What's Behind "Bullying" Behaviors in the Senior Population
by Don Drake, Connelly Law Offices, Ltd.
"Baby Boomers make up a substantial portion of the world's population and here in the United States, they represent nearly 28% of the American public, and by the year 2031, the number of adults aged 65 and older is expected to double," said certified elder law Attorney RJ Connelly III. "With this increase come problems that senior care facilities, such as low-income elderly and disabled housing, and to a lesser extent, nursing homes and assisted living programs, are being forced to deal with."
One of those problems, senior "bullying", has been downplayed by some in the eldercare field as "non-existent" or "blown out of proportion" while others in the field state that this is a major problem affecting one in every five seniors. It should be called what it truly is -- harassment, intimidation, or verbal assault (a communicated intent to inflict physical or other harm on another person, with a present intent and ability to act on the threat). Unfortunately, the term "senior bullying" has stuck, and this sophomoric phrase tends to diminish the act to a childish schoolyard behavior. But we'll use that term for the sake of clarity.
What also must now be factored into this mix is our current political climate, how the COVID pandemic has changed the face of many senior care programs, and what lingering attitudes and beliefs the baby boomers are bringing into congregate living facilities.
"It should be called what it really is -- harassment, intimidation, or verbal assault -- unfortunately, the term "senior bullying" has stuck, and this sophomoric phrase tends to diminish the act to a childish schoolyard behavior."
Our current societal climate has become so divisive, with any perceived disagreement being viewed through the lens of discrimination or any number of the other "isms", that it has forced social workers and administrators to walk a fine line when addressing these issues for fear of "offending" someone. The pandemic, which has forced major changes in program structure where those who can afford to "age in place" will do so, means that many senior living facilities will need to change how they do business and who they accept in order to survive financially. This will include the presentation of behaviors not normally seen among this age group in the past.
Let’s start with the issue of bullying. Many of the younger adults I speak to about this subject find some humor in it. There are multiple jokes about seniors bullying each other and even memes about the elderly fighting with walkers and canes. "After all," one person said to me, "how hard can a 90-year-old lady hit you?"
Besides the fact that one ninety-year-old hitting another with a weapon of any sort can be dangerous if not deadly, the psychological impact of bullying can be devasting on someone of any age, especially among the elderly. For programs that serve the disabled, it must be remembered that many who come into housing under this label may be significantly younger, stronger, and more "street-wise" than other residents, changing the perceived dynamic of the "old and frail" resident.
So, what is "bullying?" As a social construct, it is best described as a complex form of interpersonal aggression that serves contrasting functions for the aggressor and is manifested in many patterns of behaviors that can occur in different social settings. When we think about bullying, we see the aggressor, the "bully" and the target, or the "victim" as the primary players in this toxic relationship.
However, the action that the bully is engaging in serves several purposes, especially in settings such as assisted living and senior housing projects. Although it may appear to be a one-on-one interaction, the bully's behaviors will also have an impact on neighbors and staff, complicating the problem even further resulting in multiple victims and a culture of fear that is often hidden to outsiders who want to address the problem.
Bullying vs. Drama vs. Conflict
The question must then be asked, how do we distinguish between bullying behaviors and simple conflicts or drama seekers? Let's look at drama seekers.
Drama can best be compared to a stage play...it's serious to those involved but not taken seriously by the audience who is entertained by it. In the end, no one is hurt and the actors in this play are satisfied as all those involved get the attention they sought. Eventually, those initiating the drama will "raise the stakes" when their behaviors no longer garner the spotlight they seek. So, these behaviors should be monitored and addressed early and often.
Conflict is inevitable in any group setting, whether it be at the office, school, or even in social settings like bars and gyms. In a conflict, the issue is a disagreement or difference of opinion where the power is equal between the two parties. In most cases, it is an isolated incident where both parties seek a solution that benefits everyone. Teaching people to confront behaviors in a positive and appropriate way can stave off any escalation of the behavior.
