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Ethical dilemmas of reporting suspected elder abuse.

In a caregiver support group for the elderly people, group members were discussing stressful caregiving situations. Mr. Smith began talking about how he sometimes became frustrated with his wife, a victim of Alzheimer's disease. "When you say you're frustrated, what do you mean exactly?" the facilitator asked him. "Well," he answered, "I guess I mean I have to do things I would rather not have to do." "Such as what?" the facilitator probed. "Well, sometimes she won't get undressed, just real stubborn she is. I'll try showing her what I mean by taking off my clothes, but it doesn't register. So then I'll try to take off her blouse, gently, but she'll back away from me. I'll try talking to her, but nothing. So I'll slap her a few times, I'll say 'You have to listen to me!' Then she cooperates. It's real frustrating."

Contrary to the beliefs of a number of people in the United States, many frail or sick elderly people remain in their homes and are cared for by family members, mostly women, often spouses (McCallion & Toseland, 1995). Advances in medical technology may result in people in living longer (Dobson & Dobson, 1991), although not necessarily healthier, lives. Caregivers often are confronted with financial, emotional, and physical strain related to the caregiving responsibilities. Common feelings described by caregivers are isolation and loneliness. Frequently, a lack of community resources adds to the frustrations they feel in providing care.

Social workers have been advocates in developing and facilitating support groups to help family caregivers of older adults. In such groups caregivers can share their experiences in a confidential atmosphere and guided by trained social work facilitators (Toseland & Rossiter, 1989). Professional-led groups differ from mutual aid, peer-led groups in that professional facilitators should have a higher level of expertise and knowledge about aging, group dynamics, and human resources in addition to assessment skills. Because caregiver stress is one theory about why people abuse elderly individuals (Bergeron, 2001), social work facilitators are expected to refer caregivers to appropriate services for stress reduction and to increase the quality of care for the elder care recipient. Social work facilitators are also expected to function from a professional ethical code of conduct to ensure good group functioning beneficial to both the individual and group members (Association for Specialists in Group Work, 1990; Dol goff & Skolnik, 1996).

Because of the theory that stressed caregivers are more likely to abuse an elderly person, caregiver support groups strive to reduce, eliminate, or prevent that level of stress. However, are caregiver support group facilitators aware of elder abuse reporting laws? Do such caregiver support groups place professional facilitators in ethical dilemmas about reporting elder abuse when it becomes clear that a caregiver has been neglectful or abusive?

This article explores the role of facilitators of caregiver support groups and raises questions having to do with elder abuse reporting laws, ethical duties of social workers to be aware of and responsive to such laws, and ethical challenges of informing support group members of elder abuse reporting laws. We introduce the core functions of caregiver support groups and the basic premise of elder abuse reporting laws and illustrate ethical dilemmas involving caregivers suspected of elder abuse and neglect. In this article, the term "facilitator" refers to social work facilitators holding social work degrees from accredited undergraduate or graduate schools of social work, and who are either sole or co-facilitators of caregiver support groups. The term "caregiver support group" refers to support groups designed for caregivers to elderly people.

Core Functions of Support Groups for Caregivers

Toseland (1995) explained that caregiver support groups serve eight core functions of stress reduction for caregivers: (1) respite from the caregiving role; (2) reduction in feelings of isolation and loneliness; (3) a safe place to vent pent up emotions and share feelings and experiences in a supportive atmosphere;(4) a place to receive validation of their thoughts, feelings, and experiences of caregiving; (5) a place to receive affirmation of the importance of their caregiving and to become more hopeful; (6) provide education about the aging process; (7) provide techniques for problem solving and coping; and (8) to help with action plans for resolving pressing caregiving problems.

However, these core functions may result in ethical dilemmas for facilitators. As in the case study presented earlier, the facilitator invited Mr. Smith to share with the group what he meant by frustration, thereby inviting him to reveal that, in his frustration, he regularly slapped his wife for not being able to perform certain actions. Several ethical questions related to Toseland's (1995) core functions arise for the facilitator. Is the facilitator's "duty" restricted to the group setting by helping Mr. Smith to normalize such feelings? Is it the facilitator's duty to educate Mr. Smith that slapping his wife is unacceptable under any circumstance and that there are other ways to adjust to his wife's inability to undress? By the "invitation to tell us more," does the facilitator encourage Mr. Smith to reveal behavior that he was unaware could be reported to the designated elder abuse agency? Does the facilitator break confidentiality by reporting Mr. Smith's actions as possible elder abuse? Will reporting suspicions of abusive actions compromise the group atmosphere and therapeutic benefits? And, is the facilitator liable if a report is not filed and Mr. Smith, in a moment of frustration, seriously injures his wife?

