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Treatment experiences of gays and lesbians in recovery from addiction: a qualitative inquiry.

The literature has suggested that addiction treatment programs are not addressing the unique recovery needs of gays and lesbians. This qualitative study examined gay men's and lesbian women's experiences with addiction treatment and recovery. Ten themes emerged to define their experiences. These themes are described, along with implications for mental health counselors working with this population.

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Mental health professionals have long considered the gay and lesbian population to be at-risk with respect to alcohol and other drug addiction. In an extensive review of the literature, Hughes and Eliason (2002) concluded that this risk continues despite declines in actual levels of use in this population. There is also evidence to suggest that gay men and lesbian women do show differences from the general population in patterns and consequences of use (e.g., McKirnan & Peterson, 1989; Skinner & Otis, 1996). Bux (1996) reviewed the literature on prevalence rates of problem drinking among gays and lesbians and concluded that lesbian women and gay men are less likely to abstain from alcohol use than the general population, that lesbian women seem likely to be at higher risk than heterosexual women for problems related to drinking, that gay men's risk for alcohol related problems is comparable to that of heterosexual men, and that the latter is due to recent declines in use.

There is also some evidence that the gay and lesbian population may experience substance use and addiction in ways that are uniquely related to their sexual orientation (Cheng, 2003). In a study of lesbian women and gay men in recovery, participants reported that conflict related to sexual orientation was a major contributing factor to their alcoholism (Millinger & Young, 1990). Furthermore, alcohol and other drugs can become a mechanism for coping with social stigma and internalized homophobia (Cabaj, 1996; Cheng, 2003; Ratner, 1993) This is exacerbated by the fact that the gay bar is one of the most accessible routes into the lesbian and gay community for individuals coming out or exploring their sexual identity (Cheng; Gay and Lesbian Medical Association, 2001).

Despite these culturally specific experiences with substance use and abuse, the limited information available suggests that treatment providers often lack the knowledge or inclination to address them. For example, Hellman, Stanton, Lee, Tytun, and Vachon (1989) studied government funded treatment facilities in New York City. They reported a lack of information and training in working with gay and lesbian clients, a reluctance to refer clients to other clinicians who might have specialized training, and frequent failure to address issues related to sexual orientation. This is consistent with Ratner's (1993) report that 53% of the clients who entered the Pride Institute, an inpatient treatment center targeting the gay and lesbian population, had previously participated in inpatient treatment elsewhere where sexual orientation was never addressed. More recently, Eliason (2000) found that substance abuse counselors lacked information about critical aspects of gays' and lesbians' experiences and that, although many of the counselors surveyed had "tolerant or accepting attitudes" (p. 323), a large percentage had "negative or ambivalent attitudes" (p. 323). Matthews, Selvidge, and Fisher (2005) found that the organizational climate in substance abuse treatment facilities predicted the degree to which individual counselors practiced in ways that were affirmative with gay, lesbian, and bisexual clients. The more affirmative the organizational climate, the more counselors reported affirmative attitudes and behaviors in working with this population.

The question of culturally specific treatment is one that has been raised in the multicultural counseling literature for the past couple of decades. Sue and his colleagues have presented a competence-based theory of multicultural counseling, arguing that there are certain competencies that counselors who practice cross-culturally need to develop to work successfully with clients whose backgrounds are different from their own (Ponterotto, Fuertes, & Chen, 2000; Sue, Arredondo & McDavis, 1992; Sue et al., 1982; Sue, Ivey, & Pedersen, 1996). This theory is based on the premise that traditional theories of counseling are culture-bound and reflective of the European and American cultures familiar to their developers. Sue and his colleagues argued that counselors need to develop awareness, knowledge, and skills appropriate for the client's culture when working with clients who do not share the counselor's cultural background. Although Sue and his colleagues focused their work on cultural differences based on race and ethnicity, other scholars (e.g., Croteau, Talbot, Lance, & Evans, 2002; Haldeman & Buhrke, 2003; Pope, 1995) have argued that other aspects of culture such as sexual orientation are also important.

The purpose of the present study was to gain a better understanding of the experiences of gay and lesbian individuals in treatment for drug and alcohol addiction. We were particularly interested in gay and lesbian recovering individuals' perspectives on what was and what was not facilitative of recovery, as well as the ways in which mental health professionals in addiction treatment facilities are or are not addressing the unique recovery needs of gay and lesbian clients. Drawing on multicultural theory, we were interested in participants' perspectives on how important, if at all, it was for treatment programs to address issues related to sexual orientation.

METHOD

Procedures

Participants were recruited through a variety of sources likely to reach the gay, lesbian, bisexual community and/or the recovery community. This included posting recruitment announcements on listservs and sending flyers to gay and lesbian community or health centers, as well as to Alcoholics Anonymous (AA) groups. It also included an announcement at the end of a related quantitative Internet study, inviting participants of that study to participate in this study.

