Empowering and rights-based approaches to working with older people (Dr. Barbara Black)
This chapter will examine critical social work with older people, specifically as it relates to the area of the abuse and mistreatment of older people. Several critical theories will be discussed, including feminism, structural social work, and human rights based advocacy and empowerment. Critical theory aims for some manner of positive outcome for the individuals or groups identified. Thus, it is a useful perspective within which to consider ways of responding to elder abuse, both at the micro and macro level. In exploring critical social work with older people, the diversity of the older population will be highlighted and the social context discussed. An elder abuse case study will be explored; highlighting the effectiveness of rights focused advocacy and empowerment interventions.
The role of critical theory
Critical theory has its foundations in social critique tied to consciousness-raising and the possibility of positive and liberating social change (Lincoln & Guba 2000). It is useful in promoting a broad understanding of the ways in which current policies and procedures may impact on older people. It may also be used to take a wider focus and look at the effects of societal factors, such as ageism, contemporary views and responses relating to aged care services, human rights, and the forces of global capitalism. Critical theory leads to consideration of dimensions of inequality and appropriate social theory with which to critique and understand the abuse and mistreatment of older people.
In the twentieth century, gerontology emerged as a distinct perspective that sought to bring together a variety of theories and methods from several different disciplines and professions to address the 'problem' of old age (Achenbaum 1997). The critical theories which developed in relation to older people have been termed 'critical gerontology'. This stream of critical theory is seen as having a role in critically examining the social and cultural production of ageing and gerontological knowledge, while paying consideration to factors such as class, generational, gender and racial/ethnic divisions as well as ideological forces embedded in their production and reproduction (Estes 1991, in Achenbaum 1997: 22). Several strands of critical gerontology exist, reflecting the diversity of the older population and the multifaceted nature of gerontologic inquiry and these theoretical perspectives facilitate ‘...the weaving together of disparate intellectual ideas into a powerful critique of prevailing gerontological ideas.' (Achenbaum 1997: 23)
Elder abuse has become an issue of growing prominence due to increasing societal awareness of interpersonal violence and abuse of the human rights of vulnerable or minority populations, linked with issues raised by the ageing of the population. There are varying definitions of elder abuse. Some define it as any act which causes harm to an older person and occurs within an informal relationship of trust, such as that of family or friends (APEA:WA 2006), while others include abuse by institutions and paid carers in this definition (McDonald & Collins 2000; UNESCO 2002; Sadler 2006). Abuse may be carried out by an individual, a number of people, or an organisation. For example, the entire workforce of an organisation may be guilty of abusing all clients due to attitudes and practices which fail to recognise basic human rights, such as the right to privacy, make choices, and be considered and treated as an individual (Sorensen & Black 2001).
International elder abuse prevalence studies estimate that between four and six percent of the older population have experienced some form of abuse, when all types of abuse are considered (Sadler 2006). However, the prevalence of elder abuse is difficult to establish given that taboos about this issue are likely to result in under-reporting. Forms of elder abuse include financial or material abuse, emotional or psychological abuse, physical abuse, sexual abuse, social abuse, and neglect (APEA:WA 2006). Financial and psychological abuse are the most reported types of abuse in some studies (Boldy et al. 2002; Faye & Sellick 2003), while others report psychological and physical abuse as the most common (Sadler 2006).
A critical theory perspective may assist in providing structural and historical insights into the nature of the issues being examined in relation to elder abuse, paving the way for suggestions and recommendations for positive change. Several critical theory perspectives may be adopted for this purpose, including feminism, structural social work, and human rights. Advocacy and empowerment may also be used, and these perspectives will be explored later in the chapter.
It is important to consider the influence of gender in regards to the older population, as women tend to live longer than men there is a larger proportion of women over the age of 65. Work in the welfare sector in general and in aged care in particular is a highly feminised industry: the majority of welfare workers are women and it is mostly daughters or female relatives who are the ‘next-of-kin’ or the point of contact for aged care services. Thus, this area may lend itself to examination under a feminist perspective. There are many different strands of feminism, including liberal, Marxist, radical and cultural feminism (Porter 1998). It is thought that ageing may marginalize the experiences of women through interconnected oppression in terms of gender and ageing (Powell 2006). Adopting a feminist perspective may allow examination of whether a patriarchal discourse acts to dampen human rights claims for older people as well as increase the effects of ageism, and if the situation would be different if there were more men involved.
