The Role of the Mental Health Professional

The American Counseling Association Code of Ethics outlines ethical guidelines and responsibilities as they relate to the multicultural competency of mental health professionals (American Counseling Association, 2014). Within these guidelines, multicultural competence includes the understanding of the intersection of gender, ethnicity, ability, sexual-affectional orientation, and gender identity and the influence these all have on the focus of counseling (Reference Suprina, Matthews, Kakkar, Harrell, Brace, Sadler-Gerhardt and KocetSuprina et al., 2019). For this understandingto occur, mental health professionals must have achieved a level of self-awareness that protects clients from bias, discrimination, microaggressions, and other barriers to the helping process that may manifest from the professional (Reference Suprina, Matthews, Kakkar, Harrell, Brace, Sadler-Gerhardt and KocetSuprina et al., 2019). Discrimination in health care is a common barrier to treatment access for sexually diverse people and can often be a catalyst for a lack of disclosure of sexual-affectional or genderidentity needs in the counseling process (Reference Chaney, Dubaybo and ChangChaney et al., 2020).

Mental health professionals must honor clients’ right to self-determination and to express who they are. Within the assessment process, respect involves becoming aware of and working through and around preconceived biases and socialized perspectives regarding sex and gender, especially those that are unconscious and automatic (Reference Lenz, Ault, Balkin, Barrio Minton, Erford, Hays, Kim and LiLenz et al., 2022). A truly inclusive affirming diagnostic assessment or treatment planning session is one that acknowledges and incorporates a multicultural approach to understanding diversity as it relates to gender diversity. This acknowledgment recognizes that gender identity and sexual-affectional identity can be experienced in different ways based on the client’s geographic location, culture, representation, and other characteristics (Reference Kress, Dixon, Shannonhouse, Hays and ErfordKress et al., 2018).

When engaging in assessment and diagnosis, mental health professionals should affirm the broad range of expressions or identities that the client may bring to the diagnostic assessment or treatment planning process (Reference Goodrich, Farmer, Watson, Davis, Luke, Dispenza, Akers and GriffithGoodrich et al., 2017; Reference Moe, Finnerty, Sparkman and YatesMoe et al., 2015). Practitioners should also understand the barriers and limitations of standardized assessment instruments, how assessment and diagnosis have historically been used to oppress and overpathologize LGBTQ+ clients, and how stigma, stereotypes, prejudice, discrimination, and other social injustices influence the process and outcomes of assessment. With the ongoing development and revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), mental health professionals who provide affirming counseling to LGBTQ+ clients recognize the negative impact of conflating nonheterosexual and noncisgender identities and modes of lived experience with social deviance or mental disorder (American Psychiatric Association, 2017; Reference Chang, Singh and DickeyChang et al., 2018). For example, the concept of “gender dysphoria” remains as a diagnosable mental disorder. This is problematic as it continues to locate the source of distress within individual experience and not in oppressive social mores, customs, laws, and attitudes that compel adherence to a deterministic gender/sex binary across the lifespan (Reference Sumerau and MathersSumerau & Mathers, 2019).

Within this understanding, mental health professionals aim to utilize assessment instruments and diagnostic tools that provide nondiscriminatory results and are evidence based to support an affirmative approach to treatment planning with LGBTQ+ clients (Reference Goodrich, Farmer, Watson, Davis, Luke, Dispenza, Akers and GriffithGoodrich et al., 2017; Reference Moe, Finnerty, Sparkman and YatesMoe et al., 2015). Counselors and other providers should integrate intersectional identities and experiences such as age, religion, and culture along with sexual orientation and gender identities (Reference Astramovich and ScottAstramovich & Scott, 2020). Incorporating a developmental lens can help depathologize or normalize clients’ experiences as well as help avoid stereotyping LGBTQ+ clients with a uniform understanding of their specific needs. For example, our treatment planning session may change to provide affirming techniques with a client who is just coming into awareness of their gender identity or sexual-affectional identity when compared to a client who has developed through this stage several years ago. As mental health professionals, understanding that our role during the assessment, diagnosis, and treatment planning process is multifaceted requires us to view our clients as existing within a social system that will impact our service delivery. Within this chapter, we will explore issues with standardized and biopsychosocial (BPS) assessment and how to assess for and identify whether sexual-affectional and gender identity should be the focus of our clinical work.

Critiquing Standardized Assessments

Counselors employ standardized assessments for diagnosis, treatment planning, monitoring progress, screening, and personality testing. The process of creating and using a standardized assessment remains primarily based within a positivist worldview in which assessed traits are viewed as having an objective existence outside of human experience (Reference Lombardi, Compton, Meadow and SchiltLombardi, 2018). Historically, treating social concepts such as gender identity as objectively (i.e., naturally) occurring phenomena has facilitated the oppression and marginalization of people whose lived experiences do not easily conform to outcomes determined by assessment. In addition, uncritically applying positivist and universalist thinking obscures historical and current oppression, social power dynamics, and the social positions of both the user and the subject of assessment. Postpositivist, critical realist, and constructivist paradigms challenge the premises of universalist and positivistic philosophies. Through these critical lenses, assessments and knowledge production are viewed as inherently infused with the subjectivity of human social experiences, including the development of theoretical constructs and the standardized assessment tools to measure them. The construct that is measured is dependent on the power, privilege, roles, and identities of those who produced it (Reference Erby and WhiteErby & White, 2022), resulting in the perpetuation of oppressive beliefs and behaviors rooted in Eurocentric cisheteronormative societies. LGBTQ+ affirmative counselors and other providers are expected to understand the historical and social factors that have influenced the practice of assessment, to understand their own biases related to social constructs such as gender, and to reduce and eliminate the influence of bias on the assessment process (ALGBTIC LGBQQIA Competencies Task Force, 2013).

Reflexivity in developing and administering standardized psychological assessment tools is imperative in decolonizing counseling practice with LGBTQ+ people (Reference Kress, Dixon, Shannonhouse, Hays and ErfordKress et al., 2018). The quantification of aspects of sexual and gender identity diversity, such as gender assigned at birth, gender roles, gender identity, sexual orientation, and gender expression, remains primarily based on the reductionistic tradition associated with Western(ized), empirical modes of knowledge production (Reference Sumerau and MathersSumerau & Mathers, 2019). Rather than focusing on inherent and enduring categorization, critical assessment practices center questions of power, privilege, and individual and local experiences and how these interact dynamically to produce identity, relationships, and values (Reference Lombardi, Compton, Meadow and SchiltLombardi, 2018; Reference Sumerau and MathersSumerau & Mathers, 2019). In this sense, the goal of standardized psychological assessment with LGBTQ+ clients is to document how oppressive or dominant beliefs may be affecting clients’ power and well-being rather than discovering objective facts about their lives (Reference Moe, Finnerty, Sparkman and YatesMoe et al., 2015).

