one page essay due tomorrow by 4 pm eastern time

Development and Evaluation of Training for Rural LGBTQ Mental Health Peer Advocates

Tania Israel University of California, Santa Barbara

Cathleen E. Willging Pacific Institute for Research and Evaluation,

Albuquerque, New Mexico

David Ley New Mexico Solutions, Albuquerque, New Mexico

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) people in rural areas experience negative mental health consequences of minority stress, and encounter multiple barriers to accessing mental health and substance use treatment services. As part of a larger intervention study, we developed and piloted a unique training program to prepare peer advocates for roles as paraprofessionals who assist rural LGBTQ people with mental health needs. Thirty-seven people in New Mexico took part in either the initial training or a second revised training to improve their knowledge and skills to address LGBTQ mental health needs. Evaluation of this training consisted of self- administered structured assessments, focus groups, and open-ended interviews. Results for the initial training showed no significant increases from pre- and posttest scores on knowledge about LGBTQ people and their mental health issues, whereas significant increases were detected for the revised training. There also were significant increases in self-efficacy to perform tasks associated with the peer advocate role for all but a subset of tasks for the revised training. Qualitative data reveal that participants appreciated the opportunity to increase information and skills, especially concerning bisexual and transgender persons, and the opportunity to connect with others in the community who want to support LGBTQ people.

Keywords: LGBTQ, mental health, peer, rural, training

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) people in the United States experience tremendous mental health and substance use disparities (Institute of Medicine, 2011). High rates of depression, anx- iety, and suicidality within the LGBTQ popula- tion may originate in “minority stress,” which comprises chronic stigma, discrimination, and

violence (Meyer, 2003). Minority stress oper- ates within cultural institutions and social struc- tures, including health care systems (Meyer, 2003; Meyer, Schwartz, & Frost, 2008), and may disproportionately affect gender noncon- forming individuals, people of color, and rural LGBTQ persons (Díaz, Bein, & Ayala, 2006; McLaughlin, Hatzenbuehler, & Keyes, 2010; Pinhey & Millman, 2004; Williams, Bowen, & Horvath, 2005).

With regard to rural communities, LGBTQ people may face social pressure to adhere to tra- ditional gender roles and norms (Barefoot, Rick- ard, Smalley, & Warren, 2015), as well as nega- tive attitudes related to lack of contact with sexual and gender minorities (Barefoot et al., 2015; El- dridge, Mack, & Swank, 2006; Herek, 2002; Sniv- ely, Kreuger, Stretch, Watt, & Chadha, 2004). Victimization—verbal harassment, property dam- age, and physical assault—is commonly reported by rural LGBTQ people (Barefoot et al., 2015;

Tania Israel, Department of Counseling, Clinical, and School Psychology, University of California, Santa Bar- bara; Cathleen E. Willging, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico; David Ley, New Mexico Solutions, Albuquerque, New Mexico.

The project described in this article was supported by NIMH R34MH095238.

Correspondence concerning this article should be ad- dressed to Tania Israel, Department of Counseling, Clinical, and School Psychology, Gevirtz School, University of Cal- ifornia, Santa Barbara, CA 93106-9490. E-mail: tisrael@ education.ucsb.edu

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Journal of Rural Mental Health © 2016 American Psychological Association 2016, Vol. 40, No. 1, 40 – 62 1935-942X/16/$12.00 http://dx.doi.org/10.1037/rmh0000046

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Boulden, 2001; Cody & Welch, 1997; Leedy & Connolly, 2008; Oswald, Gebbie, & Culton, 2003). Some LGBTQ people migrate from rural to urban areas in search of robust LGBTQ com- munity, leaving those who remain in rural areas further lacking in social support. Geographic iso- lation, insufficient opportunity to socialize with other LGBTQ people, and the perceived need to conceal gender or sexual identities can contribute to mental distress, erode social support, and result in fewer visible LGBTQ role models in rural areas (Barefoot et al., 2015; Leedy & Connolly, 2008; Mathy, Carol, & Schillace, 2004; McCarthy, 2000; Oswald & Culton, 2003).

Rural residents in general, but especially those who self-identify as LGBTQ, report hard- ship accessing high quality mental health care, often because services are in short supply (Wil- liams, Williams, Pellegrino, & Warren, 2012). The quality of support LGBTQ people can ex- pect from available mental health and substance use treatment providers varies. Clinical provid- ers often lack culturally appropriate training and fail to recognize how minority stress affects LGBTQ people, while the broader setting where services are rendered may lack safeguards to ensure that neither individual nor institutional bias influences care (Eliason & Hughes, 2004; Israel, Ketz, Detrie, Burke, & Shulman, 2003; Israel, Walther, Gortcheva, & Perry, 2011; Mahdi, Jevertson, Schrader, Nelson, & Ramos, 2014; Walinsky & Whitcomb, 2010; Willging, Salvador, & Kano, 2006a; Willging, Salvador, & Kano, 2006b).

One means of addressing such deficits within systems of mental health and substance abuse treatment is to employ people who are members of the target community to bridge the gap in culturally competent care. Peer-based ap- proaches draw upon established community health worker models and represent a growing practice in mental health treatment (Getrich, Heying, Willging, & Waitzkin, 2007; Waitzkin et al., 2011; Weeks et al., 2009a; Weeks et al., 2009b). Peer helpers have been employed for a range of populations and medical concerns, in- cluding diabetes management (Tang, Funnell, Gillard, Nwankwo, & Heisler, 2011), serious mental illness among veterans (Chinman, Sal- zer, & O’Brien-Mazza, 2012), maternal/child health, and general health promotion (O’Brien, Squires, Bixby, & Larson, 2009). Consistent with such models, we recruited and trained

community health workers, called “peer advo- cates,” to enhance social support and access to professional services for LGBTQ residents of rural areas (Willging & Israel, 2012). These peer advocates were lay people who were mem- bers of, or strongly connected to, LGBTQ com- munities and who were willing to develop knowledge and skills to address LGBTQ mental health issues. Peer advocates were expected to undertake a wide range of complex tasks, in- cluding needs assessment, goal setting, referral, assistance navigating behavioral health systems, and community outreach, and to enhance knowl- edge about, and social support for, LGBTQ peo- ple in rural communities. These peer advocates were employed as paid, part-time community health workers who received regular coaching and support from the project staff.

Preparation of peer advocates to perform these complex roles is essential (Ruiz et al., 2012). Training can increase the ability of para- professionals, such as peer advocates, to use basic helping skills (Aladağ & Tezer, 2009; D’Augelli & Levy, 1978) and to provide effec- tive support to people seeking mental health services (Lenihan & Kirk, 1990), although ex- tant research does not offer insight into the effectiveness of training to prepare peer advo- cates to perform complex tasks beyond individ- ual helping relationships, such as organizing events or building support networks. Although training can increase mental health profession- als’ knowledge and skills in working with gen- der and sexual minorities (Carlson, McGeorge, & Toomey, 2013; Israel & Hackett, 2004), and LGB-affirmative supervision can enhance LGB counselors’ work with LGB clients (Burkard, Knox, Hess, & Schultz, 2009), prior research has not addressed training that is designed spe- cifically for lay members of LGBTQ communi- ties to assist other sexual and gender minorities with mental health concerns. Although mem- bers of LGBTQ communities may have some LGBTQ-specific knowledge based on their lived experiences, distinctions among subpopu- lations (Fassinger & Arseneau, 2007) necessi- tates training on LGBTQ issues even for mem- bers of these communities.

