An Understanding of Abuse in the Hispanic Older

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Journal of Social Distressand theHomeless, Vol.8, No.3 1999

AnUnderstandingofAbusein theHispanic OlderPerson: Assessment, Treatment,andPreventionCarmen Inoa Vazquez1andDineliaRosa2

Thisarticleoff rs adiscussionofabusein theHispanic older person populationconceptualized fromwithina culturalframework including assessmentan dtreat-ment.Basic cultural values suchas familism marianismo machismo and respetoareconsidered essential elementsto the understanding of thisframework.Accul-turation,migration and socioeconomicfactors arealso presentedas importantfactors in the understanding of thisproblem.Thisarticleemphasizes ho w expec-tationsbasedon cultura laspects andvaluescan unintentionally increasetheriskof neglect and/orabuse.The concepts of caregiverstressand dependency widelydiscussed in theolder person abuseliterature are integrated in thediscussionofolderperson abusein theHispanic.

INTRODUCTION

Untilrecently, domestic violence has been thought of as primarilyaffectingwomenand children. This perception is changing as evidenced by the numberofcasesofelder abuse thatare nowreported. During1988,theNational AgingResource Center onElder Abuse listed 140,000reportsofelder abuse receivedby 24 state adult protection agencies in the United States.New findings wererecently obtained by the National Elder Abuse Incidence Study (NEAIS) lead bytheNational CenteronElder Abuse (NCEA)andpreparedfor theU.S.DepartmentofHealth and HumanServices'Administration on Aging and Administration forChildren and Families (NEAIS, 1998).This study, which consisted of a 4-year1Director, NYU-Bellevue Clinical Internship and Clinical Associate Professor, NYU School ofMedicine.2Senior Psychologist, Bellevue Hospital Center, Psychiatric Elder CareUnit.3Correspondence shouldbe directed toCarmenboa Vazquez, Ph.D., ABPP, Director ofTraining,Bellevue Hospital Training Program, Room241 B, NewYork,NY10016.

931053-0789/99/0700-0193$16.00/0 C 1999HumanSciences Press,Inc.


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research projecttoestimatetheincidenceofelder abuseindomestic settingsintheUnited States (gatheringinformationof anationallyrepresentative sampleof15states), indicated that approximately450,000,000older persons in domesticsettings were abused and/or neglectedduring1996 (NEAIS,1998).Although, The U.S. Senate Special Committee on Elder Abuse (Fulmer,McMahon, Baer-Hines, & Forget, 1992) estimates thatover2,500,000casesofelder abuse occur each year in the United States, ahighnumber ofcasesgo un-reported. The fact thatahigh numberofcasesofelder abuse gounreportediswell-documented(Benton & Marshall, 1991; Pillemer & Finkelhor, 1988).Stud-ies estimate that only one in six cases is reported (Ashley and Fulmer, 1988;Baron&Welty,1996; Fulmer et al.,1992).This is asignificantpercentage if weconsider thatthe entire older person population(those65 years old or older) isestimatedto be28,000,000(Fleming, Richards, Santos, & West, 1986; Vazquez&Clavijo, 1995).Most recently, according to NEAIS, of the total number of olderpersons experiencing abuse and/or neglect, 16% were reported but 84% were notreported to Adult Protective Services (APS), the agencyresponsiblefor receivingandinvestigating reports on elder abuse (NEAIS,1998).Thelimitationsinobtaining appropriate statisticsand anaccurate numberofreported cases of elder abuse have been compared withlimitationsfoundamongchildabuseanddomestic violence.Forexample,thelackof uniformlegal codesand definitions of elder abuse has been documented as one of the main rea-sons for the lack of existent accurate statistics (Benton & Marshall, 1991; Jones,1994; NEAIS, 1998; O'Malley, Everitt, O'Malley,&Campion, 1983; Pillemer&Finkelhor, 1988).Thecategoryofneglect causes themost disagreement in theliterature,because it questions the causes of abuse and thedegreeof intentiononthepartof theabuser (Lachs&Fulmer, 1993; Pillemer&Finkelhor, 1989).Disagreementin theunderstandinganddefinitionofabuse existsnotonly betweenthe different theoreticians andresearchers, butalso among the different states.These discrepancies or lack of consensus in the literature and research findingscomplicateanappropriate understandingofabuse.Inparticular, they minimizetheproblem and obscure all of the risk factors involving abuse in older persons. Manycases of elder abuse go unreported because of the victim's reluctance, denial, andlackof awareness that child abuse and domestic violence laws also apply to elderabuse(Benton & Marshall,1991).The same can be said about the Hispanic olderperson population.

