Journal of Addiction Research & Therapy
Open Access

Addiction; Addiction research; Addiction therapy; Queer; Transgender (Trans); Black; Indigenous People of Color (QTBIPOC); Substance Use Disorder Counseling; Minority Stress; Affirmative Counseling; Anti-Blackness; Critical Participatory Action Research; LGBTQ+; Photo Voice

Introduction

Minimal research focuses on the lived experiences of queer, transgender, Black, and Indigenous people of color (QTBIPOC) in substance use disorder counseling due to a history of excluding QTBIPOC in counseling research and treating all minoritized groups similarly in substance use disorder counseling approaches [1]. The purpose of this study was to explore and understand QTBIPOC experiences of minority stress and affirming experiences during substance use disorder counseling. During this study, QTBIPOC participants shared their stories and experiences through PhotoVoice data. Participants also engaged in Critical Participatory Action Research, where they openly questioned and conceptualized how substance use disorder counselors and institutions can enhance treatment care with QTBIPOC. Furthermore, participants explored potential options for praxis to advocate for QTBIPOC community needs in substance use disorder counseling and improve counseling services.

QTBIPOC minority stress

While Meyer [2,3] defined minority stress as stress from experiences of stigma, prejudice, and discrimination associated with holding minoritized identities as LGBT community members, racialized perspectives of minority stress must also be considered in counseling research. For example, Childs defined minority stress as additive stress that stems from navigating environments of Anti- Blackness [4]. Geronimus et al. [5] also refer to minority stress as a type of “weathering,” which prematurely deteriorates the human body among minoritized communities when navigating oppressive environments. Specifically, research has shown that the average life expectancy of Black communities is four years less than the rest of the U.S. population [6]. In his work, author also reflects on how the harmful impacts of Anti-Blackness have been carried out through a long and ongoing history of racial oppression and murder towards Black people. Furthermore, there has been an additional reflection on the ongoing lack of accountability for violence against QTBIPOC throughout various systems in the United States. For example, the harmful impacts of Anti-Blackness occur through ongoing brutality from the criminal punishment system towards Black communities and inequitable access to education for various racially minoritized communities (e.g., Native American communities, Asian communities).

Minority stress, substance use, and targeting

To cope with ongoing minority stress and the harmful impacts of generational trauma [7], QTBIPOC may engage in substance abuse to alleviate feelings of stress, which can further promote the weathering effects of minority stress [5]. However, QTBIPOC continue to be penalized for substance use behaviors due to drug laws that systematically target QTBIPOC, which causes more minority stress for QTBIPOC as they try to navigate systemic oppression. Thus, a vicious cycle is created and perpetuated as social systems rooted in Anti- Blackness continue to punish QTBIPOC, who may use substances to deal with minority stress, instead of disrupting systemic violence that can lead to substance use in the first place. These forces of historical violence, stigma, and discrimination further lead to mental health stress for minoritized communities [3].

Understanding the harmful impacts of anti-blackness

Given that stigma and oppression harm QTBIPOC communities, substance use disorder counselors and institutions need to understand minority stress from a historical lens of Anti- Blackness and its harmful impacts. Specifically, substance use disorder counselors and institutions must understand and name the source of minority stress among QTBIPOC communities (e.g., Anti-Blackness) and address how their substance use disorder counseling practices perpetuate Anti-Blackness. Furthermore, substance use disorder counselors and institutions must understand ways that Anti-Blackness can be disrupted by adhering to counseling competencies that focus on social justice and affirming care with LGBTQ+ communities within institutional practice.

To further address how substance use disorder counseling perpetuates Anti-Blackness, substance use disorder counselors and institutions must understand the history of substance use disorder counseling and its connection to Anti-Black ideologies. For example,the late 1800s consisted of criminalizing alcohol/drug problems and poorly evaluated substance use disorder counseling and ethical abuse in substance use disorder counseling [8]. Researchers must also acknowledge the roots of psychological literature and how eugenics initially informed psychological practice to create ideas of white racial superiority. Furthermore, multicultural and social justice leaders encountered resistance in the 1990s when developing multicultural and social justice competencies to address lived minoritized experiences in counseling settings [9]. Specifically, counselors who engaged in resistance against multicultural competencies for the counseling field stated that counseling was “culture- free” and that “good counseling was good counseling” despite historical concerns of harmful counseling practices towards minoritized communities since the 1940s [10-13].

