Brownell P. Future directions for research on neglect, abuse and violence against older women (Editorial). SEEJPH 2019, posted: 19 February 2019. DOI 10.4119/UNIBI/SEEJPH-2019-205 Page 1 of 8 E D I T O R I A L Future directions for research on neglect, abuse and violence against older women Patricia Brownell1 1 Fordham University, New York City, New York, USA. Corresponding author: Patricia Brownell, PhD, LMSW – Associate Professor Emerita of Social Service, Fordham University, New York City, New York, USA. Brownell P. Future directions for research on neglect, abuse and violence against older women (Editorial). SEEJPH 2019, posted: 19 February 2019. DOI 10.4119/UNIBI/SEEJPH-2019-205 Page 2 of 8 The elder abuse field has developed significantly since its inception as a field of practice along with gerontology in the 1970s. Research on elder abuse evolved later, stimulated by the work of the late Rosalie Wolf, considered a founder of the elder mistreatment field (1). Much of this work has been interdisciplinary, with medicine, law, nursing, psychiatry and social work collaborating, as well as sociology. As a result, important research initiatives have significantly broadened our understanding of prevalence, and other dimensions of elder abuse, within aging and vulnerable adult frameworks. However, some aspects of elder abuse remain underdeveloped and open for further exploration. Feminist perspective/domestic violence Much work still needs to be done to bring elder abuse into the domestic violence field. Feminist scholars particularly in the disciplines of sociology, social work and psychology in the 1980s and 1990s began to consider elder abuse within a feminist perspective (2). Some limited intervention research on elder abuse in this frame was initiated (3,4). Feminist gerontology has also been developing as a perspective (5). Coming out of social gerontology and critical theory, this perspective seeks to focus on gender relations in gerontology and builds on the pioneering work of Mary Bricker- Jenkins and feminist social work practice (6). Bringing elder abuse within the domestic violence framework has resulted in increased understanding of why older women have been invisible as victims and survivors of intimate partner abuse (7). Some novel research methodologies have emerged from the European Union (8) and the World Health Organization (9) in examining prevalence of abuse experienced by older women. Another direction that has yet to be fully explored in the elder abuse literature with respect to older women and abuse is that of the application of complex trauma to an understanding of neglect, abuse and violence against women in later life (10- 15). Life course perspective Bringing a life course trauma-focused perspective may also address another gap in the literature on older women and abuse: the failure of gerontology and the vulnerable adult fields to focus on older women and abuse in spite of evidence that abuse is more prevalent for women of all ages, compared with men; and the failure of the domestic violence field to include women above the age of 49 in prevalence studies and to relegate older women in an “other” category (Susan B. Somers, President, International Network for the Prevention of Elder Abuse, Personal Communication, January 5, 2019). To place elder abuse within the field of family violence, we need to move beyond a siloed approach to understanding abuse only as child abuse (vulnerable dependent) and spouse/partner abuse (reproductive age women as victims/survivors). These siloes when applied to elder abuse have resulted in a misunderstanding of older adults as frail care dependent victims or as experiencing negligible intimate partner violence in later life. It has also obscured an identified risk factor in elder abuse: abuse experienced earlier in the lifespan of elder abuse victims (16). Trauma-informed care Only very recently has trauma been considered a factor in elder abuse (14,17). Social work is a leading profession that has placed trauma-focused care as a practice model in the fields of child abuse and spouse/partner abuse. However, the medical model dominating elder abuse has resulted in a lack of understanding of the role of trauma in elder abuse. Both feminist gerontology and a life course Brownell P. Future directions for research on neglect, abuse and violence against older women (Editorial). SEEJPH 2019, posted: 19 February 2019. DOI 10.4119/UNIBI/SEEJPH-2019-205 Page 3 of 8 perspective require a feminist