College of Social Work University of South Carolina Promising Practices ADDRESSING BARRIERS TO SUBSTANCE USE TREATMENT ACCESS AND UTILIZATION FOR LESBIAN, GAY, BISEXUAL, AND TRANSGENDER (LGBT) CLIENTS According to a recent study by the U.S. Department of Health and Human Services, only 5% of 13,720 qualifying substance use treatment facilities reportedly offer any specialized programs or services for LGBT individuals. 1 Unfortunately, research has shown that even in facilities offering specialized LGBT services, content was not specifically tailored to the needs of these clients. 2 While substance use treatment services are underutilized across all populations, the need is especially significant in the LGBT community. 2 Current research suggests that LGBT individuals begin drinking at an earlier age and have higher rates of lifetime substance use disorders, due to a variety of environmental factors. 3 In order to better serve this population, treatment providers must address barriers to access and ensure culturally competent services are available. 4 Four key considerations for providers and program administrators are outlined in this brief. Chapman, C., Foster, K., Clone, S., Petiwala, A., Browne, T., DeHart, D., Hock, R., & Iachini, A. (2014). Addressing barriers to substance use treatment access and utilization for Lesbian, Gay, Bisexual, and Transgender (LGBT) clients. Columbia, SC: University of South Carolina College of Social Work.
WHY ARE LGBT-SPECIFIC SERVICES NEEDED IN SUBSTANCE USE TREATMENT? In traditional substance abuse treatment programs, LGBT clients may not have the opportunity or comfort level to discuss their sexual orientation and related stressors. 5 Substance use literature finds specialized services to be beneficial when LGBT clients receive treatment in a nonjudgmental, safe environment. 2,4,5 Advocates for specialized services argue that LGBT clients would benefit from treatments that focus on the readiness of the individual to change substance use patterns. This is important in regards to the specific coping issues, societal stigmatization, and discrimination that LGBT individuals face. These issues can hinder an individual s readiness to change and should be considered when tailoring substance use treatment for the LGBT community. 4,5 Having specialized components, such as LGBT treatment groups, is sometimes more practical than designating completely separate treatment programs. 5 At a minimum, taking environmental factors into account and implementing or improving upon LGBT-affirmative programs would help better serve these individuals. 6 WHAT BARRIERS TO SUBSTANCE USE TREATMENT UTILIZATION DO LGBT CLIENTS FACE? Legal and social discrimination: Living with a stigmatized sexual orientation or identity is not only associated with more frequent and severe substance abuse problems, but can also hinder access to services and timely diagnosis because of perceived discrimination 7 and a lack of accommodating treatment programs. 8
Potential history of abuse: A significant proportion of LGBT individuals have experienced some form of violence and many, are survivors of sexual abuse. 4 Screening and assessment strategies should be inclusive and sensitive to the needs of LGBT individuals. Family and Interpersonal Issues: Especially in the primary family unit, relational problems can have a significant influence on an LGBT person s life. Many families have difficulty accepting a loved one s LGBT sexual orientation or gender identity. 4 Attention to a client s family history of substance abuse is also important in order to identify the need for early intervention and adequate resources. 3 Health concerns: Feelings of isolation and lack of acceptance can have a significant impact on mental and physical health. 4 Traumatic experiences and various external and internal stressors contribute to the prevalence of anxiety, depression, and suicide among LGBT persons. 7 Risk of relapse: Due to environmental factors, including societal stigma and prejudice, LGBT individuals who abuse substances have a higher potential for relapse while in recovery. 4 Provider competence: Practitioners working with LGBT persons can create barriers to treatment if they do not maintain self-awareness of personal biases and assumptions. Utilizing a non-judgmental approach, building a knowledgeable vocabulary, and conveying an affirming and welcoming demeanor to LGBT clients can help to eliminate some of those barriers. 9
WHAT TYPES OF POLICIES AND PROCEDURES CAN BE IMPLEMENTED TO INCREASE TREATMENT UTILIZATION AND IMPROVE CLIENT SATISFACTION? 1. Education: Agency personnel as well as community providers can improve sensitivity and cultural competence by participating in ongoing training and education on providing LGBT services. Nondiscriminatory policies, appropriate language (LGBT terminology can be found here and using password RPTIF2015), cultural factors, and resources for working with LGBT clients should be addressed. 4,10 Specifically, clinicians should gain knowledge in the following areas: LGBT support services for relapse prevention, barriers to treatment access and retention, and cultural competence and sensitivity. Role-playing challenging situations can be an effective activity for agency personnel to engage in to help identify biases. 