Interviews and Interrogations CRJ-573

Synergistic Dependencies in Partner and Elder Abuse

Robert F. Bornstein Adelphi University

Although dependency in its various forms has been widely studied, most investigations examine manifestations of dependency within individuals. Scrutiny of the literature reveals that synergistic dependencies—situations wherein both members of a dyad manifest exces- sive dependency of one form or another—play a role in some forms of partner and elder abuse. High levels of interpersonal or economic dependency in a woman coupled with high levels of interpersonal dependency in her male partner increase the likelihood of partner abuse. When family member caregivers are economically dependent on a functionally dependent older adult, risk for elder abuse increases. Although these synergistic dependencies differ across abuse domains, two prevailing themes emerge. The interpersonal, economic, and functional dependencies of abused partners and older adults are associated with feelings of helplessness, powerlessness, and an inability to challenge the abuser. The common dependency-related dynamic in perpetrators of abuse is fear—fear of abandonment leading to partner abuse, and fear of loss of financial support increasing risk for elder abuse.

Keywords: interpersonal dependency, economic dependency, functional dependency, partner abuse, elder abuse

Humans are profoundly social creatures: We go to great lengths to cultivate close ties with other people, and when deprived of interpersonal contact, we suffer physically and psychologically (Baumeister & Leary, 1995; Leigh-Hunt et al., 2017). Myriad theoretical frameworks help explain peo- ple’s need to connect with others, including those derived from sociobiology, attachment theory, object relations the- ory, and other perspectives (see Buss, 1991; Luyten & Blatt, 2013). Although cultural groups vary considerably in the degree to which they emphasize interpersonal relatedness versus individual achievement, every society has implicit and explicit norms that shape relationships with family members, friends, and romantic partners, and attitudes re- garding intimacy, closeness, and connectedness.

Some degree of interdependence is part of many human relationships, but it is possible to rely on others too much, in ways that create difficulties for one or both members of the dyad. Typically, this overreliance has been conceptualized as interpersonal dependency (sometimes called emotional dependency)—the tendency to rely on other people for help, guidance, and support even in situations in which autono-

mous functioning is possible (Bornstein, 2011).1 Beyond interpersonal dependency, psychologists, gerontologists, and others have examined the intra- and interpersonal dy- namics of functional dependency (typically stemming from physical or cognitive limitations; Ansello & O’Neill, 2010), and of economic dependency as well— one person’s reli- ance on another for financial support to meet life’s basic needs (Scott, London, & Myers, 2002).

Bockian (2006), Bornstein (2012), Disney (2013), and others (e.g., Lowe, Edmundson, & Widiger, 2009) have reviewed the theoretical and empirical literature on depen- dency, and though a number of noteworthy conclusions emerge from these analyses, in the present context, two stand out. First, although dependency is strongly linked with submissiveness and passivity in the minds of researchers, practitioners, and members of the public, evidence confirms that dependent people are capable of behaving actively— sometimes quite assertively—in various contexts and set- tings (e.g., in seeking medical help following symptom

1 Researchers (e.g., Bornstein et al., 2009; Cross, Bacon, & Morris, 2000) have distinguished unhealthy overdependence (characterized by maladaptive, inflexible dependency) from healthy interdependence (char- acterized by adaptive help and support seeking). In contrast to overdepen- dent persons, interdependent individuals show considerable behavioral flexibility and the ability to delay short-term gratification to strengthen long-term supportive relationships. Healthy interdependence is associated with use of more adaptive defenses than is maladaptive dependency, better social skills, and greater ability to self-soothe in the absence of a caregiver (see Bornstein, 2012).

This article was published Online First March 4, 2019. Correspondence concerning this article should be addressed to Robert F.

Bornstein, Derner School of Psychology, Adelphi University, 212 Blodgett Hall, Garden City, NY 11530. E-mail: [email protected]

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American Psychologist © 2019 American Psychological Association 2019, Vol. 74, No. 6, 713–724 0003-066X/19/$12.00 http://dx.doi.org/10.1037/amp0000456

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onset, in competing for the support of caregivers; see O’Neill & Bornstein, 2001; Porcerelli, Bornstein, Markova, & Huprich, 2009). Second, most studies have focused on manifestations of dependency within individuals, exploring the impact of functional dependency, economic depen- dency, or dependent personality traits on psychological ad- justment, health, and other outcomes. Comparatively few studies have examined the interaction of various manifes- tations of dependency within relationships when both peo- ple are, in one way or another, dependent. As discussed in the following sections, scrutiny of the literature reveals that synergistic dependencies—situations wherein both mem- bers of a dyad manifest excessive dependency of one form or another— can have substantial negative consequences.

