Substance Use Disorders: Assessment and Treatment, 2nd Edition _ ___________________________________
therapist who is experienced with addictions. Mrs. Rose will continue her treatment in the outpatient setting. *** Mr. Lathrop is a 70-year-old man with Wernicke-Korsakoff syn- drome (alcoholic dementia). As a result of his severe memory impairment, he is unable to live independently and requires assistance with all aspects of personal care. Neighbors report that Mr. Lathrop is a loner, and he is estranged from his wife and adult children as a result of his drinking. There is no one available to care for Mr. Lathrop. A geriatric psychiatrist has recommended that Mr. Lathrop be placed in a long-term care facility that specializes in dementia care. CO-OCCURRING DISORDERS Co-occurring mental health issues and SUDs are not a new problem. Yet only in recent years have they gained significant attention, spurring the search for more in-depth knowledge and treatment applications to address these challenging conditions. About 9.2 million of all U.S. adults in 2020 had both a mental illness and a SUD in the past year (SAMHSA, 2021). According to SAMHSA (2021), an individual has co-occurring disorders when he or she has one or more substance-related disorders as well as one or more mental disorders. This definition is predicated on the existence of both a substance use and mental health problem that reach a diagnostic level. Unfortunately, it can be difficult to identify a psychiatric disorder in an indi- vidual with a SUD. Often the symptoms of a co-occurring psychiatric disorder are seen as simply manifestations of sub- stance intoxication or withdrawal. Consequently, it is best for clinicians to use some sort of structured interview to explore the possibility of co-occurring substance use and psychiatric dis- orders (Wynn et al., 2013). Structured interview instruments such as the Comprehensive Addictions and Psychological Evaluation (CAAPE), which are well designed to identify both SUDs and frequently co-occurring psychiatric disorders, can be most valuable. However, it is important for clinicians to con- sider that many more adults and adolescents may be suffering from combinations of mental health issues and substance use issues that are at subclinical levels. Clinicians play an important role, as they may encounter these clients and provide interven- tion before the illnesses reach clinical levels. Unfortunately, many individuals with co-occurring substance use and psychi- atric disorders do not receive integrated treatment for both disorders. According to research done by Lambert-Harris et al. (2013), approximately 81.1% of substance misuse treatment programs across levels of care offer addiction-only services, 18.3% offer dual diagnosis-capable services (services that can identify and refer for treatment of co-occurring psychiatric disorders), and less than 1% offer dual diagnosis-enhanced services (services that can both identify and treat co-occurring psychiatric disorders). Relative to residential and intensive outpatient programs, outpatient programs are more likely to have greater dual-diagnosis capability.
All of the psychosocial modalities that are employed for treatment of substance use in younger populations can be adapted to work with older populations. Twelve-step programs, cognitive-behavioral therapy, insight therapy, and behavior modification approaches can all be useful techniques with older people with a SUD (Farkas, 2014). Treatment programs geared toward older adults, including inpatient, outpatient, or home-based treatments, can be successful and should be pursued with the client and his or her family. Engaging older adults to join or participate in groups can be quite challenging. It may be best for the client to first visit and observe a part of a group session, with progressive attendance and participation. The counselor or therapist leading the group can facilitate the process by introducing the person to others, if the older adult agrees. It is important to remember that, for several reasons, older adults may be uncomfortable with the idea of a “group.” For example, the older adult may be intimidated by the language used by the participants or in the group’s title. Therefore, therapeutic groups for older adults should avoid the use of psychological jargon and acronyms. If leaders do use such terms, they should explicitly describe the meanings to the group. Older adults, raised during a different generation and culture, may also prefer to remain private about life issues, including drinking and drug behavior. Counselors and others leading groups for older adults should be respectful of an older adult’s comfort level, and they should make sharing voluntary for members. Family members also can become a focus of treatment to increase their understanding and aware- ness so that they can offer informed and useful support. Treatment services can be offered in a variety of formal set- tings, with different levels of intensity, including outpatient, residential rehabilitation, inpatient, and inpatient/outpatient detoxification treatment. The following case examples illustrate different settings of care options for older adults: Mr. Pruitt is a 73-year-old man who presents to the emergency room after a fall. He has chronically abused alcohol for nearly 50 years and has an elevated blood alcohol level at the time of his emergency room visit. He has numerous medical problems, including cirrhosis, congestive heart failure, diabetes, emphysema, and arthritis. He is independent in performing all activities of daily living and ambulates well. His history of falls appears to be related to intoxication. He is estranged from his two children, but they have indicated interest in resuming a relationship with their father if he commits to sobriety. Once his acute medical status has been stabilized, the medical team recommends transfer to the inpatient detoxification unit in anticipa- tion of necessary medical oversight of his multiple health conditions during the withdrawal period. He will continue through the outpatient program after his initial inpatient detoxification treatment. *** Mrs. Rose is a 69-year-old widow who has developed what she calls a “drinking problem” after the death of her spouse 1 year ago. She is generally healthy and independent in all areas of life. However, she is severely depressed and still grieving the loss of her spouse; she tries to cope with her depression and grief by drinking. She is now seeing a
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