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Pseudo-family abuse refers to the abuse that occurs in out-of-home care settings in which caregivers abuse the residents within their care. Such abuses are found in skilled nursing homes, residential treatment facilities, youth correctional programs, foster homes, and similar settings. Scholars also refer to this type of abuse as institutional, resident, or caregiver abuse.
II. Forms of Abuse
A. Physical Abuse
B. Emotional Abuse
C. Sexual Abuse
E. Financial Abuse
III. Process of Institutionalization
IV. Maltreatment in Foster Homes
V. Common Themes Identified in Pseudo-Family Abuse
A. Institutional Factors
B. Individual Factors
C. Social Factors
The term pseudo-family abuse was first coined by Kurst-Swanger and Petcosky (2003) to place emphasis on the fact that caregivers function much like families in their role of caretaking. It is through this role of caretaking that abuses most often occur. The term pseudo families assumes two relevant factors related to family violence. ‘‘Families’’ reflects the fact that some individuals are cared for in places outside of the traditional family home, in which they are surrounded by staff, administrators, or foster families who provide for their daily needs. In that sense, residents and staff function together like a family. ‘‘Pseudo’’ reflects the fact that although they function like families, this type of family relationship is artificial at its core. There is no doubt that pseudo families are different from traditional families in very important ways. Yet, in a quest to more fully understand interpersonal violence, it has been important to expand the definition of what constitutes a family. Scholars have long recognized that abusive relationships do not just occur within married couples and biological families, but in a wide range of familial relationships. Thus, today scholars consider abuse within all types of family structures, including stepfamilies, same-sex intimate partner relationships, adoptive families, extended families, and cohabiting and noncohabitating intimate relationships, and are also taking seriously the role of pets within a family.
Pseudo families, like other types of families, exist in many settings. For example, work environments, sports teams, church communities, fraternities, clubs, etc., are often viewed as tight-knit groups in which members might consider themselves a type of pseudo family. Since a great deal of time is spent with individuals in these social groups, close bonds and attachments are formed, and one might consider one’s peers to be ‘‘like family’’ and embrace them as such. Abuse may occur in these relationships.
However, because of the intense nature of the caregiving relationship, this research paper will consider pseudo-family abuse in circumstances in which individuals are living in a twenty-four-hour congregate care setting or foster home where staff are paid a stipend or salary to provide some level of care. Although staff are biologically unrelated to the residents they care for, they are generally considered responsible for the emotional and physical well-being of the individuals in their care, unlike other types of pseudo families. In addition, the pseudo-family relationship assumes that the resident is living in the out-of-home care setting for a period of time.
Both children and adults are placed in out-of-home care settings for a variety of reasons. They may need specialized medical or psychological treatment, may be working toward developing independent living skills, may be in need of behavior modification, or may be unable to care for themselves due to their age or physical condition. Most are in need of some type of professional care or supervision. In some cases, individuals are placed in out-of-home care because their own homes are unsafe due to abuse and neglect. Most vulnerable to out-of-home placement are children, adults with disabilities, and the elderly. Examples of out-of-home care settings include facilities for children and adults with mental illness or developmental disability, long-term care or skilled-nursing facilities for the elderly or adults with chronic illness or disease, residential treatment programs for youth, group homes, and foster families that provide care for children and/or vulnerable adults. For the sake of simplicity, this research paper will not cover adult correctional facilities, such as jails and prisons. Such facilities certainly represent a unique type of out-of-home care, and inmates are undoubtedly abused and neglected in those settings; however, adult correctional institutions serve a very different purpose and have different goals and responsibilities than other types of out-of-home care environments.
