Journal of Addiction Research & Therapy
Open Access

QTBIPOC Minority stress in substance use disorder counseling

In this research study, QTBIPOC community members openly identified the most salient stressors they experienced in substance use disorder counseling settings by reflecting on each other’s photos and dialogues. QTBIPOC participants further described how these experiences in substance use disorder counseling settings were not helpful to their ongoing recovery from substance use. Specifically, as QTBIPOC are seeking out support from minority stressors and various stressors that contribute to substance use, QTBIPOC can still encounter sources of minority stress when seeking out counseling in oppressive environments. These QTBIPOC collective experiences speak to the prevalent issues experienced in substance use disorder counseling environments by QTBIPOC, such as not feeling understood or accepted by their substance use counselors. The following themes that were identified when exploring minority stress in substance use disorder counseling among QTBIPOC include, 1) visible discomfort about QTBIPOC topics among counselors, 2) feeling unseen regarding minority stress experiences, 3) lack of acceptance regarding QTBIPOC identities, 4) experienced discomfort with being open with counselors, 5) the need for connection to other community members, and 6) lack of authenticity. These themes were analyzed by being sorted into either “expected codes, surprising codes, or codes of conceptual interest,” as described in table (Table 1):

Table 1: Research Question One Data Categories.

Visible discomfort about QTBIPOC topics among counselors

During focus group sessions, QTBIPOC community members discussed how some of their counselors expressed visible discomfort when addressing QTBIPOC issues in counseling. These dialogues illuminated a specific issue that can occur for QTBIPOC in counseling environments, in which their counselors demonstrate discomfort with QTBIPOC identities and lived experiences. For example, Beck described the following interaction with their counselor:

So getting to open up, to tell them, ‘This was me,’ you could literally see that they weren’t into that. They weren’t comfortable with someone like me, which restricted me from sharing how I felt or what help I needed. I would say that was why the first place I went to wasn’t effective.

Through experiencing discomfort from counselors in substance use disorder counseling, QTBIPOC community members also described feeling unseen in substance use disorder counseling, which is described in more detail in the following section.

Feeling unseen regarding minority stress experiences among QTBIPOC

Based on the ongoing dialogue produced by QTBIPOC in their focus groups, community members described feeling as if their minority stress experiences were unseen by their counselors, which served as a significant issue that impedes adequate counseling care among QTBIPOC. For example, Kevin openly described how their counselor made them feel unseen regarding their minority stress-based lived experiences:

I realized that he was looking down on me. He would see me as if I had an issue. I was trying to explain to him how I experienced stigma based on the color of my skin or from my relatives. It really affected me, so I turned to substance use…

During this group dialogue, Kevin shared that despite trying to share their lived experiences of minority stress in counseling environments, they felt as if their counselor instead viewed them as the central issue regarding substance use rather than the minoritized stressors that significantly impacted Kevin and other QTBIPOC. The blaming of substance use struggles that can happen to QTBIPOC stems from the biomedical focus of the mental health industrial complex, causing QTBIPOC to feel as if they are to blame for their own stressors rather than the systemic stressors they face in their environments (Greene, 2019). Furthermore, when trying to seek out support for experienced trauma as QTBIPOC, Michael B. described how their counselors “were not ready” to hear about their traumatic experiences:

I went into the treatment center for counseling, after my friend was shot by the police at (university), and they did not know how to handle that, at all. Like, I had talked about it in group, and I finished talking, and there was silence. Because, I think a lot of the people that they were used to dealing with were little white kids who smoked weed, and their parents sent them to rehab for weed. It’s like, no, I’m there because I have a heroin addiction with PTSD, and I don’t know what to do. They were at a loss. It always came down to how they wanted me to handle it, like, ‘What’s in your power?’ Like, a lot of the things that were happening weren’t because of me, and I don’t have any power over them. Asking me to deal with the aftermath of my friend dying because of another mental health crisis is unfair to ask. I don’t know, they just, they were sympathetic, but they didn’t have the skills, training, or life experience necessary to figure out how to work with people who didn’t steal their mother’s alcohol because they were rebellious, instead of having the experience to work with systemic issues [1].

Michael B.’s experiences with seeking out counseling support due to experiencing police brutality are important for substance use disorder counselors to consider when working with minoritized communities. Without understanding the harmful impacts of police brutality, substance use disorder counselors fail to acknowledge the trauma caused by police brutality, which contributes to ongoing mental health issues and stressors due to feeling unseen during traumatic events (Alang et al., 2021). Through their shared picture, Michael B. also described how their experience in substance use counseling was “not great” due to their counselors not supporting them in their struggles with minority stress. As a result, these stressors were not able to be seen and heard by their counselor, such as what is described when Michael B. shared their picture during the study:

It’s just a really low-lit room with a mirror, and the lighting has a neon sign that you’re reading regularly that says, ‘You are a star,’ but the reflection says, ‘You bastard.’ Um, I didn’t have a great experience with the substance abuse counseling that I went to. There was a lot of shame around it. I went for a dual diagnosis; I was a voluntary admit to a local psychiatric hospital. I went through two months there; there was a week of inpatient and then outpatient. At the time that I was supposed to leave inpatient, they told me that they didn’t have the ability to deal with what I was struggling with and that I should go to a treatment facility on the other side of the country. Like that was feasible?

Despite this code being expected due to previous literature, this is an important theme that needs further exploration in QTBIPOC literature, given that this reported experience proved to be a salient influence on substance abuse struggles among QTBIPOC community members.

Furthermore, QTBIPOC community members overall did not feel accepted in counseling relationships, which is explained further in the following section.

Lack of acceptance in counseling

The third theme explored in PhotoVoice focus groups with QTBIPOC consisted of the perceived experience in which QTBIPOC did not feel accepted in substance use disorder counseling. For example, John described how their counselors mainly focused on trying to change their gender expression rather than on understanding presenting issues in counseling:

His objective was more about changing who I am than understanding and getting to know me. It seemed like a problem for me, getting him to accept my nature. Like, by insisting that I try to get myself out there to the other gender to prove something, which I myself knew that I just wasn’t into it. He tried making me think that I did not try enough. I am old enough to know what I want. He tried changing me by not accepting me.

Dialogues such as these describe how QTBIPOC community members can feel demoralized in counseling environments when working with counselors who focus on changing QTBIPOC clients rather than supporting and understanding them during recovery from substance use. This theme also speaks to the previous theme of feeling unseen in counseling, given that the counselor’s main focus was on trying to change QTBIPOC clients rather than seeing their presenting minority stressors that contribute to substance use. Without feeling accepted in substance use disorder counseling, QTBIPOC community members can experience feelings of discomfort in opening up with counselors about their personal struggles in navigating Anti- Blackness, which is vital to the QTBIPOC recovery process.

