Saturday, 1 November 2014

Elder abuse: MSF eyes law to better protect vulnerable adults

New legislation would give social workers greater powers of access to such individuals in cases of suspected abuse
By Laura Philomin, TODAY. 31 Oct 2014

The Ministry of Social and Family Development (MSF) has announced its plan to introduce a new law by the end of next year, which would allow the state to intervene and better protect vulnerable adults who are unable to care for themselves or have been abused.

By plugging the gaps in existing legal framework such as the Mental Capacity Act (MCA), the new law would cover issues not stipulated clearly in the MCA, such as assigning vulnerable adults to public deputies who will act in their best interests on financial and health matters, said Social and Family Development Minister Chan Chun Sing yesterday.

It would also give social workers greater power of access to these individuals who are suspected to have suffered abuse or neglect.

The majority of vulnerable adults, although defined as individuals above 18 years old who lack the mental or physical capacity to care for themselves, are, in fact, usually the elderly. The MSF was unable to provide statistics on this group, but Ms Tan Ching Yee, centre director of TRANS SAFE Centre, which specialises in dealing with family violence, said it sees about 80 to 100 fresh cases of elderly abuse every year. That is about a third of the centre’s total caseload.

Of these, about 10 per cent have restricted access, which can affect investigations into the cases.

In some of these cases of suspected abuse, Ms Tan said the perpetrators — usually family members who are the primary caregivers — have restricted social workers’ access to these vulnerable elderly. Other cases have involved the elderly refusing to seek medical treatment or denying abuse to protect their family members.

“The families see our centre as a centre that gives them an opportunity to look at helping the (vulnerable adult) but … we have no mandate,” said Ms Tan, adding that she hopes there will be a mechanism that allows social workers to engage families and have more powers of investigation.

Speaking to the media after a dialogue session with about 20 TRANS SAFE management and staff, Mr Chan said this has yet to be a pressing issue, but he stressed the importance of putting in place now the support structures to protect this group, whose numbers are expected to grow.

“So we have enough time before we are hit with the problem in 10 to 15 years’ time,” he said.

Stressing that legal instruments should always be the last resort, Mr Chan said his ministry also plans to ramp up support for care-giving family members, as well as strengthen the capabilities of family service centres and specialist centres to help vulnerable adults and their families.

More details will be announced.

Help coming soon to those who cannot ask for it
By Janice Tai, The Straits Times, 31 Oct 2014

A SON could be thrashing his elderly mother every evening, but a social worker cannot step into their home to help without permission. A frail old man with dementia, living in filth, could also suffer in solitude because no one knows he is in trouble.

By next year, a new law will likely be in place to protect such vulnerable adults, through deputies who will act on their behalf. Social workers and professionals like doctors will also be given more powers to get them the help and treatment they need.

The proposed law, announced by Social and Family Development Minister Chan Chun Sing yesterday, will give powers to the State to intervene, as a last resort, if the person is at risk of serious harm.

"By 2030, we may have up to 900,000 elderly and we are concerned that in time to come, there might be an increasing number of vulnerable adults who are not able to care for themselves or people who are unable to make judgments for their own well-being," said Mr Chan.

So public deputies, drawn from a pool of "public spirited" professionals like doctors, lawyers or social workers will be appointed to act in their best interests. Social workers will also be empowered to enter the homes of, say, suspected abuse victims, and take them somewhere safe.

Currently, Singaporeans can decide who will make decisions for them if they are unable to do so themselves, under the Lasting Power of Attorney (LPA) scheme.

But some people would not have appointed anyone to act for them, while others may have no one willing to do so. And in some cases, there may be questions over whether the appointed deputy is acting in the person's best interests. A case in the spotlight involves a former China tour guide who was granted the LPA by an 87-year-old widow, giving him control of her $40 million assets.

Social workers lauded the new move, saying they are often refused entry into homes when it comes to abuse cases.

The authorities are also working out how to better support caregivers, as well as how agencies can detect cases earlier.

Mr Chan stressed: "We don't want a situation where just because we have this, then inadvertently, we have the unintended consequence of people pushing responsibilities to the State.

"It is the final safeguard, the last resort."

"They are too poor to buy their own flat, but they have made my life hell. Sometimes I feel so scared that I cannot sleep at night."

