GENS_spring2020

Taking Action Against Elder Mistreatment SPRING 2020 volume 44 number 1

Journal of the American Society on Aging

Taking Action Against Elder Mistreatment

The National Collaboratory to Address Elder Mistreatment: a roadmap to safer lives

Adult Protective Services and multidisciplinary

Our national shame: where is funding for elder abuse prevention?

teams: a powerful collaboration

American Society on Aging and the USC Leonard Davis School of Gerontology are partnering again to bring you five different 5-week online courses. • Advanced Concepts in an Aging Society • Fundamentals of Gerontology • Managing Health and Chronic Conditions in Older Adults • Understanding Abuse and Neglect (April 20-May 22) • Prevention of Abuse and Neglect (August 31-October 2) Successful participants will earn a certificate of completion from USC, and CE credits are offered from select accreditation providers. Courses are offered April 20–May 22 and August 31–October 2. www.asaging.org/USC-gero

is the quarterly journal of the American Society on Aging.

Each issue is devoted to bringing together the most useful and current knowledge about a specific topic in the field of aging, with emphasis on practice, research, and policy.

Peer review consists of the following practice: the Genera­ tions editorial board invites a guest editor, selected because of prominence within his or her subject area, to organize an issue of the publication around themes identified by the board. Authors are then proposed by the guest editor and are evaluated by the board on the basis of demon- strated knowledge, achievement, and excellence in their respec- tive fields. All manuscripts are reviewed by the guest editor, editor, and, when appropriate, members of the editorial board. As occurs in any peer review process, revisions may be re- quired, and articles that do not meet the editorial standards of Generations will not be published. Generations (ISSN 0738-7806) is published quarterly by the American Society on Aging, 575 Market Street, Suite 2100, San Francisco, California 94105-2869. www.generationsjournal.org www.asaging.org The American Society on Aging (ASA) is the essential resource to cultivate leadership, advance knowledge, and strengthen the skills of those who work with, and on behalf of, older adults.

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Volume 43 . Number 4 | 1

GENERATIONS – Journal of the American Society on Aging

American Society on Aging welcomes Peter Kaldes as our new President and CEO

We look forward to working with you to achieve our mission to be the go-to source to cultivate leadership, advance knowledge and strengthen the skills of our members and others who work with and on behalf of older adults.

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Taking Action Against Elder Mistreatment

ASA Executive Committee Chair, Board of Directors Karyne Jones, Washington, DC Chair-Elect Michael Adams, New York, NY Secretary Jean Accius, Washington, DC Treasurer Lisa Gables, Alexandria, VA Member at Large Deborah Royster, Washington, DC ASA Board of Directors Ginna Baik, San Diego, CA Connie Benton Wolfe, Fort Wayne, IN Richard Browdie, Alexandria, VA

GENERATIONS STAFF Editor

Alison Hood Senior Editor Alison Biggar Typography & Production Michael Zipkin | Lucid Design, Berkeley Generations cover and book design by Lisa Rosowsky, Blue Studio. Generations Editorial Advisory Board Wendy Lustbader Chair Susan C. Reinhard Immediate Past Chair Tobi Abramson Jean Accius Patrick Arbore David Bass

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Robert Espinoza, New York, NY Maria Henke, Los Angeles, CA Brooke A. Hollister, San Francisco, CA Karen N. Kolb Flude, Chicago, IL Daniel Lai, Hong Kong Rebecca C. Morgan, Gulfport, FL Scott Peifer, San Francisco, CA Kevin Prindiville, Oakland, CA Phil Stafford, Bloomington, IN Joyce Walker, Richmond Heights, OH ASA President and CEO Peter Kaldes

Sam Fazio Sarah Jen

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Kevin Prindiville Anne Tumlinson

