This article will examine three issues: (1) the context within which family treatment of chemically dependent gay men and lesbians takes place; (2) the concepts which underlie any understanding of how to provide quality treatment to them; and (3) examples of practical approaches to providing such treatment.
When chemical dependency counselors work with lesbians and gay men, it is important for them to consider both the context of their clients' lives and the concepts that influence them. First, as is true of all people struggling to recover from chemical dependency, the situations, feelings and attitudes that gay and lesbian people must deal with are often complex. Counselors need, however, to learn about, become sensitive to, acknowledge, and respond to the stressors specific to being lesbian or gay in this society.
Many of the difficulties experienced by lesbians or gay men that are unique to this population are generated by homophobia. For example, growing up as a gay man or lesbian in a heterosexual and
homophobic family and having to keep secret one's sexual identity and affectional preference creates a powerful dysfunction that is a result not of the individual's homosexuality but of society's homophobia.
Thus it is not enough to say that clients' chemical dependency is always the only justifiable focus early in treatment. There are times when people's concerns about their sexual orientation may demand attention if they are to get or stay clean and sober. For instance, counselors need to recognize that sometimes it is very important to validate client's bitter or pained assertions that homophobia has seriously contributed to their chemical dependency.
Second, the definitions of family are changing in this culture, and the meanings of these new definitions need to be applied to lesbian's and gay men's lives. All too often there is a tendency to see lesbians and gay men primarily, if not solely, as individuals rather than as members of families of origin and as creators of new family systems. These families of creation may serve as additions to and/or placements for nuclear families.
Therefore, a new comprehensive perspective on family is called for. Counselors need to know that gay men and lesbians may have children from earlier heterosexual relationships or may choose to have children by artificial insemination or through adoption. Furthermore, gay people who do not have children usually create a family system comprised of friends, some of whom may be current or ex-lovers.
In the 1970's, many chemical dependency counselors did not tend to "think family" when they worked with their chemically dependent client. If they thought about the family, it usually was to consider whether or not the spouse (usually the wife) could or would be helpful to the addicted client's recovery. But most counselors were not trained to think of the individual client as part of a larger system that impacted upon the client's efforts to recover from alcoholism or other drug abuse. That perspective has changed significantly in the past ten or fifteen years. Most professionals now treat chemical dependency as a family illness--at least with clients who are heterosexual or presumed to be so.
Unfortunately, this family perspective often does not get applied to clients who are lesbian or gay. All too frequently, counselors view and treat lesbian or gay clients as if they were single, discrete beings who hail from some distant and unknown planet without any human relationships. Counselors who do not assess lesbian or gay clients within the context of their families and friendships may provide these clients with good individual treatment, but too often ignore their larger, critically important human systems.
Perhaps because so many heterosexual counselors have little if any knowledge of or personal acquaintance with gay men or lesbians, they regard the lesbian or gay client as different and foreign to their experience. Thus, all too often, clinicians who know that a family perspective is vital to good treatment because chemical dependency is a family disease do not recognize the relevance of that perspective to gay men and lesbians who are chemically dependent.
The third consideration counselors need to bear in mind is that growing up lesbian or gay in a "heterosexual family" is, by its very nature, a dysfunctional process--unless the family is not homophobic. Unfortunately, most families are at least somewhat homophobic. We are not saying that being lesbian or gay is dysfunctional. Rather, we are contending that when people grow up in a family system where they cannot be or say who they truly are, they are placed in a position of dysfunction. The prejudicial and oppressive values of the system and the actions based on those values make the system, not the individual, dysfunctional.
A system is dysfunctional when it forces its members to create a "false self" in order to survive. And that is precisely what children or adolescents who become aware of same-sex feelings and attractions do to survive. They create a false self which is different from who they really are and which prevents them from being known by even those closest to them. They must "split off" and hide a central part of themselves and must live a lie within the heart of their family. If other dysfunctional features exist in the family system--for example, chemical dependency--then the lesbian or gay child must contend with intensified problems, a kind of "double trouble."
This context and these concepts need to form the backdrop for all considerations about treatment approaches. Otherwise, we will add to our lesbian and gay male clients' problems, rather than contribute to their solutions.
