In recent years, both the ethics and efficacy of affirmative mental healthcare have been debated on a national stage. In 2022 alone, Florida state legislators have proposed a “Don’t Say Gay” bill, Alabama passed a law outlawing gender-affirming medical or mental healthcare for teens, and more than a dozen states like Ohio have followed in their wake. Conservative lawmakers feel that things have “gone too far” by allowing transgender and gender nonbinary (TGNB) people access to care that validates their identity, especially youth, and are using their power and influence to limit that access.

While these dog whistles may be daunting, it is important for mental health providers to have all the evidence when making decisions about clinical care. To be clear: the literature of the field strongly reflects that providing gender-affirming care is associated with positive outcomes for TGNB clients. In this article, we will address arguments against providing affirmative care and summarize recent evidentiary support and best practices.

Criticisms of gender-affirming care

A common criticism of gender-affirming care is that children and adolescents are not mature enough to self-identify their gender. Any psychotherapist with an understanding of human development can easily debunk this claim. According to the work of Lawrence Kohlberg, a foundational theorist in the field of psychology, children develop a sense of gender identity as early as preschool (Sravanti & Sagar K, 2019). Many gender-expansive youth opt to socially transition long before entering puberty, though the standard approach in our field is that of “watchful waiting,” in which the child’s medical team closely observe their exploration of gender until puberty (Ehrensaft et al., 2018).  In contrast, a gender-affirmative approach stresses the importance of self-identification by allowing the child to socially transition at any age, access puberty blocking medication if desired, and pursue medical transition after the onset of puberty (Ehrensaft, 2017). Both of these approaches have been heavily researched in recent years, yet the public consensus remains that we don’t (or can’t) know enough to establish gender-affirming care as a best practice.

One reason is that concerns about regret and detransition abound — though there is a paucity of research to support this. One study of adults who identify as transgender in the United Kingdom found that out of 175 individuals, only 12 reported detransitioning in the 16 months after receiving cross-gender hormone treatment (Hall et al., 2021). Out of that already small sample, only two patients reported feeling regret (Hall et al., 2021, p. 7). However, many clinicians actually recommend against further research on detransition or “desistance” rates, stating that it contributes to public mistrust and skepticism without serving youth. Academics have raised concerns about the methodology of desistance studies, as well as the working definition of “gender identity” that is used by other researchers, as lacking consensus may muddy the waters (Brooks, 2018). 

Research in support of gender-affirming care

So how do we reach this consensus? Emerging research strongly indicates that affirmative care improves the mental health of transgender and gender nonbinary clients. A 2021 study of 104 TGNB youth at Seattle Children’s Hospital found that receiving gender-affirming interventions such as puberty blockers or gender-affirming hormones was associated with 60 percent lower odds of moderate to severe depression and 73 percent lower odds of self-harm or suicidal thoughts during their first year of involvement in gender care (Tordoff et al., 2022). A recently published secondary analysis of the 2015 United States Transgender Survey found that out of over 3,500 respondents reporting gender-affirming surgeries in the prior two years, undergoing surgery was associated with lower past-month psychological distress and was not associated with greater lifetime risk of suicidality (Almazan & Keuroghlian, 2021). The authors of this analysis answer earlier concerns about the methodology of “desistance” studies by controlling for baseline mental health status in their work (Almazan & Keuroghlian, 2021). 

Similarly, a 2018 study published in JAMA Pediatrics found that out of 68 trans masculine patients undergoing chest reconstruction (top surgery), only one reported experiencing regret “sometimes” (Olson-Kennedy et al.). This study found no statistically significant differences between participants who underwent top surgery before age 18 and those who had surgery as adults (Olson-Kennedy et al.). The inverse effect can be observed when taking the impact of the COVID-19 pandemic into consideration — an international survey of 964 TGNB people conducted between April and August 2020 found that 55 percent of respondents experienced reduced access to gender-affirming resources, and this was correlated with higher prevalence of depression, anxiety, and suicidal ideation (Jarrett et al., 2020). 

Conclusions

The literature of the field reflects clear conclusions: increasing access to gender-affirming care improves mental health outcomes, and limiting access negatively impacts them. Our profession’s division over best practices for the mental healthcare of TGNB clients has laid the groundwork for public uncertainty, as well as legislative harm. It is crucial that we continue to pursue research into mental health outcomes for TGNB clients and publish these findings in ways that are accessible outside of academia — not hidden behind a paywall or requiring institutional access. For cisgender psychotherapists, we need leverage our privilege and be generous with our labor, sharing this information with friends, family, colleagues, and writing to our elected representatives. It is an issue worth the extra time and effort, and can have life-altering consequences.

Learn more about working with transgender and nonbinary clients

References

Almazan, A. N., and Keroughlian, A. S. (2021, April 28). Association between gender-affirming surgeries and mental health outcomes. JAMA Surgery 156 (7), 611-618.

Brooks, J. (2018, May 23). The controversial research on ‘desistance’ in transgender youth. 

Ehrensaft, D. (2017). Gender nonconforming youth: current perspectives. Adolescent Health, Medicine, and Therapeutics (8)1, 57-67.

Hall, R., Mitchell, L., and Sachdeva, J. (2021, October 1). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review. British Journal of Psychiatry 7(6), 1-8. 

Jarrett, B. A., Peitzmeier, S. M., Restar, A., Adamson, T., Howell, S., Baral, S., and Beckham, S. W. (2020, November 4). Gender-affirming care, mental health, and economic stability in the time of COVID-19: a global cross-sectional study of transgender and non-binary people. medRxiv: the preprint server for health sciences (2), 1-32.

Olson-Kennedy, J., Warus, J., Okonta, V., Belzer, M., and Clark, L. F. (2018, May). Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatrics 172(5), 431-436.

Sravanti, L., and Sagar K, J. V. (2019). Gender Identity: Emergence in Preschoolers. Journal of Psychosexual Health I(3-4), 286-287. 

Tordoff, D. M., Wanta, J. W., Collin, A., Stepney, C., Inwards-Breland, D. J., and Ahrens, K. (2022, February 25). Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Pediatrics (5)2, 1-13.

 Over the last two years of the COVID-19 pandemic, community relationships have shifted  to a location primarily online. The centrality and importance of technology-mediated relationships is now an established interest within the fields of social work and psychology (Trepte et al., 2017, Okdie et al., 2018) along with social and relational conflicts like cancel culture. Technologies such as dating apps, social networking platforms, collective chat channels and mutual aid networks became primary tools for connection during months of quarantine. 

Cancel Culture & Digital Relationships

The prevalence of online communities as sites for disclosure and support is a call for therapists to consider new ways of assessing and engaging clients about digital community social norms. Therapists also transitioned our work to online platforms. We experienced our lives in quarantine parallel with our clients’, growing more reliant on technology to mediate resources and professional community.  

Relationships mediated by technology have been shown to decrease isolation, loneliness, and anxiety (Juvonen et al., 2021) and to satisfy unmet needs for belonging (Iannone, 2017).  Best practices for evaluating the impact of online social interactions and relationships on client mental health are quickly emerging for providers. Specifically, we are tasked with engaging clients in conversations about harmful experiences with online social presence and connection. 

As I have  continued to use telehealth with my clients this year, a few key questions have emerged. As therapists, how do we position ourselves within a larger understanding of digital community membership and online social relationships? How do we hold space for the experience of losing online community?  Do online relationships hold the same value, quality, and importance as in-person relationships? How do our personal views and values impact our capacity to engage with clients who are experiencing relational trauma from the loss of online community? 

Digital Community and Belonging

As you read this, I am  curious if you can recall experiences of the last few years in which clients (or maybe your own community) experienced a fragmentation due to a public call to cancel someone.  How did your community hold this experience? Did this impact your client’s sense of connection to their community? What was your response? Therapists are currently tasked with both understanding the nature and meaning of online relationships, while also supporting individuals impacted by online community fractures. Here, I will suggest strategies for strengthening our digital literacies to meet these unique challenges. I will define digital literacy as well as a few key tools to affirm our knowledge about digital communications. I will also suggest  best practices for trauma-informed approaches, specifically through use of Cultural Betrayal Trauma Theory (Gómez, 2019) to develop clearer understanding and response to harm and experiences of online cancel culture.

Digital Literacy

Digital literacies are “the various skills, competencies and knowledge about information communication technology (ICT) and our capacity to apply this knowledge within our work and personal spheres” (Iordache et al., 2017,p.6). Essentially, digital literacy is our ability to engage with technologies and to understand the complex dynamic present between technology and human behavior.  

As LGBTQ2S+ therapists, we have a unique imperative  to join our clients in session with strong knowledge about the impact of online relationships.  We understand the power that can come from “finding our people” and not feeling alone. Because of this, we have a crucial need to develop our capacity to understand the potential of ICTs to positively transform or situate harm within clients’ lives.  What forms of digital communication do your clients engage with? Are they using online dating apps? Social media chats? Do they share joyful or upsetting text message threads in session?  

Digital relationships have their own intimacies. In fact, social scientists studying online intimacies have found “a number of factors may influence the way in which intimacy is expressed and perceived by users in interpersonal exchanges online” (Lomanowska, 2016, p.139). These factors include the type of online platform being used, prior familiarity with the people being engaged, and the social parameters of the platform (Lomanowska, 2016). Therapists might consider: are their clients meeting an online acquaintance for the first time, or have they met in-person before? Will this be a 1-to-1 conversation, or publicly available on a platform with a large audience?

You may already be thinking about a particular client or set of clients who have disclosed about their relationships built online. This may also bring to mind  the intense emotional and psychological connection they have felt to online support networks. You may also be thinking about your clients’ anxiety or grief regarding community conflicts or social media call-outs. This year I supported multiple clients in coping with both the rapid development of online romantic connection and the devastation of distancing from individuals who they never met in person. Digital intimacies are subjective, but without a baseline understanding of ICTs, therapists can miss opportunities to attune to their clients’ socioemotional needs in these relationships.  

You may want to consider the addition of some of the following questions in your assessment of client’s social connections, sense of belonging, or sources of stress.

Understanding Cancel Culture and Online Social Belonging

In the past two years there has been a rise in writing and attention placed on cancel culture. As a trauma therapist, I had multiple clients engaged with political organizing communities share with me their anxieties about being “canceled” in their online communities. Navigating vulnerability, discernment about disclosure online, and the nuances of activist projects became a central theme in much of my work. With the increase in popularity of social media, the relationship between online self-disclosure and social support has emerged as a relevant topic (Trepte, 2017, Valkenburg & Peter, 2007) for clinicians as well.  

So what is cancel culture? Hervé Saint-Louis (2021) writes that “…cancel culture’s origin stems from many online and off-line forms of public discourse in the public sphere. Cancel culture refers to the cancellation of individuals through online denunciations which results in the ostracisation and shaming of people” (para.22). Online cancel culture utilizes tactics of shaming that may be triggering to bystanders who come from family environments in which shame was used to control and take power over others. I have  found  it useful to use a trauma-focused lens when clients are disclosing or processing  about witnessing an attempt to cancel a community member. In her book “we will not cancel us: and other dreams of transformative justice” (2020) adrienne maree brown speaks to the dynamics of intragroup cancellation, specifically to how cancel culture is a reification of systems of punishment. Later, brown illuminates that acts of public shaming do not transform, but rather reinstate harm within marginalized communities (2020).

 In parallel, Cultural Betrayal Trauma Theory (CBTT) provides a “contexualized framework for examining how within-group trauma in minority populations (e.g ethnic, sexual, gender, religious minorities) may be harmful because of the societal context of inequality” (Gomez, 2019, p. 238). CBTT is a useful frame for unpacking the experiences of Queer, Trans and Gender Non-Conforming , Black, Indigenous, Mixed, People of Color clients who have shared about disappointment, hurt and harm within QTGNC online communities during the COVID-19 pandemic. It is important to note that “betrayal trauma refers to relational trauma independent of post traumatic stress reactions” (Freyd,1996 in Gomez et al., 2015, p.167). Relational-cultural approaches that emphasize connection and healing through the therapeutic alliance offer a QTGNC-affirming frame for holding these traumas. 

 A CBTT-focused perspective utilizes the language of betrayal to understand how breaches of intracultural trust impact marginalized communities. For example, QTGNC BIPOC communities and other activist communities that use online platforms as primary tools for intimacy and trust building may be especially susceptible to this loss of trust. One incidence of such a breach might include a client who is experiencing intimate partner violence turning to a member of their community for support and being met with disbelief in their experience or minimization of its impact.  Breaches of intracultural trust may stem from not being supported by key bystanders who share a client’s identity, or culturally-based responses that minimize the impact of such experiences. Additional examples of cultural betrayal include seeking mental or physical health support from a provider of a shared cultural background, and experiencing stigmatizing or shaming behaviors from the provider; or experiencing a breach in confidentiality within a shared cultural community. 

Questions for Mental Heath Providers

• As therapists how do we position ourselves within a larger understanding of digital community membership, online social relationships, and the subsequent loss of these? 
• Do we  value online relationships and hold them as containing the same quality and importance as in-person relationships? 
• How might our own views and values then impact our capacity to engage with clients who are experiencing emotional trauma due to the loss of online community due to cancel culture or call out culture? 

Cancel Culture and our clients:  A Brief Case Example

In 2020, I had multiple queer and trans BIPOC clients share their fears about not attending street-based protests. Large-scale Black Lives Matter protests and healthcare workers demonstrating in response to the COVID-19 pandemic were happening throughout the world. My clients with chronic illness, previous arrests and protest traumas, as well as those who were family caregivers, assessed that their voices would be best used within online organizing, mutual aid network leadership, and direct donation. I heard from multiple clients that they feared they would be judged or directly canceled regarding their choice to not attend direct actions.

 We explored the fear, noting that it was rooted in a concern about no longer belonging, or being perceived as “not committed” enough. Through a trauma-informed lens, we were able to identify that witnessing call-outs of community leaders and  out-group experiences due to trans or queer identity informed their anxieties about how they may be perceived. Memories about “being left behind,” “not being included,” or “not being seen as a real activist” surfaced. Together we were able to work through these past experiences and better understand the cognitive and somatic messaging they were carrying. 

In particular, it was useful to note clients’ fears about being perceived as betraying their community by not attending, and  how frequently social media played a role in this. Some sessions, we would talk about Instagram images of protest, Facebook photo banners, and online performances of activism as a method for “ensuring that people know I’m committed.”  

Often questions about shame emerged as clients recognized how much they were working to not be publicly shamed for their choices. In his work on shame and the social bond, Thomas Scheff (2021) posits that “shame is a result of threat to the bond” (p. 97) and explores how shame is the most social of our basic emotions. Cancel culture, it seems, has the potential to unlock deep wounds of socially located childhood shame for many BIPOC QTGNC individuals. It can  threaten social bonds that developed as a means of survival and belonging – a particularly heightened need in times of crisis,such as a global pandemic. While mutual support, sense of belonging, and cultural community can come from online relationships, the digital literacy required to navigate social media and build resilient responses to harm is key to sustaining these communities through community breaches and potential experiences of cancel culture. Therapists must draw from trauma-informed approaches to healing when clients perceived to have stepped outside the social norms of online culture are experiencing shaming and community isolation. Online social norms may include expectations about the depth and forms of personal disclosure considered acceptable on personal social media pages, norms regarding the content of personal images shared visually, or acceptance of use of the block feature now available on many social media platforms. 

Building our Capacity

Debriefing the experience of witnessing community cancellation can illuminate behavioral and attitudinal patterns regarding conflict, punishment, shame, and coping with strong emotions. adrienne maree brown writes “we won’t end the systemic patterns of harm by isolating and picking off individuals” (2021, pg.8). The author, brown, offers a nuanced understanding of the emotionality of betrayal and response. As QTGNC providers, we can strengthen our practice through asking more about the experiences of clients within online social communities.  

Online relationships offer both the potential for intracultural social intimacy, increased vulnerability, and personal disclosure during crisis (Blose et al., 2021), as well as the potential for intracultural betrayal trauma. It has become clearer to me that this poses a twofold need for LGBTQA2S+ therapists: firstly, to develop digital literacies to better attune to clients who use online communities as primary spaces for social engagement, as well as to also locate supportive frameworks for trauma-informed approaches to cancel culture within online spaces. Therapists have a unique capacity to engage with digital culture and to develop best practices for supporting a larger vision of healing community incidences of violence and harm. If you are working to strengthen your digital literacies and to locate a framework that feels right for your practice, please consider some of the resources below.

Additional Resources

• Reflection Questions for Digital Literacy in Social Work
• Digital Capabilities Statement for Social Work
• The Mental Health Effects of Cancel Culture
• We Will Not Cancel Us: and other dreams of transformative justice 

Learn More about working with Transgender and Non Binary Clients

References 

Blose, T., Umar, P., Squicciarini, A., & Rajtmajer, S. (2021). A study of self-disclosure during the Coronavirus pandemic. First Monday. https://doi.org/10.5210/fm.v26i7.11555

brown, adrienne maree. (2020). We will not cancel us: Breaking the cycle of harm. AK Press.

Gómez, J. M. (2019). What’s the harm? Internalized prejudice and cultural betrayal trauma in ethnic minorities. American Journal of Orthopsychiatry, 89(2), 237–247. https://doi.org/10.1037/ort0000367

Gómez, J. M., Lewis, J. K., Noll, L. K., Smidt, A. M., & Birrell, P. J. (2016). Shifting the focus: Nonpathologizing approaches to healing from betrayal trauma through an emphasis on relational care. Journal of Trauma & Dissociation, 17(2), 165–185. https://doi.org/10/gg5ndn

Juvonen, J., Schacter, H. L., & Lessard, L. M. (2021). Connecting electronically with friends to cope with isolation during COVID-19 pandemic. Journal of Social and Personal  Relationships, 38(6), 1782–1799. https://doi.org/10.1177/0265407521998459

Iannone, N. E., McCarty, M. K., Branch, S. E., & Kelly, J. R. (2018). Connecting in the Twitterverse: Using Twitter to satisfy unmet belonging needs. The Journal of Social Psychology, 158(4), 491–495. https://doi.org/10.1080/00224545.2017.1385445

Iordache, C., Mariën, I., & Baelden, D. (2017). Developing digital skills and competences: A quick-scan analysis of 13 digital literacy models. Italian Journal of Sociology of Education, 9(1).

