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CHAPTER FOUR: DISCRIMINATORY AND PSYCHOLOGICAL ABUSE
Introduction
4.1 This chapter defines and considers the potential signs and indicators of discriminatory and psychological abuse, and details the support and protection measures for adults "at risk" of these types of abuse.
Definition of discriminatory abuse
4.2 Discriminatory abuse can be defined as:
"Making an unjust distinction on the basis of race, colour, age, or gender, etc." .
4.3 'No Secrets' (DoH, 2000a) defines discriminatory abuse as:
"including racist, sexist, that based on a person's disability, and other forms of harassment, slurs, or similar treatment." .
Definition of psychological abuse
4.4 Psychological abuse can be defined as:
"the attempt to negate an adult's independent choices and to create over-dependence, including the denial of basic human rights to follow spiritual and cultural beliefs that maintain self-esteem." .
Characteristics of discriminatory abuse
4.5 Discriminatory abuse can involve prejudice based on a person's sex, race, religion, disability, age, and/or sexuality . Discriminatory abuse can describe serious, repeated, or persistent prejudice that can result in:
- Exclusion from mainstream opportunities resulting in social exclusion
- Segregation within health and social care; for example, issues with access for refugees, and subsequent impact on service delivery; for example, services that are not sensitive to cultural diversity
- Infringement of civil liberties or the individual's status within the community; for example, the "Bournewood" case where an individual who lacked capacity was unlawfully detained, infringing on the individual's right to liberty
4.6 Adults "at risk" of discriminatory abuse can range from:
- Older adults reporting (age) discrimination which contributes to social exclusion and impacts on their access to health and social care, financial and retail services, and social security
- Adults with mental incapacity who experience social exclusion, as a result of their illness and of negative attitudes within both the community and health and social care services
- Homeless adults who are often 'invisible' to services, including the health and social care sector . Older homeless adults are even more likely to experience exclusion from both the community and statutory services on account of their destitute status and age and are prone to undetected and untreated illnesses
- Adults with impaired communication who are often perceived as having learning difficulties and are deemed particularly "at risk" of social exclusion
- Refugees and asylum seekers who are at risk of racist or religious discrimination are often stereotyped, with these issues affecting service provision and accessibility (including health and social care) . Additionally, single women refugees and asylum seekers can often be denied the support of the community due to a lack of culturally appropriate places of contact within the community
- Offenders who are also at risk of abuse : see 6.4
- Sex Workers, with initial vulnerability often predicting an individual's entry into prostitution . The framework of legal and social protection available to adults in prostitution is generally spread across various frameworks, contrasting with frameworks for children in prostitution who are treated as victims of abuse
Characteristics of psychological abuse
4.7 The majority of existing literature refers to psychological abuse as mistreatment .
4.8 Psychological abuse may include emotional abuse, harassment, humiliation, blaming, controlling or coercion, intimidation, threats of violence or abandonment, deprivation of contact, verbal abuse, and/or isolation or withdrawal from services or other supportive networks .
4.9 There is an increasing awareness of psychological abuse ; however, psychological abuse often remains hidden due to a lack of clear evidence . As a result, it is important that service and agency professionals are aware of this type of abuse.
4.10 High levels of stress amongst informal carers is often a common predictor of abuse, especially of older family members .
Support and protection
Primary intervention
4.11 The Human Rights Act 1998, and in particular Article 14, prohibits discrimination against an individual:
"The enjoyment of the rights and freedoms set forth in this convention shall be secured without discrimination on any ground such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status." (Human Rights Act, 1998: Chapter 42, available online).
Although the Human Rights Act (1998) operates as primary legislation, it enables clarification in regards to rights and freedoms of individuals 9 and places the responsibility for promoting these rights with public organizations and services . The Disability Discrimination Act 1995 also enforces the rights and legal protection of people with dementia (Alzheimer Scotland, 2005; Disability Discrimination Act 1995).
4.12 The Crime and Disorder Act 1998 can be implemented to prevent crime throughout the UK. This can be achieved at the local level by police and local authorities forming community safety partnerships ; The Crime and Disorder Act, 1998). For example, local crime audits have been successfully employed to generate crime reduction strategies . An example of good practice is Liverpool's crime and disorder reduction partnership which ensures that the violence and discrimination experienced by vulnerable adults is effectively examined by crime reduction agencies and supported by adult protection experts (Perry, 2004; 2007). This type of collaboration has led to several convictions.