Elder Abuse Overview

In recent years, elder abuse by family members has been identified as a growing problem in our society. Since the beginning of the first congressional investigation of elder abuse in 1978 (Olinger, 1991), every state has implemented some form of elder abuse reporting law with an agency designated to accept reports of suspected elder abuse, investigate such allegations, and provide intervention for the elderly victim (Bergeron, 2001).

According to the National Elder Abuse Incidence Study (National Center on Elder Abuse, 1998) "the best national estimate is that a total of 449,924 elderly people, aged 60 and over, experienced abuse and/or neglect in domestic settings in 1996" (p. 4), and of that number approximately 16 percent were reported to elder protection agencies. Experts in the field say that elder abuse is grossly underreported for several reasons: the isolation of elderly people, lack of uniform reporting laws, and the general resistance of people, including professionals, to report suspected cases of elder abuse and neglect (Tatara, 1993). Because most perpetrators of domestic abuse are family members (National Center on Elder Abuse), facilitators must be aware that members of caregiver groups may be guilty of abusive actions.

Elder Abuse Law

Many states combine protection of elderly people with the protection of disabled adults; thus, elder abuse laws are often referred to as adult protection services laws (Simon, 1992). Research has shown, however, that approximately 70 percent of reports to adult protection services agencies involve people over age 65 (Simon). Therefore, because this study is concerned only with elderly victims, the term elder abuse protection (EAP) will be used in this article.

States laws differ slightly in the categories of abuse, but generally all recognize five basic types of elder abuse: neglect, either self-imposed or by another person; physical abuse; sexual abuse; financial exploitation; and emotional, including verbal, abuse.

Nationally, EAP laws have three major functions in common: (1) to collect reports of suspected abuse, neglect, and financial exploitation and manage statistical data and assess for client services needs; (2) to make every effort to reduce or eliminate risk to elderly individuals by providing community education and intervention through casework and referrals to community services; and (3) to interface with the courts and law enforcement agencies in certain types of cases, for example, incompetent clients in need of guardians (Simon, 1992; Tatara, 1995).

Because elder abuse laws differ from state to state, it is important to know the elder abuse laws applicable for the clientele receiving services (Bergeron, 1999). Three major differences exist. First, some states require mandatory versus voluntary reporting, meaning that the reporter is obligated by law to file suspicions of elder abuse. The second major difference refers to the targeted elder population served by the law. For example, some states, in an effort to restrict intrusion into the private lives of citizens, limit their laws to vulnerable or incapacitated elders. Although the terms vulnerable and incapacitated include incompetent elders, they are much broader in definition and refer to elders who by emotional, physical, or mental limitations are unable to ensure their own safety. Third, laws differ in the authority granted to the EAP practitioner to conduct investigations of alleged abuse and neglect and to intervene in cases that are substantiated. For example, some states require the EAP worker t o seek permission from the alleged victim in all phases of the investigation and intervention, unless the alleged victim is deemed incompetent. Other states give the EAP worker authority to conduct investigations without the alleged victim's permission.

Thus, facilitators' invitation for group members to share their concerns with each other may encourage disclosure of abusive actions requiring reporting to an EAP agency. Unfortunately, the group work literature is almost devoid of attention to this issue, thereby depriving those social workers doing group work the opportunity to examine the issue and develop some guidelines.

