4 Tips for Managing Prescription Medicine in Recovery

Dr. Jerome Lerner, Director of Sierra Tucson's Pain Recovery Program

Are you anxious about undergoing a medical procedure while in addiction recovery? Are you hesitant to take prescription medications for fear of relapsing? These dilemmas pose unique sobriety challenges for those in both early and long-term recovery. With a little planning and a proactive approach to post-operative care, the following tips from Jerome Lerner, MD, director of Sierra Tucson’s Pain Recovery Program, can help lower the risk of relapse and guide recovering addicts into a successful healing process.

  1. Get Honest with Your Provider

Prior to surgery, talk to your health care provider and let him or her know you are in recovery. When treating a patient for pain, a doctor needs to look for potential risk factors of substance abuse. Having a conversation about your concerns of relapse will prompt your doctor to carefully assess your situation and select an anesthetic and/or medication that will be in the best interest of your recovery. When a situation warrants medication, it is not safe to under-medicate or over-medicate—the most effective route for managing pain is to consult your provider for post-operative recovery techniques and a tailored treatment plan.

  1. Ask for Help

If you are concerned about having medication in your home, ask someone else to monitor your follow-up treatment and dispense your medicine at the designated times. If that is not an option, a pharmacist can partially fill a prescription on a schedule.

  1. Take a Non-Narcotic Approach

Similar to tip #1, maintain regular conversations with your doctor after surgery and secure his or her permission to switch to non-narcotics as soon as possible. Examples of non-narcotics include Tylenol (chemical name: acetaminophen); non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, Motrin or Advil (chemical name: ibuprofen), Aleve or Naprosyn (chemical name: naproxen sodium); and hot and cold packs, to name a few. This approach to pain management post-surgery may help expedite the healing process, thereby resulting in less pain, and reducing the risk of opioid dependence.

  1. Get Real with Your Recovery Network

Honesty and open-mindedness are essentials in addiction recovery. Don’t be afraid to seek counsel or talk with your sponsor or support system if you are experiencing cravings or feelings of withdrawal or despair. There is strength in numbers—realizing you are not alone and that intense feelings will pass can help you stay sober throughout the process.

Surgical pain is common and often expected, but each individual’s pain tolerance varies. If symptoms evolve into chronic pain that disrupt normal movement, functioning, and daily activities, adversely affecting your overall quality of life, seek professional help without delay. At Sierra Tucson, we understand how debilitating chronic pain can be. Our Pain Recovery Program is tailored to meet the needs of men and women who are struggling with complicated pain and the conditions that cause it.

Click here to learn more about Sierra Tucson’s Pain Recovery Program, or call (800) 842-4487. For more information about the safe and appropriate use of medicines in honor of “Talk About Your Medicines” month, visit www.talkaboutrx.org.



Identifying, Screening and Treating Depression

screening for depressionBy Valerie M. Kading, DNP, MSN
Director of Medical Operations, Sierra Tucson

October marks two days dedicated to highlighting depression and the potentially devastating effects of the loss of a pregnancy or child. National Depression Screening Day, on October 6, is devoted to educating the public on stigma reduction and improvement of access to treatment for individuals and families suffering from depression. Pregnancy and Infant Loss Remembrance Day, on October 15, is a day in which those who have suffered a miscarriage, stillbirth, ectopic pregnancy, or loss of an infant, can commemorate their babies.

Depression is a global health burden and leading cause of disability that affects over 350 million individuals worldwide. In the United States, over 15 million adults (or 6.7 percent) experience depression, which is the primary cause of disability for individuals ages 15 to 44. At any given time, more than 1 out of 20 Americans older than 12 years of age report current depressive symptoms. Approximately 42,700 individuals will die by suicide each year (CDC, 2016) and sadly, most suicides may have been prevented.

Depression takes a devastating toll on the individual and his or her loved ones. Depression can present throughout one’s life and can occur during childhood, adulthood, pregnancy, postpartum, and later years. Major depressive disorder (MDD) is diagnosed when a person experiences five or more or the following symptoms for at least two weeks: depressed mood, anhedonia, weight or appetite changes, psychomotor agitation, sleep disturbances, lack of energy, thoughts of death, or difficulty concentrating. These symptoms can cause significant impairment in a person’s relationships with others, work performance, and daily functioning. Depression is associated with trauma and/or significant life events such as divorce, loss of a loved one, medical impairments, and comorbid psychiatric conditions including anxiety, disordered eating, and substance use. Untreated depression is also associated with an increased risk of suicide and other causes of mortality, including heart disease.

