Out On The Couch
Self-Disclosure and Community Building
We know that LGBTQIA+ community members are resourceful and resilient. We also know about startling disparities in the mental health of queer and trans individuals v. that of cisgender and heterosexual ones. As a queer femme clinical social worker who has spoken openly and published about my own lived experience of major depression and trauma–thereby “coming out” many times over the years–I posit that normalizing such experiences through mindful self-disclosure benefits LGBTQIA+ therapists and can make for healthier workplaces. One way in which we can help de-stigmatize lived experience among clinicians, as I will explore in this article, is by building online community via social media. My hope is that, through establishing online outlets for support and authentic discussion with other lived-experience practitioners, LGBTQIA+ psychotherapists living with mental health conditions ourselves can build stronger and genuinely thriving communities of practice.
Self-Disclosure in Clinician Communities
Therapist self-disclosure (TSD) has been examined and categorized in specific ways in extant literature, and clinicians may be familiar with some terminology surrounding immediate v. non-immediate TSD; deliberate v. unavoidable TSD; and accidental, inappropriate, and client-initiated TSD (Alfi-Yogev et al, 2020, Zur, 2009) to clients. Some literature also explores disclosure to and identification with LGBTQ+ clients, and how this shows up both in queer and TGNB community as well as in relational practice (Hansbury and Bennett, 2014). But the possibilities for positive change when we share about our own lived experience with other practitioners, particularly via social media, have not been explored at length.
In other words, we can easily find commentary and research on the risks and benefits of TSD to clients. But what about the risks and benefits of disclosure within communities of practice, i.e. among therapists in a clinic or group practice setting–or between clinicians and workers such as certified peer specialists, whose lived experience is a requirement of their position because it is seen as a strength (Byrne et al., 2016, Marino & Child, 2015)? King et al. (2020) frame mental health professionals with lived experience as an underutilized resource, one whose presence and authenticity can help lessen stigma and foster healthier mental health service-oriented workplaces overall. At the same time, practitioners such as peer specialists face “the unique challenges of…being professionally isolated, feeling outnumbered and ostracised,” especially when few of them are employed in a given workplace (Moran et al., 2013, as cited in Byrne et al., 2016, p. 11).
Self-Disclosure and Resilience
First, we might consider here the stress induced by identity concealment, and how research has shown that the pressure of hiding our true selves as LGBTQIA+ people results in negative psychological responses associated with PTSD (Alessi & Martin, 2017). Support from online communities can potentially help mitigate these stressors for those of us who are both queer and living with mental health conditions, allowing for therapists with lived experience to be seen and valued for the unique gifts we bring to the workplace.
While self-help models have long been grounded in the principles of discussing lived and shared experiences, and peer models can indeed be enhanced by self-disclosure (Psychopathology Committee of the Group for the Advancement of Psychiatry, 2001), it seems that few conversations are happening about how TSD among practitioners–LGBTQIA+ ones in particular–can benefit us. Yet I have found that my own self-disclosure has led to my sense of increased authenticity and even self-efficacy. This is especially salient considering that lived experience is a form of expertise, albeit one that is frequently undervalued in mental health care professions, unto itself.
In exploring the idea of online TSD, we may consider that some transparency is simply unavoidable, as it would be if we were living in a small town; in fact, Zur (2015) conceptualizes the Internet as a “global village.” This is particularly relevant to social media use–in addition to shared physical social spaces–among LGBTQIA+ community, which tends to be surprisingly small and deeply interconnected even in major metropolitan areas such as my hometown of New York City.
Both Zur (2015) and Longley (2021) caution that therapists may not be aware of the information clients have uncovered about them online, thus leaving them unable to appropriately address unintentional disclosures in session. Clinicians considering issues of disclosure around lived experience will want to bear this in mind. If we operate from the assumption that our clients as well as our colleagues have read any- and everything we have written for publication, online or off, we will be better prepared for the possibility of our authentic selves to show up in the therapy room as well as the conference room–or the Zoom rooms! Further conversations about self-disclosure from different intersections have been explored in previous articles published by The Affirmative Couch by Mandy Simmons and Jerry St. Louis.
