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BY: JOHN D. (JACK) RUDNICK, JR, Ed.D.

Dr. Rudnick is administrator, Holy Family Home, Melbourne, Ky., assistant professor, business administration, Thomas More College, Crestview Hills, Ky.

Clergy and Health Care Providers Should Be Positioned to Spot Abuse

Because elder abuse victims, abusers and stakeholders often seek help from faith-based entities, clergy and faith communities need to be prepared with appropriate intervention responses, concept awareness and knowledge concerning elder abuse and neglect as an emerging health and social crisis.¹ The following article explores fundamental descriptions and reasons for elder abuse and neglect in the United States. Suggestions and intervention strategies are provided for clergy and faith communities, as well as for health care providers, to show how they can witness to the Gospel message of Jesus Christ by assisting victims, abusers and family members.

An Escalating Problem
The world is in the throes of a demographic revolution, according to the World Health Organization.² An anticipated increase in the number of older persons in the United States supports this contention. On its website, the U.S. Bureau of the Census predicts that people 65 and older will outnumber children by the year 2020 and will comprise 25 percent of the nation's total population by the year 2050. Experts predict that the frequency in occurrences of elder abuse and neglect is likely to increase proportionally as the population ages.³ Elder abuse is an escalating global phenomenon requiring further awareness, inquiry and research.⁴

Literature reveals that there are as many variations and descriptions of what constitutes elder abuse as there are researchers studying this growing concern. According to the National Center on Elder Abuse, federal definitions of elder abuse, neglect and exploitation first appeared in the 1987 Amendments to the Older Americans Act. A general description is the intentional or neglectful acts by a caregiver or "trusted" individual that may lead to harm of the vulnerable elder.⁵ An interesting observation from the historic literature is that early studies focused heavily on caregiver stress as a major cause of elder abuse.⁶ However, researchers worldwide discovered that this social problem is far more complex.⁷ Later and more recent research has broadened the scope of studies to include expanded risk factors.

In public health and social research, incidence is the number of new cases occurring over a period of time; prevalence refers to the number of cases in a given population at a point in time.⁸ The 1998 National Elder Abuse Incidence Study⁹ reported that a lack of uniformity, consistency, and standardization of what defines and constitutes elder abuse worldwide prevents its precise incidence and prevalence from being known. The National Center on Elder Abuse reinforced this premise — a lack of a commonly agreed-upon definition — because the precise number of older Americans being abused, neglected or exploited cannot be determined.¹⁰ Because definitions vary, no uniform reporting system has been established for state statistics, and comprehensive national data are not collected. However, with estimates that 10 percent of Americans older than 65 are abused, elder abuse strikes with the frequency of other common chronic illnesses that plague older persons, such as diabetes.¹¹ The National Elder Abuse Incidence Study strongly confirmed the validity of the "iceberg theory," which has been accepted by experts on aging since the 1970s. Based on information provided by the trained National Elder Abuse Incidence Study "sentinels" (those who watched out for signs of abuse), this theory projected that only 18 percent of elder abuse cases were actually reported, resulting in an estimate of five times as many cases that were not.¹²

Dr. Pamela Teaster, a professor at the University of Kentucky's Sanders-Brown Center on Aging, notes that "from an awareness perspective, elder abuse is where child abuse was 20 years ago."¹³

While definitions differ among states, the National Center on Elder Abuse broadly defines three categories of abuse: domestic, institutional, and self-neglect. Domestic abuse refers to forms of maltreatment by someone who has a special relationship with the older person — a spouse, sibling, child, friend, or caregiver — that occurs in the home of the older person or caregiver. Institutional abuse refers to maltreatment that occurs in elder residential facilities — nursing homes, foster homes, group homes, and board and care facilities — where perpetrators are paid caregivers, staff members or professionals who have a legal or contractual obligation to provide elderly people with care and protection. Self-neglect refers to the behavior of an older person that threatens his or her own health or safety, such as failing to provide him- or herself with adequate food, water, clothing, shelter, personal hygiene, medication or safety precautions.¹⁴ Most forms of abuse can be sorted into one of these three categories.

