Running head: TREATMENT PREFERENCES OF OLDER ADULTS

Treatment Preferences of Older Adults with Substance Use Problems

Jason M. Holland1, Vincent Rozalski

1, Lisa Beckman

1,

Liya M. Rakhkovskaya1, Kara L. Klingspon

1, Brad Donohue

1,

Carl Williams2, Larry W. Thompson

3, and Dolores Gallagher-Thompson

3

1University of Nevada, Las Vegas

2VA Southern Nevada Healthcare System

3Stanford University School of Medicine

This study was funded by a Faculty Opportunity Award, which was awarded to Dr. Holland by

the University of Nevada, Las Vegas. Correspondence regarding this manuscript can be directed

to Jason M. Holland, Department of Psychology, University of Nevada, Las Vegas, 4505 S.

Maryland Parkway, Box 455030, Las Vegas, NV 89154-5030. Phone: (702) 895-3703, Fax:

(702) 895-0195, Email: jason.holland@unlv.edu.

In press, Clinical Gerontologist

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

Abstract

Alcohol and drug abuse are growing problems among older adults. There is some evidence to

suggest that seniors may have better outcomes in age-specific substance abuse programs.

However, little is known about the specific treatment preferences of older adults with histories of

drinking and/or drug problems. Thus, this qualitative study investigated the treatment

preferences of older adults with recent histories of substance abuse problems and their

impressions regarding the most helpful and unhelpful aspects of treatment. Based on extensive

interviews with 15 participants, older adults were found to prefer programs that are: (1)

accessible, (2) led by warm, caring, and non-confrontational therapists, (3) able to provide peer

support and individual attention, and (4) open to friend and family involvement.

Keywords: Alcohol, Drugs, Substance Abuse, Geropsychology, Gerontology, Treatment

Preferences

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

Treatment Preferences of Older Adults with Substance Use Problems

The past two decades have seen dramatic increases in the need for geriatric substance

abuse treatment. From 1992-2009, the proportion of individuals age 50 or older admitted for

treatment of alcohol abuse increased from 6.6% to 12.7%. The problems faced by these

individuals has also become more severe, with 42% of admissions reporting combined alcohol

and drug abuse in 2009, compared to only 12.4% in 1992 (SAMHSA, 2011). In light of this

growing prevalence, evidence-supported treatment programs are sorely needed for substance

abusing late middle-aged and older adults. Substance abusing older adults who participate in

elder-specific interventions stay in treatment longer, attend more sessions, and have better

outcomes, compared to those in more generic forms of treatment (Blow et al., 2000; Kashner et

al., 1992; Kofoed et al., 1987). However, 82% of substance abuse treatment centers do not

provide special services for older adults (Rothrauff et al., 2011).

Although there are some findings that suggest that older adults may prefer a supportive

and non-confrontational approach to substance abuse treatment (Kashner et al., 1992; SAMHSA,

1998), little information has been collected about the specific treatment preferences of older

adults with substance abuse problems. Therefore, the purpose of this study is to systematically

examine the treatment preferences of older individuals who have recently received treatment or

formal support for substance abuse-related problems.

Method

Participants

To be eligible for this study, participants needed to have received treatment (e.g.,

residential program or outpatient therapy) or formal support services (e.g., regular attendance at

Alcoholics Anonymous meetings) for a substance abuse problem at age 50 or later. Participants

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

were recruited by hanging flyers on community bulletin boards, posting online announcements,

publishing newspaper advertisements, and snowball recruitment efforts. Individuals were paid

$30 each for their participation.

Following institutional review and approval, 15 participants were recruited. Participants

were interviewed in a small focus group format in six separate groups. On average, 2.5

individuals were in each group (Range = 1 to 6 participants). The mean age for the sample was

59.86 (SD = 4.28 years), and the sample was predominantly comprised of men (86.7%) and

military veterans (73.3%). Most participants identified as African American (60%), with 33.3%

identifying as European American and one participant (6.7% of the sample) identifying as Asian

American. Participants’ most recent experiences with treatment or formal support services for

substance abuse were diverse. Some received treatment for either alcohol (26.7%) or drugs

(26.7%), but others had sought treatment for both (46.7%). The most commonly reported types

of recent treatment included group-based outpatient treatment (73.3%), 12-step-based programs

(60%), individual outpatient treatment (53.3%), and residential treatment (46.7%), all of which

were received after age 50 (within the last five years for 80% of the participants). Most (64.3%)

indicated that their recent treatment experiences were generally helpful (as indicated by a score

of 7 or more on a scale from 1-10); whereas, 28.6% and 7.1% had more neutral (with scores

from 4-6) or negative experiences (scoring 1-3), respectively.

