Groupwork Vol. 24(1), 2014, pp.xx-xx. DOI: 10.1921/8101240206 63 Psychosocial groupwork for older adults having substance use and mental health issues Psychosocial groupwork for older adults having substance use and mental health issues: The participants speak Marilyn White-Campbell1 , Lea Luketic2 , and Stephanie MacDonald3 Abstract: Community Outreach Programs in Addictions (COPA) is a Canadian organization that assists older adults who live with substance misuse and mental health issues. COPA College, a psycho educational mutual aide support group consists of weekly group sessions. The program uses a Solution Focussed approach ( De Jong, Insoo Kimberg, 2008) which provides support to socially disadvantaged older adults with substance and mental health issues through a group format. This article sets out to evaluate participant reactions and determine if participants decrease substance use following completion of the group. One-on-one semi-structured interviews with ten participants were conducted. Participants were asked to rate the importance of different aspects of the program and discuss alcohol intake following involvement in the group. Aspects of the program rated highly by all the participants included learning new information, the breadth of topics discussed and the harm reduction approach taken by the program. Finally, the general atmosphere of the group was considered very important, especially being comfortable in the group and combining humour with learning, and an opportunity for reflective, sharing peer support. Keywords: geriatric; addictions; mental health; concurrent disorders; peer support; groupwork; group work 1. Geriatric Addiction Specialist, Community Outreach Programs in Addictions, 2. University of Toronto Medical School 3. McMaster University Address for correspondence: Marilyn White-Campbell, Community Outreach Programs in Addictions, Toronto, Ont. M5V 2T2, Canada. m_whitecampbell@copacommunity.ca Date of first (online) publication: 64 Groupwork Vol. 24(1), 2014, pp.6xx3-xx. DOI: 10.1921/8101240206 Marilyn White-Campbell, Lea Luketic, and Stephanie MacDonald Background The major determinants of health in older adults include shelter, income, social security and access to health services. While these are indeed important determinants of health in the older adults, one that is important and often overlooked by both the medical community and the public is substance misuse. The National Survey on Drug Use and Health in the US (SAMHSA 2002/2003) indicated that 45.1% of those surveyed admitted that they drank alcohol in the last month, with 12.2% reporting binge drinking and 3.2% reporting they had used alcohol heavily SAMSHA, 2002/2003). A Canadian study of older adults found that alcohol misuse could be clinically detected in 8.9% of the population studied. The impact of this alcohol misuse was apparent when the same population was examined 18 months later and it was found that mortality was much higher in those with clinically detected alcohol misuse ( Thomas & Rockwood, 2001). From these numbers it becomes clear that alcohol misuse is a common, yet often under recognized problem in older adults. It is instructive to consider the key factors that compel older adults to use alcohol. A report by Alcohol Concern (2002) split the factors inducing older adults to drink into two important broad categories: emotional and social problems, and medical problems (SAMHSA, 2002/2003). The emotional and social problem category encompassed factors such as bereavement, loss of occupation, loss of social status, family conflict, impaired self-care, reduced coping skills, altered financial circumstances and dislocation from previous accommodations and reduced self-esteem. In the medical problems category, older adults often experience multiple co morbidities such as; chronic pain, reduced mobility and cognitive impairment, all of which could be factors that provoke them to drink. Alcohol use disorders in older adults can cause many health problems, which can be divided into physical, psychological and social problems. Increased drinking can put older adults at increased risk of a wide range of devastating diseases, including coronary artery disease, hypertension, stroke, osteoporosis and liver problems including cirrhosis (Department of Health, 1995). Being under the influence of alcohol can affect gait, and can increase the risk of falls in older adults, which is one of the main causes of mortality in older adults (Dar, 2006). Groupwork Vol. 24(1), 2014, pp.xx-xx. DOI: 10.1921/8101240206 65 Psychosocial groupwork for older adults having substance use and mental health issues Heavy drinking can also cause many problems relating to self-neglect, such as poor nutrition and poor hygiene (Woodhouse, Heathing & Coleshaw, 1987). Since it is clear that alcohol misuse in older adults affects so many areas of health, we can hypothesize that alcohol misuse in older adults generally affects their overall quality of life. Unfortunately, alcohol misuse in older adults is often overlooked. Many reasons could be proposed to explain this. Often older adults hold traditional views, including the attitude that problems at home are best kept to themselves, thus preventing them from discussing problems and trying to get help for them. In addition, alcohol misuse and addiction in the elderly can often mimic symptoms of normal aging, making it harder to detect than in younger populations. The views and beliefs of those working directly with older adults is another reason alcohol misuse can go undetected. Those working with older adults, such as case managers, often do not consider alcohol misuse as a determinant of