Rhonda was a thirty five year old married housewife living in a medium sized midwestern city who had three prior admissions for detox. Each of her relapses had occurred while she was attending AA and ostensibly "working her program." She presented as seriously depressed and freely talked about wanting to hurt herself. During an individual counseling session, Doris, a lesbian nurse on the inpatient unit, shared with Rhonda that ten years earlier she had almost killed herself with prescription drugs and alcohol when this appeared to be an easier solution than leaving her husband of twelve years because she could no longer pretend that she was not attracted to women. Rhonda's eyes widened and she began to ask the nurse questions about her experience, without once ever admitting that she might have similar feelings. A few weeks after Rhonda was discharged Doris ran into Rhonda at an AA meeting. Rhonda told Doris that her disclosure provided for the first time in her adult life hope that perhaps she could stop using.
When questioned about why she had chosen to take this therapeutic approach, Doris explained that she had considered all other possible reasons for Rhonda's continued relapsing. As far as she could see there were no valid explanations for Rhonda's inability to maintain her sobriety when she was apparently doing everything right and going to AA every day. "I asked myself what could possibly be going on for this woman that I didn't know about or hadn't asked about that would explain her picking up. Something in the kind of pain that Rhonda was expressing reminded me of my own pain and conflict before I got sober," Doris said. "So I decided to take a chance by sharing my story with this patient. She was too fragile for me to ask directly about the possibility that she might be lesbian.
Chemical dependency workers can learn an important lesson from this case. The lesson is that when a patient is relapsing in active drug/alcohol use without any obvious or apparently understandable reason, unresolved sexual identity conflict may well be the cause. Counselors need to be willing and ready to explore this possibility with appropriate patients.
One suggested intervention is to share Doris's story with a client and say "I don't know if this has any relevance for you, bu! thought I would just share this anyway." When questioned about what in addition to her own intuition and the seeming lack of a reasons for Rhonda's inability to remain sober had clued Doris in issues about lesbianism, Doris said she remembered that when s asked about Rhonda's marriage and sex life with her husband Rhonda had ever so slightly shuddered and looked away. She denied any sexual or other abuse from her husband who was a non drinker in Al-Anon. "This subtle reaction, that Rhonda was probably not even aware of, just rang a bell," Doris explained. Retelling Rhonda's story would be an excellent use of metaphor during treatment, a well-accepted family and systems technique.
Rhonda's case is a good illustration of why counselors need question all clients about sexual orientation. It is the responsibility of each counselor to take the lead in this area the same way Counselors routinely question early family history, dynamics of shame denial and spirituality. By omitting questions about sexual orientation, or the more subtle questions about sexual or affectional feelings or fantasies for a person of the same sex, the counselor is obtaining information about all the possible contributing factors achieving and maintaining sobriety.
Thus during interviews or counseling sessions counselors should specifically and routinely be asking all clients questions about significant love relationships or spouses and lovers instead of only using the words marriages, husbands and wives. However, directly asking a patient who is only a few days sober, "What is your sexual orientation?" may be too threatening for the client to answer honestly. A gentler way of opening this area up is to ask, "Have you ever had erotic or romantic feelings, fantasies or dreams that involved a person of the same sex even if you have never acted on these feelings?" Even if the client doesn't answer these kinds of questions and appears uncomfortable, counselors shouldn't take this silence as an indication that questions or statements about sexual orientation are not on target. Furthermore, it is important for counselors to ask them in order to convey to a frightened patient that the counselor is willing to talk about and hear issues pertaining to sexual identity.
Yet if a client's denial about his or her own sexual orientation is life threatening, the way it clearly was in Rhonda's case, then this denial must gently and empathically be addressed. If Rhonda had not even heard that there was a professional who could articulate her intimate concerns, she probably would have continued to use or possibly would have killed herself. Generally these are patients who have had chronic slips for no apparent reason, or people who wind up In psychiatric units following an unexplainable suicide attempt. Very often these are heterosexually married individuals who appear to be the farthest thing from lesbian or gay. They often have children. For these people, finally having a health care or substance abuse professional help them to look at this part of themselves in a nonjudgmental manner may be the only road to recovery.
A family or systems perspective that includes the varieties of diverse family types that increasingly more Americans have created for themselves is essential in the field of substance abuse even if the identified patient is definitely not lesbian or gay. The authors are familiar with a case where a young adult was in rehab. His mother is a lesbian who has lived with her woman lover for the past twelve years. The lover was and remains an important parental figure to this young man. Even after both women visited him during rehab, none of the staff ever asked who his mother's friend was or about the nature of this young man's relationship with this woman.
When this man was discharged from rehab, he went to live with these two women, one of whom is in recovery and the other a long time member of Al-Anon. Thus he went directly from rehab to live in a family system that the treatment facility knew nothing about.
