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Diversity in Treatment & Recovery: Serving Lesbian, Gay, Bisexual, Transgender (LGBT) Clients

Diversity in Treatment & Recovery: Serving Lesbian, Gay, Bisexual, Transgender (LGBT) Clients



Presentation at 2013 Annual Tuerk conference

Presentation at 2013 Annual Tuerk conference
April 9, 2013 with Pablo McCabe



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    Diversity in Treatment & Recovery: Serving Lesbian, Gay, Bisexual, Transgender (LGBT) Clients Diversity in Treatment & Recovery: Serving Lesbian, Gay, Bisexual, Transgender (LGBT) Clients Document Transcript

    • 4/9/2013 DIVERSITY IN TREATMENT & RECOVERY: SERVING LESBIAN, GAY, BISEXUAL, TRANSGENDER (LGBT) CLIENTS Bernie McCann, Ph.D., CEAP Pablo McCabe, LCSW LEARNING OBJECTIVES1. Understand the differences in LGBT life experiences that may impact substance use, substance use disorders (SUDs) & other mental health conditions among these clients.2. Understand unique features & approaches to treatment for & recovery support with SUDs among LGBT clients.3. Learn how to connect the uniqueness of LGBT experience with a best practices approach to delivering services for treatment success & maximizing recovery. 1
    • 4/9/2013 PART ONE Have a subtitle for here?? HETEROSEXISM & HOMOPHOBIA Heterosexism - a predisposition, weighted attitude or bias towards heterosexuality & over other sexual orientations, and specifically against LGBT people. Heterosexism is not the same as Homophobia (a fear of or irrational hate towards lesbians, gays, etc.) but rather the discrimination or bias towards non- heterosexuals or (perceived non-heterosexuals). Heterosexism is another form of institutional discrimination, just like racism or sexism. 2
    • 4/9/2013 LGBTS IN US POPULATION In a 2012 Gallup Survey, 3.5% of adults identified as LGBT, which represents appx. 9M Americans. Specifically, 1.7% of adults identify as gay or lesbian, 1.8% as bisexual, & 0.3% as transgender. Women are substantially more likely to identify as bisexual. Bisexuals comprise more than 1/2 of the lesbian or bisexual female population, while for gay men the reverse is true. Minorities were more likely to identify as non-heterosexual: 4.6% of Blacks and 4% of Hispanics vs. 3.2% of Whites. 6.4% of those aged 18-29 identified as LGBT – 3X more than those over age 65 (1.9%). Rates of adults reporting any lifetime same-sex sexual behavior (8.2% or 19M) & those acknowledging any same-sex sexual attraction (11% or 25.6M) are substantially higher than those identifying as lesbian, gay or bisexual. HOW MANY ADULTS IDENTIFY AS L/G OR B? Gay/ Lesbian Bisexual National National General California NationalEpidemiological Survey of Social Health Survey of Survey on Family Survey, Interview Sexual Alcohol & Growth, 2008 Survey, Health & Related 2006-08 2009 Behavior,Conditions, 2005 2009 3
    • 4/9/2013 LGBTS, SUDS & MH CONDITIONS Gay men & lesbians are heavier users of alcohol & other drugs than either heterosexuals or the general population. In a recent study, the odds of substance use for LGBT youth were 190% higher than heterosexual youth. Substance use & some mental health conditions (mood & anxiety disorders, psychological distress) are more prevalent among LGBT adults than heterosexual adults. Individuals with minority sexual orientation experience a greater prevalence of comorbid behavioral disorders. Some studies indicate gay men & lesbians are higher users of MH services than the heterosexual population. IMPACT ON LGBT PERSONAL SAFETY Physical abuse, violence & victimization are more frequent for LGBT individuals & may have long-lasting psychological effects. Studies of GLBT youth in schools reveal a significantly higher frequency of verbal harassment & physical assault than heterosexual peers. 38% of gay men & 31% of lesbians reported physical attacks in the past 5 years. Rates for heterosexuals were proportionately lower. Lesbians reported the highest rates of actual physical harm and/or bullying behavior. 54% of gay men & 56% of lesbians had committed self harm, as opposed to 41% of straight men & 50% of straight women. LGBT teens & young adults have one of the highest rates of suicide attempts. 4
