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Special Problems

Chapter 12

  1. History of Elder Abuse and its frequency
    Cynthia Madden, M.D. reports that we tend to think of elder abuse as a recent problem:

".  .  .   however, in pre-industrial Europe, [elderly] peasants arranged, through contracts, for the retention of certain property rights on the transfer of their assets to offspring. Such documents contain references to the right of the parent to sit at the family table or use the front door of the house".

 

  1.        The first modern reports of battering older adults was originally reported in the British Medical Journal, in 1975. The  phenomenon was called "Granny Battering" and prompted small case-controlled studies in the United States. These studies confirmed that the problem was common in this country as well. 

  2.        During the mid-1970's, the U.S. Senate Special Committee on Aging released a number of reports on abuse and neglect, and, in 1981, victims of elder abuse told of their plight before the House of Representatives Select Committee on Aging. In 1990, the Secretary of the U. S. Department of Health and Human Services created an Elder Abuse Task Force which developed an action plan to identify and  prevent  elder abuse in  homes, communities, and nursing facilities. 

  3.        The National Institute on Elder Abuse was established as part of the Administration on Aging: Elder Care Campaign. This established the existence of an Adult Protective Services agency in every state to serve vulnerable adults in cases involving abuse and neglect in the community setting (Aravanis, et. al., 1993).

  4.       Today, nearly every state has mandatory reporting laws that require health care workers and others to report cases of abuse in the community.

  5.       Most experts consider reporting laws less effective in identification, prevention and treatment of elder abuse than professional awareness.  In-home services are considered the most effective factor for both prevention and treatment (U.S. General Accounting Office, 1991).

 

  1.  Why the Increase in Concern?

  1.       Concern about elder abuse is increasing because we know that the numbers of older people is increasing and, thus, for each of the years grafted below, the number of abuse cases has increase.

Substantiated Reports of Elder Abuse by Category (2006)

The graph below presents the most recent national survey data from the National Center on Elders

Abuse (Teaster, et al., 2006)
taken from http://www.umaine.edu/mainecenteronaging/documents/issuebriefelderabuse.pdf

1. Self-neglect was the most common category of substantiated reports (37.2%),

2. Caregiver neglect (20.4%),

3. Financial exploitation (14.7%)

      Congressional studies put the estimate of abused older people currently at two million per year.  Experts worry that because of the rapid increase in the number of people over 65, (expected to jump from 33.2 million in 1994 to 80 million by 2050) there will also be a rapid increase in the number of elder abuse cases (Harvard Health Newsletter, 10-95). 

  1.       It is difficult to gauge the scope of elder abuse because families go to great lengths to conceal it (e.g. elderly people are isolated, victims are reluctant to report, signs of abuse may be subtle), and therefore have a great potential to pass undetected by neighbors and medical professionals. As a society, we expect old people to decline and thus bruises and broken bones do not arouse suspicion (Jones, et. al., 1988).

  2.      We seldom consider that an impairment or disability could stem from abuse or miss treatment.  In 1994,  241,000 incidents involving mistreatment of older people were reported in the U. S. and experts believe that most cases go unreported. 

  1. Types of Elder Abuse Maltreatment (2005) Refer to handout:
            Source: 2005 National Center on Elder Abuse, Wash. D.C.

A.   Most experts agree that the reporting and investigation of elder abuse is hampered by a lack of standardized definitions. What constitutes abuse? Who is an elder ( age 55, 60, 65)?  What is the definition of a "responsible" caretaker (for a dependent adult )?  Who is responsible for identifying gaps in care? Does a non-caregiver have a duty to prevent abuse or neglect?  Can an elderly person abuse themselves, and is that action criminal?  

 For example:

      The American Medical Association describes elder abuse and neglect as" actions or the omission of actions that  result in harm or threatened harm to the health or welfare of an elderly person " ( Madden, 1995).

      Other authors define abuse and neglect as a "state of . . . suffering".

      Yet others  note that it is the "actions"  taken by other people.

               

           It is extremely difficult to reach agreement on the definition of abuse by experts. It seems fairly clear that no ultimate definition exists since different definitions serve different purposes and different professionals. It is unlikely that the same definitions will serve lawyers, researchers and practitioners ( McCreadie, 1993).