- MADAM TAN (not her real name), 57, a retired dishwasher who says she has been abused and assaulted by her unemployed son and his wife

My child, my abuser
A third of those who beat or berate elderly victims depend on them for income, says new study
By Radha Basu Senior Correspondent, The Sunday Times, 2 Nov 2014

An elderly widow entrusted the sale of her Housing Board flat to her only child, only to have her daughter pocket the proceeds, dump her mother in hospital and disappear.

Three years on, the daughter is still missing. The mother is still alive, with dementia and in a nursing home.

Around a third of close to 100 victims of elder abuse were cheated of their savings or property or harassed for money by family members, according to a new study by Trans Safe Centre, a voluntary welfare agency which specialises in the issue.

More than half of the victims were physically abused - beaten up, punched, pushed or scratched - and seven in 10 reported being psychologically abused, facing threats, taunts and insults.

Eight in 10 victims were women, usually mothers, while half of the abusers were sons, and a fifth of them, daughters.

The study by social workers Odelia Chan, Ho Gang Hiang and Tan Ching Yee looked only at "substantiated" cases of abuse, where there was physical evidence of wrongdoing or where the abuse had been witnessed by a third party. The victims were aged 60 and above.

While there were fewer cases of financial exploitation than verbal or physical abuse, the numbers may well rise with the increase in the number of better-off older people, said Ms Chan, the main author of the Trans Safe report.

"It's happened in countries like the United States. More cases may well happen here," she said.

Those who face physical or verbal violence can take out court-sanctioned personal protection orders (PPOs) against their abusers, but these orders cannot prevent financial abuse, noted Ms Chan.

Minister for Social and Family Development Chan Chun Sing announced during a visit to Trans Safe last Thursday that Singapore would have a new law next year to better protect vulnerable adults, including the elderly.

Social workers like Ms Chan hope the new law will strengthen protection against financial abuse.

She spent two years trying to find the woman who disappeared after selling her mother's flat. "We lodged a missing persons report and spent months trying to track her down, but with no luck," she said.

The centre has seen cases of adult children fleeing overseas after pocketing the proceeds from the sale of their parents' flats.

The study found that older people are abused not only by caregivers stressed by the burden of providing constant care and financial support. In fact, 30 per cent of the abusers were financially dependent on their elderly victims. Less than a quarter of the victims were financially dependent on the abuser.

Ms Tan, the centre director, said that in many cases, relationship problems exist before the abuse begins. But financial abuse is by no means the only area of concern.

She recalled how a social worker found an elderly man sprawled on black garbage bags on the floor of a flat a couple of years ago.

He was all skin and bones, wearing only a diaper and delirious from the lack of food and water.

A photograph she showed of the man when he was found is too distressing to be published. He was taken to hospital and recovered, but died subsequently.

"Our social worker spent more than four hours on the eve of a public holiday trying to convince the family to allow her access to the old man," said Ms Tan. "Had they refused, there would have been nothing we could have done."

The centre's report recommends mandating access to vulnerable adults who are not in a position to seek help themselves.

Ms Tan hopes the new law will do just that.

There are no recent official estimates of how many elderly people are abused in Singapore, but Trans Safe Centre saw 60 new cases in the first six months of the current financial year, double the number it saw in the previous year.

Pave, the lead agency for family violence, said it has seen 25 cases, including several of sons harassing their mothers for money.

More parents are also applying for PPOs against their children. There were 254 applications last year, up from about 160 a year in the mid-2000s.

The available numbers may well be only the tip of the iceberg.

Ms Tan said it is especially hard for parents to speak out against their children, so few are willing to report such cases. "You can divorce an abusive husband, but you can never divorce your own child," she said.

One of her centre's clients is Madam Tan (not her real name), a retired dishwasher who says she has been abused and assaulted by her unemployed son and his wife.

The younger couple live with Madam Tan in her three-room flat. She is only 57, but looks a decade older.

She said that after an argument over money in May, her daughter-in-law twisted her left hand and pushed her, fracturing a finger. The younger woman, she claims, is mentally ill.

After another argument in July, she said, her daughter-in-law hit her head repeatedly against the iron grille on the front door. It knocked out a front tooth and left her with a bleeding scalp and gums.

