Addiction in LGBTIQ Youths and Its Relationship to Suicide Ideation and Stigma

Members of the lesbian, gay, bisexual, transgender and questioning (LGBTQ+) community are more likely than the general heterosexual population to develop substance use disorders (SUDs) and also to seek counselling and psychotherapy services. However, in seeking treatment, LGBTQ+ clients experience myriad challenges associated with their sexual orientation and gender identity. The present research study aimed to review and synthesise the findings of the available empirical research to explore and identify the challenges faced by the LGBTQ+ community in accessing group therapy for SUDs.

The findings of this review reveal multiple challenges that affect this demographic, which include fears and anxieties that characterise their lives and treatment experiences, the social and cultural contexts that anchor group therapy, the high prevalence of mental health problems and substance use severity among this population group, and a lack of adequate counsellor education and training in LGBTQ+ issues.

Additional challenges include the fluidity and non-binary nature of the sexual orientation and identities of LGBTQ+ clients, a failure by clinicians to create a safe environment for members of the LGBTQ+ community to participate in group therapy, and difficulties in getting the right number of sexual minority clients to participate in group therapy at any one time. Several practice recommendations have been provided, which include ensuring the provision of LGBTQ+-affirmative services, integrating substance abuse treatment with mental healthcare services, and ensuring clinicians receive adequate education and training on how to provide LGBTQ+-affirmative services and culturally adapted interventions.

 

• Chapter 1: Introduction
• Chapter 2: Literature Review
• Chapter 3: The Foundational Aspects of Group Therapy
• Chapter 4: Analysis and Discussion of the Research Findings
• Chapter 5: Conclusion, Recommendations, and Future Areas of Research
• References

 

 

Chapter 1: Introduction

 

Background

Members of the lesbian, gay, bisexual and transsexual (LGBTQ+) community continue to elicit varying interests in scholarly and practitioner discourses due to their unique needs as a sexual and gender minority group. The accruing evidence base associate's members of the LGBTQ+ community with increased drug and substance use (Flentje et al., 2015), elevated uptake of counselling services for substance use disorders (SUDs) (Flentje et al., 2016; Parent et al., 2019). Researchers have also explored the parameters that inform how members of the LGBTQ+ community access treatment services for SUDs (Johns, 2010; King et al., 2007). One research looks into how members of the LGBTQ+ community encounter manifold problems and challenges when attempting to access treatment for SUDs.

 

Problem Statement

A recent study documented in Tagliareni (2020) estimates that between 20% and 30% of the LGBTQ+ population suffer from SUDs compared to 8.4% of the heterosexual population. Research also shows that members of the LGBTQ+ community with SUDs experience multiple challenges that dampen efforts by clinicians to optimise service delivery targeting this population group (Flentje et al., 2015; Green & Feinstein, 2012). These challenges are more pronounced in group therapy programs, in large part due to privacy and confidentiality violations characterising these environments (Cooper et al., 2017; Corey, 2016).

The high prevalence rate of SUDs among the LGBTQ+ community, along with the multiple challenges faced by members in accessing treatment, highlight the need to adopt effective recovery programs to optimise service provision. Such effective recovery efforts, however, cannot be actualised without understanding the challenges experienced by LGBTQ+ clients in using group therapy to access treatment for SUDs.

 

Statement of Purpose

The present study reviews and synthesises the findings of the available literature to explore and identify the challenges faced by the LGBTQ+ community in accessing group therapy for SUDs. The reason for choosing group therapy for LGBTQ+ is that it allows these members to identify feelings of being associated with a “hidden minority" groups, and to also express these feelings. Additionally, being in group sessions allow others to validate such feelings, seeing as they also share in a similar status (DeBord & Perez, 2000).

Besides, group therapy gives LGBTQ+ clients an opportunity to candidly express, examine and comprehend experiences that are unique to this community. A secondary research method is employed to identify and document the challenges faced by this population group during group therapy interventions for SUDs. The goal is to help in improving the existing group therapy programs for the identified group of individuals for improved service delivery.

 

Research Question

The present research study aims to respond to the following research question: What challenges do the LGBTQ+ community encounter during group therapy for SUDs?

 

Rationale and Significance

The main justification for the present study is to ensure that members of the LGBTQ+ community have access to treatment services for SUDs. A secondary justification is to assist clinicians in designing and implementing effective SUD treatment programs targeting members of the LGBTQ+ community by incorporating their needs and challenges. The study has three main benefits for practice: first, the findings of this study will provide insights into understanding the various aspects that act to impede the effectiveness of counselling and psychotherapy interventions aimed at addressing SUDs among the LGBTQ+ community.