For example:
Law enforcement will not investigate an incident unless there is a "victim". According to social workers who intervene and advocate for the elderly, they do not agree that elderly people who are abused are necessarily served by the label "victim". An important part of most intervention plans is to empower abused adults, and a label like "victim" is counterproductive to that goal.

          These definitions become important when deciding when one has actually broken the law or when to call adult protective services or law enforcement. Defining the type of abuse is also important in relation to determining why abuse occurs, what the risk factors are, and what kinds of interventions are useful, since different types of abuse may have different causes and risks associated with them.                
        

  Types of Abuse:

        Defining abuse is also difficult  because there are several different kinds of abuse. There is, however, a reasonable agreement for consensus over the following six categories of abuse.
            1. physical 
            2. psychological abuse      
            3. sexual abuse             
            4. financial abuse         
            5. neglect
            6. abandonment

   

      To simplify -- information that is reported to the Department of Social Services  by the 58 counties in California separates elder abuse into two categories:

1. types of abuse by others

2. types of abuse by self 

  1.        Types of abuse by others first, the signs that abuse may have occurred, and some possible reasons for the abuse. 

Physical Abuse:  The California Department of Aging defines elder abuse as including but not limited to:

       The following are signs or clues of physical abuse (but do not necessarily mean that abuse has occurred):

Reasons often given by people to account for these signs are:

  • it was an accident

  • medication is responsible

  • elderly person bruises easily

  • caregiver stress

  • self-defense

  •  falls

  •  someone else is responsible

  • consent ( sexual abuse)

 Many experts include sexual abuse as part of physical abuse.  It is     
                    characterized by rape, rape in concert, incest, sodomy, oral copulation     
                    or  penetration of genital or anal opening by a foreign object.

       It is difficult for many of us to imagine that elderly people can be victims of sexual assault.  Experts theorize that this stereotype prevents a large number of cases of sexual assault from being reported or investigated.

       SART teams (Sexual Assault Response Teams) are specially trained doctors and nurses who can examine and document sexual assault. They work with law enforcement to document the abuse and help the victim through the acute phase of the assault. The SART team in the Sacramento Area is located at U.C. Davis Medical Center. 

          Elder abuse victims commonly experience strong feelings of shame and         
   humiliation, particularly if that abuse includes sexual or extensive physical assault or if it was  
   committed by a family member. 

 

                 Psychological Abuse 

       Psychological  abuse is the infliction of mental anguish (e.g. calling names, treated as child, frightened, humiliated,  intimidated, threatened, isolated, etc.), (POST, 1997). It also includes verbal assaults,  harassment, serious emotional distress, or withholding emotional support. 

       An elder person may show signs of depression which include downcast eyes, an expressionless face, a tendency to lean away from others or prolonged silence.  Adults that are slow to respond to questions , or who provide one syllable answers to most questions may be exhibiting signs of depression [related to psychological abuse].

                  Some authors note two types of psychological  mistreatment: 

1.            psychological neglect

2.            psychological abuse.

       Psychological neglect occurs when an elderly person is left alone without social stimulation for long periods of time. An example of this type of neglect is a caregiver who provides adequate food, clothing , and medical care, but who never engages in conversation with the older person and actively discourages other people from visiting or telephoning.

       Psychological abuse occurs when subjects are subjected to verbal abuse and threats.  Some caregivers may be unaware of the harmful effects of such degradation. Others may deliberately use verbal assaults to threaten an elderly family member or to coerce them into submission. Verbal assaults include constant criticisms,  or accusations, threats of institutionalization, and other verbal assaults that make the elderly person feel unwanted by their caregivers. These assaults remind older people that people find them useless and a bother.

Indications of psychological abuse are:

  • insomnia or sleep deprivation

  • change in appetite

  • unusual weight gain or loss

  • tearful

  • unexplained paranoia

  • low self-acceptance

  • excessive fear

  • ambivalence

  • confusion

  • resignation

  • agitation

        Health care workers are often in a position to hear comments that suggest abuse. These conversations may provide a clue to the treatment of the elderly person.

For Example:

       Caregivers may make negative statements about their elderly relative, such as  what a great burden caring for the older person is on them. Family members may speak harshly or interrupt the older person. 

         Sengstock and Steiner recommend that health care providers look for positive or negative   
  non-verbal cues when the elder person is in the presence of their caregiver.