Interviews

The guiding and overarching research question of this qualitative study was: What do

older adults with recent histories of substance abuse believe are the most helpful and unhelpful

aspects of substance abuse treatment? Specific interview questions were designed to elicit

responses that would address this overarching research question. Because of our interest in

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

substance abuse treatment preferences in late-middle and older adulthood, these questions

focused largely on “recent” treatment experiences, rather than those that may have occurred

during earlier developmental periods. Questions were kept fairly broad and open-ended with

little prefatory information, so as to not lead participants or bias their responses. Specifically, the

interview centered on six questions:

1. What did you find most helpful about your most recent treatment for alcohol or drug

problems?

2. What did you find least helpful?

3. If you could change one thing about the most recent treatment you received, what would

it be?

4. What kinds of barriers did you encounter in your most recent treatment experience?

5. How might your therapist have helped you overcome these barriers?

6. What are the most important pieces of information a therapist needs know about working

with someone your age that is facing problems similar to the ones you’ve faced in your

life?

Using these questions, a semi-structured interview protocol was collectively developed

and refined by the study authors for use in this study. Each focus group was facilitated by two

trained interviewers with interests and expertise in geropsychology. Interviews were generally

conducted in about one hour and were audio-recorded with a digital recorder.

Data Analysis

The focus group interviews were transcribed verbatim by a team of four research

assistants. Some portions of the interview were mutually deemed to be unintelligible, due

primarily to one participant with significant cognitive difficulties. Transcripts were divided into

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

meaning units, which were segments of the transcript, ranging from 7 to 307 words in length,

deemed to capture a singular idea or core meaning expressed by the interviewees. Meaning units

that were jointly determined to be irrelevant to the overarching research question were removed

from the analysis. These included brief agreements with other statements, general questions

about the study, and personal anecdotes that were unrelated to treatment preferences.

Consistent with grounded theory analysis (Glaser & Strauss, 1967), the remaining 221

meaning units were then organized into categories by the first (JMH) and second (VR) authors

through an inductive process, which involved comparing and differentiating each meaning unit

with the other meaning units. These categories were then compared with each other to derive

higher order factors, each of which was comprised of two or more categories. As a final step, a

codebook was created by the first and second authors, describing each category and its defining

characteristics. Using this codebook, the third author (LB) then independently categorized 70%

of these 221 meaning units to establish inter-rater reliability1.

Results

Overall, 18 different categories of responses were identified, and inter-rater reliability for

this coding scheme was found to be good (Cohen’s kappa = .70). These 18 categories were then

divided into three higher order factors, which included Individual Factors, Treatment Factors,

and Outside Factors that either helped or hindered the treatment process. These categories are

presented in Table 1, along with exemplars from the interviews.

Individual Factors

Many participants discussed individual or personal factors that may have served as

strengths or vulnerabilities in their substance abuse treatment. Specifically, participants

1 The remaining 30% of meaning units were used as practice responses by the independent rater.

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

discussed: (a) the importance of setting relational boundaries, (b) the stress of managing their

finances and difficulties affording treatment, (c) the strength derived from their faith in God or a

higher power, (d) health problems that make treatment attendance difficult and interfere with

their sobriety, (e) the importance of being able to cope with emotions and cravings, (f) the need

to take personal responsibility and stay motivated, and (g) difficulties due to stigma and shame.

Treatment Factors

Beyond these more individual or personal factors, participants’ responses also focused on

Treatment Factors, which consisted of helpful or harmful aspects of treatment programs

themselves, including the counselors working there and the program rules. In particular,

participants discussed the importance of: (a) being seen as a person, (b) having a counselor that

genuinely cared, (c) being honest in treatment, (d) receiving individual attention (even in group-

based settings), (e) having structure without strict rules that may be stifling, (f) receiving

psychoeducation about addiction and recovery, (g) good therapist self-care, (h) support from

other clients/group members, and (i) providing tangible needs, like food, clothing, and shelter.

Outside Factors

Participants also discussed Outside Factors, which the client and/or program had limited

direct control over. Participants specifically noted that: (a) friends and family can be both a

source of stress and support, and (b) identifying accessible treatment programs and obtaining

transportation can be difficult.

