Out On The Couch
LGBTQIA+ Affirmative Mental Health During the Pandemic
The stress and anxiety wrought by the COVID-19 pandemic may be universal–so many of us face fears of the virus itself, not to mention job loss, illness striking our loved ones, and myriad missed social, professional, and financial opportunities–but all of us experience these differently. Just as everyone’s mental health needs are unique, therapy is not one size fits all. LGBTQIA+ clients in particular need to work with therapists who can understand and validate the unique experiences impacting their emotional wellbeing. Although no one is immune to the detrimental psychosocial effects of the pandemic, LGBTQIA+ clients can face some identity-specific challenges that make affirmative therapy especially crucial at this time.
Affirmative Psychotherapy & Unsupportive Families During the Lockdowns
These include extended time with family of origin and overall decreased social interaction. Pandemic-induced social isolation can hit LGBTQIA+ individuals harder, as many queer and trans people have strained relationships with their families of origin and thus rely heavily on friendships and chosen families for support. Being stuck in toxic family environments due to the pandemic, and enduring sustained lack of contact with friends, can constitute a dangerous combination for any client. LGBTQIA+ people living with family members who don’t respect their gender identity or sexuality may find their mental health negatively affected. This experience can also contribute to dysphoria and has been linked to substance abuse (Newcomb, 2019).
Affirmative Therapy & Lack of Social Connections During COVID-19
Further, lack of social connection is linked to suicidality, for which LGBTQIA+ populations are already at higher risk (Kaniuka, 2019). Prolonged feelings of loneliness can be self-perpetuating; when we feel disconnected, we might start to doubt our ability to connect with others, and we avoid opportunities for socializing out of fear. Happily, ongoing therapy sessions with a therapist who “gets it” and makes us feel seen can serve as a form of connection and help break the cycle of isolation. As we know well, the therapist’s office should be the one place in which clients don’t have to worry about appearing awkward or facing judgment. It can serve as a safer space in which a client can brush up on rusty social skills and build confidence.
Finally, more free time and solitude can make space for greater self-reflection, which may in turn bring up complex emotions in clients just discovering their sexuality and/or gender identity. It’s important for therapists to welcome discussions of these realizations with curiosity and validating support, whether we fully understand them or not. Other difficult topics that can emerge during extended periods of solitude and self-reflection–the trauma related to minority stress that so many LGBTQIA+ people face, for instance–may be challenging to navigate on one’s own but can provide rich fodder for the virtual therapy room as well.
Training in Affirmative Therapy
Simply put, now more than ever, LGBTQIA+ clients need therapists who can treat them without bias. They may be coming into sessions with a lot of self-doubt about their gender identity and/or sexuality. They may have wanted support before now, but perhaps did not feel confident approaching a provider due to the double stigma of being LGBTQIA+ and having a mental health condition. If you are an affirmative provider who is welcoming a client like this into your practice, congratulations on ensuring a safer space. Taking the time to get training in best practices for working with LGBTQIA+ communities makes you an invaluable resource for clients and a genuine lifeline during this unbelievably challenging time.
Alessi, E. J., Dillon, F. R., & Van Der Horn, R. (2019). The therapeutic relationship mediates the association between affirmative practice and psychological well-being among lesbian, gay, bisexual, and queer clients. Psychotherapy (Chicago, Ill.), 56(2), 229–240. https://doi.org/10.1037/pst0000210
Feder, S., Isserlin, L., Hammond, N. Norris, M., & Seale, E. (2017). Exploring the association between eating disorders and gender dysphoria in youth, Eating Disorders, The Journal of Treatment and Prevention, 25:4, 310-317, DOI: 10.1080/10640266.2017.1297112
Johnson, K., Vilceanu, M. O., & Pontes, M. C. (2017). Use of Online Dating Websites and Dating Apps: Findings and Implications for LGB Populations. Journal of Marketing Development and Competitiveness, 11(3). Retrieved from https://articlegateway.com/index.php/JMDC/article/view/1623
Kaniuka, A., Pugh, K. C., Jordan, M., Brooks, B., Dodd, J., Mann, A. K., … & Hirsch, J. K. (2019). Stigma and suicide risk among the LGBTQ population: Are anxiety and depression to blame and can connectedness to the LGBTQ community help? Journal of Gay & Lesbian Mental Health, 23(2), 205-220.