Second, this study represents a scoping review for service optimisation with this cohort. Finally, the findings of this study serve to illuminate the gaps that clinicians need to address to optimise SUD treatment programs provided to the LGBTQ+ community using the group therapy approach.

 

Chapter 2: Literature Review

 

Drug Misuse in the LGBTQ+ Community

Several studies (for example, Flentje et al., 2015; Lytle et al., 2014) have explored specific differences in drug use between heterosexual communities and sexual minority groups. According to a 2013/14 Home Office report LGBTQ+ adults were more than 3 times more likely to have taken illicit drugs in comparison with their heterosexual counterparts, at 28.4% and 8.1%, in that order (Home Office, 2014).

The LGBTQ+ group shows more inclination to substances such as cocaine and methamphetamine as their primary problem substances, and report later age of initiation to primary problem substances (Drabble & Eliason, 2012; Flentje et al., 2015). Flentje et al. (2015) note that members of the LGBTQ+ community report later drug or dependence relative to the heterogeneous population. This finding is important since it “may suggest that a unique pathway to substance use disorders exists for this demographic" (p. 335). Overall, these findings underpin the need for clinicians working with the LGBTQ+ community to consider the unique patterns of drug use shown by this demographic.

Several studies have endeavoured to assess the prevalence of drug use among the LGBTQ+ community in Ireland. For example, Sarma (2007) undertook a study to assess drug use among the Irish population of the LGBTQ+ community. The study was commission by "BeLonG to drugs report". This is a youth project that works with young people in Ireland, and in particular, the LGBTQ+ community. Based on the study findings, 65 % of the LGBTQ+ youths conceded to having experimented with drugs. Additionally, 21 % of the LGBTQ+ youths interviewed conceded to being systematic drug users. This means they have used one or more drugs on over 60 occasions. This is a clear indication that drug use is quite entrenched among the LGBTQ+ community in Ireland, and especially young adults and teenagers.

Elsewhere, Barrett et al (2015) undertook a national survey directed at men who have sex with men (MSM). The aim of this online survey was to determine the prevalence of drug use amongst this population and the associated risk factors. Based on the research findings, 36% of the MSM interviewed indicated they had used one or more recreational drugs in the past 12 months. Another 33% conceded to having uses poppers. Of the MSM who took part in the national survey. Five percent had tested positive for HIV. Consequently, Barrett et al. (2015) concluded that MSM in Ireland are more predisposed to using recreational drugs. The prevalence is especially high among MSMS testing positive for HIV.

Other studies, such as Kidd et al. (2018) have focused attention on identifying the factors that mediate drug and substance use and misuse among the LGBT community. The findings of these studies show that, compared to the heterosexual population, the LGBTQ+ community shows a higher predisposition for drug and substance use and misuse due to factors such as stigmatisation, victimisation, and discrimination due to their sexual orientation (Drabble & Eliason, 2012; Flentje et al., 2016; Parent et al., 2019); social isolation and rejection by parents or peers (Parent et al., 2019); difficulties involved in the “coming out" process (Troutman & Packer-Williams, 2014); high levels of stress and anxiety (Drabble & Eliason, 2012); and affiliation with gay culture and HIV status (Green & Feinstein, 2012). T

he study by Drabble and Eliason (2012) notes that the LGBTQ+ community shows a high predisposition for drug use and misuse due to elevated levels of minority stress, which consists of “internalised heterosexism, such as feelings of shame, guilt, isolation, and alienation stemming from moral and religious attitudes about sexual minority people” (Drabble & Eliason, 2012, p. 277). Overall, a synthesis of these findings underscores the need for clinicians working in group therapy environments to consider significant mediators to drug and substance use among the LGBTQ+ community. This is because an understanding of the mediating factors will enable clinicians to develop treatment programs aligned with the individual needs of members of such a therapy group.

 

Counselling and Psychotherapy as a Treatment Program

A research study has found that LGBTQ+ clients exposed to a combination of contingency management (CM) and cognitive-behavioural therapy (CBT) produce significant reductions in substance use and abuse than those exposed to CBT alone (Green & Feinstein, 2012; Nyamathi et al., 2017; Reback & Shoptaw, 2014). These authors also report studies that have compared the use of standard CBT approaches and gay-specific cognitive behavioural therapy (GS-CBT) to treat substance misuse among members of the LGBTQ+ community.