4.13 The Mental Welfare Commission for Scotland, under the Mental Health (Care and Treatment) (Scotland) Act 2003, has duties to safeguard the rights and welfare of people with mental incapacity who are deemed "at risk" of abuse or harm (Benbow and Cohen, 2006; Mental Health [Care and Treatment] [Scotland] Act 2003). These statutory duties can involve the provision of advice, guidance, and assistance (Age Concern Scotland, 2003; Social Work (Scotland) Act 1968; White, 2004) and include the protection of individuals based in their own homes, or within community care .
4.14 The 'National Service Framework for Older People' (DoH, 2001b) seeks to prevent age discrimination in relation to access to health and social care services . Independent organisations, as well as providers of health and social care services, need to utilise their own procedures and mechanisms in order to prevent situations of psychological abuse . This may involve examining the policies, provisions, and procedures of other organisations for examples of best practice, and educating staff and vulnerable adults to increase awareness of abuse and preventive interventions.
4.15 A number of charitable organisations exist to actively support particular groups of "at risk" adults through the provision of advice, support, and information to individuals and their carers.
- 'Sense' provides advice, information, and support services to people with deaf blindness and associated disabilities, as well as their carers . A priority of the organisation is to increase awareness of protection policies for people with impaired communication and associated disabilities . Sense actively nurtures partnerships with other organisations to protect "at risk" adults.
- Depression Alliance Scotland is an organisation that provides support and advice to individuals with depression .
- Alzheimer Scotland aims to eliminate discrimination and provide protection through advocacy services for people with dementia . Alzheimer Scotland also implements an 'involvement policy' which enables individuals with dementia to provide their perspective ( e.g. through the Scottish Dementia Working Group).
4.16 Vulnerable adults' rights to advocacy services are included in the Mental Health (Care and Treatment) (Scotland) Act 2003, due to their potential susceptibility to abuse, harm, or exploitation. Advocates are also required to provide advice and support to "at risk" adults when their needs are being discussed, or at times of transition . The ASP Act also requires councils to consider the importance of the provision of support services, including independent advocacy, to an adult at risk when intervening to offer protection. A list of advocacy agencies has been compiled by the City of Edinburgh Council to assist "at risk" adults in accessing independent advocacy services 10.
4.17 Independent Advocacy has developed considerably over the last three years . However, there is still a long way to go before independent advocacy is available to all who need it within Scotland. This is in part due to significant variances in the total funding of independent advocacy between NHS Boards and Local Authorities. The Advocacy Safeguards Agency plays a specific role in supporting health and local authority commissioners to develop independent advocacy across Scotland, across all health and social care groups.
4.18 Along with advocacy services, interpreters are important in facilitating access to services for "at risk" adults. For example, outreach services are offered to refugees and asylum seekers in the UK by the Bayswater Family Centre . Interpreters are an important component of empowering people who lack capacity, individuals classed as "at risk" of abuse, and other "at risk" groups; for example, refugees. Poor interpreting can contribute to an individual's vulnerability to abuse (Williams, 2004); therefore it is important to improve communication for "at risk" adults who may have impaired communication. A toolkit for individuals who require interpreters within mental health and learning disability settings has been developed by the Mental Welfare Commission for Scotland and includes checklists for service providers, service users, and interpreters.
Secondary intervention
4.19 Training for health and social service staff with regard to recognising discriminatory abuse, as well as "whistle blowing" procedures, have been shown to support and empower staff within services ; see also 6.12. Training is important in reducing the likelihood of abuse, but also in recognising potential instances of abuse and preventing occurrences becoming long-term. "Whistle blowing" policies, as well as increasing staff awareness of organisations, such as the Royal College of Nursing ( RCN) and Public Concern at Work ( PCAW), reduce staff barriers to reporting abuse; see 6.12.
4.20 In cases of suspected discrimination or abuse, advocacy services should be involved at the start of any investigation to support and counsel the "at risk" adult throughout the process . Separate interpreters may be required during the investigatory process to ensure the voice of the "at risk" adult is heard. The use of advocacy services at the start of an investigation may have a positive effect resulting from the empowerment of "at risk" adults in situations of potential abuse (Clark and Squires, 2005; Williams, 2004).