Newcomb, M.E., LaSala, M.C., Bouris, A.,Mustanski, B., Prado, G., Schrager, S.M., & Huebner, D.M. (2019). The Influence of Families on LGBTQ Youth Health: A Call to Action for Innovation in Research and Intervention Development. LGBT Health, 6:4, 139-145. DOI: http://doi.org/10.1089/lgbt.2018.0157
Coloring Books in Therapy
Coloring books aren’t just for children anymore: adult coloring books have gained great popularity in the last few years. They have been found to reduce symptoms of anxiety and depression; increase perseverance; and provide short-term stress relief (Eaton & Tieber, 2017; Flett et al., 2017; Rajendran et al., 2020; Simmons, 2016). Adult coloring books have also been used to promote relaxation, help people unplug from technology, and even increase socialization in groups (Blackburn & Chamley, 2016). Many adult coloring books have themes similar to those designed for children: whimsical scenes in forests and the ocean, cute animals, or meditative images like mandalas.
As therapists, we need to be mindful about what we keep in our offices and how we utilize the tools we have on hand. Fortunately, the reaction in my office to the five affirmative coloring books I was given the opportunity to review and use has been overwhelmingly positive. These books, which include Butch Lesbians from the 20s, 30s, and 40s; Butch Lesbians from the 50s, 60s, and 70s; Transgender Heroes; Queer Heroes; and Resistance: The LGBT Fight Against Fascism in WWII, were created to provide education about the history of the LGBTQIA+ community in a fun and creative way.
Since I brought the coloring books into my office, clients commented on how safe they felt coming in. Several have mentioned the sense of inclusivity that seeing one of these books on the coffee table or on my bookshelf imparted. Some clients travel a good distance to see me, and will often bring a partner along to get a meal together after therapy. I have walked out of my office after a session to find a client’s partner with one of these books–either coloring it or reading the historic facts about the individuals featured.
Clients with children have commented on their appreciation of these coloring books, too, as their children sometimes use the books while the clients are in session. Some clients have asked where they can find similar books, whose educational aspect they welcome, as they want to expose their children to history that includes more than solely cisgender and heterosexual people.
One transgender client teared up when they saw the Transgender Heroes coloring book, expressing appreciation that it included a wide cross-section of transgender community members rather than focusing in on only certain gender identities and expressions. The book’s representation of trans male and non-binary characters, in addition to that of trans women, makes for a genuinely inclusive experience that one may not always find in other forms of media.
I recommend these coloring books for any clinician who wants to make their office a safer and more inclusive space, as well as for educating the general public about LGBTQIA+ history and individuals. The books are not recommended for individuals with sensory processing disorders who do not like the feeling of paper on their skin. I would love to see coloring books published that are geared specifically toward gay men, femme lesbians, or pan- and bisexual individuals, as well as ones that focus on alternative relationships and sexual practices such as polyamory, relationship anarchy, and kink.
LGBT Resistance: COVID-19 and WWII Parallels
I took these coloring books home from my waiting room and perused them at more length in order to finish writing this article after COVID began. I particularly enjoyed flipping through Resistance: The LGBT Fight Against Fascism in WWII. As someone with an interest in history and some newfound free time, I spent quite a while reading the stories of numerous activists highlighted in this book. Their stories are not ones that we commonly see in our history books or discuss in our history classes. Although each biography is short–about a page and a half for each person–it brings to light every figure’s individual relationships within the context of history.
For example, the tale of Charlotte Wolff, a Jewish psychotherapist, sexologist, and palm reader living in Nazi Germany, was far more humanizing in this format. From her short biography, I learned about her falling in love with an artist named Lisa, who later broke up with her. In 1931, she was warned by the Nazi government to stop her work on women’s reproductive health services, and in 1932 her lover of nine years left her because by then, it was dangerous to be associated with Jews in Germany.
This intermixing of the personal and political dialogue during WWII is intriguing and particularly relevant as we experience the current global pandemic. Our politics, our health, and our personal lives are all entwined; wars and pandemics do not stop breakups, heartache, trauma processing, grieving, or food insecurity, nor do they stop the celebrations of graduations, pregnancies, new love, weddings, or home ownership–although they can make these things more difficult to celebrate. We may forget that these things were still happening when we learn about WWII or any other major historical event. But now we are living through a worldwide crisis ourselves, and are learning new ways in which to grieve or celebrate our personal amidst the political.
