There is no question that in order to provide quality treatment, counselors must possess good counseling skills, thorough knowledge of substance abuse, and high ethical standards. But above all they must have "heart" - empathy, a belief in the miracle of recovery, and the ability to reach out and offer hope. Having heart also includes cultural competency - the ability to provide effective treatment based on knowledge of and respect for each person's culture. Culture may be defined as the "customary beliefs, social norms, and material traits of a racial, religious, or social group. It affects the group members' viewpoints: how they act; how they think; and how they see themselves in relation to the rest of the world ..." (Wright et al., 2001).

Cultural competency

It is important for counselors to know about the culture their clients come from in order to understand their way of life and the stresses and traumatic effects resulting from membership in that world. For example, a counselor who is treating a Latina substance abuser needs to understand the role of the family in her recovery and the importance of privacy about personal matters.

Counselors need to know about the substance abuse "culture" so they can use their knowledge to connect with their clients. That is essentially the premise that AA and NA are built on - "I know, at least a little, of what you are experiencing." Most counselors are quite familiar with the "culture" of substance abuse (e.g., the denial and self-delusion, the world of raves and shooting up) and tend to know a good deal about the traumatic effects of substance abuse (physical, emotional, spiritual devastation).

But all too often, counselors are not familiar with the cultures of lesbian, gay, bisexual, and transgender (LGBT) individuals and therefore lack the information and understanding that would help them provide culturally competent treatment. In addition, many counselors are not aware of the traumatic effects of being LGBT in a homo/bi/transphobic, heterosexist society. Furthermore, they are often not "tuned into" the fact that LGBT substance abusers are doubly traumatized by the stigma of an LGBT identity as well as the devastation of substance abuse. An experience is classified as traumatic if it: 1) is sudden, unexpected, or non-normative, 2) exceeds the individual's perceived ability to meet its demands, and 3) disrupts the individual's frame of reference and other central psychological needs and related schemas (McCann and Pearlman, 1990). Herman (1992) notes that, "Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning." It is generally accepted that addictions traumatize people (Clark, 2001). Bean (1981) describes alcoholism as a "catastrophic experience" that traumatizes alcoholics. Brown (1998), Khantzian (1998), and Levin (1998), also explain how alcoholism and other drug addictions have a profoundly traumatic result on individuals.

Although not all LGBTs are traumatized by the heterosexism and homophobia/biphobia/transphobia, many do suffer. Alvarez (1994) points out that gay people are frequently victims of emotional and often physical abuse (Herek, 1995). Bohan (1996) contends that relentless hatred directed at LGBT people traumatizes them. Finnegan (2001) and Finnegan & McNally (1996) also note the trauma visited on bisexual women and lesbians and on all LGBT people (in press). Various writers discuss the emotional and physical abuse suffered by transgendered people (Brown & Rounsley, 1996; Clements, 1999; Israel & Tarver, 1997; Lombardi & van Servellen, 2000; Marcel, 1998). And we have only to look at the killings of Matthew Shepard and Brandon Teena to verify the extreme and destructive results of such traumatizing abuse. The interplay between the traumatic effects of substance abuse and the oppression of LGBT individuals lies at the heart of understanding how to best help LGBT substance abusers. Thus, an examination of some of these effects and the interactions between them provides important information for counselors.

The effects of dual traumas

Herman's (1992) schema of Complex Post-Traumatic Stress Disorder which categorizes various alterations caused by trauma is illuminating. While it is well known that alterations of many kinds occur in substance abusers, what is not so well known is that these same alterations may well occur in many LGBT people as a result of the trauma of oppression.

Alterations in affect regulation. Herman (1992) lists "persistent dysphoria, chronic suicidal preoccupation, [and] self-injury" as effects of trauma. Certainly, many substance abusers suffer from one or more of these, as do some LGBT people who are exposed to the soul-shriveling effects of homo/bi/transphobia. In fact, one form of self-injury that some LGBT people engage in is substance abuse in order to soothe and anesthetize their pain. Dysphoria, depression, and at times suicidal preoccupations are understandable responses to the vicious contempt and hatred directed at many LGBT people on an on-going basis. Krystal (1988) discusses the traumatized person's difficulty with self-reflection and self-evaluation, a difficulty that blocks people's ability to ascribe feelings and meanings to their actions. Thus substance abusers may not be able to see the consequences of their behavior, and LGBTs may have trouble developing a positive identity in the face of traumatic oppression.

