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| Stressors and Treatment of Gay, Lesbian and Bisexual Substance Abusers |
| Feature Articles - Cultural | |
| Thursday, 30 November 2000 | |
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Alcohol and drug use among the gay male, lesbian and bisexual population has been the focus of much controversy. Research on counseling approaches and treatment of homosexuals is limited, and most training institutes offer courses in cultural awareness and sensitivity, but do not address issues faced by homosexuals. Although one study shows that approximately 20 to 35 percent of homosexuals suffer from alcohol and drug addiction, in comparison to 10 to 12 percent of the heterosexual population (Cabaj, 1992), researchers argue that the few studies that have been done are skewed. In 1988, Mosbacher points out "the extent of the problem has never been reliably documented. The few available studies are limited by small sample size, lack of controls, nonrandom samples or inconsistent definitions of homosexuality." Ratner, in 1988, noted that many gay men, lesbian and bisexual individuals are unwilling to answer questions about their sexuality or their abuse of substances. An additional confound, with regards to such studies, is that the definition of the term alcoholism may vary depending on the individual (Nardi, 1982). Stressors unique to homosexuals Reasons why alcohol and drug abuse is greater in the homosexual population may be related to stressors that are not faced by the heterosexual population. McDonald and Steinhorn (1990) reported "lesbians and gay men experience stressors that are unique to their lifestyle that they often try to minimize by the use of alcohol and other drugs." The following stressors are unique to homosexuals. 'Coming out' Coming out is defined by McDonald and Steinhorn (1990), ""as a lifelong process that all people experience when they allow themselves and/or others to discover who they really are." Gay men, lesbians and bisexuals must deal with coming out every time they meet new people, change jobs, relocate, find a therapist or otherwise interact with others. Coming out has the probability of creating paranoia, internalized homophobia, non-acceptance of self and fears of "coming out" (Finnegan & McNally, 1987). This occurs especially if the individual has not been permitted to express his or her feelings about the "coming out" process, or if he or she is fixated in the stage of non-acceptance of self. Homophobia A homosexual must cope with two categories of homophobia. The first category is internalized homophobia and the second is externalized homophobia. Internalize homophobia can be defined as "hatred of ones own homosexuality" (Kominars, 1995). A major cause of continued chemical dependency among the gay male, lesbian and bisexual population is internalized homophobia (Finnegan & McNally, 1987). According to Ratner (1993), "internalized homophobia often is a theme in all areas of the client's life". An individual's internalized homophobia may be the result of gay stereotyped behaviors observed by an individual in their adolescence (Ratner, 1993). Ratner also reports that gay men and lesbians are so affected by internalized homophobia that they are not able to engage in sexual activity with an individual of the same sex without using drugs or alcohol. According to Smith (1979), blackouts experienced from the use of alcohol become beneficial to the individual, because one does not remember the act that is considered shameful and embarrassing. Smith further states, alcoholism may reduce one's sexual desire and functioning, therefore, alcoholism becomes a barrier to sober sex. Cabaj (1989) adds, internalized homophobia may also be so strong that some gays cannot walk into a gay bar without using a substance. He says, "many men have had their first homosexual experiences while drinking or being drunk to overcome their internal fear, denial, anxiety or even revulsion about gay sex." External homophobia is "the irrational response to gay men or lesbians, or the idea of homosexuality" (Kominars, 1995). This added stressor results from the fear of what others may do if the world knows an individual is gay. Homophobia results in feelings of anger, fear, guilt and isolation in an individual. Such feelings increase the probability of an individual using substances to cope with these intense feelings (Kominars, 1995). HIV A high prevalence of HIV exists among homosexuals. According to Shernoff and Springer (1992), "gay men in recovery, who may have given up risky drug-related behaviors years ago, can find a new pull toward drug use due to their anxieties about HIV". Other stressors related to HIV includes individuals who have not been HIV tested and do not want to know their status. These persons have fears about their past sexual behaviors and therefore have an added stress not observed as frequently in the heterosexual population (Shernoff & Springer, 1992). In addition, "gay