Structural social work
Social institutions, or structures, are an inherent, built-in part of our society (Mullaly 2007). Structural social work looks at the structures of society as a focus for change, and not solely the individual. Traditional critical social theory emphasises social structures as the major source of social problems (Mullaly 2007). Because these structures are generally established and operated by a particular social group, such as white middle class males, etc., they may reflect and reinforce the assumptions, views, ideals, culture and interests of this group (Mullaly 2007). Social structures may be imbued with sexism, racism, and ageism etc., in that there is a dominant group within each that has more social, political and economic power than the subordinate groups. The domination of powerful over the powerless has often been so internalised into the structures of society that it has become an intrinsic part of the workings of these social institutions (Mullaly 2007). Consider, for example, the poorly funded and highly regulated environment of residential aged care and the impact this institutional context has on the rights of its residents. Awareness of the oppressive nature and functions of social structures is an essential element of structural social work theory and practice.
The human rights discourse has gained prominence and widespread recognition over the last half century. Human rights have been defined in various ways. A simple way to describe them is as universal rights that belong to all people, regardless of national origin, race, culture, age, gender, or anything else (Ife 2001). The idea of human rights has a broad visceral appeal to our sense of fairness and equality. It is a powerful discourse which seeks to overcome divisiveness and sectarianism and unite people from all walks of life into a single movement asserting human values and the universality of humanity (Ife 2001).
Human rights have been defined and understood in different ways throughout history, shifting and changing in response to changes in society and different social movements. Over time, perceptions of human rights have changed to encompass an ever expanding demographic. However, there are still individuals and groups of people at the margins whose rights are not fully protected or realised. The utility of focusing on rights rather than care and service provision is that a rights focus is more inclusive, as it views older people as part of humanity, and therefore entitled to the same rights as everybody else. It may also serve to highlight the fact that older people are often discriminated against, 'infantilised', and treated as if they do not know what is in their own best interests.
Key to understanding the phenomenon of abuse and mistreatment of older people is an examination of social context. The next section explores ageing issues in Australia, including the ageing of the population and age discrimination, known as ageism.
Older people in Australia
In common with most Western countries, Australia’s population is ageing. This has largely come about as a consequence of increasing longevity and declining birthrates (Office of Seniors Interests 1997). Over the last century, male life expectancy at birth has increased from 55 to 79 years, while female life expectancy has increased from 59 to 83 years (ABS 2008). The current generation of older people is the largest that Australia has ever experienced, and as such has considerable political influence (Legge & Cant 1995).
Disability and illness are not necessarily associated with the ageing process; however, the risk of developing a debilitating illness or disease does increase with age (Sax 1993). As a consequence, use of health and aged care services generally also increases with age (AIHW 2007). As people get older they are more likely to be affected by chronic illness, such as rheumatism or arthritis, as well as physical deterioration. The most frequent effects of this are impaired mobility and difficulty with self-care. Communication difficulties may develop in relation to deterioration in sight and hearing. Impaired mental functioning may also be an issue, with conditions such as dementia affecting older people. Small changes in physical capability can have major social effects and often tip the balance between relative independence and dependence for individuals. Injuries caused by falls can have drastic consequences, including the loss of the ability to live independently and a loss of confidence (Bishop 1999).While there is a large increase at older ages of people requiring assistance with activities of daily living, it is interesting to note that the majority of these people continue to live in the community rather than in residential aged care (AIHW 2003).
Dementia is a term used to describe the symptoms of a range of illnesses that cause a progressive decline in a person’s mental functioning. Impairment may be caused in multiple higher cortical functions, including memory, intellect, rationality, social skills and normal emotional reactions (Alzheimer's Association 2005). Dementia is not a normal part of ageing, but a pathological condition, and there are a number of different forms of dementia, each with their own causes. The most common is Alzheimer’s disease. Of particular concern associated with the ageing of the population is the increase in the number and proportion of the older population with dementia as well as the associated need for care in the home and in residential care facilities (AIHW 2003).
