Consistent with previous research, emotional abuse, poor physical health, low social support and functional impairment were associated with higher rates of self-reported emotional distress (e.g.,
Cooper et al., 2006). Interestingly, although the low incidence of sexual mistreatment reported by the current sample prevented further data analysis, only emotional mistreatment, not physical mistreatment, remained significant in the final model. This suggests that the relationship between physical mistreatment and emotional symptoms may be better accounted for by the association of physical mistreatment with other known correlates of psychological distress in older adult populations (i.e., low social support, poor health status, functional impairment). That the relationship between emotional mistreatment and emotional symptoms remained significant after controlling for the other correlates of distress suggests that emotional mistreatment may have a direct and salient impact on the psychological health of older adults. It is somewhat counter-intuitive that emotional mistreatment is more likely to be associated with negative mental health outcomes than physical mistreatment, and this finding highlights the need to consider this abuse type when developing services, policies, and criminal justice system responses. Verbally abusive behavior directed toward older adults is too often overlooked or considered inert next to more objectively identifiable acts such as physical abuse, and this appears to be an incorrect conceptualization. Older adults who experience chronic emotional mistreatment may internalize their abuser's verbal aggressions leading to lower sense of self-efficacy, learned helplessness, and an external locus of control, factors associated with depression and anxiety. In turn, negative beliefs about self-efficacy may lead emotionally mistreated older adults to interpret potentially neutral interpersonal interactions as hostile and coercive, further perpetuating emotional distress.
Implications for the Development of Intervention and Prevention Programs
Results from the current study underscore the need for routine screening for mistreatment and psychological symptoms in the elderly by health care professionals. Although research suggests that older adults living in rural areas may be less likely to receive routine medical care than their urban counterparts, rates of emergent care utilization for acute health problems among rural and urban-residing elders are comparable (Probst et al., 2006). Thus, it may be especially important for emergency medical departments in rural areas to implement universal screening policies that would require all patients over the age of 60 to be assessed for emotional, physical, and financial mistreatment and associated psychological symptoms. To the extent that rural elders face barriers to care, community outreach programs that seek to identify at-risk older adults and facilitate service utilization may provide cost-effective, albeit “grass-roots,” interventions.
Furthermore, the significant associations between low social support, poor functional status, and emotional symptoms have implications for the development of intervention programs.
Comijs and colleagues (1999) found that strong social support and sense of self-efficacy were associated with lower levels of psychological distress in a sample of older adults who had experienced chronic verbal aggression, physical aggression, and/or physical mistreatment. Thus, programs that aim to increase socialization and functional status may provide simple, effective, low-stigma interventions for a population who may be unlikely to disclose mistreatment and/or mental health problems or to seek psychiatric care. A benefit of such interventions is that they are “low threshold” in terms of inclusion criteria and “high threshold” in terms of benefit. Unlike physical mistreatment which can result in visible injury and which may be more readily reportable by victims, the perpetrators, and the community as “abuse,” emotional mistreatment most often occurs beneath public awareness and bystanders may be more likely to tolerate a victim's ambivalence as to whether or not emotional mistreatment constitutes a reportable offense. Thus, health providers, family members, and community members need not “confirm” cases of emotional mistreatment to facilitate increased social interaction among socially isolated older adults or to improve sense of self-efficacy among functionally-impaired older adults.
Importantly, the alleviation of emotional distress, an important treatment target notwithstanding, may lead to other benefits. Recently,
Amstadter et al. (in press) found that emotional symptoms mediated the relationship between physical and emotional mistreatment and self-reported poor health status; of older adults who endorsed physical and/or emotional mistreatment, those who reported emotional symptoms reported poorer health, suggesting that the reduction of emotional distress may lead to improved sense of physical well-being, which could reduce costly overutilization of health care services and contribute to increased quality of life.
Limitations and Future Directions
Several limitations are noteworthy. First, the assessment of emotional symptoms was not comprehensive. Thus, we cannot infer mental health diagnosis; future research should expand the number and diagnostic specificity of questions related to the psychological health correlates of mistreatment. Second, the temporal direction of the relationship between emotional mistreatment, emotional symptoms, poor health status, requiring assistance with ADL's, and low social support cannot be determined by this cross sectional study. As previously discussed, it may be that older adults who experience emotional distress, including depressive symptoms, are more likely to have negative attributional biases and to endorse an external locus of control, leading them to interpret social interactions as “emotional mistreatment.” Furthermore, older adults who are physically impaired and have functional limitations may have a low sense of self-efficacy which can serve to exacerbate depressive symptoms; future investigations should attempt to establish a timeline between mistreatment incidents, emotional distress, and poor health and functional status. Finally, the current study did not stratify participants according to county of residence; thus, no comparisons can be made regarding the prevalence of elder mistreatment and emotional symptoms between older adults living in urban versus rural counties; future research should include rural/urban residence classification as a dependent variable and assess whether residential locality mediates or moderates the relationship between elder mistreatment and other identified risk factors.
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