Online Communities for Therapists
We might look to Facebook and Twitter for an idea of what intentional social media-based disclosures within communities of practice can look like. Both are homes to LGBTQIA+ mental health discussions in the forms of groups and chats, but it can be difficult to find dedicated space to share support around being a queer therapist with lived experience. Frustrated with the lack of such spaces, I started a small, private Facebook group in early 2020, inviting a few clinicians I knew who had openly shared their status as peers. The intention was to create a safer space in which we could discuss our work and lives. Some themes that have emerged include professionally navigating dual identities as clinicians and peers; potential over-identification with clients with similar lived experiences; and how much disclosure, and to whom, feels safe. With fewer than 20 members at present, the group is low-traffic, but an available and hopefully growing resource for LGBTQIA+ therapists with lived experience.
Risks and Benefits of Online TSD
The risks and benefits of TSD in terms of client impact is familiar terrain in the literature. Risks include violating boundaries and burdening the client with extraneous personal information that detracts from focus on the client, while benefits include potentially enhancing trust and strengthening the therapeutic alliance (Alfi-Yogev et al., 2020; Johnsen & Ding, 2021; Lehavot, 2010; Longley, 2021; Moody et al, 2021; Psychopathology Committee of the Group for the Advancement of Psychiatry, 2001; Zur, 2009). Some psychotherapeutic modalities, including dialectical behavior therapy (DBT) and relational therapy, may better lend themselves to TSD than others, such as traditional psychoanalytic models (Hansbury and Bennett, 2014; Psychopathology Committee of the Group for the Advancement of Psychiatry, 2001).
Worth noting, per Lehavot et al. (2010), is the tension of the generational divide between therapists born into an Internet-savvy world v. those born prior to the Internet’s omnipresence, and how this can factor into differing attitudes about online TSD. Generational and cultural differences persist, and different schools of thought on privacy-related values may clash. Traditional psychotherapeutic views on self-disclosure, online or off, may certainly err on the side of conservatism and eschew clinician authenticity; after all, in classical psychoanalysis, “self-disclosure was thought to result in gratification of patients’ wishes rather than analysis of them” (Psychopathology Committee of the Group for Advancement of Psychiatry, 2001, p. 1489).
Meantime, more modern viewpoints support that some self-disclosure can provide role modeling and confirm what is already publicly available online, thereby deepening trust with clients (Johnsen & Ding, 2021). Therapists who choose to disclose should be mindful about their rationale and have thoughtful responses at the ready, considering that revealing a diagnosis can elicit bias from clients, colleagues, and employers. This is why I encourage us all to reflect on the validity of lived experience as a form of expertise, and consider sharing pertinent literature–such as some of the articles in the below reference list–as tools for further learning.
Further education can help those who harbor bias and stigmatize individuals with lived experience unlearn harmful attitudes, and perhaps even their own internalized oppression. It is difficult to locate any data regarding the risks and benefits of LGBTQIA+ therapists themselves disclosing to each other, whether online or in person. What we do know is that LGBTQIA+ community members frequently use social media to discuss their mental health concerns and care. Interestingly, researchers have found social media usage to be both a risk factor for and a protective factor against depression for LGB people. Per Escobar-Viera et al. (2018), who draw on the Meyer minority stress model, social media can be conducive to the formation of social support and connection among queer folks, thereby encouraging stress reduction and forming protective factors against depression. At the same time, social media use can also foster social comparison and yield experiences of cyberbullying and stigmatization, leading to such negative outcomes as lowered self-esteem and symptoms of depression (Escobar-Viera et al., 2018).
Perhaps we can extrapolate some ideas from existing literature about the general benefits of sharing in alleviating self-stigma. Normalizing disclosure among not only “lived experience practitioners,” such as certified peer specialists, but also licensed mental health clinicians can provide both personal and community-wide benefits, eliminating feelings of isolation, being outnumbered and stigmatized in the workplace, and easing distress around identity concealment (Byrne et al., 2019; King et al., 2020). When we, as LGBTQIA+ clinicians, share about our lived experience and provide support to each other online, discussing our experiences of workplace challenges, we can make it more feasible for ourselves and each other to disclose to colleagues in our clinics, agencies, and organizations. This kind of effort can lead to further understanding of diverse experiences, identities, and states of mind, which ultimately benefits everyone.