Positive Cues                                   

Negative Cues

Financial abuse

       According to the law (Welfare & Inst. Code 15610.30), "Fiduciary abuse means a situation in which any person who has the care or custody of, or who stands in a position of trust to, an elder or dependent adult, takes, secretes, or appropriates their money or property to any use or purpose not in the due and lawful execution of his or her trust".

      What that means is the unauthorized and improper use of money, property or any resources of an older person is abusive (McCreadie, 1995). Financial abuse includes: theft, embezzlement, misuse of funds or property, extortion, fraud. 

        Indicators of financial abuse: 

    Defenses used by abuser:

       There are agencies that can help an elderly person manage their money, pay their bills, and make sure their funds are protected. Every county is required by law to have an agency that is authorized to act as the conservator of a person residing in their county.

  Neglect

       Neglect is defined as the refusal or failure to fulfill a care taking obligation including:  attempts to inflict physical or emotional stress (e.g. deliberately abandoned or deliberately denied food or health-related services). Any person having the care or custody of an elder or dependent adult must exercise a degree of care which a reasonable person in a like position would exercise. Neglect includes, but is not limited to, all of the following: failure to 

  •  assist in personal hygiene, or provide food, clothing or shelter

  •  provide medical care for physical and mental health needs

  •  protect from health and safety hazards

  •  prevent malnutrition

       Research shows that neglect is the most commonly reported  form of abuse. Experts believe this is because there are no clear and consistent definitions of elder neglect. Lack of a definition, in turn, leads to absence of helpful protocol and guidelines to identify neglect in older people.  

      Terms such as "caregiver neglect", "self-neglect", and separation of  "passive neglect" (omitting needed services) from "active neglect" (doing something to harm) complicate the recognition of neglectful abuse.  These terms also offer little help in deciding how to distinguish neglect from the effects of age and disease. 

      When a child is referred for possible neglect, doctors use guidelines and screening tests to decide "normal" from "abnormal" development . These guidelines may include items such as  the weight a child should attain at a certain age, the specified range of motor activities that are normal for the age of the child, and the clean and healthy manner in which a baby presents.

      This is not the case with older adults. When older adults are assessed for neglect, doctors must factor in the possibility of a number of chronic diseases, functional limitations that have been acquired over a lifetime, and the mental capacity of the elderly person to determine their own lifestyle. 

       According to Fulmer and Gould, the signs and symptoms of arthritis, heart failure, and cancer can hide the signs of neglect. 

       Other examples of the aging process masking abuse or neglect is a broken hip or a stress fracture. It can be due to osteoporosis or it could be due to pushing or shoving an elder person down, or inadequate assistance with ambulating. 

      Poor hygiene is another example. Poor hygiene can be due to decreased vision, rheumatoid arthritis (pain), or inadequate self-washing (Fulmer & Gould, 1997). It can also be due to neglect. 

       Signs that an elderly person is at high risk for neglect are:

              Direct neglect -

  Caregiver or Family Issues that may increase the incidence of abuse include:

Types of abuse by self:

       Self abuse is conducted by clients who threaten their own health or safety. Experts differ on their opinions as to whether a person can be charged with self-neglect.  Competent elder adults who have difficulty performing their ADL's may refuse assistance despite the resulting problems. This can threaten autonomy and independence. 

       Some experts think that self-neglect reflects a failure of society more than it does elder abuse. The Department of Social Services offers these categories of self-abuse.

  1. Intentional versus Unintentional Abuse (active versus passive)

       The American Association of Retired Persons (AARP) defines abuse and neglect as being active or passive. According to active and passive abuse theories, individuals who abuse elderly people fall into two main categories: those who have no spiteful intent (passive abuse) and those who are  vengeful or vicious (active abuse). 

       Passive neglect is the unintentional failure to fulfill a care taking responsibility that causes distress. The caretaker is not conscious nor willful of committing abuse. Passive neglect can also include a types of abuse by self (self-neglect.)

        Examples :

         Passive self-neglect :

  • an elderly person with dementia, living alone, with physical signs of neglect.

            Passive caregiver neglect 

  •        may occur due to an overburdened caretaker with family obligations, and lack of enough financial resources to provide the needed care. She may feel unhappy that she can not do more for her mother.

       These individuals who have no malevolent intent may be well-intentioned, basically capable people who normally do not abuse, but may lash out in anger or impatience when overwhelmed or stressed. They often admit their abuse, feel remorseful, and recognize the harmful effects of their actions on the older person.  This type of abuse tends to be episodic rather than ongoing.

