Out On The Couch
*Content warning: eating disorders, substance use disorders in LGBTQIA+ youth
LGBTQIA+ youth are more susceptible to developing a substance use disorder than people not in this group (Garcia et al., 2019). Affirming therapists must be cognizant that LGBTQIA+ clients are more likely to make impulsive decisions and have a high rate of dysphoria around body image (Garcia et al., 2019). This complicated symptom presentation can be challenging in substance use disorder treatment, as lower self-esteem increases the client’s risk of impulsive behavior.
LGBTQIA+ youth are at a much higher risk of developing a substance use disorder than the heterosexual population (Fish et al., 2021, Eisenberg et al., 2022). It is easy to understand the susceptibility of LGBTQIA+ youth to substance use from a systemic perspective: navigating heteronormative social standards, stigmatization, family and peer rejection, bullying, discrimination, and victimization are all factors that may lead someone to cope by using substances (Fish et al., 2021). This article aims to help clinicians balance the need for effective impulse control interventions with affirmative interventions to empower clients to feel comfortable with who they are. This article will develop understanding around this presentation through the use of a case study and review of current literature.
Substance use and Impulse Control
Treatment interventions must focus on reducing client impulsivity to mitigate risky behaviors. Disparities with all gender minorities in tobacco, alcohol, and marijuana use are present at age 12 and persist into adulthood (Fish et al., 2021). For this reason, it is vital to increase early screening and intervention for this at-risk group. In addition, LGBTQIA+ youth with body dysmorphia are at a higher risk of engaging in impulsive actions due to lower self-esteem and a desire to cope or fit in with their peers (Garcia et al., 2019, Watson et al., 2020). It is important to understand how this is seen in a real example.
Case Example with LGBTQIA+ Youth
I worked with a 17-year-old cisgender female client in a residential setting. The client utilizes she/her pronouns. This client had a significant history of victimization and family rejection due to her sexual orientation. With this history in mind, the client spoke at length in therapy sessions about how she didn’t care about what happened to her because “no one seemed to care.” When a client is facing discrimination and ostracization because of their sexual orientation, it is common for them to feel like their actions do not matter (Eisenberg et al., 2022).
In our work together, the client utilized aggressive verbal communication and explicitly stated that she didn’t care about her risky behaviors, such as being out late and using alcohol and marijuana. The client would engage in binge drinking and reported blacking out and waking up in an unknown location several nights per week. This client shared that the only time she felt comfortable was using substances because she didn’t have to worry about not being accepted. This is also a common response to experiencing trauma (Eisenberg et al., 2019). Many teenagers may receive substances from their friends, which creates a level of social acceptability around this behavior. Social acceptance of substance use normalizes the behavior, creating a situation where teens are more likely to use substances.
In working therapeutically with this client, I found it helpful to utilize a Emotion-Focused Therapy approach. This set of interventions is helpful to understand and name emotions. I additionally provided unconditional positive regard, and provided psychoeducation about distorted thinking. Interventions from Acceptance and Commitment Therapy proved effective in helping the client understand herself. She was able to commit to her goals of improving her communication skills and identifying her emotions.
I helped the client understand the influences of systemic oppression and discrimination as an LGBTQIA+ person, as well as the impact of family rejection. To do this, I focused heavily on building rapport by utilizing the Gestalt approach of calling attention to the client’s body language to show that I was in the room with the client and make her feel seen. This approach is theorized to be effective LGBTQIA+ clients because Gestalt psychology has an intense focus on the present and connecting the body with thoughts and emotions in an affirming way.
By providing an empathetic space for her to feel heard, the client began to show improvement in caring about the impact of her behaviors. The client showed consistent improvement as she became more engaged with treatment. This led to an improvement in her self-esteem and decreased her impulsivity.
Systemic Considerations and Progress of Substance with LGBTQIA+ Youth
It is well known that people who identify as part of the LGBTQIA+ community may experience victimization, bullying, ostracization, and social isolation specific to their identities. These factors put clients at greater risk of using substances to cope with added stressors(Chien et al., 2021, Fish et al., 2021).
