Five themes were identified, and are presented in detail below. Three of these relate to how older adults actually manage abusive experiences: 1) self-reliant coping strategies, 2) restoring dignity in relation to others, and 3) needing formal and informal help. The remaining two themes pertain to factors influencing disclosure of abusive experiences, a prerequisite for both restoring dignity in relation to others and help-seeking: 4) inner resistance to disclosure and 5) external barriers and facilitators for disclosure (Fig. 1).
Self-reliant coping strategies
One recurrent strategy for managing the experiences of abuse was either to minimize the significance of the abusive experiences or to repress emotions and memories of it, i.e., a form of avoidance coping. Many respondents talked about putting the abusive experiences behind them and avoiding thinking about what had happened, or repressing their feelings. For some, this was an active decision, but for others it occurred more passively. One woman who had been subjected to emotional and controlling violence from a family member for most of her life said:
“So many things have happened, so my feelings are kind of numbed.” (Woman, aged 85)
For some, this seems to have been a successful strategy. However, for others it was instead a fruitless attempt to escape difficult feelings. Over time, different circumstances often triggered a reaction to or a recollection of the abuse, sometimes long after it had occurred.
Another coping strategy used by some respondents was similar to behavioral activation. By shifting the perspective and for example deciding to create a positive atmosphere for their children or to care for their grandchildren, the informant consciously decided to focus on something valued as positive instead of the abusive experience. One woman talked about financial abuse by home care personnel. Her niece wanted her to report it to the police, but she herself did not want to use her limited energy during her final years in life for such negative things:
“Perhaps my niece said to me ‘Should we get it [the police report] going…?’ and then perhaps I said that I do not have the energy… one does not really have the energy for negative things.” (Woman, aged 73)
One way to cope with the experience of abuse was by trying to understand why it had happened and attributing guilt. Some focused on the individual responsibility of the home care staff, and said that they trusted the permanent staff but not the temporary staff. Others blamed the health or social care recruitment process for letting in employees who were not suited for the job. Some older adults subjected to neglect in health care instead expressed an understanding of the abuser but blamed the system, i.e., a lack of time and resources for health and social care workers.
”They [the home care staff] have certain time [limits], 5 minutes here and there […] Yes I understand, a lot of things to do maybe, many things that puts a pressure on them” (Woman, aged 84)
Excuses for the abuser were also made by older adults suffering in other kinds of relationships, e.g., a woman suffering from abuse by her husband blamed it on alcohol.
Blaming oneself for the abuse was common, and some reflected on different ways they could change their own behaviors to avoid future victimization. For example, home care personnel had stolen jewelry from one older woman, and she blamed herself for leaving her jewelry box in plain sight. To protect herself from future victimization, she had made plans to start hiding her valuables and to start noting the names of the personnel that came to care for her.
“I had thought beforehand that I would re-arrange some of the things at home. So that… so there is no temptation [for the home care staff]. […] And now when I called [for help due to my illness], I crawled up… I have barely any jewelry left at home, but I put away the jewelry box, so as not to leave it out.” (Woman, aged 73)
Restoring dignity in relation to others
Interactions with others, e.g., professionals, friends, and family, were important for the process of restoring one’s dignity. Signs of respect from others, e.g., being listened to and believed, as well as signs of self-respect, e.g., standing up for oneself to prevent abuse, was a recurrent theme in the interviews. The need to be taken seriously, to feel respected, and to feel validated was repeatedly emphasized by the informants. One woman subjected to childhood abuse as well as intimate partner violence during many years of adult life realized that it might not be in the health care providers’ power to change her life circumstances, but she returned to the importance of being believed. When asked for her advice to health care professionals, she responded:
“Well, first of all, the very first thing, is that they believe what you say, that is the most important thing. And then, if they can do something to stop it [the abuse], they should do it. But anyway, they should listen, and they should believe what you say. And you should not get a lot of crap thrown back in your face. That is all I have to say.” (Woman, aged 72)
Likewise, the participants conveyed that it was important for formal complaints to be taken seriously. A few informants had submitted police reports about financial abuse by health care professionals. Although they could rarely explain what had happened with their report or in some cases knew that the report had been dropped, it was important for them that it had been taken seriously by the police officer or the manager responsible for the accused health care professional. When abuse had occurred in health or social care, one expression for the desire to be taken seriously was a wish that the health care system should learn and take active measures so that abuse did not occur again. Some suggested that their stories should be brought up at internal staff training sessions, so that staff could learn from what had happened to them and prevent similar abusive events in the future. For some, it seemed to be a comforting thought that their negative experiences could help to prevent others being abused.
