Providers Must Be Cognizant of LGBTQ Patients’ Unique Treatment Needs

When seeking treatment for substance use disorder (SUD), LGBTQ patients can face challenges within heteronormative treatment models. Providers may find that in addition to seeking sobriety, LGBTQ patients may experience lessened self-esteem and have a view of a world that lacks safety, interrupts developmental phases, and creates pressure to “fit in.”

At the recent Rocky Mountain Symposium on Addictive Disorders, John Sovec, MA, LMFT, clinical consultant for The Life Group LA, adjunct faculty at Phillips Graduate Institute, and a member of the California Board of Behavioral Sciences, presented a session on the development of addiction treatment approaches that are sensitive to the unique needs of LGBTQ clients.

Addiction Professional recently caught up with Sovec via email to discuss how heteronormative treatment models have fallen short for LGBTQ patients, and how addiction can become a coping mechanism in LGBTQ identity development. He also shared practical tools and best practices for delivering trauma-informed care for LGBTQ patients.

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional: How have hetero-normative models of addiction treatment fallen short in addressing the unique needs of LGBTQ patients? 

John Sovec, MA, LMFT: When most LGBTQ patients walk into treatment, an assumption is made that they are cisgender and heterosexual. The default approach of most recovery programs is based on cis/hetero norms, and much of the training that providers have received is delivered based on that same assumption. It is then the LGBTQ person’s unique challenge to either come out and see where the chips will fall in the treatment center they are attending with the current population or keep their identity under wraps as a means to protect themselves.

Neither of these responses creates an environment where the deep work of recovery can take place. Just as in real life, it becomes the burden of the LGBTQ person to manage their story in what can often feel like unsupportive and unsafe spaces. The heteronormative model of treatment has long been the standard of care for treatment centers with little respect to or validation of the unique needs of LGBTQ patients. 

AP: What are the psychosocial environmental stressors that are unique to the LGBTQ community and can interfere with identity development? 

Sovec: For most LGBTQ people, there is an underlying hypervigilance that they walk though their day with, a constant attention to, is the space safe? Is this person safe? These stressors add up over a lifetime and interfere with many of the developmental milestones that cisgender, heterosexual people go through.

Many of the first messages that an LGBTQ person receives in life tell them that who they are and what they feel is not part of the cultural norm. This sense of being an outsider can stall identity development and place extreme stress on the day-to-day lived experience of LGBTQ people. Many studies have revealed that LGBTQ people take more risks by[BM1]  using substances and that this need is often driven by developmental trauma closely related to their identity. LGBTQ patients identify these traumas in 5 major categories:

1. Family of origin issues, including rejection and exclusion from their biological family, and/or social exclusion based on their sexual orientation or gender identity
2. Experiencing social oppression based on their sexual orientation or gender identity, including oppression from family, peers, teachers, employers, co-workers, and/or members of the public
3. Internalized LGBTQ-phobia based on social rejection and lessened self-image
4. Broken relationships or repeated, unsatisfying relationships
5. Sexual or physical abuse

In seeking relief from these traumas, LGBTQ patients turn to substance use at a higher rate with longer-term, more intense usage reported. It is vital that treatment for LGBTQ patients focus on the above relational traumas and treatment plans that can assist in developing a positive identity. 

AP: What should practitioners know with regards to addiction being a coping mechanism in LGBTQ identity development? 

Sovec: A variety of coping mechanisms can show up for LGBTQ people attempting to manage their life stressors. Some come across as positive attributes (i.e.pursuit of success, perfectionism, and taking on a helper role) while others can be seen as detrimental (i.e. emotional distancing, substance use, ambivalence). All of these coping mechanisms, however, can develop from a place of insecurity, anxiety, stress, and fear, with the purpose of trying to ameliorate the outside feelings that many LGBTQ people experience while going through identity development. Substance use in the LGBTQ community is widespread with many of the social aspects and interactions taking place in environments that prioritize substance use. Ageism, discrimination, stigma, and marginalization are all pressures that LGBTQ people experience, which can open the door to substance use as a means to ease deep trauma, stressors, and anxieties.

AP: Can you provide practical tools and best practices to help practitioners deliver trauma-informed care for LGBTQ patients? 

Sovec: First off, clinicians need to not assume that everyone they meet in this line of work is straight or cisgender. This cultural default is rampant in the world, and addressing it will immediately influence the relationship between clinician and client.

Instead, be curious and open. Remove assumptions from the equation to allow people to unveil who they are in a safe, supportive environment. Bring in clinicians with training in trauma modalities such as EMDR, brainspotting, TRM, and other current approaches to be an active part of the treatment plan. Many LGBTQ people arrive in treatment with high [adverse childhood experiences (ACE)] scores and it is important to address those experiences with compassion, caring, and proper training. Include ongoing education in the treatment of LGBTQ people as part of clinical development for all members of a center’s team, realizing that training in LGBTQ-affirming care is not a one and done experience, but rather a coordinated, ongoing effort by management to address the particular needs of this population.

Reference

Sovec J. LGBTQ treatment approaches and the influence of developmental trauma. Presented at: Rocky Mountain Symposium on Addictive Disorders. Aug. 5-7, 2022. Denver, Colorado.