Hispanic elder abuse has not been explored in great depth. The need for moreaccurate research and relevant statistics is overdue to gain a better understandingofthespecifics that applytothis population.Anunderstandingof therelevanceofculturalvaluesand howthey impact boththevictimand theabuserisessentialinordertobetterassess,treat,andpossibly prevent abuseinHispanicolderpersons.

The latest statistics on Hispanics indicate that this is the fastest growingminority group in the United States. The United States Bureau of the Censuspredicts thatby thebeginningof the 21st century,thenumberofHispanics in

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theUnited States will surpassthe30,000,000mark (Valdes&Sedane, 1995).Thesepredictions for growth have also been applied to the Hispanic older adultpopulation. In fact,the growth for Hispanics over age 55 is estimated to be at147%withinthe next twodecades.We have already seen that during the last twodecades,theHispanic elder population growby75%. This growthwasthree timesthatof the Anglo American older person (Vazquez & Clavijo,1995).Accordingto American Association of Retired Persons (AARP; 1994) statistics the Hispanicolder person populationisexpectedtoincreaseby555% between 1990and2030.

This article provides a conceptualframeworkthat illustrates the significanceofculturein theunderstandingofabuseinHispanic older persons. Wewillalsoexplorehowthis understandingwillfacilitateabetter assessmentandtreatmentofboth thevictimand theabuser.Culturalaspects thatserveasprecipitating factorsfor theabuse, and/or prevent abusefrom occurringwillbehighlighted.The firstpartof this article discusses Hispanic elder abuse from the perspective of thevictim.Theliteratureonelder abuse focusesmainlyon thevictimandlesson theabuser, which is consistent with the literature on other patterns of abuse/abuser. Toproperlyassess,treat,andpossibly preventfurtherviolencetothis population,webelieve that there mustbe anunderstandingof thespecifics that referto theabuser.To thiseffect, thesecond pan ofthis discussion willaddresstheissue from theabuser's perspective.

THE SPECTRUM OF ELDER BUSE

The literatureoffers little that explores the spectrum of elder abuse amongHispanics that could guide the clinician and other providers ofservicesto betterserve this population. Thefocusof studies on elder abuse in the general populationhasbeen mainly geared toward institutional settings, ignoring abuseby thefamily.Onlyrecently have we seen a shift toward recognizing family-mediated abuse(O'Malleyetal.,1983).

While there is no nationwide consensus on what is considered elder abuse, alldescriptions of abuse of older adults include violent acts carried out with the in-tention of causing pain. Mostdefinitionsalso include sexual, psychological and/oremotional abuse,financialabuse, threatofabandonment, neglect,andself-neglect(NEAIS,1998).However, the overall spectrum of elder abusefallsmainly withinthree bigcategories:physical, psychological, and financial.

Physical abuse refers to the use of physical force that may result in bodily in-jury, physical pain, or impairment, including physical punishment (NEAIS,1998).It may varyinintensity rangingfrom beratinganddemeaningtobrutalizingtheindividualbyphysicallyorsexually assaultingandrobbing them. Physical abusemayalso include medical health mismanagement, neglectbyselforothers,andbodily assault (Benton & Marshall,1991).Financial abuse involves the misuseorblockofaccesstomoney, property,orpossessionsby acaregiver (Benton&

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Marshall, 1991; NEAIS, 1998).Psychological elder abusehasbeen definedasmental suffering deliberately inflicted on anolder adult encompassing humilia-tion, harassment, andmanipulation (Benton&Marshall, 1991).It also includestheinflictionof anguish, pain, or distress (NEAIS, 1998).This type of treatmentmayleadto adisplayofpsychological symptomatology, suchasdepression,anx-iety,andcognitive impairment,and inworstcases,suicidal tendencies (Benton&Marshall,1991).Manyof similarities can be drawnfromthe general spectrum discussed above.Butagain, it is important to recognize thatthe general literature hasmanygapsthatneglectamore complete understandingofabuse Hispanic olderpersons.