The mental health industrial complex also perpetuates systemic violence by centering mental health struggles as biomedical issues rather than public health issues related to racial violence. Specifically, this shift in focus allows the mental health counseling field to continuously profit off structural violence in the United States rather than work with minoritized communities to address community concerns about racial violence [14].

Furthermore, Anti-Blackness utilizes harmful stereotypes to criminalize, dehumanize, and disenfranchise QTBIPOC, as well as target QTBIPOC through “the war on drugs,” which contribute to harmful mistreatment of QTBIPOC in substance use disorder counseling.

Understanding the trauma and minority stress exposure model

Furthermore, substance use disorder counselors and institutions need to learn how to hold affirming spaces for minoritized clients to avoid further minority stress experiences in counseling spaces. To further affirm QTBIPOC in substance use disorder counseling, substance use disorder counselors and institutions must be aware of how minority stress is experienced in counseling. The Trauma and Minority Stress Exposure Model can be utilized when conceptualizing how QTBIPOC experience internal forms of stress resulting from external stressors experienced during substance use disorder counseling, including traumatic experiences. The Trauma and Minority Stress Exposure Model originally stems from the Gender Minority Stress Model. The Gender Minority Stress Model indicates that as trans individuals experience stress from discrimination and microaggressions, they also experience personal responses to this stress, such as fear of rejection, internalized anti-LGBTQ+ bias, and concealment of one’s minoritized identities, which can further lead to impaired mental health and risks of substance use behavior. However, the Trauma and Minority Stress Exposure Model expands upon the Gender Minority Stress Model by adding experienced trauma related to direct assault as a source of minority stress for QTBIPOC.

Specifically, medical experts define sympathetic overactivity as a condition when one’s body experiences social threats. Goosby et al. further state that trauma from being a minority in predominately white spaces adds additional burdens that impact bodies and negatively affect long-term health. Therefore, chronic racial trauma stresses the body and leads to depression, anxiety, headaches, back pain, high blood pressure, cardiovascular disease, and diabetes (Goosby et al., 2015). Furthermore, the body suppresses the harmful experiences of racial trauma, which overall contributes to chronic health issues [15].

Overall, discrimination (e.g., denial of access to resources), microaggressions (e.g., microinsults, microassaults, microinvalidations), and trauma (e.g., assault) can be salient stressors for QTBIPOC as they receive substance use disorder counseling services. This literature review examines how QTBIPOC experience discrimination, microaggressions, and trauma when receiving substance use disorder counseling services to understand the significance of this study further. This literature review also examines current substance use disorder counseling approaches in their utilization with QTBIPOC and the need to expand research on how substance use disorder counseling can speak to QTBIPOC lived experiences. Furthermore, this literature review examines how affirmative QTBIPOC counseling practices promote recovery by creating support spaces, utilizing multicultural counseling perspectives, as well as illuminating minority strengths and resilience during the recovery process.

QTBIPOC experiences of discrimination in substance use disorder counseling

QTBIPOC can experience difficulties accessing treatment programs for substance use disorder counseling and access to healthcare and general counseling services. Different barriers that present themselves when attempting to access generalized counseling services include issues with counseling outreach efforts for QTBIPOC, sensitivity in counseling outreach materials, and outreach networking with key stakeholders for QTBIPOC communities. Furthermore, when QTBIPOC obtain access to counseling for substance use, addiction treatment centers can endorse Trans- antagonistic policies and programming such as binary gender-segregated housing, bathrooms, and sessions.

According to survey data conducted by Senreich, seven out of eleven QTBIPOC participants reported lower levels of perceived support and experienced stigma when receiving substance use disorder counseling services. For example, according to survey and interview data, QTBIPOC reported that they felt unwelcome, unsafe, and isolated by others when receiving substance use disorder counseling services. QTBIPOC have also experienced binary gender segregation when receiving group counseling due to staff labeling based on their presumed genitalia. QTBIPOC were also less likely to complete substance use disorder counseling than straight, gay, and bisexual peers. These are significant issues that must be addressed among substance use disorder counselors and institutions, given that QTBIPOC may not feel safe or encouraged enough to seek help when trying to cope with minority stress and substance abuse due to feeling mistreated and misunderstood when asking for help.