Experienced discomfort in being open with counselors

QTBIPOC community members also described that due to the previously described themes and examples of minority stress in substance use disorder counseling settings, there was a perceived discomfort in being open with counselors. Specifically, QTBIPOC community members such as John shared that their experiences in counseling did not allow them to open up about experiences of minority stress, including traumatic experiences, that influenced substance use. In conjunction with previously described themes, this theme indicates a perceived cultural mistrust with counselors who are not knowledgeable about QTBIPOC minority stress, focus on trying to change QTBIPOC, and are not accepting of QTBIPOC [2].

Community members such as Tyron Rose also reported feeling unsafe in counseling settings because there was a lack of counselors that they could relate to during the counseling process. Richard also described feeling intruded upon by counselors when forced to share their gender identities in counseling. Specifically, Richard reported embarrassment in being openly asked about their gender identity and preferred counseling settings where their gender identities were discreetly understood and respected. These reported experiences in substance use disorder counseling settings further speak to perceived cultural mistrust that can be experienced between QTBIPOC clients and counselors who are not knowledgeable about QTBIPOC experiences and needs. Not only did QTBIPOC participants wish for comforting counseling spaces in substance use disorder counseling, but QTBIPOC participants also reported that they wished to connect with other QTBIPOC community members to avoid feeling alone during the recovery process.

The need for connection to other community members

During the group dialogue, QTBIPOC participants also discussed the importance of connecting to other QTBIPOC community members while navigating substance use recovery. For example, Kevin shared the following narrative when sharing with their group members:

One of the things I really wished for was that he could have connected me with other transgender members, to try and discuss and meet with new people, open up, he can even try to link me to people who can explain to me their perspective of being transgender.

Sharing is very important. Maybe from his side he was biased because he wasn’t experiencing the same thing I was. So, I think that from the way he acted, I think he should have done better to try to find someone who was having the same problem as me, to find an elder person who went through the same things, to try and open up with me to understand me, and I think that could have been better [3,4].

QTBIPOC community members, such as Kevin, stated that being connected to fellow community members is an essential part of the recovery process, especially when addressing minority stressors related to feeling isolated in substance use disorder counseling settings. While Michael B. reported that they felt connected to fellow QTBIPOC in substance use counseling environments, they became disheartened when they found out that they were not allowed to maintain contact with QTBIPOC peers in recovery after treatment, as described in this narrative:

They started a small group for LGBTQIA folks after regular meetings but also keeping contact with people after discharge was breaking the rules, so any bridges that were built were abandoned.

This experience caused Michael B. to experience isolation from fellow QTBIPOC in recovery due to harmful institutional practices. Furthermore, QTBIPOC community members stated that they experience adequate counseling support through experiencing authenticity from their substance use disorder counselors.

Lack of authenticity

QTBIPOC community members also cited a lack of authenticity from their counselors as a source of minority stress experienced in counseling settings, especially when related to overcoming cultural mistrust with counselors. For example, Kevin shared the following experience in counseling:

But now when I realize that he was just trying to please me, I became so stressed that the anxiety and depression that I had before came back in full force, and I felt like the whole world was against me. But the good things I enjoyed, I enjoyed opening up to him at first, because he was so friendly. He would make me feel at home. I felt like it was the right place at first. But after some time, I realized that something wasn’t right.

According to previous literature, counselors from minoritized backgrounds demonstrate more ease and comfort in working with minoritized communities in counseling settings than counselors who predominantly hold dominant social identities. This observation raises concerns about the authenticity exhibited by counselors with mainly dominant social identities when working with minoritized clients, especially as counselors and institutions are working to develop their knowledge and awareness about multicultural issues. Specifically, without adequate cultural representation in counseling settings and multicultural training, QTBIPOC receive counseling services from counselors who exhibit discomfort and lack awareness about QTBIPOC issues, which does not help or support QTBIPOC in building trust with their substance use counseling environments. This noted experience illuminates an issue of conceptual interest that requires further exploration through ongoing research.

Substance use disorder counselors can benefit from understanding QTBIPOC experiences and needs as described by insights that respond to the first research question. Specifically, through understanding experiences of discomfort to and from counselors, lack of acceptance, and feeling unseen by counselors, substance use disorder counselors and institutions can feel more prepared in providing affirmative counseling services to QTBIPOC by anticipating QTBIPOC lived challenges and unlearning harmful institutional responses when working with QTBIPOC in substance use disorder counseling. Therefore, to further inform QTBIPOC affirmative substance use disorder counseling, the following research question elaborates lived experiences of QTBIPOC affirmative substance use disorder counseling practice [5].

Research Question Two

QTBIPOC affirmative substance use disorder counseling experiences

QTBIPOC photos and group dialogues also illustrated how QTBIPOC affirmative counseling environments present themselves in actual practice. Specifically, QTBIPOC community members described elements of affirmative counseling care that positively impacted their recovery from substance use. QTBIPOC participants further shared these experiences during the research study hoping that substance use disorder counselors and institutions can learn the essential elements necessary to support QTBIPOC in counseling. The following themes that were identified when exploring affirmative counseling experiences in substance use disorder counseling among QTBIPOC include, 1) companionship experienced through the counseling process, 2) feeling accepted by their counselors, 3) perceived concern about QTBIPOC experiences and feelings, 4) feeling encouraged to openly share about QTBIPOC experiences in counseling, 5) experiencing diversity and representation in substance use disorder counseling, and 6) receptive to trauma experiences. These themes were analyzed by being sorted into either “expected codes, surprising codes, or codes of conceptual interest,” as described in table (Table 2).

Table 2: Research Question Two Data Categories.

Companionship experienced through substance use counseling

During their time in the focus group, QTBIPOC community members discussed various benefits of substance use disorder counseling settings that were affirmative to their QTBIPOC identities. Specifically, QTBIPOC community members discussed how substance use counseling settings addressed their community concerns by providing opportunities for companionship and support. For example, Beck described the following picture of how they experienced companionship and support during substance use disorder counseling:

The image I wanted to show was of a woman holding another person’s shoulder. That reflected on the support I got. The help I got. The other image I had was of someone holding their head while stressed, so that was me before getting help. The other image I had was of someone being really happy. That is basically me after getting help.

As Beck described their positive experience in substance use disorder counseling settings, Beck also illuminated how receiving companionship and support brought about feelings of joy during the substance use recovery process. Specifically, Beck was able to experience affirmative substance use disorder counseling through being introduced to support groups, as illustrated during this dialogue:

There were support groups. I would say that was really effective. I met some friends there. Getting to know and have people to contact, when you’re feeling low, that really helped. I would say this experience really aided in my recovery. My recovery happened really fast. It was helpful because everyone was really open to helping me. That really sped up the recovery process.