Aged care services
A range of aged care services are available to provide support and assistance to older people. A large proportion of these services are community based, such as meals on wheels, home nursing, and domestic assistance, and are provided in the older person's home. Otherwise, if unable to be supported to live at home, older people may move into residential aged care. The issues mentioned earlier, including increasing rates of disability and dementia that occur with age, make older people receiving aged care services quite dependent on other people for assistance. This renders them vulnerable to rights abuses and often less able to support and maintain their own rights and best interests. People who live in residential aged care are potentially disadvantaged by many factors, including disability, mental incapacity, and living in a somewhat restricted, regimented institutional environment where their lives are largely regulated by the staff and management of their facilities. It is also important to understand that while some people move into aged care facilities as the result of choice and planning, many people move into facilities quite suddenly, as a result of a fall or accident. This relocation can be a stressful experience accompanied by multiple losses, including the loss of independence, home, possessions, family relationships, and pets (Nay 1993).
As sites for change and action in relation to elder abuse, consider institutions such as aged care facilities and hospitals. The very nature of institutional care serves to multiply the impediments to residents exercising their rights. This may also be exacerbated by the fact that residents may have lost the capacity or will to exercise their rights as a consequence of illness, disability or adaptation to the strictures of the institutional environment. Although there are many complaint, monitoring and accountability measures available, there are several obstacles to their effectiveness. One difficulty is the vulnerability of many older people. Often the people most in need of having their rights protected are those who have little way of accessing complaint mechanisms and communicating their needs due to physical limitations, communication difficulties, or a lack of knowledge of their rights, entitlements, and the complaint mechanisms available (Black 2004). There are also the social barriers of feeling too intimidated to complain, not wanting to be seen as a ‘whinger’, not wanting to damage their relationship with staff and management, and feeling grateful for the care they do receive (Black 2004).
Institutions are protective and often paternalistic by nature, and this may place restrictions on people's rights where there is a conflict with the institution's duty of care. Older people's rights are also often of lower priority to other concerns, and rights issues may give way under strictures such as limited funding. For example, residents may not be able to have showers whenever they wish because there is not enough money to employ enough staff for this purpose. For these reasons, it is imperative that there are strong monitoring, accountability, and complaint mechanisms in place in order to support people's rights with these structures (Black 2004).
Ageing and Ageism
When working with older people, it is important to have an awareness of the impact of different societal views of older people. This feeds into an awareness of critical theory frameworks highlighting the links between experiences, material conditions and the dominant ideologies in society (Pease et al. 2003). Having an awareness of these ideologies and educating people about them allows us as social workers to challenge those affected by oppression to take appropriate action to transform their situation.
There are varying views and stereotypes of older people in our society. These range from comforting images of the 'rocking-chair granny', to views of older people as frail and vulnerable. Older people are often stereotyped as being incapacitated by illness and disability, 'clogging up' the health system and dependent on others for care. Ageing is commonly associated with stereotypes of deterioration, disability, dementia and death, with the effect of stigmatising older people (Legge & Cant 1995). Such negative stereotypes and denigration may translate into lack of societal concern for older people, and place them at greater risk of marginalisation and denial of equality in accessing opportunities, resources and entitlements (UNESCO 2002). This is known as 'ageism' and in the context of this chapter references to the concept of ageism refer to age discrimination against older people. The term ‘ageism’ was first used to describe the process of ‘systematic stereotyping and discrimination against people because they are old’ (Butler 1975, in Sax 1993: 2). However, more recently ageism has also been used to refer to any form of discrimination or stereotyping on the basis of age, whether the person is old or young (Sax 1993).
Ageism has served to legitimate the use of chronological age to systematically deny resources and opportunities to people based on age, and older people may suffer variations of this ranging from well-meaning patronage to unambiguous discrimination (Blytheway 1994). Many positive stereotypes of older people also exist. These images include that of the caring grandparent as well as the sage of all wisdom and experience. However, these images are relatively weak in comparison with existing negative stereotypes. Society's preoccupation with youth and beauty, combined with the dominant stereotypes which imply that ageing equals debility, have largely eroded the images of wisdom, power, benevolence and respect which were once associated with elders.