QTBIPOC experience significant stress associated with being misunderstood by individuals who are not knowledgeable about QTBIPOC identities and experiences, which can be detrimental when seeking out institutional support during substance use disorder counseling. Despite the benefits QTBIPOC can receive when receiving support from QTBIPOC counselors, 30.4% of counselors in training reported that their substance use disorder counseling sites were not accepting of QTBIPOC counselors working at their site, according to survey data from a qualitative research study, which limits access to counselors who QTBIPOC clients can relate to Gates & Sniatecki. Overall, discrimination can harmfully impact QTBIPOC when receiving substance use disorder counseling services due to barriers of access to treatment, Trans- antagonistic policies and programming present in counseling services, lower levels of perceived support, and lack of QTPOC representation in substance use disorder counseling settings. These discriminatory obstacles can promote distrust towards counseling spaces and prevent QTBIPOC from seeking recovery from substance use. This study will further examine experiences of minority stress and discrimination among QTBIPOC in substance use disorder counseling from QTBIPOC perspectives to understand better how affirmative substance use disorder counseling can occur with QTBIPOC.

QTBIPOC experiences of micro aggressions in Substance use disorder counseling

Research has linked experiences of micro aggressions to mental health stress, such as depression, among communities of color. Furthermore, approximately 50% of trans individuals who struggle with substance use were discouraged from seeking out substance use disorder treatment due to concerns related to experiencing micro aggressions. Micro aggressions can take specific forms towards minoritized communities, such as micro insults, micro assaults, and micro invalidations. Specifically, QTBIPOC can experience micro insults from substance use disorder counselors and institutions who do not understand QTBIPOC identities and experiences. Micro insults are defined as interpersonal and environmental forms of communication that consist of stereotypes and insensitivity about minoritized identities and experiences. For example, QTBIPOC reported that their substance use disorder counselors did not understand their treatment needs and that they would try to enforce stigmatized beliefs about QTBIPOC during counseling (e.g., be told that they are not acting like a normal two-spirit individual).

Micro assaults are defined as explicit verbal, non-verbal, and environmental attacks meant to harm targeted populations. For example, trans and Indigenous community members reported experiences of micro assaults in substance use disorder counseling, such as harassment and verbal assault (e.g., name-calling) from other clients.

Furthermore, QTBIPOC reported that they experienced social rejection from peers while in substance use disorder counseling, which caused them to feel as if they did not belong when receiving counseling. Based on the lived experiences of QTBIPOC described through interview data, these micro aggressions can lead to isolation and premature departure from substance use disorder counseling services among QTBIPOC.

Micro invalidations are defined as environmental forms of communication that exclude and negate the experiences of targeted populations. Specifically, QTBIPOC can face the possibility of being required to discontinue hormone replacement therapy, be identified by their birth names instead of their chosen names, and be exposed to LGBTQ+ non-affirming clinicians and cis-normative policies when engaging in substance use disorder counseling. Considering how QTBIPOC experience micro aggressions when receiving substance use disorder counseling, there is a need to examine the possibility of enhancing counseling services when working with QTBIPOC in substance use disorder counseling. This study addresses and explores recommendations for maintaining safe spaces to prevent micro aggressions in substance use disorder counseling settings with QTBIPOC.

Trauma and assault among QTBIPOC in substance use disorder counseling

Not only can QTBIPOC experience trauma and assault at home, at school, and at work, but QTBIPOC can also experience trauma and assault when receiving counseling services. Specifically, QTBIPOC reported experiences of sexual and physical assault from other clients while receiving substance use disorder counseling, such as sexual harassment, physical altercations related to sexual harassment, and physical threats. Furthermore, there is a history of QTBIPOC experiencing physical and verbal abuse from staff when receiving substance use disorder counseling (The Transgender Substance Abuse Treatment Policy Group of the San Francisco Lesbian, Gay, Bisexual, and Transgender Substance Abuse Task Force, 1995). QTBIPOC have also ended substance use disorder counseling services prematurely due to inadequate support from counselors and staff when experiencing trauma in counseling settings.

Since these environmental stressors are salient for QTBIPOC in counseling, affirmative counseling is essential as QTBIPOC experience adjustment issues in counseling settings related to trauma exposure. However, there is not much research available on QTBIPOC experiences with trauma and assault when receiving substance use disorder counseling services due to underreporting of assault, as well as a lack of data collection in rural areas and focus on QTBIPOC identities.