The findings of Green and Feinstein's (2012) shows that GS-CBT is more effective over standard CBT in reducing substance use and abuse among members of the LGBTQ+ community. Other studies (for example, Bockting et. al., 2006; Orecchia, 2008; Troutman & Packer-Williams, 2014) have reported similar findings, which suggest that tailoring CBT to specific issues associated with the LGBTQ+ community generates superior long-standing benefits than standard CBT, conceivably because of the capacity of GS-CBT to address the cultural aspects of substance abuse.

The success of GS-CBT over standard CBT approaches, according to Green and Feinstein (2012), embeds in its capacity to integrate “relevant cultural aspects of drug use (particularly methamphetamine use) by [the LGBTQ+ community] with CBT, including skills training to reduce drug use and sexual risk behaviours, identify relapse triggers, interrupt cravings, and return to abstinence should relapse occur” (p. 273). Overall, therefore, these findings underpin the importance of customising treatment protocols to respond to the unique cultural needs of LGBTQ+ clients with SUDs, rather than providing standard CBT.

Studies have also evaluated the effect of counselling and psychotherapy based on parameters such as drug use severity, length of the outcome, and existing deficits. Studies by Kerqeli and Kadriu (2017) and Lytle et al. (2014) underscore the effectiveness of CBT approaches over motivational interviewing (MI) and social skills training in LGBTQ+ clients with high drug dependence severity and also to attain long-term outcomes. In existing deficits, studies by King et al. (2007), Bockting et al. (2006), and Lytle et al. (2014) underscore the need for counselling and psychotherapy training institutes to instil in clinicians core knowledge of LGBTQ+ issues of sexual identity, heteronormative bias, internalised bias, self-disclosure, and gender identity.

Finally, researchers have assessed the basic pathways to substance abuse treatment using counselling and psychotherapy. The general consensus embeds in the fact that clinicians should pursue a client-centred approach to substance abuse treatment with the view of supporting the choice of treatment goals and treatment modalities provided by LGBTQ+ clients (Bockting et al., 2006; Flentje Livingston & Sorensen, 2016). An effective program targeting members of the LGBTQ+ community with SUDs, according to Bockting et al. (2006), “follows the principles of harm reduction, with possible goals ranging from reduction of chaotic, consumptive, or risky patterns of use to total cessation of drug or alcohol consumption” (p. 34).

Moreover, for counselling and psychotherapy to be effective in treating SUDs among LGBTQ+ clients, clinicians must develop the capacity to understand the multitude of factors that drive this demographic into addiction and make it difficult to reverse or stop their substance use behaviours (Bockting et al., 2006; Kerqeli & Kadriu, 2017). Treatment alternatives must predicate upon the drugs and substances being used by the LGBTQ+ clients (Lytle et al., 2014), as well as whether these clients have co-occurring mental health issues and co-existing gender concerns (Troutman & Parker-Williams, 2014). Following this elaboration, there is a need to expose LGBTQ+ clients with SUDs and comorbid mental health issues to an integrated program with the capacity to treat both conditions.

 

Hindrances to the LGBTQ+ Community in Pursuing Group Therapy

Group therapy offers members of the LGBTQ+ community a viable alternative for addressing SUDs and other impairments. Cooper et al. (2017) note that “group therapy can provide a rich and rewarding opportunity for exploring the turbulent waters of human nature and relationships" (p. 231). However, as demonstrated by Flentje et al. (2016), LGBTQ+ clients face multiple challenges that hinder their capacity to benefit from services offered by clinicians in group therapy contexts. This subsection reviews the available scholarship to identify challenges that members of the LGBTQ+ community encounter in pursuing group therapy for SUDs.

Fear and anxiety by the LGBTQ+ community on account of their sexual orientation can be a hindrance to treatment. The available scholarship shows that people generally feel inhibited to seek psychological assistance using the group therapy model due to factors such as “the fear of losing control, fear of self-disclosure, fear of criticism, and fear of rejection” (Schechtman & Kiezel, 2016, p. 572). Such an experience may be less pronounced in individual therapy as the client only has to disclose to his or her therapist.