Treatment options for depression include counseling, pharmacological interventions, naturopathic remedies, exercise, acupuncture, transcranial magnetic stimulation (TMS), psychoeducation, and integrative therapies. While various treatment modalities for depression exist, significant barriers delay or prohibit the treatment of depression. One barrier is stigma. Individuals often feel embarrassed or ashamed to seek help. Also, family members, loved ones, or health care providers may not support treatment based on negative societal views or personal beliefs about mental illness. Another barrier is a health care provider’s knowledge on how to identify, screen, or treat depression. He or she may not know how to comfortably engage in conversations and assess for depression, or may have time constraints that impact his or her ability to adequately identify and comprehensively treat depression.

Screening for depression is vital in the identification and treatment of depression. In September 2016, the U.S. Preventive Services Task Force (USPSTF) clearly articulated recommendations for screening the general adult population, including pregnant and postpartum women. The USPSTF also recommended that screening occur in the context of availability of adequate resources for diagnosis, treatment, and follow-up care. Several tools are available to screen for depression in adults, with the Patient Health Questionnaire (PHQ-9) being the most common. The PHQ-9 is a brief and validated self-administered tool that health care providers can give to patients and is easily accessible online. An appropriate screening tool for the elderly population is the Geriatric Depression Scale, while the Edinburgh Postnatal Depression Scale (EPDS) is the appropriate screening tool for pregnant and postpartum women.

Health care providers should routinely screen all patients for depression. It is especially vital to screen those who have a known family history of depression and/or suffered a recent loss or traumatic event. Once screening has been completed, treatment is warranted. Appropriate referral to a psychiatric provider or more intensive psychiatric care may be necessary if depressive symptoms are significantly impacting the person’s ability to function or remain safe.

Please call our Admissions Coordinators at (800) 842-4487 for more information about Sierra Tucson’s residential treatment for depression. There is hope.

Article by Alison Broderick

Alison Broderick became a part of Sierra Tucson’s Alumni Relations team in the fall of 2015. Her desire to help others discover the joy of recovery and stay connected is heartfelt. “Through my own experience in recovery, I have developed a passion for helping others find freedom,” she says. Prior to joining Sierra Tucson, Alison served as the Alumni Coordinator at MARR—a long-term drug and alcohol treatment center in Atlanta, Ga. Her commitment to our alumni, as well as recovery, helps the Alumni Relations team connect Sierra Tucson’s miracles from all over the world. Based in Atlanta, Alison focuses primarily on alumni outreach in the eastern region of the U.S. She says, “I believe in the quality treatment we offer. Recovery is a gift, and I am thankful for the opportunity to share that gift with our remarkable alumni community.” Telephone: (470) 955-4516 E-mail: ABroderick@SierraTucson.com

Individualized Treatment for Professionals

Struggling ProfessionalBy Michael Genovese, MD, JD
Chief Medical Officer, Sierra Tucson

At Sierra Tucson, we recognize that our residents share much in common, but that we must also be mindful of the stressors and circumstances facing each individual. Men and women who are in high-pressure professions may be the first to offer help to others but the last to recognize the need within themselves. Even if they do, many put off treatment because they feel it would take too much time away from work.

We have developed a curriculum at Sierra Tucson in which professionals can receive world-class, discreet treatment that includes mindfulness and stress-reduction practices, bodywork, offsite 12-Step meetings, and SMART Recovery. Psychiatrists and other providers deliver treatment based on the unique circumstances of professionals who are struggling with addictions and co-occurring disorders. We take the real world into account during treatment by offering accommodations such as “healthy electronics” time, which allows residents to address business needs in a structured, caring environment. We also cater Family Program work in a manner relevant to the professional and his or her loved ones.

Phil Mitchell, MA, MFT (CA), MAC, a primary therapist at Sierra Tucson who works closely with professionals, poses the following questions to this population:
  • Despite your successes, are there areas in your life that you feel are lacking or unfulfilled?
  • Is there an addictive behavior that takes the quality of life away from you and your loved ones?
  • Have you been moving so fast in your life that you’re losing touch with who you are and who you want to be?
  • Have others – friends, loved ones, colleagues, a professional board – noticed certain changes in your behavior and encouraged you to get help and support?
  • Are you open, interested, perhaps eager to regain a sense of quality and higher purpose in your life?

