Category: LGBT

Rick Miller on the Clinical Challenges of Working with Gay Sons, Mothers, and Families

Posted on by Psychotherapy.net Team

Gay Sons and Their Mothers

Lawrence Rubin (LR): You may be known to our readers as the founder of Gay Sons and Mothers. But they may not be familiar with how extensively you’ve been trained and how long you've been practicing as a psychotherapist with a personal interest in working with gay men and their mothers. 

Rick Miller (RM): I'm a gay man who grew up really appreciating the bond and love of my mother. And, in hindsight, as an adult, what it meant for me was that I got to be myself. She didn't necessarily know that I was gay, or maybe she did, but she never forced me to do anything differently than what I did.

And growing up in a world in the 1960s where it was prescribed, this is what boys do, having a mom who let me be me — and we did a lot of things together — was pretty miraculous. I hear so many stories about people growing up whose parents abused them or forced them to do things differently.

I wrote a book several years ago for clinicians about doing hypnosis with gay men. I thought it would be relevant to do the research or to seek out research about gay men and their mothers. I looked at the literature about gay men and their mothers to include in the book. You'd think this a cliché topic and that there would be way too much information to use. I couldn't find anything! I thought, I’ll write an article about this, and it ended up turning into video interviews. And from there, I started a nonprofit called Gay Sons and Mothers.

We are educating the public about the special bond between mothers and their gay sons and how she contributes to his sense of well-being in the world. It's a multicultural story that looks at strength, at disappointment, and is a very emotional topic.   

LR: So, even before you and your mother had a conversation about being gay and you knew, you had no particular concern over sharing it with your mom. You didn’t worry how she would take it, how you'd be perceived, how you'd be treated. You were just free from the start to be you. 

RM: Well, I was free to be me, but I didn't come out to them — meaning my parents, my mother and my father — until I was 21. So, it was interesting that I had the freedom to be me, but I didn't feel 100 percent free to be me because I waited longer to come out than I probably needed to in hindsight. Today, many kids are coming out at a much younger age to their parents. Of course, the world is very different.

LR: If you intuitively felt accepted by your mom and weren’t censored or limited in any way from being you — you haven't talked about your dad — why do you think it took you as long as it did to become public about it? 

RM: Well, so, it was the early 80s. So, AIDS was hitting the press big time, and I suppose on one level, I was protecting her or them from thinking that something would happen to me, which, knock on wood, did not happen. I was afraid that I'd be rejected, and, not to sound callous, they were paying for my graduate school education, and I just made a mental note in my mind I was going to wait until I finished school to come out, which is so stupid. 

Knowing my parents, of course, they wouldn't have done anything differently. It took them a while to come around, a month or so, which I thought was horrible at the time. But I look back and I think that my parents had to go through their own grieving when I came out to them. Of course, they knew I was gay long before I came out, but hearing it was definitive. And it took them a short time to acclimate and appreciate it. I was incensed at the time. And, often, I say to children and to parents, it's okay to grieve.

LR: Incensed about? 

RM: They were not 100 percent supportive the second I came out to them. And the first thing my father did when I came out was to become a little weepy saying, “the world is unfair, and I'm worried about what that will mean for you.” I took it as supportive, for sure. And then he kind of changed the tune for a bit, and that is when things turned ugly, and again that lasted a few weeks and then everything turned around. 

LR: Smooth sailing with your parents and especially your mom ever since. 

RM: Yep. And I had a partner that I was moving in with at the time. So, what I did, which I shouldn't have done, was when I came out to them, I told them that I was moving in with the person they knew as my friend all at once, so that threw them a little bit. 

LR: Overload! Going back to the second part of the earlier question about your foundation; how do you think clinicians can benefit from awareness of it? 

RM: There's so much inherent in the videos that we share through Gay Sons and Mothers. It's not only about the relationship between a mother and a son, but that part in and of itself is so affirming. Clinicians can watch stories of sons and their mothers and appreciate what it is being gay. And it's not only mother in these interviews. Families are talked about. Extended families are talked about. Culture and religion are addressed in these videos.

So, there's a lot there, and, when mothers are struggling with their kids, I send them videos from Gay Sons and Mothers. On our website, there's a link to our Instagram page. We have a YouTube page. Sons watch. Most people — therapists included — watch these videos and have a deep emotional resonance around the issue of being included, being loved, being supported, being rejected. It's hard not to feel something when you're watching videos pertaining to these themes.   

LR: A connection. How would you respond to a therapist or to a non-therapist who’s visited your site and says, “Yeah, well, what about gay sons and their fathers?” 

RM: There's way more information in the literature about gay sons and their fathers than there is about gay sons and their mothers. And if there hadn't been any with fathers, I would have pursued that, as well. I grew up with a great relationship with my mother. I had the fame of saying to my siblings, “Mommy likes me best.” It carried me through. So, it seems completely perfect that that would be the focus of my work.  

Historically, mothers in the 1970s — or even earlier in the psychiatric and the medical field — mothers were blamed for making their sons gay. And, so, with the lack of literature out there, what's missing is that mothers have the power to raise sons who are mentally healthy, just from being a good enough mother. And, so, that premise is so important to me that I've focused exclusively on mothers and sons.

The issue of fathers and extended family is embedded in the work anyway. So, this project, Gay Sons and Mothers, is inclusive of the entire family. And we're also expanding beyond just gay sons and mothers. We're talking about trans children and all sorts of things. 

Intersecting Identities

LR: How has your advocacy and clinical work been informed by your own personal evolution? 

RM: Oh, gosh, that's such a big question, but I think I can get there. I came out in 1983 — I was already a clinical social worker. In the 1980s, AIDS was emerging, and gay men were dying in big cities, and people were afraid. Homophobia was on the rise because people were afraid of catching AIDS. I was working in the AIDS field, doing volunteer work at this time, and I started working with the gay community from the start.

Boston, where I lived, was a progressive place. So, I was known in Boston as being an out gay male therapist. I mean, there was no web at that time, but anyone who knew me would know that I was gay. But I was also practicing in a very conservative place, Boston, Massachusetts, very hierarchical, very psychodynamic. So, in the professional world that wasn't the world of AIDS, I worked in a hospital. I kept a very low profile, and I felt like I didn't fit in the hierarchy of psychiatrists, psychologists, social workers.   

I'm a social worker, and looking back at my evolution and my history, I wish I had put myself out there more because the contributions that I'm now making to the field in the last ten years as a writer, as a teacher, as someone who's done Gay Sons and Mothers, if I had the confidence to do some of this earlier, I would have done more research focusing on gay men, on gay men and their mothers, gay families. And I think I could have made a bigger contribution to the field.

What happened for me is I started my private practice in the mid 80s, and I switched to full-time private practice. So, I left the hospital. I left the agency where I was doing AIDS work, and basically, I hid in my office with the door closed for decades. And I was very successful in private practice, in part because of my clinical skills, in part because of my personality, and I got to hide.

Once I wrote my first book and I started teaching about working with gay men, I could no longer hide. And, at the time, I was probably 52 years old — 10 years ago. And I'm really glad it happened, but it forced me beyond a comfort level that was really important and good for me, and I wish I did that sooner.  

LR: So, you came out of the closet before you came out of the office. I can see that your personal story could be used as an exemplar, not only for gay therapists, but for gay men, whether still not out or out. I would imagine that you don't impose your story on others. But by living it and being genuine, as you've always struck me, you are an unintended role model.

RM: Well, thank you for saying that, and it served me very well in my practice. I grew up in an upper-middle-class family with well-being and mental health and good physical health. And, to me, that's how everyone lived in the world, and that is so not the case. And so, as a gay man who had a sense of self, who worked with gay men, I served as a role model to other gay men, to all my clients really but specifically to other gay men who didn't have the good fortune that I did or didn't have the personality that I did.  

So, my being outgoing was a very good clinical skill, and, fortunately, in my early 20s, I was in therapy with a therapist who was gay, who had a very good sense of himself, who had a great sense of humor, and who allowed me in the process of therapy to love myself. If I had chosen one of those uptight, analytical therapists in Boston instead, I don't know where I would be right now.

When I was looking for a therapist, I was given the name of eight different people. Back in 1983, I was calling their answering machines. On some, I was hanging up because I was frightened by them. Others shamed me through their tone, and thank God, I didn't work with them. 

Clinical Challenges of Working with Gay Men (and their Mothers)

LR: What are some of the clinical challenges you've found in working with gay sons and their mothers? 

RM: Long before I ever knew I'd be working with gay men and their mothers, I had a gay male client who was really struggling with confidence. He grew up in the projects outside of Boston, and his father left the family, and deprivation was a big part of his upbringing. So, one day, for whatever reason, I had his mother join him in a session and it was like the heavens opened up.  

I understood him so much more, and the bond and the strength of their relationship was amazing. It helped so much in the clinical work. He was a catalyst that led to this project, Gay Sons and Mothers. Every now and then, I'd have another mother and son together, but it wasn't why they were in therapy. Once I started working on this project, various people consulted with me, families for help with their families. For some, in the field of psychotherapy, for others, through the nonprofit where, for free, I just consult with people and help them along.  

What's been interesting is one mother and son that I'm working with right now in therapy are enmeshed with each other, and they're seeing me every two weeks. On certain days, it feels like couples therapy and I really have to work with them to detangle and let go of their expectations with each other. And, so, this is a divorced mom with an only child who's gay, and they expect each other to meet needs that goes well beyond what they should be for a mother and a son.

This isn't the case in all circumstances, but I think it's a great example of how it can be a bit of a burden on both ends to have this close bond that goes kind of way too far on both ends.   

LR: So, enmeshment is one of the challenges. I imagine acceptance is another. 

RM: So many gay men are way too careful, and they're not coming out to their families as soon as they might, or they give absolutely no details about their private lives to their families who really want more from them. So, that is another challenge, that in being careful, even once they come out, being careful continues to be their MO, even when they don't need to be, and people want more from them. They want to hear more details about their day-to-day lives or what they struggle with, or are they in a relationship with someone?

LR: And I wonder if these particular men are so cautious and close to the chest with their families, if they're even more so outside of the home. 

RM: Correct. I'm working with a bunch of men in their 50s, let's say in their 60s, who came out in an era where it wasn't okay to be gay. And even though it's fine now and they have jobs where they are out, they, without even realizing it, are kind of slipping into modes of privacy and protecting themselves because it's a habit that's been with them through their life.

LR: I was going to ask you a little bit later about working with elderly gay men. But this seems like a good point to interject the question of, “what are some of the clinical challenges in working with elderly gay men whose mothers, I imagine, have long passed?”

RM: The most significant challenge is that they grew up in an era where they couldn't be out, where it wasn't safe, and many older men were kind of forced indirectly or even directly to live conventional lives and got married and had children without even questioning the freedom of living life as a gay man.

I had a great-uncle who was gay, and he never came out to my family. When I came out to my parents, they said, “Well, Paul has lived a good life. So, we know that you'll live a good life, too.” But this great-uncle, my grandmother's brother, was in his 80s when I came out. And he said to me, “I really appreciate that you have freedom that I didn't have, and I hope that you will keep my secret from your family because I just don't feel comfortable being out there.” 

LR: Well, I wonder if that fear of abandonment, being cast out by remaining family is that much greater to an elderly man?

RM: He had an incredible social network. He lived in Washington and was cryptographer for the CIA because keeping secrets was something that they did well. So, he had the love of a community of people, and my mother, his niece, and us, meaning my mother's children who were generations below him. And he was still worried about our knowing. It was just a pattern that was ingrained for the time with which he was raised. It's that simple.

LR: Can you imagine taking homosexuality, or any significant part of your identity, to the grave?

RM: When he died, my mother and I went to Washington to clean out his house — he saved everything. There was a pile of letters that his gay friends wrote to him in the 1950s and the 1960s about falling in love with men that they met in cruising areas in parks, and how they couldn't tell their spouses and how tortured they were.

We were cleaning out his house with three of his close friends. My mother came to me, without saying anything, handed me the pile of letters, and I read them. And I thought poor Uncle Paul would die if I kept these letters, so I shredded them and threw them out. And it is my biggest regret because in these letters was the reality of gay history lived by all these men.

But, in my desire to be loyal to my great-uncle, I threw them out. And this was maybe three or four years after I had come out. I was still living in a careful way and more worried about loyalties. If I had these letters now, what they would mean? Oh my God.  

LR: What clinical challenges have you experienced working with gay sons of mothers from other cultures, the Caribbean culture, the Asian, the Southeast Asian, or even African, where homosexuality is shunned and punished, sometimes even fatally?  

RM: In these cultures, homophobia is rampant and masculinity and norms around masculinity are such that fathers are not accepting of their gay kids. Religious norms are such that being gay is a sin and these are beliefs that communities buy into without questioning. So, fathers are often emotionally and physically abusive to their sons. Mothers are forced to choose between their husband or their child.

Some mothers choose their husband over their child. I had a guy that I interviewed who was Latino, and his mother said to him, “First comes God, then comes your father, and then comes you.” So, when he came out, they sent him to an aunt's house far away to Texas where he would somehow have a different life for himself. He ended up responding to a personal ad from someone who he didn't know at the time was a human sex trafficker, and he became a victim of human sex trafficking. It's a tragic story, and he's now an advocate for all of this. But his parents kicked him to the curb and still don't accept him. 

LR: Have you worked with men and mothers and their parents from other cultures, where the parents themselves were afraid of being sanctioned, punished, or harmed?

RM: You're saying that with a great degree of sensitivity and attunement. Most situations, that is exactly what the parents are feeling, but they don't recognize that in themselves. What they recognize is what they're supposed to believe, and that's what they've gone along with. I've worked with Mormon families who have rejected their children. I've interviewed a Latino Mormon man whose mother read his journal and packed up his bedroom one night and put all his belongings in the garage and said, “You're not going to live here anymore. What you're doing is a sin.”  

Eventually, they came around and made up years later. These horror stories unfortunately exist. Some families that are less severe than the examples I gave don't let their kids come to family holidays. They insist that they not come out to extended family that there’s all these conditions. There's a woman named Caitlin Ryan who’s done a lot of research through her organization called the Family Acceptance Project. Her work shows that LGBTQ family members can gain acceptance with their children or their siblings through being exposed to other people that give a message that it's okay.

And that's essentially what we're doing through Gay Sons and Mothers. We're sharing stories saying, “Look, we're out in the world and everything is fine.” And as family members realize that it's okay, they are far more accepting of their gay children. So, that's the message that we need to get out into the Latino, the Asian, the Black communities, and the best way that they're going to accept it is by hearing stories through people like themselves.

If they're hearing from a gay social worker who's White that it's okay, maybe some percentage of people will listen to me and be comforted, but they're going to hear it most from another father who's found through his own experiences that it's better to have a relationship with their child than to reject them.   

And that's essentially what we're doing through Gay Sons and Mothers. We're sharing stories saying, “Look, we're out in the world and everything is fine.” And as family members realize that it's okay, they are far more accepting of their gay children. So, that's the message that we need to get out into the Latino, the Asian, the Black communities, and the best way that they're going to accept it is by hearing stories through people like themselves.

If they're hearing from a gay social worker who's White that it's okay, maybe some percentage of people will listen to me and be comforted, but they're going to hear it most from another father who's found through his own experiences that it's better to have a relationship with their child than to reject them.

LR: I imagine there’s a significant number of these families that don’t make it successfully through therapy with you. This young man is left feeling just as isolated and rejected as before.

RM: Right. Or the young man will stay in therapy and build his own community, but, unfortunately, not with his family, outside of the family and elsewhere. That said, I am a family therapist. I’m a couples therapist. I'm totally optimistic. I never give up on families reuniting. And, last year, I worked with a fundamentalist gay man in his 30s, really successful in his career and in his life. But he didn't come out until his 30s to please his parents. I had three joint sessions with him and his mother, with the hopes of bringing them together. He never thought it would happen.

I met with her alone first, and she was talking about the Bible and blah, blah, blah, blah. They didn't stick with the sessions, and eventually started talking to each other. A couple of months ago, she was potentially diagnosed with cancer, and that's what brought them together more than anything else. And I wish it could have been sooner.

LR: How would you advise straight therapists working with gay men, beyond the standard of “unconditional acceptance?”   

RM: You raise a very important issue about unconditional acceptance, and many well-intentioned straight therapists try way too hard with their gay clients. In my life, socially, I'll go to a party, and they'll say, “Oh, do you live where all the gay people live? And do you know so and so, and so and so, and so, and so?”

LR: Gay Jewish geography.

RM: Exactly, and often I do. But therapists who try to promote unconditional acceptance and convince their clients that they're gay-affirming and then offer, “Oh, I have a neighbor who's gay,” which actually may induce a lack of trust. The best way to promote unconditional acceptance is to simply say, “I’m straight. Are you comfortable working with me? I am accepting, and I've worked with other gay clients. But, please, if you feel any bit of discomfort, let me know. Let's talk about it.” To me, that's unconditional acceptance, and that's more welcoming than doing a sales pitch that ends up sounding like a microaggression more than anything else.

So, my mentor, Jeff Zeig, accepted me for who I was, and he’s a straight man. There was something so profound in that experience for me. Was he the first straight man that accepted me? No, but it was wonderful to have a mentor who didn't care if I was gay, didn't pathologize me, and said, “Write a book about working with gay men, the field is lacking this information.” It was so validating. And so, what he did for me, which all therapists ideally do for their clients, is embrace, love, support, and send me out into the world to be successful.

