Social workers dealing with situations of abuse against adults and older people: a research study in an Italian region

Abuse against older people and adults with disabilities is recognized by the World Health Organization (WHO) as a significant public health problem (WHO, 2008) and it is considered a violation of human rights (Araten-Bergman and Bigby, 2023).

The WHO estimates that globally, at least one in six individuals over the age of 60 has experienced an episode of abuse in the past year (WHO, 2022). Research indicates that adults with disabilities, particularly those with intellectual disabilities, are at a higher risk of experiencing abuse (Stone, 2018). Similarly, older individuals with dementia are also more vulnerable to acts of abuse; however, the phenomenon is likely to remain underestimated (Sethi et al., 2011). Studies agree that when abuse occurs within family contexts, it becomes particularly challenging for social or health service practitioners to identify, because people tend to hide it or refuse help (Norrie et al., 2018). Hulko and colleagues (2020) identified several reasons why people hesitate to ask for help: fear of not being believed, shame, fear of being stripped of the ability to make their own decisions and reluctance to be seen or labeled as “victims.”

Other studies (Taylor et al., 2014; Wydall and Zerk, 2017) have shown that older people have explicitly stated that the main obstacle is the fear of being placed in a residential facility and moved away from their familiar environment, as well as losing contact with family and friends. Clarke et al. (2015) use the concept of “interdependence” to describe situations in which the victim depends for assistance on the perpetrator (almost always a child with personal issues) and the perpetrator in turn depends on the victim (almost always a parent) for financial support.

Research shows that older people who experience abuse are more likely to enter a residential facility than the rest of the same-age population (Phelan and O’Donnell, 2020). The decision to intervene by admitting an individual into a facility or taking actions that maintain professional control over the situation often depends on the approach adopted by the social workers and the other professionals involved. A “legalistic” approach (Brownell and Wolden, 2003; Hall, 2019) involves social workers primarily focusing on their legal duties to protect vulnerable individuals. This approach often emphasizes compliance with legal requirements to avoid omissions or liabilities, resulting in actions prioritizing control over the situation. On the contrary, adopting a critical approach (Torres and Donnelly, 2022) involves, among other things, questioning professional assumptions and promoting the expression of the point of view of those directly affected, even if this may slow down interventions (Donovan and Regehr, 2010) and accept a certain amount of risk (Dixon, 2023).

This paper presents the results of a research study that gathered the perspectives of social workers on the issue of abuse against vulnerable adults and older people within the Italian context. In Italy, there is a notable lack of research on this issue and no official data to quantify the extent of this phenomenon (Ministry of Labour and Social Policies, 2010). The issue of abuse against adults and older people in Italy is not specifically addressed at either the regulatory level or in the organization of the welfare system. At a local level, there are some important experiences with the establishment of the role of the Older People’s Rights’ Guarantor, who has the purpose to monitor the situation of older people, promote respect for their rights and verify the existence of an adequate level of care. Its functions also include reporting situations of risk or abuse against older people; however, these are sporadic initiatives in some regions or municipalities. In most areas and at a national level, there are no services dedicated to the protection of adults, nor procedures or guidelines for social workers. Indeed, although there is legislation to address gender violence in Italy ^[1], these measures are often partial because they focus primarily on situations where the victim is a woman and do not adequately consider cases involving older adults or individuals with disabilities. The fragmentation of services, coupled with expenses that may exceed the coverage provided by the public health-care system, results in some cases in the failure to provide an adequate response to people’s needs.

In cases of serious crime, social workers are legally required to file a complaint: according to the Article 331 of the Code of Criminal Procedure, public officials are required to report to the judicial authority, directly or through the police, any crimes punishable ex officio by law and of which they become aware in the exercise of their functions. In other situations, where an adult or older person is unable to make decisions for themselves, the law allows for a report to be sent to a judge to request an assisted decision-making order. Depending on the individual’s remaining decision-making ability, the judge may appoint a guardian, a curator or a support administrator. The difference between these three institutions is based on the individual’s ability to make decisions: the guardian assumes responsibility for all acts, the curator for extraordinary administrative acts and the support administrator for specific areas as specified by the judge on a case-by-case basis. Requesting an order involves filing an appeal to the Court, and the time to obtain a response is often very long.