"They are too poor to buy their own flat, but they have made my life hell," she told The Sunday Times during a teary interview, clutching a plastic bag full of police and medical reports chronicling the abuse.

She is trying to evict the couple. The Sunday Times did not contact the son and his wife to avoid compromising Madam Tan's safety.

"Sometimes I feel so scared that I cannot sleep at night," she said.

Mental illness a key factor
By Radha Basu, The Sunday Times, 2 Nov 2014

Mental illness has been flagged as a key factor in elder abuse, for victims and perpetrators alike.

More than 40 per cent of those accused of physically or emotionally mistreating their loved ones or financially exploiting them were diagnosed with or suspected to have mental illness, according to a study by Trans Safe Centre.

One in three victims surveyed was also suspected to be mentally ill, while nearly a quarter had lost the ability to remember, reason and love.

Calling mental illness a "red flag", the study's main author, Ms Odelia Chan, said she hoped mental health professionals could screen clients better for signs of abuse. "Cases should also be rigorously followed up," she said.

Senior consultant psychiatrist Tan Lay Ling from Changi General Hospital, who sees many older patients, is not surprised by the link between mental illness and elder abuse.

Elderly people with mental illnesses may not be able to fend for themselves and so are more vulnerable, she pointed out.

Those with severe dementia or psychotic disorders should be regularly screened for potential abuse by their caregivers.

"Similarly, the emotional well-being of caregivers needs to be reviewed regularly by health-care providers too," she said.

Vulnerable adults need greater protection - even from 'loved ones'
By Radha Basu Senior Correspondent, The Straits Times, 6 Nov 2014

SOCIAL workers are seeing a growing number of cases of vulnerable adults being mistreated by their own loved ones - usually grown-up children who should be caring for them.

Some of these "carers" taunt and torment; others beat, or berate. Yet others cheat their parents of their savings or property proceeds.

The abuse is not limited to the elderly alone. The disabled and the mentally ill with limited cognitive capacity are sometimes not spared either.

Several hundred such cases surface here each year, and the numbers may well be the tip of the iceberg, say social workers.

With their tormentors often their caregivers - and almost always their own flesh and blood - the victims are sometimes too scared to complain. Yet others have already lost the capacity to do so.

However, next year, Singapore will have a new law to better protect them, Social and Family Development Minister Chan Chun Sing said last week during a visit to the Trans Safe Centre, a voluntary welfare agency which specialises in helping victims of elder abuse.

The law - which is yet to be drafted - is likely to give powers to state representatives to intervene in cases where an individual is likely to be harmed. Deputies or guardians will be appointed by the state to act in the best interests of the vulnerable adult if they have no relatives.

Social workers and medical professionals will also be given powers to enter homes where a person is suspected to be a victim of abuse, investigate the matter and remove the person where necessary.

These foot soldiers in the battle against domestic abuse say the planned law will make it much easier for them to protect victims, who often suffer in silence and solitude cloistered at home.

Son made mum beg for money

INDEED, one of the biggest gaps in the system to protect abused adults has to do with access. Social workers from agencies dealing with family violence such as Trans Safe, Project Start and Pave say that if they receive a tip-off that an adult is being abused at home, currently they have no powers to act if the owner of the home refuses them permission to enter.

In one case handled by Trans Safe, a son in his 40s lived off state welfare payments paid to his 83-year-old widowed mother, yet made her beg for money as he pushed her around the streets in a wheelchair. Not only that, but the son would also ration her food to save money and leave her bed sore wounds undressed. When his siblings, who did not live with them, expressed concern and wanted to remove their mother to a nursing home, he threatened suicide. Finally, after much cajoling, he has agreed that she go to a nursing home.

Then there are cases where families abandon older folk at home, with minimal care, just waiting for them to die. In one such case, after pleas and requests that lasted four hours, social workers at Trans Safe were allowed access to an emaciated elderly man clad only in adult diapers, who was found lying on black garbage bags. He was delirious from a lack of food and water. He was removed to hospital, recovered, but died subsequently.

Homecare doctors and social workers emphasise that these are just the cases where they are lucky enough to make a breakthrough and enter a home. There could be many others, where victims may be dying the same way they lived their last years - suffering slowly in silence.