Individuals who responded to the announcement received a Letter of Informed Consent, which described the study in more detail and allowed them to formally indicate their consent to participate, along with a Background Questionnaire, which gathered contact and demographic information. Once the first author received the signed consent form and background questionnaire, one of us contacted the participant to schedule an interview.

We conducted semi-structured interviews via telephone, which were audiotaped with participants' knowledge and permission. A series of open-ended prompt questions were used to initiate discussion and to ensure a common protocol among interviewers; however, participants were encouraged to add or expand upon topics that seemed important to them. The prompt questions are listed in the Appendix. Interviews lasted about an hour. A professional transcriptionist transcribed the audiotapes. Prior to analysis, an individual not connected with the research team compared the transcripts to the audiotapes to verify the accuracy of the transcriptions. In addition, we sent each participant a copy of the transcript for his or her interview to verify that the transcript was correct and accurately represented his or her thoughts. Where indicated, changes were made to the transcriptions. The study was approved by the university's Office for Regulatory Compliance.

Participants

As is characteristic in qualitative research, we used purposive sampling procedures (Creswell, 1998; Jones, 2002). Criteria for participation were that participants self-identify as gay, lesbian, or bisexual and as being in recovery from alcoholism and/or other drug addiction for at least one year. The one-year minimum for sobriety was chosen to ensure that length of sobriety was long enough that participation in the study would not likely jeopardize recovery and also to allow enough recovery time to be able to reflect on the process. The initial working plan developed by the research team was to include only those individuals who had attended at least one formal treatment program (inpatient, outpatient, or intensive outpatient/partial hospitalization). The recruitment announcement specifically mentioned an interest in treatment experiences. This plan was revised when several individuals indicated that their treatment experience had been exclusively through 12-step programs but they believed they had something to contribute. Since qualitative research is an emergent process based on interaction between researchers and participants (Armino & Hultgren, 2002; Jones, 2002), the decision was made to include 12-step programs in the definition of treatment experience. Given that many, if not most, treatment programs include active involvement with 12-step programs as an integral part of the treatment experience, this seemed consistent with the overall purpose of the study.

A total of 23 individuals responded to the recruitment announcement. Twelve people returned the signed and completed consent and background information; however, two of them failed to respond to repeated attempts to schedule an interview. This left a final sample of 10 participants, six women and four men. All of the women identified themselves as "lesbian" or "dyke;" all of the men identified themselves as "gay" or "homosexual." The sample was predominantly European American (N=9), with one participant identifying herself as African American. Ages ranged from 31 to 69 (M=46.9; SD=13.5). Five of the participants were in their thirties; three were in their fifties; two were in their sixties. Participants came from southeast, mid-Atlantic, mid-west, and west coast states.

Participants reported a range of one to four treatment experiences and all participants mentioned involvement with AA. For two participants, this was their only treatment experience; another indicated an outpatient therapy experience that was not addiction-specific but that did address issues related to addiction. Four of the participants reported outpatient experiences, four reported inpatient experiences, and two reported intensive outpatient/partial hospitalization experiences. In some instances, participants had more than one type of experience. The 10 participants were in recovery from alcoholism for a mean of 13 years (range = 4 years, 5 months to 26 years, 3 months). Seven of the participants were also in recovery from other drugs for a mean of 6 years, 1 month (range = 4 years, 5 months to 15 years, 7 months).

RESULTS

Data Analysis

We analyzed the data using a phenomenological and consensual qualitative approach. We began with immersion, or getting a sense of the data as a whole (Cohen, Zahn, & Steeves, 2000). Each of us independently read all of the complete transcripts twice and began reducing the data (Cohen et al.; Creswell, 1998; Moustakas, 1994). Then we met to discuss the general themes that each of us pulled from the data. After reaching consensus on the major themes, we independently returned to the data to confirm the accuracy of the themes, then met again to refine the themes as needed (Hill, Thompson, & Williams, 1997).

Once the themes were determined, we began thematic analysis (Cohen et al., 2000). After independently reading the transcripts a fourth time and selecting the passages that addressed each of the 10 themes identified during data reduction, we met to reach consensus on the passages and their association with particular themes. For each of the 10 themes, we moved back and forth between the data and discussion (Hill et al., 1997; Polkinghorne, 1989) until we reached consensus on an understanding of the meaning of each theme. Once this meaning was determined, we independently and then collectively identified exemplars, direct quotations from the data that best provided a voice for the meaning of each theme (Cohen et al, 2000). Many of these are cited below.

Emergent Themes

Table 1 provides a synopsis of the themes that emerged, with rich discription and participant comments provided below.

Attention to Gay and Lesbian Issues. This theme addressed the extent to which treatment facilities or meetings did or did not address issues that are particularly relevant to gay and lesbian clients. It includes counselor awareness, knowledge, and skills in working with this population. Nine of the 10 participants, five women and four men, made comments pertaining to this theme. The remarks were both positive and negative, meaning that in some instances participants identified situations that they experienced as particularly helpful and in other instances they identified attitudes or behaviors that they perceived to be detrimental. Sometimes experiences that participants identified as positive were explained as the absence of overtly negative, or homophobic, reactions. That is, they expected homophobic reactions and when they did not occur, participants interpreted the experience as positive.