RISK FACTORSThe risk factorsassociated withviolence in the general older person popu-lationhave been well documented in the literature (Fulmer et al., 1992; Kosberg,

1988; Pillemer &Finkelhor, 1988, 1989; Quinn&Tomita, 1986; Steinmetz&Amsdem,1983).Theserisk factors includenonwhiteethnicity, unmarried status,socialclass,lackofinsurance, documentationofdeliriumordementia,ahistoryoffamilyviolence, alcohol and/or abuse of other drugs, and the resentment createdby the dependence of an older person on a caretaker. Dependency on the care-taker hasbeen considered one of themostsignificantriskfactorsforelder abuse(Pillemer&Finkelhor1998).This dependencyseemsto behighlycorrelated withaging andfragility.Elder adultssufferemotionalandphysical stresses causedbydiminishinghealth, loss of earning capacity, physical powers, andisolation.Thesestressorsplace the old population at a higher risk for abuse or neglect by theircaretakers, whether they arefamilyor institutions.Althoughsimilarities can be drawn from the risk factors previously listedfor elder abuse in general, whatis lacking in this list is the impact of cultural,socioeconomic, immigration,andacculturationprocessstressors.Regardlessof thecauses for elder abuse, itseemsthatfor the Hispanic olderpersons,thestressorsexperienced by immigration and low socioeconomic status, exacerbated by theacculturation processcan become risk factors that promote abuse. The culturalconsiderations,defined in the nextsection,should not be viewed solely as riskfactors.However, sensitivity and understanding ofthesecultural values and theirsignificancefor this population can serve the clinician in theassessment,treatment,andpreventionofHispanic older person abuse.

CulturalConsiderationsThefamilyandprimary institutions, suchasschoolsandchurches, pass cul-turalvalues fromgeneration to generation. Values areoftenvery well ingrained

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within theindividual,and not tofollow these cultural guidelines carries a sig-nificant senseof guiltand failureon the individual.DefiningHispanic cultureis difficult predicated on the heterogeneity ofLatin America.Theindividualscomprising the Hispanic population in the United States are represented in de-mographics that illustrate marked differencesinmigration pattern, sociopoliticalexperiences,socioeconomic, religious, education, class and levels of accultura-tion.Forexample,thediversityin theHispanic populationintermsofeducationcanbe very important. The literature indicates that the percentage of older Latinoswithless thananeighth grade education ishighestforPuerto Rican (77%), forMexicanAmerican (75%),and forCubans (57%). These demographics impactonutilization ofservices,abilitytocommunicate withtheprovider,andadherenceto cultural values. However, certain value found among most Hispanics seem tohold asignificantlevelofadherenceandintensity. These values includefamilism,marianismo,machismo,respeto,acculturation, and migration stressors.

FamilismAlthoughsome researchers have questioned whetherfamilismhasbeenro-

manticizedandoveridealized (John&McMillan,1998),it isconsideredone of themostpowerfulandwell represented concepts withintheHispanic cultureand hasdirectimplications on the understanding of elder abuse. Familism is the prescribesthatthe family iscentralto the lifeof theindividual. This expectation requiresthatloyalty andunitybe top priorities: sentidodeobligacion (asenseof duty).ForHispanics,thefamilyincludes nuclearandextended membersandoften closefriends,neighbors,andcommunity members (Bernal, 1982).

Familismhasbeen identifiedas anobstacleinfamiliesseeking necessary helpprior to feeling overwhelmed (Alfaro-Correa, 1994).The concept of caregiving,defined as acommitmentto thewelfareofanother,is anintrinsic componentoffamilism.Noreference appearstoexistin theelder abuse literature recognizingtheconnection between caregivingandfamilism.Becausefamilismhasbeenidentifiedas apossible obstaclein thehelp-seeking pathway priortofeeling overwhelmedamongHispanics, it is possible that it applies to Hispanic elder abuse.