perspective and an understanding of domestic violence as part of the life course. While theory has laggedobservation, a growing body of research has identified a correlation between abuse early in the lifespan and elder abuse (16,18). This required challenging the ageist bias in the field of domestic violence, as well as the well- meaning but misguided effort to address a perceived sexist bias in gerontology research by applying a gender neutral lens (19). Practitioners and researchers are beginning to develop and assess trauma-focused interventions and care. Among promising models include psycho-educational support groups, groups promoting spirituality among older women who have experienced familial abuse, and interventions intended to target depression and abuse (4,20,21). Acknowledgement of trauma as a central factor in abuse for girls and women of all ages not only provides an explanatory framework for what has been identified as a risk factor for elder abuse, experiencing abuse as a child, but can also provide a practice framework for interventions across the lifespan. It also has the potential for integrating older women into a life course perspective on neglect, abuse and violence against girls and women: older women are too often relegated to an “other” category as though old age renders older women gender neutral (see Susan B. Somers, above). Interventions for children who have experienced abuse, as well as younger women who are victims of domestic violence, may mitigate against vulnerability to abuse in later life as older women. Also, interest in unresolved trauma in later life has led to models of intervention that can begin to address late life trauma or earlier unresolved trauma. Theoretical advances in understanding neglect, abuse and violence across the life course The field of elder abuse research has been hampered by lack of a unifying theory that explains abuse of older adults in domestic settings (22). This is also the case for understanding neglect, abuse and violence against older women from a life course perspective, and in explaining how abuse experienced in childhood can be a risk factor for abuse in later life. An understanding of trauma across the life course provides one framework for conceptually linking abuse experienced earlier in life to risk of late life abuse (23). Research has found that the effects of childhood trauma may persist or surface intermittently with mental or physical effects that include continued revictimization (24). Early life trauma has been associated with later life physical and mental health problems; in addition, the broad scope of early traumatic experience is also evident in risk behavior studies. One comprehensive literature review found that the correlates and consequences of childhood trauma on later life consequences is compelling (25). The effects of early trauma can be life-course persistent and negatively affect the well- being of individuals, families and communities. Understanding this from a life course perspective can help to identify multiple points of intervention, with trauma-informed research and practice models. Childhood trauma effects can persist into old age (26). The Adverse Childhood Experiences (ACE) Study conducted by Kaiser Permanente in California has found that the more adverse experiences subjects reported experienced in childhood, the more difficulties they reported encountering in later life (27). In addition, Brownell P. Future directions for research on neglect, abuse and violence against older women (Editorial). SEEJPH 2019, posted: 19 February 2019. DOI 10.4119/UNIBI/SEEJPH-2019-205 Page 4 of 8 older women who report interpersonal violence earlier in their lives experience adverse cumulative emotional and health symptoms that affect wellbeing later in life (28,29). Lifetime prevalence of gender-based violence in women and the relationship with mental disorder and psychosocial functioning is often overlooked in prevalence studies of neglect, abuse and violence against older women (30). Survey questions about interpersonal abuse within the past year or even five years might lead to misleading conclusions that older women experience minimal if any gender- based violence compared to younger ones, when in fact abuse experienced earlier in life can continue to be vividly experienced in late life as well. Complex trauma and relevance to abuse in later life Individuals with a history of interpersonal trauma rarely experience only a single traumatic event, and may