Bullying Among Older Adults: Not Just A Playground Problem

Editor's note: This text-based course is a transcript of the webinar, Bullying Among Older Adults: Not Just A Playground Problem, presented by Kathleen Weissberg, OTD, OTR/L.

Learning Outcomes

• After this course, participants will be able to recognize the incidence, characteristics, and impact of bullying behaviors in senior living.
• After this course, participants will be able to identify the five different types of bullies and their intended targets.
• After this course, participants will be able to identify the impact of bullying on older adults and recognize occupation-based interventions aimed at the organization, bully, and target that may help to minimize community bullying.

Introduction

I have two school-aged children, and we often hear about bullying in that context or cyberbullying. When I heard about senior bullying, I thought, is this even a thing? Sure enough, it is. The more I talk about this topic, the more stories I hear. For example, when I was in California recently discussing this topic, somebody said, "Yeah, I work in a veteran's community. We have those from the Army going up against those from the Navy. It started with ribbing each other, but it has taken on a new direction. Now, it is bullying."

Our goal today is to recognize the incidence, the characteristics, and the impact of bullying behaviors in senior living. When I say senior living, this is any place seniors are convening, like skilled nursing, assisted living, independent living, senior housing, adult day health, or the general community. We will also identify the five types of bullies and discuss their targets. We will also discuss the impact of bullying on older adults and recognize some occupation-based interventions aimed at the organization, the bully, and the target that may help us to minimize community bullying.

The Stories

I am going to start with some stories. Every story you hear me talk about today is 100% real, but the names may have been changed. The first example occurred in a highrise where a woman saw herself as the queen of the parking garage. If somebody parked in her parking space, too close to her, or offended her somehow, she keyed their cars.

Another example is laundry rooms. Remember, in college, if you did not get to your laundry promptly, your laundry was on a table or floor. We see the same thing in senior living. Laundry rooms are vicious places. People have their detergent stolen, their clothes thrown on the floor or the trash, and stuff like that.

We also see disputes in the bingo room. Newcomers may be badgered or accused of cheating by some of the veteran players. They may be told, "That seat's taken," or "You can't sit there." In the worst cases, bullying goes far beyond the bingo squabble.

Here is a true story. Marsha Wetzel moved into an apartment complex in Niles, Illinois, for those aged 50 and older after her partner of over 30 years died. Her partner's family evicted her from the home that the couple had shared for years. In this community, she was met with relentless bullying, primarily focused on being a lesbian. Examples include a man hitting her scooter with his walker and calling homophobic slurs.

Additionally, a woman rammed her wheelchair into Wetzel's dining table, flipping it over and saying, "Homosexuals will burn in hell." People would also spit on her in the elevator. The worst digression happened in the mail room, where someone hit her on the back of the head with a blunt object. These incidences go beyond bullying and are assaults. She said, "I would go to my room, barricade my door, and pray. I did not feel human. I felt like a person in a pool of piranhas." She has since moved out of that community.

What is Bullying?

• Unwanted aggressive behavior
• Observed or perceived power imbalance
• Repetition of behaviors or high likelihood of repetition
• Direct or indirect

The definition of bullying is the same for our seniors as it is for anyone else in the general population. According to the federal government, bullying is defined by the core elements of unwanted aggressive behavior, observed or perceived power imbalance, a repetition of behaviors, or a high likelihood of those behaviors being repeated. There are direct or indirect broad categories.

Direct bullying is where the bully is in the same presence as the targeted individual. Indirect bullying is spreading rumors or gossiping, sniping, and those types of things. We will talk more about that in a minute.

Incidence of Bullying

• Between 10 and 20 percent of older adults living in senior living communities are bullied (AARP, 2012).
• In many ways, bullying looks similar to that among younger age groups.
• Bullying can happen in any number of places, contexts, or locations, including online.
• Most senior-to-senior aggression is verbal abuse.
• Men and women are equally likely to be the victim as well as the aggressor.

(Hazelden Foundation, 2008; U.S. Department of Health & Human Services, n.d.; Senior Bullying, 2015)

The incidence is interesting because senior living can be a wonderful thing. You have moved out of your home, for whatever reason, and moved into a community. This may be an excellent opportunity to make new friends, convene with others with similar interests, and get involved in activities. However, the reality is that often that is not the case. There can be the formation of cliques and other social behaviors that can be very detrimental. Even seniors living in their own homes can be the victims of bullying. They may not be invited to a neighborhood barbecue or other event or be shunned in their social circle.

