Minority Stress, Substance Use, and Harm Reduction

In case anyone’s interested, I thought I’d post a small paper I just did for my Groups Dynamics class about gay men, drugs, and harm reduction as a prevention technique. This is the paper I went to interview the therapist for a couple of weeks ago. If you’re interested, enjoy. If not, that’s fine too! (Incidentally, I’ve taken out the therapist’s full name so that if his name is Googled by himself, or anyone else, this paper won’t come up.)

Abstract – The purpose of this paper is to look at the phenomenon of “minority stress” in relation to the mental health and stress levels of marginalized groups in society, particularly gay men. These groups have shown repeatedly to have higher levels of substance abuse and risky sexual behaviors, but the concept of harm reduction is seeking to rein in some of the collateral damage. Mike B. is a Portland-area LPC who leads a weekly harm reduction group for gay men in the Hollywood neighborhood. I spoke to him extensively about his practice, his group, and why he believes in harm reduction for at-risk groups.

Introduction
Harm reduction is a prevention method that interests me because it feels like a realistic way to work with at-risk populations without condescending to them, or forcing your own agenda upon them. Harm reduction acknowledges an individual’s right to make their own decisions about what to do with his or her life, but to make those decisions in a way that will have less negative impact not only on their life, but on the lives around them. Being the analyst at heart that I am, I also can’t help but think that by giving at-risk individuals the tools to live their lives with just a little more integrity, this will have a ripple effect in other areas, and perhaps encourage them to be more thoughtful and respectful towards themselves in a larger picture.

It was also very important to me to focus on something involving sexual minority populations in this project. This is the population that I ultimately hope to primarily serve in my future practice. Urban gay men, especially, seem to be a high-risk group for both substance abuse and HIV infection, both of which, I think, are reflective of a larger pattern of internalizing negative societal attitudes. A whole generation of gay men has already been lost due to the decimation by the AIDS plague in the 1980’s, and as poll after poll reflects HIV infection on the rise again, it’s time for health care professionals to act in the swiftest and most effective ways possible to help prevent that from happening again.

Literature Review
Although our society is rapidly progressing toward total acceptance of gay men and lesbians, homosexual individuals in the United States still make up a very small minority of the population, ranging from 3% to 10%, depending on where you look, and homosexuality itself is still illegal in 24 states (Meyer, 1995). But like members of any other marginalized group of people, gay men and lesbians must deal everyday with stigma and negative social attitudes, leading to a phenomenon known as minority stress (Meyer, 1995). Meyer defines minority stress as “psychosocial stress derived from minority status” (1995). Minority stress has sometimes even been cited as the core foundation of all social stress, defining as it does, the conflict that minority and dominant values create within the social environment experienced by any minority group member (Meyer, 1995). As a consequence of this conflict, minority group members often develop adaptive and maladaptive responses that usually include mental health symptoms termed “secondary deviance” (Meyer, 1995).

In this paper, I will focus solely on gay men at the exclusion of lesbians, but only because the group facilitator I interviewed leads groups only for gay men. And while it has been shown that lesbians have their own minority stress issues to deal with, the symptoms often manifest themselves in different ways from gay men. Past studies have shown that gay men in particular are not more stressed, overall, than their heterosexual male counterparts, but do show more distress in typical minority stress conceptualizations, such as self-acceptance, alienation, and paranoia (Meyer, 1995). When gay children grow into adolescence, they have already spent a good 10-12 years witnessing negative attitudes directed at homosexuals, leading to, usually, an internalization of homophobic attitudes. As they grow into their sexuality and begin to realize that they have same-sex attraction, they begin applying those same negative attitudes toward themselves, and attitudes that once seemed an abstract concept now become personally applicable (Meyer, 1995). It is at this age that most gay men tend to develop a hyper-vigilance as a coping tool for their stigmatization (Meyer, 1995). This hyper-vigilance is explained as having a high level of perceived stigma, leading to expectations of rejection, discrimination and violence, in reaction to their interactions with dominant group members (society) (Meyer, 1995). Over time this stress leads to a generalized fear and mistrust of the larger society, as gay men feel that they must remain constantly vigilant to avoid being harmed, either emotionally or physically (Meyer, 1995).