Bullying, however, is based upon an imbalance of power with an intentional attempt to do harm to the victim. It is repeated behaviors that cause emotional and/or physical injury to another and do not stop despite multiple requests from others to cease the inappropriate actions.
The Impact of Bullying
There exists a copious amount of research showing that stress, which bullying causes, can exacerbate biological vulnerabilities and activate cognitive vulnerabilities in some, which will lead to significant negative short and long-term consequences. These include the expected outcomes such as chronic depression, thoughts of suicide, PTSD, substance abuse, withdrawal from relationships, and ongoing fear and intimidation resulting in ongoing stress, like that caused by bullying, which may contribute to the development of dementia.
It has certainly been known for decades that stress has a negative impact on both physical and mental health. But today, increased research is finding that chronic stress has severe and lasting detrimental effects on the brain, attributed to the stress hormone cortisol.
Stress-related cognitive decline is thought to occur because of prolonged exposure to elevated levels of cortisol which target specific brain regions including the hippocampus, amygdala, and prefrontal cortex. For researchers, the hippocampus, an area that is critical for certain types of memory and is considered the initial site of the neuropathology of Alzheimer's disease, has received the most attention as a target of this flooding of cortisol. And remember, this stress does not just live with the target but with those who witness the behavior as well, so it is a problem for the entire residential community.
From my own experience, senior-on-senior aggression is woefully under-estimated based in treatment programs as well as elderly and disabled housing projects (and to a lesser extent in assisted living and nursing facilities), with some of these behaviors being outright criminal acts. But with the pandemic changing the face of those seniors or disabled who may become residents of assisted living or nursing homes, staff may also be witnessing a rise in such activity. Let's explore this further.
Those with the money and resources to remain in the home will do so while those who do not will be entering senior living facilities. Once we separate some of the underlying pathologies of bullying such as mental illness, dementia, and delirium, we are left with the one that is most concerning and untreatable in most cases, personality traits and personality disorders. We do know that with these types of "bullies" there exists an underlying need for power and control with all their behaviors that include patterns of inappropriate social interactions aimed at accomplishing that goal.
These types of bullies have lifelong patterns of such behaviors and usually have histories of alcohol or drug abuse, criminal activity, and homelessness. Unfortunately, all trends are pointing to this type of personality becoming more prevalent in institutional care with the problem of bullying behavior increasing.
Why the Expected Problems
The baby boomers will be bringing behaviors and activities into institutional care that neither staff nor administrators have had to deal with previously, in such large numbers. Much of this is due to the mindset of boomers and the demographics of this group, which include socioeconomic factors. Let’s explore some facts about aging baby boomers.
Here are some statistics on drug use by baby boomers. Among this group, substance abuse more than doubled in the last decade. Here are some numbers:
Marijuana abuse leading to treatment increased from 0.6 percent to 2.9 percent and will expand even more with the legalization of recreational pot.
Cocaine abuse treatment rates increased from 2.9 percent to 11.4 percent.
Heroin abuse treatment rates more than doubled from 7.2 percent to 16 percent, and much of this increase can be traced back to the opioid crisis.
Prescription drug abuse treatment rates increased from 0.7 percent to 3.5 percent.
The rate of overdose deaths among people fifty-five and older, regardless of drug type, nearly tripled.
According to Dr. David Oslin, a behavioral health expert at the University of Pennsylvania's Perelman School of Medicine, baby boomers are carrying their substance abuse habits "with them as they age, with binge drinking, and prescription drug use being concerns in this population."
Sexually Transmitted Diseases
But it’s not just drug abuse and addiction that they are bringing into old age, it’s also sexually transmitted diseases and promiscuous activities. Here are a few facts:
Patients over age 60 comprise the largest increase of in-office treatments for sexually transmitted diseases.
Diagnosis rates for herpes simplex, gonorrhea, syphilis, chlamydia, hepatitis B, and trichomoniasis rose 23 percent in patients over age 60 between 2014 and 2017.
The increase here can be attributed to everything from the use of drugs like Viagra to the mindset of the 1960s. And unbelievably, drug and alcohol abuse and sexual promiscuity go hand in hand even with seniors.