In this paper, the research results will be analyzed through the concept of dangerous care (Sherwood-Johnson et al., 2023), that is a critical framework for understanding abuse within family or intimate relationships involving older people or disabled individuals. This concept interprets the phenomenon considering the interpersonal level of abuse and the organizational conditions of welfare services and policies. Very often, indeed, in situations where abuse manifests itself in family contexts, professionals predominantly focus on the interpersonal dimension of abuse, which is the most explicit and observable level (Penhale, 2020), overlooking the influence of structural and contextual conditions (Teaster et al., 2020). According to Lonbay (2018), this happens because practitioners base their assessments on the degree of vulnerability of people and conduct interventions with a paternalistic approach that undermines the autonomy and decision-making abilities of those they aim to help. As stated by the author:

The concept of dangerous care broadens the perspective beyond just the individual, considering all the factors that interact within these complex relationships, as:

This concept has been introduced by the authors to criticize the two main theories used to explain abuse against vulnerable adults and which have influenced social policies in the UK (Bergeron, 2001): the Feminist Theory, which emphasizes the power dynamics between men and women in intimate relationships (Bricker-Jenkins et al., 1991) and the Caregiver Stress Theory, which connects the stress experienced by caregivers to a higher likelihood that they will perpetrate abuse against those they care for (Pillemer and Wolf, 1986; Fundinho et al., 2021). In the face of dangerous care situations, both theories fall short as they do not consider the full spectrum of elements at play in the different scenarios, such as the intertwined emotional, relational and practical dimensions and the cultural and contextual factors (Sherwood-Johnson et al., 2023). Some elements are decisive in identifying such situations: first, the temporal dimension, as practitioners often encounter abusive relationships that have persisted for many years but only come to their attention when one family member has reached old age (Crockett et al., 2018). In addition, within dangerous care situations, it is not always possible to apply the victim-abuser dichotomy, because sometimes the “victim” also exhibits abusive behavior toward the caregiver (Phelan and O’Donnell, 2020). One of the challenges in service interventions is that older or disabled individuals may not recognize themselves as victims of abuse or may interpret their situation differently from professionals (Taylor et al., 2014). This can happen precisely because they may resist identifying as “vulnerable” due to concerns about losing control over their lives. They might fear interventions that they do not agree with, such as being removed from their home and placed in a residential facility (Killick et al., 2015). The complexity and bureaucracy of service organizations can indeed exacerbate the risk of abuse in these situations. When services are difficult to navigate, marginalized individuals may find it even harder to access the resources they need and to seek help (Mosqueda et al., 2016). An organization of the welfare system that provides assistance by user type fails to capture the intricate and multifaceted nature of care relationships, thus leaving many situations requiring more integrated interventions unaddressed.

The study was conducted in 2023 in Brescia, a large province in Northern Italy, with more than one million inhabitants. The study was aimed at understanding whether and how social workers operating within local authorities identify abuse against vulnerable adults and older people, what interventions they propose, what collaborations they establish and what skills they rely on to combat this phenomenon.

This issue is little explored in the Italian context; therefore, the field research was preceded by a scoping review, aimed at identifying the social work research conducted in the past 20 years on the issue of abuse against vulnerable adults and older people.

Due to the exploratory nature of research, a qualitative approach was selected. In total, 49 semistructured interviews were conducted with social workers working in local social services aimed at adults and the elderly in 7 districts of the province, covering over 107 local authorities. The social workers interviewed were all female ^[2], they had an average age of 39 years old and 12 years of professional experience, 92% had a bachelor’s degree and only 8% had a master’s degree.

The interview was divided into two parts: in the first part, the social workers’ perception of the phenomenon was investigated, also in relation to its relevance within their caseload. In the second part, the typical situations, the main interventions put in place, the resources and skills the social workers could rely on and their major difficulties were investigated by requesting the social workers to describe one or more situations of abuse they were currently dealing with or had encountered in the past. It was necessary to clarify that the study excluded situations involving minors or gender-based violence unless the victim was also an older or adult person with a disability.

The interviews were conducted online using the Teams platform, videotaped with the interviewees’ consent and fully transcribed. The data analysis was conducted with the help of the Maxqda 2022 software.