This article examines the contrasting synergistic depen- dencies that play a role in partner and elder abuse—the ways that dependency in an abuser interacts with depen- dency in another person to impel or maintain an abuse dynamic. I begin by describing major categories of partner and elder abuse and the scope of the problem within the United States and worldwide, and then discuss different manifestations of dependency and how each has been op- erationalized. After reviewing research on the unique syn- ergistic dependencies that characterize partner and elder abuse, I discuss theoretical, clinical, and empirical implica- tions of these patterns.2

Partner and Elder Abuse: Scope of the Problem

More than 10 million adults in the United States experi- ence partner abuse each year; one in three women and one in four men have, at some point, been victimized by a

partner (Centers for Disease Control and Prevention, 2017). Approximately 4.3 million Americans aged 65 and older are physically abused, financially exploited, or neglected by a caregiver each year; one out of six older adults in the United States has been victimized (Laumann, Leitsch, & Waite, 2008; Roberto, 2016b). Although these figures are distress- ingly high, reluctance to report abuse and challenges in collecting accurate data are such that they likely represent underestimates of actual maltreatment frequencies. More- over, abuse rates in the United States are often lower than those in other nations, confirming the urgency and scope of the problem worldwide (see, e.g., World Health Organiza- tion, 2013).

Table 1 summarizes major categories of partner and elder abuse discussed by researchers and policymakers and the perpetrator behaviors that comprise each category. As sev- eral writers have noted, conceptualizations of abuse are influenced by cultural norms and expectations, some ex- plicit and some unstated, that impact the categories in Table 1. These differences notwithstanding, there are noteworthy common elements in cultural attitudes regarding appropriate treatment of partners and elders. Despite variations in cul- tural context, research on partner abuse conducted in Spain (Momeñe & Esrevez, 2017), France (Loas, Cormier, & Perez-Diaz, 2011), China (Chan, 2011), and Bangladesh (Hasan, Muhaddes, Camellia, Selim, & Rashid, 2014) used similar abuse definitions and categories. The same is true of studies of elder abuse in Mexico (Franco, Gray, Gregware, & Meyer, 2000), Iran (Alizadeh-Khoei, Sharifi, Hossain, Fakhrzadeh, & Salimi, 2014), Nigeria (Cadmus & Owoaje, 2012), and Korea (Oh, Kim, Martins, & Kim, 2006).

Dispositional and Contextual Manifestations of Dependency

Table 2 summarizes different forms of dependency that play a role in partner and elder abuse. As Table 2 shows, interpersonal dependency has been conceptualized in two ways: as differences in levels of trait dependency or as dependent personality disorder (DPD) symptoms and diag- noses. Scores on trait dependency scales correlate positively with indices of DPD, with rs in the .4 to .5 range (see Lowe et al., 2009), but as Bornstein (2012), Disney (2013), and others noted, trait dependency and DPD measures tap dif-

2 To obtain relevant sources for the present review a series of searches of the PsycINFO, Medline, and Google Scholar databases were conducted in mid-2018. Dependency-related terms included in these searches were dependency, dependent, dependent personality, emotional dependency, in- terpersonal dependency, economic dependency, financial dependency, physical dependency, and functional dependency. Abuse-related terms were domestic violence, domestic abuse, intimate partner violence, partner abuse, partner maltreatment, elder abuse, elder maltreatment, elder mis- treatment, dementia abuse, late-life abuse, and late-life violence. Each dependency-related term was paired with each abuse-related term in a series of searches.

Robert F. Bornstein

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714 BORNSTEIN

ferent features of dependency. DPD symptoms emphasize the more submissive aspects of interpersonal dependency (e.g., “has difficulty making everyday decisions,” “needs others to assume responsibility for most major areas of his or her life”; American Psychiatric Association, 2013, p. 675), whereas measures of trait dependency capture depen- dency’s active components as well as its more compliant features. Although DPD is associated with a number of negative consequences, studies confirm that DPD diagnoses and symptom ratings are only weakly associated with global indices of psychological dysfunction and overall personality impairment (see, e.g., Wright, Hopwood, Skodol, & Morey, 2016).3

Along somewhat similar lines, researchers have distin- guished two distinct but overlapping forms of economic dependency. Objective economic dependency is reflected in income disparity and other quantifiable external factors (e.g., access to housing and social services), whereas sub- jective economic dependency reflects an individual’s per- ception of their financial vulnerability, which is determined in part by income disparity but by other factors as well (e.g., the presence of children). Subjective dependency scores correlate positively but modestly with indices of objective economic dependency (see Strube & Barbour, 1983).

Functional dependency reflects the degree to which a person relies on others for carrying out activities of daily living— everyday tasks like dressing, bathing, managing money, and managing medication that are required to func- tion independently. Functional dependency can result from physical limitations, cognitive limitations, or both, and the term is most commonly used in describing older adults and individuals with physical or cognitive challenges.

Synergistic Dependencies in Partner and Elder Abuse

Research confirms that some forms of partner and elder abuse are characterized by unique configurations of perpe-

trator and victim dependencies, which interact to increase abuse risk. There are dynamic elements to these synergistic dependencies as well: Not only are various manifestations of dependency associated with increased likelihood of abuse, but exposure to particular forms of abuse may in- crease dependency in a victim, sometimes temporarily and sometimes more permanently. In the following sections, I discuss the ways that interpersonal, economic, and func- tional dependencies impel and maintain these abuse dynam- ics.