4.21 In situations where discrimination has been alleged, a named social worker should be assigned to the "at risk" adult in order to monitor the process and improve interagency collaboration . The social worker should be involved throughout the process ensuring no information is lost and that the vulnerable adult's voice is heard, whilst providing emotional and professional support to the vulnerable adult.
4.22 Advice services and charitable organisations (Age Concern Scotland, Alzheimer Scotland, etc.) provide information and support to individuals who have been abused, and may provide the "at risk" adult with a feeling of gaining control over the situation . For example, outreach services to prostitutes have shown success in improving overall quality of life (for example, mental well-being, sexual health, etc.) and assisting the "at risk" individual to leave prostitution .
4.23 The 'Protecting Vulnerable Adults: Ensuring Rights and Preventing Abuse' guidelines seek to identify the needs of "at risk" adults and the respective legal position, potential assistance, and appropriate routes for assessment . Partners who have signed up to this document include East Lothian Council, Scottish Borders Council, NHS Borders, NHS Lothian, The City of Edinburgh Council, Midlothian Council, West Lothian Council, and Lothian and Borders Police. This document provides the same starting point for each of these partners, enabling the policies and procedures already available to evolve to take into account specific issues e.g. geographical issues and population demographics.
Tertiary intervention
4.24 Within Scotland, the criminal law sanctions the prosecution of an individual accused of a criminal offence; the local police authority should be contacted to investigate if a particular incident is within or outside criminal law . In both situations of single occurrence abuse and long-term abuse, immediate action can be taken by the police.
4.25 A person who is being abused, or who feels they are at risk of abuse or harm, has recourse to civil law remedies which can be used against a potential or an actual perpetrator of abuse .
"A person who has suffered harm or fears that he may be harmed can seek certain remedies in the civil courts, such as a court order declaring void a transaction which he was improperly induced to enter (reduction); a court order forbidding that abuser from acting improperly (interdict); or a court order ordering the person at fault in an action of negligence or delict to pay damages or compensation." (Age Concern Scotland, 2003: 20).
Free legal advice can be provided by various legal advice centres; for example, Adviceguide Scotland and the Citizens Advice Bureau are free, confidential, and impartial organisations.
4.26 More specifically, if discrimination against the "at risk" adult is alleged, the Disability Rights Commission may provide assistance through support or advice, using the Sex Discrimination Act 1975 and/or the Disability Discrimination Act 1995 in a civil court case. If racial abuse has been alleged against the "at risk" adult, the Disability Rights Commission may provide support and advice, with the Race Relations Act 1976 used in a civil court case.
4.27 Counselling is a therapeutic intervention with the aim of supporting a vulnerable adult who has been subjected to abuse. The Counselling Directory 11 provides a comprehensive list of counsellors within the UK, and provides confidential support, advice, and information. Counselling has been shown as effective in supporting the vulnerable adult subjected to either single occurrences of abuse, or longer term abuse; the use of self help groups and victim support and counselling for victims has been indicated as most effective in reducing the adverse impact of abuse (Wolf & Pillemer, 2000).
Conclusions
4.28 Independent organisations, as well as providers of health and social care services, need to successfully utilise their procedures and mechanisms to prevent situations of psychological abuse and discrimination. Increasing both public and professional awareness of abuse and the available protection and support for "at risk" adults will also assist in identifying examples of good practice in adult support and protection.
4.29 A multi-agency approach involving professionals from the health and social care sector, from crime reduction partners, as well as links with relevant charitable organisations involved with "at risk" adults is important in preventing occurrences of abuse.
4.30 Civil law is increasingly appropriate in the protection and support of "at risk" adults and includes various pieces of legislation specific to discrimination, such as the Human Rights Act 1998, the Sex Discrimination Act 1975, the Disability Discrimination Act 1995, and the Race Relations Act 1976. The Protection from Abuse (Scotland) Act 2001 provides options for victims of domestic abuse.
4.31 Other protective legislation within Scotland includes the Adult Support and Protection (Scotland) Act 2007, Adults with Incapacity (Scotland) Act 2000, Regulation of Care (Scotland) Act 2001, Community Care and Health (Scotland) Act 2003 and the Mental Health (Care and Treatment) (Scotland) Act 2003.
4.32 Several 'safeguarding agencies' also have a role in complementing the available legislation, including the Mental Welfare Commission, the Care Commission, the Office of the Public Guardian ( OPG) (separate bodies exist for Scotland and England; see 5.8 for further details) and the Disability Rights Commission.
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