MarianismoMarianismo isdefinedas thecultoffemalesuperiorityand theexpectation thatwomenarecapableofenduringallsuffering.Inthis cult, womenare theprovidersand caretakers of others, particularlyoftheir family members (Gil&Vazquez,

1996; Stevens, 1973).This cultural value, mandatingsuffering for women, holdsdemanding expectationsandrequires caringforrelativeswithlittle support. TheseWomenadhere to the expectations themselves as well as the entire family andsocietyingeneral. Thisoftencausesirritability, problemswitheatingorsleeping,

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andother symptomsassociatedwithdepression.W e believe that ma rianism o anddepression are highly correlated, given that apossible theoretical explanationsfor the cause of depression is psychosocial pressure, such as different rearingenvironments,less favorable economic opportunities, and different social roles.Accordingto theHispanic H ANE S (citedinMoscicki, Race,Reiger,1987),PuertoRicanwomen had a higher rate of majordepressionat an earlier age (20 to 24),whileMexican Am ericanandCuban womenhad ahigher rateofdepression at alaterage(betweentheagesof 55 and 64).This concept of marianismo impacts both the victim and the abuser. Thevictimmaysee herself as needing to have a higher threshold of tolerance for the abuse. Inthecaseof a female abuser, she m ay take more responsibilities and burden than shecouldpossibly handle. A male abuser, for example, may have high expectationsfromeither his partner or mother about how he should be cared for, and get veryupsetand abusive when these are not met. O ften, for a clinician, understanding thesenseofdutybasedonmarianismo's powerful mandatesisdifficult.

MachismoAnother cultural value thatcanhave significance in the understandingofolder person abuse among Hispanics is machismo. Machismo has been definedas a socially learned and reinforced set of behaviors in Latino society, whichguides male behaviors (Gil Vazq uez,1996).Machismo and marianismo areculturalconcepts with very positive values. M acho m en take care of their families,protect them against all odds, and are expected not to have their female partnersgotowork outsideof thehouse. Marianismo expect womento be thecaretakers,thenu rturing forces athomewhow ill maintain equilibriumin thefamily. Bothconcepts also carry negativeaspects,particularly when Hispanics find them selvesacculturating.Theintegrationofdifferentcultural valuescanoftencreate conflicts

within the individual thatnot only produce anxiety, depression, or poor copingresponses leading to alcohol or other drug abuse, but that could exacerbate anabusive situation.

RespetoRespeto referstoexpectationson howothers should treatus andvice versa.It implies obedience,duty, and deference. Respeto is expected to guide us ininterpersonal relations andconnotes arecognition of others' placeinsociety in-cludingpower, achievements, w ealth, other gains, and m ost especially age (M arin VanOss, 1991; Vazquez Bukki,1998).A violation of this cultural value isconsidered a major m oral offense, even m ore powerful w hen the lack ofrespectistowardanolder person. This alonecan beinterpreted asabuse.

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MigrationMigrationis not considered a cultural value, but it is asocial phenomenon

embedded in the experience of all Hispanics residing in the United States. Eitherbydirect or indirectcontacts,Hispanics have experienced the impact of migra-tion in all spheres of their lives. The migratoryexperiencehas been consideredasourceofstressthat places people in avulnerable position with lackofcontrolof their environment. This experience may be highlighted for Hispanic older per-sons because of the lack of physical, physiological, and psychological resources tofacilitatetheir adaptationprocess.Migration may also promote nonconventionalliving arrangements,whichmay place older persons at risk of abuse. For example,a typical arrangement in which grandparents are expected to care for members ofyounger generations in anunfamiliarenvironment maybecomea source ofstressas they may lack the necessary resourcestocope effectively. This may lead tosituations of burden and abuse.