That is unconditional love, and that is what straight therapists can do for their gay clients. And what I say in the work that I do is you're giving your clients a bigger gift of healing than you would even recognize because your clients are coming into your office with their presenting problem, whatever that happens to be. It may have nothing to do with being gay. And, through the love and the acceptance and the respect that you're showing to them, they're getting additional healing from the experience of being in your office.  

So, frequently, when people want a referral to a therapist who's a gay client, frequently I'll say, “Why don't you work with a non-gay therapist? Because there is extra work that you can have done, as a result.” Some people will do that, some people won't.

LR: I used to think it important to be colorblind, but we must see color to validate the experience of the “other.” that idea. Similarly, one can’t be gay blind, because being blind to that does not suggest acceptance. It suggests walling off and not affirming that person, not accepting that person. So, I imagine that a clinician working with a gay person has to be very cognizant of the stories, the history that this person brings into therapy.

RM: Yes. The words that are coming to my mind are cultural competence. And that's what we need in the field these days. And I, too, did the same that you just described. I worked with an Asian gay man and a Black gay man, and I cringe when I think to myself or I even probably said things aloud that it's not as bad as you perceive it to be, which is absolutely not true.

LR: It’s not affirming.

RM: Right. The best thing that we can do is to hear the experiences that our clients are bringing to our offices and trust that to be true. The other best thing that we can do to become culturally competent is to go to workshops or watch videos like this or read a few books or speak to your gay friends and family members about their experiences to get educated. It's not hard to do. I find that in our field of mental health there are many people who are well-educated and liberal in their thinking, so that they feel like they have all that they need to know.

But their gay clients are testing them indirectly and don't feel safe because they're presenting a norm that may be uncomfortable. The other thing that I found, and I've mentioned this to you before, is that the field in general, of course, is run by metrics and numbers. And the most successful clinicians and teachers in the field have large numbers of followers and huge turnouts to their conferences. When I teach, sometimes I get 20-25, maybe 40 attendees, if I'm lucky, at a big mental health conference. Well, that's not good for the conference.

So, I'm not advancing as I'm teaching about working with LGBTQ people. And there are very few courses offered at huge conferences, which is unfortunate. So, my advice to people who are organizing conferences is to put us in panels with other people, and that way we can kind of gain exposure and educate people.

LR: So, the idea of a gay-affirming therapist is more cliché than anything else I would think because if you're not a person-affirming therapist, you're not going to be a gay-affirming therapist. Am I getting it, right? 

RM: Yeah, yeah. And I mean, interesting. A clinician that's worked a lot with the gay man or the LGBTQ population by nature is gay-affirming. I know through conversations with a person who has worked a lot with the LGBTQ population is gay-affirming, and they've cultivated acceptance and skills that are affirming and comfortable. As a person, are you a gay-affirming person? I'm not asking you that. I know that you are, but I'm asking people who are listening to this. Do you understand what it's like living life as an LGBTQ person in today's world?

And if you're honest with yourself, maybe there are things you don't understand, and there's ways of getting information. If you pretend that you are, you're fooling yourself. People are going to see beyond that.

LR: They’re going to catch up.

RM: So, when you go to therapy, you should be talking about your sexual life. Many gay clients, out of shame, won't even broach the idea of sex with their therapists. Or, when they talk about sex, their therapist winced because they don't believe in open relationships, or they think that gay men are too sexual, and their biases are coming forward. I h

Mommy Liked Me Best (And Why It Matters as a Gay Son)

Posted on by Psychotherapy.net Team

Unconditional Love

I knew that title would get your attention — it usually does! And better still, it’s true. My mother, while not unloving with my siblings, did like me best — and, growing up, I rubbed it in at every opportunity. It gave me a sort of tangible superiority.

The superiority I felt vis-à-vis my siblings was profound. I got to flaunt my power — and, boy, did that feel good! Let me explain. I’m gay, I felt different, I was different. Convincing myself that Mommy liked me best was not only the way I managed to navigate childhood and adolescence but has since become a major area of my clinical research and work.

I didn’t just use that expression throughout my childhood; I also used it in my opening line for my TEDx talk, The Mother Factor: Acceptance Works Both Ways. I always knew this truism meant the world to me, but for a long time I couldn’t understand why. Little did I know that decades later, much of my professional work would be devoted to researching and understanding the relationships between mothers and their gay sons, not just for me, but for the world at large. This topic is both crucial and, unfortunately, overlooked. But not by someone whose mother really did love him best!

When I was growing up, I thought everybody was like me. I was raised in an upper-middle-class family in an affluent suburb in the 1960s and ‘70s. The notion of a traditional, intact family with the financial means to live well, go on family vacations in the station wagon, and enable children to get a good education was very much how we all lived.

When I was a kid, I didn’t have the vocabulary to know I was gay, but I certainly knew that I was different. Our neighborhood had lots of kids, roaming the streets and playing together after dinner and on weekends. While I always had best guy friends nearby, I gravitated toward my sister and her friends. Their activities were way more fun for me! Hopscotch with colored chalk drawn on the street, playing with Barbie dolls and their accompanying accessories… it was all an endless source of fascination.

I never got scolded by my mom for breaking in and “making outfits” for Barbie, though now she’ll claim she didn’t know. How could she not? I think she knew and was just waiting for me to understand myself. The truth is that many boys were humiliated, mocked, even physically abused for preferring dolls over baseballs. My sister had no patience for my playing with her toys — understandably — so my maternal grandmother got me a Ken doll outfitted with a khaki military suit…which did absolutely nothing for me.

My sister’s attempts to sway me away from Barbie failed! At the same time, my grandfather tried to engage me in sports, teaching me to play catch and to try and enjoy baseball. He bought me a baseball glove, and while I enjoyed the feel and scent of the new leather, I wasn’t particularly inspired. Another failed attempt.

Fortunately, my mother never tried to influence me or have me do things differently. I was fortunate, though I didn’t know it; I assumed all mothers were like her. My parents owned a woman’s clothing store, so style, fashion, and fabric were a common language for my family. My mother was always stylish and — as you can imagine — I enjoyed helping her with her outfit choices, and she relied on my skill set.

She and I also did a lot of activities together. I was the youngest of three, and even though my siblings weren’t that much older than me, I had a lot of time alone with my mom. We went skiing from when I was 6 through my college years, rode bikes, shopped, raised various household pets together, did yard projects, wallpapered (and re-wallpapered!) the house, and did most of these things enjoying each other’s company.

Growing Up Gay

What I later learned, as a therapist, is that a “good enough” mother allows her child to be who they want to be. She might not know it’s what she’s doing, but she’s safeguarding the child’s sense of well-being and mental health. I was fortunate to receive this kind of acceptance, especially because she most likely knew my “secret,” my difference from the other boys, and none of it mattered to her.

Our relationship was steady and reliable, and the fact that my mother lived up to the expectations of how a good mother raises her child (let alone a gay son) was crucial to my own mental health. Decades later, as I did research about this relationship, it became clear to me that a mother’s intrinsic awareness and support is a lifeline for so many gay boys who were humiliated or alienated in so many other settings.

When I was growing up, my mother was athletic, thin, good-looking, casual, and a little irreverent. People loved these qualities about her; for me, they defined how she was special, and how her specialness reflected on me. I was her son, and I loved how she was admired by others. It was as if I were the one getting complimented! Some would have defined this as enmeshment (not that she was enmeshed with me; it was, rather, me with her).

But during the early ‘70s, the messages mothers received from the medical and mental-health communities were that they were responsible for making their sons gay by indulging them. The very thing that we now know was essential for our well-being was exactly what was pathologized by the medical and mental-health communities. Many mothers who conformed to authority followed the advice of those communities, thereby wounding their children, while other mothers, like mine, had the strength not to conform to expectations. They just kept mothering. This simple act is more significant than anything else.

My teenage years at times were not easy, like many other gay teens. My love of style was supported by my mother with shopping trips and clothes purchased based on my likes. I was aware of feeling different, my peers were starting to make fun of me, and it continued until I graduated high school.

One of the more shameful moments was my new slate blue bell-bottom corduroy pants with a plaid fabric insert and a matching jacket I got in 8th grade (As you can see, I remember this outfit well). Just one driveway away from my house, the taunting began, because of the outfit that I was feeling like a million bucks in. This was only one time of many. To this day I can list who taunted me and it was humiliating.

I remember feeling miserable, feeling too ashamed to tell anybody about being made fun of, and wishing I could go to a private school where (hopefully/maybe) this wouldn’t happen. But I never had the courage to tell my parents about my feelings since it would only reveal my secret. Instead, I endured the pain.

Luckily, I had several friends who, throughout my high school years, turned into a large peer group that was totally close and fun. Their bonds saved me.

Aside from my friends being accepting of me, there was also my mom. We didn’t have any discussions about life, or feelings — that wasn’t anything she’d have felt comfortable with. No surprise that I later became a therapist. But what I got from my mom surpassed any conversations we might have shared. Acceptance and her good company were key.

When I was a teenager, we took day trips together, our bikes strapped to the car so we could ride around coastal towns and beautiful places. We went skiing together and did home projects that were a lot of fun. We always got along well and enjoyed our time together. She was easy to be with, and casual. It was just that simple. Imagine that such simple acts could lead to self-esteem and a healthy sense of self as an adult.

My mother got something concrete out of the relationship as well: as long as she had a son who had talents in certain domains, why not take advantage of his skills by enlisting his help in outfit selections and wallpaper designs? That she did!

Though I grew up in an upper-middle-class Jewish family where friends, neighbors, and community members embodied the stereotypes of Jewish habits and activities, everybody who knew my mom knew she had her own way of relating to the world. Oh, it passed the aesthetic tests of Jewish motherhood, but she was humorous and casual and never felt a need to conform.

Two examples of how my mom was different involved a Playgirl Magazine and her red sports car. My mother was always a collector (and still is). She knew what would be worth saving over the years — sometimes a few too many things — and somehow the year I was 12, in 1973, she got the first edition of Playgirl Magazine with TV actor Ryan MacDonald in the centerfold. The magazine sat on top of the avocado side-by-side refrigerator for years, and she pinned the centerfold in the cabana by the pool where guests changed into bathing suits. It remained pinned on the wall though my high school years; I’ll leave you to consider its impact on my level of excitement.

Then there was her sports car, a red 1974 Datsun 260Z. I wasn’t quite driving yet when she got it. Since it was a two-seater, we had many fun trips à deux. I learned to drive standard on that Datsun, and I drove it pretty much through high school when she didn’t need it. Now, in our suburban town not many mothers had a car like this, and the license plate bearing the name SUZAN was quite recognizable as well! I now own the car, with the old license plate hanging in my garage; and of course, she gave me the Playgirl Magazine as well — a sign of her acceptance of me.

Evolving into a Therapist

As I have matured and listened to so many clients’ experiences with their mothers, I realize how fortunate I’ve been. My sense of self and success as a psychotherapist is attributable to both of my parents, yet my bond with my mother has been the most important to me.

Over the years, I’ve occasionally and for various reasons asked my gay male clients to bring their mothers in for a session. I quickly learned I wasn’t the only one that was mom’s favorite, that this similar dynamic existed in many gay son/mother dyads. My interest in this dynamic prompted me to look for literature about gay sons and their mothers, and surprisingly, on the whole web, there was only one article and one short blog post. The relationships between gay sons and their mothers were obviously overlooked — and, let’s face it, this project had my name on it.

So now researching, writing, and teaching about this topic, along with establishing the nonprofit Gay Sons and Mothers is my life’s work. It is a project of passion and also a legacy.

At the start of all this, I recorded an audio file for Mother’s Day entitled “Thanks, Mom” and posted it on YouTube. I said, “I recognize how fortunate l have been to enjoy my mother’s unquestioning love throughout the years. My ordinary story is actually an extraordinary one, and I am so grateful to her.

From my mother’s love, I have had the courage to take risks and have the confidence to be myself. A successful career, a sense of style, putting myself out there, making eye contact and trusting that I am a likeable person are just the qualities of who I am today as a result.”

Sharing it with her a few years ago on Mother’s Day allowed us to have a brief but intimate conversation that synopsized our relationship. For the first time ever, she told me that I’d been a joy to raise, an easy child, and that we’d always had fun times together. She didn’t come out and say I was her favorite, but she did say the bond we shared was quite different from her experiences with her other children. I felt so good hearing this, and I’ll remember this conversation forever as something both casual — and pivotal. She refers to this Mother’s Day piece as her eulogy, and as I will undoubtedly be the one delivering a eulogy that I plan when the time comes, I know already exactly what I’ll say.

“Your love will stay with me for a lifetime. Thank you, Mom.”

Should Transgender Youth Care be Guided by Beliefs or Science?

Posted on by Psychotherapy.net Team

Introduction

The current American approach to transgender-identified youth and adults is strongly affirmative. Many professional organizations in the United States have endorsed the safety and efficacy of social transition, puberty-blocking hormones, cross-sex hormones, and breast, genital, and facial surgeries as the ideal treatment of gender dysphoria.
 

These prestigious decade-old endorsements have led to the development of gender specialists in over 70 US clinics where children, adolescents, and younger and older adults are seen. It also has led to affirmative care being taught in medical schools, residency training programs, and various mental health continuing educational programs. For half a century, WPATH has been the key nongovernmental organization that has gathered specialists, provided courses that promulgate clinical principles, and published standards of care. WPATH represents itself as an advocacy, policy, and scientific organization.

Its membership recognizes a great need for social change as discrimination in housing, employment, health care, intrafamilial and peer relationships, and incarceration are significant cultural sources of stress for the transgendered. WPATH considers its recommendations to be scientific, even though its author-committees recognize a need for improved scrutiny of outcomes of social, medical, and surgical interventions. While it recognizes that the quality of supportive evidence is objectively low, nonetheless, it treats affirmative care as a settled scientific matter. DSM-5-TR and ICD-11 diagnostic criteria exist, elective treatment sequences have been defined, and many clinicians and patients consider affirmative care to be life-enhancing and sometimes lifesaving.  


Affirmative care, however, is not a scientifically settled matter. There is much justifiable ferment. Affirmative care is far more fraught and uncertain than WPATH and professional associations have suggested. (1-3) It is a paradox for WPATH to portray itself as a trustworthy authoritative advocacy, policy, and scientific organization in the face of uncertainties about long-term treatment outcomes, the unexplained dramatic explosive incidence of new gender identities, and the increasing recognition of de-transition.

There is an ongoing culture war within the US about the treatment of transgender youth who are uncomfortable with their bodies. (4) The political aspect of this culture war addresses transgender treatments as a conflict between those who support and those who oppose the civil rights of LGBTQI+ individuals. Those who question the wisdom of affirmative care are described as “anti-trans.” A medical perspective begins with a different question: Is the scientific basis for affirmative care sufficiently established? If the answers are either no or uncertain, three other questions follow.  

  • Can gender specialists separate their beliefs from what is scientifically known about etiology, incidence, psychopathology, and the long-term benefits and harms of affirmative interventions?  
  • Can these specialists provide parents and patients with the legal and ethical requirements for informed consent? (5)    
  • Can high-quality research be designed and funded to answer the current relevant clinical uncertainties?  


Usually when health is the topic the medical profession leads the way, relying first on rigorous science, and second on the values of individual patients and their families. In the arena of trans care, however, values have historically played a more important role than science. This may be summarized as eminence-based or fashion-based medicine dominating over evidence-based medicine. As has been seen with the COVID vaccine, mask mandates, the opioid epidemic, and the FDA approval of a drug for Alzheimer’s disease, trust in the medical profession is far from universal. Consequently, what individual doctors, gender care clinics, professional societies, and mental health professionals may have to say about the ideal care of trans persons may not be the most powerful force governing social policy.    


Forces Shaping Attitudes About Transgender Care

Transgender phenomena elicit intense feelings among laypersons and professionals. Such passion, which is destructive to objective scientific appraisal, derives from many personal sources. While numerous factors influence attitudes toward transgender care, their confluence makes it difficult to judge their relative contributions to how individuals and institutions regard trans healthcare.  

There are five universal potential influences.      

1. Fascination with sex change. The intriguing question, “Can sex be changed?” has long been explored in the arts, where men and women have for centuries been presented as the opposite sex in humor, drama, dance, opera, drag, and popular music. Today, it is better understood that in a basic biological sense, sex cannot be changed, but gender presentation can, with or without medical assistance. 

2. Political sensibilities. The Left may consider transgenderism the courageous pursuit of self-expression, a civil right, a movement to improve diversity in all walks of life, and a praiseworthy social movement to eliminate discrimination. Their political values lead them to view studies and clinical services with trust. The Right, on the other hand, may consider transgenderism morally wrong, threatening to societal health, and dangerous to the health and well-being of individuals and families. These assumptions lead to a skeptical approach to studies and clinical services.

3. Religious sensibilities. These value-laden thought patterns derive from theological assumptions. They may resemble the Right or the Left. In the United States, the most vocal religious institutions on this topic lean to the political Right. 

4. Sexual orientation sensibilities. Membership in the heteronormative or sexual minority communities often generates opposite responses — the former may have initial unease with, and the latter, initial comfort with trans phenomena. One’s sexual orientation, per se, does not guarantee a particular attitude any more than one’s political or religious affiliations do. However, many of the leaders who advocate trans care identify as a sexual minority.

5. Intuitive age-related sensibilities. Intuitive sensibilities are best reflected through age. Younger and older generations have different life experiences with which to be intuitive regarding attitudes toward the transgender experience. The very existence of sexual minority communities and their entitlement to civil rights are far more visible today than was the case when older persons were growing up. These generational differences reach into each group’s system of values. 

There are four influences that are unique to professionals.  