       Well-intentioned, impaired (mentally or lack of knowledge) abusers may also admit their harmful actions,  but they do not recognize the harm in their actions. They may consider the abuse to be a deserved punishment or an appropriate method of forcing the elderly person into a more desired or appropriate behavior.

       In either case, the intervention used is to provide services to reduce the caregiving burden and to increase the caregivers' capacity to provide high-quality care (Ramsey - Klawsnik, 1997).

        Check your handout : Do's If Your Parent Lives With You And Tips For Self-Care for Caregivers

       Active or malevolent intent abusers

       In some cases people who come in contact with the elderly person may have sadistic personalities. These offenders purposely inflict pain and suffering and may enjoy terrifying, exploiting, and assaulting vulnerable people. This type of abuse tends to be multifaceted in nature and ongoing rather than one- time. 

       Sexual offenders are more likely to be in this category because being overwhelmed or ignorant does not cause people to be sexually abusive. 

      These  offenders often lack guilt for their abusive actions and have no empathy for their victims. They are unlikely to admit wrongdoing and often intimidate their victims into silence. They may seek opportunities to gain power and control over vulnerable people. They can be manipulative and convincing, with good interpersonal skills, and a likable personality (Ramsey - Klawsnik, 1997).

       Examples of Active caregiver neglect:   
A caregiver who willfully withholds food and hygiene assistance

  1.  Risk Factors: What makes one vulnerable to abuse?

       Most of the literature agrees that there is no concrete evidence of the risk factors involved in elder abuse. Some studies say it is one's age (the older the more likely abuse will occur), sex (females more than males), race or income level (low income are more likely to be dependent on the caregiver and elders with high incomes  often contribute to the support of the abuser) that makes elderly people at risk of being abused (Mc Creadie,1993).  Others argue that additional factors like living alone, mental and physical impairments, and marital status also contribute (spouse abuse may continue throughout the lifecycle) ( McCreadie, 1993).

       Different kinds of abuse tend to have different explanations (Mc Creadie, 1993). Early studies that examine the cause of elder abuse  by the U. S. House Select Committee on Aging  identified a number of potential causes:

Direct interviews of victims and perpetrators has identified six major causes.

  1.        Psychopathology in the Abuser- this includes alcohol, drug abuse, or psychiatric illnesses.  Interestingly, studies have shown that the adult child most likely to be the caregiver is the one who is the least socially integrated . Often these caregivers have problems of their own.

  2.        Trans-generational Violence-  : "Many researchers have concluded that abuse and neglect is learned in the home and passed from one generation to the next. Thus elder abuse may be a cyclic phenomenon with parents and children mistreating each other throughout their lifetimes" (Jones et. al ).

  3.        Caregiver Stress- it is important to realize that the stressed caregiver theory does not explain why individuals in nearly identical situations respond differently. Most people experience stress at one time or another and do not mistreat their elders. Stress may not be as much of an underlining cause as it may be a trigger.

  4.       The Web of dependency - the caretaker is dependent on the elder for housing and money or the elder is dependent on the caregiver for daily activities (ADL's).

  5.        Care giving Context - the victim is isolated and shares living arrangements with the caregiver. Primary caregiver is the spouse (i.e. physical abuse) or the primary caregiver is an adult child (i.e. neglect). There may be a lack of close family ties and lack of community support or access to resources.

  6.        Social-Cultural Climate- these include: inadequate housing or unsafe conditions in the home

  1.  Profile of the abuser- Consider this rhyme:

 

When I was a laddie

I lived with my granny

And many a hiding ma granny dilled me

Now I am a man

And I live with my granny

And do to my granny

What she did to me  (unknown)

  1. Cyclic Nature of Violence:

       Some elder abuse may be interactive in that there is a cycle of violence much like that seen in child abuse and other domestic violence.

       Domestic Violence is a learned behavior and normative in some families.  If a person is abused as a child, he/she is more likely to be an adult abuser.  In families where screaming and battering have always been part of the landscape, elder mistreatment simply continues a violent pattern that started years earlier ( Harvard Health Letter, 1995). 

       Researchers extrapolate from this work that abusing parents are at a higher risk for abuse as they age.  Trans-generational violence can happen in families - the abuse of a child, a battered spouse, and an elderly parent  can occur concurrently.  That is, the parents are abusing the child, the spouse is battering the other spouse and granny is abused by the adult children. 

