The participants shared their experience and knowledge of elder abuse prevention and intervention, highlighting service gaps and areas needing improvement. In the follow section, key themes are summarized into: 1) identification and assessment (avenues for case identification, worker awareness and readiness, organization culture and support, risk and case assessment); 2) essential skills and attitudes (respecting client autonomy and privacy, building rapport, active listening, refraining from rushing into the helping mode); 3) effective interventions (providing tangible support, strength-based approach and post-traumatic growth, support and self-help groups, addressing complicated family relations, supporting caregivers, follow-up support), 4) collaborative efforts (multidisciplinary and cross agency collaboration, effective use of community resources), 5) raising elder abuse awareness (professional training, public education, addressing bystander effect).
Identification and Assessment
Timely and effective case identification is essentially the first step for any elder abuse intervention. Although elder abuse is relatively difficult to detect as compared to other forms of domestic violence, the situation is not entirely hopeless. Participants in this study shared their experience and provide suggestions for effective detection and identification.
Avenues for case identification. Detection and identification of cases is the first, essential step for any elder abuse intervention effort. Previous studies have demonstrated that most elder abuse victims choose not to seek help or contact formal support services (Burnes, Acierno, et al., 2019; Rizzo et al., 2015). This pattern has also been observed in Hong Kong (Yan, 2015). Participants made similar observations and highlighted the importance of inquiring into elder abuse issues when providing routine services:
We always ask for additional information when [clients] apply for other services [unrelated to elder abuse]. We only learn about an abusive situation when they tell us more. Clients very rarely disclose that they are being abused when they first come to us. (Amelia, Social Worker, Elderly Services)
Many people do not come in seeking elder abuse services. They may need someone to escort them to medical appointments, need help with household chores, have financial difficulties, have difficult relationships with family members, etc. It is only when we dig deeper that we realize it is an elder abuse case. Very few people would tell you spontaneously that their family hit them. (Carmen, Social Worker, Elder Abuse Shelter)
Given that many victims do not seek help on their own, participants brought up the importance of involving “knowledgeable others.” This is consistent with findings from a previous study which showed that around one quarter of cases are referred by someone from the victim’s social network (Yan, 2015). Non-abusing family members, friends, or significant others can encourage victims to seek help from services (Burnes, Acierno, et al., 2019). In this study, participants suggested that persons in close contact with older persons, such as neighbors, janitors, security guards, and district councilors, are of great help in identifying cases of elder abuse:
Security guards in residential buildings have lots of opportunities to communicate with older residents. Workers on food delivery teams only contact them if they are using their services, and many would avoid mentioning suspected elder abuse for fear of getting themselves in trouble. If we could provide some training to security guards, they could easily keep an eye on older residents while they are on duty. (Amelia, Social Worker, Elderly Services)
It is very helpful when the building manager is a senior living in the building. Having lived in the same building for so long he/she pretty much knows everybody. Sometimes they tell me that an older resident hasn’t been going out in recent weeks, that there have been fights in the household, etc. (Florence, Center Director, Shelter for Domestic Violence Victims)
Mobilizing community stakeholders in elder abuse detection would not only help identify elder abuse cases, but also encourage older victims to seek help. It is thus essential to raise public awareness of elder abuse issues and promote the community services available to abuse victims and families:
Most of our cases are referred to us by helping professionals. Our address is confidential, and we do not share much information about our organization with the public. Older adults can be very watchful of scams. It is helpful to have someone they are familiar with to do the referral. (Gloria, Social Worker, Shelter for Domestic Violence Victims)
Different helping professionals refer cases to us. The most common are social workers from District Elderly Community Centers and Neighborhood Elderly Centers. We receive lots of referrals from the police, too, when they receive calls to mediate. And from hospitals when the victims have physical injuries or suspected injuries. (Amelia, Social Worker, Elderly Services)
Many older persons in the community visit their family doctors or hospitals on a regular basis. Medical settings offer another effective avenue for elder abuse identification. Frontline professionals’ sensitivity to and awareness of elder abuse issues are of primordial importance:
I once saw an old woman in the triage station with both hands scalded by hot water. It was pretty abnormal that it was both hands, so I suspected that someone had done it to her. When asked about the injuries, she eventually told me that her son had scalded her. We do that with unusual injuries, either nurses at the triage station or physicians in the examination rooms. (Iris, Nurse, Hospital Accident and Emergency Unit)
Our hospital has this mechanism where we must engage geriatricians or medical specialist and geriatric nurses if there is a suspected elder abuse case. Even if our colleagues in the accident and emergency unit are not certain, nurses and nurse managers will always alert us if they suspect elder abuse … I have great confidence in our medical team’s ability to identify elder abuse. They alert us [the medical social work team] if they spot the slightest irregularities. Then, of course, we also seek opinions from medical doctors. (Kate, Medical Social Worker, General Hospital)
When we receive referrals from accident and emergency units, we first check the severity of the injuries and the condition of the older patients, then we discuss with the patient whether it is safe for him/her to return home. We will suggest that the attending physician admit the patient so that we can have a “buffer” period to ascertain what happened. Patient safety always come first. (Mandy, Medical Social Worker, General Hospital)
Workers awareness and readiness. In elder abuse identification, frontline professionals’ awareness and readiness to address elder abuse cases are also of critical importance:
We must be alert of the irregularities of the injuries. You cannot simply take everything a patient says about their injury at face value. This could be tricky for junior colleagues, but most senior colleagues with more experience can tell the difference between an accident and abuse. (Iris, Nurse, Hospital Accident and Emergency Unit)
A client may have many internal struggles, they may feel too ashamed to tell us what happened. Under such circumstances, social workers’ readiness is of critical importance. If a worker chooses to turn their back, the client will just continue to hide abuse. If the worker is willing to listen, however, and is ready to dig deeper into the issue, clients will be more willing to share and positive change can happen. Social workers need to know themselves, to be ready all the time, and to continually reflect on the reasons why they might avoid addressing elder abuse issues. (Carmen, Social Worker, Elder Abuse Shelter)
Organizational culture and support. Organizational culture and policy may also shape workers’ willingness and motivation to identify elder abuse cases. Support from management is especially important when resources are scarce:
Many older patients tell us they tripped and hurt themselves when they are being physically abused by their family members. We always admit a patient [even though hospital beds are scarce] when an accompanying person tells us that their injuries were caused by violence, or if we suspect it is an elder abuse case. We really can’t afford lots of time to talk with the patient at the accident and emergency unit. Luckily, most patients are willing to stay in hospital, and that allows us more time to communicate with them, to find out whether it is elder abuse. (Iris, Nurse, Hospital Accident and Emergency Unit)
When the attending doctor sees that an injury is in an uncommon location, he/she will always consult a more senior doctor who specializes in the study of suspected elder abuse. The Hospital Authority has specific guidelines requiring that every hospital has at least one medical doctor or nurse responsible for handling suspected elder abuse cases. We work with them very closely to determine whether the case is elder abuse or just a regular accidental injury. (Liz, Medical Social Worker, General Hospital)
Risk assessment. The primary goal of elder abuse intervention is to ensure client safety. Participants discussed the importance of risk assessment:
From the moment an older client contacts us, regardless of whether he/she comes in person or contact us by phone, we always start with a thorough risk assessment to ensure his/her safety, and the alert for any potential danger. (Helen, Social Worker, Shelter for Domestic Violence Victims)
We assess the case severity, whether a hospital visit is required, whether there have been similar incidents in the past, etc. This indicates how risky the current situation is. Especially in cases of long-term domestic violence, it could be extremely dangerous for us to leave the client at home with the perpetrator. (Gloria, Social Worker, Shelter for Domestic Violence Victims)
The participants rely on a range of methods, from quantitative assessment tools to examination of case history and clinical judgment, to determine the risk level of individual cases. It is worth mentioning that the latter highly depends on helping professionals’ practice wisdom and it is essential to exercise caution. A combination of objective and subjective measures can be used to obtain a comprehensive picture.