have experienced exposure to sustained, repeated or multiple traumas: this has been proposed to lead to a complex symptom presentation that includes not only posttraumatic stress symptoms but also those predominately in affective and interpersonal domains (31). This is known as complex trauma, a type of trauma that occurs repeatedly and cumulatively and within specific relationships and contexts (32). While initially thought to be related to child abuse, including child sexual abuse, the expanded understanding now extends to all forms of domestic violence, including emotional abuse, and attachment trauma occurring with the context of family and other intimate relationships over extended periods of time (33,34). While complex trauma (developmental disorder for children) has been proposed as a diagnostic category for the DSM-5, to date it has not been accepted as a distinct diagnostic category (35). The 11th revision to the World Health Organization’s International Classification of Diseases (ICD-11) does include Complex Post Traumatic Stress Disorder (CPTSD) as a diagnostic category distinct from PTSD (36). The ICD-11 CPTSD includes not only the three symptom clusters associated with PTSD (re-experiencing the trauma in the here and now; avoidance of traumatic reminders; and a persistent sense of current threat manifested by exaggerated startle and hypervigilance) but in addition three additional clusters, identified as disturbances in self-organization. These include affective dysregulation; negative self-concept; and disturbances in relationships (37). The basis of the concept of complex (developmental) trauma is attachment theory, originally formulated by Bowlby (38). Other clinicians and theorists began to examine the developmental timing of trauma exposure and emotional dysregulation in adulthood (39,40), the impact of the developmental timing of trauma exposure on PTSD symptoms and psychosocial functioning among older adults (10), and the relationship between childhood trauma and complex posttraumatic stress disorder symptoms in older adults (15). With a theoretical basis for understanding complex trauma from a developmental perspective, researchers and practitioners have begun to understand the links between childhood experiences of interpersonal trauma and abuse with experiences across the lifespan, including old age (14,17,31). As this understanding developed, intervention strategies evolved with gerontologists taking the lead in implementing and evaluating them (20). In addition, translational collaborations between researchers and clinicians have resulted in formulating clinical applications of the attachment framework (13) as well as designing phase-oriented clinical interventions (41). Brownell P. Future directions for research on neglect, abuse and violence against older women (Editorial). SEEJPH 2019, posted: 19 February 2019. DOI 10.4119/UNIBI/SEEJPH-2019-205 Page 5 of 8 Interventions for later life interpersonal victimization related to lifetime trauma history necessarily require cognitive capacity, access to treatment modalities with skilled practitioners, and motivation on the part of the victim, and may also require access to safe living alternatives and other community and social supports (42). Cultural beliefs about the role of girls and women within the family, as well as perceived responsibilities of older mothers toward impaired adult children who are abusive (43,44), are salient, even without past histories of abuse. Abuse of older women with dementia and/or severe physical care needs, particularly within care settings, requires different intervention strategies targeted to institutional or criminal justice remedies (45). However, for cognitively unimpaired victims living in the community who are struggling to resolve chronic abuse particularly as perpetrated by family members or trusted others, and who disclose a history of abuse as children and young adults, trauma focused interventions may be indicated. Conclusion Chronic interpersonal abuse experienced earlier in life, particularly if not within an enabling environment and if left unaddressed and unresolved, may predispose some victims to continued trauma during their lives, according to trauma-informed researchers (16,18). Adoption of a public health framework to address trauma can assist researchers, practitioners and policy makers to develop a theoretically informed multi-faceted prevention and intervention strategy to address what is known as complex trauma (14). Recently evolved methodologies for assessing, measuring (46,47) and treating this in older adults, including older adult victims of abuse, are beginning to make this feasible. Conflicts of interest: None. References 1. Bonnie RJ, Wallace RB. Elder mistreatment: abuse, neglect, and exploitation in an aging America. Washington DC: The National Academies Press; 2003. 