Lomanowska, A. M., & Guitton, M. J. (2016). Online intimacy and well-being in the digital age.  Internet Interventions, 4, 138–144. https://doi.org/10.1016/j.invent.2016.06.005

Okdie, B. M., & Ewoldsen, D. R. (2018). To boldly go where no relationship has gone before: Commentary on interpersonal relationships in the digital age. The Journal of Social Psychology, 158(4), 508–513. https://doi.org/10/ghdx75

Saint-Louis, H. (2021). Understanding cancel culture: Normative and unequal sanctioning. First  Monday. https://doi.org/10.5210/fm.v26i7.10891

Trepte, S., Masur, P. K., & Scharkow, M. (2018). Mutual friends’ social support and  self-disclosure in face-to-face and instant messenger communication. The Journal of 

Social Psychology, 158(4), 430–445. https://doi.org/10.1080/00224545.2017.1398707

A key aspect for therapists practicing affirmative psychotherapy is deconstructing heteronormativity. Defined by the American Psychological Association as “the assumption that heterosexuality is the standard for defining normal sexual behavior,” heteronormativity stems from a long-standing, embedded cultural belief that traditional gender roles are unchanging and omnipotent. (2022) Taken a step further, heteronormativity becomes compulsory heterosexuality – the belief that every person must be straight, even if they have attraction to people of the same gender. Angeli Luz writes in the “Lesbian Masterdoc,” “compulsory heterosexuality easily ties in with the misogyny that causes women’s sexualit[y] and…identities to be defined by our relationships with men.” (2021) Sometimes abbreviated as comphet, compulsory heterosexuality pervades even benign interactions between therapists and clients.

As affirmative therapists, our work with LGBTQIA+ clients must break down the immutable belief in compulsory heterosexuality both for their clients and themselves. It impacts every stage of psychotherapy, from engagement to termination. In this article, we will explore the ways in which comphet erodes the therapeutic alliance, the challenges this poses to treatment, and how to begin deconstruction in your therapy practice.

Defining Compulsory Heterosexuality

The concept of compulsory heterosexuality was introduced in 1980 by the lesbian feminist writer Adrienne Rich in her groundbreaking essay, “Compulsory Heterosexuality and Lesbian Existence.” Her article describes compulsory heterosexuality as a “bias,” an automatic assumption that all women are heterosexual, and that “lesbian experience is perceived on a scale from deviant to abhorrent, or simply rendered invisible” (Rich, 1980, p. 1).
Queer theorist Michael Warner expanded on Rich’s work in his 1991 publication “Introduction: Fear of a Queer Planet,” in which the author introduces the concept of heteronormativity. Warner writes, “the task of queer social theory…must be to confront the default heteronormativity of modern culture with its worst nightmare, a queer planet” (1991, p. 17). Theoretically speaking, heteronormativity represents the status quo: a culture where everyone is presumed straight, enacted by compulsory heterosexuality.
In the decades since these words were published, our understanding of gender and sexuality has changed a lot. We can pay homage to the radical nature of Rich and Warner’s work in context while also acknowledging that they are further reaching than originally thought. For example, comphet does not only affect lesbians – bisexual, pansexual, and omnisexual people often experience a combination of erasure and stigmatization. With increasing visibility and representation of queer people in our modern era, we are closer to Warner’s idea of a “queer planet” than ever before, but still with further to go.
Armed with an understanding of the etiology and meaning of compulsory heterosexuality, it is easy to see how this mindset persists in psychotherapy. Although this article will focus on heterosexism, it is important to note that endosexism, cissexism, racism, and other biases also impact treatment. To begin the work of unlearning this unconscious bias, we must first learn to identify it.

How Compulsory Heterosexuality Erodes Psychotherapy

1. The therapist assumes that their clients are straight.

Many therapists might even believe that to suggest a client is LGBTQIA+ is impolite or inappropriate, and avoid addressing the topic in therapy sessions. Others might simply assume that a client is straight because they are themselves, because they don’t “look gay,” or they are unfamiliar or uncomfortable with queer identity. But the root of this issue is just as Rich wrote back in 1980 — that there is something “deviant” about queerness, or that someone would not want to be thought of in this way (p. 1).
Instead of allowing our clients to be “straight until proven otherwise,” therapists can invite conversation about sexuality and identity early in treatment. We become better therapists by treating our clients as the experts on their own experience, and letting them teach us about their sexual identities. It is well-established that a person-centered approach and strong alliance between therapist and client are reliable predictors for positive outcomes in psychotherapy, especially when paired with an affirmative approach for LGBTQIA+ clients (Davis et al, 2021). We can build the therapeutic alliance with our clients by creating a safe space for discussion of sexuality and identity. And overall, we can challenge our assumptions about sexuality and gender presentation through education, consultation, and rigorous self-reflection.

2. The client believes that they “should” be straight.

Similar to how a therapist might assume a client is straight based on their own internalized comphet, a client may have been socialized the same way. Our culture sends strong messages about what sexuality looks and feels like, which can be hard to parse through alone. Clients may have been taught to view their experiences with sexuality and identity through a lens of straightness.
In 2005, the New York Times published a piece by Stephanie Rosenbloom describing the phenomenon of a “girl crush.” Rosenbloom posited that “women, especially young women, have always had…feelings of adoration for each other,” differentiating a girl crush as “romantic but not sexual” (2005). Critics pointed out that many people experience romantic and sexual attraction separately, including those who are queer-identified. Another example would be straight women using the term “girlfriend” to describe their friends and peers – while this refers to the close and intimate nature of their relationship, it also dilutes the meaning of “girlfriend” as a romantic identifier. This is comphet in action: erasing the experiences of queer women by creating a new term to reassure straight women of their heterosexuality. As affirmative therapists, we can reframe this experience with our clients, and encourage them to adopt a more complex view. We can explore the meaning of sexual identity with our clients, and start to construct a new lens through which to view attraction.

3. The therapist interprets a client’s identity as pathology.

Affirmative psychotherapy firmly centers the belief that LGBTQIA+ identities are valid, and acknowledges their experiences of homophobia and oppression (Hinrichs & Donaldson, 2017). We acknowledge the harmful legacy of our profession’s work with the queer community, and how institutional oppression persists today. The DSM only removed homosexuality from its pages in 1973 – until this point, professionals were trained to believe that LGBTQIA+ identity was a disease state to be treated (Drescher, 2015).
Compulsory heterosexuality frames any experience of sexuality outside of straightness as “deviant,” as Adrienne Rich wrote. While the literature of the field reflects a shift in attitude in the years since this DSM update, there are still practitioners who were trained under this belief. There are may be others, too, who hold a personal bias that queerness is wrong or immoral. According to the Family Equality Council, conversion therapy is still legal in 25 states and 4 territories (2019). Affirmative psychotherapy believes that clients’ mental health symptoms may be due to such stigma and discrimination, but are not caused by their queerness.

4. The client intellectualizes their desire.

Intellectualizing is a defense mechanism in which clients create distance from their emotions through excessive overthinking (Bowins, 2021, p. 1). When clients intellectualize their problems, they are defending against the negative emotion by focusing instead on logical or rational explanations… even when their emotions are telling them otherwise. Some might argue that Rosenbloom’s description of a “girl crush” is intellectualizing by creating new terminology to describe romantic attraction between women (2005). A client who intellectualizes questioning their identity might search for an alternate explanation for their emotions that aligns with the belief that they must be heterosexual.
It is important to remember that we cannot equivocate desire or attraction with identity, and some people may identify as straight while experiencing romantic attraction to the same sex. Psychotherapists should help clients to move towards the belief that identity is far more expansive than simply “straight” or “not” – combating compulsory heterosexuality by encouraging non-judgmental exploration and expression of their sexuality.

Deconstructing Compulsory Heterosexuality in Your Practice

Once you have an understanding of compulsory heterosexuality, it can be overwhelming to think about how to implement a change to your therapy practice. As in much of affirmative psychotherapy, a good place to start is with yourself. Hinrichs and Donaldson define affirmative therapy as “a set of attitudes or approaches rather than specific techniques” (2017, p. 947). Reflect on the ways comphet shows up in your own practice. Do you default to gendered terminology for clients’ partners or dating interests? Are you comfortable sitting in ambiguity with a client who is questioning their sexuality without prematurely applying labels?
While much of the work of unpacking comphet happens at intake, you can deconstruct its influence throughout treatment. Taking an affirmative and client-centered approach, focus on what they see as the problem. Think of yourself as an advocate and collaborator with your client as you identify compulsory heterosexuality and experiences of homophobia or discrimination together. After all, meeting your client where they are at does not stop after the first session – therapists walk alongside our clients throughout the journey.

Learn more about working with LGBTQIA+ Clients

References

American Psychological Association. (n.d.). Compulsory Heterosexuality. American Psychological Association. Retrieved February 16, 2022, from https://dictionary.apa.org/heteronormativity.

Bowins, B. (2021). Psychological defense Mechanisms. In B. Bowins (Ed.), States and Processes for Mental Health: Advancing Psychotherapy Effectiveness (1st ed., Vol. 1, pp. 23–40). essay, Academic Press. Retrieved February 16, 2022, from https://www.sciencedirect.com/science/article/pii/B9780323850490000039?via%3Dihub#!.

Davis, A.W., Lyons, A. & Pepping, C.A. Inclusive Psychotherapy for Sexual Minority Adults: the Role of the Therapeutic Alliance. Sex Res Soc Policy (2021). https://doi.org/10.1007/s13178-021-00654-y

Drescher J. (2015). Out of DSM: Depathologizing Homosexuality. Behavioral sciences (Basel, Switzerland), 5(4), 565–575. https://doi.org/10.3390/bs5040565.

Family Equality Project. (2019, December 18). Conversion therapy laws. Movement Advancement Project. Retrieved February 18, 2022, from https://www.familyequality.org/resources/conversion-therapy-laws/.

Hinrichs, K., & Donaldson, W. (2017). Recommendations for Use of Affirmative Psychotherapy With LGBT Older Adults. Journal of clinical psychology, 73(8), 945–953. https://doi.org/10.1002/jclp.22505.

Luz, A. (2021). Copy of am I A Lesbian_ masterdoc.pdf. Am I A Lesbian_Masterdoc.pdf. Retrieved February 18, 2022, from https://www.docdroid.net/N46Ea3o/copy-of-am-i-a-lesbian-masterdoc-pdf#page=2.

Rich, A. (1980). Compulsory Heterosexuality and Lesbian Existence. Signs, 5(4), 631–660. http://www.jstor.org/stable/3173834.

Rosenbloom, S. (2005, August 11). She’s So Cool, So Smart, So Beautiful: Must Be A Girl Crush. The New York Times. Retrieved February 16, 2022, from https://www.nytimes.com/2005/08/11/fashion/thursdaystyles/shes-so-cool-so-smart-so-beautiful-must-be-a-girl-crush.html.

Warner, M. (1991). Introduction: Fear of a Queer Planet. Social Text, 29, 3–17. http://www.jstor.org/stable/466295

Before getting into this article, I would like to locate myself. I am a white, bisexual, able-bodied, ambiamorous, cisgender woman with anxiety and a chronic illness who has been in both monogamous and polyamorous relationships. As someone who identifies as bisexual, has navigated both polyamorous and monogamous relationships, and specializes in working with these communities, I believe that it is important for clinicians to understand the unique experiences of bisexual polyamorous individuals.

As an affirmative therapist throughout the COVID-19 pandemic, I have worked with clients with marginalized identities who have been experiencing higher-than-baseline levels of anxiety and depression due to the pandemic. This has filtered into much of our work, even if their primary presenting problem was originally to navigate their sexual orientation or relationship orientation, or to navigate concerns within their relationships. COVID-19 has highlighted the fact that, as clinicians, it is important to recognize that our clients’ identities do not exist in a vacuum – just as our own identities do not exist in a vacuum. Therefore, it is always important to take into account the impact of both internal and external factors in clients’ lives while working with them – as well as how our own experiences may or may not come into the therapy room. 

Potential Benefits of Polyamory for Bisexual Clients

Bisexuality has been defined as “the potential to be attracted – romantically and/or sexually – to people of more than one gender, not necessarily at the same time, not necessarily in the same way, and not necessarily to the same degree” (Ochs, n.d.). Studies show that bisexual people prefer polyamorous or open relationships in greater frequency than people of other sexual orientations (Weinberg, Williams, & Pryor, 1994). One benefit of polyamory for bisexual people is: “polyamory and bisexuality propose a plurality of loves, both in the number of partners and genders thereof” (Anderlini-D’Onofrio, 2004). Polyamory can be a beautiful thing for many bisexual individuals who want to add diversity to their sexual and romantic lives with people of more than one gender. 

However, they don’t always have a “preference” in their partner’s gender; it is more about the people they are dating and how polyamory enhances their lives. In fact, 70% of bisexual polyamorous participants in one study did not care whether their partners were of the same or different genders at any one time (Weitzman, 2006). Their preference for polyamory, therefore, may come from the fact that more bi-identified men and women tend to believe that monogamy in relationships is less enhancing and more sacrificing than gay-identified or straight-identified individuals (Mark, Rosenkrantz, & Kerner, 2014). 

Bisexual Erasure and Strategic Identities

Polyamory offers an exceptional way to provide a buffer against bi erasure or invisibility and challenges the risk of falling into heteronormativity (Robinson, 2013). In fact, non-monogamy has been identified as a “strategic identity” to maintain bisexual visibility in the world (Klesse, 2011; Moss, 2012; Robinson, 2013; Weitzman, 2006). A strategic identity is an identity that serves a political, social, or interpersonal function. In this case, the function of polyamory could be visibility and support of bisexuality as an authentic identity. When bisexual individuals can express their identity more fully and be visibly bisexual, especially in the context of a polyamorous relationship, they also tend to have more: 

• Freedom to have partner choices of all genders, 
• Freedom to speak openly about the full range of their attractions and fantasies,
• Opportunities for group sex, and 
• Sexual and romantic enjoyment of different genders. 

Therefore, if bisexual individuals engage in polyamorous relationships, they can express their sexuality more freely – both for themselves and within the larger world. 

Potential Disadvantages of Polyamory for Bisexual Clients

There are also unique disadvantages to being both bisexual and polyamorous. These individuals may be doubly stigmatized as “confused” or “promiscuous” (McLean, 2011; Weitzman, 2006). They may experience prejudice and discrimination from both the gay and straight communities (e.g., prejudice from gay partners about other-gender partners; prejudice from straight partners about same-gender partners). This internalized stigma and biphobia from partners (either monosexual or bisexual partners) can also lead to potential increased rates of intimate partner violence. Turell, Brown, and Herrmann (2017) found that bi-negativity and the oversexualization of bisexual individuals was a risk factor for higher rates of jealousy and IPV. This risk was highlighted by bisexual participants who are also polyamorous. 

On an individual level, bisexual people may experience guilt about reinforcing the stereotype that “bisexual people aren’t/can’t be monogamous.” And, they may also experience their own or others’ misperceptions that same-gender relationships are somehow less important than other-gender relationships (Weitsman, 2006). 

As clinicians, it is our duty to challenge these cognitions if we have any of them; by reinforcing these stereotypes, we would be harming our bisexual clients as well. We can challenge our own thoughts and feelings through: 

• Being curious about clients’ lived experiences
• Identifying and being curious about our own reactions and expectations for our clients’ lives
• Reading, following, and engaging with media created by bisexual polyamorous folx 
• Educating ourselves about the reality of bisexuality and polyamory
• Seeking supervision or consultation with another polyamory-affirmative clinician

Clinical Work with Bisexual Polyamorous Clients

Having explored the potential advantages and disadvantages of polyamory for bisexual individuals, clinicians will hopefully be better positioned to provide a safe space for their bisexual polyamorous clients. Helping bisexual polyamorous clients with their relationships may include talking about safer sex practices with many genders, assessing for biphobia, assessing and creating safety plans for IPV, as well as addressing any other clinical issues.

Clinical work may include an exploration of how competition shows up in their relationships (if it does at all). Some partners of bisexual individuals may take comfort in knowing that they are currently the only person of a particular gender that the person is dating; therefore, they may feel as though there is less of a risk of their bisexual partner leaving them. For others, they may be acutely aware that their body is different from that of their metamours’; therefore, they may be concerned about never being able to fulfill a particular role or sexual desire for their partner (Armstrong & Reissing, 2014).

In doing this work, affirmative clinicians should also be on the lookout for any potential biphobia or IPV within a relationship. Couples’ therapy or multi-partner relationship therapy is not recommended in cases where IPV is prevalent. 

Unique Stressor: A “Choice” 

Bisexual polyamorous people also often are asked to make a choice between a partner and their relationship orientation. This is because potential other-sex partners of bisexual individuals tend to have expectations of monogamy (Armstrong & Reissing, 2014). This decision is a frequent reason couples end up in my office: one person craves non-monogamy, while the other can only envision a monogamous relationship for themselves. This is not always related to one person having a bisexual identity, but it can be one aspect of mono-poly relationship experiences. When faced with a monogamous-minded partner, some bisexual individuals do end up feeling like they have to make a choice, and may explore their options in our office. Some questions a bisexual client may be struggling with are:  

• Do I stay in a monogamous relationship, or do I go? 
• What does this say about my identity? 
• Am I being true to myself?
• What will my community think?
• Will I be rejected from bisexual spaces or polyamorous spaces? 
• Would I be a “sell-out” for choosing a partner of one gender or choosing a monogamous relationship? 

Bisexual erasure happens to bisexual folx all the time; it is a weight we often feel, even if we aren’t expressing it. Therefore, an affirmative clinician should try to be aware of both the explicit and implicit choices that a client may be making when they are exploring the pros and cons of their relationship structures and how they are designing their relationships. While polyamory may help some bisexual folx combat bi erasure and be more visible, it also brings other difficulties with it. There is no one “correct” way to structure relationships, but exploring the various options, benefits, and disadvantages with bisexual individuals may help clients find the best choice for themselves and live more authentically in their life. 