SocioeconomicFactorsAnothercrucial component necessary tounderstandtheU.S. Hispanic older

person population is the socioeconomic factors they face. Hispanics are twice aslikelytolive belowthepoverty level than non-Hispanics (CouncilonScientificAffairs[CCA],1991).Lack offinancialresources observedamong Hispanic olderpersons may place them at a high risk for physical abuse of the medical health mis-management type. Hispanics are more likely to be uninsured as compared to thegeneral population, and may be more exposed to theconsequencesof medical ne-glect. Lackofmedications,andinadequateaccesstohealth carecan be consideredasubtlebutdetrimental formofelder abuseforHispanic olderpersons.

Lack of financialresourcescanalsobe a contributing factor for physicalneglect inthat it may affect living conditions. Constraints inaffordable livingarrangements forHispanic olderpersonsableandwillingtolive independentlyforces them to live under physical conditions that mayplace them at risk forphysical abuse or that may compromise their health. Although lack of financialresourcesis notnecessarily adirect causeofelder abuse, itplaceseldersathighriskbecause they mustresidewith otherfamilymembers, who mayhavedifficultycopingwiththeir ownstresses.

THE VICTIMA research study conducted by the New York City Department for the Aging

(NYC/DFTA) listed by Baron and Welty(1996)found that most victims of elderabuse were female and more than half of the perpetrators weremales,ranging in

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ages from 13 to 96 years of age. This was recentlyconfirmedby NEAIS(1998).Theyconcluded thatfemaleelders were morelikelyto be thevictimsof allcate-gories ofabuse.Women werethe victimsof76.3% of emotional/psychologicalabuse, 71.4% of physical abuse, 63.0% of financial/material exploitation, and60.0% ofneglect (NEAIS, 1998).Elderly persons living alone have lowerratesof abuse,andwidowed, divorced,andnever marriedarelesslikelyto beabused.Physically dependent older personsare athigherrisk forphysical, psychological,andfinancialabuse (O'Malley et al.,1983).

Theprocessofacculturationmayproduce significant stressfor thevictimcausingorexacerbating existentdepression,anxiety,andmaladaptive copingre-sponses,suchasalcohol and/or drug abuse. Similarly, adjustmentto neweconomicrealities as part of the immigrantprocesscan contribute to changes in the familythat couldbe toodifficultfor theolder persontochangeor tocopewith.

Thevast majorityofHispanic older persons belongto the firstgenerationofimmigrants, which has been shown to acculturate to the American culture moreslowlythanthesecondandthird generations (Inclan, 1979; Rosa, 1996; Torres-Matrullo, 1976; Towns-Miranda, 1985). Less acculturated groups tendtoremainisolated and to depend more onfamiliarsources to negotiate their environment(Berry, 1980).Because of this isolation and dependency, acculturation can be averystressfulprocessfor the older person, particularly if addedstressorssuch aspovertyandabuseareadded.

Acculturation can alsoinfluenceaperson'smental health and willingness toseekservices.Imbeddedinacculturationcan be alackofEnglish languagefluency,distrust of the system, and belief innontraditionalhealing practices. Hispanic olderpersons,facinglimitations due to language barriers and isolationfromthe outsideworld, may be at a higher risk for abuse because of the dependency on familymembers who can speak the English language.

Acculturation in theorydoesnot have to be stressing, but when combinedwithdiscrimination, poverty,andpoor coping mechanisms,it canplace boththevictimandtheabuserat ahigherrisklevel.ForHispanic olderpersons,theacculturationprocesscanrender them more vulnerableto financialdependencyonothersand todifficulty negotiating the system because of language barriers, and lack of generalfamiliaritywith the system.

Thevictim's dependencyon theabuseras acause forelderabusehasreceivedrecognition and is perhaps the most widely cited risk factor (Pillemer & Finkelhor,1989).There is lackofconsensus on the source of dependency. Some studiesemphasize thatthevictim's dependencyon theabuseris thecauseof theabuse,while others indicatethecontrary,thatis theabuser'sdependencyon thevictimasaresultof theabuser's stressfullifeandemotional problems (Anetzberger, 1987;Pillemer&Finkelhor, 1989,p.180). Hispanic olderpersonswithalower levelofacculturationmay be at ahigherrisk ofdependencyonfamilymembers than thosewhoaremore acculturatedto thesystem.