The National Center on Elder Abuse reported that elder abuse in the United States occurs primarily in domestic situations, with adult children being the most likely perpetrators.¹⁵ The center also found that crimes committed by family members were the least likely to be reported and prosecuted. Nationally, one in 14 cases of abuse and neglect are reported to adult protective services or the police. Age, a risk factor, also increased the likelihood of abuse, neglect and exploitation. More than 43 percent of victims of abuse were over 80 years old, 36 percent were between 70 and 79 years old, and 21 percent were between 60 and 69 years old.¹⁶

As the aging population increases, the incidence of elder abuse is likely to grow. The projected increase in the needs of United States residents aged 60 and over, coupled with a rising number of residents in this age category, is likely to result in a "social tsunami."¹⁷ Health care providers and faith-based communities need to be adequately equipped to cope with this impending storm.¹⁸

Health Care Organizations and Clergy Have Pivotal Roles
Health care organizations and systems can serve as conduits for community awareness and information on elder abuse and neglect. Organizations and systems can link interested members to community and web-based resources and services. Health entities can provide further awareness and more detailed education and training and offer intervention strategies concerning where to report suspicions of abuse and where stakeholders can seek assistance (e.g., Adult Protective Services, police, counseling services). There is a critical need for credible research data and statistics to establish benchmarks for determining incidence and prevalence, and to measure outcomes. Both are ways that organizations and systems can contribute toward ameliorating this social and health issue.

Health care organizations have opportunities to provide vigilant oversight for intervention when abuse or neglect is suspected at entry points into the organization's system, such as emergency and home health divisions. Information can be provided via presentations to those who work in the offices of medical staff members, newsletters and other communications to the wider community. Organizations can weave high-risk screening criteria and possible factors that predispose older adults to abuse into clinical assessments and coordinate support resources. Employee orientation offers an opportunity for sharing the collective responsibility of all members of a health care organization to be alert and attentive to possible abuse and neglect. Parish health outreach services, where available, might consider enlisting their ministers in sharing information about abuse and neglect with community and congregation members.

Inclusion of information about abuse and neglect may be especially relevant to those organizations and systems with "women's centers," given that women are typically most affected by direct care responsibilities. Organizations and systems can consider support in the business health and employee assistance program areas, because many in the work force are feeling the "sandwich generation" squeeze (i.e., caring for older adults and children while holding down a job) and may need to be aware of warning signs of self-neglect and vulnerability of older parents to financial and material exploitation. (Employees may be susceptible to caregiver stress and strain, which can contribute to abuse and neglect scenarios; employee assistance programs may be a sound resource to help defuse potential neglect and abuse.) Community organizations targeted for information sharing can include financial institutions and their staffs, as well as public servants, including police, fire and rescue departments, social service agencies and attorneys.

The concept of religious community is especially significant as a support for those coping with health or social illness. Individuals and families often seek help from clergy members and church staff in times of crisis. Statistical reports indicate that some 300,000 Protestant ministers, 49,000 Catholic priests, and 4,000 rabbis serve in 500,000 churches and temples in the United States.¹⁹

Little has been written in the peer-reviewed literature on the roles of faith-based organizations and clergy in addressing elder abuse and neglect in the United States. Canadian researchers Podnieks and Wilson argued the following two points: The role of the clergy is significant because clergy members are among the most likely groups of front-line support caregivers to encounter and be entrusted with communication concerning elder abuse and neglect, and training is needed to educate clergy members on the important roles they can play in elder abuse prevention, intervention, and treatment.²⁰ The Kentucky Elder Readiness Initiative asserted that clergy plays an important role in helping older adults experience relief from physical, emotional, and spiritual suffering in that state.²¹ However, while members of the clergy could also play an important role in relieving the potential looming crisis related to elder abuse and neglect, they may not be prepared to do so.

Faith communities, like health organizations, can play a critical role in highlighting public awareness and providing intervention services. Faith leaders are among the most likely professionals to encounter abuse occurring in members' homes. However, clergy and faith communities are not prepared to deal with the needs of aging members. Further, there is a significant gap in their understanding of elder abuse²² and of ageism — a biased negative view against the aged, which is prevalent in many cultures.

Faith-based organizations, including Catholic hospitals, faith communities and clergy can be proactive conduits for the well-being and safety of older adults. Increased awareness, a mechanism to inform seniors, and training are among the intervention initiatives recommended to promote clergy effectiveness. Parish nurses were cited as a resource for holistic nursing services.²³ Sensitivity to the unique needs of congregants is important. For example, some victims may be reluctant to report abuse. They may be intensely private individuals or they may have grown up in families where abuse was not discussed. Training is an effective means of educating religious leaders to impart knowledge on improving effectiveness in prevention, intervention and treatment roles.²⁴ Culture and context are also important when considering elder abuse prevention needs — especially in a global or transient community where people from various countries and backgrounds have different and unique needs.²⁵ Plans and methods are also needed to address the future needs and expectations of special interest groups (e.g., baby boomers and immigrants from countries where cultural norms differ).