We report here on our effort to train LGBTQ community members to function as peer advo- cates. This study was part of a larger project to design, implement, and assess the acceptability, feasibility, and preliminary outcomes of the

41TRAINING RURAL LGBTQ PEER ADVOCATES

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overall LGBTQ peer advocate intervention model. To obtain the knowledge and skills needed to implement this model, peer advocates took part in a 4-day series of didactic and in- teractive training exercises that were evaluated and subsequently refined based on feedback from training participants. Because they were based physically in dispersed rural communi- ties, peer advocates were to participate in indi- vidual and group coaching sessions conducted remotely rather than receive onsite supervision. Thus, it was important for peer advocates to be able to deliver interpersonal and community interventions fairly independently. Research on the effectiveness of training initiatives that pre- pare paraprofessionals for such roles is an im- portant component of developing evidence- based interventions (O’Brien et al., 2009; Ruiz et al., 2012; Tang et al., 2011).

The aim of the present study was to use a two-step process to develop, implement, evalu- ate, and revise the LGBTQ peer advocate train- ing. Evaluation involved quantitative measures of knowledge, self-efficacy, and participant re- sponses to specific aspects of the training, as well as qualitative analysis of focus group and

individual semistructured interview data. This study offers new insights by (a) focusing on training rural residents, (b) training members of LGBTQ communities to work within these communities, (c) assessing helpers’ skills be- yond those used in a one-on-one helping rela- tionship, and (d) employing a mixed-method evaluation approach to capture short- and long- term impacts of the training.

Method

Description of Training

Development and initial training. The training was developed and administered by the authors, an academic psychologist/educator, a medical anthropologist, and a practicing psy- chologist/service agency administrator who col- lectively have expertise in three areas pertinent to this study: (a) LGBTQ mental health, (b) engaging LGBTQ people in rural New Mexico for research or clinical purposes, and (c) curricu- lum development. As shown in Table 1, the initial training was organized into 12 modules, with de- scription, purpose, and learning objectives articu-

Table 1 Content of Initial and Revised Training

Initial training Revised training

Part 1

Introductions, icebreaker, communication Introductions, icebreaker, communication Key information about LGBTQ populations LGBTQ people and communities; helping skills Understanding LGBTQ populations in rural New

Mexico Mental health and substance use among LGBTQ people LGBTQ people and suicide Diversity within LGBTQ communities and cultural inquiry Mental health and substance use treatment services for

LGBTQ populations

Mental health and substance abuse among LGBTQ people

Mental health and substance use services for LGBTQ populations

Helping skills Suicide risk, crisis intervention, and other

emergencies

Part 2

Empowerment protocol Overview of Peer Advocate role Ethics and boundaries Communication with service providers and others Conducting outreach and cultivating social

support resources Challenging situations, closure

Working individually with LGBTQ community members (solution-focused approach, needs assessment, collaborative planning)

Working with service providers and others Ethics and boundaries Self-care Outreach, advocacy, presentations, social support Self-assessment of helping and leadership for LGBTQ

community (including privilege)

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lated for each module (for more details on the modules see the Appendix). Suggestions for participant recruitment, training content, for- mat, and strategies to support the work of peer advocates were provided by 32 rural commu- nity members who participated in five focus groups, and two community advisory boards that met on a quarterly basis and included mental health professionals, government offi- cials, representatives from statewide LGBTQ organizations, educators, and LGBTQ com- munity members with lived experience re- lated to mental health and substance use is- sues. Both groups were characterized by diversity in terms of ethnicity, gender, and sexuality.

Based on the input from the focus groups and community advisory boards, the training in- cluded didactic presentations about the basics of mental health and substance use, LGBTQ mi- nority stress factors, protective factors (such as social support), suicide prevention, and rural treatment systems. The training also covered cultural competence, including information about LGBTQ subpopulations and experiences of LGBTQ people in rural New Mexico, based on specific suggestions provided by the focus group participants and the community advisory boards. These suggestions generally emphasized the importance of dispelling misinformation and confronting biases within local LGBTQ commu- nities (e.g., lack of awareness of Native Amer- ican Two-Spirit experiences, erroneous beliefs about bisexuality, and culturally situated imper- atives to disclose sexual orientation). Finally, the training included role plays, group discus- sions, and other interactive training techniques to refine the helping and self-care skills of the trainees, enable them to identify and critically reflect on their power and privilege in relation to others, ground them in professionalism and eth- ics, and bolster their capacity for both face-to- face and community outreach. Initial training took place over two consecutive weekends, with a total of 28 hours across four day-long ses- sions.

Revised training. As a result of the feed- back following the initial training, we integrated helping skills into each topical module rather than relegate them to separate standalone mod- ules (see Table 1). We also reorganized material to reduce lengthy didactic segments, overly conceptual material, and redundancies. The re-

vised training was implemented over two non- consecutive weekends: Part 1 on the first week- end, and Part 2 on the second weekend, two weeks later. Part 1 was designed to include information and skills that could be useful for all members of LGBTQ communities, including their allies. Participants completed a pretest, and then the training opened with an overview, followed by introductions, an icebreaker activ- ity, and discussion of communication tools. Key information about LGBTQ populations was ad- dressed, including distinctions among sex, gender identity/expression, and sexual orientation; soci- etal messages; and information about LGBTQ subpopulations. Participants continued to have opportunities to learn and practice helping skills (including active listening, open-ended ques- tions, and culturally appropriate inquiry when working with a population that is diverse both socially and economically) by applying them within the context of the topical material.

Participants were informed at the beginning of the training that only a limited number would be selected to complete the second half of the training, and that peer advocates would be iden- tified from this smaller pool (see Figure 1 – Timeline). We selected potential peer advocates after Part 1 to make the broader community- based training available to a wide range of in- dividuals, respect participants’ time by offering them a realistic idea of whether they might be selected as a peer advocate, and create a smaller training group to provide more intensive prep- aration for those eligible to become peer advo- cates. At the end of Part 1, participants had the option of applying to receive additional training to be eligible for selection as a peer advocate. Fourteen participants completed a written appli- cation that included queries regarding their in- terest in being an LGBTQ Peer Advocate; their current involvement in their local, statewide, and/or national LGBTQ community; involve- ment in local helping activities; and strengths, challenges, and anticipated support needed. Ad- ditional review criteria centered on primary res- idence to ensure aspiring peer advocates would not be concentrated in any one locality. Appli- cants who were not selected for the second half of the training as peer advocates were informed that we were not able to accommodate everyone who wanted to be a peer advocate from their particular geographic area because of limited resources. Based on the application and trainer

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observation of skills demonstrated in Part 1, eight individuals were selected for inclusion in Part 2 of the training, four of whom were ulti- mately invited to become part-time, paid peer advocates.