Furthermore, there is a lack of research on how substance use disorder counselors support QTBIPOC when they experience trauma during substance use disorder counseling. Ongoing research is needed to support QTBIPOC when they experience trauma in substance use disorder counseling settings due to how experienced trauma can contribute to substance abuse (Matsuzaka & Koch, 2019; Shipherd et al., 2019). This study addresses these gaps in the literature and examines how QTBIPOC can experience support from counselors and institutions when experiencing trauma and assault in counseling settings.

Affirmation and validation within QTBIPOC substance use disorder counseling

Due to how prevalent sources of minority stress can be for QTBIPOC when seeking out substance use disorder counseling, substance use disorder counselors and institutions must remain aware of ways to provide affirmative support to QTBIPOC in counseling spaces. Per the collective voices of LGBTQ+ communities and advances in counseling research, developing spaces of affirmation and validation for QTBIPOC in substance use disorder counseling requires creating supportive spaces that foster understanding and acceptance, as well as a focus on multicultural perspectives and identifying sources of strength and resilience among QTBIPOC in recovery.

Creating QTBIPOC supportive substance use disorder counseling environments

According to ALGBTIC (2009a, 2009b), counselors and institutions can create supportive counseling environments with QTBIPOC by creating physical spaces that welcome QTBIPOC, attending to the holistic needs of QTBIPOC, and openly exploring the impacts of trans antagonism and Anti-Blackness on QTBIPOC identities. Specifically, counselors must focus on how they integrate QTBIPOC supportive brochures and holistic resources when providing counseling services to QTBIPOC. In addition, QTBIPOC report that positive experiences in various counseling settings include feeling accepted, having their gender identities respected by staff and fellow clients, and clinicians being familiar with QTBIPOC terminology/experiences.

Utilizing multicultural perspectives in substance use disorder counseling with QTBIPOC

Substance use disorder counselors are encouraged to discuss and explore cultural identities with minoritized communities in substance use disorder counseling to promote affirmative care. Substance use disorder counseling with QTBIPOC can be effective when counselors and institutions utilize QTBIPOC worldviews in their counseling modalities. Specifically, a focus on understanding the social narratives of QTBIPOC can contribute to effective substance use disorder counseling practices. In addition, culture-centered counseling provides effective strategies for addressing various QTBIPOC needs, especially when exploring the impacts of minority stress.

Regarding culture-centered counseling, honoring diversity is another way QTBIPOC are affirmed in counseling work. Specifically, counseling spaces that affirm varying narratives across QTBIPOC individuals honor their diversity, relieving QTBIPOC from feeling as if they have to conform to gender expectations in counseling settings. In addition, counseling work that allows QTBIPOC to share their unique identities and experiences without feeling stigmatized promotes safe spaces where QTBIPOC can openly share their gender identities and expression.

Embracing cultural and diagnostic complexity is also an essential feature of affirmative counseling work with QTBIPOC. Specifically, embracing cultural and diagnostic complexity encourages clinicians and institutions to take more time in their assessments with QTBIPOC and challenge pre-existing mental health theories that reinforce cis-genderism present in the mental health industrial complex. In addition, embracing cultural and diagnostic complexity is congruent with Intersectionality Theory because it focuses on the complex intersections between QTBIPOC life experiences and mental health experiences.

Multicultural perspectives in substance use disorder counseling allow counselors to challenge preconceived ideas rooted in racism and cis-genderism when supporting QTBIPOC in recovery. Counselors and institutions can challenge these preconceived ideas by centering non- eurocentric and non-heteronormative perspectives in counseling, honoring diversity, and embracing cultural and diagnostic complexity when working with QTBIPOC in counseling. In addition, multicultural perspectives in substance use disorder counseling remove stigma from understanding QTBIPOC experiences and address systemic issues that influence substance abuse behaviors.

Incorporating minority strengths and resilience in QTBIPOC substance use disorder counseling

To enhance substance use disorder counseling services, counselors and institutions must utilize minority strengths and resilience to help QTBIPOC find empowerment in recovery.

Minority strengths models illuminate personal and cultural community strengths that can help QTBIPOC navigate minority stress and stigma. Specifically, QTBIPOC can utilize cultural community strengths to share resources and create community, enhancing social support in recovery from substance abuse. Minority strengths models also illuminate how social and communal support are linked with positive health behaviors and how identity pride, self-esteem, and resilience are related to mental health. Research has also demonstrated that QTBIPOC discover minority strength by utilizing personal flexibility and awareness about coping with minority stress. Therefore, substance use disorder counselors and institutions can benefit from incorporating both personal and cultural community strengths in substance use recovery management.