Alterations in consciousness. Herman (1992) notes that "amnesia ... for traumatic events, transient dissociative episodes, [and] depersonalization" are all consequences of trauma. A well-known effect of substance abuse is amnesia or dissociative episodes in the form of blackouts or brownouts. Even in recovery, people are in danger of relapse when they dissociate from realistic perils (e.g., "I just went into the bar to say 'hello' to my old buddies"). Krystal (1988) describes "psychic numbing" in which traumatized people are conscious of "blocking their affective responses," therefore they function but are not in touch with feelings about their functioning.

Many LGBT people who are emotionally (and sometimes physically) battered by a homo/bi/transphobic society learn to survive by "numbing out." They tend not to hear (at least on a conscious level) the abusive jokes, whispers, and name-calling directed at them. Often they don't see the looks, the gestures, or the rejections. In order to block out these assaults, they dissociate and split off a part of themselves to protect their vulnerable sense of self. The price of such self-protection is dissociation and psychic numbing which, if mixed with substance abuse, can lead to emotional deadness and an inability to assess and evaluate real dangers to oneself.

Alterations of self-perception. Three major characteristics in this category are a "sense of helplessness," "shame, guilt, and self-blame," and a "sense of defilement or stigma" (Herman, 1992). A sense of helplessness and concomitant despair are common to substance abuse. LGBT individuals are frequently rendered powerless in the face of societally sanctioned discrimination and oppression (e.g., loss of jobs, housing, custody with no recourse to legal protection). Despair would seem to be an appropriate reaction to such overwhelming threats and assaults. Almost inevitably substance abusers suffer from shame, guilt, and self-blame. All too often LGBTs are made to experience these feelings because society exposes them to great scorn and shames them.

A fourth characteristic of alterations in self-perception is a "sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or nonhuman identity)" (Herman, 1992). Early on, Alcoholics Anonymous addressed this deadly response to trauma by helping alcoholics realize they were not special or unique and therefore not alone or different. Substance abuse treatment focuses on this response as a primary treatment issue. However, the homo/bi/transphobia prevalent in American society insists that LGBT people are indeed completely different from others (i.e., heterosexuals). They are viewed as the "Other" - the dark, strange, outlawed, subhuman - a threat to society's stability and values. The trauma inflicted by such virulent homo/bi/transphobia can be enormously destructive to LGBTs, especially if they are also struggling with the feelings of complete difference induced by substance abuse. Alterations in self-perception coupled with alterations in consciousness, especially dissociation, make it extremely difficult for LGBT individuals (as well as substance abusers) to develop one of the two primary requisites of identity - "a sense of internal coherence" (Josselson, 1987).

Alterations in relations with others. All of the conditions that Herman (1992) cites in this category are unnervingly familiar to those who treat substance abusers: "isolation and withdrawal; disruption in intimate relationships; repeated search for rescuer; persistent distrust; repeated failures of self-protection." These occur during an individual's active substance abuse, but they also continue far into recovery (Bean, 1981; Brown, 1998; Khantzian, 1981, 1998). For lesbian, gay, bisexual, or transgendered individuals, these are common ways of reacting to the traumatizing effects of homo/bi/transphobia. Many LGBT people feel threatened because of their sexual orientation and/or their gender identity and may respond by withdrawing. Being LGBT means having to choose between keeping their orientation and/or gender identity secret, an action that is destructive to close relationships, or coming out which puts them at risk of rejection. This traumatic effect of disrupted relationships to others has serious effects on people's attempts to develop and define their identities. One central part of one's identity is having a "sense of meaningful relatedness to the real world" (Josselson, 1987). When homo/bi/transphobia destroys that sense of meaningful relatedness, it becomes extremely difficult for LGBT people to develop a stable sense of identity.

Alterations in systems of meaning. This category is marked by a "loss of sustaining faith [and a] sense of hopelessness and despair" (Herman, 1992). Active substance abusers almost inevitably fall prey to these conditions. Recovery often requires an active struggle to regain faith and restore hope (Bean, 1981; Brown, 1998; Kurtz & Ketcham, 1992). As for LGBT people, it becomes extremely difficult to sustain faith in a social system that grants privilege only to those who fit its rigid strictures of "normality" and that systematically disconfirms those who don't fit. And in the face of society's betrayal of them, many LGBTs fall prey to hopelessness and despair.

It is helpful for counselors to keep in mind the startling similarities between the traumatic effects of substance abuse and homo/bi/transphobia. If lesbian, gay, bisexual, or transgendered people become substance abusers, they are exposed to not one but two traumas and the concomitant destructive effects are doubled.

