LGBT Adolescent Substance Abuse: Therapies and Interventions

Introduction

The path to sobriety for substance-abusing adolescents who are gay, lesbian, bisexual, transgender, and questioning (LGBTQ) is not a well-marked route. For many LGBT adolescents there are detours, barricades, slippery slopes, and other hazards along the way, and there is not an abundance of readily available services for these young people. There are, however, recovery strategies and rehabilitation programs available for this minority population, and this paper describes several of them.

Literature on Substance Abuse Treatment for LGBT Adolescents

In a national survey of substance abuse disorders within the LGBT community, the Office of Applied Studies in the U.S. Department of Health and Human Services reports that the "extent of substance abuse disorders" within the LGBT population is significant. Indeed, between 20 and 30 percent of LGBT individuals are currently abusing alcohol, drugs, or both (OAS). Moreover, the National Survey of Substance Abuse Treatment Services (N-SSATS) reports that as of 2008, of the 13,688 substance abuse facilities surveyed, 777 facilities (about 6%) offer specialized services for the LGBT population. Of those 777 facilities, 5.7% provide substance abuse services only; 3% offer mental health treatment only; 7.1% provide a mix of mental health and substance use services; and 2.3% provide general health care (OAS).

The U.S. Department of Health and Human Services (SAMHSA) offers a wide range of research information for healthcare professionals approaching the delivery of services to substance-abusing LGBT clients. The Executive Summary of the 228-page A Provider's Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals explains that those involved with programs designed to treat this minority population should adhere to the following principles: (a) clients' confidentiality must be respected; (b) clients need to be advised to "think carefully about how self-disclosure information will be received" prior to acknowledging their sexual orientation to others; (c) staff members must be fully educated regarding regulations that apply to LGBT persons; and (d) clients should be encouraged to take a thorough inventory of their legal rights and the steps necessary to protect those rights (SAMHSA).

The federal government has identified some treatment programs as "LGBT-tolerant" (token awareness of the need for specialized services for LGBT clients); some as "LGBT-sensitive" (LGBT people are "treated with respect and dignity" but their special needs are not specifically addressed); and others as "LGBT-affirmative" (services that "actively promote self-acceptance of an LGBT identity as part of recovery") (Cabaj et al., 2008, p. 49). Dr. Cabaj references a Pride Institute study showing that "acknowledging one's sexual orientation" is pivotal in any recovery program. An empirically based Pride study referenced by Cabaj (Ratner, Kosten, & McLellan, 1991)—grounded in an "LGBT-affirmative" program—shows that after a 14-month follow-up with verifiable reporting, "74 percent of all patients treated 5 or more days abstained from alcohol use continuously, and 67 percent abstained from all drugs" (Cabaj, p. 52). When compared with four similar studies using facilities that are "LGBT-sensitive" rather than "LGBT-affirmative," the results are dramatically different: follow-ups taken between 11 and 24 months show abstinence rates of "43, 55, 57, and 63 percent" (Cabaj, p. 52). Clearly, facilities fully prepared to be LGBT-affirmative do the most effective job in helping adolescents in that minority community.

Local 12-step programs such as Alcoholics Anonymous (AA) are open to LGBT individuals, Cabaj explains, but with an important caveat. Members of AA may hold "prejudices" against LGBT persons, and moreover, some Narcotics Anonymous (NA) and AA groups incorporate religion into their recovery programs. As a result, LGBT people often avoid attending NA and AA meetings "since many religious institutions denounce or condemn homosexuality" (Cabaj, p. 57).

Enhancing treatment for the lesbian population first requires an educated, open mind about lesbians, according to Dr. Dana Finnegan. "There is no one lesbian client," Finnegan explains; indeed, there is "tremendous diversity among lesbians" (Finnegan, 2008, p. 73). Counselors and therapists working with lesbians struggling with substance issues should be aware that due to the "effects of homophobia and heterosexism," lesbian clients recovering from alcoholism or drug addiction are "vulnerable and easily hurt and can relapse when wounded or unsupported" (Finnegan, p. 76). Wise recovery interventions should include: (a) empowering the client, "the primary goal, no matter how it is reached"; (b) using "nonjudgmental language" and avoiding labels; (c) avoiding confrontational approaches, instead using supportive and explorative dialogue; (d) fully respecting the client's stated position, whatever it may be; and (e) respecting lesbians' unwillingness to attend NA or AA because lesbians feel that these are "male institutions with no room for them as women" (Finnegan, p. 77).

Dr. Fred Rachman believes that treatment for adolescent substance abusers within the LGBT community can be greatly enhanced if caregivers and healthcare professionals embrace strategies aligned with fairness and justice. For example, when gathering baseline information, practitioners should consider: (a) whether relevant medical and social issues are "effectively and comfortably identified" for LGBT clients; (b) whether the data collection system is acceptable to LGBT clients; (c) whether educational programs are accessible not only to LGBT clients but also to their significant others and family members; (d) whether program assessments account for "the special needs of LGBT clients" and whether the information system allows for "tracking performance and outcome data for the LGBT client base"; (e) whether client satisfaction surveys are used; and (f) whether focus groups are employed to examine service quality and whether data are maintained to indicate the success or lack of success of therapy for the LGBT client.