Many research studies have shown a strong correlation between internalized homophobia in gay men, prejudice events, which have a tendency to invoke deep feelings of rejection in gay men, and violence directed at gay men, with suicidal ideation, AIDS-related traumatic stress behavior, sex problems, difficulty finding and maintaining intimate romantic relationships, and higher levels of substance abuse (Meyer, 1995 & Halkitis, et al., 2001). Links have also been found to drastically higher levels of HIV infection among gay men who use recreational drugs compared to their peers (both homosexual and heterosexual) that don’t use drugs recreationally (Halkitis, et al., 2001). Methamphetamine use, in particular, has proven itself to be a drug popular among gay men, mostly because of the effects of the drug when used in association with sex (Halkitis, et al., 2001). In San Francisco, for instance, data gathered from the Young Men’s Health Study indicated that as many as 30% of the gay men there had used methamphetamine at some point in the year prior to being interviewed; in New York City, the rate is estimated to be somewhere near 13%; and in Boston, methamphetamine use is estimated to be around 7% of the gay and bisexual population (Halkitis, et al., 2001). HIV infection is 1 to 4 times more likely to occur among men who participate in recreational drug use in general, due to inhibiting effects, and a demonstrated increase in insertive/receptive anal intercourse while under the influence (Halkitis, et al., 2001). Meth, especially, was related to unprotected anal intercourse, with up to 22% of substance-abusing gay men reporting unprotected receptive anal intercourse while under its influence (Halkitis, et al., 2001). In a Los Angeles treatment demonstration of gay men, 32% of the patients receiving treatment for substance abuse reported a lack of condom use during sex (Halkitis, et al., 2001).

So why harm reduction? Well, in the Meyer study, he concluded that estimates suggested that minority stress is related to a two- to three-fold increase in risk for high distress levels in gay men, directly adversely affecting mental health (1995). Evidence has indicated for years that there is a strong correlation between psychiatric problems, mental health disturbances, and substance misuse (Laker, 2007 & DiClemente, 1999). In 1995, the American Journal of Public Health made a formal plea for federal drug policies to be based on a model of harm reduction, rather than “use reduction,” owing to less harm per unit of use overall, and encouraging reducing “aggregate harm,” to help persuade a user to cease consumption (Marlatt, 1996). Harm reduction is considered by many to be a pragmatic, cost-effective solution, since it has proven effects, and takes no special training to administer (Laker, 2007). There is no significant difference between harm reduction and motivational interviewing, another tested and proven treatment, over the long-term, in reducing substance use (Laker, 2007). This possibly suggests that focused intervention by nurses or other mental health care practitioners, using therapeutic intervention and effective communication could show just as much benefit to patients as more specialized training techniques (Laker, 2007).

Harm reduction has shown to be most effective in secondary prevention, meaning with clients who already use, but for whom it has not yet become a big problem in their life (DiClemente, 1999). But harm reduction can also be a promising bridge to integrating help from the mental health community to particularly at-risk substance-using communities, like adolescents, African-Americans, and urban gay men (Marlatt, 1996). Imani Woods, an internationally known specialist in harm reduction, states emphatically that the harm reduction message must match the population with which you are working (Marlatt, 1996). This is part of the “meeting clients where they live” philosophy of both harm reduction and the Stage of Change process of Motivational Interviewing (Marlatt, 1996). This means being intimately familiar with the cultures in which your clients live, their norms, standards, and to help them learn how to help themselves; harm reduction tries only to supply the tools (Marlatt, 1996). For many urban gay men, whose rates of recreational drug use are far higher than their heterosexual counterparts, harm reduction can be a useful tool to help stop even riskier behavior, and severely limit the spread of HIV and AIDS. As a public health alternative to the criminal or extended inpatient models of substance treatment, harm reduction advocates for abstinence, but promotes actions that create less harm overall (Marlatt, 1996).

Interview
Mike B. is a Portland-area CADC III certified LPC in private practice. Each Wednesday night he leads the M.2M. (name skewed for Googling purposes – ed.) Recovery Group, “to provide an affordable, low-pressure venue for gay, bisexual, and questioning men who want to explore their relationship with drugs and alcohol, past or present.” Mr. B. defines his group as a “harm reduction/relapse prevention” model, though the group is far from being made up of men solely in recovery.

In Mr. B’s. opinion, there is a huge gap in official treatment of substance abuse and 12-step, peer-run groups that a lot of individuals fall through. Many people need more support than a 12-step can give them (and are still using), but can’t afford official treatment, and these are the people Mr. B hopes to serve. He has intentionally created the group with as low a barrier as possible to get into, with minimal expectations. He charges only ten dollars per 90-minute session, and really has only three criteria for exclusion: psychotic tendencies, homicidal tendencies, and suicidality. He works from no charts, and there is no diagnosis involved. He also has every prospective client fill out a “Life Event Stress Scale,” with various events and corresponding scores, such as “Death of Partner or Spouse” ranking with the highest score of 100, and “Minor Violation of the Law” with the lowest score of 11. In between are things like “Retirement,” “Change in Living Conditions,” “Jail Term,” “Christmas Season,” and so on. Then there is a 3-scale Score Scale with Low, Medium, or High susceptibility to stress-related illness.