Critical consciousness is also essential for deconstructing the purpose, use, and validity of diagnostic categories. Still considered to be an essential element in mental health care provision, uncritical application of diagnoses can be used to recreate systems of cisheteronormative domination and control (Reference Moe, Finnerty, Sparkman and YatesMoe et al., 2015). Members of LGBTQ+ populations continue to demonstrate higher rates of mental disorder and substance use disorder because of their developing within primarily oppressive social contexts. Access to housing, social support, education, and other social determinants of health are all influenced by discrimination and oppression. Counselors, therefore, should be aware of their own cultural biases and values and work to avoid imposing them on clients via diagnosing and rather conduct an ecological assessment, identifying cultural and environmental factors that may be contributing to the client’s symptoms (Reference Kress, Dixon, Shannonhouse, Hays and ErfordKress et al., 2018).

Along with power and privilege, the assumption of universality should also be critiqued and deconstructed. Universality entails believing that theories, concepts, and constructs are valid throughout diverse cultures and groups, no matter where and by whom they were developed. Scholars have long asserted that universality in scientific thinking is saturated by Western(ized) beliefs that are marginalizing of alternative ways of knowing (Reference Kress, Dixon, Shannonhouse, Hays and ErfordKress et al., 2018). Within the literature base, empirical research continues to primarily sample White heterosexual and cisgender people (Reference Moradi, Tebbe, Brewster, Budge, Lenzen, Ege, Schuch, Arango, Angelone, Mender, Hiner, Huscher, Painter and FloresMoradi et al., 2016). Within the available literature focusing on LGBTQ+ samples, White and cisgender male people continue to make up most research participants (Reference Moradi, Tebbe, Brewster, Budge, Lenzen, Ege, Schuch, Arango, Angelone, Mender, Hiner, Huscher, Painter and FloresMoradi et al., 2016). Counselors should critically evaluate measures for heterosexist and cisgender-normative assumptions, as well as other culturally rooted values such as the Eurocentric focus on the individual over the group or family (Reference Goodrich, Farmer, Watson, Davis, Luke, Dispenza, Akers and GriffithGoodrich et al., 2017). The standards for multicultural assessment outlined by the Association for Assessment and Research in Counseling provide important considerations for adapting and using assessments, including with clients not represented by the norming sample in instrument development (Reference Lenz, Ault, Balkin, Barrio Minton, Erford, Hays, Kim and LiLenz et al., 2022). Counselors should strive for complex assessments of variables instead of monolithic ones to decrease oversimplification. In addition, counselors should address norms and issues of test construction to account for subjectivity and cultural influences in construct development, and they should also consider the appropriateness of such constructs for diverse populations to ensure the validity of the concept for the client. The assessment process should be clear and transparent to all clients, with the client serving as the ultimate authority on whether a construct of theory is applicable to their presenting concerns. Client personal statements, artistic and musical expression, imagery, and the input of trusted family members and community members are some of the alternative or qualitative assessment techniques that could be considered to complement or replace traditional sources of assessment data.

Biopsychosocial Assessment

Counselors working with individuals identifying as lesbian, gay, bisexual, transgender, queer, or other diverse gender and sexual-affectional identities have a responsibility to provide affirming and critical counseling services via a multidimensional approach across gender development and human sexuality (Reference Moe, Finnerty, Sparkman and YatesMoe et al., 2015). Since counselors often provide their first mode of contact through a BPS assessment, also called an “intake session,” the nature of the subsequent counseling relationship depends on the rapport established and information gathered in that session (Reference Meyer and MelchertMeyer & Melchert, 2011; Reference Skaistis, Cook, Nair and BordenSkaistis et al., 2018). The BPS assessment is often the only formal assessment process used to synthesize information on presenting concerns with data about the client’s life, identities, and personal ecology. Though considered a more client-driven mode of assessment, the BPS assessment can still be overdetermined by biases that mental health providers hold about LGBTQ+ individuals.

The BPS assessment was created in 1977 by George Engel as a means of holistically gathering information related to sociocultural and psychological factors in addition to traditional biomedical information (Reference Meyer and MelchertMeyer & Melchert, 2011). Reference Skaistis, Cook, Nair and BordenSkaistis et al. (2018) examined the types of information asked during a BPS assessment and noted that how clinicians collect this information may depend on the setting. For instance, some practices or agencies require clients to complete forms ahead of their appointment, whereas other practices may have clients and clinicians collaboratively complete such paperwork. For clients identifying as gender or sexual-affectional minorities, this paperwork influences the course of the counseling relationship. Reference Skaistis, Cook, Nair and BordenSkaistis et al. (2018) reported the dangers of asking clients to identify themselves on a binary for sex and gender identification, as this type of designation can be invalidating. Additionally, attitudes related to monogamy, the relative stability or fluidity of identity, preferred modes of gender expression that conform to binary thinking, and other attitudes can become salient as therapists inquire in more detail about clients’ personal lives (Reference Moe, Finnerty, Sparkman and YatesMoe et al., 2015). Expecting clients to prioritize their LGBTQ+ identities and related developmental issues represents another bias, whereby well-meaning counselors may be recreating oppressive and othering dynamics (Reference Moe, Perera and RodgersMoe et al., 2023). As with other areas of LGBTQ+ affirmative counseling, basing questions on identity and relationships on intersectionality helps counteract biases that seek to prioritize single, inherently stable identities over multifaceted and dynamic ones.

Clinicians face various challenges when gathering information during the BPS assessment and sometimes only view clients within a specific identity or independent of oppressive social norms. Reference Moe, Finnerty, Sparkman and YatesMoe et al. (2015) described areas in which clinicians prioritize information-seeking and screening, such as for substance use, suicidality or safety risks, and intimate partner violence. However, clients may feel hesitant to disclose particularly vulnerable information about themselves without the establishment of rapport and trust. Clinicians who ask clients to label their gender identity and/or sexual-affectional identity prior to the session often perpetuate LGBTQ+ clients’ expectations that counseling is invalidating (Reference Skaistis, Cook, Nair and BordenSkaistis et al., 2018). It is important to remember that clients hold agency in deciding when and what to disclose, as some clients may not associate their LGBTQ+ identity with part of a concern to be addressed.

Despite there being limited research on intake paperwork, some researchers offer recommendations for clinicians when completing BPS assessments (Reference Meyer and MelchertMeyer & Melchert, 2011; Reference Moe, Finnerty, Sparkman and YatesMoe et al., 2015; Reference Skaistis, Cook, Nair and BordenSkaistis et al., 2018). Researchers encourage clinicians to operate from a critical perspective in which they consistently engage in self-reflection while observing their own biases and privilege (Reference Astramovich and ScottAstramovich & Scott, 2020; Reference Moe, Finnerty, Sparkman and YatesMoe et al., 2015). For instance, clinicians can utilize self-report measures to assess their own subjectivities and biases, such as the LGBT Development of Clinical Skills Scale (Reference BidellBidell, 2017) or the Genderism and Transphobia Scale assessment (Reference Hill and WilloughbyHill & Willoughby, 2005). Additionally, clinicians’ critical examination of their own or their practice’s intake paperwork is recommended, specifically the areas where clients are prompted to identify their gender and sexual-affectional identity (Reference Skaistis, Cook, Nair and BordenSkaistis et al., 2018). While many forms include checkmark or drop-down options, some intake forms include an option labeled “Other” for clients to describe their answer; however, an alternative, more affirming approach includes giving clients an option to self-identify, whereby clients can comprehensively describe their identity (Reference Skaistis, Cook, Nair and BordenSkaistis et al., 2018). Another recommendation for revising intake paperwork includes providing a disclaimer to clients that they are only responsible for answering as much information as they feel comfortable providing in lieu of clients perceiving that they must complete every question even if they are unsure or uncomfortable (Reference Skaistis, Cook, Nair and BordenSkaistis et al., 2018). All of these recommendations reflect clinicians adopting a multidimensional, affirming, critical approach in which biases are observed and oppressive status quo procedures are challenged.