Substance use disorder counselors and institutions must consider and become knowledgeable about how perceived lack of support plays a role in the recovery process for QTBIPOC and how to create supportive spaces for QTBIPOC when seeking out substance use disorder recovery. QTBIPOC affirmative substance use disorder counseling also consists of conveying acceptance to QTBIPOC as counselors and institutions build supportive spaces for QTBIPOC in recovery.

Feeling accepted by counselors as QTBIPOC

The second theme that presented itself in focus group sessions with QTBIPOC included the idea of feeling accepted by counselors and institutions during the recovery process. For example, Beck described the following experience in feeling accepted by their substance use counseling institution:

Where I got help, they were really open. They didn’t care where you were from, what you do, or what you are. They were just there to help you. Richard could relate to similar experiences in counseling as described in their dialogue:

ssexdAt the end of it all, I was not judged, and I think that my needs were attended to. I felt great about sharing my experiences. Yeah, because I thought that the counselors were very engaging and positive about me.

This experience also connected to previous literature on what affirmative counseling can look like for QTBIPOC. According to previous literature, QTBIPOC reported that they felt positive about their substance use disorder counseling when feeling accepted and respected in their counseling environments (Lyons et al., 2015). These experiences speak further to the need for open and supportive spaces for QTBIPOC in substance use disorder counseling. As part of promoting supportive spaces for QTBIPOC in recovery, QTBIPOC also recall the benefits of experiencing perceived concern from their counselors when receiving substance use disorder counseling.

Perceived concern about QTBIPOC experiences and feelings

QTBIPOC community members also reflected on experiencing affirmative substance use disorder counseling when their counselors focused on QTBIPOC experiences and feelings. For example, Beck described the following experience in substance use disorder counseling settings:

I would say they responded positively. They didn’t just help me process; they literally covered everything. They asked about my feelings.

Not only did Beck experience concern and care from their substance use disorder counselor, Beck indicated that their counselor “covered everything” in their counseling relationship. This insight from the group dialogue illuminates the comprehensive counseling care that QTBIPOC can receive from affirmative counseling environments. Also, these perspectives in substance use disorder counseling support the benefits of multicultural perspectives that embrace cultural and diagnostic complexity when utilized in counseling with QTBIPOC (Jost & Janicka, 2020) [2].

By developing awareness, knowledge, and skills related to honoring QTBIPOC experiences in counseling, substance use disorder counselors and institutions can convey empathy and affirmative care to QTBIPOC when hearing about their lived experiences in substance use disorder counseling. Furthermore, QTBIPOC clients in substance use recovery can feel encouraged to share their experiences and engage further in the recovery process.

Feeling encouraged to openly share about QTBIPOC experiences in counseling

QTBIPOC community members reported that through affirmative experiences in substance use disorder counseling, QTBIPOC felt encouraged to share their life experiences and how they play a role in substance use struggles. For example, Beck could recall times when they felt hesitant about sharing their life experiences in non-affirmative counseling environments, such as what is described in their dialogue:

They weren’t comfortable with someone like me, which restricted me from sharing how I felt or what help I needed.

However, when Beck found an affirmative counseling environment, Beck described the following account of their counseling experiences:

At first, it was really hard to open up and process how I felt. I was holding back. But after time, I didn’t hold anything back. I just spit it all out, and that really helped. I would say this experience really aided in my recovery [3,6].

Through Beck’s shared experiences, affirmative counseling environments can help QTBIPOC open up about the various stressors that impact their substance use disorder recovery. Likewise, through Michael A.’s shared experiences, their counselor provided them with a safe space to share because they could relate to Michael A.’s experiences, which encouraged them to be open in substance use disorder counseling, as described in the following narrative:

They understand what you’re saying and that helps you open up; even if they give you practical support, you can see that their advice works. What they say is something they know about. They’re not guessing.

Michael A. further shared how they were encouraged to share by counselors who were willing to advocate alongside them, through dedication to help them and willingness to fight alongside them, as described in this dialogue: Yeah, yeah, and so at the time, I was afraid of being reported to law enforcement. And unfortunately, one of the friends I did drugs with was alerted to the authorities with the therapist. Regardless of whether they were going to go down, my therapist affirmed to us that they were only interested in helping us.

This narrative is congruent with previously published counseling literature highlighting the benefits of culturally affirmative spaces and advocacy in counseling. Furthermore, community members reflected on how they felt empowered to share their struggles with substance use when encouraged to share their life experiences.

QTBIPOC community members also reported that interacting with QTBIPOC counselors further empowered them to share their experiences and engage in recovery practices, as described in the next theme.

Experiencing diversity and representation in substance use disorder counseling

This theme was highly significant throughout focus group sessions during the study. Specifically, for various reasons, almost all participants expressed the need for QTBIPOC representation when receiving substance use disorder counseling. For example, Edward described their experience with a Trans counsellor through the following account: Personally, I would say it was awesome because my counselor was trans also. I was quite lucky. I guess that’s why my experience was so successful because I was able to open up. I felt like he could understand what I was talking about [4,7].

Furthermore, Edward described how meeting with a trans counselor allowed them to receive adequate support services, such as connections to other trans community members who could relate to struggles with substance use. Lastly, Edward felt they could open up in talking with a trans counselor, unlike previous accounts, which described a perceived discomfort in opening up to counselors who could not understand QTBIPOC experiences.

Community members also shared how experiencing diversity and representation of trans identities in substance use disorder counseling settings could help counter minority stress events experienced by QTBIPOC in substance use disorder counseling. For example, Edward made the following statement about John’s experiences in substance use disorder counseling: Let’s say, for example, like what happened with John and his counselor; John was trying to express himself. I was just trying to be me. John’s counselor was trying to change him, which was wrong. With more trans counselors out there, I would definitely choose a trans counsellor. Experiences such as these are also noted within counseling literature, given that QTBIPOC benefit from working with counselors who are familiar with QTBIPOC experiences and counsel from multicultural perspectives.

However, there is a dearth of literature on QTBIPOC experiences in receiving supportive counseling from QTBIPOC counselors due to harmful gatekeeping processes that exclude QTBIPOC from becoming counselors in the counseling field [8]. Therefore, further counseling research needs to be conducted that advocates for increased QTBIPOC representation in counseling settings to provide adequate support to QTBIPOC in substance use disorder counseling. Through being able to receive support from QTBIPOC counselors during the recovery process, QTBIPOC community members can more easily receive support regarding traumatic experiences that can occur in substance use disorder counseling settings, as described in the following theme.

Receptive to Trauma Experiences in Counseling

Some QTBIPOC community members reflected on how their counselors were helpful and supportive when exploring traumatic experiences in counseling settings. For example, Beck described the following positive experience that they received in counselling: I would say that my counselor was really helpful because they wanted to know what my experiences were, what was running through my mind at those times, what led to those moments, so I would say that they were really effective through every part of it, because counsellors knowing what caused it, how it started, will help them be able to chip in and help me manage it. Explaining what happened to them really helped them help me.