If the individual answers yes to any of these questions, Sierra Tucson can provide him or her with an opportunity to reset and recalibrate–mind, body, and spirit. We ensure confidentiality in a safe, structured environment that respects the privacy of each professional.

Each resident at Sierra Tucson receives a core team, which includes an experienced and skilled psychiatrist and psychotherapist, and many holistic specialty therapists and practitioners. Residents participate in educational lectures and workshops amid the breathtaking setting of the Santa Catalina Mountains; engage in mindfulness, meditation, yoga, equine and challenge course therapy, Somatic Experiencing®, and EMDR, to name a few; and take part in Family Week, which offers a powerful healing experience for the individual and his or her loved ones.

The End of Chronic Pain

painBy Jerome Lerner, MD

I understand that it’s a bold idea to declare the end of chronic pain. I have worked in the field of pain management for 30 years, most recently as the director of the Pain Recovery Program at Sierra Tucson. I have literally helped thousands of people suffering from seemingly endless pain to find relief. And yet, I dare to declare the end of chronic pain. Why? How?

Chronic pain is not a person, place, or thing. It is a concept – an idea or belief that some people are and will be stuck in suffering and misery forever. I simply do not have faith in this philosophy anymore.

What Is Chronic Pain?
The Merriam-Webster Dictionary defines the word chronic as “marked by long duration, by frequent recurrence over a long time, and often by progressing seriousness.”

According to the American Academy of Pain Medicine, pain is described as “an unpleasant sensation and emotional response to that sensation.”

Putting these two words together – chronic pain – inadvertently creates a phrase of implied hopelessness and powerlessness that, in my opinion, is unwarranted. It tells us nothing about why pain and suffering persist. It provides no insight or strategy into resolving or healing the situation.

Seeing Is Believing
As director of the Pain Recovery Program at Sierra Tucson, I guide my department with knowledge that is based on three decades of observation, experience, and an in-depth study of science and medicine:

We have directly observed that the vast majority of painful conditions resolve or recede to the background – within the 90-percent range.

We feel it is the birthright and natural condition of every person to expect that painful injuries and medical conditions can, will, and do get better with time and correct care.

We understand that when painful conditions fail to resolve or recede to the background, there must be some complicating factor or factors that are interfering with the natural process of healing.

We trust – and have frequently observed – that when these complicating factors are identified and addressed, the pain does indeed resolve or recede to the background.

We are committed to discovering what these complicating factors are and how to address them effectively. Often, we witness improvements in our residents whom others believed could not get better.

And that is why I believe and declare the end of chronic pain.

Chronic v. Complex
What I propose is that we replace the old language and conceptual model with a new one: “complex pain.”

When a painful condition gets better as expected, it is referred to as “simple pain.” When it does not, complicating factors are involved; and, is then identified as “complex pain.”

At Sierra Tucson, our residents experiencing complex pain may require additional medical and, rarely, surgical care to support healing. Yet in any case, simple or complex, I propose that pain as an experience can and does resolve or recede with time and good care when there are no complicated issues getting in the way.

The good news: almost anyone can understand the reasons that interfere with healing, and there are effective strategies to address them all. The tougher news: it takes a strong determination and perseverance to apply the strategies consistently over time to get the desired results. Because of the challenges along the way, residents often benefit from coaching or guidance to untangle the complicating factors and achieve their goals. When challenges are more severe or deeply imbedded, coordinated expert treatment directed at the complex issues is required.

The Four Factors
My studies and explorations have led me to identify four major complicating factors that interfere with the natural healing of painful conditions. All four factors must be addressed in a coordinated fashion to unlock a complex pain scenario.

1. Biomechanical Stressors – Alignment, stability, flexibility, and endurance challenges needed for the body to function
2. Hypersensitization – Primarily deals with the over-activity of the sympathetic nervous system and the changes to brain activity that occur over time with unresolved pain
3. Metabolic Inflammation – Chemical changes in the blood, which lead to increased tenderness to touch and movement
4. Inertia – The negative thoughts, beliefs, and judgments that keep people ‘stuck’

The Sierra Tucson Approach
Sierra Tucson’s Pain Recovery Program offers treatments and experiences that help individuals discover where and how they have become trapped in their pain. Residents learn a variety of ways to change the negative patterns that hold the pain, both physically and psychologically. The program places a strong emphasis on physical restoration, utilizing the benefits of physical therapy and personal training in individual and group activities. Massage, acupuncture, chiropractic, and other therapeutic bodywork are available to help relieve pain.