Front cover image ©iStockPhoto/ duncan1890 © 2020 American Society on Aging

Union Bug

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Volume 44 . Number 1 | 3

GENERATIONS – Journal of the American Society on Aging

ins ide generat ions Taking Action Against Elder Mistreatment

connect ing sys tems : fol lowing an e lder ’s potent i a l journey through sys tems 44 EAGLE and DETECT—Innovative Tools Helping First Responders to Combat Elder Abuse By Brad Cannell, Lori Mars, and Julie Schoen 51 EM-SART: A Scalable Elder Mistreatment Screening and Response Tool for Emergency Departments By Timothy F. Platts-Mills, Theresa Sivers- Teixeira, Andrew Encarnacion, Brian Tanksley, and Bonnie Olsen 59 Connecting Community-Based Resources and Health Systems to Keep Older Adults Safe By Kristin Lees Haggerty, Alice Bonner, and Debi Lang 67 Advancing the Elder Abuse Work of Adult Protective Services Through Participation on Multidisciplinary Teams By Risa Breckman, Deborah Holt-Knight, Lisa Rachmuth, and Rima Rivera 74 Elder Abuse Shelter Programs: From Model to Movement By Malya Kurzweil Levin, Daniel Reingold, and Joy Solomon 81 The Weinberg Center for Elder Justice: A Place to Shelter By Joy Solomon 84 The Role of Civil Legal Aid in Elder Abuse By Sarah Galvan and Vivianne Mbaku 91 Elder Mistreatment Intervention: Strategies for Connecting with Diverse and Rural Populations By Carmel Bitondo Dyer, Cristina Murdock, Julia Hiner, John Halphen, and Jason Burnett

6 Our Guest Editors

Kristin Lees Haggerty, Rebecca Jackson Stoeckle, and Terry Fulmer

e lder mi s t reatment : prevent ion , percept ion , and a ca l l to act ion 8 A Roadmap Toward Safer, Happier Lives: The National Collaboratory to Address Elder Mistreatment By Kristin Lees Haggerty, Rebecca Jackson Stoeckle, and Terry Fulmer 10 The Might of Metaphor: Strengthening 17 Reframing Elder Abuse By Laura Mosqueda, Alyssa Neumann, and Eden Ruiz-Lopez 20 Elder Mistreatment Across Diverse Cultures By Mengting Li, Ruijia Chen, and XinQi Dong hea l th sys tems , older adul t s , and e lder mi s t reatment 26 Connecting Models of Care to Address Elder Mistreatment By Shrien Alshabasy, Benjamin Lesiak, Amy Berman, and Terry Fulmer 33 The National Collaboratory on Elder Mistreatment By Rebecca Jackson Stoeckle and Scott Bane 38 The Power of Data Can Support Effective Response to Elder Mistreatment in Hospital Emergency Departments Support for Elder Abuse Prevention By Daniel S. Busso, Moira O’Neil, and Andrew Volmert

By Kim Dash, Tony Rosen, Kevin Biese, Timothy F. Platts-Mills, and Ula Hwang

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

4 | Spring 2020

Taking Action Against Elder Mistreatment

pol i cy and act ion aga ins t e lder mi s t reatment 98 The Future of Elder Justice: A Perspective from the Administration for Community Living By Elizabeth Petruy and Hilary Dalin 101 The U.S. Department of Justice Defends Against Elder Financial Fraud and Abuse By Andy Mao 103 Getting Ahead of the Curve to Prevent Elder Mistreatment in the United States By Linda L. Dahlberg 106 Elder Justice Policy: Where We Are Now and Where Do We Go Next? By Robert B. Blancato and Meredith Whitmire

111 Building a National Elder Justice Movement, State by State By Georgia J. Anetzberger, Risa Breckman, Paul L. Caccamise, Iris C. Freeman, and Lisa Nerenberg 117 Our National Shame: Little to No Funding for Elder Abuse Prevention and Response By Kathy Greenlee 124 Elderabuse.org: A National Charity Fighting Elder Abuse via Direct Service, Research, and Advocacy

By Mark S. Lachs, Ronald Adelman, Risa Breckman, and David Burnes

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

Volume 44 . Number 1 | 5

GENERATIONS – Journal of the American Society on Aging

Our Guest Editors

Passionate and Pragmatic: A Trio of Advocates Work to Eradicate Elder Abuse S pring 2020 Generations co-Guest Editors Kristin Lees Haggerty,

interventions aimed at improving health (especially among older adults, but with a primary focus to prevent and remedi- ate elder mistreatment). Jackson Stoeckle serves as a vice president at EDC and is director of its Private Sector Partnerships, where she oversees initiatives in health, technol- ogy, aging, and systems change. For thirty years, she has designed innovative, technology-based projects to address major challenges in health and economic opportunity, especially around improv- ing healthcare for older adults with dementia and for those who have expe- rienced abuse. Jackson Stoeckle is the principal investigator of the Elder Mis- treatment Initiative (The Collaboratory) and the co-investigator for the national dissemination of the UCLA Alzheimer’s and Dementia Care Programmodel for community-based care. She is a mem- ber of the National Academies of Science, Engineering, andMedicine Forum on Aging, Disability, and Independence, as well as the World Health Organization’s G7 Advisory Group on Aging and the Environment. She also serves as a U.S. Expert for the International Standards Organization Technical Workgroup on Aging Societies. As president of The John A. Hart- ford Foundation, Terry Fulmer is chief strategist for the Foundation, which is dedicated to improving care for older adults. She is an elected member of the National Academy of Medicine and pre-

