Thursday, August 16, 2012

Elder Justice Comes of Age

Last June’s White House symposium on elder abuse was a watershed event. Delegates, many of whom had been advocating for decades for more federal involvement, were assured by high ranking administration officials that elder justice was a priority. Hosts, speakers, and delegates were near giddy in their fervor, and murmurs of “Is it for real?” wafted through the crowd.  

It coincided with something I’d been feeling for awhile: that elder abuse prevention had entered a new era. After years of making excuses for its protracted infancy, perhaps we were finally witnessing our field’s coming of age. 

Clearly, thinking about elder abuse had matured. “Elder justice” has emerged as the dominant new paradigm, offering a more expansive view. Defined by the framers of the Elder Justice Act as “the right to live free from abuse, neglect, and financial exploitation,” elder justice suggests that abuse isn’t just a matter of personal and interpersonal dysfunction, but rather, it’s about ensuring fairness, human rights, and equal access to resources and protections for all older adults. That’s a mighty big leap.

How this new perspective plays out remains to be seen. Hopefully, for starters, we’ll acknowledge that older adults are a distinct group with specific needs and circumstances rather than an add-on or “special population” within broader realms like victim rights or domestic violence. The “special” designation has led to plugging clients into services designed for other groups, which often aren’t a great fit. It has sometimes also meant buying into premises that don’t apply (e.g. that abuse is motivated by the drive for power and control, which domestic violence theory assumes) or pressuring victims into options they find unacceptable (e.g. reporting abusive family members to authorities in order to qualify for victim services). Defining our field through other disciplines’ lenses has forced us to make false choices (“elder abuse is ______” where the correct answer is: a woman’s issue, a hate crime, a caregiving issue, domestic violence, and so on, depending on whom you talk to).  That limit the options for helping victims.   

Pigeonholing elder abuse this way has had other consequences. It’s lead to conflicts within our ranks and kept us from gaining traction from an advocacy perspective. We’re remained politically marginalized, divided, disorganized, and powerless. 

Elder justice lets us start fresh and think bigger. It encourages us to rally our forces and find a common voice instead of arguing among ourselves about the “right” analyses. 

This expanded way of thinking has parallels in our research. The new “ecological” models of elder abuse that theorists have proposed acknowledge that personal, interpersonal, societal, and economic factors all play a part in abuse, thereby freeing us from the old dogmas about how situations should and shouldn’t be handled. They lend themselves to multifaceted and holistic solutions that include clinical, public health, and public policy interventions. 

Understandably, some may assume that elder justice just means ensuring that older people have access to the legal system. Clearly, that’s important. But, to a great extent, the legal system focuses on situations in which individuals‘ rights have already been violated, and elder justice can be much more. The California Elder Justice Coalition has adopted a proactive approach that I like to think of as “justice promotion.” It calls for taking affirmative steps to protect autonomy and self determination; ensure fair access to health, social, and legal services; thwart predation; and strengthen responses to abuse. It requires that we focus on capacity assessment and enhancement, ethical considerations in decision making, and safe advance directives. It includes consumer protections that focus on age-related vulnerabilities, keeping dangerous people out of the long-term care workforce, and heightening consciousness among those who serve older adults about high risk situations. 

Clearly, the federal commitment to elder justice displayed at the White House event marked a step forward. The Financial Consumer Protection Bureau, Administration on Aging, Social Security Administration, Department of Justice, and others, in partnership with financial institutions, have acknowledged that consumer protection is part of the elder justice equation by addressing predatory lending, scams, and other forms of exploitation. 

But there are countless other opportunities to promote elder justice. Consumer protections are needed in “consumer-driven” long term services and support (LTSS) programs. Focusing the elder justice lens on programs that transition Medicare and Medicaid beneficiaries into managed care or that provide in-home care requires that we establish strict screening and accountability measures for providers and that we develop realistic criteria for evaluating vulnerable consumers’ ability to choose and monitor their care.We know from recent research that the deficits that render people vulnerable can be subtle, and our network can play an important role in identifying potential problems and building in safeguards. Instructing LTSS providers in how to recognize deficits in decision-making capacity, asking them to be on the lookout for clients who have recently taken out reverse mortgages or who’ve been targeted by predators, and urging them to add  a few questions to assessment tools to identify risk could have a huge impact. 

Instituting these measures requires federal leadership. Let’s hope that our dynamic new federal leaders will connect the dots and see the possibilities for making elder justice an integral component of the service delivery system rather than as a field apart. 

Sunday, June 03, 2012

Remembering Toshi Tatara

I have on my desk a lovely little gold-leaf box for business cards that Toshi Tatara gave me when I visited him in Japan a couple of years ago. It’s filled with irregular cards from other countries in various sizes, shapes, and languages that don’t fit into the US-centric card file that sits beside it.  Toshi too was of a different cut—distinctive and larger than average in his thinking, his commitment to the field of elder abuse prevention, and in his generosity toward those he mentored and championed. 