This man had not even discussed with his counselor how stressful it was for him to be living with two lesbians, even though he really liked both of them. This man has tremendous conflicts that stem from his being ashamed that his mother is a lesbian. He never talked about this during rehab, and for a long time never shared this information either with his sponsor or during meetings. Had one of these women been an active alcoholic or drug addict his prospects for continued sobriety would have been even more threatened.
A related area that needs to be explored is asking heterosexual patients in treatment about siblings who might be lesbian or gay. One seventeen year old woman just entering rehab for the first time was very frightened about her older sister. She adored this sister who was a lesbian and feared this might mean that she was one also. In addition, she was very ashamed that her beloved sister was a lesbian, and that if her friends found this out, they would tease her. If this young woman's counselors in the rehab had not asked about her family members in enough detail so that her sister's lesbianism was unmentioned, they could not have helped her deal either with her fears regarding her own sexual orientation or her shame about her sister. If either of these issues were left undiscussed in the early phase of recovery, they could have contributed to this person's relapse.
If parents have had a difficult time accepting the homosexuality of the brother or sister of the individual in treatment, or if this is a shame-filled family secret, probing this can offer valuable insights into how rigid and/or dysfunctional the family system is. This information is essential for the counselor to learn in order to ascertain what appropriate discharge and after-care planning will consist of.
Long term treatment for the lesbian or gay man who is in recovery must take a family perspective which accounts for both his o, her family of origin as well as any family systems that he or she has created. This is crucial because many lesbians and gay men grow up feeling terribly isolated. This sense of isolation persists and increases if they marry and have families. Even for some well-integrated lesbians or gay men who have friendship groups, lovers and perhaps even children, there often remain feelings of isolation and alienation that stem from unresolved feelings about their own homosexuality and society's homophobia.
As mentioned earlier, an important consideration counselors need to bear in mind is that growing up gay or lesbian in a family that assumes the heterosexuality of all its members is, by its very nature, a dysfunctional process--unless the family is not homophobic.
Sam, always his grandmother's favorite, knew that he was attracted to other boys for most of his life, and somehow also knew that he couldn't talk about this with anyone. One day when he was ten, he was reading Time magazine with his grandmother. In response to a story about homosexuals she casually said, "We have to pray for those sick people." Sam recounted in a therapy session that he clearly remembers how much this comment frightened him and made him sad because he knew that grandma was talking about him but that she had no idea he was one of those people she was talking about. For the first time in his life he felt very distant from her since he now began to doubt whether she would love him if she knew that he was "one of those sick people."
For Sam this was the beginning of creating a false self that resulted in his having a dysfunctional relationship with an otherwise generally stable and loving family. His resolve to hide his strong feelings for other boys and men grew after this incident. Perceiving that in order to keep his family's adoration he needed to pretend to be different from who he really was caused Sam to develop a lot of shame about some of his most central and most normal feelings. In order to protect his status of being loved and valued by his family he began trying to deny that he even had feelings for boys because his feelings were different from what was expected of him by his family. He also carefully avoided discussing these feelings and tried to behave in the manner that would assure the continued respect and love of his family. This was the beginning of Sam's behaving in co-dependent manner that has plagued him ever since. Luckily aside from normal unexamined homophobia and heterosexual bias Sam's family was not dysfunctional in other ways. Thus there we not secrets related to alcoholism, violence or incest that also had be hidden and would have become additional sources of shame guilt
Once again we reiterate that we are not saying that being lesbian or gay is in itself dysfunctional. Rather we are pointing out that society's prejudicial and oppressive values that simply assume that everyone is the same, i.e., heterosexual, result in the majority children who grow up to be lesbian or gay feeling like outsiders within their own families. This feeling of difference becomes translated into being wrong or bad. If other dysfunctional features exist in the same family system--for example, alcoholism--then the gay or lesbian child must contend with intensified problems which compound the hurt they already feel living as a member of their particular family.
As the authors do long term intra-psychic therapy, we are increasingly finding that even after many years abstinence from alcohol or drugs our clients discover memories of early childhood abuse and incest that have been buried deep in their unconscious. Very often the abuse or incest occurred even before the child knew he was gay or she was lesbian. Most often the shame and sense of difference caused by the abuse predates any sense of sexual identity formation. During the course of therapy, most gay men or lesbians will easily recall early childhood memories of feeling different and bad which they connect to their homosexuality. While these memories and feelings are important to explore, the skilled therapist must also lead his or her client in a search that could turn up feeling self-loathing and low self-esteem that occurred even before their feelings for persons of the same sex began to emerge. The counselor then can help the client differentiate between internalized homophobia and other sources of shame.
