Reflections from the therapist’s chair

By Sarah E. Burgamy, PsyD

Every morning, I set up my clinical space — I have a penchant for the chair facing into the room, back to the door, window and outside world. As a true habitual creature, I place my Day-Timer (yes, Day-Timer…and a shameless plug for the merits of the Franklin Planner) in the back corner of the table between the chairs, grab a coaster (Type A much?), rest my coffee into its morning hour cockpit and prepare myself to ground out in this therapeutic space for much of the next eight hours. Day after day, year after year, it goes much the same.

In a way, I set this scene for two purposes; one, to offer some description of my daily base experiences as a clinician preparing to work with my clients each day, and, two, to convey something of the “normal” I have created and come to expect from most days, whether in my clinical chair or out in day-to-day life, running odd errands at odd times of day between clinical hours. I am sure many of you, my fellow clinicians, have found yourselves in something of a twilight zone since Nov. 7, 2016.

Personal political affiliations or leanings aside, the November election virtually hijacked the sacred clinical space with so very many of my clients. In my practice, I specialize in identity development, specifically along the lines of sexual minority/diversity competency as well as transgender and gender variant issues with adults, adolescents and children. Roughly two-thirds of my clinical caseload concerns folks who embody a target (see Hays, “Addressing Cultural Complexities in Practice, Second Edition: Assessment, Diagnosis, and Therapy”, 2008) status in these arenas of human identity. I work with children as young as 3 years old, along with their families, up to adults in their 50s and 60s. Here is a rough sample of the kinds of concerns and fears I have heard just before and since Nov. 7, 2016:

  • “I am afraid we’ll be rounded up in camps, like the Japanese internment camps during World War II.”
  • “I am more afraid more than ever to use the public restroom.”
  • From a 13-year-old: “I just don’t go to the bathroom while I am at school.”
  • From a parent of a 5-year-old, calling in a panic: “Should I go ahead and get [child’s name]’s passport and social security card changed to the other gender? We might only have a small window. I don’t know what to do. Should I do that just in case?” We had only barely begun clinical work together.
  • From the parent of a 15-year-old, same panicked voicemail: “I know we don’t see [physician in Colorado with speciality competency working with children and adolescents with gender dysphoria] for another few weeks, but could you do something to help us get that DMV [Department of Motor Vehicles] letter signed? I want to make sure we can get [client]’s gender marker changed before it becomes impossible.” Tearfully: “I don’t want my child to suffer.”
  • “I’m afraid my marriage [same gender] will be nullified.”
  • “Now people will feel permission to hate me out loud and without being checked.”
  • Client reacting to President-Elect (at the time) Trump’s cabinet appointments: “I don’t know how to feel better. Every time I think things can’t get worse, they do.”

I am certain many of you could add to my list. The things you have heard; the fears your clients have expressed. What do you say? It is generally considered a culturally competent best practice to validate “healthy paranoia” — some level of increased vigilance for target status individuals. In essence, fear of mistreatment, prejudice or oppression is real, even if covert, and some elevation of vigilance for one’s safety, both psychological and physical, is considered healthy and functional. Pertaining to gender identity work, this aspect of personal gender expressive presentation can be a fine line between healthy paranoia and maladaptive social anxiety. I know how to do this work with my clients. After Nov. 7, as a clinician, even I could not tell the difference at times.

What do you do when the world you have learned to expect — the one you have come to anticipate in all its imperfect glory, but reasonably predictable variation — suddenly turns on its ear? I found myself in very unfamiliar territory. The kind of territory where “expertise” has significantly exacerbated limits. In the days immediately following the election, as I heard some rendition of the above summarized comments on repeat, I found myself sitting more and more with how self-disclosure was or was not clinically relevant or necessary. How much disclosure was therapeutic; how do I maintain therapeutic distance or, better yet, be authentic yet manage countertransference? Even though I was accustomed to not having the corner market on assuaging anxiety and fears in people’s unique lives, I felt more without an anchor to assuage anything at this time. I had no more of an idea as to what the future held than did my client. What did people need?

