Out On The Couch
By Rachel Jones, M.A.
Keywords: Suicide, Grief/Loss, Self-Care
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.
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
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.
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.
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.
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.
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.
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.
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).
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.
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
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
Teresa Theophano, LCSW
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?
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.
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.
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.
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.
R. (2018, April 07). Abbi Jacobson is bisexual: Ilana Wexler has called dibs though. Retrieved
Blay, Z. (2015, October 19). 12 words Black people invented, and white people killed. Retrieved
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
Reddish, D. (2018, June 14). Guillermo Diaz, the ‘Scandal’ star who made out & proud look easy. Retrieved from
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:
- The Polyamory-Friendly Professionals Directory: https://www.polyfriendly.org
- The Kink Aware Professionals Directory (KAP): https://www.ncsfreedom.org
- The Open List: Openingup.net/open-list
- The Polyamory Loving More Member Professionals List: https://www.lovingmorenonprofit.org
- 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.
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