Although the term family means different things to different people, one might ask, why include pseudo-family abuse in a volume that focuses on domestic violence? Some scholars and practitioners may disagree, but there are a number of valid reasons for its inclusion. First and foremost, some of the factors involved in the abuse that occurs within traditional families and intimate partner relationships are markedly similar to the factors associated with the abuse that occurs in out-of-home care settings. In particular, the types of abuses endured by victims and the short-term and long-term consequences of such victimization are similar. In addition, the conditions that place individuals at risk for victimization and the characteristics of perpetrators are comparable. Therefore, researchers and scholars have much to gain by studying the intimate and complex nature of caregiving and the interpersonal and dynamic relationships that sometimes result in abuse. Second, the experiences of those children and adults who reside in these alternative living environments, even for relatively short periods of time, are crucial to their emotional and physical well-being. Abuses that occur while residing in an out-of-home care environment can have profound consequences for victims and occur with enough frequency to warrant public concern. In addition, some children and vulnerable adults are placed in such facilities by the courts and/or the human service system because biological families are unable or incapable of providing minimum standards of care and/or safety. Therefore, abuses that occur within institutional settings or foster homes only compound the difficulties originally experienced within families of origin. Finally, it is important to recognize the impact that institutional living has on its residents. There is often an emotional and/or physical price to be paid by residents once a move is made to institutional living. Since thousands of children and adults reside in out-of-home settings at any given time and the likelihood that the demand for out-of-home care settings will only increase in the future to accommodate a growing elderly population, it is imperative that attention be paid to the needs and safety of residents. Also, since taxpayer dollars finance these types of services, it is important to ensure that government funds are utilized in an appropriate manner.
The research on pseudo-family abuse is limited and there are currently no national prevalence data available that comprehensively consider all aspects of the problem. Researchers and scholars must rely on reported incidents of abuse, which is likely to paint only a very small picture of the actual abuse that occurs. Since several different human services systems operate to provide care for adults and children residing in various out-of-care settings, reporting mechanisms also differ across systems. Some states have established ombudsperson and protection and advocacy programs on behalf of the rights of residents and handle abuse complaints; however, these are fragmented and are meant to serve only discrete populations of people with specific disabilities or problems. Local law enforcement officials have historically followed up on reports of abuse; however, few police departments or prosecutors have had the resources to pursue investigations in a proactive fashion. As a result, sometimes it is unclear who is responsible for investigating and prosecuting crimes occurring in such settings. Since 1978, Medicaid Fraud Control Units (MFCUs) have had primary law enforcement jurisdiction over the investigation and prosecution of maltreatment occurring in facilities receiving Medicaid funding. These units are funded with both state and federal monies, and the vast majority of them are housed in state offices of attorneys general. With a dedicated commitment to the investigation and prosecution of such abuses, agents have been very successful in securing thousands of convictions for abuse and fraud and have recovered millions of dollars from out-of-home care providers who have committed fraud.
II. Forms of Abuse
The maltreatment of residents in caregiving institutions and/or foster homes takes many forms. As in traditional families, residents can be physically, emotionally, or sexually abused. Residents can suffer from neglectful care, which can have devastating consequences. Financial abuse, especially in the form of fraud, is of special concern in the case of pseudo families. Simply making the transition from independent living to an institutionalized setting can have negative consequences, even if no other abuses are present. Therefore, the impact of ‘‘institutionalization’’ will also be discussed.
Pseudo-family abuse encompasses acts of both commission and omission, meaning that both overt acts of abuse are considered as well as situations in which the caretakers fail to provide necessary care for the resident. Kurst-Swanger and Petcosky (2003) provide a working definition of pseudo-family abuse, which takes into consideration a standard definition of family violence (Pagelow 1984):
Pseudo Family Abuse includes any act of commission or omission by individuals responsible for the daily care of others in an out-of-home setting, and any conditions resulting from such acts or inaction, which deprive individuals of equal rights, and liberties, and/or interfere with their optimal development and freedom of choice. (Kurst-Swanger and Petcosky 2003, p. 187)
This definition purposefully includes language to highlight the importance of equal rights, liberties, and freedom of choice. Congregate care, by its very nature, often is inherently void of such personal liberties, since institutions are often caring for a large number of people at once. Unlike one’s own personal home, residents often have little choice or input into their daily activities, meals, physical living environments, roommates, etc. In fact, it is often the restriction of choice that makes living in an out-of-home placement so very difficult for residents, rendering them helpless and powerless. Although such caregiving institutions cannot reasonably replicate the type of freedom of choice and liberty one might be able to experience in his or her own home, institutions which exhibit total control over their residents may be at greater risk of maltreatment. Like traditional families, power differentials between staff and residents may increase the risk of abuse. However, some out-of-home settings may be providing care for a population in which the behavioral and emotional problems exhibited by the residents present many challenges for staff and administrators. In some instances, the staff is at greater risk of victimization, and therefore the abuse of staff will also be considered in this discussion of pseudo-family abuse.
