a victim about how to enhance safety (e.g., get weapons out of the house, have a plan of who to call in a dangerous situation, get a cell phone or lifeline alarm pendant). However, domestic violence advocates are trained to do comprehensive safety planning with victims. Many victims benefit from talking with an advocate and developing a safety plan. Victims' plans respond to the range of barterer-gcnerated and life-generated risks. "Life-generated risks and circumstances are aspects of battered womens' lives over which they have limited control such as physical and mental health, financial limitations, or racism or other discrimination" (Davies & Lyon, 1998, p. 5). The process of planning may include evaluating whether remaining in or ending a relationship will reduce or increase risks, and how the abuser will react (Davies & Lyon, 1998).
Safety planning is a process whereby a helper and a victim jointly create a plan. The safety plan is victim driven and victim centered. It is based on the victim's goals, not the professional's opinions.
Abusers often isolate victims and do not allow them to make their own decisions. Safety planning is a process that restores power and control to victims as they make decisions about how to enhance their own safety. A good safety planning process provides the victim with information and an array of options to choose from. Then the victim decides whether to stay with the abuser or to leave, and how to remain as safe as possible under the existing circumstances.
Safety plans include the following:
* Prevention strategies. Preventing future incidents of abuse (e.g., going to a shelter or moving to another residence, obtaining a restraining or protective order, hiding or disarming weapons, changing schedules and routes to avoid being found).
* Protection strategies. Discussing methods victims can use to protect themselves during an abusive or violent incident (e.g., having an escape route, or having the victim seek shelter in a room where a door can be locked, with a working phone available or where weapons are not present).
* Notification strategies. Developing methods for seeking help in a crisis situation (e.g., cell phones, emergency numbers readily available, alarm pendants, security systems, a towel in the window or other coded method to notify a nearby neighbor to call the police, code words that can be used during phone conversations with friends, family, or neighbors to alert them that the victim needs help; for example, if the victim says "apple pie" in the phone conversation, it is a coded message to call die police).
* Referral services. Recognizing and utilizing services that can offer assistance (e.g., domestic violence, sexual assault, adult protective services [APS], criminal justice, aging and disability network, faith and community organizations).
* Emotional support. Considering methods of emotional support and ways to become less isolated (e.g., music, exercise, yoga, reading positive or spiritual materials, hobbies, friends, support groups, and other community activities).
Recognize that the victim may want to stay with the abuser, may be in the process of leaving or returning to the abuser, or may have left and ended the relationship. In each of these situations, the five components of safety planning listed previously are crucial.
For Victims Who Have Left or Are Leaving. For victims who have left or are leaving, additional issues will need to be considered.
Where Will the Victim Live?
* Can the person remain in his or her home safely?
* Is there an emergency shelter in the community?
* Is living with friends or family an option?
* Are church groups or other organizations an option?
* Where does the person want to live after the immediate crisis?
Money
* Can the person get money for the short term?
* Are financial programs available to assist the person? APS may be helpful in assessing eligibility for benefits.
Health
* What health-related items (e.g., medications, eyeglasses, walker, hearing aids, etc.) will the victim need to live without the abuser?
* Who is the victim's primary health care provider? Has the victim considered talking with a health care provider about the abuse to get help with health issues and documentation? In most states, health care providers are mandatory reporters, so discuss with the victim whether he or she is comfortable with reporting.
* Is respite care available through social services?
Who Else Is Affected by the Abuse?
* Who can help with children, grandchildren, or other persons living with the victim?
* Can a friend or family member care for pets or livestock if the person can't take them along? (If not, local domestic violence programs may have information about safe haven programs for pets.)
Legal
* Has the abuser been arrested? If yes, what support does the victim need?
* Does the victim want a protective or restraining order? Local domestic abuse programs or APS may be able to assist with obtaining restraining and protective orders.
* Are there immigration issues? Contact a local domestic abuse program or a legal aid program or lawyer specializing in immigration.
Safety Planning Steps
Quality safety planning involves the following steps:
1. Building rapport and listening to the victim.
2. Learning about what the victim fears, from both the abuser and the consequences of any action that might be taken.
3. Asking what the victim wants to do and why. Learning the motivation behind the victim's decisions can help a worker understand the victim's goals. The worker may be able to suggest other options or methods of reaching the same goal. For example, the victim may state that she does not want to leave the abuser. If the worker asks why, she may find that the victim is afraid to leave her three cats behind. The worker can let the victim know about safe haven programs for pets.