men and lesbians in general have suffered many losses since the HIV epidemic began, and grief overload can be a pull towards drugs as a coping mechanism" (Shernoff & Springer, 1992). Gay male and lesbian HIV-positive individuals, who are also chemically dependent, tend to feel unique and different from others in their community. Due to this feeling of uniqueness, these individuals use drugs and alcohol in order to cope with their loneliness (Pohl, 1995). Religion Father Leo Booth in 1995, stated "people of many faiths and ethnic backgrounds have suffered from religious persecution, but most of them had a faith or religion in which they could feel wanted and accepted. Gays are the only group who has been religiously condemned, not for what they do, or what they believe, but for simply being who they are. Negative religious teachings about homosexuality have created a deeply embedded core of shame and self-loathing which surfaces in a host of dysfunctional attitudes and behaviors." Further support comes from a statement made by Brown in 1985: "Organized religion has contributed significantly to the wounding of gay men and lesbians, through a long history of negative bias that has been extensively documented." Limited social contact Unlike the heterosexual population, the gay male, lesbian and bisexual community is limited in available places in which they can meet and socialize. So, they tend to congregate and socialize in bars more frequently in comparison to the heterosexual population. Diamond and Wilsnak (1978) note that due to bars being the central meeting place for homosexuals, this subculture most likely encourages, or at least tolerates, heavy levels of drinking. With the recent development of attempts to mainstream homosexuals and educate heterosexuals, via school groups, various outreach programs, television shows and movies, socializing opportunities are changing. As a result of these changes, bars may not be as strong of a meeting place as in the past. McKeirnan and Peterson in 1986 surveyed 3,400 gay males and lesbians. Their survey reported that these subjects experience depression, alienation, anxiety and low self-esteem on a frequent basis. Due to this negative affectivity, these individuals were more likely to use alcohol to reduce tension and to use bars as a primary meeting place. Furthermore, many of these individuals socialize with other substance abusers or isolate themselves (Ratner, 1993). Leading a double life Many homosexuals believe they must pretend to be heterosexual in general society or their workplace in fear of rejection or discrimination (Smith, 1982). This double life may result in individuals following social expectations instead of their personal desires. Some gay men, lesbians or bisexuals may marry an individual of the opposite sex and raise a family, creating a stressful situation not experienced in the heterosexual population (Cabaj, 1996). Mckirnan and Peterson (1988) speculated that the higher incidence of problem drinking may be related to expectations associated with role changes such as marriage, children and other family responsibilities that occur among heterosexual adults. These role changes may assist in decreasing excessive drinking in the heterosexual population. The homosexual population experiences such role changes in small percentages. Families of homosexuals have difficulty accepting the person for his or her sexual orientation. This tends to isolate the individual. When the family member is also a substance abuser, the isolation increases, which tends to result in continued substance abuse by the individual (Ratner, 1996). Ratner also reports "secretiveness and fragmentation of one's identity can be a major factor in keeping the chemically dependent people chemically dependent". Developmental issues Researchers have also identified developmental issues experienced by this population. It has been stated that the development of a homosexual or gay male identity occurs in the context of stigma (Troiden, 1989). This population, prior to adolescence, has already identified themselves as different (Minton & McDonald, 1984). When these individuals become adolescents, they begin to feel that they are not like the general population, thus resulting in placing themselves in a "devalued group" (Hetrick & Maartin, 1987). According to Shifrin and Solis (1992), "Alcohol and drug use for the lesbian and gay youth is multifunctional: it medicates the anxiety caused by the need to conceal one's identity; helps to discharge sexual impulses more comfortably; decreases the depression and dissonance that is generated by the adolescent's discovery of his or her sexual identity; acts as an antidote to the pain of exclusion, ridicule and rejection of the family and peer group; provides a feeling of power and self-worth to counteract the youths sense of being devalued; and offers a sense of identity, wholeness and a soothing that is missing in his or her daily experience." Experiences that are unique to