health in older adults. This belief can prevent health care providers and clinicians from investigating alcohol misuse further. (Bowman & Gerber, 2006). The medical community is particularly implicated in overlooking alcohol misuse in older adults. In a study conducted in the United States by The National Center on Addiction and Substance Misuse at Columbia University, 94% of primary care physicians failed to diagnose substance misuse when presented with early symptoms of alcohol misuse in an adult patient. Even more surprising were the views of the primary care physicians themselves, as they did not have confidence in their abilities to detect alcohol misuse when presented with it, with 81% admitting they would be unable to detect alcohol misuse. (NCASA, 1999-2000) Even aside from screening issues, there remains the question of what to do with these individuals once they have been identified. Indeed, the medical community does believe that there are not many effective options once alcohol misuse has been detected. In the same study in which primary care physicians admitted to feeling that they had inadequate abilities to detect alcohol misuse in older populations, an overwhelming amount felt that treatment for alcoholism would not be very effective, with less than 4% of those studied thinking that effective treatment is possible NCASA survey 1999-2000). Interestingly these negative perceptions are not justified in the few studies that have been conducted on treatments. Current studies show that alcohol treatment programs can indeed be effective in older adults. A study by (Curtis, 66 Groupwork Vol. 24(1), 2014, pp.6xx3-xx. DOI: 10.1921/8101240206 Marilyn White-Campbell, Lea Luketic, and Stephanie MacDonald Geller & Stokes, 1989) showed that older adults were at least as likely to benefit from treatment as younger people. Older adults in fact, appear to follow treatment regimens more assiduously and have as good if not better treatment outcomes than much younger patients. (Oslin, Pettanati & Volpicellie, 2002). However, while there is some evidence to clearly suggest that older adults are as likely to benefit from treatment as younger adults, there is not a great deal of data to suggest what the best treatment is. One thing that is clear is that older adults tend to have better outcomes in elder-specific rather than mixed-age programs. (West & Graham, 1999). Treatmentoptionsforsubstancemisusebyolderpeople Age, illness and lack of acknowledgement of the substance use problem can present as barriers to treatment for many older adults. Many traditional addiction treatment programs typically require the individual to admit to a problem in order to gain admission into the program. Similarly most require abstinence as a treatment goal. Older adults in denial would therefore be excluded from treatment. The World Health Organization recognizes that alcohol and substance use is often under diagnosed in older adults, since it is assumed to be a problem of younger adults. Subsequently many older adults do not access addiction treatment services. There are negative attitudes toward older adults, and inappropriate age cut offs for therapeutic services. (WHO Position paper 2002). Most treatment programs offer group; however these may not be specific to older adults. Older adults in the COPA program often indicated age as a factor in dropping out of attending treatment programs, including Alcoholics Anonymous, because they could not relate to the issues of younger persons. Older adults who deny their substance use problems are considered to be in the precontemplative stages of change or ‘not ready for treatment’ (Prochask, Di Clémente, Schlundt, & Gemmell, L. (2004) , and so may never access treatment for addiction. All clients in the COPA program are viewed by mainstream treatment programs as not ready for treatment as they were precontemplative. Low barrier programs which include a harm reduction approach and outreach can reduce barriers and stigma associated with seeking help. Community Outreach Program in Groupwork Vol. 24(1), 2014, pp.xx-xx. DOI: 10.1921/8101240206 67 Psychosocial groupwork for older adults having substance use and mental health issues Addictions (COPA) where the older person need not admit to an addiction or have insight into their problem is one such program. In groupwork for addictions treatment, traditional psychotherapeutic models such as Levin and Yalom ( in Papel & Rothman, 2008) where treatment objectives are; (1) supportive, (2) interpersonal, insight development, (3) intra-psychic insight development are key components of treatment. Admission of a problem can preclude the older adult from accessing treatment and groups. The COPA College groupwork model was developed to help reduce barriers to access treatment and in particular to increase acceptance of groups with a population which typically would not access groups. The group model is a reflection and extension of the principles of the COPA program where the treatment is self-directed and may or may not include abstinence. Previous attempts to engage participants in groups using a psychotherapeutic approach have resulted in poor retention rates (McKee & White-Campbell, 1997), clients simply stopped attending. Prescribed group rules and norms/ regarding relapse, missed meetings were factors which contributed to participants dropping out. Confrontation and discrepancy clarification around the substance use which is often a key area of discussion in addiction treatment groups, negatively impacts the older adult and can contribute to low retention rates. Changes in groupwork approaches which were aligned with mainstream social work group