Members of the LGBTQ+ community may find it particularly difficult to self-disclose their sexual or gender identities to other members of the group due to the fear of criticism and rejection (Israel et al. 2008), which in turn may impede treatment adherence and treatment success (Cochran et al., 2007). Members of the LGBTQ+ community may also fear to disclose their sexual and gender orientations in a group therapy environment to avoid shame and stigma, particularly in contexts where treatment is taking place in collectivist cultures (Troutman & Parker-Williams, 2014).

Secondly, the social and cultural context may serve as an impediment to pursuing group therapy among the LGBTQ+ community. Members of the LGBTQ+ community may be less likely to seek treatments in contexts where they may not receive LGBTQ+ friendly-affirmative services (Flentje et al., 2015). Consistent with this finding, the study by Israel et al. (2008) who found that practice settings that do not offer LGBTQ+ friendly-affirmative services not only trigger delayed entry into treatment but also nurture more risky behaviours upon exposure to treatment.

Still, the study by Flentje et al. (2016) note that the social context that exists in substance abuse treatment settings play an important role in determining when members of the LGBTQ+ community experience negative bias while seeking services for SUDs. A review by Drabble and Eliason (2012) reveals that most treatment sites offering LGBTQ+ community services neither differentiate the unique needs of each category of the sexual minority group nor train clinicians to uphold affirming beliefs and attitudes about members of the LGBTQ+ community. Such an orientation, according to these authors, reduces the uptake of counselling and psychotherapy services among this demographic since it makes it difficult for some members to find supportive and accepting communities in therapy groups.

Another hindrance relates to the high prevalence of mental health problems and substance use severity among the LGBTQ+ community. Evidence from studies by Cochran and Cauce (2006), Drabble and Eliason (2012), Flentje et al. (2016), and Russell and Fish (2016) reveal that LGBTQ+ clients seeking treatment for SUDs show a high prevalence of comorbid mental health conditions, elevated psychopathology, greater drug use severity, and higher medical service utilisation relative to the heterosexual population. Such challenges, in turn, make it difficult for the LGBTQ+ community to reap optimum benefits from group therapy environments due to the many mental and physical health needs exhibited by this demographic (Russell & Fish, 2016). Overall, these findings underscore the need for clinicians to demonstrate more awareness of substance use severity and specific mental health challenges afflicting members of the LGBTQ+ community seeking treatment for SUDs.

Moreover, the lack of adequate counsellor/psychotherapist education and training is well documented in the literature. The study by Drabble and Eliason (2012) acknowledges that a significant proportion of counsellors lack adequate knowledge and training to address "internalised oppression, legal issues such as domestic partnerships or power of attorney, and concerns related to family of origin” (p. 280). This particular study also notes that almost five in ten clinicians hold negative or ambivalent views and perceptions toward members of the LGBTQ+ community due to a lack of adequate training on cultural diversity.

Studies by Israel et al. (2008), Mericle et al. (2018), and Troutman and Packer-Williams (2014) show that the lack of adequate counsellor training makes it difficult for clinicians to provide affirmative practices to members of the LGBTQ+ community during group therapy for SUDs, which in turn lowers treatment adherence and completion, treatment success, and satisfaction with treatment. Mericle et al. (2018), in recommending a solution to this problem, notes that “measures of organisational LGBTQ+ competence are needed to assess the effects of training and policies to enhance LGBTQ+-sensitivity" (p. 406). Overall, this challenge underscores the difficulties that the members of the LGBTQ+ community face in finding substance abuse treatment services that are sensitive to their sexual orientation and needs.

Another challenge is captured by Cooper et al. (2017), who acknowledge that many clinicians may lack the awareness and self-reflection needed to understand the fluid and often non-binary nature of the sexual orientation, sexual identity, and gender identity of members of the LGBTQ+ community seeking treatment for substance abuse behaviours in a group therapy environment. The inability of some clinicians to relate with the unique sexual and gender identities of LGBTQ+ members makes it difficult for these clients to develop higher intensities of connection and contentment with their substance use treatment programs (Mericle et al., 2018). Green and Feinstein (2012) note that members of the LGBTQ+ community who are also involved in substance abuse presents a unique challenge during treatment compared to the heterosexual population.

Researchers have also examined the difficulties involved in creating a safe environment for members of the LGBTQ+ community to participate in group therapy for SUDs alongside members from the heterogeneous population. Here, Cooper et al. (2017) underscore the need for clinicians “to foster a safe environment for LGBTQ+ clients to explore themselves in the group and for other group members to explore their responses” (p. 231).