There were three characteristics associated with this theme. The first was active homophobia. This occurred when participants experienced hostility or negative repercussions that they linked directly to their sexual orientation. For example, one woman remembered a time when she had been struggling and asked another woman for a comforting hug, which was common practice in the facility. In her case, the staff interpreted the request as a sexual advance. A second and more predominant characteristic was assumption of heterosexuality. This occurred when counselors or people at meetings took for granted that all participants were heterosexual. One 32-year-old woman commented, "but I can recall generally that I don't remember a single thing ... that would have been necessarily welcoming being a gay/lesbian person ... I don't specifically remember any explicit homophobia or anything like that; I think it was sort of your standard compulsory heterosexuality." Another participant, a 31-year old-woman, provided a more specific example, "We would have sort of general discussions about how to have healthy relationships and that kind of stuff was really geared towards a heterosexual person ... I don't think we ever had any kind of role-playing or a discussion about how this might look different in a lesbian couple or a gay male couple."

The third and final characteristic pertained to recommendations participants had for mental health counselors working with gay and lesbian alcoholics and addicts. Consistent with the overall theme, some of the recommendations were things the participants experienced positively and thought should be included in treatment, others pertained to negative experiences that needed to be done differently, and some referred to experiences missing in their own treatment but that they believed should be included. Perhaps the most consistent suggestion was the need for mental health counselors to address substance abuse and sexual orientation directly rather than waiting for clients to raise these issues. Participants particularly stressed the importance of being open with respect to sexual orientation rather than assuming everybody is heterosexual. Another common suggestion was for mental health counselors to become knowledgeable about both addiction and sexual orientation, as well as how they interact. Participants also spoke about the need for mental health counselors to move beyond political correctness or tolerance to affirmation based on knowledge.

In discussing the degree to which counselors and programs attended to gay and lesbian issues, participants seemed very attuned to the difference between talk and behavior. They recognized that simple statements of affirmation did not necessarily mean that a treatment facility or meeting was affirmative. A 69-year-old man pointed out that, "embracing it [gay or lesbian sexual orientation] in words doesn't necessarily mean that deep down within the person is not biased or not discriminating ... I've seen some subtle discrimination go on in treatment programs by people who were thought to be very sensitive ..."

In addition, some participants indicated that part of understanding sexual orientation includes understanding that it is only one aspect of a person's identity. For example, two of the women participants pointed out that sexual orientation is not always the most salient factor for those who identify as gay or lesbian. One of them reported irritation with the male focus of the program she attended and its failure to address issues specific to women. This male focus extended to Alcoholics Anonymous as well. The second, an African American woman, found racial discrimination to be a bigger concern for her than sexual orientation.

Mixed versus Gay and Lesbian Specific Programs/Meetings. Nine of the 10 participants, five women and four men, spoke about the value of programs or meetings that were specifically gay and lesbian oriented compared to those that both non-heterosexual and heterosexual individuals attended. Only one of the participants had attended a gay and lesbian specific treatment facility; all nine of them had attended gay and lesbian 12-step meetings. Thus, most of the comments referred to experience with meetings. Overall, participants found value in exclusively gay and lesbian meetings and events for several reasons. For example, these meetings provided an opportunity to come into contact with others who were both gay or lesbian and alcoholic, helping participants to learn self-acceptance through a sense of acceptance by others. In describing what gay and lesbian exclusive meetings offered, a 38-year-old woman explained, "I think more acceptance. I mean it's not a secret. You can't really go out into the general population and talk about your life as a lesbian and expect to be affirmed." Additionally, meeting others who were both gay or lesbian and in recovery also offered hope. This is further addressed in the theme below, "Importance of Role Models." Finally, meetings also provided an alternative to the gay bar, helping connect participants to a sober gay community. A 37-year-old woman noted, "I feel like I have a place in this community that isn't necessarily an anonymous place on a bar stool."

Although most of the participants found gay and lesbian specific meetings or events important to their recovery, one of the participants, a 32-year-old woman, preferred mixed meetings and mixed treatment facilities, indicating that this was more helpful to her because it better reflected the real world. "I think I would do best in a place that was both gay and straight ... I think that's the real world. There are very few people who live in a strictly gay world and I would want a recovery center that reflected what the rest of my life was going to be like." Another participant thought that gay and lesbian meetings could feel riskier to some because one would out oneself simply by attending.