Research on this topic moving forward should focus on the outcomes and benefits of disclosure in online communities formed specifically for this purpose–to provide support for queer and trans clinicians with lived experience. Worth noting is my own positionality in writing this article as a white cis femme for whom being doubly “out” as queer and having mental health-related diagnoses is, in some ways, relatively safe. Risks may be more significant for community members facing multiple forms of marginalizations; it is crucial to take an intersectional lens to the impact of self-disclosure and social media use on, for instance, LGBTQIA+ Black, Indigenous, and people of color communities (BIPoC) (Marino & Child, 2015). Future directions in research should address this when also examining how disclosure and authenticity in the workplace–i.e. outpatient clinics, group practices, and agency-based settings–benefits LGBTQIA+ clinicians with lived experience.
Alfi-Yogev, T., Hasson-Ohayon, I., Lazarus, G., Ziv-Beiman, S., & Atzil-Slonim, D. (2020). When to disclose and to whom? Examining within-and between-client moderators of therapist self disclosure-outcome associations in psychodynamic psychotherapy. Psychotherapy Research, 1–11.
Alessi, E. J., & Martin, J. I. (2017). Intersection of trauma and identity. In K. L. Eckstrand & J. Potter (Eds.), Trauma, resilience, and health promotion in LGBT patients (pp. 3–14). Springer. DOI 10.1007/978-3-319-54509-7_1
Byrne, L., Roennfeldt, H., Davidson, L., Miller, R., & Bellamy, C. (2021). To disclose or not to disclose? Peer workers impact on a culture of safe disclosure for mental health professionals with lived experience. Psychological Services. https://doi.org/10/gj7w6r
Escobar-Viera, C. G., Whitfield, D. L., Wessel, C. B., Shensa, A., Sidani, J. E., Brown, A. L., Chandler, C. J., Hoffman, B. L., Marshal, M. P., & Primack, B. A. (2018). For better or for worse? A systematic review of the evidence on social media use and depression among lesbian, gay, and bisexual minorities. JMIR Mental Health, 5(3), e10496. https://doi.org/10.2196/10496
Hansbury, G., & Bennett, J. L. (2014). Working relationally with LGBT clients in clinical practice: Client and clinician in context. In Relational social work practice with diverse populations (pp. 197–214). Springer.
Johnsen, C., & Ding, H. T. (2021). Therapist self-disclosure: Let’s tackle the elephant in the room. Clinical Child Psychology and Psychiatry, 26(2), 443–450. https://doi.org/10/gmvf8w
King, A. J., Brophy, L. M., Fortune, T. L., & Byrne, L. (2020). Factors affecting mental health professionals’ sharing of their lived experience in the workplace: A scoping review. Psychiatric Services, 71(10), 1047–1064. https://doi.org/10/gk87w8
Lehavot, K., Barnett, J., & Powers, D. (2010). Psychotherapy, professional relationships, and ethical considerations in the MySpace generation. Professional Psychology: Research and Practice, 41, 160–166. https://doi.org/10/btg4mw
Longley, H. (2021). A psychotherapist’s experience of self-disclosure, when practising in the digital era: A heuristic self-study [PhD Thesis]. Auckland University of Technology.
Marino, C. “Khaki,” Child, B., & Campbell Krasinski, V. (2016). Sharing Experience Learned Firsthand (SELF): Self-disclosure of lived experience in mental health services and supports. Psychiatric Rehabilitation Journal, 39(2), 154–160. https://doi.org/10/f8rkjh
Moody, K. J., Pomerantz, A. M., Ro, E., & Segrist, D. J. (2021). “Me too, a long time ago”: Therapist self-disclosure of past or present psychological problems similar to those of the client. Practice Innovations. https://doi.org/10/gmvf8x
Moran, G. S., Russinova, Z., Gidugu, V., & Gagne, C. (2013). Challenges experienced by paid peer providers in mental health recovery: a qualitative study. Community Mental Health Journal, 49(3), 281-291.
Psychopathology Committee of the Group for the Advancement of Psychiatry. (2001). Reexamination of therapist self-disclosure. Psychiatric Services, 52(11), 1489–1493. https://doi.org/10/bnhpwc
Zur, O., Williams, M. H., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the Internet age. Professional Psychology: Research and Practice, 40(1), 22. https://doi.org/10/bss28g
Zur, O. (2015). The Google factor: Psychotherapists’ intentional and unwitting self-disclosure on the net. Zur Institute. http://www.zurinstitute.com/onlinedisclosure.htm
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/