Basically, it was positive. While these experiences contradict what is published in counseling literature, Beck described interactions with a counselor who was open to embracing the complex lived experiences of QTBIPOC, which indicates affirmative curiosity and support that allows counselors and institutions to be genuinely present for QTBIPOC in their minoritized stressors. Moreover, being receptive to traumatic experiences among QTBIPOC is a step forward for all counselors to engage in social justice work. Specifically, affirming traumatic experiences allows minoritized communities to reclaim their lived experiences in empowering ways through story-telling.

Through examining experiences of affirmative substance use disorder counseling for QTBIPOC, substance use disorder counselors and institutions will be able to develop their knowledge base on affirmative strategies that support QTBIPOC during the recovery process. Furthermore, through immersion with the lived experiences of QTBIPOC, substance use disorder counselors and institutions can use affirmative support to counter experiences of minority stress in substance use disorder counseling settings, which helps promote overall recovery for QTBIPOC who struggle with substance use and experienced trauma. The following research question will further explore the concrete steps proposed by QTBIPOC community members to enhance substance use disorder counseling with QTBIPOC [9].

Research Question Three

Improving substance use disorder counseling with QTBIPOC

During this study, the second focus group session mainly focused on creating a space for QTBIPOC and the lead researcher to collaboratively brainstorm ideas to improve substance use disorder counseling with QTBIPOC. This data is insightful and essential to the study as part of the action-building stage for promoting social justice change and addressing community concerns. Furthermore, these ideas serve as a route of empowerment for QTBIPOC community members who wish to make a difference in their community through addressing stated community concerns. The following themes that were identified when exploring strategies for enhancing substance use disorder counseling with QTBIPOC include 1) increased representation of trans/queer counselors, 2) increased support/community opportunities for QTBIPOC, 3) social platform to connect trans/queer counselors with community members, 4) increased access to counseling services, and 5) increased awareness about QTBIPOC issues among counselors. These themes were analyzed by being sorted into either “expected codes, surprising codes, or codes of conceptual interest,” as described in table (Table 3).

Table 3: Research Question Three Data Categories.

Increased representation of QTBIPOC counselors The first and most prominent issue in the data reflected on not having enough counselors who represent QTBIPOC identities in counseling settings. In providing further insights into this need in counseling, Beck reported the following perspective during the group dialogue:

Yeah. I think counselors who are in the same shoe as those that are affected; I would really be open with them and comfortable with sharing my story or my experience with someone who can put themselves in my shoes, instead of getting someone who is not like you. You can get someone who is not like you and can understand you, but that would be something rare. But having someone who has been in your shoes that would really help me be open, spit it out, and let it go. I think that will really help.

QTBIPOC members, like Beck, felt as if working with QTBIPOC counselors would allow them to open up more in counseling settings, which provides increased support opportunities during the recovery process. Furthermore, this point speaks to previously cited issues in the literature about discrepancies present in access to work sites for QTBIPOC counselors (Gates & Sniatecki,2 016). This discrepancy reveals a significant problem in the counseling field for adequately meeting the needs of QTBIPOC community members since QTBIPOC community members feel more open in seeking support from QTBIPOC counselors who can more easily understand QTBIPOC lived experiences. With increased QTBIPOC representation in counseling settings, QTBIPOC perspectives indicate that their community needs, especially regarding struggles with substance use, can appropriately be addressed within their communities. QTBIPOC community members also reported feeling that increased opportunities for community building can address community needs in substance use disorder counseling.

Increased community/support opportunities for QTBIPOC

QTBIPOC community members shared that they wished they knew about available opportunities to connect with fellow QTBIPOC to seek out support during times of minority stress and for struggles with substance use. For example, Edward described some benefits that they received in being connected with QTBIPOC community and support during the recovery process:

Through meeting other Trans community members, I was introduced to activities that involved more trans community. I do believe that if we have a Trans community, either online or physical, that would be quite helpful because if I was able to share my trans counselor with other trans people, I’ve been hearing stories about trans people being with counselors who were trying to change them. So if a person shared that story with me, I could have introduced them to my counselor. So I have a part to play. Through this perspective, QTBIPOC community members described how increased access to community/support groups during the recovery process could help QTBIPOC adapt mental health coping strategies and connect to QTBIPOC affirming counselors and institutions [10].

Counseling research also illustrates the importance of counselors learning how to provide resources in counseling care as part of engaging in community action alongside minoritized clients (Singh et al., 2020b). During data analysis, this theme was recognized as a theme of conceptual interest due to the benefits of future research projects that further support the creation and implementation of QTBIPOC support groups, including social platforms for access to QTBIPOC counselors and support groups, during the substance use disorder counseling process.

Social platform to connect trans/queer counselors and community members

QTBIPOC community members also discussed the importance of developing a social platform where QTBIPOC counselors can connect with QTBIPOC community members to provide substance use counseling support. Specifically, John brought up the following idea during the group dialogue: Maybe getting us some way to get our experiences known out there, us sharing on a platform where we could freely talk.

During further group dialogue, the following idea began to take form, as described in this narrative: A group that is open to all transgender people so that we can join together, share experiences there. We can help those who feel unable to handle situations. I think we can do much in that group. We have an association where we can be a community, fight for our rights, share our own experiences, to celebrate.

In describing strategies to meet QTBIPOC community needs of connection, QTBIPOC community members agreed on the importance of developing a shared social space where QTBIPOC can have easier access to connections with counselors and fellow community members as they navigate minority stress and QTBIPOC community concerns. Furthermore, social platforms can increase opportunities for QTBIPOC to meet with counselors who share their identities and experiences, which is a community concern that must be addressed to create supportive QTBIPOC community networks during recovery. This theme is described as a theme of conceptual interest, given the benefits of performing further research and advocacy to create social spaces that connect QTBIPOC when experiencing personal struggles in recovery and minority stress. The researcher and QTBIPOC community members agreed to meet for additional group sessions to build and develop this social support space for QTBIPOC community members. Through further research and advocacy, increased access to counseling services can also enhance substance use disorder counseling with QTBIPOC [11].

Increased access to counseling services

Some QTBIPOC community members also expressed concern over not being able to access or afford essential counseling services when struggling with substance use. Community members such as Tyron Rose and Joel expressed the immediate need for affordable and available counseling services as described in their group dialogue: I wish that services would be free or very affordable because sometimes you can find free services/counseling, but it can be far.

Victim further elaborated on the need for more available and affordable counseling as described in the following narrative: I can say that my experience with counseling was a really hard moment for me because of my poor background. Things were expensive and I had to stop sometimes and come back to counseling later.

