TITLE: A review of literature on effective interventions that prevent and respond to harm against adults, 2007
AUTHORS: Halina Kalaga, Paul Kingston, JoyAnn Andrews (University of Staffordshire) with Bridget Penhale (University of Sheffield)
The Adult Support and Protection (Scotland) Act 2007 and a range of recent initiatives, such as the ministerial review of No Secrets and the introduction of the Safeguarding Vulnerable Groups Act 2006 show that much is happening in the area of adult safeguarding. But there is little evidence of “what works” when abuse or neglect is suspected or revealed. This review of the literature sets out what is known about support and protection measures.
The aim of the review was to document the use of various interventions, ranging from legal to welfare responses. It sought to identify empirical evidence of what works, but sadly it found that the effectiveness of interventions is rarely addressed. We know little about what works and for whom, the extent to which safeguards transfer appropriately from one setting to another or from one situation to another. This review aimed to critically analyse the interventions currently in use to protect adults at risk of harm and abuse. It had little to go on.
Methods used to locate interventions were investigations of case studies, anecdotal reports, research studies and policy documents. This range of information sources covers the UK and draws on experiences from other English-speaking countries.
The review structures interventions on three stages: primary intervention, aiming to prevent abuse, secondary intervention, aiming to identify and respond directly to the allegations of abuse, and thirdly, tertiary intervention, aiming to remedy negative consequences of the abuse, including preventing further abuse or harm. These three stages are used in discussion of different types of abuse that form the basis of each chapter. These are discriminatory and psychological abuse, financial or material abuse, institutional abuse and neglect, sexual abuse, and physical abuse and domestic abuse. The review further divides interventions into two categories: legal interventions and therapeutic interventions.
The evidence base for legal interventions and for therapeutic interventions is described as “sparse”.
At primary intervention levels, there is an array of legislation that prohibits discrimination, prevents crime and disorder, and provides safeguards for people who are at particular risk, such as those who have mental health problems. A variety of public bodies, such as regulators and inspectors, play roles in adult safeguarding. These are underpinned by advice, advocacy and information resources at therapeutic levels and these may respond to risks of psychological and other forms of abuse and neglect. There is some evidence of what works at population levels from these approaches, suggesting the value of partnership-working and of not concentrating on the vulnerability of certain adults but seeing their risks in the contexts of crime reduction and public safety.
Financial abuse interventions generally centre on the existence of measures to protect the interests of adults who have limited capacity to act on their own behalf or who require protection from exploitation. Public awareness of these risks is said to be helpful in ameliorating them and there seems to be greater knowledge of the risks of financial abuse than other areas.
Prevention at primary levels of institutional abuse and neglect is a key purpose of regulation and inspection. This is a legal intervention. Similarly, education is depicted as a major primary prevention method. Legal and regulatory frameworks of enforcement promote this more therapeutic intervention but the two are linked. The prevention of sexual abuse at primary level includes developments of public health sexual abuse prevention strategies that are inclusive of vulnerable adults, though little evidence seems to have been found about sex education programmes and their role in prevention of abuse. In respect of primary interventions in physical abuse and domestic violence, both education and public awareness are depicted as helpful and have received some positive evaluations.
At secondary levels of intervention, there are specific training and systems for investigation, and further advice, information and support are available for alleged victims. Much of the work of local adult safeguarding networks might be included under this heading. In relation to financial abuse, professional involvement in managing clients’ money is a legal approach that is used to provide greater safeguards.
A similar set of responses arises in respect of institutional abuse and neglect. Secondary prevention here is characterised by numerous policies, codes of practice and procedural documents and practices. Likewise, responses to allegations of sexual abuse at secondary level are discussed in relation to good practice in recording incidents and risk assessments, making people safe, and in providing support to reduce distress. Similar work appears effective in responding to physical abuse, including greater engagement with healthcare professionals. It is suggested that forms of screening might be effective in identifying cases of physical abuse in healthcare settings, such as hospitals. There is little knowledge about the interface of domestic violence and adult safeguarding systems and services, although this area is under development by the voluntary and community sector. The review contains some examples of this activity.
At tertiary levels, there are legal remedies but also therapeutic responses for alleged victims such as counselling and self help or support groups. In instances of financial abuse, victims can be prevented from being exploited by legal interventions and official bodies can be called upon to resolve disputes. In institutional settings, tertiary prevention is linked to recruitment practices, and the broadening legal requirements placed upon many employers to prevent “risky” staff from working with vulnerable groups. At this level responses to sexual abuse concern legal safeguards to ensure the person’s safety and to prevent any further harm or repetition of the event. Here, there is some evidence of what can be done to work with abusers, some of whom are likely to be vulnerable adults themselves.
However, examples of tertiary prevention are few and far between. This does not mean that it does not happen but that there is little literature on how professionals seek to moderate the harm of abuse or neglect. We do not know how people are kept safe, but clearly the legal framework is used here to separate people from known abusers, and some services are likely to build up people’s confidence and trust. The language of self-efficacy and recovery is not really found in the literature. Support groups and helplines are reported but only rarely.
This report sets out the limits of knowledge and evidence in this field at a timely moment. The review of No Secrets is focusing interest in adult safeguarding at the same time as there is increasing interest in proportionality, that is, not responding to risk as uniformly dangerous or unwelcome. There is much confusion in responses, not just what works, but who is responsible for what. The classification system used in this report is helpful, although it reveals a great deal of overlap between what is depicted as legal and what is therapeutic. It is interesting to see that there has been greater concentration in the UK on legal safeguards. Whether this is right is hard to judge as we have such limited evidence of what might be termed therapeutic responses.
The second emerging point is that while it is traditional to separate out different forms of abuse or neglect, there are numerous interconnections. We know little about whether legal safeguards that address matters of money enable people to feel safer in other areas of their lives. We know little about whether investigation processes end with therapeutic responses or fizzle out or about the types of help that might be termed tertiary and what can minimise distress and long-term damage.
It is common for researchers to end with calls for more research. This report is no exception. However, it is clear that there is actually little evidence about interventions and that is unusual in an area of public and political concern. The report identifies many areas of activity and these need to be evaluated, notably to find about what does not work as much as what does. There is much going on in the area of support and prevention and an array of regulation and legal measures now exists. There are opportunities to compare activity in Scotland and in England and Wales. Finally, there seems to be no evidence about the costs and benefits of activities. Both legal and therapeutic interventions have costs but we are far from determining what these are.
Jill Manthorpe is professor of social work at King’s College London and Director of the Social Care Workforce Research Unit
LINKS & RESOURCES
● This report is available on the Scottish Government Social Research