    • 4/9/2013 MYTHS ABOUT LGBTS Myth: Sexual abuse by men or bad relationships with men causes lesbianism. Myth: Lesbians hate, are afraid of, or want to be men. Myth: Same-sex sexual behaviors can be blamed on using alcohol & drugs; once a client achieves sobriety, they will no longer desire/seek same-sex sexual relations. Myth: Gay men are not interested in, nor able to engage in committed relationships, only in sexual encounters. Myth: Most gay men are overly enmeshed with their mothers & have cold or indifferent fathers. CASS’ MODEL OF SEXUAL IDENTITY - 6 STAGES 1. Identity Confusion: "Could I be gay?" Person is beginning to wonder if "homosexuality" is personally relevant. Denial & confusion is experienced. Task: Who am I? - Accept, Deny, Reject. 2. Identity Comparison: "Maybe this does apply to me." Will accept the possibility that they may be LGBT. Self-alienation becomes isolation. Task: Deal with social alienation. 5
    • 4/9/2013 CASS’ MODEL OF SEXUAL IDENTITY, CONT.3. Identity Tolerance: "Im not the only one“. Accepts the probability of being homosexual & recognizes sexual, social, emotional needs that go with being LBGT. Increased commitment to being LBGT.Task: Decrease social alienation by seeking out other LGBTs and/or welcoming environments.4. Identity Acceptance: "I will be okay“. Accepts, rather than tolerates, LBGT self-image. There is continuing and increased contact with LGBT culture.Task: Deal with inner tension of no longer subscribing to social “norms”, attempt to seek congruence between private & public view of self. CASS’ MODEL OF SEXUAL IDENTITY, CONT. 5. Identity Pride: "Ive got to let people know who I am!" Immerses self in LGBT culture. Less & less involvement with heterosexual community. Us-them quality to political/social viewpoint. Task: Deal with incongruent views of heterosexuals. 6. Identity Synthesis: Develops holistic view of self. Defines self in a more complete fashion, not just in terms of sexual orientation. Task: Integrate LGBT identity so that instead of describing a role, it becomes an aspect of self. 6
    • 4/9/2013 MYTHS ABOUT LGBT FAMILIES Myth: Lesbians & gay men do not have children. Myth: Children raised by LGBT parents will not have proper male & female role models & are likely to turn out to be LGBT themselves. Myth: Children who are in contact with gay men or lesbians face increased risk of being sexually abused. Myth: LGBT individuals have unstable relationships that make them inadequate parents. Myth: The only acceptable home for a child contains a mother & father who are married to each other. 6 STAGES OF GLBT FAMILY DYNAMICS 1. Shock: a) Greater if they have no idea; b) some know or suspect 2. Denial: Parents suspect confusion or need for counseling 3. Guilt: They feel they did something wrong 4. Feelings expressed: Emotions related 5. Making Decisions: The fork in the road 6. Acceptance: Their own coming out story 7
    • 4/9/2013MOST LBGT EMPLOYEES STILL HIDE AT WORK 22% 51% 27% Source: Human Rights Campaign Foundation, 2011 SOME OBSERVATIONS ON COMING OUT "People think they’ll lose everything if they come out. This did not happen to me at all. In fact, everything came back tenfold.“ - Melissa Etheridge, pop singer "Almost everyone I know had a better experience coming out than they thought they would.“ - Barney Frank, former U.S. congressman "…to me, it was like being in a black-and-white movie that suddenly converted to color." - Andrew Sullivan, writer & TV commentator 8
    • 4/9/2013 COMING OUT – LGBT VENUES Bars and Clubs – once “the pillar of the community,” now have a less central role Internet – Often the first opportunity individuals have to explore LGBT identity, both a positive & negative Gay Pride Events - Numerous events nationwide Student Groups – In high schools & universities Community Centers, Bookstores & Coffee shops - Mainly in urban settings THE NEXT LGBT GENERATION A more openly gay generation: Queer Youth Increase in Gay-Straight Alliances (GSAs) in high schools & college campuses Greater gay & lesbian visibility in entertainment & sports Greater access to LGBT- positive information (Internet as a huge resource, with some downsides) More heterosexual friends & families support equality Changing social expectations about accepting workplaces, civil liberties, marriage equality 9