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THEABUSERWhilethem ajorityof thevictimsofabusearewomen, abusersarerepresented

inboth genders. Astudy conducted by theNational Aging Resource CenteronElder(NARCEA)citedbyBaronandWelty(1996)foundthat over two-thirdsof thevictimswere females. The abusers were mainly males. Men have beenfoundto bethemostfrequentperpetrators for abandonment (83.4%), physical abuse (62.6%),emotional abuse (60.1%), and financial/material exploitation (59.0%) (NEAIS,1998). Adult children were the most frequent abusers (47.3%). Another studyconducted by Pillemer and Finkelhor (1998) presents a contradictory view. Theyconcluded thatspouses,rather than adult children, makeup agreater proportionofelder abuser. However, according to the NEAIS(1998)spouses represented19.3%of theabuse.The agecategory with themost perpetrators was the 41 to59 age group(38.4%),and elderly people themselves comprised 34.3% of theperpetrators (NEAIS, 1998).Perpetrators offinancial/materialexploitation wereyoungercompared to other types of abusewith85% under the age of 60.

Among the characteristics associated with the abuser arepossessiveness,tendencyto externalize blame and displace anger, poor impulse control, lack ofempathy,and past history of violence (Fulmer, Street & Carr,1984).Other char-acteristics include the mental illness, cognitive impairments, and abuse of alcoholor other drugs (Pillemer & Finkelhor,1989),livingarrangements, stress, emotionsand familydynamics and dependency (Benton & Marshall, 1991; Jones, 1994;O'Malley et al.,1983).Thefinancialdependence of the abuser on the elderly vic-tim isalsoanimportant riskfactorinelder abuse. Pillemer(1985)foundthat64%of theabusersin hissample werefinanciallydependentontheir victims,and 55%weredependent on housing.

Changesin thefamily systemaswellasalcoholism, drug abuse,andotherdeviantbehaviors could result in alossofpowerbyabusers, making them moreprone to act on theirsenseof powerlessness and placing their mental health at risk.This expressioncan be in theformofabuse towardtheelderlyfamily member.

The process of acculturation can alsosign ificantlyimpact the abuser. For theabuser, acculturationstresscombined withsocioeconomic and cultural pressuresmaycause maladaptive behaviorthatcould impactthetolerance necessarytodealwiththe burdenassociatedwith caregivers. Recognition of these realities doesnot condone abuse; it merely presents a reality that should be included in theunderstanding ofelder abusein theHispanic population.

Caregiver stress has been considered a main risk factor in elder abuse, althoughtherearediscrepant viewsin theliteratureinthisregard.Pillemer &Finkelhor(1989)conducted a study that did not demonstrate caregiver stress as a risk factor.In fact,when abused olderpersonswere compared with nonabused, therewas nosignificantdifference found. Theirfindingsindicate thattheabuse seemsto be aresultof theproblemsof theabuser, rather thantheotherwayaround.

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Theliteratureoncaregiver stressorburden, relatingtoHispanicsandabuse,isnonexistent. Cultural valuesandexpectationstillinfluenceMexican Americans(John McMillan,1998).If weextrapolatefromJohnandMcMillan s studieswithMexicanAmericansand on ourclinical experience,w econclude that utilizationofnursing homesforHispanicingeneralisstill viewedasunacceptableandcarriesagreat source ofguilt.T heexpectations from familismoandrespeto still placethe family as the highest priority, although for people who faceacculturationin theUnited States this might bemorethecase intheory thaninreality.Newfamilypatterns requiredbysocioeconomic realities require longer hoursofwork,verycrowded quarters,andsometimes distances inplacesofresidence thatlimitthe resource poolofmanycaretakers.Many relativeswithintheHispanic culturemay feelembarrassedandashamedtoadmit that they cannotfulfill their family sobligations.Theconceptnotonlyoffamilismomandates these behaviors,butalsoof marianismoandmachismo.In theHispanicfamilythis dependency dynamicof theabuserto anabusedolder personbecomeseven more complicated againby theconceptof familismo.Theneedtopreserve thefamily secretof themistreatmentby afamilymemberreinforces thedysfunctional dyad.Anothersourceofstresscan berelatedto thesenseofpride attachedto theconceptofmachismo. Because machismo promotesasenseofcareandprotectionforthefamily,havingtodependon anolder person relativecanbecomeanaddedsourceofstressfor theman.