Assessing Sexual-Affectional Identity

According to the multidimensional perspective that is suggested as best practice for conceptualizing sexual orientation, there are hundreds of possible identities and positions within the LGBTQ+ community. In addition, language is always changing and evolving. So, how do we as counselors begin to accurately assess what our clients’ LGBTQ+ identities mean to them? What questions do we ask and how do we ask them? Before we ask clients about themselves, it is important that we ask ourselves about our own biases and beliefs. How are our own identities going to impact how we conceptualize sexual orientation, and what will this communicate to our clients? When constructing an assessment about sexual orientation, we first must understand how power, privilege, and the intersection of our identities converge to create our modes of lived experience and expression (Reference Moe, Finnerty, Sparkman and YatesMoe et al., 2015). When thinking about this, we should consider the importance of queer and feminist frameworks and how they can guide our work to support us in asking more inclusive questions (ALGBTIC LGBQQIA Competencies Task Force, 2013). These ideas can help us remove heteronormative, cisnormative, and Eurocentric language operating in our assessments (Reference Oberheim, Swank and DePueOberheim et al., 2017). Identity, like language, is continuously evolving throughout the lifespan, and clients should be encouraged to view their identities as dynamic and informed by social contexts and, ultimately, as a mode of self-expression. It seems pertinent not only to be aware but also to be open-minded to the new terminology that LGBTQ+ people use to express themselves.

The National Academies of Sciences, Engineering, and Medicine (2020) outline several key factors in this area, including how the question of sexuality should be asked as well as what answers should be offered to the client. The text states that terms such as “sexual orientation” can be interpreted in many ways by clients. Rather than asking the client to define their sexual orientation, asking a more open question such as “Which of the following do you consider yourself to be?” or “Which of the following best describes you?” can provide more accurate and less loaded information. Also, adding in free-text options can allow clients to describe themselves in their own words rather than choosing an arbitrary category that the clinician prescribes. As mentioned earlier, it is important to also consider the use of terminology from Indigenous cultures, such as “Two Spirit.” Considering other language that exists at the intersection of culture and queer identity can allow space for the decolonization of queer language and allow the client to describe their identities more comprehensively. The question and response options in Table 10.1 are examples of questionnaire items that could be used as a guide for sexual-affectional assessment.

Gender Identity Assessment

Understanding and assessing gender identity is a crucial aspect of providing effective counseling to transgender and gender-nonbinary (TGNB) individuals. This task requires the utilization of appropriate assessment tools that are both culturally competent and evidence based. The current guidelines for care of TGNB individuals emphasize the importance of conducting thorough psychological evaluations (Reference Coleman, Radix, Bouman, Brown, De Vries, Deutsch, Ettner, Fraser, Goodman, Green, Hancock, Johnson, Karasic, Knudson, Leibowitz, Meyer-Bahlburg, Monstrey, Motmans, Nahata and ArcelusColeman et al., 2022). During these assessments, it is crucial for counselors to create a safe and supportive environment in which TGNB individuals can openly discuss their experiences and concerns, fostering a holistic approach to their mental and emotional well-being. The World Professional Association for Transgender Health (WPATH) Standards of Care Version 8 require mental health professionals to assess both gender dysphoria and its associated distress (Reference Coleman, Radix, Bouman, Brown, De Vries, Deutsch, Ettner, Fraser, Goodman, Green, Hancock, Johnson, Karasic, Knudson, Leibowitz, Meyer-Bahlburg, Monstrey, Motmans, Nahata and ArcelusColeman et al., 2022). These guidelines stress the necessity of psychological assessment, which should encompass the influence of discrimination and bias on an individual’s psychological well-being and may entail diagnosing gender-related conditions.

To assess gender identity effectively, a counselor should begin by familiarizing themselves with the range of tools available. These tools encompass measures of gender dysphoria, gender identity, and gender expression (Reference Shulman, Holt, Hope, Mocarski, Eyer and WoodruffShulman et al., 2017). They often include self-report questionnaires and structured interviews. It is crucial to select tools that align with the specific goals of the assessment and consider the individual’s cultural background. Additionally, counselors must be aware of the limitations of each assessment tool, including potential biases or outdated terminology. For example, some tools may not adequately address nonbinary or genderqueer identities. Counselors should be prepared to use multiple tools to gain a more holistic understanding of an individual’s gender identity (Reference Shulman, Holt, Hope, Mocarski, Eyer and WoodruffShulman et al., 2017).

Along with asking clients how they self-identity, counselors can facilitate the assessment of other factors such as the degree to which an individual contemplates their gender identity, including positive and negative thoughts (Reference Bauerband and GalupoBauerband & Galupo, 2014). The degree of congruence between one’s ideal and current gender expression could also be an important focus for clinicians working with TGNB clients (Reference Shulman, Holt, Hope, Mocarski, Eyer and WoodruffShulman et al., 2017).

Gender identity is a complex and evolving aspect of a person’s life and may change over time as individuals gain a deeper understanding of themselves. Therefore, periodic reassessment is crucial to ensure that the support and interventions align with the individual’s evolving needs and goals. Qualitative methods, such as open-ended interviews, can complement quantitative assessments by allowing individuals to share their unique experiences related to their gender identity. Lastly, counselors should prioritize cultural competence and sustainability in their assessments. Understanding cultural nuances and intersections of identity is essential for providing inclusive and affirming care to TGNB individuals. This approach recognizes that gender identity is not isolated from other aspects of a person’s identity and experiences.

The Focus of Counseling: Sexual-Affectional Identity or Gender Identity

Sexual-affectional identity and gender identity are social constructs that have historically been related to a person’s mental health, psychological wellness, and other areas of clinical conversation (Reference Ginicola, Ginicola, Smith and FilmoreGinicola, 2017). While both are socially constructed terms, it is important to disaggregate sexual-affectional identity from gender identity when determining the focus of counseling (Reference Galupo, Davis, Grynkiewicz and MitchellGalupo et al., 2014). Gender identity describes a person’s sense of experience of being either feminine or masculine that includes societally influenced norms, roles, and behaviors that can change over time (Reference Moe, Perera and RodgersMoe et al., 2023). Cisgender bias operates in tandem with heteronormative bias when clinicians assume that gender identity determines sexual orientation and vice versa (Reference Moe, Finnerty, Sparkman and YatesMoe et al., 2015). Sexual-affectional identity refers to the self-perception a person has of their biological, emotional, and physiological romantic and sexual attraction toward others and may be experienced as nonexistent, as in the case of asexual people (Reference Ginicola, Ginicola, Smith and FilmoreGinicola, 2017; Reference Suprina, Matthews, Kakkar, Harrell, Brace, Sadler-Gerhardt and KocetSuprina et al., 2019). Considering the role of sexual-affectional identity in counseling, mental health professionals approach this construct with the understanding that affectional orientation is fluid and therefore can change over the course of the client’s lifespan (ALGBTIC LGBQQIA Competencies Taskforce, 2013). How clients currently identify in their sexual-affectional and gender identity will assist the mental health professional with understanding what types of interventions are appropriate (Reference NicholsNichols, 2021). Research shows that positive mental health is aided by a healthy sexual-affectional and gender identity, with positive integration of these constructs into the client’s self-concept being associated with higher levels of self-esteem and lower rates of depression, anxiety, and behavioral problems (Reference Chaney, Dubaybo and ChangChaney et al., 2020).