Partner Abuse

Murphy, Meyer, and O’Leary (1994) were the first to hypothesize that dependent personality traits increase the likelihood of perpetrating partner abuse because dependent adults fear abandonment by their partner more intensely than do less dependent adults. Consistent with the core tenets of Murphy et al.’s framework, research confirms that

3 In part as a consequence of its initial conceptualization as passive- dependent personality disorder in early versions of the diagnostic manuals, DPD symptoms emphasize the more passive, acquiescent features of in- terpersonal dependency. Not surprisingly, DPD diagnoses and symptom ratings tend to correlate strongly with indices of low self-efficacy, external control, lack of agency, and submissiveness (see Bornstein, 2011, 2012, for reviews of evidence bearing on these issues). In contrast, trait dependency scales tap dependency’s more active features as well as its passive com- ponents; unlike DPD symptoms, high scores on measures of trait depen- dency predict active help seeking in medical and academic settings, com- petition for the favor of potential caregivers (including efforts to undermine potential rivals), and conscientiousness in adhering to medical and psy- chotherapeutic regimens (O’Neill & Bornstein, 2001; Porcerelli et al., 2009). Items tapping dependency’s active features on widely-used trait dependency scales include “I very often go out of my way to please or help people I am close to” (on Blatt, D’Afflitti, & Quinlan’s, 1976, Depressive Experiences Questionnaire [DEQ]) and “In my relationships I am comfort- able offering support when the other person needs it, and asking for support when I need it” (on Bornstein et al.’s, 2003, Relationship Profile Test [RPT]). Items tapping dependency’s passive features on trait dependency scales include “Without support from others who are close to me I would feel helpless” (on the DEQ) and “I am happiest when someone else takes the lead” (on the RPT).

Table 1 Major Categories of Partner and Elder Abuse

Category Definition

Physical abuse Intentional acts that cause or have the potential to cause physical injury, pain, disability, or other harm; misuse of physical or chemical restraints to control another person

Sexual abuse Nonconsensual involvement of a partner or older adult in sexual activity; forcible exposure to sexual acts or material Psychological abuse Acts or omissions intended to cause psychological distress or emotional upset (e.g., verbal abuse, threats and coercion,

deliberate failure to respond to reasonable requests from a care-receiver); verbal and nonverbal communications intended to diminish another person’s dignity

Neglect Deliberate failure on the part of a caregiver to provide appropriate age-appropriate care (e.g., food, medication, hygiene, supervision, shelter) or to provide access to health, mental health, or social services

Financial abuse/ exploitation

Inappropriate control or seizure of another person’s funds or property, including theft, fraud, or other unauthorized use of funds or other resources; refusal to allow a partner or older adult to earn, save, or spend money

Note. Discussions of these categories are provided by Centers for Disease Control and Prevention (2017) and Schiamberg and Gans (2000). Less widely studied forms of abuse include stalking in partners, and abandonment, spiritual abuse, cultural abuse, and rights abuse (i.e., violation of civil rights and/or right of self-determination) in older adults.

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715SYNERGISTIC DEPENDENCIES AND ABUSE

a key element of interpersonal dependency is the belief that one is incapable of functioning without others’ help and support (what Bornstein, 2011, termed the dependent per- son’s “helpless self-concept”). As a result, when dependent people believe their romantic relationship may be at risk, they employ an array of strategies to strengthen ties to the partner (e.g., performing favors, emphasizing their vulner- ability). When these more benign strategies fail, the depen- dent person may resort to aggressive strategies to prevent the partner from leaving. Within this framework, partner abuse represents a form of intimidation designed to preclude abandonment by a valued other (Bornstein, 2006).

Many people who have been mistreated by their partner terminate the relationship, so why do some remain? Just as high levels of dependency have been hypothesized to in- crease the possibility of abuse perpetration due to fears of abandonment by the partner, high levels of dependency have been hypothesized to increase the likelihood of vic- timization, and tolerance of abuse, because the dependent person’s helpless self-concept makes it difficult for them to terminate a close relationship even if that relationship brings significant negative consequences. Economic dependency has also been implicated in tolerance of abuse, in that a person with limited resources has few options for exiting a dysfunctional relationship (Barnett, 2001).

Abuse perpetration. More than a dozen studies have assessed the association between level of interpersonal de- pendency and likelihood of perpetrating partner abuse. Eight of these investigations operationalized dependency in terms of scores on a trait measure, and all eight obtained significant positive correlations between level of dependency and abuse perpetration (Buck, Leenaars, Emmelkamp, & van Marle, 2012; Carney & Buttell, 2006; Holtzworth-Munroe,

Stuart, & Hutchinson, 1997; Kane, Staiger, & Ricciardelli, 2000; Mellinger & Carney, 2014; Momeñe & Esrevez, 2017; Murphy et al., 1994; Wigman, Graham-Kevan, & Archer, 2008). Consistent with findings involving U.S. samples, stud- ies conducted in Great Britain (Wigman et al., 2008) and Spain (Momeñe & Esrevez, 2017) also obtained significant, positive trait-dependency/abuse-perpetration links. Most studies in this area examined male abusers; the one study that assessed both women and men was conducted by Momeñe and Esrevez (2017), wherein a regression analysis found no moderating effect of sex and an overall correlation (r) between trait de- pendency and abuse perpetration of .54.4

