Aftercare Policies and Procedures

Aftercare is critical for any client being discharged from a substance abuse treatment program. Establishing the following policies and procedures will help ensure adequate post-discharge care for LGBT clients.

• Identify a contact person who is an openly LGBT staff member and who will be available to LGBT graduates if they face any recovery crisis after discharge.

• Establish training procedures in which all staff members are educated about issues LGBT individuals face upon discharge. Include workshops on relapse triggers specific to LGBT individuals in recovery.

• Ensure that discharge procedures help LGBT clients develop relapse prevention strategies for high-risk situations specific to them, such as reentering bar-oriented LGBT communities, coming out to their family of origin if they decide to do so, and dealing with homophobia, discrimination, and/or gay bashing.

• Ensure that discharge procedures include providing each LGBT client with a comprehensive list of LGBT-specific and/or LGBT-sensitive community resources and services, along with clear information about how to access these services.

Training and Education

As lesbian, gay, bisexual, and transgender (LGBT) individuals become more accepted and visible, they are seeking culturally sensitive, if not culturally specific, substance abuse treatment services. To help develop LGBT-sensitive care, providers can find competent care standards in the Center for Substance Abuse Treatment (CSAT) Technical Assistance Publication #21, Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice (1998b), and in the 1999 CSAT publication, Cultural Issues in Substance Abuse Treatment (1999b).

Training and education programs seek to improve understanding of the complex issues with which LGBT individuals struggle. To support the diverse LGBT population, educators, administrators, substance abuse treatment professionals, nurses, clinical supervisors, students, other professionals, and local communities all should be considered in the educational process.

A holistic approach to treatment is most likely to enable LGBT individuals to effect real change in their lives. Therefore, a multifaceted approach is suggested to improve the present situation, wherein treatment professionals and society have incomplete and inadequate information that often leads to a misunderstanding of LGBT issues and even a denial that LGBT individuals have special needs.

Substance abuse treatment professional training programs, faculties, institutions, administrators, health care “gatekeepers,” and community settings all require education and training. Targeting certain community dimensions is crucial to the success of a training or education program.

The following information could be included in a training or educational program.

Barriers to Treatment Access

Barriers to adequate substance abuse treatment for the LGBT community have been touched on in other chapters. In addition to the reasons any prospective client might have, the reasons LGBT individuals may avoid or delay seeking professional care include fear of disclosing their sexual orientation or gender and previous experiences with health care providers who attempted to convert them to heterosexuality, who attributed their substance abuse to their sexual or gender orientation, or who were otherwise judgmental and unsupportive.

Engagement and Retention

LGBT individuals may leave treatment prematurely for the same reasons as non-LGBT clients. But LGBT clients may have additional treatment difficulties if a facility lacks culturally specific services, if it lacks self-identified LGBT practitioners or sensitive counselors, if it has few contacts with the non-substance-abusing LGBT community, or if it fails to engage non-LGBT clients in exploring their prejudices or honoring diversity.

Relapse Prevention

While many programs address relapse prevention, LGBT clients may need additional help to find LGBT-specific resources, which may be scarce outside metropolitan areas. LGBT clients may have difficulty addressing problems with their sexual or gender orientation and may have difficulty with their families of origin, complications related to other addictive behaviors, and issues related to HIV/AIDS, such as grief and loss or medication compliance. Additional counseling referrals for these issues may be required.

Lacking specific and often essential information about the special problems of LGBT clients, professionals may attribute treatment failures to the clientele rather than to the insufficient training and education about LGBT issues that resulted in inappropriate treatment by the providers.

Strategies

An integrated training and education system addresses both content and process and uses experiential as well as didactic methods. It addresses six components:

• Trainees

• Faculty or trainers

• Program

• Institutional systems

• Professional peers

• Community.

Improving present treatment conditions for LGBT clients requires a comprehensive training approach that includes the six components. Long-term results are more likely with an approach that addresses these components. The process of implementing training and program change begins with a commitment to action by decision makers. The intention of training and continuing education is to increase the sensitivity and competence of the staff and, ultimately, to improve treatment outcomes. The learning objectives are to:

• Raise awareness of culturally specific issues and the sensitivity of all involved persons

• Identify and become fluent in LGBT appropriate and sensitive language

• Implement explicit nondiscrimination policies and procedures

• Develop skills to support LGBT individuals in substance abuse treatment services

• Compile a resource list of local, regional, and national support services.

Training should at least result in LGBT-tolerant treatment. Beyond that, however, training can help practitioners help their clients be more comfortable with themselves and their lives. In gender-specific treatment, services should include attention to LGBT issues. Assuming that the separation of men and women will enable practitioners to address LGBT needs is false. Treatment that is LGBT antagonistic should be changed but with the realization that great effort and patience will be required.

Program content should be specifically shaped by the target audience’s understanding of LGBT issues.