The Pain Recovery group at Sierra Tucson meets five days per week to discuss and explore pain-related issues. Pain education is strongly encouraged. Unresolved trauma – common in this population – is addressed with integrative therapies such as EMDR and Somatic Experiencing®. Medication and natural/herbal solutions are examined extensively among the resident’s multidisciplinary team of professionals, with an effort to minimize or eliminate addictive substances. Each resident receives individualized care. Our exceptional clinical team is committed to learning new strategies and applying evidence-based techniques to help resolve complex pain, and improve the quality of life for those who are suffering.

Sierra Tucson Is ‘On the Air’ with That Sober Guy Radio

SoberGuyRadioSierra Tucson is proud to have been a part of the 2016 Innovations in Behavioral Healthcare conference in Nashville, Tennessee, presented by Foundations Events. The goal of this annual conference is to “powerfully impact the sustainable health of your organization, your career and most importantly, your patients.” This year, Foundations Events joined forces with That Sober Guy Radio, hosted and founded by Shane Ramer. Ramer’s podcast discusses alcoholism, addiction, and recovery, and includes guests who are living sober, as well as treatment professionals in the field.

Sierra Tucson’s own Chief Medical Officer Michael Genovese, MD, JD, and Chief Marketing Officer Lisa Jane Vargas had the pleasure of joining Ramer for a podcast interview at this year’s conference. They spoke on the unique treatment provided at Sierra Tucson, specifically for trauma and addiction recovery.

“Education, for both those inside and outside of the behavioral health industry, is a vital social change that we want to bring about as a community. Starting the conversation in our homes, our local communities, and with other wellness professionals is just one of many ways to educate the public about the addiction epidemic,” Vargas says.

“Where you thought there was no hope before, the one thing I can tell you is that we can find something to be hopeful about.” – Dr. Michael Genovese, Sierra Tucson

There is hope. There is a conversation to be started and heard by many.

We invite you to listen online as Genovese and Vargas speak about the 32-plus years of treatment Sierra Tucson has provided, and the thousands of individuals and families impacted through our comprehensive services and prolific partnerships in the industry.


Family Matters: How Family Week Supports Lasting Change

WSM_1924-X2By Michael G. Simpson, MSC, LAC
Family Therapist at Sierra Tucson

Sierra Tucson has been conducting Family Week with its residents and their families since its inception over 32 years ago. Both alumni and referents alike have been effusive in their praise through the decades for the transformations that occur within families and individuals who complete our Family Program. Family Week isn’t an aside from primary treatment; instead, it is an integral part of primary treatment here at Sierra Tucson. Many recent studies have confirmed what Sierra Tucson pioneered in 1983 — the integration of family therapy with primary care improves treatment outcomes across several metrics when compared to primary treatment without family therapy, and when compared to primary treatment separate from family treatment.

Sierra Tucson’s Family Week is a four-day-long, eight-hours-per-day commitment, and family members must fully participate in order to be eligible. An essential part of our Family Program, Family Week is held 52 weeks out of the year, including holidays. How do we get family members to take time away from their busy lives and make such a commitment? By the time an individual has set aside the time and resources necessary to attend 30 days or more of residential treatment, dysfunction, distress, and dissonance within his or her life and the lives of his or her family members has risen to the point whereby all members collectively recognize something must change if personal and relational catastrophe are to be avoided. This is a pivotal moment in which the pain of staying the same seems greater than the pain of changing, for both the resident and the family. In this moment of crisis, Sierra Tucson presents a means for hope and healing that the resident and family can acknowledge as an opportunity to be seized before it passes.

We combine lectures with opportunities to put the knowledge just learned into practice immediately with family members in live interactive settings. This is very powerful. Each family member and resident is encouraged to safely talk about the behaviors of the other person around which they have felt the most pain, hurt, guilt, shame, anger, sadness, or fear. Through this difficult emotional process, we help both parties identify the most important opportunities for change and healing in their relationship with one another. Then we teach them the self-empowering benefits of becoming responsible for their own thoughts, feelings, and behaviors, as opposed to feeling forced to react by circumstances or the behaviors of others. We guide them through proactive steps for self-evaluation and self-care that can transform negative experiences into positive ones.

