Considerations When Counseling Older Adults With Substance Use Disorder

The National Institute on Drug Abuse (NIDA) estimates that almost 1 million people age 65 and older have a substance use disorder (SUD), based on research conducted in 2018 by the Substance Abuse and Mental Health Services Administration (SAMHSA). Studies have also shown that though these individuals are less likely to seek help, they can benefit from treatment just as well as those in other age brackets. 

To compound the problem, senior adults also face barriers to care, including cost, insurance coverage, unfamiliarity with the technology associated with telemental health, and fewer geriatric SUD programs. 

We spoke with Aimee N. Callicutt-Keesler, MS, NCC, LCAS-A, LCMHC-A, who manages a private practice and works in community mental health with federal probation clients. Callicutt-Keesler has served in many settings, including hospice/bereavement, outpatient, hospital behavioral health inpatient, and Medication-Assisted Treatment. “Counselors must work skillfully and collaboratively alongside these clients so that they confront their reflections with compassion, tenderness, and truthfulness,” she says, adding that “your tenacity, passion, and authenticity are the most extraordinary tools in your arsenal for the benefit of your clients.” 

How can substance use disorders (SUDs) affect an older person’s mental health? How do these older clients typically present in sessions (common co-occurring mental disorders)? 

It is important to be mindful that substance use disorders in older populations can be emotionally overwhelming and confusing for both the client or patient, as well as the older person’s support system. Tactful and appropriate screening is an instrumental element in ensuring that older persons with substance use disorders receive the sensitive support that they need. Concurrent illnesses and other chronic conditions may mask substance abuse. Older folx facing major life transitions or changes could be a key to unlocking and eventually treating underlying SUDs in older populations. 

These older clients can come to session with issues that present similarly to common mood disorders such as depression, anxiety, post-traumatic stress disorder, or even bipolar disorder, when in reality, there is a veiled issue of co-occurring substance abuse just under the surface. Therapists or counselors may be met with challenges of stigma, denial, or even anger if older clients are not met with person-centered language and strategic intervention including thoughtful and discerning assessment.  

Many older clients with SUDs remain underdiagnosed and underserved. Why do you think that is? 

Older clients with substance use disorders remain underdiagnosed and underserved because people 65 and older consume more prescribed and over-the-counter drugs than any other age group in the United States. This population’s use and possible overuse of these medications has been historically normalized. 

As people age, they are prescribed more medications by providers, and the aging body becomes more susceptible to the effects of those medications that are consumed. The effects of these medications may be chalked up to natural aging processes when they should be attributed to harmful side effects or misuse. There is also a notable element of shame that comes with older adults relying on drugs or alcohol to cope with stress, which can lead to the gravity of this issue being underreported or never reported at all.  

How much of a problem are prescription drugs for these clients? Are these SUDs often accidental? 

The older population is certainly not immune to the horrible repercussions of the opioid epidemic or the possible unfavorable reactions between alcohol and other prescription drugs, among other SUD issues. Some of these substance use disorders are absolutely accidental.  

Substance use disorders of prescription drugs and non-prescription drugs can become a very real nightmare for anyone by accident or not, young or old.  

What are some of the more common challenges when counseling these clients? 

A common challenge in counseling these clients is the embarrassment and stigma that older populations face when being asked to acknowledge and confront substance use issues later in life. Opting for the use of nonconfrontational, strength-based, psychoeducational, and motivational approaches can help show older clients the most support through SUD identification and treatment. Motivational and psychoeducational approaches with older populations may be most beneficial for folx who struggle with anxiety, collecting and understanding data, and emotional regulation due to age and compounded substance use or misuse. 

According to the National Institute on Drug Abuse (NIDA), one study suggests that people addicted to cocaine in their youth may have an accelerated age-related decline in temporal lobe gray matter and a smaller temporal lobe compared to control groups who did not use cocaine. Being as the temporal lobe is the hub for pleasure, emotion, and behavior, these older adults with SUDs may have more difficulty with anxiety, emotional regulation, and collecting data. The challenge of working with older adults who struggle with data collection, anxiety, and regulating their emotions is ensuring comprehensive care that focuses on thorough explanation, reassurance, and emotional support.  

Are there certain counseling theories, models of care, or techniques you prefer to use when working with them? 

Ideas that seem to work best for these clients are often focused on motivational interviewing (MI) and person-centered (Rogerian) theories. MI is concentrated on gauging a person’s readiness to change and cultivating ambivalence. Embracing the flux of an elderly person’s choice between growth and stagnation can lead them to examine the benefits of change more closely and ultimately determine the course of action that is best for them. Putting their mindset under a therapeutic microscope can assist clients in deeply contemplating their substance use within the context of the trajectory of the remainder of their lives.  

Person-centered or Rogerian theory gives the client autonomy while also asking open-ended questions to provoke thought about why certain behavioral patterns continue to be beneficial or not. The role of the counselor in this methodology is simply to facilitate a safe environment for self-exploration and self-actualization. 

How can working with these clients affect us as counselors? What sort of self-care measures do you recommend to prevent compassion fatigue and burnout? 

Working with clients in this population can certainly create a lot of frustration, burnout, and compassion fatigue. Counselors can experience many problematic mental health symptoms when burnt out such as toxic negativity; isolation or social withdrawal; anhedonia (loss of interest); or feeling keyed up, angry, or on edge.  

Self-care is highly individualized and isn’t always about bubble baths, face masks, or meditation and yoga. Self-care can be as simple as taking a moment out of your day to center yourself on a single point of positivity, nurturing a sustainable gratitude and self-compassion practice, or fostering your own individuality and creativity in mediums of expression: painting, music, dance, writing, therapeutic movement . . . (OK, I stole that last one from my own therapist), but literally any way you can think of! Just as we encourage the sovereignty of our clients, we MUST invigorate our own forms of proclaiming our purpose as people. We are not just working folx in the helping profession! We are human beings ourselves! 

What other advice would you give someone who is interested in working with these clients? 

Assessment and early intervention are instrumental. You are a detective. Look for clues that others might not pick up on. Put the puzzle pieces together that may fit into a bigger picture. Throughout it all, ask questions with compassion and genuine curiosity, and be authentic and gentle with your clients and patients.  

Are there any recommended trainings or other resources you’d recommend to help counselors gain a better understanding of working with these clients? 

Nicole Hiltibran, MA, LMFT, is a wealth of knowledge on aging and long-term care. I took one of her trainings through CE4Less.com and gleaned so much information on how to work with this specific population. 

The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse (NIDA) collect various data pieces on how to better serve the elderly population that may be suffering from co-occurring disorders. The National Institute on Aging (NIA), under the umbrella of the National Institute of Health (NIH), also has information on aging and Alzheimer’s research that can be beneficial to therapists working with older adults suffering with substance use disorders. 

Aimee N. Callicutt-Keesler, MS, NCC, LCAS-A, LCMHC-A, (they/she) received their bachelor’s degree in English and pedagogy and the mind from East Carolina University and their master’s in clinical mental health counseling and substance abuse counseling from East Carolina University. She is the owner of Cosmic Mirror Counseling, PLLC, in North Carolina. Callicutt-Keesler has worked in nearly every sector of counseling as an associate licensed clinician, including hospice/bereavement, outpatient, hospital behavioral health inpatient, Medication-Assisted Treatment (MAT), and federal probation programming. They are anticipating their full licensures as an LCAS and LCMHC in early 2024.