Importance of Role Models. Six of the participants, three men and three women, addressed the significance of being exposed to potential role models. These role models included peers, counselors, and other members of the treatment staff. The role models were often individuals who were gay or both gay and in recovery. When discussing the counselor as a role model, participants pointed out the importance of having access to gay counselors. A 69-year-old man mentioned, "I think a lot more programs should do an active recruitment of gay counselors so that whatever gay clients they have feel they can be safe with at least that person." Some of the participants also commented on the importance of gay affirmative staff. A 37-year-old woman advised counselors to, "be a good role model whether you are straight or gay and being open minded because people are scared." One of the participants talked about a parallel between hiring counselors in recovery and hiring gay counselors, saying that clients need counselors who understand on a different level.

Beginning treatment for addiction provided access to other sober gay people, an association which had previously been lacking for some participants. Attending gay and lesbian exclusive AA meetings or treatment programs helped these participants to feel understood and be encouraged in their recovery process. According to some participants, the presence of other gay individuals helped to facilitate sharing. This involved sharing either their sexuality or their addiction status. For example, a 69-year-old man commented "being with other people who were gay and could admit it and also in recovery was a big, big help."

Two characteristics related to the importance of role models ran through the participants' stories. The first was connection. This addressed the sense of feeling alone in the world and feeling different from others. Finding somebody willing to share her or his story provided a sense of connection and identity. These role models helped the participants see that it was possible to be both gay and sober. A 57-year-old man noted how important it was to "... meet some other recovering alcoholic gay people that were happy and productive ... and I said wow, you know, you can be gay and ... sober and ... happy and ... have relationships and have a good job." In the spirit of giving back that is fundamental to AA, some participants intentionally attended mixed meetings as well as gay and lesbian meetings to be available for others who needed role models. As others had helped him, a 69-year-old man stated, "One of the reasons I'm at the point of sharing my gayness in meetings is because there are always people in the rooms who have not been able to share or who are afraid of sharing."

The second characteristic of the importance of role models was safety, which seemed to be facilitated for these participants by having access to role models. For example, the 69-year-old man mentioned, "Having people who could be honest about their sexuality and honest about their addiction was a fantastic example for me. They helped me accept who I am and not be ashamed of it." It seemed that finally these participants had found a place or people with whom it was safe to be who themselves.

Role of Alcoholics Anonymous (AA). All of the participants attended AA meetings and eight of them discussed the role that AA played in their recovery from addiction. Six of the participants spoke positively about AA, stating that it had been an important part of their recovery and continued to be a significant piece of sobriety even after a number of years. As an example, a 55-year-old man said, "I go to two or three [meetings] a week normally, sometimes more ... I continue to stay active and associate with a lot of AA people." In addition, these participants spoke specifically of the importance of sponsors and working through the twelve steps. Meetings were often a place to meet role models. As discussed above, gay and lesbian-exclusive meetings and mixed meetings seemed to offer different things to participants. A few participants also spoke of the empowering feeling of attending gay and lesbian AA conventions.

One 37-year-old female participant expressed negative views about AA and another female, although she attended, was rather ambivalent. The negative opinion seemed largely related to the way AA portrayed women. "I definitely felt alienated by the big book. I thought it was just the most misogynistic piece of--just so outdated and ... didn't address women today."

Shame. Eight of the 10 participants, four men and four women, addressed this theme. We experienced it as the most moving and intense of all the themes because the pain it generated was evident, even after many years and in people who had moved beyond it. Participants spoke about the profound sense of shame in being both gay and alcoholic. One 38-year-old woman who had worked with a therapist for years around sexual abuse issues stated that even that felt less shameful. "After working with her [therapist] for a couple of years, it almost felt like even after all the [sexual] abuse stuff, it almost felt like the most shameful thing I had to tell her." The experience of shame seemed compounded exponentially by the interaction of two factors that each brings shame independently, being gay and being an addict. Drinking could provide access to and a cover for gay sexual experiences, which they believed to be wrong due to the homophobia they experienced. A 55-year-old man stated, "I drank because it allowed me to be who I wanted to be." It also served as a coping mechanism. A 62-year-old man explained, "A lot of my drinking was to cover up the fact that I was gay." As participants came to understand the importance of honesty to recovery, they also realized the ways in which hiding and secrecy regarding sexual orientation reinforced the denial that was part of their addiction. Some participants mentioned the role that religious and/or geographic factors played in contributing to the shame they felt. For example, participants with a conservative religious upbringing seemed to struggle with overcoming messages they had learned about homosexuality growing up.

Working through shame to self-acceptance emerged as essential for recovery. Participants found that treatment facilities or meetings that were able to help them achieve this were particularly important A critical piece of this was feeling safe enough to be open and honest. Feeling accepted by others who had full knowledge of who they were helped them to accept themselves. A 69-year-old man commented, "And they did know who I was. They knew I was a gay male in the grips of an addiction and that knowledge helped me begin to get aware of who I was." A 37-year-old woman said, "It was in that place that I felt free enough to come out and also, you know, part of that had to do with ... like not feeling like a freak ... and being able to accept myself after looking at myself and saying, you know, that's okay." Participants also stressed that self-acceptance could come only with sobriety. The importance of sobriety for self-acceptance is discussed further below in the interaction between sexual orientation and addiction theme.