approaches such as the inclusion of play as well as work, humor as well as serious reflection (Lang, Papell & Rothman, 2008) resulted in improved attendance in group and greater group cohesion (McKee & White-Campbell, 1997). Research on addictions and older adults suggests that traditional addiction treatment approaches which may include confrontation and the need for client insight, may be inappropriate for older adults. Programs offering addiction treatment to older adults need to be designed for them with a focus on the substance use, mental health and late life issues which the older adult may experience (Graham, Birchmore Timney, Flower, Saunders, White-Campbell & Ziedman Pietropaulo, 1995); Blow, Walton, Chermack, Mudd & Brower, 2000). A review of the literature on groupwork with older adults with substance use and mental health issues revealed paucity in the research. Pool, Gardner, Flower & Cooper (2009) conducted a study of older adults with substance use and mental health issues in groupwork using Narrative Therapy. Narrative Therapy is an approach which allows 68 Groupwork Vol. 24(1), 2014, pp.6xx3-xx. DOI: 10.1921/8101240206 Marilyn White-Campbell, Lea Luketic, and Stephanie MacDonald people to experience themselves as separate from the problem. It shifts the conversation to the relationship between the person and the problem instead of the problem-person. It encompasses the person’s social context emphasizing his/ her strengths, abilities, successes and possibilities. The research revealed that this approach in group was positively suited to older adults coping substance use and mental health issues. Furthermore Narrative therapy worked well in a group setting. Alcohol and drug use is often perceived as a weakness and a personal choice. There is a great deal of shame and guilt associated with getting help. When the COPA College model was developed, the goal was to provide support for older adults to engage in a group process which destigmatizes addictions, mental health and aging. The group model was intended to provide a positive group experience that emphasised empowerment and competency for the clients who in late life were perceived as hopeless and impossible to help. The stigma of being old, not being able to learn or change is challenged by the COPA College model. It was clear from the outset as the clients received their letters of acceptance inviting them to attend group, to learn and grow, that this group would be different. Anecdotally, one of the first letters of acceptance was hand delivered to an older male resident of a long term care facility. He was identified as a resident with behaviours including smoking, and illicit drug use. He was considered someone who could not be helped. Upon reading the letter of acceptance inviting him to come to COPA College group to learn and make healthy choices, in a tearful voice he said, ‘Imagine, at my age? I’m going to college’. It was abundantly clear that the letter of acceptance set the ground work for acceptance. It eliminated the stigma of seeking treatment for the older adult with addictions. In particular, for early onset drinkers who may have tried and failed in treatment numerous times, and for late onset drinkers it helped reduce the shame and embarrassment of getting help for a problem which they may have hidden from families and health care providers. Instead of being seen as alcoholic, they were going to group to learn how to better manage their substance use and mental health. The participants were eager to learn and make healthy choices. The group was the setting for a collective dialogue which helped the participants to gain insight. This paper is an evaluation and presentation of the voice of the clients who participated in the first groups offered with the COPA College model. Groupwork Vol. 24(1), 2014, pp.xx-xx. DOI: 10.1921/8101240206 69 Psychosocial groupwork for older adults having substance use and mental health issues CommunityOutreachProgramsinAddiction(COPA) Community Outreach Programs in Addiction (COPA) is a communitybased organization located in Toronto that is committed to helping adults over 55 years who live with substance misuse problems that have an impact their daily lives. COPA provides many services, including support groups, counselling, crisis intervention and case management, telephone consultations, education and training for professionals & organizations. Participants can be referred to this agency by many individuals, including physicians, family members, hospitals agencies and long term care facility employees. COPA has taken an innovative and new approach to dealing with substance misuse in older adults because of their belief that differential treatments specific to the individual are necessary when dealing with alcohol misuse in older adults. Existing treatments are often inappropriate for older adults. The reasons for this include the fact that many of the affected older adults deny that they even have a substance misuse problems and thus limiting their access to traditional programs. Second, because of their advanced age, they are often not able to travel to treatment programs and even if they can, they often have a hard time participating due to their physical health problems and sensory deficits. A final reason is the requirement of many traditional treatment programs for complete abstinence before participation. For these reasons, the programs at COPA are considered harm-reduction programs, aiming not for complete abstinence, but rather for decreased substance misuse in older adults. Other features of the COPA program which are unique to the addictions field are as follows: 1. Non-confrontational