interview with Charmaine Spencer and Jeff Smith
Charmaine Spencer, a research associate and adjunct professor
at the Gerontology Research Centre in Vancouver, reviewed the
literature on elder abuse, she found that 157 publications identified
substance abuse as a risk factor. However, she also found that
virtually no intervention programs acknowledged this connection.
When Jeff Smith, a substance abuse specialist at the Older Adult
Recovery Center in Ann Arbor Michigan, observed the same link
and tried to stimulate collaboration between protective service
and substance abuse professionals, he discovered that the two
fields were divided by "clashing paradigms."
Let's start by fleshing out the connection between elder abuse
and substance abuse. What have you observed?
Spencer: Sometimes it's the perpetrator who has a substance
abuse problem. When substance abusers have tapped out other sources
to pay for their drugs, some turn to their elderly parents. If
they can't intimidate the older person, the next step is to physically
assault him or her. Some people abuse while they're intoxicated
but we don't know exactly what the relationship is between substance
abuse and violence. Some think that alcohol lowers inhibitions
but we also know that certain people use substances to rationalize
the other hand, it may be the victim who has the substance abuse
problem. High levels of alcohol consumption negatively affect
people's health, mobility, and short-term memory, and may lead
to cognitive impairment and respiratory problems. All of these
conditions increase risk by undermining the older person's independence.
In families where a parent has a substance abuse problem, the
kids may have withdrawn and aren't available to provide care when
the elderly parent needs it, raising the specter of abuse by others
or neglect. Or, it may be that an estranged child ends up providing
care and resents it. We also know that children of long-term substance
abusers are likely to develop irritable or controlling personality
traits. For some victims, particularly women, alcohol is their
escape or coping strategy. We also know that women who experienced
child abuse, sexual abuse, incest, or date rape, are far more
likely to have substance abuse problems. So, what we're seeing
with some older substance abusers are the long- term consequences
of abuse that started thirty, forty, or fifty years ago.
Jeff Smith: A scenario we're seeing is where an older adult
lived alone until a younger relative, typically a grandchild they
raised, returns home. The younger person moves in "temporarily"
but then starts dealing drugs or engaging in other criminal activity.
When the elders get nervous and ask them to leave, the younger
adults may threaten them. But they realize that if they harm the
elders, they'll lose their base of operation, so, instead, they
entice or even force them into taking drugs. They may expose the
seniors to their own drug of choice or give them alcohol. Or the
older persons may turn to alcohol to deal with the threats and
With all of these connections between elder abuse and substance
abuse, why aren't we seeing more cross-referrals or coordination
between substance abuse and protective service programs?
I see it as a problem of "clashing paradigms." When I was at the
University of Utah, we hosted a discussion for traditional substance
abuse treatment folks and Adult Protective Service (APS) workers.
When we threw out a couple of cases, it became very clear that
members of the two professions came up with very different solutions.
If an elderly person is unsafe as a result of substance abuse,
APS workers will do things to make them safe. Many of these actions
would be viewed by substance abuse treatment therapists as "enabling,"
because they enable the person to continue their substance abuse.
To substance abuse professionals, success is getting the older
person treatment for their addiction so they're able to make decisions
that will keep them safe.
How realistic is it to treat someone who's eighty for substance
Traditional substance abuse approaches have limitations. Most
insist that the person stop right now and detoxify before they
get services, which may be unrealistic for seniors. Also, traditional
approaches have a strong cognitive component that involves thinking
through where the person is with their life. People with limited
education, health problems, or who have trouble thinking in abstract
terms are going to struggle with it. There are also practical
barriers. Realistically, Alcoholics Anonymous (AA) is one of the
few resources available across the country. The meetings are almost
always in the evening when seniors don't go out. Inpatient programs
are set up so that you go in for 28 days and you're processed
like you're in a little factory. The pace isn't geared to seniors.
Some of the programs assume that people may need to "hit bottom"
before they're ready to accept help. For seniors, hitting bottom
can mean death. Or, it may mean becoming so incapacitated that
they're institutionalized. And the "helping hand" may not be there
That's because traditional substance abuse programs in the
United States aren't set up to do outreach. The culture in AA
is "if you like our message, come and see us."
