Best Practices in Substance Use Treatment for LGBT Clients

1. Best Practices in Substance Use  Treatment  for LGBT Clients Barbara E. Warren, Psy.D. Director, LGBT Programs and Policies, Office for Diversity and Inclusion Mount Sinai Health System Assistant Professor of Medical Education, Icahn School of Medicine at Mount Sinai Bwarren@chpnet.org This product is supported by Florida Department of Children and Families Office of Substance Abuse and Mental Health funding.

2. Drivers – Why 1 2 3 4 5

3. Basic SOGI: Keeping it Simple Gender Identity Sense of oneself as male,female, masculine, feminine, both, neither, leaning towards It involves social and personal identity, behaviors and roles Transgender: Describes a person whose gender identity or expression is different from the sex assigned to them at birth Sexual Orientation Romantic, sexual and affectional attraction to others Includes straight or heterosexual, gay, lesbian, bisexual, asexual, polysexual LGBT= shorthand for lesbian, gay, bisexual and transgender.

4. A rose by any other name………. …LGBTQI, gay, lesbian, bisexual, queer, dyke, MSM, WSW, same gender loving, transgender, trans* transsexualtransmantranswomantransvestite crossdressergenderqueerandrogyne bigenderpangender drag queen drag king femme queenambigender non-genderedagender gender fluid intergenderDQ T-girl TG FTM MTF Two-SpiritMixu’gaNa’dleehHe’eman Agi/AxiWi’kta/Wingkte’ Lila WitkowinKwido IhamanaOsha’puHoobukBote /Bade Biatti /MiatiHijiraFa’afafineKathoeyMahu…

5. Population Data About 1.4 million adults in the United States identify as transgender, 0.6 percent of the adult population, double a widely used previous estimate, according to an analysis based on new federal and state data Drawing on information from four recent national and two state-level population-based surveys, the analyses suggest that there are more than 8 million adults in the US who are lesbian, gay, or bisexual, comprising at least 3.5% of the adult population

6. Same-sex couples per 1,000 households by census tract 2010 (adjusted) in Florida http://williamsinstitute.law.ucla.edu/uncategorized/florida/

7. Some Historical Perspectives • 1940s and 1950s-Same-sex sexual 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. ------------------------------------------------------------------ • 2010-US Department of Health and Human Services, SAMHSA and HRSA enact LGBT cultural competency and research initiatives; IOM LGBT Report issued. • 2011- Joint Commission publishes Field Guide to LGBT Care with guidelines for policies and practices

8. Some Historical Perspectives • 2012- State of California enacts legal ban against reparative therapies for homosexuality • 2013- DSM V changes gender identity disorder to gender dysphoria which depathologized transgender identity • 2014- LGBT populations included in the Affordable Care Act • 2015- the U.S. Supreme Court struck down all state bans on same-sex marriage, legalized it in all fifty states, and required states to honor out-of-state same-sex marriage licenses in the case Obergefell v. Hodges • 2015-CMA mandates capacity to collect sexual orientation and gender identity data in electronic health records • 2016-NIH designates LGBT people as an official health disparity population

9. WHY • Moral, legal and ethical obligations as counselors and helping professionals • Number of LGBT people in our programs • LGBT people at greater risk • LGBT clients’ special needs

10. Sexual Orientation and Estimates of Adult Substance Use and Mental Health: Results from the 2015 National Survey on Drug Use and Health www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm

11. Treatment Engagement

12. Minority Stress describes chronically high levels of stress faced by members of stigmatized minority groups. It may be caused by a number of factors, including poor social support and low socioeconomic status, but the most well understood causes of minority stress are interpersonal prejudice and discrimination .

13. Minority Stress • Same-sex individuals 2X as likely as heterosexuals to have experienced discrimination in their lifetime; • 5 X more likely to indicate that discrimination had interfered with having a full and productive life; • Perceived discrimination correlates with mental disorders including substance use disorders

14. Approaches and Best Practices • Creating a welcoming, safe and supportive Environment • Clients • Staff • Assessment • Counseling approaches • Recovery support

15. Defining LGBT Affirmative Care • LGBT- tolerant Aware that LGBT people exist and use services • LGBT-sensitive Aware of, knowledgeable about, and accepting of LGBT people • LGBT-affirmative Actively promotes self-acceptance of a LGBT identity as a key part of recovery

16. Visible Indicators - Post policies - LGBT brochures and literature - Gender -neutral bathrooms and changing rooms - Rainbow pins

17. RESPECT- Referring to spouses appropriately - Using correct names and pronouns-tip sheet- Pronoun signage at front desk- Forms that refer to “parents” not “mother “and “father “- Confidentiality considerations

18. Video Clips and Discussion

19. Assessment Checklist • Level of comfort of being a LGBT person • Stage of coming out • Family/support/social network • Health factors • Milieu of use • Drug use and sexual identity or sexual behavior connections • Partner status and partner use • Legal status, history of incarceration • “Gay bashing” –anti-LGBT violence • Same-gender domestic violence • Out as LGBT in past treatment experiences • Correlates of sober periods

20. Transgender Clients • Minority Stress and Trauma Responses • Body Image – Gender Dysphoria Triggers • Gender Non Conformity • Grief and Loss • Sexuality, Sexual Practices, Romantic Relationships • Social Isolation – Community Support

21. Residential Issues • Room assignments • Bathroom • Urine testing • Access to hormones • Same sex group participation • Other issues ?