As a bisexual therapist navigating the personal and political intersections of my own identities, I have had to balance discussions about politics, health and safety, and personal relationships with all of my clients. These are intertwined, as they had been for the people written about in these coloring books. We may forget about the personal lives of activists from history, and we rarely learn of the very real relationships, emotions, and experiences they had. Laura Antoniou puts it well in the foreword to Resistance: The LGBT Fight Against Fascism in WWII: these are the stories “of people who, nevertheless, persisted.” We are persisting in today’s world as we strive to calm our anxieties, survive, and continue to love during this pandemic. Looking back on our LGBTQIA+ brothers and sisters, we may be able to draw strength from the struggles of the past as we look to the future.
Note: These coloring books were supplied to The Affirmative Couch for review purposes by the publisher at no charge. The Affirmative Couch does not supply affiliate links and does not profit from any resulting sale of these books.
Want to learn more about how to support your clients throughout the challenges posed by the COVID-19 pandemic? Check out the related courses from our catalog:
- From a Distance: Navigating Polyamory During a Pandemic (1 CE) Presented by Esther Benoit, PhD, LPC (VA)
- HIV/AIDS Retraumatization During the COVID-19 Pandemic (3 CEs) Presented by Samuel Donath, MS
- The Psychological Impact of Suppressing Kink Identity (2 CEs) Presented by Elyssa Rice, MA, LMFT
Learn affirmative therapy with Stephanie M. Sullivan, MS, LLMFT:
- Feminist Structural Family Therapy with Polyamorous Clients (2.5 CEs) Co-Presented with John Wall, MS, ALMFT
- Multiplicities of Desire: Working with the Intersection of Bisexuality and Polyamory (3 CEs)
- Polyamorous Clients in Therapy: What You Didn’t Know You Need to Know (3 CEs)
You can get all of these courses and more with Annual Membership or the Lifetime Membership.
If you run a group practice or clinic, learn more about making collective and systemic changes toward a more welcoming culture with our affirmative organizational consulting and training.
Avery, T. M. & Cameron, G. (Eds.). (2019). Transgender heroes coloring book. Stacked Deck Press.
Blackburn, H., & Chamley, C. E. (2016). Color me calm: Adult coloring and the university library. Criss Library Faculty Proceedings & Presentations, 6(1), 1-11.
Cassell, A. (2018). Resistance: The LGBT fight against fascism in WWII (D. Kanzler, Ed.). Stacked Deck Press.
Cassell, A. & Macy, J. (Eds.). (2018). Butch lesbians of the 50s, 60s, and 70s coloring book. Stacked Deck Press.
Cassell, A. & Macy, J. (Eds.). (2017). Butch lesbians of the 20s, 30s, and 40s coloring book. Stacked Deck Press.
Eaton, J., & Tieber, C. (2017). The effects of coloring on anxiety, mood, and perseverance. Art Therapy: Journal of the American Art Therapy Association, 34(1), 42-46.
Flett, J. A. M., Lie, C., Riordan, B. C., Thompson, L. M., Conner, T. S., & Hayne, H. (2017). Sharpen your pencils: Preliminary evidence that adult coloring reduces depressive symptoms and anxiety. Creativity Research Journal, 29(4), 409-416. doi:https://doi.org/10.1080/10400419.2017.1376505
Macy, J. & Avery, T. M. (Eds.). (2016). The queer heroes coloring book. Stacked Deck Press.
Rajendran, N., Mitra, T. P., Shahrestani, S., & Coggins, A. (2020). CME information: Randomized controlled trial of adult therapeutic coloring for the management of significant anxiety in the emergency department. Society for Academic Emergency Medicine, 27(2), 91-99. doi:10.1111/acem.13838
Simmons, C. (2016). Effects of coloring on immediate short-term stress relief. Sally McDonnell Barksdale Honors College: Honors Theses. https://egrove.olemiss.edu/hon_thesis/230
By now, we are all experiencing the impact of the ubiquitous trauma and stress surrounding COVID-19 in some way. What might have started with a distal awareness of the problem quickly snapped to a reality that the world will forever be changed by this virus. You might have also noticed the varying “stages of grief” through which our clients and we ourselves are shifting, the unfortunate stage of denial being the one that has caused the most irrevocable damage to the world.