An alternative approach that's gaining acceptance in Canada is
the "harm reduction" model. Does it hold promise model for working
The harm reduction approach sees drug use as complex and multifaceted,
and non-judgmental. It looks at related issues like isolation,
past trauma, poverty, and discrimination, which can affect vulnerability
and a person's ability to deal with the harm that arises from
their substance abuse. It recognizes that while alcohol or drugs
are harmful, there may be other harms that are more serious at
a particular point in time. It helps them deal with the immediate
threat so that they have a choice about their substance use down
A concern that some people have with the model is that it "aids
and abets" the substance abuser. It does, if you assume that abstinence
is the ultimate goal. If the ultimate goal is improving the person's
situation - their health, their environment, or stopping elder
abuse, then it's not. It's facilitating the person's independence
and helping them get to the point where they're better able to
make decisions about their own lives. Many of the strategies that
APS workers use - reducing isolation or referring clients to meal
programs and support groups - are harm reduction strategies.
I'm very familiar with the harm reduction model. If a person is
admitted to our treatment program, I don't feel comfortable treating
them with harm reduction when abstinence seems to be the preferred,
and probably more effective, model for treating them. Where I
do practice harm reduction is in our case finding program. We
now have an outreach worker who provides a variety of services
to make people safer - things that would be considered treason
under a traditional substance abuse treatment model - but we go
beyond that. While we're providing support, we leave literature
about alcohol and talk to clients about their use of alcohol.
If a client tells us they've fallen, we ask if they'd had anything
to drink before the fall and if they think that may have had anything
to do with it. I totally agree that it's too risky to let an older
adult "hit bottom." But there's denial associated with chemical
dependency, and with older adults, it's more than just psychological
denial. It's fueled by shame, poor self-esteem, and short-term
memory loss. The drugs affect the tools that an individual needs
to change his behavior. So you need to bring a "controlled bottom"
up. You give the person feedback and consequences but, at the
same time, offer support to deal with the consequences.
In the elder abuse prevention network, we're starting to see substance
abuse treatment techniques being used. Will we also start seeing
codependency groups, comparable to AA's groups for adult children
of alcoholics, for seniors whose children are substance abusers?
First, let me start by defining codependency. Someone who is chemically
dependent is dependent on the chemical. Someone who is codependent
is dependent on the person who's dependent on the chemical. They
structure their lives, decisions, and emotions around the needs
of the chemically dependent person.
type of program you're talking about already exists. It's the
growing "grandparents as parents" movement. If you look at the
majority of grandparents raising grandchildren, the missing generation
is missing because of substance abuse. We do training with a local
group and again, we need to modify the "hard line," substance
abuse model. That's because a non-enabling approach would be "don't
raise your grandchildren - it's your children's responsibility."
Instead, we offer skills and support for dealing with the grandchildren
but also talk about codependence. We address the grandparents'
sense of guilt and responsibility, how they think they made mistakes
raising their own kids, and the anger they feel at having to be
parents, instead of grandparents, to the children.
What are the mistakes you've seen professionals in the field of
aging make in dealing with substance abusing victims or perpetrators?
JS: They're not recognizing it. The typical symptoms of
older adult substance abuse are identical to those of a lot of
other diseases associated with aging, including short-term memory
loss, depression, high blood pressure, uncontrolled diabetes,
isolation, and incontinence. My frustration is that workers aren't
even asking about substance abuse, either with the victim or the
Substance abuse also raises such strong emotional reactions. A
few years back, a hospital here did a survey of professionals
in which they asked how many of the responders had family members
with substance abuse problems. One third responded that they did.
So workers' experiences, either positive or negative, are going
to affect how they see the problem. They may assume that the person
brought the problem upon himself, they may want to rescue him,
or they may get frustrated with other family members who don't
want to break off their relationships. There's also ambivalence
about older substance abusers. Some consider it a matter of choice.
They say, "well, he's an old guy with so few pleasures left in
his life, why not let him have this?"
JS: Aging service providers also have misconceptions about
traditional substance abuse treatment. They make the assumption
that if a client is alcoholic, they'll have to confront him and
confrontation is something that nobody likes. But there are lots
of ways to present the information.
minute some APS workers see that either the perp or the victim
is a substance abuser - particularly if the perp is an elderly
substance abuser - their eyes glaze over and they assume they
can't do anything. They get incredibly overwhelmed and a hopelessness
sets in. It's a self-fulfilling prophecy. If you're feeling hopeless,
then you're right, there's no way to help them. But a few studies
have shown that once someone over 60 gets treatment, they are
more likely to stay sober for a year than someone under 60.
I agree that there is hope. People come to a different understanding
of their situations when they get older. They start to think about
how they want to spend the rest of their lives. Things that they
were willing to put up with five years ago, or even last month,
may not be okay today. That's true for both substance abuse and
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