Working with older adults who struggle with substance abuse is extremely complex. Each individual has a different story to tell. Many older adults, who have used substances over the course of their life spans, often have a tremendous amount of shame, remorse, and sadness. Many of these individuals endured some form of trauma and many speak about disappointing others, losing relationships, and missing opportunities. Aside from the psychological, biological, and physical changes associated with getting older, substance abuse often plays a role in the assessment of safety and risk. Moreover, despite enduring years of substance usage, there are many individuals who hope to live out their life with a sense of serenity and peace within themselves.
Maxine, “Maxi,” said the people on her block called her “hot stuff” when she was younger. She grew up in a close-knit community of South Philadelphia. Her parents were working class folks. Her father was a cook in a local restaurant, and her mother cleaned houses to get by. She described her parents as hard working but distant and abusive. She had a younger brother named “Mikey,” and Maxi described their relationship as close. They were only two years apart in age and often hung out with the same circle of friends. They first experimented alcohol together. Maxi was 14 and Mikey only 12. Maxi reported her father raped her as a child and she felt protective of her brother. Maxi dropped out of school in the 11th grade after becoming pregnant with her first child. It was a crisis time in her life. She had begun drinking heavily during her pregnancy, and the baby was eventually turned over to social services when Maxi was just 16 years old. As Maxi tells her story, the tears begin to fall, for this would be the beginning of a 50-year battle with substance use which included alcohol, marijuana, crack/cocaine, and eventually heroin which would become her drug of choice.
Today Maxine is 67 years old. She suffers from years of trauma and abuse, and is being treated for depression, diabetes, hypertension and Hep C. She is in and out of hospitals for both psychiatric and medical reasons. Maxine recently shared with her therapist that she feels helpless and out of control. She is quite lucid, when sober, and candid about how getting high offers her a sense of control in an otherwise chaotic world. This dichotomy is not unusual for people with addictions and for older adults, like Maxine, who have endured many years of trauma and rejection. There is most definitely a self-fulfilling prophecy at play here. The decision to address her painful past is often masked by self-medication and self-loathing.
Vincent, “Vinny,” is 72 years old. He worked for many years in construction and grew up in an Italian-American enclave in Brooklyn. He described his childhood as normal but regimented. His parents were demanding and emotionally cold. He started going to the dance halls when he was 18. Jim Beam became his best friend. He’d often stay out for days on end and had numerous girlfriends. He was arrested on numerous occasions for quality of life crimes. On one occasion he was mandated to attend AA meetings and see a counselor due to his anger management issues.
When Vinny was 25, he married and eventually had two children. For a number of years, the marriage appeared stable, but Vinny started drinking more heavily and using Quaaludes and speed. He was increasingly more explosive at home, and his children began to fear him. His wife began to question his late-night outings and elusive behaviors. Confronted by his wife, a drunken Vinny became enraged and assaulted her. He found himself in jail and was once again mandated to treatment. This time he was diagnosed with Bi-Polar I Disorder, Manic type. The diagnosis confused the family, and Vinny denied it for many years. Eventually, Vinny’s wife divorced him and he lost contact with his family for a time.
Vinny’s story is an all-too-common and disheartening tale. During most of his adult life, Vinny found himself in and out of jail, rehab, and psychiatric hospitals. Attempts to reconcile with his former wife proved fruitless; however, his grown children helped him obtain treatment, and their relationship has improved.
Now living in a supported housing program, Vinny has been sober for over 10 years. Through his recovery, the assistance of a therapist, and a home health aide, he has learned to manage his anger and handle daily activities. While his family relations remained strained, there has been some improvement. Vinny is grateful and takes life one day at a time.
As Laura Kerr writes in her article Taking That Leap of Faith, (2013) “Being human is a fallible and messy enterprise, especially when traumatic stress is thrown in the mix.” Approaching a person with interest rather than judgment, or asking ‘what happened to you’ instead of ‘what’s wrong with you,’ is an important step in building and strengthening the relationship.” While there is no one right way to approach older adults with histories of substance use it is essential to maintain the basic tenets of behavioral health practice which includes treating all individuals with dignity and respect. Change can be particularly slow for older adults. Working thru years of trauma, shame and neglect often evokes painful memories and the therapist must be prepared. While there are a myriad of approaches used in the treatment of substance abuse, adapting a cognitive behavioral treatment (CBT) approach challenges our clients to re-imagine what new relations may look like instead of dwelling on the past. Similarly, as was the case with Vinny, Dialectical Behavioral Treatment, a form of therapy that teaches patients how to regulate emotions was effective in helping him to get more in control of his anger. Through his course of treatment, homework was assigned, and Vinny learned to socialize with others in ways that felt more congenial and less volatile. Vinny also benefited from the structure of attending his psycho educational groups and being around others. He recognized the dangers of isolating which often triggered his temptation to drink. Mindfulness techniques are another effective tool that helps individuals to envision new ways of living. Despite their age, older adults may be encouraged to see their later years filled with happy, healthy relationships that also involve sober living.
It’s particularly important for staff, who work in the field of substance abuse with older adults, to be aware of their own expectations regarding change. As clinicians we need to meet the client where they are and not where we want them to be, as everyone is unique. With empathy, lots of patience, understanding, and consistency, the possibility for change can be realized. Whether meeting with a Substance Abuse Counselor, or therapist or participating in group therapy the vision of a hopeful future must be preserved and reinforced. Older adults who have used substances often hide in the shadows. Therapists must acknowledge the survival skills of the individuals who have lived with years of pain. As Frederic Blow, Professor in the Department of Psychiatry at the University of Michigan and a specialist in addictions states “Older adults can recognize all kinds of benefit from treatment. There are often direct health benefits, improved cognition, more independent living, more and better social connectedness, and new hobbies. The benefits are enormous.” It’s all about hope and resilience.
Debora Dawson, BA, is a Substance Abuse Specialist at ICL’s Stepping Stone Residence; David Kamnitzer, LCSW-R, is Senior Vice President of Residential, Rehabilitation & Support Services at ICL; and Darren Pelled, LCSW, is Associate Director of the Stepping Stone Residence at ICL.