QTBIPOC also find resilience and coping skills through defining themselves and resisting stereotypes, embracing self-worth, being aware of oppression and its influence, connecting with supportive communities, practicing self-care, engaging in social activism, and cultivating hope for the future. Valente et al. [10] also determined the importance of exploring how family support can be utilized in counseling, which is beneficial for recovery in substance use disorder counseling due to how family rejection can contribute to substance abuse among QTBIPOC.

Fostering future orientation is also helpful and affirmative in working with QTBIPOC in counseling, especially when promoting QTBIPOC resilience.

Specifically, fostering future orientation can be restorative for QTBIPOC as they build resilience when dreaming about and planning for a hopeful future during times of minority stress. However, further research needs to be conducted on the full benefits of minority strengths models in substance use disorder counseling settings with QTBIPOC. This research will illuminate how discussing QTBIPOC minority strengths in substance use disorder counseling settings contributes to QTBIPOC affirmative counseling during the recovery process.

Despite the limited literature available on personal experiences of substance use disorder counseling among QTBIPOC, this study expands on what positive experiences in substance use disorder counseling look like for QTBIPOC to further inform the counseling field on ways to broaden affirmative counseling with QTBIPOC (Lyons et al., 2015). To understand the holistic and lived experiences of QTBIPOC in substance use disorder counseling, affirmative research methods and epistemologies must be utilized to accurately portray the lived experiences of QTBIPOC in substance use disorder counseling.

Method

As I explored the experiences of QTBIPOC in substance use disorder counseling, my research questions produced more insight into the following areas of inquiry: (1) How, if at all, do QTBIPOC experience minority stress in substance use disorder counseling?, (2) How do substance use disorder counselors provide affirmative QTBIPOC counseling?, and (3) How can substance use disorder counselors enhance their counseling practice with QTBIPOC to promote affirmative counseling? These research questions are based on QTBIPOC community needs, as expressed in QTBIPOC counseling literature.

Critical Participatory Action Research is the epistemology that guided this study. Critical Participatory Action Research is defined as a research tradition that critically examines and challenges positionality and power dynamics in research perspectives while gathering collective and diverse perspectives of knowledge to create social action. Critical Participatory Action stems from Freire’s Critical Pedagogy, which promotes knowledge building, grassroots efforts, and collaborative leadership in its research tradition. In addition, Critical Participatory Action Research provides collaborative opportunities for dialogue, social change, and advocacy between the researcher and participants to articulate community needs to counseling providers as part of the knowledge-building process.

This research tradition is salient to the purpose of this study, given that this study placed QTBIPOC as co-constructors of their minoritized experiences to reflect on their diverse experiences and create social action towards enhancing QTBIPOC substance use disorder counseling. Critical Participatory Action Research has been recently utilized in working with LGBTQIA+ communities in promoting LGBTQIA+ voices and increasing further understanding of their intersectional identities and salient experiences.

Furthermore, this research tradition requires the researchers to examine their research practices through a critical lens to address how positionality influences who is telling the stories of QTBIPOC in research.

Procedure and Sampling

Given that this study explored the lived experiences of QTBIPOC in substance use disorder counseling, purposive sampling identified members of those communities to invite for participation in the research study. This study recruited 12 participants to participate, which Johnson and Christensen recommended when engaging in CPAR/Photo Voice focus group research.

Recruiting participants in this study consisted of a two-step process. The first step in recruiting participants was administering fliers to local and LGBTQ+ friendly substance abuse community meetings throughout various parts of Georgia, with permission from coordinators of the substance abuse community meetings. Furthermore, listservs were utilized through the University of Georgia, the Counselor Education and Supervision Network, and the Georgia Therapist Network to recruit more participants through counselors working with QTBIPOC communities. The lead researcher’s contact information was provided on the fliers and listservs for participants who would like to participate in the study. To qualify for participation in the study, participants needed to have a herstory, history, or t-story of substance use disorder counseling within the last 10 years and be at least 18 years old to consent for research participation.

