Connecting Crime and Abuse Victims to Mental Health Services

Abstract:

Older adult victims of abuse and crime have significant unmet mental health needs, with high rates of depression and anxiety. But few victims are offered mental health care, and there are no standardized, effective programs to address their specific mental health needs. PROTECT, a manualized therapy offered as an adjunct to victim support services was developed and tested and is unique in its demonstrated effectiveness to reduce depression among victims. PROTECT, which is offered remotely (by video and phone), has been found to be effective, offering a shift in delivery that increases its potential dissemination beyond current use in New York City.

Key Words:

depression, mental health, elder abuse, crime

Elder abuse is defined as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person” (World Health Organization, 2022, p. 1). In the United States, it is estimated that 1 in 10 older adults are victims of abuse (Acierno et al., 2010; Rosay & Mulford, 2017). According to a most recent prevalence study conducted in New York, 141 out of 1,000 older adults experienced elder abuse, with the highest rates of abuse occurring in New York City (Lachs & Berman, 2011). Elder abuse includes physical, sexual, financial, and psychological abuse, as well as caregiver neglect, and studies have shown that psychological and emotional abuse have the highest mean prevalence (Pillemer et al., 2016). Most elder abuse victims remain outside of formal institutional response systems and, when offered abuse resolution services, often underuse them.

Sadly, depression is common among elder abuse victims: roughly a third of elder abuse victims also are depressed. Victims with depression have higher rates of mortality and nursing home placement (Dong et al., 2009; Lachs et al., 1998). There is a bidirectional relationship between depression and elder abuse, with victims showing higher rates of depression following abuse, and depressed individuals being more likely to experience abuse later in life.

Circumstances that put older adults at risk for mistreatment and abuse were exacerbated during the COVID-19 pandemic. While necessary for public health concerns, social distancing and stay-at-home orders further isolated older adults at risk of elder mistreatment and greatly limited opportunities for in-person social engagement activities, as well as access to health and aging services (Chang & Levy, 2021; Elman et al., 2020). For example, many NYC agencies had to quickly shift from in-person service delivery to remote. Although agencies made efforts to maintain services during this time, there was a significant decrease in services in general, and in mental health services in particular (Liu et al., 2022).

While many older adults already deal with loneliness and lack of social support, the COVID-19 pandemic resulted in an increase in social isolation, which is a demonstrated risk factor for elder mistreatment (Pillemer et al., 2016). The combination of an increase in social isolation and a shift in normal service delivery in healthcare settings, as well as aging services, increased older adults’ vulnerability. These circumstances posed greater challenges for older adults at risk of elder mistreatment, now confined to their home, potentially with their abuser and unable to access services.

Research from the first years of the COVID-19 pandemic showed an 83.6% increase in elder abuse during the pandemic as compared to pre-pandemic estimates. Research shows that 1 in 5 (21.3%) older adults reported elder abuse in the beginning of the pandemic (Chang & Levy, 2021). This finding represents a dramatic change from pre-pandemic elder abuse prevalence reports, which estimated that 10% of older adults experienced mistreatment.

The COVID-19 pandemic highlighted an already present immense need for effective and accessible mental health services for older adults, especially for victims of elder abuse. Additionally, it proved the need and potential for remotely delivered mental health interventions designed specifically for this vulnerable population.

How Does Crime Affect Older Adults?

Crime remains prevalent in the United States, with serious psychological consequences. The Bureau of Justice Statistics reported an increase in rates of violent victimizations in urban areas from 19.0 to 24.5 per 1,000 persons of all ages between 2020 and 2021 (Thompson & Tapp, 2022). Almost 10 of every 1,000 violent crimes were committed against adults ages 65 and older (Truman & Morgan, 2016). The psychological effects of crime victimization can range from short-term negative thoughts to long-term psychological distress, including guilt, shame, fear, isolation, heightened risk of alcohol or other drug use, suicidal ideation, posttraumatic stress disorder (PTSD), depression, and anxiety (Boccellari et al., 2007; Wasserman & Ellis, 2007).

In older adults, these difficulties can have lasting effects given concurrent life events, such as physical frailty or financial difficulties (Satchell et al., 2022; Serfaty et al., 2020). Despite the prevalence of crime against elders, few interventions or targeted services exist to address the mental health needs of these victims.

The impact of the COVID-19 pandemic was perceived on elder abuse victims as well as in crime against elders. While early pandemic research showed crime rates decreased in the first months of the pandemic, these decreases were mainly in violent crimes, theft, and burglaries (Abrams, 2021). Certain types of crime remained prevalent, such as fraud and identity theft.