4. Thinking creatively, together, about a variety of options and ideas.
5. Building a safety plan that is victim centered.
Safety planning involves problem solving, in advance, about what a victim can do during and after a crisis. Simply making referrals to other agencies is not safety planning. In addition, safety planning is a fluid process. Life circumstances change for the victim and the abuser. Safety plans need regular updating to remain current (National Clearinghouse on Abuse in Later Life & Wisconsin Coalition Against Domestic Violence, 2003).
Safety planning with persons with cognitive disabilities creates unique challenges. In some cases, the victim will remember only one or two steps of the plan-such as "call Alice" or "call 911." Posting 911 stickers on telephones may be helpful in some situations. In many cases, the safety planning process will need to be done with a caring individual who will work with the victim with cognitive disabilities. A sample safety planning tool for persons working with someone with a cognitive disability is available from the National Clearinghouse on Abuse in Later Life, a project of the Wisconsin Coalition Against Domestic Violence, on the Web at http://www.ncall.us.
Traditional safety plans are available from local domestic violence programs or statewide coalitions. Sometimes these tools are not in large print or appear to be written for younger women, so they may need to be modified to meet the needs of older victims. Sample safety planning tools for older people and for victims with physical or cognitive disabilities also are available from the National Clearinghouse on Abuse in Later Life, on the Web at http://www.ncall.us.
Collaborative Response to Enhance Victim Safety
In addition to safety planning with victims, using a collaborative approach with the tools from multiple systems can be the most effective method to enhance the security and well-being of the victim.
Worker Safety
In addition to the need to focus on victim safety, workers who enter homes where abuse is occurring need to be mindful of potential danger. Workers conducting home visits have been threatened, hit, and held hostage at knifepoint or gunpoint while completing an investigation. Professionals should also be aware that they may become targets if a perpetrator believes they have the power to decide what will happen to the client or if the perpetrator blames them for the situation and seeks revenge. Therefore, throughout the investigation, assessment, and execution of the intervention plan, continued focus on whether the perpetrator poses a risk to the victim and others must occur. Even when a plan is developed that addresses safety, ongoing evaluation of risk mandates that if the danger level rises, the case plan may need alteration (Heisler & Brandl, 2002a, 2002b).
Professionals who conduct home visits should prepare beforehand by gathering information. Questions about prior calls for service, number of occupants, weapons, substance abuse, any known mental health history, and presence of dangerous animals should be asked. Workers should also take steps to enhance their personal safety before leaving the office. They should notify other office staff of where they are going and update that information upon arrival at the location and again as they leave. In the field, service providers should carry appropriate safety devices, such as flashlights and a fully charged cell phone. The cell phone should have a button set for the local law enforcement agency's emergency number. Workers should know how to contact law enforcement for a rapid response and what to say to assure a high-priority response. Workers should take safety precautions once they arrive at the home. Considering where to safely park and assessing the situation for dangerous animals and other potential problems before entering the home is a best practice. When in doubt, workers should not conduct visits alone and should bring law enforcement if deemed necessary (Heisler & Brandl, 2002a).
Some victims of elder abuse have communicable diseases, and professionals must protect themselves, as well as other clients and patients with whom they may have contact. Professionals must be mindful of the potential for personal harm and employ universal precautions to avoid spreading infections and other diseases. Avoid contact with any bodily fluids, including blood, saliva, urine, feces, vomitus, seminal fluid, sputum, and open wounds. Every professional should receive training in universal precautions, and team members should carry appropriate protective gear when in the field (e.g., gloves, masks).
Case Illustration
The case of Leroy will be used to demonstrate a multidisciplinary approach to enhancing victim safety.
Presenting Issues. Leroy, age 64, worked as a janitor at the local brewery. He kept to himself and did not socialize with other employees. His coworkers noticed that he showered at work every day. Occasionally they saw welts and bruises on his back and chest.
A gas meter reader took monthly readings in Leroy's neighborhood. Several months in a row, the meter reader watched Leroy go through a cellar door and not come back out. She wondered if something was wrong and called APS.
Initial Investigation. The APS worker started the investigation by going to Leroy's home. Before conducting the home visit, the APS worker gathered as much safety information as possible. The worker learned that no previous APS or police reports had been filed from this residence. Without talking directly to the family, the worker was unable to ascertain whether large dogs or guns were on the property.
Before leaving the office, the worker told other staff the address where she would be conducting the home visit and when she expected to return. She made sure she was wearing comfortable flat shoes in case she needed to leave quickly. She turned on both her cell phone and her pager.
The worker approached Leroy's home cautiously. She parked on the street, not in the driveway where she could be blocked in. She noted that the neighborhood appeared to be a safe, quiet residential setting with older homes set fairly close together. As she approached the home, she looked for evidence of large dogs and found none.
