Substance Abuse Treatment for Lesbian, Gay, Bisexual, and

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					WI Bureau of Mental Health and Substance Abuse
                                       Services

                       Weston M. Edwards, PhD
                        Licensed Psychologist



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 Weston   M Edwards, PHD LP
 • PhD from UMN, Counseling Psychology
 • Research in the area of Measuring Sexual Health
 • Licensed Psychologist, MN Board of Psychology




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   Pride Institute, Director of Program Development
    • Enhancing current programming
    • Development of residential sexual compulsivity program

   Sexual Health Institute
    • sexualhealthinstitute.org
    • Private practice

   Walden University
    • Instructor in the School of Psychology
      Instructor in the Mental Health Counseling Program
    • Currently teaching Diagnosis and Assessment
      (Psychopathology)

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   Introduction to basic sexology regarding LGBT
   Understand how behavioral psychology and
    twelve-step traditions can be used concurrently
    to produce optimal treatment results
   Understand the effects of societal heterosexism
    on substance use in their LGBT patients
   be able to identify common co-occurring
    compulsive behaviors that present in LGBT
    patients.


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 Brief   Review of Current research

       Selected approaches to treating
 Review
 chemical dependency

        why a LGBTQ treatment
 Address
 program is important.



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6
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   While this article does not suggest that all homosexuals
    are child molesters, the overwhelming evidence finds
    that "mainstream" gay activists and publications
    regularly flirt–indeed promote–the notion of pederasty
    (sex between adults and children of the same sex). 295-
    296.
   Again, this is not an attempt to turn the "guilt by
    association“ tactics of gay activists on them–it would be
    defamatory to imply that homosexuals in general are
    the moral equivalent of serial killers. Nonetheless,
    evidence strongly suggests that there is a
    disproportionately high rate of violent sex crimes
    among male homosexuals (pg 333).
                      Article posted to the SASH listserv, March 19, 2008 by Judith Riesman.



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 We  simply do not know. We have best
  estimates of population
   • Kinsey’s 10% (1950’s) having same sex behavior –,
     not identity.
   • Michael’s meta-analysis (1996) showed 10% male
     and 5% female
       self-identify as GL (therefore, today’s estimate is 7-8% being
        “out”)
 Bisexual
   • CDC studies in 2002
      Self-identification of men at 11% and women at 3%.
      Lifetime behavior for men at 54% and women at 11%
 Transgender
   • Bockting studies of HIV risk in 2003 indicate 6%
      may be high due to studies sexual behavior focus

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 Researchdistinguishes between
 behavior and identity
  • identity as a process – when does one identify?
  • behavior separate from identity (MSM through
   HIV efforts)
    more recent aversion to labels (ex. – queer, bi-
     gendered)
    reluctance to disclose – stigma and discrimination
    convenience sampling that biases results




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 Models of Coming out
  • Cass (1978) Intrapersonal 6 stages
  • Coleman (1982) Psychosocial 5 stages

 Getting stuck in process
  • addictive behaviors
  • Mental Health Concerns




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   Higher rates of addiction/use.
    • Research studies suggest that, when compared to the general
      population, lesbian, gay and bisexual (LGB) individuals are likely to
      use drugs and alcohol, have higher rates of substance abuse, are less
      likely to abstain from substance use, and more likely to continue heavy
      drinking into later life (Center for Substance Abuse Treatment, 2001).
   Prevalence
    • 23-35% higher in LGBT (>3x hetero)
   Relapse Rates
    • relapse is more frequent in LGBT
    • periods of sobriety between relapses are shorter for LGBT
       LGBT social reliance on bars / drinking events
       struggles with “God” and spiritual messages of 12-Step groups
       multiple minority lables (women, ethnic minorities, etc.)
       lack of support (family abandonment, lack of affirming 12-step groups)
       co-occurring with compulsive sexual behavior
       co-occurring mental health issues.



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   Much energy is current being focused.
   Current Epi
     • NSDUH data estimate approximately 5.2 million people had COD in
        2005 (SAMHSA, 2006).

   Depending on the survey, some estimates are up to 10
    million.
   Treatment Approaches
     • Because the treatment of COD is a relatively new field, there has not
        been time for the development and testing of a large number of
        Evidence Based Protocols.


    Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services Center for
    Substance Abuse Treatment. (2007) Understanding Evidence-Based Practices for Co-Occurring Disorders. COCE
                                         Overview Paper 5. DHHS Publication No. (SMA) 07-4278. Rockville, MD:.



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   Principle 2. An integrated system of mental health and
    addiction services that emphasizes continuity and quality.
   Principle 5. The system of care must reflect the importance
    of the partnership between science and service, and
    support both the application of evidence- and consensus-
    based practices.
   Principle 6. Behavioral health systems must collaborate.
   Principle 9. Empathy, respect, and belief in the individual’s
    capacity for recovery are fundamental provider attitudes.
      Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.( 2006)
    Overarching Principles To Address the Needs of Persons With Co-Occurring Disorders. COCE Overview Paper 3.
                                                              DHHS Publication No. (SMA) 06-4165 Rockville, MD.