It takes a monumental commitment of finances, personnel, facilities, programming, and clinical expertise to maintain an effective family program. Through a 32-year process of practice, outcome assessment, and program adjustment, Sierra Tucson has developed a premier, world-renowned Family Program. This provides our residents and their families with help, hope, healing, and the opportunity for lasting change. And, we enthusiastically demonstrate our commitment week after week, because we know that family matters.

Changing the Shape of Eating Recovery

image011Integrative models to support a healthy lifestyle
By Scott Frazier, MSC
Eating Recovery Program Manager at Sierra Tucson

When residents struggle with their identity, they inevitably struggle with attachment. This leads to a craving for attaching to others and may create a loss of attachment to self. One can easily be imprisoned in the early Psychosocial Crisis stages that removes autonomy and causes mistrust in many facets of his or her life. A maladaptive pattern of behaviors usually includes self-taught coping skills. Individuals develop them to address mood disturbances, trauma, grief, loss, or a combination of disorders that influences their overall functionality. One historically attaches onto patterns of behaviors that he or she can control as a means to rationalize desired feeling(s). This can show up in different forms to include addiction, eating disorders, emotional regulation problems, and other maladaptive behaviors.

Eating disorders are no exception, as one may lose his or her self-identity. Attachment then becomes a key part of the individual’s destructive cycle. A person may attach to an image of who he or she should be and engages in disordered eating to acquire the desired image. Examples of maladaptive coping skills may include a trauma resident attaching to the idea of control and engaging in restriction of diet in a means to control the feelings around the trigger. With a mood disturbance, a resident may capture the feelings of comfort by bingeing or purging to cope with anxiety or depression. The instrumental assessments and treatment of the individual is important, as many providers focus on just treating the symptoms rather than the person as a whole. Historically, eating recovery has been a medical-based model, in which stabilization of the client is the goal of the provider.

A new approach is being utilized at Sierra Tucson that combines several best practices to treat the whole person. As a resident enters treatment, he or she experiences an integrative health model that focuses on a combination of medical, psychiatric, and clinical work. Therapies such as EMDR, Somatic Experiencing®, grief and loss, addiction treatment, psychiatric stabilization, and naturopathic medicine, work in unison with eating wellness, sleep hygiene, dietician-tracked meal plans, and therapy for relapse prevention.

In truly identifying a focus of treatment that impacts the resident for a positive outcome, Sierra Tucson’s Associate Medical Director Tena Moyer, MD, and I lead the treatment team in which the modalities’ emphasis is on identifying early developmental relational trauma and its impact on eating disorders in adolescents and adults.  As a provider, examining the role of both the sympathetic and vagal nervous system, as well as exploring the psychodynamic implications of attachment and development that leads to disruptions in the genesis of disordered eating, is crucial to providing integrative care. Examining the “value” of disordered eating beliefs and behaviors helps us as we guide and encourage residents to illuminate the meaning of such behavior. Talk therapy can then help develop healthier strategies for managing emotional and somatic dysregulation.

The clinical work needs to be individualized and resident-driven. Providers may need to adapt to the individual, which may take on many forms; for example, helping a resident heal through modeling expression and using metaphor and symbolism as resources. Family dynamic work may incorporate the history of messages sent to the individual that reinforces maladaptive eating behaviors. Encouraging family participation, facilitating healthier ways to communicate, improving the family system, working through codependency, and setting boundaries all work to support a healthier lifestyle. In essence, treating the resident with integrative models that incorporate medical, psychiatric, and clinical services in a unison approach with wraparound continuing care and a lifetime of alumni services is providing a world of change for individuals struggling with eating disorders.

A Note on the State of Managed Care

Rich_Appert_DSC04193_cl_112315A Word from Our Director of Admissions:
Rich Appert

A recent admission to Sierra Tucson had me reflecting on our industry’s current interaction with commercial payers and managed care as a whole. While legislators and advocacy groups continue to trudge forward from a bureaucratic perspective (moderately successfully), it’s hard not to grow mildly disconcerted at the “one step forward, two steps back” nature of the relationship. The downward trend in residential lengths of stay is not really improving despite the apparent progress of both the Mental Health Parity Act (MHPA) and the Affordable Care Act (ACA). While discussing the aforementioned case both internally and with the referral source, the realization that the onus is on us (providers, employer groups, referral sources) to affect positive change has become exceedingly evident. The pushback has to become more severe. The alternative is that the residents we care so much about won’t get the help they so desperately need.