The qualitative data obtained from the interviews were subjected to thematic analysis of the content (Braun and Clarke, 2006). The analysis was carried out by two researchers, each of whom first read the interviews to familiarize themselves with the content and carried out an initial coding, identifying some very broad open codes. The researchers compared the open codes and then conducted the analysis of the first five interviews together, sharing the semantic content of the main themes. Each researcher separately analyzed the remaining interviews and a final comparison was made in which the themes and subthemes were jointly reviewed and redefined.

The data were collected and processed to guarantee anonymity and the research was conducted according to the Code of Ethics of the Catholic University of Milan, approved with Rectoral Decree no. 9350/2011. This article will present the results of the second part of research, in particular the typical situations described, and the interventions conducted by the social workers.

The social workers interviewed described over 50 situations of abuse encountered in their practice. All types of abuse were included: physical, psychological, economic, sexual and various forms of neglect. In most situations, multiple forms of abuse coexisted.

The results of the study show how social workers try to deal with situations of abuse, which mainly occurs within family relationships, without having precise guidelines or standardized procedures. Some of the typical interventions implemented in most situations have been described; however, there are many critical elements, both in the implementation of the interventions and in the relationship between social workers and the people they assist.

Abuse was perpetrated by people outside the family (acquaintances, neighbors and professional caregivers) only in five cases among the situations presented, in all the others, abuse occurred within the family unit. In most cases, these were families with children or partners with addiction or mental health issues, who cared for people who were not self-sufficient. Abuse manifested itself in different forms: physical aggression, verbal or psychological abuse and economic violence. Often the difficulties and needs of the non-self-sufficient person were not recognized, leading to neglect or risky situations as the older or disabled individual was left alone for extended periods, despite their inability to care for themselves.

In these situations, social workers were often faced with ambivalent attitudes on the part of the victims of abuse: on the one hand, they requested help; on the other hand, they did not want to separate from the abuser, and, especially in the case of children, they intended to continue taking care of them, even financially. Social workers reported facing many challenges in intervening in these situations. The choice has almost always been to take care of all the vulnerable people in the family, both victims and abusers, albeit with great difficulty. The professionals report that they had to engage in delicate mediation efforts and numerous attempts to encourage abusers to seek help from specialized services, often hindered by denial by those involved and poor cooperation from other services. In the following quote, a social worker described the complexity of these situations and the importance to respond to different needs:

Given the complexity of the situations, the decision to file a criminal report, even in serious cases, was not automatic and was evaluated on a case-by-case basis, depending on the perpetrator’s characteristics, their relationship with the victim and the interventions that could be implemented. In the quote below, a social worker talks about the decision not to file a criminal report in a situation of domestic violence that had lasted for many years, but that came to the attention of the services only during the perpetrator’s old age. In this case, both the victim and the abuser were older people:

The interviews revealed a variety of interventions that were implemented both to protect victims and to address the abusers’ issues. To sum up, three types of interventions were carried out more frequently and the respondents highlighted the critical issues of each one of them.

In most situations, home care services were activated. The main purpose of this intervention is to respond to the needs of non-self-sufficient people and relieve family members from assistance. However, the social workers interviewed consider that this intervention is not enough, as home services can only be activated for a few hours a day, and it is difficult to obtain a place in a day care center. So, the care burden falls heavily on family members, who must manage extremely draining circumstances and sometimes have to face aggressive behaviors both physically and verbally. Such circumstances elevate the stress faced by family caregivers and escalate the potential for abusive behaviors. As the following quote illustrates, a lack of support at home can bring caregivers to the breaking point:

In the situations described, the home care service also aims to monitor the situation, gather information and keep track of any worsening of the abuse, while providing assistance at home, as this social worker stated:

There are two main critical issues related to this purpose: first, the professionals are concerned about going to a house while abusive individuals are present, leading to potential involvement in dangerous incidents. Second, the intention to monitor the situation is not always made explicit, for fear that families will reject the intervention and this creates a lack of clarity for people.