Component 1: Trainees

Trainees include behavioral health professionals; licensed and/or certified counselors; students enrolled in counseling education programs; conference and seminar attendees; staff at in-service training; primary, secondary, and tertiary caregivers; staff of health maintenance organizations (HMOs); case managers; primary care physicians; probation officers; and so forth.

Action Steps

• Recruit and select LGBT individuals of diverse ethnicity for counselor education programs and work settings.

• Develop students’ awareness of the need to understand LGBT issues.

• Provide counseling and other appropriate measures for students struggling with their own homophobia or negative attitudes toward LGBT persons.

Component 2: Faculty or Trainers

The faculty or trainers are members of counseling and social work departments responsible for curriculum development, course delivery, and practicum supervision. They prepare professionals and support staff for the behavioral health professions and provide training at seminars and workshops as well.

Action Steps

• Develop faculty and agency awareness of the need for improved understanding of LGBT issues.

• Attain and maintain a diverse faculty with theoretical and practical expertise in LGBT treatment and care.

• Recruit LGBT faculty and staff who can provide instruction, supervision, and services.

• Encourage and support all faculty and staff to continue their education in LGBT treatment areas.

• Support faculty and staff research in LGBT treatment.

• Assign decisionmaking roles to faculty who are knowledgeable about LGBT issues.

Component 3: Program

Managed care organizations, consumers, and quality improvement measures demand that health care be evidence based. Therefore, any training or educational program needs to be based on current research findings. Training elements should include assessment of need, attitudinal behavior changes, skills training, methods development, training and education program evaluation, and actions to implement change.

Action Steps

• Conduct an assessment of the current level of tolerance, sensitivity, and affirmation of the treatment agency staff.

• Gather and review pertinent research and theoretical material.

• Recruit skilled professionals as trainers and educators, and/or develop an interagency training alliance.

• Develop program materials and methods that are site- or client-specific.

• Determine methods for evaluating the effectiveness of the training or educational program.

Attitudinal Behavior Changes and Skills Training

• Utilize experiential exercises that uncover hidden biases in a safe manner (e.g., roleplay a 21-year-old coming out to his parent or ask participants to introduce themselves as lesbian, gay, bisexual, or transgender individuals).

• Encourage exploration of stereotypes and language, values, and behavior differences.

• Use various methods incorporating adult learning styles to increase skill development.

• Use additional resources available on videos and films.

Methods Development

• Make LGBT sensitivity and competency training a priority in the basic curriculum or in the inservice training schedule—an important first step in implementing this type of program.

• Redesign existing programs to include LGBT-related competencies. Use a team approach involving academic and clinical staff and, if possible, a team member from the LGBT community at large.

• Develop courses awarding continuing education units (for academic and/or professional credit) for professionals and support staff.

Evaluation

• Give pretests and posttests to evaluate training.

• If possible, make videotapes or audiotapes of clinical sessions before and after training to ascertain whether there have been changes in the ability to treat LGBT clients.

• Collect client satisfaction and followup data from LGBT clients treated at the same site over time.

• Conduct quality improvement studies focusing on the effects of LGBT sensitivity and competency training.

Component 4: Institutional Systems

For the purpose of this volume, the phrase “institutional or agency systems” refers to the individuals who serve as gatekeepers: administrators of organizations, departments, and schools who are responsible for the delivery of programs and services; boards of directors; and other staff.

Action Steps

• Gain administrative awareness of the need for improved understanding of LGBT issues.

• Create an administrative environment supporting LGBT care, treatment, and confidentiality.

• Require LGBT competency and sensitivity at all levels, including policy development.

• Institutionalize a policy for ongoing recruitment and selection of LGBT administrative, professional, and support staff.

• Encourage and support the use of LGBT staff and faculty to provide instruction and supervision.

• Institute administrative and clinical policies to endorse LGBT sensitivity and competency training, LGBT treatment, and unbiased care.

• Allocate curriculums, time, and resources for training.

Component 5: Professional Peers

Effective techniques for training and skills development and “what works” often are the subject of consultations among professionals. This important dimension of the training process plays a significant role in introducing important ideas to newcomers and improving practice by long-term practitioners as well.

Action Steps

• Increase professional peers’ awareness of the need for improved understanding of LGBT issues.

• Articulate the need for implementing programs at all levels of practice in professional associations.

• Convene conferences about LGBT treatment.

• Involve LGBT professionals in policymaking.

Component 6: Community

The family, neighborhood, town, city, State, and region in which LGBT clients are treated is their “home.” The response of the community to LGBT clients is a crucial factor in their care and treatment.

Action Steps

• Provide counseling services to the families of LGBT clients at all socioeconomic levels.

• Provide information on treatment and the special needs of LGBT clients to relevant parties in the community: government officials, police, and all criminal justice professionals.

• Create task forces to work directly with LGBT interest groups.