”What I think is that the health care system should know about it […] When physicians have some sort of meeting and have lectures and so on, one could bring this up [my abusive experience] as an example” (Woman, aged 88)
Another side of being restored in relation to others was standing up for oneself. Informants described how they had taken a stand and expressed that the abusers had no right to treat them in an abusive way. One woman talked about a man who used to live in the same nursing home as her, and who was rolling around in his wheelchair, yelling and threatening residents and staff:
“I gave him an earful and then… and then he was swept away from here.” (Woman, aged 81)
Several informants found it more difficult to stand up for themselves and their rights when there was a dependence embedded in the relationship, e.g., in contact with health care professionals. Also, examples of standing up for oneself were mostly described by those respondents who had been abused for the first time as older adults and less so by polyvictims. By contrast, a few older adults described abusive experiences throughout life but that they had started to stand up for themselves at an older age, either by speaking up against the abuse or by threatening a police report.
Needing help from formal and informal sources of support
Most informants expressed a need for some degree of help or support from formal or informal sources of support. Some only expressed a vague feeling of needing help but did not know what kind of help or where to get it, while others articulated emotional, practical, or health-related needs for help to manage the abusive experiences or prevent future victimization.
Some preferred emotional support given by informal helpers, e.g., friends and family, while others preferred formal helpers, e.g., health care professionals. Sometimes an informal helper acted as a bridge to obtaining formal help. Mixed feelings were often expressed about the experience of talking about abuse. It was found to be sensitive and difficult in the moment but generally positive in the long run. Some had experiences of talking to therapists who had given them practical assignments as parts of the therapy, e.g., painting or writing, which had been helpful. However, the most commonly expressed need was simply someone to talk to. One woman still living with an abusive intimate partner said:
“I also have to get it off my chest sometime, otherwise I will break.” (Woman, aged 71)
Practical support sought after could be financial aid, a new place to live, or a general realization of needing others when deciding to leave an abusive intimate partner relationship. For some, the need was related to physical dependence due to an aging body, e.g., not being able to live alone in an apartment or to care for a pet alone due to physical illness. For older adults with high level of dependence, it was suggested that a proxy would be valuable; someone who could help to speak up for the older adult’s rights, especially in relation to health and social care. A combination of different forms of help was often needed. Some expressed a desire for medical help to treat their traumatic experiences, e.g., counseling or medical help for sleep disturbances. In some cases, the informant stated that it was really the abuser who needed the help, including medical help, e.g., for alcohol dependence. However, it was acknowledged that this might be difficult, as such help would be dependent on the abuser’s willingness to accept help. One woman living with an abusive husband talked about the alcohol being a reoccurring problem in their relationship and a reason for the violence. However, her husband was not willing to seek help for it:
“I talked with him about the wine. I said, you absolutely can not drink any wine. I have asked him the same thing before, but no, he falls back into it you know. I think it will be the same thing again. His father was an alcoholic […] And then they [staff at the psychiatric clinic where she had sought help] said that it is not you who should come, it is your husband. I could not get him to go [seek help]. He does not want anything do with such things. No, he does not” (Woman, aged 71)
Another form of help needed was someone who could prevent the abuse in the situation, e.g., bystanders who would react and intervene. One man had been subjected to neglect as well as psychological and physical abuse by health care professionals while hospitalized. On one instance, two nurses had been in the room and one of them had struck him on his head with a pillow.