    • 4/9/2013 PART TWO Best Practices in providing SUD Services to LGBT clients CONSIDERATIONS WITH LGBT CLIENTS Understanding individual’s comfort level with LBGT sexual identity & impact in various settings - work, community/social situations, family dynamics Past experience with anti-gay violence or oppression; legal problems related to workplace discrimination, partner benefits, survivor rights, sexual behavior, police harassment Unique support systems that may include friends, intimate relationships in addition to family members Specific health concerns, e.g., HIV/AIDS, PTSD 10
    • 4/9/2013 CULTURALLY SENSITIVE = QUALITY TREATMENT & RECOVERY SUPPORT The quality of treatment & recovery support for substance use disorders improves with the incorporation of approaches that take account of patients’ preferences and values along with scientific findings about effective care.* Adopting a culturally sensitive SUD approach spans the full range of treatment & recovery support aspects: environment, service components, provider staff, etc.*Source: National Institute of Medicine, Improving the Quality of Health Care for Mental and Substance Use Conditions, 2006 UNIQUE ASPECTS OF LGBTS & SUDS Negative effects of discrimination appear to result in an increased risk of substance use disorders (and other mental conditions) among LGBT individuals. Pre-existing mental health conditions & SUDs may be intertwined with LGBT sexual identity and/or behavior. Struggles due to religious/social beliefs about LGBTs - for many individuals (and their families), these can result in an increase in shameful feelings. Lack of acceptance by one’s own family & community may severely limit access to resources for counseling, SUD treatment, or other health issues. 11
    • 4/9/2013 LBGT BARRIERS TO TREATMENT Lack of familial & social support for LGBT clients, thus difficulties with alcohol & other drugs may also be seen as “part of the lifestyle”. Living in a heterosexist society, most LGBTs experience isolation, fear of rejection, confusion, fear of the future; all increasing the difficulty of help seeking & access to services Lack of LGBT-sensitive treatment environments (creates the anxiety of being “the only one” in treatment). For lesbians with children, even more rare to find suitable, welcoming accommodation.UNDERSTANDING TREATMENT UN-READINESS We can use the Stages of Change Framework* as a way to view how some of the unique life concerns of LGBT clients may interact to increase ambivalence & decrease motivation to enter treatment for SUDs  Confusion about sexual orientation/gender identity  Anxiety regarding disclosure & coming out  Abuse, discrimination, anti-LGBT violence  Health concerns, such as HIV/AIDS, PTSD  Can anyone provide a case example? * Also known as the Transtheoretical Model 12
    • 4/9/2013 STAGES OF CHANGE MODELPROMOTING TREATMENT READINESS Using the same approach of Motivational Interviewing (MI) as with other SUD clients, we can explore the “layered” ambivalence of LGBT individuals, & with knowledge of their unique life experiences, then meet the resistance. Key to motivating clients is to match the type & level of help to the stage of readiness to change. The two phases of MI are: 1. Building client motivation 2. Strengthening client commitment to change 13
    • 4/9/2013THE MOST POWERFUL TECHNIQUE IN COUNSELING“What most people really need is a good listening to” - Mary Lou Casey SOME ASSESSMENT QUERIES FOR LGBTSCan you describe……your level of comfort with/being LGBT & your current stage of coming out/self disclosure?…your level of family/social support?…any connections between alcohol/drug use & sexual identity/behavior?…substance use by friends/partner(s)?…any legal problems related to sexual identity/behavior?…any history/fears of LGBT-related abuse or violence?…any previous treatment/sober periods & concerns relative to above? 14
    • 4/9/2013 MOTIVATING & SUPPORTING CHANGE1. Facilitating clients to visualize change  Use key questions to explore the advantages of change  Experimentation with new approaches to change2. Strengthening commitment  Identifying attainable goals  Considering the menu of change options MOTIVATING & SUPPORTING CHANGE3. Arriving at a plan to change  Narrowing and negotiating available options  Matching client to type & level of treatment4. Supporting change from treatment to recovery  Consolidating continuous direction of growth  Avoid “the heartbreak of relapse” – encourage clients to be realistic & optimistic 15