Although evidence confirms that members of the Lesbian, Gay, Bisexual, Transgender, Queer, and Questioning� community experience partner abuse at rates compared to or higher than those typically reported in large-scale commu- nity surveys, there have been relatively few empirical stud- ies examining the dynamics of partner abuse in couples with nontraditional sexualities (see Russell, 2015). Two studies have assessed the dependency/abuse-perpetration link in homosexual couples; both used qualitative methods to ex-

4 As is true in other areas of dependency research, the majority of studies assessing interpersonal dependency in perpetrators of partner abuse have used global indices of dependency that are manifested across different relationships (e.g., the Interpersonal Dependency Inventory; Hirschfeld et al., 1977). The two investigations that assessed partner-specific depen- dency in perpetrators using Rathus and O’Leary’s (1997) Spouse Specific Dependency Scale (Holtzworth-Munroe et al., 1997; Murphy et al., 1994) obtained dependency-abuse links comparable to those obtained when global indices of dependency were used. Moreover, in the only investiga- tion to contrast directly the magnitude of dependency-partner abuse asso- ciations in global versus partner-specific indices of dependency, Murphy et al. (1994) found virtually identical links (F � 12.86, p � .001, for global dependency, and F � 12.02, p � .001, for partner-specific dependency).

Table 2 Conceptualizing and Assessing Dependency

Form of dependency Definition Operationalization/assessment

Trait dependency Marked need for nurturance, protection, support, and reassurance, even in situations in which the person is capable of functioning autonomously

Self-report (typically questionnaire) or performance-based test data tapping dependency-related motives, thoughts, behaviors, and emotional responses

Dependent personality disorder Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation

Questionnaire or diagnostic interview assessing dependent personality disorder (DPD) symptoms

Objective economic dependency

Degree to which one person relies on another for financial support

Disparity in income between members of a dyad (typically romantic partners, siblings, or parent and adult child); may be affected by factors such as availability of housing and access to social services

Subjective economic dependency

Person’s subjective perception of financial reliance/ vulnerability

Self-report (i.e., interview or questionnaire) data from less well-off member of a dyad

Functional dependency Reliance on others to carry out one or more activities of daily living (ADLs)

Standardized measure of ADL capacity (typically interview, observation, or review of archival records)

Note. See Bornstein (2011, 2012) for discussions of trait dependency and DPD; Scott, London, and Myers (2002) and Strube and Barbour (1984) for descriptions of objective and subjective economic dependency; and Ansello and O’Neill (2010) for an overview of functional dependency.

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amine this dynamic (McClennen, Summers, & Vaughan, 2002; Renzetti, 1992). The results of these studies are consistent with those obtained in heterosexual couples. When Renzetti (1992) obtained open-ended descriptions of relationship dynamics in lesbian couples wherein one part- ner was physically, sexually, or emotionally abusive, de- scriptions of the abusive partner were characterized by themes of dependency, insecurity, possessiveness, and jeal- ousy. Similar themes emerged in McClennen et al.’s (2002) study of abuse dynamics in male couples. Overall, 48% of abused women in Renzetti’s study and 30% of abused men in McClennen et al.’s investigation identified their partner’s unacknowledged dependency as a core dynamic of the relationship.

Seven studies assessed the association between DPD symptoms/diagnoses and partner abuse perpetration (Beasley & Stoltenberg, 1992; Goldenson, Geffner, Foster, & Clipson, 2007; Gondolf, 1999; Hastings & Hamberger, 1988; Porcerelli, Cogan, & Hibbard, 2004; Sellbom, Waugh, & Hopwood, 2018; Waltz, Babcock, Jacobson, & Gottman, 2000). All studies except one examined the DPD/ abuse-perpetration relationship in men; Goldenson et al. (2007) assessed this relationship in women attending court- mandated domestic violence treatment. In contrast to stud- ies involving trait dependency, which invariably yielded significant dependency–abuse links, all studies that opera- tionalized dependency in terms of DPD symptoms and diagnoses reported nonsignificant results.

Victimization. Two studies assessed interpersonal dependency–victimization links using measures of trait de- pendency (Benotsch et al., 2017; Bornstein, Porcerelli, Hu- prich, & Markova, 2009); five assessed this relationship using measures of DPD symptoms (Coolidge & Anderson, 2002; Davins-Pujols, Perez-Testor, Salamero-Baro, & Castillo-Garayoa, 2012; Loas et al., 2011; Pico-Alfonso, Echeburua, & Martinez, 2008; Watson et al., 1997). Both studies assessing the trait-dependency/victimization link yielded positive results, as did four of five studies assessing DPD–victimization links (Pico-Alfonso et al., 2008, ob- tained a nonsignificant association between DPD and vic- timization in Spanish women; r � .16, p � .12). All studies but one included only female victims; Loas et al. (2011) obtained similar DPD–victimization links in French women and men seeking protective services following physical abuse by their partner.

