Recommendations for Improving Substance Abuse Treatment Interventions for Sexual Minority Substance Abusers

To improve substance abuse treatment efforts, some have suggested that interventions should be adapted to cultural characteristics of target populations [1]. In line with these recommendations, empirical investigations of culturally-tailored interventions for individuals diagnosed with substance use disorders (SUD) have gained momentum. In this commentary, I first present recommendations to improve empirical investigations of substance abuse interventions for lesbian, gay and bisexual (LGB) individuals who abuse or are dependent on substances. I then argue for increased clinical training in LGB cultural sensitivity to improve substance abuse treatment for LGB clients.

Improving Investigations of Substance Abuse Interventions for LGB Individuals

Significant resources and training are needed to deliver culturally-tailored substance abuse interventions to LGB individuals with SUDs. Given the increased efforts needed to deliver these culturally-tailored interventions, it is essential for researchers to establish that such efforts improve the efficacy and eventual effectiveness of interventions aimed at reducing maladaptive substance use and SUD symptoms in LGB substance abusers. Two broad types of intervention studies examine treatment outcomes among LGB participants. One type administers generalised, empirically-supported treatment interventions (e.g. 12-step facilitation, cognitive-behavioural therapy, contingency management, motivational interviewing), adapting materials and messages to observable characteristics of the target population [1]. For example, these studies may utilise recruitment materials that highlight treatment options in LGB-friendly settings. The second type of study implements alterations to generalised interventions that address “cultural, social, psychologic, environmental, and historical factors” [p. 273, 1] thought to potentially contribute to substance abuse in LGB populations. These studies incorporate LGB-specific issues into the content of the intervention that are relevant to substance abuse and addiction, such as identity acceptance and disclosure, childhood and adult victimisation, family rejection and coping strategies for encountering substance use within peer groups.

The potential for studies to inform an understanding of which aspects of LGB-tailored substance abuse interventions contribute to treatment benefits is essential for advancing future tailored-intervention design and dissemination efforts. Proponents reason that because LGB-specific factors (e.g. affiliation with gay culture, minority stress) are common contributors to substance misuse among LGB individuals, successfully-tailored interventions should address these factors [2]. However, to date there is no consistent evidence to suggest approaches that extensively adapt materials and programs to be culturally relevant for treatment-seeking LGB individuals are any more successful at reducing or eliminating substance abuse compared to approaches which are minimally altered [2]. Thus, it remains unclear how much tailoring is necessary to effectively adapt interventions for LGB populations.

I would also encourage researchers to attempt to identify common “critical ingredients of care” which are part and parcel of successful substance abuse interventions [3], and those aspects that enhance treatment outcomes for LGB substance abusers. For example, Senriech [4] found that gay/bisexual men retrospectively reported feeling more “connected” to others in tailored programs compared to those in “traditional” programs. Further research may support that fostering a common identity among LGB substance abusers is essential for leading to greater investment in treatment programs and generating downstream success for efforts to reduce or eliminate substance abuse.

Regardless of differences in substance use following treatment, efforts to identify clinically significant benefits of culturally-tailored interventions would provide additional support for their value [5]. LGB substance abusers may find that, in addition to reducing or eliminating symptoms of SUDs, tailored interventions provide benefits that improve their everyday quality of life. For example, they may benefit from gaining more adaptive coping strategies and peer social support. There is wide variability, however, in the extent to which alternative, clinically significant benefits are assessed in interventions with LGB substance abusers.

The Need for Specialised Training in LGB Cultural Sensitivity

Providing interventionists with training in LGB cultural sensitivity will enhance culturally-competent care. Additional training may be incorporated as a formal component of generalised training for substance abuse interventionists. Alternatively, continuing-education workshops might focus on providing tools and information that interventionists might use to improve care for LGB substance abusers. If nothing else, treatment programs could incentivise self-directed supplemental training efforts for interventionists. Generalised substance abuse interventions are already recommended to be individually adapted [2] and thus, treatments administered by an interventionist who is sensitive to the unique stressors of LGB individuals may prove to be as equally effective as a tailored intervention.

Further, training in LGB cultural sensitivity is likely to improve therapeutic relationships and decrease barriers to care [6]. Previous findings suggest that a majority of interventionists are generally insensitive to the unique needs of LGB substance abusers [7]. LGB substance abusers characterise substance abuse interventionists as biased and ill-informed with regard to sexuality issues [8], suggesting an increased need for training on these topics. Ultimately, training pertinent to LGB substance abuse may also benefit other [heterosexual] clients who abuse substances to cope with related issues (e.g. a man abusing substances due to concerns with sexual functioning).

Identifying which generalised, empirically-supported substance abuse interventions are most effective for LGB populations is a worthwhile pursuit for researchers. For example, there is a need to identify approaches that reduce SUDs in LGB populations when delivered, for example, in a mixed-group setting (i.e. with heterosexuals) and to LGB clients with severe substance dependence. Further, empirical support for the effectiveness of generalised interventions may be particularly valuable for treatment-seeking LGB individuals living in areas with few other LGB substance abusers or for interventionists with limited access to culturally-sensitive materials and training. Unfortunately, effectiveness studies [9] seeking to establish that benefits of generalised treatment programs extend to LGB substance abusers in real-world settings are in short supply.

It is important to be thoughtful regarding the ways in which tailored interventions address various reasons and motivations for substance abuse in specialised populations. The current recommendations are meant to advance the field by urging for future investigations of which components of generalised and tailored substance abuse interventions are most successful in providing treatment benefits (e.g. reducing hazardous use, acquiring helpful coping strategies, ameliorating distress and impairment associated with SUDs) for LGB substance abusers. If implemented, these recommendations could benefit both research and clinical efforts by providing an improved understanding of factors that contribute to successful treatment of SUDs for LGB substance abusers.