Working with LGBT Students with Substance Use Disorders at Job Corps

1. Working with LGBT Students with Substance Use Disorders at Job Corps Christy Hicks, LCADC/CADC/CSW Regional TEAP Specialist Chicago, Dallas, Atlanta Regions

2. Objectives • Understand the epidemiology of substance abuse among the LGBT population. • Understand special issues in working with LGBT students. • Understand how to provide quality, fair, ethical and competent to LGBT students. • Understand how as a counselor you can become more aware of their bias and how to manage them. • Be able to identify key terms with LGBT students.

3. Limitations • Lack of reliable date • Reluctance to disclose • Use of convenience samples • Collecting data in gay bars • Collecting data at events like Pride Parades • Collecting data at HIV service organizations

4. History • 1940s and 1950s-same sex attraction and behavior was a mental disorder. • 1957-Dr. Evelyn Hooker’s landmark study finds gays and lesbians “normal”. • 1973- The American Psychiatric Association removes homosexuality as psychopathology from the DSM.

5. Terms • Categories • Sex • Gender/ Gender Role • Sexual Orientation • Gender Identity • Descriptions • Lesbian • Gay • Bisexual • Transgender • Transsexual • Heterosexual • Queer • Masculine • Male • Female • Feminine • Intersex

6. Terms Continued • Categories • Sex • Male • Female • Gender/Gender Role • Male • Female • Masculine • Feminine • Descriptors • Sexual Orientation • Lesbian • Gay • Bisexual • Heterosexual • Queer • Gender Identity • Transgender • Transsexual

7. Core Aspects of Identity • Family of origin • Race • Ethnicity • Age • Class • Sexual orientation • Gender identity • Abilities • Appearance • Religion • Other

8. Definitions • Stereotyping • Prejudice • Myths • Stigma

9. Homophobia and Heterosexism • Homophobia is an irrational fear of gay and lesbian people or fear of same-sex relationships. In its most extreme form, homophobia is a hatred for or violence against LGBT persons. • Heterosexism is an assumption of heterosexuality and the heterosexual perspective as the predominant or meaningful viewpoint. • Biphobia is fear of and hatred for bisexuality. • Transphobia is fear of and hatred for transgender persons.

10. Cultural Pain A feeling “insecure, embarrassed, angry, confused, torn, apologetic, uncertain or inadequate because of conflicting expectations of and pressure from being a minority.”

11. Assimilation An adaptation to a new culture by taking on a new identity and abandoning the old cultural identity.

12. Acculturation Refers to accommodation to the rules and expectations of the majority culture without entirely giving up cultural identity.

13. Culturally Immersed Individuals have rejected mainstream culture and their emotional and spiritual needs are met exclusively in their ethnic community or in the gay community.

14. Core Aspects of Identity • Family of Origin • Race • Ethnicity • Age • Class • Sexual Orientation • Gender Identity • Abilities • Appearance • Religion

15. Approaches, Levels and Continuum of Care, and Access to Treatment • Treatment-readiness approaches • Sexual orientation and gender identity issues • Coming out • Social stigma and discrimination • Health concerns, such as HIV?AIDS • Homophobia and heterosexism • Level of care • Residential vs IOP vs Outpatient • LGBT community based support services • Continuum of Care • LGBT specific vs mainstream

16. LGBT Student Do’s and Don’t • Staff Sensitivity • Knowledge, skills and attitudes • Assessment Practices and Issues • Facilities and Modalities • For example, room assignments and shared bathrooms • Individual, groups, and family interventions • Discharge, Aftercare and Relapse Prevention

17. Defining LGBT Affirmative Care • LGBT-tolerant • Aware the LGBT people exist and use their services • LGBT-sensitive • Aware of, knowledge about and accepting of LGBT people • LGBT-affirmative • Actively promote self-acceptance of an LGBT identity as a key part of recovery.

18. Special Assessment Questions to Consider • What is the students level of comfort being a LGBT person? • What stage of coming out is the student in? • Family/Supports/Social Network? • Health Factors? • Milieu of Use? • Drug Use and sexual identity or sexual behavior connections? • Partner/ lover drug or alcohol use? • Same-gender domestic violence?

19. Research based Interventions • PROP(Positive Reinforcement Opportunity Project) • Low intensity contingency management intervention in both outpatient and community settings • Preliminary efficacy at reducing methamphetamine use • Gay Specific CBT Groups • Significantly reduced depressive symptoms in sample of gay and bisexual men

20. Clinicians Guide to working with LGBT students in SUD Treatment • Understand the “coming out” process and its impact • Understand clinical issues and effective interventions with lesbian, gay men, bisexuals, transgender individuals, and LGBT youth • Have skills for working with LGBT families • Be able to identify and assess related health and mental health issues • Demonstrate skills for evaluating and improving counselor competence in treating GLBT students.