Comprehensive case assessment. Having determined clients’ immediate risk and ensure his / her safety, a comprehensive case assessment is need:
All cases who use our shelter service complete the IMPACT scale assessment. We try to investigate how the abuse incident may have impacted the client, for example sleep problems or their physical condition. We also provide the older adults the Activities of Daily Living and Montreal Cognitive assessments, to assess their physical and cognitive functions and basic self-care ability. (Ofelia, Social Worker, Shelter for Elder Abuse Victims)
The Accident and Emergency Department screens cases and refers them to the Geriatric Unit for assessment. This is largely for the purpose of developing a care plan to minimize the likelihood of readmission. We also recommend services such as home care, meal delivery, and home visits for physiotherapy, etc. We provide environmental safety assessment to minimize fall risk at home. Such services are available whether the patient is admitted to hospital or not. (Iris, Nurse, Hospital Accident and Emergency Unit)
Essential Skills and Attitudes
Respecting client autonomy and privacy. Elder protection programs differ from intimate partner violence programs, which place a stronger emphasis on perpetrator intervention. And, unlike child protective services, elder protection programs are voluntary unless the older adult lacks cognitive capacity (Burnes et al., 2016). Besides their own physical and psychological safety, victims may also be concerned about family relationships, personal needs, cultural considerations, etc. (Ng et al., 2020). Even when their decisions are likely to expose them to an unsafe situation, professionals should respect their autonomy once they have given them advice (Burnes, 2017):
I had a hotline case where the client explicitly indicated that she didn’t want to leave, for fear that it would affect her son and her husband. She was also worried about the abuser’s criminal liability. I tried to persuade her by telling her that the abuse could escalate if she stayed and the abuser would face even greater liability, and that leaving an abusive situation does not necessarily mean involving the police. In a way, we are also helping the abuser by diffusing the situation before it becomes irreparable. (Patty, Social Worker, Elder Abuse Shelter)
Many clients may not be able to articulate their own physical or emotional states when they first arrive at our shelters. We need to provide them with a sense of psychological safety, a breathing space. Clients need to feel they are respected, and that they are safe with us. Eventually they tell us their stories. At times we may need to control our urge to jump in to protect clients and let them progress at their own pace. (Patty, Social Worker, Elder Abuse Shelter)
Even if the client understands that he/she is being abuse, we must still respect his/her wish as to whether any follow-up is needed, or whether we can bring legal action against the family member. (Wesley, Social Worker, Elderly Services)
Related to client autonomy, participants also raised the issue of privacy:
Older persons really resent people knowing about their family problems. We take extra care to protect our clients’ privacy at our meetings. It is comforting for them to know that no one else will hear anything about our conversation. Without such reassurances, many would just leave. If you are meeting a client at an elderly community center, many of the rooms have large glass windows where other people can peek in. That would be most undesirable for a meeting with a potential elder abuse victim. (Patty, Social Worker, Elder Abuse Shelter)
Many older persons are very sensitive. Especially members of community centers. They worry that other members hear what they have to say. Many of our discharged cases avoid going to community centers for fear that other people will find out they are victims of abuse and have spent time at a shelter. (Nina, Social Worker, Elder Abuse Shelter)
Rapport building. Engaging elder abuse victims is essential for effective intervention. The engagement process is critical in building a relationship of trust and strong client-practitioner relationships usually lead to desirable intervention outcomes (Burnes, 2017). Rapport building is also a major theme addressed in the focus groups:
Some clients may maintain that “it’s better to keep the skeleton in the cupboard,” but then after several meetings they decide that you are trustworthy and are willing to listen and then they start talking. (Scarlet, social worker, elderly services)
Some clients may have a long history of “building a wall between themselves and the rest of the world” and are wary of other people. We need extra time and effort to build a relationship of trust with them before moving on. I feel that everything starts with trust: without trust. clients will only tell you superficial things … one small step at a time, it takes time. (Scarlet, Social Worker, Elderly Services)
Active Listening. The therapeutic technique most commonly used by practitioners is active listening (Adkins, 2015). The participants in this study identified active listening and patience as the two essential elements to support victims of abuse:
To build rapport with client, we need to put aside our presumptions and try to understand the person sitting in front of us as a unique individual with unique experience. (Patty, Social Worker, Elder Abuse Shelter)