6.Personal clinical experience. The 7th edition of WPATH’s Standards of Care (SOC) downgraded the importance of a comprehensive assessment of psychiatric co-morbidities in determining the next step. 6 The process of evaluation was then pejoratively referred to as gatekeeping. Prior to 2012, adults who immediately wanted hormones or surgery were often impatient, demanding, rude or dishonest about their histories. With the 2012 guidance, adults and older adolescents were assumed to know best what should be done. Respect for Patient Autonomy became the primary ethical principle to follow. The frequency of unpleasant clinical experiences dramatically diminished. When professionals experience unpleasant patients, those with conspicuous emotional impairments, or those who deteriorate with hormonal treatment, they are more likely to be avoidant of future encounters. Positive experiences with appreciative patients and families yield more willingness to engage. 

7. Knowledge of clinical reports from clinical innovators. Positive outcome studies of transgender treatments typically consist of retrospective case series without control groups and without predetermined measurement instruments. Such outcome reports are numerous for each intervention. Positive results tend to be more often published than negative or uncertain outcomes. The most influential studies for minors were published in 2011 and 2014, and while they too lacked a control group, they were interpreted as establishing the concept that selected prepubertal cross-gender identified children could benefit from affirmative social, endocrine, and surgical care. (7),8 

Clinicians cannot be expected to keep up with the burgeoning literature; they trust what they read, heard about, or were taught. Such learning reflects a chain of trust that is basic to all medical education. It has become apparent that the chain of trust is not necessarily trustworthy, as positive studies are published in peer-reviewed journals only to have their conclusions criticized by knowledgeable academics. Once clinicians begin to facilitate patients’ transitions based on the studies they have seen, they believe they are facilitating happy, successful, productive lives even without having the reassuring follow-up information to verify their beliefs.

8. Scientific studies. Groups of studies demonstrate patterns that individual studies do not. Scientific data are widely assumed to dominate institutional policy. This is not necessarily so, however. For example, high desistance rates in trans children have been demonstrated in 11 of 11 studies, (9) but a committee of pediatricians created a policy of supporting the transition of grade school children. (10) As a result of these often-conflicting processes and sources of data, comprehensive evaluation and psychotherapy rather than affirmative care are increasingly being recommended

9. Source of income. With 70+ clinics in the United States, with many individuals in private practice who practice affirmative therapies, and with special units within prisons to support trans inmates, the attitudes of new-to-this-arena clinicians may be quickly determined by their work environment. In these settings, disapproval of affirmative care, which may grow with experience, as it did for many psychologists at the Tavistock Clinic, means resignation or job loss. 


Sources of Controversy about Affirmative Care

1. Morality — Conservative citizens, religious denominations, politicians at local, state, and federal levels, and some gay, lesbian, and feminist groups view affirmative care as dangerous. They ask, “What are we doing to these young people? What will be the outcome for them and their families? Do doctors really know what is best for my son or daughter? Why is it acceptable to sterilize young people? Why is the suicide rate high after completion of medical and surgical interventions?” Such questions burrow down into moral values.

Some religious groups assert that since God made male and female, this provides fundamental guidance to decision-making. However, because these groups have historically been similarly against homosexual lives, the power of this theological assumption is politically diminished for many others.

Some gay and lesbian organizations see affirmative care of feminine boys and tomboys as an attempt to eliminate gay and lesbian people. Almost all groups recognize that cross-gender identification is nothing new. What is new is its dramatically increased incidence and Medicine’s response to it.  
 

2. Questions Emanating from Medical Ethical Concerns

  • Are children and adolescent patients experienced enough, cognitively mature enough, to make life-altering decisions that will predispose them to known challenges such as sterility, sexual dysfunction, decades-long medical care, discrimination, and loneliness (11, 12)  
  • Do their frequent co-existing psychiatric diagnoses further impair their ability to thoughtfully consider the consequences of each of the steps of affirmative care? 
  • Are affirmative professionals knowledgeable about the limitations of their recommendations? 
  • Do they know the inadequacies of the outcome data supporting the policies of socialization of children and endocrine and surgical interventions with adolescents?
  • Do they know the fate of most patients given hormones a few years after they age out of pediatric endocrinology?
  • Are they aware of the rates of complications, physiological consequences, long term unhappiness after the surgical procedures that they recommend?
  • Are parents sufficiently informed about the limitations of outcome data?
  • Are they told of Sweden’s, Finland’s, UK’s, and France’s shifts towards psychotherapeutic-first interventions?
  • Are they informed about the social, economic, vocational, physical, and mental health problems of transgendered adults? 
  • Are they told about detransition following hormonal and surgical treatments? 
  • Are they told about the elevated suicide rates after surgical treatment of adults? 

3. Confirmation bias — When defending a particular position, authors tend to quote studies supporting their position and ignore contrary findings or glibly dismiss them as methodologically unsound. This confirmation bias creates important scientific concerns on both sides of the debate. Science advances by defining controversy and designing a study that may better answer a specific question. Independent reviews have concluded that the evidence is not convincing that puberty blockers and cross-sex hormone administration lastingly improve mental health, decrease suicidal ideation, or eliminate gender dysphoria. (13) 

The Endocrine Society acknowledges a low level or very low level of supportive evidence. Advocates, however, portray certainty that science has already demonstrated these lasting benefits without significant harm. When they list supportive studies there is no mention of the published criticisms of them. A scientific review is characterized by balance; it is not performed only by those who deliver the treatment. (14,15) Trustworthy reviews point out the limitations of studies and ideally suggest a study design to answer the specific question.  

4. Political — Nowhere in Medicine has free speech been as limited as it has been in the trans arena. Skeptics are being institutionally suppressed. Critical letters to the editor in journals that published affirmative data are refused publication, symposia submitted for presentation at national meetings are rejected, scheduled lectures are canceled, and pressure has been exerted to get respected academics fired. A notable exception to this pattern occurred when a paper investigating the long-term mental health outcomes of trans adults (a basic unanswered question) was published in the American Journal of Psychiatry.

It, of course, had undergone a peer review process by experts in gender care. When the authors asserted in their online publication that their data supported increased access to surgeries, the editor received seven critical letters. In response, Dr. Kalin had two independent statisticians review the work. They agreed with the twelve authors of these letters to the editor that the data did not demonstrate improvement in mental health. The editor published the original article, the seven letters, and the authors’ response. The authors retracted their conclusions. (15,16) When critical letters have been sent to other journals, they have been rejected. As a result, they are published in separate journals.

This makes it more difficult for clinician readers of the original journal to know about the critique. Unless published with open access, the original flawed article’s limitations are difficult to access in another journal. A significant paywall is often encountered to obtain articles in journals to which the professional does not subscribe. Given the well-known attacks on those who question the prevailing wisdom of affirmative care, it is not surprising that many mental health professionals avoid working with these individuals and their families for fear of being labeled as anti-trans, transphobic, or conversion therapists.  
 

5. Familial — The parents, siblings, and extended family members, each of whom have different relationships and responsibilities for the trans-declared person, typically have intense feelings about their relative’s gender change. Family members’ affects, attitudes, and behaviors derive from one or more of the five sources discussed above but take on a new poignancy. While parents are the only ones that professionals deal with, the intrafamilial ramifications affect everyone.

Parents have realistic, reasonable concerns. What will gender change mean for my child’s developmental future physical, social, and mental health? Their assumptions that the outcome will be negative often create an acute depression. This intensifies when their expectation of informing the mental health professional (MHP) about the child’s development, personality, and previous challenges.

Many parents are distressed when the MHP seems far more interested in making the diagnosis and declaring their belief in affirmative care. Parents who have not previously seen behavioral evidence or heard expressions of cross-gender identifications prior to puberty want this new identity to be taken away. Other concerns emerge over time. How will the gender change impact siblings and grandparents? How to discuss it with others? How to ensure we don’t lose our relationship? What to do with one’s anger at the child and one’s guilt of not seeing this earlier? How to find an MHP who will not quickly affirm but is willing to spend time understanding the family situation? 

Parents who are not supportive are often described as transphobic by their child. They often learn this accusation on the Internet. A more accurate and kinder description of these parents might be trans-wary or trans-opposed. When transphobic is used, it induces some adolescent patients to behave hatefully toward their parents. While the medical profession focuses on the patient, parents are immersed in a dramatic conflict within the home. Gender specialists only gradually become aware of this when they follow the family. This is one of the reasons for an extended evaluation process. (8, 17)   


Problems Facing Transgendered Persons

There is agreement about the challenges that transgender adults as a group are facing. The medical profession has been repeatedly told that the explanations for the poor state of physical and mental health and the diverse health disparities are minority stress, discrimination, and barriers to health care. (18) There is no mention in such discussions of the possibility that the mental health of a trans person may be intrinsically compromised even though many studies have shown the poor mental health of children before the diagnosis of gender dysphoria is made. (19) 

Rather, discrimination experienced by some in healthcare settings and fear of mistreatment in health facilities by others are emphasized. Higher rates of cardiovascular diseases, obesity, cancer, sexually transmitted diseases including HIV, syphilis, hepatitis C, and papillomavirus, and shorter life spans have been noted. Higher rates of depression, anxiety, substance abuse, suicide attempts, and suicide, (20) as well as seeking psychiatric services have been documented. 21 Gender minorities are more likely to live in poverty, be unemployed, be victimized by domestic partners, be homeless at some time, and be on disability. (20)   


Nowhere in these well-documented patterns is the suggestion that what is known about adult trans populations should create more caution about affirmative care for minors. Rather, many articles urge better medical education to promote affirmative care for young persons, (20, 22) or for medical institutions to fight against the legislative forces that are attempting to limit affirmative care to minors. (23, 24) These authors ignore the more cautious approaches developing in Europe.  
 

Affirmative Care Assumptions

The following concepts, sometimes articulated as principles of care, (6) enable the conviction that more, rather than less, affirmative care is indicated. When these ideas are presented as unproven, those who practice or support affirmative care of youth

20 Seconds: Coming Out to a Client

Posted on by Psychotherapy.net Team

“Were you in the Olympics?”

               The statement gave me pause. Just as I was looking to build rapport, my client was earnestly wanting to know more about me. He was, of course, referring to the rainbow rings dangling from my pride necklace.

A delicate moment.

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I’ve been out and proud long enough not to worry too much about casual disclosure. When I was younger, I protected my gender identity, and even my sexuality, as something precious and fragile. Fast forward through a decade of resilience, self-actualization, mindfulness and graduate school. I’m an affirmative therapist with a rainbow necklace.

My client however was a blatantly straight young man. His priorities were football scholarships, drinking buddies and hot babes, in that order. Like a lot of hyper-masculine dudes I’ve worked with in therapy, he was reluctant to tackle his emotions, but self-aware enough to acknowledge his tendency to self-sabotage. Depth was sidetracked by sexual humor, vulnerability was hidden by pride and as our sessions progressed, he liked to deflect from himself by trying to “bro-out” with me. This of course, also revealed his deep desire to connect, as he valued fraternity a great deal. It’s only natural to hunt out similarities and differences in order to relate to someone, and he was doing that now. In his world, colorful rings meant sport.

Typically, I recommend LGBTQ+ therapists tack on a little about themselves in the very first session. A brief statement in your informed consent paperwork describing your office as a safe space can make a natural segue. Cisgender and heterosexual therapists have a unique privilege here, as they need not address issues of gender or sexual orientation with their client on day one. It is largely a non-issue. LGBTQ+ professionals, however; often have to contend with a delicate but necessary balancing act, as not everyone is comfortable having a queer counselor. For some, there may be a moral, religious or cultural objection to our identity. For other prospective clients, our “outness,” which is to say our open authenticity, maybe too challenging for where they’re at in their process, especially if they’re wrestling with issues of denial. Admittedly, this can be disappointing but it’s important to maintain a sense of unconditional positive regard. We have to meet a client where they’re at, which is why I believe in goodness-of-fit, first and foremost. If a client is not comfortable, I find it’s healthier for all parties involved to refer them out.

I usually give a quick twenty second nod to who I am noting how “as a nonbinary person, I understand the importance of confidentiality” or “as an active member of the LGBTQ+ community, I value emotional safety.” This is usually enough, and if I do forget to mention it in our first session, my rainbow necklace is a decent clue. With my young adult clients, a nonbinary pin or a pansexual T-shirt is like carrying a little safe-space bubble with me wherever I go.

Regrettably, I’d missed my twenty seconds in our first session, and now my client thought I was an Olympian.

Having dropped into our first session red hot and fuming, we had to regulate his rage and prioritize his pain. He was angry at his parents, his coach, his ex-girlfriend, himself and that had consumed the hour. Obviously, we addressed safety and confidentiality, but we’ve all had that fiery intro where the paperwork has to be set aside momentarily for crisis management. Addressing the nuances of who I am simply wasn’t relevant at the time, as the only thing that mattered was my ability to hold a safe container for his process. Round one was damage control. We didn’t even identify any long-term therapeutic goals until round two. Now, in round three, he was opening up and showing his curiosity.

Keep in mind, LGBTQ+ therapists don’t go around introducing our sexuality or gender any more than heterosexuals walk around saying: “Hi, I’m Straight Robert but my friends call me Vanilla Bob.” Sure I market myself as a Queer Counselor, and sure I published ACT for Gender Identity: The Comprehensive Guide, but my gender and sexuality aren’t the fulcrum of my identity. Important, yes, but not my every waking thought. So when my client asked about my necklace, I found myself scrambling, for the first time in years.

I have learned that it’s important for LGBTQ+ therapists not to hide who we are as our lived experiences are incredibly valuable to clients in need of personal insight, relational connection or a rainbow role model. These days, because of my reputation, people tend to seek me out when they’re wrestling with genderqueer liminality, transgender self-actualization, shame, shame, and more shame, queer trauma, queer euphoria and the excited limerence of forbidden love. Being out and proud, I kind of expect people to know who I am and that was my mistake.

My client wasn’t the sort to read my website. He was here because his parents—the architects of his academic career—were also the architects of his mental health journey. His mom literally drove him to and from our sessions. To my amazement, he didn’t know anything about rainbows or transgender people, and for a second my closeted inner child wanted to lie. I should just tell him I used to throw the javelin. What am I saying? Just tell him you like gymnastics!

I was finding out first hand how hard it can be to check my own transference as a queer therapist working with a very straight client. In twenty seconds, his inquiry had brought up all my outdated evasion tactics so I answered his question with a question. Rather than simply out myself, I asked if he’d ever been to a pride parade. This roundabout response was a defense mechanism designed to gauge his open-mindedness while shifting myself away from the focal point. If this maneuver seems contradictory to being out and proud, just know that I, like a lot of queer people have spent a lifetime being bombarded by unsolicited opinions and inappropriate questions. When our very existence is deemed politically polarizing, we have to develop little ways to gauge safety and evade conversational traps. On the street, that’s quite easy as we can be fierce and forward, but in professional settings?

We’re ten seconds into this exchange now.

In no uncertain terms he told me about spirit day, back in high school, and how everyone wore colors, because that’s what he thought I meant. School pride.

We’re just getting muddled.

When I finally found my community after years of isolation, I wrapped that sense of belonging around me like a cozy blanket. My social circles marched and still do with me so I honestly hadn’t encountered someone this sheltered in a very long time, nor had I ever had to deal with it in session. My rainbow references had no power here. My wink and nod meant nothing, and in our short back and forth I worried about alienating my client. Would our differences present a divide too vast to bridge? Was our budding rapport doomed from the start? Did he open up to me so readily because, in his eyes, I looked like a man? Would my authenticity jeopardize our ability to work with each other?

So much happens in twenty seconds of conversation. So many thoughts flit by when we have to assess disclosure. My task is not to give my client a crash course on Queer studies, nor counter his views of the world, however contrary they may be to my own. This makes labels and micro-labels tricky, as they can sometimes spur more questions than answers when people have never encountered them before. If I tell him I'm nonbinary, we may spend way too long defining what that means. Yet, as both a person and a professional, my authenticity is paramount, as it is the authenticity within the therapeutic relationship which is so healing.

So as not to get bogged down in lingo, I told him that I never really connected with school pride, and that I was a part of the LGBTQ+ community.

“Oh, so you’re like a fag.”

I corrected this in my ally-trainer voice. If you’re unfamiliar with the tone, pay attention the next time someone asks a diversity trainer a wholly uninformed question and note how diplomatically they answer. My client wasn’t trying to be offensive. In his world that’s what people like me are called, yet I must also humanize myself, so I told him quite simply how disrespectful the term was.

And he apologized. And he flip-flopped. And he gave me his two-cents, telling me about a friend of his who came out last year, but how he was definitely straight himself, in case anyone was wondering. I asked if it would be an issue. He said no. In the long run, the details of my sexual and gender identity were irrelevant to his process, but not the disclosure itself. We would refer back to this moment a few times during the course of our work together, as an example of giving someone the benefit of the doubt, of reaching across the aisle, and of connecting with people very different from ourselves. For my client, struggling with his sense of anger and impulsivity, this brief exchange exemplified compassion, curiosity and how to make amends.

Given all my therapeutic concerns pertaining to disclosure, I sometimes have to remind myself that it’s the authenticity of the therapist that encourages the authenticity of the client. Mental health professionals have to navigate the ethics of disclosure on a case-by-case basis, and there are many effective approaches one can take. I know some masterful person- centered therapists who become pure mirrors for their client, just as I know a few gestalt therapists with very vibrant personalities. In kind, I know a few affirmative therapists who share anecdotal stories to normalize and humanize their client's lived experiences just as I know a few affirmative therapists who prefer a more psychoeducational route so as not to get too personal. Yet regardless of our therapeutic approach, people will inevitably react to who we are whether we like it or not. And in just twenty seconds of disclosure, one can gain a great deal of insight, not just about the client, but about the whole therapeutic relationship itself. Curiosity, distinction, concern, alienation, alliance, amends and acceptance can all happen concurrently just as we may not understand someone, but still like them anyway.   