Except for Benotsch et al. (2017) and Bornstein et al. (2009), all studies in this area examined dependency exclu- sively in victims of physical abuse. Benotsch et al. found significant dependency–victimization links in sexually abused women receiving outpatient treatment for sexually transmitted diseases. When Bornstein et al. examined links between trait dependency and various forms of victimiza- tion assessed by the Conflict Tactic Scales-2 (CTS-2) in a sample of low-income urban women seeking medical ser-

vices, they found that level of trait dependency predicted severity of physical abuse (r � .24), prevalence and severity of sexual abuse (rs � .28 and .25), and prevalence and chronicity of psychological abuse (rs � .27 and .28).

Gelles (1976) was among the first researchers to obtain evidence linking economic dependency with victimization, finding that women with low-paying occupations were less likely than women with higher pay to terminate abusive relationships. Similar results were obtained by Woffordt, Mihalic, and Menard (1994). In a community sample of 100 abused women, Rusbult and Martz (1995) found that in- creased economic dependency was associated with de- creased likelihood of terminating the abusive relationship. Consistent with these earlier results, Golden, Perreira, and Durrance (2013) found that women’s economic dependency predicted victimization risk in a nationally representative sample of mothers with young children. In addition, two studies found increased victimization risk in women who were both economically and functionally/physically depen- dent, with this link of similar magnitude in the United States (Thomas, Joshi, Wittenberg, & McCloskey, 2008) and Ban- gladesh (Hasan et al., 2014). Three studies assessed the differential relationships of objective and subjective eco- nomic dependency indices to risk for physical abuse in women (Kalmuss & Straus, 1982; Strube & Barbour, 1983, 1984), all finding that objective dependency scores were stronger predictors of abuse risk than were subjective de- pendency scores.

No studies have examined changes in levels of interper- sonal dependency in partners as a consequence of abuse. As Arriaga, Capezza, Goodfriend, and Allsop (2018) noted, however, abuse victims often use cognitive strategies to downplay a partner’s aggression (e.g., attributional dis- counting, altering standards for acceptable behavior in the partner). Although such strategies may be effective in main- taining the relationship in the near term, they also result in diminished self-esteem and increased feelings of helpless- ness. Physical abuse may also result in increased economic dependency as a consequence of work missed due to injury, the abusive partner’s disruptive presence in the workplace, or other factors (Golden et al., 2013). Abuse may lead to increased functional dependency as well, in that abuse vic- tims show elevated risk for depression, anxiety, posttrau- matic stress disorder, substance use disorders, and other psychological impairments (Thomas et al., 2008).

Conclusion. Studies indicate that high levels of trait dependency are associated with abuse perpetration in men, but high levels of DPD symptoms are not. These patterns likely reflect the fact that DSM DPD symptoms tap the more submissive aspects of interpersonal dependency, whereas measures of trait dependency capture dependency’s active components. High levels of interpersonal dependency are associated with increased likelihood of victimization in women, and with lower likelihood of terminating an abusive

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relationship, regardless of whether dependency is assessed using trait or DPD measures. Economic dependency also increases tolerance of abuse in women, and evidence sug- gests that victimization may lead to increased economic and functional dependency in women stemming from the abuse.

Elder Abuse

Pillemer’s (1985) mutual dependency model of elder abuse postulates that economic dependency of a caregiver on a care-receiver increases maltreatment risk when this economic dependency is coupled with high levels of func- tional dependency in the care-receiver. According to the mutual dependency framework, an economically dependent caregiver feels “tethered” to the care-receiver, unable to attenuate or terminate caregiving for fear of losing the care-receiver’s financial support. As a result, stress and frustration build, leading to increased likelihood of momen- tary loss of control— or systematic abuse or neglect— by the caregiver.

Some writers have suggested that increased maltreatment risk in an economically dependent caregiver may be exac- erbated when caregiving responsibility falls to a family member with an unstable financial and housing situation (Schiamberg & Gans, 2000). Joubert and Posenelli (2009, p. 706) put it well when they noted, “The care of an older relative often becomes the responsibility of the least socially integrated adult child. In this situation, the adult child may be unemployed or experience other psychosocial stressors that contribute to the risk of abuse.” Consistent with this hypothesis, studies have shown that abusive caregivers show higher levels of psychopathology than do nonabusing caregivers, and higher rates of substance use as well, both of which exacerbate their economic dependency on the care- receiver (Lachs & Pillemer, 2004; Roberto, 2016b).

Empirical support for the mutual dependency model. A number of studies have tested the hypothesis that caregiver economic dependency on a functionally im- paired care-receiver increases risk for elder abuse; all yielded positive results. When Wolf, Strugnell, and God- kin (1982) surveyed two social service agencies in the northeastern United States regarding abuse incidents dur- ing the preceding 6 months, they found that in about two thirds of cases, the caregiver was economically depen- dent on the care-receiver. Pillemer (1986) conducted a more rigorous test of this hypothesis, comparing 42 phys- ically abused elders with 42 matched controls, and found that abusive caregivers were significantly more finan- cially dependent on their functionally dependent care- receivers than were nonabusive caregivers. Similar re- sults were obtained by Anetzberger (1987), Greenberg, McKibben, and Raymond (1990), and Pillemer and Fin- kelhor (1989) in separate community samples. Consistent with these earlier results, DeLiema, Yonashiro-Cho, Gas-

soumis, Yon, and Conrad (2018) found that economic dependency of the caregiver was a significant risk factor for maltreatment of functionally dependent older adults in a mixed-sex sample of 336 abusers, with abuse data gleaned from Adult Protective Service records.