It takes lots of courage to leave an abusive situation. Social workers should let clients know we are there to accompany them at every step. This would give them peace of mind about later changes. When a client finally opens up to share his/her stories, the story inevitably stirs up lots of tears, deep-seated feelings, and emotional fluctuations. We need to provide clients with a safe space to tell their stories, both physically and psychologically. (Carmen, Social Worker, Elder Abuse Shelter)
Refraining from rushing into “helping mode”. Voluntary acceptance of intervention is critically important for intervention outcomes (Burnes & Lachs, 2017). Some victims struggle for a long time before they are willing to take steps to stop abuse (Burnes et al., 2016). The participants also pointed out that abuse victims, especially male victims, may resist services if they are shown a “helping” attitude in the early phase of interaction with workers:
We assume the role of friends or neighbors, merely there to show care, and slowly build up a friendly relationship. If we start off showing that we are there to help, that social workers are there to help you, it can hurt their ego and lead them to turn away. This is especially true for older males: some of them have quite a big ego. (Scarlet, Social Worker, Elderly Services)
Workers may be inclined to bombard cases with information, telling them what sort of assistance and services are available, rushing into clinical assessment, etc. and that can be scary for clients. From my own experience, the “hard sell” approach can be a real turn off. Whether they reach us through our hotline or an outreach program, we always let our clients understand that they have a choice, and it is their decision to make. Even if a client chooses to return home to their abuser after going to the police station, we just discuss the safety plan and let them go home. (Ofelia, Social Worker, Elder Abuse Shelter)
Effective Interventions
Providing tangible support. Many elder abuse victims leave the abusive situation swiftly and with little preparation. They may require tangible support such as financial assistance, clothes, and shelter. Researchers in the area maintain that, apart from providing a physically and psychologically safe environment, shelter services should also meet victims’ daily needs and provide them with community support services (Adkins, 2015; Pillemer et al., 2016):
Tangible needs are of the utmost importance to clients. Many residents in our shelter suffer financial hardships. They may have left home abruptly. Some only have their personal identity card with them, no mobile phone, no money, no clothes. They lack security and may not even let you know that they are not wearing enough clothes after arriving at the shelter… Tangible support, like food from food banks, a television to keep updated on the news, warm clothes and bedding, etc. increases their sense of security. Their acceptance of such tangible support is a huge step for them, helping them to accept the changing situation. (Carmen, Social Worker, Elder Abuse Shelter)
Many elder abuse victims may not have a clear plan as to where they will go after they leave [their home]. Those who are with us [at the shelter] may not have all the necessary resources, so it is imperative that we provide basic necessities to them. Tangible support shows that we care about them. (Carmen, Social Worker, Elder Abuse Shelter)
Strength-based approach and post-traumatic growth. Identifying victims’ strengths can help empower and rebuild their identity, thereby speeding up recovery (Brandl et al., 2003; Ernst & Maschi, 2018). The participants in our study also reported employing the strength-based approach in working with clients:
Many clients who have left our shelters come back and visit every now and then. Apart from using our services, they actually want to contribute to society, to demonstrate their abilities. They volunteer to support the newcomers at the shelters, and use their own experience to help other abuse victims. (Gloria, Social Worker, Shelter for Domestic Violence Victims)
Burnes and Lachs (2017) posited that the process of recovering itself has therapeutic effect and fosters growth. Post-traumatic growth is evident in many of the cases that our participants have worked with:
To quote a client, “being abused at 60 years old is most unfortunate, but it’s just a phase.” There is still a long way ahead and he could still contribute to his family and society between 60 and 80 years old. (Florence, Center Director, Shelter for Domestic Violence Victims)
Members of our Buddy Program1 are former residents of our shelters who have fully recovered from their traumatic experience. They have received training on therapeutic groups, and start assisting colleagues with group work. They engage in a wide range of volunteer work from assisting in groups to designing and running new services. Some even join public awareness and professional education programs, to share what can be done to help elder victims of abuse from their own perspectives. (Carmen, Social Worker, Elder Abuse Shelter)
Many members of the Buddy Program share that they no longer feel ashamed speaking of their experiences of abuse, and that they have transformed the feeling of shame into motivation to help other seniors who suffer abuse. (Patty, Social Worker, Elder Abuse Shelter)