Next, participants were invited to participate in two back-to-back focus group sessions through Zoom via informed consent. The purpose of the study was fully detailed for potential participants through an informed consent form, which was provided to each participant for personal review. The informed consent also explained to participants that upon agreeing to participate in the study, they had the right to withdraw their participation at any time.

Furthermore, individual semi-structured interviews were offered to participants as an alternative option in case participants felt uneasy about participating in focus groups. Informed consent also reviewed confidentiality measures with potential participants, including the availability of provided pseudonyms or the option of only sharing one’s first name during focus group sessions. Furthermore, informed consent reviewed options for establishing secure communication with which participants feel most comfortable throughout the research process (e.g., phone conversations, texting, email).

As part of agreeing to participate in the study, informed consent also asked participants permission for the lead researcher to record the focus group sessions and reach a consensus about preferred methods for recording to ensure that they feel comfortable with having their experiences recorded for data analysis. Participants were also provided with an explanation of the group sessions’ structure (e.g., time, group size, zoom link) and rules to iterate the importance of confidentiality and respect between group members when they shared their experiences. Furthermore, participants were made aware that informed consent was a continuous dialogue between the researchers and participants if any additional questions or concerns arose throughout the research process. Finally, as participants provided informed consent for participation, demographic information was recorded through demographic forms to gather information related to age, as well as racial, gender, and sexual identities and previous experiences in substance use disorder counseling, to determine inclusion criteria and accurately collect participant data that may inform further studies about specific cultural experiences in substance use disorder counseling.

Data Collection

This study utilized visual data collection methods through Photo Voice and focus groups to discuss and reflect on photos that speak to QTBIPOC experiences in substance use disorder counseling. Photo Voice is a participatory action research-based methodology based on the understanding that people are experts on their own experiences. Furthermore, Photo Voice is a technique that stems from photoelicitation, which allows participants to record and reflect on their communities’ strengths and concerns, enhance critical knowledge about salient issues through group discussions about the photographs, and promote social justice action with policymakers.

This methodology allows participants to obtain photos representing their lived realities and ask questions about “why situations are occurring” and how social change can occur. Also, Photo Voice is essential as part of Participatory Action Research, given its ability to provide power and voice to historically minoritized communities. For example, Photo Voice has been used in empowering queer and trans youth by providing space to process and share their struggles with visibility, representation, and minority stress. Furthermore, Photo Voice research methodologies have explored advocacy themes and created safe spaces among LGBTQ+ communities during the research process. Finally, Photo Voice has been used to explore strategies for resilience among QTBIPOC communities. Through the core elements of story-telling, community dialogues, and action, Photo Voice becomes a form of social justice action that engages in liberation from community oppression .

To begin the Photo Voice process, the researcher asked participants to obtain one to three photos representing their various experiences in substance use disorder counseling. Originally, Photo Voice provided participants with cameras to describe their lived experiences through photographs. However, this methodology was altered for the sake of this study so that participants would have more freedom in utilizing available photos from their own means (e.g., internet, photo devices), which made collecting photos more feasible for participants. The researcher also explained to participants that the photos they collected could represent their thoughts and feelings when receiving substance use disorder counseling services, rather than actual photographs of their experiences while present in counseling. Once participants were asked to obtain at least one to three photos representing their experiences in substance use disorder counseling and provided informed consent for participation, the researcher invited the participants to participate in two back-to-back focus group sessions through Zoom links. The links provided to each participant were provided with passcode requirements to ensure privacy and security when meeting with participants during data collection.

In Photo Voice research, the photos engage participants in dialogue about personal and community issues. In this study, photos were used to engage QTBIPOC participants in dialogue about their experiences in substance use disorder counseling and how these experiences inform affirmative counseling care towards QTBIPOC who struggle with substance abuse. Furthermore, these dialogues promote ideas about social change to bring to policymakers. In this particular study, dialogues about QTBIPOC experiences in substance use disorder counseling were utilized to brainstorm ideas for social change, which can then be related to communicating community needs to substance use disorder counselors and institutions.

Freire in Wallerstein and Auerbach described that a listeningdialogue- action- reflection approach could be utilized in Participatory Action Research focus groups to engage in the knowledge-building process with QTBIPOC community members. Specifically, focus group sessions were used in this research study due to their usefulness in obtaining various perspectives, developing insight into participants’ points of view, examining the lives of participants, and generating action-based ideas with the collective power of the group, which is congruent with the theoretical tenets of Critical Participatory Action Research. The two focus group sessions were created around these theoretical tenets and lasted up to 90 minutes each.