Conclusion

When considering two socially constructed dimensions of personal experience, mental health professionals may find themselves questioning whether the sexual-affectional or gender identity of the LGBTQ+ client should be the focus of counseling. For the LGBTQ+ affirming mental health professional, the answer to this question is truly client centered, as the role and influence that sexual-affectional identity and gender identity have on the client are heavily influenced by their identity development, culture, stressors, and other factors unique to the client at that time (Reference Chaney, Dubaybo and ChangChaney et al., 2020). Considering this client-centered perspective, mental health professionals utilize thorough assessment and affirmative therapy techniques, exercise counselor self-awareness, and build safe counseling relationships that would create a foundation for clients to actively explore their sexual-affectional orientation or determine which identity they fit into and what this means for their current lives (Reference NicholsNichols, 2021; Reference Rose and BaltrinicRose & Baltrinic, 2017).

Case Example: Intake with Sexual-Affectional Minority Women

Amber, a 34-year-old African American-identifying woman, has come to counseling to cope with difficulties related to her new promotion at work and how the resulting stress has influenced her romantic relationships. The counselor began the session by asking Amber about presenting concerns and coping strategies. She reports feeling fatigued and anxious since there has been an increase in her responsibilities at both home and work. Amber reports having to bring work home and feeling like she is constantly being scrutinized when working. The clinician then informed Amber of today’s plan for the BPS assessment and gave her space to ask any additional questions before reviewing informed consent and starting the session. Amber described spending time with friends, infrequent exercise, and occasional alcohol consumption that she described as being sometimes excessive during the weekends. The counselor noted Amber’s alcohol use for additional screening. Amber was asked to rate her concerns with work, social support, and overall stress using a 1–10 scaling question. Amber identified moderate concerns in all areas, feeling overwhelmed at work and in her personal life.

Using a questionnaire, the counselor facilitated exploration of Amber’s romantic and sexual attraction to the same and other genders. The questionnaire then provided a space for her to identify her pronouns and explain further about her gender identity. Amber had stated that she views herself as pansexual, polyamorous, and interested in having romantic relationships with multiple partners of various gender identities. She also circled the pronouns “she/her” and did not further comment on her gender identity or expression. The clinician inquired about the history of her relationships and learned that Amber and her partner have recently welcomed a new girlfriend into their relationship. While Amber currently lives with her long-term partner, they are interested in possibly having their new girlfriend live with them in the future. The counselor broaches the topic of sexual-affectional identity and sexual orientation, and Amber states that her current relationship and identity are very important to her and for understanding how she experiences the world.

The clinician broached Amber’s family of origin as the client described some conflict with her parents. The clinician avoided misgendering Amber’s parents or assuming that she came from a nuclear family. Amber reported a strained relationship with her parents due to her current identification as polyamorous. Amber also reported support from friends and her partner’s family. The clinician later shifted to broaching the topic of safety, both within the relationship and related to suicide risk. The clinician openly gathered information about Amber’s mental health history, including hospitalization history, psychotropic medication history, and outpatient treatment history. The clinician assessed for passive or active suicidal ideation. Amber denied any current ideation or intent and described a history of ideation as an adolescent. The clinician validated Amber’s disclosure and provided space for her to add any other information before moving forward to gauging treatment goals.

The clinician lastly used open-ended questions to further explore Amber’s goals for counseling, in response to which she reported wanting to address the following: regulating emotions and symptoms related to her new work responsibilities, improving communication within her romantic relationship, and processing previous childhood trauma. The clinician thanked Amber for disclosing these goals, and the clinician informed her of the collaborative approach to be used in the therapeutic relationship for future sessions. Although the clinician still has some questions about Amber’s various intersecting identities, the clinician followed her lead and used a critical yet affirming approach to gather information rather than assuming Amber specifically wanted to address her status as a gender, sexual-affectional, and/or racial minority.

Goal 1: Client Will Increase Self-Acceptance Related to Their Gender Identity

1. Objective 1: Client will explore and increase understanding of client’s gender identity as evidenced by client’s journal and in-session discussion.

2. Objective 2: Client will identify unhelpful thought patterns that diminish client’s acceptance of their gender identity as evidenced by the completion of in-between session work, client’s journal, and in-session discussions.

3. Objective 3: Client will reframe unhelpful thought patterns that diminish client’s acceptance of their gender identity as evidenced by the completion of in-between session work, client’s journal, and in-session discussions.

4. Updates: [quarterly]

Goal 2: Client Will Reduce Gender Identity-Related Anxiety

1. Objective 1: Client will develop coping strategies to manage gender identity-related anxiety, as evidenced by the completion of relaxation exercises and reported reduction in anxiety levels.

2. Objective 2: Client will identify specific triggers and situations that exacerbate gender identity-related anxiety and develop a personalized plan to address them, as evidenced by the creation of an anxiety reduction plan and discussions about its implementation in sessions.

3. Objective 3: Client will practice mindfulness and grounding techniques to effectively manage and decrease gender identity-related anxiety, as evidenced by consistent daily practice recorded on a calendar and self-reports of reduced anxiety levels during in-session discussions.

4. Updates: [quarterly]

Goal 3: Client Will Increase Their Support System

1. Objective 1: Client will identify and reach out to at least three new sources of support within their community or social network, as evidenced by a record of contacts.

2. Objective 2: Client will learn and practice effective communication skills to express their needs and seek support from their support system, as demonstrated by role-playing exercises.

3. Objective 3: Client will develop a personalized plan for maintaining and nurturing their support system, including setting boundaries and managing conflicts, as evidenced by the creation of a support plan and discussions during session.

4. Updates: [quarterly]

Evidence-Based Practices for Common Concerns of LGBTQ+ Persons

Evidence for Group Modalities

Affirmative and strength-based integrated group interventions (e.g., counseling, psychotherapy, support, education) are valuable treatment modalities with LGBTQ+ persons, offering benefits that promote therapeutic wellness, social connection, and personal growth (Reference Ali and LambieAli & Lambie, 2019; Reference Chen, Boyd and CunninghamChen et al., 2020; Reference Expósito-Campos, Pérez-Fernández and SalaberriaExpósito-Campos et al., 2023; Reference Hambrook, Aries, Benjamin and RimesHambrook et al., 2022; Reference Hobaica, Alman, Jackowich and KwonHobaica et al., 2018; Reference Skinta, Lezama, Wells and DilleySkinta et al., 2015). LGBTQ+ affirmative and strengths-based frameworks contend that LGBTQ+ identities and expressions are normative and not pathological and that LGBTQ+ individuals are inherently resourceful and resilient, and they counter negative messages and narratives of stigma and oppression (Reference Nakamura, Dispenza, Abreu, Ollen, Pantalone, Canillas, Gormley and VencillNakamura et al., 2022). Group modalities can also be cost-effective means for LGBTQ+ persons needing services across a variety of agencies, such as schools, colleges/universities, veterans’ affairs hospitals, medical centers, rehabilitation agencies, community clinics, and private practices. However, these interventions are only effective if the MHPs offering these services are critical, self-reflective, mitigate any implicit and explicit bias that may contribute to their therapeutic work, and promote wellness and resilience when working with LGBTQ+ persons in group contexts (Reference Chen, Boyd and CunninghamChen et al., 2020; Reference Nakamura, Dispenza, Abreu, Ollen, Pantalone, Canillas, Gormley and VencillNakamura et al., 2022).