The higher predisposition of group therapy to experience difficulties in creating and fostering a safe environment for members of the LGBTQ+ community with SUDs, according to Schechtman and Kiezel (2016), not only increases scepticism but also lowers the preference for utilising groups among this demographic. In their study, Mericle et al. (2018) found that a safe environment for substance abuse treatment targeting members of the LGBTQ+ community can be achieved by "structuring the physical setting to project inclusivity, staffing the program to affirm diversity, individualising treatment planning to address the specific needs of clients” (p. 404).

Lastly, studies reveal many practice settings that offer substance abuse services to LGBTQ+ clients experience difficulties in getting the right number of sexual minority clients to participate in group therapy at any one time. The challenge of having limited numbers of sexual minority clients in substance abuse treatment programs makes it difficult for clinicians to provide specialized groups (Mericle et al., 2018), adopt culturally tailored interventions (Hughes & Eliason, 2002; Sue & Sue, 2008), and address the unique needs affecting this population group (Lytle et al., 2014).

Green and Feinstein (2012) underscore the difficulties involved in mixing sexual minority clients with heterosexual clients in the same treatment groups for SUDs, particularly in terms of identifying client-specific circumstances and factors, addressing antecedents and triggers of substance use, and prescribing individualised treatment protocols. Moreover, many drug and substance abuse programs use gender-specific parameters to recruit clients, which then pose “a problem for individuals who do not identify with a binary identity as well as those who are visibly transgender and do not feel they will fit in with other women or men in the program" (Bockting et al., 2006, p. 34). However, Stevens (2012) underscores the need to provide substance abuse treatment for LGBTQ+ clients with SUDs in a mixed setting to reduce additional segregation and marginalisation of this demographic.

 

Chapter 3: The Foundational Aspects of Group Therapy

Group therapy embeds in the need to not only resolve interpersonal conflict affecting members but also to address their situational concerns and enhance greater self-awareness and insight (Ajufo, 2008). Group therapy, according to Shay (2017), allows members to discuss their personal concerns and challenges at an affective level under the guidance, direction, or leadership of the clinician. Group therapy is often done for preventive and remedial purposes, implying that it can be an effective approach when applied to LGBTQ+ clients with SUDs due to its applicability in creating an interpersonal helping climate which allows each client adequate latitude not only to develop insight into their substance use behaviours but also to attain healthier personal adjustment (Pachankis, 2014).

Group therapy has distinct principles and theoretical foundations. The available literature on group therapy shows that the main principles of this therapeutic practice include instillation of hope, universality, imparting information, altruism, corrective recapitulation, development of socialisation techniques, imitative behaviour, interpersonal learning, group cohesiveness, and catharsis (Kabir, 2017; Shay, 2017; Yalom, 2005). The literature is clear that “the power in group therapy lies in the unique opportunity to receive multiple perspectives, support, encouragement and feedback from other individuals in a safe and confidential environment” (Kabir, 2017, p. 197).

Some of the theoretical models used in group therapy include cognitive behavioural group therapy, mindfulness, strategic/interactional therapy, brief group humanistic and existential therapies, group psychodynamic therapy, modified dynamic group therapy (MDGT), and modified interactional group process (MIGP) (Kabir, 2017; Wandrekar & Nigudkar, 2019). Clinicians can use these models to assist members of the LGBTQ+ community with SUDs to get the support and encouragement of other clients in the group (Ajufo, 2008), share their hopes and fears on substance abuse behaviours (Shay, 2017), share experiences and feedback (Pachankis, 2014), and look up to other members of the group as role models (Johnson, 2009; Kabir, 2017). Adopting these models will help therapists understand and create awareness of dynamics occurring in individuals attending the treatment groups.

Each of the models mentioned above is beneficial to the LGBTQ+ community and, when implemented by a skillful leader, can offer in-depth therapeutic experiences for the LGBTQ+ individuals in the group sessions. Nonetheless, there is a need for the therapists to ensure they match each model with the specific needs of the individuals receiving treatment. Therefore, the choice of a particular model is determined by the underlying goals of the treatment plan.

The available scholarship underscores several advantages associated with group therapy. Cooper et al. (2017), for example, highlights “the power of the group to reveal, through transference and projection, essential information about [clients'] histories and their impact on present-day relationships” (p. S231). These authors also note that group therapy has the capacity not only to nurture shifts in clients' characters and interpersonal style but also to provide an enabling environment for clients to learn how to develop and sustain healthy relationships.

