Interactional perspectives on the mistreatment of older and vulnerable people in long-term care settings

This article draws on a study aimed at developing theoretical and methodological understanding of the abuse and neglect (mistreatment) of older people in long-term care settings such as care homes and hospitals. It presents an interactionist account of mistreatment of older people in such establishments. Starting with an outline of definitional issues surrounding the topic, the allied concept of dignity is also briefly explored, and one important model described; we present dignity as the converse of mistreatment. The article argues for the potential of a positioning theory analysis of mistreatment. Positioning theory proposes that interactions are based on taking of 'positions', clusters of rights and duties to act in certain ways and impose particular meanings, which enable or prohibit access to certain storylines. It is argued that 'malignant' positioning can contribute to the creation of a climate that allows mistreatment to take place, or fails to prohibit its development. Mistreatment of people with dementia is used as an illustration, and it is argued that this is potentially generated by negative feedback loops of behaviour patterns, interpretations and malignant positioning by staff or family carers and subsequent response to these interpretations by the person with dementia. Positioning theory also allows for an explanation of the importance and impact of organizational cultures and social factors such as ageism. Individual staff members take positions, use meanings and develop storylines imbued with such factors. This understanding therefore overcomes some of the potential confusions created by concepts such as organizational or institutional abuse, removing the need to ascribe intentions and personal responsibility to such constructs. The article concludes with some suggestions for further research to develop an understanding of the kinds of cultures that allow mistreatment and consequently to inform the development of protective measures.