Group modalities can be highly effective with LGBTQ+ youth and adults to improve mental health symptomology, coping, and self-esteem (Reference Hobaica, Alman, Jackowich and KwonHobaica et al., 2018). Among LGB adults, empirical studies have shown that group modalities can help facilitate the coming-out process (Reference Ali and LambieAli & Lambie, 2019), reduce depression, anxiety, and mental health-related functional impairments (Reference Hambrook, Aries, Benjamin and RimesHambrook et al., 2022), promote healthy weight among lesbian and bisexual women (Reference Fogel, McElroy, Garbers, McDonnell, Brooks, Eliason, Ingraham, Osborn, Rayyes, Redman, Wood and HaynesFogel et al., 2016), and reduce HIV-related stigma and distress among gay and bisexual men living with HIV (Reference Skinta, Lezama, Wells and DilleySkinta et al., 2015). From a systematic review that included 12 empirical studies that evaluated the effectiveness of group modalities with transgender and gender-nonbinary persons, Reference Expósito-Campos, Pérez-Fernández and SalaberriaExpósito-Campos et al. (2023) reported that group modalities were effective at decreasing symptoms of depression, anxiety, gender-related minority stress, suicidality, and post-traumatic stress disorder. Further, group interventions facilitated improvements in resilience, positive identity development, self-esteem, support, and coping.

A Guided Case Study: Thinking About EBP with Kaleem McKnight

Kaleem McKnight is a 20-year-old Black, cisgender, queer male. He grew up Methodist in the suburbs of Atlanta, Georgia. During Kaleem’s freshman year of college, he experienced a spinal cord injury (SCI) below the waist. After 6 months of intensive physical and psychosocial rehabilitation, Kaleem decided to return to college as an undeclared major with an unclear career goal. In his intake paperwork, Kaleem stated: “I need help with my transition back into college. I really need help managing my anxiety and depression. I feel nervous, on edge, have difficulty focusing and sleeping, and have many days that I feel sad. I’m also scared that I’ll be by myself for the rest of my life because of my disability.” Thinking of the first three steps identified in Table 11.1, what might be one area of clinical focus in this case? How would you go about searching for the best available evidence to support your clinical focus? What factors would you consider as you appraise the available evidence and research?

During the intake session, the MHP learns that Kaleem’s parents divorced when he was 12 years old, and Kaleem took on many household responsibilities and duties as he was the eldest child. He was active in sports and high school extracurriculars, and he volunteered as a big brother mentor at his church. However, after coming out as queer, he participated less in church functions. Kaleem’s mother was incredibly supportive of him after he came out as queer, but his father did not support “his lifestyle choice.” At the time of the injury, Kaleem was living with his mother and siblings.

After his SCI, Kaleem experienced a dramatic shift in his family system. Kaleem’s mother became his caregiver, providing support for his activities of daily living, while his younger siblings were asked to take on more household responsibilities. Although he had a large friendship group during his first year of college, he had only a very small group of queer friends. He is unaware of any of his friends living with a disability. During the intake session, Kaleem described feeling isolated and having little desire to connect with others, and he described a sense of hopelessness for his future. Thinking of steps (4)–(8) identified in Table 11.1, what identity and cultural context would be important to critically synthesize in this case? How would you begin to conceptualize Kaleem’s presenting issues, and what initial considerations would you factor into his treatment plan? What would you monitor in treatment, and how would you monitor progress? Lastly, what type of consultation/supervision and training would you seek at this time?

Barriers to Accessing Crisis Response Services

Reference Holt, Botelho, Wolford-Clevenger and ClarkHolt and colleagues (2024) describe the barriers to crises response services facing LGBTQ+ individuals at the individual level, such as time constraints, shame, and internalized oppression, and at the interpersonal level, such as discrimination and rejection. At the structural level, barriers abound. Specific barriers to care include intersecting minority identities such as race and ethnicity, cultural preconceptions, cost, problems with insurance coverage, geographic location, religious and political barriers, and lack of community support. These structural barriers are discussed in the following subsections.

Suicide and Self-Harm Prevention with LGBTQ+ Clients

Suicide and self-harm are particularly prevalent within the LGBTQ+ community, especially among the adolescent population (Reference Lucassen, Stasiak, Samra, Frampton and MerryLucassen et al., 2017). According to Reference Cipriano, Cella and CotrufoCipriano et al. (2017), self-harm is prevalent across the lifespan in this population. Although risk factors are higher in adolescents and young adults, due to the ongoing issues impacting the LGBTQ+ population, as evidenced by the barriers discussed earlier in the chapter, depression and anxiety that can lead to suicidal ideation, self-harm, and/or suicide completion are prevalent throughout the community. A possible prevention strategy for suicide and self-harm is to focus on protective factors (Reference Burish, Wilcox, Pollard and SimsBurish et al., 2023). According to Reference Burish, Wilcox, Pollard and SimsBurish et al. (2023), optimism is an important factor to focus on in work with LGBTQ+ clients. In addition to optimism, Reference Moody, Fuks, Peláez and SmithMoody et al. (2015) stress the importance of focusing on social connectedness and family support as well. Additionally, a crucial element of prevention is also access to care (Reference Poquiz, Moser, Grimstad, Boman, Sonneville, Turpin and EganPoquiz et al., 2021). Telehealth services have increased access to care (Reference Moody, Fuks, Peláez and SmithMoody et al., 2015) and will quite possibly assist in the prevention of suicide and self-harm in LGBTQ+ populations.

Responding to Individual, Group, and Community Violence

Mental health professionals are often called upon to serve and support individuals, groups, and communities who have experienced crisis events. The immediate aftermath of an event that has a capacity to overwhelm or distress an individual or community is known as a crisis. A crisis event has three main components: (1) the event; (2) perception of the event as distressing by the individuals who experience it; and (3) a lack of adaptive coping as the event has overwhelmed the coping and resilience capacities of the people involved (Reference Jackson-Cherry and ErfordJackson-Cherry & Erford, 2018). If a crisis event remains unresolved or is not met with resilience, adaptive coping skills, or positive support systems, the experience might overwhelm the person and lead to traumatic stress reactions (Substance Abuse and Mental Health Service Administration, 2014).