22. Vanessa Goes to the Doctor Used with permission of Liz Margolies, executive director of the National LGBT Cancer Network. https://www.youtube.com/watch?v=S3eDKf3PFRo

23. Vanessa Goes to the Doctor

24. Building on Joseph Neisen's3-Phase Model for Recovery From Shame (Trauma Informed ) Phase One : Breaking the Silence parallels the process of coming out. It is important for LGBTindividuals to tell their stories and to address the pain of being different in a society in which LGBT identities and relationships are and have been stigmatized. Counselor Tasks: • Facilitate client discussion of experiences 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 aware of and to address residual effects

25. Neisen’s Phase Two: Establishing Perpetrator Responsibility( Social Determinants of Health ) Allows clients to understand their struggle in the context of minority stress, societal discrimination and prejudice and other challenges such as lack of access to care, socio-economic stressors, mental and physical health conditions . Counselor Tasks: • Facilitate focusing and managing anger constructively, not destructively • Facilitate understanding of how marginalization can activate same parts of the brain that experiences physical pain • Help client understand and accept any negative self-image as socio 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.

26. Phase Three: Reclaiming Personal Power (Positive Recovery) 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 • Integrate intersectional identities • Build a support network, connect to community

27. Assessing Interpersonal and Social Support

28. Recovery Support • LGBT community-based resources • Partner/family counseling and support • LGBT 12-step meetings • LGBT affirmative health care providers • For transgender clients, access to hormones and surgery • LGBT recovery coaching • LGBT community engagement

29. John is being seen for an intake appointment on referral from a community-based outreach program, after taking an HIV rapid test in front of a popular dance club. He tested negative , but he expressed some concerns about his drug use so the HIV outreach worker referred him to your treatment center. Dwayne is 22-years-old and worked as an administrative assistant for a financial corporation. He was laid off six months ago, lost his apartment and is sleeping on a friend’s couch while he is looking for a job. He reports that he used to have a small circle of good neighborhood friends from his high school days, but that he started to get lonely when most of his friends married or moved away. He says that he dated several women but no one seriously. When he started going out alone, he was drawn to the gay bar scene. Hehas been drinking alcohol -- mostly wine and beer -- since he was 15, but started to smoke crystal meth with some of the men he met there. He says that crystal makes him horny so he started staying in, smoking meth at home and going on line to hook up with men. John says that since he lost his job, he has been spending more time in the bars or hooking up on line. He complains of having bad headaches, which cause him to sleep late and miss appointments for job interviews. His old high school friend is getting tired of Dwayne’s late nights and his always being on the living room couch asleep. Dwayne wants to stop using meth and hooking up online for sex with men. He thinks that if he can do that, perhaps he can get another job, meet the right girl and settle down like his old friends have done. He is not gay-identified at work, to his family or to anyone he knows. Questions for Discussion • What are the key recovery issues John is facing? • What issues are John facing that are particular to his sexual orientation? • What kind of interventions would you make in this situation and what would you suggest if you were his ongoing counselor?

30. Liliana was referred to your treatment program through a friend who is a client of your program. . Questions for Discussion • What are the key recovery and support issues Liliana is facing? • What issues are Liliana facing that are particular to or related to her sexual orientation and gender identity? • How would you as a counselor work with Liliana and what interventions would you suggest? • What are the challenges for working with Liliana in the residential setting and how should you/ your program handle them? Liliana is 22-years -old, identifies as Cuban and African American, and recently tested HIV positive. She has been admitted to your residential program to stop using drugs. She has been homeless for the past few years, sleeping between shelters, friends’ apartments and when desperate, in the street. She dropped out of high school because she was harassed and assaulted for being too effeminate. Last winter she got a severe case of the flu, ended up in the hospital with bronchitis and had to live for a couple of weeks with her father and stepmother. They do not accept that she is transgender even though she has transitioned to living full time as a woman, is injecting street hormones and has changed her name. They insisted on calling her by her male name and they insisted that she wear male clothing. After a fight in which her father hit her and threatened to throw her out of the house, she left. She has been homeless again since. She admits that when she needs money for drugs or food, she sometimes engages in sex work and although she prefers using condoms, she gets paid more for not using protection.

31. You and your colleague are co-leaders of a motivational enhancement group for formerly incarcerated men who are in the outpatient drug treatment program. . Questions for Discussion • How do you and your co-leader handle this immediate situation? • What interventions do you use for the group to effectively address diversity issues within the group? • How do your address issues that are particular to or related to sexual orientation and gender identity for group members? It’s the fourth session of your group, and the topic is “relationships.” One of your group members shares about having had a “boyfriend” in jail, but now not being sure he is really gay even though he still has sex with men. Several of your other group members loudly and adamantly insist that it’s not natural, or normal to do that, and definitely not OK once you’re on the outside, and that he needs to “get straight.” Two of your group members say that because of their religious beliefs, they can’t accept anyone who engages in same-sex behaviors because it’s against God’s will. Another group member states that it’s nobody else’s business anyway who he, or anyone in the group, wants to have sex with, so the group should not even be discussing this issue. So far you have not directly addressed sexual orientation and same-sex sexual behaviors in this group.

32. Questions and Wrap Up

33. Resources Centers for Disease Control and Prevention, Social Determinants of Health: Know What Affects Health. http://www.cdc.gov.socialdeterminants/ National LGBT Cancer Network: http://www.cancer-network.org/ National LGBT Health Education Center: http://www.lgbthealtheducation.org/ Substance Abuse and Mental Health Services Administration, A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual and Transgender Individuals. http://store.samhsa.gov/product/A-Provider-s-Introduction-to-Substance-Abuse-Treatment-for-Lesbian-Gay-Bisexual-and-Transgender-Individuals/SMA12-4104 The Williams Institute, a research institution dedicated to conducting research on sexual orientation and gender identity law and public policy. http://williamsinstitute.law.ucla.edu/mission/