Ageism has had many negative consequences for older people in our society. It has generated and reinforced fear and denigration of the ageing process, and given rise to negative stereotypes and presumptions regarding the competence of older people and their need for protection (Blytheway 1994). These negative stereotypes may influence attitudes and decisions concerning older people. They may also influence older people's images of their own self-worth (Westhorp & Sebastian 1997). In this sense, ageism is comparable with sexism and racism, as all of these ideologies depend on prejudice, which justifies forms of inequality (Blytheway 1994). Where ageism differs is that the whole of society has an interest in it as it is something which will eventually affect us all, should we live long enough, unlike issues of race or gender.
The notion that the vast majority of older people are a burden on the community and are being ‘looked after’ has been challenged by much research data. Older people today are more visible, active and independent than ever before. The overwhelming majority of older people live in private accommodation—only six per cent live in non-private dwellings, which include aged care homes and hospitals (AIHW 2007). Even among those aged 85 years and over, 74 per cent live in private dwellings. Almost a quarter of men aged 65–69 years participate in the workforce, along with thirteen per cent of women in the same age group. Also, despite having relatively low average levels of income, research data shows that 24 per cent of all older Australians provide direct or indirect financial support for adult children or other relatives living outside the household (AIHW 2007).
Ageism, when combined with dimensions of disadvantage, such as poverty, disability, and cultural and linguistic diversity, may place some older people at risk of marginalisation and denial of equality in accessing opportunities, resources and entitlements. It may also contribute to some forms of elder abuse. As ageist attitudes become entrenched in our culture, older people may internalise them and believe that they deserve to be treated in a lesser manner than others.
Diversity in the older population
It has been proposed that the strongest stereotype in relation to older people is that they are all the same (Victor 1991, in Vincent 1999: 142). A key aspect in countering ageism lies in establishing the diversity of old age and the different ways of living (Vincent 1999). It is important to note that older people are not a homogenous group. They are a diverse population with significant variation in factors such as age, income, health, living arrangements and past experiences (Sax 1993). As is the case with most Western countries, current populations of older people in Australia are healthier, better educated, and more likely to be financially independent than ever before (Sax 1993). However, some sections of the older population are disadvantaged in comparison with the general population due to factors such as cultural and linguistic background, disability, mental health issues (including dementia), sexuality, and economic factors.
One area of difference which needs to be considered is that of economic diversity, or differences in class. Major changes occur in the sources and levels of income as people get older, and declining participation in the workforce contributes significantly to these changes (McLennan 1999). The aged pension is the main form of income support for older people, with nearly 80 per cent of the older population in receipt of it or the equivalent service pension (ABS 2008). The living standards of older people are also supported through continued participation in the workforce and retirement benefits provided by superannuation (AIHW 2002). Although average incomes of older people are relatively low, average wealth is relatively high (AIHW 2007), with older people likely to have accumulated assets during their working lives. However, it must be acknowledged that there are great differences in assets and income across the older population, with those older people who have managed to accumulate assets enjoying a comfortable retirement, while others with little or none struggle on income support pensions. Also, as women are more likely to marry men older than themselves and have a longer life expectancy than men, the gender disparity in the older population has resulted in older women being more likely to live alone and be on limited incomes (Finch & Groves 1985; Gibson 1998).
The older population is quite culturally diverse as a consequence of Australian immigration policy. Around 35 per cent were born overseas, with 39 per cent of these coming from English-speaking countries, and 61 per cent from non-English-speaking countries (AIHW 2007). However, Indigenous Australians aged 65 years and over comprise only 0.5 per cent of the older population, a much smaller proportion than their representation among the population generally, at 2.5 per cent (AIHW 2007). This is the result of Aboriginal people having a life expectancy approximately seventeen years lower than that of the total population (AIHW 2007).
Literature and statistics in relation to gay and lesbian older people are sparse, as much of the research focuses on younger people, and much of the research on older people fails to acknowledge sexuality, either hetero or homo (Thorson 2000). Gay and lesbian older people are often regarded as a sub-culture, and subject to prejudice and discrimination (Thorson 2000). Fullmer (1995, in Powell 2006: 59) notes that 'older gays and lesbians have learned through a lifetime of experience that they will likely be discriminated against if it is known that they are homosexual'. Older gay men and lesbians have few, if any, positive role models for forming relationships, ageing, or creating alternative family structures (Powell 2006). Social structures and institutions may discriminate against homosexual older people, for example, age care services may structure activities and policy around the assumption that their clients are heterosexual.
