Out On The Couch
Non-binary Microaggressions in Psychotherapy
COVID-19 & (Re)claiming Gender
As a non-binary, genderqueer, and trans femme therapist myself, I have encountered my own fair share of microaggressions related to gender identity. During the pandemic, I have witnessed many people for the first time in their lives take a break from performing gender in a way society deems acceptable. As a result, many folx are exploring their gender identity and expression more than ever before. Many clients have questions and self-doubt about who they are with respect to their gender identity and/or gender expression. However, this is an aspect of mental health that is under-researched and is often overlooked in the graduate training of therapists, both masters and doctoral.
Because many clinicians lack in-depth training with regards to working with gender expansive people, many clients encounter harm in session. For example, being misgendered is just one of many microaggressions that occur in therapy sessions with gender expansive clients. For the purposes of this article, I will be focusing primarily on nine common microaggressions experienced by non-binary people in the therapy setting.
Before we delve into this important topic, let’s take a moment to define some key terms. Cisgender is in reference to a person who’s sex assigned at birth matches their gender. Endosex refers to people whose sex characteristics meet medical and social norms for typically ‘male’ or ‘female’ bodies, which is the antonym to intersex. Heterosexuality refers to sexual and/or romantic attraction to or between people of the opposite sexes assigned at birth.
Transgender is an an umbrella term covering a range of identities that transgress socially defined gender norms. Additionally, transgender can refer to a person who lives as a member of a gender other than the one expected based on their biological sex assigned at birth. Non-binary is also an umbrella term covering any and all gender identities that do not fall exclusively in man/male or woman/female categories. And, non-binary refers to a person whose gender identity and or expression exists between or outside the rigid gender binary system.
But first… Microaggressions – What’s that?
The term microaggression was originally coined by Dr. Chester Middlebrook Pierce, who was an African American psychiatrist and Harvard University professor who died in September of 2016 (Sue & Spanierman, 2020). Early research focused on racial microaggressions, but has since been expanded to create a series of classification for most existing systems of oppression. Microaggressions are brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults toward people with marginalized identities (Sue & Spanierman, 2020; Sue et al., 2007).
Nadal (2013) wrote the book That’s So Gay! Microaggressions and the Lesbian, Gay, Bisexual, and Transgender Community. This book is one of the first of its kind to make academic literature both accessible to a wide audience. Also, Nadal (2013) offered strategies to make the world a better place for queer and gender expansive people. Furthermore, Nadal (2013) provided distinctions between microaggressions based on sexual orientation as compared to gender identity.
Of the microaggressions highlighted for transgender and gender non-conforming (TGNC) people, the book identified ten distinct classifications (Nadal, 2013).
Why should I care about this topic?
Non-binary folx continue to encounter harm and rejection both for cisgender and transgender communities. TGNC folx experience higher rates of gender-based victimization than cis- individuals, and the highest rates of suicidality of any group (Testa et al., 2015). Additionally, TGNC folx report significantly more negative clinical encounters in therapy (Levitt & Ippolitto, 2014). Lastly, gender identity microaggressions have been associated with therapeutic dissatisfaction, reduced ability to establish a therapeutic alliance, and early dropout from therapy (Spatrisano, 2019).
So what gender based microaggressions are happening to non-binary folx in therapy?
I came to learn through my own consultations with prospective therapy clients that I wasn’t alone in my experiences of encountering gender based microaggressions. Although I don’t believe that all of the following microaggressions were intentionally meant to harm non-binary clients, it’s important to center the impact of our questions and statements as clinicians. The following common microaggressions occur to non-binary folx in therapeutic encounters:
In the following sections I will briefly explain why each of these examples is microaggressive. Alternative tips will also be provide for how to ask more affirming questions to non-binary folx.
This is the most common form of microaggression that happens both within and outside therapeutic spaces. Misgendering is when language is used that does not correctly reflect the gender with which the person identifies. This can include using a person’s “dead name” or name given at birth when the client has specifically requested that the clinician not do so. Additionally, misgendering emerges with the misuse of pronouns, whether the client is present or not. Non-binary folx experience misgendering countless times throughout the day. This can occur on the phone, in an email, while “politely” holding the door for someone, and so many other interactions. McLemore’s (2014) study indicated that non-binary folx, and people who had taken fewer steps in the transition process, were most likely to be misgendered.
What can a therapist do when misgendering happens? Firstly, I encourage folx to not make any assumptions about honorifics (Mr., Mrs., Mx.) and routinely check in with clients about pronouns. Secondly, it’s helpful to practice not using gender language and this may require an accountability buddy, which is something I continue to engage in myself. Thirdly, avoid using passive language such as: “X identifies as” and “X prefers” as this robs the person autonomy over their own identity. Lastly, make a brief apology, correct yourself, and set an intention to gender a person correctly two or three times in a follow-up sentence.
2. If you’re not a man, woman, or trans, then what are you?
This microaggression both invalidates and insults a non-binary persons lived experience. Gender is a construct, made up to control and classify people. Many non-binary folx reject the construct of the gender binary entirely. Asking a person, “what are you,” is cruel considering the fact that we are all simply humans. A more affirming question here could be, “how would you classify your gender identity and/or gender expression?” and “who are you, in terms of your gender?” Additionally, you may ask the client, “Would you be willing to share with me your experience exploring your gender and where you find yourself today?” With each of these suggestions, you allow the client the opportunity to self-identify and open up a dialogue about the client’s lived experience. As clinicians, it’s important that we do not restrict our client’s ability to explore. Above all, I encourage all therapists and wellness providers to center curiosity.
3. That (insert gender identity or neo-pronouns) sounds made up.
Woah! This one hurts to type. I like to remind folx that gender inherently is a fabricated classification system. Though for many non-binary, transgender, and gender expansive people, out lives are only just beginning to feel like our own. New terms for gender identity continue to emerge daily. A client once said in a group session, “I bet there are as many gender identities as people in the world, because we all experience life differently.” I couldn’t agree more with this comment. It would be more helpful to say something like, “I have never heard of the gender identity or pronouns you just mentioned, would you be willing to talk to me about how you define this gender identity or pronouns?” Or you may elect to offer to do research on your own time outside of session to spare your client from having to educate you, the clinician.
Though new terms like gendervague and genderfuck continue to emerge, the definitions of each of these terms will vary depending on who you ask. Neo-pronoun, or new pronouns, also continue to emerge as an outlet for non-binary folx to replace their name with a non-gendered word. Some common examples of neo-pronouns include:
If you’re anything like me, you’re probably going to need some practice using these in a sentence. Find a friend to practice with or try out this helpful website.