4 2. Organizational policies: Intake and assessment procedures may need to be adjusted to include gender identity and sexual orientation 2 in addition to screening for co-occurring disorders. LGBT clients can have mental health concerns due to family and interpersonal issues, potential history of abuse, and depression, as mentioned previously. 3,4,7 Another important organizational factor to consider is sleeping arrangements for LGBT individuals participating in inpatient programs. 4 Creating an environment where clients feel safe and secure can help LGBT individuals feel more comfortable accessing treatment services. 3. Collaboration: Broadening community ties and forming alliances with healthcare and LGBT-specific organizations are effective ways to improve service access and utilization. Some strategies for this include speaking with local LGBT organizations, attending LGBT events in the community, and collaborating with other agencies to allow LGBT clients in treatment to attend culture-specific meetings and workshops. 4
HOW CAN EVALUATION MEASURES BE UTILIZED TO IMPROVE SERVICES FOR LGBT CLIENTS? Program evaluation tools that are applicable to LGBT populations can be implemented to identify gaps in services and help inform decisions about necessary structural changes. Client satisfaction measures such as service questionnaires and exit interviews can be utilized to assess the diverse experiences in accessing and receiving treatment. Survey questions should address the effectiveness of LGBT outreach initiatives, staff s approach to issues of gender and sexuality, and efforts to create a safe, comfortable environment. Items related to client privacy, respect of personal values, involvement of significant others, and appropriateness of discharge plans may be helpful to include. Potential disincentives for LGBT clients created by agency procedures or personnel should also be identified. 4 A SAMHSA publication on substance use treatment for LGBT individuals provides an effective client satisfaction survey that can be accessed here (p.145). All clients should be encouraged to routinely participate in evaluation. Findings should be used to identify service disparities between LGBT individuals and the general treatment population to help improve and/or expand services for these clients. 4 Most importantly, LGBT clients in substance use treatment should have the opportunity to share whether they feel specific services are needed 2 and if they perceive discrimination and lack of provider competence to be barriers to recovery. 11
REFERENCES 1. Substance Abuse and Mental Health Services Administration. (2013). National Survey of Substance Abuse Treatment Services (N-SSATS): 2011 data on substance abuse treatment facilities. (BHSIS Series: S-64, HHS Publication No. (SMA) 12-4730). Rockville, MD. 2. Cochran, B. N., Peavy, K. M., & Robohm, J. S. (2007). Do specialized services exist for LGBT individuals seeking treatment for substance misuse? A study of available treatment programs. Substance Use & Misuse, 42(1), 161-176. doi: 10.1080/10826080601094207 3. McCabe, S. E., West, B. T., Hughes, T. L., & Boyd, C. J. (2013). Sexual orientation and substance abuse treatment utilization in the United States: Results from a national survey. Journal of Substance Abuse Treatment, 44(1), 4-12. 4. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (2001). A provider s introduction to substance abuse treatment for lesbian, gay, bisexual, and transgender individuals. (HHS Publication No. (SMA) 12 4104). Rockville, MD. 5. Senreich, E. (2010). Are specialized LGBT program components helpful for gay and bisexual men in substance abuse treatment? Substance Use & Misuse, 45(7-8), 1077-1096. doi:10.3109/10826080903483855 6. Grella, C. E., Greenwell, L., Mays, V. M., & Cochran, S. D. (2009). Influence of gender, sexual orientation, and need on treatment utilization for substance use and mental disorders: Findings from the California Quality of Life Survey. BMC Psychiatry, 9(1), 52. doi:10.1186/1471-244x-952 7. Mayer, K.H., Bradford, J.B., Makadon, H.J., Stall, R., Goldhammer, H., & Landers, S. (2008). Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health, 98(6), 989-995. doi: 0.2105.AJPH.2007.127811 8. Cochran, B. N., & Cauce, A. M. (2006). Characteristics of lesbian, gay, bisexual, and transgender individuals entering substance abuse treatment. Journal of Substance Abuse Treatment, 30(2), 135-146. doi: 10.1016/j. jsat.2005.11.009 9. Bowland, S.E., Foster, K., & Vosler, A.N.R. (2013). Culturally competent and spiritually sensitive therapy with lesbian and gay Christians. Social Work, 58(4), 321-332. doi: 10.1093/sw/swt037 10. Walker, J., & Prince, T. (2010). Training considerations and suggested counseling interventions for LGBT individuals. Journal of LGBT Issues in Counseling, 4(1), 2-17. doi:10.1080/15538600903552756 11. Burgess, D., Lee, R., Tran, A., & van Ryn, M. (2007). Effects of perceived discrimination on mental health and mental health services utilization among gay, lesbian, bisexual and transgender persons. Journal of LGBT Health Research, 3(4), 1-14. doi: 10.1080/15574090802226626 This Project was supported by contract number A201611015A with the South Carolina Department of Health and Human Services (SCDHHS). Points of view in this document are those of the authors and do not necessarily represent the official position or policies of SCDHHS.