SSESSMENTANDTRE TMENTFactors includedin theassessment ofelder abusein thegeneral populationinclude caregiverresources,elder attributes, amountofenergy expendedby thecaregiver, caregiver relationship withthehealth care provider, historyofrelation-ships, elder condition, whethertheelderwasperceivedasdeservingthetreatment,mentalhealth of thecaregiver, customary lifestyleof theelder, andsituationalstress (Hanson-Frost &Willette,1994).However,inordertounderstandhow toassess,treat,andprevent abusein theHispanic elderly population,onemust havean awarenessof therelevant Hispanic cultural values that guide behaviorandformexpectations onboth thevictimand the abuser. These values include conceptsalreadyreferredto anddescribed within this article, includingrespeto,familismo,

familysecrets,machismo,andmarianismo, among others.Theclinical assessmentofelder abuse, whichcan beappliedtoHispanic olderpersons should includeahistoryofpresenting illness, physical examination, psy-chologicalassessment,and riskfactor identification (Benton Marshall,1991).However,thecharacteristiclowlevelofeducationcancomplicate obtainingahis-

toryfromtheelder about existing abuse.Theeldermay be apoor historianor maynotknowhow toread about victim s rightsoravailable resources.In thephysical

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AnUnderstanding ofAbusein theHispanic Older Person 2 3

examination,the behavioral observations made by the examiner are very importantas they may revealinformationnot being reported by the Hispanic abused elder asaresultofshameandembarrassment.

The language barrier, including the variety of levels of languagep roficiencyobservedin theHispanic elderly population, is avery importantdifficultywhenassessingtheHispanic older person victimofabuse.Most Hispanic older persons,particularlythe most recent arrivals, including Dominicans and South Americansdo notspeak English well.ThelackofEnglish proficiencyoftenrequiresthe use ofanuntrained interpreter,who may notconveytheproper contentof theinterviewintendedby theclinician. Evenfurther,it maypromotethe use of theabuseras aninterpreter thus reducing the opportunities of self-disclosure fromthe victim.

Religion is avery important cultural componentof theHispanic cultureinthe assessment of the Hispanic older persons.Religious values can help in theunderstanding of views on the older person. Misunderstanding of these valuescould present a confusing picture of passivity or more severe pathologythanis thecase.Religious beliefs that include spirits or the capacity to be protected by deadrelatives can also confuse the assessment of Hispanic older persons.The cognitive assessment should take into consideration signs of brain dys-function,poor memory, dementia, and confusion (Hanson-Frost & Willette, 1994).However, assessing Hispanic older persons for cognitive deficits isdifficultagainbecause of the language barrier. The lack of standardized psychological tests inSpanishneeded toevaluateanolderperson'ssymptomatology could complicateor confound the proper diagnosis of elder abuse. Many of the standardized testsnecessarytoevaluate memoryandlanguage,depression,andcognitivefunctionsdo notexistinSpanish.Atbest,therearetranslated versions,which oftenareveryinaccurate.

The psychological assessment of abused older persons includes mental statusandemotional state. The evaluation fordepression,anxiety, or other related symp-tomatology is important. However, other factors highly associated withculturalvalues, whichmayinterfere with this assessment, areworthamention.Forexam-ple, the denial typically observed by the victim and/or the caretaker in situations ofabuse and neglect is highlighted even more in Hispanic older persons because oftheconcept offamily secrets so ingrained in the Hispanic culture. The conceptofkeeping everythingwithin the family toavoid embarrassmentin theoutsideworld mayprevent Hispanic eldersinabusive situationsfrombeingidentifiedandtreated.