Even as the new law will address these issues, existing protection measures could also be strengthened.

Under current laws, vulnerable adults - including wives and parents - who are at risk of abuse by family members can apply for a Personal Protection Order (PPO), a court-sanctioned document requiring the abuse to stop.

This PPO regime has largely worked well with victims of spousal abuse. Abusers can be fined or jailed for breaching the order.

But there are several limitations of the PPO when it comes to vulnerable groups such as the abused elderly.

Studies by Trans Safe have shown that in slightly over half the cases of elder abuse, the perpetrator is an adult son. Daughters make up another fifth of abusers. Nearly eight in 10 victims, meanwhile, are women, mostly mothers.

Social workers say that an angry wife will be far more willing to take out a PPO against an abusive husband. Parents, especially mothers, on the other hand, find it hard to act against their own flesh and blood.

Besides, victims are required to apply for PPOs themselves. Frail, illiterate older folk or those who are mentally challenged may need time to understand the process.

Even when they do, if the order is contested, the process could drag for six months or more. The new law could consider ways to speed up the PPO processes.

Giving state-appointed welfare officers the powers to remove victims at risk of further abuse to temporary shelters is another possibility the new law must look into. This could be done while the social workers identify alternative living arrangements, such as with another relative.

This is especially important since the Trans Safe study showed that in nearly three-quarters of elder abuse cases, the victim shares a flat with the abuser.

The Children and Young Persons Act gives state officers the right to assess and remove a child who is being abused or faces a threat to his life and well-being. Similar provisions could be enacted to protect vulnerable adults, too.

Need to protect against financial abuse, too

ANOTHER issue the new law should consider is whether to appoint guardians to assist even those individuals who have not lost their mental capacity altogether, but are in danger of doing so.

This is already done in countries like Japan where guardianship is calibrated according to three distinct degrees of cognitive loss.

The proposed law should also look at strengthening protection against financial abuse.

Currently, this is outside the ambit of domestic abuse laws which protect victims from physical, sexual and psychological abuse.

Countries like Australia and the United States have teams specialising in identifying and taking action in cases of financial abuse. While Singapore has adult protection teams - comprising social workers, doctors, lawyers and police officers - who offer advice on how to deal with abuse cases, these should be expanded to include professionals from the banking, insurance and housing sectors who can provide advice on tackling financial abuse cases.

It is also worth exploring whether some, if not all, adult abuse cases should be referred to a tribunal to be dealt with in a faster, more cost-effective way, compared to the usual court process. Australia, for instance, has a tribunal to consider financial abuse cases.

Announcing the new law, Mr Chan pointed out that by 2030, there will be nearly 900,000 Singaporeans aged 65 and above. With shrinking families, many may not have close relatives and need state-appointed guardians to protect their interests should they be abused or sink into cognitive oblivion.

But in many ways, the silver surge is already here. There are nearly 405,000 people aged 65 and above today, up from only 250,000 a decade ago.

Among those most at risk of abuse are those with dementia and serious psychiatric illnesses. Singapore has an estimated 28,000 dementia patients, with many more diagnosed each year.

Some are slowly but surely losing the ability to remember, to reason and to make decisions for themselves. Yet others have already lost this forever.

There are at least another 25,000 patients with serious mental illnesses in Singapore, whose powers of cognition and decision-making, too, may be diminishing day by day.

Earlier this year, social workers at Project Start, an agency which deals with family violence cases, spoke to a worried man who said his sister was refusing to allow him and other siblings to visit their ailing mother, who lived with her. He feared she was being abused.

Checks revealed she had been missing medical appointments. Other siblings and her friends said they, too, had been denied access. Neighbours said they had not seen the older woman in months.

Social workers have tried visiting the home multiple times with local grassroots leaders and even with police.

Each time, the daughter refused them entry, saying her mother was fine and that she was well within her rights to disallow them from entering.

The social workers say they just do not know whether the old woman is all right. They may not know the woman's fate till the law is passed next year.

One can only hope that by then it is not too late for her.

Elder abuse a complex, poorly understood issue
By Chong Siow Ann, Published The Straits Times, 7 Nov 2014

THIRTY-NINE years ago in 1975, a very short report in the form of a letter was published in the august British Medical Journal. The writer was a Dr G.R. Burston and the title of the article was Granny-battering.