I should mention that we are doing remarkably well at Sierra Tucson when it comes to average length of stay at the residential level of care. Through the first two quarters of the year, we have been right around 27-28 days, which is even better than it seems when one considers that we don’t utilize partial hospitalization or intensive outpatient benefits at Sierra Tucson.

“John,” the admission mentioned above, was referred to us by an advocacy group that works with first responders. John had been going to outpatient for about six months, was unable to stop drinking, had been endangering himself and others by driving intoxicated, and had shown up to his public safety job under the influence. There were some additional co-occurring mood issues as well, and it was clear to anyone with an even moderate level of cognitive awareness that this individual needed significant clinical and medical intervention to prevent anything tragic from occurring.

The employer group involved in this case had decided to outfit their employees with what appeared to be very good mental health and substance abuse benefits. The plan had low deductible and coinsurance amounts and both in- and out-of-network benefits. Obviously these types of plans are far more expensive than most HMO or other baseline plans. While the particular insurance company involved had no issue in selling this plan to said employer group, it did take exception to allowing one of the group members to actually utilize the benefits sold. Residential treatment for John was denied. Sierra Tucson appealed and Chief Medical Officer Michael Genovese, MD, JD, personally handled the peer review. Once again, treatment was denied without one single day being authorized. The recommendation was that John return to the same outpatient level of care in which he was currently failing.

This sort of thing was common not so long ago but it wasn’t supposed to happen anymore. MHPA was passed in the 1990s and basically required that coverage levels (in terms of dollar amounts) provided to medical benefits also be available for mental health. Insurers responded by implementing day limits, higher deductibles on mental health services, and other restrictions on utilization of benefits. In 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed, which closed those loopholes but still did not explicitly require that plans offer coverage for mental health treatment; it only required that plans that offer both medical and mental health have equitable coverage levels. Finally, the Affordable Care Act classified mental health coverage as an “essential health benefit” and required that it be covered (still with some exceptions), beginning in 2014. So here we are with nearly all insurance policies including coverage for mental health and substance abuse, but no way to ensure that authorization of covered benefits is actually granted. In fact, many insurers employ completely arbitrary criteria guidelines and can still deny care regardless of clinical presentation.

This is exactly where we found ourselves with John. To be fair, there are some insurance providers that are quick to authorize care and seem to generally do the right thing. Additionally, very few cases are denied from Day 1 like John’s. Nevertheless, we were at a crossroads but decided as a team not to go down without a fight. It was at this point that I contacted one of our Treatment Placement Specialists for Acadia Healthcare and the referent who also happened to represent the employer group. We approached the problem from all angles. I, along with our utilization review manager, called the payer and we worked our way up the supervisory chain. The employer, who represents a very large employer group and also signs the premium checks, called and expressed his significant displeasure at the turn of events. Then he called again…and again. After a couple of days strategizing, our small team of amateur advocates was able to secure an initial seven-day authorization. This happened after the formal appeal process was exhausted. When all was said and done, John left residential treatment after 30 days were authorized.

This particular story ends well (I recently heard from the referent that John is thriving in sobriety), but this is only the beginning. The point here is that there is no real accountability for most of the major payers. We are the accountability. Some will argue for more regulation, others will say lack of competition in the insurance marketplace perpetuates this kind of practice. But really, neither matters in the near term. The reality is that, as providers, employers, and family members, we need to work together to collectively push back when arbitrary decisions are made that can endanger a resident’s or loved one’s life. It works. I have seen it work time and time again. It requires, however, that we all join forces. If we stay quiet, it is unlikely much will change anytime soon. We must remain optimistic, though. There is significant strength in numbers and we have the distinct advantage of knowing that what we are doing is right. As it says when one enters the front gate at Sierra Tucson: Expect a Miracle.

LGBTrauma: The Importance of Cultural Competency and Trauma-Informed Care

Photo by Cheryl La Plant, Sierra Tucson

Photo by Cheryl La Plant, Sierra Tucson

By David Cato, MSW, LMSW
Primary Therapist, Trauma Recovery Program

Growing up as an LGBTQ individual in Northeast Texas was difficult. When I began to question my orientation, there were no resources. I did not know any other LGBTQ individuals and no one else knew how to help me once I began to come out. It was very scary to be the only LGBTQ person I knew and not know how to meet others in a healthy way.