    • 4/9/2013 LGBT BARRIERS TO ATTAINING & MAINTAINING RECOVERY Often a lack of familial or community understanding of or support for LGBT identity in recovery Relative lack of LGBT-welcoming treatment, recovery support & social environments Often continued successful recovery may involve coming to terms with the harmful effects of shame, oppression & accumulated psychic damage. Can you offer some additional barriers..? LGBT CLIENTS - CREATING A SAFE SPACE Agency staff is routinely educated in cultural competence – include LGBT education as a routine part of continuing educational efforts Critical to show respect/understanding for LGBT clients & their uniqueness/current situation: work, family or social situations can be complicated, may need time to sort out. Ensure confidentiality of all personal, medical & sensitive information. Assist/support self-disclosure by clients, when appropriate, respect decisions not to reveal 16
    • 4/9/2013BREAKING DOWN INSTITUTIONAL BARRIERS Implement explicit nondiscrimination policies & procedures for LGBT clients, similar to that for other groups. Review intake forms/other documents for inclusivity of LGBTs & other groups; avoiding judgmental and non- inclusive language for client histories and treatment. Ensure staff receives information on LGBT issues as regular component of training & staff development Compile resource listings of local & regional LGBT- affirmative treatment & recovery support services Are LGBT friends, partners included in the treatment plan? Are additional outreach efforts provided to welcome them? STAFF LGBT AWARENESS & TRAINING  Raise awareness & culturally-specific sensitivity of LGBT-relevant issues.  Identify & become fluent in LGBT-appropriate & sensitive language.  Develop staff knowledge of & active use of LGBT- affirmative resources for treatment & recovery support services.  When appropriate, engage clients in supportive exploration and discussion of the interaction of healthy LGBT identity & substance use behavior 17
    • 4/9/2013 HEALTHY LGBT IDENTITY IN RECOVERY  Assess how comfortable clients may be with their sexual orientation/gender identity  For example, what level of disclosure is client comfortable with at work?; In family life, including extended family, in-laws, etc.?; In faith or other community settings?  Encourage clients to assess sense of self esteem/worth & explore relationship to expressions of LGBT identity  What is client’s level of involvement in the LGBT community? Historical isolation of a closeted life may hinder ability/interest in reaching out or joining in.  Ultimate goal = Client feels comfortable in “LGBT skin” WORKING WITH LGBT FAMILIES Be aware of & sensitive to the diversity of relationships within the LGBT community. There is no universal terminology regarding significant others in LGBT community, so ask clients’ preference. Be careful of institutional and staff biases - e.g., what a family “should be” or “act like”. Don’t assume clients have no history of opposite-sex relationships. Demonstrate understanding of & support for client’s life partners & significant others. 18
    • 4/9/2013 EMBRACING THE ROAD TO RECOVERY  Identify & make LGBT-friendly recovery resources readily available, such as online resources or a daily affirmation book.  Encourage LGBT clients to explore non-bar activities in the LGBT & welcoming community: e.g., social clubs, sports teams, community involvement.  Sponsor sober events during Pride celebrations.  Connect clients with LGBT-affirming places of worship, and vice-versa. MONITORING PROGRESS Document agency LGBT-welcoming & outreach measures both established and those modified for quality improvement Collect LGBT-specific outcome measures such as  Number of LGBT-identified clients admitted  Number of LGBT-identified clients completing treatment  Number of LGBT-identified clients relapsing (within # of days)  Number of LGBT-identified clients readmitted Compare & evaluate client outcome data Compare & evaluate aggregated agency outcomes 19