       Experts cite benefits in identifying families in which violence is common. These observations have a promise for finding elderly people who are at a high risk for being abused and neglected.  It may also help professionals manage the complex problems of domestic violence.

      In the United States, offenders are usually family members . They are often dependent on the victim for financial or emotional reasons and have a history of unemployment or spotty work history. Although there is  no simple explanation, violence often erupts  when families are pressured by social, economic, and psychological forces.

       Because daughters are most likely to be caregivers, some studies say they are the most likely to be an abuser.  However other studies that include financial abuse in their statistics indicate that son's  are the most likely abusers (C. Madden, 1995). 

       The next most likely abuser is the spouse of the victim when acting in a care giving role, with the male spouse slightly more likely to be the abuser than the abused.

  1.   Reporting of Elder Abuse : What you can do?

       Most states have mandated reporting laws.  Physical abuse must be reported by workers who provide services to an elder or dependent adult, and other types of abuse may be reported as well .

Mandated reporters Include:

    Care custodians (administrators and employees of facilities who provide care) 

    Health practitioners

    Adult Protective Services agency staff 

                Law enforcement agencies

        Mandated reporters must report abuse even if they are not sure that abuse is present. By reporting it, they allow the experts a chance to investigate and decide if an elderly person is being abused.  POST advises that it is better to err on the side of caution.


Many older people will not disclose their abuse because they feel embarrassed.  Often the suspect is a child or close relative, and victims are shameful.

       Because victims often display fear of and suspicion around their offenders fear may inhibit victim disclosure.

       Often offenders threaten elderly people with severe physical or psychological harm if they seek or accept help from professionals. Ramsey-Klawsnik report that in one case:

A man repeatedly physically and sexually assaulted his wife, who was physically impaired as the result of a stroke. He threatened that he would sexually assault their two young granddaughters if his wife sought assistance.

  Elders may be threatened with institutionalization or removal from the family home.

Refer to handout: Towards Prevention, Some Do's and Don'ts

 

       Elder abuse's most effective treatment is prevention.  Elderly people who stay sociable, keep in contact with friends, develop buddy systems, and arrange for competent handling of Social Security checks and other income are less likely to be victims of abuse. 

        It is important for elderly people to consider not living with persons who have a background of violent behaviors,  alcohol or drug abuse. They should not sign documents unless someone they trust has reviewed them and should not allow anyone else to keep details of their finances or property.

  1. Crime

More than 60% of the elderly live in a metropolitan area-- most in the central city where crime rates are higher (do you remember from the lecture on "Housing" why many seniors live in central cities?).
Fear of crime ranks near the top of their concerns. This fear can be beneficial if it induces positive steps to reduce the chance of being victimized. It is non-beneficial when it leads to isolation.


People over the age of 65 are not necessarily victimized more than rest of the 
population, but are easier targets because of their poor eyesight, potential for frailty and loneliness.  

The type of crimes most likely committed against an elderly person include: purse-snatching, pick- pocketing, consumer fraud and con games. The elderly  fear crimes of violence the most, yet these occur least often than crimes of economic loss.  

Economic crime is particularly hard on the elderly because many live on fixed incomes,  20-25 % live near or at the poverty level, and  the  ability to make up lost income is less likely.  

Crimes against the elderly often result in a  psychological imprisonment. The sense of invasion, threat, and worry keep social contacts limited. They often respond to these fears by limiting their exposure. This includes not going out in public, failure to carry adequate cash, or avoiding night time social opportunities. 

Some may carry weapons to protect themselves, add additional locks to their doors and windows, or consistently  keep their lights on . 

Physically the elderly have more risk of harm when they are assaulted. Because of brittle bones, decreased muscular strength and dexterity, decreased resilience, they are slower to recover from an injury. To make matters worse, decreased hearing and slower reaction time may make the court system confusing and complex. For this reason they may not report or prosecute crimes against them. 

 

Extra Credit Video: Don't Fall for a Line: Ask for it at the LRC- send me an email with your impressions of the video for up to 5 extra credit points. Be sure to address how this video might be used.

  1. Alcohol and Drugs

  1. Drugs - Medication use and misuse among the elderly has been called 
    America's "other drug problem".

    Last year, an estimated 125,000 seniors died from adverse reactions to medications.
    Additionally, medication reaction accounts for 25% of all senior 
    hospitalizations at a cost of 3 billion dollars annually.

