A middle-aged man, in the midst of a divorce, loses his job and asks if he can move in with his elderly, widowed mother - for just a short time until he gets organized. As the days turn into weeks, he slowly but surely begins to take over her small apartment. Mom can't watch TV or move around freely in the apartment because he sleeps on the sofa - both day and night. So he suggests that he move to the bedroom and she sleep on the sofa. Then, he offers to do her shopping and buy her medicine, but he has no money. So he asks for her credit card. He also offers to do her banking and takes control of her money. As time goes on and he still has no job, he begins to get nervous and starts to yell at her, threatening to put her in a home if she protests. He fires the caregiver who comes a few times a week to help - isolating mom even more. As his outbursts become increasingly violent, his anguished mother, now totally dependent on him, is torn between complex feelings of guilt, love and self-preservation. This is the representative case in a film by JDC-ESHEL (a Hebrew acronym for the Association for Planning and Development of Services for the Aged in Israel, a non-profit supported by the government and the Joint Distribution Committee), as part of efforts to raise awareness of elder abuse, a subject which has only recently entered public consciousness in Israel. Despite recent headlines about institutional abuse by caregivers or violence against the elderly by strangers, the film presents what is, unfortunately, the true face of elder abuse in Israel today: a family affair. A nationwide study published in 2005, which was conducted by the University of Haifa's Department of Gerontology and School of Social Work, found that 18.4 percent (as opposed to between 4% to 10% in most Western countries) of the elderly interviewed (women over 60 and men over 65 living at home) had suffered from abuse during the year preceding the survey - and 90% of this abuse was committed by family members, either the victim's spouse or children. So what is going on in Israel? "It all depends on how one defines abuse," explains Noa Stollman, who deals with elder abuse in the Department for Aging of the Jerusalem municipality's Social Services Department. The World Health Organization (WHO) defines elder abuse as "a single or repeated act, or lack of appropriate action, occurring in a framework in which there is an expectation of trust, which causes harm or distress to an older person." "In the Israeli survey, a very wide definition was used that included neglect," Stollman continues. "Other countries look only at physical, psychological and financial abuse." The University of Haifa study, which included both Jews and Arabs, found only 2% of the abuse to be physical, 6.6% financial and 14.2% verbal. The largest percentage of abuse (some 18%) involved neglect - either active or passive. "What we are seeing here in the field in Jerusalem bears out the results of this survey," Stollman adds. "Almost all the abuse is by family members. It is sad that the very people who should be the support system of the elderly are the ones abusing them." Stollman relates the case of a husband and wife who had planned a trip around the world when he retired. But before they could realize their dream, the husband had a stroke. He was left physically dependent and in a wheelchair. The wife was in shock and, as her husband's sole caregiver, under tremendous stress. Neighbors called social services to report loud screaming. Upon investigation, it was found that she was telling him that he had ruined her life and if he didn't behave she would put him in a home. She was also physically abusing him. Stollman's department stepped in - providing a part-time caregiver for the husband plus part-time enrollment in a day-care center so the wife could have a respite from his care. It also arranged counseling for the wife. This enabled the husband to remain at home and the wife to better care for him. "It is important to be aware that abuse can happen even in normal families when under terrible stress," she goes on. "The public must be aware of this and aware that there is help for such families." Some of the abuse is financial. "We had one man forced to give power-of-attorney to his son after he threatened never to let the old man see the grandchildren if he didn't," Stollman notes. "Another man was told he had to make his son the beneficiary of his estate or he would be put in a home. We've seen a number of cases where children have forced parents to take out loans and give them the money. Then, they don't repay the money and the parents have to sell their assets to cover the loan." With respect to neglect, Stollman says that it can range from deliberately withholding food, medicine or care, to simply not being aware of the elderly person's needs. "We have seen elderly living in apartments with no heating or with no money for food or medication because their children are not aware of the situation or do not know where to go for help." And apparently the older and more frail the elderly person is, the more he or she is apt to fall prey to abuse. A 2006 survey, carried out among patients admitted to Rambam Medical Center in Haifa and Jerusalem's Hadassah-University Hospital at Ein Kerem found that 25.6% suffered from abuse, 7% of it physical. Women are more likely to be victims than men, both because they live longer and are less financially independent. Arab women are the most vulnerable to physical abuse. The elderly make up some 10% of Israel's population nationwide. Although Tel Aviv and Haifa have higher percentages of elderly residents (between 15% to 18%), Jerusalem, with slightly less than 10%, as Israel's largest city, has, in absolute numbers the largest elderly population in the country. Some 70,000 elderly, men over 65 and women over 60, live in Tel Aviv. According to the Israel Police, 2006 actually saw the number of violent assaults against the elderly decline. 