Part 2 entailed more specific information and skill development relevant to functioning as peer advocates. Part 2 was structured around the three primary activities in which the peer advocates would engage: (a) individ- ual work helping LGBTQ community mem- bers access mental health and substance abuse services; (b) increasing LGBTQ knowledge and sensitivity among service providers, fam- ily members, and others in rural areas; and (c) promoting social support through outreach, advocacy, and presentations. The participants undertook a variety of activities to cultivate both their understanding and their problem- solving and implementation skills in each ar- ea. Specific skills included solution-focused interventions (Trepper et al., 2010), needs

assessment, negotiating communication con- flicts, and conducting presentations. Partici- pants were prepared for their paraprofessional role with material and activities related to ethical decision-making, boundaries, and self- care. Reflection and self-awareness was en- couraged through activities on privilege and leadership roles in LGBTQ communities.

Participants

A total of 37 people took part in the initial or revised training. Fourteen participated in the initial training, and 23 participated in Part 1 of the revised training, 8 of whom were selected to participate in Part 2 of the revised training. Participant demographics are re- ported in Table 2. We used a combination of methods to recruit participants, including di- rect advertisements circulated via Internet so- licitations, email announcements, and local press releases.

Figure 1. Timeline for revised training. See the online article for the color version of this figure.

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Measures

LGBTQ Peer Advocate Self-Efficacy Inventory. We designed this 8-item measure to assess participants’ confidence in carrying out specific activities required of LGBTQ peer advocates. The instructions and scaling are based on the Lesbian, Gay, and Bisexual Affir-

mative Counseling Self-Efficacy Inventory (LGB-CSI; � � .83 to .97 for each subscale; Dillon & Worthington, 2003). Items reflect ac- tivities required of LGBTQ mental health peer advocates. Each item was rated on a 6-point scale ranging from 1 (not at all confident) to 6 (extremely confident). Sample items include

Table 2 Description of Participants

Demographic Initial training Revised training

(Part 1) Revised training

(Part 2) Total

Number of participants 14 23 8 37 Age

M 41.07 41.65 36.38 41.43 SD 11.36 14.09 8.03 12.97 Range 25–58 19–63 29–51 19–63

Sex assigned at birth Female 7 (50.0%) 15 (65.2%) 4 (50.0%) 22 (59.5%) Male 7 (50.0%) 8 (24.8%) 4 (50.0%) 15 (40.5%)

Gender identity/expressiona

Woman 5 (35.7%) 12 (52.2%) 1 (12.5%) 17 (45.9%) Man 7 (50.0%) 5 (21.7%) 3 (37.5%) 12 (32.4%) Transgender 1 (7.1%) 4 (17.4%) 2 (25.0%) 5 (13.5%) Other 0 (.0%) 3 (13.0%) 2 (25.0%) 3 (8.1%) Missing 1 (7.1%) 0 (.0%) 0 (.0%) 1 (2.7%)

Sexual orientation Lesbian/Gay 8 (57.1%) 9 (39.1%) 5 (62.5%) 17 (45.9%) Bisexual 1 (7.1%) 2 (8.7%) 0 (.0%) 3 (8.1%) Queer 1 (7.1%) 2 (8.7%) 1 (12.5%) 3 (8.1%) Heterosexual 3 (21.4%) 8 (34.8%) 1 (12.5%) 11 (29.7%) Other 1 (7.1%) 2 (8.7%) 1 (12.5%) 3 (8.1%)

Race/Ethnicitya

Hispanic 5 (35.7%) 1 (4.3%) 0 (.0%) 6 (16.2%) European American/White 9 (64.3%) 11 (47.8%) 3 (37.5%) 20 (54.1%) American Indian 1 (7.1%) 11 (47.8%) 5 (62.5%) 12 (32.4%) Other 2 (14.3%) 1 (4.3%) 0 (.0%) 3 (8.1%)

Education High school/GED 1 (7.1%) 0 (.0%) 0 (.0%) 1 (2.7%) Trade/vocational school 0 (.0%) 2 (8.7%) 1 (12.5%) 2 (5.4%) Some college, no degree 2 (14.3%) 7 (30.4%) 3 (37.5%) 9 (24.3%) Associate’s degree 1 (7.1%) 3 (13.0%) 1 (12.5%) 4 (10.8%) Bachelor’s degree 2 (14.3%) 2 (8.7%) 1 (12.5%) 4 (10.8%) Some graduate school 6 (42.9%) 2 (8.7%) 1 (12.5%) 8 (21.6%) Grad/professional degree 2 (14.3%) 7 (30.4%) 1 (12.5%) 9 (24.3%)

Monthly income Less than $500 0 (.0%) 1 (4.3%) 0 (.0%) 1 (2.7%) $500–$999 4 (28.6%) 4 (17.4%) 1 (12.5%) 8 (21.6%) $1,000–$1,999 5 (35.7%) 6 (26.1%) 3 (37.5%) 11 (29.7%) $2,000–$2,999 1 (7.1%) 3 (13.0%) 1 (12.5%) 4 (10.8%) $3,000–$3,999 2 (14.3%) 5 (21.7%) 2 (25.0%) 7 (18.9%) Over $4,000 2 (14.3%) 4 (17.3%) 1 (12.5%) 6 (16.2%)

Years in geographic area M 9.23 13.96 12.29 12.20 SD 13.30 14.60 16.34 14.12 Range 0–44 0–50 1–46 0–50

a Participants could check all that applied, thus percentages may add up to more than 100%.

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Connect LGBTQ people in my community with mental health resources and Demonstrate sen- sitivity when interacting with transgender peo- ple. This measure was scored by calculating the mean of the participants’ responses across items. Individual surveys in which an item was skipped could not be scored and were treated as missing data. The LGBTQ Peer Advocates Self- Efficacy Inventory demonstrated moderate to high internal consistency (� � .76 –.94). This was similar to reliability reported for other sam- ples of various types of self-efficacy, including the LGB-CSI (� � .83–.97 for each subscale; Dillon & Worthington, 2003); Bahora, Hanafi, Chien, and Compton’s crisis intervention self- efficacy measure (2008; � � .87–.92); Brous- sard et al.’s Self-Efficacy Scale (Broussard et al., 2011; � � .89 –.95); and King’s Self- Efficacy Scale (King, 2011; � � .91–.93).

Peer advocate knowledge of LGBTQ issues. We developed this measure as an ob- jective assessment of participants’ knowledge regarding LGBTQ issues, with a particular fo- cus on content covered in the training. This approach to knowledge assessment allowed par- ticipants to demonstrate their objective knowl- edge rather than their perceptions of their own knowledge, as the latter may not accurately measure actual knowledge (Dunning, 2011). The current knowledge measure has two sub- sections consisting of (1) matching and (2) mul- tiple choice questions. The matching section prompts participants to match terms (e.g., gen- derqueer, sexual orientation) to their respective definition. The multiple choice section covers information about LGBTQ subpopulations (e.g., “Which one of the following is TRUE about bisexuals?”), mental health and substance use (e.g., “If someone is feeling hopeless and isn’t enjoying activities they used to enjoy, which one of the following is she or he most likely experiencing?”), helping skills (e.g., “Which one of the following is NOT a good way to start a paraphrase or restate what some- one has said?”), and expectations for persons assuming the role of LGBTQ peer advocate (e.g., “Which is NOT a recommended Peer Ad- vocate response to a crisis?”). These items were informed by national and statewide data, as well as widely accepted models of helping (Hackney & Cormier, 1996). To score this measure, one point was provided for each correct answer (i.e., choosing the correct matching response or the

correct multiple choice response); the total number of points earned reflected a participant’s overall score.