References 

Anderlini-D’Onofrio, S. (2004). Plural loves: Bi and poly utopias for a new millennium. Journal of Bisexuality, 4, 1-6, doi:10.1300/J159v04n03_01

Armstrong, H. L. & Reissing, E. D. (2014). Attitudes toward casual sex, dating, and committed relationship with bisexual partners. Journal of Bisexuality, 14, 236-264. doi:10.1080/15299716.2014.902784

Klesse, C. (2011). Shady characters, untrustworthy partners, and promiscuous sluts: Creating bisexual intimacies in the face of heteronormativity and biphobia. Journal of Bisexuality, 11, 227-244. doi:10.1080/15299716.2011.571987

Mark, K., Rosenkrantz, D., and Kerner, I. (2014). “Bi”ing into monogamy: Attitudes toward monogamy in a sample of bisexual-identified adults. Psychology of Sexual Orientation and Gender Diversity, 1(3), 263-269. doi:10.1037/sgd0000051

McLean, K. (2011). Bisexuality and nonmonogamy: A reflection. Journal of Bisexuality, 11, 513-517. doi:10.1080/15299716.2011.620857

Moss, A. R. (2012). Alternative families, alternative lives: Married women doing bisexuality. Journal of GLBT Family Studies, 8(5), 405-427. doi:10.1080/1550428X.2012.729946

Ochs, R. (n.d.). Bisexual: A few quotes from Robyn Ochs. Retrieved from https://robynochs.com/bisexual/

Robinson, M. (2013). Polyamory and monogamy as strategic identities. Journal of Bisexuality, 13(1), 21-38. doi:10.1080/15299716.2013.755731

Turell, S. C., Brown, M., & Hermann, M. (2017). Disproportionately high: An exploration of intimate partner violence prevalence rates for bisexual people. Sexual and Relationship Therapy, 33, 113-131. doi:10.1080/14681994.2017.1347614

Weinberg, M., Williams, C., & Pryor, D. (1994). Dual attraction: Understanding bisexuality. New York, NY: Oxford Press. 

Weitsman, G. (2006). Therapy with clients who are bisexual and polyamorous. Journal of Bisexuality, 6, 137-164. doi:10.1300/J159v06n01_08

Check Out Stephanie’s CE Courses on working with polyamorous clients

As a reminder, my goal in writing this two-part series is to reflect on the ways in which TGNB-affirming* clinicians contribute to colonization (Part 1), while also offering, in this article, actionable ways of moving toward decolonization and gender liberation.

You may be familiar with what is now called the Multicultural & Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016). The original elements of knowledge, attitudes and beliefs, and skills originated in 1992 (Sue et al.), and the most recent expansion added the emphasis of taking action. 

This model emphasizes that our work needs to transcend the clinical skills and interventions we have been taught. We need to engage in our own self-reflection, navigate the power dynamics that are inherent in every session, and better understand and advocate for change within the very systems that perpetuate the problems our clients are facing. 

As mentioned in Part 1, I believe that a clinician’s ability to wholeheartedly and effectively serve the TGNB population requires ongoing critical awareness, examination, and acknowledgment of the following: 

• A likely skewed lens of the world
• Your approach to treatment
• How you operate around privilege and oppression (both personally and professionally)
• The history of colonization and enslavement, as well as white supremacy
• The ways in which you have benefited from various systems and/or internalized the intergenerational harmful impact of those systems

If you are unsure of how to transform your clinical work with TGNB people to work toward gender liberation with a lens of decolonization, here are some action steps and values you might find helpful: 

DIG DEEPER. 

“History has its eyes.” Actively educate yourself, acknowledge, raise awareness, and work to change historical systems of oppression related to ability, race, gender, and body diversity. Aim to move beyond affirmation and “multicultural competence” to better understand your own colonized behaviors, as well as each client’s internalized transphobia and racism, and help clients move toward liberation. Antiracism Daily can be a helpful resource in this regard.

OWN YOUR ROLE AND RESPONSIBILITY. SAY THE THING.

We have a responsibility to acknowledge the impact of our racial and gender identities, the actions of our ancestors, our mistakes, our humanness, and our own innate strength and power; I recommend checking out Nora Alwah’s Ted Talk. We also have a responsibility to be authentic and transparent, and to believe what our clients tell us is their lived experience. 

Validate client experiences rather than attempting to empathize with an experience of oppression for someone with a marginalized identity you do not hold. Bear in mind that sometimes our clients may not feel able to tell us or ask for what they need, especially if they’re accustomed to making those in positions of power feel more comfortable. 

VALUE LIVED EXPERIENCE AS EXPERTISE OF THE SELF.

Decenter your privilege of the expectation of comfort from others. For those of us in positions of power/privilege, we become accustomed to systems and interactions being shaped around our needs, so it creates a dynamic in which those in marginalized bodies spend their lives making us comfortable (e.g., when Black people “code switch” in white spaces). Center your client’s feelings and experiences. Clinically, trust your clients’ awareness and knowledge about what they need and want. 

Professionally, seek opportunities to learn from those who have lived experiences with their own BIPOC and/or TGNB identities. Honor their lived experience without questioning their training, education, and competence. And pay them for their time! For example, Sonny Jane talks more about this.

PRACTICE SELF-COMPASSION AND CULTURAL HUMILITY.

Check your shame at the door. We improve with openness to being wrong, trying, failing, and doing better the next time. Following a mistake, shame can lead to inaction and avoidance due to thoughts of being “not enough” and fear of judgment. 

On the other hand, guilt allows us to accept responsibility, act to address the hurt our behaviors have caused, and learn from our mistakes for future interactions. You are imperfect, and that’s okay. You can still strive for excellence in TGNB care. Learn more about TGNB self-compassion.

USE A TRAUMA-INFORMED LENS TO HEAL, REST, AND SEEK JOY.

To effectively support TGNB clients, pay attention to both your and your clients’ minds and bodies using a trauma-informed lens. Bodies of all races carry the intergenerational trauma of our ancestors, and it is much more difficult to create a culture of liberation and internalized antiracism without first healing and resting our bodies. I recommend Resmaa Menakem’s book My Grandmother’s Hands; you might also check out The Nap Ministry on Instagram.

 Also, part of healing is uncovering moments of joy and pleasure, both for yourself as well as your clients. For example, encourage your clients to be on the lookout for gender euphoria, which entails experiencing a strong sense of comfort and/or joy during an imagined or actual moment of connection and authenticity in one’s gender identity, body, and/or expression. There’s more about this in Laura Kate Dale’s forthcoming book Gender Euphoria. Make sure to celebrate all of the tiny victories in addition to holding space for dysphoria and marginalization. For more information about this, I recommend Adrienne Maree Brown’s Pleasure Activism and Anneliese Singh’s The Queer & Transgender Resilience Workbook.  

“UNSCHOOL” AND ANTICIPATE A LACK OF CLOSURE. 

We may never achieve some predetermined maximum level of knowledge, awareness, and language expertise. But we can work to expand ourselves beyond the “schoolishness” of doing what we’ve been taught in Western and colonized systems of education and psychology. For example, Akilah Richards’ work examines unschooling as a path to liberation (2020).

BE PATIENT. TRUST AND VULNERABILITY ARE EARNED OVER TIME.

White supremacy, racism, anti-Blackness, transphobia, and colonialism have impacted the world for centuries. It is a naïve privilege to believe that the work of one person alone can break down the barriers. Safety is not universal. Trust has to be earned. 

Clinically, we cannot rush connection, courage, trust, affirmation goals, or growth without a cost to ourselves and/or our clients. It is not surprising that our clients distrust us at first; only if and when it starts to feel safer, they may slowly open themselves up to becoming more vulnerable. 

CONNECT AND NURTURE YOURSELF.

Connect with other social justice-minded professionals who espouse the values of anti-racism and anti-oppression, such as Inclusive Therapists and Joy and Justice Collaborative. Follow and support the work of healers who actively engage in the work, such as Alisha McCullough, Sonalee Rashatwar, and Haley Jones.

Communities that work together toward these shared goals create a sense of belonging and healing together. We also need to set and maintain boundaries to ensure we are appropriately recharging, checking in about our needs and wants, and creating an environment that best allows us to do effective work. 

CHECK YOUR VALUES.

Examine how true racial and gender liberation would serve you, rather than worrying about what it might “take away.” When this work feels hard, do you pull back or move through? Do your words, behavior, commitment, and expenditures stand in line with what you say you value? For example, consider the impact of supporting organizations such as Psychology Today that have problematic histories related to race, gender, and bodies.  

You might reimagine your practice policies, fees, structure, and paperwork when reflecting on the ways in which you are reinforcing colonization. For example, please see here and here for a discussion of sliding scales as a tool for economic justice. Also, I highly recommend considering the GALAP Pledge, in which mental health providers commit to offer free or insurance-based access to gender-affirming surgery assessments from an informed consent lens. 

Finally, consider whose voices are missing from your education, training, and ongoing work to improve your competence with marginalized populations. Are you centering yourself and/or those in positions of power, or pulling back to make space for marginalized voices? 

LEAN INTO DISCOMFORT. 

If you’re doing this work, chances are that you will often feel uncomfortable. Discomfort is not bad just because we experience relief when we move away from it. It is not others’ responsibility to make us comfortable, to lead us down the “right” path, etc. View discomfort as an opportunity to get curious (you might check out this radical anger podcast episode)! 

Consider that many people experience discomfort when first exploring the sexist and racist history of fatphobia, the harmful impact of diet culture, and the ableism inherent in much of our society. (For more information, see this writer’s related articles here and here; I highly recommend reading The Body is Not An Apology and Fearing the Black Body.) But the joy and grounding that comes from liberating ourselves and our clients from those harmful systems is worth the work!

Though most of my early knowledge and training comes from white Western ideas and people, I have grown the most from queer, fat, TGNB, and BIPOC intersectional mentors, thought leaders, educators, clinicians, and other healers. I am a radically different (and better) version of myself when I am in community with others who hold similar values of anti-racism, body, race, and gender liberation, and restorative/reparative justice. So I can’t emphasize enough how important it is to expand upon this article with the intense heart and body work that comes with decolonization, restorative justice, and liberation. 

*Note: For the purpose of this article, TGNB indicates transgender and gender nonbinary populations, though you may come across other “umbrella” acronyms. No acronym will fully represent all experiences of gender diversity, so when referring to individuals, you should always use whatever language feels best for your client. The use of BIPOC sometimes represents Black, Indigenous, and People of Color (i.e., non-white people), and at other times it represents Black and Indigenous people of color primarily (Code Switch episode, Meraji & Escobar, 2020). When discussing BIPOC communities in this article, I am referring to the Black, Indigenous, and other communities of color who experience ongoing marginalization and oppression in relation to the colonized history of the Western world, including the intergenerational impact from their ancestors. 

Suggested Resources

As a reminder, there are approximately two dozen recommendations and resources listed in Part 1 in addition to the ones below. These constitute just a sampling of the vast amount of information available, and my recommendations are based on my personal experience, growth, and perception of their helpfulness. Lean into what resonates, and know that there are alternatives for anything that doesn’t. 

Communities: 

• GALAP Pledge (A group of mental health providers in the US who have committed to offering free or insurance-based accessible referral letters for gender affirming surgery). https://thegalap.org/ 
• Inclusive Therapists (A mental health professional directory, community, & justice movement). [@inclusivetherapists]. https://www.inclusivetherapists.com/ 
• Joy & Justice Collaborative (A healing and mental health professional community, education events, & justice movement). [@joyandjusticecollab]. https://www.joyandjusticecollab.org/ 
• The Blacker the Brain (Thea Monyee´ of MarleyAyo LLC is building a community of multidisciplinary practitioners & creatives to decolonize mental health/healing/wellness work). [@TheBlackerTheBrain]. https://marleyayo.com/unlearning 

Media & Web Resources: 

• Alwah, N. (clinician, she/her). (n.d.). Nora Alwah. [@noraalwah]. [Website, Instagram profile]. www.noraalwah.com 
• Breland-Noble, A. (clinician/vlogger, she/her). (n.d.). Couched in Color with Dr. Alfiee. [@dralfiee]. [Instagram profile, YouTube channel]. https://www.youtube.com/c/CouchedinColorwithDrAlfiee 
• Cardoza, N. (editor). (2020 – present). Anti-Racism Daily. [@antiracismdaily]. [Online newsletter, Instagram profile]. https://www.antiracismdaily.com/ 
• Feder, S, & Scholder, A.  (Director & Producers). (2020). Disclosure: Trans Lives on Screen [Documentary]. Field of Vision.
• Finch, S.D. (coach & writer, he/they). (n.d.). Sam Dylan Finch. [@SamDylanFinch] [Website, Instagram profile]. www.samdylanfinch.com 
• Hersey, T. (founder/blogger/coach). (n.d.). The nap ministry. [@thenapministry]. [Instagram profile; Blog]. https://thenapministry.wordpress.com/ 
• Jane, S. (peer support/lived experience counselor, they/them). (n.d.). Lived Experience Studio[@LivedExperienceCounsellor]. [Website, Instagram profile]. www.livedexperiencestudio.com 
• Jones, H. (LPC-intern & content creator, they/them). (n.d.). [@the_queer_counselor]. [Instagram profile]. https://www.instagram.com/the_queer_counselor/ 
• McCullough, A. (clinician, she/her). (n.d.). Black and Embodied. [@blackandembodied]. [Instagram profile, Website]. www.blackandembodied.com 
• McNeil, Toliver, M., Grinnell, M., & Wiltey, J. (Hosts). (2019 – Present). The melanated social work podcast. [Audio podcast]. Producer unknown. https://melanatedsocialwork.buzzsprout.com/ 
• Melanated Social Work (clinicians/podcasters). (n.d.). [@MelanatedSocialWork]. [Instagram profile, Website]. https://melanatedsocialwork.buzzsprout.com/ 
• Menakem, R. (clinician/author, he/him). (n.d.). Resmaa Menakem. [@ResmaaMenakem] [Website, Instagram profile]. www.resmaa.com 
• Mullan, J. (clinician/author, she/her). (n.d.). Jennifer Mullan – Decolonizing Therapy. [@decolonizingtherapy] [Instagram profile, Website]. https://www.drjennifermullan.com/ 
• Rashatwar, S. (clinician/lecturer/organizer, she/they). (n.d.). Sonalee Rashatwar. [@TheFatSexTherapist]. [Website, Instagram profile]. www.sonaleer.com 
• Richards, A. (writer/coach/podcaster, she/her). (n.d.). Raising Free People. [@fareofthefreechild]. [Instagram profile, Website].  https://raisingfreepeople.com/
• Taylor, S.R. (writer/poet/thought leader, she/they). (n.d.). The Body is not an Apology. [@SonyaReneeTaylor, @TheBodyIsNotAnApology]. [Website, Instagram profile]. https://thebodyisnotanapology.com/ 
• Toler, M. (Host). (2020 – Present). Hearing our own voice. [Audio podcast]. Producer unknown. https://www.melissatoler.com/podcast 

Learn more about transgender and gender nonbinary affirmative therapy with addyson tucker, PsyD (they/them)

References

Alwah, Nora. (2020, October 26). Reclaiming our power: Making ourselves seen [Video]. TEDxCU. https://www.youtube.com/watch?v=mYi42ydUe7Q&feature=emb_logo 

binaohan, b (2014). decolonizing trans/gender 101. biyuti publishing. 

Brown, A. M. (2019). Pleasure activism: The politics of feeling good. AK Press. 

Cunningfolk, A. (2015, Aug. 11). The sliding scale: A tool of economic justice. Worts + Cunning Apothecary. http://www.wortsandcunning.com/blog/sliding-scale?rq=sliding%20scale 

Cunningfolk, A. (2018, Apr. 23). How to make the sliding scale better for you & your clients. Worts + Cunning Apothecary. http://www.wortsandcunning.com/blog/a-better-sliding-scale 

Dale, L. K. (anticipated, 2021). Gender euphoria: Stories of joy from trans, non binary and intersex writers. [Book preparing for print]. Unbound: United Authors Publishing Ltd. 

Gender euphoria. (n.d.). In Gender Wikia. https://gender.wikia.org/wiki/Gender_Euphoria 

Guenther, J. (2018, October 21). Psychology Today magazine loves white people: Especially beautiful and thin white women. Therapy Den. https://www.therapyden.com/blog/psychology-today-magazine-loves-beautiful-thin-white-women 

Hemphill, P. (Host). (2020 – Present). Finding our way. [Audio podcast]. Producer unknown. https://prentishemphill.com/new-page-4 

jackson, k. & Shanks, M. (2017). Decolonizing gender: A curriculum. [Zine]  https://www.decolonizinggender.com/

Menakem, R. (2017). My grandmother’s hands. Racialized trauma and the pathways to mending our hearts and bodies. Central Recovery Press.

Meraji, S.M. & Escobar, N. (Hosts). (2020, September 30). Is it time to say R.I.P. to POC? [Audio podcast episode]. In Code Switch. NPR. https://www.npr.org/2020/09/29/918418825/is-it-time-to-say-r-i-p-to-p-o-c

Ratts, M. J., Singh, A. A., Nassar-McMillan, S. N., Butler, S. K., & Rafferty McCullough, J. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28-48. https://onlinelibrary.wiley.com/doi/10.1002/jmcd.12035 

Richards, A. (2020, Oct. 20). Raising free people: Unschooling our way to intergenerational healing. In Joy & Justice Collab: Empowered Learning Summit. [Presentation]. 

Singh, A. S. (2018). The queer & transgender resilience workbook: Skills for navigating sexual orientation & gender expression. New Harbinger Publications, Inc.

Strings, S. (2019). Fearing the Black body: The racial origins of fat phobia. New York University Press.