Providing preliminary support for the generalizability of these patterns across culture, Franco et al. (2000) found that 85% of abusive family members (primarily adult children) were financially dependent on the care- receiver in a sample of functionally dependent Mexican and Hispanic older adults (no nonabused comparison group was included in this study). Similar results were reported by Iborra (2008) in a Spanish community sam- ple, and by Sethi et al. (2011) in a large-scale survey of elder abuse risk factors and prevalence rates in 28 Euro- pean countries. In an investigation assessing risk factors for various types of elder maltreatment, Jackson and Hafemeister (2012) found that caregiver economic de- pendency combined with care-receiver functional depen- dency predicted hybrid financial exploitation (i.e., finan- cial exploitation coupled with neglect).

Limitations of the mutual dependency model. Although studies examining the combined effects of caregiver eco- nomic dependency and care-receiver functional dependency support the hypothesis that increased economic dependency in a family member caregiver is associated with increased risk for elder abuse, support for the mutual dependency model has not been unequivocal. For example, some studies indicate that increased functional dependency in a care- receiver is associated with elevated abuse risk even when the caregiver is not economically dependent on the care- receiver (Amstadter et al., 2011; Laumann et al., 2008); other studies report a nonsignificant impact of care-receiver functional dependency in the absence of caregiver economic dependency (Oh et al., 2006). In contrast to the mutual dependency model, some studies have reported that eco- nomic dependency of the care-receiver on the caregiver was associated with increased likelihood of abuse (Alizadeh- Khoei et al., 2014; Fulmer et al., 2002); other studies involving similar samples and outcome measures found no association between care-receiver economic dependency and abuse (Amstadter et al., 2011; Cooney & Mortimer, 1995; Homer & Gilleard, 1990).

Conclusion. Studies support the mutual dependency model of elder abuse, confirming that economic depen- dency in a caregiver coupled with functional dependency in a care-receiver increases maltreatment risk. Studies that assess the impact of care-receiver functional dependency by itself produce less consistent results; the same is true of studies examining the impact of care-receiver economic dependency on abuse risk. Taken together, findings suggest that the combined effects of caregiver economic depen- dency and care-receiver functional dependency have greater impact than either risk factor alone.

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Discussion

Evidence confirms that synergistic dependencies play a significant role in some forms of partner and elder abuse; these patterns are summarized in Table 3. As Table 3 shows, in both abuse domains, victims are dependent on their abusers, but the nature of this dependency varies in partners and older adults. Table 3 also summarizes the synergistic dependency processes that underlie partner and elder abuse; these processes are generally consistent with the fundamen- tal tenets of the frameworks initially proposed by Murphy et al. (1994) and Pillemer (1985).

Beyond victim dependency, the present analysis also helps answer a related, less widely studied question: Why do abusers remain in abusive relationships? Because they too are dependent, but in different ways. Partner abusers show high levels of trait dependency; elder abusers may be financially dependent on the care-receiver. Despite these differences a prevailing theme emerges: The common dependency-related dynamic in perpetrators of abuse is fear—fear of abandonment and ensuing helplessness (part- ner abuse), and fear of loss of financial support (elder abuse).

Conceptual and Theoretical Implications

The synergistic dependencies that characterize partner and elder abuse have been replicated by multiple indepen- dent researchers; these dynamics generalize across culture as well. With this as context, it is important to note that synergistic dependency patterns account for some— but not all—forms of abuse. Beyond caregiver economic depen- dency, there are many factors, dispositional as well as situational, that increase the likelihood of elder abuse (e.g., a long-standing dysfunctional relationship between care- giver and care-receiver); these have been summarized by Deliema et al. (2018), Schiamberg and Gans (2000), and Pillemer, Mueller-Johnson, Mock, Suitor, and Lachs (2007).

Similarly, it may be that high levels of trait dependency characterize one type of partner abuser, with others having different personality styles. This was first proposed by Holtzworth-Munroe and Stuart (1994), who distinguished three types of abusers: family-only, borderline dysphoric, and generally violent antisocial, with family-only abusers being more dependent than men in the other two groups. Gottman et al. (1995) distinguished two types of “charac- terological batterers,” with Type I being more antisocial/ psychopathic and Type II being preoccupied with control- ling the partner. Highly dependent men represent a subcategory of Type II batterers (obsessive men being the other). As Stare and Fernando (2014, p. 299) noted, “Type 2 males . . . feel threatened by partner independence (not a concern for Type 1 males), fear abandonment, and eventu- ally lose control emotionally and become abusive in an attempt to keep their partner engaged within boundaries that feel comfortable.”

Along somewhat similar lines, Dutton (2012) argued that some male perpetrators of domestic violence exhibit a pat- tern of abusive behavior consistent with borderline person- ality disorder (BPD), showing high levels of impulsivity, a preoccupation with abandonment, and splitting (i.e., waver- ing between idealization and denigration of the partner). Although research has shown that underlying dependency needs are central to the dynamics of borderline pathology (Bornstein, Becker-Matero, Winarick, & Reichman, 2010), the unique challenges associated with emotional lability and impulsivity that are inherent in BPD require different ap- proaches to intervention than is the case when the abuser shows high levels of interpersonal dependency in the ab- sence of borderline pathology.