The AARP's most recent statistics are from 2015, and they say between 10 - 20% of older adults are bullied. Some statistics go a little bit higher to 20 to 25%. It is very tough to tease out these numbers as they are not precise, and many acts go unreported. Bullied individuals living in these communities may be bullied, teased, or taunted, but they may keep this to themselves. They may be embarrassed or afraid that if they tell somebody, it will get worse. 

We do not hear about some of these bullying stories, but it looks similar to bullying among younger age groups. Bullying can happen in many different places and contexts, like senior centers, nursing homes, senior living communities, and any place where our seniors spend a lot of time together. They share resources like tables and chairs, elevators, stairwells, parking spaces, and TVs. We also see bullying among seniors over technology, like via phone, email, instant messaging, social media, et cetera. That is electronic bullying, and again, no different than our children. 

Some bullying may fall into other criminal categories, like harassment, hazing, and assault, as I discussed earlier in that story. 

There are gender differences, but generally speaking, men and women are equally as likely to be victims and aggressors. Typically, most of the bullying we see is verbal abuse.

Types of Bullying Behaviors

• Verbal
• Physical
• Antisocial
• Relationship-centered

There are four different types of bullying.

Verbal

The first is verbal and includes name-calling, teasing, insults, taunts, threats, sarcasm, and pointed jokes about an individual. The bully may mimic or make fun of a person's disability or how they talk. An example of this is Mary from a senior center. She was overheard talking to somebody else, saying, "You have no idea what you're talking about. Everyone knows you're crazy." On the surface, this is not a horrendous statement, but it is bullying. We would have brushed that off years ago, but that is not the case anymore.

Physical

Physical bullying includes pushing, pinching, biting, punching, hitting, hair pulling, etc. An example is two men in an independent senior housing who argued over the remote control in the community room, which resulted in blows. One gentleman punched the other in the face. I want to point out that this was not the first time these gentlemen had argued over the remote control. As in this case, bullying often escalates. It may not start physically but progresses as they cannot resolve their differences.

Antisocial

The third is antisocial, which involves shunning, mimicking somebody's walk or disability, spreading rumors, making offensive gestures and facial expressions, or turning away when somebody talks to them. This happened to me the other day. I was speaking to somebody and using the person's name. I was speaking to this person; they turned their back and would not even talk to me. Antisocial bullying includes threatening body language, encroaching on personal space, and negative body language. The list can go on and on. Shortly after Hurricane Katrina, a gentleman who lived in New Orleans, Louisiana, relocated to a senior housing community outside of Boston, Massachusetts. Somebody in that community started spreading rumors that he was a longtime homeless man. This is an example of antisocial bullying. He was the first in a deluge of formerly homeless people dumped into their building, and as a result, everyone avoided or was rude to him.

Relationship-centered

That relationship-centered kind goes hand in hand there. This includes ostracizing during meals, during activities, and forming social cliques.

Common Responses

• Reduced self-esteem, feelings of insecurity
• Overall feelings of rejection
• Depression, anxiety
• Suicidal ideation
• Functional changes
• Changes in eating and sleeping
• Increased talk of moving out
• Increased isolation
• Stress, anxiety, tension, anger, frustration, fear, and worry
• Retaliation followed by shame
• Migraines, GI tract/stomach problems, HBP

(Frankel, 2011)

What are the responses to bullying? Contrary to the adage, "Sticks and stones may break my bones, but names will never hurt me," individuals who are bullied are significantly impacted by it. As OTs, we can focus on functional changes in eating or sleeping, like overeating, undereating, oversleeping, undersleeping, et cetera. We help them manage stress, anger, fear, and worry, but it goes beyond that. If we have this bullying happening and we are not addressing it, or it is not resolved, we create an environment of fear and disrespect. We need to get the bullying under control so it is not perpetuated.

Situation and Type of Behavior Determines If Bullying

• The situation and type of behavior often determine whether or not problematic behavior is actually bullying. Some conduct violates community rules but might not be bullying.

The situation and the type of behavior determine whether or not something is bullying. I will give you a couple of examples. An upset individual may yell or strike out if they are frustrated and are not necessarily a bully. The behavior may violate community rules and be inappropriate. Still, it may not be bullying. We have to go back to that definition, including the dynamics of power and control, which we will be talking a little bit more about here in a second. Remember, we are looking for a power differential or imbalance.