Dr Burston wrote then that "it is about time that all of us realised that elderly people too are, at times, deliberately battered". Since that first report of what is now called elder abuse appeared in medical literature, there has been more attention to this very much hidden problem. Together with child abuse and spousal violence, it is the unholy trinity of domestic violence. But the research, interventions and awareness in this field lag far behind the other two.

A recent feature in The Sunday Times highlighted the issue of elder abuse - which encompasses physical, psychological and sexual abuse, neglect, as well as financial exploitation of people aged 60 and older - in Singapore.

The important service that this story has done in placing elder abuse in the public spotlight is indisputable. It was based on a study done by Trans Safe Centre, which is an agency that handles elder abuse. One of the findings was that 42 per cent of the perpetrators have "suspected or confirmed mental illness".

It could be that people with mental health issues find it more difficult to look after an elderly person, but some caution must be exercised in the interpretation of this finding, which is drawn from 93 cases of substantiated elder abuse. This highly selected and relatively small group is not representative of the actual situation. It might not only be erroneous to conclude that mentally ill people are more likely to be abusers but, in doing so, it would also further stigmatise those who are already discriminated against and marginalised in our society.

The converse is probably the case. Mentally ill people are often the victims of crime and abuse - and elderly people with dementia are particularly vulnerable, more so than those without dementia.

In a scholarly review of 28 different studies from different countries published this year in the journal Health Affairs, the rate of physical abuse of elderly people with dementia ranged from 27.9 per cent to 62.3 per cent.

The National Elder Mistreatment Study in the United States, on the other hand, reported that only 1.6 per cent of its cognitively intact elderly respondents had experienced physical abuse. Dementia is more than a loss of memory; it is also a progressive loss of comprehension, judgment, insight, speech and physical function. In the earlier stages, people with dementia can be easily cheated of their money and assets.

Such was the salutary case of Brooke Astor. She was New York's unofficial first lady who, with her fabulous wealth, made philanthropy her career. Later in life, she developed Alzheimer's disease. After her death at the age of 105, her only son was accused of neglecting her care (including forcing her to sleep on a urine-drenched couch) and of stealing her money to enrich himself - for which he was subsequently convicted.

Elder abuse in people with dementia often involves a complex interaction between the victim and the perpetrator. On one side of the calculus are the vulnerability, dependency and the psychological and behavioural change in the individual, which might make the person agitated and aggressive. This can provoke retaliation from the caregiver - with verbal abuse, blows and neglect.

On the other side is the wide cast of abusers who include family members, paid caregivers, friends and professional health-care workers. Undoubtedly, there are unscrupulous and predatory individuals who exploit the vulnerable and the weak, but the inexorable slide of dementia towards decrepitude, infirmity and death exacts an increasing toll on their caregivers.

A number of studies have shown that caregiver burden and stress are among the most common risk factors associated with elder abuse. If the relationship prior to the onset of dementia was already wretched and devoid of affection and warmth, or marred with conflict, it would make elder abuse all the more likely.

Just as history is important, so is the setting. Being cooped up with a person with dementia - the sociologists called this "living in a shared living environment" - and being cut off from other people are recipes for elder abuse.

Intriguingly, a study in Hong Kong that was published in 2011 in the International Journal Of Geriatric Psychiatry found that having a domestic help seems to reduce the likelihood of elder abuse. It could be that the additional help reduces caregiver burden and stress, and the presence of a "non-family member" within the household places a restraining hand.

Elder abuse is a complex problem that would require a raft of measures ranging from better support of caregivers and more training and incentives for those who take care of our elderly, to legislation to provide the legal instruments to better protect the elderly. There should be better public awareness and education. How many people in Singapore, for instance, know the tell-tale signs of elder abuse or are aware of the existence of the Elder Protection Team and how to make a report?

And there are many gaps in our present understanding of elder abuse in Singapore. We do not know how extensive it is, what are the engendering factors, or what are the policies and interventions that would be effective to prevent or reduce this problem.

Until we understand this phenomenon of elder abuse better, any one of us could end up being a victim, and any one of us might even end up being a perpetrator.

The writer is the vice-chairman, medical board (research), at the Institute of Mental Health.


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