We developed seven matching and 25 multi- ple-choice items to assess these areas of knowl- edge (32 items, scale score � 0 –32). The items were modified based on input from two com- munity advisory boards, described below. Fol- lowing the initial training, several items were added to the instrument or altered to reflect modifications to the training, resulting in a 35- item measure that was used in the assessment of the revised training (35 items, scale score � 0 –35). This measure was administered in two parts for the revised training, with trainees com- pleting 29 items following Part 1; only those trainees who completed the entire training were administered the six items pertaining to infor- mation presented during Part 2 of the training. The two versions of the knowledge measure demonstrated moderate internal consistency at posttest (� � .71–.83).

Participant response to training. During the initial training, we gathered evaluation data following implementation of each mod- ule. We asked each participant to indicate on an anonymous written evaluation form the extent to which each objective was met by responding on a Likert-type scale from 1 (not at all met) to 4 (entirely met). During the revised training, we elicited participant re- sponses following each morning and after- noon session by asking participants to indi- cate on a 4-point Likert-type scale how confident (1 � not at all confident to 4 � extremely confident) they were that they could accomplish the learning outcomes specified for each module. For both the initial and the revised training, participants also were pre- sented with four open-ended questions re- garding important things they had learned, lingering questions, what they liked best, and recommended changes. As recommended by Kirkpatrick (1996), items elicited quantifiable responses as well as open-ended comments.

Demographics. Participants completed a de- mographic questionnaire that included age, sex, gender identity/expression, sexual orientation, race, ethnicity, education level, income, location of residence, and length of time in the area.

Focus groups and semi-structured inter- views. Focus groups were conducted with eight participants after the first half of each

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weekend of the initial training, and 12 train- ees participated in a semistructured individual interview 12 months after the initial training. The two 1-hr focus groups consisted of eight questions that centered on participant reac- tions to the training content, teaching modal- ities utilized to convey this content and to build practical helping skills, and areas for improvement. The 1-hr semistructured inter- views were administered over the phone and included 12 questions concerning the per- sonal and professional impacts of the training over the past year; increases in and applica- tion of knowledge and skills; participant needs regarding additional support, training, or participation as an LGBTQ peer advocate; and recommendations for improving future iterations of the peer advocate training.

Procedure

Evaluation procedures. On the first day of the initial and revised training, participants completed a pretest consisting of the LGBTQ Peer Advocate Self-Efficacy Inventory, the Peer Advocate Knowledge of LGBTQ Issues, and demographic items. At the end of the first week- end, participants completed the self-efficacy measure and knowledge items pertaining to ma- terial covered in Part 1. At the end of Part 2, participants completed the self-efficacy mea- sure and knowledge items pertaining to material that was covered in the second half of the train- ing. Participants put their first name on the pretest and posttests so they could be matched and to assist with screening for those who ap- plied to be peer advocates. In addition, partici- pants in the initial training provided anonymous responses to items gauging their response to the training after each module.

Qualitative data analysis. The focus group and interviews were digitally recorded, transcribed, entered into an electronic database immediately upon collection and analyzed through a series of iterative readings. A system- atic line-by-line categorization of data into codes using the qualitative software NVivo (Version 10: QSR International, 2012) allowed us to determine prominent or recurring key is- sues described in the data. The coding and anal- ysis of the qualitative data were undertaken by the second author with assistance from a project research assistant. First, a descriptive coding

scheme from transcripts based on the specific questions asked during the interviews was de- veloped (e.g., “reactions to training content,” “applications of training-specific knowledge and skills,” “additional training and support needs,” and “areas for improvement”). Second, all transcripts were subjected to “open coding” to determine other possible issues that we did not anticipate during the initial coding of the data (e.g., “reactions to Genderbread Person,” “perceptions of instructor sexuality,” and “sui- cide prevention”). Third, “focused coding” was used to determine which of these issues were repeated most often and considered significant by the majority of participants (Corbin & Strauss, 2008). Finally, detailed memos were created to further describe and link codes in- cluded in or derived from this analysis.

The coding and analysis of the qualitative data were undertaken by the second author with assistance from a project research assistant, and the first and third authors reviewed written drafts of the findings as they became available.

We acknowledge that several factors in- formed the qualitative analysis. First, this pro- cess was influenced by the “constructivist” tra- dition in evaluation research. This tradition opposes positivism and privileges iterative pro- cesses of data analysis to understand diverse participant perspectives in relation to interven- tion objectives, encourages rich and deep de- scription, and values consensus (and contesta- tion) when arriving at conclusions predicated on study findings (Stufflebeam & Shinkfield, 2007). Second, all three authors were engaged in design and implementation of the training, as well as extensive conversations during and after each training regarding our impressions and ideas for improvement. The research assistant attended parts of the training, conducted focus groups and interviews, and shared feedback with the authors following the initial training. The qualitative data were collected and ana- lyzed simultaneously with the quantitative data. Throughout the process of data collection and analysis, we sought to remain attentive to not only our professional biases and possible self- interest in portraying the training in a positive light, but to how our own gender, sexual, and social identities and privileges might shape our interpretation of the data. We also maintained a pragmatic orientation when assessing the signif- icance of the findings, organizing the qualitative

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data to highlight aspects of the training consid- ered most beneficial or in need of modification, preliminary impacts on the participants, and suggested topics, formats, and other issues for instructors to consider for future LGBTQ peer advocate training.

Results

Quantitative results regarding knowledge and self-efficacy measures are presented first, fol- lowed by qualitative and quantitative analysis of participant response to training, and finally, summaries of qualitative data from focus groups and interviews.

Knowledge

Paired-samples t tests assessed changes in participants’ knowledge of LGBTQ issues (see Figure 2). Scores on the LGBTQ Peer Advocate Knowledge of LGBTQ Issues for participants in the pilot training were higher, but not signifi- cantly so, at posttest (M � 15.36, SD � 33.2) compared to pretest (M � 11.50, SD � 33.28). For participants in the revised training, knowl- edge increased significantly from pre- to post- test, both for the participants who took part only in the first half of the training, t(18) � �7.01, p � .001; as well as for the smaller group of participants who were selected for Part 2 of the training, t(7) � �4.75, p � .002. Further, an omega-squared effect size calculation (�2 � .55) demonstrated a large effect size. This sug- gests that participants were more knowledge- able about LGBTQ issues after completing the training. This increase in knowledge offers some evidence that the changes made for the

revised training helped participants to under- stand and retain information more effectively.

Self-Efficacy

Paired-samples t tests assessed changes in par- ticipants’ self-efficacy in working with LGBTQ community members (see Figure 3). Participant scores on the Peer Advocate Self-Efficacy Inven- tory measure increased significantly from pretest to posttest for both the pilot, t(12) � �6.09, p � .001 and the revised training, t(19) � �2.48, p � .023. Further, an omega-squared effect size cal- culation demonstrated a large effect size for the pilot study (�2 � 0.58) and a medium effect size for the revised study (�2 � 0.11). This suggests that participants felt more confident in their ability to use specific LGBTQ affirming skills after completing the training. When con- sidering only the participants in the revised training who were selected for Part 2 of the training, the scores on the subset of items that assessed self-efficacy regarding specific peer advocate skills increased from before the train- ing to after it was completed, as well as from after the first half of the training to the end of the training, but these increases were not signif- icant. Because of the small number of partici- pants in this category who completed the mea- sure (n � 8), it is possible that the t test did not detect differences (observed power � 0.52).