4. Did you have the surgery?
Eek! It’s important to note that there are numerous gender affirming medical procedures that gender expansive people can pursue. There is no ONE surgery that all non-binary folx undergo. For many non-binary folx, there is no interest in pursuing gender affirming medical procedures. While others may elect to engage in one or many gender affirming medical procedures.
As a clinician, I urge you to first ask yourself whether you ask your endosex, cisgender and heterosexual clients about their medical history. If you do not, then ask yourself why you feel entitled to ask your non-binary client this question? Two affirming questions could include: (1) what forms of transition are part of your path; and (2) have you considered gender affirming medical procedures to affirm your gender identity and/or gender expression?
Types of Transitions
With respect to transitions, they are not necessary to be a non-binary person. They are also not necessary for binary transgender people either! However, there are three distinct types of transition that could be a part of a client’s gender journey: (1) social transition, (2) legal transition, and (3) medical transition.
Firstly, social transition is in reference to the ways in which a person identifies and presents their gender in public. Some aspects of social transition include, choice of clothing and/or makeup, changing one’s name, selecting pronouns, tucking, packing, binding, and coming out.
Secondly, legal transition is in reference to the ways in which a person actualized their gender through updating legal documents. These documents can include a person’s name, social security number, birth certificate, passport and driver’s license.
Lastly, medical transition is in reference to the various procedures available to folx to actualize their gender. Some common procedures may include surgery, hormone replacement therapy (HRT), vocal training, laser hair procedures, and fertility preservation.
Please respect your client’s right to privacy as non-binary folx are often encountering invasive questions related to their body from all directions. Historically and through stereotypical media portrayals of gender expansive people, transgender and non-binary bodies have been labeled perverse, odd, and unusual for far too long. If you don’t ask your endosex, cisgender and heterosexual clients about their body parts, then why do you feel entitled to do so with non-binary clients?
Furthermore, I urge you to validate and normalize the response of “I don’t know” from a client in your care. I have found that this can be challenging for client’s to say as there are so many societal pressures to have answers. As a result, modeling and normalizing that not having an answer is acceptable can be incredibly validating to non-binary clients.
Also, it is important to mirror the language of your client when discussing aspects of the client’s physical body. I suggest asking, “how will we refer to the insert body part?”
5. How are you non-binary if you aren’t androgynous?
Just like there is no one way to look like a cisgender woman or man, there is no right way to look non-binary. This question is incredibly harmful as many non-binary folx experience imposter syndrome. Additionally, most non-binary folx experience discomfort or dysphoria due to being perceived as a cisgender person. Being androgynous is only one way in which the vastness of non-binary gender expression is embodied. Many non-binary folx experience and express their gender more fluidly.
Instead of reinforcing a false narrative of how to be a non-binary person, consider empowering your client. You may ask, “how do you embody and affirm your gender?” Or you may ask, “what makes you feel most like your fully embodied self?” Sometimes these questions will open a door of exploration and other times clients will find themselves unable to answer. If your client has no answer, I would invite you to ask them if they’d be willing to explore this with you. Furthermore, I will sometimes offer to lead a client through a creative arts or visualization exercise. This offers the opportunity for the client to move away from traditional language and engage their playful imagination.
6. It sounds like your (insert gender identity) is a product of your past trauma.
Ouch! Whether or not there could be truth to this statement, no one can go back and rewrite their history. Instead of focusing on how the past may or may not have caused a person to become gender expansive, why not focus on the now? So many non-binary folx feel disempowered and therapy is an intentional space to reclaim that power. Getting caught up in the what ifs of the past prevents clients from becoming more assured of themself in the present.
It can be powerful to validate a client’s past lived traumatic experience. I also encourage you as a clinician to assist your non-binary client with cultivating self-esteem. You might say something like, “Your past experiences have shaped the person you are today, and I am so grateful for the opportunity to know the person you’re becoming (or you have become).” Embolden your client to lead the conversation and connect to their past, if and only if that’s their own desire. Otherwise, continue to center the here-and-now of their gender journey.
7. Are you sure? I know being non-binary is trendy now.
This comment is loaded for a variety of reasons. Firstly, many folx are currently exploring their gender and identifying as non-binary for many may be the first step on that journey. Secondly, some experience gender as an aspect of self in constant movement and evolution. Thirdly, whether or not being non-binary is trendy or not, we need to reclaim our gender expansive history.
Gender diverse people have existed throughout history such as the First Nations, two spirit and Hijras, who are officially recognized as a third gender in India. Additionally, you may want to learn more about the transgender history in the U.S. and globally as well as the history of trans health care in the United States. And if you haven’t already started, it’s never too late to explore your own gender identity and gender expression in greater depth.
8. Making the assumption that all non-binary people want to talk about in therapy is gender.
There are certainly a vast number of people seeking therapy at this time to explore their gender. Then there is a large number of non-binary folx who are more confident in who they are and are seeking therapy for alternative reasons. Many non-binary folx express in consultations that their previous therapist would only ask questions about the client’s gender identity. This stifles our clients ability to be fully human and process the vastness that is the human experience.
Instead of assuming that non-binary and gender expansive clients want to discuss gender, perhaps you will ask what they would like to focus one. I, like many therapists, offer an intake questionnaire, which serves to allow the client to self-determine goals for therapy. Some clients are seeking an affirming provider with or without lived experience, but with the purpose of processing depression, anxiety, trauma, substance use, life transitions, and so much more. I can’t stress enough how important it is to allow your client to have control over their therapy goals. It also helps to add to your intake forms a place to add pronouns, salient identities, and chosen names.
9. Using words such as normal and regular as synonyms for cisgender, endosex and heterosexuality.
This is a prime example of systemic microaggressions. We have all been socialized in a world that assumes heterosexuality and cisgenderism as the baseline. There is nothing odd, unusual, or irregular about being gender expansive. For most, actualizing their non-binary gender identity and/or expression is a liberating experience. In short, this example upholds systems of oppression that harm everyone.
I recommend that all therapists engage in implicit bias exercises to identify the ways we internalize gender, gender roles, and gender expectations. The following three books are incredible resources:
- A Clinician’s Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients
- The Queer and Transgender Resilience Workbook: Skills for Navigating Sexual Orientation and Gender Expression
- You and Your Gender Identity: A Guide to Discovery.
As clinicians, we can only go with clients where we have dared to venture ourselves.
I microaggressed my client – What do I do?