After being admitted to the residence by Leroy's wife, the worker introduced herself and asked to speak to Leroy. He arrived in the living room about 15 minutes later, looking disheveled and confused. The worker attempted to talk with Leroy alone, but his wife was clearly within earshot throughout their initial conversation. Leroy told the worker that everything was fine and that he chose to sleep in the cellar because his wife snored. He said he was tired from a long day at work and asked to go rest. The worker used the interview to attempt to build rapport with Leroy without pushing for answers, since she was concerned about Leroy's safety if he disclosed too much information while his wife was listening.
The worker was glad to learn about Leroy's job at the brewery and attempted a second interview after work the following day. During this interview, which was conducted in a private meeting room, Leroy told the APS worker that his wife, Gloria, and their adult son lived in the house. Leroy was forced to live in the cellar and sleep on a lawn chair. He used the toilet and purchased food at a nearby gas station. Leroy showed the worker his ribs, which appeared to be badly bruised. He told the APS worker that Gloria had hit him with a frying pan.
Victim Safety. The worker was concerned about Leroy's safety and health, especially given his bruised ribs. They talked about whether it was safe for him to return home that night. Leroy did not feel in immediate danger. He simply wanted to be allowed to live in his house with his family.
The worker asked Leroy if there were guns in the home and how he would escape if another violent incident occurred. They discussed which rooms might be more dangerous if Leroy was trying to escape from abuse, such as the kitchen where knives were present. Leroy said that if he were in danger he could call 911 if he could get to a phone. The worker agreed to try to get Leroy a free cell phone, programmed to 911, from the local domestic abuse program. Leroy also said he would be able to go to his neighbors for help if necessary. Together the worker and Leroy developed a safety plan in case of a crisis.
In addition to planning for a crisis situation, Leroy and the worker discussed what he might need to have with him if he needed to leave quickly. Leroy realized he would need his security pass for work and some money. The worker also suggested some clean clothes and documents, like his Social Security card and health plan paperwork. Leroy also needed to be sure to pack his glasses and medications. He agreed to pack a small bag with the things he would need and want to have with him if he left quickly. Leroy also had a cat that he dearly loved and was worried that his wife would not care for the cat if he left. The worker looked into temporary housing options for the cat if Leroy needed to stay somewhere overnight.
Other Key Components of an Effective Intervention
In addition to focusing on immediate safety planning, the worker and Leroy needed to address other key components to create an effective intervention plan.
Health. Leroy did not want to go to the hospital immediately to have his ribs checked but agreed to call his doctor. He made an appointment for the next day, and the doctor found several broken ribs. Leroy also appeared depressed. He was thin and not taking care of himself. He also was incontinent, which was the reason given by his wife that he could not live upstairs. According to Leroy's wife, he was "destroying her carpeting." Leroy's doctor remembered a conversation during their last visit that indicated that Leroy drank daily at the brewery before coming home.
The challenge the doctor faced was determining how to assess the cause of the medical circumstances Leroy presented. On the one hand, the doctor asked questions about substance abuse and noted that Leroy was still drinking every day. Multiple rib fractures are seen commonly in persons who abuse alcohol. His urinary incontinence could be the result of an enlarged prostate or due to alcohol abuse. Leroy's thin appearance may have indicated malnutrition, possibly a result of or exacerbated by his drinking. Depression is another consequence of drinking and could also be contributing to his malnutrition.
The doctor also asked questions about Leroy's home life and learned about the abuse. Now the physician could attribute Leroy's malnutrition to the withholding of food. His depression could be the result of abuse, and perhaps the reason he began drinking. His rib fractures could have been caused by blunt trauma, such as the result of being pushed down the stairs. Additional blood work could help clarify the extent of his drinking and the reason for his weight loss. Unfortunately, there are no forensic markers to guide physicians in determining the cause of fractures due to abuse (Dyer, Silverman, Nguyen, & McCullough, 2002). Thus, one of the dilemmas for Leroy's doctor was differentiating which medical findings were caused by elder abuse, alcohol abuse, or both.
With collateral history from APS, more history from Leroy, and some lab studies, the physician could establish the possibility that the rib fractures and other findings were the result of abuse. Accurate documentation of the physical examination, history and lab tests, pictures of his injuries, and a clear statement about the presence of signs of abuse could greatly assist the prosecutors and others collaborating on Leroy's case. As Leroy's ribs began to heal, he felt stronger and was able to follow through with his safety plan and make decisions about how to improve his life.
Victim Capacity. While various professionals had begun working directly with Leroy, his case was brought for review to an interdisciplinary team consisting of law enforcement, APS, health care providers, and a domestic violence advocate. Initially, law enforcement suggested charging the wife with abuse of a vulnerable adult because "no man in his right mind would put up with that behavior." The APS worker and domestic advocate argued that Leroy did not fit the state definition of a vulnerable adult because he had been capable of holding down a job at the brewery for a number of years. Instead, they suggested that this was a case of domestic violence.