STDs among seniors are such a concern that medical professionals are being advised to routinely discuss this with their elderly patients. Syphilis, called one of the "great imposter" diseases because its symptoms mimic other conditions of old age, is of special concern given the insidious nature of the infection.
With the increase in the growth of casinos and the legalization of all types of gambling in general, seniors will be involved in this activity in numbers never seen. Having access to cell phones and computers, online betting will also be a problem.
And yes, I have had to intervene in more than one gambling issue in residential programming. In fact, many are calling local casinos the new “senior centers”. Here are some gambling facts:
In a 2012 study, 36 percent of the U.S. population ages 50 to 64 and 28 percent of individuals sixty-five and older visited a casino in 2017.
The fastest-growing group of problem gamblers is female seniors.
I can also tell you that older adults have traded sex for gambling losses in senior centers and treatment programs. Hard to believe? It’s not only true but the beginning of a larger issue as this problem will continue to grow.
Boomers are also bringing criminal activity along with them as well. Some of this can be directly attributed to drug use. So how much criminal activity is this age group involved in? Check this out:
Between 1993 and 2003, the inmate population aged fifty-five and older mushroomed by 400 percent and continues to rise.
Two-thirds (65 percent) of the 55+ prisoners had been sentenced for violent crimes, the highest percentage of any age group in 2017, over 25,000.
Boomers were arrested for the four index crimes of violence (murder/non-negligent manslaughter, robbery, rape, and aggravated assault).
We only need to look at our neighboring Commonwealth of Massachusetts to see this playing out. According to data from the state Department of Correction (DOC), as of Jan. 1, 2018, there were 909 men aged sixty and over imprisoned. There are twenty-two women aged sixty and over incarcerated. The average age of an inmate in Massachusetts state prisons is 42 years old — and the oldest inmate is 95 years old, according to DOC.
Nationwide, from 1999 to 2016, people fifty-five or older in state and federal prisons increased by 280 percent, according to data from Pew Research. During the same period, the prison population of younger adults only grew by 3 percent.
These boomers, once released from incarceration, will need to go somewhere. Many will have chronic health and mental health issues and end up on the street homeless. Here are some homeless stats around boomers:
Between 2007 and 2014, there was a 20 percent increase nationwide in individuals over fifty being homeless.
This group now makes up more than one-third of the homeless in the United States.
The older homeless have mental illnesses, chronic physical illnesses, diabetes, heart disease, addiction, STDs, and mobility issues.
They will be admitted to the hospital, deemed too ill to return to the shelter, and sent to rehab or other long-term care providers or housing projects for seniors and the disabled.
Aging In Place
When we couple this with the fact that the future of senior care will be focused on “Aging in Place” with Home Health Care services, that assumes that a senior will have a place to age in and the appropriate social support. So, who can age in place?
Those with the financial means to do so.
Those with property and/or housing.
Those with appropriate social support.
Those with stable health issues can be treated at home.
Who will not be able to age in place?
Those who are homeless or living in shelters.
Those with histories of incarceration and living bed to bed.
Those with histories of drug addictions and multiple relapse episodes.
Those with chronic mental health problems and living in group settings.
Those with medical conditions that cannot be addressed in the home.
This is not judgmental but realistic. If a safe environment for all residents is the goal, then providers need to accept that these changes are real and be prepared to deal with them. For instance, seniors who have a history of addiction or criminality often use bullying behaviors to get what they want because living on the street or engaging in street activities to get drugs forced them to develop a range of coping behaviors not seen in the average senior. These behaviors are long-term and ingrained meaning they are not likely to change. The same holds true for those diagnosed with some form of mental health disorder or those having prolonged periods of incarceration.
Below are two examples of behaviors that were dealt with in a program that I oversaw that provided care and treatment to older adults and seniors. To be clear, these examples do not represent most clients, but neither are they outliers and they reflect the day-to-day issues faced by staff in both short and long-term residential settings.