this population during adolescence may result in the development of habits (chemical abuse or dependence) to cope with strong feelings (Gonsiorek, 1993). Rosario, Hinter and Gwadz (1997) state, "A gay, lesbian or bisexual youth might turn to substances to escape from this set of stressors and to decrease the feelings of unhappiness created by the stigma of homosexuality." In addition, these individuals tend to be more sensitive to rejection. Substances will assist the individual in decreasing this devalued feeling (Cabaj, 1996). Treating the homosexual client According to Ratner (1990), "to treat the client successfully, the therapist must assess a wide variety of factors, including: (a) homophobia, (b) the coming-out experience, (c) social network, (d) spirituality and religion, (e) relationships with the family of origin, and (f) history of relationships and sexual behavior." When assessing the coming-out experience, the therapist must be aware that the client may be experiencing two stages of denial. One stage having to do with the possible denial of one's sexual orientation and the other being the denial associated with the disease of chemical dependency (Finnigan & McNally, 1987). Due to this possible denial of sexual orientation, it is best that the therapist does not question the client about his or her sexual orientation. By questioning the client, the therapist may be reinforcing the individual's internalized homophobia. Treatment questions regarding sexual orientation should come from the client. If the client presents openly as a homosexual, the therapist should not deny society's responses to homosexuality. This acknowledgement will strengthen the bond between the client and therapist (Ubell & Sumberg, 1992). Being gay-affirming and letting the client know that being a gay male or lesbian is a positive identity, will also assist in strengthening the bond between the two (Hall, 1985). If the therapist is unsure if the client is a homosexual, the therapist should listen to and be familiar with terminology used by this population. By doing this, it may invite the client to "come out" to the therapist (McDonald & Steinhorn, 1990). Alcohol, drugs and homophobia Due to the possibility of dual denial, a therapist must also address the issue of the substance abuse. It is important that the counselor be aware of the need for a discussion about alcohol and drugs and be ready to engage in dialogue when the opportunity arises. In working with homosexuals, the counselor needs to listen with the "third ear" for those topics that do not come up. Every helping person needs to listen for unspoken subjects and take responsibility for raising these issues to a conscious level for discussion. (McDonald & Steinhorn, 1990). Externalized and internalized homophobia must also be addressed early in treatment. First, the therapist must assess the extent of external homophobia in the client's environment and the therapist must also evaluate the amount of internalized homophobia the individual is experiencing. This can be done by assessing the client's coming-out experience and by using the Ryan Homophobia Assessment. In addition, stereotyped homosexual behaviors that have been observed by the client during adolescence and the individual's reaction to this behavior need to be explored (Ratner, 1990). Ubell and Sumberg (1992) state "support and reassurance that the client is acceptable, valued and worthy are necessary to counteract many of the previous negative messages the client has received." Ubell and Sumberg (1992) further report that the first year of treatment should focus on sobriety issues. At no point should the therapist try to deny the fact that there is homophobia in society. The therapist's honesty in acknowledging that homophobia exists can strengthen the bond between client and therapist. In addition, the therapist must pay close attention to his or her own homophobic potentials. It is helpful if the therapist has read a variety of autobiographies and novels in which homosexual relationships are described. This may provide insight into homosexuality for the therapist (Ubell & Sumberg, 1992). Obstacles to recovery Additional obstacles that may block the individual's recovery are feelings of anger, fear, guilt and isolation (Kominars, 1995). "Homophobia activates within the individual each or all of these four basic obstacles to recovery (Kominars, 1995)." Most articles that discuss dealing with homophobia from the therapist's point of view encourage the therapist to evaluate the comfort level of the client attending a heterosexual self-help group. Should the client report being uncomfortable or having difficulty relating to the participants, it is important for the therapist to be aware of gay self-help groups available in the community. A therapist must be aware that there may be an absence of support for these individuals who are attempting to enter recovery. This lack of support may be due to family of origin issues. "Struggling without