The intervention of the support administrator was requested in half of the cases described. This intervention was identified by the interviewees as the only way in which the legislation allowed for an “external” protection for the family unit; therefore, it was often activated almost automatically, without an explicit motivation or a precise purpose. In addition, some social workers highlighted that the support administrator, who is almost always a lawyer appointed by the judge, tends to adopt a stance of “extreme protection” toward the vulnerable adult or older person, risking overlooking their opinion and imposing interventions that are not shared. The following quote provides an example, where the intervention imposed by the support administrator is a placement in residential care:

The social workers interviewed reported that they often requested that the victim of abuse be placed in a residential facility, because it was the only option available to them to protect the person from imminent danger. However, the social workers believe that this form of intervention is often unsuitable for the elderly or disabled victims of abuse as care homes are not equipped for these people, and their operators are not specifically trained to face situations of abuse. In many cases, the placement in a facility led to a worsening of the person’s condition, especially on the cognitive level. On the contrary, as already mentioned, there are no facilities specifically dedicated to the care of older people or disabled adults who are victims of abuse. Another key point is that older people find it difficult to leave their homes and move to a residential facility, as it is not their choice, as described in the following quote:

Social workers portrayed this intervention as a choice that risks blaming the victim and that has often led people to refuse help. In the quote below, the social worker described a daughter’s feelings about the proposal to place her mother, a victim of violence by her father, in a residential care home:

The main issue highlighted by the social workers interviewed was the absence of specific guidelines for both identifying situations of abuse and implementing interventions. As a result, they frequently had to decide whether and in what way to intervene by themselves assuming full accountability for their decisions, without much sharing with other professionals. In the absence of operational protocols, the collaboration with doctors and other health professionals differed significantly depending on the specific case. As shown in the following quote, the result is often a fragmentation of interventions, with each professional acting without confronting the others:

Most social workers said that they could count on the support of their service managers, but also, they frequently felt powerless in their experiences, because they were tasked with managing complex situations without appropriate services and coordinated interventions, as in the quote below:

The social workers described considerable difficulties, especially in the face of the frequent ambivalent attitudes of the victims, who sometimes denied the situation or refused the help that was offered and preferred to remain in a condition of danger. The social workers said that in these situations they were faced with an ethical issue connected on the one hand to the duty to protect vulnerable people and on the other to the obligation to respect their decisions. The social workers were uncertain about the extent to which professionals can make choices for adults who may not be able to decide for their good:

The concept of dangerous care is a valuable tool for interpreting the results of this research.

The situations described highlight how abuse is perpetrated within caring relationships in which, very often, both the victim and the abuser are vulnerable people who need-or would need-to be helped. The temporal dimension is important because, although the situation of abuse had usually been ongoing, these situations often come to the attention of the services in the interested people’s old age. In Italy, the national legislation does not provide specific guidelines for professionals dealing with adults, hindering their ability to intervene swiftly, in contrast to those working with minors. They must lodge a complaint when faced with a crime that can be prosecuted without the victim’s report. However, the interviews show that often the distinctions between situations are unclear, with abuse markers not being obvious. Sometimes, even the appeals made to the judicial authority are refused. Abuse against older people and vulnerable adults is not addressed in inter-service agreements; consequently, there are no intervention protocols defining the responsibilities of the different professionals and establishing intervention procedures. The absence of proper legislation and social policies results in practitioners lacking the necessary resources or having to adapt procedures aimed at protecting minors or women who are victims of gender violence to the needs of older people or adults with disabilities. One of the consequences is that professionals may face disorientation and difficulty in recognizing abuse when it does not fit the usual patterns. It can be said that, in the specific setting of the study, adult and elderly abuse is commonly viewed as a “private matter” and, therefore, stays within the confines of personal interactions. The role of social workers is to try to enter into these dangerous relationships, each time seeking the solution to deal with highly sensitive situations. Understanding the complexity of these relationships requires acknowledging the diverse vulnerabilities at play and avoiding a polarized perspective that distinguishes victims from perpetrators to effectively meet the needs of all individuals involved. The main approach favored by experts is to address all vulnerabilities and create comprehensive pathways for aid, which appears to be the sole effective way to bring about positive change in these situations. Choosing this path, however, clashes with inadequacies at the structural and organizational levels, as a thorough initiative calls for complex and diverse interventions that integrate legal, psychological, clinical and social competencies. The division of services by type of user, on the other hand, contributes to fragmentation and, in the absence of agreements and protocols, leaves to the spontaneity of interpersonal relationships the possibility of collaborating or not in providing assistance.