This is how LGBTQ people can feel when entering residential treatment. It is important for a treatment facility to have resources available for this population, as well as experience and training in cultural competency. It is also important to be mindful and aware of the potential geographical and religious implications (trauma) that LGBTQ individuals have experienced. Growing up in the Southern Baptist Church, I learned that being anything other than heterosexual was frowned upon and even attacked. Once I believed I had found safety in the church, I was able to trust others enough to share my orientation with them, only to be rejected. After working with other LGBTQ individuals in the mental health field, I have come to understand that my experience is not entirely unique. In fact, it has been helpful to identify with these types of issues so that I can relate to our residents even more.

As mental health professionals, it is essential to maintain cultural competency in all aspects. LGBTQ individuals (lesbian, gay, bisexual, transgender, queer, questioning, etc.) have specific needs, and many factors must be considered when working with this broad population, including traumatic situations that are unique to them.


The Gay, Lesbian and Straight Education Network (GLSEN) releases a biennial report called The National School Climate Survey, which includes detailed information and statistics about how LGBTQ individuals are affected in U.S. schools. It is important for professionals to be aware of these statistics, as they can help create an understanding of what LGBTQ people experience and how these experiences can lead to potential addiction and mental health issues.

Based on the report, 74.1 percent of LGBTQ students were verbally harassed (i.e., called names or threatened) in the past year because of their sexual orientation, and 55.2 percent because of their gender expression; 36.2 percent were physically harassed (i.e., pushed or shoved) in the past year because of their sexual orientation, and 22.7 percent because of their gender expression; and, 16.5 percent were physically assaulted (i.e., punched, kicked, injured with a weapon) in the past year because of their sexual orientation, and 11.4 percent because of their gender expression. (Kosciw, 2013). In addition, the report also states that the effects of this hostile school climate resulted in lower levels of self-esteem and higher levels of depression in both victims of discrimination from sexual orientation and gender expression. Many individuals would miss quite a bit of school or cease going altogether. (Kosciw, 2013). These can be identified as LGBTQ-specific traumas that heteronormative individuals do not experience. While the survey covers crucial information, it does not mention trauma specifically. However, many of the things that LGBTQ youth and individuals experience are considered traumatic and could result in post-traumatic stress disorder (PTSD), addiction, or other mental health issues.

The report also identifies measures that can be taken to help heal these traumas. Support groups for LGBTQ individuals (i.e., Gay-Straight Alliances or similar); training for educators, staff and professionals; and increased access to appropriate educational information about LGBTQ issues are some of the potential remedies. (Kosciw, 2013). Fortunately, these same interventions can be implemented in residential treatment. Groups or psychoeducational lectures can be offered to residents, and trained, educated, and culturally competent staff can be available when LGBTQ issues arise. When an LGBTQ person (inpatient, residential or outpatient) needs help or support, he or she should have access to the available resources. Additionally, each facility and practitioner in the mental health field would benefit by being more inclusive of, and sensitive to, LGBTQ individuals and issues.


There are many terms and identifiers for people across the entire LGBTQ sexuality and gender spectrums. This is information that will continue to shift and evolve and, as mental health professionals, it is important to stay updated on changes by attending continuing education events and trainings, as well as conducting research. Part of this is understanding that the sexual orientation spectrum is different from the gender spectrum. For example, a transgender person might not identify as gay or lesbian. Labels can be important for some people while others reject them. Words like “queer” and “non-binary” help some individuals find safety in their identity if terms like “male” or “gay” do not fit. Self-determination and self-identity are incredibly important when working with LGBTQ individuals. Professionals should always ask how someone identifies, even if they feel like they are sure. (Review the list of references to find an extensive list of terms provided by the University of Wisconsin-Madison.)

Case Studies

Jason admitted into residential treatment for substance use and co-occurring issues. Jason identifies as a transgender male. He is still early in his transition process and appears female physically. Staff members at the center refuse to refer to Jason as a male because “she has breasts and looks like a woman.” Clinical staff assume Jason’s primary issues stem from being a transgender person. Jason is very offended by this and feels a lot of shame about his identity because of the way the professionals are treating him. Jason ultimately leaves treatment AMA (against medical advice) and is too afraid to enter another residential treatment program due to his identity and fear of being treated similarly again. How could a situation like this be avoided at this facility in the future?