Participant Response to Training

Participant response to the pilot training was generally positive. Trainers were rated on the written evaluation forms as meeting the stated objectives for most modules, including

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LGBTQ people and communities, behavioral health issues and services, suicide, working individually with LGBTQ community mem- bers, ethics and boundaries, and diffusing hostile situations. The two modules that least met the objectives were cultural competence and helping skills. Parts of other modules that had variable success in meeting the objectives focused on communication with service pro- viders and outreach. In response to open- ended questions, trainees indicated that they learned about a range of LGBTQ experiences, statewide demographics, treatment barriers, listening skills, ethical dilemmas, and self- care. They appreciated engaging and expert instructors, visuals, role plays, suicide inter- vention, and practice presentations. They would have liked more information on privi- lege and how to approach service providers.

Participant response to the revised training was positive as well. Participants indicated that they grasped almost all of the information and skills presented, although they felt less confident about interacting with people with serious mental illness, recruiting people to attend LGBTQ outreach events, and dealing with hostile situations. The material that most stood out to them was models of sexual ori- entation, responding to suicidality, culture, social support, crisis intervention, use of su- pervision in ethical dilemmas, cultivating compassion, and privilege. They were enthu- siastic that the training was informative, in- teractive, and included role plays and practice presentations.

Focus Groups and Interviews

The focus groups underscored that the train- ees were eager for the information provided, with one participant making two 15-hr round trips from his home to attend. Much of the information was new and desired, even by the few participants with a footing in helping pro- fessions. One trainee, a graduate student in a counseling psychology program, observed:

I really wish that it [the peer advocate training] was a mandatory part of our Master’s program or the Doc- torate program because they just do not touch on sexuality at all. . . . Even having something as basic as the difference between sex and gender and sexuality so that people can have that basic knowledge I think would be really helpful.

Other trainees were already working as nat- ural supports or de facto peer advocates, and wanted to enhance their knowledge and skills to better support other LGBTQ people. In fact, participants reported taking actions in the two weeks between the first and second weekend of the pilot training. For example, one participant reportedly intervened upon witnessing members of his church making disparaging and threaten- ing remarks regarding a transgender person, noting that he had garnered the confidence to stop functioning as part of the “silent minority” within his faith community because of the train- ing. A second participant shared that she was able to respond appropriately to a friend on the verge of killing herself, something she would not have done if she had not taken part in the suicide prevention component of the training.

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Figure 3. Comparison of self-efficacy pre- and post-test scores for pilot and revised training.

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The focus groups also provided insight into refining the nuts and bolts of the training pro- cess. Participants were encouraged to critique training materials, resulting in suggestions to streamline the content provided in module- specific PowerPoint presentations and to include more visual graphics and images of LGBTQ peo- ple that were relevant to the implementation context of New Mexico. Overall, participants appreciated the “pace” of the training, contend- ing that there was no time to become “bored” during the long training sessions. That said, they also observed that the instructors were attempt- ing to cover too much material, especially with regard to standard diagnostic nosology, the con- tent of which was later scaled back to accom- modate more group discussion and activities. Finally, to facilitate the building of rapport and trust, focus group participants called on the in- structors to disclose their own gender and sex- ualities. Such disclosures did not occur during the first weekend of the first training, which created a distraction for some participants, who admitted to becoming silently preoccupied with whether the instructors shared life experiences as LGBTQ people similar to their own.

During the initial focus groups and the later interviews, the participants affirmed that they benefited from the LGBTQ peer advocate train- ing and would take part in additional training if offered in their community, recommend the training to others, and would be happy to work in some capacity as an LGBTQ peer advocate. One of the most common comments concerned how the training increased participant knowl- edge of diversity within the LGBTQ commu- nity. One participant disclosed that the training “drastically” enhanced his ability to appreciate diversity:

Being a closeted gay man for years at least partially I was not at all comfortable with any of the other groups within the community just because of lack of knowl- edge and lack of understanding. [The training] opened my eyes drastically and made it easier to see where they’re coming from and see what problems they may be having, etcetera.

In the interviews, almost all other partici- pants noted how much the training enabled them to become more sensitive to variance within the LGBTQ community and be more aware of their own biases. The “Genderbread Person” (Killerman, n.d.), an image used to illustrate the nature of and distinctions among

gendered constructs, was remembered fondly and was utilized by interview participants to help them and their peers better understand the difference between gender expression and sexual orientation in terms of fluid conceptu- alizations instead of rigid categories. One par- ticipant showed it to her father, a second translated it into Spanish to be used for clients within a counseling consultation group, a third presented some of the training to fellow classmates, a fourth taught some of it to stu- dents learning how to use advocacy in coun- seling, while still others used it in their vol- unteer work at the local LGBTQ community center. Participants also recognized how gen- der and sexuality intersect with ethnicity, re- ligion, ability, and geographical location in the construction of identity. Three trainees stated that completion of the training helped them to become more comfortable with their own sexualities; one participant shifted from identifying as a lesbian to transgender man.

Six participants emphasized the importance of the training’s suicide prevention component and the need for additional resources during their interviews. One participant was motivated to pursue further training on this topic. A sec- ond trainee was empowered to help two of her friends get help for mental distress, while yet another utilized the knowledge and skills per- taining to suicide prevention with a foster teen in his home. The participant explained,

[The foster teen] was exhibiting signs of being de- pressed and I was able to utilize some of the things that I learned in the [LGBTQ] peer advocate training along with some things that I learned in terms of when [we] did mental health the first day to kind of talk him through what was going on and help figure out what a course of action would be other than [the] risky behav- ior that he was involved in.

All interview participants noted an increase in their knowledge of resources and their own morale simply by attending the training and meeting other individuals interested in advocat- ing on behalf of rural LGBTQ people with mental health needs. Further, four participants shared their desire to create, or at least have access to, a resource guide that contained infor- mation on local and state providers who were LGBTQ-friendly, and affirmative community groups.

Participants in both focus groups and inter- views expressed a desire to take part in future

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training opportunities related to LGBTQ mental health. They commonly observed that the train- ing had covered a lot of information in a short period of time and that they would have appre- ciated the opportunity to delve into specific topics, such as bisexuality and transgender is- sues, in much greater detail than the 4-day schedule allowed. One participant explained, “Even doing it for two full weekends, it was a lot of stuff crammed into a little bit of time but it was also important stuff.” Despite this limi- tation, the participant added that taking part in the training “was a very worthwhile use of my time.” A second participant acknowledged the challenge of making the length of similar train- ings “just right” and accessible to busy people. Suggested topics for future trainings varied and included leadership skills, analyzing privilege, relationship dynamics as applied to a variety of topics (e.g., grief and adoption), recognizing signs of mental distress and substance use prob- lems to better refer peers for counseling or treatment, diversity and cultural issues, and more practice/modeling. The most frequently suggested topics were outreach, rapport build- ing, and communication skills, especially with regard to consulting professional providers about LGBTQ health needs. The trainees also called for additional practical workshop activi- ties focused on navigating local social environ- ments and connecting to supportive profes- sional providers and community advocates and allies.