Older adults often were the victims of financial exploitation and fraud at the hands of scammers targeting a vulnerable and isolated population (Food and Drug Administration, 2023). Research showed that older adults accounted for 18% of pandemic fraud victims (Payne, 2020), and the financial losses incurred by this population were among the highest across age groups. Preying upon health anxieties, criminals took advantage of a socially isolated and vulnerable group.

The COVID-19 pandemic also brought about an increase in hate crimes. Harmful negative biases toward Asian Americans were exacerbated by the pandemic, turning this community into the main target of rising hate crimes. Physical assaults and property damage against Asian Americans rose dramatically during the pandemic; and these crimes did not spare older adults. Often, older adults were targeted specifically, most likely due to their vulnerability and isolation (Takamura et al., 2022; Tessler et al., 2020). Studies have shown that the financial and psychological consequences of these crimes can have lasting effects (Serfaty et al., 2020).

PROTECT Therapy

We developed PROTECT (Providing Options to Elderly Clients Together) in collaboration with our community partners at the Department for the Aging (NYC Aging) in New York City (Sirey et al., 2015). PROTECT is a 9-week therapy tailored to the needs and unique circumstances of older victims with depression or anxiety (Sirey et al., 2021). PROTECT was designed to address the impact of victims’ stress by setting goals, and to reduce symptoms of depression and/or anxiety by increasing engagement in pleasurable and rewarding activities, with an emphasis on social engagement.

In sessions, clients set personalized goals they would like to achieve and create “action plans” to achieve each goal. For elder abuse victims, these goals can be to help them reduce vulnerability and set limits, and for victims of crime, to take steps to reduce the effects of the victimization. In addition, clients plan how they will spend their time each week in ways that maximize being with others and engaging in pleasurable activities, using worksheets to document their plans. Each session, therapist and client review the worksheets, track progress, and problem-solve together for any current obstacles.

As mentioned above, during the pandemic, many services for older adults transitioned from in-person to remote delivery, including aging support and elder abuse services (Elman et al., 2020). Pre-pandemic studies had demonstrated that video-delivered therapy for older adults showed comparable results to those of traditional in-person therapy. To meet the needs of older adult victims of crime and abuse in this difficult time, and with the support of our funders at the Department of Justice and the National Institute of Mental Health, we shifted PROTECT to remote delivery (individual video or phone sessions).

Does PROTECT Help Reduce Depression?

You bet it does! Our group, in collaboration with our partners at NYC Aging, have tested PROTECT in carefully controlled research projects and in community service delivery projects. We summarize our work below.

Elder Abuse Victims

Our recent research with elder abuse victims shows that PROTECT is effective in reducing depression symptoms and helping participants to feel better prepared to deal with their situations (Sirey et al., 2021). In one of our studies, we compared the effect of 9 weeks of our manualized PROTECT therapy delivered by a staff clinician to the usual care elder abuse victims with mental health needs receive—a referral to a mental health provider. We found that victims receiving PROTECT got better faster than elder abuse victims who received a referral.

Additionally, more than half (55%) of PROTECT participants showed a 50% or greater reduction in depression symptoms, compared to only 17% of participants receiving usual care. And a third (33%) of PROTECT participants no longer showed significant depressive symptoms after treatment. These results show the effectiveness of PROTECT in reducing depressive symptoms among elder abuse victims. Further, when client satisfaction was assessed, more than three-quarters of PROTECT participants reported having “most or all” of their needs met as compared to 35% of participants receiving usual care (Sirey et al., 2015).

Older Crime Victims

There is a lack of evidence-based interventions designed specifically for older crime victims dealing with depression and anxiety. With our collaborators at NYC Aging, we expanded PROTECT to serve older victims of crime, given increasing crime rates in New York City. At the end of 2021 we began offering mental health services via video and phone to older crime victims. Between 2021 and 2022, we served 31 older crime victims in Spanish, English, and Cantonese. Evaluating the impact on depression we found that more than two-thirds (67.7%) of crime victims receiving PROTECT showed clinically significant reductions in depression symptoms and felt less depressed after treatment. Further, we found that PROTECT reduced depression symptoms, regardless of gender, race, and ethnicity, as well as the type and number of victimizations.

PROTECT is an effective intervention to address the mental health needs of victims of crime and abuse. In collaboration with elder abuse and crime agencies that offer support services to address victimization, PROTECT has been shown to be a highly effective intervention to reduce depression symptoms in older adults. Furthermore, it is a simple and streamlined 9-week structured intervention that has the potential to be implemented by community social workers and gain high adherence rates.

How Does PROTECT Work Remotely?