Rebecca Jackson Stoeckle , and Terry Fulmer together have an impressive number of years experience working on

preventing elder abuse, share a deep appreciation for their ongoing collaboration, and have a passion for improving care for older adults. This column exemplifes their commitment to col- laboration: in a three-way interview, they said, “While this work can be emotional

While this work can be emotional and trying, we remain optimistic, and driven to continue building solutions.

and trying, we are able to remain opti- mistic and are driven to continue build- ing solutions. We are living in a time of particular interest and momentum around improving care for older adults and are energized by the commitment of our colleagues and their willing- ness to work together to end elder mistreatment.” Lees Haggerty is proj- ect director for the National she coordinates a team of elder mis- treatment experts and clinicians from across the country, to design and test a care model identifying and respond- ing to elder mistreatment in hospi- tal emergency departments. She also serves as project director at the Educa- tion Development Center (EDC), where she designs, tests, and disseminates Collaboratory to Address Elder Mistreatment, where

Elder mistreatment is an issue that all of us can work to eradicate.

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

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Taking Action Against Elder Mistreatment

Left to right: Kristin Lees Haggerty; Rebecca Jackson Stoeckle; Terry Fulmer. All photos are courtesy Kristin Lees Haggerty.

viously served as Distinguished Pro- fessor and Dean of Health Sciences at Northeastern University. Before that, Fulmer was Erline Perkins McGriff Professor and Dean of the New York University College of Nursing. She was the frst nurse to serve on the board of the American Geriatrics Society and the frst nurse to serve as president of the Gerontological Society of America. Nationally and internation- ally recognized as a geriatrics expert, Fulmer is best known for conceptualiz- ing and developing the national NICHE program (Nurses Improving Care for Healthsystem Elders), and for her research on elder abuse and neglect. Fulmer is a distinguished practitio- ner of the National Academies of Practice and an attending nurse and senior nurse in the Yvonne L. Munn Center for Nurs- ing Research at Massachusetts General Hospital, as well as an attending nurse at Mount Sinai Medical Center in NYC. Her clinical appointments have included the Beth Israel Hospital in Boston, Massa- chusetts General Hospital, and the NYU Langone Medical Center. She is a Fellow of the American Academy of Nursing, the Gerontological Society of America, and the New York Academy of Medicine, where she served as vice-chair. She has written more than 150 peer-reviewed papers and edited ten books. Fulmer’s advisory committee and board appointments are numerous, and she has been the recipient of many

awards, including being named one of the 2016 “50 Influencers in Aging” by PBS’s Next Avenue , and in 2017 receiving the International Network for the Prevention of Elder Abuse’s Rosalie S. Wolf Award for her body of work on elder abuse. These three Guest Editors are at heart motivated by a personal connec- tion to older adults and a profound desire to prevent them from harm. In this Spring 2020 issue of Generations , “we aimed to convey that elder mistreatment is an issue that all of us—family and com-

munity members, clinicians and caseworkers, researchers and academics—can work to eradicate,” they said. “This [ journal] contex-

We hope readers will feel motivated to take action now .

tualizes the topic of elder mistreat- ment as an issue affecting older adults of diverse backgrounds and [is] one that we are all responsible for remedying. The issue provides concrete tools and strategies for identifying and respond- ing to mistreatment in a variety of set- tings, and it is our hope that . . . readers will feel motivated to take action now ,” they said. Our Guest Editors are pleased to share the tools and strategies that they and others have developed in the hope that this issue of Generations will encourage more communication and collaboration between stakeholders, motivating all to work together to end elder mistreatment. —Alison Biggar and Alison Hood