Review of Group Work Literature

Dolgoff and Skolnik (1996) reported "that specific discussions regarding ethical decision making in social group work are scarce" (p. 49). Indeed, in conducting a group work literature search, few articles were found that discussed ethical decision making by support group facilitators. Yet, professional facilitation of groups implies that facilitators "are obliged to use professional knowledge and judgment in solving dilemmas" and acknowledge that "ethical dilemmas are perplexing situations that require a choice from among alternative actions" (Houston-Vega & Nuehring, 1996, cited in Northen, 1998, p. 5). This obligation also includes protecting the "rights and welfare" of group members (Congress & Lynn, 1997). Malpractice occurs when professional group facilitators violate ethical principles or cannot uphold the standards of practice (Northen, 1998). Northen's examination of the literature revealed several articles on ethics for group facilitators, but she suggested that more are needed, particularly to assi st facilitators in critical thinking of complex ethical issues.

Paradise and Kirby (1990) upheld the idea that the issue of confidentiality is one of the most important legal concerns for group practitioners. Yet, confidentiality, "one of the most perplexing ethical principles in all forms of practice, but even more so in work with groups" (Northen, 1998, p. 11), has received little attention. She mentioned the duty of facilitators to report child abuse, as did Congress and Lynn (1997), but made no mention of elder abuse reporting mandates. Her article also raised concern about the coercion and manipulation of group members to reveal more than they intended to reveal. Yet, the group work literature does not address the self-disclosure issue regarding group members who may be unwittingly encouraged to reveal abusive acts committed against their elder care recipients or the resulting conflicting duty of the facilitator to report such disclosures to the authorities (Association for Specialists in Group Work, 1990; Capuzzi & Muffett, 1980; Congress & Lynn, 1997; Dobson & Dobs on, 1991; Dolgoff & Skolnik, 1996; Dziegielewski, 1991; George, 1990; Hasselkus & Stetson, 1991; Konopka, 1978; McCallion & Toseland, 1995; Northen; Paradise & Kirby; Schopler & Galinsky, 1993; Skolnik & Attinson, 1978; Toseland, 1995; Toseland & Rossiter, 1989).

Dobson and Dobson (1991) discussed developing caregiver support groups for people caring for aging parents, never mentioning the possibility of disclosure of parental abuse. Schopler and Galinsky's (1993) pilot study of support group facilitators, which included facilitators of caregiver groups involving people with Alzheimer's disease and cancer, sought to identify the "types of problems and the legal and ethical issues that arise in support groups"(p. 202), but did not mention the caregiver abuse of elderly people or the issue of reporting abusive actions.

Zimpfer (1991) discussed pretraining--the technique used by group facilitators to acclimate members to the group situation. He outlined guidelines for facilitators when using this technique. However, he did not discuss the usefulness of pretraining in informing group members of the limits of confidentiality and the professional duty of facilitators to report concerns regarding elder and child abuse.

Case Studies and Ethical Dilemmas

The following case examples of ethical dilemmas concerning elder abuse and neglect are taken from the authors' support group and consulting experiences. The first two cases involve elderly individuals living in the community; the third and fourth cases involve elder people living in nursing homes. The names and some of the case descriptors have been changed to protect client confidentiality.

Case 1: Edith

Edith was a 60-year-old single woman caring for her 85-year-old mother. At the first meeting of the 12-week educational support group for caregivers, Edith shared that she was an only child and had no relatives or friends to help her with caregiving. She was also attempting to work full-time. Edith was obviously under a great amount of stress and said her doctor told her she needed to come to the support group or she would have a nervous breakdown." Edith announced she had recently raised her voice to her mother on several occasions and was afraid that her frustration and exhaustion would lead her to hit her mother. In the following weeks, Edith indicated some reduction in stress and thanked people for supporting her. She never again referred to her statement of potential abuse of her mother, and when asked about this by group members she said that everything was "okay." When the group ended, members decided to continue meeting. Edith said she would like to but needed to think about it.

Dilemmas of Case 1. Of major concern was the statement made by Edith about her potential to physically abuse her mother. How far does the facilitator's responsibility go in determining if this is a real possibility or if abuse is occurring? Was it enough for the facilitator to accept Edith's response that all was well? Northen (1998) referred to the pressure of members in a group to share information before they are ready and stated that members should not be forced to disclose information prematurely. However, does the facilitator's concern for safety override this? Society's duty to protect and the individual's right to confidentiality greatly complicate the facilitator's ability to balance the needs of the individual, the group as a whole, and the greater community (Skolnik & Attinson, 1978).

