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

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/. 

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

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/.

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.

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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