Elder abuse crosses national, class, and cultural boundaries. Both men and women are abused, and older people who are physically and mentally fit are subject to abuse as well as the frail and dependent (Valsler 1996). People from what are perceived as disadvantaged or vulnerable groups are over-represented in elder abuse statistics. Research has found that people with some form of decision-making disability (such as dementia) are more likely to be subject to abuse (Boldy et al. 2002). Females are also more likely to experience elder abuse than males, although a substantial proportion of men are also abused (Boldy et al. 2002; Faye & Sellick 2003; Sadler 2006). The older aged (people aged 75 years or older) have also been found to be more likely to experience abuse (Boldy et al. 2002). In the case of residential aged care, studies have shown that abuse is more likely to occur in institutions where the approach by staff has become depersonalised and dehumanised to the extent that the older person is viewed as an object rather than a human being (Valsler 1996).
Rights-focussed advocacy and empowerment
Elder abuse responses have been linked to human rights through the use of a rights-based advocacy approach to intervention. Current Australian interventions into elder abuse tend to follow an advocacy model with strong foundations in empowerment and human rights (Black 2008). The rights-based advocacy model involves providing information and support to an older person in order to empower them to address their situation of abuse (Faye & Sellick 2003). The advocacy model works with the individual and their concerns, while seeking to redress macro level disadvantage; for example, disadvantage in relation to age or frailty, which may have contributed to the abuse (Cripps 2001). The focus is on empowering and supporting the older person to assert themselves in order to redress the abuse being experienced and to uphold their own rights and best interests, where possible.
Recognition of the need for advocacy has grown out of the human rights push for equality in Western societies and an acknowledgement that all people are not equal and some groups are at more risk of having their rights abused than others (Sorensen & Black 2001). Sometimes legislative protection is inadequate, as wrongs may be hidden because the vulnerable person may not have the means to complain (Rayner 1993, in Parsons 1994: ix). People who are marginalised, excluded or unable to participate in mainstream society are very dependent on the people who care for them, be they family, friends or care workers, to care for them appropriately and support their best interests. This dependent relationship unfortunately holds the potential for abuse and exploitation, given the unequal distribution of power between the parties (Black 2004). Advocates work to empower people, assisting them to self advocate where possible and advocating on their behalf if necessary. An advocate may provide information and advice in order to assist a person to take action to resolve their own concerns or make take a more active role in representing the person's rights to another person or organisation which has the power to make life affecting decisions for the individual. It must be remembered that advocacy is far from easy and unproblematic. It may involve being immersed in situations that are very distressing for the people involved, and a range of conflicts and dilemmas can arise. Advocates bring their own sets of values and beliefs to the situation, and these may conflict with those of the person they are advocating for. It is important to remember that the advocate’s role is to help people get justice, not to judge them, try to change their values or influence their wishes.
The following case study has been included to illustrate the way in which rights-based advocacy and empowerment may be used in situations of elder abuse.
Mr Jeffries is a 73 year old man who has recently moved into residential aged care. His friends contact a social worker to report concerns that he has been forced into residential care against his will and that his daughter, Sarah, is selling off his house against his wishes. The friends report that the aged care facility is not allowing them to visit Mr Jeffries, under instructions from his daughter, who has told the facility that they are undesirable characters who frequently borrow money from Mr Jeffries without paying it back.
There are many advocacy agencies in Australia that work to advance and maintain the rights of vulnerable groups, such as older people, people with disabilities, women, children, and people from culturally and linguistically diverse and Indigenous backgrounds. Advocacy agencies are involved in conducting community education as well as providing individual and systemic advocacy. This is undertaken with a view towards promoting positive attitudes towards older people and raising awareness of their rights and the potential for abuse that exists. Community education targets the level of social structures and is a proactive form of systemic advocacy which empowers older people by reinforcing the fact that they have rights and there is assistance available to support their rights, should they require it.
It has been proposed that critical theory has been important for social workers in providing a link between theory and practice in its insistence that theory be grounded in practice and vise versa (Ife 1999). This chapter has explored a number of theoretical perspectives which may be applied to the area of abuse and mistreatment of older people. Utilising a critical social work approach in elder abuse work permits us to focus on both macro and micro issues. Critical social work allows analysis of the relations of power within the social context as well as the individual situation, serving to highlight them and indicate sites for action.
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