2. Nerenberg L. A feminist perspective on gender and elder abuse: a review of the literature; 2002. https://ncea.acl.gov/resources/docs/arch ive/Feminist-Perspective-EA-2002.pdf (accessed: September 24, 2018). 3. Vinton L. A model collaborative project toward making domestic violence centers elder ready. Violence Against Women 2003;9:1504-13. 4. Brownell P, Heiser D. Psycho- educational support groups for older women victims of family mistreatment: A pilot study. J Gerontol Soc Work 2006;46:145-60. 5. Hooyman N, Browne CV, Ray R, Richardson V. Feminist gerontology and the life course. Gerontol Geriatr Educ 2002;22:3-26. 6. Bricker-Jenkins M, Hooyman NR (Eds.). Not for women only: social work practice for a feminist future. Silver Spring, Md.: National Association of Social Workers; 1986. 7. Crockett C, Brandl B, Dabby FC. Survivors in the margins: the invisibility of violence against older women. J Elder Abuse Negl 2015;27:291-302. 8. Luoma ML, Koivusilta M, Lang G, Enzenhofer E, De Donder L, Verté D, et al. Prevalence study of abuse and violence against older women: results of a multi-cultural survey in Austria, Belgium, Finland, Lithuania, and Portugal (European Report of the AVOW Project). Finland: National Brownell P. Future directions for research on neglect, abuse and violence against older women (Editorial). SEEJPH 2019, posted: 19 February 2019. DOI 10.4119/UNIBI/SEEJPH-2019-205 Page 6 of 8 Institute of Health and Welfare (THL); 2011. 9. García-Moreno C, Pallitto C, Devries K, Stöckl H, Watts C, Abrahams N. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva, Switzerland: World Health Organization; 2013. 10. Ogle CM, Rubin DC, Siegler IC. The impact of developmental timing of trauma exposure on PTSD symptoms and psychosocial functioning among older adults. Dev Psychol 2013;49:2191-200. 11. Ogle CM, Rubin DC, Siegler IC. Cumulative exposure to traumatic events in older adults. Aging Ment Health 2014;18:316-25. 12. Ogle CM, Rubin DC, Siegler IC. The relation between insecure attachment and posttraumatic stress: early life versus adult traumas. Psychol Trauma 2015;7:324-32. 13. Pearlman LA, Courtois CA. Clinical applications of the attachment framework: relational treatment of complex trauma. J Trauma Stress 2005;18:449-59. 14. Ernst JS, Maschi T. Trauma-informed care and elder abuse: a synergistic alliance. J Elder Abuse Negl 2018;30:354-67. 15. Krammer S, Kleim B, Simmen- Janevska K, Maercker A. Childhood trauma and complex posttraumatic stress disorder symptoms in older adults: a study of direct effects and socio-interpersonal factors as potential mediators. J Trauma Dissociation 2016;17:593-607. 16. Acierno R, Hernandez-Tejada MA, Anetzberger GJ, Loew D, Muzzy W. The national elder mistreatment study: an 8-year longitudinal study of outcomes. J Elder Abuse Negl 2017;29:254-69. 17. Bright CL, Bowland SE. Assessing interpersonal trauma in older women. J Loss Trauma 2008;13:373-93. 18. McDonald L. The mistreatment of older Canadians: findings from the 2015 national prevalence study. J Elder Abuse Negl 2018;30:176- 208. 19. United Nations (2013). Neglect, Abuse, and Violence Against Older Women. New York: Department of Economic and Social Affairs. https://www.un.org/esa/socdev/doc uments/ageing/neglect-abuse- violence-older-women.pdf (accessed: February 7, 2019). 20. Bowland S, Edmond T, Fallot RD. Evaluation of a spiritually focused intervention with older trauma victims. Soc Work 2012;57:73-82. 21. Sirey JA, Halkett A, Chambers S, Salamone A, Bruce ML, Raue PJ, et al. PROTECT: a pilot program to integrate mental health treatment into elder abuse services for older women. J Elder Abuse Negl 2015;27:438-53. 22. Jackson SL, Hafemeister TL. Understanding elder abuse: new directions for developing theories of elder abuse occurring in domestic settings. Washington DC: U.S. Department of Justice: National Institute of Justice; 2013. 23. Maschi T. Draft policy statement – trauma informed care with elder abuse prevention and intervention: a “prescription’ for better health and well-being for elders and their families and communities. Unpublished: Institute for Violence, Abuse and Trauma (IVAT); 2015. 