Sally identifies as a lesbian woman and states that she does not know if that label fits her still. She shares for the first time in a support group that she may be questioning her gender identity. The facilitator asks her what pronouns she prefers and she does not yet know the answer, though states that she has never been given the option. She is supported by her peers when sharing. The resident continues to feel more comfortable sharing with peers and other clinical staff, eventually exploring a non-binary gender identity. How was Sally able to feel safe enough to share such personal and sensitive information?

Creating Safety

Appropriate cultural competency for LGBTQ individuals means inclusion. There are many actions a treatment facility can take to help LGBTQ individuals feel welcome, accepted, and safe.

  • Intake paperwork should be inclusive.
  • Visible symbols of affirmation are displayed (pink triangle, equality symbol, etc.).
  • LGBTQ training programs are offered for all staff. (National Child Traumatic Stress Network, 2014).

At Sierra Tucson, we use these methods and hold LGBTQ support groups twice per week for residents interested in attending. Because residents may not feel comfortable disclosing sexual orientation or gender-identity issues in their process groups, our LGBTQ support groups provide an initial safe space where they can begin their healing journey.

David CatoAbout David Cato
David Cato, MSW, LMSW, serves as a primary therapist for the Trauma Recovery Program at Sierra Tucson. David began facilitating LGBTQ support groups in 2010 and identifies as an LGBTQ individual himself. He works with a team of LGBTQ specialists to ensure clinical appropriateness. David is also focusing on becoming an LCSW and is currently in a transgender-specific training to become a Transgender Care Therapist (TCT). Additionally, he is finishing training to become a Somatic Experiencing® Practitioner (SEP). David has been at Sierra Tucson for more than eight years and has served in many roles.


Kosciw, J. G., Greytak, E. A., Palmer, N. A., & Boesen, M. J. (2014). The 2013 National School Climate Survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York: GLSEN.

National Child Traumatic Stress Network, Child Sexual Abuse Collaborative Group. (2014). LGBTQ youth and sexual abuse: Information for mental health professionals. Los Angeles, CA, and Durham, NC: National Center for Child Traumatic Stress.

University of Wisconsin-Madison. (2012). Trans, Genderqueer, and Queer Terms Glossary. https://lgbt.wisc.edu/documents/Trans_and_queer_glossary.pdf

Trauma-Informed Care

shame reduction in trauma recoveryReducing one’s shame by using a non-pathologizing approach  
By James Seymour, MD
Director, Trauma Recovery Program at Sierra Tucson

At Sierra Tucson, we provide what is referred to as Trauma-Informed Care for all of our residents. Trauma-Informed Care is the recognition by the treatment program and the clinical staff that a history of childhood trauma is very often associated with and underlies many of the challenges we see. This includes substance use disorder, depression, anxiety disorders, eating disorders, various impulse control disorders, and chronic pain. In addition, we recognize that childhood trauma affects how residents experience our therapeutic interventions.

The most common emotion that nearly all individuals with a history of childhood trauma experience is a deep, abiding sense of shame – the sense that there is something inherently wrong with or bad about them. So in a way, Trauma-Informed Care is simply shame reduction, and shame reduction is Trauma-Informed Care. We make sure that all our interventions work toward reducing shame rather than creating or worsening it.

How do we do this? First, we take a positive, non-pathologizing approach. We don’t call those we treat patients. We refer to them as residents. Post-traumatic stress disorder (PTSD) is not a disease or an illness but rather, a normal nervous system response to traumatic circumstances. Although our residents have serious symptoms and interpersonal problems, we like to stress that essentially they are normal individuals. There is nothing “wrong” with them. We take an approach that focuses on the resident’s strengths and resources, not on his or her weaknesses or difficulties. This goes a long way toward shame reduction.

Also, personality disorders are not labeled as such. What we see as clinicians is simply maladaptive behaviors that arose to deal with a highly dysregulated nervous system, which is often secondary to trauma. We are extremely careful about the language we use as language that makes a difference. An example would be that we don’t describe someone as manipulative. When we see that type of behavior, it is a strong clue that the individual has never had enough trust in a relationship to think that asking for help directly would be of any benefit. We do this with other words that are frequently used to label those we are trying to help.

At Sierra Tucson, we believe that helping reduce a resident’s shame is one of the most helpful and powerful things we can do.

If you would like more information on Sierra Tucson’s comprehensive residential treatment, please call our Admissions Coordinators at (877) 801-2632.