“The [other] nurse who was present at night, when it happened, she said: ‘That’s enough now.’ […] She could have done more. She could have reported it to the manager on the ward.” (Man, aged 76)
In some cases, professionals had intervened to end the abuse. One older woman had told her general practitioner about sexual harassment she had endured from a physician at a different clinic. The general practitioner had immediately taken charge of the situation, making sure that the abuse had ended, and that the abuser was reported.
For some informants, ageist attitudes among care professionals were part of the abusive experiences. In such cases, it was sometimes suggested that professionals need to be better at considering older adults not as a homogeneous group but rather as individuals with different experiences and needs, which might be a preventive effort:
”…than maybe that person [the home care staff] is a bit patronizing and do not consider that one has been a professional… and only [see] an older person, that is the common thing. […] …within home care, it is usually so, that they tar everyone with the same brush, one is an old-timer. […] [Interviewer: What could be done to…?] Educating the staff of course. To understand that the older person has a background in whatever it is. And that, for example, the home care staff know of that [background] […], perhaps educating [the staff] to understand the individual.” (Woman, aged 84)
Internal resistance toward disclosing
Even though many informants had a strong need to talk about their abusive experiences and seek help, it was evident from the interviews that many struggled with an inner resistance against doing so. They expressed strong feelings of shame or that they considered their experiences to be too private to share with others. For those living with abusive partners, fear of reprisals was also articulated:
“Also I am afraid. Because he said, well if you talk to others – then hell! He yelled at me. So no, I do not dare. I am afraid something will happen to me.” (Woman, aged 71)
The informants also underlined that the decision to disclose experiences of abuse cannot be forced; the older adult must be ready to talk about the abuse, and should not be pressured into doing so. Likewise, it is important that professionals respect the victim’s wishes, e.g., a decision not to pursue a police report. Even though the informants expressed positive attitudes toward health care professionals who showed an interest in this issue and asked questions about abuse, several informants said that they were not sure they would disclose even if they had been asked questions. One woman who had a history of intimate partner violence as well as childhood abuse and elder abuse in health care talked about being asked questions in health care:
“Yes, I would have liked it [to be asked questions about abuse]. But the question remains whether I would have been brave enough to tell. But I would have liked to be asked the question, because then… I would feel more validated then: ‘Someone suspects that something is very wrong here.’” (Woman, aged 67)
Factors related to aging were also relevant for the informants. Some expressed resignation about their situation. They had lived with their abuse for so long that they seemed to have given up on getting out of it. This feeling of resignation could relate to both leaving an abusive relationship and seeking help to manage the abuse. For some, physical dependence on others kept them from seeking help. One woman explained that if she were to seek help, her abusive husband would have to be alongside her wheelchair and see where she went. This made it feel impossible for her to make contact with formal caregivers. Even when respondents were not as explicitly dependent on the abuser, physical illness kept them from seeking help. Several expressed that they did not have the energy to make life changes due to their illness. One woman explained that leaving her abusive partner would probably entail moving to a nursing home as well as having to get rid of two beloved dogs:
“Well, it’s the dogs of course, I have two… and I would like to bring them with me […] But he thinks that I cannot handle it. I cannot manage to have my own apartment or anything – so that is, that is difficult […]. I have thought about doing something about it […] But I do not have the energy now you know, no it will have to remain as it is […] So it is really I who should react, but I do not have the energy now, due to my heart [condition].” (Woman, aged 71)
Consideration for others also created resistance to disclosure and complicated the help-seeking process. Sometimes it was an ambivalent relationship with the abuser that led to resistance, but more often informants articulated strong concerns about how disclosure would affect other people they cared for, e.g., family members. One woman feared that talking about the abuse her brother-in-law had put her through would hurt her sister deeply, so she kept it a secret. Likewise, she did not want her children to know about the abuse her husband, their father, had put her through.