As humans, we all have the ability to harm. Apologies are opportunities to take accountability; however, refrain from lengthy apologies. When apologizing, center the harm and avoid providing an excuse for your intentions. I have and continue to make mistakes as a therapist. I welcome these experiences as opportunities to deepen the therapeutic relationship. Therefore, these instances are opportunities to collaborate and empower our clients to identify their needs.
I am also a fierce advocate for therapists engaging in their own therapy and supervision. These can certainly be expensive endeavors, but so important for our own growth both personally and professionally. For example, seek out or create peer supervision groups. Obtain adequate training from folx of lived experience with regards to providing affirming care to TGNC clients. Lastly, please Please PLEASE avoid advertising yourself as a gender affirming provider until you’ve gained specialized training.
Learn more about working with transgender and nonbinary clients
Bergner, D. (2021, July 23). The Struggles of Rejecting the Gender Binary. The New York Times. https://www.nytimes.com/2019/06/04/magazine/gender-nonbinary.html?auth=login-google
Chang, S. C., Singh, A. A., & dickey, l. m. (2018). A Clinician’s Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients (1st ed.). Context Press.
Hoffman-Fox, D. (2017). You and your gender identity: A guide to discovery. Skyhorse Publishing.
Indug. (2018, October 29). India’s Relationship with the Third Gender. UAB Institute for Human Rights Blog. https://sites.uab.edu/humanrights/2018/10/29/indias-relationship-with-the-third-gender/
Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: The experience of transgender identity development. Journal of Homosexuality, 61(12), 1727–1758. https://doi.org/10.1080/00918369.2014.951262
McLemore, K. A. (2014). Experiences with Misgendering: Identity Misclassification of Transgender Spectrum Individuals. Self and Identity, 14(1), 51–74. https://doi.org/10.1080/15298868.2014.950691
Nadal, K. (2013). That’s So Gay!: Microaggressions and the Lesbian, Gay, Bisexual, and Transgender Community (Perspectives on Sexual Orientation and Diversity) (1st ed.). American Psychological Association.
Singh, A. A. (2018). The Queer and Transgender Resilience Workbook (Skills for Navigating Sexual Orientation and Gender Expression) (1st ed.). New Harbinger Publications.
Spatrisano, J. (2019, August). Microaggressions Towards Gender Diverse Therapy Clients and the Mediating Effects of Repair Attempts on the Therapeutic Process (No. 13903396). ProQuest LLC. https://www.proquest.com/openview/628748913234c0faf3ae03f578067f7c/1?pq-origsite=gscholar&cbl=18750&diss=y
Stryker, S. (2017). Transgender History, second edition: The Roots of Today’s Revolution (Seal Studies) (2nd ed.). Seal Press.
Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271–286. https://doi.org/10.1037/0003-066x.62.4.271
Sue, D. W., & Spanierman, L. B. (2020). Microaggressions in Everyday Life (2nd ed.). Wiley.
Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77. https://doi.apa.org/doiLanding?doi=10.1037%2Fsgd0000081
Two-Spirit. (n.d.). Indian Health Service: The Federal Health Program for American Indians and Alaska Natives. Retrieved August 28, 2021, from https://www.ihs.gov/lgbt/health/twospirit/
Yee, N. & Gonzalez, M. (2021). History of Transgender Inequality in Health Care – THINQ at UCLA. Medium. https://medium.com/thinq-at-ucla/history-of-transgender-inequality-in-health-care-77e5370fd939
Bisexual Polyamorous Clients in Therapy
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.
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
Black Gay Men and Crystal Meth: My Story
I am Black, gay, and a social worker. I work in a recovery center where I help individuals attain and maintain their sobriety. I have had experience on both sides of the “social service” table, and my personal and professional experience has given me access to the elusive community of crystal meth users.
A friend of mine who experienced addiction once asked me to accompany him to a Crystal Meth Anonymous (CMA) meeting. Upon our arrival, the room buzzing with conversation, I noticed that my friend and I were two of only three people of color in the space of about 25 people. When the meeting opened up the floor to share, the only other person of color present shared about a tough time he was going through and broke into tears. He was raw in the moment, and as much as I wanted to walk over and console him, I froze. No one approached him.
I didn’t know what to do at that moment. So I waited until after the meeting and then I pulled him aside. He shared that this wasn’t the first time he had a breakdown or breakthrough in a CMA meeting, and that he didn’t expect comfort because no one had ever comforted him before. He went on to say that even in a room filled with people who share the same pain, he still felt alone.
Racism: the elephant in the room
This is not unusual: within the larger gay community, I often hear stories of cultural difference–that in these spaces of “inclusion,” there is an elephant in the room that many refuse to acknowledge or address. Many of the white men in this room were on dating and hookup sites advertising their attraction to men of color; they plastered their desire for “BBC” (big black cocks) all over these apps, accompanied by the capital letter T as a silent signal to meth users. Why is it so difficult for these same individuals to console someone in an emotional state of need? Is it because they don’t see our value outside of the bedrooms? Wealthy white men’s fetishizing and desire of Black men‘s bodies while using is not uncommon, and they dangle crystal meth like a carrot hoping for a treat from their trick.
I remember being in these rooms and feeling afraid, embarrassed and mostly alone. These dark emotions fueled my desire to use so that I could lower my inhibitions and allow myself to engage in these humiliating experiences. All for Tina. These sex rooms were eerily similar to that CMA meeting room, but here, the white men couldn’t keep their hands off me, nor anyone who looked like me. When I finally crossed paths with those who shared my same hue and were also users, I discovered that we shared that same experience. That’s when I decided to look for help, which wasn’t easy.
Addiction as a disease of isolation for Black gay men
It can be difficult as a Black gay man who has suffered from addiction, whether current or in the past, to find community support. Black crystal meth users have a harder time because it is widely seen as a “white man’s drug.” The Black gay men with whom I have worked often express their fears of sharing about their struggle with addiction even with their friends. With the fear and shame of their addiction, most of these men succumb to one of the most dangerous symptoms of crystal meth addiction: isolation.
Connection is a pillar in the Black community. Connection informs how we give and receive love, how we communicate, and also how we feel valued. Connection bonds the value and friendships that we create with our chosen families. Chosen families are an essential part of the LGBTQIA+ community; they enable us to find the support and love that our biological families might not provide. Crystal meth addiction can be detrimental to these connections, forcing the men who use it to suffer in silence. They may not share about their addiction because of how they will be viewed, or for fear of becoming the subject of the latest gossip.
Unfortunately, that fear became my reality. I had reached out for help from someone I thought was part of my circle of support, only to end up being grist for the rumor mill. These experiences severed my trust in people, scaring me from looking for help. I was afraid of sharing more with old friends, for fear that they would repeat the same behavior. I also struggled with making new connections, afraid that they would somehow find out about my addiction and want nothing to do with me.