In addition, although Edith benefited from the support of the group and experienced less stress, the facilitator had concerns about what would happen to her after the group ended. The facilitator and group members encouraged Edith to maintain contact, but she did not make a commitment to do so. At what point is the principle of self-determination overridden by concern for the safety of others? Northen (1998) acknowledged the importance of self-determination as a social work value, but also referred to the lack of information in the literature that relates self-determination to specific situations.

Finally, and most important, if this case goes unreported to an EAP agency, does Edith minimize her potential for abusing her mother? By not reporting to the designated state agency, does the facilitator deny both Edith and her mother services that might reduce Edith's stress and raise the mother's quality of life?

Case 2: Jacob

Jacob was a 50-year-old man living with his widowed father. He attended the 12-week elder care support group on the advice of the visiting nurse who felt that he needed support. Jacob, a very friendly man, quickly told everyone about his challenges as a caregiver. He was unemployed and said that it was difficult for him to find steady work. He appeared to be borderline mentally retarded. He said they were living off his father's social security check, and they had no friends or family members. He said it was very hard for him because his father would "yell and scream at me and threaten to kick me out of the house." Because of his father's abuse, he said that at times he "felt like hitting him." These concerns about the living situation prompted the facilitator to obtain permission from Jacob to speak with the social worker at the local visiting nurse's association. The social worker acknowledged that the EAP agency had assessed the situation but found nothing to substantiate abuse. The social worker reported they had hoped to place the father in a long-term care facility, but because he opposed that plan and was considered competent even with his mild dementia, it was not possible. Jacob faithfully attended the group and reported continued verbal abuse by his father. He never indicated that he responded to this abuse by physically abusing his father. When the group ended, members continued to meet on their own and Jacob made a commitment to meet with them.

Dilemmas of Case 2. This situation was particularly challenging because of the potential for abuse from both the father and son. The facilitator was concerned about Jacob's isolation and obvious intimidation by his father. Jacob described the condition of their mobile home in very negative terms. The facilitator wondered several times if this was a situation of neglect, despite the fact that protective services had investigated their situation. Jacob's ability to care for his father appeared limited and would become even more questionable as his father's health declined and if his father's dementia increased. The facilitator questioned whether her responsibility went beyond just listening.

This case raises several complex and interesting factors. Jacob was being verbally abused by his father, but was the father's verbal abuse a result of his own frustration at not being able to get his needs adequately met by Jacob? Was Jacob's limited intellectual ability preventing him from meeting his father's needs and protecting himself from his father's abusive behaviors? Exactly who was the perpetrator in this case, or were both son and father victims? As in Edith's situation, what was the facilitator's responsibility to ensure safety beyond the group, especially as the group was preparing to end? If Jacob continued to meet with the other group members and revealed his situation as worsening, would the group, without a professional facilitator, know what to do? The facilitator felt torn with the ethical responsibility to protect the group member's confidentiality, the need to support this family's self-determination, and the need to ensure safety in the home.

Further complicating the facilitator's dilemma was that this state's law included mandatory reporting. The facilitator was legally required to report her suspicions of abuse, although she knew a report had already been filed. The facilitator's dilemma was also complicated by a concern that if the state received a report, the state worker might be too aggressive and attempt to remove Jacob from this living arrangement. Should this happen, would the potential of neglect to the father increase because of the limited resources in this rural community to supplement the 24-hour care Jacob gave him? If Jacob were removed from his home and daily routine, would his emotional difficulties increase, or would new and better opportunities open up for him? Yet, the law did not allow for a team approach to address these complex questions. In addition, the literature offers little about assisting abusers suffering from mental or developmental impairments (Brownell, Berman, & Salamone, 1999).

Case 3: Mary

Mary was a resident at a long-term care facility. Her daughter, Anne, signed up for the caregiver's support group led by the social worker at the facility. The referring hospital that placed Mary sent a separate report to the facility's social worker indicating that Anne had been abusive to her mother when she was residing at the daughter's home. The abuse had been serious enough to merit hospitalization. Because of complicating factors that led to the abuse, the "solution" was to remove Mary from Anne's home and place her in a long-term care facility. Anne attended the facility's caregiver support group, never alluding to any past or current abuse of her mother.