the support of our families of origin, may result in feelings of bereft because of not having friends who are without substance-related problems" (Kominars & Kominars, 1996). It is important for the clinician to be aware of a variety of gay male, lesbian and bisexual organizations along with the gay self-help groups (Kominars & Kominars, 1996). Ratner in 1990 reports "the client's first meaningful encounters with other members of the gay and lesbian community, while not under the influence of drugs can affect their future sobriety." It is helpful if the therapist makes the client aware of gay and lesbian newspapers, encourages the client to get involved in community activities where drugs and alcohol are not involved and then processes these events with the client afterwards (Ratner, 1990). Spirituality and recovery Spirituality is an important aspect of recovery. A counselor must realize that spirituality is different from religion and be able to communicate that with the client (Kus, 1992). According to Father Leo Booth (1995), "religion is a set of man-made teachings about God which often reflect social customs of the day. It employs rituals and doctrine, which can either enhance spirituality, or damage it. Spirituality is God given. It is positive creativity, which involves choice, self-empowerment and responsibility. Healthy spirituality requires self-esteem. It encompasses mental, emotional and physical well-being." Kus (1992) reports "the counselor who realizes that spirituality consists not only of one's basic value system, but also of doing good works" can assist the individual in living a spiritual life. In a study done by Kus in 1992, he reported that gay men used bibliotherapy as part of a spiritual program. It is important for the clinician to assess the client's present spiritual development and understanding (Haldemann, 1996). It is helpful if the therapist is aware of more liberal church bodies, and the community lesbian, gay men organized religions. The clinician should be aware that religious guilt may increase during the recovery process, therefore, such issues must be addressed in treatment (Ratner, 1990). Kus in 1992, identified some other implications for clinicians who work with recovering men. He states "the clinician may help the gay man explore various conceptions of a higher power. The clinician may help the gay man pray. The clinician should be able to teach the gay client how other gay men go about doing spirituality in everyday life. Finally, giving the client positive strokes for his spiritual efforts helps him on his journey." Family-of-origin issues During substance abuse counseling, family-of-origin issues tend to arise. The therapist must not only understand the role of addiction in the family system, but the therapist must also explore the family's acceptance of the client's homosexuality (Ubell & Sumberg, 1992). Ratner (1992) recommends that the client do a genogram that will help him or her view family patterns and promote a sense of connection with his/her family of origin. According to Anderson (1996), "adequate treatment of gay men and lesbians who are chemically dependent must take a family perspective that includes both the family of origin and created family system." The created family system may include the client's gay and lesbian friends. Relationships For a client to be successful in recovery, it is important that the therapist address the individual's history of relationships and sexual behavior (Ratner, 1990). It is important to the client's sobriety that the issue of HIV is addressed. The clinician must understand that HIV will tend to increase the guilt and shame of the client. HIV-infected individuals will tend to focus on their HIV status versus their recovery. It is the clinician's job to balance therapy to address both HIV issues and chemical dependency issues (Pohl, 1995). It is also important for the clinician to listen closely to the client and to bring up unspoken subjects such as HIV (MacDonald & Steinhorn, 1990). Shernoff and Springer (1992), make the following recommendations for therapists who are working with clients who are both HIV-positive and chemically dependent. "It is important for workers to touch clients to counteract stimulus hunger, belie the feeling of toxicity and provide caring interventions in a way that will help the client. Workers tend to suffer from over-identification with the client. Clinical supervision is essential to help workers identify their own boundary weaknesses and magical thinking and take steps to counteract them." Shernoff and Springer (1992) point out that these clients will often discuss suicide. The therapist needs to understand that the client may be feeling unloved and burdensome. It will help the client if they get reassurance from caring partners and family members that they are loved and valued.
Carmine Pecoraro, PsyD, is a certified addictions professional and an              |
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