On being both client and service provider
It took some time, but I was able to connect myself with services; I credit my professional experience with helping me locate resources. My background in linking consumers to community supports like Medicaid and substance abuse programs became my reality. I was on the other side of the table, having been in the position of both client and provider.
I am confident that many out there can maneuver beyond their addiction and locate the necessary support to begin their own journeys to sobriety. However, there are so many others who are unable or are too discouraged by the daunting process.
Applying for Medicaid and enrolling in substance abuse treatment programs can be tasks within themselves. Fortunately, organizations like the D.C.-based Us Helping Us and Whitman-Walker Clinic offer streamlined services for MSM with crystal meth addiction, help with applying for health benefits, and much more. In New York, there is the Ike & Tina meeting, which centers the experiences of Black queer and trans folx seeking recovery.
But there is a tremendous need for culturally sensitive program models offered on a national level, along with greater accessibility of culturally cognizant therapists. Affirmative therapy provides safer spaces in which to unpack one’s life experiences, which is essential for anyone in or seeking recovery. My love for my profession plays an instrumental role in my search for the best way to support those with addiction. However, beyond this passion for the work that I do, my reach as an individual is limited.
It is time to tailor, on a larger scale, recovery services to our clients’ cultural experiences and needs. Community and mental health providers must seek training specifically designed to address the intersections of addiction and culture. Continuing education is vital for any and all of us providing services to clients whose multiplicity of identities and experiences we recognize and respect. In addition to pursuing ongoing training to create a workforce rich in cultural humility, providers should engage in advocacy efforts to ensure the creation and funding for recovery programs that will meet our clients where they are and propel them forward. There is much work ahead for affirmative providers!
In my third and final article in this series, I will explore the resources available to help practicing clinicians address the intersections of culture and addiction.
“Not everything that is faced can be changed; but nothing can be changed until it is faced.” – James Baldwin
Lee, C., Oliffe, J. L., Kelly, M. T., & Ferlatte, O. (2017). Depression and suicidality in gay men: Implications for health care providers. American Journal of Men’s Health, 11(4), 910–919. https://doi.org/10.1177/1557988316685492
Affirmative Therapy: Crystal Meth in the Black Gay Community
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.
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/.
Why LGBTQIA+ Affirmative Therapy is Critical During the Pandemic
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
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
Listening to our Transgender Clients: The Fear is Real
November 20th has been known since 1999 as the Transgender Day of Remembrance (TDOR). On this date, across the world, ceremonies and vigils are held to remember transgender individuals we lost to murder and suicide in the past year. Often somber and emotionally triggering, TDOR allows the community to gather and honor individuals whose stories are often ignored or incorrectly told. As this day approaches, I often think of Marsha P. Johnson.
Johnson, a transgender black woman, has long been credited within the queer and trans community for being the person who threw that first brick at Stonewall (Feinberg, 1996) and the creator of STAR, an LGBTQ+ youth shelter. Many don’t know that Johnson was an activist from early on in her life, fighting for gay rights and visibility instead of assimilation (Chan, 2018). After high school, she spent her days on the streets of New York, learning to survive and being repeatedly sexually assaulted and harassed (Chan, 2018). But the assault, harassment, and oppression she experienced due to her sexuality, gender identity, and skin color didn’t stop her for standing up for what she believed in. Knowing firsthand the discrimination the often-ignored transgender community suffered, she took an active role in ACT UP (https://actupny.org/), helping to speak out for HIV+ individuals and give a voice to people of color who were dying from the disease (Jacobs, 2016). Johnson was an inspiration to transgender individuals, especially to those of color. Her tragic death is frequently regarded as the first “notable” and documented murder of a transgender person in the United States.
In 1992, shortly after the New York City Pride Parade, Johnson’s body was found floating in the Hudson River (Feinberg, 1996). The cops ruled it a suicide, despite many people’s protests that Johnson was anything but suicidal and eyewitness reports that she was being harassed earlier during the day they believed she had died (Feinberg, 1996). The case was limitedly investigated and never solved. The media portrayed Johnson as a trans woman who was a sex worker and a drug user, leaving out the truths of her activism and every other aspect of her life (Feinberg, 1996); it is likely that had she been a cisgender white woman, media coverage would have been vastly different and much wider. Johnson’s voice, something she worked so hard to give herself while navigating major oppression in her lifetime, was taken away. Even worse, her killers were never found; to this day, minimal effort has been put into solving her murder.
You may be wondering what this has to do with psychology, and how Johnson’s death can show up for you, as a clinician, in the therapy room with your transgender clients. Well, it’s simple: the reaction of the public to Johnson’s death parallels how many transgender individuals feel about what their lives are worth to the rest of the world. It also relates to transgender people’s sense of whether others care about their safety. As a clinician who has worked in the community in varying capacities, I can attest to the fact that transgender people feel that their lives don’t matter. There is a constant threat of insufficient safety and feelings of protection, especially under the Trump administration when it seems as if transgender rights are under attack daily.
Almost every week I hear about another transgender individual, usually a trans woman of color, who has been murdered or found dead under mysterious circumstances. In many of these cases the killer is never found, or if they are, they are not named. The media often misgenders the victim, and very little coverage is given in the first place. My trans clients come to me with fear in their voices, wondering if they will be next just because they are living their authentic truths. Worse, and heartbreakingly, clients sometimes find that this fear is accompanied by wondering whether or not anyone would even care if they were gone, and if they deserve being killed due to being transgender.
Furthermore, clients have to navigate safety in many other aspects of life. Transgender clients have told me that they often don’t feel safe in their jobs and have a fear of being fired; what’s worse, nobody in their workplace will do anything to help when they are feeling threatened. I have heard about clients being assisted when buying shoes or clothing, and fearing that a salesperson will “find them out” and make a scene. Clients can fear for their safety in terms of secure housing and access to other social welfare services, the loss of which threaten their ability to survive.
So how can we, as clinicians, help with these fears? Certainly, the wrong thing to do is to try to make excuses for others or diminish the situation, because these fears are real. Also, if you are a cisgender therapist, there is no way to fully understand what your client is going through. It is best not to try to relate or use comparisons to other marginalized communities. I have heard of individuals telling their therapists about the fear of shopping, and the therapists suggesting in response to “shop online,” unsolicited advice that comes across as invalidating.