An important and largely unstudied question concerns potential links between victimization and increased risk for various forms of dependency at different stages of life. Although research in this area has been limited, some stud- ies suggest that victimization may be associated with in- creases in dependency that extend beyond the perpetrator–

Table 3 Synergistic Dependencies in Partner and Elder Abuse

Type of abuse Perpetrator dependency Victim dependency Synergistic processes

Partner physical and sexual abuse Interpersonal Economic, Interpersonal High levels of interpersonal dependency lead to fear of abandonment in men, increasing risk for partner abuse; high levels of interpersonal or economic dependency in the partner make it difficult to terminate the relationship

Elder physical abuse and financial abuse/exploitation

Economic Functional High levels of functional dependency in a care- receiver increase caregiver burden; high levels of economic dependency in the caregiver make it difficult to reduce caregiver burden and attenuate caregiver stress

Note. Male perpetrators of partner abuse show high levels of trait dependency but not dependent personality disorder. Economic dependency in victims of partner abuse may be exacerbated by abuse; the same is true of functional dependency in victimized older adults.

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victim relationship. For example, Hill, Gold, and Bornstein (2001) found that experiencing sexual abuse early in life leads to high levels of interpersonal dependency in adult- hood. Physical abuse by a partner is associated with in- creased economic dependency (in part because victimiza- tion may interfere with job performance, lead to increased absenteeism at work, or result in job loss; see Barnett, 2001). Older adults who are abused often show increases in functional dependency—including cognitive decline—fol- lowing the abuse (Lachs & Pillemer, 2004).

Assessment, Intervention, and Social Policy

The present results not only illuminate the intra- and interpersonal dynamics of partner and elder abuse, they have implications for assessment as well: Clinicians should be aware of which screening tools are (and are not) useful in working with perpetrators of abuse. As studies by Kane et al. (2000) and others (e.g., Buck et al., 2012) suggest, when assessing dependency in perpetrators of partner abuse, cli- nicians should use trait dependency scales but not rely on DPD symptoms or diagnoses. When assessing dependency in perpetrators of elder abuse, it is important to assess caregiver economic dependency, broadly construed (i.e., reliance on the older adult for housing and other assistance in addition to financial support; see Lachs & Pillemer, 2004; Teresi et al., 2016). Recommendations regarding evidence- based assessment of trait dependency are provided by Born- stein (2012); strategies for quantifying economic depen- dency in couples and caregivers are discussed by Golden et al. (2013) and DeLiema et al. (2018).

Day, Boni, Evert, and Knight’s (2017) review of the literature examining interventions to reduce elder abuse indicated that the effectiveness of extant treatment ap- proaches is generally modest, with minimal reduction in recidivism (see also Mellinger & Carney, 2014). Interven- tions to ameliorate dependency-related elder abuse are com- plicated by the fact that different manifestations of depen- dency have markedly different causes, and different trajectories, not all of which are easily modified. Many forms of functional dependency in older adults result from medical issues (e.g., mobility limitations), some of which may be minimized via proactive interventions (e.g., medi- cation to inhibit osteoporosis), but all of which require accommodation once they have reached a certain level of severity. Functional dependency may also result from cog- nitive impairments (e.g., dementia), which require support and cognitive rehabilitation.

Along somewhat different lines, evidence suggests that support groups of peers who have undergone similar expe- riences can help victimized women overcome the chal- lenges of economic and interpersonal dependency, and ter- minate long-standing abusive relationships. The same may be true of older abuse victims, and as Brandl, Hebert,

Rozwadowski, and Spangler (2003) discussed, traditional support group models can be modified for use with older adults. As research examining synergistic dependencies in elder abuse proceeds, it will be important to assess eco- nomic dependency and burden of care separately in care- givers—including partners as well as adult children—and the ways these two risk factors interact so that interventions can be targeted at one or both risk factors. It may be that beyond economic dependency, certain hidden/unacknowl- edged dependencies (e.g., resentment regarding a vulnera- ble older adult’s lost ability to fulfill the abuser’s emotional needs) play a role in late-life dependency-abuse dynamics.

Paralleling findings regarding treatment of elder abuse, outcome studies evaluating the effectiveness of interven- tions aimed at reducing partner abuse suggest that the im- pact of extant treatment programs is modest, with minimal reductions in recidivism and violence severity (Augusta- Scott, Scott, & Tutty, 2017). It may be that the impact of existing interventions is hindered by a limited treatment focus: Individual and group therapies for male abusers emphasize confronting the consequences of abuse and building coping skills to manage anger and other negative emotions more effectively (see Gover, 2011; Walker, Brown, & Hicks, 2016). Thus far, minimal attention has been paid to issues related to dependency in treatment programs for perpetrators of domestic violence. The present results suggest that these programs should include issues related to interpersonal dependency (e.g., relationship inse- curity, fear of abandonment) in addition to issues such as anger management.