When a crisis or traumatic event occurs, the response to those events by individuals or communities around which the crisis has occurred becomes significant. First, accurately assessing the event and its impact is necessary. It is important to determine whether the crisis is a situational, existential, developmental, or ecosystemic crisis (Reference Jackson-Cherry and ErfordJackson-Cherry & Erford, 2018). Unfortunately, the crises and traumatic events that the LGBTQ+ community deal with are often integrations of one or more types of crisis. The complexity and enmeshment of one crisis or trauma with another are inevitable, making it difficult to clearly assess which crisis or trauma affects the individual, group, or community the most. For example, a crisis event such as a shooting at a nightclub might coincide with systemic trauma wielded by a political or religious agenda or an existential crisis that an individual might be experiencing due to their family/community blaming or shaming them.

When responding to crisis events in the LGBTQ+ communities and with sexual and gender minority individuals, counselors might utilize interventions as per the tenets of psychological first aid (PFA) and trauma-informed care (TIC). According to the National Child Traumatic Stress Network, PFA is formulated to reduce the distress resulting from crisis situations and to promote both short-term and long-term adaptation or coping. Psychological first aid is primarily utilized for immediate crisis intervention to provide practical assistance, safety and comfort, connection to social supports and resources, and the opportunity for warm hand offs for collaboration and support within the community for future needs (National Child Traumatic Stress Network, 2012). Trauma-informed care (Substance Abuse and Mental Health Service Administration, 2014), however, is an approach that can be used during and after a crisis event has occurred. Unlike any manualized treatment for trauma, TIC operates on six key principles that are part of an approach that can be molded to any situation – crisis event or otherwise. As mentioned earlier, after understanding the event, the experience of the event, and the effect that this experience has led to (i.e., the three Es), it is imperative that MHPs recognize the signs and symptoms in individuals that can manifest as traumatic responses, respond according through the applications of this knowledge, and resist the retraumatization of survivors (i.e., the four Rs; Substance Abuse and Mental Health Service Administration, 2014).

Once oriented to the three Es and the four Rs, the six principal steps of TIC as delineated by the Substance Abuse and Mental Health Service Administration (2014) can be followed. First is establishing the safety of the survivors. This is a basic counseling skill that entails building rapport and being genuine, nonjudgmental, empathic, and compassionate about what that individual(s) is going through. The next step is to establish trust with the individual(s) and to be transparent and accountable. The third step is to help establish peer support. Individuals who are and/or identify as part of a community can provide each other with essential social support in crisis situations. The fourth step is to establish a collaborative mutual stance through which work toward short- and long-term coping can be operationalized. The fifth tenet of TIC is to provide opportunities for empowerment and for choice, as well as avenues for survivors’ voices to be heard. This step is especially important for communities that have been historically oppressed, repressed, and marginalized. However, all of these steps are meaningless without consideration of the implications of the sixth step in TIC: how historical and sociocultural realities have impacted the responses to crises or traumatic events for individuals and communities based on their gender or sexual orientation, ethnicity, immigration status, socioeconomic status, differences in religious, spiritual, or political beliefs, values, and attitudes.

Case Example: Responding to the Pulse Nightclub

Carlos presented in the office talking about his fears of being in open spaces, particularly with large crowds. He also talked about his feelings of guilt and shame and inability to commit to any long-term relationship. He further explained that he was continually experiencing anxiety in any situations in which he felt a lack of control. He denied any suicidal ideations at this time but did describe some past incidences of self-harm. Furthermore, he indicated that he had an occasional problem with alcohol use. Alcohol use was a way by which he tried to cope with some of his fears and feelings of anxiety, and it was about the only way by which he was able to socialize with others or initiate any romantic encounters. The feelings he described had been present for many years, although he had not been willing to seek care due to his reluctance to discuss his sexual orientation with anyone outside his close circle of friends. He described the feelings of isolation and rejection he had felt for most of his life due to his family’s inability to accept his sexual orientation. As we discussed his feelings of guilt and shame as well as his initial description of his fears of open spaces and large crowds, he disclosed that he had been in the nightclub Pulse on June 12, 2016, when a mass shooting took place there. Furthermore, his last partner was a victim in this mass shooting. As we began to work to address the symptoms that Carlos presented, it became evident that he was not only dealing with the aftereffects of the crisis and trauma of the mass shooting – his existing symptoms were exacerbated because of the shooting.

Conclusion

Creating collaborative and trustworthy relationships is especially important with those who have limited choice in therapy decisions due to parental influence and insistence (Reference Levenson, Craig and AustinLevenson et al., 2023). In such a case, it is necessary to empower LGBTQ+ youth to be active in their therapeutic goals. Using client-centered language and working collaboratively can mitigate feelings of powerlessness (Reference Levenson, Craig and AustinLevenson et al., 2023). Considering the minority stress model, in a world that devalues LGBTQ+ client experiences, focusing on their internal resources can also help foster empowerment. The goal is to promote resilience and growth. LGBTQ+ clients felt positively empowered when their therapist acted as an active cheerleader in their life (Reference Berke, Maples-Keller and RichardsBerke et al., 2016).

Needs of LGBTQ+ People with SUDs in Treatment

Given their high SUD prevalence rates, it is surprising that few LGBTQ+ people receive treatment. In fact, according to the Substance Abuse and Mental Health Services Administration (2022), 93.3% of LGB Americans with a SUD do not receive treatment. This rate increases to 94.4% for LGB individuals with cooccurring SUDs and other mental health disorders. These limited treatment opportunities are available through outpatient rehabilitation, outpatient mental health centers, or self-help groups. Data regarding the treatment utilization rates for gender-minority individuals are unavailable.

Competent care for LGBTQ+ individuals requires understanding the limitations of assessment instruments and the treatment barriers and dynamics that may affect client disclosures and social supports. During the assessment process, evaluate all LGBTQ+ clients for suicidal ideation and SUDs due to their increased prevalence rates in comparison to cisgender, heterosexual individuals (Reference Lassiter, Spivey, Johnson, Furr and HunsuckerLassiter et al., 2022). Further, because LGB individuals have increased rates of physical disabilities and chronic medical needs (Reference Frimpong, Rowan, Williams, Li, Solano, Chaudhry and RadiganFrimpong et al., 2020), assess these concerns and provide access to adequate medical services. Inpatient services remain an important part of the continuum of care for LGBTQ+ persons, but providers may be inadequately prepared for their needs due to restrictive policies regarding housing and bathroom spaces (Reference Lassiter, Spivey, Johnson, Furr and HunsuckerLassiter et al., 2022). Despite the increased need for these services, LGBTQ+ individuals are less likely to use or remain in inpatient mental health services (Reference Frimpong, Rowan, Williams, Li, Solano, Chaudhry and RadiganFrimpong et al., 2020). When engaging social support from family and friends in treatment, which is a common practice, some LGBTQ+ individuals may have the dual challenge of being alienated due to stigmatizing attitudes concerning LGBTQ+ identities as well as due to behaviors related to their SUD. Understanding an individual client’s social support systems is important to determining whether to include these in treatment, as some clients may decide to disclose their sexual orientation and/or gender identity to social supports as part of their recovery process (Reference Lassiter, Spivey, Johnson, Furr and HunsuckerLassiter et al., 2022).