But then what is the right thing to do? First, validate the fear, which is constantly present. Ask questions. What does this fear look like to them? How does it show up in their lives? Secondly, address the fear and help empower your client to find ways to protect themselves. While we do not teach our clients physical self-defense techniques, we can certainly teach them mental defenses. Find positive self-talk and coping techniques when encountering non-life threatening yet mentally damaging situations. Third, help your client devise safety plans and locate resources. Is there someone they can call any time of the day, or put on alert when they are encountering any new or potentially triggering situation? Is there an emergency line they can reach that they know they can trust? Having access and knowledge to trans-affirmative resources can be life saving.
With all of that said, November is always a difficult month for the transgender community. Whether or not your client is aware of this fear on a daily basis, we cannot deny that the number of deaths we recognize during TDOR and the number of clients facing fear seem to increase annually. November is filled with a constant reminder to be vigilant and that the fight is far from over. As clinicians, we must recognize this and do everything we can to support our clients in the most affirming way possible.
Learn More about working with Transgender and Nonbinary Clients
Chan, S. (2018). A transgender pioneer and activist who was a fixture of Greenwich Village street life. The New York Times. Retrieved from https://www.nytimes.com/interactive/2018/obituaries/overlooked-marsha-p-johnson.html
Feinberg, Leslie (1996). Transgender Warriors: Making History from Joan of Arc to Dennis. Boston, MA. Beacon Press
Jacobs, S. (2012). DA reopens unsolved 1992 case involving ‘saint of gay life’. New York Daily News. Retrieved from: https://www.nydailynews.com/new-york/da-reopens-unsolved-1992-case-involving-saint-gay-life-article-1.1221742
Caring for LGBTQ+ Caregivers of Older Adults
LGBTQ+ caregivers of older adults (generally people age 60+) are a special population in need of support and affirmative care. These family members and friends provide unpaid physical and/or emotional assistance to spouses and partners, parents, friends–some of whom were former partners–siblings, and neighbors. While temporary caregiving for others, when one is recovering from surgery, injury, or illness, can take place at any stage of life and is challenging in many ways, caregiving for older adults can last for many years. This article will explore the issues that some LGBTQ+ caregivers experience in the course of caring for elders.
My own experiences with working with caregivers
I have had the privilege, during my years of practice in the field of aging, of facilitating support groups for caregivers seeking out assistance. The members of my groups have openly shared their innermost thoughts and feelings about giving care with me and with each other. They have expressed feeling that there is no end in sight as more and more of their time and energy becomes consumed with caring for a loved one who will never get better–only worse. Some members have participated in these groups for years on end as they witness the gradual decline of their care recipients due to dementia, medical frailty, cancer, or Parkinson’s disease.
All of these caregivers find that their friends and acquaintances just don’t understand what they are going through and the toll that giving care takes on them. They have relied on each other, and on a trained social worker who holds space in the group setting, to help them navigate the increasingly challenging situations they encounter. When providers become more well-versed in understanding experiences of unpaid caregiving in LGBTQ+ communities, people like these can get better care and more support outside of a group setting. So here are a few things to bear in mind about these generous, caring, and often severely stressed-out individuals.
Unique considerations with LGBTQ+ caregivers
First, it is common for queer and trans people who are not related by blood or marriage to care for each other. In fact, former romantic partners will sometimes become caregivers. Mainstream service providers may not be accustomed to this, and community members have reported encountering a lack of understanding about why an ex-partner would remain closely connected. But the formation of familial relationships among our loving LGBTQ+ communities is commonplace; a number of my LGBT older adult clients have considered their exes to be family members. It is important that providers include anyone an older adult has designated as a caregiver in health care decision making processes–and also that providers recognize the significant strain such caregivers may experience.
That strain can manifest in a number of different ways and lead to negative social and health outcomes. Providing physical, emotional, and financial support for a loved one while putting one’s own needs on the back burner time and again leads to exhaustion and isolation. And LGBTQ+ caregivers face risk factors beyond those commonly experienced by non-LGBTQ+ caregivers. For instance, LGBTQ+ adults who are childless are often expected to take on all of the responsibility of caring for aging cisgender and heterosexual parents. But they may also have faced a historic lack of acceptance, potentially entailing verbal and/or physical abuse, from those parents. And same-sex partners and spouses may still face significant discrimination in the medical, senior services, and institutional settings in which their loved ones receive care.
Supporting LGBTQ+ caregivers
Without adequate support and without anyone to help share the care, caregivers risk burning out. While LGBTQ+-specific groups can be difficult to find outside of SAGE: Advocacy and Services for LGBT Elders’ NYC headquarters, caregiver support programs are available in every state. The National Family Caregiver Support Program (NFCSP), a federal initiative, provides grants to fund not only support groups but case management and some respite and supplemental services. This means that local resources–from assistance with information, benefits and entitlements, and referrals to limited financial help paying for home care and medical supplies–are available to all unpaid caregivers.
Further, an important piece of legislation affecting caregivers has been enacted in roughly 40 states so far. The CARE (Caregiver Advice, Record, and Enable) Act, known by a different name in some states, requires hospitals to ask patients, at the time of their admission, if they would like to designate someone as their caregiver. Whatever the relationship of the caregiver to the patient, the hospital must then record the caregiver’s name in the medical record, notify the caregiver of patient discharge, and provide training for performing medical tasks once the patient is home. This is an important legal consideration for LGBTQ+ caregivers without a formal or documented relationship to their care recipients.
For further reading on this topic, check out the selection of caregivers’ resources at the National Resource Center on LGBT Aging.
Learn more from Teresa Theophano, LCSW
Stewart, D. B., & Kent, A. (2017). Caregiving in the LGBT Community: A Guide to Engaging and Supporting LGBT Caregivers through Programming. Retrieved September 29, 2019, from https://www.lgbtagingcenter.org/resources/resource.cfm?r=883.
Who Helps the Helpers? 8 Tips for Therapists After Client Suicide
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.
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.
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.
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.
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.
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.
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.
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
Balon, R. (2007). Encountering patient suicide: The need for guidelines. Academic Psychiatry, 31, 336-337. doi:10.1176/appi.ap.31.5.336
Campbell, C., & Fahy, T. (2002). The role of the doctor when a patient commits suicide. Psychiatric Bulletin, 26, 44-49. doi:10.1192/pb.26.2.44
Coverdale, J. H., Roberts, L. W., & Louie, A. K. (2007). Encountering patient suicide: Emotional responses, ethics, and implications for training. Academic Psychiatry, 31, 329-332. doi:10.1176/appi.ap.31.5.329
DeAngelis, T. (2001). Surviving a patient’s suicide. Monitor on Psychology, 32(10). Retrieved from https://www.apa.org/monitor/nov01/suicide
DeAngelis, T. (2008). Coping with a client’s suicide. GradPSYCH Magazine, 11. Retrieved from https://www.apa.org/gradpsych/2008/11/suicide
Dewar, I. G., Eagles, J. M., Klein, S., Gray, N., & Alexander, D. A. (2000). Psychiatric trainees’ experiences of, and reactions to, patient suicide. Psychiatric Bulletin, 24, 20-23. doi:10.1192/pb.24.1.20.