On the one hand, many may find the universality of this experience comforting–it is rare that everyone on the planet understands the same thing to some degree. The current situation presents a valuable opportunity for emotional validation and a sense of common humanity (i.e., increased self-compassion due to awareness of the common human experience of suffering). It often takes personal experience and connection to a situation to increase empathy and compassion, and we are seeing a lot of that right now.
On the other hand, I wish there was this strong of an empathic connection and worldwide response to problems like climate change, the murder of black and brown bodies, and the impact of capitalism on class disparities. Interestingly, each of these intersects with the effects of COVID-19, especially the disparity of the impact on (and deaths of) black folks in our country.
No matter how we process and move through this situation, many feel its impact as a trauma. While we work to validate our clients’ experiences and help them make sense of something entirely unprecedented, it is also important to remember that this situation impacts different people very differently. The disparities affecting various marginalized populations are amplified during this time. It is crucial to acknowledge the potentially devastating impact on the LGBTQIA+ community, especially on transgender and gender nonbinary (TGNB) individuals, many of whom are no strangers to trauma and grief. More background on this can be found in The Affirmative Couch’s course Gender Minority Stress and Resilience in Transgender and Gender Nonbinary Clients.
How our LGBTQIA+ clients might experience a compounded impact of grief and/or trauma related to COVID-19:
Physical distancing in unsafe and/or unaffirming living situations due to quarantine
- College students who were suddenly asked to leave campus
- Those in domestic violence or other abusive home environments
- People who have not disclosed or come out to their families/housemates
Social isolation due to the pandemic
- Being physically distant from one’s chosen family or an affirming environment (e.g., at a university)
- Being unable to explore communities or experiences that might be affirming, such as closed, limited, or postponed LGBTQIA+ centers and Pride month activities
Lack of resources to access safe space and online support for LGBTQIA+ Clients
- Limited resources to pay for stronger Internet connection, or lack of multiple devices
- Lack of privacy or safe space to seek online support or therapeutic help
- Food, housing, or job insecurity during this time
COVID-19 factors specific to TGNB people
- Canceled or postponed lifesaving gender-affirming surgeries
- Barriers to beginning gender-affirming hormones, monitoring bloodwork, and receiving preventative affirming healthcare
- Risk of misgendering via phone/video and distress/dysphoria of seeing one’s face via video conference
- Inability to affirm one’s gender expression due to lack of support and/or awareness of other household members
- Limited or no access to gender-affirming haircuts (i.e., hair can make or break someone’s experience of dysphoria on a given day)
- Increased body insecurity and disordered eating in response to the fatphobia strengthened by this crisis; you can read more about this in my article At the Intersection of Fat & Trans
How therapists can help our LGBTQIA+ clients during the coronavirus crisis:
The impact of each of these concerns is amplified for those with intersecting marginalized identities related to, for instance, race, class, ability, and mental/physical health status. To make matters worse, many of our clients experience anticipatory grief for the continued losses ahead as well as for the uncertainty of when things will “return to normal.” Here are some ways in which we might help our LGBTQIA+ clients, especially members of the TGNB community, to navigate this situation and find ways to practice self-compassion, gratitude, and hope.
Supporting LGBTQIA+ Clients with boundaries during the pandemic
This is not an “opportunity” for people to do the things for which they don’t usually have time. “Productivity porn” is shame-inducing for many who are experiencing this situation as a trauma. It is okay to limit time spent on consuming the news and social media. To paraphrase an important sentiment, this is not just remote work. You are at home during a pandemic crisis and attempting to work.
Providing validation for LGBTQIA+ clients
Acknowledge to your clients that employing all self-care strategies possible still may not help beyond simply keeping them afloat during this time. Surviving a traumatic experience takes an extreme emotional and physical toll, and it’s okay if clients’ eating habits and bodies change, if they sleep more than usual, and if they struggle to get work done.