David Nylund on Narrative Therapy, Curiosity and Queertopia

Posted on by rezendevknowfully.com

Narrative Therapy 101

Lawrence Rubin: Thanks for sharing your time with our readers, David, some of whom may not be familiar with Narrative Therapy. Can you give us an overview that would do it justice? Narrative Therapy 101, so to speak.
David Nylund: Well, that’s a challenge, but I’m going to give it a go. I imagine if you asked me at a different time, I might have a different take on it. Narrative Therapy is based on a narrative metaphor and the idea that people are multi-storied. And people get locked into a singular story which tends to be deficit-based and internalized. The job of the narrative therapist is to create a conversational context, usually through questions, to trace these thin, deficit-based stories that contradict the dominant stories that are always apparent. The job of the narrative therapist is not to coach them or help them build skills, but to trace those alternative stories that are always present but, as Michael White would say, “thinly known.” And through different narrative practices like questions and letters, to help thicken that story so it begins to gain some momentum and density. And when people can step into that story, they come to maybe a different version of who they are.
LR:

Narrative Therapy is based on a narrative metaphor and the idea that people are multi-storied.

You make it sound as if it’s a process of rewriting a life script in which the therapist is a co- editor or the editor. How do they work together to rewrite this story?

DN: I like the idea of a co-editor, where it’s a collaborative inquiry. The therapist is decentered, but is definitely influential, attending to certain things and not others. It’s based on a critique of individualism. It’s a very anti-individualist approach, and it’s very much informed by post-structuralism and thinking relationally. People are always in relationship to others, to a larger cultural narrative. I think narrative pays a lot of attention to how people’s stories are shaped by larger cultural narratives, or what Foucault would call discourses. I think one of the aspects of narrative that really drew me to it was its focus on how peoples’ problems and struggles are not their own, they’re shaped by the larger culture. So, it leads narrative into a certain kind of arena of social justice, which is what I was drawn to as a social worker.
LR: So, the job of the narrative therapist is to disabuse people of those deficit-based stories they’ve been told or have come to believe are true about themselves? How directive is the narrative therapist in moving the person off center in their cherished story?
DN: The intention of the narrative therapist is to not be impositional or directive. I would refer to it as invitational.
LR: Invitational?
DN: And yet, the narrative therapist is informed by a couple of basic premises: that people are multi-storied and many of these stories contradict each other; that people always have skills and abilities and values that run in contradiction to their dominant story that is often very deficit-based or problem-focused; and that problems are separate from people. For Michael White,

the problem is the problem, the person is not the problem

the problem is the problem, the person is not the problem. Peoples’ lives and problems are always relational and informed and shaped by the larger culture, especially around issues like normative ways of being related to race, class, gender and sexuality. And some of those dominant norms help shape peoples’ lived experiences and can contribute to their problems. So, the narrative therapist enters through an invitational conversation from a stance of curiosity about these alternative stories and what they might mean. I think the job of the narrative therapist is not to determine whether these alternative stories are good or bad, but to invite their client to become curious about them. And that might be an entry point into some new stories, and that entry point is often referred to as a unique outcome.

LR: It doesn’t sound like you’re trying to be a car salesman, but you’re visiting a car lot with a person and considering new colors and new models, psychologically. So, from a traditional and individualistic perspective, a client diagnosed with depression might be referred for medication and cognitive behavior therapy. How would a narrative therapist approach that same depressed person?
DN: The first step would be to be curious about depression. Perhaps you would externalize the depression, and then you’d be curious about what the depression means to the person, to the client. I don’t want to assume some clinical DSM version of what depression is. I want to understand it from the client’s perspective and their meaning around it. Now that it’s externalized, we might explore the effects of the depression on their life. I might ask questions like, “How is the depression affecting your thoughts about yourself?” “How it is affecting your relationships?” “Who’s in league with the depression?” “What supports depression?” “If you look back on your life, were there some people or experiences that contributed to depression’s hold over your life?” Through these questions, which are referred to as deconstructive questions or relative influence questions, we always find some contradiction or gap, because no story is seamless. There’s always some event or disruption; one day, one moment where the depression wasn’t as strong. It might be the client reached out to a friend. It could even be the act of coming to therapy is a unique outcome.I might start out by asking, “Did depression want you to come to the session today?” “I’ve worked with many clients with depression, it tries to convince them that therapy won’t be helpful. So, do you think it tried to do some of that?” “How did you defy depression’s dictates to come to the session, and what does that reflect about your hopes, your values, your ethics?”

I don’t want to assume some clinical DSM version of what depression is. I want to understand it from the client’s perspective and their meaning around it

One of the things that is important in Narrative Therapy, but also one of its challenges, is that it requires clinicians to rethink some taken-for-granted ideas in our field, especially around identity. From a modernist perspective, therapists like Jill Friedman and Gene Combs refer to internal states of identity. It’s based on this idea that identity is fixed, it’s static, it’s inside the person. It’s often linked to biology, and it’s outside of language and history and context. From a narrative perspective, it’s more of what I like to call intentional states of identity.

LR: This reminds me of Kenneth Gergen saying, “We come bearing multitudes” when referring to the difference between an individualistic and relational definition of identity.
DN: I like to think of identity as fluid, performed and in context. It’s relational, and about people coming to know themselves in relationship to others and in relationship to what’s important to them, their values, their ethics, their hopes. And so, a narrative therapist is really curious about their clients: their hopes, their intentions and their values that run in contradiction to, in this case, depression. And that leads to a very creative use of language and questions to help that alternative story, maybe anti-depression, to become thicker through reauthoring questions. And these re-authoring questions might be circulated to other folks in their life such as, “I imagine some of your folks in your life have an outdated version of you. What do you think is the best way to bring them up to date in terms of your journey away from depression?”The two challenges to the narrative therapist are to rethink and to challenge some core assumptions that we’re trained in our field and in the larger culture to believe. But your main tool is the use of creative questions that come from a stance of curiosity. This is very different from, for example, CBT or some of the more traditional models where the therapist is more of the expert helping coach people to develop skills. They might make more direct statements. They might interpret the client’s experience for them. In narrative, you’re influential but you’re decentered; maybe you lead from behind and you keep up that stance of curiosity. I think therapists are curious, but

narrative therapists practice a kind of curiosity about how things might be other than what they have been – a curiosity about hope and possibility

narrative therapists practice a kind of curiosity about how things might be other than what they have been – a curiosity about hope and possibility.

LR: It’s a very optimistic type of therapy, a liberating practice in a sense.
DN: Yeah! At the same time, I think narrative gets associated with positive psychology or solution-focused; or in my field of social work, a strength-based perspective. To me, it’s much more than that. It’s like these alternative stories that speak to a whole possibility. Values are always present. There’s evidence of it, and it’s inviting people to speculate about their significance. So, it isn’t like you’re having to find them or search for them, and it’s not about applause and cheerleading. It’s like coming from that place of honoring peoples’ experience, and there’s always things that stand outside the problem.
LR: Helping the person to widen their gaze to see instances in their life when they did stand up to the story that has previously defined them. So, you’re not a cheerleader on the sideline, you’re out on the field, playing with them.
DN: That’s a great metaphor. Definitely.

The Narrative Therapist

LR: What are some of the core qualities of a clinician that would make them a more effective narrative therapist? Not all therapists favor the use of metaphor or consider themselves to be particularly creative.
DN: I think one quality would be a real ethical stance of curiosity and respect for the client. I think there must be the ability to entertain multiple perspectives and not get captured by one singular truth. It might mean having to give up some of our training of being an expert. It also might be a commitment to social justice. And I think what often what attracts folks to Narrative Therapy is its demand to be intentional. If you look at most models, like CBT, for example, you won’t see much attention placed on how, let’s say, thought distortions are shaped by racism or the larger culture or dominant norms. It’s just very highly focused on the individual. I think there’s this commitment to seeing things within the larger social context, which then opens up this ethic of justice. Narrative uses language that can be social justice-oriented. The person is not oppressed, the problem is oppressive. The narrative therapist might ask, “Is it fair that the problem of oppression is cutting you off from your hopes?

a lot of narrative therapists also have this experience of standing outside the norm in their own lived experience, in a good way, like a rebel or an outlaw

As a social worker, I have a commitment to social justice. A lot of narrative therapists also have this experience of standing outside the norm in their own lived experience, in a good way, like a rebel or an outlaw. You know, like a commitment to a broad notion of queer. It’s not necessarily tied to gender and sexuality, just this broader definition of queer as a critique of norms and of normativity. I know that a lot of narrative therapists are committed to critiquing taken-for- granted assumptions or norms. I think that a narrative therapist is also drawn to new ideas and staying curious. It requires not just learning, but kind of more of an unlearning. It can be really challenging for people, especially if you’ve invested time in a model like CBT. It can be hard to give that up a bit.

LR: Do you think it’s more important that graduate social work and other clinical students learn first before they unlearn, or can we teach them first to unlearn before they can learn?
DN: It’s a great question. My preference is to start with unlearning. I don’t think I’m the majority there. I think my classes are as much about unlearning as learning, and I tell my students that. For example, last night in my class, I was presenting an overview of different family therapy models, and most of the students are also in a class to learn the DSM.But then I said, “Here’s another way of doing assessment.” And I introduced them to Karl Tomm’s ideas of assessing relational patterns, not people. So, a lot of my teaching is offering alternatives to the ways one can do the work. It’s a kind of tension between learning and unlearning. I think everywhere in the States, you have to learn some of these dominant ways of working in terms of charting and having to do diagnoses for billing purposes. You might have to use the more traditional language as shorthand to connect with other colleagues. So, I think narrative therapists have to find a way to entertain multiple perspectives simultaneously, even if they contradict each other.

What Counts as Evidence?

LR: Narrative therapists must be subversive!You once said, “I believe in evidence, but I’m more interested in what constitutes evidence and who gets to decide what counts as evidence.” You and I well know that these days, if you’re not doing randomized controlled trial studies, if you’re not doing meta-analyses, if you don’t have outcome studies based on psychological tests, then your work is not considered valuable. How do therapists operate from this anti-evidence base that you talk about?

DN: It was a conference in Osaka, Japan, and on the panel was the top voice of CBT therapy in Japan, and he challenged me about, like, “Hey, this is all great, but what do you think of evidence-based treatment?” And that was in 2001. Evidence-based therapy is much stronger than it was even then. I don’t have an easy answer for that one. I think that you’re right, unless the way you work has evidence from that more traditional notion, quantitative meta-analysis, randomized clinical trials, it doesn’t get the same respect. And that’s been an ongoing journey and struggle for me and my work. I’m in a privileged position now because I’m a professor and I’m the clinical director of the Gender Health Center, which is an agency working with trans and queer communities, but when I was earlier in my career, I had to work in hospitals and other settings. County mental health, community mental health, hospitals at Kaiser, and I just had to learn to be subversive, kind of covert, and let the work speak for itself.And you know, I think one thing that we’ve done at the Gender Health Center is use some of Scott Miller’s ideas around feedback-informed treatment, which is considered evidence-based now and has been sanctioned by SAMHSA, Substance Abuse Mental Health Services Administration. They’ve done a lot of random clinical trials and meta-analyses proving or having evidence that it’s not the model, it’s more about the alliance.

And alliance starts with how the client is doing. You create a culture of feedback. So, it’s interesting that some of the core ideas of feedback-informed treatment line up with narrative, right? Creating a culture of feedback, checking in, privileging the client’s voice. So, that’s one of the ways, strategically, we’ve been able to give narrative a voice. We use those measurements and the online program that gives all this data.

To me, unfortunately, it’s a reality that you need to have numbers. So, that’s one way we do it, and then there is a growing body of research on the effectiveness of narrative. It tends to be mostly qualitative. So, there is some evidence, but again, qualitative doesn’t earn the same merit as quantitative.

LR: Of course.
DN: It’s an ongoing journey.

I think a lot of narrative therapists are just subversive

I think a lot of narrative therapists are just subversive, and they might also be able to work more independently in their private practices. It always helps if somebody in the agency who is a leader or director is supportive of narrative. That can help.

Narrative Thoughts on Gender

LR: I want to move into questions around gender and working with queer folk. I never thought of, and I love being challenged by new thoughts, that queer is a critique of normativity, whether it’s queer racism or queer gender or queer religiosity.
DN: Right.
LR: Queer is an adjective, it’s not a noun.
DN: Right.
LR: Interesting. So, my question, David, is in what way does narrative therapy lend itself to working with gender queer folks?
DN: Okay. And when you say gender queer, are you referring to folks who identify as non-binary or are you talking more just—
LR: Yes, around the work that you’ve done.
DN: Often, what you just referred to is a term that’s used and that comes out of queer theory and queer scholarship, is heteronormativity. The norm that heterosexuality is the only sexual orientation and that the gender binary male/female is the only healthy way of being. So, I think what you’re referring to is everybody who stands outside that heteronormative way of being in their identities or practices. I think narrative therapy lends itself well to that because narrative therapy comes from this deconstructive lens, so it really is curious about these taken-for-granted assumptions, in this case, about gender and sexuality.

Narrative Therapy is informed by post-structuralism, and one of post-structuralism’s theoretical allies is queer theory

Narrative Therapy is informed by post-structuralism, and one of post-structuralism’s theoretical allies is queer theory, so there’s this connection between queer theory and narrative, because both are informed by social constructionism and post-structuralism, which pay close attention to dominant norms and language that can oppress folks.

So, it opens up that kind of dialogue about who gets to decide what’s normal. A lot of the conversations will be around these deeply entrenched gender norms, like masculinity, femininity, and around sexual identity. And I think it gives you some vocabulary; narrative offers a vocabulary to have those conversations.

LR: Can you give an example, David, of a recent client you’ve worked with whom you helped to challenge the heteronormative discourse that’s plagued them and maybe stood between them and becoming who they are from a sexual/gender perspective?
DN: At the Gender Health Center, we often do what has traditionally been called reflecting teams or outsider witnessing. Some folks refer to them as response teams. So, I’ll be interviewing a client in the presence of my colleagues, and my colleagues will then have a conversation amongst themselves while the client and I observe or listen in on that, and they’ll reflect on what stood out in the conversation, where did it take them? The comments are situated in trying to attend to the alternative story. So, I was doing that just yesterday with a 32-year-old person who was assigned male at birth who identifies as a trans female. However, she is in a family that comes from a very conservative faith tradition, and that’s held her back because she’s afraid of losing support from her parents.So, she’s really holding back on moving forward with her transition, meaning like hormones or surgery, because of her fears of how her family and her support network will handle it. So, instead of focusing on those issues, I was really curious about how, in spite of the religion that she was raised with, she was able to challenge that. What gender norms did she have to defy in order to even come to see me? And what did that say about her hopes for her life? I asked, “When you think about a person who comes from that background like yourself, and they’re beginning to consider that they’re trans, would you have respect for that person? Do you think it would take some bravery or courage?” And then, I started to ask questions like, “Who in your life might support this idea that you’re brave?”

And from there, she discussed a friend who supports her gender identity. And that led into some of the restraints and limitations of masculinity and toxic masculinity. I just kind of hovered around that, and then I said, “If you were to get a further appreciation of your bravery in living the counter story, what difference will that make towards your next step?” And that led to a conversation of coming to one of our programs at the Gender Health Center. It’s a respite program. It’s often more of a social context for trans folks who are feeling really isolated and disconnected to meet. You know, three days a week, they have this respite program. It’s for six hours and just kind of a place to hang out, relax, be yourself. They do some narrative work there, but it’s more just a meeting place.

So, by the end, she was open to going to that place. And then we talked about her ability to be more overt in her gender expression, and I noticed that she was wearing painted fingernails and earrings. We then talked about what those acts meant about her and ability to navigate her world, given that her parents wouldn’t be supportive because of their faith. I asked her to consider, “If I move forward, does that mean I’m no longer sinning?” And these kinds of discourses. That was the conversation, and then we had a reflecting team. And of course, in the team, there was various therapists who were queer or trans, so now this client is seeing community and support. One even shared that they also came from a deeply conservative religious tradition, and they talked about their journey and how they were able to move forward in their own life. So, that kind of gave the client some hope and inspiration.

Even Well-Meaning Therapists…

LR: In a sense, you’re helped this client connect with an external reflecting team, but also helped her to consider the internalized reflecting team that has been oppressive and could now be challenged.You’ve worked with and written about transgender oppression and suggested that even well-meaning therapists can further contribute to transgender marginalization through internalized transphobia and cisgender privilege. I find that fascinating. What do you mean that otherwise well-meaning therapists can contribute to the marginalization through those two things?

DN: Most therapists, most social workers I know, including my students, come from a place of ethics and wanting to help and might see themselves as open minded and progressive. When it comes to issues around LGBTQ, however, that acronym doesn’t account for the different hierarchies of worthiness, like gay white men have more power and privilege than, let’s say, lesbians, and then bisexuals are kind of held in somewhat of a suspicious or more marginalized status, and then T is at the end. Often, the T is rendered invisible or not really discussed. So, people will say, “I’m an ally for the LGBT community,” but not really know what T means, never having worked with folks who identify as trans. And so, they might go into a session with somebody who identifies as trans with these predetermined, taken-for-granted ideas of gender.

when it comes to issues around LGBTQ, however, that acronym doesn’t account for the different hierarchies of worthiness

The client might identify as a trans woman but be expressing their gender in a way that’s read as masculine in our culture. And so, what the well-meaning clinician might do is mis-gender the person by not using the pronouns that the client identifies with. The therapist might not share their own pronouns, it’s sort of taken for granted that there’s a normal gender. They might focus more on voyeuristic curiosity about genitalia and might have normative ideas of what it means to be trans. And for trans folks, there’s no one monolithic trans experience.