A. Physical Abuse
The physical abuse of residents can involve a wide range of injurious acts. Physical abuse assumes the active engagement of maltreatment. The most common acts of physical abuse found within residential care facilities include but are not limited to hitting, kicking, pinching, slapping, punching, burning, scratching, and biting. Residents may endure hair pulling, being prodded with objects or having objects thrown at them, the inappropriate application of restraints, and/or excessive corporal punishment. In addition, residents may be given inappropriate doses of medications, such as sedatives or tranquilizers. Due to the physical vulnerability of many of the residents in care, even seemingly minor acts such as a push, shove, or shake can cause serious injury in some residents. Those at greatest risk of physical abuse are individuals whose age or physical limitations prevent them from protecting themselves or from reporting abusive acts. For example, young children, the frail elderly, and those who suffer from mental retardation or severe mental illness are among those likely to be at greatest risk.
Not all residents who are physically abused suffer physical injury, but many experience pain or hurt. However, at a minimum, even minor acts of abuse can impact the emotional well-being of victims and other residents who may witness such abuses. In some instances, residents might experience more critical physical injuries and in severe cases, residents might die as a result of the injuries they have received.
Individuals who are most closely associated with the direct care of the residents most often commit physical abuse. Staff who are responsible for the personal, daily care of residents are most likely to exhibit abuses, since their work places them in direct contact with residents. Activities such as serving meals, bathing, dressing, changing bedding, and transportation require staff and residents to engage in physical and often intimate contact, leaving opportunities for abuses to occur.
B. Emotional Abuse
As indicated above, emotional abuse, in the form of verbal attacks, is also a form of pseudo-family abuse. Emotional abuse occurs when a caretaker makes verbal comments or gestures toward a resident in which the resident is belittled, degraded, humiliated, taunted, or chastised. Residents may be subjected to verbal attacks such as yelling, screaming, name calling, or swearing. Further, residents may be intimidated by verbal threats or gestures. They may also experience emotional abuse if they are socially isolated from others or deprived of their possessions, activities, or food. Since staff tend to have almost if not total control over the environment in which residents live, staff can abuse that power by withholding things that have emotional value to the resident.
Regardless of the form emotional abuse takes, it leaves residents feeling helpless and fearful and compounds the negative impact of institutionalization. Like the emotional abuse that occurs in families, the emotional abuse in pseudo families tends to occur with greater frequency than physical abuse and often accompanies relationships in which other forms of abuse exist. Direct-care staff are more likely to engage in emotionally abusive behavior, since they have the most direct interaction with the residents. Staff members, as indicated earlier, are also at risk of being verbally assaulted by residents.
C. Sexual Abuse
The sexual abuse of residents is a phenomenon that is not well documented and is likely to be the least discussed form of abuse exhibited against children and vulnerable adults. Sexual abuse can involve a wide range of acts that may or may not involve direct physical contact with the resident. Acts in which residents are touched, rubbed, fondled, sodomized, or raped by the caregiver require physical contact with the resident. However, sexual gratification may also be achieved through watching residents undress or bath, exposing one’s genitals, viewing the resident’s genitals, or making residents engage in sexual activity with one another. In addition, any sexual act involving residents in which photographs are taken or which is filmed would be considered sexual abuse. In some instances, sexual contact between staff and residents may appear to be consensual; however, any type of sexual contact between staff and residents is inappropriate and therefore considered sexual abuse. Since the nature of the caregiver–client relationship is technically a professional one, any sexual contact between staff and resident is at a minimum unethical, but it is also likely to be considered illegal. Also, since many residents are unable to give consent legally because of their age, physical, or mental condition, the notion of consensual sexual relations between staff and residents is suspect.