The other question that comes up for me is, what about dementia? Again, I go back to the definition. With dementia, is there unwanted behavior like kicking, pinching, or yelling? Yes. Is it repetitive behavior? Yes, absolutely. Is there a power imbalance? I do not know, but there possibly could be. However, in the case of dementia, there is not somebody trying to usurp someone else's power. We need to get to the underlying reason for that behavior. What need is that person trying to meet that is manifesting itself through those behaviors?

Behaviors Causing Distress

• Loud arguments in communal areas
• Name-calling
• Being bossed around
• Negotiating value differences
• Sharing scarce resources
• Being hounded for money or cigarettes
• Listening to others complain
• Experiencing physical aggression
• Witnessing psychiatric symptoms

(Bonifas, 2011)

I love this study by Bonifas and colleagues. Although it is from 2011, the study was completed in an assisted living where they used a survey to see what behaviors were in the residents. And these were the things that people said, again, I'm not going to read everything at you. Still, name-calling, sharing resources, being hounded, listening to others complain, negotiating value differences, etc. When you look at this list, a few of these behaviors are bullying, and some are not.

It is incumbent upon us to try to understand not just bullying behavior but bullying-like behavior, as both of those behaviors are causing distress in the seniors we serve.

Individuals Who Bully

• Bullies are more likely to use power and control strategies at the expense of others.
• Typical traits of individuals who bully:
  • Lack empathy
  • Have few friends
  • "Need" power and control
  • Struggle with individual differences
  • Use power and control at the expense of others
  • Suffer from low self-esteem
  • Empowered by causing conflict or making others feel threatened, fearful, hurt

(Hazelden Foundation, 2008)

Let's talk about who the bully and the target are. To do so, let's go back to the definition, which is intentional, repetitive, aggressive behavior involving that imbalance of power or strength. When we think of that definition, the first thing that comes to mind is that the bully is trying to get power and control. Many of us want to be in control of our situation or environment, but the reality is that we typically do not do that by negatively impacting other people. Instead, we find positive, healthy ways to do that.

The bully will use their power or control at the expense of others. They find it positively reinforcing to make other people feel threatened, fearful, hurt, or contribute to conflict between people. These tendencies are even further complicated because they have difficulty tolerating individual differences. We will talk more about that on another slide. They lack empathy and have very few positive social relationships. The reality is the bully has very few friends, and many times their "friends" or peer circle are around them because of "survival of the fittest." Most of the time, they are with that bully, so they do not get bullied themselves. We call that person a secondary bully.

Types of Bullies

• Narcissistic bully
• Impulsive bully
• Physical bully
• Verbal bully
• Secondary bully

These are the types of bullies that we see. The first is the narcissistic bully. We do not see this type often, but they are incredibly self-centered. They need power and control and lack empathy. They plan their bullying by knowing who they are going after and why they are doing so. Someone told me about an individual who would tape up a swastika on a Jewish person's door or slide antisemitic types of literature under the door every night. The facility finally installed cameras in the hallway to figure out who it was. This is a narcissistic bully purposefully waking up at two o'clock in the morning to harass their neighbor.

The next type of bully is impulsive, which we see more frequently. They are spontaneous and will take it if the situation is ripe. They take advantage of that opportunity to bully somebody else, even if there are consequences, like eviction. They have a tough time restraining themselves from that type of behavior.

The physical and verbal bullies are self-explanatory. The secondary bully I already mentioned does not initiate, but they join in because they do not want to become that target down the road. They may feel bad about their actions but are more concerned about protecting themselves. It is that self-preservation or survival of the fittest. They also may want to be a cool kid.  

Gender Differences

• Women
  • Gossips
  • Snipes
  • Member of a clique
  • Passive-aggressive behavior
  • Manipulates emotions
• Men
  • Direct
  • Spontaneous
  • Verbally or physically aggressive
  • Superiority complex
  • Overly protective

As I mentioned earlier, men and women are equally as likely to be the bully and equally as likely to be the target, but there are a few gender differences. These are not absolute, but this is what is seen in the literature. Generally speaking, women are a little more passive, verbal, and indirect in their bullying. They gossip, are members of cliques, et cetera. Men, on the other hand, tend to be a little more direct. They are spontaneous and can be verbally or physically aggressive. Men are also overly protective of stuff and things, like a specific chair in the day room or the remote control, and they are also protective of staff and relationships. 

Why Do Older Adults Bully?