Support and self-help groups. Peer support groups are common and effective in interventions with abuse victims (Brandl et al., 2003). Their benefits include empowerment, an improved sense of safety, enhanced social support networks, effective coping, enhanced personal growth, and reduced feelings of isolation (Adkins, 2015; Brandl et al., 2003; Ernst & Maschi, 2018). Previous studies have indicated that healthy relationships built in support groups are conducive to building psychological resources and formal help-seeking behavior (Burnes, Breckman, et al., 2019; Wolf, 2001; Yan, 2015). In this study, social workers in shelter services reported making use of peer support programs to enhance elder abuse victims’ growth and coping ability:
Women who have left our shelter may join activities organized by community centers and family services centers. They very rarely disclose their abusive experience in such contexts. We organize activities for our “alumni” where they have the opportunity to see familiar faces, fellow survivors who used to share flats with them. Such networks are especially important after they move out of the shelter and begin to live independently, many of them may move to an entirely new district far from their former homes. In the best-case scenario, they are able to build brand new social networks in the new district but that takes time. Women who stay at our shelter share similar experiences and it’s much easier for them to connect with each other. (Gloria, Social Worker, Shelter for Domestic Violence Victims)
Another form of peer support program, involving elder abuse survivors to help “coach” newcomers, has also been used and found to be very effective:
We have an ambassador program recruiting domestic violence survivors who have successfully overcome their trauma. Our clients do not only struggle to help themselves; once they have moved on, they can jump out of their shadow and support others in difficulty. (Florence, Center Director, Shelter for Domestic Violence Victims)
Every now and then a client will say, “Just because other people can succeed doesn’t mean I can” and continue to discount his/her own ability. But then it’s always nice to be able to refer to successful cases. Our clients very seldom share their abuse history in community centers but they open up to fellow residents in the shelter, knowing that everyone here more or less has the same experience. It gives them hope. (Carmen, Social Worker, Elder Abuse Shelter)
Addressing complicated family relations. When the abuser is a family member, many older victims value that family relationship more than their own safety (Burnes, 2017; Yan, 2015). Family relationships are more complicated when the victim depends on the perpetrator for assistance in daily life (Burnes, Acierno, et al., 2019). Others refuse to seek formal social services to protect the reputation of their family and their abuser, due to strong traditional Asian values (Ng et al., 2020). The participants in this study agreed that family dynamics in elder abuse cases are complicated and need to be addressed in any intervention efforts:
Clients avoid involving the police because they do not want to annoy their families. (Amelia, Social Worker, Elderly Services)
They may have fought all the time, some [abusive family members] may ignore the older person altogether. The older person is forced to roam the streets during the day and only return home late in the evening, just to avoid conflicts at home. This is psychological abuse if you ask me. Older persons react differently to situations like this. Some may avoid conflicts but still want to look out for the abusive family member. I have a case where the adult son is not taking care of the client in any way. The client goes out during the day to avoid his son but returns home to prepare meals for him day after day. The client didn’t want to leave and only came to us when it became unbearable. (Vicky, Center in Charge, Elderly Services)
Given the complex family dynamics in elder abuse cases, the participants raised that it can be helpful to involve non-abusive family members in elder abuse interventions and to educate them to increase their sensitivity. This is consistent with previous research which demonstrates supporting non-abusive family members has a strong influence on victims’ help-seeking behavior (Burnes, Acierno, et al., 2019):
The abuser may not be easy to approach, so we can only start form other family members. (Denise, Social Worker, Elderly Services)
Families need to be educated about elder abuse. Especially family members who are willing to offer help. We need to teach them about the serious impact of elder abuse, and properly equip them with ways to handle it should it occur again. (Denise, Social Worker, Elderly Services)
Supporting Caregivers. The participants noted that caregiver intervention has the potential to help prevent elder abuse as caregiver stress can be extremely high when elder care services are inadequate. This echoes previous research which found that caregiver intervention alleviates the burden of caregiving and is effective in preventing elder abuse (Busso et al., 2020; Pillemer et al., 2016). Specific measures including education on the concept of abuse, strategies to control potential abuse, emotion management could be helpful for those who have insights into elder abuse. A broken relationship between victim and perpetrator may be restored with sufficient care and support for the caregiver (Ng et al., 2020):
I have met carers who are under great pressure, and many may be incapable of providing adequate care, especially in dual-elder families. With the long waiting time for services, many caregivers feel they are trapped in a lion’s cage. This is a common and serious problem. (Beatrice, Social Work, Elderly Services)