Residents in out-of-home care settings are particularly vulnerable to sexual abuse because their age or physical or mental conditions often place them in a defenseless position and therefore put them at greater risk of being victimized. As is the case with physical and emotional abuse, direct-care staff are more likely to perpetrate sexual abuse. The personal and intimate nature of the caregiver relationship requires that residents rely on direct-care staff for personal hygiene support, placing them in direct physical contact with staff on an ongoing basis. Also, since many residents sleep in quarters which remain unlocked, residents are especially unprotected during the evening and overnight hours when staffing is limited and unsupervised.
Neglect, a very serious form of maltreatment in traditional families, is equally, if not more, dangerous in pseudo families. Since residents are often socially isolated from others in the community, apparent signs of neglect may go undetected until it leads to serious injury, illness, or death. Caregivers have a legal responsibility to care for the residents in their care, and therefore any form of neglect, whether it is intentional, reckless, or careless, is subject to legal scrutiny and may be deemed criminal. Even relatively minor neglectful acts can have devastating consequences for residents, since residents tend to have preexisting emotional or physical conditions which require special medical treatment. Therefore, any neglectful act can have a potentially dangerous result. Administrators, facility owners, supervisors, and/or direct-care staff are all responsible for neglect.
Neglect can occur in a variety of forms, though the most common involves a failure on the part of the caregiver to do what is required for the resident based on a prescribed plan of care. This might include a failure to provide adequate and proper nutrition or hydration, climate control, dental care, supervision, transportation, medication delivery, or the proper assessment of a resident’s physical or emotional condition. In addition, neglect may be evident when injuries or illnesses go unreported, soiled clothing or bed linens go unchanged, or residents are forced to live or eat in unsanitary conditions. Violations of state standards of safety and security because of carelessness may also constitute neglect.
At a minimum, neglect negatively impacts the quality of life for residents. However, neglect can also have catastrophic consequences, especially for residents who have preexisting health concerns. Neglect can result in bedsores, dehydration, malnutrition, illness, communicable disease, burns, broken bones, or countless other problems. In the case of children, neglect can have a profound impact on their cognitive, affective, and/or physical development and growth.
E. Financial Abuse
Financial abuse, also referred to as financial exploitation, is a unique problem that occurs on a variety of levels and can take different forms. It is likely to be the most common abuse committed against adult residents of out-of-home care and can have widespread impact. Not only are individual residents personally impacted by financial victimization when fraud occurs, but the health care industry faces devastating financial losses as well. In addition, since Medicare and Medicaid, two government health care programs, finance a considerable amount of out-of-home care expenses, taxpayers are victimized by fraudulent acts. Regardless of the form that financial exploitation takes, individuals who reside in facilities in which financial exploitation occurs are also at risk of suffering from a lack of quality care.
On a personal level, individual residents may have their personal effects stolen, bank accounts drained, or financial resources commingled with facility financial accounts. In these cases, residents experience personal financial loss, often leaving them penniless. In some cases, financial abuses are perpetrated by a resident’s own family or professional advisors, such as a lawyer or accountant. In these cases, perpetrators obtain powers of attorney from residents and commit forgery or theft. Residents may also fall prey to a practice referred to as ‘‘patient dumping,’’ in which they are systematically discriminated against for having Medicaid as their primary health insurer.
On a broader scope, billions of dollars are lost each year to health care fraud. Administrative personnel generally commit health care fraud in an effort to bilk health care insurance companies. Fraud can be committed in many different ways. According to the National Health Care Anti-Fraud Association, the most common types of fraud include:
- billing for services that were never rendered,
- billing for more expensive services than were actually performed,
- executing medical procedures or services that are unnecessary, and
- submitting claims misrepresenting the medical necessity of certain procedures or services.
These and other fraudulent schemes mean significant financial losses for health insurers; however, they can also impact resident care. Fraud can drain a resident’s finite health benefits; falsely record medical conditions and diagnoses, thereby altering a resident’s medical history; and risk the health and safety of the resident through the performing of unnecessary surgeries, tests, or procedures.