• Some people were bullies when they were younger.
• Some people do not adjust well to the aging process.
• Some people experience emotional problems.
• Some people have an underlying need for power and control.
• Some people feel the need to assert their will to intimidate others.
• Some people have a difficult time transitioning.
• Some people have difficulty tolerating individual differences.
• Some people have insecurities about themselves.
• Some people have dementia.

(Bonifas & Frankel, 2012; Botek, n.d.)

We have already talked a little bit about this. Older adults may have been bullies when younger or are not adjusting well to the aging process or a new diagnosis. Transitioning is a big one. They may be at a critical tipping point where they need some care and have moved out of their home. They may feel powerless, and they take it out on others.

The other thing is that living in a communal environment can be very tough. When was the last time you lived in a communal environment? Maybe it was college or a shared apartment after graduation. For many seniors, it has been a long time. Some of them have never lived in a communal environment at all. One of our first takeaways is paying attention to those who move into our communities and are having difficulty transitioning. We need to try to help them find ways to manage this difficult time.

Bullies put others down to build themselves up, so low self-esteem plays a role. We will talk more about this a little later. How can we build up their self-esteem? They may also attempt to exert control and change public spaces into private ones. For example, they may try to make the day room their own space. Those with dementia may not have the ability to communicate verbally and, therefore, may act out in a very physical way.

Targets

There are two different types of targets for bullies.

Passive Targets

• Be highly emotional
• Have difficulty reading social cues
• Experience a heightened sense of anxiety
• Do not read social cues very well
• Others often perceive them as shy and insecure
• Have racial/ethnic, spiritual beliefs, political, sexual orientation, or gender identity that is perceived as different from their target
• Immigrants & refugees

The first is a passive target. Passive targets have trouble defending themselves. They do nothing to cause this bullying, but in many cases, their passive style makes them an ideal target. They are highly emotional, have difficulty reading social cues, and may be perceived as shy and insecure. They may not be shy and insecure; instead, they could have a developmental disorder, early-stage dementia, or some sequela related to a head injury or a CVA.

The biggest thing is they are different, and often the bully has difficulty tolerating individual differences. This target may be different racially, ethnically, spiritually, politically, or in their sexual orientation, gender identity, or economic status. Even clothing choices, hair color, or body shape or form can make them stand out. Immigrants and refugees often fall into this category because they are perceived as different. 

Provocative Targets

• Annoying or irritating to others
• Quick-tempered
• Intrusive into others' space

The target does not do anything to initiate the bullying or to bring the bullying on, but a provocative target can be annoying or intrusive. "Hey, are you going to the activity this afternoon? Can you save me a seat?" They are in your space, which is not wrong. It is just who they are. A bully does not know how to handle this behavior or how to walk away from that. 

Warning Signs of the Bully

• Intimidates staff and others
• Tells others what to do using a bossy style/tone
• Criticizes others
• Lacks empathy
• Makes repeated complaints about others

There are warning signs. Bullies criticize people and lack empathy. What I find interesting is they make repeated complaints. They may say, "So and so won't let me sit here," "or So and so did this to me." Often, the person complaining is the bully and not the other person.

Warning Signs of a Target

• Self-isolation
• Avoidance of events and activities
• Take long and often out-of-the-way routes to get to and from communal areas
• Vague complaints, "They don't like me" or "They won't let me_______ ."
• Depressed mood (acute onset)

There are warning signs of a target as well. They self-isolate and avoid activities. This person used to love going to activities or community outings; now, they do not want to go. They may use circuitous routes to get to a communal area to avoid people. They may have vague complaints, like, "I do not want to," or "They won't let me." They may demonstrate a depressed mood. We need to keep an eye on folks like this. You may want to do a Patient Health Questionnaire that looks specifically at signs and symptoms of depression.

What is the Impact of Bullying?

• It is common for facilities to take a passive stance.
• Bullying behaviors can escalate to physical violence.
• Impact is not exclusive to the recipients of such behavior.
• Individuals who witness bullying also experience negative consequences.
• Bullying can also be targeted toward staff members of organizations serving older adults.

(Bonifas, 2011)

Many facilities or senior organizations say, "Well, that's how people are. There's nothing we can do." They take a passive stance, thinking of the bullying as a social irritant with no lasting harm. Nothing could be further from the truth. This culture of fear has many negative consequences for the target and the people around them.