Boundary issues. This theme pertains to coming out as gay or lesbian, as well as being open about drinking and recovery status. We labeled it boundary issues because it specifically seemed to pertain to the factors that contributed to making openness possible or difficult. Participants spoke of their caution in disclosing these aspects of themselves to mental health counselors and others in treatment facilities or meetings, as well as in other circumstances. Nine of the 10 participants, five men and four women, addressed this theme. Eight spoke about concerns regarding coming out as gay or lesbian; two talked about caution in revealing their drinking or recovery status to others. The reasons this concern was in the forefront had to do with both the shame issues described above and with fear of the repercussions of being open. A 62-year-old man stated, "so much of this deals with fear of acceptance in society and we all want to be accepted and there is the fear that we won't be." This fear of acceptance applies not only to therapists and treatment staff, but to other clients as well. Thus, coming out to a mental health counselor involves not only that individual's personal reaction, but also concern about what he or she might do with the information. A 69-year-old man said, "a patient may not want to have that ]sexual orientation] announced, particularly in a residential setting he is going to be living and mixing with other men ... they fear a change in behavior toward them if they do acknowledge their orientation."

One of the things that made this a pressing issue was the emphasis that both treatment facilities and 12-step meetings place on honesty. Participants recognized that secrecy was detrimental to their ongoing recovery, yet also feared the consequences of being open. For instance, some participants worked in sensitive occupations or lived in conservative geographical areas or had family members who would not be accepting. Participants also understood that hiding took energy that could not be devoted to their recovery. Thus, many of the individuals we interviewed ultimately chose to come out, at least on a limited basis. A 38-year-old woman explained, "I got to the point where I had to be able to continue. I mean you can't hide something like that and work." At the same time, she realized that coming out was risky. "I guess, after working with her [therapist], I guess it was almost taking a chance because she really did become a very important person in my life ... and I relied upon her a great deal."

As with other themes, some of the comments here referred to experiences participants perceived as positive while others addressed experiences that were difficult or detrimental. In some instances participants expressed disappointment that sexual orientation was not addressed when doing so might have been helpful. For example, one woman indicated that even though she was open about her sexual orientation, it was never addressed. A man who did not come out in treatment, but who later found that addressing sexual orientation moved him forward in his recovery, stated that he would have been honest had he been asked: "I wanted sobriety bad enough that I figured if that was part of what I needed to get sober I would have discussed it."

Interaction between Sexual Orientation and Addiction. This theme addressed the ways in which being gay or lesbian and being an addict influenced each other. All 10 participants addressed this and all indicated, to varying degrees, that the two issues were related to each other. At the same time, however, the relationship was a complicated one. Several participants made a point of not blaming their addiction on their sexual orientation. Still, they talked about how interrelated the two issues were. Drinking or using drugs seemed to provide access to forbidden desires, as well as a coping mechanism for handling the psychological fallout of acting on them. A 69-year-old man explained, "Well, you see, it gave this very religious, very guilt-bound person permission to do the things he wanted to do because once I drank and used [drugs] that lowered my inhibitions. I wasn't philosophizing about the right and wrong of this ..."

In retrospect, through the benefit of recovery, participants could understand the limitations inherent in using chemicals to mask painful feelings. The man quoted above further stated, "It [drinking or using drugs] didn't change my denial. It didn't keep me from pretending that I was something that I wasn't, but it eased the guilt, permitted the behavior but didn't produce true acceptance." Just as drinking or using drugs and sexual orientation were twin struggles, recovery and acceptance of sexual orientation were also linked. Self-acceptance was necessary for long term recovery; however, such acceptance was not possible without recovery. A 51-year-old woman commented, "It's just the ability to be honest, be out, rather than always from the outside because I was so lost inside. I mean that's what rehab did ... brought me to more awareness of who I obviously was, in my own skin, not just because of alcohol and drugs but because of being a human being and being a homosexual female ... without it I don't know where I would be today."

Several participants also discussed ways in which being gay or lesbian fed their addiction. They pointed out the high level of chemical use in the gay community and commented about how easy it was to be an addict in such an environment. One 55-year-old man who spoke of using alcohol to act on his gay inclinations also said, "It seemed like wherever gay people were they were drinking, but, again, that's my view as an alcoholic. To me it really enabled me to drink a lot more and maybe hit my bottom quicker." The participants in this study seemed to recognize that they were not alcoholics or addicts because they were gay or lesbian, but being gay or lesbian influenced how they experienced their addiction and their recovery.