The lack of clergy knowledge of abuse issues, types, risk factors, and warning signs is an important concern because these knowledge voids inhibit the ability of clergy members to be effective in counseling victims and those seeking help during the healing process. Some researchers reported that clergy members lacked knowledge and familiarity with basic abuse referral procedures.²⁶ Specialized training in abuse counseling for clergy is minimal, and faith leaders need to learn appropriate knowledge and intervention skills.²⁷ Increasing education and training is a means of narrowing the gap and assisting in the education of clergy members to meet the growing needs of faith communities.²⁸

Action and strategies to increase knowledge for faith-community clergy members and staff include pursuing self-education (e.g., gerontology coursework); attending seminars; pursuing, studying, and considering adoption of best practice guidelines; and pursuing other education resources in the community.²⁹

Recommended Areas for Future Research, Discussion
The following strategies are crucial to consider when addressing the issue of elder abuse and neglect. Although these strategies specifically apply toward clergy, which was the focus of this author's most recent research,³⁰ they can certainly be applied to other faith-based organizations and health care providers.

Establish High-Risk Screening Criteria for Congregants at Risk. This can be done in conjunction with developing or updating a church's census. Technology and cross-tabulation (i.e., cross-reference) of information obtained through the census can be included to identify culturally specific factors that contribute to elder abuse (e.g., over 80 years old, lives alone, multisystem health needs, homebound).

Launch Seminary and University-Based Education for Clergy and Professionals. Results of this author's study show that it would be useful for seminaries or faith-based organizations to conduct education, training and continuing education programs on elder abuse and neglect. An evaluation of important elements and barriers to clergy effectiveness in program design (e.g., codes of conduct — non-mainstream populations), confidentiality, trust, empathy, and understanding elder abuse and neglect stakeholder behaviors should be included.^{31, 32}

Consider Adapting the VIRTUS^® Training Model. VIRTUS is an organization that combats wrongdoing by churches. It educates and trains members of congregations to be aware of and prevent child abuse. Because it serves as an established forum for communication, VIRTUS has the capability to accommodate discussion on elder abuse.³³ Explore the possibility of including a segment on the protection of older (and disabled) persons as a vulnerable at-risk population.

Use Faith-Based Community Networks to Help Expand Clergy Time and Resources. Explore avenues to find the time and resources for clergy members to be more available to assist with an elder abuse and neglect ministry.³⁴ Develop and further integrate "faith community network" (e.g., parish health nursing) ministries into congregations to strategically address elder abuse and neglect.³⁵

Further Develop Resources for Data Expansion to Advance Research and Policy Analysis. More programs and services are needed to address elder abuse and neglect. Collecting of appropriate and useful data and information on which to make factual and informed decisions is an integral part of the process.

Conclusion
Continued discussion on the issue of elder abuse and neglect is significant for the following reasons:

• It establishes opportunities for critical thinking by examining and borrowing parallel constructs from other related disciplines (e.g., child abuse and domestic violence) to establish ideas for future prevention and intervention.
• It adds dialogue and innovative dimensions to the existing body of research on this topic (i.e., the study of faith-based organizations relating to the growing social concern of elder abuse and neglect).
• It assists clergy members and other professionals in clarifying their personal understanding of elder abuse and neglect with accurate facts, identified differences in concept awareness, and more detailed knowledge on the topic.
• It identifies a baseline for awareness, education levels, and training needs that should be targeted to make the best use of available resources.
• It contributes to attracting the public's attention to the value of faith-based organizations and staff as a vital societal asset for both tangible and intangible community resources.

Faith-based communities and clergy seem to be unaware of the imminent emerging crisis that the aging of the baby boomer population poses, and communities are not prepared for the level and caliber of services that baby boomers expect. Proportionally, the incidence and prevalence of elder abuse is likely to rise. Since elder abuse is considered an interlocking element of the family of personal violence, an analysis of domestic violence as a related construct may be a useful field to explore for potential parallel research and best practices.

From a Biblical perspective, as Jesus challenged his apostles to watch out for dangerous predators in the Garden of Gethsemane, those in faith communities and the health care field can become sentinels challenged to be vigilant and watch out for the best interests of vulnerable older adults.