People feel guilt because they do not intervene, leading to poor self-worth and insecurity. There can be a lack of trust that the staff will keep them safe. It also decreases resident and staff satisfaction, overall quality of life, and care. An example happened in 2009 between two female residents of a nursing home. One was 100 at the time, and one was 98, and they shared a room. One accused the other of having two more inches of space, and they had words. The staff did not try to relocate or mediate. The situation escalated to the point that the 100-year-old nursing home resident was killed by her 98-year-old roommate. 

What Can You Do?

• Get to know the people in your community and recognize when there is a change.

As OT practitioners, we are uniquely poised to get to know the people in a facility and recognize when there is a change. The reality is the signs of bullying are very similar to the signs of elder abuse, and we are familiar with those. We may have a client who has always been fabulous, and now she snaps. Could it be a medication interaction, dementia-related, or dehydration? When we start to see sudden out-of-character behavior, it may be a way of that person asking for help. We do not want to ignore those signs.

Three-Tiered Intervention Model

• Tier 1: Universal approaches
• Tier 2: Targeted strategies for those at risk
• Tier 3: Intensive, individualized services when bullying occurs
• Organization
• Bully
• Target

Let's look at our three-tiered intervention models directly from AOTA. These are the bullying approaches they put forth for the bullying of adolescents and school-aged children, but they can also apply to our population. Tier one is universal approaches. For our purposes, we will talk about organizational approaches at tier one. Tier two is targeted strategies for those at risk or the targets. Tier three is intensive individualized services for the target or the bully. The most crucial intervention will be at the organizational level, and that is where we are going to start.

Organizational Interventions

• Develop clear rules and expectations for resident and staff behavior
• Consider adding language around bullying to admission agreements
• Hold regular group discussions about the challenges of communal living
• Provide regular employee training
• Review policies for potential revisions
• Encourage staff and residents to report incidents of bullying and take complaints seriously.
• Review state requirements to ensure compliance

Where seniors reside has a culture that defines their norms, beliefs, attitudes, and experiences. Residents and staff come to that culture with their life stories and expectations. This will positively or negatively influence our interactions and impact the organization's climate. Thus, how do we create an environment where bullying does not occur? Some of these things we are going to talk about may not be under your purview, but these are the things that should happen.

First and foremost, the organization should have clear rules and expectations for residents and staff. The seniors should have input into what those expectations are. We should consider adding language to admission agreements. I realize this is not something you are probably doing, but maybe during your evaluation, you can mention that bullying is unacceptable and the consequences of that. For example, I will take a page from my daughter's gymnastics handbook. The first time there is a specified behavior, they are asked about it. The second time they are sent to the office, and the third time their family is called. If the behavior exacerbates, the person is suspended first, and then they are removed from the team altogether for any further infractions. There should be a hierarchy of responses. If something crosses the line, we need to review state requirements, as it may move from bullying to harassment, hazing, or assault. The police may need to be called, and there may be criminal charges. 

We do not know what an individual is going through or their challenges. We hope people are talking about this, but we do not know. Group discussions or wellness activities about community living may be helpful. It is also critical to provide employee training. Typically, I am not a fan of role-playing, but this might be an opportunity for staff to look at how they would handle different situations. What went well, and what did not go well.

When reviewing policies, it may be as simple as having everyone sign a "no bullying pledge" or something like that.

We also need to know what to do when we see it. This goes back to employee training. We must train everybody, not just social work, nursing, or therapy. We may need to prepare a van driver, a volunteer, or somebody answering the phones. Everyone has to have the training to know what bullying is. We also need to convey the same message. "If you see something, say and do something." They also have to know what the process is to report that.

• Create caring communities for all residents and staff members
• Prohibit the use of obscene language, name-calling, gossiping
• Use empathy as an antidote to bullying
• Creating environments that promote empathy requires that:
  • All members are treated with respect and dignity
  • Everyone is held accountable and responsible for their behaviors
  • Everyone is encouraged to stand up for what is right
• Publicly acknowledge members of your community that go out of their way to make others welcome

We want a caring and empathetic community for not only our residents but also our staff. In a compassionate environment, there is a pervasive culture of respect, trust, and dignity where everyone is held accountable and responsible. Everyone speaks up for what is right. We can develop that sort of environment because where we have empathy and understanding, we do not have bullying. 

• Pre-move-in or new resident orientation
• Institute a "Caring Squad"
• Nominate "Kings and Queens of Empathy"
• Create a training program with role-playing
• Create a wellness program
• Help residents expand their social networks
• Host a mixer-type event
• If all else fails, seek legal consult, have legal services send the target a letter, and/or issue lease violation notices.