Suicide. There were not a lot of comments about suicide, but six of the 10 participants, three women and three men, raised the issue without prompting and when they did, their statements were strong. For example, one 32-year-old woman stated, "I didn't know I was gay when I was a teenager because I certainly think I would have killed myself." All who spoke about suicide either had considered it themselves or knew others who had. Some also mentioned the high rate of suicide in the gay community. In all instances, participants linked suicide to lack of acceptance as a gay or lesbian individual. A 37-year-old woman said, "I've heard way too many stories about people being suicidal because they could not come out to their families or they could not accept the fact that they were, you know, GLBTQ [gay, lesbian, bisexual, transgender, questioning]." Some participants speculated that use of alcohol or other drugs exacerbated the risk of suicide; some recognized addiction as a slower form of suicide. Most participants did not discuss suicide in conjunction with their treatment; however, one man who, prior to his recovery, hospitalized himself for suicidal depression indicated that the facility addressed neither his drinking nor his sexual orientation.

Treatment as a Safe Space. The key element of this theme was the belief that safety is necessary for honesty and honesty is critical to recovery. Nine of the 10 participants addressed this, five women and four men. Participants spoke about how important it was for them to be able to talk openly about their sexual orientation both in treatment and in meetings. Although participants did not always find it necessary to focus on sexual orientation, it was important that they not have to focus on hiding it. A 38-year-old woman said, "I think the best thing my therapist did was to just let me know that I was okay and that what I was feeling was okay and that it was okay to be who I am ... so if it is affirmative and okay to be who you are, then you can just move beyond the homosexuality part and move to what the real problem is."

Participants repeatedly said that they needed to know that the mental health professionals they were working with could be affirmative of their whole selves, including their sexual orientation. When that occurred, it helped participants to move forward in their recovery. A 69-year-old man said, "I think the counselor should try to make that person feel comfortable and give him the knowledge that anything he shares is going to be helpful in recovery." Participants wanted mental health professionals and sponsors to help them to strike the balance in knowing when it is important to be honest and when it is judicious to be cautious about revealing sexual orientation. They had justifiable fears about the consequences of being open, but also understood that hiding sapped their energy. They sometimes approached treatment cautiously and needed their mental health counselors to refute this in both actions and words. A 31-year-old woman stated, "I definitely think in the beginning, I felt like there would be some sort of backlash or judgment or something. She [counselor] sort of proved very quickly that that was not going to happen." About coming out to her counselor, a 38-year-old woman stated appreciatively, "It wasn't a shock ... it was just mater-of-factly okay."

A couple of participants suggested that treatment facilities need to hire openly gay and lesbian counselors, just as they hire counselors who are in recovery. These participants thought that the presence of such individuals helped to create an atmosphere of safety but the issue was complex. One participant stated that when she first entered treatment, she felt more comfortable with the lesbian counselor; however, as she got closer to termination she realized that she might encounter this person in the local lesbian community and became more cautious about how much she wanted to share. By this time, her comfort level with other counselors had increased, so she turned more to them. A 31-year-old woman indicated that she specifically looked for a facility that included sexual orientation in its non-discrimination statement. "It definitely put me more at ease from day one to know that that was included in the anti-discrimination clause." Some participants mentioned that they first observed how other minorities were treated before deciding whether or not to come out as gay or lesbian. When it was clear that bias and prejudice would not be tolerated in a facility, participants felt safer with respect to their sexual orientation.

Issues Related to Family. This theme pertained to issues participants needed to address or did address with respect to family. Seven participants, five women and two men, made comments related to this theme. The theme incorporated a number of concerns, including families of origin, lesbian or gay partners, children, and previous heterosexual marriages, as well as discussion of the facilities' understanding of family. Several participants discussed their family of origin, either with respect to a history of addiction or to struggling with the family's reaction or potential reaction to the participant's sexual orientation. A few participants expressed feeling pressure to address sexual orientation with the family of origin when participants were reluctant to do so, although this did not seem to be widespread. Failure to address sexual orientation seemed more common. For example, one female participant indicated that although her children were allowed to stay with her in the treatment facility and parenting issues were addressed to some extent, there was no discussion about specific issues facing lesbian or gay parents. Other participants indicated that although they were not in relationships at the time they were in treatment, nothing occurred that led them to believe their partners would have been included in family programming. Although it is now common practice for treatment facilities to include programming for the families of clients, a few of the participants had attended treatment prior to the widespread practice of programming for families and noted the absence of it.

The experiences were not all negative. Several participants mentioned particularly helpful experiences. These seemed to occur when treatment facilities made an effort to be inclusive. A 31-year-old woman commented, "This was really an open environment of bring whoever you want to be considered family into the family meetings and it worked. It was actually really nice."

DISCUSSION

We were interested in getting a better understanding of the experiences gay and lesbian individuals in recovery from addiction had in treatment for their addiction. The results lend some empirical support to those who suggest that there are unique issues facing this population that need to be addressed in addiction treatment (e.g., Beatty et al., 1999; Cabaj, 1996, 1997; Cheng, 2003; Ratner, 1993). From a theoretical perspective, there also seems to be some support for the idea that counselors and others who were able to respond to the participants in this study in ways that took their cultural concerns into account were most effective and most appreciated.