Dilemmas of Case 3. This case poses many dilemmas for the group facilitator. Given that the abuse was in the past, what are the facilitators' current responsibilities? Did the facilitator have an obligation to assess whether Anne was still abusing her mother on some level in the nursing home? Anne still had caregiving demands with her mother in the nursing home, such as visiting her mother who often asked for her, paying bills, directing staff regarding her mother's care, attending family conferences, shopping for and bringing in items her mother needed, labeling her clothes, and reporting Mary's progress to family members. If the stress of caregiving was the cause of the abuse, was her role change enough to eliminate the abuse? Because the facilitator felt bound by confidentiality, she could not question Anne in the caregiver support group about the abuse history and how it related to her new caregiving role. Because the staff caring for Mary had no knowledge of past abuse, the facilitator questioned whether she had a responsibility to notify staff to be especially observant when Anne visited, assessing for possible signs of abuse. When does the right to confidentiality become compromised? For example, what if by doing nothing, the facilitator allowed abusive actions to continue in the privacy of Mary's room? How does the facilitator address Anne's right to privacy and her mother's right for protection? Is it ethical for the facilitator to "coerce" Anne into a "confession" about the past abuse in the caregiver support group so that the facilitator's concerns can be addressed?

Case 4: Alexandra

Alexandra was an only child never married, whose father had died about 20 years ago. Her mother moved in with her after her father's death, and they were devoted to one another. Approximately 10 years ago her mother developed Parkinson's disease. Although her mother was blind, incontinent, suffering from dementia, and physically debilitated, she was still at home when Alexandra joined this support group, Alexandra was her legal guardian. The decision for a permanent nursing home placement was made when her mother was hospitalized near death with pneumonia. Subsequently, Alexandra went into a deep depression at not being able to fulfill her "promise" to never place her mother in a nursing home. Although the evidence was clear that a nursing home was the best choice for her mother's care, Alexandra decided to remove her mother from the nursing home and again attempted to care for her at home. These events and the complications that resulted after Alexandra's mother returned home were discussed in several suppor t group meetings.

Dilemmas of Case 4. The facilitator in this group had a good rapport with Alexandra and more than a year's worth of information about Alexandra and her mother. The facilitator was convinced the mother's health would be endangered at Alexandra's home because of insufficient in-home care. The facilitator wondered if Alexandra fully understood that her disclosures in the group could result in the filing of an abuse or neglect report. Furthermore, the facilitator was concerned about how damaging such a report might be on the psychological health of this devoted daughter whose values and cultural beliefs indicated that it was her duty to care for her mother at home. Yet, would filing a report "free" Alexandra to accept the nursing home as the only alternative? Did the facilitator have an obligation to assist this group member beyond the group setting in accepting the nursing home? And was there an ethical duty regarding the mother's quality of life, whose care would be far superior in a nursing home and who was un able now to articulate her wishes or concerns?

Recommendations

Given the abuse and neglect laws of the states, social workers facilitating caregiver support groups may find that their decisions to file elder abuse reports involve more than their "practice wisdom" (Dolgoff & Skolnik, 1996) and that they are not adequately prepared. The following are recommendations to help facilitators negotiate this complex decision process.

Know the Elder Abuse Reporting Law. Social work facilitators are obligated to know the laws in the states of their group member clientele. State law determines whether facilitators are required to report suspected abuse or neglect, or whether the reporting is voluntary. State laws also define the elder population targeted in the reporting statute and the age used to define elderly. When deciding whether to report a case, facilitators only need to suspect, not verify, that abuse is occurring. Facilitators should also be well informed about the agency designated to receive elder abuse reports and how the forms of abuse are defined. Because elder abuse laws are not criminal laws, some social services benefits are available to the victim (for example, homemaker services, visiting nurses, Meals on Wheels) at no charge to the victim if a report is filed. This benefits both the perpetrator and the victim and may help minimize negative effects that reporting may create between the facilitator and the group member all egedly abusing the care recipient.

Facilitators may research state laws on various Web sites that give information about the parameters of the laws and identify the agencies designated to receive reports. (The National Center for Elder Abuse is one excellent Web site for facilitators to use; available: www.gwjapan.com.)