NOTES

1. Graduate Center for Gerontology, Kentucky Elder Readiness Initiative: A Survey of Commonwealth Residents, Preliminary Report, (Lexington, Ky.: University of Kentucky, 2007).
2. World Health Organization, Prevention of Elder Abuse (2004), www.who.int/ageing/projects/elder_abuse/en/.
3. Diane Wieland, "Abuse of Older Persons: An Overview," Holistic Nursing Practice 14, no. 4 (2000): 40-50.
4. Wilson Bezzera-Flanders and Jennifer C. Clark, "Perspectives on Elder Abuse and Neglect in Brazil," Educational Gerontology 32 (2006): 63—72; Monica Ferreira, "Elder Abuse in Africa: What Policy and Legal Provisions Are There to Address the Violence?" Journal of Elder Abuse and Neglect 16, no. 2 (2004): 17-32; Bridget Penhale, "Elder Abuse in Europe: An Overview of Recent Developments," Journal of Elder Abuse and Neglect 18, no. 1 (2006): 107-16.
5. National Center on Elder Abuse, Fact Sheet: Elder Abuse Prevalence and Incidence, (2005), www.ncea.aoa.gov/NCEAroot/Main_Site/pdf/publication/FinalStatistics050331.pdf.
6. S.A. Compton, Peter Flanagan and W. Gregg, "Elder Abuse in People with Dementia in Northern Ireland: Prevalence and Predictors in Cases Referred to a Psychiatry of Old Age Service," International Journal of Geriatric Psychiatry 12, no. 6 (1997): 632-35.
7. 17. Elizabeth Podnieks and Sue Wilson, "Elder Abuse Awareness in Faith Communities: Findings from a Canadian Pilot Study," Journal of Elder Abuse and Neglect 15, nos. 3/4 (2003): 121-35.
8. National Council on Child Abuse and Family Violence, Elder Abuse Information (2008), www.nccafv.org/elder.htm.
9. The National Elder Abuse Incidence Study, Final Report (1998) www.aoa.gov/AoARoot/AoA_Programs/Elder_Rights/Elder_Abuse/
   docs/ABuseReport_Full.pdf.
10. National Center on Elder Abuse, Fact Sheet.
11. Wieland.
12. World Health Organization.
13. Dr. Pamela Teaster, personal communication, June 25, 2009.
14. National Center on Elder Abuse, Frequently Asked Questions (2008), www.ncea.aoa.gov/NCEAroot/Main_Site/FAQ/Questions.aspx.
15. National Center on Elder Abuse, 2004 Survey, http://chfs.ky.gov/dcbs/dpp/eaa/statistics.htm.
16. National Center on Elder Abuse, Survey.
17. Graduate Center for Gerontology.
18. Lauren M. Polson and Robin K. Rogers, "Counseling and Mental Health Referral Practices of Church Staff," Social Work and Christianity 34, no. 1 (2007): 72-87.
19. Andrew J. Weaver, "Clergy as Health Care Providers," Southern Medical Journal 98, no. 12 (2005).
20. Podnieks and Wilson.
21. Graduate Center for Gerontology.
22. Podnieks and Wilson.
23. Podnieks and Wilson.
24. Podnieks and Wilson.
25. Keren Rabi, "Israeli Perspectives on Elder Abuse," Educational Gerontology 32, no. 1 (2006): 49-62.
26. Katie Brennan Homiak and Jon E. Singletary, "Family Violence in Congregations: An Exploratory Study of Clergy's Needs," Social Work and Christianity 34,          no. 1 (2007): 18-46.
27. Podnieks and Wilson.
28. Robert J. Taylor, et al., "Mental Health Services in Faith Communities," Social Work 45, no. 1 (2001): 73-87.
29. Podnieks and Wilson.
30. John Rudnick, "Elder Abuse and Neglect: A Survey of Clergy Awareness, Knowledge, Intervention Preferences and Perceived Severity," (Ed.D. diss., Argosy University, Sarasota, Fla., 2009).
31. Eric. J. Bruns, et al, "Clergy Members as Responders to Victims of Sexual Abuse and Assault," Journal of Religion and Spirituality in Social Work 24, no. 3 (2005): 3-19.
32. Virginia L. Susman and Martha L. Bruce, "Implementation of a Program to Improve the Continuity of Mental Health Care Through Clergy Outreach and Professional Engagement (C.O.P.E.)," Professional Psychology: Research and Practice 39, no. 2 (2008): 218-28.
33. Rudnick; National Catholic Risk Retention Group, VIRTUS Online (2008), www.virtusonline.org/virtus/.
34. Bruns; Homiak and Singletary; Podnieks and Wilson; Kenneth I. Pargament and Gene G. Ano, "Spiritual Resources and Struggles in Coping with Medical Illness," Southern Medical Journal 99, no. 10 (2006): 1161-62; Evelyn Slaght and Nina Hamilton, "A Coordinated Response to Intimate Partner Violence: Lessons from an Exploratory Study," Journal of Community Practice 13, no. 2 (2005): 45-59.
35. Ana Maria Catanzaro, et al, "Congregational Health Ministries: A National Study of Pastors' Views," Public Health Nursing 24, no. 1 (January-February 2007): 6-17.