help is provided on the clients terms; 2. Admitting to a problem with substance abuse is not required; 3. Uses a broadly focused holistic approach to substance related problems; 4. Specifically directed at maintaining the client in the community; 5. Abstinence is not a requirement – focus on the reduction of alcohol while improving the client’s ability to function well in the community. In the last year COPA has initiated an innovative new program, 70 Groupwork Vol. 24(1), 2014, pp.6xx3-xx. DOI: 10.1921/8101240206 Marilyn White-Campbell, Lea Luketic, and Stephanie MacDonald called COPA College that strives to improve the quality of life of their participants that have addiction problems. COPA College holds small group sessions once a week for 8 weeks. The sessions deal with a wide breadth of topics, including sessions on substance misuse, bereavement, financial planning, and stress and anxiety management through art therapy. Many of the sessions, while not dealing directly with substance misuse, deal with factors that contribute to alcohol misuse in older adults. Unless the individual receives help for all the problems they may have, the drinking behaviour is unlikely to change. Taken together, the sessions try to deal with substance misuse, a key determinant of health in the COPA client population, with the overall goal of reclaiming quality of life and improving the health of older adults living with this condition. In addition, in each semester of COPA College, there is an outing for the class. This gives the participants an opportunity to get out of their homes, in long term care & community to share an activity and do something that they would normally be unable to do. Examples of COPA College outings were; attending a taping of the comedy ‘Royal Canadian Air Farce’ a television program and a lunch at a restaurant on the Harbour Front in Toronto. Since COPA College was still in its infancy at the time of the initiation of this study, no formal evaluations of the group had yet been conducted. Ongoing, informal program evaluation through anecdotal feedback and regular end of course reflections suggested that participants were generally satisfied with the group. Many decreased alcohol intake after completion of the program, show improved health and improved general outlook on life. The informal evaluations were useful as they guided the development of the formal evaluation. The present study therefore focuses on assessing the impact and effectiveness of the COPA College group. Information provided by the study will be used to make recommendations for improving the program. Evaluating the COPA College group was conducted at two levels of Bennett’s hierarchy of evidence for program evaluation. Two levels of the hierarchy were examined since it has been shown that evaluations are strengthened by showing evidence at several levels of the hierarchy. The two areas that will be examined are: 1. Reactions to the program: how the participants themselves viewed the program, positive or Groupwork Vol. 24(1), 2014, pp.xx-xx. DOI: 10.1921/8101240206 71 Psychosocial groupwork for older adults having substance use and mental health issues negative interest in topics addressed, and any related information. It is always very important to start at the participant satisfaction level because it will increase the likelihood of explaining any impacts observed. 2. Impact of the program: a. What effect the program had on the major determinant of health in their life – alcohol misuse (that is, did participants in COPA College decrease substance misuse?) b. What effect the program had on their quality of life (that is, did participation in COPA College increase their quality of life?) c. Do the participants themselves feel that the decreased substance misuse is associated with increased quality of life? Methods Sample Participants who had completed at least one session (8 classes) of the COPA College program were eligible for interview. Out of the approximately 20 participants that were eligible under this criteria, 10 completed interviews. The majority of those that were not interviewed were excluded, either because of cognitive impairment, or if they suffered from major depression that was not well treated, as we did not want these factors to confound our results. Procedure The Geriatric Addiction Specialist described the research to the participants and sought their permission to have a researcher telephone them and request their participation in the study. The researcher did not have access to the records of the participants and the workers on the program were not informed as to which of them agreed to be interviewed. To protect participant confidentiality, the only information available with the interview transcripts was their gender and an identification number. Participants were interviewed in their homes or their long term care facilities over a 3 month period, from January to March 2008. Verbal 72 Groupwork Vol. 24(1), 2014, pp.6xx3-xx. DOI: 10.1921/8101240206 Marilyn White-Campbell, Lea Luketic, and Stephanie MacDonald consent was obtained to participate at the beginning of the interview. Participants were also asked for approval to audio-tape the interviews. All interviews were audio-taped and transcribed, with the exception of one interview in which the recording equipment failed. In this case, notes were taken during the interview. Interviews lasted from approximately 15 to 45 minutes. A card sort method was used to evaluate participant satisfaction. Sixteen key components of the program were written on cards and then randomly sorted and read one card a time (Table 1). Participants were asked to rate