I first met Toshi in  the mid-1980s at a meeting for Administration on Aging grantees. He worked at the American Public Welfare Association and was doing some of the earliest research on elder abuse; I had a grant to replicate our fledgling San Francisco elder abuse multidisciplinary team in other communities. A few years later, when AoA solicited proposals for the first National Center on Elder Abuse, I collaborated with Rosalie Wolf on a proposal. We competed against Toshi and his partners, the National Association of State Units on Aging and the University of Delaware. Toshio’s team got the grant, but he invited us in as a partner.

During his frequent visits to San Francisco, we often met for dinner in Japan Town, or J-Town as he called it. In the 80s he was working on a project to explore risk factors in child abuse, work that he later adapted to elder abuse. “You don’t prioritize cases that are the most serious or even the most urgent,” I remember him explaining. “You go for the ones you’re most likely to fix.” It was a simple lesson that stuck.

A true internationalist, he encouraged the many Japanese students he mentored to meet colleagues from around the world. San Francisco became a stopping place for his students and colleagues visiting the States. Among the first I met was Yoshihiko Kaneko, who, a few years later, sent me a copy of his book on elder abuse. A bookmark held the page where my name appears, the lone English script on a page of Japanese, the letters stacked one on top of each other.  

The National Center thrived under Toshi’s leadership. He leveraged grants and brokered partnerships to carry out cutting-edge work. Working with the Archstone Foundation, he assembled a team of researchers that included Georgia Anetzberger, Donna Benton, Ailee Moon, Yolanda Sanchez, and Arnold Brown, to explore cultural variations in elder abuse. The project included a terrific conference that brought together not only leading figures in elder abuse, but in ethnic aging as well, including Percil Stanford and Fernando Torres-Gil. Toshi went on to edit the seminal Understanding Elder Abuse in Minority Populations. Later, he finessed funding for the first national incidence study on elder abuse.  

After moving back to Japan in 1998, he continued to promote exchange between the two counties and was particularly proud of translating the iconic National Research Council’s Elder Mistreatment: Abuse, Neglect, and Exploitation into Japanese. It was no small feat. The hefty 570- page English version translates to over 662 pages in Japanese and required the help of three professional translators and two years to complete. He stayed abreast of developments in the U.S. too and was thrilled when Bob Blancato called him personally to let him know that the Elder Justice Act had passed. 

A few years ago, I introduced Toshi to John Dussich, professor of Victimology at Cal State Fresno who also directs the International Victimology Institute (TIVI) at the Tokiwa University in Mito, Japan. Toshi visited the Institute, which he raved about, and he and John were soon dreaming up joint ventures.

In recent years, our paths crossed around the globe. In the summer of 2009, we both attended the Japanese/Korean international roundtable on elder abuse in Busan, Korea that was organized by Donghee Han. With him on the trip were Akiko Sasaki from the Tokyo Medical and Dental University and Noriko Tsukada from the Nihon University Graduate School of Business. He and Noriko worked on many projects together, including a study to explore public policy approaches to meet Japan’s shortage of health care workers by encouraging foreign workers to come to Japan. They also conducted a survey of domestic violence researchers to find out why there haven’t been more studies of secondary victimization of victims during investigation and treatment. 
It was clear that theirs was a relationship of deep affection and respect.

After the Busan event, I accompanied him back to Chiba to talk to his graduate class in aging at Shukutoku University. He’d assigned the students to come up with questions about social work in the States. Although they came to class meticulously prepared, it soon was clear that they didn’t understand my answers, so Toshi stepped in to translate. I’ve worked with translators enough to know that the length of time it takes to say something in one language may be quite different in another. Still, Toshio seemed to be taking an awfully long time with my responses. And it wasn’t just the length that differed; his tone became increasingly more inspired and intense. His face lit up, and he gestured with finger and fist. The students were totally engaged. I like to think that he gave one of his most personal and impassioned lectures that night, and feel honored to have played a role, if only as a gambit. After class, over sushi, I tried to get him to tell me what “I” had said, but all I got was one his enigmatic smiles.

The following year, we were both guests at an international workshop on caregiving sponsored by the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth in Berlin. Toshi was asked to give the closing remarks. Rather than offering up the standard, congratulatory fare, his wrap-up struck a somewhat discordant and feisty tone. He challenged the organizers to ask themselves tough questions--what were their goals and had they achieved them? It wasn’t the first time I witnessed his candor discomfort a room. He nudged us all to probe deeper.

The last time I saw Toshio was when he visited California’s three forensics centers. Over dinner in J-Town, he expressed his admiration for how American professionals were able to get past professional status and hierarchy to work together on cases. He was dubious as to whether the model could be replicated in Japan but was game to try.
Our field benefited enormously from Toshi. His legacy lives on in his many publications and in friends’ and colleagues’ fond memories of his inimitable style.  I’ll miss those J-Town dinners and hearing his expansive and insightful take on matters both personal and professional. He was a true original.   

Toshi's  Opus Magnum