Discussion

Individuals who received treatment or formal support services for substance abuse

problems in late-middle or older age discussed a variety of helpful and unhelpful aspects of

substance abuse treatment, which were reliably coded into 18 categories. These categories were

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

then broadly grouped into Individual, Treatment, and Outside Factors that either helped or

hindered the treatment process.

Individual Factors refer to ways in which the participant himself or herself facilitated or

stalled their own progress in treatment. Many of the categories subsumed underneath this higher

order factor are consistent with previous research on personal strengths and vulnerabilities that

influence substance abuse treatment outcomes. For example, participants in our study

emphasized the importance of setting boundaries, productively coping with emotions and

cravings, taking personal responsibility, and being motivated to make difficult life changes.

These findings are generally in keeping with prior studies that have found that individuals who

enter treatment with greater personal strengths (e.g., those with strong motivation, adequate

coping resources, and few comorbid psychiatric problems) tend to have better outcomes (McKay

& Weiss, 2001; Mertens & Weisner, 2000; Rounsaville, Dolinsky, Babor, & Meyer, 1987).

The frequency of such themes in these interviews provides some insight into the kinds of

treatments that may be most helpful for this population. Specifically, Dupree and Schonfeld have

developed a cognitive–behavioral and self-management intervention for older adults with

substance use problems (SAMHSA, 2005). This group-based treatment program has shown

impressive results in uncontrolled studies, perhaps due in part because of its emphasis on helping

older adults learn to process and better manage difficult emotions and loss experiences that may

trigger drinking episodes or drug use (Dupree, Schonfeld, Dearborn-Harshman, & Lynn, 2008).

Other Individual Factors mentioned in the interviews were perhaps more age specific. For

instance, financial stress, health and mobility problems, and the stigma of seeking treatment have

been noted as major treatment barriers that often prevent older adults from receiving appropriate

mental health care (Solway et al., 2010). All of these themes were expressed by the participants

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

in this study. Thus, substance abuse treatment programs targeting older adults may wish to

provide accommodations that aim to help clients overcome these barriers. For example, if costs

are not completely covered by Medicaid or Medicare, substance abuse programs may wish to

offer services on a sliding scale based on income and, if possible, even waive costs for those with

absolutely no funds. Other relevant accommodations might include offering transportation

assistance, ensuring the building is accessible to those with disabilities, and being prepared to

make necessary referrals.

A number of Treatment Factors were also discussed that concerned ways in which

therapists, group leaders, fellow clients, and the milieu of therapy itself served to help or hinder

the recovery process. Consistent with research demonstrating the importance of therapeutic

alliance and group cohesion in predicting treatment outcomes (Evans & Dion, 1991; Martin,

Garske, & Davis, 2000), relational issues with therapists and other clients were mentioned as

being vital to the change process. Participants seemed to suggest a preference for therapists who

were warm, honest, caring, and relatively non-confrontational. Specifically, participants in this

study emphasized the importance of working with a therapist or group leader who could see

them as a person, genuinely care for them, and provide individual attention. These therapist

characteristics are generally consistent with a client-centered approach (Rogers, 1961).

Interestingly, participants also discussed incidents in which they believed their therapist or group

leader was not engaging in appropriate self-care practices (e.g., being too tired or stressed). Thus,

substance abuse counselors who are working with older clients would do well to adopt a client-

centered therapeutic stance and diligently attend to their own self-care needs.

The fact that many participants found moments of individual connection with the

therapist particularly helpful suggests that substance abuse treatment programs for older adults

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

should consider including at least some opportunities for one-on-one interaction, perhaps even in

group-based settings. Although participants discussed the helpfulness of getting support and

feedback from other group members, it was also acknowledged that in group settings, other

members could hinder the process, particularly in environments where there was great

heterogeneity in terms of age, severity/type of problems, and readiness for change.

Participants also expressed some ambivalence about receiving advice and prescriptive

treatments that follow structured protocols. Some participants clearly indicated that they liked

having structure and wanted their therapist to provide expert advice. However, when the advice

or protocol somehow differed from what the participant believed would be helpful, conflicts

could arise. These findings highlight the importance of developing substance abuse programs for

older adults that are fairly structured and solution-focused, but are at the same time flexible

enough to allow for plenty of client-therapist collaboration. Programs may also wish to consider

providing some tangible support to older clients (e.g., serving a lunch), which may increase

attendance rates (Donohue et al., 2015).