Trauma theory or even models of grief processing were the closest theoretical scaffolding I could settle on to capture what was happening, in my therapy room, session after session, day after day, week after week, as November turned to the holiday season and a resurgence of anxiety and preoccupation with our nation’s political climate appeared once more nearing Jan. 20, 2017. At times, I disclosed my own surprise/shock, if it matched that of my client; I shared the uncertainty and validated their fear of the unknown. I made these decisions, case by case, and also discovered I had not actually allowed myself the time and space to process my own emotional and cognitive reactions to the political tide change. There are those times, when, as a psychologist, I find myself swimming — at times drowning — in the same ocean of collective experience as my clients. As a professionally out, identified lesbian and gender variant/queer/androgynous woman, some of the collective cultural experiences of my clients are also my own. But the timing of things is often not up to me. When something occurs — the Orlando Pulse nightclub shooting comes to mind — I am called to show up as clinician, to help my clients process their reactions, fears, anger, and make sense of the senseless. To hold space. Sometimes, these events occur so rapidly, or the reactions are so immediate, there simply isn’t the time and space to drop out of my professional role, just tell my clients to “hold, please” while I find a quiet space to absorb, experience and process my own human reactions. This has been a challenging time. I have spoken with other colleagues about similar sentiments. Consultation with colleagues, whether formal or informal, has been instrumental in this process.

So what I have I done? Many of you may be concerned that I’ve been sitting in my chair, my coffee long since gone tepid in temperature, swimming/treading water/trying not to drown in my own psychology. Fear not.

Back to basics: Part of the beauty of such a significant level of day-to-day worldview disorganization is the abrupt interruption of auto-pilot (see any mindfulness literature ever), and reinnervation of awareness. Ironically, the sudden life disorientation of many of my clients has also yielded a very powerful focus on personal values. In a way, some of my therapeutic guidance around coping with newfound stress and anxiety related to political climate has been to encourage my clients to passively absorb less — less social media bombardment, fewer auto-alerts from CNN, a reduced number of hours watching television network news. No, I have not suggested everyone go bury their overactive frontal lobes in the proverbial sand. Instead, I have borrowed technical psychotherapeutic “pages” from Acceptance and Commitment Therapy (ACT), Cognitive behavioral therapy (CBT), and a potpourri of psychodynamic theories and asked my clients to focus on what they value. To clarify what they believe is good, just and meaningful. To engage in behaviors that are deeply rooted in their most treasured personal ethics. In many ways, this period of time absolutely brought me back to basics. An emphasis on building self-efficacy in ways each individual has immediate and significant agency — persuasion over their own behaviors, and investment of energy and time.

In fact, I’ve also taken a note from my own psychological oeuvre and offered myself the time and space to get out of the office — go for a hike (I’m a Coloradan, after all), a walk, and just to stop and take several deep breaths. I sit on my porch and watch birds leap and flutter from limb to limb. Disruption exists; there appear to be definitive reasons to be concerned about the civil rights of my clients, for them to be concerned for themselves and their loved ones. But how to live a sustainable existence amidst all this uncertainty?

Postelection reflection

By Gary Howell

The world in which we live is a fascinating one and unpredictable at best given the current sociopolitical climate. I cannot help but think about the events of 2016 and wonder how much more the collective resiliency of my students, colleagues, patients and even my own resiliency can take. It took the Orlando shooting to reinvigorate the advocacy of the gender and sexual minority community and its allies. The response was extraordinary, impactful and moving. It was a testament to the resolve of our community. Unfortunately, we become complacent so easily these days; in fact, one does not have to look very hard to elucidate the effects of complacency on HIV prevention work. We made great strides with our fight for marriage equality, but quickly became complacent in our fight to protect those rights. In some states we had to be reactive rather than proactive when courts began challenging marriage equality, which is something we have done as a profession for far too long.

As an openly gay educator, administrator and psychologist, not a day passes where I am not advocating for my patients or students. I try each day to instill the passion for advocacy in those I teach. We need allies in this fight as we move ahead in dangerous and uncharted territory. I am sometimes frightened by the ignorance to these sociopolitical crises, especially when talking with the next generation of psychologists. Clinical work has been all but typical these days. On a regular basis, patients are complaining of heightened anxiety and depression, unrelenting hopelessness and fear, and they are reporting suicidal ideation far more than I would like to see in my private practice. I see a survivor of the Orlando shooting, and his trauma was triggered by the election and re-triggered by the inauguration. The promise of a wall and deportation has frightened a lot patients for those of us who work with immigrants, regardless of documentation status.

What do we do? How do we help when these daily assaults to our community are happening? Hate crimes have risen in a very short period of time, and patients see and hear about those statistics—and some ARE those statistics. How do we instill hope with marginalized communities when it is being ripped away faster than we can work with folks to tap into their already overtaxed resiliency? The reality is that just saying there are checks and balances is not enough. Rules we have lived by in our country for hundreds of years are no longer relevant to the most important political figure in the world. I will continue to fight, advocate and make my voice heard to anyone who will listen. I will sign petitions and use my media connections, if needed, to find more allies to bring to the table. We need to use the white privilege we so often minimize to help delegitimize a platform for hate and bigotry. Our academic institutions, especially schools of professional psychology, are responding to the demands in real time. We have not historically trained our students to deal with such sociopolitical issues within our own country. It is our new reality, our new normal, and we must rise up against bigotry and not stand for the rhetoric that continues to divide our country even further.