The counseling relationship

Surrey (1992) notes that addiction contracts connection (with self and others) and recovery expands connection (with self and others). Herman (1992) points out the effects of trauma shatter images of the self and ruptures connections with others. Recovery from trauma is based upon the empowerment of the survivor and the creation of new connections. Recovery can take place only within the context of relationships; it cannot occur in isolation.

Thus the counseling relationship is extremely important. The connection that occurs between counselors and clients can contribute greatly to the recovery process.

Counselor knowledge. Since counselors already know about the trauma of substance abuse, what do they need to learn and consider about the trauma of homophobia/biphobia/transphobia? What do they need to know about the LGBT cultures that will help them provide quality treatment for their LGBT clients?

First, counselors need to be aware of the "ever-presentness," the "everydayness" of possible trauma in LGBT people's lives. Just belonging to an LGBT culture automatically exposes individuals to risks and potentially subjects them to the traumatizing effects of oppression. A great cloud of anxiety looms over the lives of many LGBT people. They live in a climate of fear generated by the intense hatred and contempt of a homo/bi/transphobic society. This climate is made up of threats (and acts) of humiliation, shame, emotional abuse, physical violence, and even murder. Although these threats are not necessarily evident, overt, or immediate, they are always present, always impending, always there, waiting to happen. All too often, they do happen.

Second, counselors need to become familiar with the multiple traumas that LGBT clients may be subjected to - such as sexual abuse, growing up in a substance-abusing family, racial and/or ethnic oppression.

Third, it is especially important for counselors to have a grasp of what being LGBT and belonging to a racial and/or ethnic minority can mean. For example, if an African-American man comes out to his family and community, he may be shunned because he is violating the religious tenets. If a Chinese lesbian comes out in her community, she is going against the Chinese cultural value of maintaining personal privacy. In addition, as Smith (1997) points out, "The coming out process is. . .[seen] as a White, Western, middle-class phenomenon. ..." Thus taking on an LGBT identity may be perceived as giving in to or embracing white values and denying one's racial/ethnic roots (Chan, 1995).

As Bohan (1996) points out, gender roles and expectations underpin the well-being of the family and therefore the culture. But being transgendered challenges and transgresses traditional gender roles/expectations and thereby threatens the very structure of the family/culture. The result is often rejection by one's own birth culture.

Minority LGBTs are often caught between two worlds, discriminated against by both, often not receiving important support from either. Although this situation may afford possible opportunities for growth (Bohan, 1996), it also provides a breeding ground for the use and abuse of alcohol and other drugs. The stresses inherent in straddling, but not fully belonging to, the two most important worlds in people's lives may lead them to seek the oblivion offered by mood-altering substances (Finnegan and McNally, in press).

The counselor's role

So what do counselors need to do? In addition to learning about the traumas LGBT people experience, they need to have some knowledge and awareness of the cultures from which their LGBT clients originate. That means learning about the values of the culture and the support networks available to clients. It also means learning how family is defined and who constitutes the client's family - e.g., blood relatives, friends, lovers, or ex-lovers.

Counselors need to have a working knowledge of the resources that are (or are not) available for their particular client. That means knowing what books about LGBTs exist, what treatment resources are available, and what the attitudes of the staff at particular programs are toward LGBTs. For instance, it is dangerous to send a male-to-female transsexual client to a treatment program that knows nothing about the special issues involved. Counselors also need to know what AA/NA meetings are safe and appropriate for their LGBT clients.

Perhaps the most important thing counselors need to do is to know themselves - their values, their biases, and their reactions to working with people who are different from them. As Herring (2002) points out, "No counselor is ethically justified in assuming that the way he or she views life is the way everybody else does, is the right way, or the only way." Counselors need, therefore, to be clear about their own, deeply experienced feelings.

Counselors working with substance abusers who are lesbian, gay, bisexual, or transgendered are dealing with The Other - i.e., people who are different from them or who may represent a part of themselves they may be afraid to own. The more different a person is from us, the more likely we are to react in primitive, powerful, and often unconscious ways. Lesbians, gay men, bisexuals, and transgendered people constitute The Other, and their difference represents the "forbidden" or, according to the distorted teachings of homo/bi/transphobia and hatred, represents the "abnormal," the dark side. This "Otherness" is a threat that stirs deep, primitive fears and aggressiveness in people (Finnegan and McNally, in press).

Thus, it is critically important for counselors to monitor their countertransference - their feelings, attitudes, and behaviors - and to have good training, supervision, and support. As Herring (2002) notes, "biases don't lose their influence just because they're not discussed; in fact, they often become less amenable to change."