These dialogues speak to previously cited concerns about equitable access to counseling services and healthcare services among QTBIPOC. By expanding on previously stated ideas for enhancing substance use disorder counseling with QTBIPOC, creating a social platform to connect QTBIPOC counselors and community members may also create a specialized program that can bridge the gap in accessing affordable counseling care. Specifically, a social platform for QTBIPOC community members can develop programs that provide donation links and financial hardship resources for increased access to QTBIPOC counseling programs. QTBIPOC community members also expressed the importance of increased awareness regarding QTBIPOC issues to enhance the support provided in QTBIPOC counseling care.

Increased awareness and education about QTBIPOC issues

The last significant theme in QTBIPOC community dialogue was the wish for increased awareness of QTBIPOC lived experiences among counselors and within counseling institutions. For example, Beck described the following need to enhance QTBIPOC counseling services: Creating awareness…that would really help because most people are exposed to the fact that trans people exist. If people understand that Trans people exist, they can understand that not all trans people are the same. People could learn enough to understand more.

Counselors will meet people who are trans, so counselors should really be learning more and taking trans folks as they are.

Beck illuminated the need for increased awareness about QTBIPOC life experiences and the importance of understanding that not all QTBIPOC are the same. This statement speaks to previously cited literature about the dangers of essentialism and how equating all QTBIPOC life experiences as the same is detrimental to providing adequate care to QTBIPOC (Delgado & Stefancic, 2017). Furthermore, Beck discussed the importance of counselors and counseling institutions learning about QTBIPOC life experiences due to the inevitability of meeting QTBIPOC community members in counseling work. QTBIPOC community members also discussed the importance of counselors stepping forward to educate their peers in the counseling field, as described by Beck in the following dialogue:

I think getting some counselors to educate their fellow counselors to be more effective. Going directly to them, just someone more informed approaching someone who doesn’t have experience, to just educate their fellow counselors a bit.

Beck’s statement speaks to the advocacy necessary among counselors to educate each other about QTBIPOC life experiences to enhance the quality of counseling care that QTBIPOC receive. Increased awareness and education regarding QTBIPOC life experiences is not only an intervention that improves QTBIPOC counseling but is also an intervention directly requested by community members, making this step towards improving QTBIPOC counseling a priority in meeting QTBIPOC community needs.

Discussion

Understanding QTBIPOC minority stress in substance use disorder counseling

The findings for the first research question examined the lived experiences of QTBIPOC when experiencing minority stress in substance use disorder counseling. First, there is discomfort between both substance use disorder counselors who do not understand QTBIPOC experiences and QTBIPOC clients when opening up about their life experiences in counseling. These lived experiences of minority stress in substance use disorder counseling reveal how QTBIPOC may interact with counselors and institutions who lack the knowledge and awareness of QTBIPOC lived experiences and express discomfort in hearing about QTBIPOC lived experiences when QTBIPOC are trying to seek support in substance use disorder counselling.

These findings also speak to the discrepancy between counselors being comfortable with exploring unconscious processes with their clients and being uncomfortable in exploring their own unconscious processes. However, these findings also speak to the consequences of what happens when counseling environments conceptualize minority stress as an individual problem rather than a public health issue, causing counselors to ignore systemic stressors that impact minoritized communities during counselling work.

Therefore, counsellors must address and process any discomfort in addressing systemic violence when working with QTBIPOC communities. Specifically, counselors’ discomfort also makes QTBIPOC uncomfortable in sharing their lived experiences in counselling, which can play a role in triggering minority stress for QTBIPOC. Furthermore, QTBIPOC discomfort in opening up during the counseling process is reportedly global in scale and requires immediate attention from clinicians to improve QTBIPOC counseling. Without respect for and understanding minority stressors for QTBIPOC community members, it can be difficult for non-QTBIPOC counselors to engage with and overcome cultural mistrust with QTBIPOC in counseling. To address these issues in counseling, non-QTBIPOC counselors must be aware of the stressors that can cause QTBIPOC to feel unsafe when navigating social institutions and be prepared to focus on trust-building as a primary consideration for QTBIPOC affirmative counselling [12].

QTBIPOC community members also felt unseen regarding their experiences of minority stress and how these experiences influence substance use behaviors. Furthermore, QTBIPOC community members felt blamed for their cultural struggles and their struggles in coping with minority stress. These experiences made QTBIPOC community members feel as if they were being looked down upon by their counselors, bringing about shame and guilt when seeking out substance use disorder counseling. The source of this type of minority stress also stems from the oppressive roots of psychotherapy, in which presenting concerns were identified as inner struggles within the client, thus ignoring systemic stressors that impacted minoritized communities (Greene, 2019; Rowland & Cornell, 2021). Furthermore, the neglect to see minority experiences further leads to judgment and bias when counselors make QTBIPOC feel unseen in their struggles. Therefore, counselors and counseling institutions must take on the challenge to increase their awareness and knowledge about QTBIPOC stressors to avoid blaming QTBIPOC for their struggles with substance use. Otherwise, QTBIPOC may continue to feel unseen and unheard when seeking out support for minority stressors in their lives.

QTBIPOC also experienced a lack of acceptance when receiving substance use disorder counseling. Specifically, QTBIPOC community members felt unaccepted when encountering counselors who tried to change who they were. Previous counseling literature describes many examples of how QTBIPOC can experience a lack of safety and judgment during the counseling process, such as when QTBIPOC are grouped according to the gender binary, experience trans antagonistic policies, and experience a lack of support in counselling. These experiences speak to the results of what happens when QTBIPOC experience micro aggressions when receiving substance use disorder counselling.

Specifically, these QTBIPOC experiences exemplify how micro insults can present themselves in counselling settings. Therefore, substance use disorder counselors and institutions must be intentional about the relationships they build and hold themselves accountable in their interactions with QTBIPOC clients to effectively demonstrate that QTBIPOC are embraced and accepted for who they are in counselling.

QTBIPOC community members also documented that they can receive appropriate resources, strategies, and support while navigating the recovery process by being connected to members of their own communities. For example, QTBIPOC can receive support when connecting to fellow community members due to needing to feel accepted by those who can understand them (Meyers, 2020). Furthermore, QTBIPOC community members can struggle with feelings of isolation when navigating non-affirmative counselling spaces. With the right connections to QTBIPOC support, QTBIPOC community members can receive a variety of healing benefits when exploring the recovery process. Counselors and institutions must consider these resources when helping QTBIPOC who struggle with substance use develop recovery plans, as well as question institutional policies that discourage QTBIPOC from building authentic and supportive connections as part of post- counselling recovery.