Psychology responds to political distress — from therapy to YouTube

By Glenda M. Russell, PhD

In the aftermath of the 2016 presidential election, I was asked to give a brief talk at a community gathering. Billed as "Moving toward Collective Liberation," the gathering represented an effort to bring together multiple identity groups in the community who had been targeted by rhetoric in the presidential campaign and who faced uncertainty and fear as the country moved toward the incoming administration. I had been conducting research on the impact of noxious political events for several decades, and I was eager to share what psychology knows about the impact of such processes on people in marginalized groups and, more importantly, what we know about how to cultivate resilience in the face of these processes. At the same time, I was overwhelmed by the thought of how I was going to distill all of the research into a five-minute talk that would have a good chance of being helpful to a diverse group of people, many of whom were still reeling from the campaign rhetoric as well as from the election results.

I wondered how I could do justice to a topic that I had spent years studying and about which I had written a good deal (Russell, 2000; Russell & Richards, 2003). It was all the more daunting that I had been asked to do that in all of five minutes. Somewhere along the way — in the shower, actually — it came to me that my frustration pointed the way out of my dilemma. I decided to use the notion of a book with footnotes as the frame for my talk. I gave the talk to a large gathering of people, and it went well. Afterwards, I had requests for the text both from people I knew and from strangers. A number of people asked if there was a video of the talk. Having given many talks and consultations on surviving negative politics around the country, I had some notion that others might find the talk helpful. The community psychologist in me demanded I do my best to heed these requests, but I am generally quite reluctant to engage in activities that involve any equipment more complicated than an electrical plug.

It turned out quite serendipitously that a colleague, Karen Raforth, with whom I work on a weekly LGBTQA radio show, had taped the entire event, thinking she might use parts of it for one of her shows. And, out of nowhere, a friend of a friend — Corinna Robbins, a woman with a startlingly extensive background in television whom I had never met — offered to produce a video of the talk for free. Corinna spent untold hours working with the talk and fashioning it into a seven-minute video. She put it up on YouTube, and we each sent messages to most of the members of our contact lists.

In this brief article, I want to offer a commentary on the talk as a way of distilling this huge literature into a concise form, paying particular attention to how the content of the talk reflects sound empirical findings—both those that are specific to political events and more general findings about stigma and positive coping. With some warranted humility, I want to offer the possibility that you might find parallels between the considerations I brought to the task of making this talk and the considerations that I try to keep in mind when I work with clients who are experiencing noxious political events in particular, or working through oppressive experiences more generally. Those considerations in the therapy context are explained more directly in a chapter I wrote with Chris Hawkey for the recent revision of the “Handbook of Sexual Orientation and Gender Diversity in Counseling and Psychotherapy” (Russell & Hawkey, 2017). But I invite you to consider how these principles might apply in a therapeutic setting as I sketch them out here, and I will do the same as this paper proceeds.

In anticipation of reading this commentary on my talk, you might want to first check out the video.

In setting up the "book" in my talk, I began each new topic by announcing a chapter number. Chapter 1 opened with humor. I was a bit nervous about starting in this way, not wanting anyone to feel that I was not taking their painful responses seriously. But the humor was also a quiet invitation to acknowledge the awfulness of the situation while also stepping back and getting a bit of perspective on it. An intentional part of my initial contact with clients is to see if they have any apparent ability to laugh at any aspect of the dilemmas in which they are caught. I take it as a very good sign if they can; their laughter is a sign that they are not fully the captive of their dilemma but can step back a bit and see their problem with some perspective. Among the scores of e-mailed responses I have received about the video, many viewers have commented on how much they appreciated the humor in it.

Then, I proceeded with (the hypothetical) Chapters 1 and 2. Here, I wanted to both acknowledge and normalize the fact that many people experienced the campaign and election as significantly stressful. Implicitly, I wanted to communicate that, for many people, the election represented a disturbing and destabilizing experience that could generate a good many strong feelings—in essence, a bit of an exposure experience. At the same time, I wanted to suggest that such responses were normal and not pathological and that they were shared by many others. Much of what I typically do at the start of work with clients who have experienced stressful events is to help them to understand their reactions as understandable and sensible, given the stressor. In the talk, I began by doing the same sort of thing in an effort to normalize reactions and to reduce the felt sense that the reactions were out of control.