Appropriate treatment guidelines need to include the specific key factors thatrelate to culture andthataffectboth the victim and the abuser. The effectivenessoftreatment depends on the integration of clinical skillswithan understanding ofthecultural traditions, beliefs,andfamilyandcommunity social structures (Baron& Welty, 1996).The treatment of Hispanic elderabuse should be based on aholistic approach that includesanemphasisonunderstandingtheabusefrom aphysiological, psychological, cultural, and socioeconomic perspective.


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Ingeneral, psychoeducation hasshownto be effective in the treatmentofHispanics.It may beeffectiveaswellintreatingtheHispanicelderabused.Mucheducation to increase awareness about general abuse as well as elder abuse lawsand guidelines isneeded.This education should not only be given to victims,butalsototheir caregivers and/orstaff members. Psychoeducation canalsoad-dress psychologicalissues,such as depression and anxiety caused by the abuse,managementskills to copewithsourcesofstress,andassertivenesstraining skills.

Psychotherapy with thevictim should emphasize acknowledgementof thepaincausedby thefamilymember, includingtheexpressionofanger, resentment,andanyother negative feeling. Followingthevalue-orientation typically observedamongHispanics,thetreatment wouldbemost effectiveif itsemphasisis in thehere-and-now.Cultural factors discussed inthis article suchas family secrecy,familism,marianism,andrespeto shouldbeincludedin thepsychotherapy work.

Psychotherapywiththeperpetrator,on theother hand, should focusonhelpingtoidentifyandacknowledgethestressorsaffectingtheindividual.Theexplorationshould facusnotonlyonthoseissuesthat promotetheabuse,butalsoonotherstressorsingeneral.The aim of thetreatment shouldbedevelopmentofnewcopingskills todealwiththose sourcesofstress.Recognizingtherisks that promptanindividualto belesstolerant,andhence more abusive,isessentialfor anappropriateassessmentand forproperplanningof thetreatment.Anawarenessof acculturationstress oftenhelpstoshift asourceofblameandpresents anopportunityto findhealthiermodes of behavior and expression of feelings and emotions.

Becausetheinclusionoffamilymembersis animportant cultural value amongHispanics,thepatient shouldbeoffered theopportunityofaddressingtheissueswiththefamilygroupwithin thecontextoffamilytherapyorfamilyconsultation.Theclinician mustbeawareofrulingoutwhether thereis athreatofimmediatedanger ofabuseto theolder person.Inthese situations,theabuser shouldnot beseeninconjunctionwiththevictim,butseparately.If thevictimisreluctant, thiswishshouldberespected completely.Aclinical understandingand theneedtorecognize what possible stressorsare exacerbating an already abusive situationshouldbediscussed.

CONCLUSIONHispanicelder abusehas notbeen exploredingreat depth.Anunderstanding

of therelevant cultural factorsand howthey impact boththevictimand theabuserisessential in order to betterassess,treat, and prevent abuse in this population.Although the Hispanic populationin theUnitedStates presents with differentmigrationpatterns, social class,sociopolitical experiences,levels of education,and other demographics, certain values are consistent among most Hispanics.These values include familism, marianismo, machismo,respeto,acculturation,andmigrationstressors.

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Professionalsprovidingservices to the Hispanic elderly abusedmustdevelopculturalsensitivity aroundthe different cultural components mentionedinthisarticle. Understanding thedynamicof Hispanic elder abuse from this perspectivewillincreasetheopportunitiesofeffectivenessin theclinical intervention.Overall, there is a need for more accurate research and relevant statistics togainabetter understandingof thespecifics thatapplytothis population. Furtherknowledgeinthis areawill facilitatethedevelopmentofappropriate assessmenttools thatwilltake into considerationlanguagebarriersandcultural aspectsaswellasculturally relevant modalitiesoftreatment.

ACKNOWLEDGMENTSThispaperwaspresentedat St.John'sUniversity Eighth A nnualConference.W ewishtothankMs.Suleika Cabrera Drinane, Executive Directorof theInstitute

for the Puerto Rican/Hispanic Elderly (105 E. 22nd St., New York, NY10010),whocollaboratedinthis paperbyoffering around-table discussionwithher staff.REFERENCES

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An Understanding of Abuse in the Hispanic Older