Helping LGBTQIA+ Clients Develop Self-compassion
I can’t emphasize enough how important it is for our clients to be mindful and self-compassionate. Whatever thoughts, feelings, and behaviors emerge during this time make sense given the impact of collective traumas. Even if someone acts in a way that is inconsistent with their values, they are still worthy of self-nurturance and connection. You can learn more about these concepts through The Affirmative Couch’s course Helping Transgender and Gender Nonbinary Young Adults Develop Self-Compassion.
Finding and Celebrating little moments of joy and gratitude with LGBTQIA+ clients
- Ask clients to reflect on a vulnerable moment where they were able to nurture themselves or others
- What was one show/movie/podcast/song that made them smile or laugh?
- What is one thing they’re looking forward to in the upcoming week?
- What are three things about the past week for which they felt most grateful?
- Direct them to some of the many inspirational, hopeful, and positive ways in which people have been expressing themselves and creating via social media.
Finding meaning and connection
- Can clients volunteer virtually? Reach out to someone who is more isolated? Offer to drop off groceries for an elderly neighbor?
- What creative talents might be employed to help others?
- Engage clients in storytelling and/or writing–expressive writing exercises like these can be particularly useful–to help work through their feelings
- If they have financial resources, what organizations might benefit from their support?
- Connect virtually with supportive others, especially in spaces that are queer- and trans-affirming. Balance their socializing with meaningful conversation and moments of fun
- Help your clients explore whether local or statewide LGBTQIA+ organizations are running online groups and support spaces, and/or offering other forms of connection
Looking for Hope for the future (i.e., not focused on a specific time when things return to “normal”)
- Who is the first person a client can’t wait to hug again?
- What restaurant are they excited to go to first?
- For students, how will it feel to step back onto campus again?
- What is the first event/trip/appointment they’re looking forward to rescheduling?
A final note: These points are important for clinicians to keep in mind as well. We need these reminders now more than ever. Most of us are not at our best right now, and it is foolish to pretend to our clients that we are. This is a time for us to hold that we are all human, and that authenticity models for our clients why it is important to be less hard on themselves for struggling. At the very least, consider reading this “Dear Therapists” blog post.
Berinato, S. (2020, Mar 23). That discomfort you’re feeling is grief. Harvard Business Review. Retrieved from https://hbr.org/2020/03/that-discomfort-youre-feeling-is-grief
Thebault, R., Tran, A.B., & Williams, V. (2020, Apr 7). The coronavirus is infecting and killing black Americans at an alarmingly high rate. The Washington Post. Retrieved from: https://www.washingtonpost.com/nation/2020/04/07/coronavirus-is-infecting-killing-black-americans-an-alarmingly-high-rate-post-analysis-shows/?arc404=true
Patton, S. (2020, Apr 11). The pathology of American racism is making the pathology of the coronavirus worse. The Washington Post. Retrieved from: https://www.washingtonpost.com/outlook/2020/04/11/coronavirus-black-america-racism/
Tucker, M. (2019). Gender minority stress & resilience in TGNB clients. Retrieved from: https://affirmativecouch.com/product/gender-minority-stress-and-resilience-in-transgender-and-gender-nonbinary-clients/
Tucker, M. (2019) At the intersection of fat & trans. The Affirmative Couch. Retrieved from: https://affirmativecouch.com/at-the-intersection-of-fat-trans/
Ahmad, A. (2020, Mar 27). Why you should ignore coronavirus-inspired productivity pressure. The Chronicle of Higher Education. Retrieved from: https://www.chronicle.com/article/Why-You-Should-Ignore-All-That/248366
Tucker, M. (2019) Helping TGNB young adults develop self-compassion. The Affirmative Couch. Retrieved from: https://affirmativecouch.com/product/helping-transgender-and-gender-nonbinary-young-adults-develop-self-compassion/
Pennebaker, J.W., Blackburn, K., Ashokkumar, A., Vergani, L., & Seraj, S. (2020). Feeling overwhelmed by the pandemic: Expressive writing can help. The Pandemic Project. Retrieved from: http://exw.utpsyc.org/#tests
Katy (2020, Mar 21). Dear therapists. Navigating Uncertainty Blog. Retrieved from: https://navigatinguncertaintyblog.wordpress.com/2020/03/21/dear-therapists/
Learn affirmative therapy from M. Tucker, PsyD
All corners of our society are affected by the current global health crisis caused by COVID-19. Beyond the obvious risks of severe illness and mortality, many of our clients are managing the myriad mental health effects of financial insecurity, social isolation or co-quarantine, and general societal uncertainty. LGBTQIA+ communities face unique challenges during this pandemic. By understanding what some of these challenges are, clinicians can be better positioned to treat and empower their LGBTQIA+ clients. These challenges fall into several domains: social and emotional, economic, and physical. Additional training to help mental health professionals understand minority stressors can be helpful, especially in these unprecedented times.
