Barriers to Receiving Help

In a three year study, we examined the range of personal and systemic obstacles to treatment facing older adults with alcohol or other drug problems.  

Only a very small percentage of seniors who have a drinking problem receive treatment. Up to this point, it has generally been assumed by many that seniors who have alcohol problems are unwilling to seek treatment. Much of the responsibility (or "blame") for the discrepancy between the apparent need among the seniors and their (lack of) use of current treatment programs has been placed on their attitudes and beliefs. 

It has been assumed (and it is common to hear) that few seniors seek or receive treatment because 

• they won't admit they have a substance abuse problem, 
• they won't refer themselves to programs or 
• they are not motivated enough to stay in treatment. 

This may be only one small part of the real problem that many seniors have in accessing appropriate treatment.

Systemic issues that can significantly reduce the likelihood that seniors will be directed to treatment programs. Once in a particular program, a senior can still face major challenges in being effectively served by the program. Systemic problems may include

• alcohol and drug service policies;
• attitudes of professionals and paraprofesionals; and
• alcohol and drug treatment design.

The Need for Appropriate Treatment

• for seniors even moderate drinking can result in significant health risks and complicate the management of common disorders
• a significant percentage of the medications commonly prescribed for seniors adversely interact with alcohol (synergistic effect)
• elderly problem drinkers make up a disproportionate share of the patients seen in hospital and outpatient clinics (Lisansky, 1988)
• alcohol abuse represents a significant risk of losing independence (affects physical and mental health, cognitive functioning, personal safety seniors are usually only
• diagnosed after some form of crisis has arisen (e.g. health, housing)
• problem drinkers are often the victims of self injury or self neglect
• seniors are more likely to suffer medical sequelae associated with heavy drinking (Naik & Jones, 1994)
• the problem interferes with seniors' physical, spiritual and emotional wellbeing
  

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Types of Barriers to Treatment

In the course of talking with seniors experiencing problems and agencies that provide treatment services, we found many barriers that effectively "shut seniors out." Several of these have been noted in the gerontological  literature.

Attitudinal and Behavioural

The Senior: An older adult may deny having problem, may not recognize the symptoms of alcohol abuse, or may wrongly interpret alcohol-related symptoms as aging effects.

• "How can I have a problem? I'm not drinking any more than I did 20 years ago"
• "I can't be a drunk, I only drink sherry."
• "It helps me with my stomach troubles/ sleeping."
• "It's good for my spirits."
• "I feel better if I drink" (anticipatory beliefs)
• "My anxiety/loneliness will go away if I take drink." (relief oriented beliefs)

An older couple may face social barriers, including privacy and generational issues- such as the expectation "don't wash your dirty linen in public."

Seniors' unwillingness to enter treatment may be a result economic circumstances (they can't afford treatment). Some seniors believe that it is inappropriate to spend money on themselves for treatment (self denial; saving it for the children's inheritance)

Being labelled both "old" and "alcoholic" can create a double stigma.

Family, Friends, or Peers:

Family may feel uncomfortable discussing the issue, believing that it shows disrespect to one's elders. They may accept or rationalize the problem (ignoring the negative aspects of the senior's drinking behaviour). Family and friends may engage in enabling behaviours- shielding or in some way easing the immediate problems created by drinking or drug use (Meagher, 1987). For example, buying the alcohol for the senior because he or she can no shop. Family may engage in behaviour such as taking parents out of programs or encourage them to leave; sabotaging the help or situation; making excuses for the senior's actions:

• "Well, she's 86, she's only going to live a few years, let her have her little pleasures"

• "How much harm can a couple of drinks do?"
  

Research indicates that women have twice as many active enablers as men (Tabisz et al. 1993). Family sometimes avoid confronting the problem because it may mean having more contact with the parent or having to examine family dysfunctions. Others avoid the issue out of concern over collateral issues, such as protecting the family inheritance.

 

Seniors Organizations, Care Facilities

These are two groups that one might consider as having an important role in identifying  alcohol problems. However, there are challenges such as:

• the invisibility of the seniors who have the problem: "It isn't a problem in our facility; we don't see it"

• the belief "It would reflect poorly on our organization to talk about it"

• denial- "That stuff only happens Downtown-Eastside" or "That only happens in the city."

• "Seniors aren't interested in it as a topic"

• "That's a private matter, not something that our organization should dwell on"

• "What right do I have to tell an 78 year old man who was successful in business what he should do with his life?"

• discrimination: many care facilities and other residential settings refuse to accept individuals with a history of drinking problems

Professionals and Paraprofessionals (people in a position to detect alcohol problems) may

• have moralistic attitudes ("anyone with enough willpower can stop drinking if they want")

• fall prey to story telling "well, you know my grandmother used to keep a bottle by her bedside, and she obviously could not have had a problem"

• have pessimistic attitudes to treatment of older adults ("can't teach an old dog new tricks)

• perceive alcohol problems as a symptom of underlying mental disorder (e.g. depression)

• fear confrontation

• assume that people must be motivated to change before change or help is possible

• be in denial: treat the symptoms, not the problem (e.g. insulin for diabetes)

• give inappropriate referrals: lack of knowledge of whether an agency is capable of meeting seniors needs

• misdiagnose and masking of symptoms

• have a prescribing behaviour that (physicians are more likely to prescribe mood altering drugs to women with symptoms of anxiety or depression rather than confront an obvious drinking problem in their older patient

• lack knowledge/ act from ignorance: less likely to diagnose it than if was younger patient (Curtis et. al, 1988)

• have discomfort with their own use of alcohol or a family member's use of alcohol

• be susceptible to stereotypes: less likely to detect it among people with higher incomes, higher education

• may be susceptible to prevailing myths, such  as "Why help the 80 year old alcoholic?"