III. Process of Institutionalization
Transitioning from a private home into an out-of-home care setting can be very difficult for residents and can have a detrimental impact on their cognitive, affective, or physical development. Although out-of-home care settings are critically needed to serve the physical, emotional, and behavioral challenges that residents face, the communal and institutional character of many out-of-home care settings may mitigate against the positive services that such settings can provide. Residents tend to have little decision-making power, even regarding personal decisions such as what time to eat, bathe, or sleep; their ability to leave the facility; what to watch on television; what personal items they are allowed to possess. Residents’ lives become very structured, socially isolated, and controlled externally by staff.
Erving Goffman (1961) was one of the first to describe institutionalization as a process in which an individual has to shed elements of herself and her identity to assume the culture of the institution. Others refer to this process as the social breakdown syndrome, the syndrome of psychosocial degradation (Yawney and Slover 1973), or institutionalization syndrome. It can lead to apathy, depression, passivity, and even death. For example, some elderly people exhibit indirect self-destructive behavior in which they indirectly work toward death by refusing to take medication, eat, or drink. Residents, in effect, grow to disregard their health and well-being (Conwell, Pearson, and DeRenzo 1996). For young children, institutional living is associated with attachment and bonding problems (Bartholet 1999).
This form of maltreatment is very difficult to define and delineate, since no one person can be blamed. Even facilities which provide the highest quality of care can have residents who experience traumatic psychological and physical changes as a result of being institutionalized. Institutional factors associated with these negative consequences include lack of appropriate staff/resident ratios, high staff turnover rates, rigid rules, cold and uninviting physical spaces, lack of privacy, overcrowding, poor meals, and shared living spaces. Facilities tend to foster a culture of dependency, which can result in a loss of self-confidence, independence, and social interaction.
IV. Maltreatment in Foster Homes
Foster homes are relied upon as a preferred alternative to institutional life for both children and adults. Foster homes can provide warm, nurturing environments in private home settings where residents can participate in normal family life. Foster families are paid a stipend to provide such care. Children are often placed in foster care when there is evidence that they have been abused or neglected by their parents. Approximately 500,000 children are in foster care in any given year. Vulnerable adults may be placed in foster care when they are in need of some level of care but can manage without the medical supervision of a skilled-nursing facility.
Like other pseudo families and traditional families, abuse also occurs in foster care, where residents may be physically, sexually, or emotionally abused or neglected. Abuse in foster care settings is especially troubling given the fact that foster homes should be considered safe havens, especially for those residents who have been removed from their own homes due to abuse or neglect. A growing concern over abuse and neglect in foster homes has led the federal Administration for Children and Families (ACF) to establish national standards for the incidence of foster care maltreatment of children (U.S. Department of Health and Human Services [USDHHS] 2000). Through ACF’s Child and Family Services Review, states must demonstrate that of all the children who were in foster care in the state during a specific reporting period, only 0.57 percent or less were abused or neglected by a foster parent or facility staff member. In 2003, approximately 76 percent of the states were in compliance with this standard (USDHHS 2005).
V. Common Themes Identified in Pseudo-Family Abuse
It is difficult to determine why staff members would wish to harm or neglect their clients, since there appears to be little to be gained from doing so. If anything, staff who engage in such abuses are likely to run the risk of being reprimanded, fired, or arrested. The factors associated with the maltreatment of residents are varied and multidimensional, yet some common themes can be identified.
A. Institutional Factors
Scholars cite institutional problems as being central contributors to the occurrence of pseudo-family abuse and neglect. Residential facilities are notoriously understaffed and overcrowded. Staff-to- resident ratios tend to be very high, which causes great strain for both the direct-care staff and the residents. In addition, administrators find it difficult to attract highly qualified employees due to the low wages and the demanding schedules. The low pay and stressful working conditions often keep staff turnover rates high, which in turn results in inconsistent staffing levels and insufficient supervision of direct-care staff. Inadequate training and a lack of appropriate continuing education only compound any existing staffing problems.
