Counseling Implications for working with LGBTs with SUDs

I created a presentation that introduces counselors to the basics of working with Lesbian Gay Bisexual and Transgender individuals with Substance Use Disorders. To view the slide show, click here. 

Counseling Implications for working with

LGBTs with SUDs

David Johnson, PCCT

davidj@sandiego.edu

Why this population is different

A. Legal issues

1. Legacy of discrimination - homophobia and heterosexism

a. Disparate treatment before the law

b. Transgender barriers

c. Military acceptance

d. Complex trauma

2. Marriage equality

B. Cultural issues

1. Coming out is part of minority identity development

2. Building community for safety and mentoring

3. Diverse community, hence the rainbow

C. Health Issues

1. Hate crimes and violence

2. IPV – Intimate Partner Violence

3. Body image

4. HIV/AIDS

What the research says (and doesn't)

A. Substance use in the LGBT Community

1. Historical ties between bars and Gay community

2. Current drugs of choice for MSM: Alcohol, marijuana, psychedelics,

hallucinogens, stimulants, sedatives, cocaine, barbiturates, MDMA,

"poppers."

3. Party drugs and the party circuit associated with

methamphetamine, aka "Tina"

B. Epidemiology research

1. Late 1980s: gay men and lesbians have 70%-80% higher incidence

of moderate/heavy/problem drinking than heterosexuals.

2. 1990s: gay men and lesbians also use greater quantities of illicit

drugs than the general population.

3. Same sex couples use substances together more than opposite sex

couples

4. Being a lesbian is included in list of risk factors for women

developing alcohol dependence

C. Holes in the research

1. Precise incidence of use and abuse rates for LGBT populations

cannot be done because we do not have reliable estimates of

the LGBT population (how to define, self-reports, rapidly changing social acceptance of LGBT people)

2. Most epidemiological studies have not asked for sexual orientation

data from participants.

3. Studies cannot be compared in meta analysis because of

inconsistencies in methodologies.

General LGBT cultural competency

DO:

• Create safety for LGBT clients; protect them from others' homophobia/heterosexism.
• Get to know the LGBT population and current issues.
• Create an atmosphere that is supportive; for example, review documents for inclusive language.
• Acknowledge their significant others in the same manner as heterosexual partners.
• Let LGBT clients determine what is comfortable for them to disclose and support their decisions.
• Get training to become less heterosexist and increase your understanding of LGBT issues.

DON’T:

•  Label clients; allow them to apply labels for themselves.
• Pressure clients to come out or pursue relationships; respect where they are at.
• Ignore their significant relationships or make assumptions about the importance of a particular relationship.
•  Interpret on behalf of the client or make judgments about what/who is "good" or "bad;" rather, follow the client's lead. A comment that is empathetic in one context may be invasive in another.
• Categorize clients by gender, gender identity, partner preference or history without asking them how they identify.

Clinical recommendations and best practice

• LGBT individuals seeking treatment for SUDs have many of the same issues as heterosexual populations, but in addition, they may be having difficulty with coming out, sexual orientation, gender identity, stigma, HIV/AIDS, discrimination, same sex relationships, lack of social/family/spiritual support.
• Counselors need to understand the primacy of accepting oneself as LGBT and finding a way to feel comfortable in society.
• Two approaches have been shown effective in promoting effective recovery with LGBT clients: abstinence and stage-specific treatment
• Counselors need to assess the client's overall ability to cope with stressors when selecting treatment. One example is that methamphetamine reached epidemic levels among gay men in the past decade; abuse of this drug was linked to strong cravings and more frequent relapse.
• Discrimination and systemic historical marginalization may present real and/or perceived barriers for LGBT clients who seek treatment. This is sometimes mistaken by program staff as "resistance" in treatment.
• LGBT clients may feel more comfortable with either same or opposite sex roommates, staff, and/or counselors. For example, programs that require an observer to collect urine samples might consider asking an LGBT client which gender observer they prefer.
• Programs might consider designating a unisex toilet or shower to be responsive to transgender or gender queer clients
• Heterosexual staff should not assume LGBT clients will be more or less likely to flirt, push personal boundaries, or act out with others simply because they are LGBT.
• Get to know the Levels of LGBT Sensitivity in Treatment Model
• Be aware of a number of health related issues that affect this population such as HIV/AIDS and other STIs, sexual assault/trauma history, prostitution, (particularly with Lesbians and Transwomen), and barriers related to access to medical care.

Resources and References

Association of Lesbian Gay Bisexual Transgender Issues in Counseling, a division of ACA. www.algbtic.org. This is the leading professional association for counselors focused on LGBT topics. Their website has an extensive list of research articles. Also they have a recent document that outlines the “gold standard” of LGBT competencies for counselors.

Family Health Centers of San Diego, Gay Men's Health Services www.gaymenshealth.org. This is a leading local agency that offers a complete range of health services including HIV prevention and education, counseling, case management, AOD outpatient (including court ordered) recovery groups primarily in Hillcrest and North Park. The larger agency, www.fhcsd.org, offers free and low-cost medical, vision, and dental care for women, men, and children with over 25 locations across metro San Diego.

Josue Homes Sober Living Communities. (pronounced like “Joshua”) www.nationalaidsfoundation.org. This is a network of sober living communities that offers counseling, education, and case management with a special focus on serving women and men who are HIV+ and/or have AIDS. Since safe affordable housing is a critical need for this population

The Live and Let Live Alano Club of San Diego. www.lllac.org. Is a large recovery organization offering a variety of member-supported 12-Step programs, mutual support groups, and meetings at their location in University Heights. Their mission has a special focus on serving the LGBT community, although all are welcome, regardless of affectional preference.

National Association of Lesbian Gay Bisexual Transgender Addiction Professionals and Their Allies. www.nalgap.org. Similar to ALGBTIC, but with a special focus on addiction. Their website has loads of references and resources, plus they have rich offering of training and curriculum on the topic of LGBT issues in addiction treatment.

Substance Abuse and Mental Health Services Administration (SAMSHA) A Provider's Introduction to Substance Abuse Treatment for Lesbian Gay Bisexual and Transgendered Individuals. www.kap.samhsa.gov/products/manuals/pdfs/lgbt.pdf. It’s basically starting point for standards of practice, curricula, latest research, and practical “how to” of mental health practice. We should all have SAMSHA bookmarked on our browsers.

Stepping Stone of San Diego. www.steppingstonesd.org. A well-known local treatment center offering inpatient, outpatient, and recovery/maintenance services. Stepping Stone has a national reputation as a leader in adapting proven AOD treatments for use with for LGBT populations.