Sue, D. W., Arrendondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling & Development, 20, 64-88. https://onlinelibrary.wiley.com/doi/10.1002/j.2161-1912.1992.tb00563.x 

Taylor, S. R. (2021). The body is not an apology: The power of radical self-love. (2nd ed.). Berrett-Koehler Publishers. 

Tucker, M. (2019, June 19). At the intersection of fat and trans. The Affirmative Couch. https://affirmativecouch.com/at-the-intersection-of-fat-trans/  

The Allied Minds Collective (2020, July 31). Psychologist’s stance on the “vilification of Karens” exposes the inequities embedded within mental health care. Medium. https://medium.com/@thealliedminds.co/psychiatrists-stance-on-the-vilification-of-karens-exposes-the-inequities-embedded-within-c76a35622aee 

Tucker, M. (2019, November 22). Helping TGNB young adults build self-compassion. [Webinar Training]. The Affirmative Couch. https://affirmativecouch.com/product/helping-transgender-and-gender-nonbinary-young-adults-develop-self-compassion/ 

Tucker, M. (2019, November 27). Helping queer and trans clients navigate fatphobia during the holidays. The Affirmative Couch. https://affirmativecouch.com/helping-queer-and-trans-clients-navigate-fatphobia-during-the-holidays/ 

Tucker, M. (2020, Aug 4). Deactivating psychology today and moving forward. https://www.wholeheartedpsych.com/post/deactivating-psychology-today-moving-forward

Crystal Meth & the Gay Community

Crystal meth has had a devastating effect on the gay community. Over the last 20 years, meth has grown into a catastrophic force, contributing to about 15% of all drug death overdoses (NIDA, 2019). Gay and bisexual men use methamphetamines at a higher rate than heterosexual men (Lea et al., 2017). As a result, it is safe to assume that a high percentage of crystal meth overdoses come from within the LGBTQIA+ community.

Crystal Meth & HIV

Further, crystal meth has played an instrumental role in the increase of HIV infection rates. “Crystal methamphetamine use is a large contributing factor to a substantial increase in risky sex behaviors and higher rates of HIV infection among MSM” (Molitor et al., 1998 p. 3). During use, the neurotransmitter dopamine floods parts of the mesolimbic dopaminergic pathway in the brain, which regulates feelings of pleasure (CSAT, 2009). 

Considered a club or party drug, crystal meth is often used by young adults and teenagers to stay awake (Dowshen, 2018). In addition, a common effect shared by gay and bisexual men during crystal meth use is an insatiable sexual appetite. Drug use can result in feeling sexually adventurous and experiencing a heightened sense of pleasure, stamina, and endurance that can last for days even without the user taking proper rest. In other words, crystal meth can produce feelings of confidence, power, and invulnerability on a psychological level. Subsequently, the aforementioned increased sexual desire can overpower necessary activities of daily living like bathing and going to work. 

Crystal Meth & Chemsex

While in this state, men who have sex with men (MSM) may engage in chemsex–taking any combination of drugs including crystal meth, mephedrone, and/or GHB/GBL while engaging in sex. Since the use of crystal meth lowers one’s inhibitions, meth is often associated with multiple partners, who may contact each other via hookup apps.

Crystal meth users may also engage in what is called “tinkle tweaking,” in which they store their own urine and try to recover un-metabolized methamphetamine from it to fuel another high (Wakefield et al., 2019). Another version of this is called a “booty bump.” One way to receive a booty bump is to dissolve a shard of crystal in water and put it into a syringe without the needle, then “bump” this solution of crystal into one’s anus. A version of this may be practiced during chemsex as well, but what users may not realize is that booty bumps can result in hepatitis, parasites, and other diseases (Frankis et al., 2018).

Crystal Meth & Black Men 

In the gay world, crystal meth has been known as a rural white men’s drug. However, Black men’s use of crystal meth has increased significantly. A study conducted by MSM in New York demonstrated that Black men reported use of methamphetamines at a higher rate than white men (Halkitis et al., 2008). Filter, a New York City magazine, shared that Black men experienced more hospitalizations for amphetamine poisoning, dependence, and “nondependent abuse” in the city’s public hospitals than did all white people (Blanchard, 2019). For example, Black men reported a higher rate of usage of methamphetamines than white men and less enrollment in treatment (Saloner & Le Cook, 2013). 

Moreover, research shows that those who enroll in treatment programs for substance misuse demonstrate a higher success rate in their journey of sobriety; obviously, treatment provides access to necessary behavioral supports such as counseling, and is linked to improvement in social and psychological functioning (NIDA, 2020). Statistically, if Black men are not seeking or receiving treatment, then they are at higher risk of long-term use or succumbing to addiction. Positive responses to treatment outcomes are, of course, dependent upon the appropriateness of the intervention, as both affirmative care and client involvement are essential.

Affirmative Treatment Facilities for Gay Black Men

Meanwhile, there are not enough affirmative treatment facilities for substance use treatment of Black Gay men. For example, of the eight crystal meth treatment facilities in New York designed for gay and bisexual male patients, seven of them are located in Manhattan. Therefore, this imposes severe geographical demographic limitations. Substance abuse is significantly more prevalent among those living in poverty, as are most of the risk factors for drug abuse (Nakashian, 2019). For instance, residents of Black neighborhoods are 7.3 times more likely to live in high poverty with limited to no access to mental health services, according to the CDC (Denton & Anderson, 2005). As a result, this forces those who are seeking help to search outside of their neighborhoods for treatment and services. Furthermore, traveling outside of one’s neighborhood can be intimidating and present a culture shock. Certainly, culture can play a dynamic role in patient and provider engagement.  

Need for more accessible mental health care

There is a great need for knowledgeable and accessible mental health care and substance abuse service providers who can treat Black gay and bi men using crystal meth. Culturally cognizant psychotherapists can help to increase awareness of use of illicit drugs amongst African American communities, and can also provide culturally appropriate services targeted to consumers’ needs (Harawa, 2008). Above all, providers who understand the cultural intricacies and experiences of Black men who use crystal meth can be instrumental in their recovery.

Being client centered 

In order to keep treatment for crystal meth and other substance use client-focused, affirmative therapists can draw on Rogers’ approach to treatment. Therapists must allow clients to use the therapeutic relationship in their own way (Client-centered therapy, 2006). Certainly, this means taking into consideration the client’s cultural background and personal experiences in creating an effective treatment plan for them. Crystal meth addiction clearly transcends racial and ethnic lines, making evident the need for further outreach and support to Black gay and bisexual men who are using. Further, specific assessment and risk reduction measures to address crystal meth use and sexual behaviors and roles among these community members are warranted. In short, crystal meth addiction is a disease that shows no cultural biases. As a result, mental health providers must ensure that our services reflect that.

Learn More

References 

Blanchard, S. K. (2019, August 8). Black New Yorkers Hospitalized for Amphetamines at Alarming Rates. Filter. https://filtermag.org/black-new-york-amphetamines-hospital/ 

Center for Substance Abuse Treatment (CSAT). Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 51.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK83252/

Client-centered therapy. (January 2006). Harvard Health Publishing. Retrieved December 28, 2020, from https://www.health.harvard.edu/newsletter_article/Client-centered_therapy

Denton, N. A., & Anderson, B. J. (2005). Poverty and Race Research Action Council analysis of U.S. Census Bureau data. The Opportunity Agenda. Retrieved from http://www.opportunityagenda.org.

Dowshen, S. (Ed.). (2018, May). Methamphetamine (Meth) (for Teens) – Nemours KidsHealth. https://kidshealth.org/en/teens/meth.html. 

Frankis, J., Flowers, P., McDaid, L., & Bourne, A. (2018). Low levels of chemsex among men who have sex with men, but high levels of risk among men who engage in chemsex: analysis of a cross-sectional online survey across four countries. Sexual health, 15(2), 144–150. https://www.publish.csiro.au/sh/SH17159

Halkitis, P. N., & Jerome, R. C. (2008). A comparative analysis of methamphetamine use: black gay and bisexual men in relation to men of other races. Addictive behaviors, 33(1), 83–93. https://linkinghub.elsevier.com/retrieve/pii/S0306460307002122

Harawa, N. T., Williams, J. K., Ramamurthi, H. C., Manago, C., Avina, S., & Jones, M. (2008, October). Sexual behavior, sexual identity, and substance abuse among low-income bisexual and non-gay-identifying African American men who have sex with men. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2574823/. 

Lea, T., Kolstee, J., Lambert, S., Ness, R., Hannan, S., & Holt, M. (2017). Methamphetamine treatment outcomes among gay men attending a LGBTI-specific treatment service in Sydney, Australia. PloS one, 12(2), e0172560. https://dx.plos.org/10.1371/journal.pone.0172560

Molitor, F., Truax, S. R., Ruiz, J. D., & Sun, R. K. (1998). Association of methamphetamine use during sex with risky sexual behaviors and HIV infection among non-injection drug users. The Western journal of medicine, 168(2), 93–97.

Nakashian, M. (2019, July 26). Substance Abuse Policy Research Program. Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2012/01/substance-abuse-policy-research-program.html

NIDA. 2019, May 16. Methamphetamine DrugFacts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/methamphetamine on 2020, December 28

NIDA. 2020, September 18. Principles of Effective Treatment. Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment on 2020, December 31

Saloner, B., & Lê Cook, B. (2013). Blacks and Hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health affairs (Project Hope), 32(1), 135–145. http://www.healthaffairs.org/doi/10.1377/hlthaff.2011.0983

Wakefield, L., Maurice, E. P., Parsons, V., & Smith, R. (2019, June 26). This is why people drink their own urine after taking drugs. PinkNews. https://www.pinknews.co.uk/2018/04/30/urine-drugs/. 

This two-part series is intended to first reflect on the ways in which transgender and gender nonbinary (TGNB)-affirming clinicians perpetuate harm connected to colonization, then to present actionable ways of moving toward decolonization and gender liberation. I am a queer, white, able-bodied, and “cis-ish” person (i.e., I do not feel discomfort in my body or with she/her pronouns, though I struggle with the construct of “womanhood”). I am an uninvited guest occupying the land of the Narragansett & Wampanoag people in what is now called Rhode Island in North America (note: I strongly recommend learning more about Indigenous culture, e.g. the All My Relations podcast).

While social justice movements tend to focus on addressing the oppression of marginalized communities, decolonization involves a discrete and critical understanding of settler colonization and the movement toward reparation of land and resources (Tuck & Yang, 2012). I cannot discuss decolonization without acknowledging that I benefit from stolen land and resources as well as oppressive systems that are violent toward Indigenous and Black communities, including that of mental health care. MarleyAyo LLC (2020) defines decolonization as the “intentional repairing and reclaiming of ancestry, traditions, and values lost or violently disrupted by colonization and the transatlantic slave trade.”

“…colonization was a direct attack to our physical AND spiritual beings…they cut off a line to that ancestral knowledge and almost guaranteed that history would be lost.”  – Decolonizing Gender (jackson & Shanks, 2020)

The history of settler colonization has deep roots connected to white supremacy and racism, anti-blackness, transphobia, fatphobia, and essentially any system, community, or person that vilifies, criminalizes, punishes, rejects, and erases those who at first glance seem “different” (Morgensen, 2012). For additional context, you can learn more about the 4 I’s of oppression in this Healing While Black podcast episode. Also, consider learning about the characteristics of white supremacy culture, which can show up in any group or organization as a reflection of the attitudes and behaviors of all people (regardless of race)–for example, believing there is only one right way to do something. 

The construct of gender liberation expanded on the work of Ignacio Martín-Baró, a social psychologist who lost his life because of his revolutionary work; see Helping Queer Clients Become Their Own Liberators (Spector, 2020) for more details. Gender liberation involves shifting our focus from basic gender affirmation with the TGNB community toward liberation by addressing power dynamics, advocating for systemic and social change, and freeing ourselves and our clients from the systems of gender oppression (Singh, 2016; note: Anneliese Singh is a phenomenal speaker, writer, and researcher in this area–see also her TedX talk). This includes an awareness that the concept of “transness” itself is a historically white construct, meaning that gender fluidity and diversity existed and were accepted for centuries prior to settler colonization (e.g. A Map of Gender-Diverse Cultures; see also The Platypus Poem by J Mase III). 

I have chosen not to explore these constructs more deeply because a) individuals who have experienced that history and live it every day do not need an explanation, b) it’s not my place to tell their stories, and c) there are many other appropriate sources that do so (e.g. Adrienne Maree Brown, Rachel Cargle, & Alok V Menon). It is my responsibility to listen, learn, and do better to honor the voices, bodies, and land that have been telling the story for years and continue to do so. 

“Cisheteropatriarchy holds its roots in colonialism, and dismantling and unlearning these Western agendas forced upon us is a necessary action in the liberation of all oppressed peoples. If we are to obliterate white supremacy, a key component of that necessary project is recognizing and dismantling transphobia as an ongoing destructive phenomenon directly rooted in colonialism.” (Paramo, 2018)

Some clinicians may be completely new to these concepts and what this work looks like. Other clinicians may already be doing this work more intentionally. Still other clinicians may have no choice but to do this work because of their own personal experiences of marginalization, oppression, and intergenerational trauma. 

13 common forms of colonization-connected behaviors in your clinical work with TGNB people

To be clear, it would be toxic allyship to consider completing a ‘checklist’ as the way to do this work, given the need for decolonization to be a long-term commitment. Decolonization work is ongoing with the intention of returning land, resources, and opportunities to the populations from which they were taken, as well as supporting Indigenous and Black communities as they continue to navigate intergenerational and present-day trauma.  

Regardless, it may be helpful to reflect on possible warning signs of colonization-connected behaviors in your clinical work with TGNB people, including the following: 

1. Limited historical knowledge 

(e.g. relying on mostly white and/or cisgender people and systems to teach you what you need to know about settler colonization, antiracism and gender; understanding a lot about trans identities but less about working with BIPOC clients; having little understanding of how colonization, white supremacy, and fatphobia intersect with gender)

2. Exploitation of BIPOC and/or TGNB people 

(e.g. expecting BIPOC and/or TGNB experts to train/consult with you for free; asking TGNB and/or BIPOC clients to explain things to us; using before-and-after photos of TGNB bodies without considering the potential felt objectification and dehumanization)

3. Relying on diagnosis and “the written word” 

(e.g. doubting someone’s knowledge of their gender because of their developmental stage or another diagnosis like autism; noticing yourself getting bogged down by what is written in the DSM, WPATH manual, or trans guidelines; focusing on whether or not someone meets the criteria for gender dysphoria to accept their TGNB identity)

4. Performative/toxic allyship 

(e.g, telling yourself that you are anti-racist while rarely engaging in action steps that help you to learn, grow, and change in movement toward anti-racism; privileged ‘allies” jumping to judge others who make a mistake when talking about race/gender without inviting them into a conversation; expressing how important this work is but not being willing to pay for consultation/supervision/training to improve competence).

Deborah Plummer’s work talks more about how to take anti-racist allyship to the next level.

 “Achieving a healthy white-identity resolution and feeling racially secure enough not to exhibit racial superiority does more for eradicating racism than just being an enlightened ally.”  ~Plummer, 2020

5. Shame and shutting down

(e.g. feeling frustrated about how hard it is to to “keep up” with the movements and language; defensiveness and/or shame reaction when you make a mistake; dismissing or challenging a perspective shared by a BIPOC and/or TGNB colleague or client about their experience; feeling offended/hurt by a client’s decision to see a “lived experience” clinician)

6. Treatment barriers

(e.g. limited treatment access; high cost of full fee; not taking insurance or having an inaccessible sliding scale range; and/or requiring multiple sessions for a surgery assessment without transparency and collaboration)

7. Saviorism and lack of humility

(e.g. believing that if you don’t do this work, no one will; not seeking training/consultation/supervision when you have a growth edge, i.e. room for improvement; frequent signaling to your TGNB and BIPOC clients, colleagues, and friends the extent of your allyship)

8. Poor boundaries 

(e.g. taking on additional clients for extra money; not saying no to people because we feel guilty; not prioritizing our own self-care and work-life balance) 

“…it should not be forgotten that one of the privileges of whiteness is having a gender that is defacto more legitimate and more coherent because of the binary framework in which it necessarily exists.”   -binaohan, 2014

9. Colonized gender norms 

(e.g. making an assumption about a client’s desired gender destination; encouraging forms of social/physical expression that someone hasn’t asked for; using any language/identifiers for gender/body part/surgery etc. that the client hasn’t already expressed or without checking that the language feels okay for them)

10. Colonized race-related norms

(e.g. failing to acknowledge the impact of colonization; assuming that all clients desire and feel safe coming out in all spaces; being unaware of resources that are specific to BIPOC TGNB people; using research and clinical interventions that have not been normed on BIPOC people)

11. Colonized body and ability norms 

(e.g. reinforcing the racist history of fatphobia and diet culture by encouraging a client’s attempts at weight loss via dieting; focusing on client weight as a potential barrier to surgery rather than framing from the perspective of medical fatphobia and helping to advocate for client needs; making an assumption about a client’s health status based on their weight and/or eating habits; using ableist language, making assumptions about someone’s capacity to do something, or limiting communication and processing methods). Please see Fearing the Black Body (Strings, 2019). 

12. Time and outcome expectations 

(e.g. using language that suggests a “full transition” or “complete surgery”; assuming that trans men want to be masculine; finding yourself thinking that clients are moving too slowly and pushing someone to come out to their family and friends)

13. Insisting on comfort 

(e.g. having a shame reaction and apologizing excessively when you make a mistake or client provides feedback; mentioning how hard it is to keep up with the language; not bringing up racism or anti-Blackness unless the client mentions they are struggling with the sociopolitical climate; addressing your privilege in the room the first time and then not bringing it up again)

Decolonizing Mental Health is Hard: Take a Moment of Reflection

Notice what comes up in your body and how it feels as you reflect on the above examples. Did you notice any feelings of shame? Embarrassment? Discomfort? Denial? Guilt? Relief? Irritation? Uncertainty? 

After checking in with your body, consider how these examples are connected to your clinical training and approach to treatment, your knowledge of history  or lack thereof, and your worldview. 