We do not provide round-the-clock services. Even if we provide home help, it is for one or two hours at most, whereas family members are there 24 hours a day. It is worse if the care recipient is suffering cognitive decline. Some sleep very little and wander around at night making lots of noise, and their family still need to go to work the next morning. It can be very stressful to be trapped in this vicious cycle … and family members apply for elder care services because it becomes urgent. How is it helping if the waiting time ranges from one to three years? (Amelia, Social Worker, Elderly Services)
Our organization runs a group for male abusers. Members join for different reasons: some want to learn how to handle their emotions, because they are aware of their problem. At times it can be frustrating taking care of an older person. Many may blame their negative emotions on the care recipient. They may feel the care recipients are making their lives difficult intentionally. One needs to be empathetic, to understand their difficulties and struggles, to build a relationship with them in order to help. (Tom, Social Worker, Shelter for Domestic Violence Victims)
Some households in Hong Kong hire domestic help to assist with elder care. In 2019, there were 400,000 foreign domestic helpers in Hong Kong. Many receive a minimal wage of approximately USD600 per month and are required by law to live in their employers’ residence. They perform major caregiving tasks such as cooking, cleaning, transfer, bathing, and feeding of older care recipients. On top of the heavy workload, foreign domestic helpers may experience language barriers and difficulties communicating with care recipients. The participants in this study suggested that adequate training and support be provided to foreign domestic helpers:
There are quite a few older couples with a live-in domestic helper in our district. In these families, the main caregiver is the domestic helper. We do observe cases of borderline neglect every now and then. Available training and education programs mainly target family caregivers, but in many households the caregiving tasks are carried out by foreign domestic helpers. It is especially important to help those who are new to Hong Kong and new to caregiving tasks to establish a good relationship with their care recipients. A good start will help avoid many unnecessary misunderstandings. (Ursula, Social Worker, Elderly Services)
In addition to the formal programs, we also introduce foreign domestic helpers who have recently come to Hong Kong to our members who have some experience working here. This helps foster informal social support. There was once a case where an older care recipient fell and hit his head. The helper was very worried but was too afraid to tell her employer for fear that he would terminate her contract. We asked a fellow helper to talk to her and managed to find a solution that was agreeable to everyone. (Beatrice, Social Work, Elderly Services)
Follow-up support. Elder abuse intervention does not end when the victim is discharged from hospital or moves out of the shelter. The ultimate goal of elder abuse intervention is to allow the victim to lead a safe, meaningful, and sustainable life (Ng et al., 2020). Some victims seek to maintain a relationship with their abuser (Burnes, Acierno, et al., 2019). The participants in our study outlined the follow-up support they provide to victims of elder abuse to ensure their safety, support their daily living, and, if required, to seek ways to restore the relationship with their abuser:
Whether the older adult returns to his/her home or moves to a new community, we devise a safety plan. The plan covers their relationship with their abuser, managing emotional health, and includes the means to contact us at any time. They are fully informed that they can reach out to us any time should they have a problem or if they just want to have a casual chat with us. They may even choose to come back to the shelter. We follow up each case for a minimum of three months regardless of whether they are staying on their own, living in a nursing home, or have gone back to stay with their abuser. (Carmen, Social Worker, Elder Abuse Shelter)
We have a group therapy program catering for older adults who have left shelters. Most come to the shelter confused, there being simply too many things to manage, and they can spare very little time and energy for counseling, and some may not be psychologically ready for treatments. It is after we have settled all the practical issues such as housing and daily necessities that older adults have time to re-examine the abuse experience. (Carmen, Social Worker, Elder Abuse Shelter)
Collaborative Efforts
Multidisciplinary and cross-agency collaboration. Apart from addressing the needs of victims and families, participants also pointed out that it is beneficial to work with colleagues from other teams or disciplines. Indeed, a multidisciplinary approach has been shown to enhance the efficiency of service delivery and improve the outcome of intervention (Burnes, 2017; Pillemer et al., 2016). Frontline practitioners from different professions agreed that no single profession can handle elder abuse cases alone and that input from a multidisciplinary team is considered very helpful for intervention:
Although there are social workers at the shelter to work on the case, we still see whether there is a family social worker from the community to follow up, and make referrals if not. Social workers at shelters are responsible for client adjustment, daily necessities, emotional and physical support. But when it comes to relationship and emotional problems with family members, we refer cases to social workers from the community for family counseling. (Rose, Social Worker, Elder Abuse Shelter)
