Irish approaches to safeguarding adults

Citation

Phelan, A. (2013), "Irish approaches to safeguarding adults", The Journal of Adult Protection, Vol. 15 No. 6. https://doi.org/10.1108/JAP-09-2013-0041

Irish approaches to safeguarding adults

Article Type: Guest editorial From: The Journal of Adult Protection, Volume 15, Issue 6.

Adult protection in Ireland has followed a distinct pathway. Similar to other countries, contemporary Irish society has recognised a role in addressing issues which were traditionally considered taboo. Historically, matters of family violence were immersed in hushed conversations and generally seen as outside the realm of the State's concern. Consequently, when incidences of adult abuse within a family were suspected or known within communities, sources of understanding and support could be sparse, leading to the silent, helpless enduring of the maltreatment.

Abuse was also perpetrated within institutional settings. For example, in the recent McAleese (2013) Report, it was recorded that approximately 10,000 women were admitted to Magdalene laundries from the time of the foundation of the Irish State in 1922. For many years, the women's experiences were shrouded in “secrecy, silence and shame” (McAleese, 2013, p. 2). The average age of these women was 23.8 years, although the age of admission ranged from nine years to 89 years, with a mean stay of seven months. The Magdalene Laundries’ Report (2013) demonstrated a failure in an adequate duty of care to these women by Irish society. The report illustrated the complicity of both the State and families in the detention of the women. Although McAleese (2013) notes that women admitted via State processes were aware of why they were being interred and for how long this would last, those who entered through non-State or family lobby routes were frequently unaware about why they were confined and remained clueless as to how long this would last. In some cases, the women had been abused in their own families and the “family” solution was entry to the Magdalene laundry. Thus, a double abuse was perpetrated where victims were rendered powerless within the family and the institution. Currently, a redress system is being facilitated where survivors can claim remuneration and the Irish Taoiseach has publically apologised in the Irish parliament stating “This is a national shame, for which I say again – I am deeply sorry and offer my full and heartfelt apologies” (Kenny, 2013).

Adult abuse within the domestic violence spectrum has been generally been addressed in Ireland through a social model, wherein non-governmental agencies provided advice, support, counselling or refuge for victims. However, recognising that a co-ordinated approach was fundamental, COSC, (the National Office for the Prevention of Domestic, Sexual and Gender-based Violence) was established in 2007 to co-ordinate a government wide response to abuse and raise awareness about the topic. It is recognised that six government departments and over 100 non-governmental agencies have a remit in the prevention and amelioration of abuse (COSC, 2010). COSC's (2010) work includes the publication of Ireland's first national strategy on Domestic, Sexual and Gender-based Violence with particular priorities in primary intervention and secondary intervention in the period 2010-2014.

Although elder abuse is included in COSC's remit, formal services had previously developed within the remit of the Health Service Executive (HSE). Up until the 1990s, the issue of elder abuse in Irish society was silent. However, an exploratory report by O’Loughlin and Duggan (1998) provided the catalyst to the establishment of a dedicated Working Group on Elder Abuse (WGEA) which published Ireland's first policy report in 2002. Protecting our Future (WGEA, 2002) was a watershed in terms of establishing a multi-sectoral approach to elder abuse. This policy was particularly pertinent in the context of Ireland's rising older person population and increasing life expectancy. In the 2011 census, there were 535,393 people over 65 years resident in Ireland, representing a 14.4 per cent older population increase from the 2006 census (CSO, 2012). Irish population projections suggest an increase in the over 65 years age group to between 850,000 and 860,700 by 2026. Projections also suggest a rise in the population over 80 years from 128,000 to 470,000 to 484,000 in 2046 (CSO, 2013). As demographics change, such increases underpin the importance of comprehensively protecting older people in Irish society.

The definition of elder abuse in the Irish policy (WGEA, 2002) is based on Action on Elder Abuse's (1995) definition, which has also been used by the World Health Organisation (2008) and the United Nations (2012). However, this was augmented with a perspective relating to civil and human rights. Elder abuse was described as:

A single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person or violates their human and civil rights (WGEA, 2002, p. 25).

Irish policy identifies six types of abuse – physical abuse, sexual abuse, financial/material abuse, psychological abuse, neglect and acts of omission and discriminatory abuse. The 2002 report recognised the need for a cohesive, multi-sectorial approach which targeted not only setting up a dedicated service but an awareness raising of the topic in public consciousness, professional education, legislative reform and the establishment of a dedicated research centre to focus on the generation of Irish research on elder abuse (WGEA, 2002). Consequently, the HSE established a national steering group with regional sub groups. Within the national steering groups, four committees focus on media and public awareness group, staff awareness and curriculum group, policies, procedures, protocols and guidelines groups and financial abuse of older people group. Each of the four HSE administrative areas has steering groups which oversee the local implementation of the national elder abuse policy and link with the national committee. Each HSE area also has a dedicated regional officer for the protection of older people, while there are 32 senior caseworkers for the protection of older people who manage caseloads on a geographical basis. Since the elder abuse service was established, total referrals have risen year on year from 927 in 2007 to 2,302 in 2011. Psychological abuse is persistently the highest referral concern, with financial abuse frequently being ranked second, although a clustering and combination of abuse types in individual cases is not uncommon. Although Irish policy specifically excludes self-neglect as a form of abuse, due to the volume of referrals to the elder abuse service, in 2009, the HSE decided that serious cases of self-neglect would be incorporated into the service.