Finally, participants also discussed Outside Factors, which included friends/family and

other aspects of the environment that might have influenced their treatment experiences. In

particular, the older adults in this study expressed difficulty accessing high quality treatment

programs for substance abuse problems, due to issues like the lack of available programs,

insufficient funds, or transportation difficulties. Therefore, we would advocate that

administrators and clinicians working with substance-abusing older adults make

accommodations when possible and work with community leaders to resolve broader problems

(e.g., limited public transportation) that may prevent seniors from getting care.

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Participants also discussed friends and family who could make their recovery process

both easier and more difficult. Older adults with more friends and family who approve of

drinking and who participate in more social activities have been found to be more likely engage

in high-risk alcohol consumption (Moos et al., 2010a; Moos et al., 2010b). In contrast,

supportive, non-permissive family/social networks can serve to minimize older adults’ substance

abuse (Jennison, 1992; Satre et al., 2004), and some research suggests that spouse participation

in treatment improves outcomes for substance abusing elders (Atkinson et al., 1993). Thus, it

appears that family/social networks influence and are influenced by older adults’ substance abuse

behaviors, highlighting the relevance of potentially intervening at the family level. Notably, none

of the participants in this study reported receiving family-based services for their substance

abuse problems, suggesting that this may be an area in need of further study and development.

These findings should, of course, be interpreted cautiously, considering that we used a

cross-sectional design and relied exclusively on self-report interview methods. Nevertheless, the

breadth and depth of insights from these interviews represent a significant step forward in

developing “gero-friendly” substance use treatment programs.

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References

Atkinson, R. M., Tolson, R. L., & Turner, J. A. (1993). Factors affecting outpatient treatment

compliance of older male problem drinkers. Journal of Studies on Alcohol, 54, 102-106.

Blow, F. C., Walton, M. A., Chermack, S. T., Mudd, S. A., & Brower. (2000). Older adult

treatment outcome following elder-specific inpatient alcoholism treatment. Journal of

Substance Abuse Treatment, 19, 67-75.

Donohue, B., Azrin, N., Bradshaw, K., Fayeghi, J., Wilks C., Holland, J. M., Cross, C., & Allen,

D. (2015). Comparison of telephone-supported incentive programs in the improvement of

evidence-supported family therapy session attendance with child welfare. Manuscript

submitted for publication.

Dupree, L. W., Schonfeld, L., Dearborn-Harshman, K. O., & Lynn, N. (2008). A relapse

prevention model for older alcohol abusers. In D. Gallagher-Thompson, A. M. Steffen, &

L. W. Thompson (Eds.), Handbook of Behavioral and Cognitive Therapies with Older

Adults (pp. 61--75). New York, NY: Springer.

Evans, C. R., & Dion, K. L. (1991). Group cohesion and performance: A meta-analysis. Small

Group Research, 22, 175-186.

Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for

qualitative research. New York, NY: Aldine de Gruyter.

Jennison, K. M. (1992). The impact of stressful life events and social support on drinking among

older adults: A general population survey. International Journal of Aging and Human

Development, 35, 99-123.

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

Kashner, T. M., Rodell, D. E., Ogden, S. R., Guggenheim, F. G., & Karson, C. N. (1992).

Outcomes and costs of two VA inpatient treatment programs for older alcoholic patients.

Hospital & Community Psychiatry, 43, 985-989. doi: 10.1176/ps.43.10.985

Kofoed, L. L., Tolson, R. L., Atkinson, R. M., Toth, R. L., Turner, J. A. (1987). Treatment

compliance of older alcoholics: An elder-specific approach is superior to

“mainstreaming.” Journal of Studies on Alcohol, 48, 47-51.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with

outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical

Psychology, 68, 438-450.

McKay, J. R., & Weiss, R. V. (2001). A review of temporal effects and outcome predictors in

substance abuse treatment studies with long-term follow-ups: Preliminary results and

methodological issues. Evaluation Review, 25, 113-161.

Mertens, J. R., & Weisner, C. M. (2000). Predictors of substance abuse treatment retention

among women and men in an HMO. Alcoholism: Clinical and Experimental

Research, 24, 1525-1533.

Moos, R. H., Brennan, P. L., Schutte, K. K., & Moos, B. S. (2010a). Social and financial

resources and high-risk alcohol consumption among older adults. Alcoholism: Clinical

and Experimental Research, 34, 646-654.

Moos, R. H., Brennan, P. L., Schutte, K. K., & Moos, B. S. (2010b). Spouses of older adults with

late-life drinking problems: Health, family, and social functioning. Journal of Studies on

Alcohol and Drugs, 71, 506-514.