The Story of "Sweet" Lou
Lou was a resident in his mid-sixties and had spent most of his life in and out of shelters, treatment programs, and even correctional facilities. He had reached an age where he qualified for a senior living community and moved there from a homeless program in Boston’s Mattapan neighborhood. Lou’s behaviors were disruptive from the beginning, and he fell back to using street drugs and even began selling them to others in the community. He was sent to detox and then into a treatment program with the plan to move him back to the senior living community.
The problems that Lou presented at his apartment in subsidized housing came with him to the treatment program. He used charm to get female clients to buy him everything from coffee to cigarettes while using physical intimidation and verbal threats to get money and other items from males in the milieu. He even manipulated and coerced staff at the facility to provide him with items that were normally off-limits within the program.
In one case, Lou told a staff member, who he had brought into his confidence, a story about not having enough money to buy gifts for his grandchildren. He convinced the staff member to buy a radio from him, at a much higher price than the item was worth, so he could “give my grandchildren a wonderful Christmas”. There were, however, three huge problems with "Sweet" Lou’s story:
He did not have grandchildren.
Staff members were not allowed to buy or sell items to or from clients per the policies of the program.
The radio he sold was stolen from another resident.
Lou then used the kindness and empathy of the staff member to blackmail him into supplying his daily cigarette habit under the threat of telling the supervisor about the purchase of a stolen item that had occurred. The staff member eventually came forward and confessed to violating the policy of the program while Lou enjoyed a laugh at the naiveté of the staff member and his fellow residents in treatment.
Elizabeth the Intimidator
Elizabeth, "please call me Liza", was a disabled resident in her late fifties who was later diagnosed with a serious personality disorder. She was charming, attractive, and possessed the ability to get her needs met in many inappropriate ways. She was able to manipulate other female clients on the unit into allowing her to use their EBT or DEBIT cards, in many cases draining them. She was caught engaging in sexual activity with males from another floor in the stairwell and was able to remain in treatment stating that this activity was part of her "sexual addiction".
When confronted by a social worker on the unit, she began a campaign targeting that staff member through rumors and subtle threats. In one of Liza’s interactions with the staff, she stated, “I’m going to watch a movie tonight about a nosy social worker who caused problems for one of her clients and was found murdered in an alley. Do you want to watch that movie with me?”
Liza even went as far as to find the social worker's home address on the internet. The staff then received a letter with a blank piece of paper inside. Liza then said to the social worker several days later, “I would hate to get something in the mail and not know who sent it. Just knowing that someone knew where I lived would scare the hell out of me! You never know what kind of people they know!” The social worker who was the recipient of this veiled threat was obviously concerned about her well-being as well as those of her children and decided to transfer to another location.
What Can Be Done?
As with most things in life, identifying a problem before it occurs is key. But this is easier said than done, given the realities of operating assisted living facilities and subsidized apartment settings. Understanding that, here are some suggestions that may help:
Learn who potential bullies may be and monitor their behaviors (this is done by gathering a good biopsychosocial history and gathering information from their last living situation).
Learn who potential victims may be and monitor their interactions with others (this is also done by gathering a good biopsychosocial history).
Define to staff and residents what senior bullying is by providing example behaviors and setting clear limits and boundaries.
There are diverse types of bullying activities that need to be defined and identified.
Be aware of potential bullying situations (know that bullies will try to take advantage of proactive staff by trying to portray themselves as victims, thereby using staff by proxy to bully their intended targets).
Develop some interventions to address bullies and help other seniors learn how to confront possible bullying behaviors.
Have a discharge policy in place and have staff keep good notes and records of activities in case a discharge is necessary.
"The bottom line here is that we all are dealing with a new type of senior as baby boomers age into this demographic," said Attorney Connelly. "But because those with these behaviors lack empathy, interventions are better aimed at training staff to recognize the behaviors, supporting the potential victims, and educating others in the community rather than solely addressing those engaging in bullying-type behaviors. With them, a more black and white approach is needed, with clear-cut and unwavering consequences in place if the behaviors continue."