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

Volume 44 . Number 1 | 7

GENERATIONS – Journal of the American Society on Aging

A Roadmap Toward Safer, Happier Lives: The National Collaboratory to Address Elder Mistreatment By Kristin Lees Haggerty, Rebecca Jackson Stoeckle, and Terry Fulmer The safety and welfare of elders must be prioritized to ensure they live free from harm. T he National Collaboratory to Address Elder Mistreatment is a group of elder mistreat- ment (Acierno et al., 2010), and not nearly enough is being done to stop it. Elder mistreatment includes any “knowing,

ment experts, innovators, researchers, and clini- cians who are working together to design and test a scalable care model for addressing elder mis- treatment in hospital emergency departments. At a recent convening hosted by The Collab- oratory, the thirty participants took part in an ice-breaking activity in which they were asked to introduce themselves and describe an older adult who is important to them. Participants described grandparents, neighbors, and friends who in­ spire them with strength, wisdom, and energy. They described older adults who work hard, care for their adult children and grandchildren, and pass on important values and culture. Taking a moment to recognize the enormous influence older adults have on our lives and the incredible value they bring to our families, com- munities, and the wider society makes it easy to understand why it is important to work to ensure older adults’ right to live free from harm and to prioritize their safety. Yet, one in ten older adults in the United States are victims of elder mistreat­

intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult” (National Center on Elder Abuse [NCEA], 2019). Types of mistreat- ment include physical, sexual, and emotional abuse, neglect, exploitation, and self-neglect (NCEA, 2019). Elder mistreatment costs billions of dollars in healthcare expenditures annually (Dong, 2005), and has devastating consequences for older adults’ physical, emotional, and social health (Dong, 2015; Gibbs and Mosqueda, 2014). Rapid increases in the older adult population, coupled with changing and complicated net- works of providers and caregivers, necessitate improved resources, tools, and education for pre- venting and addressing elder mistreatment. Inside this Issue of Generations This Spring 2020 issue of Generations focuses on how to take immediate action to prevent,

abstract This article introduces the contents of the Spring 2020 issue of Generations , which tackles how to prevent, intervene, and ultimately eradicate elder mistreatment. It describes how the publication was envisioned and mentions initiatives working to end elder mistreatment. | key words : elder mistreat­ ment, elder abuse, emergency departments, the National Collaboratory to Address Elder Mistreatment, Age- Friendly Health Systems initiative, Adult Protective Services, Geriatric Emergency Care Applied Research Network

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

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Taking Action Against Elder Mistreatment

intervene, and ultimately eradicate elder mis- treatment. It provides a roadmap for clinicians and care providers, and includes tools and strategies for overcoming pressing challenges for addressing elder mistreatment in diverse settings. Foregrounding this issue is The Col- laboratory’s new model for screening and re­ sponding to mistreatment in the emergency department setting. The issue’s content is bookended with wide- lens perspectives addressing elder mistreatment, beginning with pieces that present strategies for reframing public perceptions of aging and mis- treatment and the pressing need to prioritize cultural context as research, policy, and practice advance. The issue closes out with updates on federal efforts and priorities, elder justice pro- motion at the national and state levels, and keen insights on accessing funding. In between, the issue uses a narrower lens, turning frst to innovative health systems–based strategies for mitigating elder mistreatment, including the Age-Friendly Health Systems ini- tiative, the National Collaboratory to Address Elder Mistreatment, and the Geriatric Emer- gency Care Applied Research Network. Next, issue content traces a path through the various health- and community-based settings that pres- ent opportunities for identifcation and response, zeroing in on specifc tools and strategies involv- ing frst responders, emergency departments, Adult Protective Services, legal aid, housing, and

rural and remote populations in efforts to iden- tify and respond to elder mistreatment. Interwoven throughout this issue of Gener- ations are program spots illustrating the prom- inent themes in the articles, such as a case example of two older adults’ journey to safety in the face of homelessness; the National Cen- ter on Elder Abuse’s strategies for promoting an evidence-based communication strategy; and ElderAbuse.org’s mission to eradicate elder abuse through policy, research, and public advocacy. Collectively, the articles presented herein highlight the emergence and spread of effective approaches to addressing elder mistreatment, convey the importance of early support from foundations and federal agencies to promote inno- vation and dissemination, and show the promise of collaboration across sectors and disciplines. Importantly, there remains a clear need for more research, intervention design and testing, and, especially, funding to continue this promis- ing trajectory of growth and improvement in the feld of elder mistreatment. Kristin Lees Haggerty, Ph.D., is project director for the National Collaboratory to Address Elder Mistreat­ ment at the Education Development Center (EDC) in Waltham, Massachusetts. Rebecca Jackson Stoeckle is a vice president and director of Private Sector Partnerships at the EDC. Terry Fulmer, Ph.D., R.N., F.A.A.N., is president of The John A. Hartford Foundation in New York City.

References Acierno, R., et al. 2010. “Prevalence and Correlates of Emotional, Phys- ical, Sexual, and Financial Abuse and Potential Neglect in the United States: The National Elder Mis- treatment Study.” American Jour- nal of Public Health 100(2): 292–7. Dong, X. 2005. “Medical Implica- tions of Elder Abuse and Neglect.” Clinics in Geriatric Medicine 21(2): 293–313.