each component on a scale of 1 to 5, 5 being the most important aspect to them of the COPA College program and 1 being an aspect of the program that was least important. This rating system allowed for a determination of what the participants perceive as the most and least important aspects of the program. Following the rating system, the participants were asked to discuss in as much detail as possible the three aspects of the program they rated the highest and the one aspect of the program they rated the lowest. This allowed for a broader understanding of the ratings that the participants were assigning to the different aspects of the program. This method of participant evaluation has been adapted from a study by West & Graham (1999). To assess the impact of the program, a semi structured interview was conducted specifically on the participants’ alcohol intake and the effects of the program on quality of life. The interview consisted of questions specific to changes in alcohol intake since completion of the program and any changes to health and quality of life they had perceived. In addition, specific quality of life measures from the World Health Organization Quality of Life Measurement Scale were incorporated into the questions. This included questions about sleep, energy, mood, concentration, finances and relationships. Because of the qualitative nature of this study it is not possible to make quantitative predictions or to generalize the findings to other situations, because the results may be unique to the small population we have included in our study. In addition, with qualitative research we will have to try to ensure that the researchers’ personal biases do not influence the results. Groupwork Vol. 24(1), 2014, pp.xx-xx. DOI: 10.1921/8101240206 73 Psychosocial groupwork for older adults having substance use and mental health issues Coding and data analysis For analysis of the quantitative data, the number of participants that ranked each specific component with a 4 or 5 was recorded. By recording the number of participants that ranked a specific program aspect highly, evidence was provided towards understanding the components of the program that are viewed as most important by them. Interview data from both components of the interview were examined to identify common themes and issues related to the different program components. Significant statements were identified and general themes were analysed. The results are described within the main themes identified and are illustrated with quotations from the participants. Table 1 Number of participants Program aspect rating the aspect 4 or 51 Group Sessions: Sessions deal with a broad range of topics 9 Learning New Information 10 Being with people my own age 10 Feeling that I can trust others in the group 9 Discussing problems related to alcohol use 9 Not harping on only problems with alcohol 10 Humor and fun in the group 10 Feeling comfortable in the group 7 Having something in the week to look forward to 10 Group Outings: Getting out of long term care/home 10 Feeling safe on the outing 5 Enjoying conversations with other people 10 Getting to do something I would normally be unable to 7 Overall Program Non-confrontational program 8 Abstinence is not a requirement to participate 9 Do not have to discuss alcohol if do not want to 10 1. On a scale from 1 (least important aspect of the program) to 5 (one of most important aspects of the program) 74 Groupwork Vol. 24(1), 2014, pp.6xx3-xx. DOI: 10.1921/8101240206 Marilyn White-Campbell, Lea Luketic, and Stephanie MacDonald Results The final sample of 10 participants consisted of 8 men and 2 women that ranged in age from 52 to 72. Three of the participants were still living at home. The remainder were in long term care facilities. To assess participant satisfaction with the program the number of participants who rated specific aspects of the program as a 4 or 5 are provided in Table 2. Mean ratings and the standard deviation for each specific program aspect are also provided. Although these rating provide some indication of the relative importance of the different aspects of the program, they were used as a means of focusing participants during the interview. Reactions to the program When assessing the participant’s reaction to the program three key elements of the program emerged as being very important to them; acquiring new information, the general group atmosphere and the harm reduction approach. Acquiring new information One of the major issues to emerge was the importance of education and acquiring new information in a program that is dealing with substance misuse in older adults. All the participants specifically valued the fact that the sessions dealt with a broad range of topics and that there was an opportunity to learn new information. The participants felt that they were able to learn and that what they did learn could be useful to them, as one stated, ‘I want to be a knowledgeable person.’ Most of the participants when asked to further elaborate on what they learned and which sessions they found useful, were able to recall with clarity things they had learned and what they found important. Most of the sessions had been found to have been helpful and only one person could recall a session that they did not find useful. In particular, the sessions that were consistently brought up and rated highly were the sessions that dealt with sexual health and finances. One participant in particular expressed the importance of the financial session and why he found it so helpful when he said, Groupwork Vol. 24(1), 2014, pp.xx-xx. DOI: 10.1921/8101240206 75 Psychosocial groupwork for older adults having substance use and mental health issues I found the financial session so helpful. They had a woman from the bank. I never knew how to manage my money before. She asked the class to tell her how many payments it would take to pay off a one thousand dollar loan if you were only paying 30 dollars a month, which is the minimum. The class guessed completely wrong. It turned out it would take over 100! That is paying so much more than you borrowed because of interest, more than 3000 dollars. I really learned a lot during that session. [I] can be smarter with my credit cards now. It was made clear by most of the participants that they wanted to learn new information and it was better if this information not only dealt with substance misuse, but also with any issues that were important to this age group. Many of the participants expressed the feeling that if they could be helped in many areas of their life and gain more control they might not be driven to misuse substances to the same extent. Their thirst for knowledge really helped to defeat the stereotype that older adults would not want or are not able to learn. As one participant very clearly summarized, ‘I just love learning new information. You are never too old to learn!’ Group atmosphere During the interviews it quickly became clear that all the participants consistently felt that the atmosphere of the group was important in a substance misuse program, and that their group atmosphere was a major contributor to how they viewed the program and what they got out of it. The conception that one can trust and also feel comfortable with the other members of the group was discussed by all participants and rated very highly. The participants really thought the social aspects of the program were important and many f equally rated getting to know each other illustrated by one person’s comment when asked to discuss feeling comfortable in the group, ‘That is important to me. You get to know the regulars like me’. From this quote it is clear that the person feels like they belong to a group and there is a relationship within the group. Other participants directly commented on how they were able to start new friendships because of the program. As one client said, ‘I enjoy the socialization [at COPA College]. Meeting other people in other walks of life, other jobs, you know. We are all in the same boat together’. The participants felt that they had a bond with each other and it is this bond that makes the outings, such as the taping of the comedy 76 Groupwork Vol. 24(1), 2014, pp.6xx3-xx. DOI: 10.1921/8101240206 Marilyn White-Campbell, Lea Luketic, and Stephanie MacDonald TV show Royal Canadian Air Farce’ or the lunch at the harbour front, important to them. As one person stated, ‘The outings are a good entity, because we are friends and we can talk about anything- cars, boats, trucks’. Humour and fun in the group was the only aspect of all sixteen that received a five from each member.. All the participants felt this was a vital part of the program and one person summarized the importance of humour by saying ‘You have to have that! I don’t care where you are. You have to have humour and comedy. It makes you laugh; it lifts your spirits from the floor to the ceiling’. While rating the program it was made clear by all the group members that they thought the general atmosphere in the group was very important and determined their satisfaction. One component of the general atmosphere that the group participants did not feel was important, was that the program consisted only of people their own age. As one participant commented , ‘I don’t worry too much about how old people are.’ The few participants that did feel being with people their own age was important suggested that the group was then able to relate better if people were the same age. They also discussed how younger people might have different feelings and feel more comfortable in a group if everyone was around the same age. Harm reduction approach Aspects that were consistent with a harm reduction approach were also viewed as important by the participants. Most of them stressed the importance of having a program that was non-confrontational, did not harp only on problems related to alcohol and did not require abstinence in order to take part. . Most participants thought that the non-confrontational aspect of the program was an important part of their involvement in the program. One client said, It is important that [the program] is non-confrontational. All the people in the program have had their problems in the past and it would not help us if they were constantly being confronted with those facts by the leaders. We do not need to rub salt into old wounds. Everyone did feel that it was important to discuss the substance misuse, but not only substance misuse. There were also many comparisons made to other programs that the participants had tried in the past. The level of dissatisfaction was usually the highest in Groupwork Vol. 24(1), 2014, pp.xx-xx. DOI: 10.1921/8101240206 77 Psychosocial groupwork for older adults having substance use and mental health issues programs that did not have a harm-reduction approach, but instead had abstinence as a key component of the program. Most group members stressed they would not take part in a program that required abstinence and that they were very happy that COPA College did not make that an issue. Many of the participants also expressed dissatisfaction with groups like Alcoholics Anonymous (AA), both because of the already mentioned abstinence and also because of the religious undertones. As one person stated, Let me tell you. Compared to COPA, it [AA] is a big organization and there are so many people. But, it is to me too general and there is no individuality and it has this religious overtones. I don’t believe in that. You can go to church but I don’t want to. From the interviews it became apparent that everyone viewed the harm-reduction approach to be an essential element of the COPA College Program. Impact of the program Health and Quality of Life Prior to COPA College Participation When asked about health prior to taking part in the COPA College program, most of the participants (80%) felt that their substance misuse was affecting their health. As one client’s states, ‘I would have had to have been born ignorant to say that it was not affecting my health.’ These participants also all expressed concern about what was happening to them, as one client stated, ‘I was concerned. I have seen some people that have gotten really sick on liquor and I do not want to go down that road.’ When asked to rate their quality of life only one participant said that his quality of life was good. The remainder all felt that their quality of life was not good, terrible, and in one instance, even ‘pretty piss poor.’ To further examine quality of life measures, participants were asked about different aspects of their life that have been shown to determine quality of life. Consistently many of the quality of life measures were found to be poorly rated by the participants. Sleep, memory, concentration, mood and energy were often stated to be low. One client summarized his experience with alcohol by saying, 78 Groupwork Vol. 24(1), 2014, pp.6xx3-xx. DOI: 10.1921/8101240206 Marilyn White-Campbell, Lea Luketic, and Stephanie MacDonald While you are drinking everything is fine. But then when you are not, comes the low part, you don’t feel well and you just get depressed and the depression is not worth the joy that you feel when you are drinking. An additional quality of life measure that was often a problem with the participants was relationships. Those living at home often reported having problems in their relationships with family and friends. For those participants living in long term care facilities, some had problems with the staff. One person was even on the verge of being asked to leave the long term care facility because of his behaviour. Staff were so upset with the relationship they had with him that COPA was seen as a last resort for the client. The alcohol was clearly affecting the participants, and his ability to adequately take part in society. As another person stated, Yes, I would have memory lapses. People would be upset with me and I wouldn’t remember why and then they would tell me and I had completely forgotten what they were talking about. They would ignore me. I couldn’t remember what I said. I said it wasn’t me it was the alcohol talking. Decreased substance misuse following participation in the program When asked about the changes in alcohol intake following participation in the COPA College program, 9 of the 10 participants had decreased their substance use or completely stopped. The remaining client had actually not been drinking immediately prior to starting the program so could not be assessed in this way. She had been a heavy drinker in the past. Some of the participants had been very heavy drinkers prior to starting at COPA. One client that was no longer drinking at all describes his drinking prior to the program, Before coming here I always drank beer that was my drink. I would have two beers in the morning and I would never go anywhere without having a beer or two in the car. I would take them in the trunk. I was an alcoholic. For the participants that were still drinking following involvement in the program, there were clear decreases, with the majority cutting down to three or less standard drinks per day. One client mentioned that ‘two is my max now; my friends call me the deuce.’ Groupwork Vol. 24(1), 2014, pp.xx-xx. DOI: 10.1921/8101240206 79 Psychosocial groupwork for older adults having substance use and mental health issues Health and quality of life since COPA College participation The majority of the participants, 9 out of the 10 in fact, felt that after taking part in the COPA College Program, they had a better quality of life and better health. ‘I just feel better. Because when you are drinking you may feel good at the time, but it is after [the drinking] that you don’t feel very good’. Most of the participants reported an improved outlook on life, one even summarized his experiences following participation in the program by saying, ‘I feel that I have learned a lot and that has refreshed my life. There has definitely been an effect on my life.’ Improved relationships were consistently mentioned by the participants. One participant talked about how he was getting along better with staff and how the staff would tell him he is better now. The client also talked about how he was no longer being as disruptive, did not try to hurt himself or damage things in the home. The one client that did not think there was any improvement in his health or quality of life did indeed comment on some improved quality of life measures. In particular, stating that since he had completed the program, his relationship with his family was much better. In this same regard, while he did not think that there was any change in his behaviour or attitude, he admitted that others in his life had commented on the changes that they observed. Thus, while he did not admit to changes per se, further questioning did reveal that they very likely were objective changes. Consistently participants stated that there had been memory, mood, sleep, and concentration and energy changes following involvement in the program. One client seemed to summarize the general feelings of all participants when he said, ‘[COPA College] improved my life, because it did not disrupt one area of my life, only made things better’. Discussion This study examined client’s reaction to the COPA College program, a program specifically designed for older adults that suffer from substance misuse addictions. In addition the study was specifically interested in evaluating if decreasing substance misuse after participation in the programhadanyeffectonhealthandqualityoflife.Inthisregardthestudy was assessing the effects of this determinant of health in this population. 