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.

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.

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.

Initial Contact With Clients

Receptionists and assessment staff members should be aware of the program’s advertisements, public service announcements, or other activities so that they can respond knowledgeably and professionally to telephone inquiries. Research participants report that any initial resistance or confusion by the treatment facility leads to a breakdown in the initiation process. A friendly, empathetic, and understanding atmosphere should begin with the first contact and continue throughout treatment and followup.

If possible, the BMDC component should be assigned its own phone number, and a receptionist answering the phone should respond with that component’s name. If an answering system is used, the message can distinguish the BMDC program from others offered by the agency. Callers may raise questions about BMDC’s specific components and its track record or demonstrated effectiveness to determine whether it can help them. They may be concerned about whether they will be treated in groups with people who use other drugs (e.g., cocaine) or alcohol. They may be relieved that BMDC specializes in treating “people like them” and pleased to know the program is based on scientific research. Callers need to know that the program is sensitive to their needs, that staff will take them seriously, and that the services are delivered professionally. MTP participants were apprehensive initially and wanted a counselor trained to treat marijuana problems.

Training Staff

The treatment effort begins with the assessment session. Assessment staff should be

• Knowledgeable about marijuana use and its consequences

• Trained to diagnose marijuana dependence and abuse and to document use patterns and related problems

• Sensitive to the ambivalence toward treatment of people who use marijuana

• Trained in MET and how to use the assessment information.

Counselors should be competent in MET, CBT, and case management. Staff members should be selected on the basis of their empathy, warmth, and genuineness, as well as their cognitive style, which should include receptiveness to learning new approaches and willingness to consider that several ways exist to solve a problem. A counselor who lacks empathy and openness to the client’s perspective will be ineffective.

Training should include at least three elements:

1. Training sessions covering principles and practices of MET. This manual should be distributed in advance of training sessions to introduce basic material and create interest in the BMDC method. The training should include an introduction to the stages of change and the general principles and strategies of MET. A section of the training should be dedicated to the unique characteristics of the marijuana-dependent treatment population. Incompatible treatment methods need to be identified and discussed. Training can be done individually or in a group format.

2. Regular supervision. Counselors in training should be required to provide videotapes of themselves using MET, CBT, and case management for trainers and fellow trainees to critique. Many counselors are reluctant to allow themselves to be videotaped. To allay their concern, counselors first should view tapes of their supervisors conducting sessions and rate these tapes. Next, role plays with other counselors can be taped. Finally, counselor–client sessions can be taped and discussed. This gradual exposure appears to relieve anxiety related to taping.

Trainers should continue to shape performance until counselors demonstrate competence. Training in CBT and case management may take less time and effort than MET training because experienced substance abuse treatment practitioners tend to have been exposed to the two former treatment procedures. Resistance to MET and a manual-guided approach should be expected; opposition sometimes derives from misunderstanding. Many counselors believe that motivational interviewing means cheerleading. Also, many professionals in the addiction field are committed to their approaches to treatment (traditional approaches often are confrontational and directive) and may be reluctant to try a new method, especially if the underlying philosophy differs from one they are most familiar with.

3. Ensuring the BMDC approach. Regular supervision is needed to ensure competence. Case conferences and periodic session taping are needed to make certain that counselors follow the BMDC approach correctly. Chart reviews may be conducted systematically as a means of monitoring implementation. In MTP, monthly supervision was sufficient to maintain fidelity to the model. Supervision can be done in several ways. The counselor can provide a videotape of a session to the supervisor, who rates the treatment elements employed (MET, CBT, or case management) using a session rating form similar to the one in appendix A. This form provides the counselor with helpful feedback. It also can be useful to have counselors rate other counselors’ tapes, comparing their evaluations with those of their supervisor and discussing how to implement the model in various situations.

When rating and scoring taped sessions, counselors’ criticism should be gentle, emphasizing what was done right and building on strengths of the counselor being rated. Two videotapes were created to accompany this treatment manual. The first tape highlights the problem of marijuana dependence in the United States, discusses epidemiology, and contains interviews with key figures who have studied this problem. The second tape uses three hypothetical clients to provide practical information and demonstrations of BMDC at work. These tapes are recommended for counselors, supervisors, and agency administrators who want to use BMDC to treat people who smoke marijuana. To obtain more information about the BMDC training tapes, please contact Karen Steinberg, Ph.D., Department of Psychiatry, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT 06030-1410; 860- 79-3712.

Administration

From an administrative point of view, a sustainable BMDC program requires at least three counselors to prevent disruption of service delivery. Administrators should provide uninterrupted delivery of BMDC, which may mean training backup personnel in case of resignation, vacation, termination, or prolonged illness.

Sustainability also raises funding issues. Many agencies can use public funding sources to provide BMDC, such as block grants or general revenue funds. Any funding source for outpatient treatment probably can be used for BMDC. Moreover, many persons with marijuana dependence may be willing to pay for treatment out of pocket, especially when weighing the savings that result from stopping their marijuana use.

Another important implementation decision concerns the identity of the program. One option is to offer BMDC as one of many services integrated into a variety of treatments that an agency may offer. However, use of BMDC may increase when it is promoted as a program with its own identity, distinct from other treatment programs, perhaps with its own location, for at least two reasons. First, knowing that a special program exists for people who use marijuana is reassuring to potential clients. Second, confidentiality often is important. Some clients are more comfortable when the program is not identified specifically as a drug treatment center.

Creating a distinct program identity also has the advantage of minimizing staff resistance. It makes it possible to select only those counselors among staff for whom this approach has an appeal or to recruit counselors who are eager to join a new, exciting, cutting-edge program.