Trainees suggested that the training experi- ence could be enhanced through the addition of homework between sessions to facilitate further contemplation and “absorption” of key material, and that greater time needed to be devoted to collective review and discussion, as well as questions and answers of the instructors. Fi- nally, to reinforce knowledge and skills, partic- ipants called for additional online training op- portunities of shorter duration, Web based resources, and periodic conference calls for group discussion, troubleshooting, and refresher purposes.

Discussion

The evaluation offers ample evidence that the LGBTQ peer advocate training successfully ac- complished its goal to select and prepare peer advocates to assist LGBTQ help seekers. Spe-

cifically, the training produced more knowl- edgeable, confident, and skilled advocates who were sensitive to diversity within LGBTQ com- munities. Self-efficacy increased as a result of both the pilot and the revised training (except where changes could not be detected because of small sample size). Self-efficacy influences the effort and persistence an individual applies to a task and is, consequently, a key indicator of future behavior (Alessi, Dillon, & Kim, 2015). In fact, self-efficacy has been identified as a key element for counselors to engage in lesbian/ gay-affirming practice (Alessi et al., 2015) and thus, an important element to target in training and assessment prior to placing peer advocates in the field.

The increase in knowledge, especially re- garding diversity within LGBTQ communities, demonstrates the gaps in knowledge before the training and the ability of trainees to gain accu- rate information through didactic and interac- tive training. Notably, although all trainees were either LGBTQ or allies, they did not nec- essarily possess accurate information about all LGBTQ subpopulations. Gender and sexual mi- norities, especially in rural areas, may have limited exposure to other LGBTQ people. Thus, knowledge of segments of LGBTQ communi- ties that differ from their own may be gleaned primarily from widely available societal mes- sages, many of which contain misinformation and stereotypes. Indeed, segregation and dis- crimination occur within LGBTQ communities based on gender, gender identity/expression, ethnicity, and socioeconomic status (Willging et al., 2006a). Such divisions are problematic within a community that has the potential to serve as a natural social support buffer against the effects of minority stress (Meyer, 2003). The current study demonstrated the need and a possible remedy for this problem. By educating LGBTQ people about the diversity within their own communities, greater understanding may lead to increased support and cohesion within this vulnerable population.

A pilot phase has been included in develop- ment of other peer training programs (Kinnane, Waters, & Aranda, 2011; Tang et al., 2011), and we also found that piloting the training was a worthwhile expenditure of time and resources. Conducting pilot training and then making changes to the curriculum based on this expe- rience improved absorption and retention of in-

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formation and improved participant response to helping skills. The choice to integrate helping skills throughout the training rather than limit them to one module appeared to improve par- ticipant response to this aspect of the training. In addition, the integration of skills likely sup- ported acquisition of knowledge as trainees had opportunities to apply knowledge immediately through skills-based activities.

Most published research on community health workers does not include a description of the selection process (O’Brien et al., 2009). One important facet of our training was as a screen- ing tool for peer advocates. The ability of the trainers to interact with and observe participants before the application process enhanced their confidence in their ability to select the best candidates. Furthermore, preparation of peer advocates took place in a context in which all trainees were interested in performing this role in their community, which may have increased cohesion and engagement.

Another unique aspect of the current project was the invitation for any interested members of the general public to attend the first training weekend. By opening this part of the training to a broad range of participants, we offered a com- munity service by educating the general public about LGBTQ mental health, and we were able to collect observational information about po- tential peer advocate applicants, which proved valuable in the selection process.

The direct influence on the trainees and LGBTQ community-building in a rural area was an unan- ticipated benefit of the training. Participation im- proved the trainees’ feelings about themselves as LGBTQ people and provided them with tools to talk with their friends and family. Additionally, participants appreciated the opportunity to con- nect with other LGBTQ people and allies in their local community. These findings highlight the im- portant reminder that when we are teaching people to intervene with others, we are also covertly assisting them in intervening with themselves (see also Sawyer, Pinciaro, & Bedwell, 1997 on peer health educators). Though it was not an explicit goal, by training LGBTQ individuals to assist others in defining their own sexuality, asserting their needs and understanding themselves, the trainees themselves experienced some of those same effects, reporting greater feelings of self- efficacy and confidence in addressing issues of LGBTQ stigma in their own lives. Two of the peer

advocates became increasingly involved in com- munity organizing efforts concerning LGBTQ is- sues, and described that their training had assisted them in speaking knowledgably about these is- sues. Thus, even a training to perform an inter- vention can itself serve as an intervention.

Although laudable outcomes, these benefits to the trainees may not justify the resources required to plan and implement such training. Multisession, high-quality training by national experts in rural areas is desired, but not sustainable. There are certainly more cost-effective ways to bring LGBTQ people together, but many areas may lack the infrastructure to implement such strategies. One possible solution is to combine the power of multiple resources: (a) distance learning tools, such as webinars; (b) LGBTQ community orga- nizations connected through a national network (e.g., CenterLink); and (c) existing social net- works. With these tools, rather than accessing online information in an isolated setting, LGBTQ people could gather through LGBTQ community organizations or natural social networks to obtain training. This strategy would build on the founda- tion of high-quality, accurate training content; and it would maintain the beneficial aspect of bringing together LGBTQ community members. Where LGBTQ community organizations and social net- works are lacking, broader mental health and so- cial service agencies may have the capacity to offer such outreach.

Mechanisms for outreach are necessary for sustainable community-building for an invisible or marginalized population (Minkler & Waller- stein, 2005). Unfortunately, this was one area for which the training did not adequately pre- pare the LGBTQ peer advocates. This is not entirely surprising as the training focused more on individual work than community outreach. Future iterations of the training may benefit from including more content related to commu- nity outreach, or even centralizing community outreach as the framework for the training. Such a model could help orient peer advocates to the community outreach role earlier in the training and reinforce this component throughout, much as the revised training did with helping skills.

Unique experiences of rural LGBTQ residents make this training particularly important in these areas. Given the role of minority stress in negative mental health outcomes (Institute of Medicine, 2011; Meyer, 2003), interventions to increase ac- cess to professional and community support are

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critical. Participant positive feedback about the role of the training in community building draws attention to the needs of rural LGBTQ residents for emotional and community support to combat isolation, which contributes to minority stress.

The training was designed for residents of rural settings, and it was effective in this geographic region. In terms of generalizability of the training and its effectiveness, the specific area shares char- acteristics with other rural areas, or places in which LGBTQ people are isolated and have lim- ited access to LGBTQ-specific expertise and re- sources. The training likely benefited from the inclusion of state-specific information gathered by one of the trainers, and it may be important to consider how to gather such localized data if the training is replicated elsewhere.

Some of the participants were not LGBTQ themselves, but were family members or allies of the LGBTQ community. In fact, with 78% of the participants identifying as cisgender (not transgen- der)—30% of whom were also heterosexual— participants were interested in expanding their knowledge of gender and sexual minorities that they encountered in their professional lives (e.g., school nurses caring for youth) or for personal reasons (e.g., being the parent of a child who identified as LGBTQ). It may be important to consider how the content and format of training may need to be altered for LGBTQ-specific versus more general attendees.