The onset of the pandemic encouraged us to further enhance the remote delivery of PROTECT. From March 2020 onward, we delivered PROTECT to elder abuse and crime victims fully remotely. Clients chose to have their sessions via telephone or video and met remotely for 9 weeks with their clinician to receive the intervention.

We compared the impact of PROTECT in reducing depression among elder abuse victims across different delivery modalities, which include in-person visits, telephone, or video sessions. Among a sample of 138 clients receiving PROTECT—most (70.3%) still in the abusive situation— every participant showed significant depression reductions regardless of differences in age, race, and ethnicity, supporting our previous findings on the efficacy of PROTECT for elder abuse victims. On average, there was a reduction of more than 5 points on the depression severity scale (PHQ-9).

Further, we found that all clients receiving PROTECT through the three delivery methods demonstrated statistically significant reduction of depressive symptoms (PHQ-9) at the end of 9 weeks of treatment. Both video and phone delivery methods were as effective as in-person delivery in reducing depressive symptoms of elder abuse victims over the course of the intervention. Of note, most clients (91%) receiving sessions through mixed modalities (e.g., in-person and phone, or video and phone) completed all their sessions, while only 66% of those receiving phone-only sessions completed their course of therapy. Participants receiving in-person–only therapy largely (89%) completed treatment, as well as those receiving video-only sessions (85%). These findings support the importance of flexibility when offering services to older adults.

What Can Be Done?

Mental health needs often are overlooked in later life, as well as when we provide other needed services. Sadly, elder abuse and crime are no exceptions. The PROTECT program offers a unique opportunity for elder abuse and crime victims to receive mental health services, while they are receiving services as victims. This unique partnership between elder abuse/crime agencies and a mental health agency allows us to integrate mental health care into victim support services. But these types of integrated services are only available through partnerships between providers who care for victims and mental health providers. There must be a willingness to bridge service silos and take a more comprehensive approach to the needs of older adults. This strategy may be new to service providers who work with older adults, but it is the model of services offered to children. Sadly, older adults continue to lack the support—legal and fiscal—given to children. We hope that PROTECT becomes a model of the type of integrated services offered to older adult victims.

Jo Anne Sirey, PhD, is a clinical psychologist and professor in the Department of Psychiatry at Weill Medical College of Cornell University and directs the Weill Cornell ALACRITY Center. Her research focus is on the development, implementation, and impact of interventions addressing psychological barriers and stigma to improve treatment engagement, treatment participation, and adherence, funded by the National Institute of Mental Health (R01 MH124966, R01MH132757). Isabel Rollandi, PhD, is the research coordinator of Sirey Lab at Weill Cornell Medicine. Clare Culver is a research assistant in the Sirey Lab.

Photo credit: Shutterstock/Kmpzzz

References

Abrams, D. S. (2021). COVID and crime: An early empirical look. Journal of Public Economics, 194, 104344. Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. G. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292–297. https://doi.org/10.2105/AJPH.2009.163089

Boccellari, A., Alvidrez, J., Shumway, M., Kelly, V., Merrill, G., Gelb, M., Smart, S., & Okin, R. L. (2007). Characteristics and psychosocial needs of victims of violent crime identified at a public-sector hospital: Data from a large clinical trial. General Hospital Psychiatry, 29(3), 236–243. https://doi.org/10.1016/j.genhosppsych.2007.01.008

Chang, E. S., & Levy, B. R. (2021). High prevalence of elder abuse during the COVID-19 pandemic: Risk and resilience factors. American Journal of Geriatric Psychiatry, 29(11), 1152–1159. https://doi.org/10.1016/j.jagp.2021.01.007

Dong, X., Simon, M., Mendes de Leon, C., Fulmer, T., Beck, T., Hebert, L., Dyer, C., Paveza, G., & Evans, D. (2009). Elder self-neglect and abuse and mortality risk in a community-dwelling population. JAMA, 302(5), 517–526. https://doi.org/10.1001/jama.2009.1109

Elman, A., Breckman, R., Clark, S., Gottesman, E., Rachmuth, L., Reiff, M., Callahan, J., Russell, L. A., Curtis, M., Solomon, J., Lok, D., Sirey, J. A., Lachs, M. S., Czaja, S., Pillemer, K., & Rosen, T. (2020). Effects of the COVID-19 outbreak on elder mistreatment and response in New York City: Initial lessons. Journal of Applied Gerontology, 39(7), 690–699. https://doi.org/10.1177/0733464820924853

Food and Drug Administration. (2023, January 11). Fraudulent coronavirus disease 2019 (COVID-19) products. United States Department of Health and Human Services. https://www.fda.gov/consumers/health-fraud-scams/fraudulent-coronavirus-disease-2019-covid-19-products

