by Sandy Sundeen, Member, Anti-Stigma Project
As people age, they often experience stigma and discrimination related to growing older. To make matters worse, if an older person is also living with a behavioral health problem, they face a double stigma‒ negative pre-judgments, attitudes, and behaviors against older adults as well as those about people with behavioral health challenges.
Ageism, which is the common term for the stigma and discrimination related to aging, is everywhere. Older adults are given messages about when they are expected to retire, what they are expected to do, where they are expected to live (and with whom)-- often regardless of their wishes, desires, or needs. They are frequently described as actual or potential burdens on their families or even on society as a whole. One example of this is the constant message about the burden and unaffordability of Social Security and Medicare, the very supports that enable many older adults to survive. The message underlying these expectations is that older people should take a backseat to younger folks, be quiet and fade out of life.
Terms such as “over the hill”, “one foot in the grave”, and “old fart” perpetuate stigmatizing attitudes that an older person is on the decline and unworthy. Disrespect is shown when a stranger calls an older person “hon” or “dear.” Even health and aging service providers call older people by their first names, a practice which is disrespectful unless it’s at the person’s request.
Stigma also affects the depiction of older adults in the media. For example, most of the TV commercials featuring seniors are for medications or other healthcare related services, leading to the impression that older people are in poor health, plagued by a host of issues such as high blood pressure, mobility problems, constipation, weak bladder, sexual dysfunction, and so on. It also implies that these conditions only impact older people! Historically, movies and television shows have cast older actors in the role of people who are sick or burdensome rather than vigorous and successful. Thankfully this trend seems to be changing, as more older adults are assuming leading roles and challenging negative stereotypes.
There are two major subgroups of older adults who face the double challenges of behavioral health stigma and ageism.
The first and, until now largely ignored, consists of the people who have had behavioral health challenges throughout their lives, which have impacted their somatic health. A 2006 study conducted by the National Association of State Mental Health Program Directors found that people with serious mental illness lived on average 25 years less than the general population and most of the deaths were caused by preventable conditions such as heart disease, diabetes, respiratory disease and infections such as HIV. These so-called lifestyle diseases are generally related to unhealthy behaviors such as a poor diet, smoking and substance abuse. For older adults these problems may be traced to long hospitalizations, involvement in outpatient programs that did not attend to physical health needs, or issues with medication.
As more of them age, they will need assistance in navigating systems of care for both their somatic and behavioral health needs. Behavioral health supports for older adults are often not geared to the needs of an aging population. Traditional evidence-based programs such as supported employment may not be appropriate for an older person who would like to retire, for example. There needs to be a menu of options suitable to their needs, ranging from continuing to work if they find their job rewarding, to involvement in fulfilling leisure activities and development of untapped skills and abilities. Traditional community behavioral health programs need to engage their aging consumers in identifying and planning for their retirements.
The second group consists of people whose behavioral health problems are newly identified in their later years, or have yet to be identified. The losses associated with aging, such as the loss of loved ones, mobility, and societal roles, can result in increasing isolation, depression, and anxiety, which many people try to manage with alcohol and overuse of prescription drugs. Unfortunately, the stigma associated with behavioral health issues often discourages them from seeking help, and even if they do receive help, stigma can impact the quality of care they receive. As an example, depression and substance abuse can affect cognition, leading to a misdiagnosis of dementia. Additionally, health care providers often do not realize that there is potential for improvement or even cure with this population, highlighting the intersection of stigma regarding both mental illness and aging.
The results can be catastrophic.
According to the American Foundation for Suicide Prevention, in 2014 the highest suicide rate was among persons 85 and over. There was 1 death for every 4 attempts among older adults, contrasted with 1 death for every 100 attempts in the 15-24 age group. There has been an intense focus and extensive resources directed to suicide prevention for younger adults, and it’s time for a similar preventive effort to be directed toward older adults.
So is there any good news in all of this?
In recent years there has been more attention paid to health promotion, disease prevention and early intervention as a part of comprehensive behavioral health services. This includes education about nutrition and the importance of exercise as well as smoking cessation. Folks receiving behavioral health services and supports are now more often educated about the signs of physical health problems and the importance of regular primary health care visits. On the flip side, more screening is being done in in the primary care setting to identify a behavioral health disorder that may have gone undetected. In long term care settings such as nursing homes and assisted living programs, increased attention is being given to behavioral health issues. Several states, including Maryland, have been rewarded for moving people from institutions to community settings and peer support programs have been very helpful in supporting people making this transition with behavioral health needs.
As we see more and more folks living well into old age, there is a crucial need to address the stigma of being an older person in a culture that under-values aging, as well as the stigma of being someone with a behavioral health challenge in a culture that views those challenges with fear and contempt. It is our obligation to be proactive in changing perception about both aging and behavioral health. Someday we might be standing in those shoes. We need to be more respectful of the contributions people have made in their lives despite illness and challenges. We must acknowledge the support an older person can give to a younger person who may be struggling with life or with illness. We can urge mutual support across generations and levels of ability with appreciation for talents, skills and abilities. A “strengths – based approach” needs to apply to people in any stage of life.
We have work to do.
References:
Mentally Healthy Aging: A Report on Overcoming Stigma for Older Americans. DHHS Pub. No. (SMA) 05-3988. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2005.
Parks J, Svendsen D, Singer P and Foti ME: Morbidity and Mortality in People with Serious Mental Illness. Medical Directors Council, National Association of State Mental Health Program Directors. Alexandria VA, 2006.