Rogers, C. (1961). On becoming a person: A therapist's view of psychotherapy. Boston, MA:

Houghton Mifflin Harcourt.

Running head: TREATMENT PREFERENCES OF OLDER ADULTS

Rothrauff, T. C., Abraham, A. J., Bride, B. E., & Roman, P. M. (2011). Substance abuse

treatment for older adults in private centers. Substance Abuse, 32, 7-15.

Rounsaville, B. J., Dolinsky, Z. S., Babor, T. F., & Meyer, R. E. (1987). Psychopathology as a

predictor of treatment outcome in alcoholics. Archives of General Psychiatry, 44, 505-

513.

Satre, D. D., Mertens, J. R., Areán, P. A., & Weisner, C. (2004). Five-year alcohol and drug

treatment outcomes of older adults versus middle-aged and younger adults in a managed

care program. Addiction, 99, 1286-1297.

Solway, E., Estes, C. L., Goldberg, S., & Berry, J. (2010). Access barriers to mental health

services for older adults from diverse populations: Perspectives of leaders in mental

health and aging. Journal of Aging & Social Policy, 22, 360-378.

Substance Abuse and Mental Health Services Administration (SAMHSA, 1998). Substance

abuse among older adults: Treatment improvement protocol (TIP; Series #26). Rockville,

MD: U.S. Department of Health and Human Services.

Substance Abuse and Mental Health Services Administration (SAMHSA, 2005). Substance

abuse relapse prevention for older adults: A group treatment approach. Rockville,

MD: U.S. Department of Health and Human Services.

Substance Abuse and Mental Health Services Administration (SAMHSA, 2011). The TEDS

report: Older adult admissions reporting alcohol as a substance of abuse: 1992

and 2009. Rockville, MD: U.S. Department of Health and Human Services.

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Table 1: Categories and Examples of Participants’ Responses

Category Exemplar

1) Individual Factors: Attitudes, beliefs, and

abilities that help or hinder treatment.

a) Setting interpersonal boundaries “I had problems with setting boundaries. [My counselor] gave me that [workbook] and that was one of the best

things…That turned my life around.”

b) Financial stress “When you’re a certain age, your income won’t be constantly going…you are totally facing a different situation.”

c) God or higher power “I’m never going to deny [the power of God], because if I could’ve stopped on my own, I would have stopped.”

d) Health problems “…they need to be aware of your medical history rather than just what’s going on in your head… if you have heart

disease that’s entirely different than [addiction].”

e) Managing emotions and cravings “…the isolation wants you to go back and use drugs.”

f) Motivation and personal responsibility “…the only thing that stops us is us… Everywhere I go, I’m already there… So I have to deal with me on a daily

basis.”

g) Stigma “So if somebody’s like, say 65…they have, like, a certain amount of pride. They’re not gonna, like, let people know

sometimes when things are wrong.”

2) Treatment Factors: Helpful and harmful

aspects of treatment programs.

a) Being seen as a person “It’s important to find out why I’m here, and what is my purpose.”

b) Having a caring therapist “Don’t act like you’re here just for the check… actually care about what you are doing.”

c) Being honest “You can’t come at us with a half-truth or something just to make it sound good… You just gotta put it in our face,

you know, don’t sugarcoat it.”

d) Need for individualized treatment “You… feel better talking one-on-on… As opposed to just listening to a room full of guys talk…”

e) Need for prescriptive yet flexible treatment “It may sound good on paper… do step A, B, and C and you’ll be okay… That doesn’t work. You might have to do

step B first, then C and then A.”

f) Need for education “…the only thing I would…emphasize is a little bit more education…Tell them, hey this is not magic.”

g) Therapist self-care “When they’re not so tired, not so overwhelmed, maybe they can do a better job.”

h) Peer support “That support group is really important, no matter who it is…That support group of their peers is really valuable.”

i) Tangible needs “I realized I was almost homeless, and I was like doing something about it. Instead of just continuing on as I was.”

3) Outside Factors: External factors that

influence sobriety and treatment.

a) Stress and support from outside friends or

family

“…when I’m stressed out or something goes wrong with one of my kids, I find myself saying, ‘Oh, I need a drink.’

That’s the first thing that comes out of my mouth.”

b) Accessibility and transportation “They don’t have many places for people our age to get treatment…it seems like they just kick us to the curb.”