Especially with clients who are in recovery from substance abuse, questioning them about memories they have that predate the formation of a sexual identity is essential. Some people knew that they were attracted to other boys or girls from their earliest awareness. Other people did not begin to recognize these feelings or suppressed them until puberty or even adulthood. Often gay or lesbian clients will not have looked at their lives and experiences prior to their first feelings of shame or difference that stem from the onset of homosexual feelings. In order for true healing and insight to occur, clients must learn to differentiate between the problems that have their etiology in traumas experienced as a result of situations that were distinct and separate from their homosexuality. Yet the shame about their early homosexual feelings is usually viewed by clients as the only reason they have felt different or damaged. Skilled therapy needs to help clients tease apart these separate, yet interrelated issues. One manifestation of internalized homophobia is commonly exhibited when lesbian or gay clients blame all of their early painful feelings solely upon their homosexuality. A thorough therapeutic exploration of the early family reality is necessary for both the therapist and client to gain a good understanding of what it was like for this child to grow up, and in what ways he or she was damaged long before same sex feelings emerged.
When a lesbian or gay man abuses alcohol or drugs, the dysfunction the substance abuse creates for his or her family of creation (lover, roommate or friends) is in addition to the historical dysfunction each lesbian or gay man grew up with as a member of a homophobic family. These dual aspects of dysfunctions occur simultaneously and inter-relatedly for both the person who is abusing as well as for his or her support system or lover, friends and nuclear family. For real and lasting sobriety to be achieved these different but complementary dysfunctions must be addressed and brought into the open for all parties involved.
A family or systems perspective is also useful working with lesbians or gay men who have a well integrated identity as gay or lesbian. One characteristic of men and women who have developed a positive lesbian or gay identity is that they have formed a strong family of supportive friends and perhaps are in a committed relationship. The following example illustrates how understanding the dynamics of these families can be useful when working with a ga man in recovery.
Ralph is a fifty year old gay white man who lives in Manhattan. He has been with his lover Paul for fourteen years. He sought out therapy with one of the authors because he was concerned about his alcohol and cocaine use. After the first consultation he began to attend AA and recently celebrated his two year anniversary clean and dry.
Ralph and Paul had always done a lot of cocaine together, especially when having sex. Even after Ralph entered the program, Paul continued to use in their home and would attempt to seduce Ralph into using so that they could have sex. On advice from his sponsor, Ralph elected to tell Paul that he would love to have sex with him, but only if he wasn't under the influence of any drug. This enraged Paul, and they have not had sex in over eighteen months.
In Ralph's thirteenth month of sobriety, he and Paul had an argument that escalated into a fist fight. Greatly shaken by the domestic violence, Ralph temporarily moved out of their apartment and in with his sponsor. Simultaneously he began attend Al-Anon meetings.
They eventually negotiated Ralph's moving back in on the condition that Paul stop using drugs and go to AA. Newly sober, Paul was not interested in having sex. This caused Ralph a great deal of frustration since he and Paul shared the same bed, were both committed to monogamy, and they did not have any physical affection Shortly after Paul celebrated 90 days sober Ralph and he began talking about slowly trying to resume being physical and sexual. Two days later Paul told Ralph that he had used cocaine recently.
Because the only blood family that Ralph has is one sister who lives over fifteen hundred miles away, and with whom he is not particularly close, Paul is his primary family. Their extended family of creation has shrunk since the onset of AIDS. More than ten close friends who they considered to be "family" have died in the past four years.
This couple is exceptionally stressed for several reasons. First of all they are mourning their decimated friendship group. Two of these people died in the past three months, and both Ralph and Paul were very involved in caring for these men as they got progressively more debilitated. Their relationship is currently and actively dysfunctional since Paul is still abusing cocaine. Ralph feels very dependent upon Paul even though due to Paul's drug abuse he is rarely emotionally available to Ralph. Only a family/systems approach to treatment can address the multiple stressors Ralph is currently struggling with. Ralph's treatment consists in part of encouraging him to build a new family within AA that includes his sponsor and supportive friends he has met in the rooms. The suggestion that Ralph actively pursue building a new family within AA was aimed at removing the pressure Paul felt about having to be all things to Ralph.
Using a family/systems approach to treatment helps the newly recovering lesbian or gay client to understand, value and nurture his or her relationships with lovers and friends as well as blood family In effect this form of treatment is essential for lesbians and gay men who have proven themselves remarkably resourceful in creating new families that support and celebrate their lifestyle and relationships. For recovering people who are lucky enough to live in areas where there are lesbian and gay AA meetings, sober families of recovering people have been created as well, and are an essential component to living clean and sober.