Mike B received his Master’s Degree in Educational Psychology from the University of Utah, and for his internship worked at the Cornerstone Counseling Center. It was there that B. got his first experience with groups, as dual diagnosis group treatments were the primary form of therapy, and individual sessions were considered adjunct. In 2001, he was hired at the center, where he lead 4-5 groups a week from 2001-2005. From Utah, he was hired at a treatment center in Astoria, Oregon, where he lead a dual diagnosis group for nine months, then on to Portland, where he worked at Cascadia, also leading dual diagnosis groups there. B. is now in private practice, where some of his clients are dual diagnosis, but most of them aren’t.

He describes his individual practice as an object relations/attachment style, in which he got his core training, but isn’t dogmatic about it. He prefers to remain open to whatever will work best for his clients.

In July 2007, he founded his Man2Man Recovery Group. A typical meeting begins with each member introducing themselves and their substance(s) of choice. Next each member will check in with where they’ve been with their addiction (which doesn’t have to be a substance) since the last week, or how much clean time they’ve had. Then last each member will signify if they’re interested in using group time to talk about anything at all going on in their life, regardless of what it is. When everyone is done checking in, the remaining time will be divvied up depending on who has expressed interest in talking about an issue that week.

B. refers to this as being “process-oriented,” as he prefers to talk about skills emotionally relevant to that moment. He cited Yalom when he referred to going “vertical” with each person, then “horizontal” with the group to look for universal experiences. He encourages feedback from group members to one another, and to mostly stay out of the conversations himself, because he feels it empowers the members to feel like they have things to contribute. Often a member will come in and tell another member that something they said the previous week had really stuck with them and they used it as strength during a tough time, or it made them see an issue in a different way. A major topic of conversation that B. says he likes to come back to repeatedly is a focus on specifically queer issues that the men are dealing with, such as chronic stress from living in a “heterosexist” society, and the various forms that stress takes in their lives.

B. says he does not follow research specific to harm reduction models, as his technique is more “client-focused:” what they bring to the group is what he works with. He does, however, follow trends and research specifically pertaining to the queer community and its mental health.

Mike B. is very proud of his group, small though it is. It currently has 6 members, and laughing, he said it’s taken quite a long time to even build up to that number. He says it is composed pretty much entirely of white men, that no African Americans have ever shown any interest, and the SES is across the spectrum. He sticks religiously to the $10 fee, as the group is not intended to meet the needs of homeless men, psychotics, or those in chronic crisis, and this is something he “pushes back” against quite a bit. He is not equipped to help those people, a lot of whom express interest to him about the group, and they have other resources they should seek first.

Discussion
What I learned from researching this type of group, primarily, is that there is still such a dire need for it. Harm reduction is still a controversial prevention effort: some tout its effectiveness in reducing the side effects of substance use, while others consider it a lazy and cynical approach to treatment. A little more aggressive action might be nice in theory, but in practice, it often alienates potential individuals that you could help. If someone is not ready to give up his or her substance use, there is simply no way to make him or her do so. But by focusing on safer ways of doing things, you can not only help save lives, you can return a little dignity back into the life of someone who may be using. Simply knowing someone out there cares and is keeping an eye on them can be a powerful tool for reaching people in trouble and helping to heal whole communities.

References
Halkitis, P.N., Parson, J.T., & Stirratt, M.J. (2001). A double epidemic: crystal
methamphetamine drug use in relation to HIV transmission among gay men.
Journal of Homosexuality, 41, 17-35.

DiClemente, C.C. (1999). Prevention and harm reduction for chemical dependency: a process
perspective. Clinical Psychology, 19, 473-486.

Laker, C.J. (2007). How reliable is the current evidence looking at the efficacy of harm
reduction and motivational interviewing interventions in the treatment of patients with
a dual diagnosis? Journal of Psychiatric and Mental Health Nursing, 14, 720-726.

Marlatt, G.A. (1996). Harm reduction: come as you are. Addictive Behaviors, 21, 779-788.

Meyer, I.H. (1995). Minority stress and mental health in gay men. Journal of Health and
Social Behavior, 36, 38-56.

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