80 Groupwork Vol. 24(1), 2014, pp.6xx3-xx. DOI: 10.1921/8101240206 Marilyn White-Campbell, Lea Luketic, and Stephanie MacDonald When examining reactions to the program, one thing was very clear. The participants were all generally very satisfied with it and all mentioned they would take part in another session of the program and would also recommend it to others. Most of the aspects of the program were viewed highly by all who took part , confirming the previous anecdotal evaluations and review that indicated general satisfaction with the program. While many programs, such as AA, require abstinence, it appears from this study that older adults with substance misuse issues consider the harm reduction approach to be an essential element of a successful program. This further reinforces work by Graham et al (1994) that demonstrated that many older adults refuse to take part in traditional treatment approaches. Surprisingly, two other themes were found to be important to the participants in the program in addition to the emphasis that was placed on the harm reduction approach. First, there was a great interest in acquiring new information. This educational component of the program was viewed highly by all the participants and it is suggested that this educational component is effective for them because it deals with many of the factors that lead these individuals to drink in the first place.In addition the general atmosphere of the group was found to be important for all who took part.. This study was able to demonstrate that the humour and fun in the group, trust and level of comfort very much determined how the participants viewed the program and also its success. This finding suggests that the group leaders of these programs must take great care in creating a pleasant environment for the members and be aware of any conflicts that may arise. It also suggests that at the start of a semester of COPA College it may be useful to have a session that emphasizes getting to know one another and working on group building activities. The interviews were able to demonstrate that those who took part were able to decrease alcohol intake following completion of the program. In fact, some completely stopped drinking. This further reinforces the idea that older adults can derive benefit from participation in these programs, as was proposed by Curtis et al (1989). The reinforcement of this concept is indeed exciting because it will allow for future program design and implementation. The majority of the participants also felt that the substance misuse was affecting Groupwork Vol. 24(1), 2014, pp.xx-xx. DOI: 10.1921/8101240206 81 Psychosocial groupwork for older adults having substance use and mental health issues their health and that once they decreased their intake following the program, they were generally feeling better and had better quality of life. This supports the concept that alcohol can be a determinant of health in older adults. Nonetheless, this research does have some limitations. First, we had to exclude some of the participants from the study (but not from the group) due to cognitive impairment or major depression because we did not want these variables to confound our results. This exclusion could have resulted in slightly skewed data. Currently we are unable to assess the impact of the program on these populations. In addition, because this program is still in its infancy and there have not been a large number of participants to date we are limited in our sample size. This will have to be repeated in future? with a larger sample size to ensure consistency and compared with the results we have obtained in our study. It is suggested, however, that assessment of the program at this time is essential to understanding where to move next with it, . Taken together, these results suggest that this innovative program can be a model to design future programs that reach a larger population of older adults who live with substance use and mental health issues. Important next steps for the agency are to broaden this program and allow for more participants so that in the future they can assess impact on a wider group of individuals. References Alcohol Concern (2002) Alcohol misuse among older people. Acquire, Autumn., Factsheet: Alcohol use amoung older people.[Accessed at http://www.alcoholconcern.org.uk/servlets/doc/50] February 2014 Blow, F. C., Walton, M.A., Chermack, S.T., Mudd, S.A. & Brower, K.J. (2000) Older Adult Treatment Outcomes Following Elder-specific inpatient alcoholism treatment. Journal of Substance Misuse Treatment , 19, 1, 67-75 Bowman, P.T. and Gerber, S. (2006) Alcohol in the Older Population, Part 1: Grandma has a drinking problem. Case manager, 17, 5, 44-48, Curtis, J.R., Geller, G. and Stokes, E.J. (1989) Characteristics, diagnosis and treatment of alcoholism in elderly patients. Journal of American Geriatric Society, 37, 310-316 Dar, K. (2006) Alcohol use disorders in elderly people: fact or fiction? 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