How Psychotherapists Can Help With Social and Emotional Health
Some of the social challenges that may disproportionately affect LGBTQIA+ clients are the loss of perceived social connection due to the closure of many community spaces (Green, Price-Feeney, & Dorison, 2020; Burns, 2020), the necessity to shelter in place in an un-affirming or potentially violent space whether due to familial violence or intimate partner violence (Taub, 2020), and for Asian-American and other BIPOC, the increased likelihood of experiencing racist or xenophobic harassment (Loffman, 2020).
Therapists can support clients through these social and psychological challenges by:
Maintaining continuity of treatment via telehealth, thereby ensuring that the therapeutic relationship can remain consistent through a period of uncertainty and change
Nurturing an awareness of the challenges unique to LGBTQIA+ communities (by seeking out online training and understanding the reasons behind the statistics)
Containing the client’s feelings of despair, frustration, and fear
Brainstorming with clients to identify available venues for social connection and/or connecting clients to additional resources*
*Although telehealth and video conferencing offer ways to stay connected to work, friends, and family, clinicians should be aware that transgender and gender nonbinary clients may experience an increase in gender dysphoria as a result of being on screen so frequently. Having the client hide their own view may work for some clients, but for others it may still be intolerable. Phone therapy may be a better option. Talking to your client about the best way to obtain therapeutic support will help.
How Psychotherapy Can Support Clients with Economic Challenges
As the economic impact of the COVID-19 pandemic unfolds over the coming months and year, LGBTQIA+ communities will be among the most vulnerable populations. LGBTQIA+ clients may be cut off from family financial support, may not qualify for financial assistance due to the nature of their work (as in the case of sex workers or undocumented workers), and may not have emergency savings or cushions due to the barriers to high-paying employment as a result of homo-, bi-, and transphobic discrimination (Green, Price-Feeney, & Dorison, 2020; Kuhr, 2020).
Therapists can support clients through these economic challenges by:
Where possible, negotiating financial arrangements with clients as needed, thus ensuring that clients have the option to continue treatment despite temporary financial hardship or uncertainty
Containing difficult feelings that arise in the face of financial insecurity (fear, anger, and shame)
Strategizing with them to advocate for benefits (if applicable), particularly since some clients may feel too ashamed or unworthy to advocate for their own needs
How Therapy Can Improve Physical Health
When it comes to physical health and its effects on mental health, the COVID-19 crisis has already begun to affect the LGBTQIA+ communities in the form of delayed gender-confirming surgeries and delayed appointments required to access hormones or blockers (Loggins, 2020). LGBTQIA+ clients experiencing symptoms of COVID-19 may be hesitant to seek out testing or medical care due to past negative experiences with the medical system (such as misgendering, use of dead name, discrimination, or lack of access to healthcare) (Blum, 2020; Lang, 2020).
Therapists can help clients manage the physical health challenges clients face by:
Working to minimize the psychological toll that delayed procedures can take
Containing frustration, anger, and despair as normal reactions, which is important to help clients from decompensating
Offering psychoeducation on how to bind safely (Wynne, 2020), while keeping respiratory health in mind
Exploring harm reduction options to help clients reduce stress without contributing to physical vulnerability (via smoking or vaping)
Therapists are navigating this unprecedented and stressful time simultaneously with our clients. One of the most effective things we can do is maintain an authentic, caring, and consistent therapeutic relationship when disconnection and fear are abundant.
The Affirmative Couch will be rolling out several courses that address some specific challenges that the COVID-19 pandemic creates for the LGBTQIA+, consensually non-monogamous, and kinky communities over the next few weeks.