21. Coming Out The term “coming out” refers to the experiences of lesbians and gay men as they work through and accept a stigmatized identity, transforming a negative self-identity into a positive one.

22. The Cass Identity Model • A fundamental theories of gay and lesbian identity development, developed in 1979 by Vivienne Cass. This model was one of the first to treat gay people as “normal” in a heterosexist society and in a climate of homophobia instead of treating homosexuality itself as a problem. Cass described a process of six stages of gay and lesbian identity development. While these stages are sequential, some people might revisit stages at different points in their lives.

23. The CASS Model • Stage I: Identity Confusion • Occurs when a person begins to realize that he/she may relate to or identify as being gay or lesbian, a process of personalizing the identity. • Tasks: Exploration and increasing awareness • Feelings: Anxiety, confusion • Defenses:Denial • Recovery: Having a confidential support person

24. The CASS Model • Stage II: Identity Comparison • Occurs when a person accepts the possibility that he/she might be gay or lesbian. • Tasks: Exploration of implications. Encountering others like oneself • Feelings: Anxiety, excitement • Defenses: Bargaining and rationalizing • Recovery: Meeting gays/lesbians/bisexuals/transgender persons in recovery

25. The CASS Model • Stage III: Identity Tolerance • Occurs when a person comes to accept the probability that he/she is an LGBT person. • Tasks: Recognizing social and emotional needs as a gay man or lesbian • Feelings: Anger, excitement • Defenses: Reactivity • Recovery: How to be gay, lesbian, bisexual or transgender and stay sober

26. The CASS Model • Stage IV: Identify Acceptance • Occurs when a person fully accepts rather than tolerates himself or herself as an LGBT person. • Tasks: Development of community and acculturation • Feelings: Rage and sadness • Defenses: Hostility towards straight culture • Recovery: Lesbian/gay/bisexual/transgender recovering community building

27. The Cass Model • Stage V: Identity Pride • Occurs when the person immerses himself or herself in the LGBT community and culture to live out identity totally. • Tasks: Full experience of being an LGBT person, confronting internalized homophobia • Feelings: Excitement and focused anger • Defenses: Arrogant pride and rejection of straight culture as the norm • Recovery: Integrating sexuality, identity, and recovery

28. The Cass Model • Stage VI: Identity Synthesis • Occurs when a person develops a fully internalized and integrated LGBT identity and experience himself or herself as whole when interacting with everyone across al environments. • Tasks: Coming out as fully internalized and integrated LGBT identity and experiences himself or herself as whole when interacting with everyone across all environments. • Feelings: Excitement and happiness • Defenses: Minimal • Recovery: Maintenance (end stage)

29. Neisen’s 3 Phase Modelfor Recovery From Shame Phase-1 • Breaking the Silence parallels the process of coming out. It is important for LGBT individuals to tell their stories and to address the pain of being different in a heterosexist society. • Counselor Tasks: • Facilitate client discussion of hiding LGBT feelings from others • Explore emotional costs of hiding/denying one’s sexuality • Discuss how the client has tried to fit in and at what cost • Examine negative feelings of self-blame, feeling bad or sick, and the effect of shaming messages on client • Foster client’s ability to be out

30. Phase Two: Establishing Perpetrator Responsibility • Allowed clients to understand their struggle in the context of societal discrimination and prejudice. • Counselor Tasks • Facilitate focusing and managing anger constructively not destructively • Help clients understand and accept negative self-image as social cultural, not personal • Counteract client’s experience of heterosexism and homophobia by role-modeling and by providing a treatment environment that is empowering for LGBT persons, not stigmatizing

31. Phase Three: Reclaiming Personal Power • Involves improving self-concept, self-esteem, and self- confidence • Counselor Tasks • Facilitate client’s self-concept and self-efficacy • Identify and change negative messages to affirmations • Recognize and release residual shame • Develop a positive affirming spirituality • Integrate public and private identities • Build a support network, connect to community

32. Definition of Family of Origin The birth or biological family or any family system instrumental or significant in a client’s early development.