The first focus group session focused on utilizing Photo Voice to listen to the messages within the photos taken by participants as they reflected on their experiences in substance use disorder counseling. Semi-structured interview questions encouraged the participants to share how their photos individually and collectively represented their experiences in substance use disorder counseling. Furthermore, romantic and localist interviewing styles were utilized to complement semi-structured interview formats, help minoritized communities open up in sharing their community concerns, and reduce the power distance between the lead researcher and participants.

The first session was essential to the data collection, given that this session provided additional insight into the Photo Voice data. Further, the first session provided participants an opportunity to establish roles of agency by giving them space to pose questions and insights about the data with the equitable guidance of the moderator, reducing power distance within the relationship between the researcher and participants. Furthermore, the first session aimed to empower participants, as they were allowed to share their inner world with the researcher by sharing their photographs.

The second group session focused on improving substance use disorder counseling with QTBIPOC communities. The second group session dedicated time and space for participants to generate ideas for social justice action and enhancing counseling efficacy in substance use disorder counseling with QTBIPOC. Specifically, researchers and participants collaboratively decided on ways to actively advocate for QTBIPOC community needs in substance use disorder counseling outside of the focus group sessions. As we collaborated in brainstorming social justice action steps to enhance substance use disorder counseling, we agreed that we could add additional focus group sessions to reflect on the efficacy of our efforts and future directions in advocacy.

Data Analysis

Data analysis consisted of a two-step process during this study. First, deductive coding was utilized to create two a priori codes that provide organized data for the established research questions of this study. Specifically, minority stress and affirming counseling experiences were the two a priori codes established during this study. The second step of data analysis consisted of inductive coding to create a hybrid coding approach, creating sub-categories within the already established a priori codes. The following sub-categories were organized as expected codes, surprising codes, and codes of conceptual interest.

Surprising codes are described as codes that are unexpected to emerge during the data analysis by the researcher and participants. Therefore, contradictory experiences were analyzed and included within the research, even if they did not fit in with expected themes between researchers and participants, to account for and examine the complex lived experiences of QTBIPOC in substance use disorder counseling. Codes of conceptual interest include themes that hold potential interest for the researcher, participants, and readers. Codes of conceptual interest are valuable in providing direction for further research studies that aim to explore QTBIPOC experiences in substance use disorder counseling. Codes of conceptual interest are also helpful to readers who can apply the research’s findings to their clinical practice in substance use disorder counseling with QTBIPOC. Organizing the data into these sub-categories enhances current literature on QTBIPIC experiences in substance use disorder counseling through confirming, contradicting, and illustrating needed areas of research that speak to QTBIPOC experiences in substance use disorder counseling.

Findings

I was contacted by 22 individuals interested in participating in my study. I interviewed 12 participants who qualified for the study based on the participant criteria and availability to meet for the focus group sessions. Out of the 12 participants who engaged in the study, four participants provided photos during the study to launch community dialogue about QTBIPOC substance use disorder counseling experiences. Furthermore, 10 participants met for focus group sessions, while two requested individual interviews. Out of the 10 participants who engaged in the focus groups, each group consisted of four, four, and two group members who met for two back-to-back Zoom sessions with the researcher. One of the groups (e.g., the group of two community members) could not provide any photos yet still provided valuable insights into their lived experiences in substance use counseling. Table 1 describes the basic demographic information that represented each participant during the study (Table 1).

Table 1:Participants.

Meeting the participants

This section of the study is dedicated to getting to know each of the twelve participants in more depth to humanize QTBIPOC community members and their experiences in this research.

Group members engaged in story-telling through their photos and narrative experiences, which aligned with their collective motivations in building community connections during the substance use recovery process. Beck reportedly joined this study to share their experiences and help others through their experiences. This participant originally received substance use disorder counseling in New York and received substance use disorder counseling twice throughout their life. Beck’s experiences were beneficial to this study, given that they could relate to both affirming experiences and experiences of minority stress in substance use disorder counseling, which provides a holistic perspective into QTBIPOC experiences in substance use disorder counseling.