24. Johannesen M, LoGiudice D. Elder abuse: A systematic review of risk factors in community-dwelling elders. Age Ageing 2013;42:292-8. Brownell P. Future directions for research on neglect, abuse and violence against older women (Editorial). SEEJPH 2019, posted: 19 February 2019. DOI 10.4119/UNIBI/SEEJPH-2019-205 Page 7 of 8 25. Maschi T, Baer J, Morrissey MB, Moreno C. The aftermath of childhood trauma on late life mental and physical health: a review of the literature. Traumatology 2012;19:1-16. 26. Gurnon E. Childhood trauma effects often persist into 50s and beyond; 2016. Available from: https://www.nextavenue.org/effects -childhood-trauma (accessed: December 4, 2018). 27. Cohen RA, Hitsman BL, Paul RH, McCaffery J, Stroud L, Sweet L, et al. Early life stress and adult emotional experience: an international perspective. Int J Psychiatry Med 2006;36:35-52. 28. Cook JM, Dinnen S, O’Donnell C. Older women survivors of physical and sexual violence: a systematic review of the quantitative literature. J Womens Health 2011;20:1075-81. 29. Ladson D, Bienenfeld D. Delayed reaction to trauma in an aging woman. Psychiatry (Edgmont) 2007;4:46. 30. Rees S, Silove D, Chey T, Ivancic L, Steel Z, Creamer M, et al. Lifetime prevalence of gender- based violence in women and the relationship with mental disorders and psychosocial function. JAMA 2011;306:513-21. 31. Cloitre M, Stolbach BC, Herman JL, Kolk BV, Pynoos R, Wang J,et al. A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. J Trauma Stress 2009;22:399-408. 32. Herman JL. Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. J Trauma Stress 1992;5:377-91. 33. Courtois CA. Complex trauma, complex reactions: assessment and treatment. Psychother Theor Res Pract Train 2004;41:412-25. 34. Riggs SA. Childhood emotional abuse and the attachment system across the life cycle: what theory and research teach us. J Aggress Maltreat Trauma 2010;19:5-51. 35. Sar V. Developmental trauma, complex PTSD, and the current proposal of DSM-5. Eur J Psychotraumatol 2011;2:1-9. 36. Karatzias T, Shevlin M, Fyvie C, Hyland P, Efthymiadou E, Wilson D, et al. Evidence of distinct profiles of posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD) based on the new ICD-11 trauma questionnaire (ICD-TQ). J Affect Disord 2017;207:181-7. 37. Karatzias T, Cloitre M, Maercker A, Kazlauskas E, Shevlin M, Hyland P, et al. PTSD and Complex PTSD: ICD-11 updates on concept and measurement in the UK, USA, Germany and Lithuania. Eur J Psychotraumatol 2017;8:1418103. Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5774423/ (accessed: December 22, 2018). 38. Bretherton I. The origins of attachment theory: John Bowlby and Mary Ainsworth. Dev Psychol 1992;28:759-75. 39. van der Kolk B. Developmental trauma disorder. Psychiatr Ann 2005;35:401-8. 40. Dunn EC, Nishimi K, Gomez SH, Powers A, Bradley B. Developmental timing of trauma exposure and emotional dysregulation in adulthood: are there times when trauma is most harmful? J Affect Disord 2018;227:869-77. 41. Steele K, Van Der Hart O, Nijenhuis ER. Phase-oriented Brownell P. Future directions for research on neglect, abuse and violence against older women (Editorial). SEEJPH 2019, posted: 19 February 2019. DOI 10.4119/UNIBI/SEEJPH-2019-205 Page 8 of 8 treatment of structural dissociation in complex traumatization: overcoming trauma-related phobias. J Trauma Dissociation 2005;6:11-53. 42. Solomon J. Shelter: the missing link to a coordinated community response to elder abuse. New York: The Harry and Jeanette Weinberg Center for Elder Justice; 2019. 43. Smith JR. Expanding constructions of elder abuse and neglect: older mothers’ subjective experiences. J Elder Abuse Negl 2015;27:328- 55. 44. Smith JR. Listening to older adult parents of adult children with mental illness. J Fam Soc Work 2012;15:126-140. 45. Ramsey-Klawsnik H, Teaster PB, Mendiondo MS, Marcum JL, Abner EL. Sexual predators who target elders: findings from the first national study of sexual abuse in nursing homes. J Elder Abuse Negl 2008;20:353-76. 46. Elhai JD, Gray MJ, Kashdan TB, Franklin CL.Which instruments are most commonly used to assess traumatic event exposure and posttraumatic effects: a survey of traumatic stress professionals. J Trauma Stress 2005;18:541-5. 47. Widom CS, Dutton MA, Czaja SJ, DuMont KA. Development and validation of a new instrument to assess lifetime trauma and victimization history. J Trauma Stress 2005;18:519-31. © 2019 Brownell; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.