Dong, X. Q. 2015. “Elder Abuse: Systematic Review and Implica- tions for Practice.” Journal of the American Geriatrics Society 63(6): 1214–38. Gibbs, L. M., and Mosqueda, L. 2014. “Medical Implications of Elder Abuse and Neglect.” Clinics in Geriatric Medicine 30(4): xv–xvi.

National Center on Elder Abuse (NCEA). 2019. “Frequently Asked Questions.” Washington, DC: Administration for Community Living. ncea.acl.gov/FAQ.aspx. Retrieved July 20, 2019.

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

Volume 44 . Number 1 | 9

GENERATIONS – Journal of the American Society on Aging

The Might of Metaphor : Strengthening Support for Elder Abuse Prevention By Daniel S. Busso, Moira O’Neil, and Andrew Volmert An explanatory metaphor can help people to better communicate about what elder abuse means and how to prevent it.

E lder abuse is a pervasive and enduring societal problem, affecting an estimated 1 million Americans ages 65 or older (National Research Council, 2003). However, despite researchers’ growing recognition of this issue’s importance, elder abuse has not gained similar traction with the public and policy makers. Research has shown that members of the public are largely unfamiliar with the term or the problem it repre- sents; they do not know why it occurs and, as a result, lack the necessary understanding to con- sider and evaluate appropriate solutions (Volmert and Lindland, 2016). Moving the problem of elder abuse higher up the list of public priorities and engendering a sustained public conversation around the issue require a new communications strategy centered on building an understanding of elder abuse. In this article, researchers at the Frame- Works Institute describe a multi-method, iter- ative research project that was conducted to develop an explanatory metaphor titled “Social

Supports.” This metaphor situates elder abuse in a wider social context, thereby foreground- ing the policy and systems-level changes that can prevent elder mistreatment. Explanatory meta- phors facilitate reasoning about a complex social or scientifc issue through the use of readily understood and familiar concepts (Clark, 1996; Thibodeau and Boroditsky, 2011). FrameWorks argues that metaphors can serve as vital communication tools for advocacy work, including for people engaging the pub- lic around the issue of elder abuse. Conducted by the FrameWorks Institute, the research described in this article is part of a larger project designed to introduce the topic of elder abuse as a matter of collective concern, to tell stories that situate elder abuse in a wider social context, and to advance policies and systems-level changes that prevent elder abuse and address it when it happens (O’Neil et al., 2017). The frst phase of research examined Amer- icans’ patterned ways of thinking about elder

abstract This article describes the FrameWorks Institute’s process of developing, testing, and refin- ing an explanatory metaphor so as to better communicate about elder abuse to the public. Qualitative interviews, group sessions, and a quantitative survey experiment were used to test the effectiveness of a set of candidate metaphors. FrameWorks’ study finds one metaphor (“Social Supports”) to be particularly effective in bridging gaps between experts and public understanding of the issue. The resulting findings hold important implications for advocates and other communicators looking to make elder abuse a more salient public policy issue. | key words : elder abuse, communication, framing, metaphor

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

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Taking Action Against Elder Mistreatment

abuse and pinpointed where these patterns impede efforts to advance a public understand­ ing of the issue. Next, we introduce a novel, em­ pirically tested explanatory metaphor (“Social Supports”) that can overcome these unproduc- tive ways of thinking, and detail the research that supports use of the metaphor. Finally, we conclude by offering suggestions as to how ad­ vocates can best use the metaphor to cultivate a more visible, informed conversation about the problem of elder abuse and what can be done to address it. The research began with a set of in-depth inter- views with experts and members of the public in order to identify the major gaps between the two groups’ understanding of elder abuse (Volmert and Lindland, 2016). Between February and April 2015, ten one- Conceptual Tasks for an Explanatory Metaphor hour interviews were conducted with advocates, policy experts, and researchers who had exper-