I believe that a clinician’s ability to wholeheartedly and effectively serve the TGNB population requires ongoing critical awareness, examination, and acknowledgment of the following: 

• A likely skewed lens of the world: past, present, and future
• Your approach to treatment: personally, professionally, and systemically
• How you operate around privilege and oppression inside and outside of the therapy room
• The history of settler colonization, enslavement, and genocide; white Western education, research, training; and lingering medical and mental health care trauma
• The ways in which you continue to benefit from and engage in the perpetuation of those systems that have caused harm or, for those who belong to historically marginalized communities, the ways in which you have internalized the impact of those systems

As you continue to move through this work, you will uncover the countless ways in which colonization is woven into the fabric of our personal and professional lives, which has a direct and ongoing impact on the oppression of marginalized communities. Those in power may seem to benefit in terms of resources and capitalism. But the psychological, emotional, and intergenerational impact of colonization affects everyone, not just TGNB, BIPOC, and other marginalized communities. We all will benefit by working toward racial, gender, and body liberation, as well as striving for decolonization through supporting Black and Indigenous communities to reclaim their ancestry, values, land, and rights. 

“If Black women were free, it would mean that everyone else would have to be free since our freedom would necessitate the destruction of all the systems of oppression.”  – Taylor, 2017 (in How We Get Free: Black Feminism and the Combahee River Collective)

In the next and final installment of this series, I will further discuss actionable ways to begin transforming your work with TGNB clients.  I want to reiterate that this work is multifaceted and is not meant to focus on completing a list of “to-dos.” Rather, it is an opportunity to reflect on your practice and the ways in which you can continue to do better and to help heal the harm caused by our ancestors and our modern-day systems.

Please see below for an extensive list of resources created by TGNB folx and/or BIPOC* who expand on these topics. Another resource list will be provided at the conclusion of my next article as well.

*Note: For the purpose of this article, TGNB indicates transgender and gender nonbinary populations. The use of BIPOC sometimes represents Black, Indigenous, and People of Color (i.e., non-white people), and at other times it represents Black and Indigenous people of color primarily (Code Switch episode, Meraji & Escobar, 2020). When discussing BIPOC communities in this article, I am referring to the Black, Indigenous, and other communities of color who experience ongoing marginalization and oppression in relation to the colonized history of the Western world, including the intergenerational impact from their ancestors. 

Resources for decolonizing your clinical work 

Books: 

• binaohan, b (2014). decolonizing trans/gender 101. biyuti publishing. 
• Strings, S. (2019). Fearing the Black body: The racial origins of fat phobia. New York University Press.
• Taylor, K-Y. (2017). How we get free: Black feminism and the Combahee River Collective. Haymarket Books. 

Podcasts:

• Monyee´, T. (Host). (2020 – Present). Shaping the shift. [Audio podcast]. Producer unknown. https://shapingtheshift.com/podcast 
• Quiana & Misty. (Hosts). (2020 – Present). Healing while Black podcast. [Audio podcast]. Producer unknown. https://healingwhileblackpodcast.podbean.com/ 
• Wilbur, M. & Keene, A. (Hosts). (2019 – Present). All my relations. [Audio podcast]. Producer unknown. https://www.allmyrelationspodcast.com/ 

Electronic print & audiovisual resources:

• Colorado Funders for Inclusiveness and Equity (COFIE). (2010). The four I’s of oppression. Adapted for use by the Chinook Fund. http://www.coloradoinclusivefunders.org/uploads/1/1/5/0/11506731/the_four_is_of_oppression.pdf 
• jackson, k. & Shanks, M. (2017). Decolonizing gender: A curriculum. [Zine]  https://www.decolonizinggender.com/
• Mase III, J. (2018, Aug 15). Platypus poem: Zone of rarity [Video]. YouTube. https://www.youtube.com/watch?v=mnNguCYwx1U&feature=youtu.be 
• Meraji, S.M. & Escobar, N. (Hosts). (2020, September 30). Is it time to say R.I.P. to POC? [Audio podcast episode]. In Code Switch. NPR. https://www.npr.org/2020/09/29/918418825/is-it-time-to-say-r-i-p-to-p-o-c
• Okun, T. (n.d.). White supremacy culture. Dismantling Racism. https://www.dismantlingracism.org/uploads/4/3/5/7/43579015/okun_-_white_sup_culture.pdf 
• PBS. (2015). A map of gender-diverse cultures. https://www.pbs.org/independentlens/content/two-spirits_map-html/ 
• Plummer, D.L. (2020, June 5). Not a racist? Then let’s be better antiracist. https://www.dlplummer.com/blog/not-a-racist-then-lets-be-better-antiracist
• Spector, M. (2020, Sept. 9). Helping Queer Clients Become Their Own Liberators. The Affirmative Couch. https://affirmativecouch.com/helping-queer-clients-become-their-own-liberators-liberation-psychologys-critical-contribution/ 
• Tedx Talks. (2015, June 30). Tedx Georgia State – Anneliese Singh – Trans liberation is for everyone. [Video]. YouTube. https://www.youtube.com/watch?v=-onhIoDRMdM 
• The Martín-Baró Initiative for Human Rights. (n.d.). About Ignacio Martín-Baró. The Martín-Baró Initiative for Human Rights. http://martinbarofund.org/about/ignacio/ 

General Websites & Social Media Accounts: 

• Brown, A.M. (writer/thought leader/podcaster, she/they) (n.d.). Adrienne Maree Brown.  [@adriennemareebrown]. [Instagram profile, Website]. http://adriennemareebrown.net/ 
• Cargle, R. (public academic & writer, she/her). (n.d.). Rachel Cargle. [@TheGreatUnlearn, @TheLovelandFoundation, @Rachel.Cargle]. [Website, Instagram profile].  www.rachelcargle.com 
• Mase III, J. (poet & educator, he/him). (n.d.). J Mase III. [@jmaseiii]. [Instagram profile, Website]. www.jmaseiii.com
• Menon, A.V. (author/speaker/performer, they/them). (n.d.). Alok V Menon. [@alokvmenon]. [Instagram profile, Website].  www.alokvmenon.com 

References

Decolonization. (2020). By MarleyAyo, LLC. [Definition]. In Thea Monyee´ presents: The Blacker the brain – Free to heal – Decolonizing our practices. www.marleyayo.com

Morgensen, S. L. (2012). Theorising gender, sexuality and settler colonialism: An introduction. Settler Colonial Studies, 2(2), 2-22. https://doi.org/10.1080/2201473X.2012.10648839

Peramo, M. (2018, July 17). Transphobia is a white supremacist legacy of colonialism. Medium. https://medium.com/@Michael_Paramo/transphobia-is-a-white-supremacist-legacy-of-colonialism-e50f57240650 

Singh, A. (2016). Moving from affirmation to liberation as psychological practice with transgender and gender nonconforming clients. American Psychologist, 71(8), 755-762. https://doi.org/10.1037/amp0000106  

Tuck, E. & Yang, K.W. (2012). Decolonization is not a metaphor. Decolonization: Indigeneity, Education, & Society, 1(1), 1-40. https://www.researchgate.net/publication/277992187_Decolonization_Is_Not_a_Metaphor 

Learn more about transgender and gender nonbinary affirmative therapy with addyson tucker, PsyD (they/them)

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.

Learn more about working with LGBTQIA+ Clients

References

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. http://doi.apa.org/getdoi.cfm?doi=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

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. 

References

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 more about affirmative therapy with addyson tucker, PsyD (they/them)

This is the final installment in a three-part series on boundaries. In the first article, I discussed what boundaries are and why they’re important, and in the second article, I dispelled misconceptions about boundaries. In this last piece, I will name common barriers that femmes may experience in setting boundaries, and will share some tips to help you with this.

If the boundaries discussed here are unsafe for you to set with a partner, please check out resources on intimate partner violence for more appropriate support. 

Common Barriers to Setting Boundaries

• You feel responsible for the other person or are preoccupied with how your boundaries will affect them
• You feel guilty or bad
• You don’t like yourself
• You’re afraid of losing what you have
• You’re afraid of being invisible as a femme without your partner
• You love the other person and setting boundaries feels mean and selfish
• Learning to deal with things yourself is what you’ve always done and all you’ve known how to do up to this point
• In your culture, you don’t set boundaries with your parents or elders
• You don’t feel like you need to set more boundaries because compared to your previous relationships, this one is better
• Thinking about setting boundaries makes you feel confused
• Your immediate circumstances or objective or capacity mean setting boundaries you normally would isn’t in your best interest 
• You’re afraid the person will leave you and that someone else won’t love you

Tips for Boundary Setting

Address Power Dynamics

Particularly in intimate relationships, barriers to your exercise of boundaries may exist if your partner is more masculine than you; is older than you; has more experience sexually, in relationships, or with non-monogamy than you; identifies as straight; has been out longer if they’re queer; or is less marginalized in terms of factors such as size, ability, race, education, class, or profession. If your relationship is long-term, you cohabitate, you’re married, you parent together, and/or you’re part of a polycule, setting boundaries may have significant consequences for you and others. Whether you have a history of trauma separately or together, emotional symptoms can lead to less boundary setting for the sake of shorter-term well-being. Other barriers that may come into play are lack of access to a support system; health care, including  mental health care (and care that is affirming); and income, particularly if you depend on your partner to access these things. 

Name power dynamics early on in a relationship. Having ongoing communication about power dynamics that are inherent, meaning they won’t go away, and addressing how they impact relationship dynamics can help you work with the imbalances they cause.

Take Time & Space

In browsing other articles published on boundaries, I found a definition that stated, “Simply put, boundaries are what set the space between where you end and the other person begins” (Twardowski, 2017). One very simple way in which to achieve a sense of where you end and another person begins is to take time and space. The key is that time and space in themselves differentiate you from others. Take time for self-care and to slow down your mind through journaling, walking, gardening, drawing, and similar activities so that you can clarify what boundaries are right for you. We all process in different ways and at different paces, tolerate different amounts of confrontation, and need to separate our own experiences from the influence of other people’s perspectives.

Acknowledge Your Hurt

Acknowledging the impact of others’ behavior on us helps us set boundaries. Emotions inform our decisions. Often femmes are conditioned to deal with things on our own, say “It’s fine” rather than rock the boat, and not expect things of others. Compassion towards yourself in the form of getting in touch with your feelings like sadness, grief, and anger is foundational. Anger teaches us our boundaries because we get angry when our boundaries are crossed. Once you acknowledge the harm that someone’s behavior is causing you, you can choose to set boundaries on your own behalf. If you’re having a hard time accessing compassion towards yourself, think about what you would want for a friend or what a mentor or role model would do.

Trust Your Gut

Many people say that they know when something doesn’t feel good; they just don’t listen to their gut, or it’s hard to act on that in the moment. We are conditioned to ignore our gut telling us something is wrong, because it benefits others when we are compliant rather than when we set boundaries. Trust your gut–also referred to as your intuition–as a source of information for setting boundaries. You may not be sure why until you’ve had more time to process, and that is okay.

Know Your Needs

It’s easier to set boundaries if you first recognize your needs. Of course, this isn’t always realistic, and we learn many of our boundaries through our experiences. That being said, if you know that you don’t want children, or you don’t want others to access your email, or you alternate holiday plans year-to-year, or that because of previous traumatic experiences you need someone with a certain demeanor or communication style in order to feel safe, you can prioritize these boundaries with more self-assuredness. 

Reframe Boundaries

This section revisits many of the Common Barriers listed above so that you can work through them:

• Boundaries allow you to have actual intimacy because the relationship is based on your true needs, capacity, and desires.
• Saying no isn’t about not loving the other person. With boundaries you convey, “I love you, and I also love myself” (Viado & Greer, 2019).
• Not setting boundaries with someone is actually doing a disservice to them; you’re not teaching them what’s okay or not, you’re enabling their dependence on you by doing things for them. If they’re also femme, you’re not modeling valuable skills.
• Prioritize accountability over responsibility. Rather than not setting boundaries because of someone’s manipulation, gaslighting, blaming, denial, or guilting, set a boundary in response to it. Consider that these are effective tools for avoiding accountability rather than taking on someone’s struggles or circumstances.
• Saying no doesn’t just mean losing something–it means making room for the people who are out there who will love you, support you, and see you for who you are.
• Boundaries attract people who are able to respect them.
• Becoming single doesn’t make you invisible as a femme; your essence is within you and nothing can take it away from you.
• Boundaries free up space to accept your partner and yourself as you are without trying to change each other (Viado & Greer, 2019).
• If someone isn’t able to meet your needs, it doesn’t mean you’re unlovable; it means that the two of you aren’t compatible at this point in time.
• Rather than creating conflict with loved ones, boundaries give you the opportunity to confront your relationship in a deeper, more meaningful way.
• Boundary setting allows you to truly let go of someone rather than ending the relationship out of spite, resentment, or to rebel (Viado & Greer, 2019).
• Your feelings don’t go away just because you don’t deal with them.
• You don’t need acceptance or validation from another person; it comes from within yourself.
• Setting boundaries with someone from whom you’re seeking approval isn’t what keeps them from supporting you.
• Just because something isn’t common practice around you doesn’t mean it’s not what’s best for you, nor that you’re alone in doing it.
• No one can set your boundaries for you.
• If your relationship is sustained by you not asserting your needs and you tell yourself that you’re being more passive for the other person’s sake, are you really avoiding risking feelings of abandonment?
• Setting boundaries is something you can do for your younger self now that you’re an adult with more autonomy.
• Your boundaries are tributes to all the femmes who have fought so hard for your ability to say no.
• Boundaries are a political act; they’re the basis of movements built by people collectively saying “no more.” 

Boundaries are a practice. Each opportunity to practice boundary setting is a new one. Boundaries represent a chance for you to redefine yourself in the present. I hope that this series helps ground you to say no when you feel the need in your body. Know that you are not alone–you are a part of a long legacy of femmes enacting their worth.

Learn More

References

Desano, A. (n.d.). Intimate Partner / Domestic Violence. Retrieved from https://lalgbtcenter.org/health-services/mental-health/intimate-partner-domestic-violence.

Twardowski, J. (2017, December 7). 6 Steps to Setting Boundaries in Relationships. Retrieved from https://www.huffpost.com/entry/6-steps-to-setting-boundaries-in-relationships_b_6142248.

Viado, L., PhD, & A. G., PhD (Host & Guest). (2019, February 20). 105: Everyday Codependency [Audio blog post]. Retrieved from https://lourdesviado.com/105-everyday-codependency/

In my previous article on boundaries, I talked about definitions and why setting boundaries can be difficult and important for femmes. In this, the second part of a three-part series on the topic, I’ll clarify misconceptions and broach avoiding confusion and shaming when it comes to discussing boundaries.

If the boundaries discussed here are unsafe for you to set with a partner, please check out resources on intimate partner violence for more appropriate support. 

Common Confusing Language in Intimate Relationships

These terms are all related but differ slightly from each other:

• Expectations can inform boundaries, but they don’t act as boundaries. For instance, if you expect your partner to celebrate your body and honor your bodily autonomy, you may set a boundary such as stopping sex if your body is touched or commented on in a way that doesn’t bring you pleasure.
• Standards are the criteria you use to judge a partner. Standards may include educational background, annual income, physical characteristics, etc. Like expectations, standards differ from boundaries. They can inform boundaries  but are a different entity. Your standards may determine your make-or-breaks.
• Make-or-breaks are boundaries, but not all boundaries are make-or-breaks, which definitively make or break a relationship for you. You may break up with a partner (or not enter into a relationship with someone at all) if you want an open relationship and they want a monogamous one, for instance.
• Ultimatums and boundaries can entail similar or identical phrasing. However, unlike boundaries that are based on you doing what is in your control in response to your partner, ultimatums consist of you telling your partner to do something. For instance, saying “If you don’t stop lying to me about your drinking, then I’m done” is an ultimatum. Ultimatums are more like threats, because you can’t actually control what another person does, even though they may comply (Matlack, Winston, & Lindgren, 2018). Additionally, ultimatums may be made based on your make-or-breaks.
• Lastly, rules and agreements tend to differ from boundaries because partners establish them together. They can also have less clear consequences when they’re not followed (Matlack, Winston, & Lindgren, 2018). Again, your boundaries and your partner’s boundaries are your own, respectively.

Beyond Boundary Binaries

Boundaries are considered an important part of healthy relationships, but you’ll notice that I’m not talking about boundaries in terms of healthy and unhealthy or good and bad here. That’s because I wouldn’t even know how. It’s not for me or anyone else to judge what is healthy or good for you. You may also be used to the boundary binary of strong and weak. This oversimplification can shame people who struggle with sticking to boundaries or want to set more of them. It puts blame on femmes without contextualizing our challenges within cultural systems designed to exploit our bodies, intellects, emotional labor, and other skills. Additionally, I often see boundaries talked about in all-or-nothing terms. There’s no such thing as having “no” boundaries. Boundaries are always at play. Even the simple act of turning off notifications on your phone can be considered a boundary.

Boundaries aren’t fixed, nor is their development linear. Boundaries are personal and individual; it’s for you to decide what boundaries you need at any given time in relation to any given person. Consider, too, that boundaries are set among varying factors. Who you’re with, who’s around, where you are, what kind of day you’re having, what stakes are involved, timing, previous experiences with the person, having to compartmentalize an aspect of your identity in order to reach an objective of your given interaction or for your safety, not being offended by something that on a different day would bother you or vice versa, are all factors that are quickly being assessed and play into the fluidity of boundaries.

By addressing misconceptions, I hope to have clarified many practical elements about boundaries. In the last article, I’ll name common barriers that femmes may experience in setting boundaries. I’ll also share tips that can help you with your boundaries, including reframing them in order to work through those barriers.

Learn More

References

Desano, A. (n.d.). Intimate Partner / Domestic Violence. Retrieved from https://lalgbtcenter.org/health-services/mental-health/intimate-partner-domestic-violence.

