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nexus:
Substance Abuse: Making the Connection

An interview with Charmaine Spencer and Jeff Smith

When 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."

nexus: Let's start by fleshing out the connection between elder abuse and substance abuse. What have you observed?

Charmaine 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 violent behavior.

On 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 In families where a parent has a substance abuse problem, the kids may have withdrawn and aren't available to provide care when the elderly parent needs it, raising the specter of abuse by others or neglect.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 pressure.

nexus: 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?

JS: 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.

nexus: How realistic is it to treat someone who's eighty for substance abuse?

CS: 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 for them.

JS: 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."

nexus: An alternative approach that's gaining acceptance in Canada is the "harm reduction" model. Does it hold promise model for working with seniors?

CS: 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 the road

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.

JS: 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.

nexus: 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?

JS: 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.

The 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.

nexus: 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 perp.

CS: 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.

The 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.

CS: 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 elder abuse.

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