All of the participants believed that there was some interaction between their sexual orientation and their addiction, which is consistent with other literature in the field (e.g., Beatty et al., 1999; Cabaj, 1996, 1997, 2000; Finnegan & McNally, 2002) This does not mean that one causes the other, but that participants' experience of each (sexual orientation and addiction) was influenced by the other. As such, they believed that successful recovery required attention to both issues. Sometimes this occurred in treatment; sometimes it occurred later. At the same time, it is important to pay attention to the complexities of peoples' lives. In some instances participants reported that gender or race were more salient for them than sexual orientation. Such experiences are consistent with multicultural theory (Sue et al., 1996), which advocates learning and addressing the cultural issues that are most meaningful to clients at the time of treatment.

It was not surprising that participants discussed the importance of role models. Addiction treatment programs have long recognized the value in recovering addicts offering guidance and support to those struggling to achieve sobriety. The participants in this study reported that they benefited not only from role models who were in healthy recovery but also role models who were gay or lesbian, which is consistent with the recommendations of others (Beatty et al., 1999; Cabaj, 2000). This makes sense given that there are some commonalities in experience. Gays and lesbians and people in recovery from addiction represent hidden populations that are stigmatized by the larger society. Shame is often a core aspect of both experiences, and indeed was one of the themes that emerged in this study. Other researchers have made connections between heterosexism, internalized homophobia and shame (Cabaj, 2000; Neisen, 1993); this is an area ripe for more research. Despite these commonalities, there are nonetheless barriers to connection, with heterosexism often present in the recovering community and alcohol and other drugs often prevalent in the gay and lesbian community. It thus seems important for mental health counselors to help facilitate clients' connections with people who can serve as healthy role models with respect to both recovery and sexual orientation.

Self-acceptance also emerged as an important issue related to shame and necessary for recovery. Matthews, Lorah, and Fenton (in press) also found self-acceptance to be a critical factor in their study of lesbians' recovery from addiction. This, too, seems in keeping with traditional approaches to treatment and certainly AA. Acknowledging that one is alcoholic (or an addict) is built into the 12 steps. These participants likewise found it important to be able to acknowledge and accept themselves as lesbian or gay, which is consistent with the literature (e.g., Cabaj, 2000; Finnagan & McNally, 2002) Again, affirmative treatment involves helping clients to address both of these aspects of themselves that have the capacity to contribute to shame, not simply the addiction.

We did not focus on gay or lesbian identity development in this study; however, a number of issues emerged that are consistent with theory in this area (e.g., Cass, 1979, 1996; McCarn & Fassinger, 1996). For example, most models generally agree that individuals move from a state of non-awareness of a gay or lesbian orientation through awareness to acceptance and integration of a gay or lesbian identity, with the caveat that not everybody will move all the way through. There was evidence of this with the participants in this study, especially in their discussions of the interaction between sexual orientation and addiction. Addiction interfered with their ability to develop a healthy gay or lesbian identity; healthy sobriety was necessary for self-acceptance. This suggests that more directed research regarding the influence of addiction on identity development is warranted.

These models also suggest that at some point in their development individuals actively seek out others who are gay or lesbian. This was the case for these participants. Almost all of the participants spoke of attending gay AA meetings at some point and there were some poignant comments about finding a sober gay community At the same time, participants also expressed different preferences regarding gay or mixed programs or meetings. This could possibly be reflective of different stages of identity development among the participants. We did not assess gay or lesbian identity development in this study, but this would be worth further investigation. McCarn and Fassinger (1996) addressed the issue of outness and development, cautioning that there may be important contextual reasons to remain closeted, even when one has fully integrated a gay or lesbian identity. Some of the participants addressed this concern, indicating that it was important for mental health counselors to respect their choices and to be able to help them to assess the appropriateness of being out in different contexts.

Although this is a small study, we believe that it nonetheless offers some insight that can help mental health counselors working in the area of addictions to better serve this population. Indeed, given that 25% to 85% of clients being treated for any mental health disorder also have co-occurring problems with substance abuse (Pidcock & Polansky, 2001), all mental health counselors could find the information useful. Based on our work, we offer the following recommendations as a place to begin affirmative mental health counseling with gay and lesbian clients struggling with addiction:

* Be aware of your own attitudes and behaviors with respect to both addiction and sexual orientation

* Be affirming and accepting regarding both sexual orientation and addiction

* Understand the role that shame plays with both sexual orientation and addiction

* Understand the role that bars play for many lesbian and gay individuals and be familiar with alternative resources to recommend

* Help clients access the sober gay and lesbian community

* Understand the role that family plays in recovery; be open to who gay and lesbian clients consider family; involve this family in treatment

* Be aware of the potential impact that you have on gay and lesbian clients because you may be the only person a client has shared with and your responses will be very important

* Help clients to be honest with themselves and to develop skills for assessing when honesty with others is and is not safe

* Understand the complicated interrelationship between sexual orientation and addiction and help clients to address both in recovery