2,236 complaints of violent assaults were reported to the police, compared with 2,133 complaints in 2005, a decrease of 4.6%. In addition, 626 robberies were reported by Israel's elderly in 2006 compared with 813 complaints made in 2005, a decrease of 23%. "Abuse can take many forms," says Nathan Lavon, founder and chair of Ken Lazaken, an independent advocacy group for the elderly. "It can be as simple as pulling the plug out for the TV in the case of an elderly person who is unable to get up and plug it in again. Much of it involves paternalistic attitudes toward the elderly, and sometimes the abuser is not even aware." Lavon cites a case where a woman was sick and her husband is in the early stages of dementia. Their daughter decided they should move to an apartment closer to her own. She bought, renovated and furnished a place without ever asking them or making them a part of the process. "This couple did not want to move," Lavon says. "And for the husband, this might be the worst thing. Their daughter has the best of intentions but if she had any awareness of their feelings and situation, she would never have done this without talking to them first." Lavon says that he is most disturbed by what he terms "institutional abuse" by official bodies. "The message that the state gives is that the elderly are superfluous and people can do what they want to them," he emphasizes. "For example, if an elderly person needs a nursing home and can pay NIS 15,000 to NIS 17,000 a month, he can go to a private facility. If he is indigent and doesn't own an apartment, the state will put him in a public nursing home, take 80% of his elderly allowance from the National Insurance Institute (NII) and foot the bill for the rest. "But if he is not indigent, not rich, owns an apartment and has working children, then there is a problem. His apartment must be sold and the money used toward his upkeep in the nursing home. Moreover, his children will be forced to pay, in accordance with their income, toward his upkeep. This is where the abuse comes in," Lavon explains. "The family is in crisis. Instead of the state helping, it violently sticks its hands into the family's pocketbook, forcing members to choose between the elderly parent's needs and those of the children and grandchildren. There are elderly who should be in nursing homes but are not because of this law. We think that the law should include nursing-home care in the basket of health services irrespective of income," he says. Sraya Sharabi, managing director of Ezrat Avot, a community-based facility that offers social, cultural, educational and health programs and services to the elderly poor in Jerusalem's Nahalat Zvi neighborhood, thinks that bureaucratic abuse is the most common problem the elderly face. "The government and the media have started to deal with the problem of elder abuse but they take it to the extreme and do not look at the real problem," Sharabi says. "The biggest problem is the bureaucracy. Just trying to do the most basic things is what makes the lives of the elderly miserable. We constantly see elderly who tell us how they had to spend their entire day waiting in line for this or that service." He cites the fact that the elderly are forced to wait in lines at the health funds, NII, banks, government offices and other public institutions, along with 20-year-olds. "There should be designated lines and services for them. By treating them just like everyone else we are abusing them. They need special treatment because they can't run around so much," says Sharabi. "If the government would focus on creating special services for the elderly and cutting the bureaucracy, so that getting things done would be less demanding on them, it would make their lives easier and more pleasant." Carmit Chefer of the Tel Aviv municipality's welfare department told Metro that each year the city has contact with some 24,000 elderly, including some 400 elderly who reported abuse at the hands of their family members, caregivers or any other close acquaintances. "We are aware that 400 cases is just the tip of the iceberg and we are working to reveal the unreported ones," she says. Chefer cites a unique effort to handle elder abuse that gave rise to a local model developed by Tel Aviv's welfare department, and was inaugurated in 2001. "We established a multi-professional team of psychiatrists, geriatricians, lawyers, social workers and welfare officers for the protection of the elderly. This team deals with all sorts of violence against elderly from all necessary aspects, and we found that a variety of expertise often became handy in many of these cases," says Chefer. Six years after establishing the program, a guide book focusing all the knowledge the professionals have accumulated was recently published and distributed among the senior population. "Most