Chapter 3 commented on the increased reports of hate crimes and harassment after the election. I wanted to tie the strong emotional reactions that many people are having to the external world. Again, I want to keep driving home the point: Your reactions are not pathology; they are understandable responses to actual events in the social and political world that are likely disturbing and might be frightening. Making connections between internal reactions and external oppression is a foundational aspect of feminist and multicultural therapies. In the usual course of therapy for stressful life events, it is not unusual for me to make statements of this sort on different occasions. Doing so can normalize and demystify, and it helps to prevent self-blame and the internalization of oppressive themes.

The talk then moved to address the listeners' appraisal of the sociopolitical situation that is going on around them. Chapter 4 takes up this task, which is so critical to positive coping. This chapter is very parallel to the work I do in therapy with a client: If we are going to cope effectively with a stressful situation, we have to have a way of making sense of it that creates behavioral possibilities, that moves us from feeling overwhelmed to seeing a way to move forward. In individual therapy, the client would be doing far more of the leading to create a re-frame here. In the talk, I introduced what I hoped would be an adaptive appraisal through both a commonsensical truism from history and a familiar quote from Dr. Martin Luther King, Jr .—a reference to the famous quotation about the "arc of the moral universe." My effort was to begin to install a movement perspective (Russell & Richards, 2003), a way of seeing a specific negative event as but a moment in the ongoing movement for positive social change.

I then reinforced the nature of the appraisal with the example of Colorado's 1992 passage of the anti-gay Amendment 2 — an electoral outcome that was devastating to many in the LGBT communities in the state, but that led to dramatic changes in legal and social spheres. This is the sort of example that clients in therapy might generate themselves, possibly in reaction to my questions, but often as they talk about their reactions to the stressor. In the talk, I followed up the example with a related framing that is familiar to many—recent political events as representing a backlash. Framing the election outcome as a backlash is an alternative way to understand the new appraisal that I was recommending. This framing explicitly invites viewers to consider that the election can wake us up and activate us, thus moving us out of the overwhelmed state into new possibilities for action.

Having opened up the possibility of a new appraisal, I next moved back to the emotional reactions we had named in Chapter 2. It was my hope that the new appraisal would give the possibility of working with these feelings in a different way. I addressed these feelings in a series. In actual therapy, I would more likely be talking with clients about the feelings as they brought them up — and then return to them — over the course of the therapy. In the talk, I began with the famous reframe made by the philosopher Nietzsche: "That which does not kill us makes us stronger." This chapter of the talk normalized each of the emotions that people are likely to feel, and it pushed for each to be an acceptable beginning of a new process. Thus, we can get over shocking events. It is fine — even useful — to experience and express our sadness. Fear can be dealt with, and it does not relegate us either to inaction or to unhealthy action. Anger is reasonable, but not something to be cultivated, lest it tie us to the past, especially to negative events in the past. Rather, anger needs to be harnessed and channeled. Alienation, while tempting, is a trap. It is important that we do not give our attention and energy to people who do not like us. While it is important to be aware of people and actions around us that could be dangerous, we should not give undue attention to such people. Rather, we should focus attention on building culture, creating community, and building alliances with others.

Virtually all the literature on coping with stressors in general has as its foundation the idea that active coping is preferable to passive coping. In actual therapy, encouraging clients to look at possibilities for moving out of stuck-ness and inaction might occur in many steps over the course of the therapy. In the talk, Chapter 6 moved the focus to different ways of being active. (A piece of the talk that was cut from the video emphasized the range of coping activities—from the very small gesture at an interpersonal level to major institutional actions.) I intentionally used examples of actions that real people had taken in the aftermath of the election. I wanted them to feel relevant and accessible to people who were searching for ways to respond.

Chapter 7 offered a set of simple recommendations about general self-care: getting exercise, adequate sleep and the like. It included the suggestion that viewers not devote too much time to media. I wanted people to hear that the consumption of too much media, though tempting sometimes, is akin to eating bad food or drinking alcohol in excessive quantities. These sorts of issues, of course, closely mirror the ones we raise in individual and group therapy, virtually no matter what the reason for therapy is.

Chapter 8 opens the very important topic of internalized oppression/stigma. The use of a Steven Biko quote — "The most potent weapon in the hands of the oppressor is the mind of the oppressed" — is meant to underscore the idea that internalized stigma is to be expected. The tip that follows the Biko quote invites people to take their minds back—i.e., work on their own internalized oppression. The explicit language suggests that we can intentionally fight to reduce internalized oppression. While I may never use that language in therapy (unless a client uses it), work on internalized stigma is almost always something I watch for and intervene in during therapy with people in marginalized groups, and especially if the presenting problem is related to group status and experiences (Russell, 2006; Russell & Bohan, 2006).