became targets for potential explanatory meta- phors. These gaps include the following: √ Type of Explanation: Scientific vs. Mor- alized . While experts identify proven risk fac- tors that are linked to elder abuse, members of the public tend toward a moralized explana- tion, attributing elder abuse to moral defcits in the people who commit abuse (e.g., selfshness, lack of character), or to an immoral culture that lacks respect for elders. These moralized expla- nations make it hard for people to recognize the importance of risk factors such as mental illness, substance abuse, and lack of support (e.g., senior centers and social activities for older people). √ Level of Explanation: Structural vs. Individualistic . Experts look beyond localized context to the systemic level, highlighting how formal and informal systems of support (or lack thereof) contextualize and shape the interactions of those who commit and experience abuse. By contrast, members of the public tend to look for causes only at the individual level, in attributes of the person who commits abuse, in the person who is abused, or in the relationship between the two. This makes it difficult for people to think about elder abuse as a public issue, which can be addressed in signifcant part by shifts in policy. √ Solutions: Systemic vs. Individual- ized . The solutions that experts recommend involve leveraging institutions and systems to address the underlying causes of elder abuse and to respond effectively to abuse where it occurs. By contrast, public solutions predomi- nantly involve individual actions (e.g., neighbors checking in on older people) and measures tar- geted at individual behavior change (e.g., public service announcements). Not only do members of the public lack a systemic orientation, they seem largely unaware of existing institutions that could help to address elder abuse, including Adult Protective Services, government agencies that focus on aging, and community-level orga- nizations that provide services to older people. √ The Problem: Solvable vs. Unsolvable . While experts identify a range of strategies to

‘Metaphors can serve as vital communication tools for advocacy work.’

tise on this issue. In April 2015, twenty in-depth, two-hour interviews with members of the public were conducted in fve locations: Philadelphia; San Jose and Lancaster, California; Phoenix; and Frederick, Maryland. Participants in public interviews were recruited by a marketing frm and selected to represent variation across key demographic variables (e.g., ethnicity, gender, age, educational background, political orienta- tion, etc.). Both sets of interviews were designed to elicit ways of thinking and talking about older adults and elder abuse. The resulting analysis compared the way that experts understand elder abuse and its preven- tion to the dominant ways in which the Ameri- can public thinks about it. These incongruities

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

Volume 44 . Number 1 | 11

GENERATIONS – Journal of the American Society on Aging

prevent and respond to elder abuse and highlight the possibility of identifying even more effective interventions through further research, mem- bers of the public are fatalistic about elder abuse. This fatalism is supported by the public’s assump- tions about the threats of modern life (such as the idea that families today are stretched to the limit and are unable to provide effective care while facing competing employment and rela- tionship demands); a defaulting to individualized solutions that do not suffice to address the issue effectively (e.g., informal oversight of older peo- ple by friends and neighbors); and attitudes about aging and older people that assume elder abuse is another symptom of inevitable deterioration and decline (Lindland et al., 2015). √ Older Americans: Subjects to Empower vs. Objects of Care . While experts acknowl- edge and highlight the vulnerability that comes with age, they understand older people as agents whose voices must be heard and respected. Ex­ erts emphasize the importance of measures to enable older people to participate in and con- tribute to their communities. By contrast, mem- bers of the public are deeply paternalistic toward older people, treating them as objects to be cared for rather than as full subjects. This paternal- ism leads to exclusive focus on measures to pro- tect older people and disregard for older people’s voices and concerns. Based on this analysis, FrameWorks deter- mined that an effective metaphor for communi- cating about elder abuse needed to accomplish the following objectives: cultivate an under- standing of the systemic factors that contribute to elder abuse and the institutional responses that can help to address the problem; promote a sense of collective efficacy, or the understanding that collective solutions can make a difference; and help people recognize that older people are ‘Members of the public are fatalistic about elder abuse.’

equal subjects in society rather than objects of care, with agency and voices that should be heard and respected.

Developing and Testing an Explanatory Metaphor

FrameWorks used a multi-stage process to develop and empirically test a set of explana- tory metaphors. First, by analyzing transcripts from expert and public interviews, looking spe- cifcally for underlying conceptual metaphors that surfaced in how participants speak. These metaphors were supplemented with additional metaphors that were determined to be a good conceptual “ft” for the issue—i.e., those that effectively captured some relevant aspect of the “target domain” of elder abuse (Lakoff and Johnson, 1980; Shore, 1996). For instance, through a brainstorming pro- cess, FrameWorks identifed a set of meta­ phorical domains that capture the idea of interconnected parts functioning together to provide stability and support (such as spider webs, the support beams in a building, etc.). This yielded a set of promising “candidate” metaphors, each of which was written up in a short paragraph of text. The metaphors were subjected to an itera- tive, three-stage testing process to determine their effectiveness in communicating about elder abuse. At the end of this process, one explana- tory metaphor—Social Structure—emerged as the most effective. This metaphor fosters an understanding of the ways in which social con- ditions can prevent elder abuse: that just like a stable building requires a strong set of support beams, society needs a solid social structure so that older people can live lives to their fullest, participate in their communities, and live free from abuse. The sections that follow outline the methods and fndings at each stage of the testing process, and provide evidence from each stage to justify the metaphor’s use. On-the-Street Interviews . Seven candi- date metaphors were tested in 2016 by conduct-