Group therapy environments, according to Schechtman and Kiezel (2016), provide rich opportunities to learn from other members with similar challenges, to receive meaningful feedback, and also to enjoy social and emotional support. However, group therapy is associated with distinct disadvantages, which include fear of self-disclosure and rejection (Schechtman and Kiezel, 2016), lack of privacy and security (Cochran et al., 2007), lack of interest in others (Israel et al., 2008), and an inability to address unique risk factors for substance use compared to individualised therapy (Stevens, 2002).

Group counselling may also be ineffective in excessively withdrawn clients and those with low self-esteem due to its often-confrontational nature (Ajufo, 2008) and the demand that members that make up the group must “talk with each other in a spontaneous and honest fashion” (Kabir, 2017, p. 196). These disadvantages, according to research by Schechtman and Kiezel (2016), make group therapy to be “underused despite the fact that it has proven to be an effective mode of treatment, with outcomes at least as good as individual therapy” (p. 585).

 

Chapter 4: Analysis and Discussion of the Research Findings

 

Statement of Findings

The present research study aimed to explore and identify the challenges the LGBTQ+ community encounter during group therapeutic interventions for SUDs. A review of the available literature on drug use in the LGBTQ+ community shows that this particular demographic reports a higher level of drug and substance abuse, show more inclination to substances such as cocaine and methamphetamine as their primary problem substances, and report later age of initiation to primary problem substances (Drabble & Eliason, 2012; Flentje et al., 2015).

An exploration of the evidence generated on the main issue reveals multiple challenges, which include fears and anxieties that characterise the lives and treatment experiences of members of the LGBTQ+ community, the social and cultural contexts that anchor group therapy, the high prevalence of mental health problems and substance use severity among this population group, and a lack of adequate counsellor education and training in LGBTQ+ individuals' issues. Additional challenges are failures by clinicians to create a safe environment for members of the LGBTQ+ community to participate in group therapy, and difficulties in getting the right number of sexual minority clients to participate in group therapy at any one time. These challenges are intricately tied to the problems and risk factors that continue to afflict LGBTQ+ clients with SUDs on a daily basis and the complexities of providing substance abuse treatment in a group environment.

 

Analysis and Discussion

Several important issues need some illumination to develop an adequate capacity to understand the challenges that the LGBTQ+ community encounter during group therapeutic interventions for SUDs. As demonstrated by Flentje et al. (2015), clinicians providing treatment services in a group therapy environment should develop adequate comprehension of the risk factors of substance abuse and the unique pathways followed by LGBTQ+ clients to reach drug dependence.

The identification of risk factors and pathways to substance abuse is important in developing and delivering customised substance abuse treatment interventions and identifying whether clients have mental health issues (Stevens, 2012). It may be productive to group LGBTQ+ clients based on their unique risk factors for substance abuse, such as stigmatisation and minority stress, family or peer rejection, and lack of adequate social support. Understanding these factors and pathways, according to Nel et al. (2007), may provide an avenue for clinicians to address the challenges of fears and anxieties and co-occurring mental health challenges among members of the LGBTQ+ community with SUDs.

Another important issue relates to the social and cultural contexts that anchor group therapy. Here, evidence has been adduced to show that many LGBTQ+ clients fail to seek services for SUDs using the group therapy model for fear of not receiving LGBTQ+-affirmative services and exposure to experiences of negative bias while seeking treatment (Flentje et al., 2015; Flentje et al., 2016; Israel et al., 2008).

These fears embed in the deficits of group therapy, as demonstrated by the fact that LGBTQ+ clients may experience difficulties opening up on their sexual orientation and gender identity due to fear of self-disclosure and rejection (Schechtman and Kiezel, 2016), lack of privacy and security (Cochran et al., 2007), and lack of interest in others (Israel et al., 2008). These weaknesses underscore the need for clinicians using group therapy to provide treatment to LGBTQ+ clients with SUDs to utilise LGBTQ+-affirmative services, including LGBTQ+-oriented treatment modalities such as GS-CBТ.

Furthermore, this research study underpins the issue of counsellor education and training as an important challenge for LGBTQ+ clients seeking substance abuse treatment services in a group therapy environment. Here, a review of the available scholarship underscores the gap that exists between the successful uptake of treatment services by LGBTQ+ clients with SUDs and deficiencies in counsellor education and training (Drabble & Eliason, 2012).