This is a systemic problem and needs a systemic solution. One study examined state policy interventions and discovered that 24 states with more progressive policies supporting the LGBTQIA+ community displayed lower rates of binge drinking (Chien et al., 2021). These state policies focused on reducing stigma, discrimination, and providing more protections, which resulted in lower rates of binge drinking among LGBTQIA+ people (Chien et al., 2021). This demonstrates that advocating for progressive policies can help improve discrimination and reduce substance use among LGBTQIA+ people.
Studies have examined community resources and their impact on substance use in LGBTQIA+ youth. A 2019 study tested the hypothesis that LGBTQIA+ high school students in neighborhoods with supportive community resources would have less substance use than those who were in less accepting neighborhoods (Eisenberg et al., 2019). Out of the 2454 youth surveyed, those in more affirming neighborhoods and school districts were less likely to use substances than those in less accepting areas (Eisenberg et al., 2019). These studies highlight the need for more interventions at the community and system levels to improve substance use risk in LGBTQIA+ youth.
What can you do as a Clinician working with LGBTQIA+ Youth?
As mental health providers we are in a unique position to help with multiple systemic levels of interventions. Working with individual clients is a tertiary level of intervention which is effective with that individual. A primary level intervention would impact a wide range of people as a preventative measure. In addition to individual work, affirmative therapists can advocate with local legislators, policy makers and governing bodies. These efforts will continue to adopt more progressive policies to protect LGBTQIA+ youth.
Conclusions on Substance Use with LGBTQIA+ Youth
Overall, there is a high risk for substance use in LGBTQIA+ youth compared to their heterosexual peers. As a therapist, it is vital to highlight your client’s needs for affirmation, a safe space, and empowerment in therapy. Additionally, affirmative clinicians should be consistently intervening systemically through advocacy.
Affirmative clinicians often hear similar stories of victimization, ostracization, or isolation. There are many ways to utilize the knowledge we have to decrease substance use in LGBTQIA+ youth. A few examples include working with individual clients and advocating for more progressive policies. Providing services with an empathic, affirmative stance can demonstrate to clients that they are seen, heard, and understood.
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Chien, Y.-S., Schwartz, G., Huang, L., & Kawachi, I. (2021). State LGBTQ policies and binge drinking among sexual minority youth in the US: A Multilevel Analysis. Social Psychiatry and Psychiatric Epidemiology, 57(1), 183–194. https://doi.org/10.1007/s00127-021-02119-4
Eisenberg, M. E., Erickson, D. J., Gower, A. L., Kne, L., Watson, R. J., Corliss, H. L., & Saewyc, E. M. (2019). Supportive community resources are associated with lower risk of substance use among lesbian, gay, bisexual, and questioning adolescents in Minnesota. Journal of Youth and Adolescence, 49(4), 836–848. https://doi.org/10.1007/s10964-019-01100-4
Eisenberg, M. E., Gower, A., Watson, R., Rider, N., Thomas, D. S., & Russell, S. (2022). 188. substance use behaviors among LGBTQ youth of color: Applying a novel method in two large samples to identify intersecting social positions bearing the greatest burden. Journal of Adolescent Health, 70(4). https://doi.org/10.1016/j.jadohealth.2022.01.105
Fish, J. N., Bishop, M. D., & Russell, S. T. (2021). Developmental differences in sexual orientation and gender identity–related substance use disparities: Findings from population-based data. Journal of Adolescent Health, 68(6), 1162–1169. https://doi.org/10.1016/j.jadohealth.2020.10.023
Garcia, J., Vargas, N., Clark, J. L., Magaña Álvarez, M., Nelons, D. A., & Parker, R. G. (2019). Social isolation and connectedness as determinants of well-being: Global evidence mapping focused on LGBTQ youth. Global Public Health, 15(4), 497–519. https://doi.org/10.1080/17441692.2019.1682028
Watson, R. J., Fish, J. N., McKay, T., Allen, S. H., Eaton, L., & Puhl, R. M. (2020). Substance use among a national sample of sexual and Gender Minority Adolescents: Intersections of sex assigned at birth and Gender Identity. LGBT Health, 7(1), 37–46. https://doi.org/10.1089/lgbt.2019.0066