The subject of privilege was the focus of Chapter 9. Being aware of one's own privilege can help people who have been victimized feel less like victims (Russell & Richards, 2003). That is a topic that I discuss with some clients, though it is one that some clients are not ready to explore. In the talk, I wanted to offer a commonsensical approach to the topic of privilege, which otherwise tends to generate guilt and shame. I began with a simple assertion: everyone has some level of privilege. The more we understand and work with our privilege, the less likely we are to use it destructively. Instead, in the words of Suzanne Pharr, we can spend our privilege well. One way to spend our privilege well is to stand with others who hold relatively less privilege than we do on a given dimension. I used a well-known quote by Lilla Watson at the end of this section as a reminder about the pitfalls of bringing a patronizing or condescending approach to our work as allies of groups of which we are not ourselves members (Russell & Bohan, 2016): “If you have come here to help me you are wasting your time, but if you have come because your liberation is bound up with mine, then let us work together.”

Chapter 10 carried the discussion to the issue of coalition building. Many, many groups of people have recently been the targets of denigrating rhetoric and have reason to fear potential policy changes that threaten their well-being. As distressing as that observation is, it also suggests the potential for mass mobilization by equally many groups. This reframe is yet another effort to offer an appraisal of the current political climate that has very positive potential. This is not a typical issue in most of my therapeutic work with clients. However, the value of coalition building has certainly come up more in recent months as I have been talking with clients about their reactions to the campaign and election.

Chapter 11 used a quote by Aldous Huxley to remind the audience at my talk (and viewers watching the video) to act with compassion toward themselves and toward others. This suggestion implicitly addresses the fact that we are living in a very polarized country at this time. Encouraging compassion toward self and others is a mainstay of much therapy.

The closing of the talk began with the realization that there were no more chapters in this "book," and then moved on to emphasize that this was not the ending but rather the beginning. Here, I called upon a Jill Lepore quote invoking Frederick Douglass' admonition to avoid resentment and instead to put our energy into working for equality. The closing also offered the possibility of important and meaningful action by working for justice, equity, and peace. The final words in the talk — and in the video — speak about working together.

In the time the video has been on YouTube, it has received over 100,000 views — this with no systematic effort to gain viewers, just the passing of the link by people through different media. Several score people have commented on the YouTube site, and I have received far more e-mails, mostly from strangers, attesting to the value of the video. The response to the original "book" and the enthusiastic reception of the video are testimony to how strongly people are craving information and direction that can help them navigate this difficult time. They are also reminders of how much we psychologists know and how helpful our knowledge can be to LGBTQA people who are simply trying to figure out how to respond to political changes that seem dangerous and outside their control. The message of the video — and the talk on which it was based — is that we do have power to work with others and to change the world.

References

Russell, G. M. (2000). Voted out: Psychological consequences of antigay politics. New York: New York University Press.

Russell, G. M. (2006). Internalized homophobia: Lessons from the Mobius strip. In C. Brown & T. Augusta-Scott (Eds.), Narrative therapy: Making meaning, making lives (pp. 151-173). Thousand Oaks, CA: Sage.

Russell, G. M., & Bohan, J. S. (2006). The case of internalized homophobia: Theory and/as practice. Theory and Psychology, 16, 343-366.

Russell, G. M., & Bohan, J. S. (2016). Institutional allyship for LGBT equality: Underlying processes and potentials for change. Journal of Social Issues, 72(2), 335-354. doi: 10.1111/josi.12

Russell, G. M., & Hawkey, C. G. (2017). Context, stigma, and therapeutic practice. In K. A. DeBord, A. R. Fischer, K. J. Bieschke, & R. M. Perez (eds.), Handbook of sexual orientation and gender diversity in counseling and psychotherapy (3rd ed.) (pp. 75-104). Washington, DC: American Psychological Association

Russell, G. M., & Richards, J. A. (2003). Stressor and resilience factors for lesbians, gay men, and bisexuals confronting antigay politics. American Journal of Community Psychology, 31, 313-328.

Russell, G. M. (2006). Internalized homophobia: Lessons from the Mobius strip. In C. Brown & T. Augusta-Scott (Eds.), Narrative therapy: Making meaning, making lives (pp. 151-173). Thousand Oaks, CA: Sage.

Glenda Russell is a research associate in Ethnography & Evaluation Research and a lecturer in the Departments of Psychology and Women & Gender Studies at the University of Colorado Boulder. She also has an independent practice in Boulder.