cases [of abuse] involve neglect, while some cases involve physical abuse.We found that if it is not being treated it is most likely to escalate. "We have also dealt with a small number of cases of economic abuse, and we believe that this type of assault is the most common one. We realize that revealing this type of problem is difficult, because in many cases the elderly don't know they are being abused. It can be the caregiver who goes with him or her to the bank and instead of 300 withdraws 3,000, or the drug addict grandson, or the plumber who says 20 shekels over the phone and changes it to 50 when he realizes this is a helpless man or woman who cannot protest and is afraid to protest," Chefer says. Unfortunately, says Chefer, most cases are reported by neighbors and outside people who notice something wrong going on in a particular family. Yad Riva - Legal Aid for the Elderly has also set up a special service to provide help for elderly victims of abuse. The service, staffed by volunteer lawyers and other professionals, offers legal advice concerning the victim's rights and represents the victim in court. It also organizes lectures for the elderly on what is abuse and what can be done. "Elder abuse is very difficult to prevent, especially when children are involved," states Mickey Schindler, a Yad Riva lawyer. "Most of our cases involve emotional and economic abuse by a family member. Elder abuse has many unique characteristics due to the victim's health, ambivalent attitude toward the abusing family member, etc. That is why we have a multi-professional team including not only lawyers but also social workers and doctors who work with us. The problem needs to be addressed by a multidisciplinary effort." One of the biggest problems in treating elder abuse is lack of awareness. If one were to go by the frequency of abuse found in the University of Haifa study, the municipality should be dealing with some 10,000 cases a year. In 2006, it dealt with 500 and even this represents an increase over previous years. "We know that 500 is a low number," says Stollman. "But we simply don't know about the rest of the cases. That is why we are working to raise awareness of the problem both among social workers and other professionals and the general public." By law, cases of suspected elder abuse must be reported. This can be done by contacting the police or by calling the municipality at 106 and asking for the welfare officer for the protection of the elderly (pkidat sa'ad). In order to raise awareness of the problem and develop treatment, Jerusalem municipality has embarked on a joint project with the Jerusalem Foundation, Ken Lezaken, JDC-ESHEL, Yad Riva and the Social Affairs Ministry. In addition, the Health Ministry, along with the municipality, ran a training program for nursing-home staff aimed at raising awareness and increasing reporting of abuse. During the training, staff were taught how to recognize and prevent abuse, whether by staff or by family members. As a result of the program, this year there was an increase in reporting of abuse. In 2003, the Health Ministry issued administrative guidelines concerning elder abuse. Working with ESHEL, the ministry opened courses to provide healthcare workers with information on the subject. Since the elderly visit doctors and clinics frequently, it is important to have healthcare workers aware of what to look for. To date, a multidisciplinary staff has been trained and they will begin to initiate programs in hospitals, healthcare clinics and nursing homes, which will hopefully lead to increased reporting and treatment. " Unfortunately, elder abuse is a phenomenon in the Jewish state today. People are living longer, and very often, in their last few years, they are not in good health. But on the plus side, "there is a growing awareness of the problem and many organizations and bodies are now working to address it," concludes Schindler. Learning the tricks of self protection The Barak Project, a new pilot program to protect the elderly, has already been introduced in 22 cities across the country and is set to be expanded. Chief Superintendent Dr. Avi Zelba, who heads the Police's publicity department, told Metro, "A drug addict who needs money to buy his next dose will enter the first house he encounters, steal a 4,000 shekel TV and sell it for NIS 200." A force of 60,000 police volunteers, headed by Maj.-Gen. Uzi Rosen, teach the elderly how to do small things to raise obstacles for potential attackers, as well as to decrease the chances for a burglar to enter their home. According to Zelba, "The volunteers teach the elderly not to open the door to people they don't know, help them install peep-holes on their doors, remind them to make sure the paths they usually walk don't have high bushes or dark spots where attackers might hide and many more things that in general make them feel safer and encourage them to ask for help when they need it." The entire program is also available to Russian, Arabic and Ethiopian elderly in their native languages. To report abuse, dial 100 to contact the police. For assistance or information: Ken Lezaken - 623-1156 or 652-0197; Yad Riva - 1-700-501400; Municipal Seniors' Hotline - 1-700-700120. Elderly people who live in Tel Aviv and feel abused or need information about any issue can call the municipality's elderly line: (03) 515-4400; Sun-Thu from 8 a.m. to 4 p.m.