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12 | Spring 2020

Taking Action Against Elder Mistreatment

ing intercept interviews (n=56) in Annapolis, Maryland, and Cleveland, Ohio. A researcher approached members of the public on the side- walk, and asked if they would be willing to par- ticipate in a short research project. Interviews began with a series of open-ended questions to ascertain respondents’ baseline thinking about elder abuse. The interviewer then presented one of the candidate explanatory metaphors, after which he or she asked a second series of ques- tions that paralleled the pre-exposure set. This process is designed to gauge the effect of the metaphors in shifting perspectives and under- standing about the issue. The Social Supports metaphor proved highly usable for research participants. After exposure to the metaphor, participants reasoned that simi- lar to the way support beams maintain the struc- ture of a building, the well-being of older people is held up by interconnecting systemic supports, such as transportation, the economy, and pub- lic policy. The metaphor sparked productive conversations around the need for community supports, such as resources that allow older peo- ple to remain active, and social workers in care homes to ensure they have individualized care and support. Crucially, the metaphor brought social context into view, while leaving space for older adults’ agency. As one participant put it, a social structure can “help older adults stay strong,” so that they “know they have options,” and “don’t have to accept abuse.” Finally, this metaphor was generally successful in inoculat- ing against the attitude that “little can be done” to address elder abuse, which was prominent in the interviews prior to exposure to the met- aphor, as well as in earlier in-depth interviews with members of the public. Online Survey Experiment . Next, an online survey experiment was conducted to further test candidate metaphors. This measured the perfor- mance of a refned set of candidate metaphors in relation to a set of outcome measures of inter- est (such as respondents’ perception that elder abuse is a solvable problem, their support for

policies that can address elder abuse, and their understanding of the kinds of actions that could help to address it). Three metaphors were tested, based on their success in On-the-Street Inter- views: Social Structure, Social Spotters , and Blocking Social Problems . Each metaphor treat- ment consisted of a short paragraph that laid out the metaphor and the set of similarities between the source of the metaphor (e.g., social support structures) and its target (aspects of elder abuse prevention). The experiment was administered by Survey Sampling International (SSI). The sample was composed of 1,200 American adults, selected to approximate U.S. Census distributions for age, sex, household income, race-ethnicity, and education level. Participants were randomly assigned to one of three experimental conditions (in which they read one metaphor), or to a con- trol condition (in which they read nothing). Par- ticipants then answered a set of multiple choice and Likert-style questions designed to tap into both an understanding of and application of the metaphor. Responses to these questions were aggregated to create a set of composite measures, or “batteries.” Linear regression analysis was used to determine whether there were statisti- cally signifcant differences between responses to these composite measures for each metaphor condition, relative to the control. Among the three metaphors in particular, Social Supports performed best—with signif- cant effects on participants’ understanding of the kinds of solutions that can help to address elder abuse ( p= 0.03), and marginally signif- cant effects on participants’ sense of collec- tive efficacy about addressing the issue of elder abuse ( p =0.08). No other metaphor had statisti- Participants can use the metaphor to speak about the importance of a coordinated, connected system that supports older people.

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Volume 44 . Number 1 | 13

GENERATIONS – Journal of the American Society on Aging

aphor; to evaluate how com- municable the metaphor was, or to see whether subsequent presentations of the metaphor remained true to the origi- nal; and to ascertain whether the metaphor could help inoc- ulate against some of the more unproductive ways of thinking that had been identifed in ear- lier research. Analysis of these sessions revealed three important fnd- ings regarding the effectiveness of the Social Supports meta- phor, and enabled us to iden- tify some needed refnements to the metaphor’s execution. First,