Finlayson, M., & Simmonds, J. (2019). Workplace responses and psychologists’ needs following client suicide. Omega: Journal of Death & Dying, 79(1), 18-33. doi:10.1177/0030222817709693
Ford, D. (2009). Junior clinical psychologists’ experience of processing the death of a therapy client, from a cause other than suicide: A qualitative study (Unpublished doctoral dissertation). University of Hertfordshire, United Kingson.
Fox, R., & Cooper, M. (1998). The effects of suicide on the private practitioner: A professional and personal perspective. Clinical Social Work Journal, 26(2), 143-157.
Gitlin, M. (2007). Aftermath of a tragedy: Reaction of psychiatrists to patient suicides. Psychiatric Annals, 37, 684-687.
Gladding, S. (2011). The creative arts in counseling (4th ed). Alexandra, VA: American Counseling Association.
Gorkin, M. (1985). On the suicide of one’s patient. Bulletin of the Menninger Clinic, 49, 1-9.
Hendin, H., Haas, A., Maltsberger, J. T., Szanto, K., Rabinowicz, H. (2004). Factors contributing to therapists’ distress after the suicide of a patient. The American Journal of Psychiatry, 161(8), 1442-1446. doi:10.1176/appi.ajp.161.8.1442
Horn, J. (1994). Therapists’ psychological adaption to client suicide. Psychotherapy, 31, 190-195.
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. transgender survey. Washington, DC: National Center for Transgender Equality.
Kapoor, A. (2004). Suicide: The effect on the counselling psychologist. Counselling Psychology Review, 1(3), 28-36.
Kleespies, P. M., Smith, M. R., & Becker, B. R. (1990). Psychology interns as patient suicide survivors: Incidence, impact and recovery. Professional Psychology: Research and Practice, 21, 257-263.
Knox, S., Burkard, A. W., Jackson, J. A., Schaack, A. M., & Hess, S. A. (2006). Therapists-in-training who experience a client suicide: Implications for supervision. Professional Psychology: Research and Practice, 37, 547-557. doi:10.1037/0735-7028.37.5.547
Lang, N. (2019). Nearly 40% of LGBTQ youth have contemplated suicide: Report. Rolling Stone. Retrieved from https://www.rollingstone.com/culture/culture-news/lgbtq-youth-suicide-report-846952/
Linehan, M. M. (2015). DBT skills training manual (2nd ed.). New York, NY: The Guilford Press.
McAdams, C. R., III, & Foster, V. A. (2002). An assessment of resources for counselor coping and recovery in the aftermath of client suicide. Journal of Humanistic Counseling, Education & Development, 41, 232-241.
National LGBT Health Education Center. (2018). Suicide risk and prevention for LGBTQ people. Boston, MA: The Fenway Institute.
Papadatou, D. (2000). A proposed model of health professionals’ grieving process. OMEGA: The Journal of Death and Dying, 41, 59-77. doi:10.2190/TV6M-8YNA-5DYW-3C1E
Sacks, M. H., Kibel, H. D., Cohen, A. M., Keats, M., & Turnquist, K. N. (1987). Resident response to patient suicide. Journal of Psychiatric Education, 11(4), 217-226.
Sanders, S., Jacobson, J. M., & Ting, L. (2008). Preparing for the inevitable: Training social workers to cope with client suicide. Journal of Teaching Social Work, 28(1), 1-17. doi:10.1080/08841230802178821
Shannon-Karasik, C. (2017). Therapists told us what it’s like to lose a patient to an overdose. Vice. Retrieved from https://vice.com/en_us/article/kznw4z/therapists-lose-patient-to-overdose
Strom-Gottfried, K., & Mowbray, N. D. (2006). Who heals the helper? Facilitating the social worker’s grief. Families in Society: The Journal of Contemporary Social Services, 87, 9-15.
Ting, L., Jacobson, J. M., & Sanders, S. (2008). Available supports and coping behaviors of mental health social workers following fatal and nonfatal client suicidal behavior. Social Work, 53(3), 211-221.
Valente, S. M. (1994). Psychotherapist reactions to the suicide of a patient. American Journal of Orthopsychiatry, 64, 614-621.
Veilleux, J. C. (2011). Coping with client death: Using a case study to discuss the effects of accidental, undetermined, and suicidal deaths on therapists. Professional Psychology: Research and Practice, 42(3), 222-228. doi:10.1037/a0023650
Whisenhunt, J. L., DuFresne, R. M., Stargell, N. A., Rovnak, A., Zoldan, C. A., & Kress, V. E. (2017). Supporting counselors after a client suicide: Creative supervision techniques. Journal of Creativity in Mental Health, 12(4), 451-467. doi:10.1080/15401383/2017/1281184
Breaking Mental Illness Stigma: The Broad City Way
By Briana Shewan, MFT
If you are a dedicated viewer of Broad City, then you’ve already seen “Make the Space.” Directed by Ilana Glazer and written by Jen Statsky, the fourth episode of the fifth season of the Comedy Central series, which aired on Feb 14th, 2019, focuses on mental illness by way of characters Jaimé’s hoarding and Ilana’s take on a therapy intervention.
Spoiler alert – details of this episode are referenced throughout this article.
This is not the show’s first episode dedicated to addressing mental health (for example, Ilana’s struggle with seasonal affective disorder, aluminum foil, and a light so powerful she blows a restaurant’s circuit in season four, episode five, “Abbi’s Mom”). What this current episode manages to do, though, is help to break mental illness stigma; portray queer, brown, and affirming love; and set us up to cheer on Ilana’s pursuits as a therapist.
Breaking Mental Illness Stigma
“Make the Space” is reflective of what makes Broad City so great: their unique take on a subject in a way that is relevant, upbeat, funny, and doesn’t take itself too seriously. Despite the prevalence of people experiencing mental illness and the range of media portraying these issues, this episode uses its platform to normalize anxiety and focus on positive, however comedically flawed, responses.