33. Definition: Families of Choice • LGBT people create “replacement” family networks that are made up of individuals who are significant to them, including: • Friends • Partners • Families of partners • Ex-lovers • Blood relatives • Individuals who have died or are no longer an immediate part of the client’s life because of addiction, HIV/AIDS, a relationship break- up, or other life events

34. Guidelines for Working With LGBT Families • Demonstrate support and understanding for the life partners and significant others • Be sensitive to the individual’s self identification • Be sensitive to the diversity and variety of relationships in the LGBT community • No universal terminology regarding significant others in the LGBT community • Be careful of biases re: what a family should be • Do not assume there is no history of opposite sex relationships

35. Myths and Facts about Lesbians • You can tell a lesbian by the way she looks • Lesbians hate men, are afraid of men, or want to be men • Lesbians do not form stable relationships • A lesbian identity is about sex • Sexual abuse by men or bad relationships with men cause lesbianism • Lesbianism is caused by a hormonal imbalance and could be changed by taking the right hormones

36. Myths and Facts about Gay Men • Gay men appear ad act more feminine • Same-sex sexual behaviors can often be blamed on using alcohol and drugs; once the client achieves sobriety, he will no longer desire or seek same-sex sexual relations • Gay men are not interested in or are unable to engage in committed relationships, only in sexual encounters • Most gay men are overly enmeshed with their mothers and have cold or indifferent fathers

37. Transgender Review of Terms • Gender: femaleness or femininity and maleness or masculinity • Gender roles: masculine or feminine behaviors • Gender Identity: inner sense of oneself, a person’s self-concept, in terms of gender • Sexual orientation: distinct from gender identity, describes one’s attraction to, sexual desire for, lust for, romantic attachments to others; lesbian, gay, bisexual, heterosexual

38. Definition of Transgender An umbrella term that came from the transgender community in the 1990’s and includes the spectrum and continuum of gender identities, expressions, and roles that challenge or expand the current dominant cultural values of what it means to be male or female.

39. Transgender Spectrum • Transsexuals • Cross-dressers • Drag Queens and Drag Kings • Bigender, Androgyny, Nongendered, Gender Queer

40. Clinical Issues and Implications for Treatment • Issues about appearance, “passing” and body image • History of hiding or suppressing gender identity • Lack of family and social support • Isolation and lack of connection to positive, proactive transgender community resources • Hormone therapy and use or injection history • Stigma and discrimination • Employment problems • Relationship/child custody issues

41. Treatment Do’s • Use the proper pronouns based on the students self-identity when talking to/about transgender individuals • Get supervision if you have issues or feelings about with transgender individuals • Allow transgender clients to continue the use of hormones when they are prescribed. Advocate that the transgender clients using “street” hormones get immediate medical care and legally prescribed hormones. • Gettraining on transgender issues.

42. Treatment Do’s • Find out the sexual orientation of all clients • Allow transgender clients to use bathrooms and showers based on their gender self-identities and gender roles • Require all clients and staff members to create and maintain safe environment for all transgender clients. Post a non discrimination policy in the waiting room that explicitly includes sexual orientation and gender identity.

43. Treatment Don'ts • Don’t call someone who identifies as a female “he or him” or call someone who identifies as male “she or her” • Don’t project transphobia onto the transgender client or share transphobic comments with other staff embers or clients • Never make the transgender client choose between hormones and treatment and recovery • Don’t make the transgender client educate the staff • Don’t assume transgender women or men are gay • Don’t make transgender individuals living as females use male facilities or transgender individuals living as males use female facilities • Never allow staff members or other students to make transphobic comments or put transgender clients at risk for physical or sexual abuse or harrassment

44. Mental Health Issues • Recent research on mental health issues for LGBT persons indicates that there is a higher rate of bipolar and depressive disorders in gay men than among heterosexual men. • There are higher rates of lifetime depression in homosexual make compared with heterosexual men. • They also found significantly higher prevalence rates of depressive disorders in lesbian women compared with heterosexual females.

45. Mental Health Issues Continued • Distinct barriers to mental health service utilization have been described for sexual minorities that include: • A tendency to pathologize LGBT identity • Lack of LGBT sensitive care • Discrimination and marginalization of LGBT clients • Unwillingness to address LGBT related issues in treatment • Unwillingness to work with partners and lovers of LGBT clients

46. Research on Interpersonal Violence in the LGBT Community • Overall the same rate in same-sex relationships as in heterosexual relationships • 8% rate of partner violence in a diverse non clinical sample of nearly 2,000 lesbians • 17% gay men reported having been in a physically violent relationship • 40% of 228 gay male perpetrators abused drugs • 25-33% of same sex couples report some sort of abuse

47. Questions?