B. Individual Factors
Individual Factors In addition to the institutional stresses noted above, one of the most prominent factors related to abuse is how individual employees navigate the demands of the job. The responsibility of caring for the personal needs of others is a demanding, stressful, and tiring job. Staff members are often asked to do the most unpleasant of tasks, such as changing soiled underclothing, bedding, and bedpans or cleaning up vomit or food that has been thrown across the room. Although some staff are trained in the nursing field and expect to perform such tasks, others are not emotionally prepared to handle the daily demands of the job. In addition, staff must negotiate the emotional, medical, behavioral, and cognitive challenges presented by the residents, often with little break or respite. Coping with the behaviors of emotionally disturbed or cognitively impaired individuals can be exhausting and especially difficult for staff unequipped with the types of communications skills necessary to be effective with a diverse population of residents. Individuals with disabilities or impairments are also at high risk of victimization within traditional families as well.
In addition, in some instances direct-care staff must endure frequent verbal and physical attacks from the residents or interrupt physical violence between residents. This is consistent with the dynamics of some violent families in that different family members may be involved in physical altercations with each other at different times. For example, a study done by Goodridge, Johnston, and Thomson (1996) found that nursing assistants in a long-term care facility in Canada were assaulted by residents on average about nine times per month and verbally attacked an additional eleven times per month. Conflicts were most likely to occur during personal hygiene care or when residents wanted to go outside. Parent and associates (1994), in a study conducted regarding the conditions of confinement for youth in detention or correctional facilities, reported that thousands of incidents occurred each year in which staff were injured by juveniles, compared with the hundreds of incidents in which youth were injured by staff. They also found that in any given year, approximately 24,000 incidents resulted in injury from acts committed by juveniles toward other youth, while an additional 17,000 youth engaged in suicidal acts. These studies highlight the challenges of providing out-of-home care for various populations.
While job stress may be a trigger for abuse, some staff engage in abusive behavior because there is simply ample opportunity to do so. Residents are easy targets for victimization because they often cannot fend off attackers and in some instances are incapable of even reporting abuse. A natural power differential exists between staff and residents, providing an environment in which abusive behaviors can flourish. Residents, in many instances, are at the complete mercy of the staff and must depend upon them to meet their basic needs. In addition, many facilities operate in isolation from the communities in which they reside, thereby placing residents at greater risk of victimization. These are also consistent themes in abusive families.
Financial exploitation is attractive because residents are often unaware of their own finances and are completely removed from the relationship between the administration and the health insurer. According to the National Health Care Anti- Fraud Association (2005), administrators have all the tools at their disposal with which to reap the great personal or corporate financial rewards of fraud. This includes the fact that there are generally a large number of insured patients to exploit and a wide range of medical conditions, procedures, services, and treatments on which false claims can be billed.
Aside from the factors noted here, research studies have yet to identify further the personal characteristics of perpetrators to determine whether or not abusive behavior is correlated with any other environmental, psychological, or biological factors, such as substance abuse, mental illness, personal stress or instability, or personal experiences with abuse and neglect. Since most caregivers provide care in a nurturing manner, yet are subjected to the same environmental factors as those who are abusive, it is likely that there are other social and personal factors associated with the abuse and neglect of residents.
C. Social Factors
Residents who live in out-of-home care environments represent some of the most vulnerable individuals in society. They are unable to care for themselves, and their families are in no position to provide adequate care. As such, they are often shunned and alienated by their own families, neighbors, or communities. Some are seen as social deviants. Institutional and foster care, therefore, provides an opportunity for them to be properly cared for, but out of the mainstream of society. Once removed from the community, they are often stripped of their personal identities and, in effect, dehumanized. Social isolation compounds the ambivalent and indifferent social attitude many have toward such a vulnerable population. Therefore, as a cohort, residents have little social power in society or within the out-of-home care placement. This places them at risk of victimization.
In summary, the pseudo family provides, for all practical purposes, many of the same functions as traditional families do, e.g., food, clothing, shelter, and social interaction. Maltreatment sometimes occurs within this surrogate family, not unlike in traditional families. In fact, factors such as power differentials, social isolation, stress, and lack of appropriate training and communication skills are found to exist in both types of families in which abuse and neglect is present. Yet, the abuse and neglect of individuals within pseudo-family environments has not, as of yet, been pursued with as much fervor as abuse within traditional family structures. Further research is necessary to determine the actual prevalence of abuse and neglect and the myriad of factors associated with its occurrence. In addition, an expansion of monitoring systems, protective and advocacy programs, and specialized law enforcement interventions are warranted.
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