Facilitators must also read the elder abuse literature and be proactive in requesting that local public libraries and agencies carry journals that will keep facilitators current on issues of domestic elder violence. (One journal devoted exclusively to issues of elder abuse and neglect is The Journal of Elder Abuse & Neglect, available from the Haworth Maltreatment and Trauma Press). Facilitators are also encouraged to become aware of continuing education opportunities about elder abuse, such as that offered by state legal associations, which is multidisciplinary.

Develop Rapport with EAP Practitioners. This article raises dilemmas for facilitators that have no decisive answers. Each support group member will have his or her own situation, family history, and variables affecting the potential for elder abuse. Therefore, support group facilitators and EAP practitioners should develop a dialogue before the first case needs to be reported. Facilitators and EAP practitioners must develop ways of working together, such as serving on community boards together, developing an assessment team for support group cases, discussing and identifying the conflicts and difficulties that protection policies create for caregiver support groups, and designing innovative methods to address such conflicts and difficulties.

Developing a working relationship could benefit caregivers, elder victims of abuse, and the elder abuse protective system. Such benefits include the development of grants for pilot projects for elder abuse victims and their caregivers, development of an abuse prevention reporting system for support group members, and providing access to victim services before the caregiver behavior becomes abusive.

Develop Clear Exceptions to Confidentiality. Caregiver support group members need to know the exceptions to confidentiality before making a commitment to the group and to guide their own disclosures in the group. This explanation should be part of a pregroup interview, either face-to-face with the facilitator or by telephone. Facilitators must develop clear confidentiality statements that list exceptions to confidentiality (Association for Specialists in Group Work, 1990), including the legal duty to disclose suspected abuse. The statement should be clear and simple and include examples of situations that would require reporting. Individual questions and group discussions should be encouraged to clarify any misunderstandings. Confidentiality statements should be written, and facilitators may want to consider having group members sign such statements. This would allow facilitators at the first meeting to give all members their signed statements and review confidentiality, the duty to report, and concerns membe rs may have about discussing their caregiving situations (for examples of confidentiality statements, see Appendix). In ongoing, open membership caregiver support groups, written confidentiality statements should be given to all new attendees.

Often, because of anxiety being in a group setting with strangers, group members do not remember information they receive at the first session. Therefore, it is the responsibility of the facilitator to mention the exceptions to confidentiality during the course of the group meetings, especially when they are concerned that a member may be disclosing a situation that would require filing a report.

Monitor Group Members' Self- Disclosures. Despite the best attempts by facilitators to clarify limitations to confidentiality, as group members' feelings of trust and safety increase, their willingness to share situations that may be abusive will increase. Such disclosures may happen because members feel a sense of relief that others are in similar situations, or they may feel pressured by other members or the facilitator to share more than they intended, especially if asked to clarify or elaborate on their situations. Therefore, facilitators must be vigilant about listening to members' stories and monitor the group process so that information is not being shared prematurely and to ensure that members have sufficient knowledge about the outcome of their disclosures. At the same time, facilitators must recognize when it is necessary for a member tell his or her story, regardless of the abuse content, and then effectively deal with the disclosure.

Prepare Support Group Members for the Report. Facilitators of caregiver support groups must develop policies for working with members who reveal abusive behaviors as defined by law. Facilitators may prepare group members using preinterviews, or pretraining, review conditions that cause suspicions of abuse. Educating members that filing an abuse or neglect report is not the facilitator's choice but a legal and ethical requirement can help explain why the act of reporting is not negotiable.

If a member begins to reveal abusive behaviors in the group, the facilitator may need to limit the group member's story and meet privately outside of the group to explain the law and the concerns about the behavior. A one-on-one explanation that the report of abuse is confidential and does not need to be revealed in the group may be useful in preserving the dignity and privacy of the member. Advising the group member that the report is made on the basis of suspicion of abuse, and that a report does not mean that abuse has actually occurred, can help the member to begin to process the impact of his or her actions. Informing the group member of the EAP investigative process and highlighting what services may become available as a result of filing the report may help the member understand that EAP services could be helpful in his or her caregiving situation.