Figure 1. Effects of Explanatory Metaphors on Outcomes

Source: FrameWorks Institute

cally signifcant effects on any outcome (all fnd- ings shown in Figure 1, above). For these reasons, Social Supports was brought forward into the fnal stage of testing. Persistence Trials . Following the online sur- vey experiment, FrameWorks explored the com- municability of the Social Supports metaphor in a fnal stage of qualitative testing. Persistence tri- als are designed to examine how well metaphors “hold up” when being passed between individu- als, and to determine whether or not members of the public could properly use the metaphors in conversations. Persistence trials were in 2016 conducted in Boston and Denver. At the beginning of a persistence trial, a researcher presents the metaphor to two par- ticipants, and asks them a series of open-ended questions to gauge their understanding. These two initial participants then “teach” the meta- phor to another pair of participants, who have time to ask the frst pair questions. This second pair then teaches the metaphor to a third pair, who fnally teaches it back to the initial two par- ticipants. In total, we conducted three of these trials (eighteen participants in total). These persistence trials were designed to establish whether participants were able to use the met-

participants were able to use the metaphor to speak at length about the importance of a coordi- nated, connected system that supports older peo- ple. They recognized that these “support beams” function in complementary ways, meeting the needs of older people and preventing them from “falling through the cracks.” The metaphor led participants to gener- ate examples of needed social supports beyond examples provided in the original metaphor iteration, such as senior centers, transporta- tion services, and services that prevent fnan- cial exploitation. Second, the language of the metaphor was “sticky”—that is, it tended to be repeated with fdelity across presentations of the metaphors. Many participants were able to use the language of “structure” and “foundation” consistently in their presentation and discussion of the metaphor. Finally, the metaphor was flex- ible and easy to work with. At times, participants interpreted the metaphor language of “social sup- ports” as being like a pyramid, a building (such as a house), or an umbrella. In these cases, the core meaning of the metaphor was preserved, as a set of interconnected and interdependent supports. Data from persistence trials also were used to provide an empirical basis for fnal refne-

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14 | Spring 2020

Taking Action Against Elder Mistreatment

ments to the explanatory metaphor before it was moved into the feld as a translational tool. For example, some participants’ speech following the metaphor defaulted to infantilizing discus- sions about older adults as being “like babies,” characterizing them in ways that denied their full agency and dignity. As a corrective, the fnal iteration of the Social Supports metaphor included examples of supports that situated older people in assertive, independent roles— for example, by noting that free or low-cost pub- lic transportation is a support beam that allows older people to actively form and maintain social connections with others. Conclusion The results presented here suggest that the Social Structure metaphor represents a powerful way to frame explanations of social supports and services, which often are difficult for the public to appreciate, especially in an issue such as elder abuse prevention. For these reasons, FrameWorks believes that the metaphor can help advocates effectively reframe public discourse on this issue. The above fndings suggest that research- ers, practitioners, and advocates should use this explanatory metaphor to make the following points, in the following ways: √ Preventing and addressing elder abuse requires an integrated team of professionals and services . A social structure needs support beams that are interconnected, securely joined, and frequently maintained. If one beam is weak or missing, the structure will not stand upright. √ Family members cannot be entirely responsible for preventing elder abuse . One beam alone cannot support a strong building; likewise, individuals and families cannot single- handedly prevent abuse. A broader social struc- ture is needed to support families and others who care about and care for older adults. An in­ dividual beam is important, but a strong building needs many strong beams. √ Services and supports must be con- tinually improved . Many support beams are

in place already, but new beams can be added to the existing structure to strengthen it. For the best results, bolts must be tightened and weakened beams replaced. For example, free or low-cost public transportation is one beam that allows older people to actively engage with members of their family and communities into old age. √ Elder abuse is a difficult problem that affects us all—but solutions are available . Elder abuse impacts everyone, so members of our society should work together to build and remodel systems to prevent it. The growing body of research on elder abuse holds enormous potential to signifcantly affect change in public policy. But to do so, commu- nicators must frst fnd ways of making this research available and accessible outside of the academy. FrameWorks’ research suggests that the Social Structure explanatory metaphor and the other framing strategies that emerged from testing have the capacity to fundamentally shift public thinking and public discourse around elder abuse. For these frames to matter, they need to be used on a broad scale, and FrameWorks is encouraged by the initial uptake of these frames in feld communications. Groups such as the National Council on Elder Abuse already have begun actively disseminating the Social Supports frame in their communications, and these advo- cacy efforts have resulted in important changes at the policy level, with recent legislation passed in more than twelve states. These changes in the feld’s communications are a critical frst step and perhaps presage new hope about the pros- pects for change. Daniel S. Busso, Ed.D., is a senior researcher and psychologist at the FrameWorks Institute, in Wash­ ington, D.C. Moira O’Neil, Ph.D., is a sociologist and vice president of Research Interpretation at the FrameWorks Institute. Andrew Volmert, Ph.D., is a political scientist and vice president of Research at the FrameWorks Institute.

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