Substance abuse counselors working with LGBT clients stand in a crucially important position. You can play an integral role in your LGBT clients' recovery by assisting and supporting their process of developing a positive identity both as a recovering substance abuser and as a lesbian, gay, bisexual, or transgendered person. That is a privilege not afforded to many people.

Dana G. Finnegan, PhD, CAC, (left) alcoholism counselor/consultant and Emily B. McNally, PhD, CAC, (right) licensed psychologist/consultant specialize in substance abuse, sexual/gender identity and trauma issues. They are co-authors of Counseling Lesbian, Gay, Bisexual, and Transgender Substance Abusers: Dual Identities (In press: Haworth Press) and have written numerous articles. They are co-founders and current Board Members of the National Association of Lesbian and Gay Addiction Professionals (www.nalgap.org).

References
    Alvarez, W. (1994, March). Sanctioned bias: Homophobia and its impact upon the therapeutic process. Paper presented at the Meeting of the New York State Society for Clinical Social Work, Metropolitan Chapter, New York.
    Bean, M. H. (1981). Denial and the psychological complications of alcoholism. In M.H. Bean, E.J. Khantzian, J.E. Mack, G.E. Vaillant, & N.E. Zinberg (Eds.), Dynamic approaches to the understanding and treatment of alcoholism (pp. 55-96). New York: Free Press.
    Bohan, J.S. (1996). Psychology and sexual orientation: Coming to terms. New York: Routledge.
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    Brown, S. (1998, February). Addiction, trauma, and developmental arrest. Paper presented at the Addiction and Trauma Conference, New York.
    Chan, C.S. (1995). Issues of sexual identity in an ethnic minority: The case of Chinese American lesbians, gay men, and bisexual people. In A.R. D'Augelli & C.J. Patterson (Eds.), Lesbian, gay, and bisexual identities over the lifespan: Psychological perspectives (pp. 87-101). New York: Oxford University Press.
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    Finnegan, D.G., & McNally, E.B. (1996). Chemically dependent lesbians and bisexual women: Recovery from many traumas. Journal of Chemical Dependency Treatment, 6(1/2), 87-107.
    Finnegan, D.G., & McNally, E.B. (In press). Counseling lesbian, gay, bisexual, and transgender substance abusers: Dual identities. Binghamton, NY: Haworth Press, Inc.
    Herek, G.M. (1995). Psychological heterosexism in the United States. In A.R. D'Augelli & C.J. Patterson (Eds.), Lesbian, gay, and bisexual identities over the lifespan: Psychological perspectives (pp. 321-346). New York: Oxford University Press.
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    Khantzian, E.J. (1981). Some treatment implications of the ego and self disturbances in alcoholism. In M.H. Bean, E.J. Khantzian, J.E. Mack, G.E. Vaillant, & N.E. Zinberg (Eds.), Dynamic approaches to the understanding and treatment of alcoholism (pp. 163-188). New York: Free Press.
    Khantzian, E.J. (1998, February). Addiction, trauma, and self-medication. Paper presented at the Addiction and Trauma Conference, New York.
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    Kurtz, E., & Ketcham, K. (1992). The spirituality of imperfection: Modern wisdom from classic stories. New York: Bantam.
    Levin, J.D. (1998). Case presentation. Paper presented at the Addiction and Trauma Conference, New York.
    Lombardi, E. L., & van Servellen, G. (2000). Building culturally sensitive substance use programs for transgendered populations. Journal of Substance Abuse Treatment,19, 291-296.
    Marcel, A.D. (1998). Determining barriers to treatment for transsexuals and transgenders in substance abuse programs. Boston: Transgender Education Network, Justice Resource Institute Health.
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    Smith, A. (1997). Cultural diversity and the coming-out process: Implications for clinical practice. In B. Greene (Ed.), Ethnic and cultural diversity among lesbians and gay men: Psychological perspectives on lesbian and gay issues (Vol. 3), (pp. 279-300). Thousand Oaks, CA: Sage.
    Surrey, J. (1992, December 5). Women, addictions, and codependency: A relational perspective. Paper presented at the Stone Center Seminar, New York City.
    Wright, E.M., Shelton, C., Browning, M., Orduna, J.M.G., Martinez, V., & Wong, F.Y. (2001). Cultural issues in working with LGBT individuals. In SAMHSA: CSAT (Ed.), A provider's introduction to substance abuse treatment for lesbian, gay, bisexual, and transgender individuals (pp.15-27). Washington, DC: Substance Abuse and Mental Health Services Administration: Center for Substance Abuse Treatment (SAMHSA: CSAT).

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Linda, Unregistered

Thank you for this.

 Posted 2008-04-22 17:09:40

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