Matlack, E., Winston, D., & Lindgren, J (Hosts). (2018, July 3). 178 – The Basics of Boundaries [Audio blog post]. Retrieved from https://www.multiamory.com/podcast/178-basics-boundaries

It’s your right to tell someone that you love them and you want to have a relationship with them. That they get to say, do, and believe whatever they want because that’s their business. But not with you. It’s your right to tell them the harm that their actions are causing you, the way that it’s interfering with you having a relationship with them the way you want, and that until they can support you as you are, they’re not welcome in your life.

This is what I told my client whose internalized biphobia was blocking her from recognizing the hurt that her mom’s biphobia is causing her. She knows that the relationship is strained and she’s beginning to see that she needs to set boundaries, but she doesn’t know how.

When I verbalized the above boundary to her in session, I meant it seriously, but I was also doing an exercise with her. I wanted to point out the influence of internalized biphobia on her understanding of her choices in how to interact with her mom. I wanted to say it out loud as an unashamed counterpoint because it didn’t seem like she had entertained the idea that she wasn’t responsible for her mom’s anxiety.

Ultimately, establishing this boundary didn’t feel right for her, at least not now, and we moved on to talk about her calling her mom less. And while my vision is of a femme revolution in which we lead our beautiful, queertastic lives without wasting energy on unnecessary emotional labor, the reality is that life consists of many more gray areas, that our beauty is in our ability to grapple with its complexities, and that there is revolution in the small, everyday boundaries we set.

This client is like many femmes in expressing that they don’t know how to set boundaries in relationships. When I hear this, I hear the need to break down the practical elements of what boundaries are and what, in practice, they look like. Perhaps even more importantly, I also hear the need to address the emotional blocks to establishing boundaries. 

This three-part series does both. In this first article, I will provide my own definition of boundaries and contextualize what makes boundary setting both particularly hard and important for femmes. I will then break down boundary setting and provide an example from queer pop culture. 

While these articles are written for femmes (you can check out my previous article, “Are You Femme? What Femme Isn’t and What it is” for reference on femme identity) setting boundaries in their intimate relationships, the information here can also be relevant to people who don’t identify as femme (particularly anyone who’s been considered feminine at some point). It can apply to members of non-intimate relationships, including parents and other family of origin, members of polycules, friends, housemates, and co-workers, too.

If the boundaries discussed here are unsafe for you to set with a partner, please check out resources on intimate partner violence for more appropriate support.

Boundaries Defined & Contextualized

Boundaries are acts of self-love that define your needs, capacity, and desires.

Let’s collectively pause for a moment and breathe this in. Boundaries are about self-love. Within our patriarchal, femmephobic, homophobic, biphobic, fatphobic, transphobic, xenophobic, racist, classist, ageist, and ableist culture, people believe that feminized people’s very existence is for the benefit of others, and fear emerges when we take up space of our own. This compounds our need to set boundaries and challenge the pushback we get when we do. Femmes navigate relationships within this paradigm, and we often do this while working through our own internalized “-isms.”

Therefore, when we set boundaries, they are radical acts. And because boundaries are about you, they’re about saying no, and they’re about exercising your power based on your needs, they are radical acts of self love.

Boundaries: The Breakdown

• Rather than adapting yourself for the sake of a relationship, you set boundaries so that a relationship best meets your needs.
• For boundaries to be effective, they have to be within your control, and what’s in your control is you, not the other person. Trying to control another person is toxic. Boundaries are about what you communicate and the actions you take.
• The clearest and most obvious boundary entails disengaging and removing yourself altogether, either in the moment by walking away, or ongoing by breaking up or cutting off contact with the other person.
• When you communicate a boundary, it’s up to your partner, friend, or family member to decide if your boundary works for them or not, and to proceed accordingly. Boundaries have a cause and effect that goes both ways. If the other person sets a boundary, it’s up to you to decide if their boundary works for you or not, and to proceed accordingly. You have the right to set a boundary and you have the right to decide that another person’s boundary doesn’t work for you. If your boundary doesn’t work for them, that doesn’t mean the boundary changes. It means that how you relate to each other does.
• Boundaries are not conditional on how someone else responds to them. It’s not a boundary if you’re asking someone or waiting for someone to change in order for your need to be met, because they may change–but they may not.
• You’re not responsible for anyone else’s feelings or behavior. We are each responsible only for our own.
• Boundaries are about creating your own options rather than acting according to what the other person wants. If you only act according to what the other person wants, they have all the power.
• If you find that you keep having to set the same boundary, you may need to address this as a larger issue by taking more space or evaluating the relationship overall. It is a form of gaslighting when someone denies an ongoing issue, thereby making you question your own perceptions, and responds to you by saying things like “What are you talking about?” or “No, we haven’t talked about this before.” 
• If a person’s behavior escalates when you set a boundary, it doesn’t mean the boundary is wrong. It may be from fear of change or because they don’t want things to change.
• The key is setting boundaries to which you’re able to stick. If you don’t stick to them, then they’re not actually boundaries. They’re dependent on the other person’s behavior not requiring that you stick to them. They function more as requests if they’re not enforced. Situations like this teach others that they don’t have to take your boundaries seriously.
• If you find that you’re setting boundaries in order to get a certain response from your partner (like a sign of commitment or intimacy), friend (like attention or acceptance), or family member (like approval or permission) rather than with the intention of sticking to them, these are not actual boundaries. You’re coercing a desired outcome that’s not in your control and some honest reflection may be helpful. 

Boundaries mean saying: no, I won’t just stand here while you yell at me; no, I won’t stay silent while you misgender me; no, I won’t answer my phone right now; no, I won’t remind you to do the dishes; no, I won’t spend time with you if you’re guilting me; no, I won’t stay in a relationship in which my partner continually gaslights me; no, I won’t have sex with you if you fetishize me; no, I don’t have time for you to vent to me right now; no, I won’t pay for things you’re able to afford; no, I won’t cancel my plans to come over; no, I won’t wear what you want me to instead of what I want to wear, and; no, I won’t smile and laugh when you say something that offends me.

Boundary Setting Within Queer Pop Culture

If you want an amazing example of queer boundary setting, look no further than the most recent season of Are You the One? The MTV dating show features 16 participants meant to find their predetermined “perfect match” among each other in order to win money. In its eighth season, and the first season to have an all-bisexual, -pansexual, and -sexually fluid house, the show portrays the toxic relationship between Jenna, a cis, femme-presenting woman, and Kai, a nonbinary transmasculine person, as one of the primary character arcs. Jenna and Kai continue to be drawn to each other despite Kai’s manipulative behavior (like crying, pleading, and making grand statements that contradict his actions) and despite confirming through the show’s Truth Booth that they’re not a perfect match.

The turning point several episodes in that left many queers cheering from their couches was when Jenna saw Kai’s toxic behavior play out with another femme-presenting person. When, in desperation, Kai goes back to Jenna again and tells her, “I’m madly in love with you,” Jenna responds, “But I don’t want this, because this isn’t healthy. I need to put me first. I need to love myself first right now.”

So many femmes fear that if they set a boundary with another queer, that person will be worse off and isolated. However, you can keep watching and see that after Jenna set her own boundary, the house stepped up to collectively and empathically call in Kai on his behavior. This is described in the article “How On Earth Did Are You The One Get Queer Love So Right?” by Jeanna Kadlec, which reads, “There is a rich and real no person left behind mentality, which is so distinctive to the queer community. Even as the femmes rally around each other, the entire cast is unwilling to let bad behavior go unchecked.” Kadlec goes on, “The drama affirms how much intentional work there is to be done when it comes to building relationships and examining attraction—but also how much joy and especially self-love can be found along the way” (2019).

Now you have a better sense of what boundaries are and how they work. In the next article in this series, I’ll dispel misconceptions to address confusing and shaming ways in which boundaries are commonly discussed.

Learn More

References

Desano, A. (n.d.). Intimate Partner / Domestic Violence. Retrieved from https://lalgbtcenter.org/health-services/mental-health/intimate-partner-domestic-violence.

Kadlec, J. (2019, August 30). How on Earth Did ‘Are You The One’ Get Queer Love So Right? Retrieved from https://www.elle.com/culture/a28857415/are-you-the-one-jenna-kai-queer-toxic-relationships/.

November 20th has been known since 1999 as the Transgender Day of Remembrance (TDOR). On this date, across the world, ceremonies and vigils are held to remember transgender individuals we lost to murder and suicide in the past year. Often somber and emotionally  triggering, TDOR allows the community to gather and honor individuals whose stories are often ignored or incorrectly told. As this day approaches, I often think of Marsha P. Johnson. 

Johnson, a transgender black woman, has long been credited within the queer and trans community for being the person who threw that first brick at Stonewall (Feinberg, 1996) and the creator of STAR, an LGBTQ+ youth shelter. Many don’t know that Johnson was an activist from early on in her life, fighting for gay rights and visibility instead of assimilation (Chan, 2018). After high school, she spent her days on the streets of New York, learning to survive and being repeatedly sexually assaulted and harassed (Chan, 2018). But the assault, harassment, and oppression she experienced due to her sexuality, gender identity, and skin color didn’t stop her for standing up for what she believed in. Knowing firsthand the discrimination the often-ignored transgender community suffered, she took an active role in ACT UP (https://actupny.org/), helping to speak out for HIV+ individuals and give a voice to people  of color who were dying from the disease (Jacobs, 2016). Johnson was an inspiration to transgender individuals, especially to those of color. Her tragic death is frequently regarded as the first “notable” and documented murder of a transgender person in the United States.

In 1992, shortly after the New York City Pride Parade, Johnson’s body was found floating in the Hudson River (Feinberg, 1996). The cops ruled it a suicide, despite many people’s protests that Johnson was anything but suicidal and eyewitness reports that she was being harassed earlier during the day they believed she had died (Feinberg, 1996). The case was limitedly investigated and never solved. The media portrayed Johnson as a trans woman who was a sex worker and a drug user, leaving out the truths of her activism and every other aspect of her life (Feinberg, 1996); it is likely that had she been a cisgender white woman, media coverage would have been vastly different and much wider.  Johnson’s voice, something she worked so hard to give herself while navigating major oppression in her lifetime, was taken away. Even worse, her killers were never found; to this day, minimal effort has been put into solving her murder.

You may be wondering what this has to do with psychology, and how Johnson’s death can show up for you, as a clinician, in the therapy room with your transgender clients. Well, it’s simple: the reaction of the public to Johnson’s death parallels how many transgender individuals feel about what their lives are worth to the rest of the world. It also relates to  transgender people’s sense of whether others care about their safety. As a clinician who has worked in the community in varying capacities, I can attest to the fact that transgender people feel that their lives don’t matter. There is a constant threat of insufficient safety and feelings of protection, especially under the Trump administration when it seems as if transgender rights are under attack daily. 

Almost every week I hear about another transgender individual, usually a trans woman of color, who has been murdered or found dead under mysterious circumstances. In many of these cases the killer is never found, or if they are, they are not named. The media often misgenders the victim, and very little coverage is given in the first place. My trans clients come to me with fear in their voices, wondering if they will be next just because they are living their authentic truths. Worse, and heartbreakingly, clients sometimes find that this fear is accompanied by wondering whether or not anyone would even care if they were gone, and if they deserve being killed due to being transgender. 

Furthermore, clients have to navigate safety in many other aspects of life. Transgender clients have told me that they often don’t feel safe in their jobs and have a fear of being fired; what’s worse, nobody in their workplace will do anything to help when they are feeling threatened. I have heard about clients being assisted when buying shoes or clothing, and fearing that a salesperson will “find them out” and make a scene. Clients can  fear for their safety in terms of secure housing and access to other social welfare services, the loss of which threaten their ability to survive. 

So how can we, as clinicians, help with these fears? Certainly, the wrong thing to do is to try to make excuses for others or diminish the situation, because these fears are real. Also, if you are a cisgender therapist, there is no way to fully understand what your client is going through. It is best not to try to relate or use comparisons to other marginalized communities. I have heard of individuals telling their therapists about the fear of shopping, and the therapists suggesting in response to “shop online,” unsolicited advice that comes across as invalidating. 

But then what is the right thing to do? First, validate the fear, which is constantly present. Ask questions. What does this fear look like to them? How does it show up in their lives? Secondly, address the fear and help empower your client to find ways to protect themselves. While we do not teach our clients physical self-defense techniques, we can certainly teach them mental defenses. Find positive self-talk and coping techniques when encountering non-life threatening yet mentally damaging situations. Third, help your client devise safety plans and locate resources. Is there someone they can call any time of the day, or put on alert when they are encountering any new or potentially triggering situation? Is there an emergency line they can reach that they know they can trust? Having access and knowledge to trans-affirmative resources can be life saving.

With all of that said, November is always a difficult month for the transgender community. Whether or not your client is aware of this fear on a daily basis, we cannot deny that the number of deaths we recognize during TDOR and the number of clients facing fear seem to increase annually. November is filled with a constant reminder to be vigilant and that the fight is far from over. As clinicians, we must recognize this and do everything  we can to support our clients in the most affirming way possible.

Learn More about working with Transgender and Nonbinary Clients

References

Chan, S. (2018). A transgender pioneer and activist who was a fixture of Greenwich Village street life. The New York Times. Retrieved from https://www.nytimes.com/interactive/2018/obituaries/overlooked-marsha-p-johnson.html

Feinberg, Leslie (1996). Transgender Warriors: Making History from Joan of Arc to Dennis. Boston, MA. Beacon Press

Jacobs, S. (2012). DA reopens unsolved 1992 case involving ‘saint of gay life’. New York Daily News. Retrieved from: https://www.nydailynews.com/new-york/da-reopens-unsolved-1992-case-involving-saint-gay-life-article-1.1221742

No matter the degree earned or license held, everyone who works in the mental health field shares an important common interest: preventing suicide. Suicide prevention requires a well-rounded approach, including education on risk factors, properly assessing for safety, increasing patients’ protective factors and support, and providing support for those affected by the suicide of a loved one (Balon, 2007). Surprisingly, most clinical training programs fail to comprehensively educate on the details of suicide assessment (Valente, 1994). The institutions that do include training for suicide assessment usually fail to cover the consequences of a completed suicide, thus failing to acknowledge both the personal and professional consequences on the clinician (Valente, 1994). Consistent research suggests the majority of clinicians––particularly those early in their careers––are completely unprepared for their own emotional responses as well as the reactions of the client’s family (Hendin, Haas, Malsberger, Szanto, & Rabinowicz, 2004). For this reason, among others, clinicians who have lost patients to suicide are left with a myriad of complex emotions without space to effectively process the loss, leading to professional isolation (Campbell & Fahy, 2002). Bound by HIPAA, many clinicians do not have the luxury to openly grieve around their friends and family. This is a simple yet vital part of effective bereavement processing (McAdams & Foster, 2002). Whether the relationship had been forming for weeks, months, or years, a patient’s death has a lasting impact on the clinician (Ford, 2009). 

Regardless of professional boundaries between patient and clinician, the human reaction to loss inevitably emerges. A clinician’s grief is generally inescapable upon learning of a patient’s death no matter the cause. In addition to this typical grief, client death by suicide triggers a unique reaction from the clinician due a feeling of personal responsibility (Strom-Gottfried & Mowbray, 2006). For LGBTQ+ affirmative providers, the need for proper training on suicide assessment and the consequences of completed suicide is even greater as such populations are at higher risk of suicide. For therapists and other clinicians working with LGBTQ+ communities, it is particularly important to be aware of the enhanced risks of suicide and to understand how this affects the therapeutic process for both parties involved. Client suicide may not only elicit complicated grief, but it may also trigger suicidal ideation within the providers themselves, particularly those with a history of attempts, ideation, self-injury, or depression. With so many potential multifaceted factors affecting the clinician, it is  clear there is a serious need for more understanding and support around client suicide, as it can lead to occupational hazards as well as personal danger.

Client Suicide

General prevalence

There is little pleasure in discussing client suicide, as it is a topic riddled with fear, shame, and discomfort. Nevertheless, client suicide occurs more often that most clinicians may expect. This underestimation is likely due to the response of shame and isolation associated with such an event. Roughly five percent of trainee or predoctoral therapists experience client suicide (DeAngelis, 2008). Later, the number jumps dramatically. More than 25 percent of licensed psychotherapists experience a client suicide at some point during their career (Finlayson & Simmonds, 2019). Moreover, on average, about 50 percent of psychiatrists lose a patient to suicide during their tenure (DeAngelis, 2008). For clinicians earlier in their careers, 33 percent report that a patient’s suicide impacted their personal life and 39 percent reported it affected their professional life (Dewar, Eagles, Klein, Gray, & Alexander, 2000). An overwhelming majority of trainees report obsessing over how they could have prevented it, and nine percent even consider changing careers (Dewar et al., 2000). For such little training and even less open discussion on the topic of client suicide, it is a rather prevelant issue. Further dialogue both throughout training and in the general clinical world may help promote awareness and decrease the stigma associated with being a therapist affected by client suicide.

LGBTQ+ risk factors

It is hard to separate LGBTQ+ suicides from others since sexual orientation and gender identity are rarely reported in official records (National LGBT Health Education Center, 2018). Nevertheless, a myriad of studies through self-report and quantitative research show LGBTQ people are at great risk for having suicidal ideation and are more likely to have attempts in the past (National LGBT Health Education Center, 2018). In fact, almost half of LGB youth seriously consider suicide and are five times more likely to have attempted suicide compared to their non-LGB peers (National LGBT Health Education Center, 2018). Bisexual and pansexual youth, as well as those questioning their gender identity, are also more likely to experience depression compared to their lesbian or gay peers (National LGBT Health Education Center, 2018). Approximately 40 percent of LGBTQ+ adolescents and young adults report suicidal ideation, and one third of transgender and gender nonconforming youth reported attempting suicide in the past year (Lang, 2019). 40 percent of transgender and gender nonconforming adults report attempting suicide at least once in their lifetime, and 92 percent report attempting as youth (James et al., 2016). Considering all of these factors, it is absolutely crucial for LGBTQ+ mental health providers to be aware of these risks for their patients as well as their own professional development and wellbeing. 