Finally, as Roberto (2016b) and Teresi et al. (2016) noted, because economic dependency in partners and older adults is often a function of societal factors, it is in part a social policy issue. As a result, policy changes at the local and national levels (e.g., more rapid access to housing and services for women attempting to terminate abusive rela- tionships, increased financial support for caregivers of older family members) may have greater impact than after-the- fact interventions in ameliorating the negative sequelae of partner and elder abuse (see Pillemer et al., 2007; Scott et al., 2002). As Vinton (2003) noted, domestic violence shel- ters in the United States (and domestic violence programs more generally) tend to be tailored to younger abuse vic- tims; given the frequency of partner abuse in older adults, and the increasing population of older adults in the United States, domestic violence programs and shelters should be elder-ready.

Future Research Directions

Although the synergistic dependencies that characterize partner and elder abuse are reasonably well established, a number of issues remain unaddressed. For example, the role of interpersonal dependency in partner abuse perpetration

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has been emphasized in men, whereas the role of depen- dency in victimization and tolerance of abuse has been emphasized in women. These emphases reflect long-standing stereotypes regarding the dynamics of heterosexual relation- ships and assumptions regarding gendered behaviors and relationship styles. The degree to which these dynamics generalize across sex is an empirical question, but there is no a priori reason to believe that these patterns would not also be manifest in counterstereotypic ways (e.g., with a highly dependent woman mistreating her dependent male partner).

Also reflecting long-standing stereotypes rooted in early “battered women” models, partner abuse is the only domain in which the personality of the victim is presumed to be a significant risk factor (see, e.g., Thomas et al., 2008, and Valor-Segura, Exposito, Moya, & Kluwer, 2014, for gender-based perspectives on these and other assumptions regarding domestic violence). There are few studies of women who abuse male partners despite the fact that a significant proportion of partner abuse in heterosexual cou- ples is perpetrated by women (Black et al., 2011). There are no quantitative data regarding dependency–abuse links in homosexual couples.

When an older adult is mistreated by a partner, this is often conceptualized by researchers as elder abuse rather than partner abuse, reflecting the unstated assumption that old age obviates partner-driven abuse dynamics from earlier stages of life (however, see Band-Winterstein, 2012, for a discussion of evolving partner abuse dynamics from middle through later adulthood). Given this assumption, it is not surprising that no studies of elder abuse have assessed trait dependency in caregivers despite the fact that interpersonal dependency plays a role in perpetration of partner abuse, and evidence suggests that other caregiver personality styles (e.g., aggressiveness, authoritarianism) are implicated in elder abuse (Roberto, 2016a).

Going forward, researchers should assess dependencies in both members of an abusive relationship and examine their evolution over time using multiple-respondent designs, which will facilitate an understanding of synergistic depen- dencies embedded in the broader interpersonal milieu en- compassing abuser and victim (see Marsden, 2006). It will also be important to assess the degree to which different forms of dependency co-occur within abusers as well as within victims (e.g., the degree to which economic depen- dency in an abuser may be associated with increased inter- personal dependency) and pathways linking dependency in one domain with increased likelihood of dependency in other domains. Perhaps most important, researchers should examine directly the processes that are hypothesized to underlie dependency-related partner and elder abuse, as- sessing (a) the degree to which situational (context-driven) increases in fear of abandonment precipitate abuse episodes in dependent men, and (b) the degree to which the econom-

ically dependent caregiver’s belief that they are tethered to the care-receiver— unable to attenuate caregiving and re- duce caregiver burden—increases risk for elder abuse.

Continued examination of abusers’ and victims’ broader social networks is important as well. Studies show that perpetrators of partner violence and elder abuse often at- tempt to isolate the victim from friends and family mem- bers, eroding social ties and increasing the victim’s vulner- ability and dependency on the abuser (Ansello & O’Neill, 2010). Conversely, dense social networks and the presence of others in the home have been shown to diminish the likelihood of elder abuse (DeLiema et al., 2018). Research- ers should examine convergences and divergences in these dynamics as they occur in partner and elder abuse, with a particular focus on supportive relationships that are unique to the abuse victim and do not involve the abuser. Interven- tions can then be implemented to reduce social isolation and enhance social connectedness in partners and elders who are at risk—a particular challenge in rural communities, where social networks are more dispersed (Roberto, Brossoie, McPherson, Pulsifer, & Brown, 2013).

Finally, researchers should assess various forms of abuse, within and across generations, in family units, but this has rarely been done (cf., Ehrensaft et al., 2003). Although different forms of abuse are often studied separately, in many instances, victims experience more than one type of abuse (i.e., polyvictimization). Like bullying, it is common for a victim in one domain to be a perpetrator in another (e.g., an interpersonally dependent person abused by his or her partner may, in turn, mistreat an older adult on whom both partners are economically dependent). Going forward, it will be important for researchers to look more closely at these and other process issues—the dispositional and con- textual variables that shape abuse dynamics—with respect to maltreatment risk factors and intergenerational transmis- sion of maltreatment within families.

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Received September 19, 2018 Revision received January 22, 2019

Accepted January 22, 2019 �

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724 BORNSTEIN