I pulled some examples from the literature where people went out of their way. I do not know if they would fit your organization, but these ideas came from the literature. A new resident orientation or a "caring squad" are a few examples.

We could nominate "Kings and Queens of Empathy." They might get a special monthly reward if they went out of their way to make other people feel welcome. Let's go back to the bully. The bully is looking for attention. If we nominate these people for doing an excellent job of inclusivity, they get attention for positive behaviors. Bullying is getting attention because of negative behaviors, but perhaps they can see that we are showering way more attention on these other folks. It is an operant behavioral type of conditioning.

We also talk about personal responsibility, compassion, tolerance, and empathy. It may be as simple as helping people expand their social networks. You may know that someone loves fishing, and you can connect them with someone else with the same interest. You can have them sit together for lunch or have a mixer. Finding those opportunities where people have things in common can help them develop a peer network. This is critical as the bully does not have a strong friend group.

This last bullet is interesting to me because I talk about this topic so often, and people say, I do not know what to do. Sometimes it is as simple as contacting your ombudsman. You could also contact the State Department of Health, but they sometimes are not as equipped to handle some of these issues as it is a new issue to them. Use them as a line of defense, but it is essential to use internal strategies first. Sometimes, unfortunately, you may have to evict the person.

• Recommendations from residents:
  • Offer anger management classes
  • Set limits with people who bully or "pick on" others
  • Hold regular meetings to promote resident communication
  • Develop rules and expectations for resident behavior
  • Foster partnerships between residents and facility management

(Bonifas, 2011)

In the Bonifas study, they said to the residents, "These things bother you. What do you want to see from us?" One of the recommendations was anger management classes. Anger management classes are an excellent opportunity for occupational therapy in the wellness realm.

Limit setting was another suggestion where everyone is held to them. We all must speak the same language and be very consistent with that.

Holding regular meetings was another. We already mentioned this, but we cannot assume that people are talking to each other.

Other ideas were developing rules and expectations and then going back and fostering those relationships. This goes back to what I said if you see something, say and do something. We must take every complaint seriously because if we do not, unfortunately, we lose their trust.

Creating a Caring Community

• It is important to recognize that developing a caring community is a process, and organizational change is slow; improvements will not happen overnight, but gains can be made over time.

Developing a caring community is a process. I guarantee every one of us is working in a place where we already have a caring community. I am not worried about that. We may need to tweak some things, which will not happen overnight. 

Interventions for the Bully

• Do not avoid or ignore the behaviors
• If you see something, say something and do something
• Consistently set limits with them
• Refer them to mental health provider
• Assist them to expand their social support networks
• Identify alternative methods for individuals who bully to feel in control
• Assist them in identifying appropriate outlets and alternative methods to manage anger, frustrations, etc. 
• Foster the development of positive communication skills
• Foster the development of empathy

(Beddoe & Murphy, 2004; Siegel, 2007)

Let's switch gears and talk about interventions for the bully. Some of the interventions will also relate to the target.

Again, if you see something, say and do something. Please do not ignore it. We also need to set limits consistently. It should be the same message for every person.

We also need to identify alternative methods for those individuals to feel in control or have mastery over an activity. This could be a significant role for us. We need to help individuals find appropriate outlets and alternative methods. The feelings that they have toward others are legitimate. Remember, many older people have not been socialized to welcome diversity as we all have. We cannot expect them not to feel something that they feel. We can, however, expect them to behave appropriately. We can show them appropriate ways to express that without being a bully. Is there a way to give them some control over something so they do not need to find that control through bullying? Can we use their skill set to make them shine in some way, like gardening or other activities? Activities also expand their social networks.

We can also teach them the "I" statements. Instead of saying, "Get out of my chair," they may say, "I like that chair because it reminds me of the one we had in our living room." Or, "How about if I sit there for bingo, and you sit there during lunch?"

We can foster the development of empathy. Perhaps the victim can share how they felt directly with the bully. Sharing their feelings may change some of that behavior.

Interventions for the Target

• Focus on skills development to them avoid being targeted – assertiveness training
• Encourage and support them to stand up for their rights
• Foster their self-worth and dignity and bolster self-esteem
• Refer them to mediation training
• Refer them to de-escalation training
• Refer them to a self-help group or 12-step program
• Encourage them to continue to report
• Encourage them to call 9-1-1
• If appropriate, refer them to obtain a restraining order against the bully

Interventions for the target include assertiveness training. We have to be very cautious here because individuals learning those assertiveness skills can sometimes have a lot of difficulties differentiating between assertive and aggressive behavior. Victims can become bullies, and we do not want that to happen.