Lastly, a lack of authenticity from substance use disorder counselors served as a significantm inority stressor for QTBIPOC. This issue ties into previously described themes of experienced discomfort in working with non-QTBIPOC counselors, given how a perceived lack of authenticity creates discomfort for QTBIPOC in counseling. Also, this documented issue resonates with Layton’s theory of the normative unconscious (2004, 2006), in which counselors must navigate the unconscious intersections between their personal feelings and awareness of social issues, to work with increased confidence when addressing minority stress in counseling settings. Counselors and institutions must apply this theory to analyze and disrupt overlooked harmful institutional practices when working with QTBIPOC and minoritized communities in counseling. Without this awareness and knowledge building among counselors, inauthenticity can take place in expressing empathy towards QTBIPOC issues, which is damaging to rapport in substance use disorder counseling with QTBIPOC.

Affirmative QTBIPOC experiences in substance use disorder counseling

This study also examined how substance use disorder counselors can provide affirmative QTBIPOC counseling. First, QTBIPOC community members quoted how they experienced companionship and support through being introduced to support groups during the counseling process. This theme is essential for substance use disorder counselors and institutions to be mindful of, given the perceived benefits of including support groups as part of relapse prevention work. In addition, substance use disorder counselors and institutions must ensure that they provide resources that consist of QTBIPOC affirmative support groups so that QTBIPOC can continue to receive the feelings of hope and joy that support can provide during the recovery process.

Through their counselors’ acceptance, QTBIPOC also experienced affirmative substance use disorder counseling. Specifically, QTBIPOC community members reflected on how they received support from counselors who were open to hearing about their lived experiences and accepting of their identities to want to help them authentically. Given how embraced and supported QTBIPOC community members feel when accepted for who they are by their counselors, substance use disorder counselors and institutions must embrace openness to ideas of cultural complexity, especially when learning about QTBIPOC intersectional experiences.

QTBIPOC community members also felt cared for when experiencing perceived concern from their counselors. Specifically, QTBIPOC community members described some of their counselors as positive and thorough in their questions, which speaks to the beneficial properties of narrative/cultural humility, empathic curiosity, and multicultural informed assessments in substance use disorder counseling environments. Through genuine concern and curiosity about clients’ lived experiences, substance use disorder counselors and institutions can exhibit empathy and respect as QTBIPOC clients try to navigate their counseling environments for safety and comfort [13].

Perceived care and curiosity about QTBIPOC lived experiences also contributed to effective trauma support in substance use disorder counseling settings. This lived experience is essential to affirmative QTBIPOC counseling research, given the documented ways QTBIPOC can experience trauma in counseling environments and the support needed to help QTBIPOC maintain their substance use recovery during traumatic experiences. During affirmative experiences, QTBIPOC community members described their counselors as attentive and present to ensure that the thoughts and feelings of QTBIPOC community members were heard and respected during trauma process. Working from counseling perspectives rooted in intersectionality, cultural/narrative humility, multicultural complexity, and holistic care allow substance use disorder counselors and institutions to be more present with QTBIPOC community members when dealing with the intersections of minority stress, trauma, and substance abuse.

QTBIPOC community members also felt encouraged and empowered to share in substance use disorder counseling settings when experiencing affirmative counseling.

Specifically, QTBIPOC community members explained how dedication to helping QTBIPOC and willingness to fight for QTBIPOC rights encouraged QTBIPOC community members to share and avoid holding back in counseling settings. This forward stance in advocacy and care is a position that all counselors and institutions must embrace in substance use disorder counseling to serve QTBIPOC community needs truly. However, this also means that substance use disorder counselors and institutions must avoid a neutral stance in advocating for social justice if counselors and institutions are to truly empower QTBIPOC in counseling.

Lastly, QTBIPOC community members received affirmative counseling through experiencing QTBIPOC representation in counseling services. Specifically, most of the QTBIPOC community members in this study agreed that QTBIPOC representation in counseling is essential in providing affirmative counseling for QTBIPOC. Furthermore, QTBIPOC community members stated that working with non-QTBIPOC counselors brought about messages of false hope and a disconnection from the minority stressors that influence substance use struggles among QTBIPOC. QTBIPOC counselors offer multicultural perspectives in the counseling field and can more easily understand the lived experiences of QTBIPOC, which provides them with an advantage in assisting QTBIPOC during the recovery process. With these insights in mind, further research can examine QTBIPOC affirmative counseling experiences across various age groups, given the homogenous age group represented in this sample of participants. Specifically, through understanding lived experiences of QTBIPOC across the lifespan, counselors and institutions can develop a deeper understanding of QTBIPOC experiences, strengths, and stressors.

Promoting and enhancing QTBIPOC affirmative substance use disorder counseling

This study also explored diverse strategies for substance use disorder counselors to enhance their counseling practice with QTBIPOC. First, increased QTBIPOC representation is necessary for the counseling field. Specifically, community members documented feelings of cultural mistrust when working with non-QTBIPOC counselors, given how rare it is for QTBIPOC community members to find non-QTBIPOC counselors who can understand their struggles. Without adequate representation of QTBIPOC counselors in counseling settings, there may not be enough opportunities to utilize affirmative counseling strategies or training opportunities for non-QTBIPOC counselors to learn QTBIPOC affirmative strategies.

Secondly, QTBIPOC can benefit from increased community and support access during the recovery process. While support groups are reportedly helpful for QTBIPOC in recovery, QTBIPOC community members reported that they needed to connect with other QTBIPOC who could provide them with resources, coping skills for recovery management, and connections to QTBIPOC affirming counselors. Given how many QTBIPOC struggle with isolation in dealing with minority stressors, QTBIPOC community members strongly benefit from being part of QTBIPOC support groups, where QTBIPOC no longer feel alone and feel supported during the substance use recovery process. Furthermore, these community needs should be used as advocacy interventions in substance use disorder counseling settings to empower QTBIPOC in recovery (e.g., empowering QTBIPOC to form and maintain recovery support groups, promoting more resources and opportunities for QTBIPOC recovery groups in counseling settings).

QTBIPOC can also benefit from having a social platform where community needs can be expressed to counselors and counseling institutions. Current counseling research highlights the benefits of having increased support access for QTBIPOC when struggling with minority stress and substance use cravings (Livingston, 2017; Meyers, 2020). This needed intervention is helpful to enhance substance use disorder counseling practices due to providing a space of support during the recovery process and a space of resources for QTBIPOC.

Specifically, this intervention offers an opportunity for QTBIPOC to engage in their resilience-based strengths to advocate for community needs, which can contribute to affirmative substance use disorder counseling.