A geriatric physician agreed to evaluate Leroy. He found Leroy competent and declared that he did not meet the state definition of a vulnerable adult. This information was important to the APS worker, who recognized that providing Leroy with information so he could make his own decisions about his life would be the most effective strategy. Safety planning strategics were discussed at a level appropriate to match Leroy's functioning.
Legal. Several legal interventions improved Leroy's safety. In Leroy's community, APS provided reports of any investigations that might be criminal to local law enforcement. The police reviewed the report and decided to interview Leroy, who told the same story he told to APS. Leroy asked that his wife not be arrested or hurt. Since law enforcement did not get this case immediately, there was little physical evidence at the scene to collect or document. Law enforcement used a subpoena to obtain the hospital records and learned that there was medical evidence to support that Leroy had been physically abused and neglected. Leroy's wife was charged with domestic violence under mandatory arrest laws. Law enforcement gathered evidence of domestic violence and presented it to the prosecutor. The prosecutor pressed charges against Leroy's wife. She pled guilty in exchange for agreeing to participate in an abuser's treatment program and pay a fine.
Leroy worked with a domestic violence advocate to obtain a restraining order when his wife started harassing and threatening him because she wanted the charges dropped. He was also able to obtain financial help from the Victim Compensation Fund by working with a victim advocate/witness staff person located in the prosecutor's office.
The APS worker also suggested that Leroy talk with an attorney to learn more about his options and civil remedies. Leroy learned that he could get a divorce or legal separation if he chose. He could also establish financial and health care powers of attorney to name someone other than his wife as the decision maker if he became incompetent.
Physical Environment. Initially Leroy was admitted to the hospital after his doctor's appointment for a complete examination, which gave him a few days away from home to think about his options. However, due to limited insurance, he was forced to make a decision within a day about where he wanted to live.
Like most victims, Leroy wanted to remain in his own home. However, his wife was very angry about being arrested for domestic violence. She changed the locks and screamed at Leroy whenever she saw him.
Leroy lived in a community without an elder shelter. The local battered women's program did not house men but did have vouchers allowing abused men to stay at a local hotel at no cost. Leroy stayed at the hotel for several weeks while APS and the domestic violence advocates worked with local housing experts to find an affordable apartment in a senior apartment complex.
Finances. Finances became an immediate issue for Leroy as he moved into his new apartment. He was able to return to his job but did not make much money. He was fortunate to have health insurance. Leroy was going to need financial assistance to keep the apartment. Leroy s story got the attention of the local media. Members of the community wanted to help and donated money, furniture, and appliances to help Leroy move into his new apartment. Leroy worked with a benefits specialist to apply for Social Security. He worked with a financial advisor through the Area Agency on Aging who helped with a budget and balancing his checkbook.
Social Supports. Leroy had always been described as a loner-even in grade school. He had made few friends at the brewery and had no activities outside of work. The APS worker tried a number of alternatives to increase Leroy's social network and support system. Finally, upon learning that he was a veteran, she found a program for World War II veterans that he joined and where he made a few friends.
Outcome. Leroy was able to move into his own apartment and keep his job at the brewery. A domestic violence advocate helped him get a restraining order and accompanied him to court when his wife was charged and sentenced. He spoke to an attorney about changing his will and medical power of attorney. He met with a lawyer about getting a divorce but decided not to pursue one.
The case review team continued to meet every month. Leroy's case stayed on their agenda for about nine months. The APS worker lived in Leroy's neighborhood and occasionally saw him. Even after the case was closed, she provided periodic updates to the team about how Leroy was doing, based on her chance meetings with him on the street.
As with most victims, once the abuse was identified many professionals came into Leroy's life. Their ability to work informally in the field and to use the case review team significantly improved communication, resulting in enhanced victim safety and benefits to the professionals in saved time and resources.
Unfortunately, safety planning and intervention strategies alone may not end some abusive behavior. Some perpetrators continue to harm their victims regardless of the interventions offered by professionals. Other offenders move on to new victims. These perpetrators need to be held accountable using a collaborative approach.
[Reference]
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[Author Affiliation]
Bonnie Brandl, MSW
Carmel Bitondo Dyer, MD, FACP, AGSF
Candace J. Heisler, JD
Joanne Marlatt Otto, MSW
Lori A. Stiegely, JD
Randolph W. Thomas, MA
[Author Affiliation]
Offprints. Requests for offprints should be directed to:
Randolph W. Thomas, MA
204 Cart Way
Blythewood, SC 29016
E-mail: RThomas149@aol.com