And then, I think the therapist who’s cisgender–this being a term for somebody whose gender identity is congruent with the sex they’re assigned at birth–may have a lot of unearned privilege in many areas. I am cisgender and don’t get misgendered. If I go to a doctor, the forms are very clear for me. My gender is right there, I click the box male. I don’t have to worry about spaces like restrooms and public bathrooms. I don’t have to worry about questions about my genitalia or dating or all that sort of stuff. Cisgender people don’t necessarily have to worry about being harassed in public because of their gender presentation. So, I think therapists who have cisgender privilege often don’t really take that into account in their work with transgender people.

Another thing that I’ve been really thinking about a lot more lately is the Black Lives Matter movement and some articles I’ve read around transgender allies. I see myself as an ally, but I’ve been reading some material asserting that simply being an ally is not enough. It becomes an identity, a noun, not a practice, and you know the ally almost gets centered, and people build their whole career on being an ally and profit from it, but not necessarily helping the community. That was really hard for me to look at because I do good work. I try to use my voice to support marginalized communities like trans folks. I’m writing a book on it, I do speaking engagements, and so it got me to rethink about what is my role? Am I putting myself out there? Is there any sacrifice? And so, there’s these new ways of rethinking allyship and referring to being an ally as more of a co-conspirator or an accomplice. And that’s happening in Black Lives Matter movements. We don’t want white allies, we want white co-conspirators, where you hold your white colleagues and friends accountable. So, it would be like me, as a cisgender person, really holding other cisgender people accountable for when they make transphobic comments. So, I think those are some of the things that might contribute to well-meaning therapists who are cisgender inadvertently imposing certain ideas that are cisnormative or transphobic.

LR: Elegant answer, David. Elegant. My mind is spinning with possibilities. What is queertopia, and if, in some wonderful future, we can live in that queertopia, would there be a need for therapists?
DN: That’s a great question. I don’t think so. I’m going to take that position of a queertopian, through a queertopian lens. A colleague of mine, Julie Tilson and I, wrote some about queertopia, and I’ve given some speeches on it. One was at an event called the Transgender Day of Remembrance, which is an international event – it’s a very somber, moving event about honoring and recognizing all the folks who were trans or gender nonconforming who were murdered over the past year. So, one of the years, I was asked to do a talk about what it’s like to be cisgender and then about what a queertopian world would look like.

In a queertopia, we would dismantle the gender binary. There would just be multiple genders.

In a queertopia, we would dismantle the gender binary. There would just be multiple genders. There wouldn’t be a need to police sexuality, you know, these hierarchies of gay and straight. There would be a loosening up of these strict identity categories, because I think identity categories can be useful, but they also impose restraints and limitations.

If somebody comes out as gay, there’s all these normative ideas of what it means to be gay. So, it can become another opportunity for policing and surveillance. There would be more of a loosening up of these identity categories. There wouldn’t be a DSM. There would be more work in the communities and community work rather than just individual clinical work. I think it would also be intersectional, so there would probably be a lot of focus on anti-racism and looking at some of the ideas about what it means to be male. There would be a loosening up of those ideas. And there would be a lot of just understanding of people’s identities and lived experiences, not necessarily related to their biology, their genitalia. Those are some of my thoughts about what a queertopia would look like.

LR: In queertopia, therapists might not be cloistered away in private practices behind closed shades. They’d all be social workers, they’d be co-conspirators, they’d be advocates, they’d be out in the community. There’d be more conversation about all the different ways of expressing oneself.
DN: It would be more like a deprivatization of the culture.

Hierarchies of Worthiness

LR: It’s ironic, almost paradoxical, that you have this forward-thinking vision of a queertopia, deprivatization and removal of gatekeepers of normativity. But one of the things that you do in your practice is psychological assessments for trans folks who want to pass through the portal of acceptance. Do you find yourself on the wrong side of the gate when you’re doing these assessments?
DN:

the standards of care when working with trans folks have moved a bit more towards depathologizing trans identities

We have this queertopian vision where mental health would get out of the way of people’s journey or transition, but that’s not the reality. Things are better. The standards of care when working with trans folks have moved a bit more towards depathologizing trans identities. In the DSM-IV, there was Gender Identity Disorder, now it’s Gender Dysphoria. The WHO (World Health Organization), in their next ICD – version XI, will no longer include gender dysphoria in the mental health section. It will be in the sexual health section. So, there is this movement forward. There are more trans voices, including trans folks who are providers, therapists. So, that’s the ideal, where it’s moving. But there still is this requirement by insurance companies and by physicians to diagnose a person with gender dysphoria. It needs to be medicalized in some way or psychiatricized, and since that’s the reality, I’m going to try to use my privilege, my credentials, to help make that gatekeeping as painless as possible, to not go through too many hoops.

What that might mean for me is that instead of a trans person having to see a mental health professional for a three to six session evaluation–which is a big cost and presents a barrier for so many folks, because this population is underemployed or unemployed–I don’t charge them if they need a letter. And I do it as fast as possible. I don’t really question them around whether they have a legitimate trans identity. I’m just using the letter to be an advocate, using letters as another form of co-conspiracy. It’s me saying, “You need this, I’m going to do it as fast as possible. One day, I hope we don’t have to do this, but in the meantime, you know, this is a way I’m trying to help support you.”

LR: A subversive gatekeeper.
DN: And then what I do for trans youth is to write a second letter. So, there’s the traditional clearance letter/assessment in which I diagnose them and say why they need hormones or surgery out of medical necessity, but then I’ll also write a counter letter, a narrative letter that is more about their own standards of care, their own appreciation of their gender journey, so they get two letters.
LR: That’s neat. So, you’re representing both sides of the fence, so people pass through it more easily.
DN: I think over time, I’ve figured that out. So, in my assessments, I’ve focused less on “Do you meet the standard, the criteria?” I’ll even say, “You know, I’m supposed to ask these questions. Why do you think I’m not going to ask them?” And they’ll say, “Because I already know that stuff. I know what hormones do. I know what the side effects are.” So, I focus more on their journey, on their narrative. I was working with this trans youth, where I asked him, “In your journey, have you thought about the kind of masculinities that you want to take up?” A lot of the conversations are more along those lines: their hopes, their visions of their own life, their gender identity.

Final Thought

LR: If we were to finish this interview up by trying to touch on kids, can you say a few words about what a therapist should know about working with trans kids?
DN: So, in working with trans children and teens, one thing that is really important is that young people are pretty clear about their gender identity. There are these discourses that they’re not capable of making decisions, I’m talking more teenagers where they might want to start taking hormones or hormone blockers. There’s this idea that they’re not capable and mature enough to make those decisions. As a narrative therapist, I look at how there’s a lot of discrimination like youth oppression, not honoring their voices. One thing is just to really honor their version of their gender identity and not to begin from the notion that they’re confused about their identity. That would be one thing, in terms of working with trans youth.I think another thing is to have conversations about how is it that they’re able to navigate this in spaces like schools that can be pretty tough and where there can be a lot of bullying. It is about helping them develop strategies to advocate for themselves and protect themselves. I use them a lot as consultants to other trans youth.

I’m working with one young trans man who then consulted another one of my clients and their parents because they’re earlier in their journey and had some questions. The dad is really concerned about hormones and their effects. So, I’ll use my other families’ experiences to help each other. I find that in my work with queer and trans youth, I’m always amazed and honored about how they’ve had to live their life and that they have these amazing ideas we can learn from as adults.

LR: Empowering them.
DN: Around how to look at gender and sexuality differently.
LR: Because of their honesty.
DN: Exactly.
LR: David, I’m going to draw us to a close. Thank you for a couple of things. You’ve been inspirational to me through your writings, truly. And as I did the reading and preparation for this interview, it further deepened my affection for narrative and strengthened my reserve. It’ll make me a better teacher and clinician, and I trust that our readers will also benefit, so I thank you for all you do on both sides of the fence.
DN: Thank you. I appreciate that.

Therapeutic Fanfiction: Rewriting Society

Posted on by Psychotherapy.net Team

In our work as geek narrative therapists, we’re often asked if we actually use fanfiction in session, and the answer is yes, we really do! For those who are unfamiliar with the term, “fanfiction” refers to creating one’s own stories based on beloved characters from existing pop culture narratives. Using fanfiction in therapy enables clients and therapists to rewrite the hero’s journey using narrative techniques. Since fanfiction is most often character-driven—getting inside the head of a character and asking “what if”—we can do the same with our clients, asking them to explore “what if” scenarios for themselves. For many clients, seeing themselves as the hero feels unfamiliar, and this is where fandom attachment or parasocial relationships can be uniquely helpful. Clients can use their emotional connection with fandom characters to create therapeutic fandom avatars and craft a fanfiction story that mirrors their own lives. With therapeutic support, they can begin to see their own heroism from the perspective of these beloved characters.

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Such was certainly the case for Cas (an amalgamation of several actual clients), a 25-year-old gender non-binary individual (biological gender female) of Ashkenazi Jewish descent, struggling with anger management issues and the fear that they would always be other. During our first session with Cas, they verbally noted our Adventure Time BMO, short for ‘BeMore’ tea mug, commenting that they had never seen a tea mug that was “quite so square.” We took this as an invitation to begin using therapeutic fanfiction early in our work. We shared that BMO, the gender nonbinary robot and video game console, was one of our favorite characters in Adventure Time, and asked Cas if they, too, enjoyed this cartoon. Cas eagerly explained that they loved this cartoon and that BMO resonated with them because BMO is on a journey to be “both a little living boy and girl who drinks tea.”

In the next few sessions, we fully employed the narrative tool of externalizing a problem via everyone’s favorite green superhero, The Incredible Hulk. This conversation was again initiated by Cas who remarked on the Hulk painting displayed on our wall: “Ha! That’s really true: mad does make sad.” We engaged Cas in a narrative therapy discussion around Bruce Banner, a.k.a. The Incredible Hulk, explaining to Cas that just as Bruce was not Hulk, they, i.e. Cas, were not their anger. We explained that understanding themselves as both connected to, but distinctly different from, their anger, might help them start to understand anger’s presence and reason for being in their lives. We then used the language of the Hulk comics to process their recent angry outbursts.

In subsequent sessions, we used the increased insight that Cas was gaining around both anger and the events that trigger anger to help them create a fanfiction action plan using Bruce Banner/Hulk as a stand-in for Cas. As part of this work, Cas was to pay mindful attention to their mood state, and when they noticed that they were beginning to feel angry, to place themselves into an Avengers fanfiction story in the role of Bruce Banner. They were to imagine that the team was working on a case and to ask themselves who was needed most—Bruce Banner or Hulk—playing out both scenarios to determine who would be best equipped to resolve the situation at hand. If the answer was Hulk, then they were to give themselves permission to feel anger without shame. If the answer was Bruce, then Cas was to engage in deep breathing and call upon their inner Black Widow to say soothing words to calm the inner Hulk. This was effective not only because this type of verbal play added a feeling of fun and whimsy to therapy, it also helped Cas maintain enough distance from anger so that shame was not triggered. Over the next three months of weekly sessions, Cas was able to continue the use of therapeutic fanfiction to both develop and implement strategies to de-escalate feelings of anger and to increase their frustration tolerance. They felt more in control of their inner Hulk.

At first blush, fanfiction and the hero’s journey may feel like disparate concepts for clinical work, but we have found that these concepts are not only congruous but incredibly healing in a therapeutic setting. Because there are fewer pop culture narratives made specifically for queer audiences, and because of queer marginalization in general, these conversations are all the more important and powerful. Therapeutic fanfiction allows queer clients to pick up the red editor’s pen and begin to adapt the story of their lives, creating a narrative in which they are the hero.   

Advocating for the LGBTQIAA in Psychotherapy

Posted on by Psychotherapy.net Team

I trace my commitment to serving underserved communities to my Jewish heritage. As a Jewish person, I am a member of a resilient minority group that experienced centuries of oppression and genocide. This cultivated inside me a sensitivity to discrimination and connected me to a passion for social justice. I have become active in my university’s LGBTQ+ club and feel that it is my civic duty to advocate for LGBTQIAA+ (lesbian, gay, bisexual, transgender, queer, questioning, intersex and allies) clients so they can be better served.

I’m also sensitive to others’ suffering because I grew up with a speech impediment. As a child, most people didn’t understand that my stutter was involuntary; peers told me to “slow down,” and “just relax and speak.” People didn’t understand my suffering, and I agonized in silence until I learned how to mostly overcome it. Since overcoming it, I’ve hoped to prevent similar suffering in others.

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How would you feel if the general public regularly imposed a gender and/or sexual orientation on you that did not accurately represent who you feel you are?

You don’t have to have suffered like I did to make a difference for the LGBTQ+ community, which is estimated to be 10% (and this only reflects those who feel safe to report) of the world’s population. We all have experienced a little taste of what it feels like to be discriminated against. This community has been fighting an uphill battle for their lives, with their jobs, families, and interpersonal relationships constantly at risk. They endure constant mislabeling, violence and judgment. The most covert, perhaps, is people assuming it to be a choice when it's not. Here are some questions to think about in your practice:

Do you assume couples are monogamous? Do you assume all your clients are cisgender? Do you assume heterosexuality if someone is currently in a heterosexual relationship? Do you assume the client you’re talking to is heterosexual? For example, have you, knowingly or unknowingly, asked if a female client has a boyfriend instead of a “partner(s)?”

The he-she binary inadvertently erases trans people. There is more variation to human gender than merely “ladies and gentlemen” or “men and women.” Since the vehicle of change for psychotherapists is primarily language, we can start by using inclusive, respectful, and empowering language. You can start by using person-first language, identifying your pronouns, calling out the use of terms like “mankind” and “he/she” and the existence of mostly binary bathrooms (unlike other gender-inclusive countries like Canada with primarily unisex public bathrooms). There’s even a case to call history [his-story], “her-story,” “their-story,” or our-story.” No wonder LGBTQIAA+ youth have a high suicide rate. Here’s a case example.

Al is a 14-year-old, assigned female at birth, but who identifies as a male. He has a pronounced trauma history; his father abandoned him to raise another family and, at 5 years old, his mother left him with his grandmother. He was placed in homeschool in 2017, has been isolated, and voiced suicidal ideation in the initial assessment. Virtually all his social contact has been online chatting with other trans youth.

Early in treatment, Al mentioned wanting a doctor’s note for hormone therapy. Not infrequently, psychotherapists working with trans clients receive requests for documentation that a trans person has diagnosable gender dysphoria that has caused substantial mental health issues such as suicidal ideation, and is “mentally fit” for hormone therapy and to make decisions about their own body. This helps doctors/insurers understand that hormone therapy and gender reassignment surgery can support, instead of hinder, a client’s mental health. Insurers and/or doctors may request them.

Contrary to traditional belief, I considered that it was both ethical and empowering to provide Al with this note sooner rather than later in the therapy. Here’s why.

We are not gate-keepers who decide what clients can do with their bodies. We shouldn’t block Al’s access to resources that a cis-person could access without a therapist’s permission. Best practice for me is that if a client wants a letter, I give them one. If a cis-male came in asking for a letter for their doctor to be on hormones and had limited social support, we would not impose stipulations. A trans person is equal to a cis-person and already has enough challenges to overcome to be who they are and have control over their body.

A therapist’s role is to not stigmatize. For example, if we require Al have 6 sessions before writing a hormone letter, it would be stigmatizing something that has nothing to do with mental illness. It would also be operating outside of the scope of our practice because we wouldn’t be determining if their mental stability is interfering with their identity. It is also not our role to determine if Al is sane to make the hormone decision, even if he’s a minor, without his prefrontal cortex fully developed. After we write the letter, it is the role of the medical doctor to determine if the client is medically able to start hormones and the doctor’s job to monitor the client’s physical body.

Al and I agreed that he is likely avoiding social situations because of the chronic mis-gendering he endured, and the invisibility of his identity navigating the world as a trans-person who is not presenting nor is perceived the way he desires. Hormones may be the catalyst that would help Al to make friends once he starts feeling comfortable in his own skin. Isolated, experiencing oppression, lack of control, depressive symptoms and desiring hormones (probably to look a certain way)—not accessing hormones could likely increase depression symptoms and suicidal ideation. After writing the letter, I provided Al with ample resources to connect with other trans-youth.

My role was to support Al where he was at, not dictate where he should be. Since Al was able to make decisions, there was no reason to limit when he started hormones.

I cannot emphasize enough Dr. Martin Luther King’s timeless notion that “our lives begin to end the day we become silent about things that matter.”

* I consulted on this case with Van Ethan Levy, Associate Marriage and Family Therapist, Associate Professional Counselor, and member of the community, who uses the pronouns Van/they.
 