Effective counsellor training, according to Nel et al. (2007), is effective in ensuring the application of LGBTQ+-affirmative services in group therapy environments. Such an orientation, in turn, is critical in addressing the fears and anxieties that characterise members of the LGBTQ+ community with SUDs while increasing treatment adherence and completion, treatment success, and satisfaction with treatment (Mericle et al., 2018).

The issue of creating a safe environment for members of the LGBTQ+ community with SUDs has also been illuminated as an important challenge for this demographic. This challenge grounds in the deficits that characterise group therapy, such as the fear of self-disclosure and rejection, lack of privacy and security, and the incapacity of group members to contribute to the group due to their withdrawn nature and low self-esteem (Ajufo, 2008; Cochran et al., 2007; Schechtman and Kiezel, 2016).

Research is consistent that adequate counsellor training and investments to structure the physical setting to communicate inclusivity can be used to address this particular challenge and ensure that more members of the LGBTQ+ community with SUDs participate in therapy (Cooper et al., 2017; Mericle et al., 2018). Moreover, as suggested by Mericle et al. (2018) and Schechtman and Kiezel (2016), clinicians can address this challenge by individualising treatment planning with the view to ensuring that the particular needs of LGBTQ+ clients with SUDs are successfully met. Such an orientation, however, may be difficult to operationalise and implement in a group therapy environment, and hence the need for clinicians to formulate groups based on the similarity of needs faced by the LGBTQ+ clients.

The final issue relates to getting the right number of sexual minority clients to participate in group therapy at any one time. As noted by researchers, this challenge makes it difficult for clinicians to provide specialised groups (Mericle et al., 2018), adopt culturally tailored interventions (Hughes & Eliason, 2002), and address the unique needs affecting this demographic (Lytle et al., 2014).

However, various recommendations have been offered to address this challenge, with some researchers underscoring the need to include both LGBTQ+ clients and heterosexual members in the same treatment group to reduce segregation and marginalisation (Stevens, 2012). Research also underscores the effectiveness of creating distinct groups that are based on clients' sexual orientation and gender identity to develop and reinforce the capacity not only to address risk factors of substance abuse based on distinct clusters of substance abuse behaviours but also to prescribe individualised treatment protocols based on unique characteristics of a specific therapy group (Bockting et al., 2006)

 

Chapter 5: Conclusion, Recommendations, and Future Areas of Research

This research study aimed to explore and identify the challenges the LGBTQ+ community encounter during group therapeutic interventions for SUDs. Group therapy offers members of the LGBTQ+ community a viable alternative for addressing SUDs and other impairments, in large part due to its capacity to provide rich opportunities to learn from other members with similar challenges, to receive meaningful feedback, and also to enjoy social and emotional support.

However, members of the LGBTQ+ community often experience challenges related to fears and anxieties that characterise the lives and treatment experiences of members of the LGBTQ+ community, the social and cultural contexts that anchor group therapy, the high prevalence of mental health problems and substance use severity among this population group, and a lack of adequate counsellor education and training in LGBTQ+ issues. Other challenges include the fluidity and non-binary nature of the sexual orientation and identities of LGBTQ+ clients, a failure by clinicians to create a safe environment for members of the LGBTQ+ community to participate in group therapy, and difficulties in getting the right number of sexual minority clients to participate in group therapy at any one time.

• Following these elaborations, several recommendations are proposed. The first recommendation is to ensure the provision of LGBTQ+-affirmative services. This can be done by, for example, creating an inclusive treatment environment, such as LGBTQ+-oriented treatment modalities like GS-CBT in group therapy environments.
• Secondly, clinicians should integrate substance abuse treatment with mental healthcare services in group therapy to address the many co-occurring mental health challenges that characterise LGBTQ+ clients.
• Thirdly, clinicians should receive adequate education and training on how to provide LGBTQ+-affirmative services and culturally adapted interventions such as GS-CBT in a group environment. Training on cultural competence would allow clinicians to address the needs of clients with different sexual orientations and gender identities.
• Finally, clinicians require creating a secure environment that also affords clients the privacy that they need for self-disclosure.

Two main proposals for future areas of research are made. First, future research should aim to examine how the non-binary nature of the sexual orientation and gender identity of some LGBTQ+ clients may influence treatment outcomes in group therapy. Second, there exists a need to explore whether LGBTQ+-specific treatment protocols can be applied in group environments with heterosexual clients and the impact of such an application.

 

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