Substance use disorder counselors must also advocate for increased access to counseling services. Specifically, Victim mentioned how impaired access to counseling services contributed to their number of times in substance use disorder counseling. For QTBIPOC community members to truly benefit from affirmative counseling, there must be increased access and affordability for counseling services among QTBIPOC. This point is especially salient to QTBIPOC’s ongoing struggle to afford healthcare. Counselors must also be prepared to work with communities that struggle with poverty and conceptualize ways to promote affordable and accessible counseling for QTBIPOC (e.g., meeting clients at their homes to diminish travel costs).

Furthermore, counselors must consider ways to promote resources, offer pro bono counseling, and advocate at the public policy level to raise the minimum wage and promote universal health care. Therefore, substance use disorder counselors must ask themselves and their institutions about how they are advocating alongside QTBIPOC community members and various minoritized community members to promote opportunities for affordable counseling. Furthermore, institutions must ask themselves about how their policies allow or prevent minoritized communities from accessing needed counseling services [14].

Lastly, substance use disorder counselors must co-advocate with QTBIPOC to increase QTBIPOC awareness in the counseling field. Specifically, QTBIPOC community members expressed gratitude to counselors willing to educate their colleagues and institutions on QTBIPOC issues. At the same time, QTBIPOC also wished for more opportunities to spread awareness about minority stress issues for QTBIPOC. With more awareness about QTBIPOC issues available to the public, substance use disorder counselors and institutions can provide counseling from an informed place supportive of QTBIPOC during the recovery process.

QTBIPOC community members further expressed that a lack of awareness of QTBIPOC community issues produces insensitivity, discomfort, and a reduced ability for counselors to support QTBIPOC during the recovery process. Although these steps help promote QTBIPOC affirmative counseling care, the sample of this study was limited in exploring the nuanced ways that substance use counseling can be enhanced in specific counseling settings (e.g., individual, group), which warrants further study.

Implications for counselor education training

The findings of this research study provide significant implications for counselor education training that is needed to enhance substance use disorder counseling for QTBIPOC. First, counselor education needs to offer more awareness-building opportunities for students as they encounter QTBIPOC and minoritized communities in the counseling field.

Specifically, dialogue-building spaces with QTBIPOC community leaders can be helpful for counselor educators in training as they start to become aware of minority stressors that impactQ TBIPOC communities. Through necessary dialogue building with QTBIPOC community leaders, counselor educators in training can unlearn preconceived notions or biases about QTBIPOC life experiences, which increases empathy and efficacy in working with QTBIPOC in counseling settings.

Next, counselor education needs to invest more time and space in developing the knowledge base of counselor educators in training when learning about QTBIPOC life experiences, intersectional life experiences, and the manifestations of Anti-Blackness in QTBIPOC lives. For example, counselor educators can significantly benefit from learning about the harmful impacts of the criminal punishment system (e.g., weathering) when examining QTBIPOC lives. This study contributes to the knowledge base that can inform counselor educators in training when learning essential information about how minority stress, caused by Anti-Blackness, impacts QTBIPOC.

Furthermore, counselor education programs must continuously evaluate their curriculum to ensure that they are inclusive of QTBIPOC centered theories in counseling, such as Quare/Queer Theory, Black Feminist Thought, Relational Cultural Theory, and CBT approaches such as EQuIP, to decolonize counselor education curricula and effectively transform counseling institutions as counselors begin engaging in professional counseling practice and lead counseling institutions. In addition, decentering patriarchal and white perspectives in counseling is necessary for transforming the counseling field, given how white, western, and male perspectives are still pervasive within counselor education.

Counselor education programs must also incorporate minority stress theories, QTBIPOC trauma experiences, and QTBIPOC-specific practicum courses to provide knowledge and experience in working with QTBIPOC. For example, counselors can use their knowledge of minority stress to affirm QTBIPOC experiences with discrimination and trauma, provide psychoeducation to help develop language about QTBIPOC stressors, and help QTBIPOC deal with minority stress in ways that do not involve substance abuse behaviors. Furthermore, minority stress theories can be used in counselor education curricula to provide more knowledge and resources on how subsets of QTBIPOC experience minority stress based on their unique cultural experiences (e.g., how Black communities experience minority stress compared to Latinx communities).

Minority stress must also be taught within counselor education curriculum to discuss the risk factors of substance abuse that specifically impact QTBIPOC. For example, counselor education must address how targeted exposure to substances, stressful experiences with discrimination, internalized stigma, acculturation, and generational trauma are all risk factors for substance abuse used to alleviate minority stress. Counselor education programs must also include multicultural perspectives in substance use disorder counseling to remove stigmabased attitudes in counseling institutions and address systemic issues that influence substance abuse behaviors among QTBIPOC. Without these considerations in counselor education curriculum, counselor education programs are not equipping their students with the necessary knowledge to understand or affirm QTBIPOC experiences, which leads to minority-based stressors described in the findings of this study [15].

Counselor education programs must also invest in the multicultural skill development of their students to appropriately provide QTBIPOC affirmative counseling. Specifically, QTBIPOC community members reflected on the benefits of multicultural assessment skills, narrative humility skills, and ethical advocacy skills that are needed to affirm QTBIPOC in counseling settings. By incorporating these culturally affirming skills in substance use disorder counseling settings, substance use disorder counseling can move away from treating all minoritized groups similarly during the recovery process. Furthermore, the inclusion of these culturally affirming skills can further inform the NAADAC code of ethics (2021) in its efforts to promote cultural humility in substance use disorder counseling. These culturally affirming skills can also inform multicultural counseling practices to maintain ethical standards in multicultural counseling work. Without adequate training in these skills, counselors in training can experience discomfort and a lack of authenticity when trying to build relationships with QTBIPOC in professional counseling practice, which is directly harmful to QTBIPOC in recovery.

Implications for QTBIPOC advocacy in counseling

One of the most critical ways to advocate alongside QTBIPOC in their community needs for affirmative counseling is by promoting the inclusion of QTBIPOC in counseling settings. The discrepancies in gatekeeping practices and the admission of QTBIPOC community members into the workplace must be addressed within the counseling community.

Furthermore, efforts are being made to connect QTBIPOC counselors to QTBIPOC clients to increase QTBIPOC counseling services due to a history of QTBIPOC underrepresentation in the counseling field. However, there are also concerns about the lack of QTBIPOC representation in counselor education faculty, given that white educators still predominate the faculty profession in counselor education. Also, the retention of counselor educators of color remains a significant issue in counselor education due to increased burdens in academia. Furthermore, there are concerns about a lack of understanding in teaching multiculturalism, social justice advocacy, and multicultural competencies due to a lack of representative mentors to guide multicultural training.

To promote racial justice within the counseling profession, counselor educators must also address how Anti-Blackness still influences counselor education and actively disrupt institutional practices that keep QTBIPOC counselors out of the counseling field. Specifically, counseling program coordinators need to consider the significant need for QTBIPOC in the counseling field when making admissions decisions and gatekeeping decisions about which counselors should be given further opportunities for professional practice. Without adequate QTBIPOC representation in counseling, QTBIPOC community members have already expressed that it would be harder to open up to non-QTBIPOC counselors about their minority stressors, which is a significant obstacle in affirmative substance use disorder counseling.