Another consideration in treatment is LGBTQ+ individuals’ contact with the criminal justice system. Substance use disorders are some of the few mental health disorders with significant legal consequences. LGBTQ+ individuals are overrepresented across all levels of the criminal justice system (Reference JonesJones, 2021). For some LGBTQ+ individuals, their survival through homelessness (e.g., queer youth getting kicked out of their homes) and poverty may result in criminalized behaviors (Reference JonesJones, 2021). Unfortunately, prisons are now considered among the largest inpatient mental health facilities (Reference Al-Rousan, Rubenstein, Sieleni, Deol and WallaceAl-Rousan et al., 2017), and understanding and recognizing the limitations of these settings are essential. Upon arrest and incarceration, LGBTQ+ offenders are twice as likely to be sexually assaulted by both other inmates and staff (Reference Truman and MorganTruman & Morgan, 2022). Trans people also face harassment and assault, and they are commonly denied health care services and are subject to solitary confinement (Reference JonesJones, 2021). As in other inpatient settings, trans people are subject to gender binary systems and are often subject to isolation under the guise of safety, when in fact it is used to punish and humiliate (Reference PeckPeck, 2022). Thus, ensuring trauma-informed competent care and advocacy for full access to services remains a priority across settings when working with individuals with SUDs and LGBTQ+ individuals.

Specialized Groups and Evidence-Based Treatments for LGBTQ+ Populations

Managing these challenges may be supported by specialized treatment services for LGBTQ+ clients. Such specialized services are still not widely available, particularly in rural settings, leaving many LGBTQ+ individuals to rely solely on general SUD treatment (Reference Ji and CochranJi & Cochran, 2022). Even when agencies advertise having specialized services for LGBTQ+ clients, they are often not available (Reference Ji and CochranJi & Cochran, 2022). This is even more concerning for youth early in their identity development and seeking safe spaces to confide their experiences (Reference Brubaker and ChaneyBrubaker & Chaney, 2017).

Given the likelihood for mixed clientele in groups, there is a potential for harmful (i.e., discriminatory) interactions between group members. Group leaders have a particular responsibility to promote respect within the group and establish norms that affirm the range of members’ diverse cultural expressions. The Center for Substance Abuse Treatment (2012) specifically recommends “provid[ing] a strong verbal directive that homophobia and hostility will not be tolerated” (p. 56). The Center affirms how LGBTQ+ clients should not be required to disclose their identities or related concerns in group settings. Group leaders who are affirming of LGBTQ+ identities should encourage a safer environment for all in order to promote authentic group interaction that is better able to provide support. Such groups may facilitate better outcomes for LGBTQ+ group members who may not have disclosed their identities to other group members or even the group leader.

As mental health professionals (MHPs) consider offering specialized treatment services instead of the existing evidence-based practices, increased efficacy and ethical care are key considerations, according to Reference Pachankis, Safren, Pachankis and SafrenPachankis and Safren (2019). They noted that nonadapted evidence-based treatments may still be beneficial for LGBTQ+ individuals. The abundant research supporting the role of minority stress (see Chapter 3) may be a focal point of adapted interventions.

Among the few studies on adapted evidence-based treatments for SUD, many were developed to address SUD and risky sexual behaviors among gay and bisexual men (e.g., Project PRIDE; Reference Smith, Hart, Kidwai, Vernon, Blais and AdamSmith et al., 2017). Among the fewer studies on sexual-minority women, behavioral couples therapy has been shown to improve relationships and reduce heavy alcohol use among lesbian women (Reference Fals-Stewart, O’Farrell and LamFals-Stewart et al., 2009). Treatment-related studies for trans clients are promising (e.g., LifeSkills for Men; Reference Reisner, Hughto, Pardee, Kuhns, Garofalo and MimiagaReisner et al., 2016). More recently, Reference Pantoja-PatiñoPantoja-Patiño (2020) proposed an intersectional identity framework to address multiple minority stress from an ecological perspective. Whichever approach is chosen, it is essential that MHPs use affirming practices, address minority and multiple minority stress, and attend to existing competencies for LGBTQ+ clients. This is particularly crucial to prevent relapse.

Spirituality, Recovery, and LGBTQ+ People

Best practices in substance use treatment prescribe addressing the whole person: physical, mental, and spiritual (Reference HodgeHodge, 2006). Some 75% of addiction treatment programs in the United States incorporate some form of spirituality-based element (Reference Grim and GrimGrim & Grim, 2019), including 12-step programs, which use the concept of a “Higher Power.” Spirituality is a complex concept, historically intertwined with religion, with varied understanding based on cultural, religious, and academic backgrounds, with the most common understanding being the connectedness and meaning of life (Reference de Brito Sena, Damiano, Lucchetti and Peresde Brito Sena et al., 2021). Overall, spirituality has been demonstrated to decrease substance use within LGBTQ+ communities (Reference ColemanColeman, 2003). For LGBTQ+ individuals, spirituality must address “acceptance and disclosure, family rejection, lack of social support, and stigma” (Reference Qeadan, Akofua Mensah, Gu, Barbeau, Madden, Porucznik and EnglishQeadan et al., 2022, p. 249).

By contrast, certain religious congregations convey moral orders of gender and sexuality that idealize heteronormative and/or cis-centric gender constructions (Reference Sumerau, Cragun and MathersSumerau et al., 2016). Greater exposure to religious anti-LGBTQ+ prejudice forecasted higher levels of problematic alcohol use (Reference Sowe, Tylor and BrownSowe et al., 2017). It behooves MHPs to become cognizant of the religious organizations that are supportive of members of the LGBTQ+ communities (such as those available at https://LGBTQ+.unc.edu/wp-content/uploads/2021/05/Religion-May2017.pdf) to aid those LGBTQ+ clients seeking religious affiliation. Reference Smith, McCullough and PollSmith et al. (2003) indicated that the benefits of religious affiliation come from moral order (opposition to the use of drugs or alcohol, promotion of self-regulation, control of impulses and emotions, and strong sense of self), learned competencies (social skills), as well as social and organizational ties (emotional support and social capital of networks and friendships). Finding avenues to make these benefits available to LGBTQ+ clients in recovery with or without religion is also helpful.

Finally, it is essential to engage in due diligence through discussion and assessment of religious and spiritual preferences and their strengths and challenges for the individual. Spiritual healing can also be facilitated through LGBTQ+ individuals’ affirming personal stories being built into a meaningful spiritual journey that connects beyond the body and mind, to promote psychological, emotional, and spiritual healing (Reference GoodmanGoodman, 2017) as part of the coping skills in the relapse prevention plan.

LGBTQ+ Affirmative Relapse Prevention Planning

A primary goal in substance abuse treatment with most LGBTQ+ clients is to facilitate long-term abstinence. However, sobriety is often threatened by the risk of relapse. Relapse is a setback whereby the client reverts to their original behavior targeted for change (Reference Hendershot, Witkiewitz, George and MarlattHendershot et al., 2011). In SUDs, relapse is the return to use of substances after a period of abstinence – in other words, the absence of abstinence (Reference Sliedrecht, de Waart, Witkiewitz and RoozenSliedrecht et al., 2019).