The episode features Ilana Wexler (Ilana Glazer) non-consensually going into her roommate Jaimé Castro’s (Arturo Castro’s) room. She does so to find the source of a funky smell, though not without acknowledging it as wrong, particularly given that she is white and Jaimé is brown. Jaimé later makes clear that he doesn’t excuse her breach of his privacy. When she opens his door, she finds evidence of hoarding in the form of excessive amounts of alarm clocks, newspapers, piggy banks, and the like. Ilana proceeds to recruit her best friend and co-star Abbi Abrams (Abbi Jacobson), and together they put Jaimé’s things into black plastic bags and carry them out to the trash. Just when your cringing reaches its climax, Ilana reads about hoarding in her old psych textbook that she found amongst his items and, realizing they’ve crossed a boundary, puts his room back the way it was before he returns home, thus returning his autonomy and agency.
I imagine that if I experienced hoarding or specialized in it as a therapist I might have more criticism of the portrayal of it, particularly because the episode doesn’t go into Jamié’s struggles or challenges. Despite the drawbacks in relatability of its linear and reductive approach, the episode achieves a non-pathologizing stance by focusing on his stressors.
Keeping it Queer, Brown & Affirming
When Jaimé returns to the apartment with his boyfriend, Johnny (played by openly gay actor Guillermo Díaz), Ilana facilitates a therapy session to address Jaimé’s hoarding (again, non-consensually). This is not the show’s first go at portraying queer sexuality. Many of us cherish Ilana’s love and attraction for Abbi, whose actress came out publicly as bisexual in real life.
What “Make the Space” does more than ever before on the show is contextualize Jaimé’s mental illness as a gay brown immigrant. As Ilana prompts him to reflect on the origins of his anxiety from which his hoarding may have manifested, Jaimé speaks about the lack of control he experienced due to his status before becoming a citizen as the initial source.
As a white U.S. citizen since birth, I can only imagine what the significance of this representation of Jamié and his partnership might be for queer, brown and undocumented people. As the show often does in overt and covert ways, it seemed as though Broad City was making a timely point to address our political climate, this time taking on immigration, racism, and homophobia amidst Trump’s wall-building agenda.
Finally, it’s when Ilana is constantly distracted by Abbi from attempting to be a therapist for Jaimé that he is truly affirmed. Through face-to-face conversation with Johnny in Spanish, and Johnny’s non-judgmental, supportive approach, Jamié is able to talk about his embarrassment over hoarding and his more recent source of anxiety, their relationship. Through their intimate and honest communication, Jaimé and Johnny agree to face the vulnerability of falling in love together in order to continue to grow their connection. While the 22-minute episode presents a feel-good arch to hoarding that’s just as short, doing so highlights the strengths of its queer brown characters. However unrealistic, this take is a refreshing narrative when focused on Jaimé and Johnny’s relationship.
Ilana the Therapist
As a therapist myself, Ilana’s approach with her roommate was particularly humorous. She’s dressed in all white, wearing glasses, with a neutral, calm tone to her voice (at least when she’s not arguing with Abbi) and an empty pizza box in her lap for taking notes. She’s turned their New York City living room into her “office” equipped with tissues, candles, and the empty assurance of it as a “safe space” only to have a light fixture fall off the wall. “Well, not literally safe,” she clarifies. The portrayal is a stage of therapeutic clichés.
Jaimé, Johnny, and Abbi each separately tell Ilana that the session wasn’t real and was unprofessional, from the fake statement of confidentiality to calling Jaimé “crazy” for deciding to move in with his boyfriend- because he’s her roommate- to yelling at Abbi about toe sucking and lactose intolerance (to name a few examples). Ilana asks Johnny if she was a good therapist to which he replies, “You made the space for Jaimé to talk about his issues. That’s really all you can do as a therapist, right? Just make the space.” The episode ends with Ilana sharing with Abbi that she wants to look into schools in order to pursue a therapy career. This is a particularly poignant moment. Long-time viewers have watched Ilana not take her work life seriously. While there’s nothing necessarily wrong with that, her sharing her professional goals with Abbi in this final season of the show is heart-warming character development for more than just Abbi to get behind.
I like to imagine that more people like Ilana in the field would help to disrupt patriarchal curriculum, exploitative labor practices, and the inaccessibility of mental health services due to medicalized gatekeeping and the non-profit industrial complex. I think Ilana’s unapologetic feminism and sexuality, and preference for weed over respectability politics would translate to her being client-centered, sex positive, and a harm reductionist. Even with these forward-thinking qualities, we all have things to work on. For example, if Ilana were my colleague, I might start a conversation with her about her appropriative use of African American Vernacular English, including her common use of the phrase “yasss queen” as well as her referring to Jaimé’s relationship as “going dopely” in this very episode. I would also mention that her joke about her mom looking at hoarding videos to lose her appetite when she’s dieting makes me hyper-vigilant of fatphobia.
The next order of business – processing our grief around Broad City ending.
R. (2018, April 07). Abbi Jacobson is bisexual: Ilana Wexler has called dibs though. Retrieved
Blay, Z. (2015, October 19). 12 words Black people invented, and white people killed. Retrieved
Glazer, I. (2019, February 14). Ilana glazer on Instagram: “this is one of my favorite moments from tonight’s episode of @broadcity written by @jenstatsky and directed by me! @arturocastrop is a star…” Retrieved from https://www.instagram.com/p/Bt4XGqUlzvx/
Mayo Clinic Staff. (2018, February 03). Hoarding disorder. Retrieved from
Reddish, D. (2018, June 14). Guillermo Diaz, the ‘Scandal’ star who made out & proud look easy. Retrieved from
Statsky, J. (Writer). (2019, February 14). Make the Space [Television series episode]. In Broad City. New York, New York: Comedy Central.
Trump wall. (2019, February 19). Retrieved from https://en.wikipedia.org/wiki/Trump_wall
Finding a Polyamory-Affirmative Therapist
By Stephanie M. Sullivan, MS, LLMFT
Many people, across all walks of life, occasionally need therapeutic services. Due to the stigma surrounding mental health, it can be difficult for anyone to contact a mental health therapist. However, if you are polyamorous or curious about exploring polyamory, you may struggle even more with reaching out to a new therapist or opening up to your current therapist about your relationship style, as many therapists lack knowledge and may have judgmental views of consensual non-monogamy (Schechinger, Sakaluk, & Moors, 2018). You may want to explore mental health services as an individual, to work through some aspect of your relationship, or you may want to pursue therapy with a partner, a metamour, or more than one person in your polycule. If you are currently monogamous and thinking about opening up your relationship, you may want to seek both individual and couple therapy in order to explore the relationship options available to you both alone and with your partner.