Counselors must also engage in courageous conversations with their colleagues, employers, employees, advisors, supervisors, supervisees, and students to promote multicultural competence and advocate alongside QTBIPOC in meeting their community needs. Specifically, we must address systemic issues that harm QTBIPOC in counseling settings in ways that advocate alongside QTBIPOC. While Lewis’s advocacy competencies and the ALGBTIC standards illustrate the importance of advocacy in counseling, much research still needs to be done on effective ways of advocating within non-responsive institutions, given the ongoing stigma that counseling communities hold against QTBIPOC. Furthermore, counselors must be trained to navigate resistance against social justice advocacy in counseling and community settings. However, counselors can still work with QTBIPOC clients on creative ways to elevate their voices and concerns within non-responsive institutions, whether through community projects or creative outlets of expression that can be received in various counseling institutions.

Collaborating with QTBIPOC to create a social platform can help elevate QTBIPOC voices within the community, especially when expressing their community concerns to counselors. QTBIPOC community members can feel unheard and unsupported by their counselors and counseling institutions, and a social platform restores minority strengths and resilience building through fostering hope for fellow community members. Counselors and institutions can help with these efforts by working alongside QTBIPOC to develop social support platforms and being knowledgeable about existing support spaces that QTBIPOC can join for support during the recovery process.

Lastly, counselors and institutions must consider ways to address the future development of social justice advocacy in the counseling profession. By understanding the roots of oppression that aided in creating the mental health industrial complex, counselors and institutions must disrupt the vicious cycle of exploitation that occurs from blaming minoritized individuals for suffering caused by systemic oppression. Mental illness is a political problem that requires collective advocacy between community members, counselors, and institutions to disrupt so that counseling can disrupt vicious cycles that keep minoritized communities in pain for profit. To do this, counselors and institutions must be active in understanding how oppression operates in counseling institutions and demand social justice change alongside minoritized communities as they navigate social justice issues.

All counselors and counseling institutions are called to step forward and do their part in co-advocating alongside QTBIPOC community members through advocating for affirmative public policies, addressing systemic issues with colleagues, co-developing social platforms to elevate QTBIPOC voices, advocating for QTBIPOC inclusion in the counseling field, as well as co-leading QTBIPOC social justice initiatives. Unfortunately, without taking these described action steps, counselors and institutions maintain the erasure of QTBIPOC systemic violence present in the mental health industrial complex, which maintains a vicious cycle of QTBIPOC self-blame when navigating minority stress in counseling settings.

Study Limitations

While this study provided valuable data on the lived experiences of QTBIPOC in substance use disorder counseling, some limitations were present and should be noted for future researchers who attempt to replicate this study. First, not every community member could provide a picture or image that spoke to their lived experiences in substance use disorder counseling. Despite considerations of trying to make the obtaining of photos feasible for participants, some QTBIPOC community members mentioned that they did not have enough time to obtain photos for participation in the study. However, QTBIPOC community members utilized the sharing of photos that were provided to launch their conversation about community concerns, which fulfills the main objective of PhotoVoice research.

Furthermore, the limitation in provided photos did not deter QTBIPOC community members from discussing presenting concerns and experiences in substance use disorder counseling.

While this limited the capacity to engage in photo-elicitation work among all community members, it is essential to respect the ethical rights of participants in PhotoVoice research.

Specifically, all participants should be able to choose which data they would like to share during the research process (PhotoVoice, n.d.). Furthermore, participants should be free to choose which parts of the research they are willing to participate in and how they participate during the research process (PhotoVoice, n.d.). Therefore, future researchers should consider how the breadth of PhotoVoice data speaks to community issues and whether quality or quantity should be preferred when researching photos in PhotoVoice data. Also, future researchers should consider how essential photovoice trainings can be in supporting participants in obtaining photos, even if they are using the internet to do so, to maximize photo sharing participation.

Limitations were also present, given that all 12 participants provided the researcher with basic demographic information, but not all participants submitted their demographic information forms. This serves as a limitation in the study due to the missing demographic information that could provide further insight into the lived experiences of substance use disorder counseling among QTBIPOC (e.g., how many times participants tried substance use disorder counseling during recovery, etc.). For example, most of the participants in this study received substance use disorder counseling in New York, while some participants received counseling in Georgia.

However, this study did not explore QTBIPOC experiences based on the state they received counseling in. Further research should explore these demographic details to address differences between QTBIPOC experiences across states and regions within the United States to address each state’s efficacy in providing QTBIPOC affirmative counseling care. Furthermore, the demographic questionnaire did not account for what type of substance use disorder counseling was attended (e.g., individual, group). This information can be useful to develop further data on how to promote QTBIPOC affirmative counseling across different counseling service types in future studies.

Also, the sample of participants in this study was homogenous in age range. Specifically, all participants described their ages between 20 and 30 years old, which calls for further research on QTBIPOC experiences in substance use disorder counseling across the lifespan. Furthermore, genderqueer experiences must also be explored to advocate for enhanced substance use disorder counseling among QTBIPOC. Specifically, further research needs to focus on the specific narratives of genderqueer community members to understand their experiences of minority stress and affirmative counseling and further inform culturally responsive substance use disorder counseling.

Furthermore, participants did not encounter any counseling experiences where they experienced both affirmation and minority stress from the same counselor, which could be useful in exploring the nuanced ways that minority stress may also occur in affirmative counseling environments during further research studies. Lastly, further research needs to closely examine step-by-step approaches to affirmative substance use disorder counseling to provide concrete models that can be replicated and developed by clinicians and institutions that provide substance use disorder counseling to QTBIPOC.

Conclusion

The purpose of this study was to explore the lived experiences of QTBIPOC community members in substance use disorder counseling and discuss strategies for enhancing QTBIPOC counseling care. This PhotoVoice study provided an opportunity for 12 QTBIPOC to share their lived experiences and ideas on how substance use disorder counseling can be improved with minoritized communities, especially given how minority stress can present itself for QTBIPOC when navigating counseling settings. While this study celebrates the accomplishments of substance use disorder counseling in its multicultural development, this study provides insightful implications for the need to continue developing substance use disorder counseling practices in working with QTBIPOC. The implications of this study also remind counselors and institutions of their ongoing duty to question institutional practices that harm QTBIPOC in substance use counseling. QTBIPOC minority stress in substance use counseling is not an individual issue for counselors to address but a systemic issue that counseling institutions need to unite in addressing as part of striving to provide affirmative counseling care to QTBIPOC across counseling settings.

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