Effects

While the death of a client elicits a reaction regardless of cause, client suicide is unique in the way it affects a clinician’s functioning (Coverdale, Roberts, & Louie, 2007). Clinicians who experience client suicide are left with guilt, self-doubt, shame, feelings of incompetence, and fear of judgment from colleagues (Veilleux, 2011). Upon receiving the news of a client’s suicide, clinicians have reported feelings of shock, disbelief, denial, anger, sleep disturbance, appetite changes, and difficulty concentrating (Kleespies, Smith, & Becker, 1990). In fact, research suggests clinicians mirror the reactions of a family member, especially repression and denial (Kapoor, 2004). Perhaps unsurprisingly, clinicians with fewer years of experience are likely to have a more acute response to patient suicide compared to their more experienced colleagues (Gitlin, 2007). However, while the intensity of reaction decreases as experience increases, the type of reactions are often the same regardless of years in practice (Knox, Burkard, Jackson, Schaack, & Hess, 2006). When therapists leave work, they do not turn off as people. It is necessary to recognize that clinicians are human and experience similar feelings and experiences to those of their patients. As we humanize clinicians, we can be more cognizant of how colleagues may be affected and thereby better able to provide support early on. 

Responsibility

A clinician is often the person trusted with a patient’s most vulnerable thoughts and painful experiences, and as such, they were expected to lessen the pain with which the patient could no longer cope (Shannon-Karasik, 2017). In most cases, the clinician cannot be responsible for instances outside of their control. As we are reminded: therapy cannot solve all our problems. Of course, there are some cases, although rare, where the therapist missed major red flags (Gorkin, 1985). The more experienced the therapist, the harder it is to acknowledge the possibility of contributing to the loss or knowing they may have been able to prevent it (Gorkin, 1985). For anyone, but especially for more experienced clinicians, this realization is a major hit to the ego. If this type of complex pathological grief becomes a longer-term issue, the therapist is impacted in the way they treat new clients or even their willingness to accept referrals (Gorkin, 1985). Finding a balance between professional and personal responsibility is central to normalizing the reaction to client suicide and creating a field that strengthens, rather than shames, its peers. 

Supervision

Unlike their licensed colleagues, pre-licensed clinicians have access to weekly supervision. Practicing under a supervisor’s license allows the pre-licensed clinician to experience a sense of relief, as the supervisor holds legal responsibility and is required to provide weekly consultation. A supervisor who can validate, normalize, and share responsibility for the loss provides significant support for the clinician and softens the intensity of reactions (Knox et al., 2006). Supervisors who inadvertently dismiss the clinician’s experience of patient suicide, on the other hand, can directly hinder the clinician’s bereavement process (Knox et al., 2006). A large number of clinicians lose a patient to suicide, yet the majority of those clinicians report being met with little to no support from their colleagues or supervisors (DeAngelis, 2001). Lack of support can further lead to feelings of inadequacy and fear of professional punishment (Sacks, Kibel, Cohen, Keats, & Turnquist, 1987). To those who require supervision, nonjudgmental communication and encouragement can positively affect the therapist’s professional development. 

Recommendations for Self Care

1. Seek consultation

Talking to someone is vital, as there is an innate human need for nonjudgmental support and validation (DeAngelis, 2008). Support from colleagues and peers is essential for processing effectively and preventing burnout in clinicians following client suicide (Fox & Cooper, 1998). For trainees and other pre-licensed clinicians, quality supervision and training must also be integrated into peer support In order to positively increase professional development (Knox et al., 2006). Because the supervisor plays such a significant role in a young clinician’s development, their responses and reactions to experiences like client suicide will substantially impact the trainee’s advancement for better or worse (Horn, 1994). It is important for trainees to explore feelings related to the suicide in supervision (Ting, Jacobson, & Sanders, 2008). Some may not feel comfortable consulting with their supervisors, whether the relationship is fragmented or previous attempts have been met with responses that are dismissive, shaming, or otherwise unhelpful. For trainees in such cases, it may be appropriate to consult with other colleagues or professors as long as confidentiality of the patient is maintained and no identifying information is shared. If possible, the trainee may be able to seek additional supervision from an outside supervisor contracted with their training site. For licensed mental health professionals or those not requiring supervision for other reasons, consultation groups or advisors may be helpful in lieu of individual supervision. Most consultation groups or advisors usually require some some of fee, but the therapist seeking consultation holds the power in being able to find the right fit rather than being stuck with someone who feels unsafe. Sometimes seeking consultation requires the clinician to go out of their way to an extent that may become infeasible. In such circumstances, personal psychotherapy may be a more practical option for support.  

2. Go to therapy

Outside of the professional setting, it is also important to seek support through individual counseling, which may provide a safe space for longer-term processing and safety (McAdams & Foster, 2002). Trainees may be able to access free or low-cost counseling through their educational institution or training site. Licensed clinicians who cannot afford full-fee therapists may find quality low-fee counseling in their area at training sites. Once the right fit has been established, the therapist who experienced the client suicide may benefit from journaling and letter writing exercises that can be processed with their own therapist (Whisenhunt et al., 2017). Writing a timeline of events for better deconstructing the experience may be helpful, too (Gladding, 2011). For those in areas where personal psychotherapy requires a lengthy commute, telehealth may be an appropriate alternative for receiving support from a qualified therapist through confidential video calls. Therapy comes in many shapes and sizes, and finding the right fit sometimes takes a few tries. Dedication to finding someone that feels safe and empathetic of one’s experience is worth the short-term frustration for the sake of preventing long-term issues related to client suicide. 

3. Radical acceptance

Radical acceptance means accepting what is, and acknowledging things that are out of your control or in the past (Linehan, 2015). Accepting does not mean liking what happened or being fine with it, but rather recognizing reality instead of avoiding it. Part of using radical acceptance as a way of coping with client suicide is noting therapy has its limits. As therapists, we cannot solve every problem and cannot control the choices of others (DeAngelis, 2008). Accepting the things we cannot change provides space for finding the strength to get ahead of things within our control. 

4. Check the facts

It is imperative for clinicians to read up on the research related to client suicide and the effects of grief on the provider. Normalizing the experience to the extent that the clinician better understands their reaction can help decrease feelings of isolation and shame (Sanders et al., 2005). Increasing education around death, suicide, and grief may also increase the chances of prevention in the future. This can help restore some sense of control in an otherwise disempowering situation.

5. Exercise

Activating the parasympathetic nervous system through lowering one’s heart rate can help not only with reducing fight-or-flight responses in the moment, but also through increasing the likelihood of positive mood throughout the day (Linehan, 2015). Ideally more intense exercise, even just for 20 minutes, can help with this. However, going for a walk around the neighborhood or doing jumping jacks for five minutes may also do the trick. When emotional responses feel overwhelming, this can be a helpful tool for regulating in the moment. 

6. Practice mindfulness

Increasing mindfulness helps with radical acceptance as well as increasing our ability to participate effectively in each moment (Linehan, 2015). Research shows that the practice of observing and describing present thoughts, feelings, and sensations helps to increase emotion regulation and decrease distress (Linehan, 2015). The more this is practiced, the easier it will become to regulate difficult emotions. Practicing mindfulness can be done through a yoga class or breath workshop, meditation recording, or using grounding exercises to notice the world around you. Grounding exercises can be as simple as observing five things you can see, four you can hear, three you can touch, two you can smell, and one you can taste. Mindfulness is a practice, meaning it initially requires significant effort and can increase in ease over time. Simply starting by paying attention to present internal and external experiences is an effective path toward greater mindfulness.

7. Distract

It is important to alternate between processing the loss and distracting from it (Papadatou, 2000). Outside of seeking supervision, training, and individual therapy, it is important to soothe oneself and enjoy positive experiences. For some, this may be playing with their pets, spending time with loved ones, going out to dinner with a friend, watching a funny movie, listening to their favorite music, or taking a bubble bath. It is important that these activities are not centered around the topic of client suicide or the clinician’s experience of it, as this diminishes the point of distracting. For example, the clinician should not spend time with friends talking about the incident or their feelings around it, they should not listen to music that is sad or angry, and they should not watch movies or shows about dying (Linehan, 2015). 

8. Avoid negative coping mechanisms

Of course, there are many other tools that may be appealing to some in order to self-soothe. It is strongly recommended to avoid alcohol or drugs, social isolation, lashing out at colleagues or friends, restricting food or binging, and professional withdrawal. While these may provide solace in the moment, they often make things worse. 

Implications

There needs to be a proactive rather than reactive approach to the effects of client suicide. This, of course, means continued training on the various complexities of assessing for suicidality. Instead of shying away from suicidal or otherwise higher-risk patients, clinicians must be provided with training better suited for working with these specific issues and populations (Knox et al., 2006). Marsha Linehan’s development of Dialectical Behavior Therapy is a perfect example of such a modality, as it was developed for suicidal patients in psychiatric care and has now been adapted for working with patients under the care of all levels of mental health professionals (Linehan, 2015). When trainees are provided with a framework for working with suicidal patients early in their careers, they are more likely to feel secure in their approach and assessments rather than feeling apprehension and self-doubt (Knox et al., 2006). 

A proactive approach also means there needs to be more training on coping skills for therapists after client suicide (Sanders, Jacobson, & Ting, 2008). While clinicians are often trained to teach coping skills to their patients, training does not focus on teaching clinicians how to apply those skills to their own experiences (Sanders et al., 2008). Providing education and training on this beforehand increases the chances of successful recovery from such events in the most effective manner. Trainees are more likely to feel as though they have failed as people and as clinicians, leading to a tendency to overanalyze what they could have done differently and avoid suicidal patients altogether (Brown, 1987). Training programs, educational institutions, and supervisors must invoke dialogue with nonjudgmental empathic understanding and instruction on clinical implications, promoting more effective professional development after suicide (Brown, 1987). Educators and supervisors must reiterate the importance of self-care throughout the training process and beyond. The earlier suicide is discussed, the less likely clinicians will reinforce silence around this issue. 

Suicide Prevention Resources 

Learn more from our continuing education courses

References

Balon, R. (2007). Encountering patient suicide: The need for guidelines. Academic Psychiatry, 31, 336-337. doi:10.1176/appi.ap.31.5.336

Campbell, C., & Fahy, T. (2002). The role of the doctor when a patient commits suicide. Psychiatric Bulletin, 26, 44-49. doi:10.1192/pb.26.2.44

Coverdale, J. H., Roberts, L. W., & Louie, A. K. (2007). Encountering patient suicide: Emotional responses, ethics, and implications for training. Academic Psychiatry, 31, 329-332. doi:10.1176/appi.ap.31.5.329

DeAngelis, T. (2001). Surviving a patient’s suicide. Monitor on Psychology, 32(10). Retrieved from https://www.apa.org/monitor/nov01/suicide

DeAngelis, T. (2008). Coping with a client’s suicide. GradPSYCH Magazine, 11. Retrieved from https://www.apa.org/gradpsych/2008/11/suicide

Dewar, I. G., Eagles, J. M., Klein, S., Gray, N., & Alexander, D. A. (2000). Psychiatric trainees’ experiences of, and reactions to, patient suicide. Psychiatric Bulletin, 24, 20-23. doi:10.1192/pb.24.1.20.

Finlayson, M., & Simmonds, J. (2019). Workplace responses and psychologists’ needs following client suicide. Omega: Journal of Death & Dying, 79(1), 18-33. doi:10.1177/0030222817709693

Ford, D. (2009). Junior clinical psychologists’ experience of processing the death of a therapy client, from a cause other than suicide: A qualitative study (Unpublished doctoral dissertation). University of Hertfordshire, United Kingson.

Fox, R., & Cooper, M. (1998). The effects of suicide on the private practitioner: A professional and personal perspective. Clinical Social Work Journal, 26(2), 143-157.

Gitlin, M. (2007). Aftermath of a tragedy: Reaction of psychiatrists to patient suicides. Psychiatric Annals, 37, 684-687. 

Gladding, S. (2011). The creative arts in counseling (4th ed). Alexandra, VA: American Counseling Association.

Gorkin, M. (1985). On the suicide of one’s patient. Bulletin of the Menninger Clinic, 49, 1-9.

Hendin, H., Haas, A., Maltsberger, J. T., Szanto, K., Rabinowicz, H. (2004). Factors contributing to therapists’ distress after the suicide of a patient. The American Journal of Psychiatry, 161(8), 1442-1446. doi:10.1176/appi.ajp.161.8.1442

Horn, J. (1994). Therapists’ psychological adaption to client suicide. Psychotherapy, 31, 190-195. 

James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. transgender survey. Washington, DC: National Center for Transgender Equality.

Kapoor, A. (2004). Suicide: The effect on the counselling psychologist. Counselling Psychology Review, 1(3), 28-36.

Kleespies, P. M., Smith, M. R., & Becker, B. R. (1990). Psychology interns as patient suicide survivors: Incidence, impact and recovery. Professional Psychology: Research and Practice, 21, 257-263.

Knox, S., Burkard, A. W., Jackson, J. A., Schaack, A. M., & Hess, S. A. (2006). Therapists-in-training who experience a client suicide: Implications for supervision. Professional Psychology: Research and Practice, 37, 547-557. doi:10.1037/0735-7028.37.5.547

Lang, N. (2019). Nearly 40% of LGBTQ youth have contemplated suicide: Report. Rolling Stone. Retrieved from https://www.rollingstone.com/culture/culture-news/lgbtq-youth-suicide-report-846952/

Linehan, M. M. (2015). DBT skills training manual (2nd ed.). New York, NY: The Guilford Press.

McAdams, C. R., III, & Foster, V. A. (2002). An assessment of resources for counselor coping and recovery in the aftermath of client suicide. Journal of Humanistic Counseling, Education & Development, 41, 232-241. 

National LGBT Health Education Center. (2018). Suicide risk and prevention for LGBTQ people. Boston, MA: The Fenway Institute.

Papadatou, D. (2000). A proposed model of health professionals’ grieving process. OMEGA: The Journal of Death and Dying, 41, 59-77. doi:10.2190/TV6M-8YNA-5DYW-3C1E

Sacks, M. H., Kibel, H. D., Cohen, A. M., Keats, M., & Turnquist, K. N. (1987). Resident response to patient suicide. Journal of Psychiatric Education, 11(4), 217-226.

Sanders, S., Jacobson, J. M., & Ting, L. (2008). Preparing for the inevitable: Training social workers to cope with client suicide. Journal of Teaching Social Work, 28(1), 1-17. doi:10.1080/08841230802178821

Shannon-Karasik, C. (2017). Therapists told us what it’s like to lose a patient to an overdose. Vice. Retrieved from https://vice.com/en_us/article/kznw4z/therapists-lose-patient-to-overdose

Strom-Gottfried, K., & Mowbray, N. D. (2006). Who heals the helper? Facilitating the social worker’s grief. Families in Society: The Journal of Contemporary Social Services, 87, 9-15. 

Ting, L., Jacobson, J. M., & Sanders, S. (2008). Available supports and coping behaviors of mental health social workers following fatal and nonfatal client suicidal behavior. Social Work, 53(3), 211-221.

Valente, S. M. (1994). Psychotherapist reactions to the suicide of a patient. American Journal of Orthopsychiatry, 64, 614-621.

Veilleux, J. C. (2011). Coping with client death: Using a case study to discuss the effects of accidental, undetermined, and suicidal deaths on therapists. Professional Psychology: Research and Practice, 42(3), 222-228. doi:10.1037/a0023650

Whisenhunt, J. L., DuFresne, R. M., Stargell, N. A., Rovnak, A., Zoldan, C. A., & Kress, V. E. (2017). Supporting counselors after a client suicide: Creative supervision techniques. Journal of Creativity in Mental Health, 12(4), 451-467. doi:10.1080/15401383/2017/1281184

It’s a given that finding affordable, accessible, LGBTQ-affirming mental health care can pose a serious challenge, especially if you live outside of a major metropolitan area. Even in New York City, where I live, many community members find that their care needs are not easily met. As queer and trans people living with mental health conditions, what can we do to ensure meaningful connections among each other? What are the most effective ways for us to share support and guidance with others who really “get it”? How can we best move forward to help each other cope and perhaps complement the mental health care we may receive from providers?

Advantages of peer support

Peer support can be invaluable in this regard. This entails people with lived experience of mental health conditions, also known as peers, showing up for one another in a formalized way. Peer support services have been lauded as “an established, maturing area of development and study, with great promise for the future of services to promote recovery” (Farkas & Boevink, 2018). Literature on peer services reflects that activities such as education and advocacy programs “promote hope, socialization, recovery, self-advocacy, development of natural supports, and maintenance of community living skills” (Chinman et al, 2014). All of these factors are essential for our well-being as people with multiple marginalized identities.

Creating your own peer support group

Forming a peer-led support group is one idea for taking a DIY approach to your own mental health. I put this idea into action myself back in the summer of 2014, and it was a meaningful experience. When an online group called Queer Mental Health sprang up on Facebook, I ended up joining forces with its administrator, another Brooklyn resident, to form the NYC Queer Mental Health Initiative (QMHI). Intended solely for peers, QMHI was an all-volunteer initiative that I hoped to model, to some extent, after Brooklyn Queer Support (BQS), an ad-hoc support group with which I was briefly involved in years prior. BQS had begun as a way for LGBTQ+ people in Brooklyn to show up for each other after the suicide of a community member. I attended the groups as a participant, then as a volunteer facilitator, and found them inestimable. People created a safer space where one had not previously existed, and the sense that we had one another’s backs was, for me, life-affirming.

With my fellow QMHI co-founder, I drew on and fleshed out BQS’ support group facilitation guidelines to help structure our new initiative, and soon a few people started to meet bi-weekly at the Brooklyn Community Pride Center for support group sessions. Initially I co-facilitated most of the sessions, drawing on my social work background that has helped me gain experience leading groups in other settings. Expanding on a list of therapists that had been compiled by BQS, my co-founder and I launched an online NYC-specific queer and trans mental health resource guide. It features information on not only psychotherapists and mental health programs, but also affordable medical care, local holistic practitioners, and several LGBTQ-affirmative psychiatrists. We supplemented our support group meetings with a free peer-led training on Wellness Recovery Action Plans to help our members make their wishes about their own mental health care known in writing.