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 Need to have resources for                                              dual diagnosis.
  • In MN, Rule 31, Dual Diagnosis

 Cross training.
  • Chem dep individuals trained in MH and
  • MH staff trained in Chem Dep.

 Avoidance of an either/or approach.
  • (Different from the MN Model)

 OUIMETTE P., JEMELKA, R. HALL, J., BRIMNER, K. KRUPSKI, A. & STARK K. (2007) Services to Patients with Dual Diagnoses:
                        Findings From Washington’s Mental Health Service System Substance Use & Misuse, 42:113–127




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 Medication Management
 ASAM Criteria
 12-step approaches/Minnesota Model
 Cognitive Behavioral
  • Dialectical




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 Medication          Management
    Field is very complex.
     buprenorphine and other narcotics for opioid addiction
     Multiple drugs for other drugs of choice.
     Bupropion for the Treatment of Methamphetamine
      Dependence.(Elkashef, et al (2008) Neuropsychopharmacology 33:5, 1162-1170)


 Behavioral         Approaches
    12 Step tradition
    CBT/DBT
    Variations on a theme
                                            http://www.drugabuse.gov/ADAC/ADAC11.html



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A framework for categorizing addiction
 versus a treatment approach

 Six   content areas
   1.   Withdrawal
   2.   Biological
   3.   Emotional/Psychological Issues
   4.   Treatment Acceptance
   5.   Relapse potential
   6.   Recovery Environment.


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                   The Acting Out Cycle

                          Setups
                    Emotional Triggers
                      Thinking Errors
                    High Risk Situations




  Payoffs/Costs                                Act out
Escape/Avoidance                          Sexual behavior
    Pleasure                           Other types of behaviors
     Despair
  Consequences




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Step 1 - We admitted we were                Step 7 - Humbly asked God to remove our
   powerless over our addiction - that         shortcomings
   our lives had become                     Step 8 - Made a list of all persons we had
                                               harmed, and became willing to make
   unmanageable
                                               amends to them all
Step 2 - Came to believe that a Power       Step 9 - Made direct amends to such people
   greater than ourselves could restore        wherever possible, except when to do so
   us to sanity                                would injure them or others
Step 3 - Made a decision to turn our will   Step 10 - Continued to take personal
   and our lives over to the care of God       inventory and when we were wrong
   as we understood God                        promptly admitted it
                                            Step 11 - Sought through prayer and
Step 4 - Made a searching and fearless
                                               meditation to improve our conscious
   moral inventory of ourselves                contact with God as we understood God,
Step 5 - Admitted to God, to ourselves         praying only for knowledge of God's will
   and to another human being the              for us and the power to carry that out
   exact nature of our wrongs               Step 12 - Having had a spiritual awakening as
Step 6 - Were entirely ready to have           the result of these steps, we tried to carry
   God remove all these defects of             this message to other addicts, and to
   character                                   practice these principles in all our affairs.


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Step 1 - We admitted we were powerless over
  our addiction - that our lives had become
  unmanageable
Step 2 - Came to believe that a Power greater
  than ourselves could restore us to sanity
Step 3 - Made a decision to turn our will and
  our lives over to the care of God as we
  understood God
Step 4 - Made a searching and fearless moral
  inventory of ourselves
Step 5 - Admitted to God, to ourselves and to
  another human being the exact nature of our
  wrongs
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     at the underlying human
 Look
 experience

 Attemptto understand the experience
 then provide the label.




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         Minnesota Model                    Cog. Behavioral Therapy


          “Higher Power”                       Classic Goal Therapy
                                             -what do you want in life?
           Powerlessness                    Thoughts/Feelings/Trigger
                                               as part of the cycle.
        Home/Group Sponsor                       Support Network


          Making Amends                  Taking Responsibility for behavior


      Fearless Moral Inventory                    Full disclosure


Ready to ask god to take these defects         Motivation for change


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 Primary    aftercare program is a 12-step
 tradition

Ithink we do our clients a disservice if
 we don’t help them understand the
 support network they are returning to.

        bridge the gap between
 Helping
 CBT/Minnesota Model
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   SAMSHA has a great resource.
    •   Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatments (2001) A
        Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals.
        U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Rockville, MD


   Not every “gay” program is “gay.”
    • 70% of providers offering gay identified programming that has
      no difference with their “non-gay” programming.
    • Outside of New York and California, little “gay” programming
      exists. Only 32 programs as of 2003/2004.
    • Only 7.4% could identify what they do that responded to “gay
      programming.”