    Although seniors represent only 12-14% of the population, they take 
    more than one-quarter of all prescription medications, and multiple 
    medications result in multiple mistakes for any age group.

    Seniors are less able to metabolize (kidney and liver function is slowed) medications and, therefore, face greater risks of a medication error or overdose.


Psycho-active drugs (drugs that affect the minds functioning) such as valium are particular culprits as they impair balance and the ability to reason. 

Aside from prescription medications, seniors take as much as 70% of 
all over-the-counter medications.

Aspirin alone is known to adversely affect over 34 prescription 
medications and combined with alcohol greatly increases the chances of 
bleeding in the stomach.

Records of all medications and their side-effects should be kept by a responsible person and by the older person's pharmacist. Ideally, a list should be kept in the elderly person's wallet or purse incase they are needed while outside their home. Only one pharmacist should be used when filling prescription medications because this person can then check for interactions between drugs when filling new prescriptions and can better answer questions about interactions with over the counter medications. 

Alcohol - Alcoholism is not reserved for high-stress middle-aged 
executives or skid-row unfortunates. While older alcoholics are less 
likely to drive drunk or create social problems, the health and personal 
problems of alcohol abuse affect and estimated 10 to 15% of older people.

There are an estimated 3 million American alcoholics--men and 
women--over the age of 60. Most--2-1/2 million--are over age 65.

The general public does not know, and too often disbelieves, that an
 older person can be affected  by the disease of alcoholism.

Popular myth holds that there can be but a few elderly alcoholics 
since alcoholism is acknowledged to be a killer and would have sent a 
drinker to the grave long before he or she could reach seniority.

Actually, there are 2 types of older drinkers: early-onset 
drinkers, called survivors; and late-onset drinkers, called 
reactors.

Survivors are so termed because most chronic alcohol abusers 
began drinking young, and often do die from alcohol- related causes by 
middle age.

Reactors, on the other hand, begin drinking during or after 
middle age often in response to difficult life changes: 
loneliness, bereavement, or depression.

The facts show that millions become addicted after retirement, 
when loneliness, boredom, and the feeling of being unneeded drive the 
newly "out to pasture" to seek comfort in alcohol, or suddenly increase 
their intake from "social imbibing" to excessive guzzling.

Seniors are also often encouraged by doctors, friends, relatives 
and self-styled "experts" to take "nips" to aid appetite, help 
digestion, relax nerves, to aid sleeping, and give more "pep" to life in 
general.



Alcoholism comes more rapidly to oldsters because old body organs 
and cells are less able than younger bodies to cope with any "enemy."

Science has known for generations that the older the human body, 
the less tolerance to alcohol and the greater the progress of the 
disease.



In addition, the older person is often already over-medicated.

Combining these depressant drugs with alcohol enlarges potency 
four-fold. The mixture can be lethal.

But even if there are no other drugs, the route to dependency on alcohol can be rapid.

Chronic alcohol abuse may cause permanent damage to most of the 
major organs of the body: the brain, liver, heart, stomach, and kidneys.

But why do oldster alcoholics remain hidden? There are several 
reasons.

The changed structure of their day-to-day life (living alone and 
not out in public daily) may make it harder to monitor an older 
drinker's behavior: job performance will not be 
compromised in a retiree.


Also, the elderly drink alone because they have matured during 
decades when drunkenness was held to be a moral weakness or a sin. The 
misunderstanding of peers demonstrates a stigma with which elders 
cannot cope.

They drink to escape. Guilt and shame make them lonely guzzlers.

They need not go to liquor stores; deliveries are common.

They cannot afford bar and cocktail prices.


They are falsely signed into hospitals for another ailment by 
friendly doctors who choose to ignore the real problem.

The problem is not going to decrease as long as society holds to 
its present misconceptions about elderly drinkers.

Fortunately, those who develop a drinking problem when older are 
good candidates for treatment, as they tend to stick to a program 
longer.

There is no definitive "best" treatment for alcoholism--but that 
is not to say that there is no effective treatment.

Most studies have found that out-patient treatment is as good as 
in-patient.

We still do not know which programs are best for which patients, 
but we should not be too quick to decide what works and what does not.

The key is knowing the abuser as a person, not just as an 
alcoholic.