Besides social services, workers in healthcare, legal, and even finance service settings may encounter elder abuse victims (Walter & Chang, 2021). Close collaboration and communication among different disciplines are essential to elder abuse intervention. The participants in this study have experience of collaborating with other professions in handling elder abuse cases. However, the process may not be smooth since different professions have their own points of view. Fostering understanding among different professions is essential for collaboration to be successful:
Our hospital community geriatric assessment team provides outreach services. We hold a multidisciplinary conference every few months and discuss how to manage cases. Professionals from different disciplines give opinions and suggestions. We also discuss whether we would need to report a case to the authorities if it was someone in a nursing home. (Liz, Medical Social Worker, General Hospital)
I think input from medical doctors and clinical psychologists is important. Their professional assessments can provide relevant information that will help us to confirm whether we have an elder abuse case. A medical doctor would guide the discussion most of the time. If we rule out a case of elder abuse, we work together to see how we can improve patient care. (Liz, Medical Social Worker, General Hospital)
We can only afford to manage physical injuries. When it comes to suspected elder abuse, we always refer cases to our medical social work team. (Jenny, Nurse, Hospital Accident and Emergency Unit)
Effective use of community resources. Intervention and prevention of elder abuse often involve resource provision and service referrals. Connecting abuse victims to social resources may reduce their risk of being further abused (Yan, 2015):
Besides helping clients adapt and feel psychologically safe at the shelter, we also discuss practical issues. If he/she wants to leave his/her home, we ask integrated family services centers or other social service units to help them to apply to nursing homes or find alternative accommodation. If the client wishes to deal with their family members’ mental health problems, we refer them to mental health services. In addition to individual counseling, we also advise clients to join various activities during their stay with us. (Ofelia, Social Worker, Elder Abuse Shelter)
The hospital does not force older adults to return home after discharge. In cases where grown-up children refuse to take care of older patients, our medical social work team will help provide alternative solutions, private housing or government subsidized nursing homes, or alternative housing. The goal is to minimize the stress experienced by older adults. (Jenny, Nurse, Hospital Accident and Emergency Unit)
Raising Elder Abuse Awareness
Professional Training. Researchers have noted that elder abuse awareness is far from satisfactory among frontline practitioners (Walter & Chang, 2021; Yan, 2015). Frontline practitioners not only include medical, social, and healthcare professionals, but also other professionals in legal and judicial domains, as well as those who provide primary elder care. Ideally, frontline practitioners would have both the knowledge and confidence necessary to identify and intervene in suspected elder abuse cases:
Most frontline staff, such as receptionists, personal care workers, healthcare workers, provide hands-on care to older persons. They are the first line of workers who are alert to the life circumstances of an older person. Say you visit a home and you can tell from the smell that it has been days since the older person has taken a bath. You can pick up lots of information from the living environment. Training should not be limited to social workers or health professionals, frontline staff, in particular those in supportive roles, should receive training. They spend the most time with clients and are in the best position to identify elder abuse cases. (Ursula, Social Worker, Elderly Services)
Most families eventually call the police. A police taskforce would be an effective way to refer clients to necessary resources if they could identify elder abuse cases. (Gloria, Social Worker, Shelter for Domestic Violence Victims)
It is not easy to differentiate abuse from accidental injuries, the physiological changes of aging, and/or chronic diseases (Ng et al., 2020; Walter & Chang, 2021). Medical social workers who took part in this study suggested that basic medical knowledge would be of help in differentiating elder abuse from accidental injuries:
Some elder abuse cases take place in nursing homes, among which drug-related incidents represent the majority. Say a resident with no history of diabetes was given diabetic medication and has low blood sugar as a result. It could be an honest mistake, or it could be someone playing a bad joke. At times we also see atypical bone fractures. Or the nursing home reports no falls. How likely is it that a bed-bound patient was walking around and ended up falling and breaking a bone? You can’t help but wonder whether someone hit him. I consulted a geriatrician about this. I was told that long-term bed-bound status may result in a patient’s bone being more brittle and easily breakable if too much force is used in transferring a patient. Nurses would call that “rough handling.” As medical social workers, we need more knowledge of bone fractures and injuries. It would make it a lot easier for us to understand the situation, or to collect evidence. (Kate, Medical Social Worker, General Hospital)