Cultivate Peer Supervision and Mentoring among Facilitators. Because the group work literature does not address ethical dilemmas in reporting suspected elder abuse and neglect, facilitators are left to their own decision process in resolving these dilemmas. In addition, social workers often are asked to facilitate caregiver support groups without adequate knowledge and training about abuse and neglect of elderly people. As a result, social work facilitators must seek opportunities for collaboration and support (Association for Specialists in Group Work, 1990). Facilitators should seek out and connect with other caregiver support group facilitators in their communities to discuss, debate, and review case examples and to educate and support each other about ethical dilemmas. Facilitators serving rural communities may not have colleagues available to meet and may find it necessary to develop e-mail listserves or computer-based support groups (see Finn, 1995, for examples of computer-based self-help groups).

Facilitators should seek opportunities to cofacilitate with more experienced social workers in the elder abuse field. Mentorship groups for facilitators could invite guest speakers or design continuing education programs in areas in which facilitators lack knowledge or information. Decreased isolation and a sense of connectedness are extremely important as social workers struggle with the challenging dilemmas inherent in their work with caregiver support groups.

Contribute to Research. More research needs to be practitioner driven. Facilitators must examine their group work practices and identify areas needing to be addressed by researchers. The lack of research and discussion of elder abuse issues in the group work literature is, in part, a result of the practice community's failure to provide case studies for identifying areas needing examination and empirical study. Group work research has not identified typical cases that facilitators experience in their caregiver support groups, the problems that result when reports are filed, or creative programs that could enhance caregiver attendance without compromising the safety of elder care recipients. These issues need attention by the research community and dialogue by the support group facilitators to learn how to advocate for the caregiver without compromising the well-being of the care recipient and to better understand the legal duty of facilitators to report elder abuse.

Conclusion

Facilitators of caregiver support groups need to consider the questions raised in each case example and identify implications relevant to their own group experiences. Caregiver support groups are complicated in that part of their purpose is to allow members to vent their frustrations and concerns, to normalize such feelings, and to support and assist caregivers in developing appropriate caregiving plans. Yet, normalization of feelings may send subtle messages to members that certain levels of consistent abusive actions, such as yelling, isolating the elderly person, or not obtaining adequate in-home services, are acceptable. The ethics of facilitating caregiver support groups charge facilitators to begin a dialogue with each other, EAP practitioners, and group work researchers to examine these complex issues.

In return, researchers must take a more active interest in examining the many aspects of elder abuse and neglect and how elder abuse laws affect facilitators of caregiver support groups. Special attention must be given to the effect these laws have on confidentiality and the dual responsibility of facilitators, first, to each member of the group and second, to the elderly care recipients. Understanding whether elder protection laws are in conflict with standards of group work practice and knowing the rules and procedures for carrying out such laws (or the training needed to understand these laws) is imperative for good practice.

Simultaneously, investigating how creative methods for supporting caregivers that at the same time prevent and eliminate elder abuse would enhance the group work practice with caregivers of elderly individuals.

Appendix

Sample Confidentiality Statements

Sample 1:

Confidentiality is honored by this facilitator except to seek supervision or in a case in which the facilitator suspects the caregiver has intentionally or unintentionally abused or neglected the care receiver. Such cases of suspected abuse are reported to [designated agency name] for investigation and intervention. Confidentiality of both the alleged perpetrator and victim is observed by the facilitator and [designated agency] staff.

Sample 2:

This facilitator is committed to respecting and safeguarding your right to confidentiality. Information shared by you in this group may only be given to others with your permission, with the following exceptions:

(1) It is necessary to seek supervision about your situation to provide better services.

(2) It is indicated that your safety, or the safety of someone else, is at risk. The facilitator is legally obligated to report suspicions of injury to self or others or sexual or physical abuse or neglect of a minor or elderly person. Such cases are reported to the appropriate agency for intervention.

Each agency mentioned in the exceptions will respect your confidentiality as it provides the necessary service.

Original manuscript received April 5, 2001

Final revision received August 3, 2001

Accepted August 16, 2001

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L. Rene Bergeron, MSW, PhD, is assistant professor, School of Health and Human Services, Department of Social Work, University of New Hampshire, Pettee Hall, Durham, NH 03824; e-mail: lb@cisunix.unh.edu. Betsey Gray, MSW, is clinical associate professor, School of Social Work, University of New England, Biddeford, ME.
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Author:Bergeron, L. Rene; Gray, Betsey
Publication:Social Work
Geographic Code:1USA
Date:Jan 1, 2003
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