Limitations and Directions for Future Research

The primary limitations of this study include the trainee population and the lack of existing measures to assess LGBTQ peer advocate- specific knowledge and self-efficacy. First, the participants in the initial training and Part 1 of the revised training included community mem- bers and students who were interested in learn- ing more about LGBTQ mental health and sup- port needs, but were not necessarily interested in assuming a more formal role as LGBTQ peer advocates. Thus, it is possible that particular aspects of the training may have resonated dif- ferently with these individuals compared to per- sons who were more interested in becoming LGBTQ peer advocates. Second, we were lim- ited in assessing specific knowledge and self- efficacy among the potential LGBTQ peer ad- vocates. Although we based the self-efficacy

measure on a similar, validated measure of counseling LGB clients, we did not have prior or concurrent validity data for either it or the knowledge measure. Future research would benefit from gathering validity data to support the use of both measures. Furthermore, al- though we observed participant skills in role- play simulations and used these observations in the selection of peer advocates, we did not conduct a structured assessment of skills. Re- search using more standardized tools for evalu- ating community health workers has noted the absence of direct assessment of skills (e.g., Ruiz et al., 2012), pointing to a need to develop means for conducting such evaluation within a training context. Direct evaluation of observ- able skills would be a valuable addition to fu- ture studies.

Some studies that evaluated training for peer leaders have used preestablished competency criteria to determine readiness of peers to de- liver an intervention (e.g., Tang et al., 2011). Such an approach is ideal for screening poten- tial peers following training; however, it is pos- sible only when research on the intervention is developed to the point of specifying compe- tency criteria. Because the current study was conducted in the early stage of a project that was ultimately designed to assess feasibility and acceptability of the peer advocate intervention, it was premature to identify a priori cut-off levels for learning outcomes. It will be impor- tant for future research in this area to consider available data on LGBT peer advocate interven- tions in the development of training objectives and competency criteria.

Researchers may launch from this study into a number of fruitful directions. Development and evaluation of a training framed in terms of LGBTQ community organizing could test the po- tential of training minority communities for mul- tifaceted and nuanced roles. Evaluating the effi- cacy of distance learning tools in providing LGBTQ training could explore sustainable op- tions for cost-effective capacity building for hard- to-reach LGBTQ populations. This training strat- egy and material may be easily modified to offer in-person or distance-learning for therapists and clinicians interested in acquiring evidence-based strategies and competence at providing affirmative treatment, and assisting their clients in addressing bias and stigma from other clinical professionals.

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Conclusion

The current study demonstrated the efficacy of training LGBTQ peer advocates in rural commu- nities. In addition to increasing knowledge and self-efficacy, the training helped participants feel more positive about themselves, equipped them with tools to educate others, and reduced isolation. Moreover, receiving accurate information about diversity within LGBTQ populations increased knowledge that can combat stereotypes and en- hance cohesion among LGBTQ people. Although the resources involved in providing the training may limit the generalizability of this particular model, our results call for further exploration of creative strategies for tapping into existing orga- nizational and social networks to address the con- siderable need for information and training on LGBTQ issues in rural areas.

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Appendix

LGBTQ Peer Advocate (PA) Curriculum Modules (for revised training)

Part 1

Module Module description Purpose Learning objectives

I. Introduction to Part I of training

1. Initial assessment of knowledge and self- efficacy related to LGBTQ mental health and substance use issues

2. Introduction of trainers and participants

3. Icebreaker 4. Description of the training

curriculum, communication tools, requirements, and logistics

5. Description of PA application and selection process

• Familiarize trainees with curriculum and expectations regarding their participation. Acquaint trainees with the PA position and application process. Establish baseline for measuring changes in knowledge and self- efficacy.

By the end of this module, trainees will be able to: a. Identify trainers b. Anticipate training structure,

content, and expectations regarding participation

c. Recognize PA responsibilities and supportc

d. Participate in PA application and selection process, if so desired.

By the end of this module, instructors will be able to: a. Determine participants’

baseline knowledge and self- efficacy related to PA role

II. LGBTQ people and communities

1. Concepts of sex, gender, sexual orientation

2. Helping skills: non-verbal attending and paraphrasing

3. Early messages about LGBTQ people

4. Characteristics of lesbian gay and male communities

5. Defining bisexuality 6. Other sexual orientation

identity labels (e.g., queer, pansexual, fluid)

7. Transgender people a. Categories of

transgender experience and people

b. Gender nonconformity and gender dysphoria

c. Similarities and differences from LGB individuals

• Introduce trainees to basic listening skills. Describe characteristics of lesbian, gay male, bisexual, and transgender individuals and communities. Clarify distinctions between transgender people and LGB people.

By the end of this module, trainees will be able to: a. Distinguish among concepts of

sex, gender, and sexual orientation

b. Describe models of sexual orientation

c. Demonstrate non-verbal attending and paraphrasing

d. Describe characteristics of lesbian, gay male, bisexual, and transgender people and communities

e. Recall a range of categories of transgender people

f. Articulate similarities and differences between LGB and transgender people

(Appendix continues)

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Appendix (continued)

Part 1

Module Module description Purpose Learning objectives

III. Mental health and substance abuse among LGBT people

1. Anti-LGBTQ discrimination, harassment, and violence

2. LGBTQ mental health and substance use

3. Common psychological problems for LGBTQ people (depression, anxiety, substance abuse, post- traumatic stress disorder [PTSD])

4. Particularly challenging conditions (chronic serious mental illness, personality disorders)

5. Resilience and positive aspects of LGBTQ experience

6. Open-ended questions

• Describe sources and consequences of LGBTQ minority stress. Describe common psychological problems and people who may be particularly challenging to work with. Introduce strengths and resilience of LGBTQ people. Teach open- ended questions and apply to asking peers about their mental health and substance use concerns.

By the end of this module, trainees will be able to: a. Describe anti-LGBTQ

discrimination, harassment, and violence

b. Identify factors contributing to LGBTQ mental health and substance use problems

c. Recognize common psychological problems for LGBTQ people (depression, substance abuse, PTSD)

d. Anticipate issues involved in interacting with people who have challenging conditions (chronic serious mental illness or personality disorders)

e. Identify resilience among LGBTQ people

f. Demonstrate open-ended questions

IV. LGBTQ people and suicide

1. Fundamentals of the Question, Persuade, Refer (QPR) method for preventing suicide

2. Populations at risk for suicide (overview of national, New Mexico, and LGBTQ-specific statistics)

3. Suicide prevention/intervention lines and resources

4. Practice QPR method

• Prepare trainees to identify and address risk for suicide using QPR model. Ensure that they know how to access appropriate experts and resources to handle the situation.

By the end of this module, trainees will be able to: a. Distinguish between myths and

facts about suicide b. Describe fundamentals of QPR c. Identify groups of people at

risk for suicide, and the factors underlying this risk

d. Access suicide prevention/ intervention lines and resources

e. Apply QPR method

(Appendix continues)

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Appendix (continued)

Part 1

Module Module description Purpose Learning objectives

V. Diversity within LGBTQ communities

1. Introduction of ourselves in terms of where we are from

2. Culture as context 3. Application of helping

skills to gain insight into a peer’s cultural context

4. Diversity within LGBTQ communities ΠEthnicity ΠSpirituality ΠGenerational status ΠPhysical abilities ΠSocial class ΠImmigration status ΠSexual and relational

structures and activities 5. Development of sexual

orientation identity 6. Key New Mexico

demographics 7. Experiences of LGBTQ

people in rural New Mexico

• Broaden trainees’ understanding of “culture” to focus on context. Cultivate trainees’ ability to gain insight into people’s cultural context. Increase awareness of areas about which LGBTQ people may lack information or have information based only on their own experiences (which may not generalize to others).