Some medical knowledge would come in handy for social workers, in particular medical social workers. A colleague of mine received a case of suspected elder abuse in a nursing home. A family member spotted lots of bruises all over the patient’s body during her visit. The thing is, bruises can result from a host of different conditions. Some basic medical knowledge would be useful in a situation like that. (Xania, Medical Social Worker, General Hospital)
Apart from basic medical knowledge, participants also raised that brief and reliable screening instruments for elder abuse would be useful:
Medical social workers use a validated scale to measure suicide risk. Although we cannot make any absolute diagnosis based on assessment scores, it provides a very good indicator. A risk assessment scale for elder abuse sensitive to the local context would be very helpful to fellow colleagues. Let’s say I am handling a suicide case, having a solid score on the suicidal ideation index would give me more chips when I am bargaining with other service units such as nurses and doctors, to convince them that there is an urgent need. The information would also be very useful when making case referrals. Service units that took up a case would get a better idea of it and would feel more confident handling it. (Kate, Medical Social Worker, General Hospital)
When I conduct training for social workers, trainees reflect that besides workers’ readiness to handle cases, a risk assessment tool would be very useful. Those of us who are more experienced in elder abuse crisis management look into clients’ present safety, abuse history, frequency and intensity of abuse, whether any weapon was used, etc. Trainees with less experience may not be as confident, so having an assessment tool to hand may give them more confidence. At least they would have something to fall back on, some scores that they could refer to. (Patty, Social Worker, Elder Abuse Shelter)
The participants also raised the benefits of mobilizing elder abuse survivors in professional and community training:
Elder abuse survivors are very keen to share their experience with the police, medical staff, and younger people in the community. In doing so, they not only offer first-hand accounts to trainees, but also empower other elder abuse survivors. (Patty, Social Worker, Elder Abuse Shelter)
Public education. Awareness campaigns can reduce negative labeling effects of elder abuse, and encourage help-seeking behavior among victims (Yan, 2015). Some countries even rate awareness campaigns over interventions and preventions (Pillemer et al., 2016). Campaigns can include understanding elders’ rights, and the definitions, signs and symptoms, and consequences of elder abuse. The target audience of these campaigns should include seniors and caregivers, human service professionals, policymakers and stakeholders, and the general public:
Is the older victim aware that he/she is being abuse? Not necessarily. This is exactly why we need to deliver more public education. (Wesley, social worker, Elderly Services)
An elder abuse victim may not be aware that he is being abused. Training would need to start by equipping older persons with this basic knowledge, so that they understand their own rights. (Emma, Social Worker, Elderly Services)
Caregivers should be informed of the declines associated with natural aging and be prepared for the worst scenarios. (Ursula, Social Worker, Elderly Services)
To quote domestic violence victims I have worked with: It is easy for physical injuries to heal and recover, much less so for psychological abuse. Being repeatedly told, “You are a useless creature,” “You are better off dead” has a long-term impact on victims, in terms of cognition, emotions, etc. We utilize experiential learning in our training programs. For example, we invite participants to sit and have everyone scold him for a couple of minutes, so they can experience the strong feelings resulting from verbal abuse. This exercise is very useful for younger people. They begin to understand how a slip of the tongue can have lasting effects on the recipient. (Gloria, Social Worker, Shelter for Domestic Violence Victims)
Addressing “by-stander effects” and ambivalence. “Sweep the snow from your own doorstep, don’t worry about the frost on your neighbor’s roof.” This Chinese idiom reflects the entrenched cultural belief that one should not get involved in others’ family affairs. As a consequence, many people would refrain from providing advice or offering help to an acquaintance even if elder abuse was suspected (Yan, 2015). The participants shared this experience:
I ran a community education program years ago. We recruited volunteers to do home visits and educate older persons about elder abuse, ways to communicate with suspected victims, etc. At the briefing session with volunteers, I asked them what they would do if they suspected that an older person was being abused. Some responded that they would ask them to tolerate it! And these volunteers were clients who had themselves used our elder abuse services! This reflects the deep-seated idea that it is wrong to tear families apart. Although it didn’t go as I had imagined, the program gave me a new perspective on how we should mobilize older persons to help their peers, how having a similar upbringing and values probably allows them to communicate better with each other. (Carmen, Social Worker, Elder Abuse Shelter)