As with any study, this one has its limitations. It was a small study and participants were self-selected. Thus, it is not only a convenience sample, but determination of sexual orientation and recovery status was by self-report. Furthermore, no attempt was made to determine where participants were in the process of sexual orientation identity development. Research in this area (e.g., Cass, 1996; McCarn & Fassinger, 1996) suggests that individuals may respond differently to issues related to sexual orientation depending on where they are in their own identity development. Closer examination of this is important, especially given the interaction between sexual orientation and addiction. As a qualitative study with a consensual approach to analysis, we did not examine inter-rater reliability as might be typical in other types of analyses. Retrospective accounts must also be viewed with caution. In some instances, participants' treatment experiences occurred many years before the study. Although participants in this study seemed to have vivid recollections of the experiences they described, they were, nonetheless, recollections. Furthermore, one must also wonder about the experiences that were not recalled. Still, there were consistencies between the reports of the participants in this study and Eliason's (2000) study of substance abuse counselors' attitudes toward gay and lesbian individuals. Larger, more representative studies are warranted.

APPENDIX

Prompt Questions

* Can you begin with a sort of historical overview of your treatment experiences (i.e., how many times have you been in treatment, what type of treatment, how long, etc.)?

* Please talk a bit, in a general way, about what it has been like for you to be a gay, lesbian, or bisexual individual in addiction treatment.

* Tell me a bit about how, if at all, you addressed your sexual orientation during these treatment experiences. Were you out to yourself? Your counselor? Others in the program? If you had more than one treatment experience, were there differences in how you addressed your sexual orientation? Were there differences in how the counselors and the programs addressed your sexual orientation? What are some of the factors that contributed to the ways in which you did or did not address your sexual orientation?

* Talk about some of the ways that any of the treatment programs you have been involved with addressed your sexual orientation that felt particularly affirmative or helpful to you in your recovery efforts.

* Talk about some of the ways that any of the treatment programs you have been involved with addressed your sexual orientation that felt counterproductive or detrimental that maybe even hindered or slowed your recovery efforts. Include here instances where sexual orientation was not addressed but needed to be addressed.

* Are there things related to your sexual orientation that did not occur in any of your treatment experiences that you believe would have been helpful to your recovery efforts had they been addressed?

* Were there ways that any of the treatment programs were particularly helpful or, conversely, detrimental in working with family issues related to your sexual orientation (i.e., addressed issues related to coming out, had an open enough definition of family to include those whom you consider family, even if not related by blood or law)?

* To what extent do you believe that concerns related to sexual orientation are related to your own addiction and, likewise, to your own recovery efforts (i.e., is this something that it is even necessary to address in addiction treatment)?

* What do you consider to be the most important things that addiction counselors need to do to be most helpful to lesbians, gay men, and bisexual individuals in their recovery efforts?

* Is there anything that you would like to add that we have not asked?

* Do you have any questions for us?

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Connie R. Matthews, Ph.D., is an assistant professor of Counselor Education and Women's Studies at the Pennsylvania State University, 333 CEDAR Building, University Park, PA 16802, cxm206@psu.edu, (814) 863-6153. Peggy Lorah, D. Ed., is director of the Center for Women Students and affiliate assistant professor of counselor education at the Pennsylvania State University, 135 Boucke Building, University Park, PA 16802, mal73@sa.psu.edu, (814) 863-2027. Jaime Fenton is a doctoral candidate in counseling psychology at The Pennsylvania State University, 327 CEDAR Building, University Park, PA 16802, jmf166@psu.edu, (814) 865-3427.
Table 1
Emergent Themes

 No. of
Theme Brief Description Participants

Attention to Gay and The extent to which gay and/or 5 Women; 4 Men
Lesbian Issues lesbian issues were addressed
 by the treatment facility,
 either affirmatively or with
 bias.

Mixed versus Gay and Participants' perspectives 5 Women; 4 Men
Lesbian Specific on the value of programs or
Programs/Meetings meetings specifically geared
 to gays and lesbians compared
 to ones that were more
 general.

Importance of Role The importance of having 3 Women; 3 Men
Models access to people who could
 model healthy, affirmative
 behavior with respect to
 sexual orientation, sobriety
 or both.

Role of Alcoholics Participants' perspectives on All
Anonymous (AA) the role AA played in their
 recovery from addiction.

Shame Participants' intense shame at 4 Women; 4 Men
 being both gay or lesbian and
 addicted and the importance of
 self-acceptance to recovery.

Boundary Issues Factors contributing to or 4 Women; 5 Men
 hindering participants'
 ability to be open about
 sexual orientation and
 addiction.

Interaction Between Participants' perspectives All
Sexual Orientation on the ways in which their
and Addiction sexual orientation and their
 addiction influenced each
 other.

Suicide Participants' comments about 3 Women; 3 Men
 thoughts related to suicide
 in reference to themselves or
 someone they knew.

Treatment as a The importance to recovery of 5 Women; 4 Men
Safe Space having safe space in which to
 address sexual orientation.
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