In the early 2000s, the Irish Law Reform Commission (2003) identified a need for legislative reform. In particular, legal protection for those without mental capacity was archaic. The Lunacy Regulation Act (1871) provides for those without mental capacity to enter a wardship. However, the legislation is founded on a status basis to capacity and it was recognised that a functional approach was more person centred and facilitated autonomy. In 2008, the Irish government published proposed reforms in the Scheme of Mental Capacity Bill (2008), which was further refined in the recent Assisted Decision Making (Capacity) Bill (2013). The new proposals allow for a system of appointment of persons who act as decision-making assistants, activities of the public guardian and reform to the scope of enduring power of attorney. Such reform will contribute to and consolidate the legislative protection afforded to vulnerable adults in Ireland.

Another important catalyst to societal attention on elder abuse was via media exposure of sub-standard care in a nursing home. Following an undercover television documentary by the national television broadcaster, Radió Televís Éireann in 2005, the need to have a comprehensive regulatory process for residential care for older people was apparent. The documentary served as a prominent stimulus to the establishment of the Health Information and Quality Authority (HIQA) in 2007 and regulation of all nursing homes commenced in 2009. Within the 32 HIQA standards (HIQA, 2009), the protection of older people from elder abuse was a specifically required standard in the context of staff training and each facility having a locally implemented policy to prevent, identify and respond to cases of elder abuse.

Another notable development from the WGEA (2002) recommendations was the establishment of the National Centre for the Protection of Older People (NCPOP). Based in University College Dublin, the NCPOP is a dedicated research centre lead by the School of Nursing, Midwifery and Health Systems with collaborations from the School of Applied Social Science, School of Public Health and Population Science, the School of Medicine and Medical Science and the Geary Institute. Since 2008, the Centre has produced Irish based research, most notably an Irish prevalence study (Naughton et al., 2010), a study on interactions and conflict in residential care for older people (Drennan et al., 2012), constructions of older people in the media (Fealy and McNamara, 2009) and older people's experiences of abuse (Lafferty et al., 2012). The research findings have been used in directing preventative and ameliorative legislative, policy and service responses to elder abuse in Ireland and have provided comprehensive insights into the nuances of elder abuse within Irish society.

The papers contained in this special issue of the Journal of Adult Protection focus specifically on elder abuse in Ireland. Each paper offers a distinct contribution in the following areas: a macro-perspective of older people's perceptions of what constitutes elder abuse, meso-perspectives of the experience of elder abuse by older people and a second paper focusing on particular issues related to referred cases of sexual abuse of older women to Rape Crisis Centres. The micro-perspective of case management is also presented in a practice-based case study concerning financial abuse of an older person. Each paper offers important insights into the context of elder abuse in Ireland and offers relevant recommendations for policy, practice and legislation.

In the first paper by Carter-Anand et al., the social construction of elder abuse is challenged as being imposed by a top-down approach, which minimises the subjective interpretations and experiences of the older people themselves. Thus, there is a fundamental contradiction, as in an issue that is focused on abuse of older people, older people themselves have been disempowered and rendered silent in establishing the phenomenon's parameters and understandings. The consequence of this is that policy supports the general discourses of elder abuse developed by researchers, policy makers and various disciplines and such policy dictates have inevitable consequences in how the service is practically delivered. The authors argue that a further complicating issue in the island of Ireland is the structural responses to elder abuse in terms of service. In Northern Ireland, services are focused on a protectionist, risk and protection of vulnerable adults paradigm while the Republic provides paternalistic, specific elder abuse services directed by specialist health care professionals. Such myopic approaches can deny broader social factors, namely ageist attitudes, social marginalisation and a contextualisation within a rights based approach. In an effort to redress this imbalance, Carter-Anand and colleagues undertook a qualitative study across the island of Ireland to reveal older people's understandings of elder abuse. Findings from data collected from 58 older people who resided in Irish communities (North and South of Ireland) demonstrated a more individual meaning of abuse, which was contextualised within personal, cultural and societal experiences. For example, participants commented that ageing was often perceived within a perspective of bodily decline and personal obscurity and younger generations could paternalistically deny the older person's voice, rights, autonomy and self-determination. Changes in culture translated to a perceived reduction in meaningful interactions as, for example, kinship relationships could be reduced to tasks and duty, while resistance to such experiences seemed futile within such relationship imbalances power dynamics. In the context of society, the older people identified the negative stereotypical attitudes of younger age groups and the impact this had on everyday experiences. Such ideas were often perpetuated through various encounters with professionals and within general societal actions and norms. This paper identifies how these three findings cohere to disempower older people and tacitly facilitate abuse and provide an important counter-discourse to the prevailing understandings of vulnerability, victimhood and elder abuse which are prescribed in policy and translated to practice. In addressing these gaps in understanding, Carter-Anand et al. suggest community education, age friendly initiatives and a focus on strengthening intergenerational relationships. Such initiatives are embedded in an ideological shift to empowerment of older people across the island of Ireland based on inductive, realistic approaches rather than top-down assumptions contained within policy principles.