Relapse in SUD tends to be the rule rather than the exception. In fact, substance use relapse rates of 40–60% were comparable to relapse rates in other chronic health conditions such as hypertension and asthma (50–70%; Reference McLellan, Lewis, O’Brien and KleberMcLellan et al., 2000). Like asthma, then, SUD is best viewed as a chronic and persistent health condition that needs to be managed accordingly. An anecdotal clinical rule of thumb has been called the “One-Third Rule” (Reference Broekaert, Vandevelde, Vanderplasschen, Soyez and PoppeBroekaert et al., 2002): One-third succeed and abstain, one-third fall into a mild lapse, and one-third experience a severe relapse. The first year of recovery is especially crucial given that 60–90% of clients relapse within the first year of treatment (Reference Mau, Muller and RoesslerMau et al., 2019).

Relapse is a process that often begins long before the actual relapse itself. Relapse in addiction treatment is commonplace due to the interaction between mood-altering substances and reward pathways in the brain. Repeated exposure to alcohol or drugs influences the release of dopamine in the reward centers (i.e., the ventral tegmental area and the nucleus accumbens) of the brain (Reference Stevens and SmithStevens & Smith, 2018). These physiological changes hinder self-regulation of emotions and control of cravings for substances, leading to obsessive rumination about using until a relapse occurs (Reference Volkow, Koob and McLellanVolkow et al., 2016). Unfortunately, LGBTQ+ clients in substance abuse treatment are more likely than heterosexual clients to relapse posttreatment (Reference SenreichSenreich, 2009) due to unaddressed relapse prevention needs. Therefore, it is crucial for MHPs who work with this population to adopt an LGBTQ+ affirming perspective when developing relapse prevention plans.

Relapse prevention refers to a variety of skill-based treatments and coping strategies often grounded in cognitive behavioral practices that help to prevent clients from relapsing (Reference Hendershot, Witkiewitz, George and MarlattHendershot et al., 2011). LGBTQ+ affirming counseling includes not pathologizing LGBTQ+ identities, creating psychologically safe spaces for LGBTQ+ clients to achieve optimal wellness, and MHPs engaging in a reflexive process to critically examine attitudes and biases toward and about LGBTQ+ clients (Reference Chaney and WhitmanChaney & Whitman, 2020). Thus, an LGBTQ+ affirmative relapse prevention plan identifies relapse warning signs and coping skills to avoid and manage triggers that may be unique to LGBTQ+ individuals in recovery, with the ultimate objective of promoting long-term recovery and affirming clients’ queer identities in tandem. The plan addresses: feelings, thoughts, behaviors, and situations that may lead to relapse; supportive people to contact when tempted to use; strategies to manage cravings; barriers to respective coping strategies; steps needed to implement a given coping strategy; consequences of a relapse; and benefits of maintaining sobriety. Within a safe space, the MHP and client collaboratively explore: relapse warning signs and triggers associated with antiqueer discrimination and oppression; LGBTQ+ developmental milestones (e.g., coming out, transitioning); LGBTQ+ bars, gathering places, and events; internalized heterosexism, gender dysphoria, and minority stress; and “chemsex,” sober sex, and sexual sensation-seeking, to name a few (Reference Brubaker and ChaneyBrubaker & Chaney, 2017; Reference Chaney, Brubaker and KocetChaney & Brubaker, 2014; Reference Chaney and Urhahn-SchmittChaney & Urhahn-Schmitt, 2023). The following LGBTQ+ affirmative relapse prevention plan items should be individualized for specific clients. To develop your skills, use the template below to construct an affirming relapse prevention plan for the case vignette of Mukesh provided after the following list of items.

• List feelings that you have about yourself as an LGBTQ+ person that may lead to relapse (e.g., shame, disappointment, guilt, fear).

• Identify thoughts that you have about yourself as an LGBTQ+ person that may lead to relapse (e.g., “I am not loveable because I am gay/trans”). Be specific.

• What are some behaviors that may lead to relapse (e.g., interacting or hooking up with previous partners who use, going to an LGBTQ+ bar, not calling your sponsor, missing meetings)?

• What high-risk situations and activities may trigger you to use?

• List some coping strategies to manage urges to use and/or to affirm your LGBTQ+ identity.

• What are some things that may prevent you from using the coping skills mentioned earlier?

• What are steps you may need to take to use the coping strategies mentioned earlier?

• Write down some consequences of a relapse, including how a relapse may impact your LGBTQ+ identity (e.g., feel shame, loss of trust from loved ones, increases risk of sexually transmitted infections).

• List five benefits of remaining abstinent, especially in terms of how it may impact your LGBTQ+ identity (e.g., health benefits, increased pride, decreased shame and guilt, develop supportive relationships).

• Jot down the names and contact information of three people you can call when tempted to use and who support your LGBTQ+ identity and recovery.

Case Study of Mukesh

Mukesh is a 22-year-old biracial, nonbinary, bisexual person using pronouns they/them/their. They were born to White and Asian parents. Mukesh’s parents divorced prior to their attending any formal school. Mukesh was raised Catholic by their mother and attended parochial school until they enrolled in a public high school. Mukesh regularly visited with their father, who insisted on visitation rights. Their father became more fundamental in his religious beliefs, insisting on male roles for Mukesh. Mukesh was compliant as they feared their father. During puberty, Mukesh began to realize both their sexual and gender identities as being minoritized and not fitting with what their parents expected. They stopped attending the Catholic church with their mom. They came out as bisexual, first to their mother and then to their father. While their mother was noncommittal about their sexual identity, their father refused to accept it, and he even went so far as to engage in prayer to help Mukesh find their path back to a heterosexual orientation. Their father became more demanding that Mukesh attend church with him more frequently and actively participate in the service. Their father became critical about Mukesh’s appearance and dictated how they should dress and present. After graduation, Mukesh distanced themselves from their father. Once away from visitation, Mukesh identified as being agnostic.

Mukesh began attending a public university, where they joined an on-campus sexual and gender alliance group. Mukesh also began to drink heavily and use Molly (MDMA/ecstasy) with friends. They frequently used alcohol and Molly during sexual experiences because it made them feel less guilty. Mukesh was recently arrested for drunk and disorderly conduct and had to spend a night in jail. Mukesh’s grades dropped because of missed assignments and due to them being too drunk or depressed to attend classes. Mukesh’s advisor referred Mukesh to the university counseling center. Mukesh shared this information with their mother in a heated argument related to their grades. They shared that their mother does not understand what it means to be Mukesh and what they experienced in jail. Their mother encouraged Mukesh to attend counseling and to help her understand how to be supportive of their needs. Mukesh feels isolated and disconnected from their extended family due to their multiple minoritized intersectional identities.

As a MHP, how will you proceed with Mukesh to address their spiritual needs? How should you explore Mukesh’s experience of the criminal justice system? What may be some advocacy needs that you should consider when working with Mukesh?

Conclusion

LGBTQ+ communities are at greater risk for developing SUDs compared to their heterosexual counterparts. A recurrent theme within addiction-related research is that the etiology of SUDs among LGBTQ+ individuals is significantly correlated to heterosexism and transphobia/cisgenderism. Although LGBTQ+ persons are more likely to be diagnosed with a SUD, a great majority do not seek addiction-related treatment due to poor treatment experiences and culturally incompetent providers. Further, most addiction treatments incorporate spirituality, which may not address the specific spiritual concerns of LGBTQ+ individuals seeking recovery. To bridge this gap, LGBTQ+ affirming substance use treatment and affirmative relapse prevention are necessary and are delineated in this chapter.