“But because they really cared for their father and because he has never done anything to them… One cannot take that from them. I can’t do that. If you consider that I have so many illnesses now, so I don’t have much time left […] Perhaps it is only a short time and then I get to rest. So, the children should have their perception of the situation, at least they have never been harmed [by this].” (Woman, aged 66)
Although several informants described the importance of friendships in which they could find comfort, some instead emphasized that you should not burden your friends with all your misery. Some also took a similar stand in relation to health care providers:
“Anyway, [she is] a really good physician […] But I don’t want to burden her with this.” (Man, aged 88)
External facilitators or barriers for disclosure
When deciding whether to disclose abusive experiences to health care professionals, previous experiences and expectations regarding the health care system were important. Low expectations and trust in support systems were recurrently expressed. Some informants expected – sometimes due to previous experiences – that they would not be believed by health care professionals, that the person they told would say that they only had themselves to blame, or that they would not receive adequate help. Low faith in the patient–health care provider confidentiality was also expressed by some as the reason they did not seek professional help, e.g., in the words of one woman who had a history of childhood abuse and was currently living with an abusive intimate partner:
”I don’t have confidence in them [staff at the primary health care centre]. [Name of town] is a small community with a lot of mouths. [Patient-provider] confidentiality don’t really apply there, as it should. So, I would never ever go [to the primary health care centre for help]” (Woman, aged 66)
However, health care professionals who had shown interest and commitment were repeatedly recognized for their importance. The significance of trust built over time and a good relationship with a health care provider before disclosing abuse was articulated in several interviews. One man subjected to childhood abuse, as well as elder abuse by a sister and a health care professional had started to share his story with a counselor at the clinic where he was currently treated:
“I have an illness and have been admitted several times and have regular check-ups too, once a week…. [With time] I have gained trust in some [of the staff].” (Man, aged 67)
Health care professionals asking questions about abuse was generally appreciated by the informants. When the older adult felt that a health care professional was really interested in their history, this facilitated disclosure. Although an existing trusting relationship was repeatedly recognized as important, some informants described that they had decided to share their story without prior knowledge of the health care provider. The need for a prior alliance seemed to be related to the degree of urgency for sharing their experiences. When asked about the idea of using a written screening form to identify patients with abusive experiences in health care (like the one used in this study), several informants reported that they thought that was a good idea and that such a procedure could potentially facilitate disclosing experiences of abuse, e.g., one woman who had a history of intimate partner violence as well as childhood abuse and had been subjected to elder abuse in health care said:
“It would have made it somewhat easier [with a questionnaire], to tell someone about what had happened. Sometimes it is easier to fill out a questionnaire…” (Woman, aged 67)
Some informants had been dependent on the watchfulness of others for their help-seeking, e.g., someone in the older adult’s vicinity had noticed their predicament and helped them to seek help. Also, help-seeking was sometimes triggered by life circumstances, e.g., the death of a parent or watching a television program about abuse.
“… No I think, during my career, I swept it away. Then they [the bad memories] start to resurface when you have more time to think about it, when something happens. Then you realize that it is like unresolved traumas, really.” (Woman, aged 69)
Societal changes also had an impact on the help-seeking process. The international “#MeToo” social movement that challenged the silence surrounding sexual abuse was a recurrent theme during the interviews. Several informants had started thinking and talking about their experiences because of the movement’s influence on the public debate.
The complexity of factors influencing how abusive experiences are managed
The different themes identified in this study were connected to and affected each other. The complexity of managing abusive experiences can be illustrated by one participant’s comprehensive story: Her stepfather had sexually, physically, and emotionally abused her during childhood, and she still suffered extensively as a result. For a long time, she had used avoidant coping, trying not to think about the abuse, and had told no one. Still, the memories and feelings had always been there in the background, affecting her well-being. During the fall of 2017, when #MeToo strongly influenced the public debate in Sweden, everything resurfaced for her, and she started feeling depressed. She was in regular contact with a nurse she trusted at the primary health care center due to a chronic illness. The nurse noticed that something was wrong, and because the nurse showed commitment and interest, the old woman decided to disclose her experiences and her suffering. The nurse then helped her to get a doctor’s appointment and the woman was diagnosed with post-traumatic stress disorder. At the time of the interview, she was waiting to start treatment sessions with a therapist. However, the help-seeking had been delayed by aging and illness, as the psychotherapy had to be postponed due to the same physical illness that had also led to her current hospitalization.