We can encourage them to support themselves, stand up for their rights, and foster their self-worth. 

Victims can also use "I" statements. Instead of saying, "You make me so mad when you raise your voice at me or when you make fun of the way that I walk," they can say, "I feel bad when you do that." 

Sometimes things do not work, and they may need to obtain a restraining order for the bully.

What Else?

• The best way to halt this behavior is to identify the cause and provide intervention.
• Speak out!
• Remember, there are barriers to reporting, such as shame and fear of retaliation.
• Staff training is critical.

The best way to halt bullying is to identify it, provide the intervention, and speak out. We must know the reporting protocol. We must also understand how we are addressing it and ensure that our seniors know. If you tell me something, it is not my story to tell. I need to ask if I can share it under the guise of quality of care and life. If it is a situation where there is abuse or what have you, we are mandatory reporters, so we must alert someone. If that is not the case, that person needs to know that what they tell us will be confidential, and we will use the information appropriately. We are not going to retaliate, and we are not going to tolerate anybody else retaliating against them. They have to feel protected because this is one of the barriers to reporting.

Older Adult Coping Skills

• Just let it go or tune it out
• Avoid contact
• Walk away
• Bite your tongue
• Engage in positive self-talk
• Pursue off-site activities
• Seek to see the other person's point of view
• Learn and use de-escalation skills
• Get a pet or spend time with pets
• Form relationships with other supportive individuals

Can we teach older adults coping skills? The answer is yes. It is a complex process, but we can do some of these things positively. I am not saying this is the end-all-be-all, but sometimes that helps. We can teach this both to the target and the bully.

There are also great opportunities for wellness services or classes.

For the bully, you may say, "I know that so and so is different from you, and they drive you crazy, but can you bite your tongue and walk away? My husband says this to me all the time. He'll say, "You know what you could have said there." I am like, "Nothing." We joke about this because the option is to walk away.

Can we give them a role? Go back to your roles and activities checklists.

Strategies for Residents

• Let your emotions settle before you approach
• Walk away and regain your composure
• Approach the conversation firmly and confidently
• Maintain eye contact
• Call the bully by name
• Remember, it's not your fault; the bully has the issue
• Do not make any aggressive motions or innuendos
• Have a fact-based conversation about observations
• Don't attack the individual
• Address the specific behavior you want them to change
• Do not provoke or antagonize

Let your emotions settle before you approach that person. If I address a bully, I approach them firmly and confidently. With good eye contact, I call them by name and have a fact-based conversation. We bring it back to the specific behavior we want to see changed. We are not there to attack or provoke them.

Strategies for Staff Members

• Prevent bullying with education
• Create, implement, and disseminate zero-tolerance policies and procedures
• Confront the bully and inform them that their behavior may result in an eviction
• Intervene
• Support the target
• Encourage staff members and residents to report bullying behaviors.

Some general strategies for staff members are education, confronting the bully, and supporting the target. We are on their side and need to intervene. This is behavioral conditioning, where they see us supporting this person, not them. They may think, "Could I change my behavior so that I see that support as well?" We also need to ensure that they know their behaviors' consequences.

Facility Responses

• Assess the extent of the problem within your community
• Create policies and procedures
• Train staff
• Establish ongoing bullying prevention programs
• Familiarize residents with an effective, confidential reporting process
• Provide anger management classes or counseling

Here are some facility responses. When I say the facility, this is anywhere seniors are convening. The more I talk about this topic, people will say, "Oh, this does not impact me," or "We do not have this going on in my community." On the flip side, people may say, "We have this happening all over the place. What do we do?"

One story I heard was about a clique of women sitting near a facility's social worker's office. Whenever people would come in or out of the community, they would then run and tell everybody what was happening or what someone's diagnosis was. This is technically bullying. It is not their story to tell and is gossip.

At a bare minimum, we need to figure out the conditions that may allow something like this. Do we have hotspots like the dining room, the day room, or the hallway? Are they allowed to save seats for people, or is that not allowed? Creating policies and procedures may help with these situations, but often, folks do not know where to start. I would say go to your schools because they have developed exceptional policies to address bullying and are not much different from senior communities.

Establishing bullying prevention programs and bullying awareness is aligned with the psychosocial and emotional side of wellness, and this is where we can shine. Familiarizing ourselves with the confidential reporting process, anger management classes, counseling, et cetera, are some things we can support. 