Counselors and therapists need to recognize another important issue that is relevant to family work with their lesbian and gay clients. For more than ten years now, since the onset of the AIDS health crisis, these families have lost many members. Lesbians and gay men have taken care of beloved friends with AIDS and wale helplessly as they died.
For some people like Ralph and Paul, almost entire friend' groups have been wiped out. This has created some new problems for recovering people who have achieved and maintained their sobriety in lesbian and gay AA. People with AIDS share in the rooms about their illness, deterioration, fears and early demise. Others are sharing about their pain, rage and grief at having loved ones achieve sobriety, only to watch them wither and die from AIDS. Along with the joy and serenity of sobriety, the lesbian and gay AA rooms contain an enormous amount of pain and sadness these days. Some of our clients report that they cannot go to these meetings as much anymore, or in some cases at all, because it is too painful to listen to what is being shared, to see sober friends waste away, and to sit in the room with all the ghosts of friends who died.
Gay or lesbian clients who are struggling to maintain sober today face the additional stress of living in a community increasingly devastated by AIDS. Their friends, their lovers or they themselves may be infected with HIV or may be dying from AIDS. Counselors must recognize that these friendship groups and relationships constitute families for their clients. In the counseling they must clearly communicate their understanding that these are families, and then validate and honor these family systems. Doing this will empower both the client and his or her family of creation. Only by fully empathizing with how powerful the connections are between the client and the person or people who are ill can the counselor help the client do the grief work and mourning that is necessary. Ultimately the client will need the counselor's help and support to build new relationships and family systems to replace ones that have been decimated.
It is important for chemical dependency counselors to keep certain points in mind when working with gay or lesbian clients. One is that chemical dependency is a family disease, one that intimately and powerfully affects all who are involved in the family system of the chemically dependent person, regardless of his or her sexual orientation. This fact requires a family systems perspective if one is to adequately address the ravages of the disease. Another point is that very little support or recognition is afforded to lesbian or gay love relationships, friendships, and families.
Thus the well-meaning counselor who fails to work from a family perspective with lesbian and gay clients is not helping clients to establish the foundations of long-term recovery. Rather, this counselor may be undermining the recovery process by blocking or at the least ignoring the system within which clients must recover. It imperative to know whether or not clients' support systems are positive or negative. Without this information, aftercare cannot be adequately planned or carried out. The last and most important point centers on counselors' attitudes. Unless counselors are willing to respect and honor the created families of lesbians and gay men and to work with those systems as family systems, the treatment offer, will be seriously lacking, if not directly harmful.
REFERENCES
Finnegan, D.G., & McNally, E.B. (1987). Dual identities: Counseling chemically dependent gay men and lesbians. Center City, MN: Hazelden.
Finnegan, D.G., McNally, E.B., & Fischer, G. (1984). Alcoholism and chemical dependency. In F. Schwaber & M. Shernoff (Eds.), Sourcebook on lesbian/gay issues (pp. 47-49). New York: National Gay Health Education Foundation.
Finnegan, D.G., McNally, E.B. (1988). The lonely journey: Lesbians and men who are co-dependent. In M. Shernoff & W; A. Scott (Eds.), The sourcebook on lesbian/gay health care (2nd edition) (173-182). Washington, D. The National Lesbian/Gay Health Foundation.
Hanley-Hackenbruck, P. (1989). Psychotherapy and the "coming out" process Journal of Gay & Lesbian Psychotherapy, 1(1), 21-39.
Pohl, M. (1988). Recovery from alcoholism and chemical dependence for lesbians and gay men. In M. Shernoff & W.A. Scott (Eds.), The sourcebook on lesbian/gay health care (2nd ed.) (pp. 169-172). Washington, DC: National Lesbian and Gay Health Foundation.
Ratner, E. (1988). Treatment issues for chemically dependent lesbians and men. In M. Shernoff & W.A. Scott (Eds.), The sourcebook on lesbian/' health care (2nd ea.) (pp. 162-168). Washington, DC: National Lesbian Gay Health Foundation.
Schaefer, S., Evans, S., & Coleman, E. (1987). Sexual orientation concerns among chemically dependent individuals. Journal of Chemical Dependency Treatment, 1(1), 121-140.
Shernoff, M. (1984). Family therapy for lesbian and gay clients. Social Work 29(4), 393-396.
Ziebold, T.O. & Mongeon, J. (Eds.) (1982). Alcoholism & homosexuality. New York: The
Haworth Press, Inc.
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chemical dependency, chemical dependency, chemical dependency, chemical dependency