Lafferty et al.'s paper explores the experiences of older people who have been abused and identifies ways in which supportive services can improved. Depth interview data from nine older people who had availed of the services of senior caseworkers for the protection of older people was collected. Findings revealed that older people in the study were rarely self-referred but accessed formal services through the intervention of friends or neighbours or through discovery and referral within health services. Although statistically the family are the main source of abuse, the family could also provide important support for the older person being abused. Sources of support could also come from the police, health and social care services as well as voluntary and community services. Such support was identified as pivotal in appropriating aids and entitlements, restoring confidence and self-worth. However, the older people in the study also identified how their own inability to recognise the abuse prevented access to helping sources. In tandem with the inability to recognise the abuse was the lack of awareness of services available and reluctance to access due to issues of fear, embarrassment, public exposure or confidence. Services could also pose a challenge due to a lack of access when needed and limitations such as long waits or feeling under-supported. The findings illustrate that raised awareness of abuse is vital within older people's understanding and that abuse is not to be tolerated. Consequently, responsive services should provide appropriate, practical and sufficient interventions at appropriate times.

Scriver et al.'s paper sensitively considers the issues inherent in older women's experiences of sexual abuse. Using a sample of 13 rape crisis centres in the Rape Crisis Network of Ireland's database and two non-member Rape Crisis Centres, all cases using the counselling and supportive service in 2011 were reviewed. Comparisons were made between issues related to cases of women below 55 years and women aged 55 and older. In all, 8 per cent of the total referrals were for people over 55 years (n=142). Of these referrals 115 were women who experienced abuse as a child, as an adult or as both a child and adult. The comparison of cases demonstrated that specific issues were more relevant for older women. For example, the proportion of older women with a disability accessing services was higher and the authors tentatively suggest that disability may also be a product of abuse due to the increased stress, which may be either due to recently experience abuse or enduring from abuse in the past. Mirroring statistics of older people in Ireland in general, older people in the study were also found to have less formal education than their younger counterparts in the study. This, together with the fact that sexual abuse was historically taboo in normative Irish discourses in the past, has inevitably had an impact on recognising the abuse, disclosure and accessing help. This echoes the conditions of the older person's understandings about abuse described in Lafferty et al.'s paper in this issue. Scriver et al.'s study is particularly supported through the use of two case studies which demonstrate that older women have different contextual factors than their younger counterparts and that these differences are fundamental to a comprehensive orientation of societal knowledge of sexual abuse of older women, services, practices and policy to address such unique presenting issues. Consequently, this paper succinctly identifies the varied lived experience of older women who have been sexually abused in Ireland. Conclusions demonstrate the underdevelopment of research in this area and the need to improve older women's recognition of sexual abuse and disclosure, their practical access to services, building responsive and supportive services.

Understanding the context of elder abuse in Ireland is also immersed in an examination of case studies. In this issue, Allen-Devlin and Freyne consider a case of financial abuse of a 69 years old woman by her home help. The presenting issues are identified as complex and involve issues of executive functioning capacity, difficulties within taking action within relationships where the older person considers the relationship to be “trusting”. Other issues are the increased vulnerability of older people with mental health challenges, poor social networks and a lack of regulation in for home care services. This case study presents a multi-disciplinary approach, incorporating family participation, into taking proactive steps to both stop the financial abuse and to safeguard against its recurrence. In a reflection on the context of financial abuse of older people in Ireland, the authors identify very pertinent issues in relation to the prosecution of cases, much needed legislative reform and regulation of home care as well as a lack of depth research in Ireland into the area of financial abuse.

In conclusion, this special issue of the Journal of Adult Protection charts Ireland's efforts to address elder abuse in recent years. Each paper has illuminated particular insights into practice, policy and legislation in primary, secondary and tertiary care in the protection of older people. Essentially, while services have been developed, these studies have pointed to additional changes required to provide a more comprehensive safeguarding system with empowerment of the older person as the central focus. We hope Ireland's experience will be of interest to those working in the area of safeguarding in other jurisdictions and would be happy to discuss these or similar issues at any time.

Amanda Phelan
based at Co-Director, National Centre for the Protection of Older People, School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland.

References

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