She also joined this study to share their ongoing experiences with substance use disorder counseling. This participant originally received substance use disorder counseling in California and received substance use disorder counseling three times throughout their life. Overall, She’s insights were important to the study, particularly to highlight the discomfort they perceived from substance use disorder counselors in their counseling experiences. John joined this study to mainly share their experiences in substance use disorder counseling in a supportive space. Specifically, John openly reflected on the substance use disorder counseling they received in New York. John’s lived experiences provide significant insight into what minority stress experiences could be like for QTBIPOC during substance use disorder counseling. Edward was the next participant to join this study, who shared about the affirmation and community connections they received from substance use disorder counseling because their counselor was also Trans. These experiences were insightful to the study by elaborating what affirmative QTBIPOC substance use disorder counseling represented to them as they navigated counseling environments.

Kevin also joined this study to share their personal experiences in substance use disorder counseling in New York. While Kevin was enthusiastic about sharing their experiences in substance use disorder counseling, they were curious about the researcher’s investment in the study, inviting critical dialogue between the researcher and participants about the purpose of this academic work and its intentions. Kevin provided essential points of study when describing their experiences in counseling, including feeling unseen, isolated, and looked down upon when navigating counseling environments. Victim was mainly interested in this study to share their journey during the substance use disorder counseling process. This participant stated that they originally received substance use disorder counseling in New York 10 times throughout their life. Victim further elaborated on the struggles they experienced in being able to afford consistent counseling, which speaks to ongoing issues of accessibility to counseling services among QTBIPOC communities.

Tyron Rose shared that they joined this study to hear about others’ experiences in substance use disorder counseling so that they did not feel alone in their experiences. This participant received substance use disorder counseling in Georgia and received substance use disorder counseling four times throughout their life. Tyron Rose’s lived experiences were vital to the study, given their experiences of feeling unsafe and unaccepted throughout substance use disorder counseling, to illuminate QTBIPOC experiences of minority stress in substance use disorder counseling. Therefore, this interaction was valuable to the data collection process, given that participants utilized these focus group sessions for community connections to avoid isolation, especially when processing harmful experiences in substance use disorder counseling.

Joel joined this study to share their stories of survival and resilience throughout the substance use disorder recovery process. Specifically, Joel received substance use disorder counseling in New York 16 times throughout their life. These contributions to the study were valuable due to Joel’s insights about the benefits of ongoing substance use disorder counseling and experienced companionship during the recovery process. Richard wanted to participate in this study to meet new people and be exposed to different ideas and experiences regarding substance use disorder counseling for QTBIPOC. This participant was also curious about the researcher’s investment in this academic work and wanted to know whether the researcher could relate to QTBIPOC experiences in substance use disorder recovery. From this interaction, community members reported that these focus groups were an opportunity to learn about diverse experiences and discuss various options for enhancing substance use disorder counseling with QTBIPOC.

Michael A. joined this study to share the healing transformation they experienced throughout the substance use disorder counseling process in New York. Specifically, Michael A. shared about the healing experiences they had through feeling encouraged and empowered to share about their life experiences in counseling, knowing that they had substance use disorder counselors who were willing to advocate alongside them during the recovery process. Michael B. was enthusiastic about joining this study to share their harmful experiences of minority stress in substance use disorder counseling. Specifically, Michael B. shared their experience receiving substance use disorder counseling in Georgia at a psychiatric hospital and how they did not feel affirmed when processing traumatic experiences of structural violence that influenced their substance abuse behaviors. Lastly, Allan joined this study to share how their experiences of minority stress in substance use disorder counseling scarred them as they encountered new counselors in the future. Allan’s perspectives informed this study about how cultural mistrust occurs due to minority stress experienced when navigating counseling environments as a QTBIPOC community member.

Overall, the focus group sessions served as a space where QTBIPOC community members could connect through their personal experiences, share their stories and lived experiences, and become exposed to different ideas and perspectives as they navigated counseling institutions. These motivations greatly informed the research data presented in this study due to how the motivations closely aligned with the ideals of Critical Participatory Action Research and PhotoVoice methodologies. Specifically, the collective motivations for participating in this study focused on how community knowledge is produced to create ideas of institutional change for the future. However, it is important to note that photographs and images are not visibly displayed in this work, given that QTBIPOC community members did not provide consent to have their photos shared in the study. Still, through the photos that were shared and through the dialogue built about community concerns, each of the 12 participants provided incredible insights into their lived experiences and ideas to enhance the substance use counseling field for QTBIPOC, which fulfills the primary goal of Photo Voice research. These insights are further described in the following sections.

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