Erica Anderson on Working Therapeutically Across the Gender Spectrum

Posted on by rezendevknowfully.com

Transgender 101

Lawrence Rubin: Thank you for taking the time to speak with me this morning. Transgender issues have gained much attention in the last several years, but most therapists do not have experience working with these clients. What are some of the issues a therapist needs to know?
Erica Anderson: Thank you for this opportunity. I think it is a topic much discussed in society these days, and you're right that very few psychotherapists are trained to work with people with gender issues. One of the most important things to point out is that in years gone by, those of us in the mental health field were trained to understand gender development in a very limited, binary way, namely that one was born either male or female; "M" or "F" on their birth certificate, and then they just grew up. Puberty constituted a pretty significant change, and maybe at some point, someone would declare that they were gay, but otherwise there wasn't really much to do about the development of gender.

very few psychotherapists are trained to work with people with gender issues
What we now have come to appreciate is that gender identity exists on a spectrum, and that just as Kinsey pointed out more than half-century ago, many more people have complex sexual attractions or are bisexual than we ever thought. The same is true with gender differences. We used to think that transgender people were very rare, but in fact, people who are not binary in their gender identity or whose gender identity differs from the sex that they were assigned at birth, are in greater numbers in society than we ever really understood.

Society has become more accepting of some of these differences so more patients who are questioning their gender are coming forward to therapists. They are exploring who they are and may actually be willing to talk about some of their own self-doubts or self-realizations. So, therapists need to begin to understand how to work with such people by acquiring new knowledge, developing new skills and examining their own biases or potential biases around gender issues.
LR: Can you say more about the knowledge and skills therapists need to have when working with clients presenting with gender identity issues?
EA: The first point about knowledge is reflected in what I said a moment ago; that many people have presumed that gender really is simply a binary trait of human beings, and that is not the case. If you look at the history of human civilization, there have always been people who have not lined up in their gender identity with the sex they were assigned at birth. There have always been transgender people in society. Some of them have been acknowledged, and in some cultures, there is actually recognition of this. Many native peoples have something called "two spirit," which is a recognition of someone whose gender doesn't line up with their anatomical sex—it is a mixture of gender identities. And then there are some other cultures, in India, Brazil and Asia, where there have been transgender people recognized throughout history. We now know that, depending upon what you include in the category transgender, perhaps as many as one in 200 people in America could be said to be transgender (according to a recent study from UCLA).
LR: When we think of addressing diversity issues in counseling and therapy, we think of gender, race, age and religion. You're suggesting that within some populations, their spiritual-cultural practices may intertwine with gender identity issues?
EA: That's right and it’s a very important point here that gender identity cannot be dissected apart from the other aspects of a person. We talk these days about intersectionality and multiple identities, and that becomes acute when we then consider gender issues. This is because the experience of someone who is transgender of a certain cohort and a certain racial, ethnic or economic background might be very different from someone else whose identity is different in some of those aspects. So, it's not a situation where you can say, oh well, all transgender people are X or Y. In fact,
I say all the time, when you've seen one transgender person, you've seen one transgender person
I say all the time, when you've seen one transgender person, you've seen one transgender person. That is part of the challenge in terms of training and education in clinical practice.

One of the things I hear often is, "Oh, well, you know, coming out as transgender, well, that's like coming out as gay." Well, no, it's not. Gender identity has to do with every aspect of who you are. To equate the transition of someone who is trans from maybe being perceived as one gender into being perceived in a different way, is not exactly the same as someone who may have been closeted as a gay person and then comes out as gay and is living more openly as gay. But that's a common thought for some people who are not very well versed in these issues. It’s disturbing to some trans people to be thought of as, "Oh, well, at one point in time, you're just kind of revealing something about yourself." It's a lot more complex than that!

Beyond Binaries

LR: This suggests that clinicians need to be aware of the developmental trajectory, not just of gender, but the convergence of multiple trajectories across the lifespan that include, but are not limited to, gender.
EA: Absolutely. In fact, as we know from the traditional field of developmental psychology, people develop in lots of different ways, and that development is very uneven for most individuals through childhood and adolescence, and even into young adulthood. So, we know that we can narrow in on various aspects of development. I say all the time that everybody has their own individual developmental pathway, and that where they are at any given point in time is simply that, and it's subject to change.

The other takeaway from the emerging knowledge about transgender issues is that gender identity is something that's very fluid. So, there isn't a single narrative that explains the course of development of all transgender people. In fact, people can come to an awareness of themselves very early, in early childhood, or later in adulthood. And there's a mixture of factors in any individual case that may be contributing to those differences.
LR: It seems therefore that one of the core skills for a clinician to master is to think intersectionally—to broaden their case conceptualization and treatment planning to include these multiple converging trajectories.
EA: Exactly right, which is what makes the work so interesting for those of us who are doing it now. The evaluation process involves parsing, where we look at certain aspects of the situation, traits and historical trends of an individual, and interweave these factors. And because of the highly individual nature of gender identity, we really must listen carefully to each person, no matter what their age is. We must listen to what they say about themselves because gender, as identified by an individual, is a deeply internal and personal thing and we cannot assume that we wholly understand, in a simple way, what is going on with somebody unless we spend some time focused on it.
LR: So, one of the skills that a clinician should have is being able to move past not only binary thinking regarding sexuality and gender, but beyond binary thinking about people in general.
EA: I say all the time,
there's nothing about human beings that's binary
there's nothing about human beings that's binary. If you think about psychology as a field that has attempted to study individual differences, there's really no characteristic that is simply binary–yes or no, this or that, black or white, on or off. We're not machines. We generally think about individual differences and the intensity of various traits when we think about personality. Even in medicine, we think about laboratory studies, growth charts and laboratory ranges for all kinds of characteristics. So, there's nothing binary about human beings. But thinking about that in terms of gender requires a fundamental reordering of how we bring together all the aspects of who a person is, and a recognition that they have been evolving and changing and developing, and they're going to continue to do so.
LR: I joke sometimes with my students by saying that there are two types of people in the world, those people who believe in binaries and those who don’t.
EA: I love that. That's really cute and apt.

Words Matter

LR: Therapists not particularly trained or experienced with transgender or transitioning clients may be unsure how to start, what language or personal pronouns to use, or even how to broach the subject. What advice would you give them?  
EA: This is a big challenge for all of us, even those of us who have more experience, because society has been changing rapidly. People are bringing to these discussions whatever they've known or learned or thought they knew, as well as what information is circulating now in the world, on the Internet and in professional circles. And we don’t all mean the same thing when we use the same words. I’ve seen this evolve in my career.

I was trained on DSM II which listed homosexuality as a sexual disorder. That came out in a revision of DSM II. But today's clinicians who have been trained more in DSM-IV and DSM-5 don't think about the fact that there are huge numbers of people who are still alive who were reared in an era when homosexuality was considered shameful and a psychological disorder. I had a patient years ago who was expelled from medical school because he was arrested in a gay bar for soliciting—and that’s in my lifetime.

So, the words that we use continue to evolve. An example is "gay." You know, "gay" used to be a slur, a pejorative word. It still is in some circles. But now we have the word "queer." People are using the word "queer" all the time but don't know what anybody else means by the word. So, if somebody comes in my office—and this is a tip for therapists—and starts using some of the words that have to do with gender and sexuality, I routinely will ask them, "Well, what do you mean by that word? What do you mean by queer? What do you mean by trans? What do you mean by gender? What do you mean by attraction?"
LR: So, letting the client lead in creating the definitions, and even helping them to make peace with a definition that best fits them at that point in their life…
EA:
Dr. Seuss wrote, "You are the you-est you can be. No one is more you-er than you."
Exactly, and I love to invoke my favorite philosopher, Dr. Seuss, who wrote, "You are the you-est you can be. No one is more you-er than you." You know, we really fundamentally have to accept that people define themselves. And people who have deep-seated psychiatric disorders may be defining themselves in ways that are not helpful and maybe even toxic, but we must start there. We have to start with what's going on with someone. And there is no more significant area to do this in than gender and gender identity.

Gender Politics

LR: What if a client comes to you and doesn't broach the subject of sexuality or sexual identity or gender identity? What's the therapist's role? Is it their place to ask a pointed question? Or is it sort of a Rogerian thing, to just let the client be and go with wherever they are?
EA: As you infer, I see a lot of people who come to me because they are dealing with some of these issues that we're talking about today, but not always. I will sometimes see people who are straight who have anxiety or depression. In my long career as a psychologist I've treated people with many different conditions. I don’t assume anything about what someone wants to focus on. On my website, I have a section called "Permission to Be," where I write about my philosophy. If someone comes to me and says, "I'm coming to you because I think I'm trans, or because I am trans, or because I want to explore my gender expression and identity," then we're off to the races. By contrast some clients come to me and say, "Well, I know I'm trans. I don’t really need to deal with that. But I'm really depressed" So, it depends on the particulars of a client.

In terms of advice to other therapists, I would say, don’t assume that something having to do with sexuality or gender is a problem for someone. If it is obviously a problem and they're asking you to help them with it, help them. But if they are coming to see you for other reasons, their relationship with their gender and sexual identity doesn't necessarily require any intervention.

I want to say something else about this that I think is significant. Transsexuality, as it used to be called, was categorized as a sexual perversion, and was nested in the DSM in the section on fetishes-paraphilias. But now we're at a point where we are questioning whether it is true that everyone who has a different-than-heteronormative or cisgendered identity has a psychological problem at all. In fact, the current DSM lists "gender dysphoria" to describe those who are trans, basically. The International Classification of Diseases 11 (ICD-11) that's coming out from the WHO, will be using the term "gender incongruence," and they are taking this label out of the psychiatric section and putting it into the sexual health category.

For the first time, we’re going to see a dramatic shift in de-pathologizing transgender identity
There are several reports, including ones published by SAMHSA in 2015 and documents from the American Psychological Association concluding that differences in sexual orientation and gender identity are normal variations. There is no presumption of psychological disorder.

Interestingly, there is a task force on gender dysphoria constituted by the American Psychiatric Association. They are going to be looking at the disparity between the DSM, which does in effect pathologize trans identity, and the ICD. It is going to be a challenge to reconcile those differences. I predict that the APA will come into agreement or alignment with the rest of the world, which uses the ICD and not the DSM. For the first time, we’re going to see a dramatic shift in de-pathologizing transgender identity. And I, for one, am welcoming that change. 
LR: If a transgender client visits a therapist who's not particularly experienced in transgender issues, and presents with issues seemingly unrelated to gender such as anxiety, depression or even sexuality; is it a mistake for the therapist to assume that these other non-gender-related issues are the cause?
EA: I think assumptions of any kind about etiology are always suspect. I think we must examine our own biases and expectations. A co-occurring disorder is simply that. It may be a contributing factor to distress about gender identity. Gender dysphoria often is reflected in interpersonal conflict and anxiety, sometimes depression. But it isn't necessary to treat them separately. It also is a mistake to assume that they're related in some systematic way.
LR: Some argue that therapists need not have personal experiences similar to a client’s in order to be empathetic. How does that apply here?
EA: On the one hand, I think sometimes we take therapist-client matching a little too far. On listservs here in the Bay Area, requests for referrals to therapists usually list eight or ten characteristics that they're trying to match up. I think to myself, “whatever happened to general training and the recognition of one's competencies or limitations?” However, I also think that this is an area that one shouldn't enter cavalierly. There is a limit on the empathy that a cisgender person can have towards a transgender person. The level of complexity and the extent of personal transformation that happens when someone comes to terms with a trans identity and then embarks on a gender transition is so complete that it's hard to explain simply, and it's certainly hard to imagine.

I hear all the time lay and professional people alike, saying, "I don't understand how this person can be trans. I knew them before. There was no hint of an identity other than sex assigned at birth. I don’t understand." And I say all the time that it's not so important that you understand. What is important is that you accept that this is a deeply felt identity by this person. And if they are disclosing it to other people, they've probably been struggling with it for a long time. In fact, it's well established that, at least until now, transgender people in American society have suffered trauma and continue to suffer trauma, and some more than others. I believe that if you've been transgender for more than 15 minutes, you probably have complex trauma. And that's a joke. Thank you for laughing. Because nobody is transgender for 15 minutes or three weeks or a month. It's a long, long thing.

There's another controversy in that regard that is currently swirling. There's a term being thrown around, which is not a scientific term: rapid onset gender dysphoria. Have you heard that term?

Families in Transition

LR: No. Is that like acute stress disorder affecting gender?
EA: It's a term made up by parents who are concerned that their teenage children are asserting a trans identity from out of the blue. They are worried that there's some kind of social contagion going on with teenagers where it's cool to be trans. More kids are trans than ever before, and they wonder if maybe they catch it from each other. But
I can assure you, transgender identity is not something one catches. It's not infectious
I can assure you, transgender identity is not something one catches. It's not infectious.
LR: Toilet seats and door knobs won't do it?
EA: Nope, won't do it at all. Even sexual contact between two consenting adults will not affect someone with a transgender identity. But this term has been thrown around. And one of the key issues is that teenagers, as they always have, talk with each other about things that they don’t talk with their parents about. And so they're exploring this with each other. And now we have the Internet, so they're going online and finding out all kinds of stuff, and they have friends online, and so forth. They explore for a while, and they get affirmed by their peers, and they draw their own conclusions, and then maybe they tell their parents, "I think I'm trans." The parents are, in some cases, surprised. In many cases, they're not, because there were indications earlier in the life of this child. But for those who are totally surprised, they think this is a recent phenomenon. But in reality, probably it has been percolating with this child for a while, and finally they come forward.

One of the issues for us in evaluating kids, though, is to be cautious about offering medical interventions—you know, puberty blockers or hormones, certainly surgery—until we're pretty satisfied that this really is an enduring identity of this person, and that it's the right thing, it's affirming of them, and it's medical necessary. I work at the Child and Adolescent Gender Clinic at UCSF and we see kids and their families, all ages, young children, preschool children to older teenagers and young adults. And as I was saying earlier in our conversation today, there's no one narrative, there's no one pathway that explains everybody. So, we have to be cautious where there isn't an obvious track record of development of a gender different than the assigned sex. But it doesn't necessarily rule out the legitimacy of it. It may mean that we'll have to have a longer period of observation than with some other kids, where it's quite obvious to everybody that this is a trans kid.
LR: I wonder if there's a correlation in the literature between children with rapid onset transgender disorder and parental unawareness disorder?
EA: Yeah, that's a good one. Certain parents, as you were implying by your very cute comment, find it harder to accept the reality of a child whose identity is very different than what they expect. They may have somewhat rigid views of sex and gender, and they may subscribe to the dominant gender schema of binary, and they may be, as you say, unaware of the fact that gay and trans people have been around throughout human history.
LR: How can therapists help parents enter the conversation once the kid or teen begins talking about it, even though it may have been evolving for years?
EA: Some of the basic principles that have peppered our conversation so far are relevant here, and that is, as a therapist, try to avoid bringing your own bias into the situation or the conversation. Try to maintain an open mind and be focused around listening carefully to the various people. Everyone in the family—no matter what kind of family, if it's a traditional heterosexual couple with kids or whether it's any one of the many versions of "modern family"—is coming at this from a different perspective. The
older people are coming at it having grown up in an era that was less open and less aware of some of these issues
older people are coming at it having grown up in an era that was less open and less aware of some of these issues. Kids may be bringing their own perspective, which could be quite spontaneous and quite free and quite direct. And so we need to listen to each other.

The word that's often bandied around and disregarded is "transition." A trans person goes through a transition of sorts to bring their life and even their body into consistency with their identity. Everybody gets that. But everyone else around that person is also going through a transition, and it's very uneven. Some resist it, some embrace it, and some are more troubled by it than others. Literally, I've had parents of teenagers cry in the consulting room, saying, "I thought I had a daughter, and I guess I have a son, but now I'm grieving the loss of my daughter." Or the other way around, "I thought I had a son, and now I know I have a daughter, but I'm grieving the loss of my son." These are very personal and poignant moments when someone is really trying to come to terms with the reality of what's going on. It's a very tender time and we have to be kind to each other about what we're going through. 
LR: Everyone is in transition and may have been struggling to come out of their own mental closets in acknowledging and embracing that their child or their teen has been struggling for so long.
EA: Every family is different. There are some themes that are common and that are often shared, but the nuance can be so subtle and important. I had a trans teenager in my consulting room last night, and we were talking about the resistance of their mother to their identity and the struggles that this teenager has had for years with a mother who has not found it easy to accept her child on the child's terms. It was really quite a pivotal moment in my work with this young person in that they disclosed for the first time the extent of verbal abuse that their mother had given to them throughout the years. And the child's efforts to cope with this meant that they kind of shut down and are currently afraid of going forward with transition, because they’re worried that their mother is going to say, "I can't accept this," and that their father would side with the mother. And my client is saying to me, "I'm worried they're going to kick me out. They're going to kick me out of the house."
LR: So, these kids are sometimes put in the position of bearing the burden of holding the family together or reducing conflict by remaining silent? You must be so skilled as a therapist to address this once you open yourself up to the systemic and contextual nature of it.
EA: It's a challenging thing. But in the case of this young person, critical. I have to address the dynamics between the parents and between the parents and this teenager because they’re really hurting.

Complicating Issues

LR: You were just talking about transitioning, so I'm wondering if there are different clinical needs for clients who are in surgical transition as opposed to those who, for whatever reason—health, finance or choice—can't or don’t pursue surgical transition?
EA: Each of the phases of the transition has its own set of challenges. One of the things that I'm impressed with by those who get surgery is that the characteristics of the person are all-important. So, if they're healthy, have realistic expectations and a good surgeon, they have a good result and there are no consequences. That's one process. Another might be someone who has health issues, who might be a little more likely to have some kind of untoward consequence of a surgical procedure and are then frustrated afterward because their recovery is a little choppy, and maybe the result isn't exactly what they had hoped.