                     COCHRAN, B. , PEAVY, M., & ROBOHM J. (2007) Do Specialized Services Exist for
                     LGBT Individuals Seeking Treatment for Substance Misuse? A Study of Available
                                       Treatment Programs Substance Use & Misuse, 42:161–176DOI:
                                                                      10.1080/10826080601094207



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 GLBT   Averse (Anti-gay).
  • Your sexual orientation is the cause of your
   drinking
 GLBT   Ignorant
  • We have gay people?
 GLBT   Naïve
  • OK, we have gay people, and it’s not an issue.
 GLBT Tolerant
  • We need to do something, but the needs of the
   group come first, so don’t talk about it.
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 GLBT   Accepting
 • A group/track that integrates the GLBT program
  within the larger community.
 GLBT   Affirming
 • All programming is designed to address GLBT
  issues within the GLBT culture.

                         Amico & Neisan (1997), Sharing the Secret:
                              The need for gay- Specific treatment
                              The Counselor, May/June 1997, 12-15




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   Heterosexism/homophobia, both internal and external, are
    particularly relevant
   Isolation and poor self-concept are “natural” reactions to
    systemic negative messages.
   Healthy Social outlets and forums are often
    Bars and clubs become the most available comfortable
    social outlets, and in locales where these are unavailable,
    isolation can be even greater.
   Substance use can serve as an easy relief from negative
    feelings and provide a degree of social acceptance.
       Barbara & Chairm (2004) Asking About Sexual Orientation During Assessment for Drug and
     Alcohol Concerns: A Pilot Study. Journal of Social Work Practice in the Addictions, 4(4), 89-109.



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 Heterosexism
 Homonegativity
 Homophobia


 All are related, and often interchangeable.
  • Generally negative view of homosexuality
  • Only one form of sexual orientation is healthy.
  • And the degree to which these thoughts create a
    sense of fear

 Can   be internalized and externalized.

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   Most of it is Covert Expression
   Language:
     • Do you “mind” seeing a LGBT therapist.

   Assumptions:
     • Assuming a client is “straight.”

   Failure to assess
     • Using opposite sex language when asking about partners.

   Reinforcing stereotypes
     • Not exploring/understanding stereotypes and challenging.
     • What “caused” your homosexuality?

   Avoiding the topic
     • Not following up on a topic. How did the date go?




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 Sexual Compulsivity
 Body image issues
 Minority Stress
  •   Kimmel &Mahalik (2006) Body Image Concerns of Gay Men: The Roles of Minority Stress and Conformity
      to Masculine Norms. Journal of Consulting and Clinical Psychology 73:6, 1185-1190.

 HIV       Risk /Status
  • Prevalence ~60% of HIV cases are in the MSM
    community
  • Incidence (2006) 147 of 237 cases (MDH)



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•   Queer eye for the Straight Therapist (joekort.com)
    • Don’t make assumptions
    • How do you self-identify.
      • Equally disclose as appropriate/when asked
      • Model disclosure/create safety
    • Recognize the impact of homophobia/heterosexism.
    • Be sensitive to language
      • Identify as a gay male versus “Are you gay”
      • Sexual orientation versus sexual preference
    • Acknowledged your limitations
      • Heck, even I don’t know all there is to know about the GLBT community.
      • Give yourself permission not to know. Read, ask, seek supervision
    • Make a welcoming environment
      • Lavender magazine?
      • Other magazines?
      • Forms that are inclusive
        • Married/Partnered.
        • Party 1/Party 2
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   Guideline 2. Psychologists are encouraged to recognize how
    their attitudes and knowledge about lesbian, gay, and
    bisexual issues
   Guideline 3. Psychologists strive to understand the ways in
    which social stigmatization
    (i.e., prejudice, discrimination, and violence) poses risks to
    the mental health and well-being of lesbian, gay, and
    bisexual clients.
   Guideline 4. Psychologists strive to understand how
    inaccurate or prejudicial views of homosexuality or
    bisexuality.
   Guideline 5. Psychologists strive to be knowledgeable about
    and respect the importance of lesbian, gay, and bisexual
    relationships.
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   Guideline 8. Psychologists strive to understand how a
    person’s homosexual or bisexual orientation may have an
    impact on his or her family of origin.
   Guideline 9. Psychologists are encouraged to recognize the
    particular life issues or challenges experienced by lesbian,
    gay, and bisexual members of racial and ethnic minorities
    that are related to multiple and often conflicting cultural
    norms, values, and beliefs.
   Guideline 12. Psychologists consider generational
    differences within lesbian, gay, and bisexual populations.
                      http://www.apa.org/pi/lgbc/publications/guidelines.html




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 Contact Info
  • Pride Institute
     (Residential)
      14400 Martin Drive
      Eden Prairie, MN 55344
      952-934-7554
     Outpatient (Uptown)

  • Weston Edwards, Ph.D, LP
     (direct/cell) 612 987 4482
     wedwards@pride-institute.com


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