On the operational level, therefore, social workers are faced with situations of abuse without adequate tools, often in conditions of solitude and with little possibility of comparison, even in the face of ethical and practical dilemmas (Figure 1).

The interviews confirmed that, in situations of dangerous care, there is often an interdependent relationship (Clarke et al., 2015) between the victim and the abuser that makes it very difficult to intervene with protective actions from the outside. The findings suggest that individuals avoid seeking help due to concerns about being separated from their familiar environment, yet the primary solution recommended is relocation to a residential facility. More generally, as per the study of Hulko and colleagues (2020), it can be observed that the main interventions proposed are geared to control the situation, initially in a discreet and understated manner, through home workers, and, if this does not work, with an appeal to obtain support administration. In the most serious situations, or if abuse is most evident, the proposal for intervention is the placement in a residential facility, which, according to the interviewees, is often rejected by the victims. This can lead to a model of assessing situations using a “conventional” approach (Healy, 2014), where the professional’s and the individual’s positions are in opposition. Duffy (2017) used the concept of resistance to care when people make choices that go in a different direction from the professionals’ ideas and are labeled as uncooperative, or “resistant.” In particular, professionals and individuals often have differing viewpoints on how to define risk and identify needs in complex situations (Sherwood-Johnson et al., 2022).

Findings indicate that social workers frequently find themselves in complex situations where they are compelled to intervene, even if it means acting contrary to the wishes of the concerned individuals, thus disregarding the principle of self-determination. In certain instances, social workers facing these kinds of situations chose not to intervene, because individuals were unwilling to accept any form of interference. However, the prevailing choice seems to be what Beaulieu and Leclerc (2006, p. 171) define as accompaniment: social workers endeavor to gradually engage in relationships, whether through direct interaction or with the assistance of other operators, to establish a basis of trust crucial for planning interventions, accepting that people remain for a certain period exposed to danger (Braun, 2021). However, the decision to engage in this course of action is contingent on the unique perspective of every practitioner, as there are no specific instructions or guidelines for managing abusive scenarios. Therefore, their interventions may be impromptu and conditioned by their fear of making oversights that could result in liabilities (Brownell and Wolden, 2003).

The absence of coordinated interventions between the different services also has heavy repercussions on family caregivers, who often have to arrange support on their own and reach out for assistance when necessary. This adds to the burden on family members. However, in the absence of an assessment of caregivers’ specific needs, there is a possibility that no one can address the most challenging scenarios, thus elevating the risk of abusive events.

The study findings validate the effectiveness of the dangerous care concept in interpreting cases of abuse against vulnerable adults and older people, even within the Italian context. The scarcity of resources and the absence of regulatory frameworks impact the ability of individuals to seek and receive help, as well as professionals’ interventions. In the research context, the care of older people and adults with disabilities is seen as a private matter, and this is evident in the perception of abuse. On the one hand, individuals do not request help because they do not identify themselves as victims of abuse or decide to stay in a harmful environment to maintain family ties. On the other hand, professionals suggest actions that may strengthen a disempowering perception of individuals and create more barriers to seeking assistance.

When faced with such scenarios, practitioners should consider taking a critical stance (Torres and Donnelly, 2022) that can address complexity on every level. The results of research show that abuse victims in the context of dangerous care are open to professional support as long as it encompasses all at-risk individuals within the family and acknowledges their preference to remain with loved ones and within their familiar environment. Therefore, an effective implementation of help paths necessitates an accompaniment perspective that involves initially listening to the viewpoints of those directly impacted to establish a mutual understanding of the risk level and the appropriate intervention strategies.

Collaboration with other professionals is essential for social workers when dealing with complex scenarios, especially when individuals need specific clinical, psychological and legal aid. Policymakers could enhance the coordinated management of such situations by creating agreements and intervention protocols, thus encouraging professionals from various services to work together and improving the current situation in which collaboration is built on a case-by-case basis.

The author acknowledges the Universitá Cattolica del Sacro Cuore of Milan for funding this study.