By the end of this module, trainees will be able to: a. Describe culture in terms of

context, process, and everyday circumstances

b. Apply helping skills to gain insight into a peer’s cultural context

c. Recognize variation in LGBTQ communities in terms of ethnicity, culture, spirituality, generational status, physical abilities, social class, immigration status, and sexual activities

d. Describe a range of typical experiences of sexual orientation identity development and disclosure

e. Recognize key New Mexico demographics

f. Describe experiences of LGBTQ people in rural New Mexico

VI. Mental health and substance use services for LGBTQ populations

a. Systems of mental health care and substance use treatment

b. Roles of various types of mental health care and substance use treatment professionals

c. Barriers LGBTQ people face accessing services

d. Conversion therapy e. Social support

• Increase ability to identify challenges LGBTQ people face in accessing informal and formal assistance for their mental health and substance use issues. Establish foundation to aid LGBTQ help seekers in gaining better access and navigating service delivery systems. Enhance knowledge of how social support systems for LGBTQ people operate.

By the end of this module, trainees will be able to: a. Describe various systems of

mental health care and substance use treatment

b. Identify the roles of various types of professionals in mental health care and substance use treatment

c. Identify challenges LGBTQ people face accessing formal and informal assistance for mental health and substance use issues

d. Describe the harmful effects of conversion therapy

e. Recognize ways in which social support systems can influence LGBTQ people

By the end of this module, instructors will be able to: a. Determine trainees’ knowledge,

skills, and self-efficacy related to PA role

(Appendix continues)

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Part 2

Module Module description Purpose Learning objectives

VII. Introduction to Part II of training

1. Overview of PA points of intervention

2. Training structure and logistics

3. Communication goals for training

By the end of this module, PAs will be able to: a. Identify the PAs’ points of

intervention b. Anticipate training

structure, content, and expectations regarding participation for Part II of training

VIII. Working individually with LGBTQ community members

4. Theories of social empowerment and advocacy

5. Solution-focused strategies

6. Assessment and prioritization needs

7. Development of collaborative plans to address needs

8. Role plays with individualized feedback

9. Non-suicide crisis situations

• Further clarify the responsibilities of the PA per the empowerment protocol. Create opportunities for trainees to apply the knowledge and skills they acquired to scenarios to reinforce learning and provide instructors an opportunity to assess knowledge and skill level.

By the end of this module, PAs will be able to: a. Frame PA activities in

terms of social empowerment/advocacy

b. Describe how PAs will work with individual LGBTQ community members

c. Recognize and implement solution-focused strategies

d. Conduct needs assessments and prioritize needs

e. Develop collaborative plans to address needs

f. Respond appropriately to crisis situations

IX. Working with service providers and others

1. PA role with service providers and family members of LGBTQ community members

2. Challenges and strategies for communicating effectively with service providers and family members

3. Communication conflicts 4. Role plays with

individualized feedback

• Develop skills to share knowledge gained from previous modules. This application of the material will help trainees retain the information and strategize how best to communicate with LGBTQ help seekers and their providers, family, and friends.

By the end of this module, PAs will be able to: a. Describe how PAs will

work with service providers and family members of LGBTQ community members

b. Identify strategies for communicating effectively with service providers

c. Identify strategies for communicating effectively with service providers

d. Recognize and respond effectively to communication conflicts

(Appendix continues)

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Appendix (continued)

Part 2

Module Module description Purpose Learning objectives

X. Ethics and boundaries

1. Responsibilities and limits of the PA role

2. Professionalism 3. Confidentiality 4. Multiple relationships 5. Boundary maintenance 6. Sources of ethical

guidance 7. Ethical decision-making 8. Supervision and

consultation

• Increase PA awareness of the personal and ethical dilemmas likely to arise in their helping interactions with peers, and the resources/strategies to which they can turn to help resolve them.

By the end of this module, PAs will be able to: a. Describe the responsibilities

and limits of the PA role b. Recall ways in which they

can demonstrate professionalism in their role as PAs

c. Anticipate ethical issues that may arise in their role as PAs

d. Evaluate situations in terms of confidentiality, boundaries, and multiple relationships

e. Identify sources of ethical guidance

f. Follow a process for ethical decision-making

g. Seek support through consultation

XI. Self-care 1. Self-care---generating strategies and developing a plan

2. Compassion practice to work with people who are suffering

By the end of this module, PAs will be able to: a. Articulate the importance of

self-care for PAs b. Identify a range of

strategies for self-care c. Craft a self-care plan for

themselves d. Implement compassion

practice when encountering suffering

(Appendix continues)

61TRAINING RURAL LGBTQ PEER ADVOCATES

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Appendix (continued)

Part 2

Module Module description Purpose Learning objectives

XII. Outreach, advocacy, presentations, and social support resources

1. Engaging in activities to cultivate LGBTQ affirming rural community environments

2. Getting to know your community

3. Networking and partnering with local LGBTQ groups and other key community contacts

4. On-the-spot interventions 5. Establishing social

support networks and other opportunities for interactions among LGBTQ community members, families, health care providers, and allies

6. Organizing, delivering, and practicing presentations

7. Compiling and updating resource and referral directory

8. Preventing and diffusing hostile situations

• Prepare PAs to connect with individuals and organizations in rural communities with a stake in LGBTQ mental health and substance use issues, and to stay abreast of available resources for referral purposes. Impart strategies that the PA can use to mobilize these connections to enhance social support resources for LGBTQ help seekers, and that they can use to stay safe when conducting community outreach.

By the end of this module, PAs will be able to: a. Describe how PAs will

cultivate LGBTQ-affirming community environments

b. Gather information about organizations, services, and events in their community

c. Establish relationships with key community contacts

d. Implement on-the-spot interventions

e. Establish support networks for LGBTQ community members, families, and service providers

f. Recruit people to attend an event or meeting

g. Plan and implement presentations to convey basic information on LGBTQ issues to lay audiences and service providers.

h. Prevent and diffuse hostile situations

XIII. Self- assessment of helping and leadership for LGBTQ community

a. Privilege b. Self-assessment of

helping and leadership for LGBTQ community

c. Next steps d. Post-assessment of

knowledge and self- efficacy

• Post assessment will provide a measure of changes in knowledge, attitudes, skills, and perceived self-efficacy.

By the end of this module, PAs will be able to: a. Reflect on the role of

privilege in their lives b. Assess their strengths and

challenges with respect to helping and leadership in LGBTQ communities

c. Identify the next steps for PAs

By the end of this module, instructors will be able to: a. Determine PA’s knowledge,

attitudes, skills, and self- efficacy related to PA role

Received April 1, 2015 Revision received February 23, 2016

Accepted February 23, 2016 �

62 ISRAEL, WILLGING, AND LEY

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