Alternately, you may be interested in receiving mental health services for a reason unrelated to your relationship structure. Whether you are experiencing depression, anxiety, work-related stress, processing trauma, or working on something else, you may know that your polyamorous relationship structure is not the cause of your distress but is still an important part of who you are. You don’t want a therapist who will automatically blame your relationship structure for your anxiety; you want someone who can differentiate between a healthy relationship and an unhealthy relationship (regardless of the style of that relationship) and focus on the actual causes of the anxiety you are experiencing.
For these reasons, it may be important to you to find a polyamory-friendly or polyamory-affirmative therapist. When we say a therapist is “polyamory-friendly,” this means that they are open-minded and accepting, but may not have much knowledge or experience in working with the polyamorous community. When a therapist is polyamory-affirmative, they have extra knowledge or training about polyamory, and may have gone out of their way to gain this experience. A polyamory-affirmative therapist will also be outwardly supportive of your relationship style, able to acknowledge how societal expectations and oppression may affect you, and be able to help you deconstruct these societal narratives.
Finding a therapist who is a good fit can be a challenging process for many people, but it can be especially challenging within the non-monogamous community. Many people within the community have often had difficulty with finding an accepting and knowledgeable therapist in their area (Anapol, 2010; Schechinger, Sakalk, & Moors, 2018). Some people have reported that their therapists told them their polyamorous relationship was problematic, the cause of their depression, or meant that they had an insecure attachment style (Anapol, 2010; McCoy, Stinson, Ross, & Hjelmstad, 2015). If your therapist is not aware of, comfortable with, and sensitive to your relationship style, it can be very difficult to achieve your goals in therapy, and may actually lead to more distress for you as the client (Graham, 2014; Williams & Prior, 2015).
To those who are polyamorous, it may be unsurprising to hear that relatively few therapists have heard of polyamory, and even fewer therapists have actually worked with polyamorous clients (Weitzman, 2006). It can be extremely frustrating when you go to therapy and have to spend the session educating your therapist about polyamory. Of course, every relationship is different and unique, so you will have to spend some time telling your therapist about your individual situation and what is bringing you to therapy. But you shouldn’t have to use your session time to educate your therapist on polyamory in general, or defend your relationship style to them. While therapists are slowly becoming more informed about polyamory, they are still far behind in becoming knowledgeable and competent in working with the community (Johnson, 2013).
However, this does not mean that finding an understanding and supportive therapist is a lost cause! There are many ways to find a therapist who will be accepting of your relationship, and it is important to check all of these avenues to find the person that will be the best fit for you.
First, try online searches and directories for polyamory-friendly professionals. Some of these resources include:
- The Polyamory-Friendly Professionals Directory: https://www.polyfriendly.org
- The Kink Aware Professionals Directory (KAP): https://www.ncsfreedom.org
- The Open List: Openingup.net/open-list
- The Polyamory Loving More Member Professionals List: https://www.lovingmorenonprofit.org
- The “Meet our Experts” section of The Affirmative Couch: https://affirmativecouch.com
It is important to understand that these resources do not have a process to verify the credentials of the professionals that are listed on their sites. However, most (if not all) of these professionals have had to seek out a listing on the site, which took some time and effort. Therefore, these directories are likely to have therapists who are at least polyamory-friendly, even if they are not entirely knowledgeable and competent in working with the community.
Another source to find therapists are more general directories, such as Psychology Today or Good Therapy. You can search these directories based on your location and read the profiles of various mental health therapists. These directories do verify the licensure status and credentials of the therapists listed on their websites, but you may have to read through more profiles to find someone who is supportive of your relationship style. There is no guarantee that the therapists listed here will be polyamory-friendly or affirmative, but it is possible to find someone who has listed polyamory as one of their specialties within their profiles.
Once you have a few names of therapists in your area, check out their listings on other sites or their own website. One way to determine their level of knowledge is to look at how they are marketing themselves. On these directories and other sites, do they simply say they are “open to working with polyamorous clients”? Or do they say something like, “I am familiar with hierarchical polyamory, non-hierarchical polyamory, solo polyamory, and relationship anarchy”? The second therapist in this example may be more polyamory-affirmative, more knowledgeable, or have more experience in working with polyamorous clients than the first one, as they are familiar with the expansive terminology within the non-monogamy umbrella. If the therapist has a blog or professional social media pages, it may be helpful to look at the types of articles they are writing about or sharing, as well.
If you cannot find polyamory-friendly professionals in your area, try looking at other parts of the state you live in to find a therapist who provides online services. You may be able to find a therapist who is willing to book online video chat sessions with you in order to give you the care you deserve. Or, if you have the time, funds, and ability to travel farther than you normally would, it may be worth it to drive a longer distance to see a polyamory-friendly therapist in person in order to gain access to a therapist who will understand your relationship.
If you are still struggling to find a therapist who is accepting and knowledgeable about polyamory, you may want to look at LGBTQ-Affirmative therapists, even if you identify as heterosexual. These professionals may be more open to non-traditional relationship styles and may already work with some non-monogamous clients, although they may not advertise it or consider themselves knowledgeable. This may be an option as well if you are seeking more individualized care that is not explicitly focused on navigating a polyamorous relationship.
Although polyamory-affirmative therapists are difficult to find, they do exist! It will be very beneficial to find a therapist who is right for you and understands your relationship. If you don’t want to spend hours educating your therapist about your relationship style, try using the above resources to find a professional who better suits your needs.
Learn More from Stephanie M. Sullivan
Anapol, D. (2010). Polyamory in the twenty-first century: Love and intimacy with multiple partners. Lanham, MD: Rowman & Littlefield Publishers, Inc.
Graham, N. (2014). Polyamory: A call for increased mental health professional awareness. Archives of Sexual Behavior, 43, 1031-1034. doi:10.1007/s10508-014-0321-3
Johnson, A. L. (2013). Counseling the polyamorous client: Implications for competent practice. VISTAS Online, 50, 1-10.
McCoy, M. A., Stinson, M. A., Ross, D. B., & Hjelmstad, L. R. (2015). Who’s in our clients’ bed? A case illustration of sex therapy with a polyamorous couple. Journal of Sex and Marital Therapy, 41(2), 134-144. doi:10.1080/0092623X.2013.864366
Schechinger, H. Sakaluk, J., & Moors, A. (2018). Harmful and helpful therapy practices with consensually non-monogamous clients: Toward an inclusive framework. Journal of Consulting & Clinical Psychology, 879-891. doi:10.1037/ccp0000349
Williams, D. J., & Prior, E. E. (2015). Contemporary polyamory: A call for awareness and sensitivity in social work. Social Work, 60(3), 268-270. doi:10.1093/sw/swv012