Psychology professor Karen Jordan suggests first that the origins of substance abuse among "sexual minority teens" can be linked to this group's sense of being "marginalized by society"; these adolescents seek relief from feelings of isolation and depression (Jordan, 2000, p. 201). LGBT youth are also known to experiment with drugs and alcohol out of a desire to shake off the "chronic stress associated with being stigmatized both interpersonally and intrapersonally" (Jordan, p. 201). The reason substance abuse is "disproportionately evident" in LGBT individuals can be partially attributed to the fact that young people are "ill-equipped developmentally to handle the strain of being different" (Jordan, p. 202). Jordan references a study of Hispanic and African-American gay and bisexual male youths in New York City showing that 76% were abusing alcohol, 42% were using marijuana, and 25% were using cocaine or crack (Jordan, p. 203).

Historical Lack of Attention to LGBT Adolescent Substance Abuse

Meanwhile, adolescent substance abuse has been called the most "frequently missed pediatric diagnosis," in part because substance use is considered "a nearly universal rite of passage" for all adolescents (Ryan et al., 1998). If substance abuse is not adequately catalogued within the adolescent community in general, diagnosis is likely even less reliable for LGBT young people. One study outcome referenced by Ryan shows that 60–80% of gay and lesbian adolescents admitted for inpatient substance abuse treatment "are diagnosed with depression" (Ryan, p. 86). The question remains: why did these psychological problems not surface until the young person had already become abusive toward alcohol and drugs?

There is a predominant "lack of knowledge about the needs of lesbians and gay males" that hinders the chances of LGBT adolescents receiving the treatment they need. One study of a county-funded alcohol and drug treatment program in San Francisco found that "more than half of the treatment staff (56%) had no prior training on treatment needs of lesbian and gay clients," and an equal number lacked any knowledge of "appropriate self-help/support referrals" (Ryan, p. 88). Because of this dearth of training among staff at treatment centers, Ryan suggests that agencies should be very certain of the quality of service available to LGBT adolescents before making referrals; many agencies are "still guided by outdated information based on inappropriate treatment philosophies" (Ryan, p. 89).

Counselors have obligations to the LGBT community that, according to author Carolyn Stone, they are not living up to, for reasons Stone outlines in the journal Multicultural Counseling and Development (Stone, 2003, p. 143). Since the literature clearly points to the isolation and depression that many LGBT students struggle with—which leads them, according to the research, to abuse alcohol and drugs—it seems reasonable that school counselors should be available to these students before substance abuse becomes severe. Stone insists that it is "well-documented" that "gay, lesbian, and bisexual students are severely at risk for depression and suicide"; unfortunately, "systemic support in schools is almost nonexistent" for those students (Stone, p. 146). The lack of "recognition and protection" by schools in general contributes to the "critically high level of suicide" among this community of minority students (Stone, p. 146).

Alert, contemporarily trained school counselors understand that they have the "daunting but imperative obligation to become social activists for gay, lesbian, and bisexual students," since these students are the most "stigmatized members of school environs" (Stone, p. 146). Certain legal and ethical issues do stand in the way of school counselors' freedom to help LGBT adolescents. It is a "complex landscape" for counselors; they need to use caution in discussing birth control, abortion, and drug abuse with both straight and gay or lesbian students. Moreover, since parents hold ultimate authority when it comes to counseling their children on important matters—a principle the U.S. Supreme Court has affirmed in several cases—the counselor must sometimes become a partner with parents (Stone, p. 148). Still, Stone acknowledges the counselors' dilemma: "It is hard to tackle an advocacy role in an area for which a school counselor has not received training" (Stone, p. 148).

The Solution-Focused Group Therapy (SFGT) program appears to be an excellent alternative to long-term treatment, especially for clients in the adolescent age group, who are not known for a great deal of patience. A scholarly research article in the Journal of Marital and Family Therapy, while not specifically focused on LGBT adolescents, highlights the usefulness of this approach for substance abusers. Solution-focused brief therapy (SFBT) zeros in on creating solutions—rather than merely solving problems—for substance abusers, according to Sara Smock et al. The authors' review of previous research on SFGT is extensive, including empirical work by Metcalf (1998) suggesting that "using SFGT can be uplifting, especially when working with individuals struggling with 'out-of-control behaviors' such as drug abuse" (Smock, 2008, p. 107).

Conclusion and Recommendations

The evidence gathered and presented in this paper confirms that while substance abuse is a common problem for LGBT adolescents—a fact reflected many times across the literature—there are interventions that offer verifiable support for this subculture.

This paper recommends: (a) that all staff associated with intervention services be fully trained before working with LGBT clients; (b) that therapists utilize creative interventions, in particular Solution-Focused Group Therapy and Motivational Interviewing; and (c) that school counselors be trained in effective approaches, at minimum to the extent that they can identify and refer students to the therapy most appropriate for LGBT substance abusers. Young people are perceptive enough to recognize phony solutions and empty rhetoric, and they are suspicious of interventions that rely on cookie-cutter clichés. Any intervention should therefore be intensely client-centered, and the therapist must be a practiced, professional listener who allows the adolescent to set the tone whenever possible.