• fall prey to "tardy referral syndrome"- help is not sought until it is absolutely necessary- often due to a medical crisis exacerbated or caused by alcohol consumption

• be complacent : accept the premise that the issue is too difficult due to patient denial and social isolation; that is not one worth tackling (Tabisz et. al 1993)

• have a bias against labelling a 70 year old as having an alcohol problem (especially using the label'alcoholic') (Schiff, 1988, at 41)

• be subject to decision rules developed by outreach workers-  e.g., a response to alcohol problem is necessary only if the problem interferes with the service provided (Graham & Romananiec, 1986)

• have stereotypes of the "smelly, rude, 'non-compliant' skidrow alcoholic (Willenbring & Spring, 1988, 27)

• have personal beliefs about what the goals of treatment should be - abstinence vs. controlled drinking (the senior's goals may be different)
  

Barriers within the Alcohol and Drug System

• political will

• budget restraints

• "protecting your turf"; maintaining the status quo: leads to failure to evaluate relative effectiveness of existing program

• lack of knowledge of the aging process and how that may affect seniors' ability to access the treatment system

• lack of awareness that seniors are far less likely to reach out for help; lack of awareness of the special treatment needs of seniors (Pruzinsky)

• narrow model/ theory of treatment

• assumptions about the homogeneity of clients: that all adults with alcohol problems can be served by the same approach

• lack of co-ordination of services (after care needs not being met)

• expectations for clients: There has been a heavy reliance on traditional groups (e.g. A.A.) to support the person after counselling, without considering whether seniors are willing feel comfortable with this type of approach and whether those traditional groups feel comfortable with seniors

• definition of 'productive" treatment centers that focus on non relevant goals for many seniors, such as helping clients remain employed or return to work.

Even Specialized Services for Seniors Can Create Barriers

• heavy reliance on voice mail; answering machines- hard for a senior to connect to a real person. They give up before they can start.

• waiting time to treatment; waiting lists (increases likelihood of deterioration/relapse)

• complexity of the issues (e.g. isolation, housing, health problems, financial problems, family relationships)

• staff's relative awareness of resources for collateral issues

• the reluctance (or the lack of resources) to carry demonstration projects further

• location (accessibility; safety for seniors)

• denial of the heterogeneity of seniors (lack on individualized approaches)

• designing programs for seniors but with lack of knowledge of the special ways aging affects alcohol issues

• case load pressures (off loading before client is ready)
  

Structural

Agency's mandate:
Agency's admission criteria: e.g. ambulatory, able to take care of personal needs; no medications, effectively exclude many seniors.

Staff's attitudes- at reception; on intake

• towards seniors

• towards seniors' chances for recovery

• the way in which priorities are set

• "well, if they come in they have to go by our rules"

• senior has to come to the office to show that is "motivated" (this requirement ignores the poor health of seniors who have alcohol problems)

• voice mail; answering machines

• structure of the program: the rigidity of the program (time of arrival; cognitive/ reflective focus versus concrete approach of the program)

• the effect of other participants in the program- seniors reactions to other people (senior may feel uncomfortable with younger adults especially if the younger adults use illegal drugs; seniors may feel that they different needs and issues to be addressed)
  

References

Curtis, J.R., Geller, G., Stokes, E.J., Levin, D.M. & Moore , R.D. (1989) "Characteristics, diagnosis and treatment of alcoholism in elderly patients" J. of the Amer. Geriatrics Society 37 (4) 310-316.

Graham, K. & Romaniec, J. (1986) "Casefinding vs. right to privacy: a general dilemma emerging from a study of the elderly" J. of Drug Issues 16 (3) 391-5.

Gulino. C. & Kadin, M. (1986) "Aging and reactive alcoholism" J. of Geriatric Nursing 7 (3) 148-151

Lasker (1986)""Aging alcoholics need nursing help" J. of Gerontological Nursing 12 (1) 16-19

Naik, P.C. & Jones, R.G. Jones (1994) " Alcohol histories taken from elderly on admission" Br. Med. J. 308 (6923) p.248.

Pruzinsky, E.W. (1987) "Alcohol and the elderly: an overview of problems in the elderly and implications for social work practice." J. of Gerontological Social Work 11 (1-2) 81-93.

Rehmar. M. (1988) "Sensitizing practitioners, families and elderly persons" Pride Institute J. of Long Term Home Care 7 (2) 22-29

Tabisz,

Widner, S. & Zeichner, A. (1991) " Alcohol abuse in the elderly: review of the epidemiology research and treatment" Clinical Gerontologist 11 (1) 3-18.

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