Another community member recognized the need for support groups and meditation sessions geared specifically toward LGBTQ people of color, and soon launched QTPoC Mental Health. In 2015, QMHI and QTPoCMH joined together to produce a support group facilitation training for our volunteers, led by an experienced social worker affiliated with the social justice-oriented peer support network and educational resource the Icarus Project. In order to rent a space for the training, provide refreshments to attendees, and pay our trainer an honorarium, QMHI launched a small online fundraiser and promoted it tirelessly via social media, among friends and family, and simply via word of mouth; we were fortunate enough to meet our goal within a week.

Challenges of running a peer support group

One of the biggest challenges QMHI faced was staying afloat without a substantial volunteer base. At any given time we had just a few active volunteers taking on tasks, and ideally at least a dozen would have been on board. It was a time-consuming endeavor that required organizers and facilitators to have the “spoons” (or ability to complete tasks in light of chronic illness) to be able to take on tasks from arranging two facilitators to co-lead each meeting to creating and distributing event invitations to mediating effectively when microaggressions arose. Had I stayed part of QMHI, I would have worked on procuring more training and support for volunteers around these issues, especially the latter one. But I needed to take a step back within a year of launching QMHI to focus on another major project I’d had in the works.

My hope was that QMHI would sustain itself, attracting a rotating roster of volunteers. It’s true that a few people did put in a tremendous amount of work and keep the meetings running for about three years. As with BQS, gradually QMHI’s in-person groups ceased as the tasks became too much for just two or three committed volunteers to handle. But the feedback we got from group participants indicated that our work made a major difference in the wellbeing of our community. The fact that we figured out how to provide this service to each other and our community on a volunteer basis for as long as we did is tremendously encouraging. We continue to help the community through the online resource guide, which I continue to maintain and the Queer Mental Health Facebook group, which my QMHI co-founder still administers–and we can share the knowledge that our little crew of volunteers gained about how to go about forming peer support networks. I hope some of us will be able to operationalize an in-person group again soon! I think that partnering more closely with an established institution like one of the city’s LGBT community centers and receiving ongoing support, training, and perhaps supervision from one of their staff members would be helpful. We could also recruit more people who, like me, are providers or community organizers with lived experience of mental illness to volunteer. People with social work and organizing backgrounds can bring skills to a peer support group that will help sustain it. So can people with excellent administrative skill sets. In my next article, Six Tips for Starting an LGBTQ+ Peer Support Group in Your Community, I will list some concrete suggestions for starting a peer support network in your own community.

Learn more from Teresa Theophano, LCSW

References

Chinman, M., PhD, George, P., PhD, Dougherty, R. H., PhD, Daniels, A. S., Ed.D., Ghose, S. S., Ph.D., Swift, A., MSW, & Delphin-Rittmon, M. E., PhD. (2014, April 1). Peer Support Services for Individuals With Serious Mental Illnesses: Assessing the Evidence. Retrieved April 19, 2019, from https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201300244

Farkas, M., & Boevink, W. (2018). Peer delivered services in mental health care in 2018: infancy or adolescence?. World Psychiatry : Official Journal of the World Psychiatric Association (WPA), 17(2), 222–224. doi:10.1002/wps.20530

Miserandino, C. (2013, April 26). The Spoon Theory written by Christine Miserandino. Retrieved May 26, 2019, from https://butyoudontlooksick.com/articles/written-by-christine/the-spoon-theory/

By Briana Shewan, MFT

If you are a dedicated viewer of Broad City, then you’ve already seen “Make the Space.” Directed by Ilana Glazer and written by Jen Statsky, the fourth episode of the fifth season of the Comedy Central series, which aired on Feb 14th, 2019, focuses on mental illness by way of characters Jaimé’s hoarding and Ilana’s take on a therapy intervention.

Spoiler alert – details of this episode are referenced throughout this article.

This is not the show’s first episode dedicated to addressing mental health (for example, Ilana’s struggle with seasonal affective disorder, aluminum foil, and a light so powerful she blows a restaurant’s circuit in season four, episode five, “Abbi’s Mom”). What this current episode manages to do, though, is help to break mental illness stigma; portray queer, brown, and affirming love; and set us up to cheer on Ilana’s pursuits as a therapist.

Breaking Mental Illness Stigma

“Make the Space” is reflective of what makes Broad City so great: their unique take on a subject in a way that is relevant, upbeat, funny, and doesn’t take itself too seriously. Despite the prevalence of people experiencing mental illness and the range of media portraying these issues, this episode uses its platform to normalize anxiety and focus on positive, however comedically flawed, responses.

The episode features Ilana Wexler (Ilana Glazer) non-consensually going into her roommate Jaimé Castro’s (Arturo Castro’s) room. She does so to find the source of a funky smell, though not without acknowledging it as wrong, particularly given that she is white and Jaimé is brown. Jaimé later makes clear that he doesn’t excuse her breach of his privacy. When she opens his door, she finds evidence of hoarding in the form of excessive amounts of alarm clocks, newspapers, piggy banks, and the like. Ilana proceeds to recruit her best friend and co-star Abbi Abrams (Abbi Jacobson), and together they put Jaimé’s things into black plastic bags and carry them out to the trash. Just when your cringing reaches its climax, Ilana reads about hoarding in her old psych textbook that she found amongst his items and, realizing they’ve crossed a boundary, puts his room back the way it was before he returns home, thus returning his autonomy and agency.

I imagine that if I experienced hoarding or specialized in it as a therapist I might have more criticism of the portrayal of it, particularly because the episode doesn’t go into Jamié’s struggles or challenges. Despite the drawbacks in relatability of its linear and reductive approach, the episode achieves a non-pathologizing stance by focusing on his stressors.

Keeping it Queer, Brown & Affirming

When Jaimé returns to the apartment with his boyfriend, Johnny (played by openly gay actor Guillermo Díaz), Ilana facilitates a therapy session to address Jaimé’s hoarding (again, non-consensually). This is not the show’s first go at portraying queer sexuality. Many of us cherish Ilana’s love and attraction for Abbi, whose actress came out publicly as bisexual in real life.

What “Make the Space” does more than ever before on the show is contextualize Jaimé’s mental illness as a gay brown immigrant. As Ilana prompts him to reflect on the origins of his anxiety from which his hoarding may have manifested, Jaimé speaks about the lack of control he experienced due to his status before becoming a citizen as the initial source.

As a white U.S. citizen since birth, I can only imagine what the significance of this representation of Jamié and his partnership might be for queer, brown and undocumented people. As the show often does in overt and covert ways, it seemed as though Broad City was making a timely point to address our political climate, this time taking on immigration, racism, and homophobia amidst Trump’s wall-building agenda.

Finally, it’s when Ilana is constantly distracted by Abbi from attempting to be a therapist for Jaimé that he is truly affirmed. Through face-to-face conversation with Johnny in Spanish, and Johnny’s non-judgmental, supportive approach, Jamié is able to talk about his embarrassment over hoarding and his more recent source of anxiety, their relationship. Through their intimate and honest communication, Jaimé and Johnny agree to face the vulnerability of falling in love together in order to continue to grow their connection. While the 22-minute episode presents a feel-good arch to hoarding that’s just as short, doing so highlights the strengths of its queer brown characters. However unrealistic, this take is a refreshing narrative when focused on Jaimé and Johnny’s relationship.

Ilana the Therapist

As a therapist myself, Ilana’s approach with her roommate was particularly humorous. She’s dressed in all white, wearing glasses, with a neutral, calm tone to her voice (at least when she’s not arguing with Abbi) and an empty pizza box in her lap for taking notes. She’s turned their New York City living room into her “office” equipped with tissues, candles, and the empty assurance of it as a “safe space” only to have a light fixture fall off the wall. “Well, not literally safe,” she clarifies. The portrayal is a stage of therapeutic clichés.

Jaimé, Johnny, and Abbi each separately tell Ilana that the session wasn’t real and was unprofessional, from the fake statement of confidentiality to calling Jaimé “crazy” for deciding to move in with his boyfriend- because he’s her roommate- to yelling at Abbi about toe sucking and lactose intolerance (to name a few examples). Ilana asks Johnny if she was a good therapist to which he replies, “You made the space for Jaimé to talk about his issues. That’s really all you can do as a therapist, right? Just make the space.” The episode ends with Ilana sharing with Abbi that she wants to look into schools in order to pursue a therapy career. This is a particularly poignant moment. Long-time viewers have watched Ilana not take her work life seriously. While there’s nothing necessarily wrong with that, her sharing her professional goals with Abbi in this final season of the show is heart-warming character development for more than just Abbi to get behind.

I like to imagine that more people like Ilana in the field would help to disrupt patriarchal curriculum, exploitative labor practices, and the inaccessibility of mental health services due to medicalized gatekeeping and the non-profit industrial complex. I think Ilana’s unapologetic feminism and sexuality, and preference for weed over respectability politics would translate to her being client-centered, sex positive, and a harm reductionist. Even with these forward-thinking qualities, we all have things to work on. For example, if Ilana were my colleague, I might start a conversation with her about her appropriative use of African American Vernacular English, including her common use of the phrase “yasss queen” as well as her referring to Jaimé’s relationship as “going dopely” in this very episode. I would also mention that her joke about her mom looking at hoarding videos to lose her appetite when she’s dieting makes me hyper-vigilant of fatphobia.

The next order of business – processing our grief around Broad City ending.

Learn More

References

R. (2018, April 07). Abbi Jacobson is bisexual: Ilana Wexler has called dibs though. Retrieved
From https://www.autostraddle.com/abbi-jacobson-is-bisexual-ilana-wexler-has-called-dibs-though-416956/

Blay, Z. (2015, October 19). 12 words Black people invented, and white people killed. Retrieved
From https://www.huffingtonpost.com/entry/black-slang-white-people-ruined_us_55ccda07e4b064d5910ac8b3

Glazer, I. (2019, February 14). Ilana glazer on Instagram: “this is one of my favorite moments from tonight’s episode of @broadcity written by @jenstatsky and directed by me! @arturocastrop is a star…” Retrieved from https://www.instagram.com/p/Bt4XGqUlzvx/

Mayo Clinic Staff. (2018, February 03). Hoarding disorder. Retrieved from
https://www.mayoclinic.org/diseases-conditions/hoarding-disorder/symptoms-causes/syc-20356056

Reddish, D. (2018, June 14). Guillermo Diaz, the ‘Scandal’ star who made out & proud look easy. Retrieved from
https://www.queerty.com/guillermo-diaz-scandal-star-made-coming-natural-breathing-20180614

Statsky, J. (Writer). (2019, February 14). Make the Space [Television series episode]. In Broad City. New York, New York: Comedy Central.
Trump wall. (2019, February 19). Retrieved from https://en.wikipedia.org/wiki/Trump_wall

By Stephanie M. Sullivan, MS, LLMFT

Many people, across all walks of life, occasionally need therapeutic services. Due to the stigma surrounding mental health, it can be difficult for anyone to contact a mental health therapist. However, if you are polyamorous or curious about exploring polyamory, you may struggle even more with reaching out to a new therapist or opening up to your current therapist about your relationship style, as many therapists lack knowledge and may have judgmental views of consensual non-monogamy (Schechinger, Sakaluk, & Moors, 2018). You may want to explore mental health services as an individual, to work through some aspect of your relationship, or you may want to pursue therapy with a partner, a metamour, or more than one person in your polycule. If you are currently monogamous and thinking about opening up your relationship, you may want to seek both individual and couple therapy in order to explore the relationship options available to you both alone and with your partner.

Alternately, you may be interested in receiving mental health services for a reason unrelated to your relationship structure. Whether you are experiencing depression, anxiety, work-related stress, processing trauma, or working on something else, you may know that your polyamorous relationship structure is not the cause of your distress but is still an important part of who you are. You don’t want a therapist who will automatically blame your relationship structure for your anxiety; you want someone who can differentiate between a healthy relationship and an unhealthy relationship (regardless of the style of that relationship) and focus on the actual causes of the anxiety you are experiencing.

For these reasons, it may be important to you to find a polyamory-friendly or polyamory-affirmative therapist. When we say a therapist is “polyamory-friendly,” this means that they are open-minded and accepting, but may not have much knowledge or experience in working with the polyamorous community. When a therapist is polyamory-affirmative, they have extra knowledge or training about polyamory, and may have gone out of their way to gain this experience. A polyamory-affirmative therapist will also be outwardly supportive of your relationship style, able to acknowledge how societal expectations and oppression may affect you, and be able to help you deconstruct these societal narratives.

Finding a therapist who is a good fit can be a challenging process for many people, but it can be especially challenging within the non-monogamous community. Many people within the community have often had difficulty with finding an accepting and knowledgeable therapist in their area (Anapol, 2010; Schechinger, Sakalk, & Moors, 2018). Some people have reported that their therapists told them their polyamorous relationship was problematic, the cause of their depression, or meant that they had an insecure attachment style (Anapol, 2010; McCoy, Stinson, Ross, & Hjelmstad, 2015). If your therapist is not aware of, comfortable with, and sensitive to your relationship style, it can be very difficult to achieve your goals in therapy, and may actually lead to more distress for you as the client (Graham, 2014; Williams & Prior, 2015).

To those who are polyamorous, it may be unsurprising to hear that relatively few therapists have heard of polyamory, and even fewer therapists have actually worked with polyamorous clients (Weitzman, 2006). It can be extremely frustrating when you go to therapy and have to spend the session educating your therapist about polyamory. Of course, every relationship is different and unique, so you will have to spend some time telling your therapist about your individual situation and what is bringing you to therapy. But you shouldn’t have to use your session time to educate your therapist on polyamory in general, or defend your relationship style to them. While therapists are slowly becoming more informed about polyamory, they are still far behind in becoming knowledgeable and competent in working with the community (Johnson, 2013).

However, this does not mean that finding an understanding and supportive therapist is a lost cause! There are many ways to find a therapist who will be accepting of your relationship, and it is important to check all of these avenues to find the person that will be the best fit for you.

First, try online searches and directories for polyamory-friendly professionals. Some of these resources include:

1. The Polyamory-Friendly Professionals Directory: https://www.polyfriendly.org
2. The Kink Aware Professionals Directory (KAP): https://www.ncsfreedom.org
3. The Open List: Openingup.net/open-list
4. The Polyamory Loving More Member Professionals List: https://www.lovingmorenonprofit.org
5. The “Meet our Experts” section of The Affirmative Couch: https://affirmativecouch.com

It is important to understand that these resources do not have a process to verify the credentials of the professionals that are listed on their sites. However, most (if not all) of these professionals have had to seek out a listing on the site, which took some time and effort. Therefore, these directories are likely to have therapists who are at least polyamory-friendly, even if they are not entirely knowledgeable and competent in working with the community.

Another source to find therapists are more general directories, such as Psychology Today or Good Therapy. You can search these directories based on your location and read the profiles of various mental health therapists. These directories do verify the licensure status and credentials of the therapists listed on their websites, but you may have to read through more profiles to find someone who is supportive of your relationship style. There is no guarantee that the therapists listed here will be polyamory-friendly or affirmative, but it is possible to find someone who has listed polyamory as one of their specialties within their profiles.

Once you have a few names of therapists in your area, check out their listings on other sites or their own website. One way to determine their level of knowledge is to look at how they are marketing themselves. On these directories and other sites, do they simply say they are “open to working with polyamorous clients”? Or do they say something like, “I am familiar with hierarchical polyamory, non-hierarchical polyamory, solo polyamory, and relationship anarchy”? The second therapist in this example may be more polyamory-affirmative, more knowledgeable, or have more experience in working with polyamorous clients than the first one, as they are familiar with the expansive terminology within the non-monogamy umbrella. If the therapist has a blog or professional social media pages, it may be helpful to look at the types of articles they are writing about or sharing, as well.

If you cannot find polyamory-friendly professionals in your area, try looking at other parts of the state you live in to find a therapist who provides online services. You may be able to find a therapist who is willing to book online video chat sessions with you in order to give you the care you deserve. Or, if you have the time, funds, and ability to travel farther than you normally would, it may be worth it to drive a longer distance to see a polyamory-friendly therapist in person in order to gain access to a therapist who will understand your relationship.

If you are still struggling to find a therapist who is accepting and knowledgeable about polyamory, you may want to look at LGBTQ-Affirmative therapists, even if you identify as heterosexual. These professionals may be more open to non-traditional relationship styles and may already work with some non-monogamous clients, although they may not advertise it or consider themselves knowledgeable. This may be an option as well if you are seeking more individualized care that is not explicitly focused on navigating a polyamorous relationship.

Although polyamory-affirmative therapists are difficult to find, they do exist! It will be very beneficial to find a therapist who is right for you and understands your relationship. If you don’t want to spend hours educating your therapist about your relationship style, try using the above resources to find a professional who better suits your needs.

Learn More from Stephanie M. Sullivan

References

Anapol, D. (2010). Polyamory in the twenty-first century: Love and intimacy with multiple partners. Lanham, MD: Rowman & Littlefield Publishers, Inc.

Graham, N. (2014). Polyamory: A call for increased mental health professional awareness. Archives of Sexual Behavior, 43, 1031-1034. doi:10.1007/s10508-014-0321-3

Johnson, A. L. (2013). Counseling the polyamorous client: Implications for competent practice. VISTAS Online, 50, 1-10.

McCoy, M. A., Stinson, M. A., Ross, D. B., & Hjelmstad, L. R. (2015). Who’s in our clients’ bed? A case illustration of sex therapy with a polyamorous couple. Journal of Sex and Marital Therapy, 41(2), 134-144. doi:10.1080/0092623X.2013.864366

Schechinger, H. Sakaluk, J., & Moors, A. (2018). Harmful and helpful therapy practices with consensually non-monogamous clients: Toward an inclusive framework. Journal of Consulting & Clinical Psychology, 879-891. doi:10.1037/ccp0000349

Williams, D. J., & Prior, E. E. (2015). Contemporary polyamory: A call for awareness and sensitivity in social work. Social Work, 60(3), 268-270. doi:10.1093/sw/swv012