Lachs, M. S., & Berman, J. (2011). Under the radar: New York State elder abuse prevalence study. New York State Office of Children and Family Services. https://ocfs.ny.gov/reports/

Lachs, M.S., Williams, C.S., O'Brien, S., Pillemer, K.A., & Charlson, M.E. (1998). The mortality of elder mistreatment. JAMA, 280(5), 428–432. https://doi.org/10.1001/jama.280.5.428

Liu, J., Ji, B., & Lou, Y. (2022). Impact of the COVID‐19 pandemic on community services for homebound older adults in New York City. Health & Social Care in the Community, 30(5), 1743–1753. https://doi.org/10.1111%2Fhsc.13554

Payne, B. K. (2020). Criminals work from home during pandemics too: A public health approach to respond to fraud and crimes against those 50 and above. American Journal of Criminal Justice, 45, 563–577.

Pillemer, K., Burnes, D., Riffin, C., Lachs, M. S. (2016). Elder abuse: Global situation, risk factors, and prevention strategies. The Gerontologist, 56(2), S194–S205. https://doi.org/10.1093/geront/gnw004

Rosay, A. B., & Mulford, C. F. (2017). Prevalence estimates and correlates of elder abuse in the United States: The National Intimate Partner and Sexual Violence Survey. Journal of Elder Abuse & Neglect, 29(1), 1–14. https://doi.org/10.1080/08946566.2016.1249817

Satchell, J., Craston, T., Drennan, V. M., Billings, J., & Serfaty, M. (2022). Psychological distress and interventions for older victims of crime: A systematic review. Trauma, Violence, & Abuse, 24(5). https://doi.org/10.1177/15248380221130354

Serfaty, M., Aspden, T., Satchell, J., Kessel, A., Laycock, G., Brewin, C. R., Buszewicz, M., O’Keeffe, A., Hunter, R., Leavey, G., Cuming-Higgs, J., Drennan, V., Riveros, M., Andrew, D., & Blanchard, M. (2020). The clinical and cost-effectiveness of a victim improvement package (VIP) for the reduction of chronic symptoms of depression or anxiety in older victims of common crime (the VIP trial): Study protocol for a randomised controlled trial. Trials, 21(1). https://doi.org/10.1186/s13063-020-4211-9

Sirey, J. A., Halkett, A., Chambers, S., Salamone, A., Bruce, M. L., Raue, P. J., & Berman, J. (2015). PROTECT: A pilot program to integrate mental health treatment into elder abuse services for older women. Journal of Elder Abuse & Neglect, 27(4–5), 438–453. https://doi.org/10.1080/08946566.2015.1088422

Sirey, J. A., Solomonov, N., Guillod, A., Zanotti, P., Lee, J., Soliman, M., & Alexopoulos, G. S. (2021). PROTECT: a novel psychotherapy for late-life depression in elder abuse victims. International Psychogeriatrics, 33(5), 521–525. https://doi.org/10.1017/S1041610221000430

Takamura, J. C., Browne, C., Jeung, R., Yellow Horse, A. J., Kwok, D., & Howard, D. (2022). Asian American elders: Caught in the crosshairs of a syndemic of racism, misogyny, and ageism during coronavirus disease 2019. Public Policy & Aging Report, 32(3), 87–93. http://dx.doi.org/10.1093/ppar/prac011

Tessler, H., Choi, M., & Kao, G. (2020). The anxiety of being Asian American: Hate crimes and negative biases during the COVID-19 pandemic. American Journal of Criminal Justice, 45, 636–646. http://dx.doi.org/10.1007/s12103-020-09541-5

Thompson, A., & Tapp, S. (2022). Criminal victimization, 2021. United States Department of Justice, Bureau of Justice Statistics. https://bjs.ojp.gov/content/pub/pdf/cv21.pdf

Truman, J., & Morgan, R. (2016). Criminal victimization, 2015. United States Department of Justice, Bureau of Justice Statistics. https://bjs.ojp.gov/content/pub/pdf/cv15.pdf.

Wasserman, E., & Ellis, C. A. (2007). The impact of crime on victims. In National Victim Assistance Academy track 1: Foundation-level training [chapter 6]. United States Department of Justice, Office for Victims of Crime. https://silo.tips/download/chapter-6-impact-of-crime-on-victims

World Health Organization. (‎2022)‎. Tackling abuse of older people: Five priorities for the United Nations decade of healthy ageing (‎2021–2030)‎. https://iris.who.int/handle/10665/356151