The differences between people are clear. Historically, surgery has been largely confined to adults 18 and over. But more and more, the trans kids that we're working with whose identity is clear at a young age and who have been on puberty blockers and cross-sex hormones as young teenagers, are getting surgery in their teenage years. This is, of course, with the full consent of their parents when everyone agrees that it's medically indicated.
These kids are being given a gift that someone in that situation a generation ago would never have had
These kids are being given a gift that someone in that situation a generation ago would never have had, which is to avoid some of the life experience in the gender they don’t want, and some of the physical changes in their body that they're not completely comfortable with. They're able to move ahead with their physical transition in such a way that by the time they're in middle to late teenage years, they're fully embodied as the person they see themselves to be and the gender that they assert. From that point on, all their experience is in that gender. So, they go to college and the people at college only know them that way. They've done their name and legal gender change, and so forth. That's a whole interesting set of patients.

By contrast, you also have people who are married, have children, have started a career or are deep into a career, and then they come to terms with who they are, and they transition. And I'm thinking of two people I’m currently working with who were assigned as male at birth. They are in their 30s and 40s, married with children, going ahead with the transition and all the complications that you would expect based on having to deal with the reaction of the spouse, the children and the people in their professional world. It's a whole different set of issues.

The Psychologist’s Role

LR: More and more, psychologists are being called on by doctors who are working with patients contemplating anything from gastric bypass surgery to—I don't know if I'm using the right word—gender reassignment?
EA: Currently, gender confirmation surgery.
LR: Thanks. These psychologists are being called on to perform evaluations to provide physicians with concrete validation that this person is psychologically ready for surgery. Do you have any recommendations for these psychologists?
EA: There are guidelines for this, we call such reports "letters of support." They're really what you and I would consider evaluation reports. They are a review of this person, their history, any co-occurring issues, and their life circumstances. In addition, as we would agree, a necessary part of this is essentially the informed consent, you know, to talk through what is going to happen with this surgery by a skilled surgeon who is well trained and experienced with this procedure. And then, does the person really understand the risks and the benefits of this surgical procedure? And what are their expectations of what it's going to be like for them after they have this surgery? I was referring to that earlier today as we were talking about how realistic the person’s expectations are about surgery.

Most people who think about gender confirmation surgery have done extensive research on it. So, I find that—maybe it's a selection bias—the people who come to me are those who are a little more sophisticated. But I must satisfy myself that they've gone through that process, and that they've asked and had answered all the questions that they have, and that they've thought through whatever the likely consequences are, and they've considered the possible unexpected consequences. And if they have, if we've done all of that, and if there isn't an outstanding psychological issue or an acute psychiatric problem, then I'm inclined to write the letter and say, yes, I recommend that this is medically necessary for this patient.

Surgeons do require such letters still, at least according to the standard of practice. There is an organization called WPATH, that has standards of care, currently in its seventh edition. These are standards of care for medical and psychological service to trans people. The 8th edition is currently under preparation. And just like everything else that we're talking about today, things are moving in the direction of de-pathologizing. The question in the future will be, "What is the purpose of the evaluation? Is it to screen for any contraindications? Is it to satisfy the psychologist and the surgeon that this person is a good candidate for this surgery?” Those are open questions as far as I'm concerned. But I do believe that because of the wide-sweeping consequences of a gender transition—and if you add into it gender surgery which is irreversible—that performing these evaluations requires serious skill and should not be done lightly.  
LR: Therapists and clinicians want to render the most competent services in a way that is correct, ethical and moral. So, it's not just laying a quick MMPI on someone and saying, "Yeah, ready to cut."
EA: Exactly.

Closing Thoughts

LR: What should therapists be wary of within themselves when working with clients who are either contemplating surgery or thinking and feeling deeply about gender identity?
EA: I have been doing a lot of thinking in the last few years about our whole paradigm of transference and countertransference, and how that might need to be adjusted for work with transgender people., I myself am transgender. I ask myself all the time, "Do I bring any bias to my work with an individual client or patient?" I try not to, of course. But, in a slightly different way, I know that some people come to see me not only because I'm a qualified psychologist, but because I'm trans. They want to know about me and will ask me personal questions which is historically seen as being out of bounds. And I wonder, how is that related to transference or not?
My inclination is that if client questions are not too deeply personal—nobody asks me about my sex life—I will answer them.
My inclination is that if client questions are not too deeply personal—nobody asks me about my sex life—I will answer them. These include questions like, "What is it like to go through hormone changes? What happens in the surgery?" And I will selectively tell them a little bit about me, because it does reassure them. It's kind of like, "Oh, yeah, she went through this, so I can do that too."

Some of the questions therapists can ask themselves could include, “What are you bringing to that discussion with someone? Do you really have empathy for what they're going through? Do you have a bias? Have you examined your perspective about this?” I think the therapeutic pitfalls are to assume that someone is too young to decide, to assume that someone is neglecting their family responsibilities if they transition and they're married with a family, to assume that someone is not going to be able to have sex if they change their body. There are a lot of potential assumptions, and we just have to be careful not to hold them because we have a bias.
LR: So, the same general concerns about countertransference, self-disclosure, presumptions and biases, but a little bit more finely tuned to the needs of clients who are in transition.
EA: I am concerned that therapists who are relatively inexperienced in this area may have a hard time parsing the co-occurring disorders. And so they might think, "Okay, we can't go ahead with hormones or anything else, or certainly not transition, until we deal with your depression. And we've got to cure all your psychological problems before I feel comfortable encouraging you to go ahead." That is, in my judgment, a mistake, and often kind of a rookie mistake. I think the literature on co-occurring disorders suggests that there are many situations where we treat concurrently, not consecutively. To pretend that we can separate aspects of a human being and treat one part and ignore the other or set aside the other for a while doesn't work very well in this area.
LR: We can’t surgically remove pieces of pathology, revealing the true issues—it is simplistic and naïve.
EA: Here's the challenge! We have inadequate empirical bases for a lot of the things that we're doing. We're doing what we're doing based on the data we do have. This includes longitudinal information we have about patients, comparing and contrasting patients who do well and patients who don’t do as well, and bringing into our work in this area what we know about other clinical challenges. If we waited until we had long-term treatment outcome studies on all these things, there would be a lot of people who would struggle.

As you know, the rate of suicidal ideation and suicide attempts is very high in trans people. So, we're going to lose a lot of people if we deny treatment to trans people until we have what the rigorous scientists consider to be adequate empirical justification for what we're doing. There is a five-year research study going on at UCSF, one of four sites for a multi-site NIH study of transgender kids and the first of its kind. But that's a five-year study. The research is looking at both medical and psychological factors having to do with how kids do when they go on puberty blockers and how kids do when they go on cross-sex hormones. And in five to ten years, we'll have some data that will help illuminate what we're doing.

Hopefully it's going to confirm what we think we know about best practices with kids. We're one of the more advanced centers in terms of embracing what we call the gender affirmative model. We're very interested in affirming kids and their gender, and not putting roadblocks in their way to living authentically. We work hard to reach consensus about the truth about any individual kid, and then a consensus about what we know about this kid and what we are going to do. We ask important questions including, “What's the timing of various things? Are we holding off on things for specific reasons?” It's a very individual matter with both kids and older patients and it’s about crafting a plan for the gender journey heading towards transition. It is about trying to responsibly approach each of the potential decisions and make the best decision that we can at the time based on what we know for each patient. And that is, I think, a sound approach, but it isn't necessarily justified by empirical findings.

Gender identity isn't something that easily lends itself to measurement. Earlier, you invoked the Minnesota Multiphasic Personality Inventory (MMPI). I was at the University of Minnesota for a number of years, and I interpreted thousands of MMPIs. I don't know that we're going to ever have, at least in my career, any kind of test for who's trans and who isn't, or what level of trans-ness exists, and, oh, this means that they should proceed at this kind of pace in terms of decisions regarding medical supports for identity. 
LR: You're a transgender woman. How has your own personal journey prepared you to work as a therapist? No easy question, right?
EA: Like most of us who have been psychologists or therapists for a long time, every chapter in our lives does inform who we are and gives us insight into how life is for other people. I emphatically believe that I could not do what I do without incorporating some of what I've learned about myself and the world.
I will tell you that it is amazing to have lived as a man in society and now live as a woman in society
I will tell you that it is amazing to have lived as a man in society and now live as a woman in society. Sometimes I joke with other women and say, “I’m on our team now, and I get it. I get what it's like to be treated differently by men.” I had another interview recently in which I was “mansplained” many times. It's really hilarious when I get mansplained.

The subtlety of what I've experienced is not lost on me or some of my clients in that I know what the experiential aspects of this are, exquisitely! And although I didn't keep a careful journal of what I went through, I remember many aspects of it very, very clearly. I sometimes bring this subjective understanding into my work. I'm sure you could appreciate this. Sometimes, when my clients or patients are really struggling, I lean in, and say, "You know, I really do understand what you're going through, and I want to help you." And they realize that I'm being honest and direct about it, and it means something to them.

I'll tell you one other little anecdote which is kind of special for me. When I see trans kids at the UCSF clinic, I'll say to them, "Do you know any other trans kids?" Sometimes they shake their head, and say, "No, I don't know any other transgender kids." I'll then say, "Well, do you know any other transgender adults?" They'll shake their head, and say, "No, I don’t know any other transgender adults." I look at them and say, "Well, honey, you can't say that anymore, because I'm trans." Their eyes get big, their jaws drop. Sometimes they gasp, sometimes they break into a big smile. And it's such a sweet, special moment for me. Sometimes the parents are not surprised and other times they say, "Really?" And then they say to their child, "See, honey, you can be a doctor. You can have a good life." And I feel, in that moment, like this is a gift to me, to be there with that child.
LR: A gift to you, indeed. I was reading a book by Fred Rogers who quoted someone something along the lines of, "You're not just your age; you're every age you've ever been." And that makes me think of what you just said. You're not just your gender; you're every gender you've ever been.
EA: Yep!

Janelle Johnson on College Counseling

Posted on by Psychotherapy.net Team

The Clinical Landscape

Lawrence Rubin: You’ve dedicated your career to college counseling, working with students who appear to experience many of the same problems clinicians encounter in outpatient clinics, crisis centers, and substance abuse facilities. Are college counseling centers microcosms for the clinical world outside of the campus?
Janelle Johnson: I would definitely say what we’re seeing at community colleges and at universities around the United States is reflective of what’s going on in the nation
LR: Can you give me some examples?
JJ: There has been a trend where colleges have been able to provide more support services so students can attend. In the past, these students were not able to attend because of a diagnosis or not having the right medication. They couldn’t perform in college. But now we see a lot of students coming that have schizophrenia or bipolar disorder and we have disability accessibility services to help them. Here at our college,
one third of the students we see are diagnosed with a mental health disability rather than a physical or learning disability
one third of the students we see are diagnosed with a mental health disability rather than a physical or learning disability.
LR: So, they come in with previously diagnosed mental health conditions which may run the gamut from adjustment and anxiety disorders all the way out to schizophrenia?
JJ: Absolutely. We see students every day that may have a lifelong diagnosis, who are able to come to college now, but they need resources around their diagnosis. Student counseling services often try to work with their outside providers because we see ourselves as providing supportive counseling. At larger universities, there is access to medical providers to help with monitoring medications. It depends on what your setting is at your school. If a college center does not have a medical provider, then we obtain a release, so we can actually work with a psychiatrist or a therapist that’s not on the campus, especially when it comes to monitoring medications for more serious diagnoses.

Emerging Adults

LR: So, these students that you’re seeing who have come with diagnoses are accustomed to being in treatment, are they open to being referred back into the community, even after they’re in a college counseling setting, or do they hope the counseling center will give them all they need?
  
JJ: That’s a very interesting question. It depends on their maturity level and how they’ve worked with medications in the past. Even with a seemingly simple diagnosis like ADHD students will often say, “I had these accommodations in high school. They sent me to a counselor.” Perhaps they had more of a medical professional do an assessment. But they come to college with the idea “well I’m in college now, I don’t need any of this.” I think most colleges experience students who come to college and try to maintain, but whatever their diagnosis is we also know that this is an age where certain mental illnesses start to show up.

Sometimes there’s an incident that brings a student like this to the counseling center where, depending upon its size, they may be able to receive an assessment. Large schools like the University of North Carolina has around 30 people on staff with psychiatrists, licensed psychologists and licensed counselors. But in a smaller private school or community college, we send them out into the community for some type of assessment or we refer them back to professionals they may have seen in the past

LR: So, a third of the students who visit the counseling center come with a previous diagnosis and may be accustomed to treatment, and they may be receptive to referrals back out into the community. What about the other two thirds? The ones who come to you and may not realize that they’re struggling or may have an emergent psychiatric disorder. How do you hook them?
JJ: What we see, especially with younger students, is emerging adulthood—that transition where they’re starting to be responsible for themselves. We try to talk to them about how they want to live their lives and how they want to express themselves as adults. In the past, when there have been mental health issues, a lot of that push either came from the parents or the school. Whereas in college, I think one of the mental health hooks that we offer them is saying, “you know, these are decisions you can make yourself. How do you want to be?” We give them some options as compared to the past where they were told what to do.

I’ve met a lot of students who were actually on medications for ADHD or who were taking antidepressants. Their parents said to them, “oh, you don’t need this anymore” and took them off. They were in that gray area of not functioning that well but having that parental oversight to get things done. And

then they come to college, and without their medications or follow up, the parents just expect them to do well, but they don’t
then they come to college, and without their medications or follow up, the parents just expect them to do well, but they don’t.
LR: So, these are emerging adults with whom you try to work developmentally around taking responsibility and seeking resources, which sometimes helps them to reach out for and effectively use treatment.
JJ: Yes, and at the community college level, we try to partner with community agencies so oftentimes, we can make those referrals right in our office with the student sitting here. We can put the student on the phone and facilitate appointments.

Getting Them Hooked

LR: So, you may actually be the frontline for these kids. Do you find that some of these students are resistant to the services that you provide? Or resistant to being referred out for more serious problems that they may not even think they have?
JJ: Yes, I think that we do see some resistance. The BITs (behavior intervention teams) or campus care teams sometimes need to intervene when students become disruptive in the classroom learning setting. We talk to them and try to engage them in counseling. Faculty and other students try to be patient, but I think when a student becomes disruptive, we try to figure out what’s going because we tell them that they are jeopardizing their ability to be on campus.
LR: It sounds like you have to be a little more heavy-handed or hope that the campus support teams can build enough of a relationship with the student and walk them over to the counseling center.
JJ: That’s absolutely true. You know, some people are very compliant. Other people are interested in finding out what’s going on with them because they may have that feeling like, “I don’t want to keep living like this. I don’t feel good.” But, then other students have a hard time recognizing that their behavior is disruptive or that there’s any issue. It really depends on how they’re supported when they’re at home and then how they’re treated. Sometimes I find students with very high intellectual functioning have their own unique mental health issues. It’s really difficult with some of those students because you can talk to them very intellectually and they can process what you’re saying, but
they feel like treatment is going to somehow interfere with their creativity or their ability to perform in school
they feel like treatment is going to somehow interfere with their creativity or their ability to perform in school.
LR: Is there a specific student that comes to mind?
JJ: A young male student I recently spoke with had a bipolar-one diagnosis and had recently received an ADHD diagnosis. He was watching his peers advancing on to their master’s degrees while he was struggling to complete school—but having this very fatalistic attitude about himself and about his ability to complete. But when you speak to him, when you look at his courses and grades, he’s got As. Schoolwork is not an issue but he lives in this sort of fatalistic place. “Why am I doing this? I’ll never amount to anything. I always fail at everything. Look what all my peers have already done.”

I think oftentimes a student feels overwhelmed on the campus and sort of wanders into our area hoping that someone will speak with them. What we usually do in that case is to obtain a release. We try to follow up to let the outside providers know that perhaps the student is in a downward spiral and perhaps he needs his medications checked.

That’s also where Cognitive Behavioral Therapy (CBT) comes in. It helps the students to look at thoughts that really aren’t helpful—the misconceptions that they have about themselves which sometimes can be very challenging. 

LR: Do you get a sense, at least on your campus, that there’s a stigma associated with going to the counseling center or being seen coming out of the counseling center? And if so, how do you address that on campus?
JJ: I have a sense of that most campuses are working really hard with different kinds of programs to remove that stigma around coming to the counseling center. We see different initiatives like the JED and Active Minds programs and peer support groups. I could give an example like suicide prevention. Some campuses do things where they lay out backpacks in the quad for how many students have been lost. And then they have a place where you can come out to honor somebody you’ve lost or write something about yourself—some kind of thing where you can participate. I feel like there is increasing recognition of mental health on campuses and getting help if you need it.

On our campus, in particular, and I think on a lot of campuses, we do classroom outreach. We appeal to students to refer other students to us. Sometimes we find that’s even better than faculty referring students. Staff bring students over. But we find sometimes if your peer, another student says to you, “Oh my gosh, you’re just going through a horrible time. You know there are counseling services here on campus? You know, let me walk you over there or let me show where that’s at.” We find that’s really beneficial. 

Challenges of Dual Enrollment

LR: Yours is a two-year college. But there are also high school students on campus. Do you find that these young people have unique clinical problems and challenges?
JJ: We’re seeing a lot of early admission, college dual-credit high schools on campuses. And at Santa Fe Community College we do have a high school right on our campus. It’s even happening at some four-year schools where there’s a high school house. They have some high school teachers and some high school curriculum, but almost immediately students are being placed into college-level classes. What you see happening is
they’re graduating from high schools one day and then receiving either a certificate or an associate’s degree the next
they’re graduating from high schools one day and then receiving either a certificate or an associate’s degree the next.