Responding to Incidents

• Staff member observes or is told about a situation involving bullying behavior
• Staff member assesses whether there is a potential for immediate or imminent physical danger to anyone, and if so, takes immediate steps to de-escalate the situation
• Staff member notifies the appropriate leadership
• Leadership/management assesses the potential for physical danger and if steps have been taken to safeguard the victim
• If less severe, staff may be able to help resolve the situation
• Brainstorm possible solutions
• Develop a corrective plan and implement
• If a resident is still exhibiting bullying behaviors, staff should reassess solutions

If there is an incident, what do we do? How do we handle it? The first thing is that the person observing the behavior has to ensure that there is no immediate or imminent physical danger to anyone. If there is, they must de-escalate the situation and move people out of harm's way.

The next step is to notify the appropriate leadership, like the rehab manager or director of nursing. Whoever that person is, they also need to step in to safeguard the victim and anyone else in that area. They will then take the next step to see if a crime was committed, like harassment, hazing, or assault. Other parties, like the Department of Health and Human Services, may need to be contacted. For example, if there is elder abuse, the police may need to be contacted. Family and legal guardians may also need to be told. 

We also need to figure out our OT plan of care. You can collect the accounts from witnesses and staff to devise a plan. Would the bully benefit from counseling? Do the two residents need some mediation? Is it an environmental situation where they sit next to each other at the same table at lunch or room together and need to be separated? Their therapy sessions may need to be at different times.

If it is dementia, what is the underlying reason triggering the resident, and how can we help resolve that?

You can develop a corrective action plan and implement and communicate it for those cognitively intact, and if it goes well, then great. If not, we go back to the drawing board. If the person is still exhibiting chronic, purposeful bullying behaviors, we may be able to sit down with the person and discuss their behavior.

If nothing resolves the situation, they may need to be transferred. We are not responsible for necessarily, but the community would be.

In some cases, you may be the one being bullied. I have experienced this. When I first got out of OT school, I had a patient that did not like me. I will never forget him. I planned on being in a different part of the clinic when the person was around and someone else treated him. Figure out what you need to do from a transfer perspective, but ultimately, we will not tolerate it. That is the end-all message.

In Conclusion

• Current estimates misjudge the bullying problem.
• Bullying among residents is likely to continue to rise
• Learning about the problem and adopting strategies provide elders and their families with proactive and reactive solutions so that elders are no longer ignored

I want to conclude that current estimates misjudge the bullying problem. Seniors are bullied equally as those in our high schoolers nationwide. We must acknowledge that we are seeing higher rates of bullying because we have an aging population, and many do not recognize this as a problem. The 1900s was when we started talking about bullying related to our youth. While bullying is on the decline with our youth, we see it on the rise with seniors, so we must address it. Our goal is to be proactive. Hopefully, bullying is not happening in the first place, but if it is happening, we need to use strategies to keep our seniors safe.

Questions and Answers

Would an interest checklist or survey help create an activity for people with common interests to encourage the participation of a target?

The answer to that is yes. Our occupational profile, interest checklist, or activities checklist can be helpful. For example, the PELI, the Preferences for Everyday Living Inventory, can assess common ground and bring people together to create those relationships.

What about if they disguise the bullying as humor?

What a great question. I do not think it matters. You still need to address it and say that the behavior was unacceptable. We can teach those interpersonal types of things.

References

American Health Care Association/National Center for Assisted Living (AHCA/NCAL). (2017). Bullying among seniors (and not the high school kind): A prevention and surveillance resource for assisted living providers. Available at https://www.ahcancal.org/ncal/operations/Documents/Bullying Among Seniors.pdf

Bonifas, R. P. (2016). Bullying among older adults: How to recognize and address an unseen epidemic. Baltimore, MD: Health Professions Press.

Bonifas, R. P. (2011). Understanding challenging social relationships in senior housing communities. Phoenix, Arizona: Unpublished raw data; Arizona State University.

Bonifas, R., & Casalean, M. (2017). Peer bullying and other antagonistic behaviors among older adults in independent low-income housing. Innovation in Aging, 1(Supplement 1), 919–920; doi: 10.1093/geroni/igx004.3291.

Hazelden Publishing/Hazelden Betty Ford Foundation. (2011). Bullying is a serious issue. Available at https://www.violenceprevention works.org/public/bullying.page.

Randall, P. (2005). Adult bullying: Perpetrators and victims. New York, NY: Routledge, Taylor & Francis Group.