Regarding the mental health of these particular students, some are very high functioning, very motivated, but some of these students are in this fast-track program because they’ve not done well in the traditional public high school. They’ve had conduct problems or social interaction problems. The parents think, “we’ll take you over here to our college so you’ll be able to take college classes and you’ll be in this high school but it’ll be a lot more flexible for you.” But these students who haven’t performed well in the past may have an inability to follow through and can’t really manage themselves in college. One of our counselors in particular had a student with a very high level of ADHD who didn’t come to the counseling appointments on time. This sort of high school/college program can actually create more anxiety and more unmanageability and adjustment disorders for students.

LR: So, these kids may not be in an appropriate fit for college life just yet?
JJ: Perhaps, but it’s hard to say. What schools are doing with this early college high school programs are really a positive move for a lot of students because I think high school has let a lot of them down. I think high school is a really difficult time for a lot of students because of pressures around social media and bullying. So, being on a college campus really helps them be with other college students who are motivated to get a degree. But there is always the question of whether they are developmentally ready or mentally ready. And while there is a high school counselor here for those particular students, they are spending a lot of time on other things like scheduling and achievement testing.

Addressing Suicide on Campus

LR: Suicide rates are very high in the college-age demographic. How are college counseling centers set up to address that? 
JJ: I think a lot of college counseling centers are trying to address that with different kinds of programming. The JED foundation, for example, offers programming for college campuses. Active Minds is another one that offer all kinds of wellness programming for campuses that also addresses suicide prevention. Also the American Foundation on Suicide Prevention in New York.

Suicide is the second-highest cause of death for our demographic.
Suicide is the second-highest cause of death for our demographic. Even if you go up in age a little bit, which is the demographic for a lot of community colleges, then suicide is the third-highest cause of death. So, I think on most campuses we are all actively working with programming and bringing support.

At Santa Fe Community College we actually have a certified faculty member do Mental Health First Aid Training. Mental Health First Aid is a program that originally came out of Australia that has been embraced in the United States. It’s a day-long program for people in the community who are not mental health professionals. Here at Santa Fe, it would be our campus community—our faculty, staff, other students who take the training. 

LR: So, when it comes to the more serious disorders, and suicide in particular, it’s critical that college counseling centers work in conjunction with community agencies and have programs on campus so that students are never alone. And neither are college counselors alone because they’re always linked to other resources?
JJ: Right. College counselors work with these different available resources, create their own programming or belong to these organizations that provide free programming.
The idea is to eliminate the stigma, raise awareness and have people participate.
The idea is to eliminate the stigma, raise awareness and have people participate. The campus is a community and we encourage students to participate in these suicide prevention programs and to be part of a campus community that supports helping students reach out. People need to recognize the signs and to be comfortable approaching people.

Disconnected from Families

LR: On a related note, we know that LGBT youth are at particularly high risk for suicide. How do you address the needs of these students?
JJ: A lot of campuses are looking to find ways to support students who are in the process of self-identifying or have someone on their staff assigned to programming in that area who works on removing stigma. In New Mexico, which is a very Catholic state with a lot of immigrants, some of these families persist in saying to their children, “your religion doesn’t accept this. You can’t do this. If you do this, you can’t live with us.” So, we try to work on that by asking these students, “How can you speak with your family? How do you want to live your life?” These students still recognize their religious teachings but don’t want that being used against their identity.
LR: So, you try to work within their families and with the cultural issues that impact their emerging LGBT identities?
JJ: Campuses will either look for programming or design their own programming around supporting these students, and then work with them on these issues in counseling.
A lot of these students actually feel safer on campus than they do at home.
A lot of these students actually feel safer on campus than they do at home.
LR: Speaking of unique challenges, what about first-generation college students.
JJ: I do believe they have unique clinical challenges because many of them do not have a history of going to college. Additionally, many of these young people also have to help out financially in their homes. So they live at home, come to college but also work to help pay the rent, the utilities and the car payments. And then there are issues around their transition to adulthood. We help them speak to their parents about what they need to be a successful college student.

Some of them will say “my parents are making me feel like I’m crazy because I need more time to study and I can’t take care of my little brother or pick him up from school every day.” It’s an interesting dynamic that plays into their mental health because when they don’t feel supported or understood at home, they experience anxiety, depression and acting out behaviors. It’s not that families don’t support going to college—they absolutely do. But they don’t know what that means or what it looks like.

Raising Awareness

LR: There’s a lot of research into the short and long-term effects of adverse early childhood experiences and the need for trauma-informed education. The idea is that some of these kids are coming to school with such a heavy trauma burden that they can’t concentrate, can’t relate and are at high risk for drinking or self-harm. Have you seen this on your campus and how do you deal with that?
JJ: There are different kinds of trauma. Here
in New Mexico, we have a lot of Native Americans, so we talk about historical trauma
in New Mexico, we have a lot of Native Americans, so we talk about historical trauma. In addition to these historical events, some of our students come from a background of trauma in their home or in their childhoods. In the college counseling setting, we work with these students around issues of safety, peer support and collaboration—empowering the student to have a voice while they are exploring their issues. We are not dismissing what has happened to them but we’re looking at how the therapy works for them, helping them to move forward with that trauma and not to feel re-traumatized by being in our college setting.
LR: Are drinking and substance abuse significant problems on college campuses?
JJ: We’re not seeing it as much on commuter campuses like ours that do not have housing, although I do think it is a presenting problem in our counseling centers. It’s different on residential campuses, and particularly in the dorms. But we do see students coming to campus who are inebriated, or who have problems that other students are reporting. They may be coming to class and they sound like they’re drunk or other students can smell it on them.

I do think it is an issue that is hard issue to address. College counseling centers try to work with students on maintaining their sobriety. I think if they’re actively using or they can’t even function then it is critical to refer them to treatment center. Another student may binge drink only on weekends and otherwise be high functioning, but it also starts to catch up with them. They may not be getting proper nutrition, or may be having problems with sleep, hygiene or relationships. These effects of drinking begin to interfere with their functioning in the college setting. With these students, we try to talk more about responsible drinking and help them to understand how their drinking interferes with their learning and progress and help them explore how they can be more responsible. 

Serving our Veterans

LR: You had mentioned that you have a veteran’s program on campus? Are there unique clinical needs for these students?
JJ: Often college campuses have veteran support centers which provide resources for veterans and their families. These resources include counseling services. Although we are not housed with the veteran’s service center on our campus, veterans know about our counseling services. We also have a veteran’s hospital in Albuquerque, New Mexico, which is about 60 miles away and a veteran's counseling center in Santa Fe.

Our veteran’s center also brings counselors onto our campus about once a week to meet with the veterans. This is not to say that some of the veterans don’t come to our regular college counseling center. Having served first and then coming to college can be a challenge and clinical needs depend on whether or not they are a combat veteran. The

combat veterans may feel that there is a stigma around coming to the regular college counselor
combat veterans may feel that there is a stigma around coming to the regular college counselor who hasn’t experienced what they have or have a military background. Larger campuses actually hire counselors who have served in the military. This can be helpful because veterans have trauma about reintegrating. They’re used to following authority and a more established and structured day. Sometimes they have difficulty with younger students who aren’t respectful. 
LR: Or knowledgeable!
JJ: Sometimes, these younger, less sensitive or aware students don’t conduct themselves very well in class which is very troubling for veterans. And then of course, we do have veterans that have PTSD or depression; situations that require more treatment. But a lot of times, I think it is more about adjustment, depending on how long they served and the college program they’re in.

CBT and Beyond

LR: We’ve been talking about various treatment needs of college students and I know that CBT and other empirically supported treatments are the rage these days. I’m wondering if it also dominates the college counseling landscape.
JJ: I think there is a lot of support on college campuses to use research-supported therapy modalities. CBT has a lot of related therapies including DBT, solution focused and even positive psychology. The reason it works in our setting is because we’re tasked to triage students that come in. There can be a high need for services and students oftentimes wait to get in to see a counselor or a mental health provider. So, I think we want to use therapies that we know can assist with more immediate behavior change.

We don’t have the luxury for long-term care with students.
We don’t have the luxury—and I don’t know if it is a luxury—for long-term care with students. So, those kinds of therapies can really be useful. You can give the student homework and worksheets—something they can hold onto so that they can feel like they’re moving forward and like they’ve accomplished something. I’ve even had students with whom I’ve suggested a reward system to help when they were struggling with something and want to see improvement. Larger campuses can even incorporate these kinds of therapies into a group setting and can direct students to be part of therapy groups.
LR: Would you say that college counselors are pressured to use these proven methods and not encouraged to use creative-expressive modalities that incorporate art, play and music? 
JJ: We’re not forced to do that—it would depend on the counseling center and how many staff members they have. I do see the creative going on as well. In New Mexico, Southwestern College offers a master’s degree in art therapy and I’ve had interns from there on my campus who have done art therapy with our students and they’ve really liked that.

There is some room for creativity, but you have to be working to move the student forward especially because you’re working in a limited timeframe; a college semester or a college quarter and then there’s a break and they go home. I am at a community college where we are looking toward a goal-oriented type of therapy. If they bring in extreme trauma or are in an abusive relationship or are fighting an addiction, treatment is better is referred to a community partner. We use whatever modality is supportive of their counseling and helps them to meet their goals.

And for most of them, their goal is to complete college, find a career and move forward. So, we try to facilitate that. If there is a major mental illness diagnosis, we make sure that they have a community provider who may be doing something like DBT groups. I don’t feel like college counseling can replace that.

College Counseling Competencies

LR: With regard to the provision of treatment, what are some the unique competencies that a college counselor should possess?
JJ: At the university level, a lot of schools hire licensed doctoral-level clinical directors. The counseling staff is sometimes made up of licensed counselors. In New Mexico, I’m a licensed clinical mental health counselor. Some college centers hire licensed clinical social workers who are in clinical practice. That’s is the more traditional set up. Our organization, the American College Counseling Association expects that any counselors working in a college setting be licensed.

What we see in California is an interesting example where most of the universities are using doctoral level licensed psychologists in their counseling centers. In their community colleges, they are using master’s level clinicians. But they don’t have licensure at that level. It’s hard for me to talk across the board, however the American Counseling Association has been working on licensure portability along with licensure accountability.

I would say that if you’re going to work in a college setting, you should be licensed in the same manner that you would to work in a private practice or at any other clinical facility—you need the degree and the experience that comes from practicum and internship to do this work. Unless, that is, you’re in a college where they’re calling you a counselor and you’re doing academic advising or something like that. If you’re in a college mental health counseling center, you’re doing the same kind of work anybody would be doing as a mental health professional anywhere else. The scope of your practice may be limited in that you have to do more community resource referrals. But, your knowledge and ability including understanding the DSM, various diagnoses and treatment modalities fully impacts your work every day. You need to be able to do it.

LR: Do college counselors need to like teenagers and emerging adults? Wouldn’t that be a prerequisite?
JJ: I think that you want to be able to work with that population. Three years ago, I started an internship program here at Santa Fe Communi

Straight Life Cycle/Queer Life

Posted on by Psychotherapy.net Team

It's Time

“It’s time,” my husband emailed me, along with details for an adoption orientation. We were thirty-seven. We both had careers we loved—he a lawyer, me a therapist. We had achieved some creative goals–writing, acting, cake decorating–and let go of many more. We had each lost parents way too soon. And we were not getting any younger. This was obviously the right time to have a kid, I said to myself, right?

And then I met Miles, a client whose life would collide with mine, rousing us both to rethink the concept of time.

He contacted me just as I reached the finish line of promoting a book—a period of time I have heard others describe as “the calm after the calm,” i.e., when the book release is less life-changing than the author anticipates. My book was about modern weddings, including reflections on my own wedding, and so I found myself talking a great deal in interviews about my very “normal”-sounding stages of development, along the lines of those created by psychoanalyst, Erik Erikson—e.g., First comes love, Then comes marriage…. As my husband and I had begun the adoption process, people wondered if my next book would naturally be about modern adoption. And while my exterior may have shone with a normative veneer, on the inside I felt entirely queer: off the track of social expectations.

For one thing, I missed my parental figures. I missed my father and mother-in-law, who died when I was twenty-two and thirty-one. I missed my mother who had just moved to a senior facility, halfway across the country (Erikson didn’t warn me about any of that). And while I was passionate about raising a child, gone were the illusions of moving through time as a normal-looking family with a normal set of parents (now grandparents) sagely guiding my spouse and me to the next normal milestone.

In fact, my parenting fantasies went well beyond taking home a delicious little baby to make us three. My mind flashed forward eighteen years to having a happy healthy young adult we could visit, share a meal with, hear stories about college, or simply sit on the couch and watch a good movie with. I could think of nothing more rewarding between parent and child than that. What I wouldn’t give to have such a moment with my dad today! I longed for the past and for the future.

Miles knew none of this, and only perceived what was available to him about me in the present. He had read about my book and thought I could offer guidance on his impending nuptials with his male fiancé. He was excited about his wedding but could not envision the next step, repeatedly thinking to himself, “Then comes….what?”

Miles came from an educated and accomplished family: his mother was a respected trial attorney and his father a fancy judge. Miles himself went to an Ivy League college and law school, and then he clerked for—you guessed it—a fancy judge. Meritocracy had served him well, shuttling him smoothly from one life milestone to the next. He did hit one detour along the way, though, when he came out as gay. This was challenging for him, as his parents accepted but rarely acknowledged his sexual orientation. For Miles, righting the course after this detour demanded ever higher levels of personal achievement. In addition to his robust CV as a lawyer-to-be, Miles spoke three languages, played the saxophone at jazz clubs, and showed his artwork in galleries. All of this, unbelievably, before he turned thirty.

And then Miles’ mother died unexpectedly. She had always said she couldn’t wait to sit and talk with him before his first big trial. “This was a when, not an if,” Miles said, mournfully describing this expectation.

Insult compounded injury when Miles learned that the civil rights law job of his dreams, which he had landed soon after his mother’s death and which he had worked toward for years, did not pay enough to cover his law school loans. And despite his impressive education, law firms were not interested in hiring a lawyer several years out with no private-sector experience. In order to pay the bills he had to take a non-legal job doing work that to him (and his father) seemed mediocre. Miles had lost his identity. He had been knocked to the sidelines of social expectations where for the first time in his life he was forced to watch other people, including his fiancé—a successful photographer—pass him by.

He did have one crucial milestone left, marriage, but by then even this felt uncertain. “Though he was in love with his partner and eagerly looked forward to their wedding day, he simply couldn’t picture the day after.” The day the milestone had passed. “Then comes what?” His experiences with law school, and coming out, and losing his mother—a littering of unmet expectations—had at this point left him with little hope for the future.

First Comes Marriage

Then Miles got married. The wedding was gorgeous and meaningful. I know this because he showed me pictures during one of our sessions, kneeling next to my chair and swiping his phone with a child’s glee. I absorbed each image like a proud parent. In that moment we were two peers, two married gay men in our thirties, and at the same time we were father (or mother) and son.

And therapeutically I wondered, just as Miles often asked himself, “then comes…what?”

The dark after the dawn came. Week after week Miles seemed more and more lost, stuck, and depressed in our sessions. “I just don’t know what to do,” he would say, repeating a pattern of always seeming to have the answers until he didn’t. In this state of dread he desperately hoped I would have an answer. I didn’t but desperately wished that I did.

For example, I could have taken a page from my own life and asked him if he thought about raising kids. But to bring up family planning would disguise me in the mask of Erik Erikson, the confident, arbiter of “normal”—albeit the gay version—while I squirmed in my own queer ambivalence about “stages of life” underneath.

Given Miles’ experiences of achievement and loss (as well as my own), I felt strongly that if I suggested any tangible solution existed for him at all, I would only conjure false hope. I did not want to set him up for disappointment yet again: to cross yet another finish line only to be denied another trophy.

But it was hard for me to sit with his despair. “I felt like a fraud, like I had failed to be the accomplished, gay married therapist who had it all figured out—in other words, the therapist I imagined he wanted me to be.” Were we both failures? Both lost outside of time, aimlessly floating in space?

At the beginning of one session, both of us hopeless and forlorn, I was sure he would tell me that he was done. That therapy was a waste of time.

Miles’s father had been staying with him for the previous week, and this made him feel worse than usual. “Why?” he wondered aloud. Was it because his father polished off all the leftover booze from the wedding? That he failed to show much interest in Miles or his husband during the visit? That the only question he asked was if Miles had checked in with any of the law firms that had rejected him in case they might reconsider? Was it all of the above?

As usual, I felt like I was coming up short. Miles wanted me to tell him what he should do, and I didn’t know, so I did what therapists do at such times and reflected his feelings back to him. This only made him feel worse and ask again, “What should I do?”

Caught

The feelings of failure and loss in the room were suffocating. I found my mind casting about desperately for air. I thought of the next ream of adoption papers my husband and I still had to fill out—ugh—and then I thought of something more fun. My fantasy of the future, the simple weekend visit with my grownup kid, and how nice that would be.

“What are you thinking about?” Miles asked.

Oops. He caught me. Daydreaming is not on the list of expectations for a therapist. I felt a rush of embarrassment. But I also realized there was nothing I could do but be in the moment.

As I inhaled (deeply and pensively), I began to realize how on topic my daydream actually was—which is often the case for therapists in moments like this, as it turns out. I remembered how lovely it was to sit and look at pictures with Miles, and thought how sad it was that his father had overlooked that opportunity during his visit.

“I was thinking that your father could have told you how lucky he is to be alive and to have you. How happy he is that you’ve made an interesting and loving life for yourself, and how rewarding it is just to sit and visit with you, right now.”

“Yes,” Miles said. He began to tear up. “He could have said that.”

We shared a momentary smile and sat in silence. The past and the future, the lost and the longed for, were all commingling, awake and alive in the present.